Intraoperative Cardiac Arrest due to Allergic Acute Coronary Syndrome (Kounis syndrome) Triggered by Cephalosporin

An acute coronary syndrome due to mast?cell activation in the presence of an allergen is known as Kounis Syndrome (KS). This relatively new entity of KS is being increasingly recognized among allergists, cardiologists, and emergency physicians; however, it is not well?known among anesthesiologists. We report here, a case of type 2 KS due to antibiotic administration causing sudden perioperative cardiac arrest.

Single Value of NephroCheck� Performed at 4 Hours After Surgery Does Not Predict Acute Kidney Injury in Off?Pump Coronary Artery Bypass Surgery

Background: Quantification of urinary tissue inhibitor of metalloproteinase?2 (TIMP?2) and insulin?like growth factor binding protein (IFGBP?7), which is commercially known as NephroCheck�(NC) test have been suggested as promising tools for the early detection of acute kidney injury (AKI) after cardiac surgery involving cardio?pulmonary bypass (CPB). Objectives: The aim of the present study was to test the hypothesis that single value of postoperative NC test performed at 4 hours after surgery can predict AKI in off?pump coronary artery bypass grafting (OPCABG) surgery. Setting and Design: This prospective single?center study was conducted at the tertiary cardiac center in India from December 2017 to November 2018. Methods: Ninety adult patients of both sex undergoing elective OPCABG were included. Anesthesia was standardized to all patients. Urine samples were collected preoperatively and at 4 hours after surgery for NC test. Urine output, serum creatinine, estimated glomerular filtration rate (eGFR) were also measured. AKI staging was based on kidney disease improving global outcomes (KDIGO) guidelines. Statistical Analysis: To assess the predictability of NC test for the primary endpoint, area under the receiver operating characteristic curve (ROC), was calculated. Results: Thirteen patients developed AKI in the study cohort (14.4%) out of which 7 patients (7.8%) developed stage 2/3 AKI and the remaining stage 1 AKI. Baseline renal parameters were similar between AKI and non?AKI group. The area under curve (AUC) of NC test at 4 hours after surgery was 0.60 [95% confidence interval (CI): 0.42?0.77]. Postoperative NC test performed at 4 hours after surgery did not predict AKI in this study population (P = 0.24). There were no significant differences in duration of mechanical ventilation, length of intensive care stay and hospital stay between the two groups (P > 0.05). Conclusion: NephroCheck� test performed at 4 hours after surgery did not identify patients at risk for developing AKI following OPCABG surgery

Epidemiology of antimicrobial resistance in bacteria isolated from inpatient and outpatient samples, Ecuador, 2018 / Características epidemiológicas de la resistencia antimicrobiana en cepas bacterianas aisladas en pacientes de servicios hospitalarios y ambulatorios de Ecuador, 2018 / Epidemiologia da resistência aos antimicrobianos em bactérias isoladas de amostras hospitalares e ambulatoriais no Equador, 2018

ABSTRACT Objective. To compare the epidemiology of antimicrobial resistance in bacteria isolated from inpatient and outpatient samples in Ecuador. Methods. A secondary analysis was done of data on bacteria isolated from inpatient and outpatient samples. Data were taken from the 2018 national antimicrobial resistance surveillance database of the National Reference Center for Antimicrobial Resistance. The variables included were: age, sex, inpatient versus outpatient setting, type of specimen, bacterial species identified, pattern of resistance to antibiotics, and geographic area. Results. Data from 57 305 bacterial isolates were included in the study: 48.8% were from hospitalized patients, 55.7% were from women, and 60.1% were from patients older than 45 years. Urine (42.9%) and blood (12.4%) were the most common clinical samples. Overall, 77.1% of bacterial isolates were gram-negative (83% and 71% in outpatients and inpatients, respectively). The most common gram-positive and gram-negative species were Staphylococcus aureus and Escherichia coli, respectively. Antimicrobial resistance levels were high (up to 80% for some antimicrobial drugs), and were higher in hospitalized patients compared with outpatients. A variety of carbapenemases were found to confer resistance to carbapenems (antibiotics of last resort) in gram-negative bacteria. Conclusions. The study findings provide an important baseline on antimicrobial resistance in Ecuador. This will allow the strengthening of guidelines of the surveillance system, the creation of public policies for standardization of laboratory methodologies, the proper handling of information, and the development of empirical therapy guidelines based on local epidemiology.

RESUMEN Objetivo. Comparar las características epidemiológicas de la resistencia a los antimicrobianos en cepas bacterianas aisladas de muestras de pacientes de servicios hospitalarios y ambulatorios en Ecuador. Métodos. Se realizó un análisis secundario de los datos sobre cepas bacterianas aisladas en muestras de pacientes de servicios hospitalarios y ambulatorios. Se recogieron los datos de la base de datos nacional del 2018 para la vigilancia de la resistencia a los antimicrobianos del Centro de Referencia Nacional para la Resistencia a los Antimicrobianos. Las variables incluidas fueron: edad, sexo, entorno hospitalario frente a entorno ambulatorio, tipo de muestra, especies bacterianas detectadas, patrón de resistencia a los antibióticos y zona geográfica. Resultados. En el estudio se incluyeron datos de 57 305 cepas aislamientos bacterianos: 48,8% fueron de pacientes hospitalizados, 55,7% fueron de mujeres y 60,1% fueron de pacientes mayores de 45 años. La orina (42,9%) y la sangre (12,4%) fueron las muestras clínicas más comunes. En general, 77,1% de las cepas bacterianas aisladas fueron gramnegativas (83% y 71% en pacientes de servicios ambulatorios y hospitalarios, respectivamente). Las especies grampositivas y gramnegativas más comunes fueron Staphylococcus aureus y Escherichia coli, respectivamente. Los niveles de resistencia a los antimicrobianos fueron elevados (hasta 80% en el caso de algunos fármacos antimicrobianos) y fueron más elevados en los pacientes de servicios hospitalarios en comparación con los pacientes de servicios ambulatorios. Se encontró que una variedad de carbapenemasas confiere resistencia a los carbapenémicos (antibióticos de último recurso) en bacterias gramnegativas. Conclusiones. Los resultados del estudio proporcionan una línea de base importante sobre la resistencia a los antimicrobianos en Ecuador, que permitirá el fortalecimiento de las directrices del sistema de vigilancia, la creación de políticas públicas para la estandarización de los métodos de laboratorio, una adecuada gestión de la información y la elaboración de orientaciones de tratamiento empírico basadas en las características epidemiológicas locales.

RESUMO Objetivo. Comparar a epidemiologia da resistência aos antimicrobianos em bactérias isoladas de amostras hospitalares e ambulatoriais no Equador. Métodos. Foi feita uma análise secundária de dados sobre bactérias isoladas de amostras hospitalares e ambulatoriais. Os dados foram obtidos do banco de dados nacional de vigilância da resistência aos antimicrobianos de 2018 do Centro Nacional de Referência para a Resistência aos Antimicrobianos. As variáveis incluídas foram: idade, sexo, ambiente hospitalar versus ambiente ambulatorial, tipo de espécime, espécies bacterianas identificadas, padrão de resistência a antibióticos e área geográfica. Resultados. Foram incluídos no estudo os dados de 57 305 isolados bacterianos: 48,8% eram de pacientes hospitalizados, 55,7% eram de mulheres e 60,1% eram de pacientes com mais de 45 anos. As amostras clínicas mais comuns foram urina (42,9%) e sangue (12,4%). No total, 77,1% dos isolados bacterianos eram gram-negativos (83% e 71% em pacientes ambulatoriais e pacientes internados, respectivamente). As espécies gram-positivas e gram-negativas mais comuns foram Staphylococcus aureus e Escherichia coli, respectivamente. Os níveis de resistência aos antimicrobianos foram elevados (até 80% para alguns antimicrobianos) e foram mais elevados em pacientes hospitalizados em comparação com pacientes ambulatoriais. Foram encontradas várias carbapenemases que conferem resistência aos carbapenêmicos (antibióticos de último recurso) em bactérias gram-negativas. Conclusões. Os resultados do estudo fornecem uma importante linha de base sobre a resistência aos antimicrobianos no Equador. Isto permitirá o fortalecimento das diretrizes do sistema de vigilância, a criação de políticas públicas para padronização de metodologias laboratoriais, o manejo adequado de informações e o desenvolvimento de diretrizes para a antibioticoterapia empírica com base na epidemiologia local.

Glandular Odontogenic Cyst Mimicking Dentigerous Cyst: A Rare Case Report

Background: Glandular odontogenic cyst is an uncommon developmental cyst of odontogenic origin. Till now, around 200 cases have been reported in the English literature, out of which approximately 25 of them are associated with an unerupted tooth. Herein we present a case report of a 7-year-old boy with swelling in the anterior maxillary region which was later diag- nosed as a Glandular odontogenic cyst that mimicked a Dentigerous cyst. Case presentation: A painless swelling was noted in the anterior palatal region. Orthopantamogram was advised which re- vealed a unilocular radiolucency associated with an impacted supernumerary tooth. Provisional diagnosis of Dentigerous cyst was made. The cyst was enucleated in conjunction with peripheral osteotomy. The histopathological examination revealed a cystic capsule with non-keratinized stratified squamous epithelium with 2-4 cell layer thickness, with some areas showing epithelial plaque, microcysts, hobnail cells and few clear cells. Contemplating all the histological features, final diagnosis of Glandular odontogenic cyst was given. Conclusions: The presented case emphasizes the importance of histopathological examination of the unusual and rarely ob- served Glandular odontogenic cyst which can be missed due to similarities with other entities. Recurrence rates being very high, follow up of the cases is imperative.

Circulating Tumor Cells – A Review

Context: Circulating tumor cells (CTCs) are those cells that separate from the primary tumor to enter circulation. This is facili- tated by Epithelial -Mesenchymal Transition (EMT) or through Non EMT based modalities by passive entry into circulation. CTCs are responsible for causing distant metastasis. Objectives: This review article briefly describes few of the mechanisms of CTC production and survival and few methods that are used to detect CTCs Materials and Methods: Data was collected and analyzed from published literature and electronic database searches of PubMed and Google Scholar. Result: CTCs acquire genetic alteration that differentiates them from the primary tumor. Majority of CTCs do not survive in the circulation but the few that do, do so by adapting various survival mechanisms. Conclusion: Detection of CTCs help in the early diagnosis of cancer, providing patient tailored therapy and for monitoring of cancer.

Brain and COVID: A Case Series of Neurovascular Complications

Introduction: COVID‑19 is caused due to infection with severe acute respiratory syndrome‑coronavirus‑2. A change in the epidemiological pattern of neurovascular diseases has been observed among patients who have had COVID‑19 infection. There are not enough studies which have evaluated the neurovascular manifestations among patients of COVID‑19 infection. MaterialsandMethods: This single‑center observational study was intended to evaluate the correlation between various COVID‑19‑related parameters with the outcomes of vascular events among patients of COVID‑19 who developed neurovascular complications. The study was conducted at a tertiary hospital in Pune, India, from February 01, 2021, to October 10, 2021. The study population involved patients with COVID‑19 of varying severity and associated neurovascular complications. The total number of patients was 22 in number. The deidentified data were analyzed using JMP version 10.040. Results: Among a total of 22 patients, 16 (73%) had arterial infarcts, 5 (23%) had venous infarcts, whereas 1 (4%) had intracerebral hemorrhage. Four (18%) patients had features of severe COVID‑19 and 2 (9%) of them had a modified Rankin Scale of six. There was a strong correlation between the severity of COVID infection and the severity of neurovascular complications. A positive correlation was observed between the time duration from Reverse transcriptase polymerase chain reaction (RT‑PCR) positivity to neurovascular complications with the duration of >45 days having a poorer outcome. Conclusion: COVID‑19 is more likely to cause thrombotic vascular events including stroke. The severity of COVID‑19 is directly correlated with poorer outcomes. The duration between RT‑PCR positivity and neurovascular symptoms if >45 days, has a poorer outcome

Comparative Study of Diode Laser versus Diathermy in Soft Tissue Surgical Procedures of Oral Cavity

Aims andObjectives:To evaluate wound healing and patient’s comfort after oral soft tissue surgical procedures performed by diode laser in comparison with diathermy Methods:This study includes 20 patients requiring oral soft tissue surgical procedures are randomly categorized into group A and group B of 10 patients each. Group A patients will undergo diathermy and group B patients will undergo laser therapy. Clinical assessment and photographs of patients will be done preoperatively and postoperatively on 1st day, 3rd day, 7th day, 2nd week and 4th week. Evaluation of postoperative bleeding, pain, infection and healing will be carried out. Results:At the end of the studythe assessment of parameters such as bleeding, swelling, wound healing, presence of infection were approximately similar in both the treatment methods to be insignificant, 70% of the patients included in this study under the laser group were very satisfied with the procedure & the pain experience by the patients in the same group was comparatively less, when compared to the diathermy group Conclusion:The observations suggest that both the treatment options were effective although laser proves better in terms of minimal bleeding, pain, reduced swelling, faster healing and patient’s comfort. Further research and a longer follow up period is desirable for a definitive conclusion

Smoking cessation practices and perspectives among in-patients in a tertiary teaching hospital setting

Background: The objective of the present study was to assess the in-patient’s perspectives about smoking cessation and the services they received.Methods: A descriptive study was carried out in a hospital attached to a Medical College. An interview schedule was administered in person to in-patients to assess their perspectives towards smoking cessation and services received.Results: Of the 141 in-patients interviewed, 40% were active smokers. Almost 3/4th of active smokers had moderate to high nicotine dependence. About 92% of active smokers reported being asked about smoking status and being advised to quit, but only 23% received assistance, and 8% had a follow-up arranged. Health was the top reason for the willingness to quit. Around 90% of study participants had no awareness about tobacco cessation centres and services.Conclusions: An in-patient setting has a higher proportion of smokers than the general population. These in-patients should be a prime target for cessation programs as there are relatable health reasons and opportunity for the delivery of comprehensive smoking cessation services based on 5 A’s protocol, which is currently lacking. Creating better awareness regarding smoking cessation centres and services available is necessary.

Assessment of prescribing pattern and cost analysis of topical steroids for skin disorders in dermatological outpatient department of a tertiary care hospital

Background: Topical steroid is most commonly prescribed in non-infective dermatological conditions. Periodical Prescription audit is mandatory for the effective management. Hence the present study is designed to assess the prescribing pattern and cost analysis of topical steroids for various skin disorders in the dermatology OPD of a teaching hospital.Methods: This is a prospective observational study conducted in dermatology OPD of a teaching hospital from Jan-Mar 2019 in patients prescribed with topical steroids in all age groups after obtaining IEC approval. Data was analyzed for prescription pattern and cost analysis using descriptive statistics and expressed in percentage.Results: A total of 90 prescriptions were analyzed among which males were 45% and females were 55%, the common indications were eczema-27.7%, atopic dermatitis-25.5%, psoriasis-16.6%, dermatoses-13.3%, lichen planus-7.77% etc. Topical steroids commonly prescribed were super potent (Clobetasol 34.4% and Halobetasol 22.2%). Cream and ointment formulation were commonly used. Common adverse reactions were skin atrophy, hypopigmentation, acne. In prescribing pattern, specification of strength and quantity were lacking whereas instructions regarding area of application-44.4%, route of administration-83.3%, frequency and duration-91% were noted. In cost analysis, comparison is made between similar potency and clinical outcome. Of which, Clobetasol 0.05% and Betamethasone 0.01% is found to be cost effective compared to Halobetasol 0.05% and Mometasone 0.1% respectively.Conclusions: This study provides a limelight on prescribing pattern of topical steroids and emphasize periodic audit to rationalize the prescription with cost effectiveness.

Inadvertent carotid artery cannulation with malposition of catheter tip in right ventricle in tetralogy of fallot patient undergoing total intracardiac repair – A case report

Central venous catheterization is an essential procedure in patient undergoing cardiac surgery, as it provides central venous pressure monitoring, fluid administration, and infusion of inotropes during perioperative period. In the cardiac surgery, where the patients are anticoagulated, an inadvertent arterial puncture can lead to serious complications. Hematoma following inadvertent arterial puncture is one of the common complications, which can compromise cerebral circulation. We report a rare case of inadvertent cannulation of internal carotid artery in patients of tetralogy of Fallot undergoing intracardiac repair during an attempt to cannulate internal jugular vein.

Urinary trypsinogen-2 dipstick test for point-of-care screening of acute pancreatitis

Background: Acute pancreatitis (AP) is associated with high mortality in its severe form. Conventional laboratory tests used in its diagnosis are fraught with multiple shortcomings. Early institution of intravenous fluid resuscitation can reduce morbidity and mortality. Measurement of urinary trypsinogen-2 using a bedside urine dipstick test may prove useful in early identification of AP.Methods: Patients with symptoms consistent with AP, attending the emergency department, at a tertiary care hospital in southern India, between November 2014 and November 2016, were included in a prospective observational study. The patients underwent routine investigations and additionally were tested with a urinary trypsinogen-2 dipstick test (UTT). The diagnostic performance and the time to reporting of the different investigations were compared with those of UTT. Final diagnosis of AP, made by clinicians, served as the standard.Results: The sensitivities of serum amylase, serum lipase, UTT, ultrasonography (USG) and contrast-enhanced computed tomography (CECT) were 97.1%, 94.1%, 92.7%, 98.3% and 100%, respectively. The respective specificities were 92.4%, 98.5%, 98.5%, 100% and 100%. The average time required to obtain the test report was about half hour from admission in case of UTT, compared to about 3 hours for serum amylase/lipase, 4 hours for USG and 6 hours for CECT.Conclusions: The results indicate that UTT test, due to its high performance indices, simplicity and faster availability of reports, can serve as an ideal screening test for AP and help in early institution of treatment.

Evaluation of Local Recurrence in Giant-Cell Tumor of Bone Treated by Neoadjuvant Denosumab

BACKGROUND: Giant-cell tumor of bone (GCTB) is a locally aggressive primary benign tumor presenting as an expansile osteolytic lesion affecting the epiphysis of long bones. Denosumab halts the osteolysis by giant cells thereby downstaging the tumor, helping in performing less morbid procedures to remove the tumor. Our aim was to report the incidence of local recurrence (LR) in patients operated following neoadjuvant denosumab, to investigate factors associated with LR following extended curettage for GCTB, and to compare the postoperative functional and oncological outcome of patients operated with and without neoadjuvant denosumab. METHODS: A total of 123 patients with a mean age of 29.6 years undergoing extended curettage for GCTB were retrospectively divided into group 1 receiving neoadjuvant denosumab and group 2 operated without denosumab. The mean follow-up period was 35 months. The perioperative characteristics and outcome were compared between the two groups and the factors for LR of GCTB were analyzed. RESULTS: The incidence of LR among patients operated after neoadjuvant denosumab therapy was 42.8% and was significantly high compared to that in patients without denosumab (p < 0.001). On multivariate logistic regression analysis, use of denosumab as a neoadjuvant was the only factor independently associated with LR following surgery (p = 0.002). Patients treated with denosumab had a lower LR-free survival rate (log-rank, p = 0.018). CONCLUSIONS: Denosumab was independently associated with increased LR following surgery for GCTB. Denosumab has to be used cautiously in patients in whom the burden of downstaging the disease outweighs the possible chance of LR.

Clinicopathological profile of lung cancer patients in a teaching hospital in South India

Introduction: Lung cancer is one of the leading causes of cancer related deaths in the world. The incidence of lung cancer is increasing in India and there is a need to understand the natural history of this disease. Aim of the study: To study the clinico-pathological-radiological profile of patients diagnosed with lung cancer from January 2013 to May 2015 at a tertiary care teaching hospital

Materials and Methods: Inpatient records of all patients admitted during the study period were examined and all patients with a histologically proven diagnosis of bronchogenic carcinoma were recruited. Demographic characteristics, clinical, radiological and pathological details of each patient were recorded

Results: Fifty four patients with lung cancer were identified. Forty three [79.6%] were male and 11 [20.4%] were female. Thirty two [59.7%] were smokers and 22 [40.7%] were non smokers. Cough and expectoration [61.1%] was the most common presenting symptom followed by breathlessness [59.3%]. Mass lesion [81.5%] was the most common radiological presentation and adenocarcinoma [42.6%] was the most common histological subtype. When compared to fiber optic bronchoscopy, image guided percutaneous biopsy had a better yield for diagnosing lung cancer [51.9% vs 48.1%]. But this difference was not statistically significant [p=0.892]

Conclusion: Adenocarcinoma is replacing squamous cell carcinoma as the most common type of lung cancer in India

Association between anthropometry, cardiometabolic risk factors, & early life factors & adult measures of endothelial function: Results from the New Delhi Birth Cohort.

Background & objectives: Abnormal endothelial function represents a preclinical marker of atherosclerosis. This study was conducted to evaluate associations between anthropometry, cardiometabolic risk factors, and early life factors and adult measures of endothelial function in a young urban Indian cohort free of clinical cardiovascular disease. Methods: Absolute changes in brachial artery diameter following cuff inflation and sublingual nitroglycerin (400 μg) were recorded to evaluate endothelium-dependent and -independent measures of endothelial function in 600 participants (362 men; 238 women) from the New Delhi Birth Cohort (2006-2009). Data on anthropometry, cardiometabolic risk factors, medical history, socio-economic position, and lifestyle habits were collected. Height and weight were recorded at birth, two and 11 yr of age. Age- and sex-adjusted linear regression models were developed to evaluate these associations. Results: The mean age of participants was 36±1 yr. Twenty two per cent men and 29 per cent women were obese (BMI > 30 kg/m2). Mean systolic blood pressure (SBP) was 131±14 and 119±13 mmHg, and diabetes prevalence was 12 and 8 per cent for men and women, respectively. Brachial artery diameter was higher for men compared with women both before (3.48±0.37 and 2.95±0.35 cm) and after hyperaemia (3.87±0.37 vs. 3.37±0.35 cm). A similar difference was seen before and after nitroglycerin. Markers of increased adiposity, smoking, SBP, and metabolic syndrome, but not early life anthropometry, were inversely associated with endothelial function after adjustment for age and sex. Interpretation & conclusions: The analysis of the current prospective data from a young urban Indian cohort showed that cardiometabolic risk factors, but not early life anthropometry, were associated with worse endothelial function.

Salud global 2035: un mundo convergiendo en el lapso de una generación / Global health 2035: a world converging within a generation

Con motivo del 20º aniversario del Informe sobre el Desarrollo Mundial 1993, una Comisión de la revista The Lancet reconsideró el argumento a favor de la inversión en salud y desarrolló un nuevo marco de inversión para lograr mejoras dramáticas en materia de salud para el año 2035. El informe de la Comisión contiene cuatro mensajes clave, cada uno acompañado de oportunidades para los gobiernos nacionales de países de ingresos bajos y medios y para la comunidad internacional. En primer lugar, invertir en salud acarrea enormes rendimientos económicos. Las impresionantes ganancias son un fuerte argumento a favor de un aumento en el financiamiento nacional de la salud y de asignar una mayor proporción de la asistencia oficial al desarrollo de la salud. En segundo lugar, en el modelo creado por la Comisión se encontró que es posible lograr para el año 2035 una "gran convergencia" en salud, consistente en la reducción de las tasas de mortalidad materna, infantil y por infecciones a niveles universalmente bajos. Tal convergencia requeriría la ampliación de las herramientas de salud existentes y un incremento agresivo de nuevas herramientas, y podría ser financiada en su mayor parte con recursos derivados del crecimiento económico esperado de los países de ingresos bajos y medios. La mejor manera en que la comunidad internacional puede apoyar la convergencia es financiando el desarrollo y suministro de nuevas tecnologías de salud, y frenando la resistencia a los antibióticos. En tercer lugar, las políticas fiscales -tales como los impuestos al tabaco y al alcohol- son una palanca poderosa y subutilizada que los gobiernos pueden emplear para detener el avance de las enfermedades no transmisibles (ENT) y las lesiones, a la vez que elevan los ingresos públicos para la salud. La acción internacional sobre las ENT y lesiones debería enfocarse en proporcionar asistencia técnica sobre políticas fiscales, en cooperación regional para el combate al tabaquismo y en financiar investigación sobre políticas e implementación para ampliar las intervenciones que enfrenten estos problemas. En cuarto lugar, la universalización progresiva -una vía hacia la cobertura universal de salud (CUS) que incluya desde el comienzo a los pobres- es una manera eficiente de lograr la protección a la salud contra riesgos financieros. Para los gobiernos nacionales, la universalización progresiva produciría elevadas ganancias en salud por cada dólar que se gaste en ésta, y los pobres serían quienes más ganarían en términos tanto de salud como de protección financiera. La mejor manera en que la comunidad internacional puede brindar apoyo a los países para implementar una CUS progresiva es financiando la investigación sobre políticas e implementación, por ejemplo, sobre la mecánica del diseño e instrumentación de la evolución del paquete de beneficios conforme crezca el presupuesto para las finanzas públicas.

Prompted by the 20th anniversary of the 1993 World Development Report, a Lancet Commission revisited the case for investment in health and developed a new investment framework to achieve dramatic health gains by 2035. The Commission's report has four key messages, each accompanied by opportunities for action by national governments of low-income and middle-income countries and by the international community. First, there is an enormous economic payoff from investing in health. The impressive returns make a strong case for both increased domestic financing of health and for allocating a higher proportion of official development assistance to development of health. Second, modeling by the Commission found that a "grand convergence" in health is achievable by 2035-that is, a reduction in infectious, maternal, and child mortality down to universally low levels. Convergence would require aggressive scale up of existing and new health tools, and it could mostly be financed from the expected economic growth of low- and middle-income countries. The international community can best support convergence by funding the development and delivery of new health technologies and by curbing antibiotic resistance. Third, fiscal policies -such as taxation of tobacco and alcohol- are a powerful and underused lever that governments can use to curb non-communicable diseases and injuries while also raising revenue for health. International action on NCDs and injuries should focus on providing technical assistance on fiscal policies, regional cooperation on tobacco, and funding policy and implementation research on scaling-up of interventions to tackle these conditions. Fourth, progressive universalism, a pathway to universal health coverage (UHC) that includes the poor from the outset, is an efficient way to achieve health and financial risk protection. For national governments, progressive universalism would yield high health gains per dollar spent and poor people would gain the most in terms of health and financial protection. The international community can best support countries to implement progressive UHC by financing policy and implementation research, such as on the mechanics of designing and implementing evolution of the benefits package as the resource envelope for public finance grows.

Dermatological adverse reactions to cancer chemotherapy.

The new targeted anticancer drugs as well as the older traditional chemotherapy agents are associated with adverse effects on skin, hair, nails and mucosa. These toxic effects can cause great distress to the patient leading to decreased quality of life and interruption in treatment. Aims: To study the mucocutaneous adverse effects of both single and combined chemotherapy regimens in cancer patients. Materials and Methods: We studied 53 cancer patients attending the oncology outpatient department or those admitted in the oncology ward of Father Muller Medical College Hospital, Mangalore between October 2012 and September 2013. The adverse effects of chemotherapy on skin, hair, nails and mucosa were noted. Results: The most common adverse effects observed in the study were nail changes in 33 (62.2%) patients, followed by hair changes in 20 (37.7%) patients, skin changes in 19 (33.9%) patients, and mucosal changes in 2 (3.7%) patients. The skin changes were acneiform rash in 5 (27.7%) patients, xerosis in 4 (22.2%) patients, hyperpigmentation in 4 (22.2%) patients, and toxic epidermal necrolysis, hand foot syndrome, extravasation, erythema nodosum, and supravenous hyperpigmentation in 1 patient each. The most common nail fi nding was melanonychia seen in 26 (78.7%) patients. Hair changes were in the form of anagen effl uvium seen in 20 (37.7%) patients. Mucosal changes seen were pigmentation of tongue and stomatitis in one case each. Limitations: Sample size is small. Conclusions: While these side effects are generally not life-threatening, they can be a source of signifi cant morbidity. Knowledge about the adverse effects of anti-cancer drugs will help in accurate diagnosis and management, thereby improving the quality of life.

Evaluation of soft tissue marginal stability achieved after excision with a conventional technique in comparison with laser excision: A pilot study.

Background: Soft tissue excision around natural teeth is carried out to increase the clinical crown lengths, expose the caries apical to the gingival margins and to correct irregular and un‑esthetic soft‑tissue contours. Aims: The study was carried out with an aim to evaluate the stability of the soft tissue margins after excision either with a laser or scalpel. Materials and Methods: A total of 20 patients indicated for soft tissue excision for correcting soft tissue discrepancies were selected. The patients with thick gingival biotype were included in the study. They were grouped randomly into excision by laser or scalpel methods. The change in the soft tissue positions from the time of excision to 1‑month follow‑up were evaluated immediate postoperatively, after 2 weeks and after 1‑month postrestoration. Results: The soft tissues remained stable in the laser group at 1‑month follow‑up, in contrast to the scalpel group and were found to be statistically significant, (Student’s t‑test) (P < 0.05). Conclusion: The soft tissue margins are more stable and stay at the point they were excised with lasers when compared with scalpel.

Morquio’s Syndrome: A Rare Case.

Morquio’s syndrome is an autosomal recessive disorder due to deficiency of N-acetylgalactosamine-6 sulfate. Presented here is the case of a 4-year-old girl with complaints of deformity of bilateral lower limbs since 6 months. Examination revealed widely spaced teeth, corneal opacity, pectus carinatum, bilateral genu valgum and flat feet. X-rays of femur showed minimal metaphyseal widening, widened carpal bones and pointing metacarpals and beaking of the thoracic and lumbar vertebrae. She was diagnosed to be suffering from Morquio’s syndrome. Mucopolysaccharidoses (MPS) are a rare group of metabolic disorders due to deficiency of enzymes responsible for degradation of glycosaminoglycans. Treatment is mainly symptomatic.