Clinical and metabolic characteristics of males with early-onset androgenetic alopecia

Background: Men with early-onset androgenetic alopecia (AGA) often have an abnormal hormonal milieu. Objective: To ascertain the clinico-phenotypic characteristics and the prevalence of hormonal and metabolic changes in men with early-onset AGA. Methods: Consecutive male patients less than 30 years of age with a Norwood-Hamilton grade ?3 AGA were recruited in this comparative cross-sectional study. After endocrine evaluation they were classified into two groups, that is, Group A consisting of subjects with an altered hormonal profile and Group B with normal hormonal profiles. The groups were assessed for differences in disease phenotype and severity (Norwood-Hamilton grade), insulin resistance and parameters of metabolic syndrome (ATP III guidelines). Results: Altered hormonal profiles were seen in 34 of the 100 subjects with AGA, while insulin resistance and metabolic syndrome were noted in 44 and 26 respectively. Altered hormonal profiles were significantly associated with insulin resistance and severe alopecia (grade 4 and above Hamilton-Norwood Scale). Insulin resistant Group A patients had a significantly higher prevalence of severe alopecia (>grade 4) (P = 0.0036). The prevalence of metabolic syndrome was similar in both groups. Limitation: The cross sectional study design was a drawback of this study. Further, a control arm without AGA was not included and the sample size of 100 was selected arbitrarily. Conclusion: An altered hormonal profile and insulin resistance was noted in a third of the males with early-onset AGA. Subjects with altered hormonal profiles had a higher prevalence of insulin resistance and were likely to have severe grades of AGA

Costs & outcomes of hospitalized scrub typhus infection in a tertiary hospital in south India

Background & objectives: Scrub typhus is a rickettsial infection seen along the Asian-Pacific rim and imposes a considerable burden on affected people in low- and middle-income countries. The present study was aimed to determine the direct cost of hospitalization of scrub typhus and its trend over six years. Methods: This was a retrospective, observational, hospital based study of individuals admitted to the hospital, diagnosed with scrub typhus over six years, from January 2013 to December 2018. The potential out of pocket expenditure was evaluated. Results: A total of 198 patients were included in the study. The median cost of admission (adjusted to INR 2020) for the six years (2013 to 2018) was found to be ? 37,026 (US $ 490) [interquartile range (IQR) 22,996-64,992]. The median cost for patients admitted to the intensive care unit (ICU) was ? 128,046 (US $ 1695) (IQR 71,575-201,171), while the cost for patients admitted to the ward-alone was ? 33,232 (US $ 440) (IQR 19,609-45,373). The multivariable analysis showed that ARDS and SOFA score were the independent predictors of ICU admission. Interpretation & conclusions: Hospitalisation for scrub typhus is associated with a substantial healthcare expense. The predictors of increased cost were the presence of acute respiratory distress syndrome (ARDS), shock, increasing sequential organ failure assessment (SOFA) score and duration of hospital stay

The burden of skin diseases in India: Global Burden of Disease Study 2017

Background: The prevalence of skin diseases has increased over the last few decades, and they contribute to a significant burden on health-care systems across the world. Aims/Objective: This report looks at the burden of skin and subcutaneous diseases in terms of years lived with disability and age-standardised years lived with disability in India using the Global Burden of Disease Study results from 2017. Methods: Data were obtained from the Global Burden of Disease online interactive tool. Updated estimates of the world’s health for 359 diseases and injuries and 84 risk factors from 1990 to 2017 are available in this interactive tool. Results: Years lived with disability due to skin and subcutaneous diseases accounted for 4.02% of the total years lived with disability in India in 2017. There was an increase of 53.7% in all age standardised years lived with disability for all the skin and subcutaneous diseases from 1990 to 2017. Among skin and subcutaneous diseases, dermatitis contributed maximum years lived with disability (1.40 million; 95% uncertainty interval, 0.82–2.21) in 2017, followed by urticaria (1.02 million; 95% uncertainty interval, 0.06–1.44) with percentage increases of 48.9% and 45.7% respectively. Conclusion: The burden due to infectious skin diseases (e.g., scabies, fungal skin disease and bacterial skin disease) and non-infectious diseases (e.g., dermatitis, urticaria and psoriasis) has increased over the past three decades, however the age-standardised years lived with disability for leprosy, scabies, fungal infections, sexually transmitted infections and non-melanoma skin cancer (basal cell carcinoma) has decreased. The high burden of skin and subcutaneous diseases demand that they be given due importance in the national programmes and health policy of India.

Assessment of Mental Wellness Amongst the Faculty and Students of an Educational Institute in the State of Himachal Pradesh, India — Post Lockdown during COVID-19

Background: The COVID-19 pandemic had a significant effect on the mental health of human beingsworld wide. There is a lack of information pertaining to the mental wellness of students and faculty in dental institutions in India. This study aimed to assess the overall mental well being of students and faculty of dental institution after return to normalcy post-lockdown period during COVID-19. Material & Methods: A self reporting online questionnaire was designed by the authors after speaking with various therapists and mental health coaches. This questionnaire was anonymously filled out by 492 participants which included under graduate students, post graduate students, academic staff, paramedical and clerical staff in a dental institution. Results: Majority of the subjects felt the need for counseling in their work place (53.4%). A greater number felt they were getting insufficient sleep (48.3%) and (31.5%) of the participants experienced depression and anxiety which further affected their emotional well being and their day to day activities. One-fifth (16.8%) of the participants perceived that mental health affected their relationships and 20.1% observed that physical health restricted their day to day activities. Mental wellness of females was significantly more affected than males. Additionally marital status also influenced the mental wellness of the subjects. Conclusion: Literary evidence suggests that mental wellness is not given enough importance in our country in general. This study only proved the ramifications of COVID-19 on mental wellness and suggested the provision of counselling which could’ve protected the participants from slipping into a negative frame of mind.

Toll-like receptor 2-mediated downstream cytokine levels as determinant of malaria pathogenesis

Background & objectives: Toll-like receptors (TLRs) are transmembrane proteins that recognize specific molecular patterns and activate downstream cytokine production usually for the eradication of invading pathogens. The objective of this study was to evaluate the genetic polymorphism of TLR2 Arg753Gln (rs 5743708) and soluble cytokines and TLR2 expression levels in malaria disease cases. Methods: The study included prospectively collected 2 ml blood samples from 153 individuals clinically suspected for malaria and confirmed by microscopy and RDT from Assam. Stratification of the study groups was done as healthy control (HC, n=150), uncomplicated malaria (UC-M, n=128) and severe malaria (SM, n=25). The PCR-restriction fragment length polymorphism (RFLP) method was applied for the analysis of TLR2 Arg753Gln polymorphism and following the ELISA for soluble serum TLR2 (sTLR2) and its associated downstream cytokines, viz. tumour necrosis factor (TNF)-? and interferon (IFN)-? levels. Results: Variation in TLR2 Arg753Gln gene showed no association with the susceptibility and the severity of malarial infection. Soluble TLR2 expression was significantly higher in uncomplicated malaria (UC-M) cases compared to healthy controls (P=0.045) and in terms of SM cases, the expression was also found to be higher in UC-M cases (P=0.078). The TNF-? expression was significantly higher in SM cases compared to both UC-M and control (P=0.003 and P=0.004). Similarly, significantly elevated expression of IFN-? was noted in SM cases compared to both UC-M (P=0.001) and healthy controls (P<0.001). Interpretation & conclusions: The present study suggests the association of deregulated TLR2 pathway that leads to the deleterious downstream immune response in the development of malarial pathogenicity.

Single-nucleotide polymorphism and haplotype analysis of macrophage migration inhibitory factor gene and its correlation with serum macrophage migration inhibitory factor levels in North Indian psoriatic patients with moderate disease severity: A cross-sectional study

Background: Psoriasis is associated with significant morbidity and impaired quality of life. Identification of the host genes that influence disease susceptibility and can potentially guide future, targeted therapy is the need of the hour. Aims: The aim of the study was to investigate the associations of macrophage migration inhibitory factor (MIF) gene polymorphisms, that is, a 5–8-CATT tetra nucleotide repeats at -794 (-794*CATT5–8) and a single-nucleotide polymorphism at -173 (-173*G/C) with the risk of chronic plaque psoriasis and to observe the correlation, if any, of disease determinants with genetic functional variants and circulating MIF levels. Methods: Five hundred and seventeen individuals (265 psoriasis patients and 252 controls) were genotyped for MIF gene polymorphisms. Data were analyzed with respect to disease susceptibility, serum MIF levels, disease severity, age at onset, disease duration and presence of comorbidities. Results: The presence of co-morbidities was more frequently noted in patients with late onset disease (P = 0.01). No statistically significant differences were observed either in genotype (P = 0.680) or allele frequency (P = 0.69) with respect to distribution of MIF-173*G/C polymorphism between patients and controls. The frequencies of genotypes -794*CATT 5/7 and 7/7 were significantly lower in patients (P = 0.027* and 0.038*, respectively). CATT*5/MIF-173*C haplotype occurred at a higher frequency in patients (odds ratio 3.03, 95% confidence intervals 1.09–8.47, P = 0.02). The mean serum MIF levels were significantly higher in patients as compared to controls (P < 0.001). The presence of either extended MIF -794*CATT repeats or C allele did not reveal any significant association with serum MIF levels or age at onset. Analysis of effect of various disease determinants revealed no significant association with genetic variants and serum MIF levels. Limitations: The lesional expression of MIF could not be studied. Conclusion: Our results showed that CATT*5/MIF-173*C haplotype is associated with increased susceptibility to psoriasis vulgaris.

Serum Levels of Activin A: Predictor of Insulin Resistance and Atherosclerosis in Prediabetics

Background: Pathological effects of dysglycemia and insulin resistance on atherosclerosis and cardiac remodeling starts as early as in the prediabetic state before the onset of overt diabetes. Activin A is a molecule with multiple functions, including an important part in glucose homeostatic mechanisms as well as inflammatory processes and is therefore being researched as a useful novel biomarker for prompt recognition of the risk of cardiovascular disease (CVD) in prediabetic individuals, thereby helping in disease prognostication and early institution of therapeutic measures. Objective: The study aimed to measure serum levels of activin A in prediabetic patients and evaluate them in comparison to normoglycemic controls. The association of activin A with carotid intima media thickness (CIMT), left ventricular diastolic dysfunction (LVDD), and homeostatic assessment of insulin resistance (HOMA-IR) was also studied. Materials and methods: A total of 60 prediabetic cases and 60 normoglycemic control subjects [matched as per age, gender, and body mass index (BMI)] were recruited. Measurement of serum glucose levels (fasting and postprandial) and fasting insulin levels and glycated hemoglobin (HbA1c) levels were done in all the subjects. The values of HOMA-IR were computed using established formulae. Enzyme-linked immunosorbent assay (ELISA) kits were used for the evaluation of serum levels of activin A in both groups. Parameters for the two groups were compared. In the cases, CIMT (using B-mode ultrasound) and LVDD (using two-dimensional (2D) echocardiography) were measured and correlated with activin A levels. Results: Serum fasting insulin (mIU/L) was considerably higher in cases than in the controls (p < 0.001). HOMA-IR median [interquartile range (IQR)] was 4 (3.25–4.93) in some cases, and that in the control group was 1.2 (0.88–1.5) (p < 0.001). Serum activin A levels in the cases group had a median (IQR) of 263.55 (227.1–279.5) ng/mL, which was substantially greater as compared to the control group 159.9 (150.7–178.7) ng/mL (p < 0.001). A significant positive association of serum activin A levels with HOMA-IR (? = 0.75, p < 0.001) and CIMT (? = 0.50, p < 0.001) was found. In LVDD grade I and II groups, the serum levels of activin A were 257.86 (219.3–271.2) ng/mL and 269 (244.19–291.5) ng/mL, respectively (p = 0.12). Conclusion: A substantial proportion of morbidity and mortality related to dysglycemic states can be attributed to cardiovascular complications. Elevated levels of activin A in prediabetes can act as an indicator of subclinical CVD leading to early diagnosis and intervention.

Small cell neuroendocrine carcinoma with adenocarcinoma and high grade squamous intraepithelial neoplasia of the cervix

ABSTRACT Neuroendocrine neoplasm (NEN) of the cervix is a malignant tumor and is classified into low and intermediate-grade neuroendocrine tumor (NET), and high-grade small cell neuroendocrine carcinoma (SCNEC), and large cells neuroendocrine carcinoma (LCNEC). SCNEC of the cervix is an Infrequent tumor with an incidence of less than 1% of all gynecological malignancies. It is characterized by small to medium-sized tumor cells with scant cytoplasm and neuroendocrine differentiation. Most cases of SCNEC of the cervix manifest in pure forms, and only cases show coexisting, non-neuroendocrine component of HPV-associated adenocarcinoma or squamous cell carcinoma. In this report, reviewing the literature, we present one such unique case of SCNEC of the cervix with adenocarcinoma and high-grade squamous intraepithelial neoplasia.

Morphological and functional retinal changes in neovascular age-related macular degeneration treated with intravitreal bevacizumab

Purpose: This study was conducted to determine the morphological and functional retinal changes in patients with neovascular age?related macular degeneration (nAMD) treated with intravitreal bevacizumab 1.25 mg. Methods: This was a prospective, nonrandomized, interventional study. Eighteen eyes of 18 subjects with nAMD were treated with intravitreal bevacizumab (1.25 mg) injection. Subjects underwent complete ophthalmic evaluation which included visual acuity, slitlamp examination, tonometry, binocular ophthalmoscopy, optical coherence tomography (OCT), and MP1 microperimetry before the intravitreal injection and the follow?up at 1 and 3 months. Test of significance such as Chi?squared test, paired ttest and oneway analysis of variance (ANOVA) linear trend were used to compare the pre? and post?anti?VEGF outcomes. Intraclass correlation was done to assess the intra observer variability. Results: Mean retinal sensitivity had increased from 3.77 ± 3.13 dB at baseline to 4.93 ± 2.42 dB at 3 months (P = 0.05). Visual acuity improved from 0.62 ± 0.36 at baseline to 0.52 ± 0.36 at 1 month and 0.48 ± 0.34 at 3?month followup, but overall change was not significant (P = 0.40). There was a significant reduction in central foveal thickness (CFT) from 274.61 ± 117.95 at baseline to 179.83 ± 84.18 at 1 month and 179.00 ± 126.55 at 3?month follow?up (P = 0.013). Conclusion: Intravitreal bevacizumab (1.25 mg) injection in nAMD improves retinal function, quantified by retinal sensitivity, scotoma characteristics, fixation stability by MP 1 microperimetry and morphological parameters quantified by CFT in SDOCT. These changes show the effectiveness of treatment with intravitreal bevacizumab in nAMD

Comparison of prevention of parent-to-child HIV transmission programme & national biennial HIV sentinel surveillance data for tracking HIV epidemic in India

Background & objectives: HIV sentinel surveillance (HSS) among antenatal women in India has been used to track the epidemic for many years. However, reliable tracking at the local level is not possible as ANC sentinel sites are limited in number and cover a smaller sample size at each site. Prevention of parent-to-child-transmission (PPTCT) programme data has a potential advantage due to better geographical coverage, which could provide more precise HIV case estimates; therefore, we compared HSS ANC data with PPTCT programme data for HIV tracking. Methods: Out of the 499 surveillance sites, where HSS and PPTCT programme was being conducted in 2015, 210 sites (140 urban and 70 rural) were selected using a stratified random sampling method. HSS (n=72,981) and PPTCT (n=112,832) data records were linked confidentially. The sociodemographic characteristics of HSS and PPTCT attendees were compared. HIV prevalence from HSS ANC was compared with the PPTCT programme data using Chi-square test. State- and site-level correlation of HIV prevalence was also done. Concordance between HSS and PPTCT HIV positivity was estimated using kappa statistics. Results: The age distribution of HSS and PPTCT attendees was similar (range: 23 to 27 yr); however, HSS ANC participants were better educated, whereas PPTCT recorded a higher proportion of homemakers. The correlation of HIV prevalence between HSS and PPTCT was high (r=0.9) at the State level and moderate at the site level (r=0.7). The HIV positivity agreement between HSS ANC and PPTCT was good (kappa=0.633). A similar prevalence was reported across 26 States, whereas PPTCT had a significantly lower prevalence than HSS in three States where PPTCT coverage was low. Overall HIV prevalence was 0.31 per cent in HSS and 0.22 per cent in PPTCT (P<0.001). Interpretation & conclusions: High-quality PPTCT programme data can provide reliable HIV trends in India. An operational framework for PPTCT-based surveillance should be pilot-tested in a phased manner before replacing HSS with PPTCT.

CLINICAL AND FUNCTIONAL OUTCOME OF PROXIMAL HUMERAL FRACTURE FIXATION WITH RUSHNAIL AND K WIRE FIXATOR VS PHILOS PLATING : A STUDY OF 30 CASES

Introduction- Aim- Proximal humerus fractures represent one of the most common fracture type in upper extremity. this study aimed to see clinical and functional outcome of proximal humeral fracture fixation with Rushnail and K-wire fixator vs PHILOS plating. A prospective study was conducted over 6 months of a tot Material And Method- al of 30 patients with proximal humerus fracture. Patients were divided into two groups by randomized controlled trial .Group 1 included 15 patients who were treated with closed reduction and Rushnail with percutaneous k wire fixation. Group 2 included 15 patients who were treated with ORIF with PHILOS plate .All these 30 patients were followed up for mean duration of 6 months. Mean neer s Results- core at final follow up was 90 in group 1 patients while it was 80 in group 2 patients As per the Neers scoring system. Mean neer score at final follow up was 90 in group 1 patients while it was 82 in group 2 patients. As per the Neers scoring system; 8 patients (54%) in group1 had excellent results, 7 patients(46%) had satisfactory Results. For Group 2 ,as per Neers scoring system 6 patients (40%)had excellent results,7 patients (47%) had satisfactory results,2 patients (13%) had unsatisfactory result with poor outcome. In conclusion it was found that Rushnail wit Conclusion- h K- wires fixation for proximal humerus fractures type II and type III (Neer's) gives superior results than proximal humerus interlocking system (PHILOS).

Comparison of efficacy of three commonly used alpha-blockers as medical expulsive therapy for distal ureter stones: A systematic review and network meta-analysis

ABSTRACT Introduction: The efficacy of alpha-blockers as medical expulsive therapy (MET) is well established. However, it is not known which of the three most commonly used alpha-blockers (tamsulosin, alfuzosin and silodosin) is the most efficacious. With this study we aimed to assess the efficacy of the three commonly used alpha-blockers as MET for distal ureter stones. Materials and Methods: For this review, we searched multiple databases such as PubMed/Medline, Scopus, Embase, OviD SP, CINAHL, and web of science to identify all the relevant randomized studies comparing the efficacy of tamsulosin, alfuzosin, and silodosin. Preferred reporting items for systematic reviews for network meta-analysis (PRISMA-NMA) were followed while conducting this review and the study protocol was registered with PROSPERO (CRD42020175706). Results: In this review, 31 studies with 7077 patients were included. Compared to placebo all the treatment groups were more effective for both stone expulsion rate (SER) and stone expulsion time (SET). For both SER and SET, silodosin had the highest SUCRA (94.8 and 90.4) values followed by alfuzosin (58.8 and 64.9) and tamsulosin (46.2 and 44.5). The incidence of postural hypotension was similar with all the drugs, whereas, the incidence of retrograde ejaculation was significantly higher for silodosin. Overall confidence for each comparison group in this review ranged from "very low" to "moderate" according to the CINeMA approach. Conclusion: Among the three commonly used alpha-blockers silodosin is the most efficacious drug as MET for lower ureter stones followed by alfuzosin and tamsulosin.

HIV epidemic in Mizoram, India: A rapid review to inform future responses

Background & objectives: Mizoram, a northeastern State of India bordering Myanmar, is home to several tribal clans under the ethnic group Mizo: Renthelei, Ralte, Paite, Lai, Hmar, Lusei, Mara, Thado and Kuki. Mizos also reside in the neighbouring northeastern States of Tripura, Assam, Manipur and Nagaland. The majority of Mizo people outside India live across the border in the neighbouring Chin State and Sagaing Region of Myanmar. Over the last decade, Mizoram witnessed a concerning level of rise in HIV prevalence among the general population. The present rapid review was conducted to identify various interventions that could help curb this rising trend. Methods: An electronic search strategy with broad domains of ‘HIV/AIDS’, ‘key population’, ‘community engagement’ and ‘interventions in Mizoram’ using PubMed, Embase and Cochrane was adopted; grey literature were also accessed. Evidence, thus gleaned, were synthesized. Results: Twenty eight resource materials comprising articles, reports and dissertations contributed to the current review. Changing tribal social support structure, early initiation of drugs, sexual debut at an early age and drug–sex interface were identified as factors associated with the progression of HIV epidemic in the State. Issues pertaining to the migration of people across the borders and easy access to drugs continue to be of concern. Churches and youth leaders have a strong influence on the society, at times even constraining access of key population groups to HIV prevention and care services. Tackling stigma and discrimination, ensuring uninterrupted HIV services and creation of an enabling environment in this context seems urgently needed. Incarcerated people in the State have been found with a high level of HIV infection and their linkages with prevention and care services need strengthening. Interpretation & conclusions: This review underscores the importance of drawing upon successful intervention examples from the past such as ‘Friends on Friday’ and Red Ribbon Clubs. Active engagement of community-based organizations in programme planning, implementation and monitoring is essential. Establishment of harm reduction interventions for general and key populations paired with strategic communication appear to be the need of the hour.

Impact of pathological factors on survival in patients with upper tract urothelial carcinoma: a systematic review and meta-analysis

ABSTRACT Introduction: There is an ongoing need to identify various pathological factors that can predict various survival parameters in patients with upper tract urothelial carcinoma (UTUC). With this review, we aim to scrutinize the impact of several pathological factors on recurrence free survival (RFS), cancer-specific survival (CSS) and overall survival (OS) in patients with UTUC. Materials and Methods: Systematic electronic literature search of various databases was conducted for this review. Studies providing multivariate hazard ratios (HR) for various pathological factors such as tumor margin, necrosis, stage, grade, location, architecture, lymph node status, lymphovascular invasion (LVI), carcinoma in situ (CIS), multifocality and variant histology as predictor of survival parameters were included and pooled analysis of HR was performed. Results: In this review, 63 studies with 35.714 patients were included. For RFS, all except tumor location (HR 0.94, p=0.60) and necrosis (HR 1.00, p=0.98) were associated with worst survival. All the pathological variables except tumor location (HR 0.95, p=0.66) were associated with worst CSS. For OS, only presence of CIS (HR 1.03, p=0.73) and tumor location (HR 1.05, p=0.74) were not predictor of survival. Conclusions: We noted tumor grade, stage, presence of LVI, lymph node metastasis, hydronephrosis, variant histology, sessile architecture, margin positivity and multifocality were associated with poor RFS, CSS and OS. Presence of CIS was associated with poor RFS and CSS but not OS. Tumor necrosis was associated with worst CSS and OS but not RFS. Tumor location was not a predictor of any of the survival parameters.

Inpatient characteristics, complications, and outcomes of patients with cardiac sarcoidosis: A study from the National Inpatient Sample

Although seen in ~5% of sarcoidosis patients, cardiac sarcoidosis (CS) accounts for nearly 25% of diseaserelated deaths. This study aimed to describe characteristics and outcomes among CS patients. Patients diagnosed with CS in 2016e2017 in the US National Inpatient Sample Database were evaluated to study patient characteristics, reasons ascribed to admission, in-hospital outcomes, and complications. A total of 2420 patients (median age 56 years) were included in the analysis. Most admissions occurred due to ventricular tachycardia (12.8%), followed by myocarditis (9.9%) with a mean length of stay of 7 ± 7 days. The overall incidence of in-hospital mortality was 2.5%

Mycobacterium indicus pranii vaccine immunoprophylaxis in anti-phenolic glycolipid-1-positive leprosy contacts – A pilot study from a tertiary care center in North India

Background: Contacts of leprosy patients have an increased risk of infection with Mycobacterium leprae. Contact tracing and chemo- or immunoprophylaxis are important means of preventing leprosy transmission. Aims: We aimed to evaluate the efficacy of immunoprophylaxis with Mycobacterium indicus pranii vaccine in reducing anti-phenolic glycolipid-1 titers in household contacts of leprosy patients. Methods: This prospective single-center study was conducted in a tertiary care center in North India from January 2015 to December 2016. Contacts of leprosy patients (both paucibacillary and multibacillary) were screened for anti-phenolic glycolipid-1 antibodies with enzyme-linked immunosorbent assay. Those found positive were given immunoprophylaxis with a single dose of Mycobacterium indicus pranii vaccine, and anti-phenolic glycolipid-1 titers were evaluated at six and 12 months. All contacts were clinically followed for three years. Results: Of the 135 contacts of 98 leprosy patients that were screened, 128 were recruited. Seventeen of these contacts were positive for anti-phenolic glycolipid-1 antibodies and were given Mycobacterium indicus pranii vaccine. Two contacts were lost to follow-up. After immunoprophylaxis, anti-phenolic glycolipid-1 titers were negative in all patients at all intervals, and no contact developed any clinical signs or symptoms of leprosy during the three-year follow-up. Limitations: The small number of contacts studied, the short follow-up period and the absence of a control group were limitations of this study. Dicussion: We could not find any papers on natural decline of PGL 1 titres in contacts, although in leprosy patients, these titres may even increase after completion of treatment. However the titres do correlate with bacterial load (reference: Int J Lepr Other Mycobact Dis. 1998 Sep;66(3):356-64) so if the tires decrease or become negative it may be considered as an indirect evidence of bacillary clearance. Hence we may suggest the protective efficacy. Furthermore, as the editor mentioned, considering the small number of positive patients, a control group was not possible in the present pilot study, but such studies may be carried out in the future. Conclusion: Immunoprophylaxis with Mycobacterium indicus pranii vaccine is effective and safe in preventing disease in contacts of leprosy patients. However, these findings need to be replicated in larger studies.

Monitoring the Progress of Treatment in Fracture Non-Union: The Role of Alkaline Phosphatase and Ultrasonography / Monitoramento da evolução do tratamento da ausência de consolidação da fratura: Papel da fosfatase alcalina e da ultrassonografia

Abstract Objective To evaluate the role of serum alkaline phosphatase (ALP) and ultrasonography (USG) in monitoring the progress of treatment in diaphyseal non-unions. Methods This prospective observational cohort study included adult patients with diaphyseal fractures of major long bones previously treated with internal fixation and eventually resulting in non-union. Following the definitive treatment for non-union, the patients were followed-up periodically for six months, and serial monitoring of the levels of ALP and USG were performed along with radiographs (X-rays) to ascertain the status of the union. Results After an initial rise at seven weeks, ALP levels declined to normal values in fractures which united, whereas they remained high in cases of persistent non-union. Similarly, after an elevation of the vascular resistive index (RI) at around 12 weeks in all the patients, it decreased in cases progressing to union, while it remained persistently high even at 24 weeks in fractures failing to unite. Cases of persistent non-union continued to show hypoechogenic callus at 24 weeks instead of converting into hyperechogenic callus, as observed in cases which progressed to union. Conclusion Significant changes suggestive of union appeared simultaneously on the X-rays, USG and ALP levels during the follow-up. However, a serial examination of the ALP levels and USG during the follow-up gave a hint of the direction of progress in the healing process of fracture non-union. Their role in monitoring the outcome of nonunion is more complimentary than supplementary to the X-rays.

Resumo Objetivo Avaliar o papel da concentração sérica de fosfatase alcalina (FA) e da ultrassonografia no monitoramento do progresso do tratamento da ausência de consolidação em fraturas diafisárias. Métodos Este estudo de coorte observacional prospectivo incluiu pacientes adultos com fraturas diafisárias dos principais ossos longos previamente submetidas a fixação interna sem consolidação. Após o tratamento definitivo, os pacientes foram avaliados periodicamente por seis meses, com realização seriada de ultrassonografia, determinação da concentração de FA e radiografias para verificar a presença de consolidação. Resultados Após um aumento inicial em sete semanas, os níveis de FA voltaram ao valor normal em pacientes com fraturas consolidadas, mas continuaram elevados nos casos de ausência de consolidação. Da mesma forma, após uma elevação do índice de resistência (IR) vascular em cerca de 12 semanas em todos os pacientes, o IR diminuiu nos casos que progrediram para consolidação, mas continuou alto até as 24 semanas em fraturas não consolidadas. Os casos com ausência de consolidação ainda apresentavam calo hipoecogênico às 24 semanas, que não se converteu no calo hiperecogênico observado nos casos que progrediram para consolidação. Conclusão Alterações significativas sugestivas de consolidação foram simultaneamente observadas nas radiografias, na ultrassonografia e na concentração de FA durante o período de acompanhamento. No entanto, a realização seriada de exames da concentração de FA e de ultrassonografia durante o acompanhamento indicou o progresso da consolidação da fratura. Seu papel no monitoramento da ausência de consolidação é mais complementar do que suplementar à radiografia.

Zoledronic Acid after Treatment with Denosumab is Associated with Bone Loss within 1 Year

Background@#Bone mineral density (BMD) declines when zoledronic acid (ZA) is administered. This case series describes the patterns of change in BMD when 1 or 2 doses of ZA are administered after denosumab. @*Methods@#Twelve patients who received at least 2 doses of denosumab followed by at least 1 dose of ZA and who had a dual energy X-ray absorptiometry (DXA) scan at the end of denosumab and 1 year after the first dose of ZA were included. We excluded patients with bone cancer or conditions affecting bone metabolism, including hyperparathyroidism, rickets, osteogenesis imperfecta, rheumatologic disorders, fibrous dysplasia, Paget’s disease of bone, untreated hyperthyroidism, chronic kidney disease, liver cirrhosis, malabsorption, ongoing corticosteroid therapy, and aromatase inhibitor use. @*Results@#There was a significant decline in BMD at the femoral neck within 1 year of the first ZA dose and a non-significant downward trend in the hip and lumbar spine. This trend was more severe in patients with osteoporosis at the time of drug transition. No increase in clinical vertebral fractures was observed. BMD seemed to stabilize in a smaller number of patients who received a second dose of ZA and had a DXA scan 1 year later. @*Conclusions@#A single dose of ZA administered approximately 6 months after denosumab leads to some BMD loss, mostly within 1 year of ZA administration, particularly in patients with osteoporosis at the time of denosumab discontinuation.