Exacerbation of Erythema Nodosum Leprosum Possibly Triggered by COVID-19 Vaccine : A Case Repor

Erythema nodosum leprosum (ENL) is an immune complex mediated type III hypersensitivity reaction seen in patients of borderline lepromatous and lepromatous leprosy. It can be caused by a wide array of triggers and can be seen before, during, or after completion of anti-leprosy therapy. There are multiple well-known triggers for type 2 reactions like the initiation of multidrug therapy, Mantoux testing, vaccination, mental and physical stress, and physiological states like pregnancy. Herein, we report a case of exacerbation of ENL in a middle-aged woman, probably due to COVID-19 vaccine while she was well-controlled on immunosuppressive therapy. The episode was treated with non-steroid anti-inflammatory drugs and oral steroids and the symptoms resolved within 2 weeks. Although causality was highly possible between the occurrence of ENL and COVID-19 vaccine, physicians should be aware that it can be easily managed with proper care and medicines and this should not be a basis for deferring the vaccine.

Panoramic mandibular index: Effect of age and gender related variations in the North-Indian population.

Background: Panoramic Mandibular Index (PMI) is a quantitative radiomorphometric index of the mandible. It is an important indicator of mandibular bone mineral density. Objectives: To examine the age and gender related variations associated with the panoramic mandibular index and their effect in a group of North-Indian population of Haryana. Methods: 60 adult human orthopantomographs were evaluated and divided into six age groups (35-65 years) with equal number of males and females. Panoramic mandibular index was measured bilaterally on every radiograph. The measurements were analyzed for interactions with age and sex, using SPSS (Stastistical Package for Social Studies) software version no. 18. The tests employed were Kruskal-Wallis, Mann-Whitney and the unpaired T-test. Results: The male mean panoramic mandibular index values ranged from 0.3 ± 0.025 to 0.381 ± 0.019, whereas the female mean panoramic mandibular values ranged from 0.286 ± 0.306 to 0.36 ± 0.007. Panoramic mandibular index showed significant negative correlation with age in both the sexes. Inter-age group comparisons showed statistically significant differences between the youngest and eldest age-groups in both the genders. Female values were lower than male values in all age groups, but sexual dimorphism was not observed. Conclusion: Panoramic mandibular index was influenced significantly by the variations in age but minimally by the gender related variations.

Persisting Menace of Pre Labour Rupture of Membranes Persisting Dilemmas.

Objective : Prelabour rupture of membranes (PLROM) is common obstetric problem ,one of most common clinical events where normal pregnancy can turn into high risk situation for mother as well as fetus. Present study was to know incidence of term, preterm PLROM, association with parity ,body mass index, anaemia, cervical / vaginal colonization,cervical score, amniotic fluid index. Material and Methods : Study included 550 women of 18-35 years of age, 28-42 weeks of gestation who had presented with watery vaginal discharge in whom membrane rupture was confirmed. Results : Incidence of PLROM was 6.28% of births, 4.62% term births, 1.65% preterm births. Mean age of women was 24 years, mean BMI was 21.9. Ninety seven percent of women with PLROM were anaemic 18% of women had growth of microbes in cervical vaginal swabs.Forty eight percent women had cervical score less than zero, four percent had severe oligoamnios. Conclusion : Study revealed higher incidence of term,preterm PLROM in patients with anaemia, genital infection.By identifying, modifying risk factors we can help reduce maternal, fetal morbidity ,mortality associated with term, preterm PLROM

Interpretation of Spirometry: Selection of Predicted Values and Defining Abnormality.

Spirometry is the most frequently performed investigation to evaluate pulmonary function. It provides clinically useful information on the mechanical properties of the lung and the thoracic cage and aids in taking management-related decisions in a wide spectrum of diseases and disorders. Few measurements in medicine are so dependent on factors related to equipment, operator and the patient. Good spirometry requires quality assured measurements and a systematic approach to interpretation. Standard guidelines on the technical aspects of equipment and their calibration as well as the test procedure have been developed and revised from time-to-time. Strict compliance with standardisation guidelines ensures quality control. Interpretation of spirometry data is based only on two basic measurements — the forced vital capacity (FVC) and the forced expiratory volume in 1 second (FEV1) and their ratio, FEV1/FVC. A meaningful and clinically useful interpretation of the measured data requires a systematic approach and consideration of several important issues. Central to interpretation is the understanding of the development and application of prediction equations. Selection of prediction equations that are appropriate for the ethnic origin of the patient is vital to avoid erroneous interpretation. Defining abnormal values is a debatable but critical aspect of spirometry. A statistically valid definition of the lower limits of normal has been advocated as the better method over the more commonly used approach of defining abnormality as a fixed percentage of the predicted value. Spirometry rarely provides a specific diagnosis. Examination of the flow-volume curve and the measured data provides information to define patterns of ventilatory impairment. Spirometry must be interpreted in conjunction with clinical information including results of other investigations.

Prediction Equations for Spirometry in Adults from Northern India.

Background. Most of the Indian studies on prediction equations for spirometry in adults are several decades old and may have lost their utility as these were carried out with equipment and standardisation protocols that have since changed. Their validity is further questionable as the lung health of the population is likely to have changed over time. Objective. To develop prediction equations for spirometry in adults of north Indian origin using the 2005 American Thoracic Society/European Respiratory Society (ATS/ERS) recommendations on standardisation. Methods. Normal healthy non-smoker subjects, both males and females, aged 18 years and above underwent spirometry using a non-heated Fleisch Pneumotach spirometer calibrated daily. The dataset was randomly divided into training (70%) and test (30%) sets and the former was used to develop the equations. These were validated on the test data set. Prediction equations were developed separately for males and females for forced vital capacity (FVC), forced expiratory volume in first second (FEV1), FEV1/FVC ratio, and instantaneous expiratory flow rates using multiple linear regression procedure with different transformations of dependent and/or independent variables to achieve the best-fitting models for the data. The equations were compared with the previous ones developed in the same population in the 1960s. Results. In all, 685 (489 males, 196 females) subjects performed spirometry that was technically acceptable and repeatable. All the spirometry parameters were significantly higher among males except the FEV1/FVC ratio that was significantly higher in females. Overall, age had a negative relationship with the spirometry parameters while height was positively correlated with each, except for the FEV1/FVC ratio that was related only to age. Weight was included in the models for FVC, forced expiratory flow (FEF75) and FEV1/FVC ratio in males, but its contribution was very small. Standard errors of estimate were provided to enable calculation of the lower limits of normal and standardised residuals for these parameters. The equations were found to be valid on the test dataset, and therefore, may be extended to general population. Comparison with the 1960s equations revealed lack of good agreement, and substantially higher predicted FVC with the current equations, especially in the forty-years-plus age group, in both males and females. Even in the age group upto 40 years, the level of agreement was clinically not acceptable. Conclusions. Validated prediction equations have been developed for spirometry variables in adults of north Indian origin using the current ATS/ERS spirometry standardisation recommendations. The equations suggest an improvement in the lung health of the population over time in the middle-aged and the elderly. These equations should address a long-felt unmet need and enable a more appropriate evaluation of spirometry data in different chest diseases in Indian subjects.

Influence of age on the radiomorphometric indices of the gonial region of mandible in North- Indian population.

Background: The gonial region of mandible plays a significant role in the determination of mandibular basal bone morphology. Gonial Angle is important for maintenance of a harmonius facial profile whereas Gonial Index is an indicator of the bone quality of the mandibular gonial region. Objectives: To examine the influence of age on two quantitative radiomorphometric indices of mandible, Gonial Angle (GA) and Gonial Index (GI) in a group of North-Indian population. Material and Methods: 60 adult human orthopantomographs were evaluated and divided into six age groups (35-65 years) with equal number of cases. Gonial Angle and Gonial Index were measured bilaterally on each radiograph. The measurements were analyzed for interactions with age and other interrelationships between the indices. The data obtained was subjected to statistical analysis using SPSS (Statistical Package for Social Studies) software version No. 18 and Mann- Whitney tests were used for various comparisons. Results: Gonial angle showed a significant positive correlation with age as the mean gonial angle values showed an increase with increasing age. Whereas in sharp contrast to this, gonial index showed no correlation with age as the mean gonial index values showed no pattern of either increase or decrease with increase in age. The correlation between gonial angle and gonial index was statistically insignificant (p>0.05). Conclusion: Age had a significant influence on the angular radiomorphometric index i.e. gonial angle but the linear radiomorphometric index i.e. gonial index remained independent of age.

Quality of asthma management in an urban community in Delhi, India.

Background & objectives: High prevalence and poor control of asthma make its management a major public health issue worldwide, especially in developing countries. Optimum review of asthma management in the community is essential to improve asthma control. This study was conducted to investigate the quality of asthma management, knowledge about asthma and quality of life of asthma patients referred to a public tertiary care chest hospital in Delhi. Methods: Diagnosis of asthma was confirmed by symptoms and reversible spirometry in 50 referred patients on their first visit. Patients were interviewed using three questionnaires on quality of asthma management before visiting referral hospital, asthma knowledge and asthma quality of life (AQLQ). Correlation amongst quality of treatment, asthma quality of life, and asthma knowledge was also determined. Results: Findings revealed that only 60 per cent of patients were informed about their disease, and 10 per cent had undergone lung function tests previously. Only 44 per cent of patients were prescribed inhalers. None were provided with any educational material. Patients had poor knowledge of aetiology, pathophysiology, medication and how to assess the severity of their asthma. The mean scores in AQLQ indicated a moderate degree of impairment in quality of life. Interpretations & conclusions: This study provides evidence of unsatisfactory asthma management and patient-doctor interaction as patients had limited knowledge of asthma disease, its management and had poor quality of life as measured by a standardized questionnaire. Thus, there is need to implement suitable interventions to improve asthma management according to standard treatment guidelines in the community.

Regression equations for spirometry in children aged 6 to 17 years in Delhi region.

Background. Most of the studies carried out in India to develop regression equations for spirometry in children are now several years-to-decades old and had used equipment and measurement protocols that have since changed. Prediction equations using the current standardisation protocols for spirometry are not available. The lung health of the population may have changed too. Objective. To develop regression equations for spirometry for children aged 6 to 17 years of north Indian origin in Delhi region. Methods. School children of north Indian origin, as determined by mother tongue and parentage, aged 6 to 17 years were screened by a health questionnaire and physical examination and those found “normal” underwent spirometry according to the standardised procedure recommended by the American Thoracic Society/ European Respiratory Society (ATS/ERS) task force in 2005. Pearson’s correlation analysis was carried out to identify the predictor variables for spirometric parameters. Prediction equations were developed using the multiple linear regression procedure. The independent variables were entered in sequence of height, age and weight. R2, adjusted R2 and R2 change, standard errors of the estimate (SEE), and estimates of regression coefficients were obtained and the goodness of fit was examined. Results. Data was obtained in 365 boys and 305 girls. Forced vital capacity (FVC), forced expiratory volume in one second(FEV1), peak expiratory flow rate (PEFR), forced expiratory flow rate at 50% and 75% exhalation of vial capacity (F50 and F75) and mean forced expiratory flow rate over the middle 50% of the vital capacity (F25-75) showed moderate to strong correlations with age, height and weight in both boys and girls. In both genders, the equations explained very high variability of FVC, FEV1 and PEFR as shown by the R2 values. The explained variability for flow rates was lesser, with that for F75 being the least. Conclusions. Regression equations for spirometry variables for children of north Indian origin in Delhi region have been developed. These represent the first such effort from India after the publication of the ATS/ERS task force 2005 guidelines on standardisation of spirometry.

Awareness & Misconcepts about Sexually Transmitted Diseases.

Background : Worldwide sexually transmitted diseases (STDs) continue to be a public health problem. More than 340 million people are infected each year, most of them from developing countries, many women. For prevention it is essential that people know how these disorders occur and how to prevent. Objectives : The present study was conducted to get information about women’s knowledge of STDs, source of their knowledge, misconceptions about mode of transmission and correlation of awareness and misconcepts with age, literacy, socio-economic status in the background of similar information collected a decade back. Material & Method : Information was collected by interview of 1000 randomly included women, by trained social worker with help of structured questionnaire in local language. Results Study revealed that 13% urban and 28.1% rural women had no knowledge et al. In all age groups television was the main source of knowledge. Health personnel were the source of knowledge in 14%. There was no increase in percentage of women who had knowledge of modes of transmission with increasing age. With knowledge in around 73.5% misconceptions were in 21.5%. Misconeptions were like STDs, spread through touching, sharing food and clothing, uncleanliness, urinating in pulic lavatories, excess heat. Conclusion Many women do not have desired knowledge about STDs but need to have. Misconceptions are common. Awareness is essential.

Effect of ozone on response to ovalbumin & its modulation by vitamins C & E in sensitized guinea pigs.

Background & objectives: Exposure to ozone and asthma are both associated with increased oxidative stress. Exposure to ozone therefore, may potentiate the airway response to allergens. We undertook this study to investigate the effect of ozone exposure on airway response to ovalbumin in sensitized guinea pigs and its modulation by dietary supplementation with antioxidant vitamins C and E. Methods: After in vivo measurements of specific airways conductance (SGaw) and airway hyperresponsiveness (AHR) to inhaled histamine, guinea pigs were sensitized to ovalbumin and divided into three groups: (i) sensitized; (ii) sensitized and exposed daily to ozone; and (iii) sensitized, exposed daily to ozone and given dietary supplementation with vitamin C, 2 mg/kg body wt and E, 7 IU/kg body wt. A control group of nonsensitized animals was included. After 4 wk, AHR was measured again and animals were challenged with inhaled ovalbumin. Changes in SGaw were followed for early and late airway bronchoconstrictive responses. The following measurements were obtained: (i) parameters of oxidative stress - plasma malonaldehyde (MDA) as marker of lipid peroxidation and superoxide anion generation by leukocytes and bronchoalveolar lavage (BAL) cells; (ii) antioxidant status: red cell superoxide dismutase (SOD); and (iii) glutathione peroxidase (GPx). BAL cytology was studied. Results: Ozone exposure resulted in an increase in AHR and early and late bronchoconstrictive responses after ovalbumin challenge, greater superoxide anion generation in BAL cells, higher plasma MDA levels and decrease in red cell SOD activity. Dietary supplementation with vitamin C and E prevented or ameliorated these responses. Interpretation & conclusions: Exposure to ozone at concentrations of 0.12 ppm for 2 h daily for 4 wk enhances the airway response to allergens in sensitized guinea pigs. Dietary supplementation with antioxidant vitamins E and C, affords variable degree of protection against this enhancement.

Pelvic Tuberculosis continues to be a disease of dilemma - Case series.

Tuberculosis (TB) has become a global epidemic again with emergence of HIV/AIDS and multi-drug resistant strains of TB. Female genital tuberculosis (GT) is typically a disease of young women and its occurrence in post menopausal women is rare. Amongst the genital disorders, GT is the most baffling especially because of its various presentations. So GT is notorious for evading diagnosis. A series of cases of females GT between the age 25 yrs to 40 yrs is being reported with women having spectrum of clinical features, creating diagnostic dilemma and so final diagnosis by histopathology after laparotomy. So a high degree of suspicion aided by intensive investigations may be required for the diagnosis of GT. Medical therapy is the main treatment, however some do need surgery. Research needs to be continued for early establishment of timely diagnosis of GT and modalities of effective therapies.

Effect of vitamin E supplementation with standard treatment on oxidant-antioxidant status in chronic obstructive pulmonary disease.

BACKGROUND & OBJECTIVES: Chronic oxidant burden and depletion of endogenous antioxidants have been proposed to play a key role in the pathogenesis of chronic obstructive pulmonary disease (COPD). Exogenous antioxidants have potential therapeutic implications and their role has not been explored in COPD. The objective of this study was to investigate the effect of supplementation of standard treatment (inhaled long-acting beta(2) agonists, anticholinergics and corticosteroids) with vitamin E on oxidant-antioxidant balance in patients with COPD. METHODS: The study was carried out in the outpatient setting. Patients were divided into two groups: group A- placebo group (n=14), receiving only standard therapy, and group B- vitamin E-supplemented group (n=10), receiving 400 IU of vitamin E capsules twice daily in addition to standard therapy. Spirometry and clinical assessment were carried out at the start and completion of 8 wk treatment along with measurements of several biochemical parameters of oxidant-antioxidant status in plasma, leukocytes and red cells separated from venous blood. RESULTS: Leukocyte superoxide generation was decreased in both the groups. Vitamin E-supplemented group had significantly increased levels of plasma sulphydryls and red cell catalase while the placebo group had decreased levels of plasma nitrates and nitrites. No significant differences were observed in red cell superoxide dismutase and glutathione peroxidase activities, total blood glutathione, and plasma total antioxidant capacity, lipid peroxides and glutathione peroxidase activity in either group. There was a similar degree of lung function and clinical improvement in both the groups. INTERPRETATION & CONCLUSION: Our findings showed that an 8 wk supplementation of standard treatment with 400 IU twice daily of vitamin E did not provide any additional clinical benefit although it augmented certain endogenous antioxidants in patients with COPD.

Assessment of control in asthma: the new focus in management.

Several evidence-based guidelines on the management of asthma have been developed in the last two decades. There is a consensus that a stepped-up approach with anti-inflammatory drugs based on severity forms the cornerstone of treatment. Goals of management have been defined. Studies in several countries have however shown that a large majority of patients have failed to attain the goals of treatment. This has led to a reconsideration of strategy of management. The focus is now shifting to an assessment and a treatment approach based on control. The objective is to achieve and monitor to maintain control. The previous treatment algorithms based on assessment of severity are being discarded. It has been emphasised that the state of control is a dynamic one and therefore a regular assessment and modifications of treatment according to changes in its level are necessary. There is a need to use some method to assess control. A wide range of techniques to assess control are available that can be used depending on the requirements, settings and resources. Assessment of control may be an informal global judgement by the physician or simple tools may be used. Several formal instruments to assess the state of control have also been developed and validated in different settings. These allow a more objective and a quantitative evaluation. Control needs to be assessed at every visit of a patient and treatment adjusted accordingly.

Maternal morbidity with caesarean section for non-progress of labour: an analytical study.

To estimate the maternal morbidity and mortality in caesarean section for non-progress of labour, a study was conducted over a period of 16 years at Mahatma Gandhi Institute of Medical Sciences, Sevagram among 533 cases of non-progress of labour for which caesarean section was performed. A total of 34975 women delivered including 7309 cases by caesarean section. Sixteen years records divided into 4 blocks, one each of 4 years were analysed. There was no maternal mortality but 8.25% women had intra-operative complication and 42.21% had postoperative morbidity. Timely intervention can save complication of prolonged labour as well as complications for which caesarean section was done for non-progress of labour.