Intra-psychic disarray of gender identity and sexual orientation: in the process of coming out as transsexual

The present paper takes a step towards understanding the confusion that a transgender individual undergoes, while coming in terms with one抯 gender identity. Here, we will be presenting a case study with few anecdotes to put forward concepts of negotiation, self-understanding, and disclosure. We will refer to the individual as 慼im� as the person identifies himself as a male and is in the process of transition. Here, we have introduced the coming out process as a one-way and two-way process.

Spinal epidural cavernous hemangioma with myelopathy: a rare lesion.

A case of pure epidural cavernous angioma involving the dorsal region of the spine is presented. The clinical picture was of a slowly progressive compressive myelopathy. Imaging studies only showed a dorsally located epidural mass lesion. Histology confirmed the diagnosis of this rare type of lesion. The patient improved after excision of the lesion.

Renal failure in malaria.

Acute renal failure (ARF) is seen mostly in Plasmodium falciparum infection, but P vivax and P. malariae can occasionally contribute for renal impairment. Malarial ARF is commonly found in non-immune adults and older children with falciparum malaria. Occurance of ARF in severe falciparum malaria is quite common in southeast Asia and Indian subcontinent where intensity of malaria transmission is usually low with occasional microfoci of intense transmission. Since precise mechanism of malarial ARF is not known, several hypotheses including mechanical obstruction by infected erythrocytes, immune mediated glomerular and tubular pathology, fluid loss due to multiple mechanisms and alterations in the renal microcirculation, etc, have been proposed. Increased fluid administration, oxygen toxicity, and yet unidentified factors may contribute to pulmonary edema, acute respiratory distress syndrome (ARDS), multiorgan failure and death. Mainstay of treatment consists of appropriate antimalarial drug therapy, fluid replacement, and renal replacement therapy. Loop diuretics can convert an oliguric renal failure to non-oliguric renal failure without affecting outcome of the disease though the conversion reduces the risk of volume overload. There is little evidence on beneficial effect of vasoactive drugs. Nephrotoxic drugs such as ACE inhibitors, NSAIDs, aminoglycosides, cephalosporins should be avoided. Currently, high quality intensive care, early institution of renal replacement therapy, and avoidance of nephrotoxic drugs are standard practice of the prevention and management of ARF.

Management of severe and complicated malaria.

Severe malaria is invariably caused by Plasmodium falciparum. In India, both adults and children are affected by severe malaria. However, children are more prone for developing anemia and convulsions as manifestations of severe malaria, while acute renal failure and jaundice are more common among adults. Pregnant women are vulnerable to hypoglycemia, anemia and pulmonary complications. The case-fatality rate due to severe malaria is 10-15% in spite of therapy but it increases in the presence of renal failure or respiratory distress (pulmonary edema or ARDS). Of late, multi-organ failure and high mortality figures are being reported increasingly from different parts of India. Early diagnosis and prompt treatment will reduce the mortality due to malaria. Cerebral malaria should always be suspected in a patient with altered sensorium in a malaria-endemic area. However, other causes of unconsciousness such as encephalitis, meningitis or hepatic coma should also be excluded. Parenteral quinine is the mainstay of therapy. A recent multi-centric study has demonstrated the efficacy of intravenous artesunate in reducing the mortality by 30%. The usefulness of adjunct therapy is still controversial.

Thoracic cord compression due to ossified hypertrophied ligamentum flavum.

Ossified ligamentum flavum is increasingly appreciated as an important cause of thoracic myeloradiculopathy. Fifteen patients with age ranging from 30-61 years were studied. Fourteen presented with spastic paraparesis, and radiculopathy was the only complaint in one patient. Routine skiagrams and myelograms showed non-specific changes. Baseline CT and CT myelogram, however, documented the ossification of ligamentum flavum comprehensively. MRI was done in three patients. Multiple levels of the disease were seen in two cases. Four patients had ossified posterior longitudinal ligament. Thickened ligamentum flavum should be considered as an important cause of thoracic cord compression.

Multicentric clinical trials for safety and efficacy evaluation of alpha;beta arteether in complicated P. falciparum malaria.

OBJECTIVE: To evaluate efficacy of alpha;beta arteether in patients of P. falciparum malaria presenting with complications was undertaken in a multicentric clinical trial. METHOD: Each patient who consented to undergo clinical trial with parenteral Arteether was treated with a fixed dose schedule of Arteether given intramuscularly in a dose of 150 mg once a day on three consecutive days. Every patient was followed upto 28 days with clinical, haematological and parasitological monitoring every day upto one week and thereafter at 14, 21 and 28 days. The response was assessed in terms of fever clearance time, parasite clearance time, cure rate and parasite reappearance rate. RESULTS: A total of 211 patients of P. falciparum malaria were included in the study from four centres (Bhilai, Guwahati, Jamshedpur and Rourkela). Results of this study showed that fever clearance time ranged between 24-168 hours, parasite clearance time ranged between 24-120 hours and overall mortality ranged between 4-8.5%. Out of 211, only 14 patients expired during the study, of these, 10 patients expired within first two days i.e. before completing the three day schedule of arteether therapy. Tolerability to arteether injection was good in all these patients and no untoward effects were experienced or reported during the study. Overall cure rate observed in these studies was 93%. CONCLUSION: This study shows a rapid parasite and fever clearance in patients of complicated P. falciparum malaria.

Facial nerve neurinoma presenting as middle cranial fossa and cerebellopontine angle mass: a case report.

Facial nerve neurinomas are rare. The tumours arising from the geniculate ganglion may grow anteriorly and superiorly and present as a mass in the middle cranial fossa. Only a few cases of facial nerve neurinomas presenting as middle cranial fossa mass have so far been reported. These tumours present with either long standing or intermittent facial palsy along with cerebellopontine angle syndrome.

Trigeminal evoked potentials in patients with symptomatic trigeminal neuralgia due to intracranial mass lesions.

Trigeminal evoked potentials (TEP) were recorded by electrical stimulation of the lips in 7 patients with symptomatic trigeminal neuralgia due to CT proved mass lesions involving the trigeminal nerve. All the patients showed TEP abnormalities on the affected side. Chronic compression and irritation of the trigeminal nerve may be responsible for these changes. The results obtained were compared with other similar studies and TEP abnormalities observed in idiopathic trigeminal neuralgia. As all the patients had unequivocal compression of the trigeminal nerve and all of them had TEP changes, it can be concluded that TEP abnormality is an accurate predictor of trigeminal nerve compression. TEPs may be a valuable aid in demonstrating a compressive element in patients with trigeminal neuralgia.

CSF rhinorrhoea from unusual site : report of two cases.

CSF rhinorrhoea is associated with high morbidity and mortality. Bone and dural defects may result from trauma or enlarging 'pitholes' or breach in lateral recess of sphenoid sinus. Unless surgically corrected, they tend to cause meningitis and rhinorrhoea. Unusually delayed rhinorrhoea is a diagnostic problem.

Immunochromatographic test for the diagnosis of Falciparum malaria.

The diagnosis of malaria poses great difficulty at times due to non-availability of microscope, trained personnel or laboratory set up. We undertook the immunochromatographic test in 98 suspected cases of malaria for the detection of antigen of P. falciparum in the blood and to assess its sensitivity and positive predictive value. The sensitivity was 87.06% (confidence interval 77.57 to 92.55%) and the positive predictive value was 93.67%. This is a simple, sensitive and convenient test which can be performed in remote areas.

Influence of nutritional and haemoglobin status on malaria infection in children.

Anaemia and malnutrition have been suggested to confer some degree of protection against malaria infection. Therefore, the influence of nutritional status as assessed anthropometrically and that of haemoglobin level on the incidence of malaria and the degree of parasitaemia was studied in 330 children in the age range of 1-9 years in Bisra block near Rourkela in Orissa state. Moderate to severe malnutrition as assessed from percentage of ideal weight was found in 48.8% (161/330) of children but only 8.8% (29/330) of children had some degree of malnutrition when assessed as weight for height indicating presence of chronic malnutrition. Similarly, 197 children (59.7%) had various grades of anaemia as estimated by haemoglobin level prevalence of malaria on initial examination was 27.6% (91/330), while incidence of clinical malaria in children during the year of study was 250/1000. There was no statistical difference in the Prevalence/incidence of malaria or severity of P. falciparum parasitaemia at different haemoglobin or nutritional levels (p > 0.05). No child died or developed severe complications requiring hospitalization. Therefore, anaemia or malnutrition do not appear to provide any protection against malaria or degree of parasitaemia in the children around Rourkela.

Heterogeneity in DNA content & proliferative status of human brain tumours.

Intra-tumour and inter-tumour heterogeneity in the cytokinetic organization was studied in 235 primary human brain tumours. DNA index (DI; relative tumour cell DNA content) and proliferating fraction (%PF; a measure of proliferative status) were analyzed in tumour biopsy by flow cytometry using a DNA specific fluorochrome (DAPI) and internal standards (chicken erythrocytes, CE). Incidence of micronuclei was studied in tumour biopsy tissue as well as in explants maintained in organ culture. Clonal diversity (implied by the presence of multiple peaks in the DNA histograms) was highest among medulloblastomas (44%) followed by gliomas (19%) and meningiomas (14%). Nearly 85 per cent of the malignant gliomas analyzed (histological grade III/IV) exhibited a great deal of regional variation in the proliferative status as well as micronuclei frequency as compared to meningiomas. Inter-tumoural variations in the DNA content was highest among gliomas (0.9 < DI < 3.6) and lowest among schwannomas (1.7 < DI < 2.2). Similarly, the distribution of %PF values was also broader (10-49%) in gliomas as compared to the other primary brain tumours (5-36%). Analysis of tumours taking both DI and %PF values improved the ability to discern histologically graded low and high tumours. Analysis of clonal diversity and spatial heterogeneity in the cytokinetic parameters could complement the clinicopathological findings in assessing the biological behaviour of human brain tumours, facilitating the prognostification and design of otpimal treatment regimen.

Incidence of hypoglycaemia in children with severe Plasmodium falciparum malaria around Rourkela, Orissa state.

To determine the incidence of hypoglycaemia in children suffering from severe falciparum malaria, 23 patients from Rourkela (Orissa), were investigated. Plasma glucose and immunoreactive insulin were estimated before and at hourly intervals during quinine infusion. No child had hypoglycaemia at the time of admission. Correlation between parasite count and prequinine plasma glucose was not significant. In the period of quinine infusion, 20 patients showed fall in plasma glucose during all the three hours (P less than 0.05, P less than 0.01, P less than 0.01 at the end of 1st, 2nd, and 3rd h respectively) but the decrease to hypoglycaemic level (plasma glucose less than or equal to 40 mg/dl) was observed in only one child. Concomitant increase in plasma insulin was noticed in 18 of these patients. Decrease in plasma glucose and increase in plasma insulin was found to correlate well (r-0.78, P less than 0.001). Hypoglycaemia was found to be an infrequent complication of severe falciparum malaria in children from the area studied. Though decrease in plasma glucose was observed after quinine infusion, it was less severe and did not reach the hypoglycaemic level.

Influence of serum albumin & total protein on fructosamine measurement.

To assess the effect of serum albumin and total protein on the fructosamine level 57 hypoalbuminaemic patients (serum albumin less than 30 g/1), of whom 44 were nondiabetics and 13 were diabetics, were studied. Fructosamine levels of hypoalbuminaemic diabetics was increased only marginally in comparison to healthy controls (P greater than 0.05) whereas in 122 other normalbuminaemic diabetics, the level was found to be significantly higher (P less than 0.001). In control subjects, the correlation between fructosamine and serum albumin (r = 0.69, P less than 0.001) was better than that of total protein (r = 0.42, P less than 0.01) whereas in hypoalbuminaemic patients the pattern was reversed (r = 0.51 and 0.59 respectively), indicating substantial contribution by the globulins. A working formula suggesting approximate contribution of each gram of albumin and globulin in healthy subjects was calculated. It is inferred that the use of serum fructosamine for assessment of glycaemic status could be misleading in patients with lower albumin values. Calculating serum fructosamine values from serum albumin alone in these patients is likely to be inaccurate, as it ignores the contribution of globulins which can be substantial in certain disease conditions. A gross idea regarding the glycaemic status can be obtained by comparing actual and calculated values of fructosamine from the formula.

Homozygous familial hypercholesterolaemia. Report of three cases.

Homozygous familial hypercholesterolaemia is a rare disorder encountered in one in a million in the general population. Case reports of three patients from two families are presented. A 25 year male presented with extensive myocardial infarction and had a fatal outcome. His younger brother (14 years), as also a 12 year girl from another family with multiple planar xanthomata and tuberose xanthomata, are presented.