An analysis of medulloblastoma: 10 year experience of a referral institution in South India.

BACKGROUND: Medulloblastoma is an embryonal tumor with aggressive behavior and is more commonly seen in children than adults. The aim of this study was to determine the epidemiological patterns of medulloblastoma in a tertiary care center in Southern India. MATERIALS AND METHODS: It is a retrospective study, in which the records of all the clinically diagnosed medulloblastoma cases in the last 10 years (2002‑2012) were analyzed. RESULTS: A total of 58 cases were found, with the mean age at diagnosis being 10 years. There was a slight predilection for the male sex (58.62%). The first presenting symptom was mostly related to raise intracranial pressure and the mean duration of symptoms was 200 days. Nearly, 89.6% of patients were in Stage 0 and had a central tumor location. Multimodality treatment included surgery followed by craniospinal irradiation up to 36 gray followed by posterior fossa boost up to 54 gray. Median radiation therapy duration was 6.5 weeks and concurrent single agent vincristine was the most common chemotherapy used. Most of the patients showed only a partial response to treatment, mainly because of large tumors at presentation, which could be attributed to the lack of awareness, delayed medical attention and poor follow‑up. CONCLUSION: Early diagnosis and treatment is the key to management of medulloblastoma, which still needs to be achieved. Bulky tumors have a poor outcome, efforts should be aimed at complete surgery and giving risk stratification based treatment. Resources need to be allocated to make more conformal methods of radiotherapy available, which will decrease the growth abnormalities and cognitive impairments.

An Unusual Cause of a Pulmonary Mass: Actinomycosis.

We present the case of a 62-year-old male with chronic obstructive pulmonary disease and poorly controlled diabetes mellitus who presented with haemoptysis. A radiograph of the chest showed a right lower parahilar opacity which on the contrast enhanced computed tomography was seen to be an irregular, spiculated mass localised to the middle lobe. Considering malignancy as the most probable diagnosis, a bronchoscopic endobronchial biopsy was performed which surprisingly established pulmonary actinomycosis as the diagnosis. The patient was successfully managed with amoxicillin and clavulanic acid and glycaemic control.

Clinical presentation of patients with seasonal influenza and pandemic influenza A (H1N1-2009) requiring hospitalisation.

Background. A sudden increase in the number of novel influenza A virus (pH1N1-2009) infection prompted us to compare the clinical presentation and outcomes of patients infected with pH1N1-2009 and seasonal influenza A virus during the postpandemic phase. Methods. During the period August 13 to September 27, 2010, case records of 106 patients with severe influenza like illness (ILI) and respiratory complications who underwent diagnostic testing by real-time polymerase chain reaction (RT-PCR) for confirmation of pH1N1-2009 were retrospectively studied. Results. Nineteen (17.9%) patients were tested positive for pH1N1-2009 and 78 (73.6%) were tested positive for seasonal influenza A virus. The mean age of patients infected with pH1N1-2009 was 45.2±15.3 years (range of 22 to 80 years). Common presenting symptoms included fever in 17 (89.4%), cough in 16 (84.2%), myalgia in 15 (78.9%) and breathlessness in 10 (52.6%) patients. The most common comorbidities included bronchial asthma/bronchitis/chronic obstructive pulmonary disease (COPD) in 4 (21%); followed by hypertension in 3 (15.8%) and diabetes in 3 (15.8%) patients. Overall, of the 97 influenza infected patients, 9 (9.3%) needed hospitalisation to the intensive care unit (ICU); one patient with COPD died due to multi-organ failure. Conclusions. Both the pandemic and seasonal strains were found to be co-circulating in the community. Patients with severe hypoxia, hypertension, acute respiratory distress syndrome and shock required ICU care.

Sarcoidosis in north indian population: A retrospective study.

Background. Sarcoidosis is a systemic granulomatous disease of unknown origin most commonly involving the lungs. Sarcoidosis is frequently misdiagnosed due to its clinico-radiological resemblance to tuberculosis (TB). Hence, the present study was undertaken with the aim of studying the clinico-radiological profile of sarcoidosis in the Indian context. Methods. We retrospectively studied 146 patients diagnosed to have sarcoidosis during the period 2001-2010 at one of the respiratory units at Vallabhbhai Patel Chest Institute. Results. Majority of them (70%) were more than 40 years of age; females comprised 58.2% of the patients. Before coming to our clinic, 30% patients had been misdiagnosed to have TB. Cough (89.7%) was the most common presenting symptom; joint symptoms (28.8%) and end inspiratory crepitations at lung bases (49.3%) were other salient manifestations. Cutaneous involvement and digital clubbing were rarely seen. Pulmonary function testing showed restriction with impaired diffusion in 72.7% patients. The most common radiological feature was bilaterally symmetrical hilar lymphadenopathy. Transbronchial lung biopsy (TBLB) had a very high diagnostic yield (90.8%). Conclusions. Sarcoidosis is often misdiagnosed as TB in India. Transbronchial lung biopsy has high diagnostic yield in sarcoidosis.

Analytical study of water safety parameters in ground water samples of Uttarakhand in India.

The main problem of the locality is the drinking water. Certain health problems are associated with people living in hills that are because of the presence of excess of heavy metals and other impurities. The present study was conducted to analyze the various parameters of ground water in uttarakhand, India and to check its fitness for drinking. It will also clarify the health hazards imposed on the population of this state. The present study was conducted in five regions of Uttarakhand, India (Haridwar, Vikasnagar, Mussoorie, Dehradun & Dakpathar). Ten samples of ground water were collected from each of the five regions during the pre-mansoon (Jan-Feb ) and post-mansoon (Sept-Oct )seasons.The pH was estimated by pH meter, acidity,alkalinity, sulphates,chorides,Total hardness(Ca & Mg) were determined by titration methods. The total suspended solid was calculated by the formula. The heavy metals like Mn, Al, Ba, Cd, Cr, Co, Cu, Fe and Pb were determined in the ground water samples by ICP mass spectroscopy. The concentrations of heavy metals, pH, alkalinity, sulphate, chloride, TDS & Total Hardness (TH) were compared with the standards by BIS for Drinking water (IS 10500:1991). The results shows that water pH of all the five regions showed no remarkable variation from the BIS recommended value of pH (6.5-8.5). The alkalinity was above the BIS desirable level of 200mg/l in all the samples, but was less than the maximum permissible limit. The Drinking water of all the regions contains higher amounts of TDS than the desirable limits. maximum TDS was detected in Haridwar & dehradun state. The ground water of mussoorie region shows total hardness to be above the BIS desirable level of 300mg/l. The chloride content was above the BIS desirable level of 250mg/l in dehradun only. The sulphate content was highest in haridwar (197.5mg/l) and dehradun (170mg/l) but it was below the desirable limit of 200mg/l. The Cd,Cr,&Pb content of all the five regions of Uttarakhand showed higher the BIS permissible limits of 0.01, 0.05 and 0.05 mg/l respectively. The content of Mn,Ba,Cu, Co&Fe are within the permissible limit of BIS standards for drinking water.

Identification of IgE-mediated food allergy and allergens in older children and adults with asthma and allergic rhinitis.

Background and objective. Prevalence of immunoglobulin (Ig) E-mediated food allergy is primarily reported for certain pediatric populations and adults. The present study was aimed to investigate the relative prevalence of food allergy and allergens in older children and adults with asthma and allergic rhinitis. Methods. Patients (12-62 years) were screened using standard questionnaire and skin prick-test (SPT) with common foods and aeroallergens. Specific IgE level was determined by enzyme linked immunosorbent assay (ELISA) and allergy was established by blinded food challenges. Results. Of 1860 patients screened, 1097 (58.9%) gave history of food allergy. Of the history positive patients skin tested (n=470), 138 (29.3%) showed a marked positive reaction to food extracts. Rice elicited positive SPT reaction in maximum number of cases 29 (6.2%) followed by blackgram 28 (5.9%), lentil 26 (5.5%), citrus fruits 25 (5.3%), pea 18 (3.8%), maize 18 (3.8%) and banana 17 (3.6%). The SPT positive patients showed elevated specific IgE levels (range: 0.8-79 IU/mL) against respective food allergens than normal controls (0.73 IU/mL, mean±2SD). Food allergy was confirmed in 21/45 (46.6%) of the patients by blinded controlled food challenges. The prevalence of food allergy was estimated to be 4.5% (2.6%-6.34%) at 95% confidence interval (95% CI) in test population (n=470). Sensitisation to food was significantly associated with asthma (p=0.0065) while aeroallergens were strongly related to rhinitis (p<0.01). Conclusions. Food allergy is estimated to be 4.5% in adolescents and adults with asthma, rhinitis or both. Rice, citrus fruits, blackgram and banana are identified as major allergens for inducing allergic symptoms.

Impact of domestic air pollution from cooking fuel on respiratory allergies in children in India.

This study undertaken in India was aimed at identifying the effects of the indoor air pollutants SO2, NO2 and total suspended particulate mater (SPM) generated from fuel used for cooking on respiratory allergy in children in Delhi. A total of 3,456 children were examined (59.2% male and 40.8% female). Among these, 31.2% of the children's families were using biomass fuels for cooking and 68.8% were using liquefied petroleum gas. Levels of indoor SO2, NO2 and SPM, measured using a Handy Air Sampler (Low Volume Sampler), were 4.60 +/- 5.66 microg/m3, 30.70 +/- 23.95 microg/m3 and 705 +/- 441.6 microg/m3, respectively. The mean level of indoor SO2 was significantly higher (p = 0.016) for families using biomass fuels (coal, wood, cow dung cakes and kerosene) for cooking as compared to families using LP gas. The mean level of indoor NO2 for families using biomass fuels for cooking was significantly higher in I.T.O. (p = 0.003) and Janakpuri (p = 0.007), while indoor SPM was significantly higher in Ashok Vihar (p = 0.039) and I.T.O. (p = 0.001), when compared to families using LP gas. Diagnoses of asthma, rhinitis and upper respiratory tract infection (URTI) were made in 7.7%, 26.1% and 22.1% of children, respectively. Respiratory allergies in children, which included asthma, rhinitis and URTI, could be associated with both types of fuels (liquefied petroleum gas [LPG] and biomass) used for cooking in the different study areas. This study suggests that biomass fuels increased the concentrations of indoor air pollutants that cause asthma, rhinitis and URTI in children. LP gas smoke was also associated with respiratory allergy.

Apolipoprotein E polymorphism and its relation to plasma lipids in coronary heart disease.

Background : The present investigation is aimed at examining the Apolipoprotein E (APOE) genotypic influence on coronary heart disease (CHD) risk in northwest India (Punjab), where this disease is emerging as a major threat to public-health care system. Materials and Methods: The present study comprised of angiographically diagnosed coronary heart disease patients (n = 193) and controls (n = 150) of Punjab. Genetic polymorphism of APOE gene was investigated by polymerase chain reaction (PCR), and its association with lipid levels was evaluated. Results : The allele frequencies of epsilon2, epsilon3, and epsilon4 were 0.054, 0.795, 0.151; and 0.077, 0.856, 0.067 in patients and controls respectively. The bearers of E3/E4 genotype had threefold higher propensity of developing CHD in this population (OR, 3.04; CI, 1.55-6.25; P P P Conclusions : A significant association (P = 0.016) of epsilon4 allele, especially E3/E4 genotype, with CHD was observed, along with HDL-C and LDL-C concentrations, in the population of northwest India.

Gastroesophageal reflux disease in bronchial asthma and the response to omeprazole.

The objective of this study was to determine the incidence of gastroesophageal reflux disease (GERD) in bronchial asthma and the role of omeprazole for asthmatics with symptoms of GERD. Seventy asthmatics were screened for GERD by questionnaire. Patients with a history suggestive of GERD were confirmed by Bernstein test and further investigated for airway responsiveness to instillation of HCl in the esophagus. Symptom score, drug score and spirometric values were recorded initially and after four weeks of treatment with omeprazole. It was found that 74.28% of asthmatics had a history of GERD. Forty patients tested positive by Bernstein test and also showed airway responsiveness to instillation of HCl in the esophagus. There was a significant improvement in symptom scores (p < 0.001), drug scores (p < 0.001) and spirometric values (p < 0.001) after adding omeprazole to their treatment regimen. It was concluded that bronchial asthma and GERD are associated in the majority of patients (57.14%) and such patients are likely to improve with omeprazole.

Sarcoidosis presenting as acute bilateral parotid swelling.

A case of bilateral parotid swelling of short duration, which turned out to be sarcoidosis confirmed by fine needle aspiration cytology, is presented here. The patient also had asymptomatic bilateral hilar lymphadenopathy and dryness of the eyes suggesting sarcoid involvement of the lungs and lacrimal glands. Sarcoidosis of the parotids, although rare, should be considered in the differential diagnosis of acute bilateral parotid swelling. Clinico-radiological findings of multi-organ involvement suggest the diagnosis in such cases.

Predictive value of routine hematological and biochemical parameters on 30-day fatality in acute stroke.

OBJECTIVE: This prospective study was planned to study the prognostic value of routine clinical, hematological and biochemical parameters, including platelet aggregation in patients of acute stroke, on fatality occurring during the first 30 days. MATERIAL AND METHODS: In this study 116 consecutive patients (77 males and 39 females) of stroke (within 72 hours of onset) were included. After clinical evaluation and neuroimaging, blood investigations, hemoglobin, total leukocyte count, platelet count, platelet aggregation, erythrocyte sedimentation rate (ESR), blood sugar, urea, creatinine, sodium, potassium, serum cholesterol, serum bilirubin, aspartate aminotransferase (SGOT), alanine aminotransferase (SGPT), albumin, and globulin estimations were performed. The patients were followed up for a maximum period of 30 days from the onset of stroke, and patients who expired were grouped as 'expired' and the rest as 'survivors'. Logistic regression analysis was carried out among the significant parameters to identify independent predictors of 30-day fatality. RESULTS: Univariate analysis demonstrated that among hematological parameters, high total leukocyte count and ESR, at admission, correlated significantly with an undesirable outcome during the initial 30 days. Among biochemical parameters, elevated urea, creatinine, serum transaminases (SGOT and SGPT) and globulin levels correlated significantly with death. Logistic regression analysis demonstrated that a low Glasgow Coma Scale (GCS) score along with biochemical parameters such as high serum creatinine, SGPT, ESR and total leukocyte count correlated with death. CONCLUSION: Impaired consciousness, high total leukocyte count, raised ESR, elevated creatinine and SGPT levels, estimated within 24 hours of hospitalization, are the most important indicators of 30-day mortality in patients with first-time ischemic stroke.

Tuberculosis in the elderly and their treatment outcome under DOTS.

Summary: A retrospective study of the profile and treatment outcome in the elderly TB patients taking DOTS was carried out in an urban TB clinic of Delhi. Out of 2118 tuberculosis patients treated between 1999-2001, a total of 238 (11.4%) patients were over 50 years of age and of these 45(2.2%) were over 65 years of age. A total of 78.6% of the 283 TB patients of all the categories included in the study had a successful outcome (cure/ completion). The overall case fatality, default and failure rates among the TB patients over 50 years were found to be 7.1%, 8.8% and 4.6%, respectively, despite directly observed treatment being given under RNTCP. The case fatality rate was significantly higher (15.6%) in the age group >65 years as compared to patients between 50-65 years (5.2%). The failure rate was significantly higher (13.3%) in the age group >65 years than among patients in the 50-65 years age-group (2.6%). This emphasizes the need for intensive motivation and stringent monitoring among tuberculosis patients over 65 years of age.

Comparative evaluation of market spacer and home made spacer in the management of bronchial asthma.

INTRODUCTION: A study was conducted to compare the efficacy of market available spacer (with valve) and home made spacer (without valve)--Bislery bottle. MATERIAL AND METHODS: Fifteen patients of bronchial asthma were included in the study. With the use of both devices there was significant bronchodilator effect. The reversibility using Bislery bottle was same as with spacer (market available) while comparing the FVC, FEV1, FEV1/FVC %, FEF 25-75 and PEFR value. RESULT: The difference in percent change in reversibility values by both the devices was not statistically significant (p < 0.05). CONCLUSION: We concluded that the Bislery bottle (without valve) is very cheap compared to market-available spacer and is equally effective which, therefore, can be substituted in bronchial asthma patients, who are unable to afford the cost of market available spacers.

Prevalence of allergic bronchopulmonary aspergillosis in patients with bronchial asthma.

Two Hundred patients with bronchial asthma were studied to identify the prevalence of allergic bronchopulmonary aspergillosis (ABPA). The patients selected required intermittent short courses of steroids and their mean duration of illness was 12 years. Absolute eosinophil count was > 500/mm3 in 53% of the cases. Chest X-rays showed small homogenous shadows with patchy infiltrations in 25% and fluctuating pneumonic shadows in 14% of the cases. Raised specific IgG and positive serum precipitin against Aspergillus fumigatus (AF) were present in 24% and 13%, respectively. Cases with radiological and immunological suspicion were further investigated for ABPA. Skin tests for Type-I and Type-III reactivity were positive with AF extract in 87% (n = 47) and 36% (n = 47) of the cases. A thorax CT of 31 patients showed central bronchiectasis in 24 cases, labeling these patients as ABPA-CB (ABPA with central bronchiectasis) and an other 7 as ABPA-S (serological positive). CT was not done in one case who, because of other positive findings, was also labeled as ABPA-S. Thus, these 32 asthmatics were found to have ABPA. Among them, there was raised specific IgG (100%) and raised specifc IgE against AF (100%), positive skin test for Type-I and Type-III reactivity (100% and 53%) against AF. There was elevated total IgE (100%, n = 29), a positive family history of asthma (63%), peripheral eosinophilia (100%) and a history of passage of brownish plugs (31%). Radiological findings suggested soft shadow with infiltration in 31% and fluctuating pneumonic shadows in 69% of cases. CT Thorax (n = 31) showed central bronchiectasis in 78% of theses patients. Based on the present data, the prevalence of ABPA in bronchial asthma patients is 16% (12% with central bronchiectasis and 4% only serologically positive). Therefore, patients should be investigated and diagnosed in an early phase of ABPA (ABPA-S) and should be treated to prevent permanent lung damage.

Lipoprotein(a) and coronary heart disease in Indian population.

OBJECTIVE: Present study was undertaken to evaluate the role of lipoprotein(a) in coronary heart disease (CHD) patients and its relationship with other established risk factors. METHODS: Blood samples of 67 control patients (non-cardiovascular problems) and 222 CHD patients (> or = 4 weeks post myocardial infarction) were analyzed. Lipoprotein(a) was measured in serum samples by enzyme-linked immunosorbent assay utilizing rabbit polyclonal antibodies against purified human Lp(a). Step-wise linear discriminant analysis was used to find the important parameters to discriminate CHD and non-CHD subjects. RESULTS: The LDL to HDL cholesterol ratio (p < 0.01) and serum level of lipoprotein(a) (p < 0.01) were significantly higher in CHD patients. Levels of lipoprotein(a) were found to be higher in females compared to males (p < 0.01). Positive family history of CHD did not show significant difference in Lp(a) levels. Lp(a) level in CHD patients with positive family history of NIDDM and hypertension was higher than in with negative family history. CONCLUSION: Clinical significance of serum level of Lp(a) and albumin in determining the risk of CHD has been observed. Lp(a) alone could correctly discriminate a CHD individual from a control subjects by 95%. Estimating of Lp(a) together with albumin provided 99% correct discrimination between control and CHD patients. These results also suggest that Lp(a) together with malnutrition could be responsible for the increased incidence of CHD in Indians. It is also indicated that in females atherothrombogenic potential of lipoprotein(a) remains suppressed before menopause but after this stage women lose this advantage.

Malignant pleural mesothelioma without asbestos exposure.

A 45-year-old male, non smoker and lecturer by profession was diagnosed as an advanced case of bilateral mesothelioma involving lung and pleura. He was never exposed to asbestos, which makes it a rare case.