Laryngopharyngeal Reflux and Proton Pump Inhibitors.

Laryngopharyngeal reflux (LPR) refers to the backflow of stomach contents into the throat that is into the hypopharynx.LPR is different from classical GERD. Although PPIs appear to be effective, higher doses for a longer duration are necessary as compared with esophageal GERD disease. In this study we focused on clinical characteristics and role of proton pump inhibitors in Laryngopharyngeal Reflux. Material and Methods: The prospective observational study was done in LPR patients in the Department of ENT and HNS of SKIMS Medical College and Government Medical College Srinagar for a period of 2 years from 2010 to 2012 .Sixty cases were enrolled in the study. LPR was diagnosed on the basis of RFS and RSI. Role of PPI was assessed by the changes of RSI and RFS with Proton pump inhibitors. Results: Total number of patients included in the study were 60, 42 (70%) cases were females, 18 (30%) were males. Frequent clearing of throat was the most common symptom. Mean RSI of all patients was 25.25 before treatment. Significant change in RSI occurred after first 10 weeks of therapy and no further significant change occurred in the next 10 weeks. Most common laryngeal finding was erythema/hyperaemia; Mean RFS of the patients was 13 before treatment with proton pump inhibitors. There was slight response after 10 weeks of therapy in physical findings and significant response after 20 weeks. Conclusion: LPR is a common condition presenting in ENT settings, the symptoms and signs may be complex. PPI are treatment of choice and should be continued for about 5 months because clinical symptoms take about two month to resolve while signs take about 5 months to resolve.

Effect metformin on urinary VMA levels in type II diabetic subjects

The purpose of this study was to observe the effect of metformin on 24-hours urinary VMA levels in newly diagnosed untreated type 2 diabetic subjects. The study consisted of four weeks for each participant with weekly follow up visits. Samples were collected at 0800-0900 hours after over night fast. Study was conducted in the Department of Pharmacology and Therapeutics, BMSI, JPMC, Karachi. Total duration of study was six months. Fifteen newly diagnosed untreated type 2 diabetics, with fasting plasma glucose levels >/= 126 mg/dl on two occasions and/or postprandial glucose levels >/= 200 mg/dl were enrolled in the study. Patients with concurrent illness or diabetic complications were excluded. Metformin was started from 500 mg/day and titrated at weekly intervals according to glycaemic control and the subjects tolerance to the drug. A 24-hour urinary VMA was assessed at day - 0 [before metformin therapy] and day - 28 [4 weeks after metformin therapy] by using VMA reagent kit of Biosystems Spain on Spectronic -21 spectrophotometer USA. Metformin caused highly significant [P < 0.001] reduction in mean fasting plasma glucose from 233.33 +/- 15.62 mg /dl on day-0 to 151.53 +/- 6.02 mg/dl on day - 28, and a significant [P < 0.01] decrease in 24 - hour urinary VMA levels from 5.18 + 0.50 mg / 24 hours on day-0 to 3.32 + 0.28 mg / 24 hours on day-28. Our results indicate that metformin causes highly significant reduction in fasting plasma glucose and a significant decrease in 24 - hour urinary VMA levels in newly diagnosed untreated type 2 diabetic subjects

Combined impact of polymorphism of folate metabolism genes; glutamate carboxypeptidase, methylene tetrahydrofolate reductase and methionine synthase reductase on breast cancer susceptibility in Kashmiri women

Folate and methionine play a crucial role in DNA synthesis, repair and the epigenetic profile of cell. Hence, the alterations in the folate metabolism can lead to aberrant proliferation leading to neoplasia. Most of the studies have associated polymorphisms in methylene tetrahydrofolate reductase [MTHFR] and methionine synthase reductase [MTRR] genes with reduced risk of cervical and colorectal cancer. However, the association with breast cancer is still controversial. Further, the ivolvement of Glutamate carboxypeptidase II [GCPII] polymorphism in cancer is not known. In the present study, we analyzed if the individual and combined effects of polymorphisms in folate pathway genes viz., MTHFR 677C> T, MTHFR 1298A> C, MTRR 66A> G and GCP II 1561 C>T, have any role in altering the susceptibility to breast cancer. The DNA of 35 female breast cancer patients and 33 healthy individuals, in the Kashmiri population from India, were analyzed using a PCR-RFLP approach for the above mentioned polymorphisms. Individuals carrying the MTHFR 677CT/TT and GCPII 1561 CT genotype showed a 3.5 [95% CI: 3.1-3.7, P<0.02] and 7.7 [95% CI: 6.7-9.1, P<0.001] fold decreased risk for breast cancer than the wild types [MTHFR 677CC and GCPII 1561 CC]. Subjects with MTRR 66 G-allele showed a 4.5 fold decreased risk [OR: 0.22, 95% CI: 0.20, 0.24, P<0.0005] compared to the wild type [MTRR 66A]. Further, subjects with combined polymorphisms in MTHFR, GCPII and MTRR loci revealed a significant reduction of breast cancer risk. This study indicates [i] a protective role of polymorphisms in MTHFR, GCPII, MTRR against breast cancer in the study subjects, and [ii] combined effect of polymorphisms is more pronounced than single genetic polymorphism, thereby emphasizing the role of gene-gene interaction in the susceptibility to breast cancer

Mutations in epidermal growth factor receptor gene in esophageal squamous cell carcinoma patients in Kashmir: a high incidence area of India

Activating mutations in Epidermal Growth Factor Receptor [EGFR] are common in lung adenocarcinoma of never smokers but are rare in other types of cancer. Here we have analysed mutations in exons 19 to 21 of EGFR and in exons 19 and 20 of the EGFR homolog HER2 in 54 cases of Esophageal Squamous Cell Carcinomas [ESCC] from patients recruited in Kashmir, India, a region of high incidence for this cancer. We report the detection of 3 mutations [6%] in the ATP- binding regulatory loops of the tyrosine kinase domain of EGFR [deletion 746-750, p753L, G719D]. No mutation was found in HER2. This is the first report of activating EGFR mutations in ESCC, of the same type as those detected in lung adenocarcinoma of never-smokers. This suggests that a small portion of ESCC patients in this high incidence area may benefit from treatment with EGFR tyrosine kinase inhibitors

Outcome of ST segment elevated versus non-elevated acute myocardial infarction

To determine the outcome of patients with acute ST segment elevated myocardial infarction [STEMI] versus non -ST elevated myocardial infarction [NSTEMI] in our setup. A descriptive study. Cardiology department, Liaquat University Hospital, Hyderabad - Sindh from 1st May 2005 to 31st July 2005. Out of 580 patients hospitalized for acute coronary syndrome, 428 patients of acute myocardial infarction were selected for the study. The patients were selected on the basis of raised biomarkers [CPK, CKMB, SGOT, and LDH/Trop-T] and one of the two i.e. electrocardiography [ECG] changes or history of chest pain. They were grouped into STEMI and NSTEMI. Mean age of the patients was 52 years [range 35-75 years]. Majority of patients [73%] was male and 27% were females. Out of 428 patients selected for study, 288[67.28%] had STEMI while 140 [32.72%] patients had NSTEMI. Recurrent chest pain was present in 85 [29.51%] patients of STEMI; 45 [52.94%] with ECG changes and 40 [47.05%] without ECG changes. In STEMI group, complications were common, more in patients with recurrent chest pain and evidence of ECG changes as compared to those without ECG changes i.e. 16% and 10% respectively. Mortality was also higher [10.5%] in patients of recurrent chest pain and ECG changes compared to those without ECG changes [6.8%]. Among 140 patients of NSTEMI, 48 [34.28%] had recurrent chest pain; 30[62.5%] with ECG changes and remaining 18[37.5%] without ECG changes. In NSTEMI and STEMI patients, recurrent chest pain and ECG changes are bad prognostic markers as compared to recurrent chest pain without ECG changes. These patients are more likely to suffer complications and can benefit from aggressive/invasive strategy than patients with recurrent chest pain without ECG changes. In NSTEMI group, complications and mortality are more frequent in patients with recurrent chest pain and ECG changes compared to those without ECG changes

Risk factors associated with peripartum cardiomyopathy

To determine risk factors associated with peripartum cardiomyopathy in our set up. Coronary care unit, cardiology department Liaquat University Hospital, Hyderabad- Sindh from February to April 2005. Thirty patients with signs and symptoms of heart failure including chest x-ray showing cardiomegally were included in the study. Detailed clinical review of the patients was undertaken. Diagnosis of cardiomyopathy was confirmed on M-Mode / 2D / Colour Doppler Echocardiography. All [30] patients belonged to poor socioeconomic class. Mean age was 29.1 years [range 21-42 years]. Mean parity was 4 [range 1-8] and included primipara 1[3%], multipara 25 [83.3%] and grand multipara were 4[13.3%] patients. Five [16%] patients had gestational hypertension. Twenty-five[83.3%] patients presented with shortness of breath and orthopnea [NYHA Class-IV], 5[16%] with shifted apex beat and 3rd heart sound. All [100%] patients had sinus tachycardia, raised JVP and oedema feet. All patients also showed cardiomegally on x-ray chest. Echocardiograpically, 21 [70%] were having dilated left ventricle [LVIDD>57mm] ranging from 55-75 and reduced ejection fraction i.e, [<40%] ranging from 18-40%. Nine [30%] cases had normal size left ventricle and generalized left ventricular hypokinesia with reduced EF [<40%]. Eighteen [60%] patients were having moderate MR on Colour Doppler Echocardiography. This preliminary study shows that peripartum cardiomyopathy is associated with multiple risk factors in our set up. The most common risk factor is poor socioeconomic status followed by pregnancy with increasing age [>29 years] and multiparity [para >4]

Etiological factors and clinical profile of adhesive capsulitis in patients seen at the rheumatology clinic of a tertiary care hospital in India

This study was conducted to examine the clinical profile of patients with adhesive capsulitis [AC] and evaluate various possible etiological factors. The study was conducted in the Department of Physical Medicine and Rehabilitation, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India. One hundred patients fulfilling the criteria for the diagnosis of AC were studied for the severity of shoulder pain and the range of shoulder movements. The patients were also examined for the presence of various etiological factors for AC. Age of the subjects ranged from 25-70 years and duration of symptoms averaged 3.66 +/- 2.36 months; left shoulder was more commonly involved [54%], 2% had bilateral involvement and 63% of the subjects were sedentary workers. Disease was seen most commonly in patients with diabetes mellitus [27%]. Other identifiable risk factors included previous myocardial infarction [5%], immobilization [5%], stroke and chronic bronchitis [4% each]. Fifty-six% of patients with AC had radiological evidence of cervical spondylosis. We conclude that AC mostly affects people in the fifth to seventh decade. The majority of the affected individuals are sedentary at the time of the sickness and subjects with diabetes mellitus are at particular risk

Oral Lichen Planus

In this study twenty patients of clinically diagnosed oral lichen planus were analysed in respect to age. sex, patterns and associated disease. It was found more common in females in age group 01'3050 years. Mostly patients had classical bilateral lesions mostly on the buccal mucosa. Thyroiditis with generalized vitiligo was noted in one patient while diabetes was present in one patient.

Lateral Subcutaneous External Sphincterotomy

Lateral internal sphincterotomy, even though, the most commonly used technique in United States for the treatment of fissure-in-ano has its associated post-operative complications like incontinence of flatus or faces. A better alternative in the form of lateral subcutaneous external sphincterotomy was tried prospectively on 50 patients over a period of 2 years & 4 months in the department of General Surgery at Sher-i-Kashmir Institute of Medical Sciences- Medical College, Semina. Srinagar India. Postoperative results were excellent vis- a vis pain relief and complications. We conclude that it is a better alternative for treatment of both acute as well as chronic fissure-in-ano.

Comparitive Study of Multiple Versus Single Rubber Band Ligation for Internal Hemorrhoids

Rubber band ligation for hemorrhoids was used for treating 1500 consecutive patients affected by 2nd and 3rd degree hemorrhoids over a period of 3 years (1999-2001). The patients were divided into 2 groups: Group 1,710 patients treated by the method of "multiple ligations"(2 or 3) in a single session and Group II, 790 patients treated by the method of "single Ligation" at one time over the same period. Post procedural results were satisfactory in 82% patients in Group I and 90% patients in Group II. Complication observed in Group II were significantly lower than Group 1. Thus, we conclude that rubber band ligation is a better modality of treatment for internal hemorrhoids if it is made with one ligation at a time, repeating the procedure every 3 weeks.

Internet: a major resource for toxicologists.

Use of the Internet in developing countries is now growing faster. Internet has created a new conduit not only for communication but also in the access, sharing and exchange of information among scientists. The Internet is now viewed as the world's biggest library where retrieval of scientific literature and other information resources are possible within seconds. Large volumes of toxicological information resources are available on the Internet. This review outlines some sites that may be of great importance and useful to the toxicologist.

Epidermoid Cysts of the Vocal Cords: An Undiagnosed Clinical Entity

The present study was carried out on 20 patients at SIKMS Medical College from January 2000 to March 2001. All the patients presented with hoarseness of voice. Laryngeal examination revealed smooth well-defined swelling involving left vocal cord in 12 cases, right vocal cord in 6 cases and bilateral involvement was noticed in 2 cases. Dysphonia being the main symptom, only one patient complained of some difficulty in breathing. Seventy-five percent of the patients were females. The lesion was generally located in the middle third of the vocal cord,just beneath its free border. The diagnosis was established by direct laryngoscope excision and histopathological examination of the lesion.

Trial of I/V amiodarone in paroxysmal atrial fibrillation

Amiodarone in I/V form can be a very useful tool for the control of tachyarrhythmia, in doses of 20 mg/kg/body wt. about 1/3 -1/4 of which may be given as bolus, and the rest continued as infusion till either the arrhythmia is aborted, or a good control achieved, following which a maintenance oral does may me given if required. Pre-treatment with enzyme inducers may be helpful in bringing about arrhythmic control earlier than Amiodarone alone. The number of patients in this series was however very small and further studies are required to confirm these results. However, the conversion of 14/15 from atrial fibrillation to sinus rythm is very encouraging