Pattern of use of biologics in psoriasis among Indian dermatologists – a cross sectional survey

Background and Aims: Biologics are a relatively new class of highly effective drugs in the management of psoriasis. They act on specific immune processes, achieve rapid and sustained clearance and do not cause target organ damage unlike conventional systemic therapy. It appears that their use in our country is not as widespread as in developed nations despite these benefits ; their prohibitive cost may be a major factor for the limited usage. This survey aimed to find out the extent of use and factors hindering usage of biologics for the management of psoriasis by Indian dermatologists. Methods: It was a cross?sectional questionnaire based study. The questionnaire was designed after a focussed group discussion, followed by validation. The survey was sent in the form of a link to Indian dermatologists. The responses were recorded in excel-sheet and the data was analyzed by SPSS ver 25. Results: Of the 310 participants who took part, 287 completed the survey. Two hundred (70%) were users of biologics, while 87 (30%) had never used them. Cost was the major factor which prevented biologic use. Majority of the respondents used biologics in less than 2 cases per month. Secukinumab was the most common biologic used followed by etanercept. The factors which determined choice of biologics were convenience, cost, previous experience, co-morbid conditions and recommendations by an expert. Limitations: A small sample size was the limitation of the study. Dermatologists who do not use biologics may be under?represented in the study. Conclusions: Biologics are not used optimally by Indian dermatologists for management of psoriasis. The cost, fear of adverse effects, lack of awareness and inadequate felt need are major factors which prevent their regular use

Antidiabetic effect of free amino acids supplementation in human visceral adipocytes through adiponectin-dependent mechanism

Background & objectives: Amino acids are general nutrients having anti-diabetic property. The present study was undertaken to investigate the mechanism of anti-diabetic effects of amino acids in human visceral adipocyte cells in high glucose environment. Methods: Experiments were carried out in human visceral adipocytes. Adiponectin (APN) siRNAs were designed using Ambion tools. APN mRNA expression was quantified using real-time polymerase chain reaction, and protein level was studied using ELISA. AMP-activated kinase (AMPK) activity was measured and glucose uptake by 2-deoxyglucose uptake method. Results: Amino acids (proline and phenylalanine) exposure to adipocytes significantly (P <0.01) increased APN mRNA by 1.5-folds when compared to control whereas proline increased APN secretion by 10.6-folds (P <0.01), phenylalanine by 12.7-folds (P <0.001) and alanine by 6.3-folds (P <0.01). Free amino acid-induced AMPK activity and glucose uptake were decreased with the transient knockdown of APN. Interpretation & conclusions: Antidiabetic effect of the tested amino acids was exhibited by increased glucose uptake through the AMPK pathway by an APN-dependent mechanism in human visceral adipocytes. This should be tested and confirmed in in vivo system. Newer treatment modalities with amino acids which can enhance glucose uptake and APN secretion can be developed as drug for treating both diabetes and obesity.

Effect of saccharomyces cerevisiae on survival, growth, biochemical constituents and energy utilization in the prawn macrobrachium rosenbergii.

A probiotic yeast, Saccharomyces cerevisiae was incorporated in basal diet prepared with fish meal, soybean meal, groundnut oil cake, corn flour, tapioca flour, egg albumin, cod liver oil and vitamin Bcomplex, at four different concentrations (10g, 20g, 30g and 40g kg-1) and fed to Macrobrachium rosenbergii post larvae (PL) for 90 days. The effect of this probiotic incorporation on the growth and survival performances, concentration of protein, amino acid, carbohydrate and lipid, and energy utilization was found to be significantly (P<0.05) higher at 40g kg-1 followed by 30g, 20g and 10g kg-1. 40g kg-1 S. cerevisiae incorporation was found to be established the highest rate of colony formation, 234x10-4 cfu (colony formation units). Actually, presence of Bacillus spp., Bacillus cereus, Pseudomonas spp., Escherichia coli, Streptococcus spp., and Klebsiella pneumoniae were deducted in water medium and the PL gut of control group. There is a general belief that Pseudomonas spp. and K. pneumonia are pathogenic to prawns. The establishment of S. cerevisiae colony in the gut of experimental PL has eradicated these pathogenic bacteria. Therefore, it is suggested that establishment of S. cerevisiae colony has led to better growth, survival and biochemical constituents in M. rosenbergii PL. Thus, S. cerevisiae could be taken as a useful probiotic in M. rosenbergii culture.

Growth of macrobrachium rosenbergii fed with mango seed kernel, banana peel and papaya peel incorporated feeds.

The growth promoting potential of fruits wastes, mango seed kernel, banana peel and papaya peel on the freshwater prawn, Macrobrachium rosenbergii post larvae (PL) was evaluated. Basal diet equated to 35% protein was prepared by using soybean meal, groundnut oilcake, horse gram and wheat flour. Each fruit waste powder was separately incorporated with basal diet at a proportion of 10%. Sunflower oil was used as lipid source. Egg albumin and tapioca flour were used as binding agents. Vitamin B-complex with Vitamin-C was also mixed. Feed without any fruit waste was served as control. M. rosenbergii PL (length: 1.2-1.4 cm; weight: 0.09- 0.13 g) was fed with these feeds for a period of 90 days. Significant improvements in the nutritional indices (survival rate, weight gain, biomass index, specific growth rate and condition factor), concentrations of biochemical constituents (total protein, carbohydrate and lipid), levels of non-enzymatic antioxidants (vitamin-C and E), content of minerals (Na+ and K+), activities of digestive enzymes (protease, amylase and lipase), and profiles of essential amino acids and fatty acids were recorded in fruits wastes incorporated feeds fed PL when compared with control (P< 0.003 – 0.878). The overall results indicated the fact that mango seed kernel incorporated feed was produced the best performance, followed by better performance of banana peel and good performance of papaya peel. These fruits wastes incorporated feeds enhance digestive enzymes activities and act as appetizer, which in turn enhances food utilization and ultimately yielded better survival and growth of M. rosenbergii PL. Therefore, these fruits wastes have considerable potentials in sustainable development of Macrobrachium culture.

Estrogen, progesterone and HER2 receptor expression in breast tumors of patients, and their usage of HER2-targeted therapy, in a tertiary care centre in India.

Background: This study was undertaken to document the pattern of expression of estrogen (ER), progesterone (PR) and human epidermal growth factor receptor-2 (HER2) and the usage of HER2-targeted therapy in a large tertiary care hospital in India in the year 2008. Materials and Methods: The histopathology reports of all breast cancer patients registered in the hospital in 2008 were extracted from the electronic medical record system. All the cases were immunohistochemically evaluated for estrogen and progesterone receptor status (ER and PR), and c-erbB-2 protein (HER2) expression using standard immunoperoxidase method. The use of HER2-targeted therapies was evaluated by extracting relevant information from the database of the hospital pharmacy and case charts of patients enrolled in ongoing approved trials. Results: A total of 2001 new patients of invasive breast cancers with available pathology reports were registered in the hospital in the year 2008. ER and/or PR expression was positive in tumors of 1025 (51.2%) patients. HER2 3+ expression by immunohistochemistry (IHC) was found in 335 (16.7%) and HER2 2+ in 163 (8.1%). The triple negative phenotype was found in 596 (29.8%) patients. An estimated 441 patients were eligible to receive HER2-targeted therapy based on their HER2 status. Of these 38 (8.6%) patients received some form of HER2-targeted therapy; 20 patients (4.5%) as part of ongoing clinical trials and 18 (4.1%) as part of routine care. Conclusions: The overwhelming majority of patients eligible for HER2-targeted therapy in our institution are unable to receive it because of financial constraints and limited access to health insurance. There is a higher fraction of patients with the triple negative phenotype compared to the Western population.

DOTS Reacdes Socially Marginalized Population in the Community a Study from a Rural Area of South India.

We report here that the Directly Observed Treatment, Short course (DOTS) is reaching all tuberculosis patients in the community irrespective of social classification based on the analysis from the tuberculosis prevalence survey and programme performance during 1999-2003 from a rural area in Tamilnadu, South India. New smear- positive cases treated under a DOTS programme were classified in two groups namely; scheduled caste living in colony and other population. The prevalence of smear- positive cases among the scheduled caste population was 1.9 times higher than the other population and this was reflected in the notification also. The successful treatment outcome was also similar in these two groups (75% and 78% respectively; overall 77%). From these findings it is concluded that people living in colony have equal access to DOTS as those in the village.

DOTS reaches socially marginalized population in the community: a study from a rural area of South India.

We report here that the Directly Observed Treatment, Short course (DOTS) is reaching all tuberculosis patients in the community irrespective of social classification based on the analysis from the tuberculosis prevalence survey and programme performance during 1999-2003 from a rural area in Tamilnadu, South India. New smear- positive cases treated under a DOTS programme were classified in two groups namely; scheduled caste living in colony and other population. The prevalence of smear- positive cases among the scheduled caste population was 1.9 times higher than the other population and this was reflected in the notification also. The successful treatment outcome was also similar in these two groups (75% and 78% respectively; overall 77%). From these findings it is concluded that people living in colony have equal access to DOTS as those in the village.

Consensus guidelines on pediatric acute rheumatic fever and rheumatic heart disease.

JUSTIFICATION: Acute rheumatic fever and rheumatic chronic valvular heart disease is an important preventable cause of morbidity and mortality in suburban and rural India. Its diagnosis is based on clinical criteria. These criteria need verification and revision in the Indian context. Furthermore, there are glaring differences in management protocols available in literature. These facts prompted Indian Academy of Pediatrics to review the management of rheumatic fever. PROCESS: Management of Rheumatic fever was reviewed and recommendation was formulated at national consultative meeting on 20th May 2007 at New Delhi. OBJECTIVES: To formulate uniform guidelines on management of acute rheumatic fever and rheumatic heart disease in the Indian context. Guidelines were formulated for the management of streptococcal pharyngitis, acute rheumatic fever and its cardiac complication as well as secondary prophylaxis for recurrent episodes. RECOMMENDATIONS: (1) Streptococcal eradication with appropriate antibiotics (Benzathine penicillin single dose or penicillin V oral or azithromycin). (2) Diagnosis of rheumatic fever based on Jones criteria. (3) Control inflammatory process with aspirin with or without steroids (total duration of treatment of 12 weeks). (4) Treatment of chorea according to severity (therapy to continue for 2-3 weeks after clinical improvement). (5) Protocol for managing cardiac complication like valvular heart disease, congestive heart failure and atrial fibrillation. (6) Secondary prophylaxis with benzathine penicillin and management of anaphylaxis.

Congenital immunodeficiency disorder.

A 17 year old girl, a 9th standard student with history of recurrent pneumonia and soft tissue "cold abscesses" since neonatal period, presented with fever and cough with yellowish expectoration of 2 months duration. Her clinical and radiological finding along with elevated serum IgE level were consistent with the diagnosis of hyper immunoglobulin E syndrome or Job's syndrome.

Tuberous sclerosis with portal vein thrombosis, protein C and S deficiency.

A 29-year-old lady with a bad obstetric history and portal vein thrombosis, presented to the Skin OPD for facial lesions. On examination, angiofibromas on face, shagreen patch and periungual fibromas were observed. She also had dental pits and a retinal hamartoma. Investigations revealed hamartomas in the brain and kidney. Hematological work-up showed protein C and S deficiency with Factor V Leiden positivity. Except for the cutaneous symptoms, the patient did not have any clinical manifestations in other organs affected by tuberous sclerosis. A similar association of tuberous sclerosis with protein C deficiency has been reported in only one case in literature.

Performance of a DOTS programme: Administrative and Technical Challenges - A field report from a district in south India.

Background: Performance of tuberculosis (TB) control programme depends on the functioning of health facilities (HFs). TB control programmes have been evaluated based on the programme indicators of conversion and cure. We have attempted to correlate the programme performance based on the availability of staff and their performance at the HF level. Objective: To correlate the performance of HFs to programme indicators, conversion and cure of patients treated under DOTS, in a district of south India. Design: Analysis of the data on new sputum smear-positive cases registered in 17 HFs during 1999-2003 was undertaken using TB register. The HFs with a low conversion or cure rates were identified and the reasons for the same were analysed. A scoring system was designed for the functioning of the HFs based on staff availability, supervision and review meetings which was correlated with programme performance. Univariate and multivariate analyses were performed. Results: Of 1893 new smear-positive patients registered during the study period, conversion was 1582 (83.6%) with cure rate of 76.4% (1447 of 1893), 254 (13.4%) default, 94 (5.0%) failure and 85 (4.5%) death. The conversion rates increased from 76% in 1999 to 87% in 2003; a statistically significant trend (c2 = 15.9; P<0.001). Similarly, a significant increase in trend (c2 = 4.0; P < 0.05) was observed in cure rates also (71 to 80%). The HFs were broadly classified into four groups namely; poor, fair, good and very good based on functioning scores .Correlation co-efficient was 0.77 between functioning of the HFs and conversion, and 0.76 between functioning and cure (P<0.01). Lack of regular review meetings was found to be independently associated with poor programme performance. Conclusion: Availability of staff such as Medical Officer, Laboratory Technician, and regular supervisory visits and review meetings are essential for a well functioning of programme. There is significant impact on DOTS with good functioning of HFs.

Covered stents deployed for coarctation of aorta with aneurysm.

Three patients presented to us with upper extremity hypertension and aortic coarctation. Aortic angiograms and spiral computerized tomography delineated the anatomy at the site of coarctation and the associated small aneurysmal dilation. They were taken up for percutaneous stenting of the coarctation segment with cheathum-platinum covered stents. Post-deployment, there was a significant fall in pullback gradients and exclusion of the aneurysms.

Early childhood development in deprived urban settlements.

Poverty, the root cause of the existence of slums or settlement colonies in urban areas has a great impact on almost all aspects of life of the urban poor, especially the all-round development of children. Examples from countries, across the globe provide evidence of improved early child development, made possible through integrated slum improvement programs, are few in numbers. The observed 2.5% prevalence of developmental delay in the less than 2 year olds of deprived urban settlements, the presence of risk factors for developmental delay like low birth weight, birth asphyxia, coupled with poor environment of home and alternate child care services, highlights the need for simple cost effective community model for promoting early child development. This review on early child development focuses on the developmental status of children in the deprived urban settlements, who are yet to be on the priority list of Governments and international agencies working for the welfare of children, the contributory nature-nurture factors and replicable working models like infant stimulation, early detection of developmental delay in infancy itself, developmental screening of toddlers, skill assessment for preschool children, school readiness programs, identification of mental sub-normality and primary education enhancement program for primary school children. Further, the review probes feasible intervention strategies through community owned early child care and development facilities, utilizing existing programs like ICDS, Urban Basic Services and by initiating services like Development Friendly Well Baby Clinics, Community Extension services, Child Development Referral Units at district hospitals and involving trained manpower like anganwadi/creche workers, public health nurses and developmental therapists. With the decentralization process the local self-government at municipalities and city corporations are financially equipped to be the prime movers to initiate, monitor and promote early child development programs, to emerge as a part and parcel of community owned sustainable development process.

Gingival fibromatosis and growth hormone deficiency syndrome--report of a rare case and review of literature.

Oikarinen et al in 1989 reported a syndrome associated with generalized gingival fibromatosis and growth hormone deficiency. This is a case report of a 15-year-old female patient who presented to the Government Dental College, Chennai with generalized gingival fibromatosis and growth hormone deficiency. Interestingly, the histopathology of the excised gingival overgrowth showed dense collagenous connective tissue in which were strewn calcified structures that resembled cementum. This syndrome is being reported for the second time after its first case report in 1989 by Oikarinen et al. We are herewith reporting this case for its rarity with a brief review of literature of syndromes associated with generalized gingival fibromatosis.

Malignant acanthosis nigricans with occult primary.

A case of generalized malignant acanthosis nigricans of 2 years duration is reported. In spite of the long duration of this cutaneous marker of internal malignancy, the patient was completely asymptomatic and extensive investigations revealed the presence of widespread metastasis of mucin secreting signet cell adenocarcinoma from an unknown primary site. In addition the patient also had acquired hypertrichosis lanuginose and florid cutaneous papillomatosis which are also markers of internal malignancy.

Predictive accuracy of commissural morphology and its role in determining the outcome following Inoue balloon mitral valvotomy.

BACKGROUND: Commissural morphology is an important predictor of outcome following balloon mitral valvotomy. The aim of this prospective study was to assess if the site of commissural splitting could be reliably predicted by echocardiography and whether the extent of commissural split affected the result of balloon mitral valvotomy. METHODS AND RESULTS: A total of 140 patients (mean age 29.1+/-8.6 years) were studied. Prediction of splitting was done based on the presence of echolucent dark zones as seen in the parasternal short-axis view on echocardiography. Of 102 patients in whom a split of both commissures was predicted, the prediction was accurate in 86% (88/102). Of 33 patients with a predicted unilateral split, the accuracy of prediction was 82% (27/33). In the 5 patients with bilateral commissural fibrosis (in whom none of the commissures were predicted to split), all had a unilateral split. Overall, 93 patients (66%) had a bilateral commissural split, 43 (31%) had a unilateral split, and 4 had no commissural split. All the latter 4 developed moderate-to-severe mitral regurgitation. Those with bilateral commissural split following balloon mitral valvotomy had lower transmitral gradients (5.53+/-1.46 v 7.4+/-1.2 3 mmHg, p = 0.03) and greater mitral valve area (1.83+/-0.15 v. 1.64+/-0.15 cm2, p<0.02), as compared to those with unicommissural split. The incidence of an increase in mitral regurgitation by > or = grade 1 was also lower in the former group (7.5% v. 28%). An optimal result with the first dilatation (using a balloon size <2 mm of the predicted size) was achieved more frequently in those with a bilateral split (18% vs 8%). Oversizing of the balloon by 2 mm (of the predicted size) was done more frequently (19% v. 7%) in those with unicommissural split. CONCLUSIONS: We conclude that the assessment of commissural morphology is possible with excellent predictive accuracy. In this study, those with bilateral commissural split had more favorable hemodynamic results with lower transmitral gradients. greater mitral valve area and lesser frequency of mitral regurgitation in contrast to those with unicommissural split.

Concurrent percutaneous atrial septal defect closure and pulmonary valvuloplasty.

Severe pulmonary valve stenosis in association with a large atrial septal defect is uncommon. Simultaneous percutaneous closure of the atrial septal defect and pulmonary valvuloplasty appears to be an attractive modality when compared to patients with these two lesions being subjected to surgery or being treated percutaneously at different sittings. We encountered two cases, both with significant pulmonary valvular stenosis associated with atrial septal defect (fossa ovalis type). Both lesions were successfully treated percutaneously in the same sitting. Pulmonary valvuloplasty was done initially and the atrial septal defect closed later to minimize catheter manipulation after device implantation.