Xylometazoline Induced Isolated Left Medial Cerebellar Peduncle Infarct: A Rare Case Report

Xylometazoline, a sympathomimetic available as over the counter drug, acts as a nasal decongestant and has been reported as an independent risk factor for hemorrhagic and ischemic stroke. The chronic use of xylometazoline leads to either increased release of more potent vasoconstrictor norepinephrine in the presynaptic region, or acts directly on central adrenoreceptors which leads to dysfunction resulting in chronic progressive vasculopathy that manifests as an ischemic stroke. Sympathomimetics also activate 12-lipoxygenase pathways which induce proliferation and migration of vascular smooth muscle cells. 12-lipoxgenase also plays a significant role in regulating the degree and stability of platelet activation, as its activation significantly strengthens platelet activation and uncontrolled platelet activation, which may lead to myocardial infraction and stroke. The present case reports a rare case of young adult suffering from isolated left medial cerebellar peduncle infarct related to the chronic use of xylometazoline. Acute cerebellar stroke is rare, especially in young adults and represent only 3% of total ischemic and hemorrhagic strokes. Clinical symptoms, patient age at the onset of stroke, and lesion size had no significant effect on the clinical outcome. Symptoms are frequently underestimated and misdiagnosed which further lead to serious complications and poor functional outcomes.

Epidemiología, tratamiento y mortalidad en pacientes infectados por enterobacterias productoras de carbapenemasas: estudio retrospectivo / Epidemiology, treatment and mortality in infection by carbapenemase-producing Enterobacteriaceae: retrospective study

Resumen Introducción: Las enterobacterias productoras de carbapenemasas (EPC) suponen un reto para la salud pública y la práctica clínica. Objetivo: Analizar la epidemiología, el tratamiento y la mortalidad en pacientes infectados por EPC. Material y Métodos: Análisis retrospectivo de 163 pacientes infectados por EPC en un hospital universitario desde julio de 2013 a octubre de 2015. Resultados: Klebsiella pneumoniae fue aislada en 95,1% de los casos, y la mayoría de las carbapenemasas pertenecían al grupo OXA-48 (93%). La adquisición fue nosocomial en 124 casos (77%), asociada a cuidados sanitarios en 30 (18,6%), y 7 (4,3%) fueron de adquisición comunitaria. Las infecciones más frecuentes fueron las del tracto urinario (48,4%) y las respiratorias (19,5%). Aproximadamente, la mitad de los pacientes recibieron monoterapia antimicrobiana. La tasa de mortalidad a los 30 días fue de 23,3%. El análisis multivariante identificó que la presencia de shock séptico al diagnóstico (OR 4,2; IC 95% 1,5-11) estaba asociada de manera independiente con mayor mortalidad en el primer mes, sin lograr identificar asociación con el tratamiento antimicrobiano inapropiado. Discusión: Son necesarios más estudios para aclarar si el tratamiento antimicrobiano de las infecciones por EPC debe ser combinado o si podría ser suficiente la monoterapia en infecciones leves.

Abstract Background: Carbapenemase-producing Enterobacteriaceae (CPE) has become a significant problem in terms of public health and clinical outcome. Objective: To assess the epidemiology, treatment and mortality in patients with infection due to CPE. Material and Methods: A retrospective analysis of 163 patients with CPE infection was carried out in a university hospital from July 2013 to October 2015. Results: A total of 163 patients were included over the study period. Klebsiella pneumoniae was isolated in 95.1% of cases, and most of carbapenemases belonged to the OXA-48 group (93.0%). Acquisition was nosocomial in 124 cases (77.0%), healthcare-associated in 30 (18.6%), and 7 cases (4.3%) were community-acquired. The most frequent infections identified in this study were urinary tract (48.4%) and respiratory (19.5%) infections. Approximately half of the patients received antibiotic monotherapy. The 30-day mortality rate was 23.3%. Multivariate analysis revealed that the presence of septic shock at diagnosis (OR 4.2; IC 95% 1.5-11) was independently associated with an increase in death during the first month, unable to identify association with inappropriate antibiotic treatment. Discussion: Further studies are needed to clarify whether antibiotic treatment of EPC infections should be combined or if monotherapy might be sufficient in mild infections.

Morphological variations of soft palate and influence of age on it: A digital cephalometric study

Background: Digital Lateral Cephalograms are the most commonly used radiographs for evaluating morphological variations of soft palate. It is a relatively inexpensive method and provides a good assessment of the soft-tissue elements that define the soft palate and its surrounding structures. The present study was conducted to investigate the morphological variations of the soft palate and influence of age on it. Materials and methods: The present study consisted of 150 digital cephalograms of subjects aged between 20 to 60 years taken from the department of oral medicine and radiology, Sri Sai College of Dental Surgery, Vikarabad. The subjects were categorized into five groups, group A: 20- 30 years, group B: 31- 40 years, group C: 41- 50 years, group D: 51- 60 years and group E: 61- 70 years. Digital lateral cephalograms were obtained and analyzed to categorize the soft palate into six morphological types, based on the classification by You, et al. Results: Type 1: leaf shaped soft palate was the most common type, type 4 and 6 varieties were the least common among all age groups. Type 5: S-shaped soft palate was found in considerable proportions among all the age groups (6.7% - 25.8%). There was no significant correlation found between the different age groups and the type of soft palate. Conclusion: Radiographic analysis of morphological variations of soft palate can help us better understand the velar morphology and may assist in success of surgical procedures aimed for correcting deformities of soft palate.

Level of Mercury Manometer With Respect to Heart: Does it Affect Blood Pressure Measurement.

Measurement of blood pressure is an integral part of clinical examination. Over the years various types of instruments have been used to measure blood pressure but till date the mercury sphygmomanometer is regarded as the gold standard. However, there is a myth prevalent among health professionals regarding the level of the manometer in relation to heart at the time of measuring of blood pressure. Many professionals insist that it has to be placed at the level of the heart. We argue that the limb from which pressure is measured must be at the heart level rather than the manometer. We conducted a study in which we measured the blood pressure in adults by placing the manometer at three different levels with respect to the heart. The values of blood pressure obtained at all levels were similar and did not show any statistically significant difference. We therefore conclude that the level of sphygmomanometer per se does not affect blood pressure measurement.

Blood Levels of Pyrazinamide in Children at Doses Administered Under the Revised National Tuberculosis Control Program.

Objectives: To evaluate the blood levels, pharma-cokinetics and pharmacodynamic indices of pyrazinamide (PZA) in children suffering from tuberculosis, at doses administered under the weight band system of Revised National Tuberculosis Control Program of India (RNTCP) of India. Design: Prospective, open-label, non-randomized single-dose study. Setting: 20 children in the age group 5-12 years attending outpatient tuberculosis clinic of a tertiary hospital. Outcome Measures: Blood levels of pyrazinamide after single dose administration, as per the weight band system of RNTCP. Results: Group I (n=7) included children who received pyrazinamide within the recommended 30-35 mg/kg dose (mean 31.9+0.8 mg/kg) and Group II (n=13) included those who received a dose lower than 30 -35 mg/kg (mean 28.1±0.3 mg/ kg). The Cmax (95% CI of difference 2.2, 13.2; P=0.008) and AUC (95% CI of difference 28.6, 208.1; P=0.01) were significantly lower in Group II. The duration of time for which the concentration was maintained above 25 μg ml-1 was 4-8 h in Group I and 3-5.5 h in Group II (95% CI of difference 0.1, 2.0; P=0.03). The half life, elimination rate constant, clearance and volume of distribution were comparable in the two groups. The ratios of Cmax and AUC to MIC (25 μg ml-1) in children were lower than that recommended for PZA in adults. Conclusions: Lower blood concentrations are being attained in children receiving PZA doses under the existing weight band system of RNTCP of India. The weight bands may need to be revised and dose recommendations be based on pharmacokinetic and efficacy data in children.

Use of antimicrobial agents and granulocyte colony stimulating factors for febrile neutropenia in cancer patients in a tertiary care hospital in India.

Background: Use of antimicrobials (AM) and granulocyte colony stimulating factors (G-CSF) affect the outcome and cost of treatment of febrile neutropenia (FN). There are no studies describing the AM utilization pattern or the use of G-CSF and cost incurred on them in cancer patients with FN from India. Materials and Methods: A study was conducted in a tertiary care, teaching hospital in New Delhi, India, with the objectives of describing the utilization pattern of AM and G-CSF in cancer patients with FN. The efficacy and costs of AM and G-CSF prescribed were also assessed. Results: A total of 211 patients with FN were enrolled in the study. A majority of 207 (98.1%) were in the low-risk category. The average number of AM used per patient was 2.45 ± 0.02 and the AM exposure density was 1.19. All patients were administered five different combinations of AM regimens and G-CSF, irrespective of the risk category. No difference in the time to defervesence or in the recovery of ANC counts were observed with the different AM regimens. The average drug cost per febrile neutropenia episode (FNE) was Rs 4694.45 ± 296.35 (113.95 ± 7.19$). G-CSF accounted for 76.14 - 97.58% of the total costs. Conclusion: Large variations in the pattern of AM prescribed with routine use of G-CSF, irrespective of the risk status, was observed. Guidelines for the rational and cost-effective use of AM and G-CSF in patients with FN needed to be prepared. This was especially important as treatment was given free of cost to all patients admitted in the government health facility.

Laparoscopic surgical correction of retrocaval ureter

Laparoscopic transposition and reanastomosis of a circumcaval ureter was performed in 47-year-old man with right flank pain. The ureter was transected 2 cm. below renal pelvis and the ureter was relocated from behind the vena cava. The anastomosis was completed with interrupted sutures by intracorporeal knot tying. The postoperative convalescence was uneventful. The intravenous urogram obtained 8 weeks later revealed remarkable improvement in drainage of right kidney

Gastric mucormycosis.

Systemic mucormycosis is a rare fatal fungal infection that usually involves the nasopharynx. Gastrointestinal mucormycosis is rare, occurring in immunocompromised conditions and with advanced malignancies. We report a 35-year-old man, an alcoholic, admitted with acute abdomen. Endoscopy revealed an ulcerated plaque-like lesion in the stomach. Histology revealed mucormycosis of the stomach. The patient successfully underwent treatment with amphotericin-B.

Comparative efficacy and tolerability of nimesulide and piroxicam in osteoarthritis with specific reference to chondroprotection: a double blind randomised study.

The aim of the study was to assess the efficacy, tolerability and chondroprotection afforded by nimesulide, a selective cyclooxygenase-2 inhibitor and piroxicam in a randomised, double blind, controlled clinical trial in 90 patients suffering from osteoarthritis of the knee joint. A significant improvement in the osteoarthritis severity index at 2 weeks (p < 0.01) and an improvement in physicians assessment of global arthritic condition at 4 weeks (p < 0.01) was seen with both the treatments. A significant decrease in articular index of joint tenderness (p < 0.05) at 8 weeks and in self assessment of handicap at 4 weeks (p < 0.05), in comparison to baseline, was observed only in patients receiving nimesulide. Rescue therapy was required by a greater percentage of patients being administered piroxicam. Functional capacity improved in 64% of the patients on nimesulide and 74.5% of the patients receiving piroxicam. Adverse effects were observed in 6 patients on nimesulide and 9 patients receiving piroxicam. No significant difference was found in any of the efficacy and tolerability parameters between the two treatment groups. Magnetic resonance imaging evaluation of the knee joint of 10 patients showed no significant change in the articular cartilage and associated joint structures after 6 months of therapy with both the treatments. The results show that nimesulide and piroxicam are comparable in efficacy and tolerability in patients suffering from osteoarthritis.

Treatment seeking behaviour in sexually transmitted diseases.

The present study has been conducted to assess social and behavioural factors predisposing individuals suffering from sexually transmitted diseases to seek treatment and the role of the health provider in them. Out results showed that the demographic, socio-economic and behavioural characteristics of patients seeking treatment at alternative places and those attending the referral hospital in the first instance were comparable. Inhibition, time and distance were important considerations for selecting a health facility. Private clinics were the most preferred (72.4%) source of treatment. In 60.3% of cases written prescriptions were not given and advice regarding treatment of sexual partner was not there in any of the cases. 98.3% of the patients lacked awareness about their disease and 91.4% patients about the treatment they were receiving.

Pharmacokinetics of isoniazid in pulmonary tuberculosis--a comparative study at two dose levels.

OBJECTIVES: To compare the pharmacokinetic parameters and the clinical efficacy of isoniazid, administered in 10 mg/kg or 5 mg/kg to children suffering from pulmonary tuberculosis. DESIGN: A randomized, open, controlled clinical trial. SETTING: Teaching hospital in New Delhi. SUBJECTS: Twenty children suffering from pulmonary tuberculosis in the age group 6-12 years. INTERVENTIONS: A three drug antitubercular regimen comprising of rifampicin (10 mg/kg), pyrazinamide (30 mg/kg) and isoniazid in a dose of either 10 mg/kg (Group I) or 5 mg/kg (Group II) was administered for fourteen days. On day fifteen serial blood samples were collected at 0,1,2,3,6 and 24 h of isoniazid administration and analyzed spectrofluorometrically. MAIN OUTCOME MEASURES: Serum isoniazid concentrations and clinical response in both the groups. RESULTS: In both the groups, serum concentration of isoniazid were above the therapeutic range (0.5-2 micrograms/ml) at 6 h following drug administration. The minimum serum concentration of isoniazid was within or above minimum inhibitory concentration of the drug at 24 h in both the groups. The time to achieve maximum serum concentration, elimination half life, elimination rate constant, mean residence time, volume of distribution at steady state and plasma drug clearance were also comparable. At the end of 6 months follow up, all children showed comparable clinical and radiological improvement. CONCLUSION: Isoniazid in a dose of 5 mg/kg administered with other antitubercular drugs appears adequate for treatment of pulmonary tuberculosis in children.