Clinical spectrum & changing presentation of celiac disease in Indian children

Background & objectives: Celiac disease (CD) is a genetic immune mediated disorder characterised by gluten intolerance. This single centre study, from north India was aimed to assess the clinical, serological and histological profile of CD in a large cohort of children and the changing trends in its presentation. Methods: A review of clinical details of CD children diagnosed between 2000 and 2019 and currently on follow up was performed. Information on demography, symptoms, associated conditions, serology, biopsy findings and gluten-free diet were analyzed. Results: The mean age (±standard deviation) of 891 children included in the study, at onset and at diagnosis was 4.0±2.7 and 6.2±3.1 yr, respectively. Growth faltering, abdominal pain, abdominal distension and diarrhoea were presenting symptoms in 70, 64.2, 61.2 and 58.2 per cent, respectively. A positive family history of CD was present in 14 per cent and autoimmune conditions in 12.3 per cent of children. Thyroid disorders were seen in 8.5 per cent of children and Type 1 diabetes mellitus (T1DM) in 5.7 per cent. The duration of breastfeeding had a weak positive correlation with age at onset and diagnosis of CD (P<0.001). Non-classical CD was significantly more common in children aged >10 yr and in those presenting after 2010 (P<0.01). T1DM and hypothyroidism occurred more frequently in non-compliant children. Interpretation & conclusions: This was the largest single centre study, pertaining to the presentation and follow up of CD in children. Infants and young children were more likely to present with classical symptoms of diarrhoea, abdominal distension and growth failure while older children presented with non-classical CD. There was a trend towards non-classical forms of CD in recent years.

Effect of atropine 0.01% on progression of myopia

Purpose: Myopia is the most common type of refractive error and the leading cause of functional visual loss. Increased risk of myopic maculopathy, retinal detachment, glaucoma and cataract has been seen with a myopia of as low as ?1D. This study was done to determine the effect of atropine 0.01% eye drops on the progression of myopia in children >5 years. Methods: This was a single?blind, prospective, randomized case–control study which included children of 5–15 years with myopia of >2D and were divided into treatment group (group 1) and placebo group (group 2). Children under treatment group were treated with application of 0.01% atropine at night. Children with history of any ocular surgery, chronic ophthalmic illness, squint and amblyopia were excluded from the study. The follow?up for myopia progression was done for two years. Results: This study showed a significant difference in increase of spherical equivalent and axial length among treatment and placebo groups after a duration of two years. Total duration of follow up was twenty?four months. Mean increase in axial length of group 1 and 2 was 0.115 mm and 0.32 mm, respectively. Mean increase in refraction of groups 1 and 2 was ?0.30 D and ?0.88 D, respectively, showing significant change in axial length and refraction (P < 0.0001). Conclusion: This study supports the use of atropine 0.01% eye drops in reducing the progression of myopia.

Intervention on depression and insomnia symptoms during the COVID-19 pandemic

Objectives: The COVID-19 pandemic has created significant psychological challenges globally. Evidence has been mounting of greater emotional distress and possible worsening of underlying psychiatric disorders, due to repercussions of COVID-19. In addition, the pandemic has created barriers to access for help, due to social distancing and travel restrictions. Thus, creating a major need for effective interventions that can be accessed safely from home and provide coping tools which can be learned and practiced while in isolation. An App based Yoga of Immortals (YOI) program is one such strategy to help cope with stressful situations. The objective of this study was to investigate if the YOI program can provide significant benefit for depressive and insomnia symptoms. Material and Methods: Participants in this study were asked to complete two brief online but well validated mental health screening tools before intervention. This was followed by a 7-week long YOI intervention. Following the intervention, participants were once again asked to complete the online validated questionnaires. The survey questionnaires included baseline demographic data and validated scales for measuring insomnia severity Insomnia severity Index (ISI) and levels of depression symptoms patient health questionnaire-8, (PHQ-8). All statistical analysis was performed using the Statistical Package for the Social Science. Results: SY YOI intervention of 7 weeks significantly improved the ISI scores as well as PHQ-8 scores in the study population (P < 0.0001 in all comparisons). Conclusion: YOI intervention is an effective intervention strategy for decreasing insomnia and depression symptoms, even during the pandemic

Adverse drug reaction risk assessment with prescribed renal risk drugs among hospitalized patients attending a teaching hospital in South India

Background: Renal impairment is the primary cause of mortality and morbid conditions in patients. Inappropriate drug use in patients who are with risk of renal damage causes harmful and deleterious effects. Adjusting doses based on renal function is necessary for renal risk drugs, primarily to avoid adverse reactions of medications. Aim of the present study was to assess the risk of incidence on ADRs with drugs lowering the renal function.Methods: This is a cross-sectional observational study conducted in General Medicine department. 230 Patients constituted the sample in the study. The study was conducted for a period of one year and prescriptions with renal risk drugs were evaluated. Changes in the renal functional tests were compared to the normal range and adverse drug responses were monitored.Results: A total of 230 patients who fulfilled the inclusion criteria were included in the study. The meanage of the study subjects were 50.9±15.2 respectively. 56.39% patients were men and 43.6% were women. Renal risk drugs included in the study are anti-hypertensive, antibiotics, and analgesics. Paracetamol (24.77%) followed by telmisartan (20.85%) are the predominantly prescribed renal risk drugs with high incidence of adverse drug reactions. Causality assessment by Naranjo ADR probability scale showed out of 211 ADRs, 51.6% were possible, 25.59% were doubtful, 21.8% were probable and 0.94% was definite.Conclusions: The current study signifies that patients under high risk of renal damage require continuous monitoring and optimized therapy for better disease management.

Clinical study of neurological presentation of diabetes mellitus in a tertiary care hospital

Background: A wide range of commotions affecting the central and peripheral nervous systems, either directly or indirectly, may be observed in patients with diabetes mellitus. The spectrum of neurological complications among diabetes are quite varied.Methods: Authors conducted a Cross-sectional prospective observational study to study different neurological manifestations of diabetes mellitus. at NRI General Hospital, Chinakakani, Guntur District, Andhra Pradesh. The selected patients were studied in detail with history and physical examination. The investigations included Fasting Blood Sugar (FBS), Postprandial Blood Sugar (PPBS), Glycosylated Hemoglobin (HbA1C).Results: A total of 100 subjects were included in the final analysis. Majority of participants were aged between 46 to 65 years, and 55% of them were males. Only 13% of the participants had HBA1c value below 7.5 gm%. Out of 100 participants, 82% participants had diabetic peripheral neuropathy. A total of 6 subjects had cranial neuropathy, with 5% participants having 3rd nerve and one participant had 6th nerve. Involuntary movements (Chorea) was present in 4% of patients. Among the people with Seizures, 6% participants had Hyperglycemic, and 2% participants had Hypoglycemic seizures. Out of 100 participants, 7 participants had dysautonomia.Conclusions: Peripheral neuropathy was the most common neurological manifestation among the diabetic population. The other key neurological abnormalities include cranial nerve palsy, dysautonomia, seizures and Chorea. Clinicians need to be aware the entire spectrum of neurological abnormalities among patients with type 2 Diabetes.

MRI-Targeted Prostate Biopsy: What Radiologists Should Know

Transrectal ultrasound (TRUS)-guided systematic biopsy, the current gold standard for the detection of prostate cancer, suffersfrom low sensitivity for clinically significant cancer. The use of diagnostic multiparametric MRI has increased the relevanceof targeted biopsy techniques such as MRI-TRUS fusion biopsy and direct (in-bore) MRI-guided biopsy, which have higherdetection rate for clinically significant cancer. Although primarily used in patients who remain at high clinical suspicion forprostate cancer despite a negative systematic biopsy, with the increasing use of upfront diagnostic MRI, these biopsies areexpected to replace routine systematic biopsies. This pictorial essay aims to enhance our understanding of the concepts ofthese biopsy techniques so that they can be performed safely and provide maximum diagnostic yield.

Hemophagocytic Lymphohistiocytosis (HLH) Associated With Scrub Typhus: Report Of 2 Cases

Hemophagocytic Lymphohistiocytosis (HLH) is a fatal hyperinflammatory syndrome characterized by histiocytic proliferation along with hemophagocytosis. HLH can be primary (inherited) or secondary, to any severe infection, malignancy or rheumatological disease. HLH, though rare, has also been noted in association with scrub typhus which is an acute febrile illness resulting from the bite of infected larval form of mite (also known as chigger). We hereby describe two cases of HLH associated with rickettsial infection (Oriental tsutsugamushi) in a 36-year-old male and in a 10-year-old male child. The former presented with high-grade fever and pruritic macular rash over abdomen. While the latter was presented with fever and decreased urinary output at the time of admission

The impact of non-steroidal anti-inflammatory drugs use in elderly cardiovascular patients: an observational study from tertiary care in South India

Background: Long-term use of NSAIDs, by patients having cardiovascular conditions, has shown to increase the risk of cardiovascular events and increased risk of death. Hence, the study was conducted to determine the complications related to NSAID use by the elderly patients with cardiovascular disease (CVD).Methods: The study was a single-center prospective observational study conducted November 2017 to October 2018. Elderly patients (>60 years) suffering from various CVDs and reported NSAID intake daily for at least one month were included. A questionnaire included demographic, treatment related history and complete details of NSAIDs intake including nature, dose, indication, source etc. The same questionnaire was again filled at the end of one-year follow-up.Results: A total of 100 participants were included in the study. The mean age was 72±8.6 years. Majority of the patients (93%) had hypertension, and 69% of the patient had previous MI.  Five NSAIDs (diclofenac, ibuprofen, mefenamic acid, naproxen, and ketorolac) were used routinely. At least one over the counter NSAID used was reported by 86%, 57% were prescribed at least one NSAIDs by their orthopaedics and physicians. At the end of 1-year follow-up, authors found that 71% had MI (2% increase), 4% developed reinfarction, 20% had severe left ventricular failure (4% increase), 7% had atrial fibrillation (1% increase), and 2% patients died and 63% patients reported raise in systolic blood pressure by 5mmHg.Conclusions: High prevalence of concomitant NSAID use among elderly CVD patients, which might be contributing towards increase in CVS morbidity and mortality.

Conversion Of All To Aml: A Rare Phenomenon

Among all acute leukemias, acute lymphoblastic leukemia (ALL) is five times more common than acute myeloid leukemia (AML). Lineage switch from ALL to AML is very rare. Lineage switching is a phenomenon noted in cases of leukemias where the initially diagnosed cases of leukemias of a lineage (lymphoid/myeloid) present with the opposite lineage at relapse. Here, we report the case of a 10-year-old male child who was initially diagnosed with ALL and on relapse after 4 years, presented with AML. The blast cell morphology and immunophenotype were consistent with the diagnosis of typical AML.

A study of clinical and etiological profiles of patients presenting with Pancytopenia in NRI General Hospital

Introduction: Pancytopenia is characterized by a decrease in the red blood cells, white blood cells along with the platelet count below the normal levels. It can be due to a number of pathologic mechanisms, depending on the geographic location. Early diagnosis and treatment are crucial in the management of pancytopenia. There are very few studies regarding the clinic-pathological profile of such patients. Materials and methods: A cross-sectional study was undertaken at NRI General Hospital, Chinakakani. All eligible participants more than 13 years of age were included. Data collection was done from August 2016 to August 2018. A thorough history taking along with clinical examination and laboratory investigations were performed among the study population. Data was analyzed using SPSS version 13. Results: The most common finding suggestive of etiology was megaloblastic anemia at 38.4%, which was more common among females. Aplastic anemia was the second most common finding at 24.6%. Other diagnoses included hypersplenism, myelodysplastic syndrome and acute leukemia. Fever and pallor were the most common presenting symptoms. Blood examinations demonstrated anisopoikilocytosis, hypersegmented neutrophils, erythroblasts, macrocytes and reticulocytes, which were found in differing proportions in the various etiological diagnoses. Conclusion: It is noteworthy that megaloblastic anemia, a reversible condition, is common in India compared to the higher occurrence of aplastic anemia and myelodysplastic syndrome in developed Vijaya Kumar Vasa, Sadhna Sharma, Rakesh Nukasani, Srivani Gulleli, Phani Kumar Reddy. A study of clinical and etiological profiles of patients presenting with Pancytopenia in NRI General Hospital. IAIM, 2019; 6(2): 114-120. Page 115 nations. Clinical alertness and suspicion can assure early diagnoses and treatment can prevent complications and reduce the burden. The need for more standard management protocols is immediate.

The Coagulation Profile on Pregnancy Induced Hypertensive Patients in Third Trimester of Pregnancy – The Prospective and Observational Study

Background:Hypertensive disorders are the most important cause of maternal and perinatal morbidity and mortality. The aim of present study is to know the changes in certain parameters of coagulation profile in pregnancy induced hypertensive patients in third trimester of pregnancy, so that treatment can be planned to reduce maternal morbidity and mortality. Methods: The study was undertaken at Department of Obstetrics and Gynecology, NIMS Medical College and Hospital, Rajasthan for the period of 1 year on 100 patients diagnosed with PIH. Result: Mean BT, CT were in normal range in all patients of PIH; but CT was significantly higher in E group than PE >N. Mean CRT was poor in patients with E group and normal in patients of PE & GTN group. Mean platelet counts & serum fibrinogen levels found to be decreased with severity of PIH. Prolonged mean PT & aPTT were observed in patients with E. Conclusion: Inclusion of coagulation profile with routine investigations leads to early prediction of severity of PIH and subsequent complications.

N-acetyltransferase 2 (NAT2) gene polymorphism as a predisposing factor for phenytoin intoxication in tuberculous meningitis or tuberculoma patients having seizures - A pilot study.

Background & objectives: Simultaneous administration of phenytoin and isoniazid (INH) in tuberculous meningitis (TBM) or tuberculoma patients with seizures results in higher plasma phenytoin level and thus phenytoin intoxication. N-acetyltransferase 2 (NAT2) enzyme catalyses two acetylation reactions in INH metabolism and NAT2 gene polymorphism leads to slow and rapid acetylators. The present study was aimed to evaluate the effect of allelic variants of N-acetyltransferase 2 (NAT2) gene as a predisposing factor for phenytoin toxicity in patients with TBM or tuberculoma having seizures, and taking INH and phenytoin simultaneously. Methods: Sixty patients with TBM or tuberculoma with seizures and taking INH and phenytoin simultaneously for a minimum period of seven days were included in study. Plasma phenytoin was measured by high performance liquid chromatography. NAT2 gene polymorphism was studied using restriction fragment length polymorphism and allele specific PCR. Results: The patients were grouped into those having phenytoin intoxication and those with normal phenytoin level, and also classified as rapid or slow acetylators by NAT2 genotyping. Genotypic analysis showed that of the seven SNPs (single nucleotide polymorphisms) of NAT2 gene studied, six mutations were found to be associated with phenytoin intoxication. For rs1041983 (C282T), rs1799929 (C481T), rs1799931 (G857A), rs1799930 (G590A), rs1208 (A803G) and rs1801280 (T341C) allelic variants, the proportion of homozygous mutant was higher in phenytoin intoxicated group than in phenytoin non-intoxicated group. Interpretation & conclusions: Homozygous mutant allele of NAT2 gene at 481site may act as a predisposing factor for phenytoin intoxication among TBM or tuberculoma patients having seizures.

Gastrointestinal Fistulization in Amebic Liver Abscess.

Background: Liver abscess is a common deep seated abscess in children; amebic liver abscess is associated with more local complications. Case characteristics: We report two preschool children presenting with short history of pain, fever and right upper quadrant pain. The abscess communicated with gastro-intestinal tract (ascending colon in case 1 and duodenum in case 2), and diagnosis of amebic liver abscess was confirmed by DNA PCR. Outcome: Both children were successfully managed with intravenous antibiotics and catheter drainage. Message: Gastrointestinal fistulization may be rarely seen in amebic liver abscess. Conservative management with antibiotics, catheter drainage and supportive care may suffice.

Utilisation of Maternal Health Services and its Predictors in Slum Population.

Introduction: The particularly sorry plight of disadvantaged slum population with ample scope of further research into such areas as vulnerability to health risk and access to treatment, reduced economical choice and social support besides natural disasters and emotional stress of displacement. Material & Methods: An observational (cross-sectional) study was designed on a pre designed and pre tested questionnaire to understand women’s fertility and contraceptive behavior and to study Socio behavioral Determinants of Utilization of MCH services. Results: The prevalence of <18 marriage was 78.03%.The teenage pregnancy was as high as 46.36% with 47.90% having parity of 4 or more.And of those not seeking ANC 53.42% did not feel the need for care during pregnancy. A very important finding was that 64.23% had home delivery and of these, 74% did not have any trained birth attendant. Conclusion: Levels of education in the family, caste, affordability (asset-holding) and accessibility were the factors which determined the utilization pattern. In general, those with better levels of education and those with better affordability preferred private practitioners and were willing to travel longer distances to avail health services as there was more awareness, motivation and felt need.

Analysis of the DosR regulon genes to select cytotoxic T lymphocyte epitope specific vaccine candidates using a reverse vaccinology approach

Objective/background: There is an urgent need for a more effective vaccine against Mycobacterium tuberculosis [Mtb]. Although CD4+ T cells play a central role in host immunity to Mtb, recent evidence suggests a critical role of CD8+ T cells in combating Mtb. In the present study, we have predicted HLA antigen class I binding peptides of DosR operon using an in-silico approach. This method is useful as an initial computational filtration of probable epitopes based on their binding ability and antigenicity

Methods: CD8+ epitopes were predicted by software NetMHC 3.4 and BIMAS. Self-peptides were found and excluded by indigenously developed Perl script. Antigenicity of promiscuous peptides was predicted using a Vaxijen server. The top Vaxijen scoring antigenic peptides were docked to globally relevant HLA allele using CABS dock and Hex program

Results: A total of 1436 overlapping nonamer peptides were generated which gave 46 promiscuous epitopes, 25 were predicted to be antigenic. Rv2627 epitope "SAFRPPLV" which gave the highest Vaxijen score of 1.9157 and showed binding to all the three HLA loci. The top Vaxijen scoring antigenic peptides were docked and had significant interactions with residues of the HLA class I molecule indicating them to be good cytotoxic T lymphocyte epitopes

Conclusion: Our study has generated several promiscuous antigenic peptides capable of binding to major histocompatibility complex class I with high affinity. These epitopes can become part of a postexposure multivalent subunit vaccine upon experimental validation

Study of lipid profile in hypertensive subjects

Aim : The present study was designed to investigate lipid profile in hypertensive subjects. Material and Method : The present study was carried out on 25 healthy controls and 25 hypertensive subjects of either sex and of varying age groups attending the Out Patient Department of Medicine, Dr. S.N. Medical College and Associated group of hospitals, Jodhpur. Results: The results obtained in this study showed that the results of TG ,Total cholesterol ,HDL-c ,VLDL-c ,LDL-c were highly significant in patients compared with control subjects .Conclusion: The present study indicates an increased TG ,Total cholesterol ,VLDL-c ,LDL-c & decreased HDL-c values in hypertensive subjects, which is due to many factors like obesity ,age etc.

Study of Serum Selenium Levels in Schizophrenic Patients.

Deficiency and excess amount of trace elements play an important role in several well recognized diseases, studies are going on to establish their role in schizophrenia. Selenium and other trace elements are indispensable components for certain enzymes responsible for various metabolic processes in different tissues including the brain as they play important functional roles in peripheral and central nervous systems. Objectives: In this study, we examined the levels of selenium in serum of patients of schizophrenia and compare them with normal healthy controls. Selenium was also measured in acute and chronic stage of schizophrenia categorized on the basis of PANSS score and correlated by Spearman’s Correlation Coefficient (ρ) in total cases, acute cases and chronic cases. Method: The study population comprised 150 patients and 150 age matched controls. We measured levels of Selenium by AAS (Atomic Absorption Spectrophotometer). Results: We found that selenium levels were significantly lower in patients with schizophrenia than in the control group. The levels of micronutrients studied were also correlated with disease severity and duration but found non-significant relation. Conclusion: Evaluation of selenium levels in patients with schizophrenia could prove useful. There may be role of Selenium in the pathogenesis and course of Schizophrenia and new therapeutic approaches warrants further study.

Myomectomy and Cervical Reconstruction in an Unmarried Girl with Large Cervical Fibroid.

Leiomyomas are frequently encountered tumors in women and have a wide and varied spectrum of presentation. We report a case of large cervical fibroid in an unmarried girl, presenting with acute abnormal uterine bleeding. Such cases pose a dilemma for the doctor as fertility preservation is a significant conern for the patient.

Differential signaling of inducible nitric oxide synthase induction in Mycobacterium tuberculosis infected alveolar epithelial cell line A549 in response to cytokines IFN-gamma, TNF-alpha and IL-1beta

In earlier studies, it was shown that ex vivo Mycobacterium tuberculosis-infected type II alveolar epithelial cells generate de novo nitric oxide [NO], but the mycobactericidal quantity of NO was released only by stimulation of these cells with proinflammatory cytokines, i.e. IFN-gamma, TNF-alpha and IL-1beta. In the present communication, it was demonstrated that M. tuberculosis-infected/mycobacterial antigens stimulated cells utilize both, JAK-STAT and NF-kappaB pathways for the induction of inducible Nitric Oxide Synthase [iNOS] mRNA and NO production. Alveolar epithelial cell line A549 were either infected with M. tuberculosis or stimulated with M. tuberculosis components. Confocal microscopy, NO estimation and EMSA were performed on the infected/stimulated A549 cells. Nuclear extracts prepared from M. tuberculosis infected A549 cells alone or stimulated with IFN-gamma or a combination of three cytokines [IFN-gamma, TNF-alpha and IL-1beta] formed DNA protein complexes with probes from both -5.2 kb region [specific for binding of STAT-1 protein] and -5.8 kb region [specific for binding of both STAT-1 and NF-kappaB] of the iNOS promoter. However, TNF-alpha or IL-1beta stimulated M. tuberculosis-infected A549 cells showed no protein DNA complexes with construct from -5.2 kb region. This differential response indicated that TNF-alpha/IL-1beta does not allow STAT-1 production or its translocation to nucleus in M. tuberculosis-infected A549 cells in the absence of IFN-gamma. This differential signaling of iNOS induction in M. tuberculosis-infected alveolar epithelial cells by cytokines may be responsible for controlled production of NO intracellularly.