A rare case of bronze diabetes in a patient with thalassemia

Secondary haemochromatosis (also known as bronze diabetes) is a perilous medical condition that can occur as a complication of frequent blood transfusions. Thalassemia major which occurs due to a decrease in the beta globulin chain can lead to severe anemia, extramedullary hematopoiesis and splenomegaly. Becauseof this, the affected patients requiredcontinuous blood transfusions throughout their life and as a consequence, it may lead to iron overload. A 26-year-old male presented with a complaint of darkening skin, joint pain and fever. He was a known case of thalassemia major and was undergoing blood transfusions three times a week. Further laboratory findings revealed decreased hemoglobin, abnormal liver function tests and increased blood glucose levels. The patient was managed with IV insulin and chelation therapy. The patient responded to treatment and was better on subsequent follow-up. The diagnostic and therapeutic challenges along with the epidemiological dataemphasize the need of raising the awareness of physicians to this devastating condition.

QbD enabled Process Variable Study to Develop Sustained Release Chitosan-Alginate Embedded Delivery System for Improved Patient Compliance

Abstract The current investigation entail systematic Quality by Design (QbD)-enabled approach for the development of Sustained released embedded drug delivery systems of L-Arginine employing ionic gelation technique to attain improved patient compliance. Hence, in this QbD enabled systematic approach; quality target product profile (QTTP) was defined and critical quality attributes (CQAs) were identified. Further the risk assessment studies were undertaken through Ishikawa fish bone diagram to locate the critical material attributes (CMAs) and/or critical process parameters (CPPs) for the formulation of beads that may affect CQAs of drug product. A face centered central composite design (CCD) for two factors at three levels each with α =1 was employed for the optimization process to checkout the impact of concentration of sodium alginate and concentration of chitosan as CMAs which wereprior identified from risk assessment study and further evaluated for CQAs viz. bead size, swelling index and percent drug entrapment. The optimum formulation was embarked upon by using mathematical model being developed yielding desired CQAs. Thereby chitosan coated calcium-alginate delivery system was successfully developed by strategically employing QbD approach.In a nutshell, the presentinvestigation reports the successful development of optimized chitosan coated alginate beads employing QbD approach which can serve as a platform for other drugs too.

A Comparative Assessment of Functional Outcome of Clavicular Fractures Treated by Conservative and Surgical Methods: An Institutional Based Study

Background: Clavicle fracture is a common condition mostlytreated conservatively. Newer operative modalities have comeup to obtain early fixation.Materials and Methods: The present study was conducted in30 patients of clavicle mid shaft fractures which were treatedsurgically and conservatively. Closed fresh fractures in themiddle third region, open fractures of grade 1 and 2 wereincluded and grade 3 open fractures were excluded from thestudy. Patients under the age of 18 and fractures in the medialand lateral third, Pathological fractures were excluded from thestudy. The patients are divided randomly in to operative andconservative group. Sutures removed at 10-12 days. Thefunctional outcome was assessed by Constant and Murleyscore.Results: In the present study total sample size was 30.Clavicular fractures were prevalent in males (60%). Unionoccur in maximum cases in conservative treatment in 21months whereas in operative treatment union occurs inmaximum cases in18 months. The functional outcome wasexcellent in 5 cases in conservative treatment whereas inoperative treatment it was excellent in 6 cases.Conclusion: The present study concluded that operativetreatment was better than conservative treatment for clavicularfractures.

Neuroprotective effects of Aegle marmelos (L.) Correa against cadmium toxicity by reducing oxidative stress and maintaining the histoarchitecture of neural tissue in BALB/c mice

Herbal plants have various biological and pharmacological activities and are used as chemotherapeutic agents. Aegle marmelos (Lin.) has antioxidant, anti-inflammatory and antigenotoxic properties due to its active phytoconstituents like marmenol, marmin, marmelosin, aegelin, marmelin etc. The present study investigates the protective potential of leaf extract of A. marmelos against cadmium-induced oxidative stress and histopathological manifestations involved in the neuronal tissue of BALB/c mice. Mice were given prophylactic and therapeutic treatments (pre and post) of two different doses (250 and 500 mg/kg body weight) of A. marmelos to evaluate its protective efficacy against CdSO4 (5 mg/kg body weight, i.p. for 5 days) induced neurotoxicity by estimating various biochemical and histopathological parameters. Sub-lethal cadmium exposure caused a significant elevation in levels of lipid peroxidation, a noticeable decrease in enzymatic antioxidants (Catalase, Superoxide dismutase, Glutathione reductase, Glutathione –S-transferase) and non-enzymatic (reduced glutathione) antioxidants and marked structural alterations in neural tissue. A. marmelos pretreatment significantly (P≤ 0.01) reversed increased lipid peroxidation and attenuated the decreased enzymatic (P≤ 0.05) and non-enzymatic antioxidant markers (P≤ 0.05). Furthermore, pretreatment of A. marmelos also protected the histoarchitecture of neuronal tissue. Out of all the treatments, pretreatment was found to be more effective as compared to post-treatment, evidently seen in all biochemical assay (P≤ 0.05, two-way ANOVA). Taken together, these results indicate that Aegle marmelos could be used as a potential prophylactic agent for combating adverse effects of cadmium in neural tissue.

Radiologic Evaluation of Marginal Bone Loss in Delayed vs. Immediate Loaded Implants –18 Month Results of a Prospective Comparative Study.

Aim: To compare the amount of bone loss (if any) at the mesial and distal sides in delayed and immediate loaded dental implants. Study Design: Total 20 partially edentulous (anterior region of Maxilla) patients were randomized and equally divided into two groups. Group A received delayed loaded dental implants and group B received immediate loaded dental implants. Both the groups were monitored clinically and radiographically at 3, 6, 12 and 18 months. Methodology: We included 20 patients (11 men, 09 women; age range 20-48 years) with single or multiple edentulous areas in mouth. Clinical as well as all routine hematological examinations were done. Radiographs were taken sequentially as required for 18 months. Results: There was no significant statistical difference of bone loss mesially in both the groups at 3 (P=0.99) & 6 (P=0.25) months, but there was significant statistical difference of bone loss mesially seen in both the groups at 12 (P=0.03) & 18 (P=0.01) months. There was no significant statistical difference of distal bone loss in both the groups at 3 (P=0.22), 6 (P=0.38) and 12 (P=0.17) months, but there were significant statistical difference of distal bone loss seen in both the groups at 18 months (P=0.03). The bone loss was found more with the immediate loading type of implants at both mesial and distal sides of implant. Conclusion: The immediate loading implants may provide a lot of benefits over conventional delayed loading implants but the bone loss at Crestal (Marginal) level is higher as compared to delayed loading implants when seen in maxillary anterior impants which should be considered whenever selecting any particular method of dental implantation.

A comparative study of overall efficacy and hemodynamic effects following blind oro-tracheal intubation with ILMA vs. conventional direct laryngoscopy guided intubation with Macintosh laryngoscope.

Intubating Laryngeal Mask Airway (ILMA) is a new device to guide blind oro-tracheal intubation thus offering a new approach for endotracheal intubation and is expected to produce less sympathetically driven haemodynamic stress response. The purpose of this study was to assess overall efficacy, haemodynamic advantage and complication rate with use of ILMA compared to conventional method of endotracheal intubation with use of Macintosh Laryngoscope (ML). Methods: This randomized controlled study was conducted on 60 adult patients comparable in age, sex, weight, MPC and ASA status scheduled for elective surgeries. Patients were randomly allocated into two groups of 30 each. Both the groups received similar balanced anaesthesia technique (Inj. fentanyl 2 μg/kg, propofol 2-2.5 mg/kg, rocuronium 1 mg/kg). Tracheal intubation was done using either ILMA or Macintosh laryngoscope. The intubation time, number of attempts required for successful intubation, haemodynamic changes and oro-pharyngo-laryngeal complications encountered during both the methods were recorded. Results: Time to intubation was comparatively longer in the ILMA group than laryngoscopy group (P <0.05). The success rate of intubation was 100% in both the groups. Overall haemodynamic changes in both the groups were statistically comparable (P >0.05) and ILMA appears to be offering no haemodynamic advantage over ML. The incidence of complications was rare and comparable amongst both the groups (P >0.05). Conclusions: Therefore in patients with normal airway blind intubation with ILMA is a successful and equally efficacious method without significant oro-pharyngo-laryngeal morbidity but offers no added haemodynamic advantage compared to conventional direct laryngoscopy with ML. Thus ILMA may act as a suitable alternative to ML for patients with normal airway.

Isolated Nodular Ischemic Infarcts: A Central Lesion That Presents as Peripheral Vertigo.

Aims and Objective: Giddiness is one of the commonest presenting complaints to the emergency physicians. Differentiation between ‘peripheral’ and ‘central’ etiologies is important to avoid unnecessary investigations and avoid missing a potentially serious diagnosis such as an ischemic stroke. Isolated nodular infarction can present with clinical signs that mimic a peripheral vestibular cause. We present the clinical findings in 14 cases of isolated nodular infarction and discuss their differentiating features. Study Design: Retrospective case series. Place and Duration: Tertiary care university hospital in Singapore between January 2007 to September 2012. Methods: We evaluated the clinico-radiological findings of all the patients diagnosed with isolated nodular infarction at our center during the study period. Their clinical presentations were extracted from the case records. We combined our cases to an existing series of 8 patients from Korea to strengthen the findings. Results: Of the 286 acute posterior circulation ischemic stroke patients admitted to our tertiary care center during the study period, 6 (2.1%) were found to have isolated nodular infarction. They typically presented with acute severe giddiness. Nystagmus was seen in all, which was unidirectional and beating towards the side of the lesion with no latency or fatigability. Walking was usually severely impaired due to imbalance and all patients had a negative head impulse test. All patients at our center achieved complete recovery at 3- months. Conclusions: We present the clinical spectrum of isolated nodular infarction. In addition to a high index of suspicion in patients with multiple vascular risk factors, a negative head impulse test despite severe vertigo and imbalance can help in establishing the correct diagnosis.

Implementation of a short course of prophylactic antibiotic treatment for prevention of postoperative infections in clean orthopaedic surgeries.

Background & objectives: Perioperative antimicrobial prophylaxis constitutes the bulk of antimicrobial consumption in any hospital. This study was conducted at a level 1 Trauma Centre of a tertiary care hospital of India to assess the efficacy of a short (24 h) course of perioperative antibiotic prophylactic regimen in preventing surgical site infections (SSI) in open reduction and internal fixation (ORIF) of closed fractures of limbs and to assess if the same can be implemented as a general policy. Methods: Patients of either sex, aged 18 yr or more, who were scheduled for ORIF and were willing and able to give informed consent, were included in the study. Patients were randomly allocated into two groups. Group 1 (n=100) received 3 doses of 1 g i.v. cefuroxime perioperatively spaced 12 h apart and group 2 (n=97) received the conventional existing regimen [5 days of i.v. antibiotics (cefuroxime 1 g twice daily along with amikacin 15 mg/kg in 2 divided doses), followed by oral cefuroxime, 500 mg twice daily till suture removal]. Results: Of the 197 patients, four patients developed a surgical site infection (three with methicillin resistant Staphylococcus aureus and one Acinetobacter baumanii). Of these, two patients were in group 1 and the remaining two in group 2. These patients were treated with i.v. antibiotics based on the culture and antimicrobial sensitivity reports. The cost of the short course treatment was ` 150 per patient as compared to ` 1,900 per patient for conventional regimen. Interpretation & conclusions: There was no significant difference in rates of SSI among the two groups in our study. Cost evaluation revealed that shorter course was less expensive than conventional long course regimen. Implementation of a short course perioperative regimen will go a long way in reducing antimicrobial resistance, cost and adverse reactions to antimicrobials.

An ultrasonographic evaluation of masseter muscle thickness in different dentofacial patterns.

Objectives: The aim of this study is to compare the masseter muscle thickness in different vertical dentofacial patterns and identify the possible sexual dimorphism and also to correlate masseter muscle thickness with craniofacial morphology using cephalometric parameters. Materials and Methods: The masseter muscle thickness was measured using ultrasonography in 60 subjects (30 females and 30 males). Standardized lateral and posteroanterior cephalograms were taken to determine the facial morphology. The subjects were divided into three vertical pattern groups (I, II, and III) according to their Jarabak ratio: hypodivergent ( n = 20), normodivergent (n = 20), and hyperdivergent (n = 20). The sample was further subdivided into males and female subgroups. Results: Masseter muscle thickness relaxed (MMTR) in hypodivergent group was 13.94 ± 1.51. Mean value of MMTR in normodivergent group was 12.53 ± 1.21 and the MMTR in hyperdivergent group was 11.13 ± 1.18. The mean value of masseter muscle thickness contracted (MMTC) in hypodivergent group was 15.46 ± 1.33. Mean value of MMTC in normodivergent group was 13.81 ± 1.38 and the mean value of MMTC in hyperdivergent group was 12.27 ± 1.26. MMTC showed a significant, negative correlation with mandibular plane angle and gonial angle. Posterior facial height, symphysis width, intermolar width of maxillary first molars, maxillary width, and facial width (bizygomatic width) showed significant ( P < 0.05 or P < 0.01) positive correlation. Conclusion: The masseter muscle thickness varied among the three vertical dentofacial patterns and sexual dimorphism also existed except in the hyperdivergent group. Masseter muscle thickness was found to be negatively correlated to vertical facial pattern and positively associated with transverse craniofacial morphology.

Multi-domain cognitive screening test for neuropsychological assessment for cognitive decline in acclimatized lowlanders staying at high altitude.

Background & objectives: Ascent to high altitude has been reported to cause hippocampal atrophy and cognitive impairment in mountaineers. We assessed the cognitive performance and probable occurrence of mild cognitive impairment (MCI) in acclimatized lowlanders (ALL) staying at altitudes above 4,300 m for duration above 12 months and validated a multi-domain cognitive screening test (MDCST) for future demographic studies on MCI. Methods: Following evaluation of sensitivity and correlation of the newly developed MDCST battery with Mini Mental State Examination (MMSE) and Clinical Dementia Rating (CDR) scores on a group of 28 individuals, the MDCST battery was validated on a population of 843 ALL staying at high altitude MSL >4,300 m and 862 subjects staying at MSL <230 m. EEG recordings were performed on 840 ALL staying at altitudes above 4,300 m and 743 control subjects staying at MSL <230 m. Results: Percentage prevalence of MCI was 4.18 per cent in the ALL population as assessed by MMSE while that of the LL population was <0.42 per cent. The percentage prevalence of MCI based on calculations from the MDCST scores was 12.4 per cent in the ALL population as compared to 1.19 per cent in the LL population. Decrease in alpha wave amplitude at the T3 and T4 sources in MCI subjects was observed in LL group while there was an increase in amplitude for alpha wave in these regions in the ALL groups. Domain specific MDCST showed decline in immediate recall, procedural memory and mind body co-ordination which was negligible in the LL population. Interpretation & conclusions: MDCST exhibited excellent psychometric properties in terms of sensitivity, and test-retest reliability qualifying it to be used as a more effective cognitive measure for assessment of MCI in demographic studies in comparison to traditional measures. Our findings also showed increased prevalence of MCI in ALL population staying for longer durations at high altitude which is neurophysiologically distinct from MCI leading to Alzheimer's disease.

A correlative study of dental age and skeletal maturation.

Introduction: Skeletal age had been assessed by comparison between maturation of hand-wrist with stages of cervical vertebrae or canine calcification stages in past and this had been closely related to craniofacial growth. The importance of pubertal growth spurt in various types of orthodontic therapies is already established. Aims and Objectives: Hence, this study was aimed to evaluate the relationship of skeletal maturity by hand-wrist with cervical vertebral maturation indicators and canine calcification stages. Materials and Methods: The study consisted of randomly selected 90 children from Lucknow population with 45 males (age range 10-13 years) and 45 females (age range 9-12 years). Lateral Cephalogram, hand-wrist x-ray, and periapical x-rays of maxillary and mandibular right canines were taken. Statistical Analysis: Mean, standard deviation was calculated of different groups. Correlation was made among cervical vertebral maturation, hand wrist maturation, and canine calcification stages at various age groups. Results: There was strong correlation between skeletal maturation indicator and cervical vertebral maturation indicator for both male (0.849) and female (0.932), whereas correlation between skeletal maturation indicator and canine calcification was good for both male and female (0.635, 0.891). Conclusion: It was concluded that cervical vertebral maturation indicator and canine calcification stages can also be used for assessing skeletal maturity.

Amelioration of inflammatory responses by Chlorogenic acid via suppression of pro-inflammatory mediators.

The premise of the present investigation was to evaluate the detailed anti-inflammatory properties of chlorogenic acid (CGA) and to delineate the possible mode of action. To explore the anti-inflammatory profile, we evaluated the effect of CGA on TNF-alpha expression (in vitro); carrageenan induced rat paw edema and carrageenan induce pleurisy (in vivo). In our studies, CGA significantly inhibited the TNF-alpha expression, paw edema and antioxidant enzymes in livers of rats in pre-treatment schedule but failed to exert any effect when administered 1 h after carrageenan injection. CGA was also found to be safe, as confirmed by the results of acute toxicity studies and MTT assay. CGA also caused reduction in total leucocytes count most probably by inhibiting neutrophils, but could not alter mononuclear cells count in carrageenan induced pleurisy. Inhibition of exudation was evidenced by the less exudate formation in CGA treated animals, which may be due to decrease in vascular permeability which was further confirmed in acetic acid induced vascular permeability model in mice where significant decrease in vascular permeability was observed. CGA was highly effective in reducing the arachidonic acid metabolites, nitric oxide and pro-inflammatory cytokines production in a dose dependent manner and in some conditions effect observed was almost comparable to ibuprofen. Result of the present investigation shows the anti-inflammatory effects of CGS in different models.

Evaluation of an automated erythrocyte sedimentation rate analyzer as compared to the Westergren manual method in measurement of erythrocyte sedimentation rate.

Context: Monitor 100® (Electa Lab, Italy) is a newly developed automated method for measurement of erythrocyte sedimentation rate (ESR). Aims: The aim of our study was to compare the ESR values by Monitor 100® against the standard Westergren method. Patients and Methods: This cross-sectional study was conducted at a Level I trauma care center on 200 patients. The samples taken were as per the recommendations charted out by International Council for Standardization in Hematology (ICSH) for comparing automated and manual Westergrens method. Statistical Analysis Used: Bland and Altman statistical analysis was applied for evaluating Monitor 100® against the conventional Westergren method. Results: The analysis revealed a low degree of agreement between the manual and automated methods especially for higher ESR values, mean difference -11.2 (95% limits of agreement, -46.3 to 23.9) and mean difference -13.4 (95% limits of agreement-58.9 to 32.1) for 1 and 2 hours, respectively. This discrepancy which is of clinical significance was less evident for ESR values in the normal range <25 mm/hour (-7.7 mean of difference; -18.9 to 3.5 limits of agreement). Conclusions: The fully automated system Monitor 100® for ESR measurement tends to underestimate the manual ESR readings. Hence it is recommended that a correction factor be applied for the range of ESR values while using this equipment. Further studies and validation experiments would be required.

Salmonella enterica enteritidis arthritis following trauma in a child with thalassemia major.

Osteoarticular infections caused by Non-typhi Salmonella are exceptionally encountered. We report a case of a bacteriologically documented knee joint infection due to Salmonella enterica serotype enteritidis, following trauma in a child with thalassemia major. Emergency arthrotomy combined with antimicrobial therapy was helpful in eradication of infection. Physicians should be aware of this rare manifestation of Non-typhi Salmonella infections in thalassemic patients.

Caudodontia of mandibular 2nd molar with bilateral maxillary canine – premolar transposition - a case report.

Transposition of teeth is a developmental anomaly manifested by a positional interchange of two permanent teeth. It is often associated with hypodontia, peg lateral crowding, severe rotation and malformation like dilaceration and missing teeth, retained teeth and even with impaction which are clinically important for diagnosis as well as treatment plan. However, this case is a deviation from the afore mentioned group of associated anomalies. Surprisingly, in this case bilateral maxillary canine – premolar transposition is associated with idiopathic resorption of the crown of the second mandibular molar. The persistence of only the caudal part of the tooth in such a case merits denoting it as ‘Caudodontia’ by us.

Detection of fetal malnutrition using “CAN score”.

Objective. Use of clinical assessment of nutrition status (CAN) score to assess the prevalence of fetal malnutrition among term newborns and to compare other anthropometric criteria used to assess fetal growth. Methods. Prospective study of 529 term healthy newborns assessed using CAN score .Complete anthropometric assessment and determination of weight for gestation was done. Using CAN score as a standard, the usefulness of birth weight, weight for gestation, length, head circumference (HC), mid arm circumference (MAC), MAC/HC ratio and Ponderal index to assess fetal nutrition was determined. Results. With a cut off value of 25, CAN score identified 148 (27.97%) malnourished neonates. 4% of appropriate for gestational age neonate were malnourished and 42.9 % of small for gestational age neonates were well nourished. When CAN score was taken as a standard, weight for gestation and MAC/HC had the highest sensitivity to identify malnourished neonates (92.5% & 90.5%). Conclusion. CAN score identifies malnourished neonates which can be missed by other methods and identifies well nourished neonates classified as growth retarded by other methods.

Stem cell through present and future.

Stem cell transplantation (SCT) has the potential to transform the lives of children with a wide variety of genetic diseases, ranging from inherent defects of hemopoietic cell production or function through to metabolic diseases mostly affecting solid organs. For these children life expectancy or quality of life would otherwise be very poor. It ranks as one of the most remarkable therapeutic advances of the past 40 years. Despite rapid technological improvements, however, there are still many short term risks and potential long term toxicities. Consequently, the rapid emergence of alternative therapies (including new drugs, enzyme and gene therapies), necessitate constant re-evaluation of the risk/benefit ratio for each disease and hence the appropriateness of SCT. This review describes the major aspects of the transplant process, indications for transplantation, outcome statistics, and areas where alternative therapies are becoming available. SCT remains a highly experimental therapy. Due to the relatively short history of the discipline no data exists on truly long term follow up. This is important as some organs benefit relatively poorly or problems may emerge which were never apparent as part of the untreated disease. The speed of technological change makes randomised trials on these diseases, which are individually quite rare, almost impossible to perform.