Efficacy of fixed duration multidrug therapy for the treatment of multibacillary leprosy: A prospective observational study from Northern India

Background: In endemic regions of several countries, the prevalence of leprosy has not come down to the level of elimination. On the contrary, new cases are being detected in large numbers. Clinically, it is frequently noted that despite completion of multibacillary multidrug therapy for 12 months, the lesions remain active, especially in cases with high bacteriological indices. Aim: The present study focused on finding out the viable number of Mycobacterium leprae during the 12-month regimen of multibacillary multidrug therapy, at six and 12 months intervals and, attempting to determine their role in disease transmission. Methods: Seventy eight cases of multibacillary leprosy cases were recruited from leprosy patients registered at The Leprosy Mission hospitals at Shahdara (Delhi), Naini (Uttar Pradesh) and Champa (Chhattisgarh), respectively. Slit skin smears were collected from these patients which were transported to the laboratory for further processing. Ribonucleic acid was extracted by TRIzol method. Total Ribonucleic acid was used for real-time reverse transcription-polymerase chain reaction (two-step reactions). A standard sample with a known copy number was run along with unknown samples for a reverse transcription-polymerase chain reaction. Patients were further assessed for their clinical and molecular parameters during 6th month and 12th month of therapy. Results: All 78 new cases showed the presence of a viable load of bacilli at the time of recruitment, but we were able to follow up only on 36 of these patients for one year. Among these, using three different genes, 20/36 for esxA, 22/36 for hsp18 and 24/36 for 16S rRNA cases showed viability of M. leprae at the time of completion of 12 months of multidrug therapy treatment. All these positive patients were histopathologically active and had bacillary indexes ranging between 3+ and 4+. Patients with a high copy number of the Mycobacterium leprae gene, even after completion of treatment as per WHO recommended fixed-dose multidrug therapy, indicated the presence of live bacilli. Limitations: Follow up for one year was difficult, especially in Delhi because of the migratory nature of the population. Patients who defaulted for scheduled sampling were not included in the study. Conclusion: The presence of a viable load of bacilli even after completion of therapy may be one of the reasons for relapse and continued transmission of leprosy in the community

Refractory cancer pain in young child at end?of?life: Can we alleviate the suffering?

Pain is a common and highly distressing symptom in children with advanced malignancies and it is often multifactorial at the end?of?life. The prognosis of cancer pain is reported to be worse in those with mixed pain type, high pain severity, daily opioid use, and poor emotional well?being. We describe a case of 13?year?old boy, known case of metastatic Ewing sarcoma right iliac bone, who presented to our palliative care ward with intractable pain and was finally discharged home for terminal care with high doses of morphine, ketamine, and midazolam infusion through elastomeric pump attached to a peripherally inserted central catheter (PICC line). The suffering of imminently dying children should be reduced, and judicious dose escalation of opioids along with adjuvants is appropriate and often necessary.

Clinical-epidemiological Profile of Coronavirus Disease 19 Associated Mucomycosis (CAM) and Relation with Zinc and Iron Levels

Introduction: Coronavirus disease associated mucormycosis (CAM), perturbed a lot by reaching to epidemic proportions particularly during the second wave of the pandemic. Material and Methods: This was a retrospective, observational study of patients with COVID-19-associated mucomycosis admitted in April-May 2021 at a tertiary care teaching hospital. Demographic profile, clinical and laboratory parameters were recorded Multidisciplinary treatment including antifungals and surgical interventions were noted. Results: This study included 98patients of mucormycosis, diagnosed on the basis of clinical and radiological findings and later were confirmed by microbiological investigations. Out of 98 patients, 72 had rhino orbital, 24 had rhino-orbital- cerebral and 2 had pulmonary mucormycosis. Twelve had coinfection of covid 19 while 86 had developed mucormycosis within 3 weeks. Conclusion: CAM has posed as a continuum of challenges faced during the pandemic of covid 19. This rare and life threatening complication requires high index of suspicion for early diagnosis. Multidisciplinary involvement and timely interventions including antifungal pharmacotherapy, stringent glycemic control and surgical debridement can reduce the mortality. Mucormycosis is uniformly associated with low iron levels but role of zinc needs to be further studied

Primary retroperitoneal extraovarian granulosa cell tumor

Extraovarian granulosa cell tumors (GCTs) develop from ectopic gonadal tissue situated along the embryonal route of the genital ridge. Primary retroperitoneal tumors are extremely rare, with an incidence of 02% -06% and 80-85% probability of malignancy. Only eight such case reports have been published previously. We herein, report a rare case of extraovarian retroperitoneal GCT in a 55-year-old woman who presented with intermittent left lumbar region pain of one-year duration. She had a history of hysterectomy and bilateral salpingo-oophorectomy 8 years ago for uterine leiomyoma. Laparotomy revealed a retroperitoneal mass measuring 8cm x 10cm x 20cm in size, solid cystic with areas of necrosis and hemorrhage. The gross features, classical histopathology, and positive immunostaining of the retroperitoneal mass with inhibin, calretinin, PR, WT1 and immunonegativity for EMA were characteristic of adult-type GCT. Excluding any previous history of primary ovarian GCT in this patient, a de-novo retroperitoneal diagnosis was established.

Effect of lifestyle intervention holistic approach on blood glucose levels, health-related quality of life and medical treatment cost in type 2 diabetes mellitus patients

Type 2 Diabetes Mellitus (T2DM) is a costly, lifestyle-related disorder, its management is very critical and challenging hence lifestyle intervention may a cornerstone in the reversal and management of T2DM. This study designed to assess the impact of lifestyle intervention holistic (LIH) Model on blood glucose levels (BGL), Health-Related Quality of Life (HRQOL), and medical treatment cost in T2DM patients. This prospective, quasi-experimental study was conducted among 224 T2DM patients in Delhi Diabetes Research Center (DDRC), New Delhi. The study participants were allocated into two groups-Lifestyle Intervention Counseling (LIC) group received lifestyle-based counseling through the LIH model while the Usual-care group received only standard treatment. Study outcomes were assessed at baseline, 3rd, 6th, and 12th month and data were analyzed through SPSS. Study results revealed that LIC participants had decreased in fasting blood glucose 0.26 mg dL-1(-4.37 to 4.89), blood glucose postprandial -70.16 mg dL-1(-85.15 to -55.16), HbA1C -2.82% (-5.26 to -0.37), medicine cost (p < 0.004), hospitalization cost (p < 0.011), and cost of surgery (p < 0.0005). A significant improvement also observed in HRQOL and adherence towards a holistic model in LIC group. The study concludes that lifestyle-based counseling and its adherence was cost-effective and significantly improves BGL, HRQoL, and medical treatment in T2DM patients.

Clinicopathological characterization and correlation of breast tumour with receptor status

Background: Malignancy of breast is the leading cause of cancer deaths in women. Molecular organisation of breast cancer is considered as better predictive factor for diagnosis and treatment. The present study was done with the aim to find out clinicopathological characterization and correlation of breast tumor with receptor status progesterone (PR), estrogen (ER) and human epidermal receptor protein-2/neu status (HER-2/neu).Methods: This was a prospective study done on 50 patients with breast carcinoma. The expression patterns of PR, ER and HER-2/NEU were studied. Clinical features, pathologic features such as age of the patient, tumour size, grade, and lymph node status and their correlation with receptors were compared.Results: Of the 50 patients, ER positivity was seen in 42% cases, PR positivity in 32% and HER-2/neu (3+) in 30% cases. Majority of grade I tumors were ER and PR positive and majority of grade III tumors were triple negative. Triple negative profile was seen in secretory carcinoma. ER, PR and HER2 status was not significantly associated with age of the patients and tumour size. The immunohistochemical types ER/PR +ve Her2neu +ve and ER/PR -ve Her2neu -ve are significantly related to grading of tumours.Conclusions: From the results, it was concluded that ER, PR and HER-2 status correlates well with histopathological grading. These results highlight the fact that molecular subtypes correlate with diagnosis and aid in targeted therapy.

Association of level serum 25-hydroxy vitamin D in benign and malignant breast disease in a tertiary care center in North India

Background: The study was to compare 25-hydroxy vitamin D levels in women with benign and malignant breast disease patients to the age-matched controls in a tertiary care center in North India.Methods: This was a prospective study carried out in the Department of Surgery, S.R.N. Hospital associated with M.L.N. Medical College, Allahabad. The levels of vitamin D are measured by electrochemiluminescence and the serum levels divided into normal, mild, moderate, and severe vitamin D deficiency.Results: Overall 60 patients were included. 30 was having malignant breast disease and 30 having benign breast disease. On comparing the mean value of serum vitamin D level between malignant breast disease and controls, the serum vitamin D level was found to be lesser in the former group and the difference was highly significant. On comparing the mean value of serum vitamin D level between benign breast disease and controls, the serum vitamin D level was found to be elevated in the former group, the difference was nonsignificant.Conclusions: Our study supports the hypothesis that vitamin D deficiency is an important risk factor in the development of malignant breast disease. The study was also concluded that vitamin D is not associated with the etiogenesis of benign breast diseases. There is also a possibility of using 25-hydroxy vitamin D as an adjuvant therapy during the treatment of breast malignancy.

Evaluation of changes in serum lipid profile and fasting blood glucose levels in patients with gall stone disease before and after cholecystectomy

Background: There is paucity of information regarding the effects of cholecystectomy on serum lipid profile parameters and blood glucose levels in the patients of cholelithiasis. Therefore, this study was undertaken to compare some serum lipid parameters and blood glucose levels in patients of cholelithiasis and effect of cholecystectomy on the same.Methods: The study was conducted on 50 patients of cholelithiasis who were admitted in Surgery department, MLN Medical College over a period of one year and were planned for cholecystectomy. Complete lipid profile (which included total cholesterol, triglycerides, high density lipoproteins (HDL) cholesterol, low density lipoproteins (LDL), very low density lipoproteins (VLDL) and atherogenic index) and fasting blood glucose was evaluated pre-operatively and post-operatively on the 3rd, 7th and further after 1 month of cholecystectomy. Results: Out of 50 patients, maximum of 38% were in their 4th decade with females constituting 82% of total. There was significant elevation in fasting blood glucose and HDL cholesterol on 3rd, 7th and 30th day post-cholecystectomy as compared to pre-operative values (p value<0.0001). Triglyceride and VLDL cholesterol elevated on 3rd and 7th day but it significantly decreased one-month post-cholecystectomy as compared to pre-operative levels (p value<0.0001). However, LDL, total cholesterol and atherogenic index significantly decreased on 3rd ,7th and 30th day post-cholecystectomy.Conclusions: Cholelithiasis is an important cause associated with significant pathological changes in many lipid profile parameters, which will return towards normal after cholecystectomy. This normalization will be a time dependent phenomenon with long term beneficial effects.

Step up approach for the management of late presentation of pancreatic trauma patients

Background: Pancreatic injuries are usually subtle to identify by different diagnostic imaging modalities and these injuries are often overlooked in cases with extensive multi-organ trauma. Our study was conducted to evaluate the outcome of a step-up approach in the management of pancreatic trauma patients with late presentation.Methods: The study included 15 patients who presented with grade III AAST delayed presentation of pancreatic trauma from September 2017 to 2019. In our step-up approach 2 staged procedure was done, firstly laparotomy with necrosectomy along with closure of proximal pancreatic duct with external drainage of pancreatic duct, in second stage Roux-en-Y pancreaticojejunostomy was done to drain the remnant pancreas as a definitive procedure 3 to 6 months after initial procedure.Results: In our study, blunt trauma abdomen (83.30%) (n=10) was the most common mode of injury. The main reason for delay in diagnosis of pancreatic trauma was delayed presentation of patient (83.3%) (n=10). Total of 4 patients were admitted to intensive care unit (ICU) at the time of admission. 10 patients underwent both the stages of step up approach management among which one patient had pancreatic fistula as a complication (n=1) (10%) and one patient had post-operative abscess as a complication (n=1) (10%). No mortality was noted in our study.Conclusions: The step-up approach discussed above proves to be beneficial towards management of patients with delayed presentation of pancreatic trauma in our setting.

Correlation of coagulation markers with axillary lymph node metastasis in breast malignancy: a tertiary care centre study in North India

Background: Breast cancer is the most common female cancer worldwide representing nearly a quarter (25%) of all cancers. Search for a marker which can predict lymph node metastasis in clinically negative axilla has been a matter of research for long. The present study is an attempt to evaluate role of coagulation makers with special reference to D-dimer and factor 7 and 8 in patients of carcinoma breast in predicting lymph node metastasis in carcinoma patients.Methods: The study was a prospective study conducted in 50 diagnosed patients of carcinoma breast in whom D dimer levels and factor 7 and 8 levels were measured at the time of commencement of the treatment and at six weeks after surgery.Results: Most of the patients in the study group were in the age group 41-70 (80%) years. 22% patients were of early Breast cancer. The reduction in D-dimer, factor VII and factor VIII value after 6 weeks of surgery were significant (p value 0.0001 for all three).Conclusions: D-dimer and factor VII were found to be an independent predictive factor for lymph node metastatsis, thus providing as a safe, easy, objective and convenient supplement to sentinel node biopsy in assessing metastatic disease in axilla. Combined- with other biomarkers, it may prove to be an alternative to sentinel node biopsy in assessing metastatic disease in axilla. Significant postoperative decrease in D-dimer, factor VII and factor VIII may provide objective criteria to assess completion of surgery.

Evaluation of endometrium by transvaginal ultrasonography and hysteroscopy and its correlation with histopathology in perimenopausal women with abnormal uterine bleeding at tertiary rural centre

Background: Abnormal uterine bleeding is one of the commonest clinical presentation ac-counts for 33% gynaecological consultations and this proportion rises to 70% in perimenopausal and postmenopausal age group in any gynaecology clinic. The most probable etiology of abnormal uterine bleeding relates to the patients reproductive age. Various diagnostic techniques have been evolved over the periods to determine the etiology of abnormal uterine bleeding in perimenopausal women, but their accuracy has not been compared properly. The aim of study is to evaluate the endometrium by transvaginal ultrasonography and hysteroscopy and its correlation with histopathology in perimenopausal patients with abnormal uterine bleeding.Methods: Total 96 patients in perimenopausal age group, admitted with chief complaints of ab-normal uterine bleeding were included. All patients underwent transvaginal ultrasonography and hysteroscopy, followed by hysteroscopy guided biopsy and histopathological examination. Accuracy, sensitivity, specificity, positive predictive value and negative predictive value were calculated for both methods and compared, considering histopathological diagnosis as gold standard.Results: Mean age of patients was 44.05±3.29. Hysteroscopy has high accuracy, sensitivity, specificity, positive predictive value and negative predictive value than Transvaginal sonography for diagnosis of all endometrial and intrauterine pathologies.Conclusions: Hysteroscopy results are more consistent with the results of histopathology. Hysteroscopy and hysteroscopy guided biopsy has been proven as gold standard for endometrial evaluation of patients with abnormal uterine bleeding. TVS can be used as most cost effective first step investigation in cases of perimenopausal bleeding.

Effect of Lifestyle based Edu Vaccine in Indian community: Study Outcomes of National Program for Prevention and Eradication of Heart Attack (NPPEHA)

Objective: The present study was designed to evaluate the impact of Education (Edu) vaccine in National Program forPrevention and Eradication of Heart Attack (NPPEHA).Methods: This pretest–posttest designed study was held in the SAAOL Heart Center in different cities (Delhi,Kolkata, Bangalore, and Mumbai) of India from Nov 2016 to Dec 2017. Total 6,225 community people were enrolled.An educational counseling intervention (Edu vaccine) comprising: knowledge of heart, heart disease awareness,risk factor awareness, preventive measure awareness and diagnostic, and regular medical checkups were given tocommunity people with expert doctors through face-to-face interactions and video counseling. The effect of lifestylebased counseling was assessed through pre- and post-designed Edu vaccine questionnaire.Results: The results of this study showed a significant improvement in knowledge of heart (79.6%), heart diseaseawareness (87.8%), risk factor awareness (74.9%), preventive measure awareness (89.8%), diagnostic, and regularmedical checkups (84.7%), respectively.Conclusion: The results of this study showed a significant improvement in knowledge of heart (79.6%), heart diseaseawareness (87.8%), risk factor awareness (74.9%), preventive measure awareness (89.8%), diagnostic, and regularmedical checkups (84.7%), respectively. The first phase study of NPPEHA results conclude that lifestyle-based Eduvaccine is effective, and this tool is very easy to follow and heart attack prevention methods. The next phase ofNPPEHA program is ongoing and results are awaited.

Assessment of Effect of Port Site and Intraperitoneal Instillation of Bupivacaine in Reduction of Post-Operative Pain After Laparoscopic Cholecystectomy

Introduction: Effective postoperative pain control is anessential component for care of surgical patients. Inadequatepain control may result in increased morbidity or mortality.Analgesic effects of periportal infiltration of local anesthetics,infiltration of periportal parietal peritoneum, intraperitonealspraying at subdiaphragmatic space and subhepatic spacecovering the area of hepatoduodenal ligament have beenreported. The present controlled study is aimed at assessingthe effect of port site injection and intraperitoneal instillation ofbupivacaine in reduction of post-operative pain afterlaparoscopic cholecystectomy.Materials and Methods: The present study was conductedamong a group of 180 patients diagnosed to have symptomaticcholelithiasis and who underwent elective laparoscopiccholecystectomy under General Anaesthesia. In group 1, preincisional local infiltration of 20ml 0.5% bupivacaine at the portsites and in group 2, local infiltration of 20ml 0.5% bupivacaineat the port sites with intraperitonial installation were given. Ingroup 3, no local infiltration was done and was treated ascontrol group. Pain assessment is based on a Universal PainAssessment Tool. The analysis of our study was performedone way ANOVA & Post HOC test (Scheffe’s HSD) & Chisquare tests as and when indicated.Results: Mean pain scores at 30 minutes were significantlylower in group 1 & 2 compared to control group but howeverthe values were not significantly different when compared toeach other. Similarly the mean pain scores at 4th, 8th, 16th and24th hours for the preincisional and preclosure group, does notsignify any inter group advantage. Therefore, bupivacaineprovide a substantial reduction of pain intensity upto 24 hourspostoperatively and was found to be statistically significant.However, timing of anesthesia was found to be statisticallyinsignificant in terms of preclosure vs pre incisional of the portsites.Conclusion: To conclude, instillation of bupivacaine at the portsites in laparoscopic cholecystectomy irrespective of the timingof instillation is an effective method of achieving pain control inthe post-operative period as long as 24 hours after surgery.There was no statistically significant reduction of post-operativepain between the preincisional and pre closure group.

Impact of different grades of anaemia severity during pregnancy on maternal and neonatal outcomes: a prospective study

Background: Anaemia in pregnancy is a universal health problem that may cause a number of obstetrical and neonatal complications. This prospective observational study aims to evaluate and compare maternal and neonatal outcomes in different grades of anaemia severity.Methods: A total of 400 pregnant women with anaemia in third trimester were classified into three groups according to haemoglobin (Hb) levels-group I with Hb:10-10.9 g/dl, group II with Hb:7-9.9g/dl and group III with Hb<7 g/dl. Maternal and neonatal outcomes of women with different severity of anaemia were analyzed and compared. Two groups means were compared by Student’s t-independent test and more than two groups means by one way analysis of variance test followed by post-hoc pairwise comparison using Bonferroni test.Results: The prevalence of anaemia in the study population was 35.2%. Mild, moderate and severe anaemia were found in 58% (n=232), 29.0% (n=116) and 13% (n=52) women respectively. A statistically significant difference in maternal outcomes such as Preterm labor (p=0.001), Prelabor premature rupture of membranes (p=0.044), Intrauterine growth restriction (p=0.002) and postpartum hemorrhage (p=0.001) was observed amongst the three groups. Cardiac failure occurred in 26.9% (n=14) and mortality in 13.4% (n=7) women with severe anaemia. Amongst the neonatal morbidities, the rate of low birth weight, preterm birth, respiratory distress syndrome, septicaemia, pneumonitis and jaundice revealed an increasing trend with rising severity of anaemia which was statistically significant.Conclusions: Targeted interventions addressing early detection and appropriate treatment in early pregnancy can prevent and avoid dismal maternal and neonatal consequences.

Monostotic craniofacial fibrous dysplasia: report of two cases with interesting histology

Fibrous dysplasia (FD) is a relatively rare osseous disease of unknown etiology, wherein the normal bone is replaced by collagen-rich tissue, comprising of fibroblasts and variably abundant immature woven bone. Clinically, it may involve a single bone or multiple bones. It commonly arises in the jaw bone, skull, rib, and proximal femur. Those arising in the skull and the jaw are together termed "craniofacial fibrous dysplasia." The differential diagnosis at this location includes meningioma and metastatic carcinoma. In this report, we highlight two diagnostically challenging cases presenting with orbital swelling and headache as the main complaints. Our first case was misinterpreted as meningioma on intraoperative squash smear, and paraffin sections revealed characteristic features of FD. The second case highlights the morphological feature of non-specific cystic degeneration occurring in FD. Radiographs in such cases show cystic swelling, which is indicative of a secondary aneurysmal bone cyst.

Management of early years of simple and mucopurulent chronic bronchitis with pre-defined Homoeopathic medicines ­ a Prospective Observational Study with 2-Years Follow-Up

Background Simple and mucopurulent chronic bronchitis (SMCB) is characterized by recurrent mucoid or mucopurulent expectoration in absence of localized suppurative disease. This observational open label study was undertaken to evaluate the effects of homeopathic medicine in SMCB. Methods 1902 patients were screened from 07 centres out of which 1305 were excluded. 597 patients were enrolled as per the inclusion and exclusion criteria. A total of 14 pre-defined homeopathic medicines were shortlisted for prescription after repertorizing the pathological symptoms of SMCB. Outcomes were assessed through chronic bronchitis symptom scale (CBSS) and FEV1/ FVC ratio with spirometry for over a period of two years. Appearance of any change (relief/ worse)/ status quo was immediately followed by placebo/ change in dilution/ change in remedy. Statistical analysis was done using SPSS version 20. Results: 532 patients were analyzed based on the intention to treat principle using last observation carry forward method. Mean CBS score reduced from 29.86±4.5 at baseline to 12.33±7.6 at completion of 2 years. Repeated measures ANOVA, at time points 0 (baseline), 3, 6, 9, 12 ,15, 18, 21 and 24 months, showed significant reduction in CBS scores [Wilk's Lambda 0.104, F=564, df 524; p=00001]. The FEV1 and FEV1/FVC was maintained within normal limits. 86% prescriptions included Lycopodium, Arsenicum album, Pulsatilla, Phosphorus, Stannum metallicum, Calcarea carbonica, Silicea, Bryonia alba. Conclusion: The result suggests effectiveness of homeopathic treatment in early years of SCMB patients. Controlled trials are warranted. (AU)

Relapse and Drug Resistance in Leprosy: Present Scenario and Critical Issues

The symposium was organized by The Leprosy Mission Trust India (TLMTI) on the 29 November, 2017 at India Habitat Centre, Lodi Road, New Delhi, India. The meeting was organized for the stakeholders who are engaged in the leprosy elimination programme for an exposure to the recently emerging scenario on relapse and drug resistance in leprosy. A total of sixty three participants including representatives from Government of India, WHO, ILEP, GLRA, LEPRA India, NLR, DFIT, BLP, FMR, NIMHANS, ICMR-NJIL & OMD and ICMR gathered in the symposium. Most of the famous advisors of the country, leprologists and dermatologists of TLM, Safdarjung, Guru Tegh Bahadur hospitals, PGIMER (Chandigarh, India), DLO and SLO of Delhi participated in the symposium. Leprosy researchers and scientists from different organizations across the country also gathered for the deliberations and discussions. The symposium began with a welcome address from the Executive Director, TLM which was followed by inaugural keynote addresses by the experts of the country. Scientific deliberations by the leprologists, dermatologists and laboratory researchers were divided in four main sessions. This symposium had presentations on most current areas of importance such as goals and achievements of NLEP; diagnostics with focus on different forms of disease including neuritic leprosy; newer methods such as imaging for studying CNS involvement; response to therapy; drug resistance in the context of relapses, poor responders, reactions and multibacillary leprosy, transmission, methods and strategies for detection of drug resistance and its surveillance; national and global perspective etc. The Symposium concluded with a plenary session for the road map of a future strategy with recommendations which include molecular detection of drug resistance with focus on relapses, reactions and MB leprosy; confirmation of relevance of novel mutations in animals; networks for drug resistance surveillance and epidemiology of drug resistance in leprosy.

Wooden stick penetration from the perineal region up to the thorax / 世界急诊医学杂志（英文）

@#BACKGROUND: Penetrating injuries of the perineum are rare but very dangerous. Since the genitourinary and colorectal organs may be injured, how to evaluate surgical management of the injury is very important. METHODS: The present report presents a case of penetrating injury of the perineum by a wooden stick when the patient fell on the upright wooden stick from a tree. The three feet long stick entered the perineal region just left lateral to the anal opening. Upon reaching the thoracic cavity, it broke and only a foot stick was left in the subcutaneous plane. These injuries are potentially serious with risk of damage to multiple organs. Exploratory laprotomy was done, and bladder injury was repaired. The entry wound and the track of stick was thoroughly washed and allowed for secondary intention healing. RESULTS: The post operative period was uneventful and the patient recovered fully. CONCLUSION: Meticulous evaluation and surgical management of perineal injuries are the key to prevent devastating complications.

Levofloxacin induced psychosis: a rare case report.

Levofloxacin is a commonly prescribed antibiotic for treating bacterial infections in routine clinical practice. A wide range of side-effects have been ascribed to the quinolone group of drugs, the most common being gastrointestinal. Central nervous system is rarely involved; neuropsychiartic complications are among the least reported adverse reactions. We report a rare case of levofloxacin induced acute psychosis in a young male presenting in out-patient department with signs of urinary tract infection along with pneumonitis.