Correlation of Menopausal Status with Body Composition and Abdominal Fat Distribution

Background: Body composition parameters changes in women before and after menopause which makes ageing more complex and stressful in women. Objective: to compare the body composition parameters among pre and post menopausal women. Methods: A cross-sectional study, conducted in the population around Rural Health Training Centre (RHTC), Barabanki district between May to December 2016 among women in the age group 25-65 years. Body composition parameters of 348 women (total and visceral fat distribution) by bioelectric impedance method (for Model: OMRON Hbf 375) was noted for all the pre-menopausal and post-menopausal women. The variables included -weight, BMI, body fat percentage (BF %) and visceral fat percentage (VF %), Body Surface Area (BSA), Body volume index (BVI), Body volume (BV) and Lean body weight (LBM). Result: The difference in body composition parameters in the pre and post-menopausal groups is found to be statistically significant in waist circumference, waist-hip ratio, BMI and visceral fat p<0.05. Conclusion: There is increase in body composition parameters during post-menopausal period. A deeper aspect on prevention of obesity after menopause is required to be studied.

A RARE CASE REPORT OF ALVEOLAR RHABDOMYOSARCOMA IN VAGINA OF YOUNG FEMALES

Alveolar rhabdomyosarcoma in a rare aggressive tumour which manifests in children and young adults. The site of alveolar rhabdomyosarcoma in vagina is also extremely rare. We presented a case report of 38 yrs.lady who was having complain of intermenstrual bleeding & discharge per vaginum from last 6 months. A large fleshy infiltrative bluish friable mass (3*3cm) present at the junction of middle rd rd and upper 1/3 and upper 1/3 of posterior vaginal wall . Another similar mass (2* 2cm) was also present in the lateral vaginal wall. Wide excision of both growth was done & postoperatively chemotherapy was given.

Does faulty feeding practices act as a driver to undernutrition? A comparative study on rural and urban preschool children in Western Uttar Pradesh

Background: India is home to the largest number of underweight and stunted children in the world. While several studies have focused on the determinants of child’s nutrition status in India, little attention has been given to the aspect of rural-urban variation in child’s nutritional status. Bearing in mind that around 70% of India’s population resides in the rural area, the study of rural-urban divergence in nutritional status as indicator can be appreciated naturally. Objective: The objective of the study is to compare the feeding practices of children in the initial six months of life in rural and urban setting and to find out any relation between early feeding practices and nutritional status of young children. Materials and Methods: A community-based study was conducted for 2 months in the field practice areas of a tertiary care hospital. Multistage random sampling technique was used for the selection of study subjects. A total of 117 under-five children were studied equally from rural and urban area. A pre-designed pre-tested proforma was used to assess the feeding practices. Stunting and underweight were used to proxy the child nutrition status. Data were evaluated on SPSS version 17. Chi-square test was used to compare the feeding practices and to find out their association with nutritional status in the two areas. Results: Undernutrition was found in children who initiated early artificial feeds, i.e., in the first 6 months of life, were given over diluted milk, were bottle fed, and had inappropriate weaning practices in both the areas. Conclusions: Faulty feeding practices were found in both areas, but some of the parameters were still better in urban areas. Faulty feeding practices were found to be a significant predictor for undernutrition.

Comparative study between liquid-based cytology & conventional Pap smear for cytological follow up of treated patients of cancer cervix

Background & objectives: Cancer cervix is one of the most common forms of genital malignancy among Indian women. Recurrence is seen in a significant number of cases. The conventional cervical smear technique has inherent problems and screening and interpretation errors. This study was undertaken to assess the efficacy of liquid-based cytology (LBC) as a method for cytological follow up and detection of recurrence in treated cases of cancer cervix and to compare it with conventional Pap smear technique to find the best screening method for detection of recurrence in these patients. Methods: This cross-sectional study was conducted over a period of one year. Patients attending Gynecology and Radiotherapy outpatient departments for follow up after treatment of cancer cervix were included. Pap smear and LBC were taken in all cases. Colposcopy and biopsy were done for those having epithelial cell abnormality in cytology report. Colposcopy and biopsy were taken as gold standard for diagnosis of cancer cervix recurrence. Results: Ninety four treated patients of carcinoma cervix were studied. The diagnostic accuracy for detection of recurrence of conventional Pap smear was 79.16 per cent, and that of LBC was 97.6 per cent. The difference between the two methods was significant (P<0.001). Interpretation & conclusions: Our findings showed that LBC performed better than the conventional method of cytology to detect recurrence of squamous cell carcinoma. Its sensitivity, specificity as well as accuracy were much higher than conventional method. LBC can be a better method of cytological follow up of post-treated patients of cancer cervix.

Are Early Onset Alcoholics Different : A Cross Section Observational Study from a General Hospital Psychiatry Unit.

Introduction: Alcohol dependence syndrome has been fraught with significant biopsychosocial problems. Early age of onset of initiation has been seen to complicate the issues further. Method: Clinico-psycho-social profile of all patient of alcohol dependence syndrome admitted to a general hospital psychiatric unit was assessed. Results: Ment age of onset was 25.42 years and that of first medical contact was 38.29 years. Age of onset had significant association with increased amount of alcohol consumption, early age of medical consulation, Presence of delirium, coexisting depression and deranged liver enzymes. Conclusion: Early onset of alcohol consumption had significant impact on course and outcome of the alcohol dependence syndrome. Effective strategies be formulated for early referral and targeted management.

Managing immunisation waste in a tertiary healthcare facility.

Immunisation protects children and adults against harmful infections before they come into contact with them in the community. Immunisation is given as an injection or, in the case of polio vaccine, taken as drops by mouth. The waste generated during the whole immunisation process must be disposed off properly. Improper waste disposal leads to serious health risks to recipients, health workers and the public. In King George’s Medical University (KGMU) immunisation programmes are conducted regularly. Waste generated during the process are properly mutilated, collected, transported and disposed off. In KGMU a well established biomedical waste management system which disposed offs the waste as per the norms and legislation.

Screening of efficient arbuscular mycorrhizal fungi for Azadirachta indica under nursery condition: a step towards afforestation of semi-arid region of western India

To optimize nursery practices for efficient plant production procedures and to keep up to the ever growing demand of seedlings, identification of the most suitable species of arbuscular mycorrhizal fungi (AMF), specific for a given tree species, is clearly a necessary task. Sixty days old seedlings of Neem (Azadirachta indica A. Juss) raised in root trainers were inoculated with six species of AMF and a mixed inoculum (consortia) and kept in green house. Performances of the treatments on this tree species were evaluated in terms of growth parameters like plant height shoot collar diameter, biomass and phosphorous uptake capabilities. Significant and varied increase in the growth parameters and phosphorous uptake was observed for most of the AMF species against control. Consortia culture was found to be the best suited AMF treatment for A.indica, while Glomus intraradices and Glomus mosseae were the best performing single species cultures. It is the first time in the state of Gujarat that a wide variety of AMF species, isolated from the typical semi-arid region of western India, were tested for the best growth performance with one of the most important tree species for the concerned region.

Effect of efflux pump inhibitors on drug susceptibility of ofloxacin resistant Mycobacterium tuberculosis isolates.

Background & objectives In drug resistant, especially multi-drug resistant (MDR) tuberculosis, fluoroquinolones (FQs) are used as second line drugs. However, the incidence of FQ-resistant Mycobacterium tuberculosis is rapidly increasing which may be due to extensive use of FQs in the treatment of various other diseases. The most important known mechanism i.e., gyrA mutation in FQ resistance is not observed in a significant proportion of FQ resistant M. tuberculosis isolates suggesting that the resistance may be because of other mechanisms such as an active drug efflux pump. In this study we evaluated the role of the efflux pumps in quinolone resistance by using various inhibitors such as carbonyl cyanide m-chlorophenyl hydrazone (CCCP), 2,4-dinitrophenol (DNP) and verapamil, in clinical isolates of M. tuberculosis. Methods A total of 55 M. tuberculosis clinical isolates [45 ofloxacin (OFL) resistant and 10 ofloxacin sensitive] were tested by Resazurin microtitre assay (REMA) to observe the changes in ofloxacin minimum inhibitory concentration (MIC) levels in presence of efflux inhibitors as compared to control (without efflux inhibitor). Results The MIC levels of OFL showed 2-8 folds reduction in presence of CCCP (16/45; 35.5%), verapamil (24/45; 53.3%) and DNP (21/45; 46.6%) while in case of isolates identified as OFL sensitive these did not show any effect on ofloxacin MICs. In 11 of 45 (24.5%) isolates change in MIC levels was observed with all the three inhibitors. Overall 30 (66.6%) isolates had reduction in OFL MIC after treatment with these inhibitors. A total of eight isolates were sequenced for gyrA gene, of which, seven (87.5%) showed known mutations. Of the eight sequenced isolates, seven (87.5%) showed 2 to 8 fold change in MIC in presence of efflux inhibitors. Interpretation & conclusions Our findings suggest the involvement of active efflux pumps of both Major Facilitator Super Family (MFS) family (inhibited by CCCP and DNP) and ATP Binding Cassette (ABC) transporters (inhibited by verapamil) in the development of OFL resistance in M. tuberculosis isolates. Epidemiological significance of these findings needs to be determined in prospective studies with appropriate number of samples / isolates.

In vitro effect of fl uoroquinolones against Mycobacterium tuberculosis isolates from Agra & Kanpur region of north India.

Background & objectives: Fluoroquinolones (FQs) are important drugs used for treatment of drug resistant tuberculosis and are also now being considered as fi rst line drugs to shorten the duration of treatment of tuberculosis (TB). In order to fi nd out useful FQs for treatment of tuberculosis, the comparative effi cacy of fi ve FQs, namely, ofl oxacin (OFL), ciprofl oxacin (CIP), sparfl oxacin (SPX), gatifl oxacin (GAT) and levofl oxacin (LEVX) was studied against Mycobacterium tuberculosis (MTB) isolates obtained from both treated and untreated patients from Agra and Kanpur regions of north India. Methods: A total of 162 MTB isolates [including 110 MTB isolates obtained from untreated patients (Cat-I) and 52 isolates from treated patients (Cat-II)] were tested for their susceptibilities to FQs using standard minimum inhibitory concentration (MIC) method on Löwenstein-Jensen medium. Results: Keeping in view the therapeutically achievable drug levels, it was found that in Cat-I 97.2 per cent (107/110) isolates were sensitive to GAT, 89 per cent (98/110) to LEVX at 1 μg/ml whereas 92.7 per cent (102/110) isolates were inhibited by OFL at 2 μg/ml and 73.6 per cent (81/110) to SPX at 0.5 μg/ml. Only 63.6 per cent (70/110) isolates were found to be sensitive to CIP at 2 μg/ml which increased to 89 per cent (98/110) at 4 μg/ml (higher than achievable peak serum level). On the other hand, among 52 isolates for Cat-II, 37 (71.2%) were found to be sensitive to GAT and 33 (63.5%) to LEVX at 1 μg/ml concentration, 28 (53.8%) to SPX at 0.5 μg/ml whereas 33 (63.5%) and 24 (46.2%) isolates were found to be sensitive to OFL and CIP at 2 μg/ml, respectively. Interpretation & conclusions: It appears that GAT has higher activity against MTB isolates followed by OFL, LEVX and SPX whereas CIP showed the lowest activity. GAT was also found to be the most effective FQ against multi-drug resistant (MDR) isolates both from Cat-I and Cat-II patients. Thus, except CIP, other FQs showed potential to be included in the treatment regimens of tuberculosis including MDR-TB.

Isolation of Mycobacterium bovis & M. tuberculosis from cattle of some farms in north India--possible relevance in human health.

BACKGROUND & OBJECTIVE: Infection due to Mycobacterium bovis typically occurs in cattle and animals transmit infection to each other. The choice of appropriate clinical specimen is very important for isolation of M. bovis and M. tuberculosis from cattle. The present study reports the isolation of M. tuberculosis and M. bovis from different types of specimens from cattle suspected to be suffering from tuberculosis in certain organized cattle farms in north India. METHODS: A total of 768 specimens (heparinized or EDTA containing blood (162), fine needle aspirates from prescapular lymph gland (PSLG,160), milk (154), pharyngeal swab (PhS, 98), rectal pinch (RP, 97) and faecal sample (97) from 161 cattle of organized cattle farms in north India suspected to be suffering from tuberculosis were analyzed. After decontamination by modified Petroff's method isolation of M.tuberculosis complex was done on Lowenstein-Jensen medium (with and without pyruvate). The culture isolates were identified as M. tuberculosis and M. bovis on the basis of biochemical tests. RESULTS: A total of 54 M. tuberculosis complex isolates were obtained, of them 40 were identified as M.bovis and 14 as M. tuberculosis. M.bovis were isolated from 12 of 38 animals in group A (Tuberculin +ve with signs of tuberculosis), 7 of 37 animals in group B (Tuberculin +ve and apparently healthy), 9 of 21 group C animals in (Tuberculin -ve with clinical signs of tuberculosis), 4 of 26 animals in group D (Tuberculin -ve and apparently healthy), 4 of 27 group E animals (having non-mycobacterial infection) and 4 of 12 animals in group F (having clinical signs such as debilitated condition, cough, decreasing milk production, etc). Maximum number of M. bovis (19/40, 47.5%) and M. tuberculosis (5/14, 35.7%) isolates were grown from prescapular lymph gland biopsy (PSLG) followed by blood from which 9/40 (22.5%) M. bovis and 4/14 (28.5%) M. tuberculosis were isolated. M. bovis [6/40(15%)] and M. tuberculosis [4/14(28.5%)] were also isolated from milk. Only 3/40 (7.5%) isolates of M.bovis could be isolated from 97 rectal pinch followed by 98 pharyngeal swab 2/40 (5%) and 97 fecal samples 1/40 (2.5%) while 1/14 (7.1%) M.tuberculosis isolates were obtained from pharyngeal swab. INTERPRETATION & CONCLUSION: Among the samples analyzed, PSLG was found to be most suitable specimen for isolation of M. tuberculosis complex from cattle and is thus of diagnostic importance. M. bovis in milk indicates the need to investigate the transmission to human in such settings. Isolation of M. bovis and/or M. tuberculosis from apparently healthy cattle indicates sub-clinical infection in the herd. Further, isolation of a significant number of M. tuberculosis from cattle suggests possible human-to-cattle transmission which need to be confirmed by prospective studies including tools like DNA fingerprinting.

Simultaneous use of two PCR systems targeting IS6110 and MPB64 for confirmation of diagnosis of tuberculous lymphadenitis.

PCR has emerged as a powerful technique for detection of various pathogens including Mycobacterium tuberculosis. In present study, eighty one samples of lymph node biopsies from clinically suspected cases of tuberculous lymphadenitis were examined for AFB, culture on Löwenstein Jensen medium and simultaneous use of two PCRs targeting IS6110 and MPB64. Positivity with M. tuberculosis culture and AFB was 13.6% and 28.4% respectively. All samples culture positive for nontuberculous mycobacteria were negative by both PCR systems. Higher proportion of positive results were observed with PCR targeting IS6110 by which 56 of 81 (69.1%) samples showed positive results as compared to PCR targeting MPB64 by which 39 of 81 (48.2 %) samples showed positive results. When combined, 63 out of 81 (77.8%) samples were detected positive for M. tuberculosis DNA. However, 7/81 (8.6 %) samples remained negative by IS6110 but positive by MPB64 method. Thus our data suggest that the use of one additional PCR (other than IS6110 system) can reduce false negativity of PCR results in the samples harboring zero copy of IS6110 element which is known to exist in Indian population.

Estimation of efflux mediated multi-drug resistance and its correlation with expression levels of two major efflux pumps in mycobacteria.

Multidrug resistance has been posing an increasing problem in the treatment of tuberculosis. Mutations in the genomic targets of drugs have been identified as the major mechanism behind this resistance. However, high degree of resistance in some isolates towards major drugs like rifampicin, isoniazid, ethambutol and streptomycin can not be explained solely on the basis of mutations. Besides this, certain other mechanisms like efflux pumps have also been considered as alternative mechanisms in the drug resistant isolates where there is no mutation and these mechanisms are specially important for drug resistance in non-tuberculous mycobacteria (NTM). In this study, we have estimated efflux pump mediated drug resistance in different mycobacterial species with the help of efflux pump inhibitors. All major anti-tuberculous drugs have been shown to be extruded by efflux pumps and the degree to which these drugs are extruded, vary in different mycobacterial species and isolates. The correlation of this resistance with functional activity of two major efflux pump genes pstB and Rv1258c was also assessed by reverse transcription PCR. Besides the significant role of these pumps observed, other efflux pumps, present in mycobacteria, may also be involved in drug resistance and need to be investigated.

Protective role of BCG vaccination against tuberculous meningitis in Indian children: a reappraisal.

BACKGROUND: The protective role of BCG vaccination against tuberculous meningitis (TBM) is still controversial in India, largely due to the presence of other predisposing factors such as age, nutritional and socioeconomic status, and household contact. Very few Indian studies have focused on the interaction between BCG and these factors on the occurrence of TBM. METHODS: We did an unmatched hospital-based case-control study with prospective enrolment. Children with TBM diagnosed on the basis of predefined criteria were enrolled as cases. For each case, two children admitted on the same day and who did not have any neurological symptoms were enrolled as controls. Demographic data and information on predisposing factors for tuberculosis were collected for both cases and controls and the presence of a BCG scar was charted. Cases and controls were compared by univariate followed by multivariate analysis to obtain significant independent predictors for the occurrence of TBM. To assess the interaction between other predisposing factors and protective efficacy of BCG, a stratified analysis was also done. RESULTS: A total of 91 cases and 182 controls were enrolled over a one-year study period, of which 37 cases and 111 controls had a BCG scar. The crude odds ratio for the occurrence of TBM in the absence of a BCG scar was 2.28 (range: 1.32-3.94). The time elapsed since vaccination was significantly longer in the cases. Also, the proportion with a household contact was significantly higher in the cases, the mean age of the cases was higher than that of the controls, and the mean weight and height for age percentage were significantly lower. The cases had a significantly lower socioeconomic status. On multivariate analysis, the significant independent predictors for the occurrence of TBM were positive household contact with tuberculosis (adjusted OR 4.26; 95% CCI 2.26-8.04), absent BCG scar (adjusted OR 1.98; 95%ClI 1.09-3.57) and rural residence (adjusted OR 2.07; 95% ClI 1.02-4.17). CONCLUSION: Vaccination with BCG was found to be protective even after controlling for the effect of other variables. Stratified analysis showed that protection due to BCG failed to reach significance for those > 5 years of age, if the weight was <6 0% of that expected for age, in the presence of a household contact with tuberculosis, and in socioeconomic classes III, IV and V.

Correlation of mutations detected by INNO-LiPA with levels of rifampicin resistance in Mycobacterium tuberculosis.

BACKGROUND & OBJECTIVES: Due to emergence of drug resistance in Mycobacterium tuberculosis, there is a need to have accurate and rapid methods for detection of drug resistance to important drugs like rifampicin. The present study was aimed at evaluation of a commercially available INNO-LiPA assay, for the detection of mutation in rpoB gene region of M. tuberculosis and correlate these mutations with levels of rifampicin resistance for assessing their clinical relevance. METHODS: Fifty five well-characterized isolates of M. tuberculosis deposited from various regions of India in Mycobacterial Repository Centre at the CJILOMD, Agra were subjected to susceptibility testing for rifampicin at various concentrations of drug viz., 10, 40, 64, 128 microg/ml on Lowenstein- Jensen (LJ) medium. rpoB gene fragment (260 bp) was amplified using Rif-TB amplification kit and after hybridization, detection was done by using INNO-LiPA Rif TB kit. RESULTS: The rpoB gene could be amplified from DNA extracted from all the 55 culture isolates and showed clear hybridization pattern with M. tuberculosis complex specific probes on LiPA strips. Mutations detected were correlated with degree of rifampicin resistance. All the sensitive isolates (identified by MIC) were identified as rifampicin sensitive (100%) by INNO-LiPA as they exhibit positive for wild type 'S' probes and negative for 'R' probes. Two of the 5 isolates, resistant at 10 microg/ml and 40 microg/ml had either D516V, H526Y mutations or unknown mutations. Thirty (85.71%) isolates resistant at clinically relevant levels (64,128microg/ml) exhibited double, triple or more 'R' type mutations (R(2(D516V)), R(4a(H526Y)), R(4b(H526D)), R(5(S531L))) as well as unknown mutations present at 'S' probes region whereas remaining isolates did not show any mutation by this method. This method could identify with definitiveness 60 per cent ( 21/35) isolates as rifampicin resistant as mutations observed in others were also present in isolates with low levels of resistance. INTERPRETATION & CONCLUSION: The results indicate that INNO-LiPA Rif TB test is a rapid and easy to use method for detection of mutations associated with rifampicin resistance in M. tuberculosis. However, as some of these mutations are also present in isolates with low degree of resistance which are still microbiologically sensitive to rifampicin, there is a need to improve this assay by exclusion of some of the current probes and inclusion of more probes.

Five year clinico pathological study of breast cancer.

Breast cancer is a prototype for exploring variations in pathological diagnosis and etiology. BASIC PROCEDURE: We analysed the various risk factors, age, Tamoxifen treatment and pathological diagnosis for Breast cancer. MAIN FINDINGS: We present a review of 105 cases of breast cancers diagnosed and treated at Dr Ram Manohar Lohia Hospital in a five years prospective study between 1997 and 2002. Breast cancer was most commonly found in age group 30-40 years and infiltrating carcinoma of breast was the commonest occurring in 90% of the cases. IMPLICATIONS: We demonstrated the utility of such study of ensuring greater equity and understanding in etiology. The risk factors and pathological diagnosis in cancer of breast were studied and need for comprehensive screening programme were outlined.

A preliminary report on characterization and identification of non tuberculous mycobacteria (NTM) on the basis of biochemical tests and protein / isoenzyme electrophoretic patterns.

PURPOSE: To assess the usefulness of protein electrophorograms and protein zymodemes in the identification and characterization of non tuberculous mycobacteria (NTM). METHODS: Cell free extracts (CFEs) from 22 mycobacterial isolates belonging to slow growing and other clinically relevant species were included in the study. The strains isolated from the environment were identified on the basis of their standard biochemical tests; pigmentation and growth characters. The CFEs were electrophoresed and stained for proteins and esterases. RESULTS: Most of the isolates identified on the basis of biochemical tests exhibited characteristic protein and esterase pattern for M.scrofulaceum, M.avium and M.xenopi. Others showed variations in their proteins and esterase pattern though they were identified as M.scrofulaceum, M.avium and M.xenopi. CONCLUSIONS: Based on these studies it appears that because of variability in the protein and isoenzyme patterns of NTM, it may be advisable to use them along with biochemical tests and other tests for identifying and characterizing the different mycobacterial species belonging to slow growers.

Rapid discrimination of Indian isolates of m.tuberculosis by random amplified polymorphic DNA (RAPD) analysis - A preliminary report.

PURPOSE: Due to relatively complex nature of molecular typing systems for M. tuberculosis as well as lack of applicability of some of the probes, there is a need for alternate procedures for molecular epidemiology. In this study the usefulness of RAPD analysis for typing of Indian strains of M.tuberculosis was investigated. METHODS: One hundred and three coded isolates from different parts of the country were analysed by Random amplified polymorphic DNA (RAPD) technique. Purified and amplified DNA from cultures were analysed by ethidium bromide staining after electrophoresis. The bands were confirmed by densitometry and the patterns were analysed by hierarchical cluster analysis. RESULTS: The patterns elicited by the analysis appeared to be quite discriminatory and characteristic. CONCLUSIONS: Clustering observed among isolates attending the same hospital indicates future application potential of RAPD analysis for molecular epidemiology of tuberculosis in India.

Drug susceptibility profiles of mycobacterium tuberculosis isolates at Jaipur.

PURPOSE: To find prevalence of drug resistance in Mycobacterium tuberculosis isolated from patients attending SMS Medical College, Jaipur during 1997-99. METHODS: Sputum samples from 164 patients with pulmonary tuberculosis were processed and cultured on Lowenstein Jensen medium and M.tuberculosis isolates were tested for drug sensitivity. RESULTS: M. tuberculosis was isolated in 122/164 (74.3%) samples and comprised 97.6% (122/125) of mycobacterial isolates. There were only three isolates of nontuberculous mycobacteria -one each of M.kansasii, M.avium and M.fortutium. Primary drug resistance in M.tuberculosis was estimated to be 3/44 (6.8%) to rifampicin, 6/44 (13.6%) to isoniazid and 2 strains (4.5%) were multi drug resistant i.e. resistant to both rifampicin and isoniazid. Among the isolates from cases with previous history of treatment of varying duration (acquired drug resistance) resistance to rifampicin was estimated to be 28.2% and for isoniazid to be 39.7%. 24.3% strains of these drug resistant isolates were multi drug resistant. CONCLUSIONS: While this information may not reflect true prevalence of drug resistance in the region this may help in further planning long term surveillance studies to know the trend of drug resistance in this area.

Peri-operative management of patients for video assisted thoracoscopic thymectomy in myasthenia gravis.

Three patients of myasthenia gravis, who under went video-assisted thoracoscopic surgery (VATS) were given general anaesthesia by propofol infusion and muscle relaxation by atracurium infusion. Isoflurane was added to control depth of anaesthesia on the basis of haemodynamic changes during surgery. One lung ventilation (OLV) was achieved by placement of Carlens left sided double lumen bronchocatheter. Right-sided surgical approach was used to perform thymectomy. Contrary to claimed short duration of surgery, in first patient, OLV lasted for 10 hours 30 minutes and patient developed re-expansion pulmonary oedema. OLV in second and third patient was for six hours thirty minutes and three hours 45 minutes respectively. Morning dose of pyridostigmine was omitted and atracurium (0.1 mg/kg) was found to be satisfactory for intubation and relaxation was maintained with atracurium infusion to get desired monitored effect. We could not extubate our patients due to longer duration of surgery and the sequelae there off. Post-operative elective ventilation and spontaneous weaning off the atracurium effect was thus preferred.