Predicting pregnancy outcomes from homocysteine level: an evidence from a North Indian study

Background: Hypertensive disorders of pregnancy are a major cause of adverse pregnancy outcomes. Though the etiology of spectrum of vascular disorders of pregnancy is still not understood completely, yet abnormally elevated homocysteine level has been implicated in the causal pathway and pathogenesis. Hyperhomocysteinemia has been significantly associated with increased risk of poor maternal and foetal outcomes in terms of PIH, abruption, IUGR, recurrent pregnancy loss, intrauterine death and prematurity.Methods: The present prospective study was conducted among 180 pregnant women (57 exposed and 123 non exposed) in Kamla Nehru State Hospital for Mother and Child, IGMC Shimla, Himachal Pradesh with an objective of determining association of abnormally elevated homocysteine level in pregnancy and adverse pregnancy outcomes. Socio-demographic, clinical, biochemical including homocysteine level, laboratory, ultrasonographic parameters and foeto-maternal outcomes of pregnancy of all the participants were documented.Results: The mean homocysteine level of exposed group (23.26±10.77 µmol/L) was significantly higher than the unexposed group (8.99±2.47 µmol/L). Among hyperhomocysteinemic subjects, 10.5% had abruption, 15.8% had PRES and 8.7% PPH which was significantly higher than normal subjects. Similarly, patients with homocysteinemia had significantly higher proportion (21.3%) of poor Apgar score, more (41.9%) NICU admissions and higher frequency (4.7%) of meconium aspiration syndrome.Conclusions: The present study generates necessary evidence for associating abnormally elevated homocysteine levels with pregnancy related hypertensive ailments and adverse pregnancy outcomes. It further demands the need of robustly designed studies and trials to further explore the phenomenon. Moreover, it emphasizes on a simple and timely intervention like estimating the much-neglected homocysteine levels during pregnancy which can definitely contribute in predicting and preventing adverse perinatal outcomes.

Predictors of co-morbidities in chronic obstructive pulmonary disease patients at a tertiary care centre in north India

Background: Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable disease that is characterised by persistent respiratory symptoms and airflow limitation. COPD is characterised by an intense inflammatory process in the airways, parenchyma, and pulmonary vasculature. It is possible in some cases that the inflammatory process may overflow into the systemic circulation, promoting a generalised inflammatory reaction. Patient with COPD often have concomitant chronic illness (co-morbidities). The aim of this study is to know the pattern of co-morbidities in COPD patients.Methods: This study was a cross sectional observational study conducted on 172 COPD patients (IPD and OPD) diagnosed on the basis of GOLD guideline 2017. Co morbidities were diagnosed as per standard defined criteria laid down in the respective guidelines.Results: 55.3% of the patients with COPD had co morbidities. 18/88(20.5%) patients presented with multiple co-morbidities. 49/88, 55.7% COPD patients were affected with cardiac (either only cardiac or had multiple organs affected besides cardiac), the commonest co-morbidity. Amongst cardiac, hypertension and congestive heart failure (CHF) was the commonest (n=19/49, 38.8% each) followed by CAD/CSA/IWMI/IHD/AF. Others were metabolic (n=14/88, 15.9%), GERD (n=13/88, 14.8%), Depression (n=11/88, 12.5%). Less prevalent co-morbidities were Osteoporosis (n=8/88, 9.1%), Lung cancer (n=6/88, 6.8%), Bronchiectasis (n=5/88, 5.6%) and OSA (n=3/88, 3.4%).Conclusions: Urban indwelling, advancing age and duration of illness, presentation with low mood, loss of pleasure/ interest, appetite disturbances and heart burn with relief on taking proton pump inhibitor can be predictors of co-morbidities in COPD patients. Chance of finding co-morbidities may be multifactorial. Thus, it is important to look out for co morbidities in each and every COPD patients.

Role of adipokines in obstructive airway disease and diabetes mellitus

This review summarizes the state of the current literature relating to the associations of lung disease and adipokines (proteins produced by adipose tissue) in humans. The mechanistic basis for these associations in humans is not established, although a possible role for adipokines has been invoked. Leptin, a pro-inflammatory adipokine, and adiponectin, an anti-inflammatory adipokine, are causally associated with asthma in mice. Although human studies are currently inconclusive, high-serum leptin and low-serum adiponectin concentrations predict asthma, independent of obesity, in select population groups, such as premenopausal women in the United States. In contradistinction, low-serum leptin and high-serum adiponectin concentrations are associated with stable COPD, although these associations are likely confounded by fat mass. Interestingly, leptin may promote systemic and airway inflammation in stable COPD patients. On the other hand, COPD may upregulate systemic and lung adiponectin expression. The precise mechanism and significance of the associations between these adipokines and lung disease at the current stage are confusing and frankly paradoxical in places. It is now known that adipose tissue is not an inert organ simply for energy storage, but regulates systemic inflammation via a variety of secreted proteins (called adipokines). While the associations of obesity and adipokines with cardiovascular, endocrine, and rheumatological diseases are well described, the respiratory effects of obesity and adipokines are less well known. This review will focus on the effect of obesity and adipokines on asthma and chronic obstructive pulmonary disease (COPD) in humans. This area of research needs additional study that may open up novel therapeutic strategies for these lung diseases.

Can serum homocysteine predict hypertensive disorders of pregnancy?: an evidence from a case control study in a North Indian tertiary health care institution

Background: Hypertensive disorders of pregnancy are a major cause of both maternal and foetal morbidity and mortality. Although pregnancy induced hypertension (PIH) is still regarded as a disease of theories and unknown etiology, elevated homocysteine level has been hypothesized as a key risk factor. Abnormally raised homocysteine has been significantly associated with increased risk of PIH, abruption, intrauterine growth restriction, recurrent pregnancy loss, intrauterine death and prematurity.Methods: The present case control study was conducted among 180 pregnant women (90 cases and 90 controls) in Kamla Nehru State Hospital for Mother and Child, IGMC Shimla, Himachal Pradesh with an objective of ascertaining the role of homocysteine in pregnancy related hypertensive disorders. Socio-demographic, clinical, biochemical including homocysteine level, laboratory and ultrasonographic parameters of all the participants were documented.Results: The mean homocysteine level of cases (18.30±10.81) was significantly higher than the controls (8.70±2.64).  About 62.2% cases had abnormally raised homocysteine level (>15 µmol/L), while only 1.1% controls had such level. The odds of a case having abnormally elevated homocysteine level were 146.6 (CI: 19.52-1101) times to that of controls. Eclamptics had the highest homocysteine level followed by preeclamptics and controls.Conclusions: The present study significantly associates the abnormally elevated homocysteine levels with pregnancy related hypertensive ailments and demands much needed robustly designed studies to further explore the phenomenon. A simple intervention like estimating the much neglected homocysteine levels prior to pregnancy can definitely aid in predicting and preventing perinatal outcomes.

Consequences of antepartum hemorrhage and its maternal and perinatal outcome

Background: Antepartum haemorrhage, a life-threatening event, is defined as bleeding per vaginum occurring after the fetus has reached the period of viability, considered to be 20 weeks in developed countries and 28 weeks in countries with low resource settings. We evaluated the consequences of antepartum haemorrhage, their maternal and perinatal outcome so as to outline the proper management of patient in order to improve both maternal and perinatal morbidity and mortality.Methods: This one-year prospective study totaled 133 cases of APH fulfilling the inclusion criteria were studied. Data was recorded on the MS excel sheet for further analysis and processing.Results: Total 6693 deliveries were conducted out of which 133 presented as APH and incidence of APH was found out to be 1.98%. Placenta previa was most common. APH was commonly associated with multigravida and most cases were in age group of 26-30 years. Most of the PP and abruption cases were admitted at 34-37 weeks and 31-33 weeks respectively. High risk factors included previous LSCS and D and C, hypertension, multiple pregnancies and malpresentations. Most of the patients underwent preterm LSCS. Most fetal complications were due to prematurity. 58.6% patients were transfused blood. Overall perinatal mortality was 20.1% and maternal mortality was zero.Conclusions: Early diagnoses, timely referrals and transfusion facilities along with trained team of doctors with well-equipped ICU facility goes a long way in avoiding APH related maternak and fetal complications.

Clinical and angiographic profiles and six months outcomes of smokers with acute ST segment elevation myocardial infarction undergoing primary percutaneous coronary angioplasty

Background Outcomes of primary percutaneous coronary intervention (PCI) for acute STEMI (ST-segment elevation myocardial infarction) in smokers are expected to be better than non-smokers as for patients of acute STEMI with or without fibrinolytic therapy. Objectives This comparative study was designed to evaluate the outcomes of primary PCI in patients with acute STEMI in smokers and non-smokers. Clinical and angiographic profile of the two groups was also compared. Methods Over duration of two year, a total of 150 consecutive patients of acute STEMI eligible for primary PCI were enrolled and constituted the two groups [Smokers (n = 90), Non-smokers (n = 60)] of the study population. There was no difference in procedure in two groups. Results In the present study of acute STEMI, current smokers were about a decade younger than non-smokers (p value = 0.0002), majority were male (98.9% vs 56.6%) were male with a higher prevalence of hypertension and diabetes mellitus (61.67% vs 32.28% and 46.67% vs 14.44%, p = 0.001) respectively. Smokers tended to have higher thrombus burden (p = 0.06) but less multi vessel disease (p = 0.028). Thirty day and six month mortality was non-significantly higher in smokers 4.66% vs 1.33% (p = 0.261) and 5.33% vs 2.66% (p = NS) respectively. Rate of quitting smoking among smokers was 80.90% at 6 months. Conclusion The study documents that smokers with acute STEMI have similar outcomes as compared to non smokers with higher thrombus burden and lesser non culprit artery involvement. Smokers present at much younger age emphasizing the role of smoking cessation for prevention of myocardial infarction.

Radiation therapy outcomes in muscle invasive urinary bladder cancer: A single institution experience.

INTRODUCTION: To audit the survival outcomes and loco‑regional control in muscle invasive urinary bladder cancer patients treated with external beam radiation therapy (RT). MATERIALS AND METHODS: From November 2008 through December 2011, 50 consecutively diagnosed muscle invasive urinary bladder carcinoma (T2‑4a N0‑2, M0) patients were included in this retrospective study. All these patients received external beam RT to a median dose of 60 Gy (range 30‑66 Gy), and were not suitable for radical surgery due to patients’ preference or medical comorbidities. A stepwise procedure using proportional hazard regression was used to identify prognostic factors with respect to survival. RESULTS: Completion trans‑urethral resection of bladder tumor was done in 38 (76%) patients of the cohort and 47 (94%) had transitional cell carcinoma on histopathology. Clinical stage T2 was diagnosed in 40 (80%) patients. The median follow‑up for the entire cohort was 14 ± 8.9 months (range 1‑36 months). In conclusion, 24 patients (48%) were free of disease, 5 patients (10%) had residual disease, and 13 patients (26%) had died of disease. Two‑year and 3 year overall survival of intact bladder for the entire cohort was 58% and 43.6%, respectively. Cox regression modeling strongly suggested clinical stage (P = 0.01) and RT dose (P = 0.001) as being predictors for overall survival. CONCLUSION: RT shows reliable outcomes and excellent compliance in this advanced disease. Prescribing a higher RT dose could potentially correlate to better intact bladder control rates while maintaining good quality of life in selected patients.

Co-existence of Carcinoma Tongue with Pulmonary Tuberculosis.

We present the case of a 45-year-old male diagnosed to have carcinoma base of tongue, whose chest radiograph showed bilateral lung infiltrates and was referred for evaluation of suspected pulmonary metastases. Diagnostic evaluation confirmed the diagnosis of smear-positive pulmonary tuberculosis.

Clinico-pathological Profile of Bronchogenic Carcinoma Among Females in North India.

Objective. The present study was undertaken to explore the clinico-pathological profile of bronchogenic carcinoma among females. Methods. One hundred and twenty-four female patients with histopathologically proven bronchogenic carcinoma who were hospitalised in the Department of Pulmonary Medicine, King George’s Medical University, Lucknow from July 1985 to February 2007 were retrospectively studied. Results. Their mean age was 61 years; 12.9 % of these were less than 40 years of age. Of these, 79% of female patients of lung cancer were first regarded as pulmonary tuberculosis; 76% belonged to rural area. Use of biomass fuel and kerosene oil exposure was the predominant risk factors evident among the 116 non-smoker women. Adenocarcinoma was observed in 43.5%, followed by squamous cell carcinoma in 33.1% and the remaining 23.4% cases were small cell carcinoma. The majority (77.4%) of non-small cell lung cancer (NSCLC) patients had advanced stage disease (IIIb and IV) and 58 % of small cell lung cancer (SCLC) patients had limited disease and 42 % of SCLC patients had extensive disease at the time of diagnosis. Conclusion. Adenocarcinoma was found to be the most common histopathological type of bronchogenic carcinoma among these females.

Medical Thoracoscopy: A Useful Diagnostic Tool for Undiagnosed Pleural effusion.

Objective. We aimed to assess the role of medical thoracoscopy in patients with undiagnosed pleural effusion. Methods. Patiens presenting with pleural effusion underwent three pleural aspirations. Patients in whom pleural fluid analysis was inconclusive underwent closed pleural biopsy for diagnostic confirmation. Patients in whom closed pleural biopsy was incolcusive underwent medical thoracoscopy using a rigid thoracoscope with a viewing angle of zero degrees was done under local anaesthesia and sedation with the patient lying in lateral decubitus position with the affected side up. Biopsy specimens from parietal pleura were obtained under direct vision and were sent for histopathological examination. Results. Of the 128 patients with pleural effusion who were studied, pleural fluid examination established the diagnosis in 81 (malignancy 33, tuberculosis 33, pyogenic 14 and fungal 1); 47 patients underwent closed pleural biopsy and a diagnosis was made in 28 patients (malignancy 24, tuberculosis 4). The remaining 19 patients underwent medical thoracoscopy and pleural biopsy and the aetiological diagnosis could be confirmed in 13 of the 19 patients (69%) (adenocarcinoma 10, poorly differentiated carcinoma 2 and mesothelioma 1). Conclusion. Medical thoracoscopy is a useful tool for the diagnosis of pleural diseases. The procedure is safe with minimal complications.

Anthelmintic potential of herbal drugs.

The present paper deals with the field observations recorded on the traditional indigenous therapeutic applications of the plants Butea monosperma (Lam.) seeds used by the inhabitants of the Sagar district, M.P. (India). Even today a number of plants of the local flora are used for curing various ailments and diseases. The information is given in a tabular form as scientific names of plants in alphabetic order followed by family, part used, effective against, and target animals. Information on local/vernacular names of plants, uses, parts used names of ailments and modes of usage are given in detail. Information on traditional uses and commercial uses as well as biological activities of the related species is included on the basis of the existing relevant literature so as to present a comprehensive account. In this review we compiled available literatures from libraries, scientific journals and online database query’s on plants and remedies used in traditional medicinal systems for such diseases.

IgG subclass responses to proinflammatory fraction of Brugia malayi in human filariasis.

Background & objectives: Earlier we demonstrated that immunization with F6, a proinflammatory molecular fraction isolated from the human filarial parasite Brugia malayi, protected the host and eliminated the infection in Mastomys coucha by a Th1/Th2 response including IgG2a antibody response. Whether F6 molecules become accessible to human host during natural course of infection and elicit similar response is not known. The present study was undertaken to determine the profile of IgG subclasses specifically reactive to F6 in different categories of bancroftian filariasis cases to infer any relationship between the levels of a particular F6-specific IgG subclass and the infection or disease status. Methods: Serum samples of normal individuals from filariasis non-endemic regions of India like Jammu & Kashmir, Uttarakhand, and Chandigarh [(NEN-W; n=10), healthy subjects from USA (NEN-U; n=10) and three categories of bancroftian filariasis cases from endemic areas: endemic normals (EN; n=10) with no symptoms and no microfilariae, asymptomatic microfilaremics (ASM; n=10) and chronic symptomatic amicrofilaremics (CL; n=10) were assayed for F6-specific IgG1, IgG2, IgG3 and IgG4 by ELISA using SDS-PAGE-isolated F6 fraction of B. malayi adult worms. Results: Significantly high levels of F6-specific IgG1, IgG2 and IgG3 were found in CL (P<0.001) and EN (P<0.01-0.001) bancroftian filariasis cases compared to NEN-U. Significant levels of F6-specific IgG1 (P<0.01) and IgG2 (P<0.01) but not IgG3 were found in ASM cases compared to NEN-U. The most abundant was IgG2 which when compared to NEN-U, was significantly high in CL (P<0.001) and EN cases (P<0.001), followed by ASM (P<0.01). F6-specific IgG4 response in EN, ASM and CL subjects was not significantly different from the levels of NEN-U. Among the non-endemic normals, the NEN-W subjects showed significant reactivity with IgG2 (P<0.001) but not with IgG1, IgG3 and IgG4 as compared to NEN-U subjects. IgG subclass levels were different in different categories. Interpretation & conclusions: The high levels of F6 reactive IgG1, IgG2 and IgG3 in endemic normals and chronic symptomatic bancroftian patients, and IgG1 and IgG2 in asymptomatic microfilaraemics, suggest that F6 molecules of parasite are accessible in these subjects for IgG subclass-specific immune response and IgG2 may be related to pathogenesis. Studies using individual F6 molecules will be done to identify the molecule(s) involved in infection and protective immunity.

The Effect of Mindfulness Meditation on HPA-Axis in Pre-Competition Stress in Sports Performance of Elite Shooters.

Background: Little has been known about the Hypothalamic Pituitary Adrenal (HPA) axis response to pre-competition stress (PCS) and its response to relaxation therapies such as of Mindfulness Meditation Therapy (MMT) on sports population. In shooting sports good physical as well as psychological condition is highly demanded. Researchers have been performed on the psychophysiological responses of MMT on normal and diseased persons, but little has been done on sports population especially in shooters. Objective: The purpose of current study was to estimate the contribution of MMT on Salivary Cortisol (SC), a reliable physiological marker of HPA- axis response in reducing PCS, and its effect on shooting performance (PS). Methods: 96 male elite Shooters, with mean age of 29.5±4.3years were examined as in experimental and control (48 in each). Total duration of the study was five weeks, four weeks of experimental and one week study to determine the follow-up effect. Pre, post and follow-up data of quantitative phenotypic markers of HPA-Axis activity by analysis of SC and PS were analyzed. Results: Compare to control, experimental group has shown significant result, post-intervention (p<0.001) and in follow-up (p<0.001) in SC and in PS. Resulted in reduction of PCS level and increase in PS, whereas the control group has been shown non-significant result (p<0.05).Conclusions: Results indicated that relaxation therapies such as MMT may decrease PCS and will enhance PS. It is concluded that in four weeks of MMT has an effect on HPA-Axis by decreasing the level of SC as a reliable physiological marker of PCS.

Trends of poisoning in rural area of South-West, Punjab.

The study consists of poisoning cases admitted in the emergency department of Adesh Institute of Medical Sciences and Research (AIMSR), Bathinda, situated in rural area of South-West Punjab. Out of all 784 medico-legal cases admitted during the study period of two years (Apr 1st, 2007 to Mar 31st, 2009), 95 (12.1 %) cases were that of poisoning. The cases were then analyzed on various parameters to find the trends and other significant feature of poisoning in this region of Punjab. There were 76 male and 19 female victims involved in this study and maximum cases belonged to second and third decade of life (21.1% and 43.2% respectively). Most common manner of poisoning was suicidal and their attempts (65.3%). Maximum incidences took place at home (64.2%). Most incidences of poisoning occurred between 0801-2000 hours (73.7%) and in the month of August (29.5%). Aluminium phosphide was the leading cause of poisoning (36.8%) followed by insecticides (31.6%). Maximum suicidal/attempts were reported with aluminium phosphide (56.5%) and accidental poisoning with insecticides (48.5%). Out of all 95 cases admitted 70.5% were discharged in a clinically satisfactory condition, 27.4% died and 2.1% were LAMA.

A study to evaluate asbestos fiber burden in lung and pleural malignancies.

Background: There is scarcity of data on asbestos fiber burden in lung and pleural malignancies. Aim: To evaluate asbestos fiber burden in biopsy samples of suspected lung and pleural malignancies. Study Design: This was a single-centre, observational study. Study Period: From August 2010 to July 2010. Setting: Department of Pulmonary Medicine, CSMMU, UP, Lucknow, a tertiary care hospital in India. Study Population: Suspected cases of lung and pleural malignancy. Materials and Methods: Biopsy tissues taken by computed tomography (CT)-guided biopsy, bronchoscopic biopsy, and pleural biopsy by Cope's needle were analyzed for histopathology and asbestos burden by Haq et al.'s method. Results: 20 patients were studied. Mean fiber burden was 9.25 × 10 4 fibers/g. Average burden in lung malignancies (11 patients) was 9.178 × 10 4 fibers/g and in pleural tissue (9 patients) was 9.332 × 10 4fibers/g. Among the different cell types, mean fiber burden in squamous cell carcinoma was 8.99 × 10 4 fibers/g, in adenocarcinoma was 9.71 × 10 4 fibers/g, and in small cell carcinoma was 7.54 × 10 4 fibers/g. Mean fiber burden in bronchoscopic endobronchial biopsy tissue was 10.69 × 10 4 fibers/g, while in CT-guided biopsy was 8.60× 10 4fibers/g. Conclusion: Maximum number of fibers was found in adenocarcinoma.

Profile of medicolegal cases at Adesh Institute of Medical Sciences and Research, Bathinda, Punjab.

Drawing public attention and awareness towards traumatic casualties is important to prevent unnatural deaths, this possibly could reduce incidence of such cases. A two years retrospective study from April 1, 2007 to March 31, 2009, to analyze causative agents, manner of cases and their outcome was carried out in the Department of Forensic Medicine, Adesh Institute of Medical Sciences and Research, Bathinda, a rural area of Punjab. This study was conducted to understand the magnitude and pattern of medico-legal cases in this region. The study revealed that road traffic accidents (59.4%) constituted the majority of the medico-legal cases out of total 784, followed by poisoning and fall from height (12.1% and 9.4% respectively). Male preponderance was quite evident (5:1). People between the age group of 21 – 30 years (33.8%) were most prone to such casualties. The peak time of the incidences was during 1601 to 2000 hours (33.5%) and the maximum cases admitted in the month of September (11.7%).

Blood pressure lowering, fibrinolysis enhancing and antioxidant activities of Cardamom (Elettaria cardamomum).

Elettaria cardamomum (L.) Maton. (Small cardamom) fruit powder was evaluated for its antihypertensive potential and its effect on some of the cardiovascular risk factors in individuals with stage 1 hypertension. Twenty, newly diagnosed individuals with primary hypertension of stage 1 were administered 3 g of cardamom powder in two divided doses for 12 weeks. Blood pressure was recorded initially and at 4 weeks interval for 3 months. Blood samples were also collected initially and at 4 weeks interval for estimation of lipid profile, fibrinogen and fibrinolysis. Total antioxidant status, however, was assessed initially and at the end of the study. Administration of 3 g cardamom powder significantly (p<0.001) decreased systolic, diastolic and mean blood pressure and significantly (p<0.05) increased fibrinolytic activity at the end of 12th week. Total antioxidant status was also significantly (p<0.05) increased by 90% at the end of 3 months. However, fibrinogen and lipid levels were not significantly altered. All study subjects experienced a feeling of well being without any side-effects. Thus, the present study demonstrates that small cardamom effectively reduces blood pressure, enhances fibrinolysis and improves antioxidant status, without significantly altering blood lipids and fibrinogen levels in stage 1 hypertensive individuals.

Down's syndrome and cardiac tamponade with pulmonary tuberculosis in adults.

We describe a combination case of Down's syndrome and Cardiac Tamponade with Pulmonary Tuberculosis in an adult patient.

Comparison between young and old patients with bronchogenic carcinoma.

OBJECTIVE: This study was undertaken to explore the clinicopathological profile of bronchogenic carcinoma in young patients. MATERIALS AND METHODS: The present study was conducted on 799 consecutive histopathologically proven cases of bronchogenic carcinoma that were referred from different parts of Uttar Pradesh. RESULTS: Out of 799 patients, 73 patients (9.1%; 59 males and 14 females) were < or = 40 years of age and were classified as 'young' patients. The mean ages of the subjects in the younger and older patient groups were 36 and 58 years, respectively. Among the older patients, 590 (81.3%) were smokers, and there were 53 (72.6%) smokers among the younger patients. Squamous cell carcinoma was the commonest histological subtype in both the groups, but squamous cell carcinoma was more frequently diagnosed in older patients than in younger patients. CONCLUSION: This study suggests that, regardless of age or sex, lung cancer must be ruled out in all patients who have persistent signs of pulmonary disease and a history of heavy smoking.

Avoidance of allergens by the patients with bronchial asthma.

OBJECTIVES: Association between environmental allergens and bronchial asthma is well established. A great number of substances found in the environment can precipitate or aggravate respiratory symptoms in asthmatics. Avoiding allergens is recognized as an integral part of management. Through various educational interventions the patients can be taught various measures to avoid these allergens. The present study was undertaken to evaluate the impact of 'self care manual' an educational intervention on the avoidance of various environmental allergens. METHODS: The total enrolled patients were 523 of which 260 were included in the study group to whom 'self care manual' was given and 263 in the control group with no access to self care manual. A fourteen items interview schedule consisting of three parts was administered. The first two subparts were in the form of checklist to know the various allergens which were inducing symptoms in the patients and weather they could avoid these triggers. The third part which was open ended was administered to know their ways of avoiding these triggers. All the patients were followed up at 2 weeks, 6 months and at 1 year. RESULT: Mean age of the subjects in both the groups was 36.72 +/- 11.52 years and 34.33 +/- 12.86 years respectively. Both the groups were comparable on majority of the socio-demographic variables. The number of patients whose symptoms were aggravated by a particular triggering factor reduced significantly on each successive visit in the study group. Almost all the patients started avoiding their triggers in follow-ups in the study group. In control group this change was only for few triggers. More and more patients started using inhalers on exposure to dust or triggering weather conditions. They started slowing down for exercises and diverted their attentions against triggering emotional situations. CONCLUSION: Patient education should be an essential component in the overall management of bronchial asthma. Control of asthma symptoms is better achieved with avoidance of allergens. This can be accomplished by emphasizing these facts particularly with the use of self care manuals.