Hepatitis B induced fulminant liver failure: A call for prevention

Acute fulminant hepatic failure is a condition in which a healthy liver deteriorates rapidly following an insult, resulting in the impairment of its synthetic functions. This condition is rare and is associated with high fatality rates. We report the case of a 19-year-old male who was brought to the emergency room in an unconscious state with jaundice and persistent fever for 2–3 weeks after recently commencing intravenous use of morphine. He was found to be hepatitis B surface antigen reactive, and his laboratory tests indicated severe liver dysfunction with elevated levels of serum bilirubin, aspartate transaminase, alanine transaminase, gamma-glutamyl transferase, and International normalized ratio. The patient was diagnosed with fulminant liver failure with coagulopathy and hepatic encephalopathy. The patient’s family was addressed and counseled regarding the urgent need for liver transplantation. However, due to a lack of funds and insurance, supportive treatment was the only option left. Despite all supportive measures, the patient expired within 48 h. This case highlights the importance of various socioeconomic issues involved with liver transplantation, as in a resource-limited setting, urgent transplantation seems nearly impossible. In addition, this case report raises certain ethical issues that need consideration, particularly in an injection drug use scenario. It also highlights the importance of addressing the rising issue of injection drug use among youth, particularly in the regions of Punjab.

Perinatal Transmission of Dengue: A Case Report

A single, male neonate was born at 36 weeks of gestation with birth weight of 2.62 Kg, to a 24-year-old primigravida mother by LSCS in an outside hospital. Apgar score at 1 min and 5 mins were 7 and 9 respectively and he was shifted to mother’s side. On day 4 of life, he developed respiratory distress and decreased oral intake and was referred to our neonatal tertiary care unit (NICU).Maternal antenatal history was uneventful. Mother had fever and thrombocytopenia and was diagnosed as dengue infection (Dengue NS 1 antigen and Ig M positive) 3 days before delivery and managed at same hospital.On admission, baby had respiratory rate of 64 / min, mild retractions, SpO2 of 92 % on room air and mild hepatomegaly. Cardiovascular system seemed to be normal but poor activity and sucking was there. He was started on IV fluids, antibiotics and non-invasive respiratory support. Chest X-ray was normal. Haemoglobin was 18.3 gm / dL, total leukocyte count of 4600 / mm3, absolute neutrophil count of 2681, platelet count of 1.5 lac, haematocrit of 50.8 % and C reactive protein of 7.7. Dengue NS1 antigen and IgM came out to be positive. There was no evidence of mosquito bite in neonate postnatally.Infant’s clinical condition deteriorated with increased requirement of respiratory support and SpO2 up to 40 %. Platelet count further fell to 59000 on day 2 and 13000 on day 3 of hospital stay and was managed with multiple platelet transfusions. Baby also had features of third space loss. Repeat chest X-ray suggestive of right pleural effusion and ultrasound abdomen showed mild ascites and mild hepatomegaly. But cranial ultrasound was also done which was normal. No evidence of bleeding during hospital stay. Baby was managed initially with fluids and first line antibiotics as per the unit protocol. Orogastric feeds were started as baby had clinical improvement which were built up gradually and baby switched to spoon feeds after 7 days. Baby was weaned off from respiratory support as requirement decreased. Baby was discharged with improving platelet count and absence of features of third space loss. On discharge baby was hemodynamically stable and accepting oral feed.Dengue is a systemic arthropod borne and transmitted systemic viral infection which is an emerging disease in many states of India. Major mode of transmission of dengue is mosquito bite but vertical transmission is rarely seen.1 There are some reported cases of dengue infection in pregnancy and association with many complications in neonate like low birth weight, perinatal mortality, foetal distress and preterm birth. The samples from foetal or cord blood are considered as a better source of qualifying dengue infection in utero.2 In neonates, vertical transmission of dengue from mother can produce varying symptoms ranging from fever with thrombocytopenia to intracranial haemorrhage.3As India is a resource limited country the survey for dengue cases in neonates is not done in a schematic manner, there are only a few case reports of neonatal dengue infection from India and its vertical transmission. Here we are reporting a case of vertical transmission of dengue in a neonate at our Neonatal ICU.

Study of endothelial function in pregnant women with gestational diabetes mellitus by flow mediated dilation of brachial artery

Background: The objective of the study was to assess vascular function in normal pregnant women and women with gestational diabetes and to study its temporal relationship with gestational age at 24-28-week POG and at 36-38-week POG and changes in FMD in postpartum period.Methods: Assessment of vascular function was done at 24-28-week POG, 36-38-week POG and at 6-12-week postpartum by flow mediated dilation of brachial artery in 37 healthy pregnant women and 37 pregnant women with GDM.Results: In GDM group mean FMD at 24-28 weeks of POG, at 36-38 weeks POG was lower as compared to the control group (11.225±6.20,8.464±6.09 versus 14.49±5.21, 10.898±4.12) although the difference in mean FMD in two groups was not statistically significant. It was found that the decrease in FMD at 36-38-week POG as compared to 24-28 weeks POG was statistically significant in both the groups (p<0.001).Conclusions: This study revealed that when endothelial function as assessed by FMD was compared at different period of gestation, the mean decrease in FMD at 36-38-week POG as compared to 24-28-week POG and 6-week post-partum was statistically significant in patients with GDM and as well as the control group, however this trend of change was same in both the groups and was not statistically significant when compared between the two group (GDM versus control). A negative correlation of FMD was found with BMI, and HBA1c, that was stronger in GDM group.

Status Epilepticus following a Laparoscopic Surgery in a Patient of Chronic Kidney Disease – A Case Report

Seizures may occur in close relation to surgical procedures or with the use of anesthetic agents in several situations. Thecausative factors include an interruption of treatment with antiepileptic drugs (AEDs) or inadequate blood concentrations resultingfrom impaired gastrointestinal absorption. In operative procedures not involving the brain, transient seizures can arise frommetabolic derangements or drug neurotoxicity. Other causes include hypoxia, hypotension, and embolic infarction. Seizuresoccurring shortly after injection of moderate to large amounts of local anesthetic should raise the suspicion of inadvertentintravenous injection. Seizures may also indicate withdrawal from unsuspected chronic use of excessive amounts of alcohol,sedative medications, mood-stabilizing agents, or AEDs. Rarely, sleep deprivation and drugs like flumazenil may precipitateseizures. We discuss the management of status epilepticus following laparoscopic urology procedure in a patient of chronickidney disease with a history of the previous craniotomy.

Serum uric acid levels in patients of acute myocardial infarction

Background: Following Myocardial Infarction some proteins and enzymes, CPK-MB/ Troponin-I, T, are released into the blood from the necrotic heart muscle. Serum Uric Acid (SUA) may be a risk factor and negative prognostic marker for cardiovascular diseases. Aim of the study was to study serum uric acid levels in patients of acute Myocardial infarction with congestive heart failure, its relation with stages of congestive heart failure as per Killip classification and the role of serum uric acid levels as a marker of mortality.Methods: The case control study was conducted on 120 patients divided into two groups. Group A included 60 patients of acute Myocardial infarction. Group A was further divided into two categories. One includes 30 patients of with congestive heart failure and another includes 30 patients without congestive heart failure. Group B consists of 60 control patients. Serum uric acid levels were measured in Group A on 1st, 3rd and 7th day of hospital admission and in Group B on 1st day.Results: The study showed females have higher degree of hyperuricemia than males. SUA was significantly higher in patients of acute myocardial infarction than control group patients. SUA were also higher in patients with history of IHD, in patients with BNP >100 and it correlates with Killip class and mortality rates. Patients of acute myocardial infarction with diabetes mellitus had higher degree of hyperuricemia than nondiabetic and control group. No significant difference in SUA levels were observed with regard to age, alcohol intake, lipid profile, ejection fraction and hypertension.Conclusions: In acute myocardial infarction, patients with hyperuricemia had higher mortality and may be considered as poor prognostic biomarker.

Sebaceous Cell Carcinoma- Two Rare Case Reports

Bonafide sebaceous carcinoma is extremely rare neoplasm. It may be seen as a component of Muir-Torre syndrome. It should be distinguished from basal cell carcinoma with sebaceous differentiation.

Correlation of HbA1c levels in late pregnancy with maternal and perinatal outcome in patients with gestational diabetes mellitus

Background: Estimation of HbA1c in gestational diabetes mellitus patients is not being recommended by any societies/guidelines as studies regarding the role of HbA1c for monitoring of euglycemic control and predicting the maternal and perinatal outcomes in GDM patients (unlike overt diabetes) are conflicting and sparse.Methods: This was a prospective study with an aim to evaluate the role of HbA1c estimation in late pregnancy (early and late third trimester) for prediction of pregnancy outcomes in GDM patients. 53 patients with GDM (diagnosed before third trimester) were recruited for the study. HbA1c levels were estimated in late pregnancy (at 28-32 weeks and again repeated at 37 - 39 weeks or at the time of delivery). Correlation of HbA1c levels in third trimester with maternal and perinatal outcome was studied in patients with gestational diabetes mellitus and cut off taken was 5.8%.Results: Of the total 53 patients 54.7% had HbA1c levels <5.8% and 45.3% had HbA1c ≥5.8% done at 28-32 weeks. Also when HbA1c levels done at 37-39 weeks POG/ at the time of delivery, 52.8% patients had <5.8% and 47.2% had HbA1c ≥5.8%. Approximately one-fourth of the patients had HbA1c ≥ 5.8% even with normal blood sugar levels (euglycemic) control. There was statistically significant increased incidence of polyhydramnios, LGA (large for gestational age babies) and increased mean birth weight in patients with HbA1c ≥ 5.8%, done in late pregnancy. However there was no statistically significant difference in the incidence of preterm labour, gestational hypertension or preeclampsia, urinary tract infections, vulvovaginal infections, caesarean deliveries and postpartum haemorrhage in patients with HbA1c ≥5.8% compared to patients with HbA1c <5.8%.Conclusions: The study revealed that in patients of GDM with HbA1c levels ≥5.8% done in third trimester was statistically significantly associated with increased incidence of polyhydramnios, large for gestational age babies and increased mean birth weight when compared to patients with HbA1c <5.8%.

Pigmented Basal Cell Carcinoma of Eyelid: A Case Report

Pigmented basal cell carcinoma is a rare cutaneous variant of BCC with very few cases reported. Exposure to sunlight is the most important environmental risk factor.Pigmented basal cell carcinoma is a very rare variant of basal cell carcinoma that exhibits increased pigmentation.As it is rare, thereby we report here the case of Pigmented basal cell carcinoma on eyelid. Key

Evaluation of Serum Creatinine, Uric Acid Levels and Urinary Albumin Creatinine Ratio in Patients of Primary Hypothyroidism

Background: Primary hypothyroidism is a clinical conditiondue to deficiency of thyroid hormones. Thyroid hormones haveprofound effect on renal development, renal hemodynamics,glomerular filtration rate, electrolytes and water homeostasis.The aim of this case control prospective study is to evaluatethe effect of primary hypothyroidism on renal functions.Methods: Serum creatinine, blood urea nitrogen, uric acid,urinary albumin creatinine ratio and eGFR levels wereestimated in 75 newly diagnosed and untreated patients ofprimary hypothyroidism in the age group of 20 to 60 years ofeither sex (Study group) and 75 healthy, age and sex matchedindividuals with normal thyroid profile (Control group). Followup of patients in study group was done after 8 weeks ofthyroxine replacement and serum creatinine, uric acid, urinaryalbumin creatinine ratio and eGFR levels were estimated.Results: The mean eGFR level in study group at baseline waslower and mean serum creatinine, blood urea nitrogen, serumuric acid and urinary albumin creatinine ratio (UACR) levelswere higher than control group. After 8 weeks of thyroxinereplacement; the mean serum creatinine, uric acid, bloodurea nitrogen levels were decreased and eGFR levels wereincreased. Also serum TSH shows positive correlation withserum creatinine, blood urea nitrogen, uric acid and urinaryalbumin creatinine ratio but negative correlation with eGFR.Conclusion: Primary hypothyroidism is associated withsignificant alteration in renal function which is reversible onthyroxine replacement.

Correlation between Peripheral Blood Thrombocytopenia and Bone Marrow Findings – A Study of 100 Cases

Thrombocytopenia (platelet count less than 150,000/µl) is commonly encountered in routine hematological investigations. Here we present a study done to understand the prevalence of various conditions leading to thrombocytopenia, referred for bone marrow examination. It is a retrospective study done on 100 cases of thrombocytopenia referred for bone marrow examination in a tertiary care hospital from January 2016 to October 2016. The commonest cause of thrombocytopenia for which bone marrow was sought came out to be megaloblastic anemia followed by acute leukemia and aplastic anemia. Aim: Calculate the prevalence of various conditions causing thrombocytopenia, in cases referred for bone marrow examination, and Understand the various megakaryocytic alterations in hematological disorders presenting with thrombocytopenia due to different mechanisms. Methods: A retrospective study was done on 100 patients of thrombocytopenia referred for bone-marrow aspiration in a tertiary care hospital catering to both rural and urban population from January 2016 to October 2016. All cases of thrombocytopenia (platelet count less than 1,50,000/µl) diagnosed on hematology analyzer and later confirmed by peripheral blood film examination, referred for bone marrow examination for various reasons were included in this study. Stained bone-marrow aspirate smears were examined. Records regarding the clinical indication for the procedure, peripheral blood smear reports, blood counts and significant findings on bone-marrow aspiration smears were retrieved. The role of bone-marrow aspiration in the diagnosis of hematological and non- hematological disorders was reviewed in the study. Results: The commonest cause of thrombocytopenia for which bone marrow examination was sought was megaloblastic anemia(76%), followed by acute leukemia(7%), aplastic anemia(5%), myelodysplastic syndrome (4%) which was followed by ITP(3%), and one case each of gelatinous marrow transformation, malaria and NHL spillover. Conclusion: Further studies on the evaluation of megakaryocytic alteration and their contribution to thrombocytopenia can provide growing knowledge to the pathogenesis of numerous hematopoietic disorders that may identify broader clinical applications of the newer strategies to regulate platelet count and functioning.

Incidence of Molar Pregnency on Histopathological Examination- A Retrospective Study

Hydatidiform mole is an abnormal gestation characterized by trophoblastic hyperplasia and overgrowth of placental villi. H. mole is classified as complete (CHM) and partial (PHM). The diagnosis is based on histopathology and genetic origin. In our set up, we used only histopathological diagnostic criteria. The incidence of molar pregnancy varies in different parts of the world. Objective of the present study was to determine the frequency, clinical presentation and morphological features of H. mole and compare them with those of other studies. Objectives: The aim of this populationbased retrospective study was to evaluate the trend in the incidence of molar pregnancy. The reported incidence of GTD in India is in consistent therefore we planned to do an analysis of the GTD at our institute which is a referral tertiary center of Punjab. Methods: Records of patients of GTD admitted from Dec 2016 to March 2018 were analyzed and incidence was calculated. The diagnosis of hydatidiform mole was based on the post-operative morphological and/or pathological findings. A total of 150 cases of retained products of conception received in the department of pathology were analysed. Results: Out of total 16 cases of molar pregnancy 5 were diagnosed as complete mole and 11 were diagnosed as partial mole. Out of 5 cases of complete mole, one case was of recurrent molar pregnancy. Conclusion: There is a need to look further about the association of age with molar pregnancies in future studies.

Retrospective Study of Histopathological Findings in Non-Neoplastic Cervical Lesions

The uterine cervix is prone to several non-neoplastic gynecological lesions. These lesions are a source of morbidity and mortality in women. Therefore, there is need to analyze them to provide the pattern of these lesions. AIM: Retrospective study of the findings of non-neoplastic lesions of cervix. Methods: A retrospective study was done in Department of Pathology, Government Medical College, Patiala from January 2016 to January 2018. Results & Conclusion: Out of 220 cases, the most common non neoplastic lesion recorded was chronic cervicitis (45.9%) followed by squamous metaplasia(37.2%) and nabothian cysts(36.3%).

To Study Nutritional Factors and Postnatal Growth as Predictors of Retinopathy of Prematurity in Neonates Weighing <1750g and/ or Gestation <34 Weeks

Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the developing retinal vessels of premature infants. ROP remains one of the leading causes of childhood blindness worldwide. India and other developing countries are facing the third epidemic of ROP. Various risk factors for development of ROP include low gestational age, low birth weight, hyaline membrane disease, sepsis, shock, prolonged oxygen therapy, poor nutrition and weight gain and blood transfusions. Objective: To study nutritional factors and postnatal growth as predictors of ROP in neonates weighing <1750g and/ gestation <34 weeks. Methods: It is a prospective observational study conducted over one year (May 2017 to April 2018) in NICU, Department of Pediatrics, Govt. Medical College Amritsar, in collaboration with Department of Ophthalmology. All antenatal, perinatal and neonatal factors along with nutritional factors and postnatal growth mointoring were recorded. Screening for ROP was done by indirect opthalmoscopy at 4 weeks of postnatal age and followed up till retinal vascularization was complete. Data was analysed using univariate and multivariate regression analysis to evaluate risk factors. Results: Out of 79 babies screened 44 were found to have ROP of which 4 required treatment. Important risk factors found significant on univariate analysis were low birth weight (p=0.023) gestational age (p=0.003), duration of i/v fluid therapy (p=0.004), day of start of feed (p=0.032), day of attainment of full feed (p=0.005), relative weight gain at 4 weeks (p=0.041) and 6 weeks of life (p=0.04). On mutivariate logistic analysis, relative weight gain (g/kg/day) at 4 weeks of life was found to be an independent risk factor. Conclusion: Relative weight gain (g/kg/day) at 4 weeks of life was found to be an independent risk factor for development of ROP. This result may be regarded as providing emphasis on the importance of weight gain at an earlier postnatal age.

Umbilical cord cyst: a diagnostic dilemma

Umbilical cord cyst refers to any cystic lesion associated with the umbilical cord. Cord cysts can be defined as true or false cysts and may occur in any location along the cord. They are irregular in shape and are located between the cord vessels. Authors are reporting the case of an infant with an umbilical cord tumor which had twice been misdiagnosed previously as a hemangioma, based on ultrasound image of its cystic and solid component with good vascular supply. The ultrasound image most likely suggestive of a hemangioma as a differential diagnosis led to caesarean section in our patient (based on large size of the lesion and fear of rupture of same during process of labour). The definitive diagnosis was made only after birth of the baby. Final diagnosis of true umbilical cord cyst was made after histopathological examination. Thus, there can be confusion in the diagnosis between umbilical cord hemangiomas and umbilical cord cysts based on ultrasound.

An in-depth study of drugs prescribing pattern in the Surgery Department of a Tertiary Care Teaching Institute in Northern India.

Background: In surgical patients, a number of drugs are prescribed to prevent post-operative infections and to relieve pain. Therefore, prescription audit should be periodically performed in Department of Surgery to analyze the present scenario of drugs prescribed for the surgical/post-operative patients. This will help us to use the medicines rationally and decrease the adverse effects in surgical patients. The main aim of the study was to evaluate the drugs prescribing pattern in the Surgery Department in Tertiary Care Teaching Institute. Methods: Patients’ prescriptions or case record forms were randomly collected over a period of 1 year from the Department of Surgery at GGS Medical College and Hospital, Faridkot, Punjab (India) for analysis and rationalization. Results: A total of 900 prescriptions was collected and analyzed for drugs used in surgical patients. Average number of drugs prescribed is 4.26. The most commonly prescribed drugs were anti-microbial agents (AMAs), gastrointestinal tract (GIT) related, non-steroidal anti-inflammatory drugs (NSAIDs) and multivitamins and trace elements, and their percentages were 37.90%, 23.36%, 14.14 %, and 9.11% respectively. About 95% drugs were prescribed by non-generic (Trade) names. Drugs prescribed from National Essential Medicines List (EML) and World Health Organization EML were 69.25% and 45.31% respectively. Average cost per prescription per day was Rs. 610/- (INR) or $10.34 USD in a surgical patient. Conclusions: There is a high tendency and frequency to prescribe four and more than four drugs to post-operative patients. Most drugs prescribed were AMAs, GIT related, NSAIDs and Multivitamins and trace elements. There is an urgent need to develop proper prescription writing skills in budding doctors regarding the use of EML/drugs list and generic medicines to reduce the cost of treatment.

Emerging therapies in pipeline for chronic hepatitis C.

Hepatitis C infection represents a major global public health problem; as it leads to significant morbidity, mortality, and financial burden on healthcare system. According to world health organization, nearly 2- 3% (130-170 million) of the world’s population has been infected with hepatitis C. The current standard therapy is limited both in efficacy and tolerability which highlights the large unmet medical need in this area. Recent advances in the understanding of lifecycle of hepatitis C virus and host cell interactions have led to the identification of multiple novel antiviral targets. Intense research effort is currently being directed towards translating these targets into developing more efficacious and safe treatment options for patients living with HCV infection. Current review aims to discuss the emerging therapies in pipeline for chronic hepatitis C outlining their mode of action and current stage of development in clinical trials.

Fusion of main trunks of median and musculocutaneous nerves (an anatomic variation).

Median nerve (MN) and Musculocutaneous nerve (MCN) around their origin from brachial plexus are known to have many variations. A unilateral variation in the course of MCN in 65 years male cadaver was observed during routine dissections for medical undergraduates. In the present case, MCN was observed to be formed by its normal pattern, as the continuation of lateral cord of brachial plexus. Thereafter instead of piercing coracobrachialis, it fuses for some distance with MN and then separates out to supply all the muscles of anterior compartment of the arm. It then ends as lateral cutaneous nerve of forearm. Such a case of fusion of main trunks of MN and MCN has not been clearly reported in literature. Knowledge of this variation is important owing to its numerous clinical implications.