Clinical spectrum & changing presentation of celiac disease in Indian children

Background & objectives: Celiac disease (CD) is a genetic immune mediated disorder characterised by gluten intolerance. This single centre study, from north India was aimed to assess the clinical, serological and histological profile of CD in a large cohort of children and the changing trends in its presentation. Methods: A review of clinical details of CD children diagnosed between 2000 and 2019 and currently on follow up was performed. Information on demography, symptoms, associated conditions, serology, biopsy findings and gluten-free diet were analyzed. Results: The mean age (±standard deviation) of 891 children included in the study, at onset and at diagnosis was 4.0±2.7 and 6.2±3.1 yr, respectively. Growth faltering, abdominal pain, abdominal distension and diarrhoea were presenting symptoms in 70, 64.2, 61.2 and 58.2 per cent, respectively. A positive family history of CD was present in 14 per cent and autoimmune conditions in 12.3 per cent of children. Thyroid disorders were seen in 8.5 per cent of children and Type 1 diabetes mellitus (T1DM) in 5.7 per cent. The duration of breastfeeding had a weak positive correlation with age at onset and diagnosis of CD (P<0.001). Non-classical CD was significantly more common in children aged >10 yr and in those presenting after 2010 (P<0.01). T1DM and hypothyroidism occurred more frequently in non-compliant children. Interpretation & conclusions: This was the largest single centre study, pertaining to the presentation and follow up of CD in children. Infants and young children were more likely to present with classical symptoms of diarrhoea, abdominal distension and growth failure while older children presented with non-classical CD. There was a trend towards non-classical forms of CD in recent years.

Comparison of onset of action of Intrathecal Clonidine vs Intrathecal Fentanyl as an adjuvant with hyperbaric Bupivacaine and Bupivacaine alone under spinal anesthesia for lower limb orthopedic surgeries

Background: Adjuvants are added to a local anesthetic solution to prolong the duration of analgesia. There is a paucity of studies comparing the onset of action of adjuvants like Clonidine and Fentanyl. In this study, the time of onset of action of intrathecal clonidine and intrathecal fentanyl as adjuvants to bupivacaine and bupivacaine alone were compared in the subarachnoid block for lower limb orthopedic surgeries. Materials and Methods: 90 adult patients posted for orthopedic surgery of the lower limb were divided into three equal groups of 30 each. Group A being the control group was given hyperbaric Bupivacaine(3ml) +0.5ml of Normal saline, Group B was given Intrathecal hyperbaric Bupivacaine (3 ml) +30 ?g Clonidine and Group C was given Intrathecal hyperbaric Bupivacaine (3 ml) + Fentanyl 25 ?g. The primary objective was to compare the time of onset of block and duration of analgesia. The secondary outcomes were the duration of sensory and motor block, duration of analgesia, hemodynamic parameters, and side effects. Results: The time of onset of the sensory blockade was 4.83 ± 0.64, 1.72 ± 1.47, and 3.4 ± 1.43 mins in groups A, B, and C respectively. The time of onset of the motor blockade as estimated by the time to reach level 2 on the Bromage scale, was 6.07 ± 0.55, 2.38 ± 1.32, and 5.06 ± 1.28 mins in groups A, B, and C respectively. The duration of postoperative analgesia was prolonged in the Clonidine group compared to the Fentanyl group. Conclusion: The study reveals that the time of onset of action of sensory and motor block was faster and the duration of analgesia was prolonged with adjuvants like Clonidine when compared to Fentanyl when added to Bupivacaine.

Review on the Therapeutic Protein Production in Plants

The production of protein therapeutics in plants it is great potential for increasing, improving and developing the number of therapeutic protein production, therapeutic protein help for the prevention of diseases and treatments in animals and human transgenic plants are the most promising system for the production of a human therapeutic protein. The glycoproteins produced from plants are not the same as a native therapeutic proteins produced in mammals. But using the plants has more advantages such as the low cost and the large scale production is safe. Therefore biological active plant protein has become an alternative option to animal cells for the production of the therapeutic protein.

Microalbuminuria: As an Indicator of Sepsis and to Predict Mortality in Patients Admitted to Intensive Care Unit

Background: Sepsis is an important healthcare concern in India as well as globally. This study shows how the level of microalbuminuria predict mortality of patients diagnosed with sepsis and those without sepsis. Methods: In this study total 150 patients of which 75 patients belonging to each sepsis and non-sepsis group, with age >15 years admitted in Medical Intensive Care Unit (ICU) were enroled Microalbuminuria levels were analyzed at admission and after 24 hours after admission. Results: Microalbuminuria levels were significantly high in patients with sepsis as compared to non sepsis. Microalbuminuria has highest sensitivity of 90 % and specificity of 98 % to differentiate between sepsis and non sepsis in comparison to APACHE II and SOFA scores. Conclusion: Serial monitoring of bedside urine albumin-creatinine measurement might help in the early identification of patients with sepsis that requires early targeted therapy. The 24-hour ACR assessment predicts ICU survival and may have the potential to monitor the efficacy of therapeutic interventions delivered, such as fluid resuscitation, appropriate antibiotics, vasopressors, and ionotropes that affect the endothelium.

A Cross-Sectional Study of Attitude and Practices Regarding Animal Bite Among Attendees of Anti Rabies Clinic of a Teaching Hospital, Jaipur

Introduction: Rabies is a zoonotic disease having almost100% fatality. Proper and timely management of animal bitecases can prevent the fatal disease. We conducted this studyto assess the attitude and practices of animal bite victimregarding animal bite management at Anti rabies clinic, RDBPJaipuria hospital.Methods: This observational study was conducted among 107attendees of anti-rabies clinic of Govt. R.D.B.P. Jaipuriahospital associated with RUHS College of medical sciences,Jaipur from February 2018 to July 2018. Data was collectedusing a predesigned semi-structured questionnaire. Data wereanalysed using IBM SPSS software version 20.0.Results: 107 participants were enrolled in the study. Maximumparticipants were males (72%), from age group of 26–35 years(43%), urban area (72%), and studying in 10th standard(22.5%). 76% of the participants were having good attitude butonly 36% participants were having good practices regardingmanagement of animal bite cases. Good attitude regardingreaction after animal bite, seriousness of disease, whom toconsult, what to do immediately after bite of animal, vaccinationof bite victim, pet dog vaccination and vaccination of contactswas among 55.14%, 48.6%, 88.78%, 56.07%, 93.46%,66.35% and 37.38% respondents respectively. Only 56% werehaving practice of washing wound with soap and water while16.82% were practicing application of red chilli, 14% werepracticing lime application and 13% participants were havingpractice of applying nothing on animal bite wound. 44% victimsdid not wash the wound before visiting the clinic. Majority(98.13%) visited doctor after animal bite while 1.87% visited totraditional healers first.Conclusion: Practices of applying red chilli and lime on theanimal bite wound is widely prevalent in the community.Community health awareness campaign should involvepreventive measures of rabies and immediate actions afteranimal bite.

Neonicotinoid insecticides: an emerging cause of acute pesticide poisoning

Neonicotinoids are a new class of insecticides widely applied for crop protection. Information on human exposures to neonicotinoids is limited. The most common routes of exposure were ingestion (51%), dermal (44%), and ocular (11%). These insecticides act as agonists at nicotinic acetylcholine receptors, which cause insect paralysis and death the high specificity for receptors in insects was considered to possess highly selective toxicity to insects and relative sparing of mammals. However, an increasing number of cases of acute neonicotinoid poisoning have been reported in recent years. Present study report three cases presented to us with acute neonicotinoid poisoning with different manifestations including acute myocardial infarction, central nervous system (CNS) depression, and acute kidney injury, who recovered subsequently with supportive care. A detailed literature review found that respiratory, cardiovascular and certain neurological presentations are warning signs of severe neonicotinoid intoxication. Supportive treatment and decontamination are the practical methods for the management of all neonicotinoid-poisoned patients.

Spectrum Of Imaging Appearances On Computed Tomography And Magnetic Resonance Imaging In Ankylosing Spondylitis In Hla B27 Positive Patients In Kumaon Region

AIM: To study the spectrum of imaging appearances on CTand MRI in ankylosing spondylitis with HLAB27 positive patients in kumaon region. Materials and Methods: This was a prospective study conducted in the department of Radiodiagnosis Government Medical College and Dr Susheela Tiwari Memorial Hospital,Haldwani. This study was carried out on 51 cases of ankylosing spondylitis HLAB27 positive cases. C.T. and MRI features were observed on T1weighted, T2weighted and short tau inversion recovery (STIR) sequences. The Spectrum of imaging was studied on the basis of history, clinical evaluation and characteristic radiological features on C.T. and M.R.I. Results: The disease was most commonly seen in adults with a male predominance in 37 (72.5%) cases. Backache (82.4%) was most common clinical feature followed by inflammation in (80%) cases. Lumbar spine was the most common site in 45 (88%) cases with bilaterally symmetrical involvement in 45 (88%) cases. Subchondral sclerosis was better appreciated in C.T. in 34 (66.6%) cases followed by joint erosion in 23 (45%) cases and joint space alteration in 15(29.4%) cases. Whereas, bone marrow oedema 37 (72.5%) cases was better appreciated in M.R.I followed by articular margin irregularity in 34(66.6%) cases and presence of erosion in 32 (62.7%) cases. Conclusion: Imaging is an integral part in the early detection of disease and optimizing management of affected patients for their better prognosis. CTand MRI plays a decisive role in the diagnosis and these modalities are also helpful in monitoring the disease

Pattern of hepatobiliary involvement in HIV/AIDS patients: study in a tertiary care centre

Background: Diseases of hepatobiliary system is a major problem in patients with HIV infection. It has been estimated that approximately one third of the death of patients with HIV infection are in some way related to liver disease. While this is predominantly a reflection of the problems encountered in the setting of co-infection Hepatitis B or C, it is also a reflection of the hepatic injury in the form of hepatic steatosis, that can be due to antiretroviral therapy. There had been little work done on liver function tests in HIV patients without pre-existing liver disease like viral hepatitis, or alcoholic hepatitis. So, this study was designed to assess the pattern of liver function test derangement in HIV patients. Aims and objective was to study the different pattern of hepatobiliary involvement in HIV positive patients, and to gauge the extent of liver damage.Methods: The study included 50 HIV positive patients coming to SMS hospital and Medical College, Jaipur, in medicine and HIV clinic of skin and VD department. Subjects having HIV test positive by ELISA, are included in this study. Other causes of liver function derangements were excluded from the study.Results: Maximum number of the patients were in the age group of 23-32 years. Out of 50 cases studied, 41 (82 %) cases had abnormal liver function tests, while 9 (18%) had normal liver function tests. Most of the cases had liver function abnormalities, and most common abnormality was raised SGOT/SGPT.Conclusions: Almost all types of liver function tests are found to be deranged in HIV patients. The pattern of hepatobiliary involvement varied from fatty liver, cholestasis to Toxic necrosis and granulomas.

Revisiting the role of the slit-skin smear in the diagnosis of Indian post-kala-azar dermal leishmaniasis

Background: Post kala azar dermal leishmaniasis (PKDL) is a neglected dermatosis that develops as a sequel to kala azar after apparent complete treatment. Being a non life threatening condition, patients often delay treatment thereby maintaining a reservoir of infection. The diagnosis of PKDL rests on the demonstration of the parasite in tissue smears, immune diagnosis by detection of parasite antigen or antibody in blood, or detection and quantitation of parasite DNA in tissue specimens. Sophisticated molecular tests are not only expensive but also need skilled hands and expensive equipment. To be useful, diagnostic methods must be accurate, simple and affordable for the population for which they are intended. Aims: This study was designed to assess functionality and operational feasibility of slit-skin smear examination. Methods: Sensitivity and specificity was evaluated by performing slit-skin smear and histo-pathological examination in 46 PKDL patients and the results were compared with the parasite load in both the slit aspirate and tissue biopsy specimens by performing quantitative Real-time PCR (Q-PCR). Results: The slit-skin smear examination was more sensitive than tissue biopsy microscopy. The parasite loads significantly differed among various types of clinical lesions (P < 0.05). The threshold of parasite load for detection by SSS microscopy was 4 parasites/μl in slit aspirate and 60 parasites/μg tissue DNA in tissue biopsy while that for tissue microscopy was 63 parasites/μl and 502 parasites/μg tissue DNA respectively. As detection of Leishmania donovani bodies may be challenging in inexperienced hands, the microscopic structure of these has been detailed along with a comprehensive discussion of pre analytical, analytical and post analytical variables affecting its identification. To facilitate the diagnosis of PKDL, some scenarios have been suggested taking into consideration the clinical, epidemiological, immunological and microscopic aspects. Conclusion: Such evidence based medicine helps minimize intuition, systematize clinical experience and provides a diagnostic rationale as sufficient grounds for a clinical decision.

Complete Fistula of the Second Branchial Cleft Managed by Single Neck Incision-our Experience and Review of Literature.

Introduction: Branchial fistulas and cysts, involving soft tissues of the neck, are quite uncommon anomalies of embryonic development that are commonly encountered by pediatric surgeons. Approximately 17% of all cervical masses in the pediatric age group are due to branchial anomalies. Although branchial cleft cysts are usually benign, infection, discharge, mass effect, and other surgical complications account for its morbidity. Aim: To assess 10 rare cases of a complete second branchial fistula which were diagnosed and treated in last 5 years by single neck incision in the Department of Surgery S. N. Medical College, Agra. Material and Methods: 10 cases of complete second branchial fistula were reported and managed in our institute. The age group of patients was from 2 to 12 months of age. These patients presented with an intermittent serous and mucoid discharge from an external opening in the lower aspect of the neck since birth. Most of the patients presented with opening on the right side of the neck. A pre-operative fistula gram done in all cases revealed the internal opening of tracts up to the peritonsillar fossa. In all cases, complete excision of the tracts was done by single step neck incision. Results: All the 10 patients underwent surgery with satisfactory results. Regular follow-up was done at biweekly for 1 month followed by monthly intervals up to 12 months. None developed any complications and no patient had recurrence. Conclusion: Although second branchial fistulae are common, complete fistulae with internal opening up to tonsillar fossa are rare, single step management of these cases merits the publication of this series. The report also guides on the need to perform a pre-operative fistulogram for the management of these cases.

Use of Dorsal Dartos Pedicled Flap Single or Double Layered in Preventing the Fistula Rate Following Tubularized Incised Plate Repair in Distal Hypospadias: A Prospective Randomized Study.

Introduction: Hypospadias is defined as an anomaly involving the ventral aspect of the penis with variable location of meatus from the tip with or without chordae. Objective: To study the role of dorsal dartos pedicled flap for reducing the fistula rate in tubularized incised plate (TIP) repair for distal hypospadias. Methods: Between November 2012 and August 2015, a total of 65 patients with distal penile hypospadias age between 1 and 18 years were included in this study. Patients were divided into 2 groups. Group (A) had 35 patients in which a single layer of dartos flap was used to cover the neourethra during TIP repair while in Group (B) which had 30 patients, the dartos flap was split into two halves and used to cover the neourethra in a double breasting fashion. Patients were followed regularly up to 6 months postoperatively. Results: The success rate shows no statistically significant difference between Group A 35 (94.29%) and B 30 (96.67%) P > 0.05. All successful patients had a satisfactory cosmetic result with a conical glans and vertical slit-like meatus. These results were compared with our 30 cases done previously without using a dartos flap which had a success rate of only 80%. Conclusion: Dartos pedicled coverage of TIP repair offers a significant reduction in fistula rate after TIP in distal hypospadias even though single or double layers of dartos coverage had no significant difference in results.

Murphy’s Eye: A Last Moment Saviour for Anaesthesiologist In Case of Surgery for Recurrent Vocal Cord Polyposis.

Securing the airway in Juvenile papillomas of the vocal cords and trachea is sometimes hazardous and potentially lethal. In our case, when such patient was planned under GA, her right sided chest developed decreased air entry with varying degree of severity, while her left side chest presented as silent chest gradually during surgery. On exploration, the possible reason for ventilation on the right side was found to be the presence of Murphy’s eye, which functioned as a vent, when the primary distal opening of an ETT became occluded.

Mayer-Rokitansky-Küster-Hauser Syndrome with Imperforate Anus: A Rare Association and an Innovative Surgical Management.

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is one of the rare disorder of Mullerian agenesis leading to non-development of uterus and vagina. Its association with anorectal malformation is rare. We report a case of MRKH syndrome with recto-vestibular in a female child. The child had undergone a sigmoid loop colostomy in the neonatal period. On clinical examination of the perineum, a fistula was present in the vestibule just below the urethral opening, but no vaginal canal was found. It was managed with an innovative surgical technique, preserving the fistula and lower rectum to function as vagina.

Salivary reservoir designs for patients with xerostomia: a review

Aim: The present paper aims to review the literature available on various approaches to salivary reservoir designs, the functional aspects, cleansibility, type of attachments used, and different techniques used for the fabrication of salivary reservoirs in patients suffering from xerostomia. Material and Methods: A search in the National Library of Medicine's Pub Med database, Google search and Science Direct was performed to include all case reports and reviews on prosthodontic rehabilitation of dentulous/partially edentulous/edentulous patient with xerostomia. Results: Out of the 35 articles found in the database search, 18 articles were included based on the designs they adopted for fabrication of salivary reservoirs. Conclusions: The various designs available in literature enable an operator to choose the most suitable reservoir design based on specific patient requirements. Innovations in reservoir design promise a more customized prosthesis for every patient. Further research and innovation will enable increasingly efficient salivary substitute delivery systems for the xerostomic patient.

Nonhemophilic hemosiderotic synovitis of the knee: A case report and review of literature.

Synovium is specialized mesenchymal tissue lining the inner surface of the joint capsule and is the site for a series of pathologic processes that are characteristic, and in some cases specific, to this distinctive tissue. Hemosiderotic synovitis is a rare and inadequately defined synovial proliferative disorder, which develops with recurrent hemorrhages in the joint. The most affected joint from bleeding is the knee whatever the etiology is. Repeated hemarthrosis may produce significant structural alteration of joints leading to chronic osteoarthritis. The most common cause is hereditary clotting factor deficiency diseases like hemophilia. We report a rare case of nonhemophilic hemosiderotic synovitis of the knee joint, in which the patient lacks history of any bleeding diathesis. Its definitive diagnosis was possible only by histopathological examination. The prompt recognition of this distinct subtype of hemosiderotic synovitis and awareness of underlying causes should lead to earlier diagnosis, appropriate therapy, less joint destruction, and better outcomes.

Prevalence of Mycobacterium tuberculosis with multiple copies of IS6110 elements in Gulbarga, South India

This study was carried out to ascertain the prevalence of Mycobacterium tuberculosis by insertion sequence 6110 [IS6110] based DNA fingerprinting method in Gulbarga district belonging to the southern part of India. Results showed that among the 52 M. tuberculosis isolates studied, 57.7% exhibited more than 5 copies of IS6110 showing the prevalence of M. tuberculosis with multiple copies of IS6110 elements

Development of Sequence Characterized Amplified Region (SCAR) Marker for the Authentication of Bacopa monnieri (L.) Wettst.

Aims: To develop Sequence Characterized Amplified Region (SCAR) marker for identification of Bacopa monnieri (L.) Wettst. Study design: Molecular biology tools for authentic identification of Bacopa monnieri. Methodology: RAPD-based SCAR marker was developed to identify Bacopa monnieri from its adulterant candidates namely Centella asiatica, Eclipta alba and Malva rotundifolia. 50 random primers were used for initial screening of different accessions of Bacopa monnieri, Eclipta alba and Malva rotundifolia. A putative 589 bp marker specific to Bacopa monnieri was identified using RAPD technique. This RAPD-amplicon was then sequenced and cloned. Based on the information of cloned sequences a pair of SCAR primers was designed. SCAR primers were then used for authentication of DNA samples of Bacopa monnieri and its adulterants. Market samples of Bacopa monnieri and Centella asiatica collected under the name of Brahmi was put to test with these primers. Results: Out of 50 random primers, only 14 primers were able to amplify the above plants. A 589 bp polymorphic band obtained with OPAA-3 primer which was specific to Bacopa monnieri accessions and not found in other adulterant candidates was selected. This band was eluted, cloned and further sequenced. A pair of SCAR primers (Bac F & Bac R) between 406 bp of 589 bp sequence of RAPD amplicon was designed. A single, bright, distinct band was obtained in Bacopa monnieri and not in the adulterants. Further validation was also done in the market samples. Conclusion: In essence, the study was to develop a RAPD-based SCAR marker for authentication of Bacopa monnieri. The SCAR marker was found to be useful for preventing the adulteration of other plants in Brahmi and also for screening of crude drug samples intended for export and domestic uses.

Candiduria in catheterized intensive care unit patients : Emerging microbiological trends.

Objectives: Urinary tract infection (UTI) as a result of Candida spp. is becoming increasingly common in hospitalized setting. Clinicians face dilemma in differentiating colonization from true infection and whether to treat candiduria or not. The objective of the present study was to look into the significance of candiduria in catheterized patients admitted in the ICUs and perform microbiological characterization of yeasts to guide treatment protocols. Materials and Methods: One hundred consecutive isolates of Candida spp. from the urine sample of 70 catheterized patients admitted in the ICU were collected and stocked for further characterization. A proforma was maintained containing demographic and clinical details. Blood cultures were obtained from all these 70 patients and processed. Species identification of yeasts was done on VITEK. Results: Candiduria was more common at extremes of age. The mean duration of catheter days was 11.1 ± 6 days. Other associated risk factors such as diabetes mellitus and antibiotic usage were seen in 38% and 100% of our study group. Concomitant candidemia was seen in 4.3% of cases. Non-albicans Candida spp. (71.4%) emerged as the predominant pathogen causing nosocomial UTI. Conclusion: The present study reiterates the presence of candiduria in catheterized patients, especially in the presence of diabetes and antibiotic usage. Non-albicans Candida spp. are replacing Candida albicans as the predominant pathogen for nosocomial UTI. Hence, we believe that surveillance for nosocomial candiduria should be carried out in hospitalized patients.

Competence of ethics committees in patient protection in clinical research.

Research Ethics Committees (RECs) are responsible for the protection of patients’ rights and wellbeing. In this paper, we describe the findings of a survey of ethics committee members in a south Indian state. 29 members of 11 RECs responded to a questionnaire of 56 questions on their knowledge of and attitudes towards ethics review and the practices of the RECs to which they belonged