The Combination Therapy of Oral Steroids and Nerve Decompression for Ulnar Neuritis in Leprosy - Usefulness in Prevention of Progression of Hand Deformities

Hand, being an important functional part of the body, needs healthy complementing motor and sensory nerve supply. Both these functions get compromised following involvement of ulnar nerve in leprosy, which is the commonest nerve involved in Hansen’s disease. It is commonly involved at the elbow level and results in clawing of the hand. There are two routine management protocols viz medical and surgical to manage ulnar nerve damage in leprosy. Steroid therapy along with anti-leprosy regimen is the common medical approach for treatment for ulnar neuritis. Patients not improving with medical management are taken up for surgical decompression. However, when to switch from medical to surgical intervention is topic of debate. In this study we have given steroid therapy in early (4-6 weeks) duration of ulnar neuritis along with anti-leprosy drugs and attempted to determine an appropriate period of medical treatment, beyond which there is no significant benefit in continuing sole medical management if no response is seen. Of the 247 eligible patients, 210 did not respond to 12 months of steroid therapy – the results 193 such patients, treated with steroids and nerve decompression and which were available for follow up were analysed. A total 158/193 (81.8%) cases showed the sensory recovery for touch within 4-6 weeks, deep sensation of pin prick returned in 117/193 (60.62%) cases in 6-8 weeks. Motor recovery was slow, it took 24 to 54 weeks. While 117/193 (60.62%) cases showed improved motor function, in 58/193(30%) cases there was no change and only 18/193(9.3%) cases deteriorated. It appears that period of 12 weeks is an ample time for medical treatment to start showing any form of improvement (motor or sensory) and if there is no improvement, patient should be considered for surgical decompression along with continuation of medical management (Steroid therapy). Our study shows that cases who failed to respond to exclusive medical steroid therapy by 12 weeks responded to combined medical plus surgical treatment as surgical decompression helps in the release of pressure on nerve tissue and improves the functional status.

Comparison between caudal epidural block and popliteal nerve block for postoperative analgesia in children undergoing foot surgery: a randomized controlled trial

Background: Pain following surgery in children cause discomfort, restlessness and agitation in the postoperative period which may result in an increased incidence of nausea, vomiting and maladaptive behavioural changes. Regional anaesthesia is commonly used as an adjunct to general anaesthesia for perioperative analgesia in children as part of a multimodal approach of pain relief. This study is to compare between caudal epidural block and popliteal nerve block for postoperative analgesia in children undergoing foot surgery.Methods: A prospective randomized single blind study was carried out on 30 children aged 1-12 years of either sex undergoing foot surgery. Patients were randomly assigned into caudal epidural block group and Popliteal nerve block group, 15 children each. Both groups receive 1 ml/kg of 0.25% bupivacaine. Foot surgery was carried out under general anesthesia along with regional block for all children. After completion of surgery, children were shifted to PACU and HR, BP, SPO2 were monitored. Patient was discharged from PACU after CHEOPS (1-5 years) or VAS (6-12 years) <4. Parental satisfaction, sedation score, PONV, and any other side effects were recorded.Results: Demographic data and baseline vital signs were comparable between two groups. Statistically significant difference (p=0.025) in number of attempts in giving block in group A (1.20±0.41) than group B (1.80±0.86). The mean postoperative pain scores, CHEOPS and VAS were comparable in both groups.Conclusions: Both caudal epidural block and popliteal nerve block provides comparable and adequate analgesia in children undergoing elective foot surgery.

Correlation of body fat distribution and lipid profile in males of the Northwest region of Punjab

Background: The prevalence of obesity has substantially increased over the past few decades. Central obesity, in particular, has a major role in the development of various metabolic disturbances including deranged lipid profile which leads to increased risk of cardiovascular diseases. Timely assessment of any changes in lipid profile can help the prevention of cardiovascular diseases in obese men. Objectives: The objective of this study was to evaluate the association of abnormal waist-hip ratio (WHR) with the lipid profile in healthy men. Materials and Methods: The study was conducted in the tertiary care center of Amritsar. Two groups of 50 men each of the age group of 20–40 years were enrolled in the study. Group I included men with normal WHR while Group II included men with increased WHR. Lipid profile including cholesterol, triglycerides (TGs), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and very low-density lipoprotein (VLDL) was measured by standard methods. Statistical analysis was done by Student’s t-test and correlation was established using correlation coefficient. Results: Evaluation of lipid profile showed that serum cholesterol, TGs, LDL, and VLDL were higher in Group II than in Group I while HDL was lower in Group II than in Group I. Central obesity (WHR) has direct association with deranged lipid profile. Conclusion: It can be concluded that visceral or central obesity has direct correlation with the fasting lipid profile in men of the Northwest region of Punjab and WHR is a more reliable predictor of risk.

Regulatory categories of probiotics across the globe: A review representing existing and recommended categorization.

Probiotics are friendly live microorganisms (in most cases, bacteria) that are similar to benefi cial micro-organisms found in the human gut, whenever consumed, have potential to confer benefi t to the health of consumers by maintaining, or improving their intestinal microbial fl ora and are available to consumers mainly in the form of dietary supplements and foods. All-time high interest in the fi eld of probiotics is due to emerging probiotic industry. Probiotics are available in foods and dietary supplements, even as pharmaceutical formulations (capsules, tablets and powders) and in some other forms as well, but their claims of health benefi ts may challenge the traditional border between food and medicine. A number of probiotic products have been already introduced into the international market as food supplements, dietary supplements, natural health products, functional foods and many more other categories; as a result, the position of regulatory system for probiotics within existing categories become vague and quite unclear. Common terminology for probiotic products has become a necessity to achieve adequate regulatory control for discussion of probiotic-related issues among government, producers and consumers. The lack of a consistent terminology across the globe leads to legal uncertainty and confusion instead of being a direct obstacle for development of a mature market. This article will explain differences in regulatory categorizations across the globe; discuss the terms like food and drugs with a close relationship to probiotics, the problems associated with unsatisfactorily approached categorization as well as suggestive consolidations for the new categorization which will demarcate probiotics into categories explaining their nutritive claims, health claims or both.

Taxation of smokeless tobacco in India.

BACKGROUND: The role of fiscal policy, especially taxation, though has been proved to be an effective instrument of tobacco control, its application is limited in India due to several reasons. This paper examines the tax structure, price and affordability of SLT products in order to provide evidence on how to strengthen the role of fiscal policy in tobacco control. METHOD: Secondary data on tax structure and revenue from tobacco products were collected from the Ministry of Finance, Government of India. In order to measure the rise of prices corresponding to the increase in tax rate, the retail price index (RPI) and Whole Price Index (WPI) of SLT products were compared with the price index for all commodities for the period 2006–2012. The affordability of tobacco products is calculated by dividing prices of tobacco products by per capita income. RESULTS: During the last 6 years, the tax rate on SLT has gone up leading to a rise in the prices of SLT products more than the general price rise. However, the price rise is less than the per capita income growth indicating increasing affordability. The study observed a decline in the consumption of zarda and kahini due to the price increase during 2008–2013. However, the decline in the consumption of zarda is less compared with khaini due to a very low rise in its price. CONCLUSION: The prices should be raised more than the growth in income to influence consumption. Tax administration is a major challenge for SLT products and strengthening it could enhance revenue collection from SLT products.

Banning smokeless tobacco in India: Policy analysis.

India is the second largest producer and third largest consumer of tobacco. According to GATS India Report (2009-10), the users of only smokeless tobacco (SLT) are more than double than that of smokers. SLT use is an imminent public health problem, which is contributing to high disease burden in India. It is a "unique" tobacco product due to its availability in myriad varieties, easy access, and affordability especially for adolescents. It has been studied to be a gateway product and facilitates initiation. Currently, the Food Safety and Standards Authority of India (FSSAI) have prohibited the use of tobacco and nicotine in any food products; yet, the implementation of a permanent ban on SLT across India is still pending. This paper examines how multiple legislations have failed to effectively control or regulate SLT in India and regionally; thus, there is need to strengthen SLT control efforts as "no ordinary product."

Effect of sub-lethal concentrations of lufenuron on growth, development and reproductive performance of tribolium castaneum (herbst) (coleoptera: tenebrionidae).

The effect of the chitin synthesis inhibitor lufenuron on the various developmental stages of red flour beetle Tribolium castaneum was determined by exposing them to different sub-lethal concentrations (LC10, LC20 and LC40) of lufenuron through diet for 24 hrs. There was a dose dependent effect on the larval weight, time taken for pupation, and adult emergence, percentage pupation and percentage adult emergence. When two day old larvae were fed on sublethal concentrations through diet a small proportion of pupal –adult intermediates were observed at LC20 and LC40. Adults emerging from the larvae fed on diet containing LC10, LC20 and LC40 of lufenuron did not show any variation in the fecundity and hatchability of eggs from that of control. The fecundity of adults fed with sub-lethal concentration of lufenuron (obtained against two day old larvae through diet) was not affected, however, percentage hatching and survival was affected. Interestingly there was a reversal of the effect within ten days of treatment with respect to percentage hatching and survival. When eggs were exposed to treated diet hatching was not affected. The present data suggest that lufenuron even at sub-lethal concentrations has a very good larvicidal and ovicidal activity in T. castaneum.

Measuring Obesity among School-aged Youth in India: A Comparison of Three Growth References.

Objective: To compare three growth references that can be used to assess the weight status of school-aged youth living in India, with a particular focus on identifying overweight and obese youth. Study Design: Cross-sectional study. Kappa scores were used to measure agreement between growth references. Regression models were used to test for differences in weight status by grade level, gender, and school type, using each growth reference. Setting: Private (n=4) and Government schools (n=4) in Delhi, India. Participants: Students (n=1818) in eighth and tenth grade attending the schools. Main outcome measures: Weight status was derived using age- and gender-specific cut-points provided by: (a) a national growth reference specific to India; (b) an international reference recommended by the International Obesity Task Force (IOTF); and (c) a new international reference recommended by the World Health Organization (WHO). Results: The IOTF reference consistently classified participants in a lower weight status category, compared with the national reference (κ=0.57) and the WHO reference (κ=0.69). The agreement between the WHO and the national references was higher (κ=0.84). Conclusions: To date, all published studies of childhood obesity in India have used the IOTF reference, the national reference, or an old WHO reference to measure weight status among school-going youth. The new WHO reference may be a better choice. Compared to the IOTF reference, it does not appear to underestimate obesity and can still be used to compare trends, globally.

Effect of photoperiod on the adrenal activities of male rose ringed parakeet, Psittacala krameri.

Adult male rose ringed parakeets were exposed to very long photoperiod (22 hr L: 2 hr D) and very short photoperiod (2 hr L: 22 hr D) daily for 60 days during different phases of the annual testicular cycle. Adrenal activities of the experimental birds were compared with that of parallel held natural photoperiodic birds. Marked atrophy of adrenocortical cells was noted in the glands of long photoperiod (22 hr L:2 hr D) during different phases, i.e., post-breeding, quiescent and pre-breeding phases of annual gonadal cycle. The atrophied cells were not uniformly distributed in different groups of long photoperiod responsive birds. During pre-breeding, post-breeding and quiescent phases marked atrophy of the adrenocortical cells were restricted to the sub capsular zone of the gland. The cytometric and karyometric studies also revealed significant decrease in the cortical cord width and diameter of nuclei in the cortical cells in either subcapsular zone in the gland of long photoperiodic birds considered for treatment during pre-breeding, post-breeding and quiescent phase or in both the sub capsular zone and the inner zone. The cytometric and karyometric values did not show any change from control birds.

Solitary myofibroma of the breast: a case report.

Solitary myofibromas are relatively rare neoplasms but one of the most common fibrous neoplasms occurring in infancy and childhood. Adult cases have also been reported in the literature. We describe here a case report of an eighteen-month-old child who presented with a gradually enlarging nodule in the right breast. The case is presented for an insight into contemporary knowledge about its histogenetic origin, behaviour and prognosis.

Hepatitis C in childhood.

The prevalence of hepatitis C virus (HCV) infection is relatively low in childhood. Blood transfusion has been the principal route of acquisition in children but vertical transmission is gradually occupying primacy in the developed world. The risk of vertical transmission increases with higher maternal viraemia and human immuno-deficiency virus (HIV) co-infection but current international guidelines do not suggest avoidance of vaginal delivery and breastfeeding to minimise the risk of vertical transmission. The diagnosis of perinatal transmission is different from that in older child or adult and detection of HCV-RNA is essential. Although the natural history of HCV infection in children is not well characterised, almost 50-80% will progress to chronic hepatitis among vertically infected and blood transfusion acquired hepatitis C cases. Children have a lower viral load, lower ALT values and milder histological derangement as compared to adults with chronic hepatitis C cases. Experience of treatment of chronic hepatitis C in children is limited and still evolving. Few patients achieve spontaneous remission and progression to a more severe liver disease might occur in adult life. Here, the natural history, diagnosis and management of HCV infection in children are discussed with special emphasis on features which are different from adults.

Effect of hypoxia on the circulating levels of essential mineral elements in rats.

Changes occurring in concentrations of certain trace metals and electrolytes viz. chromium, copper, zinc, sodium, potassium, calcium, magenesium and chloride in plasma of rats exposed to intermittent hypobaric hypoxia were evaluated. Batches of Sprague-Dowley rats (12 in each group) were exposed for 1, 7,14 and 21 days to a simulated altitude 7,620 m for 6 h per day and one group of unexposed animals was kept as control. There was a significant rise of 153% in plasma chromium levels of 1 day exposed group in comparison to the unexposed group which tends to normalise on subsequent exposure. There was a gradual increase in plasma copper levels of 9.0, 28.2, 62.6 and 65.6% respectively in 1,7,14 and 21 days exposed rats in comparison to unexposed rats. On the other hand plasma zinc levels were seen to be decreasing during entire exposure. Plasma sodium levels decreased initially in 1 and 7 day exposed rats and increased in later groups whereas plasma potassium levels of exposed groups remained low in comparison to unexposed group. Chloride levels were found to be elevated in 14 and 21 day exposed groups.The plasma calcium and magnesium levels were higher in all exposed groups over unexposed groups. Changes in chromium, copper and zinc observed in the present study during exposure to hypoxic stress may be responsible for the hyperglycemia and anorexia encountered during intial phase of high altitude acclimatisation.

Pulmonary function tests in beta thalassemia.

To study pulmonary function tests (PFT) in multiple transfusion recipient thalassemics, PFTs were done for 30 thalassemics and 20 matched controls. Confirmed cases of thalassemia on regular transfusion therapy were the subject of study. Apart from history and physical examination of the thalassemics, serum ferritin estimation and spirometry were done. Parameters studied included lung volumes--functional residual capacity (FRC), forced vital capacity (FVC), residual volume (RV) and total lung capacity (TLC); and flow rates--forced expiratory volume in one second (FEV1), forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC), peak expiratory flow 25-75 (PEF 25-75%) and peak expiratory flow rate (PEFR). Single breath carbon monoxide diffusing capacity (DLco) and arterial blood gas (ABG) were also analysed. The mean height and weight of thalassemics were below that of age matched controls. A restrictive abnormality in PFT was found in 86.6% cases. These patients were found to have a decrease in all the lung volumes namely FVC, FRC, RV and TLC with a proportional decrease in the flow rates, FEV1, PEF 25-75% and PEF with a normal (> 0.75) FEV1/FVC ratio. DLco was decreased in all the patients with restrictive lung disease and fall in DLco showed a good correlation (r = 0.7, P < .001) with the severity of restrictive disease suggesting that some intrapulmonary pathology is likely to be responsible for the restrictive pattern. None of the cases had an obstructive or mixed pattern of pulmonary dysfunction. No correlation was found between severity of restrictive disease and the serum ferritin levels. A negative correlation with degree of hepatosplenomegaly was found. No correlation was found between severity of the defect and age, number of blood transfusions received and hemoglobin at the time of doing the test. To conclude, restrictive lung disease is the predominant abnormality in multi-transfused thalassemics, which is probably due to pulmonary parenchymal pathology. The abnormality of PFTs is not directly related to iron overload.

Congenital diaphragmatic hernia.

Over the last two decades there has been a constant improvement in the understanding of the pathophysiology of Congenital Diaphragmatic Hernia (CDH) and its management. However, the ideal treatment remains elusive. The earlier management strategy of immediate surgery is replaced by the principle of physiological stabilisation and delayed surgery. Conventional mechanical ventilatory techniques, with high pressures and hyperventilation to reverse ductal shunting and cause alkalinization, are being questioned because of the risks of barotrauma and consequent broncho-pulmonary dysplasia. It has also been shown that paralysis with pancuronium bromide for patients on conventional mechanical ventilation results in increased incidence of sensorineural hearing loss in childhood survivors of CDH. With the introduction of the concept of permissive hypercapnia and high frequency oscillation ventilation, the complications of pulmonary barotrauma are circumvented. Although ECMO therapy is invasive, yet has improved survival by about 15% independently, especially in critically ill infants who have the predictive mortality rate of more than 80%. Further insights into the pathophysiology of CDH and the introduction of less invasive therapeutic techniques in the form of high frequency oscillation ventilation, inhalation nitric oxide, surfactant, and perfluorocarbon liquid ventilation may even make the need for ECMO redundant.

Lipid peroxide levels in chronic renal failure.

To determine presence of oxidant stress in chronic renal failure and to evaluate the efficacy of vitamin E in its amelioration, we studied 34 patients (Group I, age 32.4 +/- 11 years, M:F 3:1) and 10 healthy controls (Group II, age 27.4 +/- 5 years, M:F 4:1). The difference in baseline values of lipid peroxide (nmol/ml) was statistically significant (Group I 4.19 +/- 1.69, Group II 1.87 +/- 1.39, p = 0.004). Values of vitamin E (mg/l) were also significantly lower in Group I as compared to Group II (12.18 +/- 4.27 vs. 19.32 +/- 2.03, p = 0.003). Serum lipid peroxide values decreased significantly after supplementation with 400 mg/day of vitamin E for six weeks in Group I (4.19 +/- 1.69 to 3.21 +/- 1.13, p = 0.053) but not in Group II (1.87 +/- 1.39 to 1.03 +/- 0.87). Levels of vitamin E increased in both the groups (Group I: 12.18 +/- 4.27 to 16.01 +/- 5.13, Group II: 19.32 +/- 2.03 to 23.21 +/- 1.94, p < 0.005). No significant difference was observed in values of serum creatinine and urea before and after intervention.

Management of hydrocephalus.

The present study is an analysis of 747 patients with hydrocephalus, treated and followed up in the Hydrocephalus Clinic run by the department of Paediatric Surgery at the All India Institute of Medical Sciences, New Delhi. The distribution of patients was: congenital-46%, post-meningomyelocoele excision-28%, post-meningitic-21% and others-5% (including post haemorrhagic and post encephalocoele excision hydrocephalus. The average age was 7 months in the shunted group and 10 months in the medical group with overall male to female ratio of 2.3:1. The data were analysed to study the effect of treatment on ventriculomegaly and mental development with special reference to the type of treatment (shunt versus medical) and age at starting treatment. The probability of shunt failure was also studied. A comparison of ventricular size in US/CAT scans between the time of starting treatment and last follow-up revealed improvement in ventriculomegaly in 60% of the shunted patients but only 30% of the medically treated patients. A significant difference was particularly noted in patients with severe hydrocephalus, 72% and 22%, respectively. Comparison of the mean Mental Performance Quotient (MPQ) scores in the shunted & medically treated patients also revealed significantly better MPQ scores in the shunted group (p = < 0.001). Probability of shunt survival, as depicted by the Kaplan-Meier survival curve, revealed that there is a high rate of shunt failure in the first 12 months, followed by a dramatic slowing down. Our observations support the contention that CSF shunt surgery offers better outcome than medical management even when ventriculomegaly is severe at the time of presentation.

Evaluation of a simple technique for rapid access to left main bronchus.

A suction catheter with dual curvature at its tip was evaluated for its successful rapid access to left main bronchus. The catheter with dual curvature was passed through endotracheal tube in neutral position of head in 58 adult patients of both sexes in need of mechanical ventilation. Bedside x-ray (AP view) chest was taken to confirm its location. It is observed that this suction catheter had very high success rate of 95% in first attempt and 100% after repositioning endothracheal tube. It did not require any position alteration of head or body and easily allowed aspiration from left lung.