RESUMO
Placenta accreta is a potential grievous obstetric condition that calls for a multidisciplinary timely management. Placenta accreta refers to placenta that is firmly adherent to the myometrium.1 Three types of adherent placental attachments are, placenta accreta (the uterine decidua is absent and the chronic villi attaches to the myometrium directly), placenta increta (the chronic villi invades into the myometrium), and placenta percreta (the villi penetrate the myometrium up to the serosal layer).2The incidence of placenta accreta has increased ten-fold in the past 50 years.3 It can lead to excessive bleeding, haemorrhagic and neurogenic shock, sepsis, uterine inversion, or need for hysterectomy.4Previous obstetrics interventions like caesarean deliveries are the largest risk factor for the placenta accreta, or previous dilatation and curettage or previous manual removal of placenta. Increasing maternal age and parity, as well as other uterine surgeries also have increased risks. When placenta accrete is suspected, a multidisciplinary team with expertise should be there to take care of such cases. Although ultrasound and magnetic resonance image (MRI) may or may not indicate clearly an invasive placenta, the final diagnosis is made intra-operatively and is supported by histopathological examination.4Placenta accreta is associated with high morbidity and mortality of the mother and the foetus and has high demands on health resources. Antepartum haemorrhage may occur in such cases if there is associated placenta previa. MRI is the best modality for diagnosis when there is suspicion of placenta accreta clinically.
RESUMO
This study was conducted over 2 years period at two leprosy centers of a Tertiary Care Service Hospitals one located in Eastern Uttar Pradesh and second in northern India to assess the factors resulting in pre-mature termination of anti-leprosy treatment in patients. A total of 124 patients, undergoing treatment for leprosy who consumed MDT for at least a month, then stopped it and thereafter reported to us for various reasons, were included. It was observed that 41.1% (51/124) patients dropped out on MDT. 33% (41/124) of the patients who stopped the medication were not formally educated. Most common disease forms observed in these patients was Borderline Lepromatous (BL) and Lepromatous Leprosy in 41.1% (51/124). 49.1% (61/124) patients completed 2-5 months of therapy with MDT prior to stopping it and 38.7% (48/124) patients reported back to us within 2-5 months after suspension of MDT. Reason for reporting in 31.4% (39/124) of these patients was development of deformities while 25% (31/124) reported due to weakness of hands and feet. 23.3% (29/124) developed lepra reaction becoming the reason for their reporting to us for review. Social stigma was the most common factor leading to termination of drug therapy against advice in 25.8% (32/124) patients, 21.7% (27/124) cited loss of occupational hours while 11.2% (14/124) patients felt there was no need to take MDT. To conclude non-compliance to multi drug therapy for leprosy is one of the major obstacles in achieving a leprosy free world and we need to look into all the personal, health care related and social factors responsible for it. Although these factors may vary depending upon the region, society, efficiency of the health care system and the individual commitment level of the patients, the need for better communication at professional and user level is apparent. Focus should be on psychological counselling, motivation of patients, their families and a receptive society to reduce the source of infection, complications and deformities which are otherwise largely preventable and adherence to treat will also prevent of emergence of resistance to MDT. Modified strategy(ies) addressing the factors as identified in this study well in time can make a difference.
RESUMO
The incidence of appendicitis shows a marked variation between populations which has been attributed to dietary differences. Neural mechanisms and serotonin discharge from subepithelial neurosecretory cells have been previously implicated in pain referable to the appendix and appendicitis. Forty consecutive appendicectomy specimens from Malawi were studied by staining with haematoxylin and eosin; an alcian blue - PAS diastase sequence coupled with lead haematoxylin (PbH) and immunohistology for serotonin and NSE. The findings were compared with those in appendices removed at the Middlesex Hospital; London; to see if there were any differences between a population with a low risk of appendicitis (Malawi) and a high risk population (England). Acute transmural appendicitis was seen in fewer appendices from Malawi (27.5 per cent) than in eng appendices (58 per cent). Subepithelial neurosecretory cells identified with PbH were present in 20 per cent of appendices from Malawi and 69 per cent of eng appendices. These cells in both series showed immunohistochemical staining for serotonin. Nerve hyperplasia identified by staining for NSE in the appendix was present in 17.5 per cent and 81 per cent of non-inflamed appendices from Malawi and England respectively. Appearance of subepithelial neurosecretory cells and hyperplasia appear to be concomitants of an increased risk of appendicitis. Neural mechanisms may participate in adapting to a low residue diet and in some cases may generate appendicitis