A rare case of bilateral drain site abdominal hernia: a case report and review of literature

Use of abdominal drain is a tradition used since a long time. These is generally done to prevent or drain any post-operative intra-abdominal collection aiming to reduce morbidity and mortality and early recovery of patient. But drain has its own complication such as drain site infection, drain site hernia. We encountered a case of bilateral drain site hernia in a 55 year old female who was previously operated for perforation peritonitis. Both herniae were repaired successfully with onlay meshplasty. Drain placement has various complications like drain site infection, adhesion's, intestinal erosion, bleeding, anastamotic rupture and drain site hernia. There is greater risk of hernia in patient with poor nutritional status, obesity, ascitis, severe abdominal infection or with persistent cough. It is better to avoid unnecessary placement of drain. If a drain is placed, its removal should be done as early as possible. It is better to close the defect after removal of drain.

Role of S-100 Immunostaining in Differentiation of Borderline Leprosy from Other Granulomatous Diseases of Skin

Leprosy is a chronic granulomatous disease affecting skin, peripheral nerves and other tissues. On histopathology leprosy mimics other infectious and non-infectious lesions like tuberculosis, sarcoidosis and fungal infections, which are also common in our country. In tuberculoid and indeterminate forms, where Acid Fast Bacilli cannot be demonstrated, the diagnosis becomes more difficult. Mycobacterium leprae is the only bacterium which has the ability to infiltrate peripheral nerves leading to Schwann cell disintegration. On routine Hematoxylin and Eosin stains (H&E), the nerve fibers may not be easily identifiable in some cases , hence S-100 immunostaining is used to highlight the nerve elements and to demonstrate and compare the nerve changes in spectrum of leprosy. With widespread use of multi-drug treatment, there has been changes in the profile of disease. The aim of the present study was to observe different patterns of cutaneous nerve involvement in leprosy and to correlate these with the clinical and histopathological findings in currently referred cases for histopathological opinion. The study was conducted in the Department of Pathology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, over a period of 12 months (July 2016 - July 2017) Subjects were recruited from patients presenting in Dermatology OPD. A total 35 consecutive cases with clinical suspicion / diagnosis of leprosy were included in the study. Biopsies were processed and stained by H&E, Fite-Faraco as well as S100 immunostaining. It was observed that on S-100 immunostaining, 43.7% cases showed granulomas infiltrating the dermal nerves whereas these changes could not be demonstrated in 16.6% cases of Borderline leprosy on H&E staining alone. Thus S-100 staining appears to serve as an important tool to diagnose leprosy from other granulomatous diseases of skin even in current scenario of leprosy.

A case series on drug induced hyponatremia: uncommon adverse effect of commonly used drugs

Older patients suffering from depression and psychosis have markedly increased since last decade. So, has the use of antidepressants and antipsychotics. The prevalence of hyponatremia due to these drugs is common in general as well as psychiatric practice. It may also lead to life threatening morbidity and mortality. Loss of renal function, polypharmacy, dementia and other conditions of advanced age can either exacerbate the severity of hyponatremia or mask its onset. In this case series, total four cases were reported of hyponatremia and drugs causing it were escitalopram, quetiapine, tianeptine and oxcarbazepine. Due to polypharmacy, a chance of hyponatremia was more in these patients. Patients received infusion of hypertonic saline with salt added diet to treat hyponatremia. Symptoms of hyponatremia were improved after the treatment. In all four cases, WHO and Naranjo’s causality assessment revealed ‘possible’ causal relationship with the prescribed drug. Prescribers should be aware of such adverse effect due to these drugs.

Morbidity and drug utilization pattern among admitted pregnant anemic women and to find out rationality of drug by using Indian guidelines.

Background: Pregnancy represents a special physiological state during which the use of drug is of growing concern due to risk of teratogenicity. Anemia is common threat to mother. Therefore, our aim was to study the drug utilization, teratogenic risk among patients of anemia in pregnancy and check rationality of prescriptions. Methods: An observational, prospective study was carried out in 150 indoor patients in the tertiary care hospital. Protocol was approved by the Institutional Review Board. The data were collected in a pre-designed proforma. Data were analyzed using SPSS version 20.0 Software. Results: Among 150 patients, 23, 111, and 16 were of <20, 20-30 and more than 30 years of age respectively. Among anemic patients Pregnancy induced hypertension (18.7%), antepartum hemorrhage (12.7%) were common. About 71% women have complaint of weakness, followed by headache. Iron (93.3%) and calcium (86.0%) were the most common drugs prescribed. Iron sucrose and packed cell volume given in severe anemia. Drug risk category, Category A (90.21%) was most frequently prescribed, which is followed by Category B (8.0%) and Category C (1.8%). Percentage of drugs prescribed by generic name and from essential drug list was 70.3 and 89.2. Overall prescribing habit was rational according to Indian guideline. Conclusion: Iron, calcium, and folic acid were most commonly prescribed drugs in anemic patients. No teratogenic risk was found out during drug use. Drug and dose of the drug was rational and appropriate. There is lesser number of drugs prescribed by generic name and hospital supply.

Study of drug utilization, morbidity pattern and cost of hypolipidemic agents in a tertiary care hospital.

Background: Data on the extent of use and costs of lipid-lowering agents are not widely available. Our aim was to study the drug utilization and morbidity pattern, cost of different hypolipidemic drugs along with the risk assessment for coronary heart disease. Methods: After approval of protocol by the Institutional Review Board, an observational, prospective study was carried out in 300 patients using NCEP and ATP III Guidelines-2002 for evaluation of presence or absence of risk factors for coronary heart diseases. Data were analysed using SPSS software version 16.0and WHO Core Drug Prescribing Indicators. Results: Patient’s morbidity pattern revealed that 62%, 49.3%, 28% suffered from ischemic heart disease, hypertension and type 2 diabetes mellitus respectively. On risk assessment, 48%, 13.3% patients had borderline and high level of total cholesterol respectively; 42%, 22.7% had borderline and high triglyceride levels respectively; 71.1% men and 62% women had low HDL cholesterol levels while 17.3%, 6% and 2.7% patients had borderline high, high and very high level of LDL cholesterol levels respectively. Frequency of prescriptions was atorvastatin (82%), rosuvastatin (9.3%) and simvastatin (4.7%) among the most frequently prescribed statins drug group. The mean number of drugs per prescription was 7.34. Drugs prescribed by generic name and from essential drugs list was 24.96% and 71.81% respectively. Mean cost of hypolipidemic agents/prescription/day was 10.74 (±1.96) Indian Rupees with rosuvastatin being the costliest. Conclusion: Rational use of hypolipidemic agents with an increasing trend of statins prescriptions will significantly reduce the morbidity and mortality from coronary heart diseases.

Newer approaches in the treatment of asthma.

Asthma is a worldwide public health problem. The most effective anti-asthmatic drugs - inhaled β2-agonists and glucocorticoids controls asthma in about 90-95% of patients. However, severe glucocorticoid-dependent and resistant asthma presents a great clinical burden. Therefore, reducing glucocorticoids - related adverse effects using novel steroid-sparing agents is needed. Furthermore, the mechanisms involved in the persistence of inflammation are poorly understood and the reasons why some patients have severe life threatening asthma and others have very mild disease are still unknown. Although glucocorticoids effectively control the inflammatory process in asthma, they have little effect on the lower airway remodeling processes that appear to play a role in the pathophysiology of asthma. Several new drugs developed to target specific components of the inflammatory process in asthma [e.g. anti-IgE antibodies (omalizumab), cytokines and/or chemokines antagonists, immunomodulators, antagonists of adhesion molecules)], have not yet been proven to be particularly effective. Hence, considering the central role of T lymphocytes in the pathogenesis of asthma, drugs targeting disease-inducing Th2 cells are promising future therapeutic strategies. Some of these new anti-asthmatic treatment approaches may in the future not only control symptoms and modify the natural course of asthma, but also potentially prevent or cure the disease. Hence, the development of novel drugs may allow resolution of these changes.