A Diagnostic Journey

We describe the case of a patient who came with features suggestive of diabetic ketoacidosis. On further evaluation of DKA, we found that it was caused by acute pancreatitis. This acute pancreatitis was found to be caused by hypercalcemia, which was in turn due to primary hyperparathyroidism. Imaging studies done for hyperparathyroidism revealed a thyroid nodule which later turned out to be malignant. This patient was also incidentally found to have hypertrophic obstructive cardiomyopathy.

Formononetin alleviates diabetic cardiomyopathy by inhibiting oxidative stress and upregulating SIRT1 in rats

Objective: To evaluate the effect of formononetin on type 2 diabetic cardiomyopathy.Methods: Diabetes was induced by feeding high-fat diet for 2 weeks and administration of 35 mg/kg of streptozotocin in rats. Formononetin was administered at 10, 20 and 40 mg/kg for 16 weeks once a day. Plasma glucose, lipid parameters, and cardiac markers in blood samples were measured. Body weight and relative heart weight were recorded. Hemodynamic parameters, oxidative stress parameters and silence information regulator 1 (SIRT1) expression in cardiac tissue were estimated. Histopathological changes in cardiac tissue were also observed. Results: Formononetin significantly reduced the levels of glucose, triglycerides, cholesterol, low density lipoprotein, creatine kinase-MB, lactate dehydrogenase and aspartate aminotransferase. In addition, formononetin significantly improved hemodynamic parameters, alleviated oxidative stress and increased SIRT1 expression. Conclusions: The study indicates that formononetin can improve hyperglycemia and hyperlipemia, reduce oxidative stress and increase SIRT1 expression. It can be a potential therapeutic agent for diabetic cardiomyopathy.

Effect Of Blumea Lacera On Tissue Gsh, Lipid Peroxidation And Hepatic Cells In Ethanol Induced Hepatotoxicity In Rats

Objective: To evaluate hepatoprotective effects of ethanol extract of aerial part of Blumea lacera (BLEE) against ethanol-induced hepatotoxicity in rats. Methods: The in vivo antioxidant activity of BLEE was assessed by determining the tissue glutathione (GSH) and lipid peroxidation (LPO) levels. The BLEE at the doses of 200 and 400 mg/kg and silymarin 100 mg/kg administered to the ethanol challenged rats. The effects of BLEE and silymarin on Physical and Biochemical Parameters were measured. Similarly, histopathological changes of the liver were studied. Results: The BLEE showed in vivo antioxidant activity. A significant (P<0.001) decrease in SGOT, SGPT, ALP, total and direct bilirubin was observed in BLEE treated group at doses i.e. 200 mg/kg and 400 mg/kg as compared to intoxicated group. Liver damage in animal pretreated with BLEE was minimal with distinct preservation of structures and the architectural frame of the hepatic cells. Conclusion: These findings demonstrated the hepatoprotective effects of BLEE against ethanol-induced liver damage.

Prevalence of Pulmonary Tuberculosis among Inmates and Staff of Three Indian Prisons.

Aim: To estimate prevalence of TB among inmates and staff of three prisons in south India. Place of Study: The study was undertaken in three purposively selected prisons in Karnataka State, India, namely, Belgaum, Mysore and Mangalore prisons. Methodology: A descriptive, cross-sectional study was undertaken among a total of 2450 inmates and 280 staff at the three selected prisons. Inmates and prison staff were screened for cough of ≥ 2 weeks and the identified TB suspects were subjected to sputum microscopy for acid fast bacilli using ZN staining and fluorescent microscopy. Results: 81 TB suspects were identified among the inmates and none among the staff. Of the 81 TB suspects, none were positive for acid fast bacilli. 10 inmates at the prisons were already on DOTS for pulmonary TB. A prevalence of pulmonary TB of 4/1000 prison inmates was estimated. Unmet need for medical care was elicited among TB suspects. Past history of anti-TB treatment and history of current smoking were identified as significant risk factors for TB in the selected prisons. Conclusion: The estimated prevalence of pulmonary TB in the selected prisons (4/1000 prison inmates and staff) was almost twice that in the Indian general population (2.11/1000 general population).

Role of neo‑adjuvant chemotherapy in locally advanced breast cancer.

BACKGROUND AND AIMS: Locally advanced breast cancer (LABC) is common in developing countries. The advancement of disease leads to decreased probability of radical cure and increase in treatment cost. The study evaluated neo adjuvant chemotherapy with MRM and MRM followed by adjuvant chemotherapy and also the effectiveness of neo‑adjuvant chemotherapy in down staging advanced disease and offering radical cure. SETTINGS AND DESIGN: A rural hospital‑based prospective comparative study. MATERIALS AND METHODS: All histologically proven and investigated LABC (T3 N0, T3N1, Any T4, Any N2/N3, M0) were selected as subjects and divided into two groups. One group received neo adjuvant chemotherapy (5 fluorouracil, adriamycin and cyclophosphamide) followed by modified radical mastectomy and other group received adjuvant chemotherapy after modified radical mastectomy. Both groups were compared for disease free survival, overall survival and post‑operative complications. Tumor response to chemotherapy in neo adjuvant group was also studied. STATISTICAL ANALYSIS: All continuous variables were analyzed using student’s’ test and categorical variable by Fischer exact test. RESULTS: Thirty one patients were enrolled, of these 16 patients received neo adjuvant chemotherapy. Clinical complete response was observed in two patients (12.5%). Clinical partial response was found in 12 patients (75%) and no response was seen in two patients (12.5%). Disease free survival and overall survival was 82% in neo adjuvant group while in adjuvant group disease free survival was 75% and overall survival was 83%. Post operative complications were similar in both groups. CONCLUSION: Neo adjuvant chemotherapy helps in down staging LABC and offers opportunity in vivo to assess the effect of chemotherapy on individual basis. There was no significant difference in disease free survival, overall survival and post operative complication in between two groups.

Ectodermal dysplasia: familial report of six cases.

Ectodermal dysplasia is a hereditary disease characterized by a congenital dysplasia of one or more ectodermal structures and their accessory appendages. There are two main types, Hypohidrotic/Christ-Seimens- Tourian Syndrome and Hidrotic/Clouston syndrome. Common manifestations include defective hair follicles and eyebrows, frontal bossing with prominent supraorbital ridges, nasal bridge depression and protuberant lips. Intraorally common findings are anodontia or hypodontia and conical shaped teeth. The patient may suffer from dry skin, hyperthermia and unexplained high fever because of the deficiency of sweat glands. The present article reports unique case series of ectodermal dysplasia cases in two families, where three generations in the both the families were affected.

Thoracoscopic and endovascular management of retained haemothoarx associated with an intercostal artery pseudoaneurysm.

Intercostal artery pseudoaneurysm (IAP) is a rare entity and may complicate a percutaneous intervention through an intercostal space or follow thoracic trauma. Its rupture into the pleural space can give rise to haemothorax, which if untreated may lead to a retained haemothorax (RH). Traditionally both the IAP and the RH are managed by a thoracotomy. We report a patient who developed an IAP with haemothorax following a trauma. The diagnosis was established by computed tomography. The patient was treated by endovascular embolisation of the IAP followed by thoracoscopic decortications of the RH.

Community Based Monitoring under National Rural Health Mission (NRHM) at Village Level in the State of Maharashtra, India.

Background: Government of India, under National Rural Health Mission has established Village Health Sanitation Nutrition Committees (VHSNCs) and appointed Accredited Social Health Activists (ASHAs) in all the villages. Government of India also started Community Based Monitoring (CBM) project through Non-Governmental Organizations (NGOs). State of Maharashtra was one of the nine states selected for implementation of the pilot project. Objectives: To assess the effect of training and implementation of CBM on Knowledge, Attitude and Practices of VHSNC members including ASHAs. Design: It is a descriptive study using comparison group. Settings: The study was carried out in 90 villages, 45 each from study and comparison group, in the State of Maharashtra, India. Interventions: The study was conducted with the help of the Community Medicine Departments from nearby Medical Colleges. From each village one ASHA and three members of VHSNC were interviewed. An assessment instrument was developed having some parameters. Based upon responses to each parameter, a scoring system was also developed. Then comprehensive score was calculated for each respondent. Main Variable: Comprehensive score obtained by the interviewed individual was studied. Results: Only 41% ASHAs and 28% VHSNC members were trained in CBM by the concerned NGOs. The Mean score of ASHAs’ was 7.52. The mean score was 6.55 for trained members of VHSNC and 5.00 for un-trained members. Discussion: The interviewed members were lacking in core areas. The members are not ready to take ownership and to monitor services. Conclusions: The training and implementation of CBM did not have any difference in awareness and active participation of ASHAs. This may be due to improper coverage of training. The training helped VHSNC members in improving score but actual implementation of project did not improve the score.

Adult-onset Rasmussen’s encephalitis.

Rasmussen’s encephalitis (RE) is characterised by refractory focal seizures, unilateral cortical deficits, and progressive unihemispheric focal cortical atrophy of undetermined aetiology. A majority of these cases present in childhood, and three disease stages have been recognised: a ‘prodromal stage’, an ‘acute stage’ and a ‘residual stage’. Adult-onset and variant forms have also been described but are rare, and we report one such case with frequent refractory focal seizures, right-sided hemiparesis, aphasia, and marked atrophy of the left perisylvian cortex with a slow disease progression over 17 years. Immunotherapy with corticosteroids, IVIG, plasma exchange, and tacrolimus has been tried in RE with variable results. Hemispherectomy and disconnective techniques like functional hemispherectomy and hemispherotomy are effective in achieving seizure freedom in 62.5% to 85% cases, but carry a risk of motor and language deficits.

Monocationic surfactant induced ultra structural changes in antibiotic resistant Escherichia coli.

Background & objectives: Cetrimide is a monocationic surfactant, commonly used for disinfection of hospital floors, equipments, for cleansing of burns and wounds, hand wash, etc. We evaluated whether antibiotic resistant (AR) Escherichia coli isolates from hospital settings (nosocomial pathogens) show any evidence of significant reduction in their susceptibility to cetrimide. Also the response of AR E. coli (nosocomial pathogens) to the action of cetrimide was assessed by studying the ultra structural changes induced using transmission electron microscopy (TEM). Methods: A total of 165 clinical samples were screened for isolation of E. coli. Eighty two (49.6%) samples were positive for E. coli. Antibiotic susceptibility testing of E. coli isolates was carried out by Kirby Bauer method to isolate AR E. coli. The randomly selected AR E. coli isolate was treated with different concentrations of cetrimide and minimum inhibitory concentration (MIC) of cetrimide was determined by broth micro dilution method. This same isolate was used for performing time kill assay and TEM study. Results: The test E. coli isolate showed resistance to 12 different antibiotics. The MIC of cetrimide against AR E. coli was 312.5 μg/ml. The ultra cellular structural changes in cetrimide treated AR E. coli revealed vacuole formation, disaxilization of nuclear material, loss of cytoplasmic granularity, bleb formation and cell lysis. Conclusion: Ultra structural changes induced by the action of cetrimide revealed cell damaging changes in the AR E. coli to be dose and time dependent. The results showed that antibiotic resistance does not alter any change in susceptibility of E. coli to cetrimide, which was found to be still an effective disinfectant against a nosocomial pathogen E. coli.

Hsp90 mediates activation of the heme regulated eIF-2 kinase during oxidative stress.

The heme-regulated inhibitor (HRI), a member of the eIF-2 kinase family is crucial for regulating protein synthesis during stress. In addition to heme, stress proteins Hsp90 and Hsp70 are known to regulate HRI. The present study aims to determine the physical association of these Hsps in the regulation of HRI activation during oxidative stress using human K562 cells as a model. Extracts from the stress-induced cells were used for determining HRI kinase activity by measuring eIF-2 phosphorylation, and Hsp-HRI interaction by immunoprecipitation and immunoblot analyses. The results indicate a significant increase in both Hsp70 and Hsp90 expression during AAPH (2, 2’-azobis (2-amidinopropane) dihydrochloride)-induced oxidative stress. Further, their interaction with HRI, which correlates well with its increased HRI kinase activity leads to inhibition of protein synthesis. Thus, we demonstrate that Hsps play an important role in the regulation of initiation of protein synthesis during oxidative stress.

A cystic hepatic lesion: when to worry? / La lesión cística del hígado: ¿cuándo preocuparse?

A 16-year old female presented to hospital with abdominal pain. Features on computed tomography raised the possibility of biliary cystadenoma or cystadenocarcinoma. She underwent a liver resection, and histopathology confirmed a serous biliary cystadenoma. This case is presented to highlight the radiological features of this uncommon pre-malignant condition as well as to summarize a management algorithm for cystic liver lesions.

Una mujer de 16 años de edad acudió al hospital con un dolor abdominal. Las características observadas con tomografía computarizada apuntaban a un cistoadenoma biliar o un cistoadenocarcinoma como diagnósticos diferenciales. La paciente fue sometida a una resección del hígado, y la histopatología confirmó un cistoadenoma biliar seroso. Presentamos este caso para resaltar los rasgos radiológicos de esta condición premaligna rara, así como para resumir un algoritmo de tratamiento para las lesiones císticas de hígado.

Anesthetic consideration in downs syndrome--a review.

Downs syndrome constitutes to be the most common chromosomal disorder. Patients with Downs's syndrome are posted for several surgeries including dental procedures and even for facial reconstruction. They are associated with several congenital anomalies in different organ system. There is also increased incidence of atlanto axial instability and risk of spinal cord injury. These children are susceptible to infection and they are also considered to be hypersensitive to the effect or atropine. These all factors modify the anesthetic implication and also anesthetic management in these cases. We have highlighted all these factors and reviewed the anesthetic implication of these child posted for several procedures under anesthesia.

Critical illness myopathy.

Critical illness myopathy is one of the causes for failure to wean from ventilator. Although associate factors of dyselectrolytemia is to be ruled out and other causes for failure to wean is to be ruled out before diagnosing critical illness myopathy. Several factors play role in development of this condition. Here we present a case report of a post partum patient where we had encountered failure to wean despite several attempts and at last was successfully weaned and discharged from intensive care unit.

Primary amebic meningoencephalitis.

This case is reported with the intention of highlighting the presentation of primary amebic meningoencephalitis as acute meningitis, a rare differential diagnosis with presence of free living amoebas in the CSF.

Hypoplasia of the abdominal aorta--a case report.

Infrarenal aortic coarctation is a very uncommon vascular disease. It has been named as hypoplasia of abdominal aorta, mid aortic dysplasia, mid aortic syndrome, atrophy of aorta, atresia of the terminal aorta & atypical coarctation. The pathogenesis is still controversial. Hypertension is an almost universal feature of this disorder. We present a case report with postmortem findings of a young female patient having hypoplasia of abdominal aorta for its rarity.

Mycophenolate mofetil: a promising immunosuppressive agent.

With avaibility of newer immunosuppressive agents, incidence of acute graft rejection has decreased. Mycophenolate mofetil is one such new drug, now available in the Indian market It has been found to be useful in prevention and treatment of acute and chronic rejection after transplantation. Besides transplant it has been used successfully in primary and secondary glomerulopathies (e.g. SLE) and other autoimmune diseases. The drug is well tolerated with side effects limited mainly to gastrointestinal system in the form of epigastric pain, vomiting and diarrhoea.

Cytomegalovirus nasal polyp after renal transplant.

Infection is a major problem after transplantation. Cytomegalovirus (CMV) is the most common viral infection affecting transplant patients. We describe a case of CMV infection with rare clinical manifestation in the form of nasal polyp. Patient presented 6 weeks following renal transplantation with history of fever and stuffy nose. On evaluation he was found to have nasal polyp which was excised. Histopathology revealed characteristic CMV inclusion bodies. Patient responded to ganciclovir therapy and is presently doing well eighteen months after transplantation.