The development of Terminalia chebula Retz. (Combretaceae) in clinical research.

Medicinal plants are part and parcel of human society to combat diseases from the dawn of civilization. Terminalia chebula Retz. (Fam. Combretaceae), is called the 'King of Medicine' in Tibet and is always listed at the top of the list of 'Ayurvedic Materia Medica' because of its extraordinary power of healing. The whole plant possesses high medicinal value and traditionally used for the treatment of various ailments for human beings. Some of the folklore people used this plant in the treatment of asthma, sore throat, vomiting, hiccough, diarrhea, dysentery, bleeding piles, ulcers, gout, heart and bladder diseases. The plant has been demonstrated to possess multiple pharmacological and medicinal activities, such as antioxidant, antimicrobial, antidiabetic, hepatoprotective, anti-inflammatory, antimutagenic, antiproliferative, radioprotective, cardioprotective, antiarthritic, anticaries, gastrointestinal motility and wound healing activity. But no systematic updated information on the therapeutic effectiveness of Terminalia chebula, a popular herbal remedy in India and South-East Asia has so far been reported. This review highlights an updated information particularly on the phytochemistry and various pharmacological and medicinal properties of Terminalia chebula Retz. and some of its isolated compounds, along with their safety evaluation. This may provide incentive for proper evaluation of the plant as medicinal agent against the human diseases and also to bridge the lacunae in the existing literature and future scope which may offer immense opportunity for researchers engaged in validation of the traditional claims and development of safe and effective botanical medicine.

Antibacterial potential of hydroalcoholic extracts of triphala components against multidrug-resistant uropathogenic bacteria--a preliminary report.

"Triphala", the Ayurvedic wonder is used traditionally for the treatment of different types of diseases since antiquity. The hydroalcoholic extracts of the three components of Triphala powder demonstrated varying degrees of strain specific antibacterial activity against multidrug-resistant uropathogenic bacteria. Terminalia chebula fruit extract was active against all the test isolates followed by Terminalia belerica and Emblica officinalis. There was a close association between antibacterial activity and total phenolic content of Triphala components.The test plant extracts were also found to be non-toxic on human erythrocyte membrane at recommended and even higher doses. The preliminary results of the present study may help in developing effective and safe antimicrobial agents from Triphala components for the treatment of urinary tract infections caused by multidrug-resistant bacteria.

Perinatal outcome in pregnancies with intra-uterine growth restriction by using umbilical and middle cerebral artery colour Doppler.

There are various biophysical methods used for diagnosing and monitoring foetal well being using in intra-uterine growth restriction foetus, out of which Doppler velocimetry proved to possess the predictive capacity in diagnosing and management of intra-uterine growth restriction foetuses. The objectives were to study Doppler velocimetry of foetal umbilical artery and middle cerebral artery in diagnosing intra-uterine growth restriction and to correlate Doppler finding with perinatal outcome. Random 50 patients with singleton pregnancies admitted in RG Kar Medical College and Hospital were studied in a duration of 1 year. Umbilical artery and middle cerebral artery were studied during foetal inactivity and apnoea. Percentage of normal and abnormal Doppler velocimetry of umbilical artery and middle cerebral artery was observed and its relation with perinatal outcome analysed. Out of 50 patients, 30% had normal and 70% had abnormal umbilical artery Doppler velocimetry. Neonatal intensive care unit admission was 20% in normal and 71.42% in abnormal umbilical artery Doppler, 46.4% in normal and 68.1% in abnormal middle cerebral artery Doppler and 9.09% in normal and 69.23% in abnormal cerebroplacental index. Neonatal mortality was 0% in normal and 14.3% in abnormal umbilical artery Doppler velocimetry. Oligohydramnios was 26% in normal and 71% in abnormal umbilical artery Doppler. The study revealed that overall perinatal outcome was poor in abnormal Doppler velocimetry group in comparison to normal group. Doppler investigation of the foetal circulation not only plays an important role in monitoring of the growth restricted foetuses but also helps in detecting foetal compromises early in intra-uterine growth restriction foetuses and thereby helps to determine the optimal time for delivery.

In vitro antibacterial potential of Eugenia jambolana seed extracts against multidrug-resistant human bacterial pathogens.

The present study was carried out to evaluate the possible in vitro antibacterial potential of extracts of Eugenia jambolana seeds against multidrug-resistant human bacterial pathogens. Agar well diffusion and microbroth dilution assay methods were used for antibacterial susceptibility testing. Kill-kinetics study was done to know the rate and extent of bacterial killing. Phytochemical analysis and TLC-bioautography were performed by colour tests to characterize the putative compounds responsible for this antibacterial activity. Cytotoxic potential was evaluated on human erythrocytes by haemolytic assay method and acute oral toxicity study was done in mice. The plant extracts demonstrated varying degrees of strain specific antibacterial activity against all the test isolates. Further, ethyl acetate fraction obtained from fractionation of most active ethanol extract showed maximum antibacterial effect against all the test isolates. Phytochemical analysis and TLC-bioautography of ethyl acetate fraction revealed that phenolics were the major active phytoconstituents. Ethyl acetate fraction also demonstrated no haemolytic activity on human erythrocytes and no gross behavioural changes as well as toxic symptoms were observed in mice at recommended dosage level. The results provide justification for the use of E. jambolana in folk medicine to treat various infectious diseases and may contribute to the development of novel antimicrobial agents for the treatment of infections caused by these drug-resistant bacterial pathogens.

A randomized controlled trial comparing two different antibiotic regimens for prophylaxis at cesarean section.

OBJECTIVES: To compare the efficacy of intravenous single dose, less costly cefotaxime and more expensive amoxycillin-clavulanic acid combination for prophylaxis at cesarean section. METHOD: A double blind randomized controlled trial was undertaken on 760 subjects with two parallel treatment groups. Data were analyzed using Graphpad Instat 3 McIntosh software by Student's t test, Mann-Whitney U test, the Chi-squared test or fisher's exact test. RESULTS: Comparatively narrow spectrum low cost cefotaxime is as effective as more expensive commonly used amoxicillin-clavulanic acid with no significant difference of infectious morbidity and hospital stay (p = 0.27 and 0.11 in elective and emergency cases respectively). CONCLUSION: Less costly cefotaxime should be preferred compared to more costly amoxicillin-clavulanic acid combination for prophylaxis at cesarean section.

Normative data of cervical length in singleton pregnancy in women attending a tertiary care hospital in eastern India.

BACKGROUND & OBJECTIVES: The length of cervix predicts the risk of preterm delivery. The objective of this study was to assess cervical length in pregnancy by transvaginal ultrasonography for generating normative data for nulliparous women at no special risk of preterm labour. METHODS: An observational study was carried out in a tertiary care teaching hospital in eastern India in nulliparous women who delivered at term. A single sonologist assessed 224 women (once per subject) between 20 and 34 wk of gestation. Nulliparous women carrying a single foetus of confirmed gestational age were included; 216 subjects were finally considered for generation of normative data, excluding those delivering earlier than 37 or later than 42 wk. Other exclusion criteria were history of cerclage, any previous cervical surgery, smoking, or any medical disorder complicating pregnancy. RESULTS: Cervix length at each week of gestation gradually decreased over the study period. Length at 20 and 34 wk was 40.5 ± 1.14 mm (mean ± SD) and 34.8 ± 1.34 mm respectively. The overall shortening over this 14 wk period was 5.7 mm, with 0.58 mm per week median rate of shortening. Pearson's correlation coefficient was -0.69 (95% CI -0.75 to -0.60; P< 0.001) for cervical length vis-à-vis gestational age. INTERPRETATION & CONCLUSIONS: The serial normative data generated in our setting can be used to decide cut-off points for predicting risk of preterm labour in future studies. Validity of such prediction needs to be tested in larger cohorts of women assessed at specific gestational ages.

A comparative study on sublingual versus oral and vaginal administration of misoprostol for late first and early second trimester abortion.

To compare the effectiveness, side-effects and outcome of sublingual with oral and vaginal administrations of misoprostol for induction of abortion in late first and early second trimester of gestation (9 to 16 weeks), a comparative observational study was carried out among 258 women with a period of gestation between 9 and 16 weeks, scheduled to have medical abortion, and randomly allocated into three groups and offered sublingual, oral and vaginal routes of misoprostol administration (400 mcg of misoprostol 6 hourly, maximum up to four dosages) respectively. Primary outcome measure was complete abortion rate and the secondary outcome measures were incidence of cases where surgical evacuation required, failure rate and induction-abortion interval. Development of side-effects and subjective assessment of patient's comfort with the different routes of administration were also recorded. Rate of complete abortion was higher in sublingual group in comparison to oral (p = 0.0338) and vaginal route (p = 0.5627). Surgical evacuation was required in less number of cases in sublingual group. Induction-abortion interval was also least with the sublingual route le, p < or = 0.0001 (versus oral) and 0.0011 (versus vaginal). Failure rate was highest with the oral route and least with the sublingual route. The patients were least comfortable with the vaginal route. Gastro-intestinal side-effects were least with the vaginal route, but significant vaginal bleeding (> 250 ml) was little bit higher with this route. Though misoprostol is effective in inducing medical abortion irrespective of the route of administration, sublingual route gives better results as compared to oral (statistically significant) and vaginal routes (in some respects, not of much statistical significance).

Maternal mortality and cesarean delivery: an analytical observational study.

AIM: Pregnant women and their doctors need to know the maternal risks associated with different methods of delivery. There are few publications with ideal study design and adequate power to establish the relationship between maternal mortality and mode of delivery. The present retrospective cohort study was undertaken to evaluate the intrinsic risk of maternal death, directly attributed to cesarean delivery (CD) compared to vaginal delivery (VD), and to evaluate further the differential risk associated with antepartum and intrapartum CD. METHODS: After exclusion of medical or obstetric comorbidities, all deliveries, either vaginal or cesarean, were critically analyzed. The surviving mothers who had either method of delivery represented the two comparative groups. In the same period, relevant clinical information of every maternal death was noted. RESULTS: Twenty seven mothers died among the 13 627 CD mothers and 19 died among 30 215 VD mothers. CD was associated with a 3.01-fold increase in the risk of maternal mortality, compared with VD. The risk of antepartum CD differed from intrapartum CD (OR 1.73 vs OR 4.86). There was a significantly increased risk of maternal death from complications of anesthesia, puerperal infection and venous thromboembolism. The risk of death from postpartum hemorrhage did not differ significantly (95% CI 0.7-3.95). CONCLUSION: CD is increasingly perceived as a low-risk procedure. However, the present study clearly demonstrates that the risk of maternal death due to CD is significantly high, particularly when performed in labor. Therefore, CD should only be practiced when conditions clearly demand it.

A randomized controlled trial comparing short versus long-term catheterization after uncomplicated vaginal prolapse surgery.

AIMS: Routine catheterization following vaginal prolapse surgery has advantages like prevention of postoperative retention of urine and prevention of any adverse effect on surgical outcome. However, it increases the risk of urinary tract infection (UTI), prevent early ambulation and prolong hospital stay. This randomized controlled trial was done on how best to minimize catheter related complication after prolapse surgery. METHODS: 200 patients planned for vaginal prolapse surgery were recruited and randomized into two groups. In group I and group II catheter was removed on 1(st) and 4(th) post operative day, respectively. After removal, if patient could not void or when residual urine volume exceeds 150 mL, recatheterisation was done for another three days. Sample of urine was sent for culture during catheter removal. RESULTS: Age, parity, type of surgery and mean operation time did not differ significantly between the two groups. Mean duration of catheterization was significantly shorter (1.64 vs 4.09) and mean duration of hospital stay was shorter by 1.2 days, in first group. However a significantly higher number of retention of urine or residual urine more than 150 mL was found in the early removal group (OR 3.10) but lesser chance of development of urinary tract infection (OR 0.10). CONCLUSIONS: The early removal of catheter seems more advantageous, with lower incidence of urinary tract infection and a shorter hospital stay although associated with an increased risk of recatheterisation.

Reversible cortical blindness: posterior reversible encephalopathy syndrome.

Cortical blindness is defined as visual failure with preserved pupillary reflexes in structurally intact eyes due to bilateral lesions affecting occipital cortex. Bilateral oedema and infarction of the posterior and middle cerebral arterial territory, trauma, glioma and meningioma of the occipital cortex are the main causes of cortical blindness. Posterior reversible encephalopathy syndrome (PRES) refers to the reversible subtype of cortical blindness and is usually associated with hypertension, diabetes, immunosuppression, puerperium with or without eclampsia. Here, 3 cases of PRES with complete or partial visual recovery following treatment in 6-month follow-up are reported.

A comparative evaluation of antibacterial potential of some plants used in indian traditional medicine for the treatment of microbial infections

A comparative in vitro antibacterial potential of extracts (aqueous and ethanol) of five important medicinal plants (Aegle marmelos, Azadirachta indica, Terminalia chebula, Mangifera indica and Ocimum sanctum) were investigated using microbial growth inhibition assays against the common human pathogenic bacteria (Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli) of clinical origin. All the plant materials showed varying degrees of strain specific inhibitory action and ethanol extract of the plant materials showed higher antibacterial activity than their aqueous counterparts. Besides, T. chebula and A. marmelos had the strongest antibacterial activity out of which, T. chebula possessed a wider spectrum and a superior antibacterial potential over the others. The bioactive compounds of T. chebula might have potential as therapeutic agents for the treatment of common bacterial infections.

Maternal mortality in India: a 20-year study from a large referral medical college hospital, West Bengal.

AIM: The present study was carried out to analyze the maternal death rate and its changing trends over a 20-year period in a large referral/teaching institution in Eastern India. METHODS: A retrospective analysis of maternal deaths was carried out from January 1986 to December 2005 at the Department of Obstetrics and Gynaecology, R. G. Kar Medical College and Hospital, Kolkata, India. Records were divided into four 5-yearly periods: 1986-1990; 1991-1995; 1996-2000; and 2001-2005, for comparison of the trends. The initial interval from 1986 to 1990 was chosen as the reference period. RESULTS: The cumulative maternal mortality ratio (MMR) was 599.3 per 100 000 live births. Comparison between the first 5-year period (1986-1991) and the last (2001-2005) showed a statistical significant downward trend in MMR (683.6 vs 474.3; P < 0.001). Deaths due to direct causes are still the leading cause, accounting for 82.09% of total deaths. Hypertensive disorders (36.14%), hemorrhage (21.91%) and sepsis (19.54%) were still the major causes of direct obstetric deaths throughout the study period. Hypertensive disorders alone showed a substantial decline after the introduction of magnesium sulphate. CONCLUSION: The fall in maternal mortality has been very slow.

Complete perineal tear with rectal prolapse: an unusual case report.

The association of complete perineal tear and rectal prolapse is less reported in literature, although isolated complete perineal tear and the combinations of vaginal and rectal prolapse are not so unusual, where multiparity and unsupervised home deliveries are quiet common. An interesting case of long standing complete perineal tear with complete rectal prolapse is reported in a 60 years old lady along with review of literature, discussing the management and follow-up of the condition.

Comparative evaluation of perimenopausal abnormal uterine bleeding by transvaginal sonography, hysteroscopy and endometrial biopsy.

To evaluate the causes of abnormal uterine bleeding in perimenopausal women and to achieve the greatest diagnostic accuracy with the least risk, a cross-sectional study was done among 85 patients between the ages 40 and 55 years. Transvaginal sonography, hysteroscopy and histopathological examination of endometrium were done in all the cases. Kappa statistics was calculated to show the agreement between the different investigations. Considering histopathological report to be the gold standard, for diagnosis of hyperplastic endometrium, transvaginal sonography and hysteroscopy showed fair agreement (k=0.34) and good agreement (k=0.51) and hysteroscopic diagnosis of polyp showed strong agreement (k=0.81). Sensitivity, specificity, positive predictive value, negative predictive value for diagnosis of hyperplastic endometrium were 43.75%, 95.65%, 70% and 88% respectively whereas in polyp by transvaginal sonography they were 50%, 89.16%, 100%, 98.67% respectively; by hysteroscopy these were 50%, 95.78%, 70%, 90.36% respectively in hyperplasia and 71.43%, 100%, 100%, 94.67% respectively in polyp. Transvaginal sonography is most important for diagnosis of anatomical lesion. Hysteroscopy is most specific and sensitive for diagnosis of polyp but less specific for endometrial hyperplasia.

Caesarean section for the dead baby--an unhappy reality.

Caesarean section for the dead baby is sometimes still needed to prevent maternal complications. The objective of the study is to critically analyse the characteristics of the mother and indications for the operation in women who delivered stillbirths following caesarean section. The study period covered a 2 years span from January, 2003 to December, 2004. During this time 121 mothers (study group) underwent caesarean section for the dead baby representing 1.41% of all caesarean section operations done in the hospital. The study group was compared to the overall caesaren section done during the two years in relation to parity (parous 77.7% versus 45.7%), type of caesarean section (emergency 83.5% versus 69.8%) and timing of caesarean section within 12 hours of admission (74.4% versus 50.2%). Common indications in the study group included antepartum haemorrhage (31.4%), malpresentation (19.0%), postcaesarean pregnancies (16.5%), obstructed labour (15.7%), foetal distress (9.9%), second twin (4.1%) and eclampsia (3.3%). In some indications like obstructed labour and malpresentation, abdominal deliveries could be reduced by more destructive operations. The maternal reasons for resorting to caesarean section to save maternal lives are understandable. But caesaren section done for foetal distress was a disturbing revealation.

Two regimens of vaginal misoprostol in second trimester termination of pregnancy: a prospective randomised trial.

BACKGROUND: The search continues for a safe, effective, and cheap method for mid-trimester termination of pregnancy. Misoprostol is a strong contender in this respect. The dose schedule of misoprostol is still not fixed. The objective of our present study was to compare the efficacy and adverse events of 2 dose regimens of vaginal misoprostol for second trimester termination. METHOD: A prospective, randomised, controlled trial was undertaken in 138 women at 14-20 weeks gestation, in a teaching hospital. Subjects were randomised to receive either regime A: 400 microg of intravaginal misoprostol every 3 h, or regime B: loading dose of 600 microg, followed by 200 microg every 3 h. The main outcome measure was the success rate at 48 h, total dose required, induction-abortion interval, and adverse events. Data was analysed by Student's t-test, Mann-Whitney U-test, the chi-squared test or Fisher's exact test, using Statistica 6.0 software. RESULTS: There was no significant difference in the success rates at 24 and 48 h (Regime A: 97.18 and 98.59%; Regime B: 95.45 and 95.45%), and in mean induction-abortion interval (12.97 versus 12.13 h). However, mean misoprostol requirement was significantly higher for Regime A (1701.4 versus 1269.7 microg). The incidence of fever was significantly less in Regime B (32.4 versus 14.9%). CONCLUSION: Use of vaginal misoprostol for second trimester abortion had comparable efficacy with less drug requirement for the 600 microg loading dose followed by 200 microg 3-hourly regime compared to the 400 microg 3-hourly regime.