Therapeutic efficacy and safety of oral tranexamic acid and that of tranexamic acid local infiltration with microinjections in patients with melasma: a comparative study.

BACKGROUND: Tranexamic acid (TXA) has been used orally, intravenously, topically and intradermally (microinjection, microneedling) for treating melasma. However, the comparative efficacy of these different routes of administration remains underevaluated. AIM: To ascertain the comparative efficacy of different routes of administration of TXA. METHODS: In total, 100 consecutive patients with melasma (8 men, 92 women, age range 18-55 years) were randomly assigned to one of two groups comprising 50 patients each. Group A (3 men, 47 women) received oral TXA 250 mg twice daily, while group B (5 men, 45 women) received intradermal microinjections of TXA 4 mg/mL every 4 weeks. The treatment continued for 12 weeks in both groups. Percentage reduction in baseline Melasma Area and Severity Index (MASI) was assessed at 4-week intervals, and response was scored as very good (> 75% reduction), good (50% to < 75% reduction), moderate (25% to < 50% reduction), mild (< 25% reduction) or no response. RESULTS: The study was completed by 39 patients in group A and 41 patients in group B. Very good response was seen in 25 and 32 patients in groups A and B, respectively, while good response was seen in 14 and 9 patients, respectively. Both treatment methods were equally effective, with an average reduction of MASI at 12 weeks of 77.96 ± 9.39 in group A and 79.00 ± 9.64 in group B. The main adverse effects were mild epigastric discomfort, hypomenorrhea, headache and injection site pain, which did not warrant discontinuation of treatment. Two patients in group A had relapses at 24 weeks. CONCLUSION: TXA appears to be an effective and safe treatment for melasma, irrespective of its route of administration.

Profile of Rheumatological Manifestations in Leprosy in a Tertiary Care Hospital from Himachal Pradesh.

The rheumatological manifestations of leprosy occur singly or in varying combinations, particularly during lepra reactions. Despite being third most common, these remain under diagnosed and under reported. This study has been carried out to study the spectrum of rheumatological manifestations in leprosy patients. One hundred consecutive patients of leprosy presenting during January to December 2013 were studied for rheumatological manifestations. Complete hemogram, serum biochemistry, urinalysis, rheumatoid factor, ASO titer, C-reactive protein, ANA, and x-rays for hands, feet, chest and involved joints were performed. These 100 (M:F 66:34) patients aged between 16-80 years had indeterminate (2 patients), TT (4 patients), BT (26 patients), BB (2 patients), and LL leprosy (32 patients). 27 patients had rheumatological manifestations; arthritis involving large or small joints in 23 patients being the commonest. 7 of 24 patients in type-1 lepra reaction had enthesitis in 3 patients and oligoarthritis in 4 patients. Rheumatoid arthritis-like polyarthritis was noted in 19 patients with type-2 reaction. Tenosynovitis, dactylitis, bony changes were also noted. Except for one case, these features were present in patients having lepra reactions. Rheumatoid factor in 14, ANA in 15, C-reactive protein in 45 cases was positive. ASO was positive 34 cases. Symmetrical polyarthritis involving small joints of hands and feet, oligoarthritis, enthesitis and dactylitis are common in leprosy particularly with borderline leprosy, type-2 lepra reaction especially in the presence of positive RAfactor.

A randomized controlled trial comparing cosmetic outcome after skin closure with 'staples' or 'subcuticular sutures' in emergency cesarean section.

OBJECTIVE: To compare staples with subcuticular sutures for skin closure in emergency Cesarean sections (CS). METHODS: One hundred and thirty women (undergoing emergency CS without previous abdominal delivery) were randomly assigned to either staples or subcuticular skin closure (monocryl 3-0). Primary outcome of the study was cosmetic outcome [as assessed by patient and independent observer: Patient Scar Assessment Scale (PSAS) and Observer Scar Assessment Scale (OSAS), respectively], 6 weeks post-operative. Secondary outcomes were wound complications, operating time, post-operative pain (visual analogue scale day 3 post-operative and patient assessment of pain in scar 6 weeks post-operative), and duration of hospital stay. RESULTS: 112 women were available for evaluation of scar 6 weeks post-operative. Cosmetic result of staples was significantly better than subcuticular sutures (PSAS and OSAS: p value 0.022 and 0.000, respectively), with significantly lesser duration of surgery (24 vs. 32 min: p value 0.000) and comparable post-operative pain (pain on day 3 and 6 weeks post-operatively: p value 0.474 and 0.179, respectively) and wound complications (p value 0.737). However, duration of stay in hospital was increased (6 vs. 3 days: p value 0.001). CONCLUSION: Staples are the method of choice for skin closure in emergency CS as they are significantly better than subcuticular sutures with respect to cosmesis and duration of surgery. Post-operative pain and wound complications are comparable in two groups. However, staples are associated with significantly increased duration of hospital stay. Trial registered in clinical trial registry CTRI: REF/2013/05/005087.

Slit-skin smear in leprosy: lest we forget it!

Diagnosing and classifying leprosy solely on the basis of skin lesions as per WHO operational classification may lead to over or under diagnosis and inadequate treatment particularly of pauci-lesional multibacillary cases with consequent risk of resistance, relapse and progressive horizontal transmission. Announcing elimination of leprosy as public health problem in India under NLEP was probably ambitious aspiration. However, such a strategy is perhaps not justified scientifically at the moment in view of new case detection rate not showing significant decline. The fact remains that it is still highly desirable to provide sustained quality leprosy services to all individuals through general health services and good referral system. Being nearly of 100% specificity when performed expertly, slit-skin smear remains the simplest diagnostic technique available until new cutting-edge diagnostic tools become available for routine bedside use. However, the interest has been declining for learning this simple test among all the persons involved in leprosy work even in the teaching/training institutes. This is perhaps due to confusion over number and sites of smears, and its declining usefulness in WHO recommendations/guidelines. Various technical aspects of slit-skin smear testing are reviewed here keeping in view the need of leprosy workers in referral/teaching institutes.

Cutaneous sporotrichosis in Himachal Pradesh, India.

During the period 1990-2002 in Himachal Pradesh, India, 103 new patients with cutaneous sporotrichosis were detected. Lymphocutaneous and fixed cutaneous varieties were the most common and seen in 49% and 43% respectively. Chronic non-specific inflammation without granuloma formation was seen in 46% skin biopsy specimens, 29% showed acute or chronic inflammation and tuberculoid granuloma formation was seen in 25%. In 32% of cases Sporothrix schenckii growth was seen on Sabouraud glucose agar. A saturated solution of potassium iodide was used as first-line treatment and in 93% patients healing of lesions occurred in 4-32 weeks (average 8.7 weeks) without significant side-effects. Itraconazole, used in 12 patients, was highly effective in recommended doses. Rapid healing was seen with higher than previously used doses of fluconazole in one patient who also had unusual exacerbation of lesional inflammation with saturated solution of potassium iodide.

Epidemiology of a new focus of localized cutaneous leishmaniasis in Himachal Pradesh.

A new focus of localised cutaneous leishmaniasis has emerged along the Satluj River valley in the mountainous region of north west Himachal Pradesh. The main endemic region extends from Pooh subdivision of Kinnaur district to Kumarsain subdivision of Shimla district with adjoining Nirmand subdivision of Kullu District comprising 86 villages. The climate of the affected areas varies from temperate to subtropical. A total of 285 cases were recorded from 1988 to January, 2005. The age of these patients varied from 10 months to 75 years, with 63 children (<12Years), and a male to female ratio of 1: 0.9. The duration of disease was 15 days to 48 months with majority (85%) presenting between 1-6 months. The number of lesions varied from 1-8, and were mostly seen on exposed parts of the body. Morphologically, lesions were asymptomatic, dry, nodular or crusted nodulo-ulcerative plaques. Tissue smear positivity for amastigotes was 43%. The characterization of 14 strains of these Leishmania revealed presence of both Leishmania tropica (n=3) and Leishmania donovani (n=11). Identification of the 42 sandflies collected from the peridomestic environment of the patients, revealed Phlebotomus longiductus - 29, P. major 8, P. kandelaki 2, while 2 remained unidentified. The patients were treated with intralesional sodium stibogluconate and majority showed excellent response.

Cutaneous sporotrichosis: an unusual clinico-pathologic and therapeutic presentation.

This report presents a number of unusual clinico-histopathologic and therapeutic features in a culture proven case of cutaneous sporotrichosis. These include lymphocutaneous sporotrichosis involving face; its dissemination in an otherwise healthy patient; its histology mimicking cutaneous cryptococcosis; two episodes of severe purulent inflammatory reaction bordering the lesion during therapy with saturated solution of potassium iodide; no therapeutic response to potassium iodide therapy and rapid healing of lesion with high-dose of fluconazole.

Orofacial conidiobolomycosis due to Conidiobolus incongruus.

We report here a patient of orofacial conidiobolomycosis presenting with classical centrofacial distribution described typically for Conidiobolus coronatus infection. The culture, however, showed C. incongruus. The mode of infection and its possible correlation with patient's occupation is also discussed.

A new focus of cutaneous leishmaniasis in Himachal Pradesh (India).

This paper highlights a new focus of cutaneous leishmaniasis (CL) in the temperate area of Himachal Pradesh (India), a previously non-endemic area. In this hospital-based study, 38 new cases of CL, acquired indigenously have been detected from 1988-2000. Of these, 26 were from Kinnaur district and 12 from adjoining areas of bordering districts situated along the river: Satluj. There were 18 males and 20 females. They were between 4-75 years of age and had the disease for one month to 2 years at the time of presentation. Face involvement was seen in majority of the patients. Nodulo-ulcerative plaque was the commonest lesion. Muco-cutaneous lesions were seen in four cases. Tissue smears and biopsies were positive for LD bodies in 61.7% and 29.4% cases respectively. Intralesional sodium stibogluconate produced a consistent therapeutic response. The possible mode of its introduction in the region is postulated. The reservoir of infection, identity of the vector at this altitude (9,002,900 meters above sea level) and the strain of leishmania, remain to be identified.

Trends in detection of new leprosy cases at two centres in Himachal Pradesh, India: a ten-year study.

An impressive decline in leprosy prevalence rate (PR) in all endemic districts of India is seen in the post-MDT era. However, the new case-detection rate, an important statistical indicator in leprosy control programmes, has not shown significant decline in spite of all efforts. In Himachal Pradesh, a decline in PR from 7.8 to 0.56/10000 between 1991 to 2000 is seen, and recently the State has won national acclaim for having achieved the goal of elimination of leprosy in all the districts. The vertical leprosy programme has been integrated into general health services of the state. An analysis of data from 1991 to 2000 of two leprosy control units of Himachal Pradesh, the Urban Leprosy Clinic in Shimla (ULC-S) and the District Leprosy Control Unit in Mandi (DLCU-M), showed no significant decline in the new cases detected. 277 and 271 new cases were detected at these centres respectively; these included 2.2% and 1.5% children of less than 14 years of age. Almost 75% of these cases were males and of MB type. A steadily increasing trend in the annual detection of new cases was seen at both the centres during the decade. The cases registered at DLCU-M were mainly indigenous to the district. At ULC-S, 45 migrant cases from other endemic areas-mainly from Nepal, Bihar, and Uttar Pradesh-had also contributed to the increased number of new cases. Other possible causes discussed for this higher new case detection, e.g. overdiagnosis, detection of backlog "hidden cases" and voluntary reporting of patients, do not differ from those seen in other parts of the country or the world.

Trichotillomania and trichophagia leading to trichobezoar.

A 14-year-old female presented with the complaints of loss of hair, scalp pruritus, and pain in the abdomen. On careful work-up, she was found to have trichotillomania as well as trichophagia. Investigations also revealed a trichobezoar which completely filled the stomach. Hemogram showed moderate hypochromic anemia. Her detailed psychiatric profile showed a few additional features like obsessive hand washing, knuckle cracking, nose picking and body rocking. Her trichobezoar was removed surgically, and she had an uneventful post-operative recovery. She is being maintained on fluoxetine and is doing well. The role of a multi-disciplinary approach to trichotillomania patients is highlighted.

Chromoblastomycosis in India.

BACKGROUND: Four patients with chromoblastomycosis are presented. An additional 30 infected Indian patients are reviewed. RESULTS: These 34 patients ranged in age from 12 to 80 years with a male to female ratio of 5.8 : 1. Onset before the age of 20 years was seen in 24% of cases which was comparatively high. Culture was positive in 72% of cases and sclerotic bodies were observed in 84% of cases. A relatively higher prevalence (15%) of Fonsecaea compacta was observed. Unusual cutaneous sites afflicted were the penile shaft, vulva, and ala of the nose, and unusual extracutaneous spread was seen in the pleural cavity, ileocecal region, laryngotracheal area, and tonsils. Extracutaneous involvement was seen in 24% of cases. Overlapping infection with another fungus, Geotrichum candidum, was seen in one case. CONCLUSIONS: Combination therapy with two azoles was attempted with some success for clinical cure.

Atypical post-kala-azar dermal leishmaniasis resembling histoid leprosy.

An adult male with atypical lesions of post-kala-azar dermal leishmaniasis (PKDL) is described. He had extensive ulcerated noduloplaque lesions on his hands, feet and genitalia. He had been diagnosed and treated for leprosy in the past. He came from an area endemic for kala-azar and leprosy and had a previous history of kala-azar. There was an abundance of Leishman Donovan bodies in slitskin smears and in histopathology sections. There was a good therapeutic response to sodium stibogluconate. An ulcerative variant of PKDL has been described but is extremely rare. Extensive lesions with ulceration have not been described before to the best of our knowledge. The epidemiological significance of the case is discussed.

Theoretical and experimentally quantifiable determinants of tobacco smoking behavior for the development of successful smoking cessation strategies.

Death rates from a number of diseases linked epidemiologically to tobacco use continue to rise despite major reductions in per capita tobacco consumption, despite reductions in the total number of smokers, and despite very significant reductions in "tar", in other tumorigens and in essentially all classes of potential toxins in smoke delivered to the consumer. One concern is that smokers consume low delivery cigarettes differently and in a potentially more hazardous way than higher delivery cigarettes. The effect of nicotine reduction in cigarettes on human smoking behavior was studied in 102 human subjects by quantifiable determinants of tobacco-smoking behavior. This study indicates that reduction in nicotine delivery results in some accommodation in smoking behavior to titrate nicotine needs. In addition, smokers appear to adjust their smoking behavior as a function of taste preference, and this adjustment is as strong as the accommodation for nicotine. The theoretical application of these observations to the development of successful smoking cessation strategies is reviewed.

Tropical pancreatic diabetes in South India: heterogeneity in clinical and biochemical profile.

Clinical and biochemical studies were carried out in 33 patients with diabetes secondary to chronic calcific, non-alcoholic pancreatitis (tropical pancreatic diabetes) and in 35 Type 2 (non-insulin-dependent) diabetic patients and 35 non-diabetic subjects. Despite lower body mass indices, only 25% of patients with tropical pancreatic diabetes had clinical evidence of malnutrition. There was no history of cassava ingestion. Mean serum cholesterol concentration was significantly lower in the tropical pancreatic diabetic patients (p less than 0.01) in comparison with the Type 2 diabetic patients or non-diabetic subjects, due to a significantly decreased concentration of LDL cholesterol (p less than 0.01) and VLDL cholesterol (p less than 0.05). Basal and post-glucose stimulated concentrations of serum C-peptide were highest in those pancreatic diabetic patients (n = 11) who responded to oral hypoglycaemic drugs, intermediate in the majority (n = 17), who were insulin dependent and ketosis resistant and negligible in a small sub-group (n = 5) who were ketosis prone. The occurrence of microangiopathy in pancreatic diabetic patients was common and similar to that in Type 2 diabetic patients. Thus, tropical pancreatic diabetes in South India appears to be heterogeneous with respect to level of nutrition, severity of glucose intolerance, B-cell function, response to therapy and the occurrence of microvascular complications.