Anesthetic management of a patient with Sheehan's syndrome and twin pregnancy while undergoing a cesarean section.

Sheehan's syndrome (SS) is caused by infarction of the pituitary gland usually precipitated by hypotension due to massive uterine hemorrhage during the peripartum period. Once SS develops, it becomes a major comorbidity for the young females and predisposes them to further medical, obstetric, and anesthetic complications. Herein, we report the perioperative anesthetic management of a 28-year-old female, already diagnosed with SS precipitated by urosepsis and septicemic shock in a previous pregnancy, now presenting with twin pregnancy for elective cesarean section. Her magnetic resonance imaging brain revealed pituitary apoplexy and she had hypothyroidism with gestational diabetes mellitus. The overall successful perioperative management of the patient is described along with an emphasis on aggressive management of hypotension due to any cause in the peripartum period to prevent infarction/necrosis of anterior pituitary gland.

Phenotypic and genotypic differences between Indian and Scandinavian women with gestational diabetes mellitus.

OBJECTIVE: Gestational diabetes mellitus (GDM) is a transient form of diabetes characterized by impaired insulin secretion and action during pregnancy. Population-based differences in prevalence exist which could be explained by phenotypic and genetic differences. The aim of this study was to examine these differences in pregnant women from Punjab, India and Scandinavia. METHODS: Eighty-five GDM/T2D loci in European and/or Indian populations from previous studies were assessed for association with GDM based on Swedish GDM criteria in 4018 Punjabi Indian and 507 Swedish pregnant women. Selected loci were replicated in Scandinavian cohorts, Radiel (N = 398, Finnish) and STORK/STORK-G (N = 780, Norwegian). RESULTS: Punjabi Indian women had higher GDM prevalence, lower insulin secretion and better insulin sensitivity than Swedish women. There were significant frequency differences of GDM/T2D risk alleles between both populations. rs7178572 at HMG20A, previously associated with GDM in South Indian and European women, was replicated in North Indian women. The T2D risk SNP rs11605924 in the CRY2 gene was associated with increased GDM risk in Scandinavian but decreased GDM risk in Punjabi Indian women. No other overlap was seen between GDM loci in both populations. CONCLUSIONS: Gestational diabetes mellitus is more common in Indian than Swedish women, which partially can be attributed to differences in insulin secretion and action. There was marked heterogeneity in the GDM phenotypes between the populations which could only partially be explained by genetic differences.

Galectin-3: an emerging biomarker in stroke and cerebrovascular diseases.

The carbohydrate-binding molecule galectin-3 has garnered significant attention recently as a biomarker for various conditions ranging from cardiac disease to obesity. Although there have been several recent studies investigating its role in stroke and other cerebrovascular diseases, awareness of this emerging biomarker in the wider neurology community is limited. We performed a systematic search in PubMed, Embase, Scopus, CINAHL, Clinicaltrials.gov and the Cochrane library in November and December 2016 for articles related to galectin-3 and cerebrovascular disease. We included both human and pre-clinical studies in order to provide a comprehensive view of the state of the literature on this topic. The majority of the relevant literature focuses on stroke, cerebral ischemia and atherosclerosis, but some recent attention has also been devoted to intracranial and subarachnoid hemorrhage. Higher blood levels of galectin-3 correlate with worse outcomes in atherosclerotic disease as well as in intracranial and subarachnoid hemorrhage in human studies. However, experimental evidence supporting the role of galectin-3 in these phenotypes is not as robust. It is likely that the role of galectin-3 in the inflammatory cascade within the central nervous system following injury is responsible for many of its effects, but its varied physiological functions and multiple sites of expression mean that it may have different effects depending on the nature of the disease condition and the time since injury. In summary, experimental and human research raises the possibility that galectin-3, which is closely linked to the inflammatory cascade, could be of value as a prognostic marker and therapeutic target in cerebrovascular disease.

Genetic contribution of CYP1A1 variant on treatment outcome in epilepsy patients: a functional and interethnic perspective.

CYP1A1 gene is involved in estrogen metabolism, and previously, we have reported association of variant rs2606345 with altered anti-epileptic drugs (AED) response in North Indian women with epilepsy (WWE). The present study aims to replicate the pharmacogenetic association, perform functional characterization and study its distribution within ethnically diverse Indian population. The variant was genotyped in 351 patients to assess the pharmacogenetic association and 552 healthy individuals belonging to 24 different ethnic groups to examine the distribution in Indian population. We observed significant overrepresentation of 'A' allele and 'AA' genotype in poor responders in WWE at Bonferroni-corrected significance levels. The recessive allele was found to lower the promoter activity by ~70-80% which was further substantiated by thermally less stable hairpin formed by it (ΔTm=7 °C). Among all ethnic groups, west Indo-European (IE-W-LP2) subpopulation showed highest genotypic frequency of the variant making women from this community more prone to poor AED response. Our results indicate that rs2606345 influences drug response in WWE by lowering CYP1A1 expression.

Insulin secretion and action in North Indian women during pregnancy.

AIM: The relative roles(s) of impaired insulin secretion vs. insulin resistance in the development of gestational diabetes mellitus depend upon multiple risk factors and diagnostic criteria. Here, we explored their relative contribution to gestational diabetes as defined by the WHO 1999 (GDM1999) and adapted WHO 2013 (GDM2013) criteria, excluding the 1-h glucose value, in a high-risk Indian population from Punjab. METHODS: Insulin secretion (HOMA2-B) and insulin action (HOMA2-IR) were assessed in 4665 Indian women with or without gestational diabetes defined by the GDM1999 or adapted GDM2013 criteria. RESULTS: Gestational diabetes defined using both criteria was associated with decreased insulin secretion compared with pregnant women with normal glucose tolerance. Women with gestational diabetes defined by the adapted GDM2013, but not GDM1999 criteria, were more insulin resistant than pregnant women with normal glucose tolerance, and furthermore displayed lower insulin secretion than GDM1999 women. Urban habitat, illiteracy, high age and low BMI were independently associated with reduced insulin secretion, whereas Sikh religion, increasing age and BMI, as well as a family history of diabetes were independently associated with increased insulin resistance. CONCLUSIONS: Gestational diabetes risk factors influence insulin secretion and action in North Indian women in a differential manner. Gestational diabetes classified using the adapted GDM2013 compared with GDM1999 criteria is associated with more severe impairments of insulin secretion and action.

The thrifty phenotype hypothesis revisited.

Twenty years ago, Hales and Barker along with their co-workers published some of their pioneering papers proposing the 'thrifty phenotype hypothesis' in Diabetologia (4;35:595-601 and 3;36:62-67). Their postulate that fetal programming could represent an important player in the origin of type 2 diabetes, the metabolic syndrome and cardiovascular disease (CVD) was met with great scepticism.More recently, their observations have been confirmed and expanded in many epidemiological and animal experimental studies, and human integrative physiological studies have provided insights into some of the underlying molecular mechanisms. Type 2 diabetes is a multiple-organ disease, and developmental programming, with its idea of organ plasticity, is a plausible hypothesis for a common basis for the widespread organ dysfunctions in type 2 diabetes and the metabolic syndrome. Only two among the 45 known type 2 diabetes susceptibility genes are associated with low birthweight, indicating that the association between low birthweight and type 2 diabetes is mainly non-genetic. Prevention programmes targeting adult lifestyle factors seems unable to stop the global propagation of type 2 diabetes, and intensive glucose control is inadequate to reduce the excess CVD mortality in type 2 diabetic patients. Today, the thrifty phenotype hypothesis has been established as a promising conceptual framework for a more sustainable intergenerational prevention of type 2 diabetes.

Clinicohistopathological concordance in leprosy - a clinical, histopathological and bacteriological study of 100 cases.

Leprosy is a treatable chronic infectious disease, prevalent in South Asian countries, especially India. Before labeling a patient as a case of leprosy and starting multidrug treatment for particular type, the clinical findings should be correlated and confirmed with histopathological examination and bacteriological index of skin biopsy. Skin biopsy is an important tool in diagnosing leprosy and determining the type of leprosy. In the present study, one hundred untreated clinically diagnosed cases of leprosy were studied according to Ridley-Jopling scale for confirmation of diagnosis and classification of leprosy. The study was done by routine H & E (Haematoxylin & Eosin) staining and Fite-Faraco's staining for acid-fast bacillus. The data pertaining to age, sex, clinical and histopathological classification of the type of leprosy were collected and analyzed. In analyzing the histopathology of a lesion, special attention was given to the following features, viz., invasion of the epidermis with or without erosion, involvement of the sub-epidermal zone, character and extent of granuloma, density of lymphocytic infiltrate epithelioid cells and other cellular elements, nerve involvement and the presence of Mycobacterium leprae. Histological diagnosis of leprosy was established in 98% of clinically diagnosed cases. Clinicohistopathological concordance was maximum in LL(93.75%) followed by BL(87.5%), TT(78.5%), BT(73.8%) and least in IL(27.78%). Overall, it was 60.23%. Indeterminate type of leprosy was diagnosed more on histologythan on clinical evaluation.

Self-sustained non-equilibrium co-existence of fluid and solid states in a strongly coupled complex plasma system.

A complex (dusty) plasma system is well known as a paradigmatic model for studying the kinetics of solid-liquid phase transitions in inactive condensed matter. At the same time, under certain conditions a complex plasma system can also display characteristics of an active medium with the micron-sized particles converting energy of the ambient environment into motility and thereby becoming active. We present a detailed analysis of the experimental complex plasmas system that shows evidence of a non-equilibrium stationary coexistence between a cold crystalline and a hot fluid state in the structure due to the conversion of plasma energy into the motion energy of microparticles in the central region of the system. The plasma mediated non-reciprocal interaction between the dust particles is the underlying mechanism for the enormous heating of the central subsystem, and it acts as a micro-scale energy source that keeps the central subsystem in the molten state. Accurate multiscale simulations of the system based on combined molecular dynamics and particle-in-cell approaches show that strong structural nonuniformity of the system under the action of electostatic trap makes development of instabilities a local process. We present both experimental tests conducted with a complex plasmas system in a DC glow discharge plasma and a detailed theoretical analysis.

Genetics of hyperpigmentation associated with the Fibromelanosis gene (Fm) and analysis of growth and meat quality traits in crosses of native Indian Kadaknath chickens and non-indigenous breeds.

1. The study investigated the extent of hyperpigmentation (a trait fixed in native Indian Kadaknath chickens), bodyweight, carcase quality and leanness at 12 weeks of age in F(1) and back-crosses of Kadaknath with White Leghorn, White Plymouth Rock and Aseel Peela chickens. 2. The objective of the study was to determine if hyperpigmentation was affected by the major gene Fibromelanosis (Fm) and to evaluate the effects of different proportions of Kadaknath genes on growth and carcase quality. 3. The pigmentation pattern of skin indicated that Fm behaved as the primary locus affecting dermal-hyperpigmentation and that the sex-linked Id locus produced an epistatic effect. 4. The results suggested that variable allelic forms of Id were acting in different crosses, which resulted in variation in melanosis of the host. However, no conclusive pattern for shank pigmentation could be explained through genotyping of the Id and Fm loci. 5. Analysis of quantitative traits indicated the positive impact of a Kadaknath genomic proportion of 50% or more on meat texture and carcase leanness. Improvement in leanness occurred in White Rock crosses but not in White Leghorn and Aseel Peela crosses. 6. Thigh-meat texture was influenced more by enhanced Kadaknath genomic proportions than the breast-meat. It was concluded that introgression of Kadaknath genomic proportion beyond 50% in a cross with meat-type chickens, irrespective of the impact Fm, brought improvement in meat quality whereas no such advantage was obtained for growth traits. 7. The beneficial impact of the Kadaknath genome on meat quality calls for further studies to identify causative genes for their selective use to improve meat quality in Kadaknath crossbred chickens.

Impact of prolotherapy in temporomandibular joint disorder: a quality of life assessment.

Chronic pain and functional impairment associated with temporomandibular joint (TMJ) disorders (TMD) considerably reduce oral health-related quality of life (OHRQoL). In the present study we have assessed the influence of prolotherapy in patients with TMD by the subjective measurement of QoL using the Oral Health Impact Profile-14 (OHIP-14). Twenty-five patients diagnosed with TMD (mean (range) age 38 (18 - 70) years) were included. They had all undergone dextrose prolotherapy to the TMJ at regular time intervals (four times at intervals of two weeks) using the method suggested by Hemwall-Hackett. They were asked to answer the OHIP-14 questionnaire before and two years after prolotherapy. Seven domains of OHRQoL were rated on a 5-point Likert scale from 0 (never) to 4 (very often). Domain scores and total OHIP-14 scores were compared using inferential statistics (chi squared and Wilcoxon signed rank tests). Prolotherapy was effective over time, as all the domains' mean scores decreased considerably after treatment. The total mean score before prolotherapy was 21.20, which was extensively reduced to 13.08 after prolotherapy (p=0.001). There was statistically significant improvement in all domains, including functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap (p≤0.005 in all cases). We concluded that prolotherapy has a promising role in the improvement of OHRQoL of patients with TMD, and its beneficial effects persist at least two years after treatment.

A comparative evaluation of iliac crest bone graft with and without injectable and advanced platelet rich fibrin in secondary alveolar bone grafting for cleft alveolus in unilateral cleft lip and palate patients: A randomized prospective study.

PURPOSE: Platelet rich fibrin enhances bone healing and results in better graft intake and helps in faster periodontal healing. In this study we have used a combination of two newly developed forms of platelet rich fibrin: injectable and advanced along with iliac bone graft for secondary alveolar bone grafting and compared it with cases in which only iliac bone graft was used. METHODS: 30 patients with alveolar cleft, with age group of ≥7 years, having complete unilateral cleft alveolus were included and divided into 2 groups of 15 patients each randomly. In Group A, secondary alveolar bone grafting was done using iliac bone graft along with injectable and advanced palate rich fibrin and in Group B, secondary alveolar bone grafting was done only with iliac bone graft. Success of the treatment was assessed using radiographic and clinical methods which included: The bone resorption of the interalveolar septum height of the teeth adjacent to the cleft, evaluated as per Bergland classification, assessment of periodontal status of the teeth adjacent to cleft alveolus. RESULTS: After 3 months and 6 months postoperatively: study group had better overall scores as per Bergland criteria. Periodontal status improved in both groups but was more in study group compared to control group. For both evaluations the data was clinically favorable in the study group. CONCLUSION: On preliminary investigations it shows that combination of injectable and advanced platelet rich fibrin seems to enhance bone formation in alveolar clefts when admixed with autologous cancellous bone harvested from the iliac crest than using iliac bone graft alone. It also reduces the chances of bone resorption and show higher percentage of bone volume. Secondary alveolar grafting improves periodontal health around the cleft alveolus.

Efficacy of buffered local anaesthetics in head and neck infections.

Lignocaine is one of the most commonly-used agents to anaesthetise an area preoperatively. It can, however, cause undesirable effects such as burning on injection, relatively slow onset, and unreliable, or lack of, numbness when injected into infected tissues as a result of the acidic pH of commercial preparations (the pH is between 3.5 and 7.0 compared with the physiological pH, which is between 7.35 and 7.45). The aim of this comparative study was to evaluate the efficacy of buffered local anaesthetic on infected areas by altering the pH with 8.4% sodium bicarbonate, to measure the pain before and after the injection, and to record the time of onset of anaesthesia. All 60 patients were given 2% lignocaine hydrochloride with adrenaline 1:80,000 and 30 patients were randomly allocated to have 10:1 dilution of 8.4% sodium bicarbonate (study group). Pain was assessed on a visual analogue scale and a verbal rating scale. There was a significant difference in the amount of pain between control and study groups (p=0.025). The mean (SD) time (minutes) to onset of local anaesthesia in the study group was 1.06 (0.25) compared with 2.96 (0.81) in the control group (p<0.001). Our results confirm the efficacy of the buffered local anaesthetic solution in reducing pain on injection and resulting in quicker onset of anaesthesia. Increasing the pH of lignocaine solutions with bicarbonate immediately before use, therefore, should be considered when treating various acute infections of the head and neck.

Cutaneous Tuberculosis : A Clinico-morphological Study.

BACKGROUND: Cutaneous tuberculosis forms a small subset of extrapulmonary tuberculosis. The present study is an attempt to observe the clinico morphological pattern seen in cases of cutaneous tuberculosis over a period of 5 years, and to correlate them with mantoux reactivity and human immunodeficiency virus (HIV) status. METHODS: All cases of cutaneous tuberculosis observed among the dermatology in patients and those attending out patient department were included in the study. The basis of diagnosis was clinical, histopathological and microbiological. Intradermal mantoux test and serological test in the form of enzyme-linked immunosorbent assay (ELISA) for tuberculosis was done. HIV screening was carried out in 32 cases. CD4 counts were done in all HIV positive cases. RESULTS: A total 0.02% patient attending the dermatology centre had cutaneous tuberculosis. The spectrum of infection included 19 (51%) cases of lupus vulgaris, 7 (19%) cases of papulonecrotic tuberculids, six cases each of tuberculosis verrucosa cutis and scrofuloderma. One case had scrofuloderma and lupus vulgaris and another both scrofuloderma and papulonecrotic tuberculide. One case of lichen scrofulosorum was seen in a seven year old boy. 11 cases revealed evidence of systemic tuberculosis. Seven cases of HIV with CD4 counts between 50-500 cells/µl were observed in this study.

Systematic errors in bone-mineral measurements by quantitative computed tomography.

Bone-mineral measurements using quantitative computed tomography (QCT) are commonly based on comparisons with solutions in water of known concentrations of K2HPO4. In this paper are described theoretical and experimental studies that have led to the conclusion that large systematic errors can arise in these measurements, depending on the soft-tissue and fat concentrations in the vertebral spongiosa. In the case of single energy scanning, such large errors have been identified to be due to the varying water content (displacement effect) in the calibration samples and the varying fat content in the region of interest (ROI) within the patient. In the case of dual energy scanning, the error arises because when normalized to that of water, the mass attenuation coefficient of fat increases with photon energy while the reverse is true for K2HPO4. Our studies have also revealed that total trabecular bone density (which includes the mineral, soft tissue, and fat) can be much more accurately determined by the dual energy QCT method than bone mineral alone. This finding is especially interesting since there have been several reports in the literature suggesting that bone density rather than bone-mineral content is a better predictor of the risk of osteoporosis-related fractures.

Alteration of coronary perfusion reserve in hypertensive patients with diabetes.

This investigation was performed to determine whether diabetes mellitus has an additive effect on diminishing coronary perfusion reserve index in hypertensive patients. Coronary perfusion reserve index, thallium lung uptake, the electrocardiogram and haemodynamic parameters were evaluated by exercise thallium myocardial perfusion scintigraphy. In 18% of hypertensive and 13% of diabetic-hypertensive patients there was evidence of left ventricular hypertrophy on electrocardiogram. The maximum heart rate achieved in hypertensive, diabetic and diabetic-hypertensive patients was significantly lower (P < 0.05) than in control patients. The maximum SBP achieved in hypertensive (210 +/- 40 mmHg) and diabetic-hypertensive patients (216 +/- 36 mmHg) was higher (P < 0.05) than in control patients (186 +/- 32 mmHg). A significantly higher number of diabetic patients (53%) did not achieve the exercise rate pressure product of > 26,000 when compared with control (27%), hypertensive (24%) and diabetic-hypertensive (30%) patients. Coronary perfusion reserve index in hypertensive patients decreased significantly (P < 0.05) when compared with control (no hypertension, no diabetes) patients (1.67 +/- .14 vs. 1.79 +/- .17). Coronary vasodilatory reserve index was also reduced significantly (P < 0.05) in diabetic patients in comparison with controls (1.66 +/- .17 vs. 1.79 +/- .17), and was further reduced in diabetic-hypertensive patients when compared with control patients (1.63 +/- .13 vs. 1.79 +/- .17). Thallium uptake in the lung quantified as thallium lung to heart ratio were comparable in all four groups. The results suggest that diabetes mellitus diminishes the coronary perfusion reserve index in patients with hypertension and therefore many account for the increased cardiovascular morbidity in these patients.

Tl-201 liver uptake for assessment of jeopardized myocardium during dipyridamole stress testing.

The current study was conducted to determine the significance of Tl-201 liver activity during 4 minute dipyridamole (DP) stress testing. Two groups of subjects were examined: group I subjects (n = 52) had electrocardiographic evidence of left ventricular hypertrophy (ECG-LVH), and group II subjects (n = 114) had no ECG-LVH. Both groups were further divided into four subgroups on the basis of Tl-201 myocardial perfusion scans: 1) no myocardial perfusion defect; 2) transient myocardial perfusion defect; 3) fixed myocardial perfusion defect; and 4) transient plus fixed myocardial perfusion defects. Tl-201 liver, heart, and lung activities were quantified in the immediate anterior planar images. Left ventricular mass was quantified using tomographic short-axis slices. In the no ECG-LVH group, Tl-201 lung-to-heart ratio was significantly increased in subjects having transient, fixed, and transient plus fixed myocardial perfusion defects when compared to no myocardial perfusion defect. Tl-201 lung-to-heart ratio did not increase in the ECG-LVH group of subjects having transient, fixed, and transient plus fixed myocardial perfusion defects. In contrast, Tl-201 liver-to-heart ratio increased in both the ECG-LVH and no ECG-LVH groups of subjects having myocardial perfusion defects when compared to subjects having negative myocardial perfusion scan. Left ventricular mass was increased in ECG-LVH subjects when compared to no ECG-LVH subjects, which might have resulted in increased Tl-201 myocardial uptake and, hence, reduced Tl-201 lung-to-heart ratio in ECG-LVH subjects having myocardial perfusion defects.(ABSTRACT TRUNCATED AT 250 WORDS)

ABO blood groups and oral premalignancies: A clinical study in selected Indian population.

Background: The ABO blood group antigens are present on the surface of red blood cells and various epithelial cells. As the majority of human cancers are derived from epithelial cells, changes in blood group antigens constitute an important aspect of human cancers. The aim of the study was to establish clinical usefulness of ABO blood group as a predisposing factor in early diagnosis and management of patients with oral precancerous lesions/conditions. Materials and Methods: The study sample consisted of 50 control and 50 oral precancer (25 leukoplakia and 25 Oral Submucous Fibrosis) confirmed by histopathologic examination. All samples were subjected to blood group testing and their prevalence was compared by Z-test using STATA version 8. Results: The "A" blood group was prevalent among the precancerous group. Significant differences on prevalences of blood groups were found (P < 0.05) between control versus leukoplakia and OSMF. Interestingly, 24% gutka chewers who had higher number of grades of dysplasia were falling in "A" blood group. Conclusion: Blood group type should be considered along with other risk factors to understand the individual patient's risk and further studies in larger samples with inclusion of Rh factor is needed to elucidate the relationship with ABO blood group types.