How multimorbidity relates to road traffic accident among older adults and elderly population: insights from longitudinal aging study in India (1st wave)

Background: Multimorbidity and road traffic accidents increase with increasing age. Supplemented with increasing life expectancy at birth, both multimorbidity and RTAs will contribute significantly to the growing disease burden of the country. The objective of the study was to determine the association between multimorbidity and RTAs among older adults (above 45 years) and the elderly (above 60 years) population in India. Methods: A secondary data analysis was conducted using the Longitudinal Ageing Study in India (LASI)-1st wave data (April 2017 to December 2018). Participants having at least two chronic health conditions were described as multimorbidity. Road traffic accidents (RTAs) was taken as the outcome variable. Univariate followed by multivariable logistic regression was conducted between the outcome variable and each explanatory variable. Results: Data extracted consisted of 34704 (51.1%) older adults and 31902 (47.9%) elderly. Multimorbidity was present in 25054 (37.6%) individuals. Among the RTA group, 325 (26.5%) individuals had multimorbidity. The elderly with multimorbidity (at least two) were associated with the RTA with an adjusted odds ratio (CI) of 0.55 (0.45-0.67) and p value of <0.001 in comparison to older adults. Clerical and skilled individuals with multimorbidity were associated with RTA in comparison to unemployed individuals with multimorbidity with an adjusted odds ratio (CI) of 1.40 (1.10-1.79) and p value of 0.007. Conclusions: The RTA was evident among males aged 45-60 years with multimorbidity. Clerical and skilled individuals with multimorbidity were more prone to RTA. These individuals should be encouraged to take necessary measures to promote healthy living and adhere to them.

Mid upper arm circumference cutoffs for identifying underweight and severe underweight among infants less than six months: A Hospital Based Cross-Sectional study

Background: Prevalence of undernutrition among infants <6 months are very high in India. WAZ is the most sensitive predictor of mortality among infants <6 months as compared to other anthropometric parameters. However, taking weight and calculating z-score in the community setting have many challenges. Taking mid upper arm circumference (MUAC) is more feasible in a field setting. Methodology: A cross-sectional study was conducted with 419 infants <6 months in a tertiary care hospital in India to identify appropriate MUAC cutoffs for identifying underweight (WAZ<-2) and severe underweight (WAZ<-3) among infants <6 months by calculating sensitivities, specificities and Youden indices. Cohen kappa coefficients were calculated to assess agreements between MUAC and WAZ cutoffs. Results: The MUAC cut-offs for underweight and severe underweight were calculated as 11cm (Youden Index: 0.503; sensitivity: 83.4%; specificity: 66.9%) and 10.9cm (Youden Index: 0.504; sensitivity: 76.3%; specificity: 74.1%), respectively. Kappa coefficients to diagnose underweight with MUAC<=11cm was highest at 0.48. Conclusions: The MUAC cut-off of 11cm could reliably be used to screen infants <6 months with underweight and severe underweight for providing appropriate care in the Indian settings.

Simultaneous Estimation Of Mometasone Furoate And Formoterol Fumarate By Hplc Method In Rotacaps

Objective: To develop and validate a simple and sensitive RP-HPLC method for the simultaneous determination of mometasone furoate (MOM) and formoterol fumarate (FOR) in pharmaceutical dosage forms. Methods: In RP-HPLC method, chromatographic separation was achieved using a mixture of a solvent system consisting of methanol–water (pH 3.5) in the ratio of 85:15 % v/v at a flow rate of 1 ml/min and detection was carried out at 225 nm. Results: The run time for the simultaneous estimation of drugs for the proposed method was 10 min as drugs eluted at 5.217 min (MOM) and 8.650 min (FOR). The linearity was found in the range of 33.33-299.97 μg/ml and 1-9 μg/ml for MOM and FOR, respectively. The values of limit of detection and limit of quantification were 3.634, 0.266 µg/ml and 11.014, 0.807 µg/ml, which indicates the sensitivity of the method for the estimation of MOM and FOR, respectively. The results of recovery studies for both the drugs were within the range i.e. 98.87-101.48 % which indicates the accuracy of the method. Relative standard deviation obtained from repeatability and reproducibility studies were less than 2% indicates the precision of the method. The proposed method was validated according to ICH guidelines. Conclusion: The proposed RP-HPLC method was found to be sensitive and precise because of the low LOD, LOQ and % RSD values (<2). The proposed work does not require acetonitrile and ion pairing reagent as compared to the reported methods. Therefore, method can be used preferably for routine analysis due to its simplicity and economic advantages.

Ovarian fibroma with luteinized thecal cells and minor sex cord element: A rare case report

Ovarian fibroma with minor sex cord element (MSCE) is a rare tumor. The increased estrogen production due to the presence of MSCE and/or luteinized thecal cells within fibroma can be a risk factor for endometrial hyperplasia or carcinoma.

Validation of preoperative variables and stratification of patients to help predict benefit of cytoreductive nephrectomy in the targeted therapy ERA

ABSTRACT Objectives To further elucidate which patients with metastatic renal cell carcinoma (mRCC) may benefit from cytoreductive nephrectomy (CN) before targeted therapy (TT), and to assess the overall survival of patients undergoing CN and TT versus TT alone. Materials and Methods We identified 88 patients who underwent CN at our institution prior to planned TT and 35 patients who received TT without undergoing CN. Preoperative risk factors described in the literature were assessed in our patient population (serum albumin, liver metastasis, symptomatic metastasis, clinical ≥T3 disease, retroperitoneal and supradiaphragmatic lymphadenopathy). Patients were stratified by number of pretreatment risk factors and overall survival (OS) was compared. Results TT patients had significantly more risk factors compared to CN patients (3.06 vs. 2.11, p<0.01). Patients who received TT alone had median OS of 5.8 months. All but one patient receiving TT alone had two or more risk factors. A comparison of the CN and TT groups was performed by constructing Kaplan-Meier curves. There was no significant difference in median OS for those patients with exactly two risk factors (447 vs. 389 days, p=0.24), and those with three or more risk factors (184 vs. 155 days, p=0.87). Conclusions Using previously described pretreatment risk factors we found that patients with two or more risk factors derived no significant survival advantage from CN in the TT era. These risk factors should be incorporated in the assessment of patients for CN.

Primitive neuroectodermal tumors of kidney: Our experience in a tertiary care center.

OBJECTIVES: Primitive neuroectodermal tumors (PNET) are rare highly aggressive neoplasms. The diagnosis is made by histopathology with the support of immunohistochemistry (IHC) and cytogenetics. The aggressive multimodality treatment is recommended for the management of these tumors. The purpose of our study is to review our experiences in the diagnoses and treatment of PNET of the kidneys. MATERIALS AND METHODS: We retrospectively reviewed the data of all the patients, who were treated for the PNET of the kidneys at our institute between April and March 2011 and compared with the available literature. RESULTS: A total of eight patients were treated for PNET of the kidney. Out of the eight patients, four were males and four females. Nearly 50% of our patients had inferior vena caval thrombus at the time of presentation. The diagnosis was made on histopathology supported by IHC. Out of the eight patients, one patient had intraoperative death due to massive pulmonary thromboembolism and another died on the 7th post‑operative day due to disseminated intravascular coagulation and multiorgan failure. Rest six patients were treated with post‑operative chemotherapy or a combination of chemotherapy and radiotherapy. For these six patients, overall median survival was 45 months with a 3 year disease‑free survival of 66% and 5 year survival of 44%. CONCLUSIONS: PNET of the kidneys are rare peripheral neuroectodermal tumors with an aggressive clinical course. These tumors carry a very poor prognosis. An aggressive treatment approach using a combination of surgery, chemotherapy and radiotherapy is recommended for a reasonable survival in these tumors.

Formulation and in vitro evaluation of berberine containing liposome optimized by 32 full factorial designs.

The present study demonstrates the application of 32 full factorial design for optimization of berberine loaded liposome for oral administration. Thin film hydration method was used to prepare liposome and optimization was done by 32 full factorial designs combined with desirability function. Nine formulations were prepared by using different drug : lipid and soyphosphatidylcholine : cholesterol (SPC:CHOL) ratios and evaluated for entrapment efficiency and vesicle size. The statistical validity of model was done by analysis of variance (ANOVA). Response surface graph and contour plots were used to understand the effect of variables on responses. The optimized formulation with 0.782 desirability value was prepared and evaluated for responses. The results of entrapment efficiency and vesicle size were found to be very close with the predicted values. In addition, an optimized formulation was also characterized for zeta potential, in vitro drug release and morphology. The formulation was found to be spherical shape with an average diameter of 0.823 nm and -1.93 mV zeta potential and also shows sustained release pattern. These results support the fact that 32 full factorial designs with desirability function could be effectively used in optimization of berberine loaded liposome.

Unclassified Mucinous Renal Cell Carcinoma: A Rare Histopathological Entity

Renal cell carcinoma (RCC) with mucin production is extremely rare. We present the case of a previously healthy 76-year-old woman who underwent a robotic-assisted laparoscopic right nephrectomy for a 5-cm heterogeneously enhancing right renal mass. Pathology revealed mucin-producing epithelial RCC. We discuss the presentation and pathological features of this case and comment on its definitive treatment.

Occupational Hazard: Radiation Exposure for the Urologist – Developing a Reference Standard

Introduction To date, there is a paucity of literature offering practicing urologists a reference for the amount of radiation exposure received while surgically managing urolithiasis. This study examines the cumulative radiation exposure of an urologist over 9 months. Materials and Methods We present a case series of fluoroscopic exposures of an experienced stone surgeon operating at an academic comprehensive stone center between April and December 2011. Radiation exposure measurements were determined by a thermoluminescent dosimeter worn on the outside of the surgeon's thyroid shield. Estimations of radiation exposure (mrem) per month were charted with fluoroscopy times, using scatter plots to estimate Spearman's rank correlation coefficients. Results The total 9-month radiation exposure was 87 mrems for deep dose equivalent (DDE), 293 mrem for lens dose equivalent (LDE), and 282 mrem for shallow dose equivalent (SDE). Total fluoroscopy time was 252.44 minutes for 64 ureteroscopies (URSs), 29 percutaneous nephrolithtomies (PNLs), 20 cystoscopies with ureteral stent placements, 9 shock wave lithotripsies (SWLs), 9 retrograde pyelograms (RPGs), 2 endoureterotomies, and 1 ureteral balloon dilation. Spearman's rank correlation coefficients examining the association between fluoroscopy time and radiation exposure were not significant for DDE (p = 0.6, Spearman's rho = 0.2), LDE (p = 0.6, Spearman's rho = 0.2), or SDE (p = 0.6, Spearman's rho = 0.2). Conclusions Over a 9-month period, total radiation exposures were well below annual accepted limits (DDE 5000 mrem, LDE 15,000 mrem and SDE 50,000 mrem). Although fluoroscopy time did not correlate with radiation exposure, future prospective studies can account for co-variates such as patient obesity and urologist distance from radiation source. .

Holocord Syrinx, Tethered Cord and Diastematomyelia: Case Report and Review of Literature.

Syringomyelia refers to the presence of cavities within the spinal cord or a dilatation of the central spinal cord canal. In 90% of cases, syringomyelia is associated with a Chiari I malformation. The association of syringomyelia with tethered cord is well known but syrinxes associated with these defects are usually below vertebral level T6. Holocord syrinx associated with tethered cord is rare and is almost always associated with Chiari 1 malformation. To the best of our knowledge, only a single case report of holocord syrinx with tethered cord has been reported, but this patient had multiple overt lumbosacral defects (tethered cord, meningocele and diastematomyelia). We are reporting a three year old child with holocord syrinx with tethered cord and diastematomyelia and no evidence of Chiari malformation, meningocele or any overt spinal malformation and minimal neurological abnormalities.

Natural orifice transluminal endoscopic surgery in urology: review of the world literature

Natural orifice transluminal endoscopic surgery [NOTES] has gained momentum in the recent urologic literature as a new surgical approach for intra-abdominal organs with scarless and painless postoperative recoveries. We sought to review the published literature concerning the safety and reproducibility of NOTES in urology. PubMed literature review of articles published in the English language was performed over a 10-year period, i.e., between 2001 and 2011; all articles were critically reviewed and analyzed. Despite its novelty, pure or hybrid surgical approaches have been adapted in performing NOTES. NOTES essentially utilizes transluminal flexible endoscopic instruments along with laparoscopic instruments to gain access to abdominal, pelvic, and/or retroperitoneal cavities. The preliminary results of NOTES in surgery and to a limited extent in urology appear promising, yet further research in animal survival and human cadaveric models is requisite prior to human applications, especially for complex surgeries. Future innovative research, particularly biomedical engineering, should be directed to improving the technicality and mechanistic application of NOTES; hence, better safety and efficacy of NOTES

Correlation between the preoperative serum prostate specific antigen, Gleason score, and clinical staging with pathological outcome following robot-assisted radical prostatectomy: An Indian experience.

Objectives: To correlate the preoperative serum prostate specific antigen (PSA), Gleason score, and clinical staging with pathological outcome following robot-assisted radical prostatectomy (RARP) in Indian men with clinically localized cancer prostate. Materials and Methods: A prospective study analysis was done for 166 consecutive patients of prostate cancer who underwent RARP at our center from June 2006 to October 2009. Preoperative workup included serum PSA, biopsy Gleason score, and clinical staging. The preoperative parameters were correlated with final Gleason score, capsular penetration, seminal vesicle involvement, and lymph node status on final histopathology. Results: The mean age was 64 years (range: 50-76 years) with mean and median PSA of 17.98 ng/ml (range: 0.3-68.3 ng/ml) and 12.1 ng/ml, respectively. With increase in preoperative Gleason score, chance of organ confinement decreases (P=0.002) and capsular penetration increases (P=0.004) linearly. With increasing serum PSA, there is linear decrease in trend of organ-confined disease (P=0.03) and increased chances of seminal vesicle involvement (P=0.02). Patients with higher clinical stage have less probability of localized disease (P=0.007) and more chances of capsular penetration (P=0.04) and seminal vesicle involvement (P=0.004). Conclusion: Our data suggest that patients with higher preoperative serum PSA, Gleason score, and clinical stage have more chances of advanced pathological stage following RARP.

Renal tumors presentation: Changing trends over two decades.

Purpose: We have analyzed the changing trends in surgical treatment of renal tumors over the last 2 decades with regard to age incidence, presentation, incidental detection, and histopathology. Materials and Methods: Records of renal tumors were analyzed from January 1, 1988 to December 31, 2007. Data were split into 4 parts based on a 5-year time period, 1 for each cohort of patients: cohort 1 (1988-1992)-103 patients, cohort 2 (1993-1997)-161 patients, cohort 3 (1998-2002)-243 patients, and cohort 4 (2003-2007)-304 patients. A comparative study was performed with regard to age incidence, presentation, incidentallomas, histopathology, and management with statistical analysis. Results: Out of 811 renal tumors, 17.63% cases were benign and 82.37% were malignant. In the first cohort, 34.95% cases were detected in the seventh decade as compared with cohort 4 in which these were detected in the sixth (34.86%) and fifth decades (21.38%). Incidentallomas increased from 11 (10.67%) in cohort 1 to 84 (27.63%) in cohort 4 (P = 0.001). The cases of surgically treated tumors increased in number from 103 to 304 in cohort 4. Among the presenting features, incidence of weight loss, flank pain, and lump decreased while other clinical syndromes were constant. Only open radical nephrectomy was performed in the first 2 consecutive timeperiods. Laparoscopic radical nephrectomy was increasingly used in cohort 4 as compared with cohort 3 (121 vs 32, respectively). Similarly, open nephron sparing surgery (NSS) was increasingly used in cohort 4 as compared with cohort 3. Among the histopathologies, clear cell carcinoma was most common (73.35 %), but Fuhrman grading showed a trend toward more cases detected with grade 1 and 2 in cohort 4; 23.73% and 61.86%, respectively, as compared with 15.85% and 45.12% in cohort 1 (P = 0.001); more T1 tumors were detected (63.42% in cohort 4 as compared with 41.46% in cohort 1). Conclusions: A majority of renal tumors presented as symptomatic tumors. Recently, tumors are being detected at an early stage and grade; in the younger patients, with an increasing trend of laparoscopic and open NSS.

Epidemiological and clinical profile of irritable bowel syndrome in India: report of the Indian Society of Gastroenterology Task Force.

AIMS: To study the profile of irritable bowel syndrome (IBS), and the frequency of such symptoms among the general population, in India. METHODS: In this prospective, multi-center study, data were obtained from 2785 patients with chronic lower gastrointestinal symptoms (complainants) with no alarm feature and negative investigations for organic causes visiting physicians at 30 centers, and from 4500 community subjects (non-complainants), using separate questionnaires. RESULTS: Most complainants were middle-aged (mean age 39.4 years) and male (1891; 68%). The common symptoms were: abdominal pain or discomfort (1958; 70%), abdominal fullness (1951; 70%); subjective feeling of constipation (1404 of 2656; 53%), or diarrhea (1252 of 2656, 47%), incomplete evacuation (2134; 77%), mucus with stools (1506; 54%), straining at stools (1271; 46%), epigastric pain (1364; 49%) and milk intolerance (906; 32%). Median stool frequency was similar in patients who felt they had constipation or those who felt they had diarrhea. Information to subtype symptoms using standard criteria was available in 1301 patients; of these, 507 (39%) had constipation-predominant IBS ( 3 <or= stools/week), 50 (4%) had diarrhea-predominant IBS (>3 stools/day) and 744 (57%) had indeterminate symptoms. Among non-complainants, most subjects reported daily defecation frequency of one (2520 [56%]) or two (1535 [34%]). Among non-complainants, 567 (12.6%) reported abdominal pain, 503 (11%) irregular bowel, 1030 (23%) incomplete evacuation, 167 (4%) mucus and 846 (18%) straining at stools; a combination of abdominal pain or discomfort relieved by defecation, and incomplete evacuation was present in 189/4500 (4.2%) community subjects. CONCLUSIONS: Most patients with IBS in India are middle-aged men, and have a sense of incomplete evacuation and mucus with stools. Abdominal pain or discomfort is frequent but not universal. Importantly, stool frequency was similar irrespective of whether the patients felt having constipation or diarrhea. Most (90%) non-complainant subjects had 1 or 2 stools per day; symptoms complex suggestive of IBS was present in 4.2% of community subjects.

Protein-c deficiency presenting with subacute intestinal obstruction due to mesenteric vein thrombosis.

We describe a patient with protein C deficiency who presented with subacute intestinal obstruction due to ischaemic small bowel stricture. The patient also had left sided ileofemoral thrombosis. Venous thrombosis at unusual sites especially if associated with deep vein thrombosis of lower limb warrants a thorough screen for underlying thrombophilia. This, however, is a rare cause for ischaemic small bowel stricture.

A prospective study evaluating surgery and chemo radiation in muscle invasive bladder cancer.

AIM: The aim of our study was to compare the two standard treatment approaches in muscle invasive carcinoma of urinary bladder--radical cystectomy and chemo radiation. MATERIALS AND METHODS: Transitional cell carcinoma (TCC) of bladder of stages, T2 to T4, N0/N1/N2 and M0 were included in the study. Patients were allotted to two arms of the study. Arm A consisted of radical cystectomy. Adjuvant CMV chemotherapy was given for T3/T4 or Node positive disease only. Arm B received 2 cycles of neoadjuvant CMV chemo therapy followed by concurrent chemo radiation. RESULTS: Forty-four patients were recruited into the study. Thirty patients in the surgical arm and 13 patients in the chemo radiation arm. The actuarial two-year survival rate in surgical arm is 56% while in chemo radiation arm it is 54%. There was no statistically significant difference in disease-free survival also between the two groups. CONCLUSION: Chemo radiation yielded equivalent survival results with radical cystectomy. So it is worth giving preference to chemo radiation that will give a better quality of life for the patient.

Spontaneous resolution of delayed onset, posttraumatic high-flow priapism.

Priapism is an uncommon but serious condition with major long-term sequelae. The commoner, ischemic variety is a medical emergency requiring immediate intervention in order to avoid erectile dysfunction. However,the high flow variety is non-ischemic and the patient may not seek immediate therapy. The options of management for this rare, painless form of priapism vary from conservative therapy to embolization of the internal pudendal artery or, in some cases, surgery that may result in subsequent erectile dysfunction. We present a case of a 24-year-old man who presented with priapism of six-day duration, 10 days after perineal injury. Doppler ultrasonogram of the penis revealed a cavernosal artery pseudoaneurysm. Pudendal artery angiogram done four days later revealed no leak and the priapism subsided spontaneously with subsequent return of normal erections.

Berardinelli-Seip congenital lipodystrophy.

Berardinelli-Seip congenital lipodystrophy (BSCL) is a very rare genetic disorder characterized by lipoatrophy, hypertriglyceridemia, hepatomegaly and acromegaloid features. On the basis of mutational and haplotype analysis, BSCL families have been classified into three types BSCL 1, BSCL2 and BSCLX. We report Berardinelli-Seip congenital lipodystrophy (BSCL2 type) in three subjects from two unrelated Indian families (family1 and family2). The mutation (c.IVS2 11 A GT G ) found in affected members of family1 is a newly identified mutation. We also report the association of renal anomaly with this new mutation.

Should one vaccinate patients with chronic liver disease for hepatitis A virus in India?

BACKGROUND: Hepatitis A virus (HAV) vaccination is recommended worldwide for patients with chronic liver disease to prevent decompensation due to superinfection with HAV. India being endemic for HAV, the prevalence of pre-existing antibodies against HAV due to subclinical exposure to the virus in childhood among patients with chronic liver disease may be high and, therefore, vaccination may not be needed. However, little data are available on the prevalence of HAV antibody among patients with chronic liver disease in India. METHODS: All patients with chronic liver disease seen at Gastroenterology Center, Army Hospital R and R, New Delhi during the year 2002 and diagnosed to have either chronic liver disease were tested for the presence of IgG anti-HAV antibody in their sera (using a commercial ELISA kit). All patients with acute exacerbation or rapid deterioration of a preexisting chronic liver disease were separately studied for presence of IgM anti-HAV. In addition, a matched number of patients who attended the center due to diseases other than liver disease were also studied as controls. RESULTS: One hundred and eighty seven patients of chronic liver disease and 89 controls were studied. Mean age of these two groups was 38.6 and 42.1 years and 153 (81.8%) and 78 (87.6%) of them were males respectively. Etiology of chronic liver disease was HBV infection in 91(48.7%), HCV infection in 62 (33.2%), autoimmune chronic hepatitis in 3 (1.6%), PBC in seven (3.7%) and cryptogenic 24 (12.8%). Of these 179 (95.7%) patients tested positive for IgG anti-HAV. A total of 37 hospitalisations in 29 patients were noted during the study period due to acute exacerbation of pre-existing chronic liver disease. None of these were positive for IgM anti-HAV, while 28 were positive for IgG anti-HAV. Among the controls, 87 controls (94.6%) were positive IgG anti-HAV. The prevalence of anti-HAV positivity was similar among patients with various etiologies. CONCLUSION: Vaccination against HAV is not routinely required among patients with chronic liver disease in India as there is a very high prevalence of pre-existing antibodies in these patients. HAV superinfection as a cause of acute exacerbation of chronic liver disease was not seen in this.