Effectiveness of low-molecular-weight heparin in obstetric outcome of pregnancies having comorbidities with potential thrombotic risk

Background: The term “miscarriage” represents a demise of a fetus before it attains maturity. It encompasses all miscarriages between the time of conceive and the end of the pregnancy. Antiphospholipid antibody syndrome and in vitro fertilization (IVF) are one of the major reasons for thrombosis in pregnancy causing miscarriages. Since low-molecular-weight heparin (LMWH) produces fewer thrombocytopenia and is associated with reduced incidence of osteoporosis, it can be given once daily, therefore, it might have significant benefits compared with unfractionated heparin in at risk pregnancy. Aims and Objectives: This study aims to assess pregnancy outcomes after therapy with traditional aspirin supplemented with LMWH among women who are pregnant experiencing thrombosis-related diseases such as antiphospholipid syndrome (APLA) syndrome and IVF pregnancies. Materials and Methods: It was a retrospective analysis with a purposive sample of 61 pregnant women who had thrombosis risk factors. Thirty of the pregnancies were confirmed cases for APLA syndrome, whereas the other 30 were IVF conceptions. The comorbid factors were older age, a past of miscarriages, nulliparous IVF pregnancy, pre-eclampsia, diabetes, and obesity. IVF pregnancy accompanied with ovarian hyperstimulation syndrome was one of the cases. Study participants were administered a regular preventive medication of 40/60 mg s.c. as well as 75/150 mg of oral aspirin. All through gestation, according to patient’s registration weight, were administered every day. Heparin was stopped 24 h before the actual scheduled delivery, while aspirin had been stopped 3–4 days earlier. Results: In this study, 58 live births have been recorded, including 10 cases of preeclampsia, 10 of intrauterine growth retardation, two of eclampsia, two of intrauterine death infants, and two of abortions. There were 18 premature deliveries, nine multiple birth pregnancies, and 35 full-term pregnancies among the live births. There were no cases of HELLP syndrome, placental abruption, and stillbirths. In addition, heparin therapy cured one incidence of post-operative thrombosis of deep veins in pregnancy. It was also observed that early LMWH application to pregnant women with thrombosis risk was able to lower the incidence of miscarriages, gestational fetal death, and decreased weight at birth, and cases of HELLP syndromes. Furthermore, the therapeutic dose in high-risk case of post-delivery deep vein thrombosis of lower extremities cured the mother. Conclusion: It can be concluded from the study that the application of LMWH enhanced the obstetric outcome in pregnant women having increased risk for thrombosis. In future pregnancies with thrombosis risk factors, employing LMWH in conjunction with the documented therapeutic approach may result in a better obstetric outcome.

Evaluation of pattern of prescribing of antimicrobials in Government Doon Hospital and assessment of their rational use

Background: Rational antimicrobial therapy means that the patients receive medications appropriate to their clinical needs, in needs, in doses that meet their own individual requirements for an adequate period of time and at the lowest cost they and the community can afford. Aim and Objective: The present study was aimed at assessing antibiotic prescribing pattern in eight clinical departments of Government Doon Hospital and to assess their rational use according to the indication, dose, duration, frequency, route of administration, any drug interactions, and contraindications (suitability). Materials and Methods: It was a cross-sectional observational study carried out in the Government Doon Hospital for a period of 3 months. Total 280 prescriptions, at least 20–30 each from eight clinical departments from OPD and IPD (Medicine, surgery, gynecs, orthopedics, ENT, ophthalmology, dermatology, and dentistry), were included in the study. Results: In our study, out of total 1202 drugs prescribed to 280 patients, 493 antibiotics were prescribed. The most commonly prescribed antibiotics were b lactams (39.75) followed by nitro imidazoles (22.9%), azoles (8.11%), and aminoglycosides (7%). The type of the treatment used is empirical in 28.5% cases, prophylactic in 5% cases, and definitive therapy in 66.42 % cases. In fixed dose combinations, total FDCs prescribed were 26. The most commonly used FDCs were amoxiclav and Piptaz. The most frequently prescribed antibiotics were ceftriaxone, amikacin, and metronidazole. The majority of the diseases in which antibiotics were prescribed were alcoholic liver disease, liver abscess, burns, tinea corporis, vaginitis and pain in lower abdomen, and tuberculosis. The number of rational prescriptions in our study is 68.28% according to the indication, dose, duration, frequency, and route of administration in accordance with standard treatment guidelines. The number of irrational prescriptions is 31.72% in terms of inappropriate antibiotic (13.48%), treatment without indication (25.84%), long duration of dosing (40.44%), and inappropriate frequency (17.97%). The prescribing from hospital formulary was 71% while the prescribing from national essential drug list was 65.5% which is still less compared to the WHO guidelines. Conclusion: The irrational prescribing by use of duplicate antibiotics of the same class, using inappropriate antibiotics, using the antibiotic for prolonged periods and incorrect frequency, should be discouraged. The irrational use causes harm to the patient, dissatisfaction, and prolongs hospital stay. The injectables should be given only in case of emergency or systemic infections, reducing the cost, and inconvenience. Rational fixed dose combinations improve compliance, produce synergism and reduce the severity of adverse effects, and prevent emergence of resistance. De-escalation practice, dose optimization, and drug modification/change should be practiced to shorten hospital stay and improve the outcome.

Unmasking Brugada Syndrome with Oral Flecainide Provocation. A Case Series of Three Patients

The present case series discuss three patients who had brugada type 2/ type 3 like ECG pattern that was converted to type 1 pattern with oral flecanide challenge test. Brugada syndrome is associated with a high incidence of sudden cardiac death, typical ECG pattern being ST-segment elevation in the right precordial leads with T wave inversion. Pharmacological provocation should only be performed when the baseline ECG is not diagnostic of Brugada Syndrome. PR prolongation in the baseline ECG is also a contraindication because of the risk of inducing AV block. Drug challenge is performed under strict monitoring of BP and 12-lead ECG and facilities for cardio version and resuscitation are available. Atypical RBBB pattern/type 2/3 Brugada pattern on ECG in patients of syncope or family history of sudden cardiac arrest is commonly encountered by a cardiologist. This can be performed to provoke type 1 brugada pattern on ECG. Diagnosed cases of Brugada may be treated with ICD with proper indication if needed and thus prevent sudden cardiac death.

A Rare Case of Shone Complex, Where Coarctation was Treated Successfully with Covered Cheatham Platinum Stent

Shone complex is an extremely rare and severe congenital heart disease characterized by left -heart obstruction at multiple levels namely supravalvular mitral ring, parachute mitral valve, subaortic stenosis and coarctation of the aorta. We in the present case describe a patient of shone complex who underwent successful coarctoplasty with the help of BIB (balloon in balloon) dilatation catheter and covered CP (cheatham platinum) stent. The role of interventional cardiologist is to diagnose and choose the right approach for the specific patient, whether surgery, balloon or stent.

Drug Delivery Through Blood Brain Barrier: Taming the Bottleneck in CNS Therapeutics

Although many agents have therapeutic potentials for Central Nervous System (CNS) diseases, few of these agents have been clinically used because of the brain barriers. Physiological barriers like the blood-brain barrier and blood-cerebrospinal fluid barrier as well as various efflux transporter proteins make the entry of drugs into the central nervous system very difficult. Different strategies for efficient CNS delivery have been studied. This review presents the current approaches to facilitate penetration across these barriers for enhanced drug delivery to the CNS.

A Study of Anti-hypertensive Drug Prescription Patterns in Hypertensive Post-menopausal women

Background: Drug prescription in menopause is complex as estrogen deficiency, hypertension (HT) and other risk factors, rapidly increase the risk of cardiovascular diseases (CVD) in post-menopausal women (PMW). Objectives: To evaluate the prescription trends of anti-hypertensive drugs in PMW. Methods: This was an observational, cross sectional study conducted over a period of 1 year, on hypertensive PMW. The prescriptions were evaluated for antihypertensive drug use patterns and also as per WHO core drug indicators. Results: 21.82% of prescriptions had monotherapy, amongst which angiotensin receptor blockers (ARB) (10%) and individually, telmisartan (5.45%) were most commonly prescribed. Majority of prescriptions had two drug therapy (44.09%), among which ARB + beta-blockers (BB) (20.91%) and individually, Telmisartan + Metoprolol (13.64%) were most frequently prescribed. ARB + Diuretic (DI) (9.55%) was the most common fixed drug combination (FDC) prescribed. ARB + BB + DI (10.45%), ARB + 2DI + BB (4.09%) and ARB + 2DI + BB + Calcium channel blocker (1.82%) were most commonly prescribed three, four and ≥five drug combinations, respectively. Hypolipidemic drugs (60.45%) were maximally co-prescribed. Percentage of drugs prescribed by generic name was 4.63% and from essential drug list was 32.62%. Conclusions: A high trend of polypharmacy was observed in hypertensive PMW. HT, being a multifactorial disease, deserves a multidisciplinary and a comprehensive approach in the care of this population subgroup. Knowledge of prescription pattern and thus the rational utilisation of drugs will help achieve better control rates of HT and hence curb down the burden of CVDs in PMW.

Smear microscopy as surrogate for culture during follow up of pulmonary MDR-TB patients on DOTS plus treatment.

Background: DOTS Plus site at LRS Institute, New Delhi, covering 1.8 million population. Aims: To ascertain if sputum smear could be used as a surrogate for culture during intensive phase of treatment of MDRTB patients thereby enabling early shift from intensive phase to continuation phase, reducing the need for frequent cultures and saving time and cost in their management. Methods: The study is a retrospective analysis of 138 MDR-TB patients on DOTS Plus treatment whose sputum samples were simultaneously subjected to smear microscopy and culture, monthly during Intensive Phase and once in two months during Continuation Phase. Sputum results in the treatment card were supplemented from laboratory register, if required, and analyzed. Predictive values, sensitivity and specificity of smear were compared with culture results. Results: The Negative Predictive Value (NPV) of smear was high from the 3rd month onwards (above 91%), at four months 98% or more and approached 100% from eight months onwards. The specificity of smear test gradually increased during treatment and from five months onwards, it was above 90%. Conclusions: Considerable correlation was observed between sputum smear and culture during follow up of DOTS Plus treatment in the Intensive Phase. Accordingly, sputum smears can be recommended instead of culture.

Prevalence of Coronary Risk Factors in Type 2 Diabetics without Manifestations of Overt Coronary Heart Disease.

Aims : To find the prevalence of cardiovascular risk factors in type-2 diabetics without manifestations of overt coronary heart disease and to estimate the prevalence of silent myocardial ischaemia in these patients. Methods : Seventy seven patients of type 2 diabetes were recruited for the study (one patient lost after recruitment; 76 completed the study). History and physical examination were recorded. Laboratory investigations included fasting and 2-hour post-prandial blood sugar, blood urea, serum creatinine, lipid profile, glycated haemoglobin, and microalbuminuria. Ultrasonographic scanning of the carotid arteries was performed to measure the carotid IMT. For identification of cases of silent ischaemia, treadmill test (TMT) was performed. Results : The study group was divided into a non-CAD group (n=54), and a silent CAD group (n=22). Twenty-two diabetics were found to have silent CAD as evidenced by a positive TMT result (28.9%). The prevalence of silent myocardial ischaemia was almost similar in both males and females. Serum LDL levels more than 140 mg% had a significant correlation with the prevalence of silent CAD (p=0.04). The difference in CCA-IMT values was found to be statistically significant between the silent CAD and non-CAD groups (p=0.019). Conclusion : High LDL level and greater carotid intima-media thickness are particularly important parameters that can predict if a patient of type 2 diabetes is at risk for silent ischaemia. A high carotid IMT is a surrogate and reliable marker of higher risk of CAD amongst type 2 diabetic patients, even in those without overt CAD. The study also underlines the utility of carotid IMT as a simple, non-invasive, safe, and cheap screening test for the assessment of risk of CAD in type 2 diabetics. ©

Cryptogenic hemoptysis: role of fiberoptic bronchoscopy.

Fiberoptic bronchoscopy (FOB) was performed for recurrent hemoptysis in 79 patients with normal chest roentgenograms. Seventy per cent were females with a mean age of 31.93 years. Normal findings were obtained in 60 patients. In 19 patients with abnormal findings on bronchoscopy underlying malignant disease was discovered in 3 patients following bronchoscopy. All these patients were elderly male smokers. In three patients unexplained left recurrent laryngeal nerve palsy was discovered. Thus, FOB as a diagnostic aid for cryptogenic hemoptysis is useful only in elderly male smokers.

Pleuropulmonary complications of staphylococcal pulmonary infection in children.

A series of 44 cases of staphylococcal pulmonary infection in children is reported. Their clinical features and characteristic roentgenological manifestations have been discussed.

Pulmonary aspergilloma--radiological observations.

The radiological appearances of 49 cases of aspergilloma seen over a period of 6 years among 36,340 hospital admissions are described. All the 49 patients had pulmonary tuberculosis as underlying disease with 6 (12.2%) having bacteriologically active disease. One patient had concomitant allergic bronchopulmonary aspergillosis (ABPA). Upper zone distribution, large cavity size, moderately thick cavity wall and overlying pleural thickening were some of the prominent features observed. Two cases of multiple (3 each) and 4 of bilateral aspergilloma were seen. Of 57 aspergillomas 47 were round or oval, 7 oblong, 2 polypoidal and 1 lobulated. Positional movement was observed in 30 cases. Spontaneous lysis was seen in one case. Tomography and lordotic view were found to be very useful techniques when postero-anterior films were unrevealing. The radiologic diagnosis of aspergilloma was confirmed by demonstration of serum precipitins against aspergilli in 44 cases.

Solitary uncommon pulmonary nodule in a child.

An eleven-year-old boy attended this hospital with complaints of low grade fever and dry cough of three months duration. There was no history of any prolonged illness in the past. Child had BCG and other immunisation at appropriate age. General physical examination, respiratory system, cardiovascular system and other systems revealed no abnormal findings.

Anaerobic infection of the lung and pleural space in tuberculosis.

Prevalence of anaerobic bacterial infection in 120 sputum positive cases of pleuro-pulmonary tuberculosis was found to be 53.3 per cent-either as pure or mixed with aerobes. Bacteroides fragilis and B. Melaninogenicus were isolated in 19 (26.6%) and 12 (18.72%) cases respectively. Sensitivity studies showed that these were most sensitive to metronidazole followed by rifampicin and kanamycin. The possibility of anaerobic infection may be considered in patients of pulmonary tuberculosis who do not respond to routine treatment.