Expert consensus on the management of Androgenetic Alopecia in India.

Androgenetic alopecia (AGA), also known as androgenic or pattern alopecia, is a frequently reported disorder that affects both the sexes, with a higher incidence generally reported in men. AGA has immense psychological effects on the patient, irrespective of the age or stage of baldness. This consensus document has been developed taking into account the opinions of leading experts in the field of dermatology. The objective of this article is to provide the dermatologists with an evidence-based platform for choosing efficacious and safe therapy for patients with AGA. This review articulately summarizes the key opinions of the experts on all aspects of treatment for the effective management of AGA.

Expert consensus on the management of Telogen Effluvium in India.

Alopecia, a frequently reported problem, severely impacts the quality of life of patients and is often associated with loss of confidence and low self-esteem. Several conditions such as telogen effluvium (TE), anagen effluvium, diffuse type of alopecia areata, female pattern hair loss, hair shaft abnormalities, loose anagen hair syndrome, and congenital atrichia or hypotrichosis are associated with hair loss. The actual prevalence rate of TE is not reported since most cases are subclinical in nature. Further, since women get more distressed by hair fall and promptly seek treatment, they tend to be over-represented. However, both genders can suffer from this condition if triggering factors are present. This consensus paper was developed by taking into account opinions of renowned experts in the field and is hoped to serve as an evidence-based platform for selecting efficacious and safe therapy for patients with TE. This review presents a synopsis of the key opinions of experts on all aspects of treatment and effective management of this condition.

Circulating NT-proBNP but not soluble corin levels were associated with preeclampsia in pregnancy-associated hypertension.

BACKGROUND: Corin is a serine protease known to convert B-type natriuretic peptide (BNP) prohormone into BNP and its amino-terminal fragment (NT-proBNP). In mice lacking corin, high blood pressure and proteinuria were found at late gestational stages, with associated delayed trophoblast invasion and impaired spiral artery remodeling in the uterus. We hypothesize that both NT-proBNP and soluble corin elevation predict the presence of preeclampsia in pregnant patients with hypertension. METHODS: We prospectively enrolled 149 pregnant women with a history of chronic hypertension or gestational hypertension presenting at a tertiary-care hospital. We compared plasma NT-proBNP and soluble corin concentrations based on their preeclamptic status. RESULTS: In our study cohort, 62 patients with preeclampsia had lower gestational age than 87 patients without preeclampsia (33.3 ±â€¯3 versus 36.6 ±â€¯3 weeks; P < .001), otherwise the baseline characteristics were similar. We observed higher NT-proBNP concentrations in patients with preeclampsia compared to those without preeclampsia (304.3 [96.34, 570.4] vs. 60.8 [35.61, 136.8] ng/L, P < .001), with no differences between chronic and gestational hypertension. However, the concentration of corin was not statistically different between the two groups (1756 [1214, 2133] vs. 1571 [1171, 1961] ng/L, P = .1087). ROC curve analysis demonstrated stronger predictive value of NT-proBNP compared to soluble corin in predicting the presence of preeclampsia in our study population (AUC 0.7406 vs. 0.5789, P < .0001). CONCLUSION: While corin may contribute to mechanistic underpinnings of the development of preeclampsia in animal models, soluble corin likely has no diagnostic role in human pregnancies for preeclampsia beyond natriuretic peptide levels.

Delivery Assist Catheters : A new Device Class and Initial Experience in Mechanical Thrombectomy in Acute Ischemic Stroke Patients.

PURPOSE: To report in vivo experience of a delivery assist catheter as ascending aid for a large-bore catheter for intracranial thromboaspiration. METHODS: Retrospective data collection and analysis of stroke databases of two comprehensive stroke centers focusing on technical and angiographic parameters - primary endpoint defined as reaching the occlusion with a large-bore reperfusion catheter - from patients receiving endovascular stroke treatment using an AXS Offset™ delivery assist catheter (Stryker, Fremont, CA, USA) between May 2017 and November 2017. RESULTS: Using the delivery assist catheter, a 6F catheter could be advanced to an intracranial occlusion for direct thromboaspiration in 30 (88.2%) out of a total of 34 patients (male: n = 14 out of 34 [41.2%], age in years: mean [SD]: 75 [11], median baseline NIHSS [National Institutes of Health stroke scale]: 16 [interquartile range, IQR 12-21]). In 4 out of 34 (11.7%) cases the occlusion could not be reached with the aspiration catheter because of a preceding non-occlusive arteriosclerotic plaque (n = 1, 2.9%) or because of severe elongation and tortuosity of the arterial access route (n = 3, 8.8%). After thromboaspiration mTICI (modified thrombolysis in cerebral infarction) 2b­3 was reached in 14 out of 30 (46.7%) patients. In 21 out of 34 (61.8%) patients stent-retriever-maneuvers (median: 1 [IQR: 0­2]) were needed. In 28 out of 34 (82.3%) patients final mTICI 2b-3 could be achieved. CONCLUSION: Delivery assist catheters can be used as ascending aid for large-bore catheters for thromboaspiration in acute ischemic stroke, in particular to overcome vessel tortuosity and anatomic obstacles.

Residency evaluation and adherence design study: Young ophthalmologists' perception of their residency programs II: Academics and Research dissertation.

PURPOSE: To know the perception of young ophthalmologists about their dissertation and academics during residency training in order to improve the research output during present residency programs in India. METHODS: A survey was conducted by Academic and Research Committee of the All India Ophthalmological Society, the world's second largest ophthalmic professional's organization, in 2014-2016 of young ophthalmologists (those who completed residency between 2005 and 2012) to gauge usefulness of dissertation or thesis during postgraduate residency. RESULTS: There were 1005 respondents, of whom 531 fulfilled inclusion criteria. On a scale of 0-10, residents rated level of supervision of their dissertation as adequate (mean 5.9/10, standard deviation [SD] = 3.1, median = 6). The level of infrastructure available was for dissertation rated as 5.9/10 (median = 7, SD = 3.1), and 6.2/10 was the score that residents said about value added by the dissertation (median = 7). The dissertation was presented at local (33.5%), state (28.1%), national (15.4%), and international (4%) levels. Students, not supervisors, did most of the local and state level presentations. It was published in some forms at local 210 (39.5%), state (140, 26.4%), national (94, 17.7%), and international (39, 7.3%) levels. On a scale of 0-4, seminars (3/4) and case presentations were (3/4) rated higher than didactic lectures (2.2/4), journal clubs (2.2/4), and wet laboratory (1.1/4). CONCLUSION: Peer-reviewed publications from Indian residency training dissertations were few. Residents felt dissertation added value to their training, but there was a huge range among the responses. Journal clubs and wet laboratories were not graded high in academic programs, unlike seminars and case presentations.

Motivations, barriers and ethical understandings of healthcare student volunteers on a medical service trip: a mixed methods study.

BACKGROUND: The motivation to volunteer on a medical service trip (MST) may involve more than a simple desire for philanthropy. Some volunteers may be motivated by an intrinsic interest in volunteering in which the context of the volunteer activity is less important. Others may volunteer because the context of their volunteering is more important than their intrinsic interest in volunteering. Furthermore, MSTs may pose a variety of ethical problems that volunteers should consider prior to engaging in a trip. This study evaluated the motivations and barriers for graduate health care students volunteering for an MST to either the Dominican Republic or Mississippi. Volunteers' understanding of some of the ethical issues associated with MSTs was also assessed. METHODS: Thirty-five graduate health professions students who volunteered on an MST were asked to complete an online survey. Students' motivations and barriers for volunteering were assessed using a 5-point Likert scale and Fisher's exact test. Ethical understanding of issues in volunteering was assessed using thematic analysis. RESULTS: Students' motivations for volunteering appeared to be related to the medical context of their service more than an inherent desire for volunteer work. Significant differences were seen in motivations and barriers for some student groups, especially those whose volunteer work had less opportunity for clinical service. Thematic analysis revealed two major themes and suggested that students had an empirical understanding that volunteer work could have both positive and negative effects. CONCLUSIONS: An understanding of students' motivations for volunteering on an MST may allow faculty to design trips with activities that effectively address student motivations. Although students had a basic understanding of some of the ethical issues involved, they had not considered the impact of a service group on the in-country partners they work with.

Clinical spectrum in three families with familial hemiplegic migraine type 2 including a novel mutation in the ATP1A2 gene.

INTRODUCTION: Familial hemiplegic migraine (FHM) is a rare subtype of migraine with transient hemiplegic aura. PATIENTS AND METHODS: We describe three unrelated families with familial hemiplegic migraine type II (FHM2). Retrospectively, information on 47 family members could be obtained, 15 by personal examination and 32 by indirect anamnesis from relatives. Genetic analyses were performed in 13 patients. RESULTS: One family had a novel missense mutation in the ATP1A2 gene (c.659C>T, p.Ser220Leu) that segregated with the phenotype in three generations. Two further unrelated families with different ethnic backgrounds (one from Germany and one from Russia) had a missense mutation that has not been described as yet in FHM, but occurred in only a single patient with sporadic hemiplegic migraine (c.2723G>A, p.Arg908Gln). Clinically the patients had severe attacks lasting up to several weeks as well as epileptic seizures. Three patients with a proven mutation in the ATP1A2 gene clinically presented without hemiparesis. Furthermore, there was a possible relation of FHM2 to mental retardation in another two patients. CONCLUSION: Clinical symptoms may last for several weeks in some patients. Patients with FHM2 may also present without hemiplegia. Therefore, the full family history has to be taken into account to establish the diagnosis of FHM.

Drug-induced Stevens-Johnson syndrome: case series from tertiary care centre in Gujarat.

PURPOSE: The aims of the present article were to study clinical features and to analyse them in different drug class associated with Stevens-Johnson syndrome (SJS) in a tertiary care hospital in Gujarat, India. MATERIALS AND METHODS: A prospective hospital-based study was carried out over a period of 3 years (June 2007 to September 2009) at Sheth Vadilal Hospital, Ahmedabad, India. The diagnosis of SJS was made mainly on the basis of the clinical findings, which included extensive erythema multiforme, purpuric lesions with bullae and detachment of skin involving at least two mucous membranes. Further, in each patient suspected with SJS, various laboratory tests such as complete blood count, liver function tests, metabolic panel, chest X-ray and other serological test were carried out. SJS was confirmed on the basis of most widely accepted Bastuji-Garin definition. Causality assessment was performed using the Naranjo scale. Only 'probable' and 'definite' reactions were included. RESULTS: Antibacterials for systemic use, anti-inflammatory and antirheumatic products and antiepileptics were the drug classes most commonly associated (8 of 29 cases, each) with SJS. Individually, ibuprofen was involved in the highest number of cases (five cases, 17.2%), followed by carbamazepine (four cases, 13.8%) . The mean duration of developing SJS symptoms was 15.9 days (SD = 8.7 days) and improvement after treatment was 14.2 days (SD = 4.6 days). The duration of appearing SJS symptoms varied significantly between different classes of drugs (p < 0.001). The appearance of SJS symptom started within 10 days for anti-inflammatory and antibacterial compared with 24 days of antiepileptic agents. All the patients with antiepileptic agent-induced SJS had 7% to 9% of detached body surface area. In two patients, SJS progressed to toxic epidermal necrolysis and of which one led to death and the other developed long-term complication of conjunctival xerosis. A total of six patients developed long-term complications: four patients had conjunctival synechia, one patient had conjunctival xerosis and one patient had urethral stricture. CONCLUSION: More than 80% of the SJS events were induced by antibacterial, anti-inflammatory and antiepileptic agents with same frequency. The duration of the appearance of SJS symptoms significantly varied between different drug classes and started within 10 days for anti-inflammatory and antibacterial compared with 24 days of antiepileptic agents.

Abdominal computed tomography during pregnancy for suspected appendicitis: a 5-year experience at a maternity hospital.

The objective of this article is to evaluate the role of computed tomography (CT) in a pregnant patient with right lower quadrant pain in whom there was a clinical suspicion of acute appendicitis. During a 5-year period the clinical records of all pregnant women who underwent imaging examination for clinically suspected appendicitis were reviewed. The imaging findings were correlated with patient management and final outcome. Thirty-nine pregnant patients were referred for imaging, of which 35 underwent initial evaluation with sonography, 23 of these women underwent a computed tomographic examination, and an additional 4 patients were directly imaged with CT without earlier sonographic assessment. Surgery confirmed appendicitis in all 5 patients who were operated on on the basis of findings of appendicitis on a CT scan. Two patients underwent surgery based on an alternate diagnosis suggested preoperatively (tubal torsion = 1, ovarian torsion = 1). All patients with negative findings at CT had an uneventful clinical course. In those patients who were evaluated only with ultrasound, a diagnosis of appendicitis was missed in 5 patients. The sensitivity of CT in the diagnosis of appendicitis in our study group was 100%, compared with a sensitivity of 46.1% for ultrasound. CT provides an accurate diagnosis in patients suspected to have acute appendicitis and is of value in avoiding false negative exploratory laparatomy with its consequent risk of maternal and fetal mortality and morbidity. Although sonography is the preferred initial imaging modality as its lack of ionizing radiation, CT is more accurate in providing a timely diagnosis and its use is justified to reduce maternal mortality and mortality in patients with appendicitis.

Prospective evaluation of the value of combined mammographic and sonographic assessment in patients with palpable abnormalities of the breast.

OBJECTIVE: To evaluate the role of combined mammographic and sonographic imaging in patients with palpable abnormalities of the breast. METHODS: Four hundred eleven consecutive cases of palpable abnormalities of the breast underwent combined mammographic and sonographic evaluation. Patients who did not undergo biopsy had imaging and clinical follow-up; the mean follow-up period was 28.9 months (range, 24-33 months). RESULTS: One hundred sixty-five (40.1%) of 411 palpable abnormalities had a benign assessment; 97 (58.7%) of the 165 benign lesions were visible on both mammography and sonography; 66 (40%) of 165 benign lesions were mammographically occult and identified at sonographic evaluation. In 60 (14.6%) of the 411 cases, imaging evaluation resulted in a suspicious assessment; 49 (81.7%) of the 60 lesions categorized as suspicious underwent biopsy; 14 (28.5%) of 49 lesions were histologically proved to be carcinoma. Nineteen (31.6%) of the 60 lesions categorized as suspicious were mammographically occult and identified only on sonography; 14 (73.7%) of these 19 lesions underwent biopsy; 12 (63.1%) of 19 were benign, and 2 (10.5%) were malignant. One hundred eighty-six (45.2%) of the 411 palpable abnormalities had negative imaging assessment findings; 12 patients with negative imaging findings underwent biopsy, and all had benign findings. The sensitivity (14 of 14) and negative predictive value (186 of 186) for a combined mammographic and sonographic assessment were 100%; the specificity was 80.1% (186 of 232). CONCLUSIONS: Cancer was diagnosed in 14 (3.4%) of 411 women who underwent combined imaging for palpable abnormalities of the breast. Combined mammographic and sonographic assessment was shown to be very helpful in identifying benign as well as malignant lesions causing palpable abnormalities of the breast.

Prospective evaluation of the value of negative sonographic and mammographic findings in patients with palpable abnormalities of the breast.

OBJECTIVE: To evaluate the value of combined negative sonographic and mammographic findings in patients with palpable breast abnormalities. METHODS: One hundred seventy-two patients with 186 palpable abnormalities who had combined negative sonographic and mammographic findings were prospectively studied. Patients who did not undergo biopsy had imaging and clinical follow-up; the mean follow-up period was 28.9 months (range, 24-33 months). RESULTS: Twelve patients underwent biopsy; benign histologic diagnoses were reported in all 12 (12 [6.9%] of 172). In the remaining 160 patients who were followed, there was no interval development of breast cancer at the site of the palpable abnormality. The negative predictive value of combined negative mammographic and sonographic findings in a patient with a palpable abnormality of the breast was 100%. CONCLUSIONS: Our findings suggest that in a patient with a palpable abnormality of the breast, the negative predictive value of combined normal sonographic and mammographic findings is very high and is therefore reassuring to the patient.

Sonographic findings in focal fibrocystic changes of the breast.

The purpose of this study was to identify the spectrum of sonographic appearances in histologically proven focal fibrocystic changes (FC) of the breast to enhance understanding of imaging findings in this commonly encountered benign condition of the breast. During a 28-month period, the pathology database at two breast centers was searched to identify all patients with a pathologic diagnosis of focal FC resulting from biopsy of a focal mammographic, sonographic, or palpable abnormality and who had undergone sonographic evaluation before biopsy. The authors included lesions with a pathologic diagnosis of FC with or without a specific histologic subtype, such as stromal fibrosis, sclerosing adenosis, and apocrine metaplasia. In 58 patients, there were 60 lesions with a pathologic diagnosis of focal FC. Sonographically, focal FC appeared as solid mass in 28 cases (46.6%) and as cysts in eight (13.3%). In nine cases (15%), heterogeneously echogenic tissue was seen, and in the remaining 15 (25%) cases, there was no sonographically visible focal change. Thirteen of the 28 (46.4%) masses were classified as sonographically indeterminate. One mass was classified as probably malignant, and 14 masses were sonographically benign. A significant number of focal FC appear as solid masses. The sonographic features are not specific enough to differentiate between those that have a dominant component of focal fibrosis, sclerosing adenosis, or apocrine metaplasia from FC without a specific histologic subtype. Many of these solid masses may appear indeterminate, based on published criteria. An understanding of the imaging findings also helps to avoid repeat biopsy for discordant histologic and imaging findings.