Hepatocyte paraffin-1, CD10, and CD34 immunostaining as a diagnostic aid in cytologic diagnosis of hepatic cancer.

Background: Cytomorphological distinction between hepatocellular carcinoma and metastatic tumors to the liver may be difficult, especially when these have poor differentiation. The present study was done to assess the diagnostic utility of hepatocyte paraffin-1 (HepPar-1), CD10, and CD34 in differentiating hepatocellular carcinoma from metastatic carcinoma. Materials and Methods: Ultrasound-guided fine-needle aspiration was performed on 50 patients with space-occupying lesions of liver suspicious for malignancy on clinical/radiologic findings. The cytological assessment was done on smears stained with May-Grünwald-Giemsa and hematoxylin and eosin. Cell blocks were prepared, and immunostaining for HepPar-1, CD10, and CD34 was done. Results: In these 50 patients, hepatocellular carcinoma was diagnosed in 7 and metastatic tumors in 43 cases. The sensitivity of smears in diagnosing hepatocellular carcinoma was 100% and the specificity was 95.3%, while the sensitivity and specificity of cell block were 100%. A canalicular pattern of CD10 immunoreactivity had a 100% positive predictive value for diagnosing hepatocellular carcinoma. CD10 had a sensitivity of 57.1% and 41.9% in identification of HCC and metastatic tumors, respectively. For the diagnosis of hepatocellular carcinoma, the sensitivity of CD34 was 85.7% and the specificity of sinusoidal pattern of immunoreactivity was 100%. The sensitivity and specificity of granular cytoplasmic staining pattern of HepPar-1 were 100% in hepatocellular carcinoma. Conclusions: The staining patterns of HepPar-1, CD10, and CD34 are highly specific in distinguishing hepatocellular carcinoma from metastasis. These three immunomarkers should be included in the immunocytochemical panel for differentiating hepatocellular carcinoma from metastatic carcinoma to the liver.

Utility and Limitations of Glycated Hemoglobin (HbA1c) in Patients with Liver Cirrhosis as Compared with Oral Glucose Tolerance Test for Diagnosis of Diabetes.

INTRODUCTION: To study the utility of glycated hemoglobin (HbA1c) in the diagnosis of diabetes in patients with cirrhosis as compared to the gold standard oral glucose tolerance test (OGTT) and to see the effect of anemia and severity of cirrhosis on its performance. METHODS: Individuals (n = 100) with an established diagnosis of liver cirrhosis were recruited. The OGTT was performed as described by the World Health Organization (WHO). The severity of cirrhosis was calculated using the Child-Turcotte-Pugh (CTP) score. The severity of anemia was defined according to WHO criteria. The utility of HbA1c was compared against the OGTT results. Test sensitivity and specificity were used to describe the diagnostic accuracy of HbA1c. RESULTS: A total of 100 subjects aged 46.9 ± 9.1 years (mean ± standard deviation) participated in the study, of whom 65% were recruited from out patient department of our hospital. The overall sensitivity and specificity of a HbA1c level of ≥ 6.5% for the diagnosis of diabetes in patients with cirrhosis was 77.1% (95% CI 59.9, 89.6) and 90.8% (95% CI 81.0, 96.5), respectively. The positive and negative predictive values were 81.8% (95% CI 67.3, 90.8) and 88.1% (95% CI 80.0, 93.2), respectively. The area under the curve was 0.85 (95% CI 0.75-0.94). The sensitivity of HbA1c for diagnosing diabetes in outpatients was 87.0% (95% CI 66.4, 97.2) and was better than that for diagnosing diabetes in hospitalized patients (58.3%; 95% CI 27.7, 84.8). The sensitivity of HbA1c for diagnosing diabetes was poor in patients with moderate to severe anemia. The difference in sensitivity and specificity was not statistically different for CTP classes A, B and C. The prevalence of diabetes as defined by American Diabetes Association OGTT criteria was 35% (95% CI 25.7-45.2%). CONCLUSIONS: Taking OGTT as the gold standard, the sensitivity of HbA1c for diagnosing diabetes is good when used in outpatients with cirrhosis. However, the sensitivity of HbA1c decreases when it is used for hospitalized patients, suggesting that it is not a good test for diagnosis of diabetes in such cases. It also performs poorly if the patient has moderate to severe anemia.

Post-cholecystectomy syndrome: A new look at an old problem.

BACKGROUND: Despite being the most commonly performed operations, sometimes cholecystectomy fails to relieve symptoms; this is now a well-recognised clinical entity termed 'post-cholecystectomy syndrome' (PCS). Very few studies from India deal with PCS, and the present study was carried out to find the incidence and risk factors for PCS in patients undergoing elective laparoscopic cholecystectomy (LC). MATERIALS AND METHODS: The records of 207 patients undergoing elective LC were prospectively maintained for 6 months after surgery. Persistence or appearance of new symptoms after surgery was documented and investigated only when they persisted beyond 30 days of surgery. RESULTS: There were 185 (89.4%) female patients and 22 (10.6%) male patients with a mean age of 44.4 years (age range: 12-79 years). Conversion to open cholecystectomy was done in 18 patients (8.69%), mainly due to adhesions and unclear anatomy. The incidence of symptoms was found to be 13% at 6 months follow-up, showing a reducing trend from 58% in the 1st week after LC; the most common symptom in symptomatic patients was dyspepsia (55.56%). On investigation, a cause for symptoms could be detected in only 0.97%. CONCLUSION: Symptoms are common after LC, but they settle over time. Very few patients have a detectable cause for symptoms after LC, and it is difficult to predict which patients will become symptomatic after LC; in the present series, previous attacks of cholecystitis and presence of co-morbid conditions were the only consistent risk factors for symptoms after LC.

Successful Use of Entecavir in Hepatitis B-associated Membranous Nephropathy.

We report the case of a 7-year-old unimmunized boy who presented with generalized anasarca for the first time, along with nephrotic-range proteinuria, hypoalbuminemia, microscopic hematuria and hypertension. Special investigations revealed ELISA test to be positive for hepatitis B surface antigen (HBsAg) and hepatitis B envelope antigen (HBeAg); hepatitis B viral DNA load (HBV DNA) level (real-time polymerase chain reaction) was 54 360 903 IU/ml. For hepatitis B virus (HBV)-related glomerulopathy, he was started on enalapril and lasilactone, and percutaneous renal biopsy was performed, which revealed membranous nephropathy (MN). A diagnosis of MN secondary to HBV infection contracted via horizontal transmission was made. The patient was started on peginterferon alfa-2b (50 µg/week) for 24 weeks. He failed to attain remission and seroconversion after interferon (IFN) therapy. Then, oral therapy with entecavir was started, and he attained remission as well as seroconversion after 3 months of therapy. He maintained his seroconversion status at his 6-month and the recent 12-month (quantitative HBV DNA level was 373 IU/ml) follow-up visit. Entecavir seems a promising drug for HBV-related glomerulopathy, especially in IFN-resistant cases.

Patterns in antimicrobial susceptibility of Salmonellae isolated at a tertiary care hospital in northern India.

BACKGROUND & OBJECTIVES: Multidrug-resistant Salmonellae have emerged worldwide as also in India. The aim of this study was to study the antimicrobial susceptibility pattern of Salmonella enterica serovars isolated at a tertiary care hospital in northern India. METHODS: A total of 106 S. enterica serovars isolated from various clinical samples from January 2011 to June 2012 were tested for antimicrobial susceptibility by Kirby-Bauer disk diffusion method. The minimum inhibitory concentration (MIC) of ciprofloxacin, chloramphenicol and ceftriaxone was determined both by agar dilution method and E-test for all the isolates. RESULTS: Salmonella Typhi (73.6%) was the predominant isolate followed by S. Paratyphi A (15.1%), S. Typhimurium (9.4%) and S. Enteritidis (1.9%). Of these, 34 (32.1%) were resistant to ciprofloxacin (MIC ≥1 µg/ml by agar dilution) with MIC90 of ciprofloxacin for S. Typhi, S. Paratyphi A and S. Typhimurium being 32, 4 and 1 µg/ml, respectively. All the isolates were sensitive to chloramphenicol (MIC ≤8 µg/ml) and ceftriaxone (MIC ≤1 µg/ml). Disk diffusion method showed high susceptibility rates to cefotaxime (100%), azithromycin (93.4%) and co-trimoxazole (97.2%). Nalidixic acid resistance was seen in 105 (99.1%) isolates. Of the nalidixic acid-resistant strains, only 34 (32.3%) were found to be resistant to ciprofloxacin (MIC ≥1 µg/ml). INTERPRETATION & CONCLUSIONS: This study showed an alarming increase in MIC to quinolones and re-emergence of susceptibility to conventional antibiotics among Salmonellae.

Comparison of efficacy of haloperidol and olanzapine in the treatment of delirium.

OBJECTIVE: Till date, typical antipsychotic haloperidol is the treatment of choice for delirium. But, due to higher side effects with haloperidol, newer atypical antipsychotics (e.g., olanzapine) are increasingly being used in the treatment of delirious patients. The aim of the current research was to study the efficacy and tolerability of haloperidol and olanzapine in the treatment of delirium. MATERIALS AND METHODS: This was an open-label, randomized controlled study carried out in a tertiary care hospital at Chandigarh, India. A total of 100 patients admitted in medicine, surgery, and orthopedic wards and diagnosed as having delirium on Confusion Assessment Method scale were included in the study. Patients were given either haloperidol (1-4 mg/day either orally or by nasogastric tube) or olanzapine (2.5-10 mg/day either orally or by nasogastric tube). Severity of delirium and pattern of symptom improvement were assessed by Memorial Delirium Assessment Scale (MDAS). Extrapyramidal side effects were assessed by Simpson-Angus Scale. RESULTS: There was an improvement in delirium severity in both groups with treatment. Mean daily dose of haloperidol and olanzapine used per patient was 2.10 and 5.49 mg, respectively, and the mean duration of treatment in olanzapine group and haloperidol group was 3.57 days and 3.37 days, respectively. There was no significant difference in the mean duration of treatment in both groups. At the end of study period, the MDAS scores in olanzapine and haloperidol groups were 8.43 and 8.00, respectively, and the difference was not significant statistically with P = 0.765. Five patients experienced drug-related mild side effects. CONCLUSION: Low-dose haloperidol and olanzapine were equally efficacious and well tolerated in delirium.

Evidence-based information leads to reduction in inappropriate drug prescribing: Results from Indian older inpatients.

BACKGROUND: Although several guidelines for appropriate prescribing are available, inappropriate drug prescription remains noteworthy problem among older adults. Indian older patients are also not spare from this issue and existing literature indicates a fair level of inappropriate drug use (IDU). OBJECTIVES: Identified potentially IDU and documented their reduction based on provided evidence-based information and also identified possible predictors of IDU in older inpatients. SETTING: Three years prospective study included 1510 inpatients aged 60 years or over, of both sexes. IDU identified using the Modified Updated AGS Beers Criteria 2012. RESULTS: The patients had an average age of 67.10 ± 0.23 years and on an average were prescribed 9.29 ± 0.11 medications. Using AGS Beers Criteria 2012, total IDU was found to be 21% (n = 325). Of total 287 patients received only one inappropriate drug whereas 38 patients received two or more inappropriate drug(s). According to first list of criteria long acting benzodiazepines, anticholinergics, nitrofurantoin and digoxin were most common IDU. Prescription of theophylline in insomnia followed by aspirin in gastric ulcer and calcium channel blocker in constipation were listed from second list of criteria. 31% reductions in IDU were observed based on evidence-based information regarding each identified inappropriate drugs. CONCLUSIONS: The findings of this study provide evidence that provision of unbiased evidenced based information is the best possible means for improvement of pharmacotherapy in older patients.

Clinico-pathological study of glomerular diseases in patients with significant proteinuria in North India.

Proteinuria is a common manifestation of renal disease. The present study was carried out to analyze the clinic-pathological correlation, assess the value of histopathology and immunofluorescence (IF) as well as note the spectrum of renal diseases in patients with significant proteinuria. Fifty consecutive patients having proteinuria >1 g/24 h underwent ultrasound-guided percutaneous renal biopsy. Clinical information was correlated with the pathological findings and the results were analyzed. The patients were in the age range of 12-79 years. Males (60%) outnumbered females (40%) in all the disease categories except lupus nephritis and IgA nephropathy. The most common clinical presentation was the nephrotic syndrome, seen in 31 cases (62%). Primary glomerular diseases (72%) were more common than secondary glomerular diseases (24%) and tubulointerstitial diseases (4%). Overall, the most common pathological diagnosis was focal and segmental glomerulosclerosis (FSGS) (20%), followed by membranous glomerulonephritis (MGN) (18%). In young patients (age <20 years), minimal change disease (36.4%) was the most common diagnosis while in adults it was MGN (23.5%) and in elderly patients (age >60 years) it was FSGS (60%). IF modified the diagnosis in 12% of the cases. The concordance between clinical diagnosis and pathological diagnosis was 66%. The difference between clinical diagnosis and final diagnosis was statistically significant. Our study further reinforces the knowledge that renal biopsy helps in accurate diagnosis and, thus, helps in appropriate management of the patients. IF provides additional information that can make the morphologic diagnosis considerably more precise.

Prevalence and determinants of use of potentially inappropriate medications in elderly inpatients: a prospective study in a tertiary healthcare setting.

AIM: To determine the prevalence and predictors of potentially inappropriate medications (PIM) prescribing in elderly inpatients using the modified American Geriatrics Society (AGS) updated Beers criteria 2012 and comparing it with the Beers criteria 2003. METHODS: The prospective observational study was carried out between September 2011 and May 2012 at a public teaching hospital. Elderly inpatients aged ≥60 years were included. Multivariate logistic regression analysis was used to determine the predictors of PIM prescribing. RESULTS: The results were based on data of 502 patients; more than half (60%) were males and 66% were aged between 60-69 years with a mean (standard deviation [SD]) of 68 (7) years. Mean (SD) number of diagnoses and medications were three (1) and nine (4), respectively. A total of 81 (16%) patients were prescribed with at least ≥1 PIM according to modified AGS updated Beers criteria 2012, compared with 11% according to Beers criteria 2003. On multivariate regression, important predictors for PIM prescribing were found to be age ≥80 years (odds ratio [OR] 2.46, 95% confidence interval (CI) 1.27-3.12; P = 0.03), male sex (OR 1.35, 95% CI 1.06-1.84; P = 0.03), more than three diagnoses (OR 2.47, 95% CI 1.59-3.39; P = 0.04), ≥6 medications prescribed (OR 1.16, 95% CI 1.02-1.35; P = 0.03) and ≥10 days of hospital stay (OR 1.59, 95% CI 1.09-2.31; P = 0.02). CONCLUSIONS: The results show that PIM prescribing is common among hospitalized elderly Indian patients. It is feasible to reduce this practice through the provision of appropriate unbiased information to healthcare professionals.

Effect of the oral intake of probiotic Pediococcus acidilactici BA28 on Helicobacter pylori causing peptic ulcer in C57BL/6 mice models.

Probiotic lactic acid bacteria are being proposed to cure peptic ulcers by reducing colonization of Helicobacter pylori within the stomach mucosa and by eradicating already established infection. In lieu of that, in vitro inhibitory activity of pediocin-producing probiotic Pediococcus acidilactici BA28 was evaluated against H. pylori by growth inhibition assays. Further, chronic gastritis was first induced in two groups of C57BL/6 mice by orogastric inoculation with H. pylori with polyethylene catheter, and probiotic P. acidilactici BA28 was orally administered to study the eradication and cure of peptic ulcer disease. H. pylori and P. acidilactici BA28 were detected in gastric biopsy and fecal samples of mice, respectively. A probiotic treatment with P. acidilactici BA28, which is able to eliminate H. pylori infection and could reverse peptic ulcer disease, is being suggested as a co-adjustment with conventional antibiotic treatment. The study provided an evidence of controlling peptic ulcer disease, by diet mod

Randomized clinical trial: atorvastatin versus placebo in patients with acute exacerbation of mild to moderate ulcerative colitis.

BACKGROUND: Statins are known to possess pleiotropic anti-inflammatory properties which have been evaluated for clinical benefits in a number of disorders. Studies have demonstrated beneficial actions of statins in experimental models of colitis. Clinical evidence in acute exacerbation of ulcerative colitis (UC) is lacking. AIM: This study aims to assess the efficacy and safety of add-on atorvastatin in mild to moderately severe acute exacerbation of UC. METHODS: Patients with acute exacerbation of UC were randomized to receive either atorvastatin (20 mg) or matching placebo once daily orally for 8 weeks in addition to the standard therapy. Clinical efficacy was assessed by using partial Mayo score (PMS). RESULTS: Previously diagnosed 64 cases of UC presenting with mild to moderately severe acute exacerbation were randomized to receive either atorvastatin of 20 mg or placebo. Mean PMS increased by 1.5 points and decreased by 0.31 points in atorvastatin and placebo groups, respectively, at 8 weeks compared to the baseline values (p = 0.04). Eight (25 %) and 13 (40.6 %) patients attained the primary outcome criteria for clinical improvement in the atorvastatin and placebo arms, respectively (p = 0.18). Fifteen (46.8 %) patients in the atorvastatin group and no patient in the placebo group had ≥2 point increase in PMS after 8 weeks (p < 0.001). CONCLUSION: Atorvastatin therapy in acute exacerbation of UC may not be associated with beneficial effects. Paradoxical increase in disease activity may be seen in some patients. However, these findings need to be substantiated in larger studies.

Drug-drug interactions and their predictors: Results from Indian elderly inpatients.

BACKGROUND: In view of the multiple co-morbidities, the elderly patients receiving drugs are prone to suffer with drug interactions since they receive a greater number of drugs. OBJECTIVE: The study was undertaken to determine the prevalence of drug interactions, as well as their predictors. METHODS: The prescriptions of a total of 1510 inpatients were collected prospectively for 1.5 years from inpatients wards of public tertiary care teaching hospital. All the prescriptions were checked for drug interactions using the Micromedex® Drug-Reax database-2010 and Stockley's Drug Interactions. Regression analyses sought to determine predictors for the drug interaction. RESULTS: The patients, with the average age of 67.2 ±0.2 years, were prescribed an average of 9.15 ±0.03 medications. It was found that out of 1510 prescriptions of inpatients, 126 (8.3%) prescriptions had one or more than one drug interaction. All the identified interactions were severe in nature. The top most interacting drugs were acetylsalicylic acid and anticoagulant (n=59). The second top most interacting drug combination was clopidogrel and proton pump inhibitors (n=51). The most commonly involved drugs in interactions were C (cardiovascular system) and A (alimentary tract and metabolism). Using multivariate binary logistic regression, multiple drugs (Odds Ratio=4.5; 95% Confidence Interval: - 2.38 -9.47) and multiple diagnoses (Odds Ratio=2.6; 95%CI: -1.40 -5.57) were found to be significant predictors for drug interaction. CONCLUSIONS: The results of this study substantiate the occurrence of severe drug interactions among Indian elderly inpatients. In order to provide safer pharmaceutical care, the active involvement of clinical pharmacists is a potential option.

Drug-drug interactions and their predictors: results from Indian elderly inpatients / Interacciones medicamentosas y sus predictores: resultados de pacientes indios hospitalizados

Background: In view of the multiple co-morbidities, the elderly patients receiving drugs are prone to suffer with drug interactions since they receive a greater number of drugs. Objective: The study was undertaken to determine the prevalence of drug interactions, as well as their predictors. Method: The prescriptions of a total of 1510 inpatients were collected prospectively for 1.5 years from inpatients wards of public tertiary care teaching hospital. All the prescriptions were checked for drug interactions using the Micromedex® Drug-Reax database-2010 and Stockley’s Drug Interactions. Regression analyses sought to determine predictors for the drug interaction. Results: The patients, with the average age of 67.2 ±0.2 years, were prescribed an average of 9.15 ±0.03 medications. It was found that out of 1510 prescriptions of inpatients, 126 (8.3%) prescriptions had one or more than one drug interaction. All the identified interactions were severe in nature. The top most interacting drugs were acetylsalicylic acid and anticoagulant (n=59). The second top most interacting drug combination was clopidogrel and proton pump inhibitors (n=51). The most commonly involved drugs in interactions were C (cardiovascular system) and A (alimentary tract and metabolism). Using multivariate binary logistic regression, multiple drugs (Odds Ratio=4.5; 95% Confidence Interval: - 2.38 -9.47) and multiple diagnoses (Odds Ratio=2.6; 95%CI: -1.40 -5.57) were found to be significant predictors for drug interaction. Conclusion: The results of this study substantiate the occurrence of severe drug interactions among Indian elderly inpatients. In order to provide safer pharmaceutical care, the active involvement of clinical pharmacists is a potential option (AU)

Antecedentes: en función de las múltiples comorbilidades, los pacientes ancianos que reciben varios medicamentos son susceptibles de sufrir interacciones medicamentosas ya que reciben gran cantidad de medicamentos. Objetivo: El estudio se realizó para determinar la prevalencia de interacciones medicamentosas, así como sus predictores. Métodos: Se recogió prospectivamente la medicación total de 1510 pacientes hospitalizados de los servicios de internamiento de un hospital terciario universitario. Se revisaron todas las interacciones de los participantes usando Micromedex® Drug-Reax database-2010 y el Stockley’s Drug Interactions. Los análisis de regresión trataron de determinar los predictores de la interacción medicamentosa. Resultados: Los pacientes, con una media de 67,2 ±0.2 años, tenían prescritos de media 9.15 ±0.03 medicamentos. De las 1510 prescripciones de pacientes hospitalizados, 126 (8,3%) tenía una o más interacciones. Todas las interacciones identificadas eran de naturaleza grave. Los medicamentos más interactuante era el ácido acetilsalicílico y los anticoagulantes (n=59). La segunda combinación interactuante más frecuente era clopidogrel y los inhibidores de la bomba de protones (n=51). Los medicamentos más frecuentemente involucrados en interacciones eran del grupo C (aparato cardiovascular) y A (tracto alimentario y metabolismo). Usando la regresión logística binaria, se encontró que ‘varios medicamentos’ (Odds Ratio=4.5; Intervalo de Confianza 95%: - 2.38 -9.47) y ¿varios diagnósticos’ (Odds Ratio=2.6; 95%CI: -1.40 - 5.57) eran predictores significativos de las interacciones medicamentosas. Conclusión: Los resultados de este estudio demuestran la aparición de interacciones medicamentosas graves entre los pacientes indios hospitalizados. Para proporcionar una atención farmacéutica más segura, el empleo de farmacéuticos clínicos es una opción posible (AU)

Successful outcome with conservative management of emphysematous pancreatitis.

OBJECTIVES: Surgery is the mainstay treatment of emphysematous pancreatitis (EP). The aim of the present study was to assess the outcomes of patients with EP managed nonsurgically. METHODS: The patients with EP without organ dysfunction were managed nonsurgically with antibiotic therapy, nutritional support, and if required radiological drainage. The main outcome measure was survival. RESULTS: Nine patients were diagnosed with EP. They had computed tomographic severity index of 10, APACHE score of 11 (±3.4), and Ranson's score of 4.2 (±1.2) in the first 24-48 h. All had monomicrobial infection of the pancreatic necrosis (Escherichia coli in 4/9, Pseudomonas aeruginosa in 3/9, and Klebsiella pneumoniae in 2/9 patients). All these patients were managed with antibiotics as per sensitivity reports (piperacillin-tazobactum in 5/9, imipenem in 3/9, and ciprofloxacin-metronidazole in 1/9 patients) and nutritional support. Seven of nine patients improved within 1 week of starting antibiotics. Two patients required percutaneous catheter drainage in addition. One of the patients had progressive organ dysfunction and was subjected for surgery. All 8/9 patients who were managed conservatively survived (89 % survival). The only patient who underwent surgery expired (11 % mortality). CONCLUSION: In EP without organ dysfunction, a trial of conservative management may be successful.

Safety and efficacy of therapeutic endoscopic interventions in the management of biliary leak.

Endoscopic procedures which reduce the trans-papillary pressure gradient are the treatment of choice for management of biliary leaks. We analyzed the data of 102 patients with biliary leak managed by various endoscopic procedures like endoscopic sphincterotomy (ES), ES with stenting, stenting alone or nasobiliary drainage (NBD) alone; 90 of these patients had developed a leak after cholecystectomy. In the post-cholecystectomy group, cannulation was successful in 79 patients; therapeutic intervention was not possible in 14 of them due to complete transection of common bile duct in 6, and leak proximal to ligature in 8. In the remaining 65 patients, ES with stenting was done in 52, stent alone in 6, ES alone in 5 and NBD alone in 2. All 12 patients in other etiology group were treated with ES plus stenting. The leak closed in a mean of 3 (1-10) days in all patients. Stents were removed after 6-8 weeks. Endoscopic procedures are effective in managing biliary leaks.

Adverse drug reactions & their risk factors among Indian ambulatory elderly patients.

BACKGROUND & OBJECTIVES: Several studies have reported adverse drug events ranging from 5 to 35 per cent in all age group from outpatient setting. However, adverse drug reactions (ADRs) particularly among a large sample of ambulatory elderly patients in India has not been reported. This study has attempted to identify ADRs and assessed their causality, preventability and severity, and also their risk factors in Indian ambulatory elderly patients. METHODS: A 2 year long term prospective study included 4005 ambulatory elderly patients (60 yr or above; either sex) at a public teaching hospital. Suspected ADRs were assessed for causality, preventability and severity using Naranjo's probability scale, modified Schumock and Thornton's criteria, and modified Hartwig's criteria, respectively. RESULTS: Of the total 4005 prescriptions, 406 were identified with ADRs, giving the occurrence of 10 per cent ADRs in elderly. The total number of ADRs was 422 in 406 prescriptions. Type A ADRs accounted for 46 per cent of the total ADRs. Majority of the ADRs (88.6%) were classified as 'probable'. The definitely preventable reactions were 22 per cent. The percentage of moderate reaction was 16 per cent. Only 1.6 per cent ADRs was severe in nature. The most common type of ADR was peripheral oedema. The most commonly offending class of drug was cardiovascular drugs (57.6%). Using logistic regression analysis, the risk factors which contributed to ADRs were age above 80 yr (OR=1.7), prescription of multiple drugs (OR=1.8), longer duration of treatment (OR=2.28) and multiple diagnoses (OR=1.8). INTERPRETATION & CONCLUSIONS: In this study, 10 per cent ambulatory elderly patients were found to have ADRs. This indicates that the elderly patients should be closely monitored for ADRs, to avoid clinically significant harmful consequences. The awareness of risk factors of ADRs would help physicians to identify elderly patients with greater risk of ADRs and, therefore, might benefit from ADRs monitoring and reporting programme.

Neuroendocrine tumors of the ampulla of vater: presentation, pathology and prognosis.

CONTEXT: Neuroendocrine tumors of the pancreatic ampulla are uncommon. The final diagnosis is based on histology, and at times, it may be difficult to diagnose them pre-operatively since they present with a similar clinical picture to adenocarcinomas of this region. OBJECTIVE: To identify neuroendocrine tumors of the ampulla, as well as their presentation and management. DESIGN: A retrospective review of patients treated at a tertiary care institute was performed over a six-year period from 2005 to 2010. PATIENTS: Cases with periampullary cancers were investigated. MAIN OUTCOME MEASURES: The case records were scrutinised for the clinical presentation, management and outcomes. RESULTS: A total of 4 cases (7.7%) of neuroendocrine tumors of the ampulla were identified from 52 patients with periampullary lesions, at a mean age of presentation of 49 years. The common mode of presentation was progressive jaundice (3 of 4 patients); pancreaticoduodenectomy was performed in 3 patients. One patient underwent palliative endoscopic stenting for metastatic disease. On histopathology, 2 of the patients had poorly differentiated (neuro)endocrine carcinoma (high grade), and 2 had well differentiated (neuro)endocrine carcinoma (1 low grade and 1 intermediate). All the tumors stained positively with chromogranin A. The patients who underwent pancreaticoduodenectomy are on regular follow-up and remain free of disease. CONCLUSIONS: Neuroendocrine tumors of the ampulla are distinct entities presenting clinically with jaundice. They stain positive with chromogranin A on histopathology. Pancreaticoduodenectomy should be performed as it is associated with good outcome.

Clinical and needle autopsy correlation evaluation in a tertiary care teaching hospital: a prospective study of 50 cases from the emergency department.

With gradual fall in autopsy all over the world in recent years, the present study aimed to assess the accuracy of clinical diagnosis and efficacy of needle autopsy from the emergency department. Fifty deceased patients, who died in the emergency department during a period of 1 year, were subjected to needle autopsy of the major viscera, using spring-loaded automated biopsy gun, and the findings were correlated with clinical diagnosis. The deceased patients were in the age range of 12 to 80 years (mean [SD], 50.48 [18.41] years). The tissues yielded from various organs were as follows: lungs, 90%; liver, 82%; kidney, 48%; heart, 28%; spleen, 22%; and pancreas, 18%. Before death, 86 clinical diagnoses were recorded, of which 21 (24%) (eg, metabolic encephalopathy, cardiac arrhythmia, diabetic ketoacidosis) were impossible to verify on needle autopsy. A total of 48 new diagnoses, missed by physicians, were revealed by needle autopsy. The most frequently missed diagnoses were liver fatty change (19 patients) and pneumonitis (11 patients). Other frequently missed diagnoses were chronic hepatitis (3 patients) and cancer (2 patients: 1 lung squamous cell carcinoma and 1 lung adenocarcinoma). Major diagnostic errors (Goldman classes I and II) were noted in 16 (32%) of 50 cases. Needle autopsy can be a better alternative in the absence of conventional autopsy.