Corticosteroid-associated lupus pancreatitis: a case series and systematic review of the literature.

BACKGROUND: Acute pancreatitis is an uncommon complication that occurs in 0.85% to 4% of patients with systemic lupus erythematosus (SLE). In some patients, it occurs within days to weeks of starting medium-to-high dose corticosteroids. The authors have used the term 'corticosteroid-associated lupus pancreatitis' for these patients, and they report a case series and perform a systematic review of previously published reports. METHODS: For the purpose of this study, corticosteroid-associated lupus pancreatitis was defined as occurrence of acute pancreatitis in patients with SLE (fulfilling the 1997 ACR), within 3 weeks of starting therapy with medium-to-high dose corticosteroids - either newly initiated or escalated from a lower dose. All patients with SLE admitted in the last 2.5 years in a North Indian university hospital were reviewed, and those with pancreatitis who fulfilled the above criteria were included in the case series. For the systematic review, a PUBMED search using the keywords 'lupus' and 'pancreatitis' was performed, and reports in English were reviewed for an association with corticosteroids. RESULTS: Among 420 admissions of SLE patients, six patients (1.4%) fulfilled criteria for corticosteroid-associated lupus pancreatitis. All were female, with mean age and disease duration of 19.7 ± 3.3 and 3.8 ± 2.5 years respectively. All had active disease and developed acute pancreatitis within 48-72 hours of newly initiating medium-to-high dose corticosteroids (in three patients) or escalating them to medium-high dose (in three patients). After the development of pancreatitis, corticosteroids were continued in all except one patient. In addition, two patients received pulse methylprednisolone, two received pulse cyclophosphamide and one was started on azathioprine. Three patients died during hospitalization, all with severe pancreatitis. On systematic review, among 451 cases of lupus pancreatitis reported, 23 (5%) fulfilled criteria for 'corticosteroid-associated lupus pancreatitis'. A majority of them had pancreatitis within 3 days of starting treatment with medium-to-high dose corticosteroids. The mortality in these patients was 37.5%. CONCLUSION: In a small but substantial proportion of patients with lupus who develop pancreatitis, it occurs within days to weeks of starting medium-to-high dose corticosteroids. Many of these patients continue to receive corticosteroids, and some receive more aggressive immunosuppression. However, they have significant mortality, and further studies are required to identify appropriate treatment in this subgroup of patients.

Aetiology and trends of rates of stillbirth in a tertiary care hospital in the north of India over 10 years: a retrospective study.

OBJECTIVE: To analyse the aetiology of stillbirth and its changing trends in a single tertiary care referral institute of northern India over a 10-year period (2007-2016). DESIGN: Retrospective study. SETTING: Tertiary care hospital in the north of India. SAMPLE: Medical records of all mothers who delivered a stillborn at the institute. METHODS: Data was collected from monthly and annual perinatal audits and causes of stillbirths were classified using Simplified CODAC classification. Annual reduction rate was calculated by linear regression analysis and Cusick test for the changing trends over 9 years. MAIN OUTCOME MEASURES: Of 54 160 births, 3678 babies were stillborn. Over 9 years, the annual stillbirth rate has reduced significantly from 73.6 to 62.0 per 1000 total births with an average annual reduction rate of 1%. The most common causes of stillbirths were hypertensive disorders of pregnancy (27.6%), antepartum haemorrhage (19.5%), and congenital anomalies (9.3%). CONCLUSION: The annual reduction rate (1%) of stillbirth remains low. The aetiology of stillbirths remains unchanged over a 10-year period and hypertensive disorder of pregnancy remains the single most preventable cause of stillbirth. TWEETABLE ABSTRACT: Analysis of stillbirths over a 10-year period in an Indian institute showed a high but declining trend with annual reduction rate of 1%.

Effect of three different storage media on survival of periodontal ligament cells using collagenase-dispase assay.

AIM: To evaluate and compare the efficacy of propolis, egg albumen and Hank's balanced salt solution (HBSS) in maintaining the viability of human periodontal ligament (PDL) cells using a collagenase-dispase assay. METHODOLOGY: Fifty-five freshly extracted human teeth were divided into three experimental (HBSS, egg albumen and propolis) and two control groups. Fifteen teeth per experimental group were stored dry for 30 min and then immersed for 45 min in one of the three experimental media. The positive and negative controls corresponded to 0-min and 1-h dry time, respectively, with five teeth per control group. The teeth were then treated with collagenase II and dispase II for 30 min and labelled with 0.4% trypan blue for determination of viability. The number of viable cells was counted with a haemocytometer and analysed statistically by anova and post hoc Tukey HSD test. RESULTS: Statistical analysis demonstrated there was no significant difference between HBSS, egg albumen and propolis in maintaining cell viability. CONCLUSION: Egg albumen and propolis may be able to maintain PDL cell viability as well as HBSS.

Detection of focal lesions in the clot section with negative bone marrow aspirate and trephine biopsy—A series of 5 cases

Bone marrow aspiration and trephine biopsies are commonly used procedures in clinical practice. The practice of making a clot section by using the leftover blood from the bone marrow aspirate material is not a commonly followed practice across centers. A clot section has the advantage of studying the added material with an increased possibility of detecting focal lesions such as myeloma, lymphoma, granuloma, and metastasis in the bone marrow. Bone marrow aspirate, trephine biopsy, and clot section were compared for the detection of focal lesions in a series of 5 patients, 3 of who presented with a history of fever and 2 were already diagnosed cases of Hodgkin lymphoma. Focal lesions were detected in the 5 cases in the clot section alone, whereas bone marrow aspirate and trephine biopsy did not show any focal lesion. Granulomatous infiltration was detected in 3 patients, and lymphomatous infiltration was detected in 2 patients in the clot section, whereas bone marrow aspirate and trephine biopsy were negative for any focal lesion in all 5 cases. A clot section is particularly useful in the detection of bone marrow lesions with a focal distribution. Hence, it must be studied alongside bone marrow aspirate smears, touch smears, and trephine biopsy to increase the diagnostic yield.

Urinary-exosomal miR-2909: A novel pathognomonic trait of prostate cancer severity.

The global occurrence of prostate cancer with a range of patient outcome has prompted various investigators to explore novel molecular biomarkers that can precisely detect and track this type of cancer severity. Several studies suggest that micro-RNAs have emerged to act as a new largely unexplored class of biomarkers because of their inherent stability, resilience and recruitment into exosomes present in various human body fluids. With this study, we aim to reveal the nature of urinary-exosomal miR-2909 & miR-615-3p recruitment in patients suffering from either prostate cancer (n=90) or bladder cancer (n=60) as compared to that in either prostate disease-control subjects having benign prostate hyperplasia (n=10) or healthy subjects (n=50). Unlike miR-615-3p, the urinary- exosomal miR-2909 recruitment was not only observed conspicuously in subjects having prostate cancer in comparison to bladder cancer but also the extent of urinary exosomal miR-2909 recruitment showed characteristic variation as a function of prostate cancer aggressiveness as compared to that of either urinary- exosomal miR-615-3p level or existing widely recognised serum prostate specifics antigen (PSA) biomarker of this cancer. In summary, we propose that the extent of urinary exosomal miR-2909 recruitment may provide a potential non-invasive candidate diagnostic marker for the detection of prostate cancer and its aggressiveness.

Outcome of urethroplasty after parenteral testosterone in children with distal hypospadias.

INTRODUCTION: Pre-operative testosterone use in hypospadias surgery is known to increase penile dimensions and vascularity, which should facilitate tension-less formation of the urethral tube and tissue healing. However, androgens can have a negative effect on wound healing. There are very few randomized studies on postoperative results after androgen use, and this study attempted to understand the utility of pre-operative testosterone in distal hypospadias. OBJECTIVE: To study the effect of parenteral testosterone in children undergoing single stage urethroplasty for distal hypospadias, especially the occurrence of urethrocutaneous fistula and wound dehiscence. DESIGN: Patients were prospectively enrolled and randomized into two groups: Group 1 (control group) and Group 2 (receiving three injections of pre-operative intramuscular testosterone enanthate (2 mg/kg) at 1 monthly intervals; they were further subdivided into those operated 1 month (Group 2A) or 3 months (Group 2B) later. Patients with micropenis, previous testosterone use or any surgical intervention were excluded. Preputial skin was studied with hematoxylin and eosin (H&E) staining and CD31 immunohistochemistry. Patients were followed up for at least 18 months. RESULTS: Ninety four patients underwent urethroplasty over a 3.5-year period. Penile dimensions increased significantly after testosterone use (Summary table). On H&E staining, proliferating blood vessels and increased lymphocytic infiltrates were significantly increased in Group 2B. Group 2 patients tended to have more postoperative edema and inflammation. Although urethrocutaneous fistula rates were similar in Group 1 (n = 7) and Group 2 (n = 5) (P = 0.438), wound dehiscence occurred only in Group 2 (P = 0.01). DISCUSSION: The total number of patients in this study was small and this was a drawback. Although, several factors played a role in wound healing, the overall higher complication rate, especially wound dehiscence in Group 2, pointed to a higher incidence of inflammatory reaction and healing complication rates with testosterone use. CONCLUSION: Testosterone should be used judiciously in distal hypospadias. While tissue availability significantly increased, there was an increase in inflammatory reaction and edema, which increased the risk of wound dehiscence in cases of precocious surgery.

Are the results from the 2014 UK national survey on the management of diabetic ketoacidosis applicable to individual centres?

BACKGROUND: In 2013 the Joint British Diabetes Societies published an update to their 2010 guideline on the management of diabetic ketoacidosis (DKA). In 2014 a national survey was conducted to assess the management of DKA across the UK using the JBDS or local guidelines. Hospitals were invited to submit data on 5 people presenting with DKA. These data were published in 2016. However, whether those national results were applicable to individual hospitals remains unknown. AIM: To assess the management of people presenting with DKA at a single hospital and compare the results with the national dataset. METHODS: Using the identical data collection tool as used in the national survey we collected information on 40 subjects (a total of 52 admissions) admitted with DKA between April 2014 and July 2015. RESULTS: The data collected locally were very similar to those found in the national dataset. The management of DKA was best during the first few hours after admission, then biochemical and physical monitoring frequency decreased. The number of people who developed hypokalaemia and hypoglycaemia were very similar to the national data. Rates of biochemical improvement were slightly better locally. CONCLUSIONS: The data from the national DKA survey, even though based on a maximum of 5 people per hospital from across the UK are applicable at a hospital level.

Elevated red cell volume in North Indian students.

In a survey for beta-thalassemia carrier status among students in the State of Punjab in India, a surprisingly large number were found to have an elevated red cell volume over 99 fl. The finding was predominantly but not exclusively in females. Similar student surveys from other states showed less macrocytosis. Follow-up tests in a group of affected students were carried out. Volunteers were asked to modify their diet then after six months they were provided with oral vitamin B12. The resulting changes are reported and the implications of the probable vitamin B12 and or folic acid deficiency are considered.

Second primary malignancy: A retrospective analysis report from a tertiary cancer center of North India.

AIM OF STUDY: We analyzed the data of second primary malignancy (SPM) from one of the tertiary cancer centers of North India, and the basic aim was to retrieve incidence, prognosis, and outcomes. MATERIALS AND METHODS: A retrospective study was conducted in the Department of Radiation Oncology in a tertiary cancer center between January 1, 2011, and December 31, 2015. A total of 6000 cases of cancer were analyzed, out of which cases who presented with histological proven synchronous SPM were included in this study. RESULTS: The present study showed three cases (8.1%) of SPM who are attributed to field carcinogenesis. There were five cases in which metachronous malignancy develops in the previous radiation therapy field. There is 26% of synchronous malignancy as compared to 74% of metachronous malignancy. In the present study, most diagnosed synchronous malignancies were carcinoma breast, while in metachronous malignancies, carcinoma breast and gynecological cancers were most common. CONCLUSIONS: SPMs are not very rare. Hence, pretreatment and follow-up evaluation should be meticulous to rule out SPMs.

Outpatient oral anticoagulant management--an audit of 82 patients.

OBJECTIVE: Use of oral anticoagulants for thrombotic diseases has been increasing steadily over the years. Management practices however, are far from uniform. We conducted a retrospective audit among outpatients on oral anticoagulant therapy to assess treatment practices and overall control of anticoagulation. METHODS: Case records of 82 patients who were on anticoagulant therapy for a minimum duration of three months were reviewed. Information on pre-therapeutic assessment of patients, therapeutic control and complications seen during the course of treatment was recorded. RESULTS: Case notes of 43 males and 39 females with a mean age of 47.5 +/- 14.6 years, on oral anticoagulant treatment were evaluated. Treatment duration ranged from 3 months to 7 years for a total of 258.7 patient treatment years. Pre-therapeutic assessment of patients was inadequate with only baseline hematological and renal parameters available for most patients. Of a total of 1631 prothrombin time ratios and International Normalized Ratios recorded, only 17.8% were in the therapeutic range with 73% being sub-therapeutic. Sixteen (19.5%) patients had treatment related complications. The number of thrombotic and hemorrhagic events per 100 patient treatment years was 3.4 and 2.7 respectively. CONCLUSIONS: Pre-therapeutic assessment of patients was inadequate. The overall therapeutic control was poor with patients in a state of underanticoagulation for most period of anticoagulant treatment. The complication rate was also unacceptably high. There is a need to reassess management practices of patients on long term oral anticoagulation with strict adherence to standard accepted guidelines to make this therapy more effective and safer for patients.

An outbreak of dengue fever in periurban slums of Chandigarh, India, with special reference to entomological and climatic factors.

BACKGROUND: Dengue viral infection is one of the most important public health problem in tropical countries. AIM: An outbreak of dengue fever was investigated in a periurban slum area of Chandigarh, India, during September to December, 2002. MATERIALS AND METHODS: Blood samples from 218 patients and 30 apparently healthy contacts were tested for dengue-specific immunoglobulin M (IgM) and IgG antibodies including 80 acute samples collected within 5 days of illness were subjected for virus isolation in newborn mice. The average temperature, rainfall, and humidity of the epidemic year were compared with the number of dengue cases. STATISTICAL ANALYSIS: statistical significance was found out using c2-test. RESULTS: A total of 76 cases were positive by either dengue IgM capture assay (n = 57) or virus isolation (n = 17) or both (n = 2). Fifteen of nineteen viral isolates subjected for typing by type-specific multiplex reverse transcription-polymerase chain reaction were found to be of dengue virus. High rainfall and humidity with the temperature range from 21 degrees C to 33 degrees C during the months of August and September might have favored the breeding of mosquitoes, thus leading to an increase in the number of dengue cases in October and November, 2002. CONCLUSION: The present outbreak thus emphasizes the need for continuous sero epidemiological and entomological surveillance for the timely implementation of effective dengue control programme.

Changing trend of SSPE over a period of ten years.

Sub acute sclerosing pan-encephalitis (SSPE) is a slowly progressive inflammatory disorder of the central nervous system. A decline in frequency has been noticed in most of the developed countries, whereas it continues to be high in developing countries. Though a number of studies have been carried out, the exact trend of SSPE is still not clear. Hence the present study was carried out to analyze the trend of SSPE over the past ten years in and around Chandigarh. A total of 205 patients with clinical features suggestive of SSPE were enrolled for the study during Jan'92 to Dec. 2001. Measles specific antibodies were detected in blood and CSF by HAI method. 114 patients were found to be positive for measles specific HAI antibody with a male preponderance. The number of SSPE cases were found to be more during the period 1992-95 in comparison to the next 6 years (p < 0.05). The high incidence of SSPE in our country could be due to improper vaccine coverage, poor cold chain maintenance or circulation of atypical measles virus strain.

Spurious rise in the automated platelet count because of bacteria.

The era of automation in haematology, although improving the accuracy and precision of results, has also introduced the laboratory haematologist to a vast array of spurious parameters. The identification of these results is important so that inappropriate management decisions are avoided. The case presented here illustrates a spuriously raised automated platelet count resulting from bacterial overgrowth in the blood sample.

An audit of splenectomies in a teaching hospital in North India. Are postsplenectomy guidelines being complied with?

AIMS: Patients with an absent or dysfunctional spleen are at risk of infection by encapsulated and other bacteria. Overwhelming postsplenectomy infection (OPSI) causes most concern because it can result in significant mortality. A retrospective review of splenectomised patients in a tertiary care setting over an eight year period was carried out to determine whether current postsplenectomy guidelines were being followed. METHODS: The cases were identified from the medical records and pathology files and data such as the reason for splenectomy, the preventive measures taken regarding vaccination, and antibiotic prophylaxis, together with their documentation in the discharge notes were assessed. RESULTS: Fifty six patients were studied. Trauma, both blunt and penetrating, was the most common reason for splenectomy. Thirty six patients received pneumococcal vaccination, with 20 patients having no mention of vaccination in their case notes. The discharge notes of 50 patients mentioned their splenectomised status; however, documentation of vaccination details in the discharge summary was poor, with only three patients having the relevant information recorded. Documentation of the need for future vaccination and precautions required in the asplenic condition was also lacking. Nine patients had postsplenectomy complications, although there were no cases of OPSI. CONCLUSIONS: Adherence to standard guidelines for the management of splenectomised patients was unsatisfactory. There is a need for an improvement of the vaccination rate and careful documentation of this important health risk in the discharge summaries. Maintenance of a splenectomy registry could aid in optimising the management of these patients.

Evaluation of E test for susceptibility testing of Mycobacterium tuberculosis to primary anti tubercular drugs.

BACKGROUND & OBJECTIVES: Antimicrobial susceptibility tests for tuberculosis take weeks and delayed therapy can lead to an increase in disease incidence. The E test is a new concept for minimum inhibitory concentrations (MIC) determinations for antimicrobial agents that is based on a predefined antibiotic gradient on a plastic strip calibrated with a continuous logarithmic MIC scale covering 15 two-fold dilutions. The present study was undertaken to evaluate E test strips for susceptibility testing of Mycobacterium tuberculosis. METHODS: Twenty five clinical isolates of M. tuberculosis were tested for the four first line antitubercular drugs by E test and were compared with standard proportion method. The inoculum turbidity was adjusted to McFarland 3.0 standard and agar plates (Middle brook 7H11 agar) were inoculated and preincubated (37 degrees C in 7-10% CO2) for 24 h after which time, the E test strips were placed on the agar surface which were incubated under same conditions. The MIC was interpreted as the point at which the ellipse intersected the 'E test' strip as described in E test technical guide. RESULTS: Of the 25 strains, susceptibility as determined by both methods for isoniazid (INH), rifampin, ethambutol and streptomycin was found in 22 (88%), 20 (80%), 24 (96%) and 18 (72%) strains respectively. Agreement between E test and proportion method was 96 per cent for INH, 92 per cent for rifampin and 100 per cent for ethambutol and streptomycin each. However, sensitivity could be predicted after 7-10 days by E test and exact MIC could also be determined. INTERPRETATION & CONCLUSIONS: E test method was found to be rapid, accurate, reliable and easy to perform. It can be employed for routine susceptibility testing for antitubercular drugs.

Aldosterone-producing adrenocortical adenoma in childhood: a case report.

Aldosterone-producing adrenal tumor is an exceptional cause of hypertension in childhood. The authors describe an 11-year-old girl with hypertension and lower limb weakness who had hyperaldosteronism and left adrenocortical adenoma.

Antenatal hydronephrosis: ureteral polyp causing ureteropelvic junction obstruction.

We describe a rare case of ureteropelvic junction obstruction in a three and a half-year-old boy due to a benign ureteric polyp. This case is being reported due to the rarity of benign neoplasms of the ureter in infants and children and also because the child had been diagnosed antenatally as having hydronephrosis.

The effect of unilateral intercostal nerve transfer upon lung function.

Intercostal nerve transfer is a well-established technique in the treatment of some severe brachial plexus lesions in adults. There is, however, concern that in the presence of an ipsilateral phrenic nerve palsy it may lead to a significant compromise of respiratory function. 20 patients having intercostal nerve transfers had their lung function assessed pre-operatively and 6 weeks post-operatively. The patients were subsequently questioned about symptoms of respiratory dysfunction. There was no evidence that intercostal nerve transfer leads to a significant reduction in respiratory function in adults. It therefore appears safe to perform intercostal nerve transfers in adults following brachial plexus injuries even in the presence of an ipsilateral phrenic nerve palsy.