Diagnostic accuracy of Xpert MTB/RIF ultra for detection of Mycobacterium tuberculosis in children: a prospective cohort study.

The Xpert MTB/RIF Ultra is a recent advancement in molecular diagnostics of tuberculosis (TB) with higher sensitivity compared to its predecessor, the Xpert MTB/RIF assay. Prospective studies evaluating the performance of Xpert MTB/RIF Ultra in children with suspected TB are lacking. In this study, we evaluated the Xpert MTB/RIF Ultra for detection of Mycobacterium tuberculosis in samples from 156 children, of which one was excluded from the analysis. Of the remaining 155 samples, 6·5% (10/155), 21·3% (33/155), 20% (31/155) and 21·9% (34/155) were positive by smear examination, MGIT culture, Xpert MTB/RIF and Xpert MTB/RIF Ultra, respectively. The Xpert MTB/RIF and Xpert MTB/RIF Ultra had a similar overall sensitivity of 81·8% (95% CI: 64·5-93) and 84·8% (95% CI: 68·1-94·9), respectively. In suspected pediatric TB patients, the Xpert MTB/RIF Ultra had higher sensitivity compared to the Xpert MTB/RIF (72·7 vs 63·6). The AUC (area under the curve) of 0·905 for the Xpert MTB/RIF and 0·893 for the Xpert MTB/RIF Ultra indicate similar and good overall performance. Both Xpert assays were found to be equally efficient, however Xpert MTB/RIF Ultra showed better detection rate in suspected TB cases.

C-ARM Guided Angiogram/Angioplasty for Selected Failed Arterio Venous Fistula. A Report of a Procedure at University Hospital of Nepal.

End Stage Renal Disease is a last stage of Chronic Kidney Disease which is characterized by Glomerular Filtration rate of less than 15 ml/min/1.73 m2 . Hemodialysis is the most commonly used modality for treatment of Chronic Kidney disease. Among the access for hemodialysis arteriovenous fistula is the most common modality. However most common problems of fistula are significant stenosis of more than 50% which is characterized by limb swelling, pigmentation, tortuous veins, and difficulty maintaining flow during dialysis from AV fistula. These can be managed either by minimal intervention or with surgical intervention. Very few hospitals in Nepal and other countries have an angiographic suite to perform minimal intervention include angiogram with angioplasty. So in this case we try to address the use of C-Arm to perform angiogram or fistulogram and even angioplasty for the management of significant stenosis or complications of arteriovenous fistula.

Surveillance pouchoscopy for dysplasia: Cleveland Clinic Ileoanal Pouch Anastomosis Database.

BACKGROUND: No formal guidelines exist for surveillance pouchoscopy following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. METHODS: All adults who had previously had IPAA for ulcerative colitis, and underwent a pouchoscopy between 1 January 2010 and 1 January 2020, were included. RESULTS: A total of 9398 pouchoscopy procedures were performed in 3672 patients. The majority of the examinations were diagnostic (8082, 86·0 per cent; 3260 patients) and the remainder were for routine surveillance (1316, 14·0 per cent; 412 patients). Thirteen patients (0·14 per cent of procedures) were found to have biopsy-proven neoplasia at the time of pouchoscopy; seven had low-grade dysplasia (LGD) (0·07 per cent; all located in the anal transition zone), none had high-grade dysplasia (HGD) and six (0·06 per cent) had invasive adenocarcinoma (4 in anal transition zone and 6 in pouch). Of the six patients with adenocarcinoma, four had neoplasia at the time of proctocolectomy (2 adenocarcinoma, 1 LGD, 1 HGD); all six were symptomatic with anal bleeding or pelvic pain at the time of pouchoscopy, had a negative surveillance pouchoscopy examination within 2 years of diagnosis of adenocarcinoma, had palpable masses on digital rectal examination, and had visible lesions at the time of pouchoscopy. CONCLUSION: Surveillance pouchoscopy is not recommended in asymptomatic patients because significant neoplasia following IPAA for ulcerative colitis is rare.

ANTECEDENTES: No existen unas recomendaciones formales para vigilancia endoscópica en pacientes a los que se les ha realizado un reservorio ileoanal (ileal pouch anal anastomosis, IPAA) por una colitis ulcerosa (ulcerative colitis, UC). MÉTODOS: Se incluyeron todos los pacientes adultos a los que se les había realizado previamente un IPAA por UC y se sometieron a una endoscopia del reservorio. RESULTADOS: Se realizaron un total de 9.398 procedimientos endoscópicos en 3.672 pacientes entre el 1/1/2010 y el 1/1/2020. La mayoría de las exploraciones fueron diagnósticas (n = 8.082; 86%; 3.260 pacientes) y el resto fueron de seguimiento (n = 1.316; 14%; 412 pacientes). Se descubrió que 13 pacientes tenían una neoplasia demostrada por biopsia (0,14%) en el momento de la endoscopia; siete pacientes tenían displasia de bajo grado (low-grade displasia, LGD) (0,074%; localizada en todos los casos en la zona de transición anal), ninguno tenía displasia de alto grado (high-grade displasia, HGD) y seis (0,064%) tenían un adenocarcinoma invasivo (cuatro en la zona de transición anal) y dos en el reservorio). De los seis pacientes con adenocarcinoma, 4 tenían neoplasia en el momento de la proctocolectomía (2 adenocarcinoma, uno LGD, uno HGD). Todos estos pacientes tenían síntomas de hemorragia anal o dolor pélvico en el momento de la endoscopia, se les había practicado una endoscopia previa reciente del reservorio en los dos años anteriores, presentaban una masa palpable en la exploración digital rectal, así como lesiones visibles en la endoscopia del reservorio. CONCLUSIÓN: La vigilancia endoscópica del reservorio no se recomienda en pacientes asintomáticos porque es raro que aparezca una neoplasia después del IPAA por UC.

Immunogenicity, Safety, and Tolerability of Live Attenuated VaricellaZoster Virus Vaccine (ZOSTAVAX™) in Healthy Adults in India.

BACKGROUND: Herpes zoster (HZ) is caused by varicella-zoster virus ( VZV ) reactivation. In the United States, Zoster vaccine (ZOSTAVAX) is indicated for HZ prevention in patients ≥50 years. AIMS: To evaluate the immunogenicity, safety, and tolerability of ZOSTAVAX in healthy Indian subjects, to support its registration in India. METHODS: This open-label, single-arm study was conducted at 10 sites in India. Healthy Indians (≥50 years) received a single ZOSTAVAX dose. Immunogenicity was assessed by VZV-specific antibody titer using gpELISA assay. VZV-specific antibody geometric mean titers (GMT; Day 1 pre-vaccination, Week 6 post-vaccination) and geometric mean fold-rise (GMFR; Week 6 post-vaccination) were assessed. Safety was evaluated by the incidence of adverse events (AEs) and serious adverse events (SAEs) within 42 days of vaccination. Two-sided 95% confidence intervals (CIs) were evaluated using t-distribution with natural log-transformed values. RESULTS: Of the 250 subjects (mean age, 58.6 years) enrolled and vaccinated, 244 subjects completed the 6-week follow-up. Overall, subjects in the per-protocol population had GMT of 149.8 gpELISA units/mL (n=250; 95% CI: 132.6, 169.2) at Day 1 pre-vaccination, and 410.8 gpELISA units/mL (n=243; 95% CI: 373.0, 452.6) at Week 6 post-vaccination. GMFR of VZV-specific antibody from Day 1 pre-vaccination to Week 6 post-vaccination was 2.8 (95% CI: 2.5, 3.1). Overall, 67 subjects (26.8%) experienced AEs, with 48 (19.2%) reporting injection-site AEs and 38 (15.2%) reporting non-injection-site AEs. SAE-abdominal pain and bronchitis-was reported in one (0.4%) patient each. There was one death, which was unrelated to the vaccine. LIMITATIONS: Since ZOSTAVAX introduces a new live attenuated virus, clinical reactivation of ZOSTAVAX virus and wild-type VZV will need to be differentiated. CONCLUSIONS: In healthy Indians ≥50 years, ZOSTAVAX was well tolerated and resulted in expected VZV-specific antibody titer levels at 6 weeks post-vaccination.

Efficacy and safety comparison of combination of 0.04% tretinoin microspheres plus 1% clindamycin versus their monotherapy in patients with acne vulgaris: a phase 3, randomized, double-blind study.

BACKGROUND AND OBJECTIVES: There is an unmet need for topical treatments with good tolerability in management of acne vulgaris. The present study aimed to evaluate efficacy and safety of a novel tretinoin (microsphere, 0.04%) formulation in combination with clindamycin (1%) gel for treatment of acne vulgaris. MATERIALS AND METHODS: This phase 3 randomized, double-blind study included patients with moderate-to-severe acne. Patients were treated with tretinoin (microsphere, 0.04%) + clindamycin (1%) or one of the monotherapies (tretinoin, 0.025%; clindamycin, 1%). Key endpoints included percent change in lesion counts, and improvement in Investigator's Static Global Assessment (ISGA) score. RESULTS: 750 patients were randomized (combination, n = 300; tretinoin and clindamycin, each n = 150). At week 12, reductions in inflammatory (77%), non-inflammatory (71%) and total lesions (73%) were significantly greater with combination treatment versus either monotherapy (p < .03). Proportion of patients rated 'clear' or 'almost clear' with ≥2-grade ISGA improvement was higher with combination (46%) versus monotherapies (p < .02). Adverse events occurred in 20 patients, most were mild-moderate; no deaths or serious adverse events were reported. The discontinuation rates due to adverse events with combination therapy were low (≤1%). CONCLUSION: The once-daily, microsphere-based formulation was generally tolerable with a positive impact on therapeutic outcomes and patients' compliance. CLINICALTRIAL REGISTRATION NO.: CTRI/2014/08/004830.

Primary omental gangrene mimicking appendicular perforation peritonitis-A case report.

INTRODUCTION: Primary omental torsion is a rare cause of acute abdomen in adults and presents with variable signs and symptoms. Establishing a preoperative diagnosis may be difficult in the emergency setting. It is rarely diagnosed preoperatively as it mimics common surgical emergencies such as acute appendicitis, appendicular perforation, acute cholecystitis and perforated peptic ulcers and can lead to the clinical deterioration of patient if missed PRESENTATION OF CASE: A 47 years old male was taken to the operating room with a diagnosis of appendicular perforation peritonitis and during surgery was found to have a primary omental gangrene with pyoperitoneum, for which omentectomy and peritoneal lavage was performed. DISCUSSION: Torsion of the omentum is a condition in which the organ twists on its long axis to such an extent that its vascularity is compromised. Omental torsion can be primary (idiopathic) or secondary, depending on an underlying cause. Primary omental torsion was first described by Eitel in 1899. However, very few cases have been reported. Our case was a rare case presenting with omental gangrene with pyoperitoneum mimicking appendicular perforation peritonitis. CONCLUSION: Primary omental torsion is a rare diagnosis. A high index of clinical suspicion is required for a preoperative diagnosis. In doubtful cases a CT scan may be helpful. Surgical excision of the omentum remains the treatment of choice; however, conservative management may be attempted in an uncomplicated omental torsion.

Perception of Palliative Care among Medical Students in a Teaching Hospital.

INTRODUCTION: Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness. Palliative care must be a part of every medical personnel's practice. But still medical education curriculums have not included palliative care in its syllabus, sufficiently due to which most of the health professional are not aware about this specialty. The purpose of this study is to find out the perception of the medical students in palliative care in a teaching hospital. METHODS: A descriptive study was done among 270 undergraduate medical students studying in Institute of Medicine using a self structured pretested questionnaire. Data was entered in Microsoft Excel and analyzed by using SPSS 21. RESULTS: Of the total 270 undergraduate medical students only 152 has heard the word "palliative care". Only 84 students know, palliative care can be provided early in the life threatening illness. Total 80 students know it doesn't intend to postpone and hasten death. Though only 49 students didn't know PC is not included in our curriculum, 227 are interested to learn about it if given any opportunity. CONCLUSIONS: The perception of palliative care medicine is low in first couple of year of medical study. It is increased in clinically exposed students but is surprisingly more in fourth year than final year undergraduate medical students. However, it should be included in undergraduate medical study.

Inhibitors of phenylethanolamine N-methyltransferase and epinephrine biosynthesis. 1. Chloro-substituted 1,2,3,4-tetrahydroisoquinolines.

In a search for inhibitors of epinephrine biosynthesis as potential therapeutic agents, a series of 13 ring-chlorinated 1,2,3,4-tetrahydroisoquinolines was prepared. These compounds were tested initially for their ability to inhibit rabbit adrenal phenylethanolamine N-methyltransferase (PNMT) in vitro. Enzyme-inhibitor dissociation constants, determined for the six most potent members of the series, indicated the following order of decreasing potency: 7,8-Cl2 greater than 6,7,8-Cl3 greater than 7-Cl approximately 5,6,7,8-Cl4 greater than 5,7,8-Cl3. These compounds were subsequently examined for PNMT-inhibiting activity in intact rats and mice. 7,8-Dichloro-1,2,3,4-tetrahydroisoquinoline (13, SK&F 64139) was the most potent member of the series both in vitro and in vivo and is currently undergoing clinical investigation.

Proteinuria following transplantation. Correlation with histopathology and outcome.

A review of 693 renal transplant recipients revealed 77 (11%) in whom persistent, heavy proteinuria (greater than 2 g/24 hr) developed. Renal histology was available in all 77 patients. Twenty-one patients had received kidneys from living-related donors, the remaining 56 from cadaveric donors. The cause of proteinuria in these 77 patients was as follows: transplant glomerulopathy (30), allograft glomerulonephritis (22), chronic rejection (21), renal vein thrombosis (2), diabetic glomerulosclerosis (1), and hypertensive nephrosclerosis (1). Of the 22 patients who developed glomerulonephritis in the transplanted kidney, 6 had recurrent disease (3--membranous glomerulopathy, 2--focal sclerosis and hyalinosis, 1--membranoproliferative glomerulonephritis); 6 developed de novo glomerulonephritis; and in 10 the type of glomerulonephritis could not be classified as recurrent or as de novo because of lack of characterization of the original kidney disease. Renal vein thrombosis occurred in association with other lesions in an additional 5 cases (3--chronic rejection; 2--membranous glomerulopathy). In follow-up only 23.4% (18 of 77) of the patients maintained prolonged graft function; the majority of grafts being lost within one year of the development of persistent, heavy proteinuria. Of the 18 patients who retained their grafts, 8 had glomerulonephritis, 5 transplant glomerulopathy, and 5 chronic rejection. This study confirms the poor prognosis that has been reported with the development of nephrotic-range proteinuria in renal allograft recipients.

Sequential respiratory, psychologic, and immunologic studies in relation to methyl isocyanate exposure over two years with model development.

Of 113 methyl isocyanate (MIC)-exposed subjects studied initially at Bhopal, India, 79, 56, 68, and 87 were followed with clinical, lung function, radiographic, and immunologic tests at 3, 6, 12, 18, and 24 months. Though our cohort consisted of subjects at all ages showing a varied severity of initial illness, fewer females and young subjects were seen. Initially all had eye problems, but dominant symptoms were exertional dyspnea, cough, chest pain, sputum, and muscle weakness. A large number showed persistent depression mixed with anxiety, with disturbances of personality parameters. The early radiographic changes were lung edema, overinflation, enlarged heart, pleural scars, and consolidation. The persistent changes seen were interstitial deposits. Lung functions showed mainly restrictive changes with small airway obstruction; there was impairment of oxygen exchange. Oxygen exchange improved at 3-6 months, and spirometry improved at 12 months, only to decline later. The expiratory flow rates pertaining to large and medium airway function improved, but those for small airways remained low. There were changes of alveolitis in bronchoalveolar lavage fluid on fiber optic bronchoscopy, and in 11 cases positive MIC-specific antibodies to IgM, IgG, and IgE were demonstrated. On follow up, only 48% of the subjects were clinically stable, while 50% showed fluctuations. Thirty-two percent of the subjects had lung function fluctuations. Detailed sequential behavior over 2-4 years was predicted for dyspnea, forced vital capacity, maximum expiratory flow rate (0.25-0.75), peak expiratory flow rate, VO2, and depression score. A model for clinical behavior explained a total variance of 52.4% by using the factors of cough, PCO2 and X-ray zones in addition to above five parameters. The behavior of the railway colony group (1640 patients) revealed a similar pattern of illness. When this observed pattern of changes was transferred to the affected Bhopal city sections (with an equitable age-sex distribution), our model results were again validated. Thus the picture of MIC-induced disease seems similar despite the differences for age-sex and initial severity of illness in our cohort and in the population of Bhopal city as predicted by our model.

Tachyarrhythmias in old age.

The electrocardiograms of 1,171 patients above the age of 65 in a predominantly geriatric institution were reviewed to determine the incidence of tachyarrhythmias. Data on the overall incidence and the individual types of arrhythmias are presented. Atrial fibrillation was the most common arrhythmia observed, followed by atrial flutter and supraventricular tachycardia. Atrial fibrillation often was associated with other evidence of myocardial damage. The significance of sinus bradycardia and grade I A-V block in the pathogenesis of atrial fibrillation and the significance of the tachyarrhythmias are discussed.

Combined analysis of expression of c-erbB-2, Ki-67 antigen, and tenascin provides a better prognostic indicator of carcinoma of the papilla of Vater.

Expression of the molecular biological factors (MBFs) c-erbB-2, Ki-67 antigen, and tenascin (TN) was assessed immunohistochemically in specimens from patients who had undergone surgery for carcinoma of the papilla of Vater. The MBFs were then analyzed by histological factors (v, d, panc, n, Stage), which have been demonstrated to be outcome predictors, and by patient outcome. None of the MBFs showed any significant correlation with the histological factors. There were significant differences (p < 0.05) in the expression of c-erbB-2, Ki-67 antigen, and TN between patients who survived >5 years and those who survived <5 years. The patients with greater expression of c-erbB-2, Ki-67 antigen, and TN had a poor prognosis, whereas those with less expression had a good prognosis. They were therefore considered independent predictors of outcome for carcinoma of the papilla of Vater. Combined analysis of both histological factors and MBFs was also performed, with the result that the combined analysis of MBFs yielded a better prediction of outcome in carcinoma of the papilla of Vater than analysis of either one histological factor or MBF.

ICMR Task Force Study on hormonal contraception. Biological activity of ethinyl estradiol present in the breast milk.

A study was conducted to compare the biological activity of the estrogenic component of the endogenous steroids in breast milk samples collected during various phases of lactation with those milk samples collected from women who were on estrogen therapy. The estrogenic biological activity in the milk sample was assessed by the immature mouse uterine weight gain assay. Milk samples collected during postpartum period from six different study groups, viz., control colostrum of 1-3 days and 4-6 days, transitional milk (10-20 days) and mature milk (1-3 months) were compared with colostrum and mature milk of women treated with Lynoral (ethinyl estradiol 0.1 mg) three times a day for three days. Estrogenic activity was observed only in animals injected with milk extracts of colostrum samples from both control and Lynoral-treated women; however, they were not significantly different from each other. Therefore it is not the exogenous estrogens, but the endogenous estrogen present in large quantities in the colostrum that is responsible for the biological activity.

Analysis of synaptic quantal depolarizations in smooth muscle using the wavelet transform.

The time-frequency characteristics of synaptic potentials contain valuable information about the process of neurotransmission between nerves and their target organs. For example, at the synapse between autonomic nerves and smooth muscle, two central issues of neurophysiology, i.e., 1) the probability of neurotransmitter release and 2) the quantal behavior of transmission can be deduced from analysis of the rising phases of evoked excitatory junction potentials (eEJP's) recorded from smooth muscle. eEJP rising phases are marked by prominent inflexions, which reflect these features of neuronal activity. Since these inflexions contain time-varying frequency information, we have applied recent techniques of time-frequency analysis based upon wavelet transforms to eEJP's recorded from the guinea-pig vas deferens in vitro. We find that these techniques allow accurate and convenient characterization of neuronal release sites, and that their probability of release falls between 0.001-0.004. We have also analyzed eEJP's recorded in the presence of the chemical 1-heptanol, which reveals quantal depolarizations. These results have helped clarify the nature of the quantal depolarizations that underly eEJP's. The present method offers significant advantages over those previously employed for these tasks, and holds promise as a novel approach to the analysis of synaptic potentials.

Mycoplasma hominis infections in female genital tract & use of immunofluorescence for antibody detection.

A total of 325 women with genital tract infection and 108 healthy controls were screened for the presence of mycoplasmas. Of these, 325 patients, mycoplasmas were recovered in 186. Thirty five isolates were M. hominis and 151 isolates of Ureaplasma urealyticum. The fluorescent-antibody technique (FAT) has been employed for the rapid identification of mycoplasma colonies growing on agar plates. The method was found to be rapid for detection of M. hominis growing on primary isolation plates. The antibody titre of patient's serum was also detected by FAT. Patients' sera were diluted four fold from 1:4 to 1:256 dilutions. In 7 patients fluorescence was seen with 1:16 serum dilution, in 18 with 1:64 dilution and in 3 with 1:256. The immunofluorescence test gave a sensitivity of 96.66 per cent, specificity of 95.0 per cent, with percentage of false negativity and false positivity being 3.45 and 5.0 per cent respectively.

Detection of Chlamydia trachomatis antigen & Toxoplasma gondii (IgM) & Mycoplasma hominis (IgG) antibodies by ELISA in women with bad obstetric history.

A total of 365 non pregnant women with bad obstetrics history (BOH) were studied with a control group of 100 women who had delivered full term clinically normal infants. The presence of C. trachomatis antigen and T. gondii (IgM) and M. hominis (IgG) antibodies was assessed by ELISA test. C. trachomatis antigen was detected in 28.2 per cent of women with BOH whereas T. gondii and M. hominis specific antibodies were found in 43.83 and 27.1 per cent respectively, these were highly significant (P < 0.001) in comparison with the control group. In case, facilities for culture are not available then detection of antigen and IgM class of antibodies by ELISA can pinpoint current infection.

Preoperative biliary drainage in obstructive jaundice.

BACKGROUND/AIM: Although the role of preoperative percutaneous transhepatic biliary drainage in obstructive jaundice has been the subject of controversy in many other countries, in Japan, almost all surgeons agree that biliary decompression should be performed prior to the surgical treatment in obstructive jaundice. This study was performed in order to determine the role of preoperative percutaneous transhepatic biliary drainage in obstructive jaundice. PATIENTS AND METHODS: We evaluated 238 patients with preoperative obstructive jaundice, and also studied its pathophysiology in experimental animal models. RESULTS: Both of these studies demonstrated that this procedure should be performed if the value of total bilirubin is more than 5 mg/dl, the ICG Rmax value of the future remnant liver is less than 0.4 mg/kg/min, and the duration of jaundice is more than 3 weeks. Preoperative biliary drainage improves the liver function, so that major operations can be safely performed without major complications. CONCLUSIONS: It therefore seems preferable that patients undergo preoperative biliary decompression to reduce serum total bilirubin to below 5 mg/dl, and to improve hepatic and reticuloendothelial functions and hepatic reserve prior to any major surgical operation.

Blood cardioplegia--a comparative clinical and laboratory study.

A prospective comparative study was undertaken to determine quality of myocardial preservation during open heart surgery by crystalloid and blood cardioplegic solutions. Total 55 consecutive patients were studied. Alternate patients received blood and crystalloid cardioplegia at random. Group I had 30 patients who received crystalloid cardioplegia, and group II, with 25 patients, received blood cardioplegia. The efficacy of two solutions was assessed by serum enzyme estimation of creatinine phosphokinase, M.B. fraction of creatinine phosphokinase and serum glutamate oxalate transferase (CPK, CPK-MB, SGOT), electron microscopic study of Left Ventricular biopsy and clinical assessment of post anoxic cardiac performance. Group II patients had lower serum enzyme levels, lesser microscopic myocardial damage, and better cardiac performance during immediate post-operative period, thus proving superiority of myocardial protection by blood cardioplegia.

Radioprotective action of caffeine: use of Saccharomyces cerevisiae as a test system.

Mechanism of radioprotective action of caffeine by studying the gamma radiation -induced killing of yeast, S. cerevisae is reported. The results reveal that caffeine specifically protects aerobically (oxic) grown cells from gamma - radiation and sensitizes anaerobically (hypoxic) grown cells to some extent. Using radiation sensitive strains which lack recombinational pathway, it was found that protection by caffeine was solely brought about by reducing DNA damage, rather than by interfering with DNA repair process.