The clinico-pathological spectrum of plaque-type blue naevi and their potential for malignant transformation.

AIMS: Plaque-type blue naevi are rare melanocytic tumours presenting as large, pigmented plaques at birth or during childhood. There is a risk for malignant transformation, but no larger comprehensive studies exist and the diagnosis is challenging, especially on limited biopsy material. The aim is to describe the clinicopathological features and behaviour of the disease more comprehensively. METHODS AND RESULTS: We retrieved eight plaque-type blue naevi, presenting as large, pigmented plaques (median = 7 cm; range = 3-26) most frequently affecting the scalp (four) followed by the cheek, arm, abdominal wall and gluteal cleft (one each), with a slight female predilection. Median age at time of biopsy was 39.5 years (range = 15-90), but three tumours had been present at birth and one since childhood. Histopathologically, the tumours were poorly circumscribed and composed of cellular fascicles of uniform spindle cells in a background of variably prominent pigmented dendritic cells affecting dermis and subcutaneous tissues. The majority had mutations in GNAQ. One tumour showed malignant transformation, characterised by an expansile nodule of pleomorphic epithelioid melanocytes with rhabdoid morphology, high mitotic activity and areas of necrosis. This patient developed metastatic melanoma to lymph nodes. All patients are alive with a median follow-up of 60 months. CONCLUSION: Plaque-type blue naevi are diagnostically challenging tumours with risk for malignant transformation. Awareness and familiarity with the salient clinicopathological features are necessary for reliable diagnosis, and long-term clinical follow-up is required to monitor for malignant transformation.

Distant metastasis from morphologically low-grade spiradenocarcinoma: A report of two cases.

Malignant tumors arising from benign eccrine spiradenomas are rare. They are divided by morphology into low-grade and high-grade spiradenocarcinomas, with prognosis and metastatic potential closely linked to their histopathologic features. Tumors with low-grade morphology are known for their indolent behavior, with only two reported instances of metastatic spread. We report herein two further low-grade metastatic spiradenocarcinomas resulting in distant metastasis. Both tumors showed a background of a benign spiradenoma and subtle histopathologic signs of malignant transformation, characterized by loss of the dual-cell population, up to moderate cytological atypia and increased mitotic activity. Both patients developed metastases to the lungs years after the initial presentation, and one showed additional lymph nodal disease. We show that even the morphologically low-grade tumors may rarely show more aggressive behavior. Although often challenging, recognition of the morphologically low-grade malignant spiradenocarcinoma and long-term follow-up of the patients are important to detect metastatic disease.

The clinicopathologic spectrum and genomic landscape of de-/trans-differentiated melanoma.

Dedifferentiation and transdifferentiation are rare and only poorly understood phenomena in cutaneous melanoma. To study this disease more comprehensively we have retrieved 11 primary cutaneous melanomas from our pathology archives showing biphasic features characterized by a conventional melanoma and additional areas of de-/trans-differentiation as defined by a lack of immunohistochemical expression of all conventional melanocytic markers (S-100 protein, SOX10, Melan-A, and HMB-45). The clinical, histologic, and immunohistochemical findings were recorded and follow-up was obtained. The patients were mostly elderly (median: 81 years; range: 42-86 years) without significant gender predilection, and the sun-exposed skin of the head and neck area was most commonly affected. The tumors were deeply invasive with a mean depth of 7 mm (range: 4-80 mm). The dedifferentiated component showed atypical fibroxanthoma-like features in the majority of cases (7), while additional rhabdomyosarcomatous and epithelial transdifferentiation was noted histologically and/or immunohistochemically in two tumors each. The background conventional melanoma component was of desmoplastic (4), superficial spreading (3), nodular (2), lentigo maligna (1), or spindle cell (1) types. For the seven patients with available follow-up data (median follow-up period of 25 months; range: 8-36 months), two died from their disease, and three developed metastases. Next-generation sequencing of the cohort revealed somatic mutations of established melanoma drivers including mainly NF1 mutations (5) in the conventional component, which was also detected in the corresponding de-/trans-differentiated component. In summary, the diagnosis of primary cutaneous de-/trans-differentiated melanoma is challenging and depends on the morphologic identification of conventional melanoma. Molecular analysis is diagnostically helpful as the mutated gene profile is shared between the conventional and de-/trans-differentiated components. Importantly, de-/trans-differentiation does not appear to confer a more aggressive behavior.

A 20-year misdiagnosis: a rare presentation of a basal cell carcinoma.

Basal cell carcinoma (BCC) is the most common form of skin cancer. BCCs are seldom reported on the sole of the foot due to a lack of exposure to UV radiation which is the main risk factor. We present a brief literature review and case report of a 42-year-old female with a non-resolving lesion on the mid-arch of her left foot over a 20-year period. Tissue diagnosis identified the lesion as a BCC. Disease-free control was achieved but the patient experienced significant morbidity resulting in three separate procedures to diagnose, excise and reconstruct the defect. When evaluating lesions on the sole clinicians should consider BCC as a differential, particularly in those which do not respond to initial treatment.

Evaluation of risk of atherosclerosis in Indian adults.

OBJECTIVE: To investigate interrelationship of arterial measurements with metabolic syndrome (MS) components and zinc status in apparently healthy Indian adults. METHODS: Anthropometry and biochemical data were recorded in 110 men and 139 women (25-50 yr). Carotid Intima media thickness (CIMT), stiffness (beta), pulse wave velocity (PWV), elasticity modulus (Ep), and arterial compliance (AC) of the right carotid artery were evaluated ultrasonically. According to definition of MS, subjects were categorized as MS-1, MS-2, MS-3. Further, normal and MS subjects were divided as zinc sufficient and deficient. RESULTS: In all, 12.1% subjects had 3 risk factors for MS. Mean CIMT, beta, Ep and PWV were significantly higher by 6%, 11.6%, 29.5% and 12.4% in subjects with MS than normal (p < 0.05). AC showed significant decline in MS subjects by only 3% than normal (p < 0.05). Serum zinc was inversely correlated with beta, Ep and PWV in both the genders in subjects with MS (p < 0.05). A synergistic effect of serum zinc deficiency with MS further envisages the elevated risk of arterial stiffness. CONCLUSION: Risk of atherosclerosis is marked by increase in stiffness parameters even in presence of a single MS risk and zinc deficiency may further aggravate the risk indicating need for early diagnosis.

Atmiyata, a community champion led psychosocial intervention for common mental disorders: A stepped wedge cluster randomized controlled trial in rural Gujarat, India.

BACKGROUND: While effective lay-health worker models for mental health care have been demonstrated through efficacy trials, there is limited evidence of the effectiveness of these models implemented in rural LMIC settings. AIM: To evaluate the impact of a volunteer community-led intervention on reduction in depression and anxiety symptoms and improvement in functioning, and social participation among people living in rural Gujarat, India. METHODS: Stepped-wedge cluster randomized controlled trial was used to assess the effectiveness of delivery of psychosocial intervention across 645 villages in Mehsana district of Gujarat, India between April 2017 and August 2019. The primary outcome was an improvement in depression and/or anxiety symptoms assessed using GHQ-12 at 3-month follow-up. Secondary outcomes were improvement in (a) depression and anxiety (Patient Health Questionnaire, (PHQ-9), Generalized Anxiety Disorder (GAD-7) & Self-Reporting Questionnaire-20 (SRQ-20); b) quality of life (EQ- 5D); c) functioning (WHO-DAS-12), and social participation (Social Participation Scale SPS). Generalized linear mixed-effects models were used to assess the independent effect of the intervention. RESULTS: Out of a total of 1191 trial participants (608- intervention & 583-control), 1014 (85%) completed 3-month follow-up. In an adjusted analysis, participants in the intervention condition showed significant recovery from symptoms of depression or anxiety (OR 2.2; 95% CI 1.2 to 4.6; p<0.05) at the end of 3-months, with effects sustained at 8-month follow-up (OR 3.0; 95% CI 1.6 to 5.9). Intervention participants had improved scores on the PHQ-9 (Adjusted mean difference (AMD) -1.8; 95%CI -3.0 to -0.6), and SRQ-20 (AMD -1.7; 95%CI -2.7 to -0.6), at 3-months and PHQ-9, GAD-7, SRQ-20, EQ-5D and WHO-DAS at 8 months follow-up. CONCLUSION: Findings suggest that Atmiyata had a significant effect on recovery from symptoms of depression and anxiety with sustained effects at 8-month follow-up. TRIAL REGISTRATION: Trial registration details. The trial was registered prospectively with the "Clinical Trial Registry in India" (registry number: CTRI/2017/03/008139).

Metabolic risk factors and arterial stiffness in Indian children of parents with metabolic syndrome.

OBJECTIVE: To investigate the possible association between metabolic syndrome (MS) and arterial stiffness in Indian children with parental MS status. METHODS: A cross-sectional study was conducted in 140 overweight/obese and 60 normal-weight Indian children (mean age, 11.4 ± 2.8 years) along with one of their parents during 2008-2009. Data on weight, height, blood pressure, serum lipids, zinc, insulin, and glucose were collected. Intima media thickness (CIMT) and stiffness parameters were assessed in the right carotid artery. Physical activity and diet were assessed using structured questionnaires. Body composition was measured using dual-energy x-ray absorptiometry. RESULTS: A gradual increase in the percentage of MS children with an increasing number of MS components in parents was observed. Mean values for arterial stiffness, pulse wave velocity, and elastic modulus were significantly higher in MS children of MS parents than in MS children of normal parents (p < 0.05). A significant correlation was observed for lifestyle, metabolic, and arterial parameters among child-parent pairs (p < 0.05). Multiple logistic regression revealed that children's CIMT and arterial stiffness were significantly associated (p < 0.01) with their serum levels of triglycerides, high-density lipoprotein, and zinc, as well as with parental MS-CIMT. CONCLUSION: Parental MS status and lifestyle factors increase the risk of MS and arterial abnormalities in children.

Cutaneous Myoepithelial Neoplasms on Acral Sites Show Distinctive and Reproducible Histopathologic and Immunohistochemical Features.

Cutaneous myoepithelial neoplasms are a heterogenous group of neoplasms with mixed tumors typically affecting the head and myoepitheliomas showing a predilection for the extremities. Their malignant counterparts, myoepithelial carcinoma, and malignant mixed tumor are exceptionally rare in the skin, and the morphologic criteria for malignancy are only poorly defined. The aim of the present study was to characterize the clinicopathologic features of myoepithelial neoplasms presenting on acral skin. The clinical and histopathologic features of 11 tumors were recorded, and follow-up was obtained. Immunohistochemistry was performed for S100, SOX10, glial fibrillary acidic protein, keratins, epithelial membrane antigen, p63, p40, smooth muscle actin, desmin, and PLAG1. The tumors mainly affected the feet of adults (range: 26 to 78 y; median: 47 y) with a predilection for the great toe and a male predominance of 1.8:1. Most tumors (91%) displayed a lobular architecture composed of solid and nested growth of epithelioid cells with plasmacytoid features in a myxoid or angiomatous stroma. Scattered cytologic atypia and rare duct differentiation were frequently noted. Three tumors with confluent cytologic atypia, infiltrative growth, and lymphovascular invasion were classified as malignant. By immunohistochemistry, the tumors were positive for S100, SOX10, keratins AE1/AE3, CK5/6 and CK7, and PLAG1. Local recurrence and bilateral pulmonary metastasis were observed in a patient presenting with a histopathologically benign-appearing tumor. Two patients with malignant tumors experienced local recurrences, and 1 developed metastasis to soft tissue, lung, and mediastinal lymph nodes. All patients are currently alive, all but 1 with no evidence of disease after a median follow-up interval of 96 months (range: 2 to 360 mo). In conclusion, acral myoepithelial neoplasms show distinctive and reproducible histopathologic and immunohistochemical features. They are best regarded as a distinctive subset of mixed tumors with features reminiscent of their salivary gland counterparts. While most tumors pursue a benign disease course, histopathologic features appear to be a poor indicator of prognosis.

Carotid arterial stiffness in overweight and obese Indian children.

OBJECTIVE: The aim of the study was to evaluate carotid arterial stiffness and intima media thickness (IMT) in obese children in comparison with healthy children, and to examine associations of lipid profile and blood pressure with carotid artery morphology. METHODS: Anthropometric and blood parameters were assessed in 44 overweight, 95 obese (6-17 years) and 69 healthy age-matched normal children. Percent body fat was measured by dual-energy X-ray absorptiometry and stiffness and IMT of the common carotid artery were evaluated using Aloka alpha 10 equipment. RESULTS: Anthropometric and lipid parameters were significantly higher in overweight and obese than in normal children (p < 0.05). Stiffness (beta), pulse wave velocity (PWV), elastic modulus (Ep) and blood pressure were significantly higher in obese and overweight children than in normal children (p < 0.05). However, overweight and obese children did not show any significant difference in IMT compared with normal children (p > 0.1). Significant positive correlation of PWV, beta and Ep and negative correlation of arterial compliance with body fat and triglyceride was noted (p < 0.05). Different multinomial regression models for each e-Tracking parameter indicated that the relative risk of hypertension was highest with high PWV, followed by LDL cholesterol, Ep and body fat. CONCLUSION: PWV may be considered an important marker for evaluation of early functional changes of the carotid artery in children and adolescents.

Influence of different length linker containing DHEA-7-CMO-enzyme conjugates on sensitivity and specificity of DHEA-17-CMO-antibody.

Introduction of spacers in enzyme conjugates is known to exert an influence on the assay parameters of steroid enzyme immunoassays. We have introduced 3 to 10 atomic length linkers between enzyme and steroid moieties and studied their effects on sensitivity and specificity of dehydroepiandrosterone enzyme immunoassays. Dehydroepiandrosterone-17-carboxymethyloxime-bovine serum albumin (DHEA-17-CMO-BSA) was used as an immunogen to raise the antiserum in New Zealand white rabbits. Five enzyme conjugates were prepared using DHEA-7-CMO as carboxylic derivative of DHEA and horseradish peroxidase (HRP) as label. These were DHEA-7-CMO-HRP, DHEA-7-CMO-urea-HRP (DHEA-7-CMO-U-HRP), DHEA-7-CMO-ehylenediamine-HRP (DHEA-7-CMO-EDA-HRP), DHEA-7-CMO-carbohydrazide-HRP (DHEA-7-CMO-CH-HRP), and DHEA-7-CMO-adipic acid dihydrazide-HRP (DHEA-7-CMO-ADH-HRP). The influence of different atomic length linkers on sensitivity and specificity were studied with reference to label without linker. The results of the present investigation revealed that with incorporation of linkers, the sensitivity improves, whereas specificity only marginally improves. These differential behaviors of various linkers toward the sensitivity and specificity of assays might be due to the difference in the magnitude of overall forces of attraction between the antibody and the enzyme conjugates.

Implementation of a comprehensive surveillance system for recording suicides and attempted suicides in rural India.

INTRODUCTION: WHO reports that 78 of the 140 low-income and middle-income countries (LMICs) do not have a registration system for suicides and attempted suicides. Absence of data on suicide and attempted suicide in LMICs, which account for 79% of suicides worldwide, is a major impediment in understanding the magnitude of the problem and formulating prevention strategies to reduce suicide and self-harm. A comprehensive surveillance system has the potential to address this data gap. The objective of this study is to describe the development of a comprehensive surveillance system in rural India by adding a community based component and reflect on its added value in obtaining data on suicide and attempted suicide compared with relying only on hospital and police records. METHOD: The comprehensive system consists of three components. Community surveillance involved collecting information on suicides and attempted suicides from third party key informants such as village heads, teachers, priests, shopkeepers, private physicians, private hospitals and community health workers. The second component consisted of data from public health facilities. The final component consisted of suicide data from police records. Information was collected for a period of 12 months from August 2018 to July 2019 from 116 villages (population 377 276) in Gujarat, India. RESULTS: An average of 710 community informants were interviewed each month (mean: 6.72 informants per village). The community surveillance system identified 67 cases of suicide compared with 30 cases by hospital and police records (Cochran's Q test 67.9 p<0.01) and 70 attempted suicides compared with 51 from the hospital and police records (Cochran's Q test 66.6 p<0.01). DISCUSSION: This is the first report of implementing a large-scale comprehensive surveillance system for suicide and attempted suicide in a LMIC. The combination of community surveillance system and official data from hospital and police records addresses the problem of under-reporting of suicide and suicide attempts in India and other LMIC.

Analysis of news media reports of suicides and attempted suicides during the COVID-19 lockdown in India.

BACKGROUND: Based on previous experience there is justifiable concern about suicidal behaviour and news media reporting of it during COVID-19 pandemic. METHODS: This study used a systematic search of online news media reports (versions of newspapers, magazine and other digital publications) of suicidal behaviour during India's COVID-19 lockdown and compared it to corresponding dates in 2019. Data was gathered using a uniform search strategy from 56 online news media publications 24 March to 3 May for the years 2019 and 2020 using keywords, suicide, attempted suicide, hangs self and kills self. Demographic variables and methods used for suicide were compared for suicide and attempts between the 2 years using chi-squared tests (χ2). RESULTS: There were online news media reports of 369 cases of suicides and attempted suicides during COVID lockdown vs 220 reports in 2019, a 67.7% increase in online news media reports of suicidal behaviour. Compared to 2019, suicides reported during lockdown were significantly older (30 vs 50 years, p < 0.05), men (71.2% vs 58.7%; p < 0.01), married (77.7% vs 49%; p < 0.01) and employed (82.9% vs 59.5%; p < 0.01). During the lockdown, significantly more suicides were by hanging (64.4% vs 42%), while poisoning (8.5% vs 21.5%) and jumping in front of a train (2% vs 9.4%) (p < 0.05) were significantly reduced. Comparison of COVID and non-COVID groups showed that online news media reports of COVID cases of suicide and attempted suicide were significantly more likely to be men (84.7% vs 60.4%; p < 0.01), older (31-50 years 52.9% vs 25.8%; p < 0.01) employed (91.5% vs 64.3%; p < 0.01), had poor mental (40.1% vs 20.8%; p < 0.01) and poor physical health (24.8% vs 7.9%;11.8, p < 0.01). CONCLUSION: Increase in online news media reports of suicides and attempts during COVID-19 lockdown may indicate an increase in journalists' awareness about suicide or more sensational media reporting or may be a proxy indicator of a real community increase in suicidal behaviour. It is difficult to attribute changes in demographic profile and methods used only to changes in journalists' reporting behaviour and should be further explored. We therefore call upon the Government of India to urgently release national suicide data to help devise a comprehensive suicide prevention strategy to address COVID-19 suicidal behaviour.

Atmiyata, a community-led intervention to address common mental disorders: Study protocol for a stepped wedge cluster randomized controlled trial in rural Gujarat, India.

BACKGROUND: While lay-health worker models for mental health care have proven to be effective in controlled trials, there is limited evidence on the effectiveness and scalability of these models in rural communities in low- and middle-income countries (LMICs). Atmiyata is a rural community-led intervention using local community volunteers, called Champions, to identify and provide a package of community-based interventions for mental health, including evidence-based counseling for persons with common mental disorders (CMD). METHODS: The impact of the Atmiyata intervention is evaluated through a stepped wedge cluster randomized controlled trial (SW-CRCT) with a nested economic evaluation. The trial is implemented across 10 sub-blocks (645 villages) in Mehsana district in the state of Gujarat, with a catchment area of 1.52 million rural adults. There are 56 primary health centers (PHCs) in Mehsana district and villages covered under these PHCs are equally divided into four groups of clusters of 14 PHCs each. The intervention is rolled out in a staggered manner in these groups of villages at an interval of 5 months. The primary outcome is symptomatic improvement measured through the GHQ-12 at a 3-month follow-up. Secondary outcomes include: quality of life using the EURO-QoL (EQ- 5D), symptom improvement measured by the Self-Reporting Questionnaire-20 (SRQ-20), functioning using the World Health Organization's Disability Assessment Scale (WHO-DAS-12), depression symptoms using the Patient Health Questionnaire (PHQ-9), anxiety symptoms using Generalized Anxiety Disorder Questionnaire (GAD-7), and social participation using the Social Participation Scale (SPS). Generalized linear mixed effects model is employed for binary outcomes and linear mixed effects model for continuous outcomes. A Return on Investment (ROI) analysis of the intervention will be conducted to understand whether the intervention generates any return on financial investments made into the project. DISCUSSION: Stepped wedge designs are increasingly used a design to evaluate the real-life effectiveness of interventions. To the best of our knowledge, this is the first SW-CRCT in a low- and middle-income country evaluating the impact of the implementation of a community mental health intervention. The results of this study will contribute to the evidence on scaling-up lay health worker models for mental health interventions and contribute to the SW-CRCT literature in low- and middle-income countries. TRIAL REGISTRATION: The trial is registered prospectively with the Clinical Trial Registry in India and the Clinical Trial Registry number- CTRI/2017/03/008139. URL http://ctri.nic.in/Clinicaltrials/regtrial.php?modid=1&compid=19&EncHid=70845.17209. Date of registration- 20/03/2017.

Evaluation of the SPIRIT Integrated Suicide Prevention Programme: study protocol for a cluster-randomised controlled trial in rural Gujarat, India.

BACKGROUND: Suicide is a major public health challenge globally and specifically in India where 36.6% and 24.3% of all suicides worldwide occur in women and men, respectively. The United Nations Sustainable Development Goals uses suicide rate as one of two indicators for Target 3.4, aimed at reducing these deaths by one third by 2030. India has no examples of large-scale implementation of evidence-based interventions to prevent suicide; however, there is a sizeable evidence base to draw on for suicide prevention strategies that have been piloted in India or proven to be effective regionally or internationally. METHOD: The SPIRIT study is designed as a cluster-randomized superiority trial and uses mixed methods to evaluate the implementation, effectiveness and costs of an integrated suicide prevention programme consisting of three integrated interventions including (1) a secondary-school-based intervention to reduce suicidal ideation among adolescents, (2) a community storage facility intervention to reduce access to pesticides and (3) training for community health workers in recognition, management, and appropriate referral of people identified with high suicidal risk. DISCUSSION: Combining three evidence-based interventions that tackle suicide among high-risk groups may generate a synergistic impact in reducing suicides at the community level in rural areas in India. Examination of implementation processes throughout the trial will also help to prepare a roadmap for policymakers and researchers looking to implement suicide prevention interventions in other countries and at scale. TRIAL REGISTRATION: Clinical Trial Registry of Indian Council of Medical Research, India: CTRI/2017/04/008313. Registered on 7 April 2017. http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=18256&EncHid=&userName=SPIRIT Trial registry was last modified on 28 June 2019.

Rhabdomyoblastic differentiation in malignant melanoma in adults: report of 2 cases.

Two cases of malignant melanoma are reported in adults exhibiting rhabdomyoblastic differentiation to alert pathologists to this rare variant of malignant melanoma. One of the cases presented as a metastasis in a submandibular lymph node, and the other was a primary skin melanoma. There are only a few published reports on melanocytic tumors with rhabdomyoblastic differentiation, mainly occurring in giant congenital nevi. Both cases reported here were confirmed by immunohistochemistry. Both cases were also studied by electron microscopy, and one showed distinctive ultrastructural features of striated muscle.

Growth status of small for gestational age Indian children from two socioeconomic strata.

AIMS: To assess growth and factors associated with growth in children born small for gestational age (SGA) from two socioeconomic strata in comparison to age- and sex-matched healthy controls. METHODS: Retrospective study conducted at two hospitals in Pune, 0.5-5 years, 618 children: 189-SGA from upper socioeconomic strata (USS), 217-SGA from lower socioeconomic strata (LSS), and 212 appropriate for gestational age healthy controls were randomly selected. Birth and maternal history, socioeconomic status, length/height, and weight of children were recorded. Anthropometric data were converted to Z scores (height for age Z-score [HAZ], weight for age Z-score [WAZ]) using WHO AnthroPlus software. RESULTS: The HAZ and WAZ of the SGA group were significantly lower as compared to the controls and that of the LSS SGAs were lower than USS SGAs (P < 0.05). Thirty two percent children were stunted (HAZ <-2.0) in USS and 49% in LSS (P < 0.05). Twenty nine percent children in the USS SGA group were stunted at 2 years and 17% at 5 years. In the LSS SGA group, 54% children were stunted at 2 years and 46% at 5 years. Generalized linear model revealed normal vaginal delivery (ß = 0.625) and mother's age (ß =0.072) were positively associated and high SES (ß = -0.830), absence of major illness (ß = -1.01), higher birth weight (ß = -1.34) were negatively associated for risk of stunting (P < 0.05). CONCLUSION: Children born SGA showed poor growth as compared to controls. Special attention to growth is necessary in children from LSS, very low birth weight babies, and those with major illnesses during early years of life.

Menstrual characteristics and prevalence of dysmenorrhea in college going girls.

BACKGROUND: Dysmenorrhea is a common gynecological condition with painful menstrual cramps of uterine origin. Prevalence of primary dysmenorrhea is not yet clearly studied in central India. OBJECTIVE: To study prevalence of primary dysmenorrhea in young girls and to evaluate associated clinical markers of dysmenorrhea. MATERIALS AND METHODS: In a cross-sectional study, data was collected among 310 girls (18-25 years) on age at menarche, presence and absence of dysmenorrhea, dysmenorrhea duration, pre-menstrual symptoms (PMS), family history, menses irregularities, menstrual history, severity grading using visual analogue scale (VAS) using a semi-structured questionnaire. RESULTS: Dysmenorrhea was reported in 84.2% (261) girls and 15.8% (49) reported no dysmenorrhea. Using VAS, 34.2% of girls experienced severe pain, 36.6% moderate and 29.2% had mild pain. Bleeding duration was found to be significantly associated with dysmenorrhea (χ(2) = 10.5; P < 0.05), girls with bleeding duration more than 5 days had 1.9 times more chance of getting dysmenorrhea (OR: 1.9; 95% CI: 1.7-3). Moreover, girls with the presence of clots had 2.07 times higher chance of having dysmenorrhea (OR: 2.07; 95% CI: 1.04-4.1) (P < 0.05). Almost 53.7% girls who had some family history of dysmenorrhea, 90.9% experience the condition themselves (χ(2) = 11.5; P < 0.001). Girls with family history of dysmenorrhea had three times greater chance of having the same problem (OR: 3.0; 95% CI: 1.5-5.8; P = 0.001). CONCLUSION: Dysmenorrhea is found to be highly prevalent among college going girls. Family history, bleeding duration and presence of clots were significant risk factors for dysmenorrhea.

Arterial stiffness in obese children: Role of adiposity and physical activity.

OBJECTIVE: To explore association of adiposity and physical activity with arterial stiffness and to propose optimal waist circumference cutoffs, corresponding to 90(th) percentile of NHANES (National Health and Nutrition Examination Survey) for Indian children and adolescents. MATERIALS AND METHODS: Data on weight, height, waist circumference, physical activity and right Carotid artery Intima-Media-Thickness (CIMT), pulse wave velocity (PWV), elasticity modulus (Ep), stiffness index(ß), arterial compliance (AC) were assessed in 250 children (72 normal-weight and 178 overweight/obese) aged 6-17 years from Pune city, India. Body composition was measured using Dual energy X-ray absorptiometry. RESULTS: Total, 37.1% normal-weight and 98.2% overweight/obese children had high adiposity (>95(th) body fat percentile). Positive association of PWV and Ep (r = 0.5) also ß(r = 0.25) with BMI (Body Mass Index), waist circumference and body fat (P < 0.05) was observed. Physical activity was inversely associated with PWV (r =-0.2), ß(r =-0.13), Ep (r =-0.12) and positively with AC (r = 0.12) (P < 0.05). PWV significantly increased with increasing body fat for each tertile of physical activity (P < 0.05). Regression analysis revealed waist circumference, BMI, body fat and physical activity as independent associates for PWV after adjusting for age (P < 0.05). The cutoff of waist circumference yielding sensitivity and specificity for predicting the risk of high PWV was (-0.43, -0.44) for boys and girls with sensitivity in boys (girls) of 78% (87%) and specificity in boys (girls) 51% (70%). The observed cutoffs are less than the NHANES-III cutoff values of waist circumference for 90(th) percentiles according to age and sex. CONCLUSION: High adiposity and low physical activity are adversely related to arterial stiffness in Indian children.

Muir-Torre syndrome in a haemodialysis patient.

Muir-Torre syndrome (MTS) is a rare inherited cancer syndrome with variable penetrance. MTS follows an autosomal-dominant pattern of inheritance, and is a subtype of Lynch syndrome [formally known as hereditary non-polyposis colorectal cancer (HNPCC)]. MTS is caused by mutations in one of several mismatch repair genes. Patients typically present with sebaceous neoplasms (sebaceous adenoma, sebaceous epithelioma, or sebaceous carcinoma) or with multiple keratoacanthomas. These patients also have an increased lifetime risk of visceral malignancies, typically affecting the colon, ovary, endometrium, genitourinary tract and small bowel. We describe a case of MTS in a haemodialysis patient and implications for transplant listing.

Diet and exercise intervention, with special reference to micronutrients, reduces cardiometabolic risk in overweight children.

OBJECTIVE: To study the effect of lifestyle intervention in the presence of multivitamin-zinc supplementation in improving the cardiometabolic status of overweight children. MATERIALS AND METHODS: Data were evaluated in 74 overweight children (11.3 ± 2.9 years) randomly assigned to three groups of intervention for 4 months as follows: group A: diet-exercise counseling with multivitamin-zinc supplementation; group B: diet-exercise counseling; and group C: placebo. Anthropometric, biochemical, carotid arterial and lifestyle parameters were assessed. RESULTS: Lifestyle counseling resulted in significant reduction in inactivity, energy and fat intakes and increase in micronutrient density of diets and physical activity in groups A and B in comparison to group C. Percent decline in body fat was more in group A than in groups B and C. Percent change in triglycerides (-13.7%) was significantly higher in group A than in groups B (-5.9%) and C (5.7%). Pulse wave velocity and elasticity modulus reduced and arterial compliance improved significantly in group A than in group B. CONCLUSION: Multivitamin-zinc supplementation with lifestyle intervention has a positive effect of on the cardiometabolic status of overweight children.