Effect of vitamin D supplementation, directly or via breast milk for term infants, on serum 25 hydroxyvitamin D and related biochemistry, and propensity to infection: a randomised placebo-controlled trial.

We assessed the effect of vitamin D supplementation on related biochemistry, infection and dentition of the infant. In a double-blind, placebo-controlled trial conducted in Lucknow, India (latitude 26°N), 230 mother -newborn pairs were randomised to receive, for 9 months, 3000µg/month oral vitamin D3 by the mother (group A) or 10µg/d by the infant (group B) or double placebo (group C). All babies received 15 min of sun exposure (unclothed) during massage. Infants' median 25-hydroxyvitamin D (25(OH)D) was lower in group C (median 45·3; interquartile range (IQR) 22-59·5 nmol/l) than in groups A (median 60·8; IQR 41·3-80·5 nmol/l (P7.5µkat/l) was significantly more frequent in group C babies (16 %) than in group A (4 %) or group B (0 %) babies. The number of days with respiratory or diarrhoeal infection by 9 months of age was higher in group C (median 46·5; IQR 14·8-73·3 d) than in group A (median 18·5; IQR 8·8-31·0 d (P<0·01)) or group B (median 13·0; IQR 7·0-28·5 (P<0·05)). We conclude that monthly maternal or daily infant supplementation with vitamin D along with sun exposure is superior to sun exposure alone in maintaining normal infant 25(OH)D at 3·5 months, and provide protection from elevated alkaline phosphatase and infectious morbidity.

Calcitonin gene- and parathyroid hormone-related peptides in normotensive and preeclamptic pregnancies: a nested case-control study.

PURPOSE: To identify whether CGRP and PTHrP serve as screening biomarkers for early detection of preeclampsia or even before the development of preeclampsia in early pregnancy. METHODS: It was a nested case-control study. The subjects were divided into normotensive (controls) and preeclamptic (cases) groups. Serum samples of 132 cases and 132 controls were collected during pregnancy at three different gestational periods and one sample post delivery, from within the cohort of pregnant women reporting to antenatal clinic. Circulating levels of CGRP and PTHrP were analyzed by enzyme-linked immunosorbent assay. RESULTS: Maternal serum concentrations of CGRP and PTHrP increased with the advancement of gestation age in both normotensive and preeclamptic pregnancies but the significantly less increased levels were observed in preeclamptic pregnancies as compared with normotensive pregnancies. In postpartum period level of CGRP significantly falls in both groups although level of PTHrP continues to increase even after delivery. Maternal serum CGRP and PTHrP concentrations were positively correlated with the infant's birth weights. CONCLUSION: Maternal circulating CGRP and PTHrP concentrations were significantly lower in women with preeclampsia, which may contribute to the development of preeclampsia.

Efficacy of TrueNat cartridge extracted DNA for detecting drug resistant tuberculosis by line probe assay.

BACKGROUND: Currently for diagnosing Mycobacterium tuberculosis and its drug resistance, two sputum samples are required. One of them is subjected to TrueNat™ and if positive the other sample is subjected to line probe assay (LPA). This study was done to evaluate whether TrueNat extracted DNA can be directly used for performing LPA in a diagnostic laboratory setting to decrease patient turn-around time. METHODS: Total 45 smear positive sputum samples were subjected to TrueNat™ MTB detection and first and second line (FL and SL) LPA testing in parallel. DNA extracted by Trueprep® Cartridge was also tested by LPA and results were compared. Further, TrueNat extracted DNA from 20 samples was divided into 6 aliquots each, two of which were stored at 4 °C, 37 °C and 55 °C (under humidification) each. One aliquot from stored DNA at each temperature was used for FL & SL LPA on day three and the other on day eight. The blots thus obtained were compared with those of conventional LPA at day 1. RESULTS: For FL-LPA, TrueNat extracted DNA gave valid results for all 45 (100%) samples but conventionally extracted DNA could give results for 44 (97.8%) samples. Likewise, for SL-LPA, valid results were obtained for 40 (88.9%) and 35 (77.8%) samples respectively using TrueNat extracted DNA and conventionally extracted DNA respectively. All samples with invalid LPA results had Ct values ≥ 28 by TrueNat PCR. LPA results were obtained for all the 20 samples using stored DNA at all temperatures and duration. CONCLUSIONS: TrueNat extracted DNA can be used for performing LPA under field conditions for selected samples.

High frequency of isoniazid and fluroquinolone resistance among patients with rifampicin sensitive tuberculosis.

This study was done to determine frequency of isoniazid (INH) and fluoroquinolones FQ resistance among rifampicin sensitive strains of Mycobacterium tuberculosis and to study their mutation patterns. Retrospective analysis was done for samples with M. tuberculosis detected by Cartridge based NAAT (CBNAAT). They were tested sequentially by first line (FL) and second line - line probe assay (SL-LPA) depending on their drug resistance pattern and following diagnostic algorithm. Total 9722 (74.1 %) of 13124 NAAT positive samples were sensitive for rifampicin. On FL-LPA, 833 (8.6 %) were resistant to INH and of which 110 (13.2 %) were also resistant to FQ by SL-LPA. Most common mutations observed for INH resistance were katG S315T1 mutation in 615 (97.3 %) strains, inhA C15T mutation in 174 (86.6 %) strains and for FQ resistance were gyrA D94G mutation in 46 (41.8 %) strains. Heteroresistance, inferred mutations, combination of mutations and unique mutations were also observed in all genes.

Association of Serum Ferritin Level in Early Second Trimester of Pregnancy with Development of Gestational Diabetes Mellitus: A Prospective Observational Study.

Background: Gestational diabetes mellitus (GDM) is associated with various maternal and perinatal morbidities. Serum ferritin is a major storage protein of iron and also acts as acute phase reactant which is increased in inflammatory conditions. GDM is a state of insulin resistance and associated with inflammation. The aim of this study was to find the correlation between serum ferritin and development of GDM. Objectives: To determine the serum ferritin concentration in nonanemic pregnant women and its correlation with subsequent development of GDM. Methodology: In this prospective observational study, 302 nonanemic pregnant women with singleton gestation between 14 and 20 weeks, attending antenatal OPD, were enrolled. Serum ferritin was measured at the time of enrolment, and they were followed till 24-28 weeks of gestation and subjected to blood glucose test by DIPSI method. A total of 92 women had blood glucose level ≥ 140 mg/dl and were labeled as GDM, and 210 pregnant women with blood glucose level < 140 mg/dl were labeled as non-GDM. Result: Mean serum ferritin level of women with GDM (56.44 ± 19.19 ng/ml) was found to be higher as compared to non-GDM (27.62 ± 12.11 ng/ml), and this difference was found to be statistically significant (p < 0.001). The cutoff value of serum ferritin > 37.55 ng/ml was found to be 85.9% sensitive and 81.9% specific. Conclusion: We can infer that serum ferritin is associated with development of GDM. Based on the findings of the current study, serum ferritin level can be used a predictive marker for the development of GDM.

Effect of time, temperature and pH on Mycobacterium tuberculosis culture positivity of gastric aspirate: An experimental study.

BACKGROUND: The culture of gastric aspirate (GA) has been used for bacteriological confirmation of pulmonary tuberculosis in children and patients who are unable to expectorate. Sodium bicarbonate neutralization of gastric aspirates is commonly recommended to increase culture positivity. We aim to study Mycobacterium tuberculosis (MTB) culture positivity of GA collected from confirmed case of pulmonary tuberculosis after storing it at different temperature, pH & time. METHODS: GA specimens from 865 patients of either sex predominately non-expectorating children/adults with suspected pulmonary TB were collected. Gastric lavage was performed in the morning after an overnight fasting (at least 6hrs fasting). The GA specimens were tested by CBNAAT (GeneXpert) and AFB microscopy & those who were positive on CBNAAT were further processed with MTB culture on Growth Indicator Tube (MGIT™) culture. pH neutralized and non-neutralized CBNAAT positive GA specimens were culture within 2 hours of collection and 24 hours after storage at 4 °C & room temperature. RESULTS: MTB was detected in 6.8% of collected GA specimens by CBNAAT. Culture positivity of neutralized GA specimens when processed within 2 hours of collection, was higher compared to paired non-neutralized GA specimens. Neutralized GA specimens had higher contamination rate than non-neutralized GA specimens. Storage of GA specimens at $Deg C had better culture yield than those stored at room temperature. CONCLUSION: Early neutralization of acid in Gastric aspirate (GA) is essential for better culture positivity of M. tuberculosis (MTB). If there is a delay in processing GA, it should be kept at 4 °C after neutralization; however, positivity decreases with time.

Acute kidney injury in obstetrics: Hospital-based cohort study.

Obstetric acute kidney injury (AKI) is a serious unsolved global health-care problem and is a significant contributor to the overall burden of AKI resulting in devastating maternal and foetal outcomes. We studied the characteristics of obstetric AKI and the factors related to its unfavourable outcome. A total of 110 patients developed AKI among 10,138 admission giving a frequency of 1.08%. The commonest risk factor was pre-eclampsia followed by haemorrhage and sepsis. Complete recovery of renal function occurred in 40.9%. However, 9.1% were left with end-stage renal disease. AKI due to sepsis, delayed referral and deranged renal function on admission was associated with unfavourable outcome. AKI in pregnancy merits special attention because it involves risk to two lives, mother and foetus. Early identification of risk factors coupled with timely and efficient management will result in reducing obstetric AKI and associated maternal morbidity and mortality.

Agreement between CBNAAT, liquid culture and line probe assay for detection of Mycobacterium tuberculosis and anti-tubercular drug resistance in extrapulmonary samples.

PURPOSE: Cartridge based nucleic acid amplification test (CBNAAT) has been endorsed by the WHO as the screening test for diagnosing extrapulmonary tuberculosis (EPTB). In the present study we report the agreement between CBNAAT (Xpert MTB/RIF), liquid culture (LC) and line probe assay (LPA) for diagnosis of Mycobacterium tuberculosis and detection of drug resistance among EPTB cases. METHODS: The EP samples were subjected to CBNAAT (Xpert MTB/RIF, Cepheid, USA) and wherever possible, to LC (MGIT 960, Becton Dickinson, USA) followed sequentially by first line and second line-LPA (FL-LPA, SL-LPA, Hain Lifescience, Germany) on the isolates. RESULTS: Total 566/4080 (13.9%) EP samples were detected positive for M. tuberculosis on CBNAAT. Aspirates from lymph nodes were most often positive (11/30; 36.6%), followed by pus (240/873; 27.5%) and CSF samples (166/104; 15.8%). The detection of M. tuberculosis was more in adults than children except in tissue biopsy samples. Rifampicin resistance was also higher among adults except CSF in which resistance was more in children. Total 185 of 566 (32.7%) CBNAAT positive and 770 of 3510 (21.9%) CBNAAT negative samples could be cultured of which 110/185 (59.4%) and 33/770 (4.3%) respectively turned positive. FL-LPA and SL-LPA of 143 culture isolates showed that 27 isolates had drug resistance, of which 3 (2.1%) were XDR, 11 (7.7%) were Pre-XDR (FQ) and 13 (9.1%) were MDR. Of these 27 resistant isolates, 12 were negative by CBNAAT and two were mislabeled as Rifampicin sensitive or indeterminate based on the unique RpoB gene mutation patterns on LPA. The positive and negative agreements between LC and CBNAAT for detection of M. tuberculosis were 67.1% and 92.7% respectively and between LPA and CBNAAT for rifampicin resistance detection were 98.9% and 92.9% respectively. CONCLUSIONS: For EPTB, CBNAAT should be accompanied with LC wherever possible irrespective of the CBNAAT result.

Detection of novel coronavirus from chest X-rays using deep convolutional neural networks.

With over 172 Million people infected with the novel coronavirus (COVID-19) globally and with the numbers increasing exponentially, the dire need of a fast diagnostic system keeps on surging. With shortage of kits, and deadly underlying disease due to its vastly mutating and contagious properties, the tired physicians need a fast diagnostic method to cater the requirements of the soaring number of infected patients. Laboratory testing has turned out to be an arduous, cost-ineffective and requiring a well-equipped laboratory for analysis. This paper proposes a convolutional neural network (CNN) based model for analysis/detection of COVID-19, dubbed as CovCNN, which uses the patient's chest X-ray images for the diagnosis of COVID-19 with an aim to assist the medical practitioners to expedite the diagnostic process amongst high workload conditions. In the proposed CovCNN model, a novel deep-CNN based architecture has been incorporated with multiple folds of CNN. These models utilize depth wise convolution with varying dilation rates for efficiently extracting diversified features from chest X-rays. 657 chest X-rays of which 219 were X-ray images of patients infected from COVID-19 and the remaining were the images of non-COVID-19 (i.e. normal or COVID-19 negative) patients. Further, performance evaluation on the dataset using different pre-trained models has been analyzed based on the loss and accuracy curve. The experimental results show that the highest classification accuracy (98.4%) is achieved using the proposed CovCNN model.

Molecular Epidemiology and Polymorphism Analysis in Drug-Resistant Genes in M. tuberculosis Clinical Isolates from Western and Northern India.

Introduction: The mechanistic details of first line drug (FLD) resistance have been thoroughly explored but the genetic resistance mechanisms of second line injectables, which form the backbone of the combinatorial drug resistant tuberculosis therapy, are partially identified. This study aims to highlight the genetic and spoligotypic differences in the second line drug (SLD) resistant and sensitive Mycobacterium tuberculosis (Mtb) clinical isolates from Mumbai (Western India) and Lucknow (Northern India). Methods: The rrs, eis, whiB7, tlyA, gyrA and gyrB target loci were screened in 126 isolates and spoligotyped. Results: The novel mutations were observed in whiB7 loci (A43T, C44A, C47A, G48T, G59A and T152G in 5'-UTR; A42C, C253T and T270G in gene), tlyA (+CG200, G165A, C415G, and +G543) and gyrB (+G1359 and +A1429). Altogether, the rrs, eis, and whiB7 loci harbored mutations in ~86% and ~47% kanamycin resistant isolates from Mumbai and Lucknow, respectively. Mumbai strains displayed higher prevalence of mutations in gyrA (~85%) and gyrB loci (~13%) as compared to those from Lucknow (~69% and ~3.0%, respectively). Further, spoligotyping revealed that Beijing lineage is distributed equally amongst the drug resistant strains of Mumbai and Lucknow, but EAI-5 is existed at a higher level only in Mumbai. The lineages Manu2, CAS1-Delhi and T1 are more prevalent in Lucknow. Conclusion: Besides identifying novel mutations in whiB7, tlyA and gyrB target loci, our analyses unveiled a potential polymorphic and phylogeographical demarcation among two distinct regions.

Model for Early Prediction of Preeclampsia: A Nested Case Controlled Study in Indian Women.

Purpose: Preeclampsia (PE) affects 5-7% of the pregnancies worldwide, and is one of the most dreaded disorders of pregnancy contributing to maternal and neonatal mortality. PE is mostly presented in the third trimester of pregnancy. Here, we used serum placental growth factor (PIGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) to develop a model for predicting PE in Indian women in early second trimester. Methods: In this case-control study, a total 1452 healthy pregnant women were recruited. Blood samples were collected at the following gestational weeks (GWs), 12-20 (GW1), 21-28 (GW2) and 29-term (GW3), and post-delivery. Body mass index (BMI) was calculated by anthropometric measurements. Serum sFlt-1, PIGF and VEGF were analyzed by ELISA. A predictive model for PE was developed using multivariable logistic regression analysis. Results: In PE cases, serum PlGF and VEGF levels were significantly lower at each GW, while serum sFlt-1 was lower only at GW1, relative to age-matched controls, (n = 132/group). Age-matched comparison between PE cases and controls indicated that sFlt-1 was associated with decreased PE outcome (Odds ratio. OR = 0.988, CI = 0.982-0.993), whereas sFlt-1/PlGF ratio (OR = 1.577, CI = 1.344-1.920) and BMI (OR = 1.334, CI = 1.187-1.520) were associated with increased PE outcome. Logistic regression was used to develop a predictive model for PE at GW1. Using testing dataset, model was externally validated which resulted in 88% accuracy in predicting PE cases at 0.5 probability cutoff. Conclusion: Prediction model using sFlt-1, sFlt-1/PlGF ratio and BMI may be useful to predict PE as early as 12-20 weeks in women with optimal sensitivity and specificity.

Emergence of Specific gyrA Mutations Associated High-Level Fluoroquinolone-Resistant Mycobacterium tuberculosis among Multidrug-Resistant Tuberculosis Cases in North India.

Aim: This study aims to determine the frequency and pattern of gyrA/B mutations in multidrug-resistant (MDR) Mycobacterium tuberculosis (MTB) strains and also to assess the association between different gyrA/B mutations with phenotypic resistance to moxifloxacin (MOX) at clinical breakpoint (CB) drug concentration. Method: A total of 106 clinical MTB isolates carrying gyrA/B mutations were included consecutively. Culture-based MOX susceptibility was tested at CB (1.0 µg/mL) followed by its correlation with gyrA/B mutations using Genotype MTBDRsl assay. The mutations associated with phenotypic resistance were further analyzed on a large dataset of 1,825 MDR tuberculosis (TB) patients. Result: D94G and A90V mutations within gyrA were significantly associated with resistance and susceptible phenotype (p < 0.001), respectively. Of 1,825 MDR patients, gyrA/B mutations were found in 58.8% cases, of which fluoroquinolone (FQ) resistance was concluded among 97.9%, 0.8%, and 1.3% patients due to mutation in gyrA, gyrB, and in both the genes, respectively. D94G alone (45.9%) followed by A90V (21.2%) mutations in gyrA gene was most frequent. Conclusion: Our study showed that MDR-TB has emerged in northern India with additional FQ resistance. Different selection pressure and transmission may result in prevailing accumulation of specific gyrA mutations causing high-level FQ resistance, therefore, current control measures need to be strengthened.

Fluroquinolone drug resistance among MDR-TB patients increases the risk of unfavourable interim microbiological treatment outcome: An observational study.

OBJECTIVES: Sputum culture conversion at the end of the intensive phase of multidrug-resistant tuberculosis (MDR-TB) treatment is a key predictor for successful treatment outcome. This observational study was undertaken to assess the interim microbiological outcome of a cohort of rifampicin-resistant (RR)-TB patients with variable resistance to second-line drugs. METHODS: During Jan-Apr 2018, we consecutively enrolled 100 RR-TB patients, who underwent phenotypic drug susceptibility testing (DST) to assess baseline resistance to second-line drugs. Following RR-TB diagnosis, these patients were started on MDR-TB treatment. After 6 months of treatment, sputum culture conversion status was determined. Data were analysed to assess the impact of resistance to second-line drugs on culture conversion. RESULTS: DST of 100 RR-TB patients showed a high resistance to fluoroquinolones (FQs; levofloxacin 56%; moxifloxacin 44%) followed by kanamycin (8%) and capreomycin (6%). None of the patients were resistant to the other drugs tested (amikacin, clofazimine and linezolid). At 6-month treatment follow-up, 28 patients had been lost to follow-up and eight had died. Microbiological outcome was obtained from the remaining 64 patients, but successful culture conversion was achieved in only 62.5% of the patients. FQ resistance was found to be a strong predictor (P<0.001) for unfavourable microbiological outcome. CONCLUSION: The rate of FQ resistance in RR/MDR-TB is high and has strong association with unsuccessful interim microbiological outcome of conventional MDR-TB treatment.

Study of Association of Fetal Cerebroplacental Ratio with Adverse Perinatal Outcome in Uncomplicated Term AGA Pregnancies.

BACKGROUND: The cerebroplacental ratio (CPR) is emerging as a predictor for adverse perinatal outcome in term pregnancies. Earlier, it has shown a role in small for gestational age (SGA) pregnancies, but a proportion of appropriate for gestational age foetuses (AGA) despite of good size have impaired growth velocity and are thereby at risk of adverse outcome. CPR has implication for assessment of well being of SGA and AGA foetuses close to term. OBJECTIVE: To investigate the association between foetal CPR and adverse perinatal outcome in uncomplicated term AGA pregnancies. METHODS: This was a prospective observational study done in Department of Obstetric and Gynaecology, King George Medical University, Lucknow, over a period of one year. Women > 37 week singleton pregnancy with no known risk factor who had Doppler USG done within a week of delivery were included. CPR was calculated by dividing the Doppler indices of middle cerebral artery (MCA) by umbilical artery (MCA PI/UA PI). CPR < 1 was taken as abnormal. These patients were followed up till delivery to look for various perinatal outcomes. Results Out of 127 low-risk AGA pregnancies who went for USG colour Doppler scan, 117 patients who met our inclusion criteria were analysed; out of 117 patients 23(i.e. 19.65 %) were having CPR < 1 and 94 patients (i.e. 80.34%) were having CPR>1. Among 23 patients with CPR < 1, 22 (91.30%) had adverse outcome as compared to only 20.21% patients with CPR > 1, and this is found to be statistically significant (p < 0.001). CONCLUSION: Our study found CPR measure to be a very promising tool for optimising the identification of at risk foetus in low-risk AGA pregnancies.

An Evaluation of Applicability of Salivary Uric Acid Measurement in Preeclampsia and Normal Pregnancy and Its Correlation with Serum Uric Acid.

PURPOSE: Hypertensive disorders complicate 5-10% of all pregnancies and contribute greatly to maternal morbidity and mortality. There are various biomarkers for detection of preeclampsia. Several studies have reported that positive correlation exists between serum uric acid (UA) levels and adverse maternal and fetal outcome. Significant advances have been made toward validation of salivary biomarkers. We conducted this study to determine levels of salivary UA and its correlation with serum UA normal pregnancy and preeclampsia. METHODS: Present cross-sectional study was conducted in tertiary care teaching hospital in North India. One hundred and fifty participants were divided into control group (50 healthy non-pregnant females), study group I (50 normotensive pregnant females), study group II (50 pregnant females with preeclampsia), and both salivary and serum UA was estimated at the same time. RESULTS: Saliva UA of study group II (4.86 ± 2.37 mg/dl) was significantly higher (p < 0.001) than that of control group (2.09 ± 1.33 mg/dl) and study group I (3.32 ± 1.77 mg/dl). Serum UA of study group II (6.63 + 2.78 mg/dl) was significantly higher (p < 0.001) than that of control group (2.94 + 1.94 mg/dl) and also study group I (5.18 + 2.31 mg/dl) (p = 0.0006). CONCLUSION: UA is present in the saliva of women with preeclampsia and has linear correlation with serum UA. Therefore, salivary UA can be used in place of invasive serum UA to monitor women with preeclampsia. Saliva collection is easy, noninvasive and cost-effective. Salivary UA testing may be useful for monitoring preeclampsia at home-based and hospital setting.

Association of IL-10 Gene Polymorphism (-819C > T, -592C > A and -1082G > A) with Preterm Birth.

OBJECTIVE: To analyze the association of IL-10 gene and its polymorphisms with preterm birth (PTB). METHODS: Five hundred and fifty nine women with term birth and 559 with preterm birth were recruited from Lucknow, India. Genetic association analysis was conducted between cases and controls. Subjects recruited as cases were women (aged between 18-40 y) with singleton delivery before 37 wk of gestation and controls were with delivery after or on 37 wk. The genotyping was performed for rs1800871, rs1800872 and rs1800896 for assessing the allelic distribution, haplotypic association and linkage disequilibrium analysis. IL-10mRNA levels were evaluated by real time quantitative polymerase chain reaction (PCR) method. RESULTS: The risk of PTB was found significant in women carrying IL-10 (-1082) GA genotype [OR=1.72(1.7-2.5), p=0.006]. The haplotypic analysis of studied polymorphisms for rs1800871, rs1800872 and rs1800896 depicted the association of ATA (p=0.02) and ATC (p=0.01) haplotypes with PTB. The IL-10 mRNA levels were significantly lower in cases (p=0.05). CONCLUSIONS: IL-10 marks a protective impact in the inflammatory pathway of PTB.

Circadian periodicity of plasma lipid peroxides and other anti-oxidants as putative markers in gynecological malignancies.

BACKGROUND: The chronome (from chronos, time, and nomos, rule), or time structure, of lipid peroxidation and anti-oxidant defense mechanisms may relate to prevention and curative chronochemotherapeutic efficacy and management. PATIENTS AND METHODS: Newly diagnosed women with gynecological malignancies (N = 30), 30-60 years of age, and age-matched clinically healthy women (N = 35) provided blood samples every 6 hours for 24 hours under standardized conditions. Plasma malondialdehyde (MDA), superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) and glutathione reductase (GR) activities, and serum ascorbate, urate and high-density lipoprotein cholesterol (HDL-C) concentrations were determined. RESULTS: Each variable underwent circadian variation (p < or = 0.002). Patients differed from controls by their overall chronome-adjusted mean value (MESOR) and by the circadian dynamics in the spectral element of their chronome. CONCLUSION: Chronomes of putative anti- and pro-oxidants should be mapped to explore their putative chemotherapeutic role as markers in cancer chronoprevention and management of established disease.

Molar pregnancy in postmenopausal women: a rare phenomenon.

Benign gestational trophoblastic disease generally occurs in women of the reproductive age group and is extremely rare in postmenopausal women. We describe a case of complete hydatidiform mole in a 60-year-old postmenopausal woman who was referred with diagnosis of suspected malignancy/myoma resulting in delay in management. This case highlights the fact that gestational trophoblastic disease can occur in menopausal woman and this should be included in the differential diagnosis of perimenopausal and postmenopausal haemorrhage to prevent delay in diagnosis and treatment.