Unusual presentation of hairy cell leukemia: a case series of four clinically unsuspected cases

Hairy cell leukemia (HCL) is characterized by pancytopenia and usually associated with massive splenomegaly, however the same may not be true in the clinical settings. Here we report four cases of HCL and all of them were without the classical clinical feature of splenomegaly. This is an observational study conducted between January 2013 to March 2014 where we could diagnose ten cases of HCL in Department of Hematology, All India Institute of Medical Sciences, New Delhi. Of these, four cases attracted attention because of absence of classical clinical features of HCL. Of the four cases, three presented with weakness/fatigability while fourth patient presented with recurrent respiratory tract infection. Surprising finding in these cases was absence of splenomegaly, both clinically and on imaging which demerit the suspicion of HCL clinically. All four had bi/pancytopenia and bone marrow examination coupled with immunophenotypic analysis confirmed the diagnosis of HCL. Three patients received chemotherapy with cladribine and achieved complete hematological remission. One patient did not receive chemotherapy due to poor general condition and was subsequently lost to follow up. To conclude, HCL can and do present without splenomegaly and this should not restrain one from suspecting HCL based on histomorphology which needs to be further confirmed by ancillary techniques. This finding in our series could be because these cases were picked early in their natural course of the disease. A high index of suspicion is essential for diagnosing and appropriately managing such cases.

Myocardial infarction following bee sting

Bee stings are commonly encountered worldwide. Various manifestations after bee sting have been described. Local reactions are common. Unusually, manifestations like vomiting, diarrhoea, dyspnoea, generalised oedema, acute renal failure, hypotension and collapse may occur. Rarely vasculitis, serum sickness, neuritis and encephalitis have been described which generally develop days to weeks after a sting. Acute coronary syndromes after hymenoptera stings and other environmental exposures are referred to as the Kounis syndrome or allergic myocardial ischaemia and infarction. We report a 60 year old male who developed myocardial infarction after multiple bee stings over his body.

Factors determining intention to quit tobacco: exploring patient responses visiting public health facilities in India

Introduction

Intention to quit and setting a quit date are key steps in the process towards improving quit rates and are thus an integral part of tobacco cessation efforts. The present study examined various motivating factors of “intention to quit” and “setting a quit date” in patients visiting public health facilities in two states of India.

Methods

A total of 1569 tobacco-users visiting public health facilities in 12 districts of the states of Andhra Pradesh and Gujarat were assessed through an interviewer-administered questionnaire. Bivariate and multivariable logistic regression was performed to assess the effect of socio-demographic characteristics, nicotine dependence, previous quit attempts and motivational factors on “intention to quit within 30 days” and “setting a quit date”.

Results

Only 12% of patients intended to quit tobacco within 30 days and about 11% of them were ready to set a quit date. Respondents aged above 25 years were 53% less likely to quit tobacco within 30 days when compared to those below 25 years (95% Confidence Intervals [CI]: 0.22 to 0.99). Smokeless tobacco users were associated with an odds ratio (OR) of 2.05 (95% CI: 1.15 to 3.65) for “setting a quit date” when compared to smokers. Those with 1 to 5 previous quit attempts (in the past twelve months) were associated with an OR of 2.2 (95% CI: 1.38 to 3.51) for “intention to quit” and 2.46 (95% CI: 1.52 to 3.96) for “setting a quit date”. “Concern for personal health” and “setting an example for children” were associated with ORs of 3.42 (95% CI: 1.35 to 8.65) and 2.5 (95% CI: 1.03 to 6.03) respectively for “setting a quit date”.

Conclusions

This study is amongst the first in India to explore factors associated with the “intention to quit” and “setting a quit date” among patients visiting public health facilities. Our findings suggest that socio-economic and individual-level factors are important factors depicting intention to quit and setting a quit date. We recommend the need for well-defined studies to understand the long term effects of factors influencing tobacco cessation for patients visiting public health facilities in India.

Hot electron attenuation of direct and scattered carriers across an epitaxial Schottky interface

Hot electron transport of direct and scattered carriers across an epitaxial NiSi2/n-Si(111) interface, for different NiSi2 thickness, is studied using ballistic electron emission microscopy (BEEM). We find the BEEM transmission for the scattered hot electrons in NiSi2 to be significantly lower than that for the direct hot electrons, for all thicknesses. Interestingly, the attenuation length of the scattered hot electrons is found to be twice as large as that of the direct hot electrons. The lower BEEM transmission for the scattered hot electrons is due to inelastic scattering of the injected hot holes while the larger attenuation length of the scattered hot electrons is a consequence of the differences in the energy distribution of the injected and scattered hot electrons and the increasing attenuation length, at lower energies, of the direct hot electrons in NiSi2.

Impact of neuraminidase inhibitor treatment on outcomes of public health importance during the 2009-2010 influenza A(H1N1) pandemic: a systematic review and meta-analysis in hospitalized patients

BACKGROUND

The impact of neuraminidase inhibitor (NAI) treatment on clinical outcomes of public health importance during the 2009-2010 pandemic has not been firmly established.

METHODS

We conducted a systematic review and meta-analysis, searching 11 databases (2009 through April 2012) for relevant studies. We used standard methods conforming to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using random effects models.

RESULTS

Regarding mortality we observed a nonsignificant reduction associated with NAI treatment (at any time) versus none (OR, 0.72 [95% CI, .51-1.01]). However we observed significant reductions for early treatment (≤48 hours after symptom onset) versus late (OR, 0.38 [95% CI, .27-.53]) and for early treatment versus none (OR, 0.35 [95% CI, .18-.71]). NAI treatment (at any time) versus none was associated with an elevated risk of severe outcome (OR, 1.76 [95% CI, 1.22-2.54]), but early versus late treatment reduced the likelihood (OR, 0.41 [95% CI, .30-.56]).

CONCLUSIONS

During the 2009-2010 influenza A(H1N1) pandemic, early initiation of NAI treatment reduced the likelihood of severe outcomes compared with late or no treatment.

PROSPERO REGISTRATION

CRD42011001273.

Outcomes of deliveries in a midwife-run labour room located at an urban health centre: results of a 5-year retrospective study

BACKGROUND

We report the short-term maternal and neonatal outcomes for all deliveries conducted in a midwiferun labour room located at an urban health centre serving an urban population of Vellore, Tamil Nadu.

METHODS

This 5-year (2005-10) retrospective study included all birth records including those of women and neonates transferred to our tertiary care referral centre. Maternal and neonatal outcomes were analysed among deliveries in the urban health centre and at the tertiary care referral centre.

RESULTS

There were 1873 deliveries during the study period. One-third of women (679, 36.3%) were referred to the tertiary care centre. Seven (0.6%) women had postpartum haemorrhage. There were neither any maternal deaths nor any women with postpartum sepsis. Among the neonates, there were 20 (1.7%) stillbirths, 4 (0.3%) early neonatal deaths and 56 (4.7%) born with an Apgar score of <8.

CONCLUSION

Skilled midwife care during the antenatal period and during labour leads to good maternal and neonatal health outcomes. Implementing similar programmes could immensely improve the maternal and neonatal health indicators of India.

Stroke after multiple bee sting

Bee stings are commonly encountered worldwide. Various manifestations after bee sting have been described. Local reactions are common. Unusually, manifestations like vomiting, diarrhea, dyspnea, generalized edema, acute renal failure, hypotension and collapse may occur. Rarely vasculitis, serum sickness, neuritis and encephalitis have been described which generally develop days to weeks after a sting. We report a case of a 25-year-old male who developed left sided monoparesis and transient visual loss following multiple bee stings. Unlike the previous case reports, in our case there has been involvement of both the anterior circulation and posterior circulation territory to the brain. We report this case due to it's rarity.

Integration of Multi-Level Copper Metallization into a High Performance Sub-0.25μM Technology

We report the integration of six levels of Cu interconnects using dual inlaid patterning in a 0.2 μm logic technology. A review of process technology as well as device performance shortcomings using conventional aluminum metallization has been presented. Two tantalum based barriers, TaNx and Ta-Si-N as well as a titanium based barrier, CVD TiN, have been evaluated for their applicability. The use of embedded barriers wherein the barrier is formed below the surface of the dielectric has also been discussed as a potential option. No degradation to the device front-end parametrics were found with the choice of an appropriate barrier. Planarization by Cu CMP introduces surface topography that needs to be minimized in order to process multiple levels of interconnects within specified sheet resistance distributions for a range of line widths. Excellent results with highly planarized levels of metallization have consistently been achieved through an optimization of the unit processes and device integration.

Indian scales and inventories

This conceptual, perspective and review paper on Indian scales and inventories begins with clarification on the historical and contemporary meanings of psychometry before linking itself to the burgeoning field of clinimetrics in their applications to the practice of clinical psychology and psychiatry. Clinimetrics is explained as a changing paradigm in the design, administration, and interpretation of quantitative tests, techniques or procedures applied to measurement of clinical variables, traits and processes. As an illustrative sample, this article assembles a bibliographic survey of about 105 out of 2582 research papers (4.07%) scanned through 51 back dated volumes covering 185 issues related to clinimetry as reviewed across a span of over fifty years (1958-2009) in the Indian Journal of Psychiatry. A content analysis of the contributions across distinct categories of mental measurements is explained before linkages are proposed for future directions along these lines.

Mathematics Anxiety, Mathematics Performance and Overall Academic Performance in High School Students

This paper examined the relationship between Mathematics anxiety, Mathematics performances and overall academic performance in high school students. 424 (111 males and 113 females) of high school students from three states in South India, responded to a Mathematics Anxiety Scale and Socio Demographic Questionnaire. The effects of gender on Mathematics anxiety, Mathematics performance and overall academic performance were examined and after data collection Pearson Correlation Analysis and two Independent Sample T test were used to analyze the data. Consequences reveal that Mathematics Anxiety significantly has negative correlation with Mathematics performances and overall academic performance. Moreover it was found that there is significant gender difference in Mathematics anxiety, whereas there is no significant difference between boys and girls in Mathematics performances and academic performance.

Transgenic resistance by N gene of a Peanut bud necrosis virus isolate of characteristic phylogeny

The nucleocapsid protein (N) gene of a Tospovirus devastating tomato crop in the south Indian state of Tamil Nadu was cloned and characterized. The high identity of the cloned sequence to a Peanut bud necrosis virus (PBNV) tomato isolate (97.8/99.6% nucleotide/amino acid) and a PBNV peanut isolate (94.4/96.3% nucleotide/amino acid) identified the Tospovirus as an isolate of PBNV, designated PBNV Coimbatore tomato (PBNV CT) isolate. Phylogenetic analysis of PBNV CT N gene provided useful insights into the movement and evolution of PBNV within Indian Territory. The characteristic phylogeny of PBNV CT N gene implied its potential to be an efficient transgene to confer effective PBNV resistance on crop plants. The efficacy of PBNV CT N gene in conferring PBNV resistance was studied by generating tobacco (Nicotiana tabacum L. cv Wisconsin) lines transgenic to the sense or antisense version of the gene. Several transgenic lines showed transgenic mRNA and/or protein accumulation, ranging from very high to undetectable levels, accompanied by different degrees of PBNV resistance. The undetectable or very low levels of transgene transcripts in certain PBNV-resistant sense or antisense N gene transgenic lines suggested RNA-mediated resistance by post-transcriptional gene silencing (PTGS) mechanism. However, PBNV resistance of certain transgenic lines with high levels of N gene transcripts was suggestive of possible operation of RNA-mediated non-PTGS mechanism(s) of resistance in those lines. Moreover, the high levels of N protein in certain PBNV-resistant sense N gene transgenic lines suggested protein-mediated resistance. The results predict the potential of PBNV CT N gene to confer effective PBNV resistance on tomato and other economically important crops.

Pulmonary hypertension in rheumatoid arthritis--relation with the duration of the disease

Isolated pulmonary hypertension with clinical implication is rare in rheumatoid arthritis. We sought to study the prevalence of pulmonary arterial hypertension in an unselected population of 45 patients with rheumatoid arthritis (classified according to the ARA criteria) without cardiac disease and corresponding age and sex matched controls by Doppler echocardiography. The pulmonary artery systolic pressure was higher in patients with Rheumatoid Arthritis (27.49+/-12.66 mm Hg) than in controls (20.40+/-8.88) (p=0.003). Incidence of pulmonary artery systolic pressure>30 mm Hg suggesting pulmonary hypertension was significantly higher in patients with RA (26.7% versus 4.5% in controls; p=0.03) and 20% of patients had pulmonary hypertension without lung disease or cardiac disease evident on pulmonary function testing, and echocardiogram respectively. There was also a strong correlation between the pulmonary artery pressure and the disease duration (r=0.68, p<0.0001) suggesting a subclinical involvement of the pulmonary vasculature with disease progression and may be relevant to the high incidence of cardiovascular deaths observed in patients with Rheumatoid Arthritis.

Diastolic function abnormalities in rheumatoid arthritis: relation with duration of disease

INTRODUCTION

There are limited studies on the prevalence of diastolic dysfunction in rheumatoid arthritis (RA) from the Indian subcontinent. The aim of this study was to evaluate left ventricular filling abnormalities in patients with RA without clinically-evident cardiovascular manifestations, and to correlate it with disease duration.

METHODS

45 patients affected with RA according to the American Rheumatism Association criteria, were selected without evidence of cardiac disease, and compared with age- and sex-matched control subjects. All patients and the control group were submitted to M-mode, two-dimensional and Doppler echocardiography. The following diastolic parameters were evaluated: peak of early diastolic (E) and late diastolic (A) mitral flow velocity, E/A ratio, isovolumic relaxation time (IVRT), ejection fraction and fractional shortening.

RESULTS

In RA patients, left ventricular filling abnormalities were found characterised by a reduced E/A ratio (mean [SD] 0.98 [0.22] versus controls 1.09 [0.11]; p-value equals 0.004), prolonged IVRT (75.77 [8.12] ms versus 70.43 [2.94] ms; p-value equals 0.001) and increased late diastole flow velocity (76.91 [11.61] cm/s versus 70.11 [5.32] cm/s; p-value equals 0.001). In the group of patients, a negative correlation was found between E/A ratio and disease duration (Pearson correlation, r equals -0.56, p-value equals 0.001), indicating diastolic dysfunction with increasing disease duration. A strong correlation was also found between IVRT and disease duration (r equals 0.66, p-value equals 0.01) and also between late diastolic flow velocity and disease duration (r equals 0.61, p-value equals 0.001).

CONCLUSION

The present study confirms a high frequency of left ventricular diastolic dysfunction characterised by impaired E/A ratio, prolonged IVRT and increased late diastole flow velocity in patients with RA without evident cardiovascular disease. The correlation between transmitral flow alteration and disease duration suggests a subclinical myocardial involvement with disease progression. This may be relevant to the high incidence of cardiovascular deaths observed in patients with RA.

Glucose Production in the Human Placenta

Glucose transfer from mother to fetus by placental facilitated diffusion is the dominant mechanism by which the fetus acquires glucose. In small for gestational age pregnancies, fetal glucose concentrations tend to be lower than normal and this persists following delivery. GLUT1 is the major glucose transporter in human placenta but there is no evidence of GLUT1 deficiency as a cause of the lower fetal glucose concentration in small for gestational age pregnancy. The physiological and pathological roles of the other glucose transporters (and there are 14 currently described) are unknown. In recent years, the possibility has been raised that the placenta is itself capable of supplying glucose for fetal needs. This hypothesis derived from glucose isotope studies in normal pregnancy, where dilution of glucose isotope was demonstrated in blood samples taken from the fetal circulation during intravenous infusion of glucose isotope in the mother. Although other gluconeogenic enzymes were known to be present, the placenta was previously considered incapable of glucose secretion because it lacked functional glucose-6-phosphatase. Recent studies, however, have suggested that specific glucose-6-phosphatase may be present in placenta but it may be the product of a different gene from conventional hepatic glucose-6-phosphatase. The presence of the specific transporters necessary for glucose-6-phosphatase activity is currently being investigated. The role of placental glucose secretion in normal and growth-restricted pregnancies is an area of current study.

Patterns and predictors of prehypertension among "healthy'' urban adults in India

Cardiovascular disease is still on the increase in India owing to changing socioeconomic factors and unhealthy lifestyles. Better understanding of the role of hypertension (HTN) has led to new Joint National Committee (JNC-7) guidelines for its diagnosis and management. The authors aimed to evaluate the predictors and correlates of prehypertension (PreHTN) among adults in urban India. Study design is a cross-sectional survey among 2,007 adults in Chennai in July 2003; 1,505 men and 502 women over the age of 18 years were studied. Demographic data collected by direct interview were the following: age, smoking, alcohol intake, type of work, exercise patterns, and monthly income. Anthropometric data of height, weight, and waist and hip dimensions were measured. Blood pressure (BP) was recorded thrice, with at least 15 minutes between readings 2 and 3. The mean of readings 2 and 3 was taken for the study. Of the 2,007 people studied, 951 (47.4%) had PreHTN and 696 (34.7%) had HTN. PreHTN was found in 46.6% of the men and 49.8% of the women. PreHTN was prevalent in 47.4% of adults, and another 34.7% had hypertension (Stage I, 20%, and Stage II, 14.7%). In urban India less than 18% of adults have normal BP of less than 120/80. Multiple logistic regression analysis after age and sex correction identified obesity, diet, family history and middle-income group as correlating with PreHTN. The factors that predict HTN were age, sex, smoking, alcohol intake, sedentary lifestyle, and type of work.

Efficacy and optimal dose of sildenafil in primary pulmonary hypertension

PURPOSE

We aimed to assess the effects of sildenafil and evaluate optimal dosing in primary pulmonary hypertension (PPH). Sildenafil selectively inhibits phosphodiesterase 5 (PDE5), which is abundant in pulmonary and penile tissue. This results in increasing nitric oxide (NO) at tissue level leading to pulmonary vasodilatation.

SUBJECTS AND METHODS

Our study was a prospective study of sildenafil in 15 consecutive patients with severe symptomatic PPH of NYHA class III-IV. All patients were stabilized for a minimum period of 5 days with antifailure medications. Sildenafil was started at 50 mg twice daily for 4 weeks and increased to 100 mg bid for 4 more weeks in a step-up protocol. Primary end-points were change in Borg dyspnea index, NYHA class and 6-min walk distance, estimated at baseline 1, 2, 4 and 8 weeks.

RESULTS

NYHA class (baseline 3.8 +/- 0.4 vs. 4 weeks 2.4 +/- 0.5, p = 0.002), Borg dyspnea index (8.1 +/- 1.7 vs. 4.4 +/- 1.9, p = 0.0007), 6-min walk distance (234 +/- 44 vs. 377 +/- 128 m, p = 0.001) and Pulmonary artery pressure (125 +/- 15 vs. 113 +/- 18 mm Hg p = 0.05) are significantly improved with sildenafil 50 mg bid at 4 weeks. Increasing the dose to 100 mg bid did not produce further benefit. Echocardiography parameters of right heart dimensions and functions did not change markedly in the study period.

CONCLUSION

Sildenafil is well tolerated with no adverse effects in severe pulmonary hypertension. It reduces symptoms, improves effort tolerance and controls refractory heart failure significantly by 2 weeks in 70% of patients at 50 mg twice daily. Three patients (20%) failed to respond with sildenafil.

Increased leucine turnover in women during the third trimester of uncomplicated pregnancy

Plasma amino acid concentrations decrease in pregnancy despite increased requirements for both maternal and fetal protein accretion. There are few published data on changes in amino acid turnover in pregnancy. The aim of this study is to test the hypotheses that (1) whole body nonoxidative leucine disposal (NOLD) is higher and (2) whole body oxidative leucine disposal (OLD) is lower in the third trimester of pregnancy than in the nonpregnant state. After an overnight fast 8 pregnant women between 33 and 35 weeks gestation had a primed infusion of labeled [1-(13)C] leucine and a prime dose of NaH(13)CO(3). Carbon dioxide production was measured using indirect calorimetry. Gas chromatography-mass spectrometry was used to determine (13)CO(2) enrichment of expired air and oxidative and nonoxidative leucine turnover by measuring (13)C keto-isocaproate plasma enrichment, which reflects intracellular leucine enrichment. Women acted as their own controls after the puerperium. Whole body leucine turnover expressed per unit body weight was increased in pregnancy (median [interquartile range or IQR]: pregnant = 103.1 [14.9] v nonpregnant = 90.1 [10.9] micromol/kg/h). The mean (+/-SD) of the differences was 11.4 +/- 5.6 micromol/kg/h, P =.0006. NOLD was increased in pregnancy (pregnant = 86.8 [10.1] v nonpregnant = 73.3 [9.5] micromol/kg/h). The mean (+/-SD) of the differences was 10.6 +/- 5.4 micromol/kg/h, P =.0008. OLD was not significantly altered in pregnancy (pregnant = 17.3 [4.5] v nonpregnant = 15.91 [2.4] micromol/kg/h). The mean (+/-SD) of the differences was 0.84 +/- 1.94 micromol/kg/h, P =.26. In conclusion, women have significantly higher NOLD in the third trimester of pregnancy than when not pregnant but there are no significant changes in OLD.