Statins Ticagrelor and Rhabdomyolysis: A Coincidence or a Drug Interaction?

Objective

Statins play a key role in the management of atherosclerotic cardiovascular disease for both primary and secondary prevention. However, their increasing usage has correspondingly led to a higher incidence of adverse effects, with muscle symptoms being the most common. An intriguing drug interaction exists between ticagrelor and high-intensity statins, which may exacerbate the adverse effects of statin-induced rhabdomyolysis, leading to significant consequences. This study was conducted to examine the profile of patients who have experienced statin-induced rhabdomyolysis while undergoing percutaneous transluminal coronary angioplasty (PTCA).

Methods

This was an observational study that included 1,862 patients who underwent PTCA at our institute over the course of 1 year.

Results

Over a 1-year period, we encountered four patients who were being treated with high-intensity statin therapy following acute coronary syndrome. These patients presented with muscle weakness and kidney injury. A notable commonality among all patients was the co-prescription of ticagrelor. Two patients died, while the other 2 were successfully managed through hydration, electrolyte balance, dialysis, and alternative lipid management drugs.

Conclusion

The concomitant use of ticagrelor and high-intensity statins should be carefully considered due to the additional risk of rhabdomyolysis and kidney injury. Future pharmacokinetic studies are needed to establish a causal relationship and predict potential drug interactions, which, if not avoided, could be fatal.

Prophylactic bilateral internal iliac balloon occlusion to control hemorrhage in placenta accreta spectrum: a boon for obstetricians

BACKGROUND

Placenta accreta spectrum (PAS) is abnormal placental adhesion beyond superficial myometrium, which may lead to severe life-threatening hemorrhage requiring massive blood transfusions in the peripartum period. Prophylactic balloon catheterization of bilateral internal iliac arteries with or without additional embolization with Cesarean hysterectomy in patients with PAS prevent excessive intraoperative hemorrhage and may also obviate the need for hysterectomy.

PURPOSE

To study the efficacy of intervention radiological procedures in controlling intraoperative hemorrhage in patients with PAS.

MATERIAL AND METHODS

This ethically approved prospective study was conducted between November 2017 and October 2019 and written informed consent was obtained from all patients. Consecutive patients diagnosed with PAS during the antepartum period were evaluated. A total of 18 patients with PAS underwent prophylactic balloon catheterization of the bilateral internal iliac arteries followed by delivery of the infant. Interventional and intraoperative data of these patients were collected and compared with retrospectively collected data of patients (control group) who underwent hysterectomy without prophylactic balloon occlusion over the past four years (January 2016-November 2019).

RESULTS

Significantly lower intraoperative blood loss (2.8 L vs. 4.7 L; P = 0.048) and pure red blood cell (PRBC) requirement (P = 0.026) between patients who had hysterectomy with and without interventional radiological management was observed. Significantly higher blood loss (P = 0.006) and fluid requirement (P = 0.007) was observed with a higher degree of placental invasion. Only 1 (6%) major procedure-related complication was observed.

CONCLUSION

Interventional radiological procedures are effective in significantly reducing intraoperative blood loss and blood product requirement in patients with PAS.

Origin of all Three Coronaries from Single Ostium: A Rare Case Report

Origin of coronary arteries from the opposite sinus of Valsalva is rare and origin from a single ostium is extremely rare. Patients with these anomalies may have myocardial ischemia because of altered ostial configuration, exit angulation from the aorta, the course between great arteries, and atherosclerosis. Usually, these anomalies are diagnosed during coronary angiography either by computed tomography or catheter-based. Management depends upon the coronary anomaly and associated clinical condition.

An evaluation of Composite Reference Standard (CRS) for diagnosis of Female Genital Tuberculosis

BACKGROUND

Female genital tuberculosis (FGTB) is a common cause of infertility in developing countries. Its diagnosis is difficult due to its paucibacillary nature, with no single test having high sensitivity and specificity. This study is to share the experience of using Composite Reference Standard (CRS) for the diagnosis of FGTB.

METHODS

This is a prospective study conducted between September 2017 to June 2019, over 100 infertile females found to have FGTB on composite reference standard which consisted of acid-fast bacilli on microscopy or culture, histopathological evidence of epithelioid granuloma, positive gene Xpert on endometrial sample or definite or probable finding of FGTB on laparoscopy.

RESULTS

A total of 100 infertile women (78% primary, 22% secondary) found to have FGTB on CRS were enrolled in this study. Mean age, body mass index, parity and duration of infertility were 28.2 years, 23.17 kg/m², 0.24 ± 0.12 and 2.41 years respectively. Various symptoms were scanty menses (16%), irregular cycle (7%), dysmenorrhea (11%), pelvic pain (11%). Various signs were vaginal discharge (65%), adnexal mass (6%), tubo-ovarian mass on ultrasound (15%), abnormal hysterosalpingography findings (57.14%), positive polymerase chain reaction test (65%) and abnormal hysteroscopy (82.2%). The positive findings on CRS were positive AFB on microscopy or culture (3%), positive gene Xpert (28%) (done in some cases), epithelioid granuloma on histopathology (13%), definite findings on laparoscopy like tubercles, caseous nodules and beaded tubes in (57.19%) patients while probable findings of FGTB like straw colored fluid in POD, extensive dense pelvic, peri-tubal, peri-ovarian adhesions; hydrosalpinx; tubo-ovarian mass; thick fibrosed tubes; mid tubal block; peri hepatic adhesions (Fitz Hugh Curtis Syndrome); hyperemia of tubes/blue uterus on chromotubation were seen in (48.8%) patients. All patients found to be positive on CRS were given 6 months of anti-tubercular therapy.

CONCLUSION

This study demonstrates the high reliability of use of composite reference standard for diagnosis of FGTB.

Role of Magnetic Resonance Imaging in evaluation of tuberculous tubo ovarian mass

OBJECTIVE

Role of Magnetic Resonance Imaging (MRI) in diagnosis of tuberculous tubo-ovarian (TO) mass.

METHODS

MRI was performed on 33 patients of tuberculous TO mass of female genital tuberculosis (FGTB).

RESULTS

Mean age, BMI, and parity was 27.5 ± 4.2 years, 22.7 ± 3.6 kg/m², and 0.27 ± 0.13. All patients (100%) had infertility; primary infertility (72.72%) and secondary infertility (27.23%) with mean 5.8 years. Abdominal/pelvic pain 33 (100%) cases, abdominal lump 4 (12.12%), adnexal mass 33 (100%). MRI findings showed pelvic masses 33 (100%), bilateral TO masses 11 (33.33%), cystic lesion 4 (12.12%), solid cystic lesion 3 (9.09%) with bilateral pyosalpinx 1 (3.3%), homogeneous content with ascites 1 (3.03%), rim enhancing lesion abutting pelvic wall in 1 (3.03%). Right adnexal mass 11 (33.33%), right adnexal cyst 2 (6.06%), right adnexal cystic mass in 1 (3.03%), right sided complex TO mass 1 (3.03%), right sided hydrosalpinx in 1 (3.03%) case, right sided TO mass in 4 (12.12%) cases and right sided para-ovarian cyst in 2 (6.06%). Left sided adnexal mass was seen in 11 (33.33%), cystic lesion in 1 (3.03%), ovarian cyst in 3 (9.09%) cases, left sided hydrosalpinx in 2 (6.06%), left ovarian cyst 2 (6.06%) cases, left sided ovarian cyst with encysted ascites 1 (3.03%) case and with left sided paraovarian cyst 2 (6.06%) case. Miscellaneous finding were generalised ascites (6.06%), encysted ascites (3.03%), pelvic (1; 3.03%) and mesenteric lymphadenopathy 1 (3.03%). Incidental finding were fibroid 3 (9.09%) and adenomyosis 1 (3.03%) case.

CONCLUSION

MRI appears to be useful diagnostic modality for tuberculous TO masses where differential diagnosis is malignancy but molecular diagnosis remains the gold standard.

Marker-assisted transfer of leaf and stripe rust resistance from Triticum turgidum var. durum cv. Trinakria to wheat variety HD2932

A marker-assisted backcrossing program initiated to transfer leaf rust resistance gene LrTrk from Triticum turgidum cv. Trinakria to hexaploid wheat variety HD2932 cotransferred a stripe rust resistance gene, YrTrk, along with LrTrk. The cross of hexaploid recurrent parent HD2932 with tetraploid donor parent Trinakria produced pentaploid F₁ plants. F₁s were backcrossed with recurrent parent HD2932 to produce BC₁F₁ generation. Foreground and background selection was conducted in each backcross generation to identify plants for backcrossing or selfing. While foreground selection for LrTrk was carried out with linked and validated molecular marker Xgwm234, for background selection, 86 polymorphic SSR markers from the A and B genomes were used. Single selected plants from BC₁F₁ and BC₂F₁ generations backcrossed and selfed to produce BC₂F₁and BC₂F₂ generations, respectively. Background selection resulted in 83.72%, 91.86%, and 98.25% of RPG recovery in BC₁F₁, BC₂F₁, and BC₂F₂ generations, respectively. A total of 27 plants with LrTrk in homozygous state were identified in BC₂F₂ generation and selfed to produce 27 BC₂F₃ NILs. All the NILs were tested for leaf and stripe rust resistance at the seedling stage using seven Puccinia triticina and one Puccinia striiformis f.sp. tritici rust pathotypes. All the 27 NILs were found to be resistant to both leaf and stripe rust pathotypes. So, these NILs are designated to carry leaf and stripe rust resistance genes LrTrk/YrTrk.

Obstetrics outcome in pulmonary tuberculosis

BACKGROUND

To evaluate the maternal and perinatal outcome in pulmonary tuberculosis cases as compared to low risk pregnancies in a tertiary referral hospital.

METHODS

A total of 15 cases of pulmonary tuberculosis over a period of two years who delivered in our unit was studied in the retrospective study. The maternal and perinatal outcome in them was compared with 191 low risk pregnancies who delivered at the same time in the hospital after taking into account inclusion and exclusion criteria.

RESULTS

The mean age and mean parity was 25.73 ± 2.85 and 28.75 ± 3.11, 2.1 and 1.9 in the 2 groups. Symptoms of pulmonary tuberculosis were cough (100%), chest pain (80%), expectoration (100%), hemoptysis (33.3%), fever (93.33%), anorexia (86.66%) and loss of weight (80%). Symptoms in study patients were significantly more common in study patients. The presence of associated medical problems was similar in the 2 groups. The prevalence of oligoamnios, gestational diabetes mellitus, antepartum hemorrhage and intrahepatic cholestasis was similar in the 2 groups. Prevalence of preterm labor was 53.33% in study group which was significantly higher than in controls (8.9%). Risk of premature rupture of membrane was also significantly higher in the study groups (53.33%) as compared to control groups (8.9%). Mean gestational age was also significantly lower (36.2 weeks) in study group as compared to 38.6 weeks in control group. The incidence of cesarean delivery was similar in the 2 groups (26.66% vs 28.79%). The mean birth weights was 2308.6 gm in the study group as compared to 2707.56 gm in control group. Fetal growth restrictions and Respiratory distress syndrome in babies was significantly higher in study group than in control group. Low APGAR score (<8) was also higher (33.3%) in study group as compared to control group (2.61%).

CONCLUSION

Pulmonary tuberculosis during pregnancy is associated with increased perinatal morbidity, low birth weight, poor APGAR and increased respiratory distress rates.

Assessment of preoperative and postoperative cardiac function in children with adenotonsillar hypertrophy: a prospective cohort study

PURPOSE

Chronic upper airway obstruction caused by adenotonsillar hypertrophy is one of the major cause of morbidity in children. It can lead to Obstructive Sleep Apnoea Syndrome, Pulmonary Hypertension, Cor Pulmonale and right heart failure. The study aimed to evaluate and compare various parameters of cardiac function with the help of echocardiography preoperatively and postoperatively in children undergoing adenotonsillectomy.

METHODOLOGY

A prospective cohort study was conducted on 23 patients at an apex care institute, under the age group of 4-12 years, who were diagnosed with adenotonsillar hypertrophy. Preoperative symptom analysis and Echocardiographic examination were done. After the assessment, all patients underwent surgery in the form of adenotonsillectomy. Follow-up symptom analysis and echocardiographic examination was done after 3 months postoperatively.

RESULTS

Significant improvement in the obstructive symptoms were noted in postoperative group as expected (p =  < 0.001) and also in parameters such as mPAP (p =  < 0.001), TAPSE (p =  < 0.001), TAV (p = 0.001), Ejection fraction (p = 0.027) and RVMPI (p = 0.044) were improved in postoperative group. 4 patients had Grade 1 Right ventricular diastolic dysfunction, which disappeared in three patients postoperatively.

CONCLUSION

We have concluded that there can be subclinical cardiac dysfunctions which occurs as a result of chronic upper airway obstruction due to untreated adenotonsillar hypertrophy. Routine cardiac screening in children presenting with sleep disordered breathing associated with adenotonsillar hypertrophy may be helpful in identifying and preventing the development of cardiopulmonary complication. These changes can be reversed by performing adenotonsillectomy.

Incidentally Detected High SSTR Expression in Uterine Leiomyoma on DOTANOC PET/CT

ABSTRACT

A 38-year-old woman with a 2-month history of per vaginal bleeding and episodes of palpitations, headache, and vomiting underwent 68Ga-DOTANOC PET/CT for evaluation, which revealed a left suprarenal mass and a large uterine mass, both of which were intensely tracer avid. Histopathology of the masses after surgery revealed a left pheochromocytoma and uterine leiomyoma. SSTR-expressing leiomyoma is an uncommon finding and must be kept in mind as a differential diagnosis of DOTANOC-avid uterine mass.

A Cross-sectional Case-control Study of Depression in Incontinent Women

Background:

Urinary incontinence (UI) presents in over 50% menopausal women affecting their quality of life leading to depression and hence needs addressal and treatment as very few of them seek medical help.

Aims:

Our aim was to determine the prevalence of depression, and the correlation of severity of UI with depression in incontinent women versus continent controls.

Methodology:

A cross-sectional case–control study of previously diagnosed 100 incontinent women (Stress/Urgency/Mixed) was done over a period of 3 months. The severity of UI was assessed on Patient Incontinence Severity Assessment (a form of Likert scale) and depression was assessed on a validated Patient Health Questionnaire-9 scale.

Statistical Analysis:

The statistical analysis was performed using SPSS version 19.0.

RESULTS:

Most of our cases were 51–60 years, with Urge UI being the most predominant (88%). Hundred percent of our incontinent patients were depressed, with 48% and 45% being severely and moderately severely depressed, respectively. A highly significant correlation was found between the severity of incontinence, amount of leakage, leaking pattern, and depression.

Conclusion:

All of our incontinent patients were depressed, with the severity of depression increasing with the severity of incontinence.

Short and Long Term Follow up and Efficacy of Trans Obturator Tape for Management of Stress Urinary Incontinence

Background

Stress urinary incontinence (SUI) is involuntary leakage of urine on raised intra- abdominal pressure which adversely affects quality of life usually requiring surgical treatment.

Methods

This is a prospective study of efficacy, cure rates and complications of tension free transobturator tape (TOT) surgery on 85 women with SUI. Pre-operatively and 6 months post-operatively International consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) scores were calculated for all patients to know the severity of incontinence and efficacy of tape.

Results

Mean age, parity, body mass index and mean duration of symptoms were 45.78 years, 2.68, 26.38 kg/m2 and 3.85 years, respectively. SUI was demonstrated in all cases on cough stress test and Bonney's test. Mean operative time, blood loss, post-operative analgesic injections, post- operative stay and post- operative catheterisation were 23.28 min, 45.50 ml, 1.2 injections, 1.2 days and 1.2 days. Various complications noted were excessive bleeding (3.52%), urinary retention (7.05%), urinary urgency (8.23%), urinary tract infection (2.35%), surgical site infection (1.17%), groin pain (28.23%) and mesh exposure (3.52%). At 6 months follow-up, the complete cure rate was 83.52% , partial cure rate was 11.76% and failure rate was found to be 4.70% whereas it was 79.16%, 12.0% and 8.33% respectively at 3 years follow up. 2 patients (2.35%) required burch colposuspension and 12 patients (14.11%) required pelvic floor exercises and duloxetine therapy for their symptoms. Mean pre- operative ICIQ-SF score reduced post- operatively (17.8 ± 4.67 to 2.71 ± 1.42) (p value = 0.001).

Conclusion

Study demonstrates short and long-term efficacy and safety of TOT for surgical management of SUI.

Pre treatment and post treatment positron emission tomography-computed tomography (PET-CT) to evaluate treatment response in tuberculous Tubo-Ovarian masses

PURPOSE

Female genital Tuberculosis (FGTB) causes infertility and formation of Tubo-ovarian (TO) masses. The study showed treatment response of PET-CT in evaluation of anti-tubercular treatment response in patients of infertility with tuberculous TO masses.

METHOD

It's a Prospective study on 47 confirmed cases of FGTB with infertility having TO masses. All patients were subjected to 18F-FDGPET/CT to see the glucose uptake by the TO mass and extent of the disease. Category I treatment under DOTS was given for 6 months. All underwent follow-up of PET/CT to see the response to ATT. Results of pre ATT PET/CT were compared with post ATT PET/CT.

RESULTS

TO masses was in 42 (89.36%); bilateral in 18 (38.29%) FDG uptake in 14 (29.78%) and without FDG uptake in 4 (8.51%) cases. Right sided mass in 13 (27.65%) FDG uptake in 9 (19.14%) and without FDG uptake in 4 (8.51%) cases. Left sided mass in 11 (23.40%) FDG uptake in 7 (14.89%) and without FDG uptake in 4 (8.51%) cases. Post ATT, there was significant decrease in most parameters. Repeat PET-CT done in 44 cases showed TO mass in 9 (20.45%); bilateral in 4 (9.09%) (FDG uptake in 2.27%) (p < 0.001), right sided in 3 (6.85%) (FDG uptake in 2.27%) (p < 0.002) and left side in 2 (2.27%) FDG uptake in 1 case (p < 0.004). Pelvic and mesenteric lymphadenopathy without FDG uptake was in 1 case (p value = 0.03) while omental and peritoneal deposits without FDG uptake in 1 and 2 cases, respectively.

CONCLUSION

PET-CT is useful in treatment response evaluation of tubercular TO masses.

Clinical characteristic, red blood cell indices, iron profile and prognosis of heart failure in females

Background: Heart failure is a leading killer worldwide, with concurrent anaemia and iron deficiency portending sepulchral prognosis. Anaemia is rampant, with 53% prevalence in Indian females, but iron deficiency can be present even without anaemia. Therefore, this study was planned to determine the clinical profile, red blood cell indices, and effects of iron deficiency, on the course and prognosis of heart failure in Indian females.

Materials and methods: This was a hospital-based observational study, conducted at a tertiary care teaching institute in India. Data from 147 females enrolled in the study between September 2017 to March 2020 was collected out of all patients enrolled in ongoing heart failure registry at the institute. Clinical characteristics at presentation, iron profile, red blood cell indices, treatment and mortality data was collected.

Results: Mean age of the subjects (n = 147) was 53.31 ± 17.1 years with 55% non-rheumatic and 45% with rheumatic heart disease. The patients with rheumatic heart disease were younger, with a higher prevalence of atrial fibrillation. Non-rheumatic patients had a higher prevalence of CV risk factors like diabetes, hypertension, renal failure, more patients in NYHA IV, and 83% patients had LVEF ≤40%. Anaemia was present in 49%, however iron deficiency was present in 89% (absolute iron deficiency in 80% and functional iron deficiency in 9%) with no significant difference between rheumatic and non-rheumatic group. Red blood cell indices showed no significant difference across the spectrum of iron deficiency and anaemia, except lower mean corpuscular volume in patients with both iron deficiency and anaemia. The mean survival time was 840 days, with no significant difference between groups. There was significantly higher mortality in patients with iron deficiency (log rank 0.045).

Conclusion: Iron deficiency–with or without anaemia–is very high in Indian females, worsening survival in heart failure. Proper diagnosis with iron supplementation will improve the prognosis.

Efficacy of myoinositol in treatment of gestational diabetes mellitus in Asian Indian women: A pilot randomized clinical trial

OBJECTIVE

To compare efficacy of myoinositol as an adjuvant to dietary modification for treatment of gestational diabetes mellitus in Asian Indian women compared to controls.

STUDY DESIGN

Setting: This pilot randomized open label trial was conducted in a single antenatal clinic in India.

SUBJECTS

One hundred women with singleton pregnancy and gestational diabetes diagnosed between 14-28 weeks' gestation were included. Overt diabetes, twin pregnancy, pre-existing renal disease, heart disease and other chronic medical disorders were exclusions.

INTERVENTION

Participants were randomized in two groups (1:1 ratio) by opaque envelope method. Individualized nutrition counseling with dietary modification and routine antenatal care was provided to all. Fifty women received myoinositol 1000 mg twice daily; 50 controls did not receive myoinositol. Fasting and postprandial glucose levels were assessed after two weeks. Women not achieving glycemic targets (fasting glucose <95 and postprandial glucose <120 mg/dL) were given pharmacologic therapy. Contributory factors in women requiring additional pharmacologic therapy, maternal and fetal outcomes were noted.

STATISTICAL ANALYSIS

Between group comparisons reported relative risk and mean difference. To assess predictive factors for need for pharmacologic therapy, univariate and multivariable logistic regression analysis were used.

RESULTS

Baseline characteristics were comparable in both groups. Except one woman in the myoinositol group, all women provided glycaemia data throughout their pregnancy. Glycemic control was achieved in 44/ 49 (89.8 %) women in myoinositol group which was significantly higher than 34/50 (68 %) in the controls ((relative risk 0.31, 95 % confidence interval 0.13 to 0.80, p = 0.008). Mean duration of myoinositol treatment was 17.6 weeks (standard deviation 5.3). Additional treatment with metformin/insulin was needed in all women failing to achieve glycaemic control. The mean (range) dose of insulin was 25.3 units in myoinositol group compared to 14.27 units in controls (p = 0.058). Secondary outcomes were similar in two groups except baby weight which was higher in controls (p = 0.018).

CONCLUSIONS

Oral supplementation with myoinositol in dose of 1 gm twice-daily, when started soon after the diagnosis of GDM, is effective in achieving glycemic control and decreasing the need for additional pharmacological therapy in Asian Indian women.

Tuberculosis (TB) in pregnancy - A review

Tuberculosis (TB) is a common infectious pathology especially in low-income countries, which may complicate pregnancy. Although pulmonary TB is more common in pregnancy than extra pulmonary TB (EPTB), EPTB is becoming more common especially in those living with human deficiency virus (HIV) co infection or have other comorbidities. The diagnosis of TB may be delayed in pregnancy due to the masking of its symptoms by those of pregnancy. If diagnosed and treated on time both pulmonary TB and EPTB are associated with excellent maternal and perinatal outcome. If, however, there is delay in diagnosis and treatment then there could be adverse maternal and fetal consequences like preterm labour, fetal growth restriction and even stillbirths. Similarly severe forms of TB like disseminated disease (miliary TB) or multi drug resistant TB (MDR TB) are associated with poor outcome. Diagnosis and management is same as in non-pregnant patients. Both drug sensitive pulmonary TB and EPTB are treated with four drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) orally daily for 2 months followed by three drugs (isoniazid, rifampicin and ethambutol) orally daily for 4 months. Drug resistant TB is treated with second line drugs with caution, as some of these drugs are teratogenic. Optimum antenatal care and nutrition therapy along with anti-tuberculosis drugs provide for optimum maternal and perinatal outcome. This review discusses maternal and perinatal outcomes, diagnosis and management of pulmonary TB and extrapulmonary TB as well as perinatal tuberculosis.

Autologous Fascial Slings for Surgical Management of Stress Urinary Incontinence: A Come Back

Stress urinary incontinence (SUI) is a common type of urinary incontinence adversely affecting the quality of life of women. For mild SUI, life style changes, pelvic floor exercises and medical treatment with duloxetine may help. Most patients of moderate to severe SUI usually require surgical treatment. Various surgical treatment options include Kelly's plication, Burch colposuspension, bulking agents and sling surgeries. Although, suburethral fascial slings including the autologous rectus fascia slings were in vogue before 1990, they were overtaken by minimally invasive, faster and easier artificial midurethral slings (tension free vaginal tape and transobturator tape). However, observation of serious long-term and life changing complications of synthetic midurethral slings like mesh erosion, chronic pelvic pain and dyspareunia led to their adverse publicity and medico legal implications for the operating surgeons. This led US FDA (Food and Drug Administration) to issue a warning against their use. Currently, their use has significantly decreased in many countries, and they are no longer available in some countries. This has led to renaissance of use of natural autologous fascial sling, especially rectus fascia for surgical management of SUI. Although performing rectus fascia sling surgery is technically more challenging, takes longer, has more short-term morbidity like voiding dysfunction, their long-term success is high with very little risk of serious complications like mesh erosion, chronic pelvic pain and dyspareunia. However, multicentric trials and longer follow ups are needed before it's routine recommendation This review discusses the role of autologous fascial sling (especially rectus fascia) for the surgical management of SUI in the current time and the need of ongoing training of this procedure to gynecology residents and urogynecology fellows.

Clinical practice recommendations for the detection and management of hyperglycemia in pregnancy from South Asia, Africa and Mexico during COVID-19 pandemic

The human coronavirus disease 2019 (COVID-19) pandemic has affected overall healthcare delivery, including prenatal, antenatal and postnatal care. Hyperglycemia in pregnancy (HIP) is the most common medical condition encountered during pregnancy. There is little guidance for primary care physicians for providing delivery of optimal perinatal care while minimizing the risk of COVID-19 infection in pregnant women. This review aims to describe pragmatic modifications in the screening, detection and management of HIP during the COVID- 19 pandemic. In this review, articles published up to June 2021 were searched on multiple databases, including PubMed, Medline, EMBASE and ScienceDirect. Direct online searches were conducted to identify national and international guidelines. Search criteria included terms to extract articles describing HIP with and/or without COVID-19 between 1^st March 2020 and 15^th June 2021. Fasting plasma glucose, glycosylated hemoglobin (HbA1c) and random plasma glucose could be alternative screening strategies for gestational diabetes mellitus screening (at 24–28 weeks of gestation), instead of the traditional 2 h oral glucose tolerance test. The use of telemedicine for the management of HIP is recommended. Hospital visits should be scheduled to coincide with obstetric and ultrasound visits. COVID-19 infected pregnant women with HIP need enhanced maternal and fetal vigilance, optimal diabetes care and psychological support in addition to supportive measures. This article presents pragmatic options and approaches for primary care physicians, diabetes care providers and obstetricians for GDM screening, diagnosis and management during the pandemic, to be used in conjunction with routine antenatal care.

Practical consensus recommendations on duration of adjuvant hormonal therapy in breast cancer

Optimization of adjuvant systemic therapy in women with early-stage hormone receptor-positive breast cancer includes the consideration of chemotherapy and duration of hormone therapy. Adjuvant hormonal therapy significantly improves long-term survival of breast cancer patients with hormone receptor-positive disease. Despite the proven clinical efficacy of tamoxifen and aromatase inhibitors, many breast cancer survivors either fail to take the correct dosage at the prescribed frequency (adherence) or discontinue therapy (persistence). Expert oncologist discussed on the duration of adjuvant hormonal therapy for improvement of OS and quality of life of breast cancer patients by providing reduction in recurrence and mortality. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Molecular mapping of a new recessive wheat leaf rust resistance gene originating from Triticum spelta

TSD276-2, a wheat genetic stock derived from the cross Agra Local/T. spelta 276 showed broad spectrum resistance against leaf rust pathogen. Genetic analysis was undertaken using F₁, F₂, F_2:3 and BC₁F₁ generations derived from the cross TSD276-2/Agra Local. The results revealed a single recessive gene for leaf rust resistance, tentatively named as LrTs_276-2, in TSD276-2. Molecular mapping of leaf rust resistance gene LrTs_276-2 in TSD276-2 was done using SNP-based PCR and SSR markers. For Bulked Segregant Analysis (BSA), two bulks viz. resistant bulk and susceptible bulk, and the parents TSD276-2 and Agra Local were genotyped for SNPs using AFFYMETRIX 35K Wheat Breeders' AXIOM array. T. spelta 276 was also genotyped and used as a check. BSA indicated that the gene for leaf rust resistance in TSD276-2 is located on chromosome arm 1DS. Putatively linked SNPs on chromosome arm 1DS were converted into PCR-based markers. Polymorphic SSR markers on chromosome arm 1DS were also identified. Final linkage map was constructed using one SNP-based PCR and three SSR markers. The rust reaction and chromosomal location suggest that LrTs_276-2 is a new leaf rust resistance gene which may be useful in broadening the genetic base of leaf rust resistance in wheat.

A novel leaf rust resistance gene introgressed from Aegilops markgrafii maps on chromosome arm 2AS of wheat

A novel leaf rust resistance gene, LrM, introgressed from Aegilops markgrafii and mapped on chromosome 2AS using SSR- and SNP-based PCR markers will aid in broadening the genetic base of rust resistance in wheat. A new leaf rust resistance gene tentatively named LrM was introgressed from the diploid non-progenitor species Ae. markgrafii (2n = 2x = 14, genome CC) into common wheat using the nulli-5B mechanism. The introgression line ER9-700 showed a high degree of resistance against a wide spectrum of Puccinia triticina pathotypes. Genetic analysis was performed using the F₁, F₂, F_2:3 and BC₁F₁ generations derived from the cross ER9-700/Agra Local. The results showed a single dominant gene for leaf rust resistance. The resistance gene LrM was mapped on chromosome arm 2AS using SSR- and SNP-based PCR markers. Preliminary mapping with SSR markers in the F_2:3 population from the cross ER9-700/Agra Local identified two SSR markers flanking the LrM. SNPs were identified in the genomic region flanked by SSR markers, and SNP-based PCR markers were developed to construct the final map. Three SNP-based PCR markers co-segregated and mapped closest to the resistance gene at a distance of 2 cM. The gene LrM was distinguished from all the other genes designated and mapped on chromosome arm 2AS by molecular markers and rust reaction. All five markers used in the mapping amplified identical alleles in the donor Ae. markgrafii accession and introgression line ER9-700. The chromosomal location and rust reaction suggest that LrM is a novel leaf rust resistance gene that may be useful in broadening the genetic base of leaf rust resistance in wheat.

COVID-19 pandemic and stent thrombosis in a post percutaneous coronary intervention patient-a case report highlighting the selection of P2Y12 inhibitor

The current pandemic of novel coronavirus disease 2019 (COVID-19) has posed a great threat to people's health worldwide, with specific implications on patients with underlying heart diseases. During this challenging period, nearly all major societies have recommended for conservative approach, even for patients with relatively stable acute cardiovascular diseases. Selection of specific antiplatelet therapy in an uncomplicated post percutaneous coronary intervention (PCI) patient can, at times, be crucial issue in such strained circumstances. We report a case of 64-year-old male, who was taken for urgent coronary angiogram (CAG) in view of non ST elevation acute coronary syndrome. Successful PCI with implantation of drug eluting stent was done for right coronary artery (RCA) and left anterior descending (LAD) artery lesions. On day 5th post-PCI, he developed acute inferior wall STEMI due to subacute stent thrombosis (ST), and despite all efforts, patient could not be saved as he didn't receive timely intervention. Increased travel time to emergency department due to lockdown because of COVID-19 and along with extra time required for donning of personal protection equipment (PPE) and other COVID-19 related safety measures prolonged the ischemic time. Potent P2Y12 inhibitor based dual antiplatelet therapy might have prevented this subacute ST, and thus mortality, as the patient was discharged on clopidogrel after PCI. While selecting specific P2Y12 inhibitor in a post PCI patient, apart from clinical condition of patient and complexity of procedure, we should also consider current COVID-19 pandemic. Current circumstances may favour ticagrelor over other P2Y12 inhibitors in view of its potent, rapid, and reversible antiplatelet action along with its optimistic effect in pneumonia.

A comparative study of autologous rectus fascia pubovaginal sling surgery and synthetic transobturator vaginal tape procedure in treatment of women with urodynamic stress urinary incontinence

OBJECTIVE

To compare short term results of autologous rectus fascia pubovaginal sling surgery with synthetic transobturator vaginal tape procedure in treatment of female stress urinary incontinence (SUI) STUDY DESIGN: It was a comparative study on 30 women between 25-65 years of age with urodynamic proven SUI who were randomly allocated to autologous rectus fascia pubovaginal sling surgery (Group I)(15 women) and synthetic transobturator vaginal tape procedure (Group II) (15 women). Preoperative and postoperative ICIQ (International Consultation on Incontinence Questionnaire) score, urodynamic study and serum CRP and IL-6 were done in all cases.

RESULTS

The baseline characteristics in terms of age, body mass index (BMI), parity, mean ICIQ score and mean preoperative CRP and IL-6 levels were similar in two groups. Mean operative time was significantly longer (55.60 ± 5.77 vs 25.27 ± 4.32 minutes, p = 0.001) in group I than group II. Mean hospital stay of 7.1 ± 1.2 vs 1.2 ± 0.4 days, mean duration of catheterization 5.8 vs 1.2 day (<0.01) and postoperative urinary retention requiring recathterization were all significantly higher in group I than II. Wound infection was more in group I than in group II (p = 0.01) while groin pain was significantly more in group II (p = 0.01). One patient developed vesicovaginal fistula, while one patient required cutting of tape in group I. Pdet at Q max (Detrusor pressure at peak urine flow) increased significantly in both the groups after surgery. ICIQ score was zero in both the groups indicating 100 % success. Surgical trauma was more in group I as shown by significantly higher CRP levels.

CONCLUSION

The success rate of the two groups was similar but, autologous rectus fascia sling surgery took longer, had more complications and urinary retention as compared to transobturator vaginal tape procedure.

Obstetrics and COVID-19

Coronavirus disease (COVID-19) is caused by severe acute respiratory syndrome corona virus 2 (SARS-Cov-2), an RNA virus which has caused pandemic in the whole world. It has put an unprecedented burden on healthcare system globally, and neither obstetricians nor labour rooms are spared as deliveries and caesarean sections cannot be postponed. There is a threat of collapse of healthcare system in maternity wards and labour rooms due to risk for transmission to healthy patients, obstetricians, midwives and other staff. It is not possible to screen all pregnant women especially in developing countries but due to asymptomatic cases, risk of infection looms large. Many countries including India have declared lockdown to stop the transmission but delivery services have to continue. Proper planning and division of the healthcare system into COVID-positive and negative areas with separate staff can help minimise the spread and preserve precious resources. Hospital staff must protect themselves by wearing personal protective equipment (PPE) in COVID-positive and suspected cases.

Effectiveness of an integrated perinatal oral health assessment and promotion program on the knowledge in Indian pregnant women

BACKGROUND

Oral health during pregnancy plays a crucial role in the overall health and well-being of pregnant women. Evidence shows that most young children acquire cariogenic organisms from their mothers. Poor maternal knowledge about oral diseases combined with inappropriate feeding can lead to severe caries among young children. The aim of study was to assess the oral health status of pregnant women and to evaluate the gain in their knowledge after educational session in an antenatal setting.

MATERIALS AND METHODS

It is a pre- and post-intervention study carried out on the pregnant women (n = 198) attending an antenatal clinic in a tertiary care hospital. A specially designed semi-structured 14-point questionnaire was used to assess the pre- and post-knowledge and attitude to the oral health. Each participant was educated for self and infant oral care with the help of a specially prepared colored printed booklet. Kruskal-Wallis test was used to explore the associations between the age, education and socioeconomic class and knowledge; Wilcoxon signed-rank test was used to compare pre- and post-knowledge score.

RESULTS

Median preoral health knowledge-attitude score was found to be 4 (0-8) and was found to be associated with the level of education (P = 0.014) and socioeconomic class (0.019). There was a significant improvement in the median postknowledge score to 7 (2-10) (P < 0.001) following oral health educational session in all categories.

CONCLUSIONS

An integrated preventive oral health checkup and educational program to pregnant women can benefit the dental health of the women and children. Prenatal care workers can be involved to disseminate the oral health awareness to pregnant women during antenatal visits.

Prevalence and reproductive manifestations of macroprolactinemia

PURPOSE

Macroprolactinemia is characterized by predominance of macroprolactin molecules in circulation and generally has extra-pituitary origin. Macroprolactin is viewed as biologically inactive, therefore asymptomatic, and thus may not require any treatment or prolonged follow-up. In addition, data on prevalence of macroprolactinemia and its clinical manifestation are also rare. Therefore, the present study was aimed to find out prevalence of macroprolactinemia and its association, if any, with reproductive manifestations.

MATERIAL AND METHODS

Macroprolactin was measured in 102 hyperprolactinemia cases (>100 ng/ml prolactin level), 135 physiological hyperprolactinemia cases (50 pregnant and 85 lactating females; >100 ng/ml prolactin level) and 24 controls. Poly ethylene glycol (PEG) precipitation method was carried out to screen macroprolactin. Prolactin recovery of <25% was considered overt macroprolactinemia. Detailed clinical data was recorded which included complete medical history, physical examination and hormone measurements besides CT/MRI for pituitary abnormalities.

RESULTS

Prevalence of macroprolactinemia was 21.57% (22/102) in hyperprolactinemia (prolactin >100 ng/ml). There was no case of macroprolactinemia in physiological hyperprolactinemia, or healthy control females. Reproductive manifestations were present in 72.73% (16/22) macroprolactinemia cases, out of which macroprolactinemia was the sole cause of associated reproductive manifestations in 68.7% (11/16) cases. Reversal of reproductive dysfunction/s was observed in five cases with appropriate treatment for high macroprolactin.

CONCLUSION

Macroprolactinemia prevalence was found to be 21.5%, out of which 72.73% cases had associated reproductive dysfunctions.

Obstetrical and perinatal outcome in pregnant women with extrapulmonary tuberculosis

Tuberculosis (TB) is a major health problem and a leading cause of illness and death from infectious disease. Tuberculosis in pregnancy has been associated with increased risks of prematurity and small for gestational age (SGA)infants.The present study is aimed to examine obstetrical and perinatal outcomes among women who had extra-pulmonary tuberculosis.

MATERIAL AND METHODS

It was retrospective study involving patient who presented with extra pulmonary tuberculosis over a period of ten years (2008-2017)was reviewed. Diagnosed women were compared with controls in the ratio of six controls for each case. Data included age, parity and complications in the antenatal, intrapartum and postpartum periods. The mean birth weights of infant and the frequency of small for gestation age, neonatal depression and still births were used for perinatal outcome.

RESULTS

During the period of study 30 pregnant women were booked for extra -pulmonary TB. 22/30(73.3%) were diagnosed having extra pulmonary -TB prior to pregnancy and were taking ATT (anti-tubercular therapy) during the pregnancy, in 8/30(26.6%) it was diagnosed during pregnancy. Age, parity were similar in two groups. There was significantly increased incidence of oligoamnios and preterm rupture of membrane (P = 0.001). Mean gestation age of delivery in TB cases was 36.15 ± 1.8 weeks as compared to37.5 ± 0.5 weeks in low risk patients (P = 0.001). The mean birth weight of the infants of mother with extra pulmonary TB was 2324.26 ± 379.5 grams and 2712.3 ± 635.7 for control group(P = 0.001).

CONCLUSION

This study emphasize on the need for early diagnosis and treatment of tuberculosis preferably before pregnancy, regular medical follow up and good perinatal care.

H3K4/K9 acetylation and Lr28-mediated expression of six leaf rust responsive genes in wheat (Triticum aestivum)

Development of leaf rust-resistant cultivars is a priority during wheat breeding, since leaf rust causes major losses in yield. Resistance against leaf rust due to Lr genes is partly controlled by epigenetic modifications including histone acetylation that is known to respond to biotic/abiotic stresses. In the present study, enrichment of H3K4ac and H3K9ac in promoters of six defense responsive genes (N-acetyltransferase, WRKY 40, WRKY 70, ASR1, Peroxidase 12 and Sarcosine oxidase) was compared with their expression in a pair of near-isogenic lines (NILs) for the gene Lr28 following inoculation with leaf rust pathotype '77-5'; ChIP-qPCR was used for this purpose. The proximal and distal promoters of these genes contained a number of motifs that are known to respond to biotic stresses. The enrichment of two acetylation marks changed with passage of time; changes in expression of two of the six genes (N-acetyltransferase and peroxidase12), largely matched with changes in H3K4/H3K9 acetylation patterns of the two promoter regions. For example, enrichment of both the marks matched with higher expression of N-acetyltransferase gene in susceptible NIL and the deacetylation (H3K4ac) largely matched with reduced gene expression in resistant NIL. In peroxidase12, enrichment of H3K4ac and H3K9ac largely matched with higher expression in both the NILs. In the remaining four genes, changes in H3 acetylation did not always match with gene expression levels. This indicated complexity in the regulation of the expression of these remaining four genes, which may be controlled by other epigenetic/genetic regulatory mechanisms that need further analysis.

A study of transcriptome in leaf rust infected bread wheat involving seedling resistance gene Lr28

Leaf rust disease causes severe yield losses in wheat throughout the world. During the present study, high-throughput RNA-Seq analysis was used to gain insights into the role of Lr28 gene in imparting seedling leaf rust resistance in wheat. Differential expression analysis was conducted using a pair of near-isogenic lines (NILs) (HD 2329 and HD 2329+Lr28) at early (0h before inoculation (hbi), 24 and 48h after inoculation (hai)) and late stages (72, 96 and 168 hai) after inoculation with a virulent pathotype of pathogen Puccinia triticina. Expression of a large number of genes was found to be affected due to the presence/absence of Lr28. Gene ontology analysis of the differentially expressed transcripts suggested enrichment of transcripts involved in carbohydrate and amino acid metabolism, oxidative stress and hormone metabolism, in resistant and/or susceptible NILs. Genes encoding receptor like kinases (RLKs) (including ATP binding; serine threonine kinases) and other kinases were the most abundant class of genes, whose expression was affected. Genes involved in reactive oxygen species (ROS) homeostasis and several genes encoding transcription factors (TFs) (most abundant being WRKY TFs) were also identified along with some ncRNAs and histone variants. Quantitative real-time PCR was also used for validation of 39 representative selected genes. In the long term, the present study should prove useful in developing leaf rust resistant wheat cultivars through molecular breeding.

Comparative study on maternal and fetal outcome in pregnant women with rheumatic heart disease and severe mitral stenosis undergoing percutaneous balloon mitral valvotomy before or during pregnancy

INTRODUCTION

Mitral stenosis due to rheumatic heart disease is a common problem in India causing significant morbidity and mortality. We have compared the maternal and fetal outcome of women with severe mitral stenosis undergoing percutaneous balloon mitral valvotomy before or during pregnancy.

METHODS

A total of 24 women of severe rheumatic mitral stenosis who underwent balloon mitral valvotomy before pregnancy (14 women, group 1) or during pregnancy (10 women, group 2) were included in the retrospective descriptive analysis.

RESULTS

The mean age was 25.5±3.6 yrs in group 1 and 25.7±3.5 yrs in group 2. There was no difference in characteristics -primigravidas, time since diagnosis from pregnancy, NYHA (New York Heart Association) class and associated medical problems in the two groups. There was significant difference in cardiac events during pregnancy in the two groups. New York Heart Association class deterioration was observed in only 3(21.4% women in group 1) as compared to all (10; 100% women) in group 2(p<0.001). The incidence of arrhythmias and atrial fibrillation was not different in two groups. Obstetric events were similar in the two groups. Mode of delivery and caesarean section rate was also similar in the two groups. There was no significant difference in mean birth weights (2399.75±601.8gm vs. 2641.70±580.6gm),rate of fetal growth restriction, still birth and congenital malformation rates in the two groups.

CONCLUSION

Percutaneous mitral valvotomy for patients with severe mitral stenosis can be safely performed during pregnancy and has equivalent maternal and fetal outcomes as that performed before pregnancy.

Maternal and fetal outcome in operated vs non-operated cases of congenital heart disease cases in pregnancy

OBJECTIVES

To study pregnancy outcomes in operated vs non-operated cases of congenital heart disease cases during pregnancy.

MATERIALS AND METHODS

A total of 55 patients of congenital heart disease who delivered in the authors unit in last 10 years were taken in this retrospective study. These were divided into two groups Group 1:29 (52.7%) patient who had no cardiac surgery and Group 2: 26(47.2%) who had cardiac surgery to correct their cardiac defect before pregnancy. All patients were evaluated for cardiac complications and outcome during pregnancy. Obstetric complications, mode of delivery and fetal outcome was compared in the two groups using statistical analysis.

RESULT

The commonest lesion was atrial septal defect (ASD) seen in 22(40%) patients followed by ventricular septal defect (VSD) in 16(29%) .Congenital valvular disease 8(14.5%) and patent ductus arteriosus in 4(7.2%) cases. The mean age was 25.9 ± 3.15 years in Group 1 and 26.3 ± 4.53 years in Group 2. The baseline characteristics were similar in the two groups. There was no difference in cardiac complications, NYHA deterioration and need of cardiac drugs in the two groups. Obstetric complications and mode of delivery were also similar in the two groups.Mean birth weight was 2516.65 ± 514.04 gm in Group 1 and 2683.00 ± 366.00 gm in Group 2 and was similar. APGAR < 8, stillbirth rate and other neonatal complications were also similar in two groups.

CONCLUSION

The maternal and fetal outcome was excellent in patients with congenital heart disease and was similar in unoperated and operated cases.

Identification and validation of salivary proteomic signatures for non-invasive detection of ovarian cancer

Ovarian cancer (OC) is one of the most lethal cancers among all gynecological malignancies. An effective and non-invasive screening approach is needed urgently to reduce high mortality rate. The purpose of this study was to identify the salivary protein signatures (SPS) for non-invasive detection of ovarian cancer. Differentially expressed SPS were identified by fluorescence-based 2D-DIGE coupled with MALDI/TOF-MS. The expression levels of three differential proteins (Lipocalin-2, indoleamine-2, 3-dioxygenase1 (IDO1) and S100A8) were validated using western blotting and ELISA. Immunohistochemistry and qRT-PCR were performed in an independent cohort of ovarian tumor tissues. 25 over expressed and 19 under expressed (p<0.05) proteins between healthy controls and cancer patients were identified. Lipocalin-2, IDO1 and S100A8 were selected for initial verification and successfully verified by immunoassay. Diagnostic potential of the candidate biomarkers was evaluated by ROC analysis. The selected biomarkers were further validated by immunohistochemistry in an independent cohort of ovarian tissues. The global expression of selected targets was also analyzed by microarray and validated using qRT-PCR to strengthen our hypothesis. Tumor secreted proteins identified by 'dual-omics' strategy, whose concentration are significantly high in ovarian cancer patients have obvious potential to be used as screening biomarker after large scale validation.

Sheehan's Syndrome-The Most Common Cause of Panhypopituitarism at Moderate Altitude: A Sub-Himalayan Study

BACKGROUND

Panhypopituitarism is a rare disorder with varied clinical presentation having various etiologies. Sheehan's syndrome (SS) is decreasing in frequency worldwide and is a rare cause of panhypopituitarism in developed nations.

METHODOLOGY

A retrospective study done between May 2011 and May 2015 in tertiary care hospital. We reviewed the records of patients with hypopituitarism. Clinical features, hormonal profile and radiological investigations noted.

RESULTS

Total 14 patients of panhypopituitarism included with average duration of symptoms 1.93± 1.96 years. four (28.57%) were males and ten (71.43%) were females with mean age of diagnosis 37.78± 13.68 years. Sheehan's syndrome (SS) was the most common cause of panhypopituitarism in 57.14%(8 patients), followed by post surgery in 14.28% (2 patients). 80% of women had SS with a mean duration of symptoms 2.39±1.54 years.

CONCLUSION

Sheehan's syndrome is not uncommon in developing countries, High degree of clinical suspicion is desired as clinical features are most often subtle.

Role of thioridazine in unexplained infertility

A total of 452 women with unexplained infertility were selected for the present study. From them 310 women were put on thioridazine tablet (5 mg), 1 h after dinner from the 8th day of the menstrual cycle to the 18th day in each cycle. Coitus was advised about 1-2 h after the drug intake and proper posture was advised to the patients. The other 142 patients were given placebo therapy. Patients were followed up for pregnancy for 1 year which was confirmed by ultrasonographic examination. Ninety-four patients (30.2%) in the study group conceived in contrast to 22 (15.42%) in the control group (P less than 0.001). Incidence of abortions, congenital malformations and perinatal mortality and mode of delivery were not significantly different in the two groups. Thioridazine due to anxiolytic effect in low dosage appears to be promising in the treatment of unexplained infertility.

Flavoxate in the symptomatic treatment of overactive bladder: a meta-analysis

OBJECTIVE

Overactive bladder is a syndrome of urinary frequency and urgency, with or without urge incontinence, in the absence of local pathological factors. Since multiple causes are responsible for OAB, it requires proper diagnosis and comprehensive management. For decades, flavoxate is a globally used and accepted molecule by the urologists and the general physicians for the symptomatic treatment of OAB. In spite of its extensive use in OAB, a meta-analysis of the available publications for efficacy, safety and tolerability of flavoxate has not been conducted. This paper evaluates the strength of evidence of clinical effectiveness of safety and tolerability of flavoxate in the symptomatic treatment of OAB.

METHODS

Review articles, original studies and case reports on MEDLINE, the Cochrane Library, Google Scholar, Scirus, internal repository, etc. were searched using the keyword "flavoxate". For the primary outcome, the comparative data of flavoxate versus comparator was extracted for following parameters - overall efficacy and its side effect profile. Similarly as for secondary outcome, data were extracted for flavoxate per se for overall efficacy, frequency, urinary incontinence, mixed incontinence, nocturia, unpleasant urination, stranguria and its side effect profile and were analyzed using Comprehensive Meta-Analysis (CMA) software version 2.0.

RESULTS

In the current meta-analysis, 43 relevant published studies were considered which clearly demonstrated that flavoxate had improved clinical efficacy than placebo, emepronium, propantheline, and phenazopyridine.

CONCLUSIONS

Amongst all the interventions studied, flavoxate was effective and well-tolerated, with almost negligible side effects, making it worthy of consideration for the treatment of OAB.

Caesarean section surgical techniques: 3 year follow-up of the CORONIS fractional, factorial, unmasked, randomised controlled trial

BACKGROUND

The CORONIS trial reported differences in short-term maternal morbidity when comparing five pairs of alternative surgical techniques for caesarean section. Here we report outcomes at 3 years follow-up.

METHODS

The CORONIS trial was a pragmatic international 2 × 2 × 2 × 2× 2 non-regular fractional, factorial, unmasked, randomised controlled trial done at 19 sites in Argentina, Chile, Ghana, India, Kenya, Pakistan, and Sudan. Pregnant women were eligible if they were to undergo their first or second caesarean section through a planned transverse abdominal incision. Women were randomly assigned by a secure web-based allocation system to one intervention from each of the three assigned pairs. All investigators, surgeons, and participants were unmasked to treatment allocation. In this follow-up study, we compared outcomes at 3 years following blunt versus sharp abdominal entry, exteriorisation of the uterus for repair versus intra-abdominal repair, single versus double layer closure of the uterus, closure versus non-closure of the peritoneum, and chromic catgut versus polyglactin-910 for uterine repair. Outcomes included pelvic pain; deep dyspareunia; hysterectomy and outcomes of subsequent pregnancies. Outcomes were assessed masked to the original trial allocation. This trial is registered with the Current Controlled Trials registry, number ISRCTN31089967.

FINDINGS

Between Sept 1, 2011, and Sept 30, 2014, 13,153 (84%) women were followed-up for a mean duration of 3·8 years (SD 0·86). For blunt versus sharp abdominal entry there was no evidence of a difference in risk of abdominal hernias (adjusted RR 0·66; 95% CI 0·39-1·11). We also recorded no evidence of a difference in risk of death or serious morbidity of the children born at the time of trial entry (0·99, 0·83-1·17). For exteriorisation of the uterus versus intra-abdominal repair there was no evidence of a difference in risk of infertility (0·91, 0·71-1·18) or of ectopic pregnancy (0·50, 0·15-1·66). For single versus double layer closure of the uterus there was no evidence of a difference in maternal death (0·78, 0·46-1·32) or a composite of pregnancy complications (1·20, 0·75-1·90). For closure versus non-closure of the peritoneum there was no evidence of a difference in any outcomes relating to symptoms associated with pelvic adhesions such as infertility (0·80, 0·61-1·06). For chromic catgut versus polyglactin-910 sutures there was no evidence of a difference in the main comparisons for adverse pregnancy outcomes in a subsequent pregnancy, such as uterine rupture (3·05, 0·32-29·29). Overall, severe adverse outcomes were uncommon in these settings.

INTERPRETATION

Although our study was not powered to detect modest differences in rare but serious events, there was no evidence to favour one technique over another. Other considerations will probably affect clinical practice, such as the time and cost saving of different approaches.

FUNDING

UK Medical Research Council and the Department for International Development.

Female sexual dysfunction: Assessment

Female sexual dysfunction (FSD) is a common complex clinical condition, with multiple etiologies, association and pathophysiologic correlations. This review includes the definition, etiology, and diagnosis of FSD. It calls for a bio psychosocial approach to FSD management, which incorporates, but is not limited to, only the psychological aspects of FSD.

Scrub Typhus Presenting as Acute Cerebellitis

Scrub typhus is known to present with varied presentation including involvement of central nervous system. We present a case who presented with fever and features of isolated cerebellitis. Serum showed IgM antibodies to scrub typhus by ELISA. Patient showed rapid response to doxycycline and dexamethasone.

Cationic antimicrobial peptide, magainin down-regulates secretion of pro-inflammatory cytokines by early placental cytotrophoblasts

BACKGROUND

Human placental villous cytotrophoblasts exhibit relative externalization of negatively charged moieties to the outer leaflet of the plasma membrane during the time of syncytialization rendering their reactivity to positively charged cationic antimicrobial peptides (CAMPs) during the window of implantation and early placentation. Vaginal administration of a synthetic CAMP, Ala(8,13,18)-magainin II amide (AMA) inhibited blastocyst implantation and early placentation in monkeys. Furthermore, the administration of AMA resulted in significant inhibition of cell differentiation, enhancement in apoptosis and loss of viability in first trimester placental villous cytotrophoblasts in primary culture. The present study examines the effect of in vitro application of different doses (0, 1, 10, 100, 1000 ng/ml) of AMA on the secreted cytokine profiles of cytotrophoblasts obtained from placental villi samples (n = 13) collected during 8-9 weeks of gestation and grown on three-dimensional collagen matrix in vitro.

METHODS

A panel of forty-eight (48) cytokines in conditioned medium was analysed using multiplex immunoassays technique. Further, the steady state transcript levels of four cytokines (CCL4, CCL5, IL1B, IL6), the concentrations of which were affected by AMA in the isolated cytotrophoblasts, as well as, two cytokines (IL1A and TNF) which were not affected by AMA were estimated. Input list of cytokines secreted by cytotrophoblasts and showing differential secretion in response to AMA were used in enrichment analysis for the generation of biological networks.

RESULTS

Placental cytotrophoblasts secreted 27 cytokines, 13 of which are affected by AMA in vitro with significantly decreased secretion of CCLs-2, 3, 4, 5, CXCLs-1 and 8, FGF2 and MCSF and that of IL1B, IL6 and MIF, and increased secretion of IL16 and IL-2RA. Of the above cytokines showing differential secretion, only IL-2RA, IL16 and MIF showed significant correspondence in the steady state expression of their respective transcript levels. Post-hoc Enrichment analysis revealed Toll-like receptor (TLR) mediated pathways were the top-scored target pathways that were affected by AMA.

CONCLUSIONS

Administration of a CAMP causes shift in the balance of immune-inflammatory responses involving downstream pathways of TLRs in cytotrophoblast function. Further verification of functions of placental trophoblasts on administration of CAMP with pregnancy outcome is necessary.

Scrub typhus with visual hallucinations

The occurrence of psychiatric symptoms in scrub typhus is not commonly reported in literature. We present a case of scrub typhus with visual hallucinations.

Feto-maternal outcome in pregnancies complicated by isolated fetal congenital complete heart block

A retrospective analysis of eleven pregnancies complicated by isolated fetal congenital complete heart block (CCHB) in anti-SSA/Ro antibody positive women was carried out at a tertiary hospital in India to study the perinatal outcome. The mean gestational age at the time of detection of fetal CCHB was 24.5 ± 3.1weeks. Six mothers were asymptomatic; two had Sjögren's syndrome and three had systemic lupus erythematosus. Oral dexamethasone was given to all the patients after the diagnosis was made. There was one case of intrauterine death. Seven (63.6%) neonates needed a permanent pacemaker. There was no significant difference in the perinatal outcome in asymptomatic women with fetal CCHB and in women with connective tissue disorder and fetal CCHB. To conclude, fetal CCHB is associated with high morbidity but the presence of underlying connective disorder in the mother does not worsen the prognosis of the affected neonate.

CORONIS - International study of caesarean section surgical techniques: the follow-up study

Background

The CORONIS Trial was a 2×2×2×2×2 non-regular, fractional, factorial trial of five pairs of alternative caesarean section surgical techniques on a range of short-term outcomes, the primary outcome being a composite of maternal death or infectious morbidity. The consequences of different surgical techniques on longer term outcomes have not been well assessed in previous studies. Such outcomes include those related to subsequent pregnancy: mode of delivery; abnormal placentation (e.g. accreta); postpartum hysterectomy, as well as longer term pelvic problems: pain, urinary problems, infertility. The Coronis Follow-up Study aims to measure and compare the incidence of these outcomes between the randomised groups at around three years after women participated in the CORONIS Trial.

Methods/Design

This study will assess the following null hypotheses: In women who underwent delivery by caesarean section, no differences will be detected with respect to a range of long-term outcomes when comparing the following five pairs of alternative surgical techniques evaluated in the CORONIS Trial:

1. Blunt versus sharp abdominal entry

2. Exteriorisation of the uterus for repair versus intra-abdominal repair

3. Single versus double layer closure of the uterus

4. Closure versus non-closure of the peritoneum (pelvic and parietal)

5. Chromic catgut versus Polyglactin-910 for uterine repair

The outcomes will include (1) women’s health: pelvic pain; dysmenorrhoea; deep dyspareunia; urinary symptoms; laparoscopy; hysterectomy; tubal/ovarian surgery; abdominal hernias; bowel obstruction; infertility; death. (2) Outcomes of subsequent pregnancies: inter-pregnancy interval; pregnancy outcome; gestation at delivery; mode of delivery; pregnancy complications; surgery during or following delivery.

Discussion

The results of this follow-up study will have importance for all pregnant women and for health professionals who provide care for pregnant women. Although the results will have been collected in seven countries with limited health care resources (Argentina, Chile, Ghana, India, Kenya, Pakistan, Sudan) any differences in outcomes associated with different surgical techniques are likely to be generalisable throughout the world.

Trial registration

ISRCTN31089967

A prospective study on role of dehydroepiandrosterone (DHEA) on improving the ovarian reserve markers in infertile patients with poor ovarian reserve

AIM

The aim of this study was to evaluate the role of dehydroepiandrosterone (DHEA) supplementation on the ovarian reserve markers in infertile patients who were poor responders in previous in vitro fertilization (IVF) cycles.

STUDY DESIGN

A prospective clinical trial was conducted on 30 patients with history of poor response in previous IVF cycles. These patients were treated with DHEA, (Tab Eema-D, Corona Remedies Pvt Ltd., Ahmedabad, Gujurat, India) 25 mg thrice a day for four months. Ovarian stimulation was done using the previous protocol. Clinical parameters were measured before and treatment with DHEA. Results were analysed using Student's "t" paired test.

RESULTS

DHEA resulted in a significant increase (p < 0.05) in the serum Antimullerian hormone in all age groups (35, 36-38 and >38 years). Peak estradiol level on the day of human chorionic gonadotrophin administration also increased significantly (p < 0.05). A significant decrease (p < 0.05) was noted in Day 2 follicle-stimulating hormone (FSH) in all age groups. There was no statistically significant difference in the antral follicle count (AFC). Pregnancy rate was 16.7% after treatment. Thus, DHEA has a significant effect in improving the ovarian reserve in poor responders with previously failed IVF cycles. It can help in enhancing clinical pregnancy rate in these patients.