CURRENT TRENDS IN PRESCRIBING PATTERN OF ANTI-MIGRAINE DRUGS IN PATIENTS OF MIGRAINE AT A TERTIARY CARE TEACHING HOSPITAL

Background. An inappropriate prescribing pattern of antimigraine drugs by doctors may often encourage inappropriate self-medication by patients because of the asymmetry of medical information. Objective. The study is aimed to assess the current trends in prescribing patterns of anti-migraine drugs, rationality of prescription, and pattern of migraine severity in patients of migraine. Methods. A cross sectional study was conducted at a tertiary care teaching hospital. All the prescribing details including patient’s demographic details, diagnosis, details of drug therapy (drug name, dose, duration, and frequency) were recorded. Rationality of prescription was assessed using the WHO core drug prescribing indicators and the pattern of severity of migraine was assessed using MIDAS scoring system. Results. Out of 85 patients, 71 were female (83.5%), mostly around 21-30 years of age, and 27 (31.7%) patients had other comorbidities. Naproxen was the most commonly used NSAID for termination of acute migraine attack (15.3 %). The most common drugs prescribed for prophylaxis included beta adrenergic blockers (Propranolol, 14.66%), antidepressants (Amitriptyline, 9.33% and Fluoxetine 3.33%), and antipsychotics (Prochlorperazine, 4.66%). Domperidone (17.30%) was the most commonly prescribed antiemetic. Prescription of triptans was low (2.66%) with Rizatriptan as the most commonly prescribed triptan. Conclusions. The current study revealed that further improvements are required in prescribing practices especially in average number of drugs per prescription, prescription of drugs with generic names, and prescription of drugs of the essential drugs list.

Clinical outcomes and adverse drug reactions in COVID-19 patients treated with hydroxychloroquine and azithromycin alone or combined

Background. Use of Hydroxychloroquine with or without Azithromycin is repurposed in SARS-CoV-2 in the absence of definitive treatment. Objective. To evaluate the association between the use of Hydroxychloroquine and Azithromycin when given alone or in combination on clinical outcomes and adverse drug reactions among lab confirmed SARS CoV-2 positive patients admitted in a COVID tertiary care hospital of a University Medical college. Methods. a retrospective observational comparative study was conducted. COVID-19 positive patients admitted in study hospital for management of COVID-19 were enrolled into the study. The patients were categorized into 4 treatment groups based on having received the following treatment during hospitalization: (A) Hydroxychloroquine with Azithromycin, (B) Hydroxychloroquine without Azithromycin (Hydroxychloroquine alone), (C) Azithromycin alone, and (D) Neither drug, defined as no receipt of either Hydroxychloroquine or Azithromycin in the record; other medications may have been dispensed. Results. 800 patients were enrolled. Mean±Standard deviation of duration of hospital stay (in days) for study Group A was 11.37±7.11, for Group B was 8.37±4.77, for Group C was 18.22 ± 5.69 and for Group D was 6.12±2.97. Mortality in Group A was 29.74%, Group B – 33.16%, Group C – 0% and in Group D – 1.32%. Conclusion. Among hospitalized patients with COVID-19 treatment, Group C was associated with good clinical outcome. However, the interpretation of these findings may be limited by the observational design.

Quality of life and well-being of population at the end of third phase of lockdown in india against the COVID-19 pandemic

Background. On March 24, 2020, a nationwide Lockdown for 21 days was ordered by the Government of India which was then extended till May 31, 2020. Researchers have predicted lockdown is a necessary step to prevent COVID-19 spread. However, others have also stated that it could cause serious damage to the economic, mental, social, and physical well-being of the people. Objective. The aim of the study is to evaluate the impact of lockdown on the quality of life and well-being of the Indians. Methods. It is a cross sectional prospective web-based questionnaire study. A link (https://forms.gle/pX25VuahP5NxT88QA) was created. Total 426 responses were received via that link and the data was included in the statistical analysis. Results. Our study revealed that during the lockdown 61.5% of the respondents were performing physical activities lesser than before. More than half responded they had a reduced financial satisfaction. Most answers on emotional well-being and social-family wellbeing were also positive, but some responses showed disturbing too, like 22% felt anxious and nervous over half of the days. It was found in the study that physical, financial, emotional, mental, social and family wellbeing were disturbed during the lockdown and quality of life was also hampered. Conclusion. Though, may be Nationwide Lockdown was the most required action at that point of time to prevent virus spread, but our study revealed that uncertainty regarding its cure and management guidelines like lockdown and social distancing has badly affected quality of life and wellbeing of the population.

Sexual fantasies, subjective satisfaction and quality of sexual life in patients of sexual dysfunction: A comparative study

Introduction

Exploring the ways in which sexual fantasies may affect sexual experience and satisfaction is of relavence in the clinical setting involving sexual dysfuntion.

Objectives

To observe how the sexual fantasy scores differ in their relationship with sexual satisfaction, experience and quality between sexual dysfunction cases and normal controls.

Methods

Scales included: Wilson’s sex fantasy questionnaire (WSFQ), Arizona Sexual Experience Scale (ASEX), Sexual Quality of life Questionnaire (SQoL), and a subjective sexual satisfaction meter. Differences in resposes of both groups on WSFQ (item-wise and domain-wise) were analysed using T-tests. Two-way ANOVA was applied to see how other scales affected sexual fantasy.

Results

Cases scored significantly higher on ASEX scale, and low on satisfaction, SQoL and WSFQ

	Cases N=1OO	Controls N=100	t-test
Satisfaction Mean(sd)	4.27(1.85)	7.82(1.31)	t=3.052;df=198,p=0.0026
Asex	17.52(4.73)	8.28(1.34)	t=15.24;df=198,p<0.0001
SQoL	29.41(12.12)	49.5(6.67)	t=14.52;df=198,p<0.0001
WSFQ	26.80(17.61)	30.59(15.32)	t=1.62,df=98,p=0.106

Majority of WSFQ responses, both in cases and controls, fell in the intimate and impersonal domains. Sexual fantasy scores and sexual satisfaction had a strong positive and significant correlation in controls but no linear correlation in the case-subjects. sexual fantasy scores contributed to 5.7% of difference in the scores of SQoL between groups. Major variance in scores of satisfaction in our subjects depended on presence or absence of sexual dysfunction(46.5%)but sexual fantasies also contributed to 8.8% of the variance.

Conclusions

The study showed that fantasies contribute to positive sexual outcomes only in absence of sexual dysfunction. ANOVAanalysis revealed that in case-subjects sexual satisfaction briefly increases initially with increase in fantasy scores but starts to decline as fantasies increase.

Disclosure

No significant relationships.

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Indomethacin dosing strategy and neonatal patent ductus arteriosus closure

BACKGROUND

Few studies exist that have evaluated the effects of indomethacin dosing frequency as a factor associated with successful patent ductus arteriosus closure in very low birth weight neonates. The objective of this study is to determine if indomethacin dosing strategy is associated with efficacy for initial patent ductus arteriosus management in very low birth weight neonates.

METHODS

This retrospective review compared every 12 hour and every 24 hour indomethacin regimens primarily for efficacy in initial patent ductus arteriosus management, defined as an absence of repeat medical and/or surgical treatment, and secondarily for safety in both univariate and multivariate models.

RESULTS

One hundred three very low birth weight neonates were included: 56 (54%) received every 12 hour and 47 (46%) underwent every 24 hour indomethacin dosing. Repeat medical and/or surgical patent ductus arteriosus treatment rates were similar between groups. Less ligation of the patent ductus arteriosus occurred with every 12 hour versus every 24 hour dosing (11% vs. 26%, p = 0.05), though this effect was mitigated controlling for birth weight and gestational age. Renal function, respiratory outcomes, feeding outcomes, length of stay, and mortality were similar between groups.

CONCLUSIONS

Neither the every 12 hour nor the every 24 hour indomethacin regimen demonstrated inferior efficacy or safety for initial management of patent ductus arteriosus. Further prospective analysis of indomethacin dosing strategy is warranted.

Clinical and equipment-related factors associated with the adequate peripheral blood stem cell collection in autologous transplant at a tertiary cancer center in Kerala - A retrospective cohort study

BACKGROUND

PBSC collection using apheresis is the preferred source of hematopoietic stem cells transplantation. However, apheresis procedures fail to harvest adequate CD34 yield in 5 to 40% of patients during the first collection. Therefore, this study aimed to study both the clinical- and equipmentrelated factors influencing CD34 yield among the autologous patients and to compare the collection efficiency of two apheresis equipments(Haemonetics MCS+ and Terumo Spectra Optia).

METHODS

Retrospective analysis of 69 patients underwent PBSC collection from 2015 to 2018. Frequency, clinical- and equipment-related factors responsible for adequate CD34+ cells (≥2 x106 cells/kg) yield during the first collection was studied. Factors such as collection efficiency, percentage platelet loss and percentage hemoglobin loss were considered to compare the two apheresis system.

RESULTS

Two-third (72%) patients of the study population had adequate CD34 stem cells yield during the first collection. Factors such as exposure to lenalidomide-based pretreatment regimen, peripheral blood WBC count and CD34 count are associated with the adequate CD34 yield. Optia had a slightly better collection efficiency than MCS+ (50 and 44; p=0.37). Optia had lower product volume (237 vs 298 ml) and lesser procedure duration (277 vs 360 min), whereas the median Hb loss (3.0% and 2.3%) and mean platelet loss (49% and 34%) were higher with MCS.

CONCLUSION

This study infers that the collection efficiency of both the equipments in collecting CD34 stem cells was similar. However, during PBSC collection, procedures using Optia can be preferred to MCS+ on the patients with risk of anemia and thrombocytopenia.

Transjugular liver biopsy using Tru-cut biopsy needle: KEM experience

BACKGROUND AND AIM

Transjugular liver biopsy is accepted procedure in patients in whom percutaneous liver biopsy is contraindicated. We report our experience with this procedure, its indications, efficacy and safety in Indian population over 5 years.

MATERIAL & METHODS

A retrospective study of 145 consecutive patients who had undergone transjugular liver biopsy from May 2002 to Nov. 2007 was done from the database maintained in our department. We evaluated the indications, technical success, complication and impact of histological diagnosis on the management of those patients.

RESULTS

145 Transjugular liver biopsies were performed of which 74 were males and 71 were females aged between 5 and 74 years. Two procedures were abandoned due to failed hepatic vein cannulation because of venous occlusion. Out of 143 biopsies, 4 were inadequate while 139 yielded adequate tissue for histopathological diagnosis. Histopathological examination in our study showed cirrhotic changes in 56, hepatitis including both acute and chronic in 48, periportal fibrosis in 9, Wilson's disease in 5 and obstructive cholangiopathy in 2 patients. The remaining 19 were normal. Minor complications occurred in 2 patients.

CONCLUSION

Transjugular liver biopsy is a safe procedure in the trained hands and provides adequate tissue for diagnosis when percutaneous liver biopsy is contraindicated.

Bacterial lipases: an overview of production, purification and biochemical properties

Lipases, triacylglycerol hydrolases, are an important group of biotechnologically relevant enzymes and they find immense applications in food, dairy, detergent and pharmaceutical industries. Lipases are by and large produced from microbes and specifically bacterial lipases play a vital role in commercial ventures. Some important lipase-producing bacterial genera include Bacillus, Pseudomonas and Burkholderia. Lipases are generally produced on lipidic carbon, such as oils, fatty acids, glycerol or tweens in the presence of an organic nitrogen source. Bacterial lipases are mostly extracellular and are produced by submerged fermentation. The enzyme is most commonly purified by hydrophobic interaction chromatography, in addition to some modern approaches such as reverse micellar and aqueous two-phase systems. Most lipases can act in a wide range of pH and temperature, though alkaline bacterial lipases are more common. Lipases are serine hydrolases and have high stability in organic solvents. Besides these, some lipases exhibit chemo-, regio- and enantioselectivity. The latest trend in lipase research is the development of novel and improved lipases through molecular approaches such as directed evolution and exploring natural communities by the metagenomic approach.

Statistical medium optimization and production of a hyperthermostable lipase from Burkholderia cepacia in a bioreactor

AIM

Statistical medium optimization for maximum production of a hyperthermostable lipase from Burkholderia cepacia and its validation in a bioreactor.

METHODS AND RESULTS

Burkholderia cepacia was grown in shake flasks containing 1% glucose, 0.1% KH2PO4, 0.5% NH4Cl, 0.24% (NH4)2HPO4, 0.01% MgSO4.7H2O and 1% emulsified palm oil, at 45 degrees C and pH 7.0, agitated at 250 rev min(-1) with 6-h-old inoculum (2% v/v) for 20 h. A fourfold enhancement in lipase production (50 U ml(-1)) and an approximately three fold increase in specific activity (160 U mg(-1)) by B. cepacia was obtained in a 14 litre bioreactor within 15 h after statistical optimization following shake flask culture. The statistical model was obtained using face centred central composite design (FCCCD) with five variables: glucose, palm oil, incubation time, inoculum density and agitation. The model suggested no interactive effect of the five factors, although incubation period, inoculum and carbon concentration were the important variables.

CONCLUSIONS

The maximum lipase production was 50 U ml(-1), with specific activity 160 U mg(-1) protein, in a 14 litre bioreactor after 15 h in a medium obtained after statistical optimization in shake flasks. Further, the model predicted reduction in time for lipase production with reduction in total carbon supply.

SIGNIFICANCE AND IMPACT OF THE STUDY

Statistical optimization allows quick optimization of a large number of variables. It also provides a deep insight into the regulatory role of various parameters involved in enzyme production.

Duodenal leiomyoma--a rare cause of haematemesis

Leiomyoma of the duodenum is a rare tumour. Small intestinal tumours contributing to upper gastrointestinal bleed is still rare. They usually present with malena and anaemia, rarely hematemesis. We report a case of leiomyoma of duodenum diagnosed on endoscopic ultrasound that presented with massive haematemesis.

Endoscopic sclerotherapy in children with extrahepatic portal venous obstruction

BACKGROUND

Extrahepatic portal vein obstruction (EHPVO) is a common cause of variceal bleeding in children in India. There is paucity of data regarding the results of treatment with endoscopic sclerotherapy.

METHODS

Fifty-nine children (mean age 11 +/- 3.8 years; range 7 months to 12 years; 36 males and 23 females) were studied from February 1990 to September 1999. EHPVO was diagnosed on the basis of portal cavernoma on ultrasonography in 55 patients and on splenoportovenogram in 4 patients. Endoscopic sclerotherapy was caried out at weekly intervals for the first three weeks and at 3 weekly intervals thereafter till complete or near complete thrombosis was achieved. All patients were followed up with check endoscopy every 3-6 months after thrombosis of oesophageal varices.

RESULTS

Over a mean follow up of 25.4 months (range 3 to 87 months) total thrombosis was achieved in 53 (89.8%) of 59 children. The mean number of sclerotherapy sessions required were 7.5 +/- 2.2. The mean number of blood transfusions required per bleeding episode was 3.8 +/- 3.2. Of the 59 children 21 (35.6%) rebled, of which 17 (28.8%) bled during and 4(6.8) after thrombosis of varices. Seven (11.9%) children had more than one episode of bleeding. Once thrombosis of the varices was achieved 15 (26%) of 59 children developed fresh varices on follow up. Gastric varices were detected in 47 (60%) children. In 39 (66%) children it was present at the onset and in 8 (13.5%) children it developed after thrombosis of oesophageal varices. Bleeding from gastric varix occurred in 7(9%) children. Ascites developed in 6(10.6%) children. One child developed oesophageal stricture. There were 3 (5%) deaths. Two died due to upper gastrointestinal bleed while on sclerotherapy schedule and one died due to cerebral abscess.

CONCLUSION

EHPVO is an important and common cause of upper gastrointestinal bleeding in children in Western India. EST is safe and useful in controlling oesophageal variceal bleeding in children.

Colonic tuberculosis: colonoscopic appearance and clinico-pathologic analysis

BACKGROUND

There has been a resurgence of interest in intestinal tuberculosis because of acquired immunodeficiency syndrome (AIDS) epidemic sweeping our country. Role of colonoscopy and colonoscopy directed histology for diagnosing the disease have been emphasised since last few years.

AIMS AND OBJECTIVES

To know the colonoscopic features in patients with intestinal tuberculosis and to study the clinicopathological findings in the same.

METHODS

We studied twenty-one patients with intestinal tuberculosis referred to us between 1993-1997. Colonoscopy was done in all patients and biopsy specimens were collected from the site of lesion during the procedure.

RESULTS

Ileocaecal disease was found in 9 patients, ileocaecal with contiguous ascending colon involvement in eight and segmental colonic tuberculosis in four cases. The colonoscopic findings included nodules in seven patients, nodules with ulcerations in three, ulcerations alone in seven, nodules with strictures in three and polypoidal mass in one patient. Eight cases revealed granuloma on histopathology.

CONCLUSIONS

Though bacteriological and histological assessment of tissue is essential to differentiate tuberculosis from other disorders, we stress the importance of colonoscopic appearances in diagnosing tuberculosis. We also recommend antituberculous chemotherapy in patients with high clinical suspicion of tuberculosis on the basis of colonoscopic appearance alone after ruling other causes on histopathological examination.

Foreign bodies in gut

BACKGROUND

Foreign body ingestion is common and a frightening experience to the patients and relatives. We report our experience with 102 patients, (78 children and 24 adults), with foreign body ingestion.

METHODS

After locating foreign bodies radiologically, 34 (43.6%) foreign bodies in children and 13 (54.2%) foreign bodies in adults were removed endoscopically. General anesthesia was used in 32 children and overtube was used for all sharp foreign bodies.

RESULTS

In our study, 78 (76%) patients were below 12 years of age. Coins (79.5%) were commonest foreign bodies in children while dentures (25%) were commonest in adults. Foreign bodies were most commonly sited in stomach (25.6%) in children and esophagus (58.3%) in adults. In 41 (52.6%) children and in three (12.5%) adults, i.e. total 44 out of 102 (43.1%) patients passed foreign bodies spontaneously. The largest foreign body that passed spontaneously was 4-cm long nail in a child. In 34 (43.6%) children and in 13 (54.2%) adults foreign bodies were removed endoscopically. Only 3.8% children and 33.3% adults required surgery.

CONCLUSIONS

There was no mortality in our series. Majority of foreign bodies do not require any intervention. Sharp foreign bodies are commonest indication for surgery. However, endoscopic removal is safe, effective and is the method of choice for most patients.

Colonic lithobezoar

We report a four-year-old girl with large number of stones in the colon presenting with subacute intestinal obstruction.

Bleeding duodenal varix in splenic vein thrombosis and chronic pancreatitis

Isolated duodenal varix is rare. We report a patient with bleeding duodenal varix with splenic vein thrombosis due to chronic pancreatitis.

Hepatic artery pseudoaneurysm associated with amebic liver abscess presenting as upper GI hemorrhage

We report the case of a 40-yr-old man who presented with recurrent hemorrhage of the upper GI tract who was found to have hepatic artery pseudoaneurysm and amebic liver abscess. Our patient is unique in having hepatic artery pseudoaneurysm and amebic liver abscess diagnosed simultaneously, the association of which has not been previously described.

Primary gastric lymphoma in a boy

Primary gastric lymphoma is an extremely uncommon entity in children, and diffuse large-cell-type lymphoma in this age group is still rarer. An 11-year-old boy with primary gastric lymphoma who responded to CHOP regime is reported.

Esophageal tuberculosis with intramural pseudodiverticulosis

Esophageal tuberculosis is rare, and its association with intramural pseudodiverticulosis is not widely appreciated. We report a patient with dysphagia who proved to have esophageal narrowing, mediastinal lymphadenopathy, and intramural pseudodiverticulosis. Results of endoscopy and biopsy were nonspecific, but biopsy of the supraclavicular node showed histology consistent with tuberculosis. The patient experienced a dramatic response to antitubercular therapy, with resolution of the esophageal narrowing, mediastinal lymphadenopathy, and esophageal intramural pseudodiverticulosis.