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   2016| Oct-Dec  | Volume 6 | Issue 4  
    Online since October 19, 2016

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Efficacy and safety of Carica papaya leaf extract in the dengue: A systematic review and meta-analysis
Jaykaran Charan, Deepak Saxena, Jagdish Prasad Goyal, Sandul Yasobant
Oct-Dec 2016, 6(4):249-254
DOI:10.4103/2229-516X.192596  PMID:27857891
Background: Dengue is an infectious disease associated with high mortality and morbidity. Being a viral disease, there is no specific drug available for treatment. There are some reports that Carica papaya leaf extract may improve the clinical condition of dengue patients; however, to support this, at present, there is no systematically searched and synthesized evidence available. Objectives: This systematic review and meta-analysis was designed to search the available evidence related to the efficacy and safety of C. papaya leaf extract in dengue and to synthesize the evidence in meaningful form through meta-analysis so that inference can be drawn. Materials and Methods: Randomized controlled trials related to the efficacy and safety of C. papaya leaf extract in dengue were searched from PubMed, Cochrane Clinical Trial Registry and Google Scholar. The primary endpoint was mortality, and secondary endpoints were increase in platelet count, hospitalization days, and Grade 3 and 4 adverse events. Data related to primary and secondary endpoints were pooled together and analyzed by review manager (Review Manager (RevMan) Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, Denmark) software. The random effect model was used. The bias was analyzed by the Cochrane risk of bias tool. Results: Total four trials enrolling 439 subjects were included in the analysis. Of 439 subjects, data of 377 subjects were available for analysis. C. papaya leaf extract was found to be associated with increase in platelet count in the overall analysis (mean difference [MD] =20.27 [95% confidence interval (CI) 6.21–34.73; P= 0.005]) and analysis after 4th day (MD = 28.25 [95% CI 14.14–42.37; P< 0.0001]). After 48 h, there was no significant difference between C. papaya and control group (MD = 13.38 [95% CI − 7.71–34.51; P = 0.21]). There was significant decrease in hospitalization days in the C. papaya group (MD = 1.90 [95% CI 1.62–2.18; P< 0.00001]). Because of nonavailability of data in published clinical trials, mortality, and adverse events cannot be pooled. Conclusion: C. papaya leaf extract can be considered as a potential candidate for increase in platelet count in patients of dengue, however; there is need of high-quality evidence in the form of large clinical trials before a decision related to the use of such extract is made.
  6 5,666 812
Pregnancy luteoma: A rare case report
Vaishali Verma, Surinder Paul, KS Chahal, Jaspreet Singh
Oct-Dec 2016, 6(4):282-283
DOI:10.4103/2229-516X.192600  PMID:27857898
Pregnancy luteomas are rare, nonneoplastic lesions of the ovary thought to be caused by the hormonal effects of pregnancy. Most of these patients are asymptomatic with the ovarian enlargement being incidentally discovered during imaging or surgery. Some patients develop hirsutism or virilization during late pregnancy. Luteomas spontaneously regress postpartum. It may be a diagnostic and management challenge as it can mimic the presentation of malignant ovarian tumors. We present a 33-year-old female with an enlarged ovary discovered incidentally at the time of cesarean section.
  4 1,917 182
Possible role of elevated serum testosterone in pathogenesis of renal stone formation
Kapil Gupta, Gurpreet Singh Gill, Rajiv Mahajan
Oct-Dec 2016, 6(4):241-244
DOI:10.4103/2229-516X.192593  PMID:27857889
Background: Urolithiasis or renal stone formation occurs with three times higher frequency in males and decreases with age in parallel with the serum testosterone levels, suggesting a role played by male sex hormones. Androgens appear a promotion action and estrogens an inhibitory action on kidney stone formation in several animal models suggesting a study to be carried out to deduce the role played by serum testosterone in the formation of renal stones. Aim: The aim of this study is to define the involvement of serum total testosterone, free testosterone, and dihydrotestosterone in the pathogenesis of urolithiasis in males by comparing the results with healthy males with no present or past history of urolithiasis as controls. Materials and Methods: A case–control study was undertaken with 108 participants: 78 males diagnosed with urolithiasis and 30 age-matched healthy males. Results: The difference between mean age and body mass index of patients and controls were found to be nonsignificant. The total serum testosterone levels, serum dihydrotestosterone levels, were found to be higher in patients when compared to controls, and the difference was found to be significant. The levels of free testosterone and serum estradiol were also found to be higher in urolithiatic patients. Conclusion: The study demonstrates that elevated levels of serum testosterone and serum dihydrotestosterone might be involved in increased incidences of stone formation. The higher levels of estradiol do not seem to be a protective factor in males with urolithiasis with higher serum testosterone levels.
  4 2,451 424
Orthokeratinized odontogenic cyst masquerading as dentigerous cyst
Devi Charan Shetty, Ajit Singh Rathore, Anshi Jain, Natasha Thokchom, Neha Khurana
Oct-Dec 2016, 6(4):297-299
DOI:10.4103/2229-516X.192597  PMID:27857903
The orthokeratinized odontogenic cyst (OOC) is a rare developmental odontogenic cyst that has been considered as a variant of the keratocystic odontogenic tumor until Wright (1981) defined it as a different entity. Recognition of OOC as a unique entity has long been due, yet its inexplicable clinical, radiographic presentation resembling dentigerous cyst due to its association to an impacted tooth, and its histological features makes it rather perplexing. This is the report of a case of OOC in relation to an impacted maxillary canine and its immunohistochemical analysis with Ki-67.
  3 1,902 234
Successful pregnancy after excision of cesarean scar endometriosis with uterovesicocutaneous fistula: A rare case report
Sunil Kumar Juneja, Pooja Tandon, Isha Chopra
Oct-Dec 2016, 6(4):300-302
DOI:10.4103/2229-516X.192586  PMID:27857904
Scar endometriosis is an infrequent type of extrapelvic endometriosis. The most common extrapelvic form of endometriosis is cutaneous endometriosis, involving scar tissues occurring after obstetric or gynecologic procedures such as episiotomy, hysterotomy, cesarean section, and even laparoscopic surgery. The clinical presentation of scar endometriosis, i.e., tender swellings, mimics other dermatological and/or surgical conditions and delays the diagnosis. Scar endometriosis very rarely can get complicated with uterocutaneous fistula with a reported incidence of very few cases in world literature. We report a case of a 36-year-old woman presenting with scar endometriosis with complicated uterocutaneous fistula 11 years after her last lower segment cesarean section, managed successfully with laparotomy-fistulectomy and sleeve resection of the bladder with repair followed by successful subsequent spontaneous conception and pregnancy terminated by lower segment cesarean section.
  2 1,729 161
Prevalence of thyroid disorders in hepatitis C virus positive patients on interferon and antiviral therapy
Gitanjali Goyal, KMDS Panag, Ravinder Garg
Oct-Dec 2016, 6(4):245-248
DOI:10.4103/2229-516X.192587  PMID:27857890
Background: Hepatitis C virus (HCV) infection is common worldwide. The treatment typically involves a combination of interferon-alpha (IFN-α) and ribavirin (RBV) therapy; however, the use of IFN-α is well documented to be associated with thyroid disease, the most common autoimmune disorder associated with IFN-α. Aim: The aim of the present study was to know the prevalence of thyroid abnormality in the HCV-positive patients on IFN and antiviral therapy. Materials and Methods: Fifty known HCV positive patients were enrolled for the study. All the patients were on IFN (3 million unit subcutaneously 3 times/week) and antiviral therapy (oral RBV 1000–1200 mg/day). Thyroid function tests were performed first at the start of treatment and then after 12 weeks of treatment. Results: 13 (26%) of the patients were found to develop hypothyroidism, and 1 (2%) patient developed hyperthyroidism in the course of 12 weeks therapy. Conclusion: HCV patients on IFN and antiviral therapy have an effect on the thyroid gland, so these patients should be regularly screened for thyroid disorders and appropriately treated to maintain euthyroid status.
  2 2,011 298
Buccolingual course of the inferior alveolar canal in different mental foramen locations: A cone beam computed tomography study of an Iranian population
Atieh Safaee, Sanam Mirbeigi, Fatemeh Ezoddini, Leila Khojastepour, Alireza Navab-Azam
Oct-Dec 2016, 6(4):262-266
DOI:10.4103/2229-516X.192589  PMID:27857894
Context: Better understanding of the anatomical location and course of the mandibular canal is necessary to avoid damaging inferior alveolar nerve. Aims: The aim of this study was to investigate the buccolingual course of the inferior alveolar canal (IAC) in different mental foramen locations, using cone beam computed tomography. Materials and Methods: Three hundred and twelve hemimandibular images were evaluated in this study. The location of mental foramen in relation to the apices of mandibular premolar and molar teeth were recorded. Nine measurements (in millimeters) were taken at the level of the IAC and posterior mandibular premolar and molar root apices. Relative distances of IAC to buccal and lingual mandibular cortex were calculated for different mental foramen types. Statistical Analysis Used: Data were analyzed by one-way analysis of variance and P< 0.05 was considered to be statistically significant. Results: The distribution of subjects according to the type of mental foramen includes: Type 1 = 50.3% (at the level of second premolar apex), Type 2 = 33% (between the apices of first and second premolars), and Type 3 = 16.7% (between the apices of second premolars and first molars). The buccolingual ratio of the IAC position was statistically significant in different mental foramen types (P = 0.00). Conclusion: The position of IAC was affected by the location of the mental foramen. The direction of IAC gradually changed from lingual to buccal and from posterior to anterior.
  2 2,055 286
Complete agenesis of the dorsal pancreas: A rare clinical entity
Ambooken P Robert, Showkathali Iqbal, Mathew John
Oct-Dec 2016, 6(4):290-292
DOI:10.4103/2229-516X.192599  PMID:27857901
Complete agenesis of the dorsal pancreas (ADP) is an exceedingly rare congenital anomaly, compatible with life. The first case was reported in 1911 and so far around 100 cases have been reported in the world literature. Majority of the patients with this anomaly are asymptomatic or associated with abdominal pain, hyperglycemia, diabetes mellitus, and acute or chronic pancreatitis. We present a case report of a 34-year-old male with ADP, diagnosed incidentally during radiological evaluation for abdominal pain. Magnetic resonance cholangiopancreatography confirmed the absence of neck, body, and tail of the pancreas along with duct of Santorini and the minor duodenal papilla. Because of its rarity of occurrence, clinical awareness of the ADP can expand the differential diagnosis and improve patient management in pertinent light of the world literature.
  1 2,046 172
Severe congenital cyclic neutropenia: A case report
Vidyavathi H Patil, Shivayogi M Hugar, Girish Balikai, Sudha Patil
Oct-Dec 2016, 6(4):293-296
DOI:10.4103/2229-516X.192598  PMID:27857902
Congenital cyclic neutropenia syndrome is a constitutional genetic disorder which is characterized by very low number of neutrophils (neutropenia). Patients suffering from this disorder clinically present with neutropenia at early age, history of recurrent fever, ulcerations in the oral cavity, gingivitis, and other recurrent infections. This paper describes a case report of a child with recurrent mouth ulcers, fever, and later diagnosed with severe congenital cyclic neutropenia. This also emphasizes the importance of identification of rare causes of immunosuppressive conditions in children presenting with recurrent oral ulcers and poor dental hygiene, to prevent long-term complications of oral cavity and also morbidity and mortality secondary to neutropenic sepsis.
  1 2,429 301
Prevalence of Abelson murine leukemia viral oncogene homolog-breakpoint cluster region fusions and correlation with peripheral blood parameters in chronic myelogenous leukemia patients in Lorestan Province, Iran
Ali Asghar Kiani, Farhad Shahsavar, Mojtaba Gorji, Kolsoum Ahmadi, Vahideh Heydari Nazarabad, Banafsheh Bahmani
Oct-Dec 2016, 6(4):271-275
DOI:10.4103/2229-516X.192591  PMID:27857896
Context: Chronic myelogenous leukemia (CML) is a chronic malignancy of myeloid linage associated with a significant increase in granulocytes in bone marrow and peripheral blood. CML diagnosis is based on detection of Philadelphia chromosome and “Abelson murine leukemia viral oncogene homolog” (ABL)-“breakpoint cluster region protein” fusions (ABL-BCR fusions). Aims: In this study, patients with CML morphology were studied according to ABL-BCR fusions and the relationship between the fusions and peripheral blood cell changes was examined. Materials and Methods: All patients suspected to chronic myeloproliferative disorders in Lorestan Province visiting subspecialist hematology clinics who were confirmed by oncologist were studied over a period of 5 years. After completing basic data questionnaire, blood samples were obtained with informed consent from the patients. Blood cell count and morphology were investigated and RNA was extracted from blood samples. cDNA was synthesized from RNA and ABL-BCR fusions including b3a2 and b2a2 (protein 210 kd or p210), e1a2 (protein 190 kdor p190), and e19a2 (protein 230 kdor p230) were studied by multiplex reverse transcription polymerase chain reaction method. Coexistence of e1a2 and b2a2 (p210/p190) fusions was also studied. The prevalence of mutations and their correlation with the blood parameters were statistically analyzed. Results: Of 58 patients positive for ABL-BCR fusion, 18 (30.5%) had b2a2 fusion, 37 (62.71%) had b3a2 fusion and three (3.08%) had e1a2 fusion. Coexistence of e1a2 and b2a2 (p210/p190) was not observed. There was no significant correlation between ABL-BCR fusions and white blood cell count, platelet count, and hemoglobin concentration. Conclusions: The ABL-BCR fusions in Lorestan Province were similar to other studies in Iran, and b3a2 fusion had the highest prevalence in the studied patients studied.
  1 1,706 187
Interleukin-4 and interferon-γ are possible allergic markers in pediatric patients with β-lactam hypersensitivity
Khaled H Mahmoud, Abdullateef A Alzolibani, Zafar Rasheed, Yasser Farouk, Ghada Bin Saif, Ahmad A Al Robaee
Oct-Dec 2016, 6(4):276-281
DOI:10.4103/2229-516X.192595  PMID:27857897
Background:& #946;-lactam agents are known to elicit T-cell-mediated immune responses that play a central role in the onset of allergic reactions, but the involvement of specific type of cytokines in drug allergy remains largely unexplored in humans. Objectives: This study was undertaken to investigate the role of cytokines involvement in pediatric patients with β-lactam hypersensitivity and to determine whether involvement of cytokines in drug-mediated reactions are important for the perspective of allergic patient's management. Methods: β-lactam-induced hypersensitivity reactions in eighty pediatric patients were determined by clinical manifestations and skin prick or intradermal testing. Production of T-helper (Th) type-1 cytokine interferon (INF)-γ, Th-2 cytokine interleukin (IL)-4, regulatory T-cell cytokine IL-10, and other cytokines IL-6 and IL-12 were determined by sandwich ELISAs. Results: Diagnosis of β-lactam allergy was confirmed in 53 pediatric patients. IL-4 secretion in patients' sera was significantly higher as compared with healthy controls (P < 0.05). However, INF-γ level in patients' sera was significantly lower as compared with controls (P < 0.05). No significant alterations were found in the protein secretion of IL-10, IL-12, and IL-6 in allergic patients as compared with controls (P > 0.05). Conclusion: We conclude that IL-4 is specific marker for the diagnosis of β-lactam-induced hypersensitivity. Moreover, IL-4 in combination with INF-γ is more sensitive for the diagnosis of these reactions. This study also concludes that both IL-4 and INF-γ may play an active role in the onset of allergic reactions against β-lactam antibiotics.
  1 1,637 143
A study on the aac-(61)-lb-cr gene prevalence among ciprofloxacin-resistant strains of uropathogenic Enterobacteriaceae
Nirupa Soundararajan, Priyadarshini Shanmugam, Caroline Devanbu, Shameem Banu Abdul Sattar
Oct-Dec 2016, 6(4):258-261
DOI:10.4103/2229-516X.192603  PMID:27857893
Introduction: Urinary tract infections (UTIs) are very common. Indiscriminate use of antibiotics has led to the development of resistance to most of the commonly used antibiotics including quinolones. Aim: This study aimed to find out the prevalence of ciprofloxacin resistance among the uropathogenic Enterobacteriaceae, to determine the virulence factors of these isolates, and to detect the aac-(61)-lb-cr gene among those isolates with minimal inhibitory concentrations (MICs) of ciprofloxacin >256 mcg/ml. Materials and Methods: Urine samples reaching the microbiology laboratory were processed, pathogens belonging to the Enterobacteriaceae family were isolated from those with significant bacteriuria, and antibiotic sensitivity testing was performed according to the CLSI guidelines. MIC of ciprofloxacin for the isolates resistant to ciprofloxacin was determined by using the E–test, and virulence factors such as hemagglutination, hemolysis, and mucoid colonies were analyzed. aac-(61)-lb-cr gene was analyzed by polymerase chain reaction for those isolates with MIC > 256 mcg/ml. Results: Escherichia coli was the most common isolate (62%) with the highest ciprofloxacin resistance (68%). Fourteen percent of them had MIC > 256 mcg/ml and all of these isolates harbored the aac-(61)-lb-cr gene. Conclusion: Plasmid-mediated drug resistance can rapidly spread and lead to selection of drug-resistant mutants if not controlled.
  1 1,583 173
Hypoglycemia and revisable ST-elevation induced by Movento
Mohammad Moshiri, Seyed Reza Mousavi, Leila Etemad
Oct-Dec 2016, 6(4):284-286
DOI:10.4103/2229-516X.192590  PMID:27857899
Spirotetramat (STM), an active ingredient of insecticide Movento 100 suspension concentrate (M100), is an inhibitor of acetyl-CoA carboxylase (ACC). The ACC is catalyst of acetyl-CoA to malonyl-CoA (MCA) reaction. MCA is the rate limiting steps of fatty acid biosynthesis. An 18-years-old man, who was referred to our ward from a local hospital, ingested 100 ml of M100, 18 h before. When we visited him, he was confused with stable vital signs and complained of vomiting and epigastric discomfort. He experienced hypoglycemia (blood sugar = 31 mg/dl) that was treated by hypertonic 20% dextrose serum and continued by maintenance DW10% (100 ml/h) up to 3 h. The first electrocardiogram showed ST-elevation. The results of urgent bedside echocardiography findings were normal. His first troponin I value was 0.01 ng/ml and at 1 and 6 h later were zero. The elevated ST segment gradually returned to baseline through next 6 h. STM ingestion can cause hypoglycemia and ST changes.
  - 1,534 127
Sudden death of a middle-aged man with an artificial vagina in situ
Muditha Vidanapathirana, Rohan P Ruwanpura, Sriyantha RRG Amararatne
Oct-Dec 2016, 6(4):287-289
DOI:10.4103/2229-516X.192592  PMID:27857900
Artificial vaginas are designed to imitate the female sex organ. This is the first reported case in the forensic literature of a man being pronounced dead with an artificial vagina in situ. A middle-aged man was found unconscious in a bathroom when the door was forced open and was pronounced dead on admission. Autopsy revealed that the penis was inside an artificial vagina. There were no injuries, but there were left ventricular hypertrophy, myocardial fibrosis, and narrow coronaries. The cause of death was ascertained as ischemic heart disease due to coronary atherosclerosis and the comments included were no evidence of violence, and ischemic heart disease could have been precipitated due to abnormal sexual activity. If removal of artificial vagina was done before the admission, this circumstance could not have ascertained. Removal of such devices before admission to hospitals could be the reason why such incidents do not come to light.
  - 2,078 167
The relative buccolingual position reflects the horizontal course of the inferior alveolar canal more accurately than morphometric measurements
Wei Cheong Ngeow, Phrabhakaran Nambiar
Oct-Dec 2016, 6(4):235-236
DOI:10.4103/2229-516X.192602  PMID:27857887
  - 1,904 3,791
The “Triple-Q Algorithm:” A practical approach to the identification of liver topography
Omar Bekdache, Ahmad Zarour, Ayman El-Menyar, Yassir Abdulrahman, Husham Abdelrahman, Mohammad Ellabib, Ruben Peralta, Hassan Al-Thani
Oct-Dec 2016, 6(4):237-240
DOI:10.4103/2229-516X.192588  PMID:27857888
The descriptive identification and interpretation of liver pathology continue to raise debate, especially for trainees and junior physicians. There is wide diversity in the description of liver segmentation with sometimes contradictory terminology between French and American literature. Attempts were made to create a unified nomenclature that simplifies the problem. We propose a simple approach to describe the location of liver pathology in different settings by referring to an algorithm based on three questions. Explanations to answer these questions and correctly describe the location of liver pathology are herein described. In conclusion, we think that the adoption of such an algorithm called arbitrary “the Triple-Q Algorithm” will facilitate the understanding of liver topography for the young physicians, as well as it will allow for the accurate description and localization of the pathological lesions in the liver. This could be achieved after testing and validating this algorism in prospective studies. This could have academic and clinical implications in the medical education and the patient care.
  - 2,124 1,238
Angiotensin-converting enzyme insertion/deletion polymorphism is not associated with vasoocclusive complications of sickle cell anemia
Sana Abass Mahjoub, Enaam Abdelrhman, Mohammed Elfatih Mohy El-Deen, Mustafa Sharf Eldin Mustafa, Elshazali Widaa Ali
Oct-Dec 2016, 6(4):267-270
DOI:10.4103/2229-516X.192594  PMID:27857895
Context: Sickle cell anemia (SCA) is a group of hemoglobin disorders in which the sickle β-globin gene is inherited. It is associated with many complications; most of them are related to thrombotic events. Aim: This study aimed to investigate the association between angiotensin converting enzyme (ACE) insertion/deletion polymorphism and complications of SCA. Settings and Design: A case–control study was conducted in Khartoum state. Subjects and Methods: A total of 50 patients with SCA and 40 healthy volunteers as a control group were enrolled in this study. Three milliliters of ethylenediamine tetraacetic acid anticoagulated blood were collected from each subject, DNA was extracted by salting-out method, and target DNA regions of the ACE gene were amplified using allele-specific polymerase chain reaction. Statistical Analysis Used: Data of this study was analyzed by Statistical Package for Social Sciences. Frequency of qualitative variables was calculated, and correlation was tested by Chi-square test. Regression was used to investigate the association between the polymorphism and complications of SCA. Results: The frequencies of the DD, ID, and II genotypes were 42%, 50%, and 8%, respectively, for patients, whereas in the control group, it was 80% for DD genotype and 20% for ID, while II genotype was totally absent. The regression analysis showed no statistically significant association between the disease complications and each of the ACE polymorphic genotypes. Conclusion: No statistically significant association was found between ACE polymorphism and complications of SCA.
  - 1,559 158
Arterial ammonia levels: Prognostic marker in traumatic hemorrhage
Anurag Singla, Satinder Kaur, Navjot Kaur, CS Gill
Oct-Dec 2016, 6(4):255-257
DOI:10.4103/2229-516X.192601  PMID:27857892
Background: In blunt trauma, extent of hemorrhage cannot be determined by physical examination, and vital signs may also not give clear picture in all the patients, especially young healthy ones. Hemorrhagic shock has been reported to increase blood ammonia levels. Arterial ammonia was analyzed in blunt trauma abdomen patients and correlated with shock index (SI). Its predictive value was determined for timely decision of intervention. Materials and Methods: Hundred blunt trauma abdomen patients presented in the emergency ward of tertiary care hospital were included in the study. Group I comprised 62 patients requiring either blood transfusion ≥2 units and/or intervention to control bleeding within 24 h following admission. Group II had 38 patients: Not requiring transfusion/intervention during hospital stay. Arterial blood sample was taken immediately after admission; ammonia was analyzed within 20 min of sampling on Cobas 6000 (Roche). SI was calculated. Predictive value of ammonia was determined using receiver operating characteristic curve. Results: Ammonia levels and SI were significantly (P < 0.001) higher in Group I compared to Group II patients (68.55 ± 14.36 umol/L vs. 37.55 ± 7.41 umol/L and 1.28 ± 0.5 vs. 0.74 ± 0.12, respectively). Significantly higher number of patients in Group I (88.7% vs. 13%) had SI > 0.9. Ammonia levels were significantly higher in patients with complications and in those expired. Conclusions: Ammonia levels were significantly higher in patients requiring blood transfusion/intervention in 24 h of admission. The best cutoff value to maximize sensitivity and specificity was ammonia >58.85 μmol/L. Ammonia estimation at admission can be clinically significant indicator of traumatic hemorrhage needing intervention.
  - 1,543 257