Background: Approximately 25–38% of chronic kidney disease (CKD) patients with anemia suffer absolute or functional iron deficiency. This deficiency is estimated and monitored primarily through two iron indices, viz., transferrin saturation (TSAT) and serum ferritin. However, both these parameters suffer from several lacunae and search continues to establish more true measures. This study enquires into the role of soluble transferrin receptors (sTfR) and ratio of sTfR and log ferritin index (sTfR index) as potential measures of the true iron status in patients. Material and Methods: This prospective cross-sectional study comprised a total of 126 CKD patients with anemia on erythropoietin (EPO) undergoing hemodialysis (HD). Of these 126 patients, 55 had iron deficiency anemia (IDA). Estimations of serum iron, TSAT, serum ferritin, and sTfR and sTfR, indices were performed in each patient. Bone marrow aspiration (BMA) was carried out to determine cellularity, cytomorphology, and myeloid: erythroid (M/E) ratio, and was stained with Prussian blue stain. The results of the bone marrow iron status were taken as the gold standard. Subsequently, receiver operating characteristic (ROC) curve analysis was carried out to assess the discriminative power of the sTfR and sTfR indices for evaluation of iron status in patients with CKD. Results: The cut-off value of sTfR index at its maximum sensitivity (71.8%) and specificity (62%) was found to be 1.39, whereas that of sTfR at its maximum sensitivity (63.6%) and specificity (64.8%) was 3.00. Statistically significant correlations were found between sTfR index (Pearson correlation (r) = –0.379) and serum iron (r = –0.38; P < 0.01), TSAT (r = –0.31; P < 0.01), and serum ferritin (r = –0.399; P < 0.01). sTfR was found to correlate significantly (r = –0.445) with serum iron (P < 0.01), TSAT (r = –0.365; P < 0.01), and hemoglobin (r = –0.179; P = 0.04) but not with serum ferritin (r = 0.12; P = 0.153). Conclusion: sTfR and sTfR index values are useful tools for assessment of iron status in patients with CKD, however, they are at best complementary to the existing indices of serum ferritin and TSAT. Between sTfR and sTfR index, the latter has a greater discriminating power.

Introduction: Coronary artery disease (CAD) is a leading cause of death in both women and men worldwide. There is under-recognition and under-diagnosis of CAD as a cause of high mortality rates in women. There is paucity of data regarding comparison of sensitivity, specificity, and accuracy of myocardial perfusion imaging-single photon emission computed tomography (MPI-SPECT) study in women and men in Indian population. Hence, this study was carried out to compare the sensitivity, specificity, and accuracy of MPI in women and men in the Indian population. Material and Methods: This retrospective study included 275 patients, 49 women and 226 men. Only patients who had coronary angiography (CAG) done within 6 months of the stress ^99mTc-sestamibi MPI-SPECT study were included in the study. Two arbitrary cut-off points on CAG, i.e., ≥50% and ≥70% were used for the determination of extent of CAD. Results: Considering CAG as the gold standard with ≥50% coronary stenosis as the cut-off criteria for significant stenosis, the overall sensitivity, specificity, and accuracy, respectively, of MPI- SPECT was 80%, 65%, and 72% in women and 82%, 70%, and 76% in men (P value not significant). Considering ≥70% coronary stenosis as the cut off criteria for significant stenosis, the overall sensitivity, specificity, and accuracy, respectively, of MPI-SPECT was 88%, 57%, and 66% in women and 87%, 59%, and 70% in men (P value not significant). No significant difference was found in the sensitivity, specificity, and accuracy of left anterior descending, left circumflex artery, and right coronary artery coronary vessels among women and men for both ≥50% and ≥70% coronary stenosis as the cut off criteria. Conclusion: ^99mTc-sestamibi MPI-SPECT has comparable sensitivity, specificity, and accuracy for the detection of CAD in women as it does in men.

Objective: To study the role of uric acid (UA) in the outcome of thrombolysis after stroke. Materials and Methods: Our observational study was conducted over 5 years at the KMC Hospital, Mangalore from July 2011 to July 2016. All patients above the age of 18 years presenting to the hospital within 4.5 hours of stroke onset were included into the study. The patients' stroke severity was calculated by National Institute of Health Stroke Scale (NIHSS) score, whereas the outcome was measured by modified Rankin Scale (mRS) score. The patients were divided into good outcome, poor outcome, and expired groups of patients depending on the mRS score (<3, ≥3 but <6, and 6, respectively). UA in the blood was measured and recorded in all the included patients. At the end of the study, significance was calculated by standard statistical methods. Results: A total of 71.9% patients were found to have a good outcome, 24.2% patients had poor outcome, and the rest were in the expired group of patients. Among the good outcome patients, UA was found to be 4.6 ± 1.4 mg/dL, in the poor outcome group UA was 3.7 ± 1.1 mg/dL, and in expired group UA was 3.2 ± 0.6 mg/dL (P = 0.002). Conclusion: Our results suggest that UA has neuroprotective actions and can predict a good outcome among patients undergoing thrombolysis.

Background: The two main measures of a successful primary total knee arthroplasty (TKA) are relief from pain and increase in the range of motion. Because the lifestyle in the Indian subcontinent requires bending of knee beyond 90° during the course of numerous daily chores, the range of knee flexion achieved following surgery is an important clinical outcome measure. This outcome can, however, be influenced by several variables. Objective: This study tried to analyze the possible difference in the postoperative knee flexion among patients undergoing primary TKA and establish the interrelationship among different covariates. Materials and Methods: Thirty-three patients of primary TKA were recruited in the study. Newly operated cases were followed up till 6 months postoperatively. Knee flexion as a part of knee society scoring was carried out as a part of the follow-up. The results obtained were suitably analyzed using the standard statistical tools. Results: Knee flexion in patellar resurfaced post-TKA group (114.17 ± 9.42; P = 0.01) was significantly higher than that in patellar nonresurfaced post-TKA group. Patients who were used to employing some kind of support while negotiating stairs had significantly worse pain scores (41.11 vs. 48.33; P = 0.007] and reduced knee flexion (105.56 vs. 119.17; P = 0.001) compared to those who did not use any support. Compared to males, females were more likely to use support while negotiating stairs (Wald chi square = 4.151, P = 0.04 OR = 8.0). Among all post-TKA patients, males were found to have a greater degree of knee flexion than females (120 vs. 105.37; P = 0.002). No significant difference in knee flexion was observed among age groups and type of arthritis or side of the operated knee. Conclusions: Patellar resurfacing and male sex was associated with a greater degree of post-TKA knee flexion in the study participants.

Introduction: The keystone of definitive management in active squamosal chronic otitis media (COM) is surgical correction. Numerous surgical strategies are in vogue, and the choice of surgery is largely governed by the underlying anatomic and pathologic condition. Of recent, much interest has focused on adopting a flexible approach which combines a number of sequential steps that aim to eradicate the disease and reconstruct the hearing apparatus in a single stage procedure, rather than following a traditional approach of modified radical mastoidectomy. Patients and Methods: This randomized, prospective double-blind study comprised 30 patients of various ages and both sexes, diagnosed with a unilateral or bilateral active squamosal chronic otitis media (COM). Of them, 12 (40%) patients were submitted to canal-wall down mastoidectomy, whereas 18 (60%) underwent a canal-wall up procedure. Each patient was followed up for a period of 6 months. The success of the procedure was measured in terms of achieving dry ear; a successful uptake of graft; and improvement in hearing. Results: Post surgery, at the end of 6 weeks, a dry ear was achieved in 25 (83.33%) patients, while the graft was taken up well in 29 (96.67%) patients. At 6 months, the number of patients with dry ear grew to 27 (90%), while the graft was taken up well in 28 (93.33%) patients. Two (6.66%) patients had graft failure. Of the 12 patients with canal-wall down procedure, 9 (75%) patients recorded a hearing improvement of air bone gap (ABG) ≤30 dBHL, while among the 18 patients who had a canal-wall up procedure, 94% had a hearing improvement of ABG ≤ 30 dBHL. Conclusion: Pursuing a flexible approach to tympanomastoidectomy offers a number of distinct benefits. Because the procedure is tailored to the gravity of otologic disease recognized intraoperatively, it fosters a total eradication of the disease and allows a suitable reconstruction of the auditory mechanism. Because the procedure is completed in a single stage, it reduces the time, effort, cost, and discomfort to the patient, while also diminishing the expense and burden on the public healthcare facility.

Orexin is a neuropeptide secreted by a group of hypothalamic neurons. Orexin neurons in hypothalamus have widespread projections throughout the brain and peripheral structures. Orexin actions are mediated by calcium and raise cytoplasmic Ca⁺² via a mechanism based on G-protein. Orexin activity is modulated by the biological clock. Orexin-A influences the hypothalamic and pituitary hormone release along with a role in arousal, energy homeostasis, goal-orientated behavior, and autonomic nervous system control. Orexin neurons receive indirect circadian signals that integrate with metabolic signals to regulate energy homeostasis. The metabolism of carbohydrates and fats is also linked to orexin. Orexin-A increases metabolic rate; insulin-induced hypoglycemia activates orexin-containing neurons, thus orexins regulate energy metabolism. The orexin-induced increase in energy metabolism is not simply due to increased wakefulness and physical activity but orexin increases metabolism independent of sleep/wake, locomotion, and food intake. Thus, orexin appears to be an essential factor for maintaining energy balance and body weight. Excess energy intake and decreased energy consumption due to sedentary lifestyle are the main contributors to the metabolic syndrome epidemic, and whether there is any correlation of metabolic risk markers with orexin levels is yet to be established. Orexin efficiently protects against the development of peripheral insulin resistance induced by ageing or high-fat feeding. Hyperglycemia caused by insulin insensitivity during ageing or by consumption of a high-fat diet leads to reduction in orexin expression in hypothalamus, which further exacerbates peripheral insulin resistance. Therefore, orexin receptor controlling hypothalamic insulin/leptin actions may be a new target for future treatment of hyperglycemia in patients with type 2 diabetes.

A genetically monomorphic, human-restricted bacterial pathogen that causes 21 million cases of typhoid fever and 200,000 deaths each year, predominantly in southern Asia, Africa, and South America, Salmonella enterica subspecies serovar Typhi has a long and colored evolutionary history. Based on studies relating to the population genetic structure of Typhi by mutation discovery within 200 gene fragments from a globally representative strain collection of 105 strains, researchers have drawn up a phylogenetic tree for Salmonella typhi. It is surmised that the first ancestral strains of the bacteria appeared somewhere in Indonesia between 43000 and 10000BC. That despite the passage of millennia of years since the setting up of its first footprints on Mother Earth, Salmonella typhi has persisted as a highly homogeneous tribe, may have much to do with the asymptomatic carrier state in humans that they can dig into to survive. This process of neutral evolution and genetic buffering in Typhi coupled with the relatively more recent adaptive evolution, a sequel of rapid transmission of phenotypic changes through acute infections, has led to production of its antibiotic-resistant strains has made the task of public health physicians even more daunting and complex. These chronicles dwell on the historical truths and multihued accounts relating to the epidemiology of a disease that once changed the course of European history, battles, and wars, and, narrates, how, over time, the bacteriologists, pharmacologists, and physicians of the times came up trumps against the slayer bacteria.

Lymphangioma circumscriptum is a benign dilatation of lymph channels localized to the skin and subcutaneous tissues. This dermatological condition is generally found localized to the oral mucosa, tongue, proximal parts of arms and legs, groin, axilla, and trunk. Primary vulvar involvement is very rare. This report dwells on a 61-year-old female presenting with multiple itchy translucent warty papules on the left vulva. These lesions had been present for the past 3 years, and were gradually increasing in number and size. She had undergone a hysterectomy for uterine carcinoma 13 years ago, and had subsequently developed lymphedema of the left leg. Histopathologic examination of the biopsied vulvar papule demonstrated hyperkeratotic epidermis and dilatation of thin-walled lymph vessels in superficial dermal papillae. The physiopathological features helped clinch the diagnosis of vulvar lymphangioma circumscriptum.

Primary esophageal cancers rarely metastasize to the brain. On the rare occasion that such an event occurs, the histological cell type is mostly a squamous cell carcinoma. These brain metastases are picked up on contrast computed tomography typically as multiple ring enhancing hypodense lesions. In the histological spectrum of esophageal cancers, a mucoepidermoid carcinoma is rather rare. The possibility of it metastasizing to the brain is rarer still. That such a metastatic lesion be hemorrhagic is truly atypical, yet this case in point uncovers such an event, where an upper esophageal mucoepidermoid carcinoma in a 55-year-old male led to a hemorrhagic metastasis in the vermis of the cerebellum.

While conducting a Holmium Laser Excision of Prostate (HoLEP), it is a standard practice to use normal saline as an irrigation solution. Usually, the amount of saline absorbed systemically during HoLEP ranges between 200 and 900 mL. However, rarely this amount can become excessive and lead to toxicity. Currently, two methods are used to measure the quantity of normal saline absorbed during a HoLEP – a volumetric fluid balance method and ethanol tagging of saline. These methods, however, have certain limitations. They can possibly be supplemented by a third method – a real time “parotid area sign.” This case report highlights the significance of this clinical sign in a 67-year-old male, who while undergoing HoLEP, developed frank signs of toxicity due to massive saline absorption.

A 12 year old boy presented with history of cyanotic congenital heart disease with dyspnea on exertion since last 9 years. Patient was diagnosed as a case of Tetralogy of Fallot 5 years before he came to us and he had underwent a palliative Blalock Taussig Thomas shunt for the same. An intracardiac repair was attempted 4 years back which was abandoned due to unknown reasons. His symptoms persisted after the two procedures. On admission to our hospital a detailed echocardiogram was done that showed Tetralogy of Fallot with absent pulmonary valve with post stenotic dilatation of left pulmonary artery and an anomalous origin of right pulmonary artery from ascending aorta with a blocked B-T shunt. A high risk intracardiac repair was advised.

Acquired external auditory canal stenosis is an uncommon entity which can arise from a number of different causes including infection, trauma, neoplasia, inflammation, and radiotherapy. Posttrauma stenosis is extremely rare; only 10% of stenosis is caused by trauma in many series. Patients generally suffer from conductive hearing loss. Surgery is the treatment of choice for posttraumatic canal stenosis. The main objective of the surgery is to produce a dry, patent ear canal by removing the stenotic segment, enlarging the bony canal, and performing wide meatoplasty. In this paper, we report a case of posttraumatic external auditory canal stenosis, following foreign body reaction which was entrapped in the canal during trauma, which was managed successfully 1 year after the trauma.