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Background: Axillary lymph nodes are surrogate markers for mapping the optimal management of axilla in breast cancer, and their assessment is pivotal to management and outcome. Until now, the assessment of axillary lymph nodes largely relies upon sentinel node biopsy (dual method) or conventional lymph node dissection. The morbidity of axillary lymph node dissection, however, is well known. Sentinel node biopsy is thus considered the standard of care in a node-negative axilla. However, developing economies face the dilemmas and challenges of matching up to the high cost of gamma probe, the vagaries of its learning curve, and, often, the advanced stage of disease at which the patients present. Also, with the advent of neo-adjuvant chemotherapy, the axilla can now be downstaged to a node negative status (N0). In this setting, a targeted four-node sampling (FNS) can offer a simple, reliable, and cost-effective approach for assessment of the axilla. Material and Methods: A total of 50 patients with locally advanced breast cancer who had received neo-adjuvant chemotherapy form the nucleus of this study. In each patient, axillary mapping was done using periareolar injection of 3 mL of methylene blue dye immediately before surgery. Four blue nodes from the specified anatomical site at level-I were picked up and subjected to frozen section. The axillary dissection was subsequently completed in a conventional manner in all patients irrespective of the outcome of frozen section and the entire specimen was the sent separately for histopathological examination. The outcome of frozen section was compared and correlated with the actual histopathological assessment of entire axilla to find out the sensitivity, specificity, and false negative rates of the technique. Results: The sensitivity and specificity of FNS were found to be 89.5% and 93.3%, respectively. The negative and positive predictive values were found to be 84.6% and 100%, respectively. Conclusions: It was observed that "targeted" FNS using methylene blue dye can serve as a reliable and inexpensive alternative to other techniques for addressal of axilla even in locally advanced breast cancers. This is particularly relevant in developing economies where majority patients still present as locally advanced; and high-end facilities, such as gamma camera and isotope studies, are scarce.

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Introduction: A wide variety of chemotherapeutic agents are currently in use for the treatment of hematological malignancies in children. A spectrum of mucocutaneous adverse effects has been attributed to these agents, however, the data largely consists of case reports and case series. Material and Methods: Proforma of all pediatric patients up to 18 years of age, with confirmed hematological malignancies (lymphoma and leukemia), undergoing chemotherapy, and attending the pediatric hemato-oncology clinic of a tertiary care hospital over a period of 2 years were analyzed. A detailed history, mucocutaneous examination and investigations were recorded as per  the proforma. The results are presented as mean ± standard deviation. The prevalence of various side effects of chemotherapy is presented as percentages. Results: The age of the patients ranged from 1.2 to 14 years (mean age: 6.6 ± 3.2 years). The duration of the disease ranged from 2 to 122 weeks. Mean duration of chemotherapy was 23.9 ± 24.7 weeks. The analysis consisted of 38 (76%) males and 12 (24%) females (M: F: 3.2:1). Seventy-four percent of the patients had B-cell acute lymphoblastic leukemia (ALL), 6 patients had T-cell ALL, 3 patients had Philadelphia chromosome (+) T-cell ALL, 3 patients had non-Hodgkins lymphoma (NHL) and one patient had hemophagocytic lymphohistiocytosis (HLH). Methotrexate (72%) was the most common agent used followed by vincristine (68%), 6-mercaptopurine (58%), daunomycin (48%), and asparaginase (30%). Hyper-pigmentation was the most common cutaneous side effect noticed in 6 patients. Three patients developed abscess. Two patients each developed tinea corporis, petechie, and thrombophlebitis. One patient each had scabies, pityriasis versicolor, miliaria rubra, allergic contact dermatitis, lip lick cheilitis, ear discharge, and conjunctivitis. One patient developed acute methotrexate toxicity. A total of 24 patients developed mucosal lesions, with aphthous ulcer (20%) being the most common, followed by oral candidiasis (12%) and herpes labialis (12%). Seventeen (34%) patients had diffuse anagen effluvium. Most common change affecting the nails among the study patients was Beau's lines for both fingernails (26%) and toenails (36%). Other less common changes included melanonychia, leuconychia, Mees lines, Muehrcke's nails, half and half nails, etc. Conclusion: The mucocutaneous manifestations associated with chemotherapy cause significant morbidity and possibly mortality in children. A proper knowledge of these manifestations can help in early identification and withdrawal of the offending agents and preventing the morbidity with appropriate and timely management.

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Objective: This prospective study was planned to study the prognostic value of time to presentation to the hospital, clinical scales and examination, hematological and biochemical parameters as predictive factors of mortality in ischemic stroke. Materials and Methods: In this study, 188 consecutive patients of ischemic stroke were included. The patients were subjected to relevant history taking, clinical evaluation, blood investigations (total leukocyte count [TLC], capillary blood sugar, potassium, high-sensitivity C-reactive protein (hs-CRP), troponin I (Trop I)), electrocardiogram (ECG) and neuroimaging. The patients were followed up till their final outcome in the hospital, and patients who expired were grouped as 'Mortality Group' and the rest as 'Discharged Group'. Logistic regression analysis was carried out among the significant parameters to identify independent predictors of mortality in cases of ischemic stroke. Results: After statistical analysis, it was found that late presentation to the hospital, pyrexia (temperature >99°F), low diastolic blood pressure at the time of admission, hypoxia (saturation of oxygen [sPo2] <94%), National Institute of Health Science scale (NIHSS) score >15, modified Rankin score (MRS) greater than 3, Glasgow coma scale (GCS) less than 8, hyperglycemia (random blood sugar >200 mg/dL), raised total leukocyte count and hs-CRP (>10 mg/L), are positive predictive factors of mortality in cases of ischemic stroke. Conclusion: Late presentation to the hospital, pyrexia (temperature >99°F), low diastolic blood pressure at the time of admission, hypoxia (sPo2 <94%), more severe stroke (NIHSS score >15, MRS >3, GCS <8), high TLC estimated at the time of hospitalization, are the most important predictive prognostic factors of in-hospital mortality in cases of ischemic stroke.

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Background: Infected pancreatic necrosis is associated with the risk of considerable morbidity and mortality. Preventing the development of infection in pancreatic necrosis may help reduce the poor outcomes in patients with severe acute pancreatitis (SAP). Aim : The aim of the current review was to determine the benefit of selective digestive decontamination (SDD) in improving outcomes in SAP. Materials and Methods: A systematic literature search was conducted using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Database of Abstracts of Reviews of Effects and Health Technology Assessment, until June 2011 without any restrictions. Papers reporting on experimental animal studies and clinical studies on patients with acute pancreatitis (AP) who were treated with SDD, either alone or in combination with intravenous antibiotic and antifungals in comparison with other interventions, antibiotics, or placebo, were eligible for inclusion. Outcome data collected were duration and regimen of SDD used, short- and long-term morbidity and mortality rates, length of hospital stay, incidence and rates of bacterial/fungal infection. Results: A total of 53 articles were identified from the literature search of which 10 (7 animals, 3 humans) were eligible for inclusion in this systematic review. There was only one randomized controlled trial among the human studies. Most studies used a combination of SDD and intravenous antibiotics precluding a clear interpretation of the individual benefit of SDD. Although SDD significantly reduced pancreatic infection rates, its benefit on patient survival is unclear. Conclusion: Although SDD significantly reduced pancreatic infection rates and overall survival in experimental animal models, in human studies this benefit is not clearly appreciated owing to the confounding effects of concurrently administered intravenous antibiotics. Hence, further controlled studies are needed to determine the benefit of SDD in AP in humans.

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In the current Indian medical practice, consent is not well understood, and practical obstacles tend to hinder meaningful applications of the concept. Consent cannot simply be bolted onto existing practices; old models of decision-making need to change, and now is the time to examine the underlying ethics. India in many ways is at a crossroad in terms of how clinical decisions are made, when and in particular, by whom. Some difficulties are structural, having to do with health care delivery and resources within the public sector; others are more subtle, having more to do with attitudes and cultural norms. Either way, there are no “quick fixes,” although detailed guidance on standards of consent would surely be a help, backed up by educational interventions for health care professionals on autonomy and consent. As an aid to this process, a flowchart for clinicians is included at the end of the paper, with potential applications for use in end-of-life, intensive care, and other clinical settings.

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Leprosy, an infectious disease, described since ancient times and endemic in India since then, has been eliminated (elimination defined as a prevalence of less than 1 case per 10,000 population) as a public health problem in December 2005. World Health Organization and National Leprosy Eradication Program (NLEP) have now focused on reducing the disease burden in the population. Data indicates that annual fresh case detection rate remains high with a high incidence of multibacillary cases. A review of present NLEP figures and those reported in a number of studies reflect a discordance and caution by dermatologists. A review of present policy, epidemiological status in the population, and our experience is presented. Data from Base Hospital, Delhi Cantonment, over the past 3 years, including patients treated as well as those on surveillance is presented. A higher incidence of paucibacillary cases was seen, with a high incidence of pure neuritic involvement (15%), reactions (24.7%), and deformities (28.37%). Tenosynovitis was observed with increasing frequency. Future challenges in containing the epidemic to reduce the disease burden in population will require regular assessment of treatment measures, especially the use of fixed drug therapy as well as rehabilitation of the affected. Dermatologists shall play a central role in any such endeavor in the management of this disease.

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Over half million cases of multidrug-resistant (MDR) tuberculosis (TB) occur every year globally, and a significant number of them are affected by extensively drug-resistant (XDR) strains of Mycobacterium tuberculosis. There is limited access to reliable diagnostic facilities to drug-resistant (DR) TB in most developing countries. The treatment of MDR/XDR-TB is unfortunately very expensive, long, and toxic and the success rate is largely unsatisfactory (<50% among MDR-TB and <20% among cases with resistance patterns beyond XDR).The aim of this review is to summarize the available evidence-based updated international recommendations to diagnostic methods and treatment of MDR/XDR-TB, and briefly discuss the shorter MDR-TB regimen and the role of newly developed drugs as well as repurposed drugs. This review will help the reader to formulate treatment regimen for DR-TB patients based on currently available newer rapid diagnostic tests.

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We report a case of an anomalous unilateral single right pulmonary vein resembling a scimitar sign on chest X-ray. Only a few cases have been reported in the literature describing this interesting rare anomaly that is often confused with arteriovenous malformation and hypogenetic lung syndrome (scimitar syndrome). This report briefly discusses the embryology of the pulmonary veins, classification of the pulmonary venous anomalies, and various causes of scimitar sign.

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Recent epidemiologic and demographic public health data highlight the growing need for emergency medicine (EM) services in India and highlight its importance as a recognized medical specialty. Developing a comprehensive and recognized EM program for training physicians in India is of utmost priority and should not be neglected at any point of time. This review article attempts to highlight the development of a post-graduate program in EM in the country.

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Background: Metabolic bone disease of prematurity due to reduced bone mineralization is mostly described in infants of less than 1500 g. Although various guidelines recommend calcium and phosphate supplementation for low birth weight (LBW) newborns less than 1500 g and on exclusive breast feeding but there are no guidelines for those weighing above 1500 g and on exclusive breast feeding. Moreover, there is insufficient data on incidence of rickets and serum biochemical status in these babies of birth weight more than 1500g and on unsupplemented breast feeding and among term growth retarded babies. Objectives: To determine the incidence of rickets and changes in biochemical profile including serum calcium, phosphate, and alkaline phosphatase in preterm appropriate for gestational age (PTAGA) and term small for date (TSFD) babies with birth weight between 1500 and 2000 g and on unsupplemented breast feeding. Materials and Methods: It is an observational cohort study done at a tertiary care centre in northern India over a period of one year, including LBW babies between 1500 and 2000 g and on unsupplemented breast feeds. In group I, 116 PTAGA babies with birth weight 1500-2000g and on unsupplemented breast feeds were enrolled and 100 PTAGA babies completed follow up till 6 months. In group II 124 TSFD babies with birth weight 1500-2000 g and on unsupplemented breast feeds were enrolled and 100 TSFD babies completed follow up till 6 months. Biochemical parameters were done at baseline (before discharge) and were followed-up for a period of 6 months. Radiological assessment was done if clinical features of rickets appeared or serum biochemistry was suggestive of rickets. Results: Both groups, of babies, developed progressive decrease in serum calcium and phosphate levels, which was statistically significant as shown by time trend. Serum alkaline phosphatase showed significant increase from baseline in both the groups. Fourteen out of 200 (7%) babies developed radiological rickets at end of 3 months, which increased to 34/200 (17%) at end of 6 months. Serum alkaline phosphatase showed most consistent correlation with occurrence of rickets. Conclusion: LBW babies 1500-2000 g and on exclusive breast feeding are at significant risk of developing metabolic bone disease including rickets and need extra supplementation with calcium and phosphate besides Vitamin D.

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Background: Hemangioblastomas are rare, benign, vascular neoplasm. According to the World Health Organization classification of tumors of the nervous system, hemangioblastomas are classified as meningeal tumors of uncertain origin and are Grade I neoplasm. Hemangioblastomas arise either in the setting of von Hippel-Lindau (vHL) disease or more often as solitary sporadic lesions. They account for 1-3% of primary central nervous system (CNS) tumors. The most common location is the cerebellum followed by spinal cord. Supratentorial lesions are rare. Aims: The aim was to study the prevalence of hemangioblastoma. Materials and Methods: A retrospective observational study of 7 years duration was carried out in the department of pathology of a tertiary referral center. The sample received was processed by standard formalin fixing, paraffin embedding method. Serial sections and special stains were studied as and when required. Results: During the period of 7 years, we reported total 679 cases of primary CNS tumors, of which 11 (1.62%) cases were of hemangioblastoma. Ten of them were intracranial, and one was spinal. There were seven male and four female patients that clearly indicate male preponderance. Conclusions: In our study, prevalence of hemangioblastoma was 1.62% (11 cases) out of 679 primary CNS tumors, which is low as per literature. There was a male predominance with male:female ratio 2:1. Cerebellum was the most frequent site (81.8%). No association with vHL disease was noted.

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Introduction: Health care workers are mentors to general populations for a healthy life. Life style disorders are not just limited to the general population but even the doctors and nurses who guide them on their prevention are also getting victimized. The current study was carried out to collect the data on the lifestyle-associated disorders among health professionals in India. Objectives: The aim was to assess the prevalence and associated risk factors (modifiable and non-modifiable) of lifestyle disorders among Health professionals. Materials and Methods: This was a hospital-based cross-sectional study carried out in a secondary level/block level hospital of north-west Delhi. A study tool based on the World Health Organization (WHO) STEPS questionnaire for assessing non-communicable diseases and their risk factors was used. Fasting venous blood sample was collected to assess the lipid profile and fasting blood sugar. Anthropometric measurements of the participants were also taken. Data were analyzed using SPSS version 17. Results: Of the total 100 participants who consented to participate, 60% were females and 40% were males. The prevalence of diabetes and hypertension among health professionals were 5% and 10%, respectively. There were 52 participants who had abnormal waist-hip ratio. According to the WHO classification for Asians, 42% were overweight, while 22% were found to be obese. Alcohol intake (P=0.005), gender (P=0.00), occupation (P=0.018), total cholesterol levels (P=0.038), and triglycerides levels (P=0.046) had a significant association with waist-hip ratio, whereas alcohol intake (P=0.01), hypertension (P=0.05), moderate intensity sports (P=0.025) were significantly associated with body mass index. Conclusions: The prevalence of risk factors for lifestyle diseases was high among the health professionals. Thus, there is a need to motivate them to practice healthy lifestyle for prevention against lifestyle diseases and that they can advocate their patients.

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Introduction: Kangaroo Mother Care (KMC) is a nonconventional low-cost method of newborn care. We tried to understand the difficulties faced by mothers during KMC and profile the corrective action. Materials and Methods: Over 3½ years, mothers of inborn low birth weight babies were taught and motivated by clinical nurse researcher to implement KMC. Gross congenital abnormality or nonconsenting mothers were exclusion factors. After demonstration sessions, KMC was implemented for 1 h on 1st day, 2 h on 2nd day, 3 h on 3rd day and then scaled up for as long as a mother felt comfortable. After discharge, KMC was continued at home till the infant attained 2500 g weight or 40 weeks corrected gestational age. Difficulties being faced both in hospital and at home were probed and remedial measures suggested accordingly. Results: Of 300 mother-baby pairs studied, 35 (11.67%) mothers could not implement KMC satisfactorily in hospital itself. Causes of failure related to mother, infant or socioeconomic factors, such as mother not feeling well enough, need to visit toilet, feeling hungry, lack of self-motivation, soiling of nappies, and interfering family members (especially maternal grandmother). To overcome these problems, both mother and father, and when required, other family members were counseled. Mother was instructed to visit the toilet just before KMC session and to take adequate food beforehand. Before discharge family support person was identified. After discharge, 6 (2%) additional mothers faced problems from lack of privacy, discouragement by mother-in-law or neighbors, lack of time and uncomfortable summer environment. Motivation and counseling at every follow-up visit rescued the situation. Conclusion: Regular supervision and counseling along with adequate initial demonstration are necessary for successful implementation of KMC.

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Background and Objectives: Urinary tract infections (UTIs) are commonly seen in clinical practice and are most often caused by Escherichia coli (E. coli). To administer appropriate antibiotic therapy and reduce morbidity, it is crucial to know the local resistance patterns of E. coli. This study aims to show long-term changes in the resistance of E. coli to commonly used antibiotics over the past two decades in a hospital in southern India. Materials and Methods: This study was carried out at Dr. Jeyasekharan Medical Trust, a multispeciality teaching hospital in southern Tamil Nadu. It analyzed data from records of all urine samples received, cultured, and tested for resistance in its microbiology laboratory between 1991 and 2012. Results: A total of 44% of the urine cultures grew organisms. E. coli was present in 73% of the positive cultures. A trend of increasing resistance to gentamicin, fluoroquinolones, and cephalosporins was noted over the study period. The development of resistance was faster with the fluoroquinolones and cephalosporins than gentamicin. Chloramphenicol resistance showed a downward trend. Amikacin and nitrofurantoin were the most effective antibiotics with 10% and 28% resistance levels, respectively, over the period that they were used. The levels of resistance to second-line antibiotics did not show any definite trend. Interpretation and Conclusions: This study shows changing patterns of E. coli resistance over a period within an institution. Monitoring urinary cultures and resistance patterns regularly can assist in developing guidelines for selecting appropriate first guess antibiotics, thereby optimizing patient outcome.

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Background: Allergic Rhinitis (AR), a common health problem, imposes a substantial burden on public health. New evidence suggests a possible link between AR and Vitamin D deficiency. This study was done with the purpose of determining whether serum Vitamin D levels are altered in AR as opposed to healthy controls and whether such alterations modify the severity of the disease. Materials and Methods: A cross-sectional study was done on 100 adults aged 18–50 (50 clinically diagnosed with AR and 50 age and sex matched controls). They were evaluated clinically and by determining serum levels of 25-hydroxyvitamin D [25(OH) D]. Results: The most common symptom was paroxysmal sneezing (96%). The mean concentration of serum 25(OH) D was 16.52 ng/ml in test patients and 22.47 ng/ml in controls. This study demonstrated a statistically significant Vitamin D deficiency (defined as serum 25(OH) D, <20 ng/mL) among patients with AR as compared to healthy controls (P = 0.001). The deficiency was significantly more (P = 0.01) in patients with moderate–severe AR (n = 28, mean serum 25(OH) D = 12.36 ng/ml) than that in mildly symptomatic patients (n = 22, mean serum 25(OH) D = 21.82 ng/ml). Conclusions: A strong association exists between low serum Vitamin D levels and AR in this population sample of AR patients, suggesting that suboptimal levels of Vitamin D may modify the disease behavior. Supplementation can be a useful therapeutic adjunct.

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Introduction: Ischemic stroke is a major cause of morbidity and mortality. However, the interface of various premorbid medical conditions, vascular risk factors prior, prior antithrombotic or statins medication use, and in-hospital complications in effecting outcomes is not clearly established. We attempt establishing factors associated with improved outcomes after an acute ischemic stroke (AIS). Materials and Methods: Using the prospectively collected database, University Health Consortium from 1999 to 2004, a national USA database, multivariate step-wise backward regression analysis was performed and we were able to define premorbid characteristics, and medications that affect the outcome of AIS. Results: Initial stroke severity and poststroke in-hospital complications were associated with a poor outcome, while prior antiplatelet drug use was associated with an improved outcome. Statin use demonstrated a trend toward an improved outcome.

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Glaucomatous visual changes and defects are almost irreversible, with the visual field changes of glaucoma being noticed by the patient after significant disease progression due to a relative lack of alerting symptoms. Reduction of elevated intraocular pressure (IOP) is the only as yet proven approach to protect against visual field loss in patients with primary open-angle glaucoma (POAG) or ocular hypertension (OHT). When they first entered the ophthalmic market about 10 years ago, prostaglandins were viewed skeptically as a potential first-line therapy for glaucoma patients. Yet in less than a decade, glaucoma specialists' preferences have changed, with most reporting that they prefer prostaglandins over beta blockers as their patients' initial medication. Latanoprost has truly withstood the test of time and has indeed proved to be one of the best anti-glaucoma medications when used as monotherapy or as adjunctive therapy. Bimatoprost 0.01% has a similar overall safety profile, a favorable hyperemia profile, and less overall discontinuation compared with Bimatoprost 0.03%. In lieu of its poor efficacy, Unoprostone has lost its hold in the anti-glaucoma palate. Travatan Z (travoprost) is a new formulation of Travatan solution in which benzalkonium chloride is replaced with Sofzia, a robust ionic buffered preservative system that is gentle to the ocular surface. Tafluprost, the newest addition to the prostaglandin brigade, is a fluorinated analogue of prostaglandin-F 2α and is available as a sterile ophthalmic solution of 0.0015% (0.015 mg/ml) being approved by the US-FDA on 10th February, 2012. A new futuristic glaucoma therapeutic management paradigm where clinical success is no longer simply measured by achieved level of intraocular pressure control but also long-term preservation of visual function and patient's quality of life is expected to dramatically improve upon current treatment algorithms for ocular hypertension and glaucoma.

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Study design forms a core component of research, mainly determined by the study objectives, and it in turn further decides the type of statistical analyses to be carried out. Observational studies are devoid of the investigator's control over assignment of a subject to the treated or control group, in contrast to interventional studies Even though randomized controlled trials are seen as the best study design, evidence shows that properly conducted observational studies give similar results, and is relevant in medical research where ethics and feasibility concerns assume great significance. Observational studies point out towards possible causal associations, are less resource intensive than trials and have a better external validity. This review article discusses various types of observational study designs such as case reports, cross sectional, cohort, case-control and nested case-control studies with real literature examples.

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Foreign bodies in maxillary sinus, whatever their origin or nature, are unusual. However unilateral unexplained chronic rhinosinusitis should arouse clinical suscipicion. The diagnosis is based on radiological findings. The range of such foreign bodies is wide; those of dental origin such as tooth roots, burs, dental impression material, root-filling materials, dental implants, and needles take precedence over all others, but rarely, they may relate to blast injuries and penetrating objects. This special report highlights the unusual case of a pressure cooker nozzle lodged in maxillary sinus of a 28-year-old female who suffered a facial injury caused by explosion of a pressure cooker at home. The acuteness of the event and the flight of the foreign body were such that neither the casualty felt the ingress of foreign body nor was the diagnosis entertained by the surgeon who first examined her. Each blast injury therefore must be thoroughly evaluated for such possibility. While a radiological examination can clinch the diagnosis, treatment lies in endoscopic or surgical foreign body removal, with Caldwell luc procedure being a preferred technique.

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