Periodic limb movement (PLM) and Restless leg syndrome (RLS) are types of sleep disorders that are not very well recognized in clinical practice. While RLS is a clinical diagnosis, the diagnosis of PLM is made by polysomnography. They share the same pathophysiology and often respond to the same treatment. To date all the epidemiological studies have reported the prevalence between 2% and 15%. It has recently become known that mild obstructive sleep apnea and upper airway resistance syndrome (UARS) can masquerade as PLM syndrome. New discoveries have been made with regard to genetics and PLM and RLS. Detailed review on this subject should improve the awareness of these disorders, both among general physicians and specialists. Extensive review of journals in the past 20 years was made using Medline search.

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Background : There is need to investigate the use of liposomal amphotericin B in cryptococcal meningitis in India. Aims : To compare the efficacy, safety, duration of treatment and cost of two doses of liposomal amphotericin B (Amp B) (Fungisome ^TM ) in cryptococcal meningitis in HIV/AIDS patients. Settings and Design : Prospective, randomized, multicenter study in tertiary care hospitals across India. Materials and Methods : Adult patients with culture-proven cryptococcal meningitis with HIV/AIDS were randomized to receive either 1 (Group A) or 3 mg/kg/day of Fungisome (Group B). Clinical efficacy and tolerability, laboratory evaluations and mycological response were assessed daily, twice weekly and weekly respectively. The patients were assessed at four and eight-week follow-up. Statistics : We calculated average and standard deviation for the various parameters. Results : The time to show clinical response was 13.66 days (1 mg) and 9.55 days (3 mg). In Group B (n=6 complete response), 50% patients responded within one week by microbial conversion, 83% in two weeks and 100% in three weeks. Patients with 1 mg dose (n=4 complete response), none showed microbial conversion within one week, 75% responded in two weeks, whereas one patient took four weeks. The average duration of treatment was 36.5±14.4 and 26.5±5.89 (S.D.) days in 1 and 3 mg/kg/day respectively. Drug was tolerated with little renal, hepatic or hematological toxicity. The cost was found to be 3.81 lacs and 1.74 lacs with 3mg/kg/day and 1mg/kg/day respectively. Conclusion : Higher dose showed better efficacy and quicker microbial conversion of Cerebrospinal fluid (CSF) (cerebrospinal fluid) than 1 mg/kg/day. It shortened the duration of treatment in days by 27% while drug cost almost doubled (Clinical trial registration number: ISRTCN 52812742)

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Background : The rapidly growing mycobacteria (RGM) causing human infections primarily consist of the Mycobacterium fortuitum group, Mycobacterium abscessus and Mycobacterium chelonae. The antibiotic susceptibility testing is important to determine the appropriate therapy as the antibiotics used to treat RGM are different from those used for treating infections caused by slow growers of mycobacteria. Aim : To determine antibiotic susceptibility of RGM using Kirby Bauer method and following Clinical and Laboratory Standards Institute (CLSI) guidelines. Settings and Design : Larsen and Toubro Microbiology Research Centre, Vision Research Foundation, Sankara Nethralaya, Chennai, Retrospective study. Materials and Methods : The antibiotic susceptibility testing was performed following CLSI method for the drugs Amikacin, Azithromycin, Tobramycin, Ceftazidime, Cephotaxime, Cefuroxime, Cefaperazone, Ceftriaxone, Ciprofloxacin, Ofloxacin, Norfloxacin, Gatifloxacin and Moxifloxacin. Results and Conclusions : Out of the 148 RGM isolates 146 (98%) were susceptible to amikacin, 138 (91%) to gatifloxacin, 132 (87%) to moxifloxacin, 122 (76%) to ciprofloxacin and 116 (74%) to Norfloxacin. Majority of the RGM were resistant to Ceftazidime, Cephotaxime and Cefaperazone. All the M. abscessus isolates were resistant to tobramycin. The in vitro antibiotic susceptibility testing by disc diffusion method showed that majority of the RGM were sensitive to Amikacin followed by Gatifloxacin, Moxifloxacin and Ciprofloxacin

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This review is devoted to current and emerging techniques in gastrointestinal (GI) imaging. It is divided into three sections focusing on areas that are both interesting and challenging: imaging of the small bowel and appendix, imaging of the colon and rectum and finally liver and pancreas in the upper abdomen. The first section covers cross-sectional imaging of the small bowel using the techniques of multidetector computed tomography (MDCT) (including CT enterography) and magnetic resonance imaging (MRI). The evaluation of mesenteric ischemia and GI tract bleeding using MDCT angiography is also reviewed. Current imaging practice in the evaluation of appendix is also reviewed and illustrated. The second section reviews CT and MR colonography and imaging of the rectum. It describes CT virtual colonoscopy (CTVC) with emphasis on the advantages and disadvantages of the technique with discussion of the role of CTVC in screening. The intriguing topic of MR colonography (MRC) is also reviewed. Imaging of the rectum with emphasis on imaging of rectal cancer is described with the roles of CT, MR, endoluminal ultrasound and positron emission tomography scanning discussed. The final section reviews current and emerging techniques in liver imaging with the role of ultrasound including contrast ultrasound, MDCT and MR (including contrast agents) discussed. The new developments and applications of imaging of pancreatic disease are discussed with emphasis on the role of MDCT and MRI with gadolinium. This review highlights the current role and advancement of imaging techniques with new diagnostic and prognostic information pertinent to gastrointestinal disease continuing to emerge.

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Tumefactive demyelinating lesion, a variant of multiple sclerosis, is a solitary large demyelinating lesion, which mimics cerebral neoplasm. Distinguishing tumefactive lesions from other etiologies of intracranial space-occupying lesions is essential to avoid inadvertent surgical or toxic chemotherapeutic interventions. We report two unusual cases of tumefactive demyelinating lesion. The first patient presented with recurrent right focal tonic-clonic seizures with secondary generalization of three-month duration. Her neurological examination was normal. Another patient presented with right homonymous hemianopia. In this patient, the diagnosis was established after biopsy of the lesion, which revealed perivascular lymphocytic infiltrate and aggregates of foam cells in white matter with relatively uninvolved grey matter, suggestive of tumefactive demyelinating lesion. Administration of intravenous methylprednisolone resulted in rapid clinical improvement in both the patients and the brain lesion decreased in size. Both, epilepsy and homonymous hemianopia, are unusual manifestations of tumefactive demyelinating lesions. In our cases, cerebral tumors were initial diagnoses. Presence of an open ring or incomplete ring lesions and other magnetic resonance characteristics helped in differentiating demyelinating lesions from other neoplastic and infective diseases of the brain. Differential diagnosis of tumefactive demyelinating lesions, at times, may prove to be a challenging task for the treating physician.

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Posaconazole is a novel second-generation Triazole oral antifungal agent. It is highly effective in the prophylaxis of invasive fungal infections in immunocompromised patients. It is used as a first-line agent as well as for salvage therapy in invasive fungal infections including aspergillosis, oropharyngeal and esophageal candidiasis. It has a good adverse effect profile. With the rising incidence of invasive fungal infections due to the HIV pandemic and medical advancements in transplantation and cancer therapy, these features make posaconazole a valuable addition in the family of antifungal agents.

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Imaging has always been an important component of the clinical evaluation of pediatric patients. Rapid technological advances in imaging are making noninvasive evaluation of a wide range of pediatric diseases possible. Ultrasound and magnetic resonance imaging (MRI) are two imaging modalities that do not involve ionizing radiation and are preferred imaging modalities in the pediatric population. Computed tomography (CT) remains the imaging modality with the highest increase in utilization in children due to its widespread availability and rapid image acquisition. Emerging imaging applications to be discussed include MR urography, voiding urosonography with use of ultrasound contrast agents, CT dose reduction techniques, MR enterography for inflammatory bowel disease, and MR cine airway imaging.

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This review discusses the current and emerging techniques in urinary tract imaging. Recent technical advances and novel discoveries make this an exciting but challenging time for urinary tract imaging. The first section describes the imaging of the adrenal gland which has made great strides in the last decade, the current major adrenal imaging modalities as well as new applications are discussed with particular attention to the role of imaging in the incidentally detected adrenal lesion. In the second section the role of ultrasound, computed tomography (CT) and magnetic resonance (MR) in evaluation of the renal tract are discussed with the new technical advances leading to earlier detection and characterization of renal lesions. Complementary to this is the emerging role of CT and MR urography in assessment of the urinary tract and bladder in contrast to the demise of plain film studies/intravenous urography. The role of CT angiography in assessment of the renal vasculature is also discussed. The third section discusses the role of prostate imaging in the diagnosis, staging and management of prostate cancer. Transrectal ultrasonography, can be used to guide biopsy, CT is frequently used in staging, with bone scintigraphy and positron emission tomography having roles in advanced disease. Currently, all imaging modalities, especially MR are evolving to improve disease detection and staging. The final section discusses the recently encountered adverse reaction of nephrogenic systemic fibrosis in patients post gadolinium-enhanced MRI and how to help prevent this adverse reaction.

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Common diagnostic challenges in gynecology and the role of imaging in their evaluation are reviewed. Etiologies of abnormal uterine bleeding identified on pelvic sonography and sonohysterography are presented. An algorithmic approach for characterizing an incidentally detected adnexal mass and use of magnetic resonance imaging for definitive diagnosis are discussed. Finally, the role of F18-fluorodeoxyglucose positron emission tomography in the management of gynecological malignancies, and pitfalls associated with their use are examined.

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Context : The erratic lifestyle of resident doctors may affect their serum 25-hydroxy vitamin D [25-(OH)D] levels and bone mineral density (BMD). Aim : To study BMD and the effect of environmental factors on it in resident doctors. Settings and Design : Prospective, cross-sectional study conducted in a tertiary healthcare centre. Materials and Methods : BMD was obtained by dual-energy X-ray absorptiometry and was correlated with various factors including weight, height, body mass index (BMI), sun exposure, physical activity, parathyroid hormone, 25-(OH)D, dietary factors. Statistical Analysis : SPSS software Version 10 (Unpaired t test was used to compare BMD of different groups and Pearson's correlation coefficient was used to calculate correlation). Results : Two hundred and fourteen apparently healthy resident doctors were enrolled in the study. Based on Caucasian normative data, osteopenia was noted in 104 (59.7%) males and 27 (67.5%) females. Thirty-two (18.39%) males and five (12.5%) females had osteoporosis. The BMD values of males were 0.947±0.086, 0.911±0.129 and 1.016±0.133 at lumbar spine, femur neck and total hip while those in females were 0.981±0.092, 0.850±0.101 and 0.957±0.103 respectively. BMD of our cohort was lesser by 12.5-18.2% and 4.2-14.5% than the Caucasian and available Indian figures, respectively. BMD had significant positive correlation with weight, height, BMI, physical activity, and dietary calcium phosphorus ratio. 25-(OH)D levels were insufficient in 175 (87.5%) subjects but had no correlation with BMD. Conclusions : Young healthy resident doctors had significantly lower BMD, contributors being lower BMI, lower height, reduced bioavailability of dietary calcium and inadequate physical activity. Deficiency of vitamin D did not contribute to low BMD.

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Background: Primary hyperparathyroidism (PHPT) has a variable clinical presentation and symptomatic PHPT is still the predominant form of the disease in India. Data from western India is lacking. Aim : To present the clinical profile of PHPT from western India. Settings and Design : This retrospective study was conducted at a tertiary care referral center. Materials and Methods : We analyzed the clinical presentation, biochemical, radiological features, and operative findings in adult patients with PHPT (1986-2008) and compared with our published data of children and adolescent patients with PHPT. Statistical Analysis : was done with SPSS 16 software. Results : Seventy-nine patients (F: M-2:1) with age ranging from 21 to 55 years (mean 33.5±8.82) were analyzed. Skeletal manifestations (75.5%), renal calculi (40.5%) and proximal muscle weakness (45.5%) were the most common symptoms of presentation with mean duration of symptoms being 33.70 (median: 24, range 1-120) months. Biochemical features included hypercalcemia (total corrected calcium 12.55±1.77 mg/dl), low inorganic phosphorus (1.81±0.682 mg/dl), elevated total alkaline phosphatase (mean: 762.2; median: 559; range: 50-4930IU/L) and high parathyroid hormone (PTH) (mean±SD: 866.61±799.15; median: 639.5; range: 52-3820 pg/ml). Preoperative localization was achieved in 74 patients and single adenoma was found during surgery in 72 patients. Hungry bone disease was seen in 30.3% and transient hypoparathyroidism developed in 62% patients. In comparison to PHPT in children there were no significant differences with regard to clinical, laboratory and radiological features. Conclusions : PHPT in western India is symptomatic disorder with skeletal and renal mani-festations at a much younger age. Clinical profile of PHPT in children is similar to that of adults.

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India is becoming one of the hubs of clinical research. Commensurate with these advances, the government funding for biomedical research in thrust areas is also increasing. The Indian Council of Medical Research (ICMR), Department of Biotechnology (DBT), Department of Science and Technology (DST) are some of the government organizations which provide financial support for various research projects. The results of the funded research projects are published in various international journals. Most of these journals have an access to paid subscribers only. Hence it is unethical to use the research grants from government (people's money) and not allow the scientific community free access to the results of the study. To tackle such issues, these agencies should sign the Berlin declaration and create open access repositories. A public access policy should be formulated and listed in JULIET. The funding bodies in India should also join Pubmed Central (PMC) to form PMC India so that every investigator who has received grants would submit the full text of the paper published from his study and these can be made freely accessible to everyone. Universities and research institutions should also develop institutional open access repositories. The public access policy has definitive advantages and should be implemented.

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Cardiac magnetic resonance imaging (MRI) and computed tomography (CT) scan have made big inroads as modalities used for evaluation of various pathologies of the heart. Cardiac MRI is typically used for perfusion and viability studies as well as to study various cardiomyopathies, valvular diseases and the pericardium. It has been used in the evaluation of congenital heart diseases over the last two decades. Cardiac CT is used mainly for the evaluation of the coronary arteries, typically in the setting of "to rule out coronary artery disease".

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Diagnostic imaging plays a pivotal role in cancer management. Imaging has made rapid strides in the past few years with new modalities and new indications getting added all the time. Molecular and metabolic imaging with 18F Flurodeoxyglucose Positron Emission Tomography (FDG PET) and other non-FDG isotopes have revolutionized oncologic imaging and changed our approach towards cancer diagnosis, staging and imaging surveillance. The evidence for the use of FDG PET is mounting every day with newer indications getting added to the literature. The main focus of our discussion will be to understand the basic principles of FDG PET imaging and to study a few of its clinical applications in oncology.

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Neuroimaging is presently utilised in clinical practice for initial diagnosis and mapping of disease extent and distribution, noninvasive, preoperative grading of tumours, biopsy planning, surgery and radiation portal planning for tumors, judging response to therapy and finally, prognostication. Newer advances include magnetic resonance (MR) diffusion and diffusion tensor imaging with tractography, perfusion imaging, MR spectroscopy and functional imaging using the blood oxygen level-dependent contrast technique. Neuroimaging plays a pivotal role in various degenerative and neoplastic diseases, improving diagnostic accuracy, affecting patient care, monitoring dynamic changes within the brain during therapy, and establishing them as the arbiter of novel therapy that may one day prove cure of various brain diseases a reality.

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Autoimmune pancreatitis is a rare form of chronic pancreatitis, which commonly mimics pancreatic carcinoma. Immunoglobulin G4-associated cholangitis (IAC) is a rare type of autoimmune pancreatitis associated with bile duct involvement, which can present with or without pancreatic involvement. Usually, the bile duct involvement is in the form of multiple intra-and extra-hepatic strictures mimicking primary sclerosing cholangitis. Rarely, there can be an isolated stricture which mimics cholangiocarcinoma. Differentiating these from cholangiocarcinoma, though extremely difficult, is of critical importance since it can be treated without surgical intervention. Most cases with rare presentation mimicking cholangiocarcinoma have been reported in elderly patients. We present one such rare presentation of autoimmune pancreatitis in a young 13-year-old patient in whom hepaticojejunostomy was done for a hilar stricture, which later turned out to be related to IAC. To our knowledge this is the first reported case of its kind from India.

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Hyper-IgE syndrome is a congenitally acquired primary immune deficiency condition. We report a case of possible hyper-IgE syndrome who presented with multiple cold skin abscesses and chest infection due to Staphylococcus aureus and hyper-IgE findings. Patient also had tricuspid valve acute bacterial endocarditis with purulent pericarditis which is very rare. This case is presented to highlight that early diagnosis and treatment in such cases decreases the mortality and morbidity in phagocytic disorders.

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