Multiple ring-enhancing lesions of the brain are one of the most commonly encountered abnormalities on neuroimaging. These can be caused by a variety of infectious, neoplastic, inflammatory or vascular diseases. Distinguishing non-neoplastic causes from neoplastic lesions is extremely important because a misdiagnosis can lead to unwarranted neurosurgery and exposure to toxic chemotherapy or potentially harmful brain irradiation. Diligent clinical evaluation and a battery of tests are required for making a definitive diagnosis. Newer advanced diagnostic techniques, such as diffusion-weighted magnetic resonance imaging (MRI), perfusion-weighted MRI, magnetic resonance spectroscopy, single-photon emission tomography and positron emission tomography may help in establishing the etiology. However, early brain biopsy is often needed because several of these diseases are potentially life-threatening.

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Background : DNA methylation is an important epigenetic feature of DNA that plays a pivotal role in gene expression regulation during spermatogenesis. The enzyme methylenetetrahydrofolate reductase (MTHFR) catalyses the formation of folate intermediates that are vital for DNA synthesis and methylation reactions. C677T and A1298C variants of MTHFR result in reduced plasma folate and increase the susceptibility to various multifactorial disorders. We have already shown that homozygosity for 677 (C ®T) mutation in the MTHFR gene, is a risk factor for idiopathic male infertility in an Indian population. Aim: Recently, we showed that homozygosity for the 677(C;T) mutation in the MTHFR gene is a risk factor for idiopathic male infertility and now we aim to assess whether the A1298C mutation in the same gene is an additional risk factor for idiopathic male infertility in an Indian population. Setting and Designs : In a case-control study 151 idiopathic male infertile patients and 140 healthy fertile control individuals were recruited from the University hospital and infertility clinics in Varanasi city, India. Materials and Methods: Genotyping for A1298C change of the MTHFR gene was done by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Statistical Analysis : Allele frequencies were calculated using Fisher's exact test. Odds ratio was calculated as the measure of the association between the MTHFR genotype and idiopathic male infertility. Results : The homozygous (C/C) A1298C polymorphism of the MTHFR gene was present at a statistically high significance in idiopathic azoospermic infertile men (OR=3.4494, CI: 1.0092 to 11.7899, P<0.05). Conclusion : The MTHFR 1298CC genotype is an additional genetic risk factor for idiopathic male infertility in an Indian population.

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Background : The laryngoscope has been identified as a potential source of cross-infection, because of blood and bacterial contamination. In India, there are no guidelines for cleaning and disinfection of anesthesia-related equipment. Practices for decontamination of laryngoscopes vary widely and in most healthcare institutes, laryngoscope blades are re-used after cleaning with tap-water. Materials and Methods: We prospectively compared two techniques for decontamination of laryngoscope blades - a) washing with tap-water and b) washing with tap-water followed by disinfection by immersing in 5% v/v (volume/volume, 1:20 dilution) aldehyde-free biguanide agent for 10 min. We calculated the cost-effectiveness of using 5% v/v aldehyde-free biguanide agent for disinfection of laryngoscopes. We also conducted a survey to assess the decontamination practices in other Indian hospitals. Results : Overall bacterial growth was 58% (29 out of 50 blades) after tap-water cleaning (of which 60% were pathogenic organisms) versus 3.4% (one out of 29 blades) after tap-water cleaning followed by immersion in disinfectant (all of which were commensals). The cost of disinfection with biguanide was Indian Rupees 1.13 (20 US cents) per laryngoscope. Most hospitals in India do not have guidelines regarding laryngoscope decontamination between uses, and cleaning with tap water is a commonly used method. Conclusion : Cleaning of laryngoscope blades with tap-water is a commonly used but inadequate method for decontamination. Washing with tap-water followed by disinfection with 5% v/v aldehyde-free biguanide for at least 10 min is an effective and inexpensive alternative. National guidelines for the decontamination of anesthesia equipment are necessary.

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One of the landmarks in clinical genetics is prenatal diagnosis of genetic disorders. The recent advances in the field have made it possible to diagnose the genetic conditions in the embryos before implantation in a setting of in vitro fertilization. Polymerase chain reaction and fluorescence in situ hybridization are the two common techniques employed on a single or two cells obtained via embryo biopsy. The couple who seek in vitro fertilization may screen their embryos for aneuploidy and the couple at risk for a monogenic disorder but averse to abortion of the affected fetuses after prenatal diagnosis, are likely to be the best candidates to undergo this procedure. This article reviews the technique, indications, benefits, and limitations of pre-implantation genetic testing in clinical practice.

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Background : The goal of asthma therapy is to achieve clinical control and near normal lung functions. Many patients with persistent asthma fail to achieve this goal with a single controller medication add on to a inhaled corticosteroid. We have checked whether another controller medication add on to inhaled corticosteroid and long-acting β₂ agonist helps in achieving the asthma goal or not. Objectives : To identify the effect of controller medication add on to inhaled corticosteroid and the long-acting β₂ agonist on the clinical symptom, lung function, and compliance in patients with asthma. Materials and Methods : We conducted a randomized, open-labeled, comparative trial in 50 participants with moderate-to-severe persistent asthma. The study duration was of 10 weeks. During the first two weeks of the run-in period all the participants received a dry powder inhaler drug delivery of budesonide (400 mcg/day) and formoterol (12 mcg/day) combination. At the end of the run-in period the participants were randomly allocated into three groups: group A (n = 16) received oral montelukast (10 mg/day); group B (n = 17) received oral doxophylline (400 mg/day), and group C (n = 17) received inhaled budesonide (400 mcg) as add on to the above-mentioned drugs of the run-in period. The primary outcome was improvement in forced expiratory volume at 1 second (FEV ₁ ). Results : All the participants of the three groups had significant improvement in FEV ₁ (P < 0.001) and asthma symptoms at the end of 10 weeks. The mean increase in FEV ₁ (% of predicted) from the baseline, in groups A, B, and C was: 24.6; 21.33, and 19.86%, respectively. Conclusions : All add on controller medications helped, with a significant improvement of lung functions and asthma symptoms.

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Background : Scorpion venoms cause a massive release of neurotransmitters. Either anti-scorpion venom serum (AScVS) or prazosin has been used in the management of severe scorpion envenomation. Aims : To compare the time taken for clinical recovery by patients with severe scorpion envenomation after AScVS therapy with that following prazosin therapy. Settings and Design : A prospective, open-labeled clinical trial was undertaken to compare the effects of the AScVS and/or prazosin on clinical recovery in scorpion-stung patients. Materials and Methods : Eighty-one patients from rural districts of Maharashtra presenting with severe scorpion envenomation were assigned to three treatment groups (AScVS: n = 28; prazosin: n = 25; AScVS + prazosin: n = 28). Severity of scorpion envenomation was graded using a proposed composite clinical scoring system to assess the therapeutic efficacy. AScVS was administered as an intravenous slow bolus, ranging from 40 to 100 ml, depending on the severity of envenomation. Prazosin was given as 1 mg every 3 h. Statistical Analysis Used : The non-parametric "Kruskal-Wallis" test was used in the statistical analysis and a P-value of 0.05 was considered significant. Results : Mean composite scores of patients from the three groups at the time of admission were comparable. Complete clinical recovery was noted in 4.14 ± 1.6 h and 19.28 ± 5.03 h in the subjects who were administered AScVS and prazosin, respectively (P < 0.001). There was no incidence of anaphylactic reaction to AScVS. Conclusions : Intravenous slow bolus of AScVS given based on the clinical severity of envenomation leads to early recovery than prazosin alone and is well tolerated.

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The concurrence of the intracranial multiple primary tumors (MPTs) consisting of acoustic neuroma (AN) and pituitary adenoma is very rare. Here, we report a 42-year-old female who presented with left AN associated with pituitary adenoma. A total of three such cases have been reported before and which also presented with left AN with pituitary adenoma. Recently, a new "field cancerization" model has been proposed, which could explain MPTs and is consistent with the pathogenesis of such cases. The model also indicates that when a pituitary tumor or AN is detected separately, we might consider the development of "expanding field" after oncological treatment especially after radiotherapy in order to prevent the second field tumor occurring.

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Background : Gallbladder cancer (GBC) is the commonest gastrointestinal cancer in women of north India. Precursor epithelial lesions in GBC are known; however, the role of xanthogranulomatous (XG) inflammation in the pathogenesis of GBC is unknown. Aims : To analyze the role of precursor lesions in the pathogenesis of GBC we studied the immunohistochemical (IHC) expression of p53, carcino-embryonic antigen (CEA) and carbohydrate antigen 19.9 (CA-19.9) in GBC, chronic cholecystitis (CC), XG cholecystitis (XGC) and precursor lesions. Materials and Methods : The study included 51 GBC, 68 CC, 42 XGC and 10 normal gallbladders. All cases were evaluated for presence of precursor lesions and IHC was performed. Results : p53 immunoreactivity was found in 55% GBC, 32% of dysplasia with malignancy and in 14% of dysplasia with CC. Sixteen percent GBC had associated XG inflammation. Normal and metaplastic epithelium in CC and in XGC did not express p53. CEA expression was apical in normal and inflammatory GBs (CC, XGC), while cytoplasmic focal to diffuse positivity was seen in 82% GBC. CA-19.9 expression was seen in all cases of normal and inflammatory GBs; however, foci of antral metaplasia were negative. Seventy-five percent of GBC expressed CA-19.9; all negative cases were high-grade on histology. Conclusions : Altered CEA expression is seen in GBC as compared to normal and inflammatory gallbladders. Loss of expression of CA19.9 in antral metaplasia and poorly differentiated GBC may indicate that it is a marker of biliary differentiation. p53 over-expression seen in GBC and in dysplasia associated with malignancy and with CC suggests that p53 mutation and dysplasia are early events in the evolution of GBC. Epithelial metaplasia and XG inflammation are often associated with GBC but do not appear to play a role in its pathogenesis through the p53 pathway.

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The pandemic caused by the 2009 H1N1 influenza A virus has been a cause of great concern for healthcare professionals and the scientific community worldwide. Due to the widespread resistance of the virus to adamantanes, pharmacotherapy is currently limited to neuraminidase inhibitors, oseltamivir and zanamivir. The use of neuraminidase inhibitors in India is primarily associated with issues of patient and physician awareness, variability in disease management guidelines, safety and efficacy in the Indian population, need for active drug safety monitoring, and development of resistance due to possible misuse. In addition, other issues like availability of the drugs in retail and stockpiling by the public health authorities need careful introspection. The development of influenza vaccines in India and its adequate availability to the country's populace also poses significant challenges in the management of the pandemic. In light of the limited therapeutic options available for the management of the disease, research on novel targets and pharmacological agents would also be beneficial in addressing the challenges of future outbreaks.

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Background: Postgraduate specialities require a combination of knowledge and clinical skills. The internship year is less structured. Clinical and practical skills that are picked up during training are not well regulated and the impact is not assessed. In this study, we assessed knowledge and skills using objective structured clinical examination (OSCE). Aim: To evaluate the clinical skills of new first-year surgical residents using orientation programme and OSCE as a tool for assessment. Settings and Design: Observational study. Materials and Methods: Twenty new first-year surgical residents (10 each in 2008 and 2009) participated in a detailed structured orientation programme conducted over a period of 7 days. Clinically important topics and skills expected at this level (e.g., suturing, wound care etc.) were covered. The programme was preceded by an OSCE to test pre-programme knowledge (the "pre-test"). The questions were validated by senior department staff. A post-programme OSCE (the "post-test") helped to evaluate the change in clinical skill level brought about by the orientation programme. Statistical Analysis: Wilcoxson matched-pairs signed-ranks test. Results: Passing performance was achieved by all participants in both pre- and post-tests. Following the orientation programme, significant improvement was seen in tasks testing the psychomotor and cognitive domains. (P = 0.0001 and P = 0.0401, respectively). Overall reliability of the OSCE was found to be 0.7026 (Cronbach's coefficient alpha). Conclusions: This study highlighted the lacunae in current internship training, especially for skill-based tasks. There is a need for universal inclusion of structured orientation programmes in the training of first-year residents. OSCE is a reliable, valid and effective method for the assessment of clinical skills.

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Oculogyric crisis (OGC) is a dystonic and distressing side- effect which occurs immediately after the administration of high-potency antipsychotic drugs and is usually reported as a subtype of dystonia. We report a case of a young woman with schizophrenia who presented with tardive OGC related to amisulpride.

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Carbonic anhydrase II (CAII) deficiency syndrome characterized by osteopetrosis (OP), renal tubular acidosis (RTA), and cerebral calcifications is caused by mutations in the carbonic anhydrase 2 (CA2) gene. Severity of this disorder varies depending on the nature of the mutation and its effect on the protein. We present here, the clinical and radiographic details along with, results of mutational analysis of the CA2 gene in an individual clinically diagnosed with renal tubular acidosis, osteopetrosis and mental retardation and his family members to establish genotype-phenotype correlation. A novel homozygous deletion mutation c.251delT was seen in the patient resulting in a frameshift and a premature stop codon at amino acid position 90 generating a truncated protein leading to a complete loss of function and a consequential deficiency of the enzyme making this a pathogenic mutation. Confirmation of clinical diagnosis by molecular methods is essential as the clinical features of the CAII deficiency syndrome are similar to other forms of OP but the treatment modalities are different. Genetic confirmation of the diagnosis at an early age leads to the timely institution of therapy improving the growth potential, reduces other complications like fractures, and aids in providing prenatal testing and genetic counseling to the parents planning a pregnancy.

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The development of biliary casts is very rare, especially in non-liver transplant patients. The etiology of these casts is uncertain but several factors have been proposed which lead to bile stasis and/or gallbladder hypo-contractility and promote cast formation. Here, we report a 54-year-old male, with diabetes and ischemic heart disease, who presented with recurrent attacks of cholangitis. Magnetic resonance cholangiopancreatography revealed linear T1 hyperintense and T2 hypointense filling defects in the right and left hepatic ducts extending into the common hepatic duct, and a calculus in the lower common bile duct, raising a suspicion of worm in the biliary tree. In view of failed attempts at extraction on endoscopy, patient underwent surgery. At exploration, biliary casts and stones were extracted from the proximal and the second order bile ducts, with the help of intraoperative choledochoscopy and a bilio-enteric anastomosis was accomplished. Although endoscopic retrieval of the biliary cast can be employed as first-line management, surgery should be considered in case it fails.

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We report a 35-year-old male with recurrent respiratory infections and cough associated with ingestion of food for 15 years. He was diagnosed to have benign esophago-bronchial fistula and proximal jejunal stricture secondary to a tumor, which was surgically resected. In view of recent surgery, endoscopic closure of the fistula was attempted initially with an endoclip resulting in partial symptomatic relief. The fistula was later completely occluded endoscopically with cyanoacrylate glue. A barium swallow at eight-months follow-up revealed no evidence of esophago-bronchial communication. A high index of suspicion is required in the diagnosis of this rare entity in adults with recurrent respiratory infections of obscure etiology. Surgical resection is the standard treatment. Here we report a rare case of idiopathic benign esophago-bronchial fistula in an adult, treated with endoscopic approach.

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Cardiac syndrome X (CSX) is defined as a typical anginal-like chest pain with a transient ischemic electrocardiogram, but without abnormal coronary angiography. It is usually accepted that endothelial dysfunction, inflammation, oxidative stress and estrogen deficiency are the main reasons of CSX. There are some methods to treat CSX including statins, b blocker, angiotensin converting enzyme inhibitors, nitrates, estrogen, and so on. The estrogen replacement therapy (ERT), in particular, has been reported by many researchers to significantly reduce the frequency of chest pain after administration of estrogen, which has been explained as estrogen acting on its receptor to improve the endothelial function. However, it has been suggested that ERT must not be used for coronary heart disease due to its adverse effects. However, some selective estrogen receptor modulators (SERMs) can inhibit inflammatory response as well as oxidative stress, and improve the endothelial function, to reduce the occurrence of chest pain. Here, we hypothesize that SERMs may be the beneficial selection for patients with CSX.

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