Well-documented drawbacks of traditional anticoagulants have lead to the quest for an ideal anticoagulant resulting in a surge of novel anticoagulant molecules. These newer agents directly target specific steps in coagulation cascade and include newer low molecular weight heparins (adomiparin), ultra low molecular weight heparins (semuloparin, RO-14), inhibitors of activated factor II (dabigatran, AZD0837), X (rivaroxaban, apixaban, edoxaban, betrixaban), IX (REG1,2), XI (antisense oligonucleotides, BMS 262084, clavatadine A), VII/tissue factor (tifacogin, PCI 274836, and BMS 593214), V (recomodulin, solulin), VIII (TB402), dual thrombin/factor X inhibitors (EP21709, tanogitran), and newer vitamin K antagonists (tecarfarin). Direct thrombin inhibitors and Factor X inhibitors are the most clinically advanced. This article discusses the recent advances in the development of novel targets of anticoagulants. Medline, EMBASE, cochrane database, medscape, SCOPUS, and clinicaltrials.gov were searched using terms "anticoagulants", "blood coagulation inhibitors", "anticoagulants and venous thromboembolism", "anticoagulants and atrial fibrillation", and "'antithrombins." Journal articles published from 2007 to 2012 discussing pharmacology and/or clinical trials were screened.

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Background: Increasing prevalence of hypertension is a public health problem in India. Aims: To study prevalence, correlates, and awareness of hypertension among tribal adult population in Kerala. Setting and Design: A community-based, cross-sectional study was carried out in tribal areas of Kerala by adopting multistage random sampling procedure. Materials and Methods: Data was collected on socio-demographic and behavioral factors, and anthropometric measurements were carried out. Body mass index (BMI) was categorized using the classification recommended for Asians. Waist circumference ≥90 cm for men and ≥80 cm for women was used cut off for defining an abdominal obesity. Bivariate and multivariate analysis was carried out to study association of hypertension with socio-demographic variables, personal habits, and obesity. Results: A total of 4,193 adults (men 1,891, women: 2,302) of ≥20 years of age were covered. The overall prevalence of hypertension was 40% (n=1671). The prevalence of hypertension increases with increase in age among both the genders. Regression analysis showed that the risk of hypertension was significantly (P<0.001) lower among educated and among higher socio-economic status group. Sedentary activity had 1.3 times (CI=1.09-1.60) and alcohol consumption had 1.4 (CI=1.17-1.73) times higher risk of hypertension. The risk of hypertension was 1.7 times higher among overweight/obese subjects. Overall, only 10% (n=164) of the adult population was aware of hypertension status, and about 8% (n=129) were on regular treatment. Conclusion: It was observed that the prevalence of hypertension was higher among tribal adult population of Kerala and was associated with age, gender, education, HHs wealth index, physical inactivity, alcohol consumption, and overweight/obesity.

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Ataxia is a symptom of cerebellar dysfunction. Slowly progressive ataxia, dysarthria in an adult with a positive family history suggests an inherited cerebellar ataxia. We present an adult with gradually progressive ataxia and slow saccades. There was history of similar illness in his son. Genetic testing for spinocerebellar ataxia 2 was positive. We discuss the various inherited ataxias, causes of acute, progressive ataxia syndromes, episodic ataxias and ataxia associated with other neurological signs like peripheral neuropathy, pyramidal features, movement disorders and cognitive decline.

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Background: Feedback provided by integrating students' examination performance and the reflection on learning process may assist medical students to identify the essential learning processes required for better understanding of learning material. Aims: To investigate the relationship between the student's learning process and examination performance and to explore students' perspectives on professional feedback given by integrating the self-reflection on learning process and individual examination performance. Settings and Design: At the end of every medical school block examination, faculty provided descriptive feedback to students regarding individual performance in each subject area. The study had a quasi-experimental design. Materials and Methods: Students' (n=153) self-reflection on learning process was collected using a reflection-in-learning scale. The learning process of the students categorized in fail, pass and first-class categories were compared. Students' self-reflection-in-learning and common mistakes found in answering essay questions were used to offer feedback. Students' perspectives regarding feedback were collected using a validated questionnaire. Statistical Analysis: Kruskal-Wallis test and Mann-Whitney test were used to analyze the data. A P<0.017 was considered as statistically significant. Results: The median score of each item related to reflection was ≤4 (Scale 1-7) in all categories of students (n=153) reflecting a low level of reflection. There was a statistically significant difference in total reflection scores between fail (n=46) and first class category (n=42) students (P=0.002). The majority of students agreed feedback assisted in examination preparation, enhanced individual learning and allowed examinations to be viewed as more objective. Conclusions: This study shows the usefulness of the integration of medical students' reflection-in-learning practices and examination performance in providing descriptive feedback. This modified feedback process may have improved students' awareness leading to acceptance and a conscious practice of self-reflection and enhanced students' examination performance.

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Pulmonary arteriovenous malformations are rare vascular anomalies which rarely present in childhood. We discuss a nine-year-old male child who presented with the classical triad of exertional dyspnea, cyanosis and clubbing since six years of age. Pulmonary arteriovenous malformation was suspected on chest radiography and was later confirmed on computed tomography scan. A bubble contrast echocardiography showed the presence of an extracardiac shunt. Pulmonary angiography was done to delineate the anatomy of the pulmonary vasculature and to plan embolization. The child has undergone two sittings of transcatheter coil embolization with improvement in oxygenation.

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Proximal spinal muscular atrophy (SMA) or type 1 SMA is a fatal autosomal recessive disorder usually caused by homozygous deletion of exons 7 and 8 in the survivor motor neuron (SMN) gene. Additional deletion of the neuronal apotosis inhibitory protein (NAIP) gene exacerbates the clinical severity. Isolated exon 8 deletion has been reported in a single case series of SMA types 2 and 3 and never with SMA type 1. While extraocular muscles are typically spared, there are a few case reports documenting associated external ophthalmoplegia. Optic atrophy is a hitherto unreported association of SMA. We report a 10-month-old male infant with SMA type 1 with optic atrophy due to isolated deletion of exon 8 of the SMN gene with intact exon 7 and NAIP gene.

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Background: Influenza A (H1N1) hit the headlines in recent times and created mass hysteria and general panic. The high cost and non-availability of diagnostic laboratory tests for swine flu, especially in the developing countries underlines the need of having a cheaper, easily available, yet reasonably accurate screening test. Aims: This study was carried out to develop a clinical feature-based scoring system (CFSS) for influenza A (H1N1) and to evaluate its suitability as a screening tool when large numbers of influenza-like illness cases are suspect. Settings and Design: Clinical-record based study, carried out retrospectively in post-pandemic period on subject's case-sheets who had been quarantined at IG International Airport's quarantine center at Delhi. Materials and Methods: Clinical scoring of each suspected case was done by studying their case record sheet and compared with the results of RT-PCR. RT-PCR was used to confirm the diagnosis (Gold Standard). Statistical Analysis: We calculated sensitivity, specificity, positive and negative predictive values of the clinical feature-based scoring system (the proposed new screening tool) at different cut-off values. The most discriminant cut-off value was determined by plotting the ROC curve. Results: Of the 638 suspected cases, 127 (20%) were confirmed to have H1N1 by RT-PCR examination. On the basis of ROC, the most discriminant clinical feature score for diagnosing Influenza A was found to be 7, which yielded sensitivity, specificity, positive, and negative predictive values of 86%, 88%, 64%, and 96%, respectively. Conclusion: The clinical features scoring system (CFSS) can be used as a valid and cost-effective tool for screening swine flu (influenza A (H1N1)) cases from large number of influenza-like illness suspects.

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Background: Drugs with complex pharmacology are used in the management of drug use disorder (DUD) and HIV/AIDS in Malaysia and in parts of South-East Asia. Their multiethnic populations suggest complexity due to the genetic polymorphism, such as CYP2B6 that metabolizes methadone and anti-retroviral. Aims: Our aim was to explore the genetic polymorphism of CYP2B6 among Malays, Chinese, Indians, and opiate-dependent individuals in Malaysia. Settings and Design: The study utilized DNA from our previous studies on CYPs and new recruitments from opiate-dependent individuals. Materials and Methods: For the new recruitment, after obtaining consent and baseline demography, 5 ml blood was obtained from patients attending methadone maintenance therapy (MMT) Clinics. Genomic DNA was extracted using standard methods. 10 nucleotide changes associated with CYP2B6*10, CYP2B6*2, CYP2B6*17, CYP2B6*11, CYP2B6*8, CYP2B6*14, CYP2B6*9, CYP2B6*4, CYP2B6*6, CYP2B6*27, and CYP2B6*20 were determined using multiplex nested allele-specific PCR. Statistical Analysis: Descriptive statistics were used to summarize demographic data. Differences in allele frequencies between populations were tested using Chi-squared test and were corrected using the Bonferroni test. Results: CYP2B6 polymorphism in Malaysia is variable with trends that suggest an ethnic difference. Reduced activity CYP2B6*6 occurred in 13% to 26% among Malays, Chinese, Indians and opiate-dependent individuals. Another 'reduced activity', CYP2B6*2 allele, was found at much lower percentages in the groups. Conclusions: The relative commonness of reduced-activity CYP2B6 alleles in our study called for attention in terms of dosage requirements for MMT and ARV in Malaysia. It also implored follow-up association studies to determine its relevance and consequences in personalized medicine for drug use disorder and HIV/AIDS.

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Background: Specific learning disability (SpLD) often remains undetected, resulting in the afflicted child experiencing chronic poor school performance. Aims: To measure and analyze the self-perceived health-related quality of life (HRQoL) of children with newly-diagnosed SpLD. Settings and Design: Cross-sectional questionnaire-based study in our clinic. Materials and Methods: From February to December 2008, 150 children consecutively diagnosed as having SpLD were enrolled and their HRQoL documented using the DISABKIDS chronic generic module self-report version instrument. Statistical Analysis: Multiple regression analysis was carried out for determining the 'independent' impact that each of the clinical and socio-demographic variables had on a poor facet score outcome and on a poor total score outcome. Results: Clinically significant deficits were detected in all 6 facets, namely: 'large deficits (effect size ≥−0.8)' in "social exclusion", "emotion", "limitation", "treatment", and "independence"; and 'medium deficit (effect size −0.5 to <−0.8)' in "social inclusion"; and 'large deficit' in "total score". Multivariate analysis revealed that: (i) not belonging to the upper socio-economic strata of society was an independent predictor of a poor "independence" facet outcome (P=0.010, OR=1.99, 95% CI: 1.18 to 3.37); (ii) not having experienced class detainment was an independent predictor of a poor "emotion" facet outcome (P=0.008, OR=3.04, 95% CI: 1.34 to 6.85); (iii) first-born status was an independent predictor of a poor "limitation" facet outcome (P=0.022, OR=2.60, 95% CI: 1.15 to 5.90); and (iv) female gender was an independent predictor of a poor "social exclusion" facet outcome (P=0.024, OR=0.28, 95% CI: 0.09 to 0.85) and a poor "overall health" outcome (P=0.025, OR=0.32, 95% CI: 0.12 to 0.87). Conclusions: Children with newly-diagnosed SpLD perceive their psychosocial, physical, and overall HRQoL to be significantly compromised.

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Background: Injuries related to the Hindu festival of Dahihandi where a human pyramid is formed and a pot of money kept at a height is broken, celebrated in the state of Maharashtra, have seen a significant rise in the past few years. The human pyramid formed is multi-layered and carries with it a high risk of injury including mortality. Aims: To evaluate the nature, extent and influencing factors of injuries related to Dahihandi festival. Settings and Design: We present a retrospective analysis of patients who presented in a tertiary care center with injuries during the Dahihandi festival in the year 2010. Materials and Methods: 124 patients' records were evaluated for timing of injury, height of the Dahihandi pyramid, position of the patient in the multi-layered pyramid, mode of pyramid collapse and mechanism of an injury. A binary regression logistic analysis for risk factors was done at 5% significance level. Statistical Analysis: Univariate and multi-variate binary logistic regression of the risk factors for occurrence of a major or minor injury was done using Minitab™ version 16.0 at 5% significance. Results: Out of 139 patients presented to the center, 15 were not involved directly in the formation of pyramid, rest 124 were included in the analysis. A majority of the patients were above 15 years of age [110 (83.6%)]. 46 (37.1%) patients suffered major injuries. There were 39 fractures, 3 cases of chest wall trauma with 10 cases of head injuries and 1 death. More than half of the patients [78 (56.1%)] were injured after 1800 hours. 73 (58.9%) injured participants were part of the pyramid constructed to reach the Dahihandi placed at 30 feet or more above the ground. 72 (51.8%) participants were part of the middle layers of the pyramid. Fall of a participant from upstream layers on the body was the main mechanism of injury, and majority [101 (81.5%)] of the patients suffered injury during descent phase of the pyramid. Conclusions: There is a considerable risk of serious, life-threatening injuries inherent to human pyramid formation and descent in the Dahihandi festival. Safety guidelines are urgently needed to minimize risk and prevent loss of human life.

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Germ cell tumor (GCT) is relatively uncommon in intracranial locations. They constitute ~ 0.3-0.6% of intracranial neoplasms and encompass a wide pathologic range. The majority occurs in young adults and occupies the midline locations like pineal gland followed by suprasellar compartment. These tumors are rare in the cerebral hemisphere, basal ganglia, thalamus and ventricles. Neuroimaging studies cannot differentiate GCTs from other tumors, and therefore, the diagnosis usually requires histological confirmation. Germ cell tumors can be divided into major groups including germinomas and nongerminomatous GCTs (NGGCTs). Their proper identification as well as histopathological typing is important as treatment and prognosis vary greatly between different groups. Germinomas have a superior prognosis and are more radiosensitive as compared to non-germinomatous germ cell tumors. Standard management is still controversial. In this case series we are presenting three cases of intracranial germ cell tumors arising in two unusual locations, that is intraventricular and thalamic region. Apart from the clinical, radiological, histopathological and surgical details we also discuss the various aspects of intracranial germ cell tumors.

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Medical practice is in crisis - the sophistications are enormous and expensive, and the outcomes leave much to be desired. An epistemologic evaluation that weighs the scope and limitations of any -pathy or any procedure seems to be the need of the day. As an example, described herein is the logic of such an exercise; and a sample of the exercise itself, taking cancer as an example.

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Context: Infections caused by influenza viruses are a major health burden, both in developed and developing countries worldwide. Nevertheless, the overwhelming majority of influenza reports originate from industrialized countries in northern and southern temperate zones. Aims: The aim of this study was to determine the epidemiology of influenza viruses in patients seeking treatment for acute febrile illnesses in rural Bangladesh. Settings and Design: As part of our research on the causes of febrile illnesses in rural Bangladesh, nasopharyngeal swabs from patients with signs and symptoms consistent with influenza were collected from 2008 onwards. Materials and Methods: Viral infection was established using two independent rapid diagnostic tests (RDTs) and later confirmed by RT-PCR. Results: A total of 314 fever cases were enrolled in a survey of febrile illnesses carried out in Bandarban District in southeastern Bangladesh, out of whom 38 (12.1%) tested positive by RDT. Molecular subtyping showed that seasonal H3 strains (N=22; 7.0%) as well as the new H1N1v pandemic influenza subtype (N=13; 4.1%) had been circulating at the time of our investigations resulting in a PCR-adjusted positivity rate of 11.1% (95% CI 8.0 - 15.3). The positive predictive values for the RDTs used were 90.9% and 94.4%, respectively. Conclusions: This study provides a first insight into influenza epidemics in one of the most remote parts of Asia. Our findings suggest that respiratory illnesses due to influenza viruses are underreported in areas with limited access to health care and show a distinct seasonality also in rural areas of tropical countries.

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Patients with upper aerodigestive epithelial cancers frequently develop second primary cancers due to common risk factors or develop distant metastases depending on the locoregional status of the primary tumor. In most instances, the organ affected is the lung. Pulmonary spread usually occurs due to hematogenous or lymphatic dissemination. The following is a report of two patients with upper aerodigestive tract squamous cell carcinomas who developed lung metastases due to aspiration, a route not well documented in recent literature.

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The most common casues of acute abdomen during pregnancy are acute appendicitis followed by acute cholecystitis. The case presented is a 33-year-old patient in 16 weeks' in vitro fertilization and embryo transfer pregnacy who developed acute cholecystitis. Previously there were two unsuccessful cycles, one complicated with ovarian hyperstimulation syndrome. Due to clinical deterioration during intravenous antibiotic therapy laparoscopic cheolecystecomy was performed and acute cholecystitis found. The postoperative course was uneventful. During the first 24 h tocolysis with intravenous fenoterol in addition to peroral atenolol 2 Χ 50 mg was administered. Postoperative course was uneventuful with further normal pregnancy. Elective cesarean section was made in term pregnancy (39 weeks) with singleton with Apgar 10/10. Current guidelines do not recommend prophylactic tocolysis in pregnant population with acute abdomen but there is no mention of the IVF-ET subpopulation of patients. Also, there are no guidelines for thromboprophylaxis in such patients with increased risk of thromboembolic accidents. To our knowledge this is the first case report of a laparoscopic cholecystectomy during IVF-ET gestation.

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Scrub typhus is a mite borne infectious disease caused by Orientia tsutsugamushi. It is a common cause of undifferentiated febrile illness in the Indian subcontinent. We present a case of scrub typhus with a rare ophthalmic manifestation.Our patient presented with fever and opsoclonus, was diagnosed to have scrub typhus and completely improved upon treatment. Opsoclonus complicates various medical diseases, including viral infections, toxin, encephalitis, brain tumors, and paraneoplastic syndromes. There has been only one previously reported case of opsoclonus in scrub typhus. This phenomenon highlights the increasingly complex presentation of common diseases. It also indicates there is much to be discovered about the immunopathogenesis of this infectious disease.

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