Ravulizumab for treatment of paroxysmal nocturnal hemoglobinuria

FDA approves ravulizumab for treatment of paroxysmal nocturnal hemoglobinuria
https://www.mdedge.com/internalmedicine/article/191740/anemia/fda-approves-ravulizumab-treatment-paroxysmal-nocturnal
Lucas Franki, Internal Medicine News

Dec 21st, 2018 - The Food and Drug Administration has approved ravulizumab(Ultomiris) injection for the treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH). Wikimedia Commons/FitzColinGerald/Creative Commons License "The approval of Ultomiris will change the way that patients with PNH are treated.

Ravulizumab (ALXN1210) in patients with paroxysmal nocturnal hemoglobinuria: res... Preview
https://www.ncbi.nlm.nih.gov/pubmed/30171081
Blood Advances; Röth A, Rottinghaus ST et. al.

Sep 2nd, 2018 - Ravulizumab (ALXN1210), a humanized monoclonal antibody to complement component C5, was engineered from eculizumab to have a substantially longer terminal half-life, permitting longer dosing intervals for paroxysmal nocturnal hemoglobinuria (PNH) treatment. Two phase 1b/2 multicenter open-label studies evaluated efficacy and safety of multiple doses and regimens of ravulizumab in ...

Drug is convenient alternative for PNH, doc says
https://www.mdedge.com/content/drug-convenient-alternative-pnh-doc-says
Jen Smith

Jun 22nd, 2018 - Photo from EHA Session at the 23rd Congress of the European Hematology Association (EHA) STOCKHOLM—Results of a phase 3 study suggest the long-acting C5 complement inhibitor ravulizumab produces similar results as eculizumab in patients with paroxysmal nocturnal hemoglobinuria (PNH). Treatment with ravulizumab every 8 weeks proved noninferior to treatment with eculizumab every 2 w.

New Drug for PHN Taken Only Once Every 8 Weeks
https://www.medscape.com/viewarticle/898793

Jul 2nd, 2018 - STOCKHOLM, Sweden — A new drug under development for the treatment of paroxysmal nocturnal hemoglobinuria (PNH),  ravulizumab (ALXN1210, Alexion Pharmaceuticals), has shown noninferiority compared with eculizumab (Soliris, Alexion Pharmaceuticals), currently the only therapy approved for the syndrome. But it achieved similar outcomes while being administered by intravenous (IV) infusion ...

FDA OKs New Options for Two Rare Blood Diseases
https://www.medpagetoday.com/hematologyoncology/hematology/77084

Dec 21st, 2018 - WASHINGTON -- The FDA announced new approvals for two rare and life-threatening blood diseases on Friday, as blastic plasmacytoid dendritic cell neoplasm (BPDCN) gets its first approved agent and paroxysmal nocturnal hemoglobinuria (PNH) gets a new drug that drastically cuts the frequency of treatments. BPDCN Gets First Approved Drug The FDA approved the infusion therapy tagraxofusp (Elzonris) ...

Elzonris (tagraxofusp-erzs) for blastic plasmacytoid dendritic cell neoplasm (BPDCN)

FDA approves Elzonris for blastic plasmacytoid dendritic cell neoplasm
https://www.mdedge.com/hematologynews/article/191723/rare-diseases/fda-approves-elzonris-blastic-plasmacytoid-dendritic
Laura Nikolaides, Hematology News

Dec 21st, 2018 - The Food and Drug Administration has approved tagraxofusp-erzs (Elzonris) infusion for the treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN) in adults and pediatric patients, 2 years of age and older. Approval was based on efficacy in two cohorts of patients in a single-arm clinical trial.

Drug under priority review for BPDCN
https://www.mdedge.com/content/drug-under-priority-review-bpdcn
HT Staff

Aug 15th, 2018 - Photo by Bill Branson Vials of drug The US Food and Drug Administration(FDA) has accepted for priority review the biologics license application seeking approval for tagraxofusp (Elzonris, SL-401) to treat blastic plasmacytoid dendritic cell neoplasm (BPDCN). The FDA expects to make a decision on this application by February 21, 2019.

FDA OKs New Options for Two Rare Blood Diseases
https://www.medpagetoday.com/hematologyoncology/hematology/77084

Dec 21st, 2018 - WASHINGTON -- The FDA announced new approvals for two rare and life-threatening blood diseases on Friday, as blastic plasmacytoid dendritic cell neoplasm (BPDCN) gets its first approved agent and paroxysmal nocturnal hemoglobinuria (PNH) gets a new drug that drastically cuts the frequency of treatments. BPDCN Gets First Approved Drug The FDA approved the infusion therapy tagraxofusp (Elzonri...

Acta Medica International

http://www.actamedicainternational.com/currentissue.asp?sabs=n

Simulation in anaesthesia Sanjeev Kumar Jain, Rohit Kumar Varshney Acta Medica International 2018 5(2):53-54

Features of acid–base balance of bone marrow Lyudmila P Nikolaeva Acta Medica International 2018 5(2):55-57 Context: Bone marrow (BM) pH has rarely been measured, and the long BM has barely been studied at all because intravital obtaining of the long BM is impossible due to the extreme strength of the long bone tissue. Aims: The study aimed to investigate the acid–base balance of the BM and to compare the acid–base properties of long BM and flat BM. Subjects and Methods: Forty flat BM samples were extracted by sternal puncture. Forty long BM samples were extracted from the femora in patients who had to have a limb amputated. A blood gas and acid–base status analyzer were used to determine pH. Results: Flat BM pH is similar to blood p; the long BM pH is acidic and ranges from 6.7 to 6.9. Hematopoietic stem cells occur in both acidic and slightly alkaline environments. The blood gas and acid–base status analyzer used in this study are suitable for determining the acid–base properties of BM. Conclusions: The acid–base status appears to be an important factor of stem cell differentiation. This paper can be of interest to biotechnologists and researchers who investigate possibilities to influence the differentiation and properties of the stem cells.

Incidence of atrial fibrillation after cardiac surgery and its pharmacological management Persis Ann George, Anila Varkey, Adithya Nandan, Uday Venkat Mateti, Mundayat Gopalakrishnan, Rovin Mathew Theempalangad Acta Medica International 2018 5(2):58-62 Aim: Postoperative atrial fibrillation (POAF) is one of the most commonly occurring complications after cardiac surgery. The study aims to determine the incidence of POAF and to analyze its pharmacological management in patients scheduled for cardiac surgery. Methodology: A prospective observational study was carried out for 6 months (October 2016 to March 2017) in cardiothoracic surgery. Drug therapy details by medication chart review and clinical review in patients who underwent coronary artery bypass graft, mitral valve replacement (MVR), and aortic valve replacement was carried out and analyzed for the incidence of POAF. The statistical analysis was performed using SPSS. Results: A total of 83 patients were recruited for this study. The POAF incidence was 18.07% with the highest incidence on the 2nd postoperative day. The mean age of patients with POAF was 49.40 ± 12.77 years. Rheumatic heart disease and alcohol were identified as the predisposing factors of POAF. The incidence of POAF was the highest following MVR (80%) than other cardiac surgeries. Patients who developed POAF had a longer length of hospitalization (median 9 vs. 7 days). Amiodarone, metoprolol, verapamil, atorvastatin, clopidogrel, and aspirin were the most frequently prescribed drugs for the management of POAF. Administration of metoprolol, nebivolol, atorvastatin, bisoprolol, metoprolol + atorvastatin + aspirin, and other combinations before cardiac surgery reduced the risk of developing POAF. Conclusion: The overall incidence of POAF was 18.07%. Amiodarone (13.3%), metoprolol (40%), verapamil (66.7%), aspirin (26.7%), clopidogrel (13.3%), and atorvastatin (20%) were found to be safe and effective in the treatment of POAF patients.

Caregivers' awareness and perception of cardiopulmonary resuscitation: Our experience Ibrahim Aliyu, Abdulsalam Mohammed, Zainab F Ibrahim Acta Medica International 2018 5(2):63-68 Introduction: Adverse health-related events such as cardiac arrest can occur at any location: it is broadly classified as out-of-hospital or in-hospital cardiac arrest. The location of cardiac arrest however affects outcome; the actions of caregivers and bystanders may influence the outcome of witnessed out-of-hospital cardiac arrest; therefore, their knowledge of cardiopulmonary resuscitation (CPR) is relevant. Materials and Methods: This was a questionnaire-based cross-sectional study conducted at the Paediatric Outpatient Clinic and Paediatric Specialty Clinic of Aminu Kano Teaching Hospital. Results: There were 120 (33.3%) males and 240 (66.7%) females, with a male-to-female ratio of 1:2. Only 57 (15.8%) respondents were aware of CPR. However, 69 (19.2%) respondents were aware of chest compression. One hundred and twenty-nine (35.8%) respondents reported that they could perform mouth-to-mouth resuscitation on their own children; however, 66 (18.3%) respondents reported willingness to perform mouth-to-mouth resuscitation on another person's child if the need arose. Only 15 (4.2%) respondents had training on CPR. Six (40%) respondents were trained at school. However, caregivers in the chronic illness subgroup were more willing to perform mouth-to-mouth resuscitation. Caregivers of children with acute illnesses would use palm kernel oil to treat convulsion; however, those of the chronic illness group would mostly use herbs to treat convulsion; this observation was statistically significant (Fisher's exact test = 32.457, P = 0.00). Conclusion: There was poor awareness of CPR among respondents; furthermore, there was lack of willingness to perform CPR by most respondents on children.

A comparative analysis of the baska mask versus I-gel for general anesthesia in surgical patients undergoing laparoscopic cholecystectomy Usha Kumari Chaudhary, Som Raj Mahajan, Monika Mahajan, Charu Sharma, Mukesh Sharma Acta Medica International 2018 5(2):69-73 Background and Aims: Baska mask is a newly introduced membranous cuffed supraglottic device whereas I-gel is made up of thermoplastic elastomer, both suitably designed from the anatomical perspective of the airway. Settings and Design: We conducted randomized controlled comparative trial of the Baska mask versus I-gel in a patient undergoing laparoscopic cholecystectomy. Subjects and Methods: A total of 100 adult patients in the age group of 20–70 years undergoing elective laparoscopic cholecystectomy were randomly divided into two groups as follows: (1) Baska mask group and (2) I-gel group. The primary outcome was to compare oropharyngeal leak pressure (OLP) of Baska mask and I-gel groups. The secondary outcome was the ease of insertion and removal, number of attempts, insertion time, leak fraction, and laryngopharyngeal morbidity. Statistical Analysis Used: Demographic details were compared using the Chi-square and t-tests. Student's t-test for independent variables was used to compare means of data obtained. Results: Mean OLP was significantly higher in Baska mask group than I-gel group at insertion (29.54 ± 1.41 cm H2O vs. 23.16 ± 3.07 cm H2O, P = 0.02) and 30 min after insertion (33.54 ± 1.16 cm H2O vs. 25.97 ± 2.25 cm H2O, P = 0.001). Insertion time was 12.33 ± 2.61 s with Baska mask and 11.31 ± 1.84 s with I-gel (P = 0.02). Insertion was very easy in 58% of patients in Baska mask and 76% of patients in I-gel (P = 0.03). The leak fraction of Baska mask was significantly less than I-gel (3.56 ± 3.6 vs. 7.16 ± 2.45, P = 0.01). Laryngopharyngeal morbidity was comparable in the two groups. Conclusion: Baska mask is more effective in providing greater OLP compared to I-gel without any increase in laryngopharyngeal morbidity.

Chromosomal aberrations in multiple myeloma: A study on Indian population Angel Beula P. Royal, Syeda Sabiha S. Lubna, P Beaulah Angel, Vijaya V Mysorekar, TS Sundareshan Acta Medica International 2018 5(2):74-78 Aims: The aim of this study was to evaluate the complexity of the chromosomal abnormalities in multiple myeloma (MM) cases and to correlate the findings with the previous reported cases. Materials and Methods: Bone marrow samples were obtained from patients with MM and sent for cytogenetic study. The patient's details were logged and the cytogenetic test was performed. The karyotypes were analyzed and interpreted as per the standard guidelines. Results: Of the compiled data of cases from 2013 to 2016, 34 patients were diagnosed with MM. About 15% were below the age of 50, maximum patients were between ages of 61 and 70 years (50%). There were 25 male and 9 female. Twenty-one cases had normal karyotypes and few cases showed structural rearrangements and numerical abnormalities. Conclusions: From the data compiled, only a total of 34 cases were positive for MM, indicating that the disease is quite rare in our population. It has been previously reported that the disease usually occurs in people over the age of 50 years, however, in this study, 5 (15%) were below the age of 50 indicating that MM can affect the age group below 50 years as well. The numerical, structural abnormalities and few clonal abnormalities observed in our study added a few more to the previously reported abnormalities. However, the interesting finding of our study was a case with a combination of clones of hypodiploidy, hyperdiploidy, hypotetraploidy, and hypertetraploidy which was in contrary to the reported literatures, which were only one type of ploidy were observed. Thus, the heterogeneity and complexity of the chromosomal abnormalities in MM and the challenge in staging the disease have been proven in our study.

Prevalence of exclusive breastfeeding and knowledge related to breastfeeding among mothers attending immunization center and well-baby clinic Shuvendu Roy, Ashish K Simalti, Bindu T Nair Acta Medica International 2018 5(2):79-83 Background: The World Health Organization defines exclusive breastfeeding (EBF) as giving baby only breast milk for the first 6 months without adding any additional drink including water or food. We undertook this study with an objective to assess the prevalence of breastfeeding among mothers in North Indian setting. Aims: The aims of this study were to assess the prevalence of EBF among mothers attending a well-baby clinic and to look for variable significantly impacting probability of breastfeeding and assessing the challenges faced and existing knowledge regarding breastfeeding. Materials and Methods: This was a questionnaire-based one-point survey to assess the prevalence of EBF. The questionnaire was based on the review of literature and included parameters considered significant by various studies. Mother's knowledge regarding breastfeeding was assessed by another questionnaire. Results: A total of 970 mothers were approached who visited immunization center and well-baby clinic during the study. After taking out those who were unwilling and did not meet the criteria, we had 634 mothers who participated in our study. They were divided into two groups based on whether they exclusive breastfed their babies for 6 months or not. Comparison of both these groups revealed breastfeeding counseling to be the most important variable. Statistical Analysis Used: It is a cross-sectional type of study with a questionnaire-based one-point survey. The minimum sample size required was calculated using Daniel's formula: n = z2pq/d. Consequent sampling was done. Chi-square test for independence was done to assess the association between both the groups for all the parameters recorded. Conclusions: All mothers were aware that breast milk is beneficial for their baby; however, the biggest problem was anxiety regarding the adequacy of their breast milk. There is also need for a widespread campaign related to harm done by prelacteals and substitutes of breast milk including cow milk.

Treatment of patients suffering from exercise-induced asthma: Prevention of exercise-induced bronchial spasm – Literature review Leonid Oleksijovych Bezrukov, Olena Kostiantynivna Koloskova, Lorina Alimivna Ivanova, Tetiana Mykhailivna Bilous, Olena Grygorivna Grygola, Yuliia Igorivna Voitkevich Acta Medica International 2018 5(2):84-89 Exercise-induced bronchial asthma (EIBA) or exercise-induced bronchial spasm is all terms that describe the phenomenon of transient obstruction of the bronchi after intensive physical stress. This article presents the recommendations about the rational administration of pharmacological and nonpharmacological methods of treatment of EIBA that in the majority of cases enables to provide considerable control over the disease without limitation of the physical activity of patients.

Penile entrapment: A case where innovation is the need of the hour Gajanan Shripad Bhat Acta Medica International 2018 5(2):90-91 Penile entrapment is a rare and unique condition requiring urgent decompression to preserve the organ function and prevent complications. There is no universal method that is applicable to all cases as there are hardly any guidelines. Management of a 35-year-old male who presented to our emergency room with a metal ring around his penis has been described here. The case report highlights the need to devise one's own method to decompress the entrapped penis based on the available technology and manpower on hand in a given situation.

The effectiveness of continuous venovenous hemodiafiltration in phenobarbital intoxication Yasemin Çoban, Dinçer Yildizdas, Özden Özgür Horoz, Nagehan Aslan, Didar Arslan Acta Medica International 2018 5(2):92-94 Phenobarbital continues to be widely used in childhood epilepsy. Incorrect drug prescription can sometimes lead to intoxication, particularly in young children. A 40-month-old female infant presented to our emergency department due to failure to awaken. The patient was assessed in terms of etiology of coma, and her history revealed that she had been given a 100 mg phenobarbital pill instead of 15 mg. Her blood phenobarbital level was high (>80 mg/dl). At physical examination, her Glasgow coma score was 6, the pupils were isochoric, pupillary light reflex was bilateral positive, deep tendon reflexes were absent, respiration was superficial, and pulmonary bilateral diffuse secretory rales were present, and the patient was intubated. Continuous venovenous hemodiafiltration (CVVHDF) was performed due to prolonged coma, intubation, and potentially fatal phenobarbital level. Blood phenobarbital levels at 4 and 12 h improved to >80 and 33.4 mg/dl, and the patient was extubated at 14 h. CVVHDF was effective in intoxication despite long-acting barbiturate phenobarbital not binding to protein. We think that this is a useful method capable of use in phenobarbital intoxications.

Pediatric Respirology and Critical Care Medicine

http://www.prccm.org/currentissue.asp?sabs=n

Outcomes and prediction Rina Triasih Pediatric Respirology and Critical Care Medicine 2018 2(4):57-57

Obstructive sleep-disordered breathing in children: Impact on the developing brain Lisa M Walter, Rosemary S C Horne Pediatric Respirology and Critical Care Medicine 2018 2(4):58-64 Obstructive sleep-disordered breathing (SDB) affects up to 11% of children and forms a continuum of severity ranging from primary snoring to obstructive sleep apnea. Children with SDB exhibit significant neurocognitive and cardiovascular dysfunction, which is associated with repetitive hypoxia and sleep fragmentation that characterize the condition. We reviewed the recent literature pertaining to the effect of SDB on the brain in children. These include studies that utilized near-infrared spectroscopy to determine cerebral oxygenation and structural and functional magnetic resonance imaging (MRI) of the brain. Studies have identified that the effect of SDB on cerebral oxygenation in children is minimal and not clinically significant. There are conflicting reports on the association between the measures of cerebral oxygenation and peripheral arterial oxygen saturation (SpO2), and further research needs to be conducted to elucidate the relationship between peripheral SpO2, cerebral oxygenation, and SDB in children. MRI studies have reported significant structural and functional changes to the brains of children with SDB, in brain regions associated with neurocognition, behavior, and autonomic function. These include reduced white and gray matter and structural changes to a multitude of brain areas including, but not limited to, the hippocampus, cortex, amygdala, insula, thalamus, cerebellum, and basal ganglia. These studies utilize a variety of MRI techniques to address different research questions, but contribute to the gradually developing picture of the adverse effects of SDB on the brain in children.

Validation of a modified pediatric risk of mortality III model in a pediatric intensive care unit in Thailand Kanokpan Ruangnapa, Sittikiat Sucheewakul, Tippawan Liabsuetrakul, Edward McNeil, Kantara Lim, Wanaporn Anantaseree Pediatric Respirology and Critical Care Medicine 2018 2(4):65-72 Objective: The objective of this study is to compare the performance of a modified Pediatric Risk of Mortality (PRISM) III model with the original PRISM III in prediction of mortality risk in a Thailand pediatric intensive care unit (PICU). Subjects and Methods: Children aged 1 month to 18 years who stayed in the PICU for more than 8 h during November 2013 to December 2016 were included in the study. Results: The medical records of 1175 PICU patients were included in the analysis. The patients were randomly split into two equal groups: a development (n = 588) and a validation (n = 587) sample. A modified PRISM III model was derived from the original PRISM III by omitting arterial blood gas parameters and adding selected clinical variables. The model was developed using a multiple logistic regression model on the development sample and assessed using the area under the curve (AUC) obtained from a receiver operating characteristic curve. The modified PRISM III scores were significantly higher in nonsurvivors (median = 9, interquartile range [IQR] = 4 − 13) compared to survivors (median = 2, IQR = 0 − 5). The modified PRISM III model had similar discriminative performances compared to the original PRISM III in predicting 2-day mortality (AUC: 0.874 vs. 0.873), 7-day mortality (AUC: 0.851 vs. 0.851) and overall mortality (AUC: 0.845 vs. 0.956). The modified PRISM III model was calibrated in the validation sample, and the standardized mortality ratios (SMRs) were similar. Conclusions: The performance of a modified PRISM III model in predicting mortality risk was comparable to the original PRISM III. Both had similar discriminative performance and SMR for overall mortality prediction in a PICU.

Pulmonary function abnormalities in Nigerian children with sickle cell anaemia: Prevalence, pattern and predictive factors Bankole Peter Kuti, Samuel Ademola Adegoke Pediatric Respirology and Critical Care Medicine 2018 2(4):73-79 Background: Advances in care of children with sickle cell anaemia (SCA) have increased their chances of survival to adolescence and adulthood though this is often associated with multi-organ system pathologies including lung dysfunctions. This study aimed to determine the prevalence, pattern and factors associated with pulmonary function abnormalities in Nigerian children with SCA. Methods: Pulmonary functions of 104 children with SCA in steady state and 104 age- and sex-matched haemoglobin AA controls aged 6 to 16 years at the Wesley Guild Hospital, Ilesa Nigeria, were assessed using Spirolab III (Medical International Research, Italy) spirometer following standard protocol. Socio-demographic characteristics, nutritional status and pulmonary function parameters of these children were compared, and the predictive factors of pulmonary function abnormalities in SCA children were determined using binary logistic regression. Results: SCA children had lower lung volumes and capacities and higher prevalence of pulmonary function abnormalities compared to controls, and a restrictive ventilatory pattern (22.1%) was the most predominant form. Adolescent age, previous acute chest syndrome (ACS), repeated painful crises and multiple hospitalisations in the previous year were significantly associated with pulmonary function abnormalities (P < 0.05). Only adolescent age group (odds ratio [OR] = 3.738; 95% confidence interval [CI] = 1.480–9.440; P = 0.005) and previous ACS (OR = 8.500; 95% CI = 2.044–12.959; P = 0.044) independently predicted pulmonary function impairments among the SCA children. Conclusion: SCA predisposes children to pulmonary dysfunction, particularly during adolescent years and in those with ACS, multiple crises and hospitalisations. Routine pulmonary function assessment in these children will facilitate early recognition and prompt management.

Glioma

http://www.jglioma.com/currentissue.asp?sabs=n

Nanoparticles drug-delivery systems and antiangiogenic approaches in the treatment of gliomas Maria Caffo, Salvatore Massimo Cardali, Elena Fazzari, Valeria Barresi, Gerardo Caruso Glioma 2018 1(6):183-188 The prognosis of patients with cerebral gliomas remains noticeably poor. Total surgical resection is almost unachievable due to considerable infiltrative ability of glial cells. Furthermore, adjuvant treatments are burdened by considerable limitations. Angiogenesis is the mechanism by which new blood vessels are formed from preexisting ones, thus supporting neoplasm progression. Gliomas are characterized by extensive microvascular proliferation. The extent of neovascularization in brain tumor correlates directly with the biological aggressiveness, degree of malignancy, and clinical recurrence of the tumor. Although a plethora of molecules can act as inducers of angiogenesis, the major growth factors include members of the vascular endothelium growth factor family. The new therapeutic approaches envisage the identification of specific biomarkers involved in this process and try to inhibit them, thus slowing down the neoplastic progression. Nanoparticles (NPs) show the ability to pass the blood–brain barrier, and moreover, when suitably modified, they can bind to specific overexpressed receptors in the glial cells. As carriers, they are able to protect the therapeutic agent and allow their sustained release. In this review, we describe some NP delivery systems which target specific biomarkers to intervene in the process of angiogenesis.

Intraoperative fluorescence-guided resection of high-grade glioma: A systematic review Lin Yang, Yan Xiang, Guo-Hao Huang, Hong-Yao Lyu, Ke-Jie Mou, Sheng-Qing Lv Glioma 2018 1(6):189-195 High-grade glioma (HGG) is a devastating disease with very poor prognosis. Maximal resection of HGG improves survival and maximal visualization of the tumor, if reliable, improves the resection. Fluorescence is widely used as guidance mechanism and has demonstrated potential in maximizing the extent of HGG resection. Our goal is to summarize the current techniques using fluorescence during the resection of HGG and demonstrate how its use increases gross total resection rates, overall survival (OS), and progression-free survival (PFS). However, further prospective, multicenter, randomized controlled trials are still in need to prove the advantage of fluorescence-guided surgery on patients' OS/PFS.

Histologic characterization of the immune infiltrate in isocitrate dehydrogenase wild-type and mutant World Health Organization Grade II and III gliomas Josine A. E. M. Jansen, Wim G. M. Spliet, Wendy de Leng, Pierre Alain Robe Glioma 2018 1(6):196-200 Aim: This study aims to describe the immune infiltrations in low-grade glioma (LGG) with respect to their histological classification, isocitrate dehydrogenase 1 and 2 (IDH1/2) mutation status and survival. Materials and Methods: The IDH1/2 status (mutant or wild-type) of 66 World Health Organization Grade II and III gliomas were defined using next-generation sequencing or multiplex ligation-dependent probe amplification. The immune infiltrates of these tumors (46 mutant IDH, 20 wild-type IDH) were assessed immunohistochemically using a panel of antibodies (CD3, CD4, CD8, FOXP3, CD20, CD68, and CD163). Confirmatory analyses were performed on a cohort of lower grade gliomas from the Cancer Genome Atlas (TCGA). Statistical analyses were performed with Mann–Whitney U-tests and Kaplan–Meier survival estimates. Results: There was no relation between the amount of CD3+, CD4+, CD8+, or CD20+ lymphocyte infiltration and IDH mutation status in the tumors. FOXP3+ T regulatory cell infiltrates were rare, but more frequent in IDH1/2 wild-type tumors (P = 0.046). While the presence of these cells did not correlate with overall survival, FOXP3 messenger RNA expression was associated with survival in a distinct cohort of LGG from the TCGA (P < 0.05). CD4+ lymphocyte infiltrates, on the other hand, tended to prevail in astrocytic tumors as compared to oligodendrogliomas (P = 0.056). While CD68 (M1) microglial/monocytic cells were equally abundant in IDH mutant and wild-type tumors, the presence of round, activated M1 CD68+ microglia significantly associated with a mutant IDH status (P = 0.015). Conclusion: FOXP3+ expression and activated CD68+ M1 cells associated with IDH status in LGG, and might contribute to their differential evolution.

Assessment of microvascular patterns and density in glioblastoma and their correlation with matrix metalloproteinase-9, p53, glial fibrillary acidic protein, and Ki-67 Karuna Jha, Ishita Pant, Ritika Singh, Ajay Kumar Bansal, Sujata Chaturvedi Glioma 2018 1(6):201-207 Background and Aim: Microvascular patterns (MVPs) and microvessel density (MVD) can influence the progression of glioblastomas. This study aims to study MVP and MVD using immunohistochemistry, and examine any correlation with the expression of matrix metalloproteinase-9 (MMP-9), p53, glial fibrillary acidic protein (GFAP), and Ki-67 labeling index (Ki-67 LI) in 24 cases of glioblastoma multiforme. Materials and Methods: MVPs and MVD were studied by a dual staining method using periodic acid–Schiff stain with CD34 (MVDCD34), CD31 (MVDCD31), von Willebrand factor (MVDvWF), and factor VIII (MVDFVIII). The expression of MMP-9, p53, GFAP, and Ki-67 LI was analyzed using immunohistochemistry. The Pearson coefficient of correlation and intraclass correlation were obtained using SPSS software. Results: Five distinct categories of MVP were found: Microvascular sprouting (MS)/simple vessels, vascular clusters (VCs), vascular garlands, glomeruloid tufts, and vasculogenic mimicry. Of the MVPs, MS was the most common pattern and was present in all cases. On calculating the Pearson's correlation coefficient, different MVPs gave varying results regarding their correlation with MMP-9, p53, GFAP, and Ki-67 LI. MSCD34, CD31, vWF showed significant correlation with MMP-9 and Ki-67 LI, while MSFVIII did not show any correlation with Ki-67 LI. Only VCCD34 had a correlation with Ki-67 LI. No correlation between any of the MVPs and GFAP and p53 was appreciated. MVD ranged from: CD34 (9.2–41.9/hpf), FVIII (6.05–40.5/hpf), CD31 (5.1–40.7/hpf), and vWF (8.7–35.5/hpf). MVDCD34 and MVDCD31 correlated with MMP-9 and Ki-67, whereas, MVDvWF and MVD FVIII correlated with MMP-9. Interobserver agreement was seen only in the assessment of MVD and the MS type of MVP. Conclusion: MVD and MVPs had correlation with MMP-9, p53, GFAP, and Ki-67. These results could impact the development of strategies using antiangiogenic therapies.

O-6-methylguanine-DNA methyltransferase promoter methylation can change in glioblastoma recurrence due to intratumor heterogeneity Valeria Barresi, Maria Caffo, Giuseppa De Luca, Giuseppe Giuffrè Glioma 2018 1(6):208-213 Background and Aim: The standard-of-care for patients with glioblastoma (GBM) is surgery followed by concurrent chemotherapy with temozolomide and radiotherapy. O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation is commonly assessed in GBM as a predictive marker of response to temozolomide. Although MGMT methylation status has been shown to change between primary and recurrent GBM, no indication exists on retesting MGMT in recurrent GBM. In addition, what causes the change in MGMT methylation has yet to be identified. In this study, we aimed to investigate whether MGMT promoter methylation in recurrent GBM was influenced by intratumor heterogeneity in the initial GBM tumor. Materials and Methods: We investigated the status of MGMT promoter methylation in different samples taken from concentric layers of 24 GBMs and in 11-paired surgically resected recurrences. The neoplastic nature of samples submitted for methylation analysis was preliminary verified through histological examination; the fragments were accurately chosen to have adequate cellularity and minimal amount of nontumor contaminants. Results: About 27% (3 out of 11) of the recurrences had changed MGMT methylation status compared to the initial tumor. Initial tumor heterogeneity might play a role in this change, as all three cases had intratumor heterogeneity (with the central part of the tumor methylated and the peripheral part unmethylated) in the primary GBM. Conclusion: This study suggests that MGMT methylation variation in recurrent GBM may depend on intratumor heterogeneity in the initial tumor. Intratumor heterogeneity and possible changes in the recurrence should be taken into account when testing MGMT promoter methylation status as a predictive factor orienting therapeutic decisions in patients with GBM.

Pediatric Nephrology

http://www.ajpn-online.org/currentissue.asp?sabs=n

Challenge of congenital abnormalities of the kidney and urinary tract RN Srivastava Asian Journal of Pediatric Nephrology 2018 1(2):49-51

Epidemiology of acute kidney injury in critically ill children living in the Kingdom of Saudi Arabia Jameela Abdulaziz Kari Asian Journal of Pediatric Nephrology 2018 1(2):52-55 Acute kidney injury (AKI) is very common in children admitted to pediatric intensive care and affected children are at increased risk of morbidity and mortality. The epidemiologic characteristics of children with AKI have not been well described in children living in the Kingdom of Saudi Arabia (KSA). This review of the epidemiology of AKI in critically ill children in KSA shows that AKI is common in this population and is chiefly attributed to sepsis, other infections and postcardiac surgery. The occurrence of AKI is linked to increased mortality and length of hospital stay. The severity of AKI correlates with increased inhospital mortality as well as risk of mortality after discharge. A considerable proportion of survivors develop evidence of chronic kidney disease. Cystatin C and urinary neutrophil gelatinase-associated lipocalin are useful in enabling early diagnosis of AKI in critically ill children.

Therapies for steroid-sensitive nephrotic syndrome RS Thalgahagoda, A H. H M. Jayaweera, UI Karunadasa, AS Abeyagunawardena Asian Journal of Pediatric Nephrology 2018 1(2):56-61 Nephrotic syndrome (NS), a common childhood kidney disease, is associated with significant morbidity and mortality due to disease complications. Most patients who respond to corticosteroids show a relapsing course that requires repeated courses of therapy, and frequent relapses or steroid dependence are common. Most children with steroid-sensitive relapses show minimal change disease upon biopsy. Focal segmental glomerulosclerosis is the predominant histology in patients with steroid-resistant NS where renal biopsy is recommended, and a complicated disease course is anticipated. Patients with frequent relapses are at risk of severe infections, thrombosis, and hypovolemia and receive repeated and prolonged courses of prednisolone that often result in corticosteroid toxicity. These challenges have led to the use of numerous corticosteroid-sparing agents or regimens to reduce the risk of relapses as well as cumulative corticosteroid burden. This review discusses therapy-related aspects of steroid-sensitive NS and compares different regimens of corticosteroid and other immunosuppressive medications that are used in managing this condition.

Nationwide pediatric renal biopsy audit by the Indian Society of Pediatric Nephrology Rajiv Sinha, Nimisha Arora, Manpreet Kaur, Arpana Iyengar, Pankaj Hari, Abhijeet Saha Asian Journal of Pediatric Nephrology 2018 1(2):62-66 Objective: The survey was conducted to identify current renal biopsy practices in India and compare them with the British Association of Pediatric Nephrology (BAPN, 2015) standards. Methods: A 53-question survey questionnaire was sent to 48 centers across the country by electronic mail. Questions included were related to the number of biopsies performed, indications, prerequisites and procedure of biopsy, monitoring, and complications. The results were compared against the BAPN 2015 standards. Results: Thirty (62.5%) out of 48 centers responded to the questionnaire. Real-time ultrasound was the favored method at 24 (80%) centers. Most (80%) of the biopsies were performed by nephrologists alone. The biopsy was usually (80%) an inpatient procedure with overnight hospitalization; 20% of the centers performed it as a day-care procedure. The 18-gauge needle was preferred by 60% of the centers. Biopsy was achieved with three or fewer passes in 93% of the centers. Almost half (47%) of the centers considered 10 or more glomeruli on light microscopy as adequate to reach a diagnosis. The rates of gross hematuria were <5% in 80% of the centers surveyed. Death following biopsy was reported by two centers. Conclusion: Majority of the centers surveyed across India achieve BAPN standards in most parameters. Such audit of practices against the standards for kidney biopsy enables comparison between units as well as for monitoring of individual center's performance over time.

Determining the optimal dose of cholecalciferol supplementation in children with chronic kidney disease (C3 Trial): Design of an open-label multicenter randomized controlled trial Arpana Aprameya Iyengar, Nivedita Kamath, V Hamsa, Susan Uthup, Jyoti Sharma, Jyoti Singhal, Sudha Ekambaram, Rukshana Shroff Asian Journal of Pediatric Nephrology 2018 1(2):67-73 Introduction: 25-hydroxyvitamin D (25OHD) deficiency is common in children with chronic kidney disease (CKD) and can affect bone mineralization and cardiovascular morbidity. It is important to treat 25OHD deficiency appropriately in a manner that ensures not only replenishing stores but also sustaining adequate 25OHD levels without causing toxicity. The present study was planned to determine the appropriate dosing regimen for oral cholecalciferol that achieves and maintains normal 25OHD levels in children with CKD stage 2–4 and to assess the effect of various dosing regimens on bone biomarkers, secondary hyperparathyroidism, and vitamin D toxicity. Methods: We present the design of an open-label, multicenter randomized controlled trial conducted across four pediatric nephrology centers in India. Children in CKD stages 2–4 with 25OHD levels <30 ng/ml will be randomized to one of three therapy regimens for oral cholecalciferol (3000 IU daily, 25,000 IU weekly, or 100,000 IU monthly) given for 3 months, allowing an equivalent cumulative cholecalciferol dose in all arms over this intensive replacement therapy phase. After 3 months, patients with 25OHD levels ≥30 ng/ml will continue on maintenance therapy, administered at 1000 IU cholecalciferol orally daily for 9 months. Outcomes include the median change in the level of 25OHD from baseline to the end of intensive phase; proportions of children in each limb that attain and maintain normal 25OHD levels after intensive replacement and maintenance treatment; the change in levels of bone biomarkers and the incidence of adverse effects with each therapy regimes. Conclusion: The study design of a multicenter randomized controlled trial in children with CKD is described. Trial Registration: Clinical Trials Registry of India; www.ctri.nic.in; CTRI/2015/11/010180.

Long-term outcome of childhood steroid-sensitive nephrotic syndrome Nada Kalakattawi, Halimah Alghamdi, Najlaa Alotaibi, Khalid A Alhasan, Jameela A Kari Asian Journal of Pediatric Nephrology 2018 1(2):74-77 Background: The long-term outcome of childhood steroid-sensitive nephrotic syndrome (SSNS) needs further evaluation. In this study, In this study, we report the long-term outcome of childhood SSNS at our center. Patients and Methods: This is a retrospective review of cohort of children with SSNS followed by cross-sectional follow-up evaluation. We included all children aged ≥16 years with a history of childhood SSNS. Of 45 children diagnosed with SSNS and contacted for follow-up, only 9 children were available for evaluation of long-term outcome. Demographic, socioeconomic, and disease history data were collected through a questionnaire. All the patients were examined and had their urine and blood samples collected for investigations. The data were analyzed using SPSS. Results: The mean age at onset for the 45 children was 7.3 ± 3.9 years. Follow-up revealed that 65.1% had frequent relapsing or steroid-dependent nephrotic syndrome and 34.9% had infrequent relapses. Of nine patients were included in the follow-up study for a median (range) duration of 11 (5–18) years, 2 of the patients were relapsing at the time of the study and two had one or more relapses during the previous year. Estimated glomerular filtration rate (eGFR) declined in two children and the mean eGFR for the whole group was lower at the time of last follow-up than at baseline (P = 0.032). Conclusion: Children with SSNS need careful long-term monitoring of disease activity and kidney function. A larger prospective study is required.

Eculizumab as treatment in dense deposit disease in children Saeed M Alzabli, Abdulkarim Al Anazi, Hassan Y Faqeehi, Muhammad Amin Ur Rahman, Mohamed E Suliman, Khawla A Rahim Asian Journal of Pediatric Nephrology 2018 1(2):78-83 Background: Dense deposit disease (DDD), a subtype of C3 glomerulopathy, is a rare disease that occurs secondary to hyperactivity of the alternative complement pathway. Renal biopsy typically reveals electron-dense deposits in the glomerular basement membrane. However, treatment options are limited. Till date, to the best of our knowledge, no evidence exists for specific treatment influencing the disease course. Eculizumab, a monoclonal antibody, has been reported to prevent membrane attack complex formation by binding to C5 and leads to improvement in clinical findings. However, the number of reported cases in which eculizumab was administered, particularly in children, is limited. Subjects and Methods: In this report, we present our experience with three pediatric cases of DDD receiving eculizumab treatment. All three patients were diagnosed with DDD on kidney biopsy. All patients showed acute kidney injury, high blood pressure, proteinuria >1 g/day, and decreased C3 levels. Immunosuppressive therapy, which included high-dose methylprednisolone, prednisolone, mycophenolate mofetil, or plasma exchange (in the third patient), as well as antihypertensive drugs, was administered to all the patients. Eculizumab treatment was initiated early in two patients but was initiated later in the third patient, who underwent dialysis initially. Results: The two patients with early initiation of eculizumab treatment showed significant improvement of proteinuria and renal function within weeks of treatment. C3 levels were normalized in one patient but remained decreased in the other. The third patient showed no response. She ultimately progressed to end-stage renal disease and eventually needed maintenance dialysis. Conclusions: Early initiation of eculizumab was associated with decreased proteinuria and improved renal function in two patients. These findings were in agreement with previous reports on the beneficial effects of eculizumab in DDD patients.

Nephrogenic systemic fibrosis: A rare complication following exposure to gadolinium-based contrast media Habib Qaiser, Vina Tresa, Sabeeta Khatri, Irshad Bajeer Ali, Ali Lanewala, Seema Hashmi Asian Journal of Pediatric Nephrology 2018 1(2):84-86 Nephrogenic systemic fibrosis (NSF) is a rare complication following exposure to gadolinium-based contrast media. Gadolinium-based contrast agents (GBCAs) are widely used for imaging throughout the world. NSF, formerly known as nephrogenic fibrosing dermopathy, is a rare progressive fibrosing disorder associated with administration of GBCA in patients with severely compromised renal functions. The condition is well reported in adults, but pediatric cases are rarely reported. Out of 1280 cases in the literature of NSF associated with GBCA, only 12 were found in the pediatric age group. We are reporting a pediatric case of a 7-year-old child with chronic kidney disease Stage VD, who developed NSF following magnetic resonance imaging.

Metanephric adenofibroma in a child with impaired renal function Juliana Mancera, Daniella Chacón, Juan Pablo Luengas Asian Journal of Pediatric Nephrology 2018 1(2):87-89 A 5-year-old girl presented with a history of bilateral reflux nephropathy and a left kidney mass, suspicious of Wilms tumor on imaging studies. She underwent radical nephrectomy according to the National Wilms Tumor Study protocol. The pathology report was consistent with metanephric adenofibroma (MAF), for which radical nephrectomy was considered curative. MAF is a benign, uncommon tumor, which is frequently confused with Wilms tumor on diagnostic imaging; histopathologic studies reveal the diagnosis. The diagnostic and management approach to MAF is discussed.

Hypertension with metabolic alkalosis Aakanksha Sharma, Priyanka Khandelwal, Aditi Sinha, Sanjeev Kumar, Pankaj Hari, Arvind Bagga Asian Journal of Pediatric Nephrology 2018 1(2):90-92 Severe hypertension in children is chiefly renal parenchymal or renovascular in origin. Renovascular hypertension is usually symptomatic and rarely presents with renal tubular dysfunction. We describe a 2-year-old child with polyuria, failure to thrive, hyponatremia, hypokalemia, metabolic alkalosis, hypercalciuria, low molecular weight proteinuria, and medullary nephrocalcinosis. Evaluation revealed severe hypertension and discrepant renal sizes. Doppler ultrasonography and digital subtraction angiography showed right main renal artery stenosis. Hypertension and electrolyte abnormalities abated following percutaneous angioplasty. Unilateral renal artery stenosis may manifest with symptoms of renal tubular dysfunction alone. Hypokalemia and metabolic alkalosis must prompt consideration of renovascular hypertension and monogenic causes. Angiography is essential for confirmation of renovascular hypertension and enables angioplasty, the mainstay of management.

BLDE University Journal of Health Sciences,BLDE (Deemed to be University), formerly BLDE university, is a Single Faculty (Medical Science) institution with Shri B. M. Patil Medical College, Hospital & Research Centre as its constituent college (Est. 1986). The Government of India conferred deemed to be university status onto the institute u/s3 of UGC Act 1956 vide MHRD notification no. F.9-37/2007-U3(A) dated 29-02-2008.

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Moving toward competency-based medical education Tejaswini Vallabha BLDE University Journal of Health Sciences 2018 3(2):67-68

Health analytics and disease modeling for better understanding of healthcare-associated infections Martin Lopez-Garcia, Meghana Aruru, Saumyadipta Pyne BLDE University Journal of Health Sciences 2018 3(2):69-74 Healthcare-associated infections (HAIs) are a growing challenge and a major cause of health concern worldwide. It is difficult to understand precisely the dynamics of spread of hospital-acquired infections owing to the usual involvement of different populations, risk factors, environments, and pathogens. Mathematical and computational models have proved to be useful tools in providing realistic representations of HAI dynamics and the means of evaluating interventions to minimize the risk of HAIs.

An evidence-based review on quackery in dentistry Shail Kumari, Sunil Kumar Mishra, Pankaj Mishra BLDE University Journal of Health Sciences 2018 3(2):75-78 BACKGROUND: Uncustomary medicine has been known since ancient period and is very commonly practiced by many individuals. Due to traditions and religious beliefs, these different unconventional practices were followed in the form of quackery. PURPOSE: This review is done to focus the quack practices done in dentistry affecting the oral health of the individuals and what measures to be taken to totally eradicate it from the society. MATERIALS AND METHODS: In April 2018, an electronic data search was done to find the published literature in PubMed, Medline, and EBSCOhost database. The search was focused on reports on quack practices in dentistry, reason behind such practices and their effects on oral health of the individuals. The titles and abstracts obtained in relation to focused questions were screened. Handsearching of other printed articles was also performed. The articles published in only English language were considered for the study. RESULTS: The initial search resulted in 102 papers. The abstracts of the articles related to the focus question were independently screened by the reviewers. Eighty-seven articles were excluded for not being related to topic or not in English or whose abstract is not available. Handsearching of literature resulted in one additional paper. A total of 16 articles were included in the review, of which five articles reported dental treatment of subjects poorly treated with quacks and one article is on patient's perception toward dental quacks. CONCLUSION: Quackery in dental field is growing fast in cities and villages and it is going to be a major challenge to populations due to unsterilized instruments being used. This gives unethical practices, giving invitation to certain major health hazards in the form of AIDS and hepatitis to individuals. It is the major responsibility of the government organizations and dental councils to interfere in the current scenario, so that quack practices in dental field can be eliminated from its roots, and to provide good oral treatment and education to the population who are in real need of it.

Clinical and laboratory profile of diabetic ketoacidosis in elderly with type 2 diabetes mellitus B Anupama, P Chandrasekhara, MS Krishnamurthy, Mohsin Aslam BLDE University Journal of Health Sciences 2018 3(2):79-84 INTRODUCTION: Diabetic ketoacidosis (DKA) in elderly is rare and poses a special problem because of high degree of mortality, comorbidity, age-related impairment of functional ability, and increased chances of hypoglycemia. OBJECTIVES: The main objective is to study the precipitating factors, clinical and laboratory profile of DKA in elderly. MATERIALS AND METHODS: A total of 100 type 2 diabetes mellitus (T2DM) patients, ≥60 years, admitted in a rural tertiary medical center were included in this study. RESULTS: Most of them had prolonged diabetes with mean duration of 7.3 ± 4.6 years. 24 patients were newly detected diabetes mellitus. Systemic infections seen in 67 patients (respiratory –32.8%, sepsis – 28.4%, acute gastroenteritis – 22.4%, and urinary tract infections– 16.4%), were the main precipitating factors, followed by noncompliance to drugs (34). Osmotic symptoms were reported by most (62) followed by pain abdomen (56). Dehydration was seen in 72 patients, whereas altered sensorium in 48. Blood glucose at presentation (493.12 ± 72.38 mg/dl) and HbA1c levels (9.63 ± 0.94%) were found to be elevated with lowered arterial pH (7.14 ± 0.07) and bicarbonate (13.7 ± 4.2 mEq/L). 22 had severe acidosis and 10 had mild acidosis. There was no mortality in the present series. CONCLUSION: DKA is more common in T2DM than anticipated. The most common precipitating factor is infection followed by noncompliance even in elderly. Majority had poor glycemic control. All elderly diabetic patients with high serum glucose level must be investigated for ketosis as the symptoms of DKA are minimal and morbidity and mortality are high in these patients.

Effects of static stretching in comparison with Kaltenborn mobilization technique in nonspecific neck pain Faria Riaz, Rizwan Haider, Muhammad Mustafa Qamar, Ayesha Basharat, Anum Manzoor, Akhtar Rasul, Azhar Ayyoub, Waqas Ahmad BLDE University Journal of Health Sciences 2018 3(2):85-88 BACKGROUND: Neck pain is a common medical problem resulting from any diseases or biomechanical disturbances. In mechanical/nonspecific neck pain, muscles become tighten, leading to restricted neck mobility. The study purposed to determine the efficacy of Kaltenborn mobilization technique and static stretching in pain and regain of a normal cervical range of motion (ROM) in patients with nonspecific/mechanical neck pain. MATERIALS AND METHODS: Forty-four patients suffering from non specific neck pain were randomly divided into two groups. Group A, in which participants received static stretching (n = 22) and Group B, in which participants received Kaltenborn mobilization technique (n = 22). Pain intensity was measured by numeric rating pain scale and active ROM (AROM) by neck disability index at baseline and poststudy. RESULTS: At baseline, there was no difference in pain intensity and ROM in both groups. At poststudy, a significant improvement was found in both groups in improving ROM and pain. However, no intervention was superior. CONCLUSION: Both the Kaltenborn mobilization technique and static stretching are effective in reducing nonspecific neck pain and increasing cervical AROM.

Medical ethics in a resource-constrained context: A cross-sectional study of awareness, attitude, practice, violations of its principles, and ethical dilemmas experienced by medical professionals in Abia State, Nigeria Gabriel Uche Pascal Iloh, Prince Ezenwa Ndubueze Onyemachi, Miracle Erinma Chukwuonye, Chukwuneke Valentine Ifedigbo BLDE University Journal of Health Sciences 2018 3(2):89-96 BACKGROUND: Ethics of medical care are global health concerns. It is universally acknowledged that medical practice should be guided by ethical principles which serve as yardsticks for regulation of professional conduct and discipline. AIM: The study was aimed at describing the awareness, attitude, practice, violations of ethical principles, and ethical dilemmas experienced by medical professionals in Abia State, Nigeria. MATERIALS AND METHODS: A descriptive study was carried out on a cross-section of 210 medical practitioners in Abia State, Nigeria. Data were collected using pretested, self-administered questionnaire that elicited information on awareness, attitude, practice, violations of ethical principles, and ethical dilemmas. Attitude and practice of principles of medical ethic (ME) were assessed in the previous 1 year. Violations and ethical dilemmas were assessed over lifetime practice as a medical doctor. RESULTS: The age of the participants ranged from 26 to 77 years. There were 173 (82.4%) males and 37 (17.6%) females. The participants were most commonly aware of principles of autonomy (100%) and nonmaleficence (100%), while the least was justice (91.9%). The positive attitude to principles of ME was predominantly oriented toward autonomy (92.4%) and the least was justice (76.2%). The most adequately practiced principle was autonomy (78.1%) and the least was justice (71.4%). The most violated ethical principle was autonomy while the most common ethical dilemma was issues related to rights of patients. The attitude (P = 0.042) and practice (P = 0.034) of principle of autonomy were significantly associated with >10 years of medical practice. CONCLUSION: Awareness of principles of ME was very high but did not translate to appropriate positive attitude and adequate practice orientations. The most violated principle was patients' autonomy and most common ethical dilemma was issues related to the rights of the patients.

Space travel in a high-altitude environment: One more step in human BioSpaceForming Gustavo Rafael Zubieta-Calleja, Natalia Mariela Zubieta-DeUrioste BLDE University Journal of Health Sciences 2018 3(2):97-103 BACKGROUND: Currently, space programs use sea-level pressures (760 mmHg) and normoxia (21% oxygen fraction) in space capsules. When astronauts need to go for a spacewalk, the pressure has to be reduced to 1/3 that of sea level (240 mmHg). This implies that in order to avoid decompression sickness (DCS) and acute mountain sickness (AMS), complex and time-consuming procedures need to be carried out. Furthermore, space suits have to sustain such pressure and protect them from radiation. A cooling vest is also used in order to keep the body temperature within normal values. This makes the space suits very voluminous and hence with rigid structures in order to sustain the pressure in space. Astronauts suffer, among many other complex microgravity alterations, anemia, that upon return to sea level, has to be correspondingly normalized to preflight levels. The reason that anemia presents is in part due to a lower requirement of oxygen by orthostatic muscles in microgravity. Exercise in space, reduces bone and muscle wasting. Over 200 million high-altitude residents live above 2000 m (6560 ft) of altitude and have adapted perfectly to life in the mountains. They live their life as if they were at sea level. They reproduce and practice sports, all this with a higher hematocrit. They even have proved extended longevity. METHODS: The knowledge acquired during 47 years of medical practice at high altitude, is applied to a proposal for a most efficient capsule environment for the human exploration of space. RESULTS: A cabin pressure similar to the city of La Paz, Bolivia (495 mmHg), that is, 2/3 that of sea level (760 mmHg) would not only maintain the hematocrit for reentry, but furthermore, could significantly accelerate the preparation for extravehicular activity that currently takes up several hours. High-altitude residents can tolerate lower levels of oxygen (hypoxia) providing them with an advantage of survival in oxygen poor environments. We likewise propose that a lower pressure (149 mmHg) be used in space suits, making them more flexible and thereby reducing the risks of DCS and AMS. This implies only 346 mmHg in pressure difference, from space capsule to space suit, as compared to 520 mmHg in the current methodology. CONCLUSIONS: The laws of physics in relation to pressure changes cannot be broken. However, human biology with adaptation to lower pressures and lower levels of oxygen and carbon dioxide, which is the case of high-altitude residents, can reduce the pressure gap significantly. Thereby, biology breaks the limitations of the laws of physics. Space travel will always have hypoxia as a fundamental threat, hence a hypobaric, normoxic space capsule environment results beneficial, practical, and one more step in “BioSpaceFormin” of human beings.

Awareness and utilization of postpartum intrauterine contraceptive device among postnatal women in Vijayapur Anita Nath, Archana Kulkarni, Shubhashree Venkatesh, Mohan Kumar BLDE University Journal of Health Sciences 2018 3(2):104-107 BACKGROUND: A fair proportion of women face an unmet need for family planning during the 1st year following childbirth. The postpartum period is an optimal time for effective contraception as the new mother is more receptive to accept family planning. OBJECTIVE: The objective of this study is to determine the awareness and utilization of postpartum intrauterine contraceptive device (PPIUCD) among postnatal women belonging to Vijayapur district in Northern Karnataka. MATERIALS AND METHODS: This was a cross-sectional study conducted over the duration of 1 month among postnatal women admitted at Vijayapur district hospital. RESULTS: Only 20% of the women were aware, 6% had accepted, and 17% were willing to accept. Most of the acceptors were younger in age, better educated, and primipara and had delivered male baby, although there was no statistical significance. A significant number of acceptors were from urban areas and had undergone cesarean section. CONCLUSION: Awareness and acceptance of PPIUCD are extremely low. Concerted effort is needed to be boost the utilization rates of this effective and safe contraceptive during the postpartum period.

A quasi-experimental study to assess the effectiveness of music therapy on pain level among cancer patients admitted to regional cancer hospital Indira Gandhi Medical College, Shimla, Himachal Pradesh Navjeet Kaur, Jansi Kesava BLDE University Journal of Health Sciences 2018 3(2):108-110 INTRODUCTION: Cancer is an uncontrolled growth and spread of abnormal cells. About 53% of patients suffer pain in various stages of their illness. There are different nonpharmacological measures that are used widely for reducing pain. Music is believed to reduce pain and also the intake of analgesic. AIM: This study aims to find the effect of music therapy in reducing pain among cancer patients. SETTINGS AND DESIGN: A nonrandomized control group design study was conducted in Regional Cancer Hospital Indira Gandhi Medical College, Shimla, Himachal Pradesh. MATERIALS AND METHODS: A total of 50 individuals were selected based on inclusion criteria through nonprobability purposive sampling technique. They were divided into experimental and control groups nonrandomly. Background information was collected using structured interview schedule. The pain level was assessed by using a numerical pain rating scale. Indian classical instrumental music was administered for 20 min in the morning and evening for 3 consecutive days. RESULTS: Majority of the individuals (52%) were in the age group of 41–50 years, and higher proportions (84%) of individuals were females out of which 64% had cancer of cervix in experimental as well as control group. In the experimental group during the posttest, pain level was less than the pretest pain level which was statistically significant (F = 47.21, P < 0.001). However, in the control group, there was no change in pre- and post-test pain level (P = 0.177). CONCLUSIONS: The findings of the study showed that the pain level in the experimental group during the posttest was less than that in the pretest as compared to the control group which showed that music therapy was effective in reducing the pain level among cancer patients.

"Graph's disease" and students' anxieties in understanding physiology Hwee-Ming Cheng, See-Ziau Hoe BLDE University Journal of Health Sciences 2018 3(2):111-115 Graphs are visual summaries that explain the phenomenon in different disciplines. Students who approach physiology in rote-learning mode usually have more difficulty and anxieties to understand the graphical information. Graphs can be used in many ways to conceptualize much of physiology. The relationship between the X-axis and Y-axis variables can indicate a cause and effect scenario as in the hemoglobin-oxygen association/dissociation. Temporal, sequential events are illustrated with the X-axis as the time parameter and several changing parameters can be followed along the Y-axis in a dynamic way as in the Wigger's cardiac cycle diagram. Graphs can also provide a different perspective on the fluctuations between two parameters that is produced by a third physiologic event as seen in the ventricular volume-pressure loop. Hopefully, this article on physiological graphs will help students to relax and enjoy looking and thinking through the different line profiles in graphs they face in their “Physbook.”