Indian Summer

This story is about my experience with the Oglala Lakota (Sioux) on the Pine Ridge Indian Reservation in South Dakota. For 6 weeks, as part of my last elective in the Community Health Intercultural Nursing Program at the University of Maryland, I made home visits with a Community Health Representative (CHR). Dianne Iron Bird, the CHR with whom I traveled, and a woman who was close to my age and stage of life, was largely responsible for my view of the reservation and for the level of acceptance I had in people's homes. My experience was rich and rewarding. It afforded me the opportunity to participate in a different kind of health care. I used this exercise in story-telling to test my knowledge and understanding of the Lakota's world view. By definition, it is my view of both my world and theirs. Using literal rather than abstract language helped me to see both worlds from a new perspective.     

Multidetector computed tomography imaging of congenital anomalies of major airways: A pictorial essay

Congenital airway anomalies can be asymptomatic or may cause severe respiratory distress requiring immediate treatment.These anomalies can present early in life,or may be just incidental findings.It is important to recognize these entities to realize their clinical significance and to avoid false diagnosis.In this article, the various congenital airway anomalies and their imaging features by multidetector computed tomography (MDCT)are reviewed in order of occurrence during the embryological timeline.This pictorial essay reviews the various distinct congenital airway lesions and their MDCT manifestations.It also provides insight into the embryological basis of the congenital airway lesions encountered.     

CT patterns of nodal disease in pediatric chest tuberculosis

AIM:To highlight various patterns of nodal involvement and post treatment changes in pediatric chest tuberculosis based on contrast enhanced computed tomography(CECT) scans of chest.METHODS:This was a retrospective study consisting of 91 patients aged less than 17 years,who attended Paediatrics OPD of All India Institute of Medical Sciences with clinically diagnosed tuberculosis or with chest radiographs suggestive of chest tuberculosis.These patients had an initial chest radiograph as well as CECT of the chest and follow up imaging after 6 mo,and in some cases 9 mo,of completion of anti-tubercular treatment(ATT).CECT of these patients was reviewed for the location and extent of nodal involvement along with determination of site,size,enhancement pattern and calcification.RESULTS:Enlargement of mediastinal or hilar lymph nodes was found in 88/91 patients(96.7%),with the most common locations being paratracheal(84.1%),and subcarinal(76.1%).The most common pattern of enhancement was found to be inhomogenous.The nodes were conglomerate in 56.8% and discrete in 43.2%.In addition,perinodal fat was obscured in 84.1% of patients.In the post-treatment scan,there was 87.4% reduction in the size of the nodes.All nodes post-treatment were discrete and homogenous with perinodal fat present.Calcification was found both pre-and post-treatment,but there was an increase in incidence after treatment(41.7%).There was hence a reduction in size,change in enhancement pattern,and appearance of perinodal fat with treatment.CONCLUSION:Tubercular nodes have varied appearance and enhancement pattern.Conglomeration and obscuration of perinodal fat suggest activity.In residual nodes decision to continue ATT requires clinical correlation.     

Pattern of bone mineral density in patients with sporadic idiopathic hypoparathyroidism

OBJECTIVE: Measurement of bone mineral density (BMD) in patients with hypoparathyroidism directly addresses the effect of chronic under-exposure of bone to PTH. Because post-thyroidectomy hypoparathyroidism is potentially complicated by the pre-existence of thyrotoxicosis and the need for postoperative thyroxine replacement, we have studied a large group of patients with sporadic hypoparathyroidism who have been followed up in our endocrine clinic. Studies conducted in limited number of patients with sporadic idiopathic hypoparathyroidism (SIH) have suggested an increase in BMD in such patients. In this current study, we have measured BMD in a large cohort of patients with SIH and have assessed the relationship of BMD with duration of disease and with the adequacy of treatment, as indicated by follow-up serum calcium, phosphate and alkaline phosphatase levels. DESIGN: Case control study and intra-group comparison. SUBJECTS: Forty-seven patients (M : F ratio 23 : 24) with SIH who had been reviewed during 2003-2004 in our endocrine clinic were recruited for this study. Their mean age (+/- SD) was 34.6 +/- 13.6 years and the duration from the time of initial diagnosis was 9.6 +/- 8.5 years. Forty-eight match healthy volunteers were recruited from hospital staff and from normocalcaemic relatives. METHODS: Bone mineral density was measured at total lumbar spine (L1-L4), hip and forearm by dual energy X-ray absorptiometry (DXA). The relationship of BMD was analysed with duration of disease symptoms (group I, < or = 1 year, group II, > 1 and < 5 years and group III, > or = 5 years) and mean serum total calcium observed during follow-up (group A, calcium < or = 1.79 mmol/l and group B, > or = 1.80 mmol/l). RESULTS: Patients with SIH showed significantly higher BMD at total lumbar spine and hip when compared to controls (1.098 +/- 0.187 vs. 0.936 +/- 0.131 g/cm2 and 0.967 +/- 0.141 vs. 0.882 +/- 0.149 g/cm2, P < 0.001 for both). BMD in the forearm was not significantly different in patients and controls. The age- and BMI-adjusted lumbar spine BMD showed correlation with duration of disease (r = 0.348 and P = 0.019). Patients with longer duration of hypoparathyroidism had higher BMD at lumbar spine (group I vs. group III, 0.951 +/- 0.132 vs. 1.156 +/- 0.180 g/cm2, P < 0.05). There was no significant correlation between BMD values in patients with SIH and their mean serum total calcium levels during the period of follow-up (r = 0.192, P = 0.206). Neither was the mean BMD significantly different between group A and B. Serum total alkaline phosphatase showed a significant negative correlation with BMD at lumbar spine (r = -0.445, P = 0.012). CONCLUSIONS: Patients with sporadic idiopathic hypoparathyroidism have increased mean BMD in the lumbar spine and hip but not in the forearm, compared to normal matched healthy controls. The increase in BMD is related to the duration of the disease rather than the serum calcium levels.     

Formulation optimization of hydrodynamically balanced oral controlled release bioadhesive tablets of tramadol hydrochloride

The directly compressible floating-bioadhesive tablets of tramadol were formulated using varying amounts Carbopol 971P (CP) and hydroxy-propylmethyl cellulose (HPMC), along with other requisite excipients. In vitro drug release profile, floatational characteristics and ex vivo bioadhesive strength using texture analyzer were determined, and systematically optimized using a 3² central composite design (CCD). The studies indicated successful formulation of gastroretentive compressed matrices with excellent controlled release, mucoadhesion and hydrodynamic balance. Comparison of the dissolution profiles of the optimized formulation, with optimal composition of CP:HPMC :: 80.0:125.0, with that of the marketed controlled release formulation other indicated analogy of drug release performance with each other. Validation of optimization study using eight confirmatory experimental runs indicated very high degree of prognostic ability of CCD with mean ± SEM of −0.06% ± 0.37. Further, the study successfully unravels the effect of the polymers on the selected response variables.     

Lessons from developing and running a clinical database for colorectal cancer

BACKGROUND: Recent policy developments in the UK require the routine monitoring of the performance of cancer services. Developing and using clinical databases is one approach to meet this objective, but to date their implementation has been challenging. OBJECTIVE: To describe the development of the Thames Cancer Registry clinical database for colorectal cancer, and to present the lessons learnt in the first five years since its establishment. METHODS: Planning of this clinical database began in 1998. Detailed variables for the data set were derived by analysis of national standards and guidelines. Structured pro formas were designed to abstract data from clinical notes. A pilot study over 12 months collected 400 cases from seven hospital trusts in one cancer network. Data collection over the wider North Thames area began in 1999. RESULTS: The number of new records entered each year into the database rose from 747 in 1999 to 1107 in 2002. By 2004, it held a total of 8500. However, participation and completeness of data collection varied between trusts. Currently only 18 of 26 trusts in the area submit data and only 12 have done so every year. Overall completeness for key demographic and treatment variables has been between 80 and 100% but less so for more detailed diagnostic and treatment variables (40-60%). Barriers to implementation in trusts could be grouped as organizational, professional and data-related. Organizational barriers have included changes in the cancer networks, variability in trust commitment to different data sets and lack of personnel to enter data consistently. Professional barriers have included competing priorities and varying commitments within the multidisciplinary clinical teams. Data-related barriers include the wide range of database formats that are used in trusts, and a tendency for data to be collected at the end of the year rather than continuously. CONCLUSIONS: Creating and maintaining a clinical database is a time-consuming and complex undertaking. Completeness of ascertainment and quality are major issues of concern. Key lessons from this project have been that the commitment of clinicians and the ability of trusts to provide consistent support for data collection are crucial.     

Design,development, physicochemical,in vitro and in vivo evaluation of monolithic matrix type transdermal patches containing nitrendipine

The matrix type transdermal drug delivery systems (patches) of Nitrendipine were prepared by film casting technique. The patches were characterized for physical, in vitro release studies and ex-vivo permeation studies (human cadaver skin). On the basis of in vitro drug release and skin permeation performance, formulation B3 was found to be better than the other formulations and it was selected as the optimized formulation. The final optimized formulation (B3) was subjected to skin irritation, pharmacokinetic, pharmacodynamic and stability studies. The maximum percentage drug release in 48 hours was 94.67 ± 3.25 for B3 and 91.43 ± 2.106 for A2 formulation. Again formulation B3 (0.0627 mg/cm²/h) and A2 (0.0566 mg/cm²/h) showed maximum skin flux in the respective series. Patches prepared with Plasdone S-630 were more flexible as compared to PVP K 30 containing patches. Patches prepared with PVP K 30 showed drug release and skin permeation at higher percentage as compared to those containing Plasdone S-630. The interaction studies carried out by comparing the results of ultraviolet, infrared, TLC and DSC analyses for the pure drug, medicated and placebo formulations indicated no chemical interaction between the drug and excipients. The TDDS was found to be free of any skin irritation as suggested by skin irritation score of 1.16 (< 2.00) under Draize score test.