The pancreatic duct and its arteriovenous relationship: an underutilized aid in the diagnosis and distinction of pancreatic adenocarcinoma from pancreatic intraepithelial neoplasia. A study of 126 pancreatectomy specimens

Pancreatic intraepithelial neoplasia (PanIN) may be difficult to differentiate from isolated glands of pancreatic adenocarcinoma. We studied the normal relationship between the pancreatic ducts and the pancreatic muscular blood vessels in 126 pancreata, 64 of which were removed for pancreatic adenocarcinoma and 62 for other diagnoses. We also examined the effects that atrophy and PanIN have on this relationship. In normal pancreatic parenchyma and in mild to moderate atrophy, blood vessels are guideposts of the interlobular space. The pancreatic acinar parenchyma ensheathes the pancreatic ductal system and separates it from the muscular pancreatic vasculature. Since these blood vessels do not accompany the pancreatic ducts, the presence of a well-differentiated duct-like structure, which may resemble PanIN, located adjacent to a pancreatic blood vessel should be a clue to the infiltrative and hence malignant nature of that gland. Ducts showing PanIN appear to resist atrophy. Since lobular outlines and vascular landmarks are ultimately lost in severe atrophy, they cannot be relied on to aid in the distinction between PanIN and invasive carcinoma. However, it is unusual to see PanIN1 in such severe atrophy (2%), and although the normal vascular landmarks are no longer there to aid in the interpretation, the presence of well-differentiated duct-like structures resembling PanIN1 in this background should be viewed with suspicion for well-differentiated adenocarcinoma.     

Effectiveness of generic fixed-dose combinations of highly active antiretroviral therapy for treatment of HIV infection in India

OBJECTIVE: To assess clinical and immunologic effectiveness and acute toxicity to nevirapine (NVP)-based fixed-dose combinations (FDCs) in antiretroviral-naive HIV-1-infected patients in India. DESIGN: Observational study of patients initiated on NVP-based combination therapy delivered as FDCs. METHODS: Antiretroviral-naive HIV-1-infected patients initiated on FDCs (zidovudine/lamivudine [3TC]/NVP or stavudine/3TC/NVP) were assessed clinically and with CD4 counts periodically. Adverse events to NVP were assessed clinically and by laboratory markers. Frequency and risk factors for development of adverse events and clinical outcomes were determined. RESULTS: Of the 1291 patients started on therapy, 1253 completed a minimum of 3 months of follow-up. Rash and hepatitis were documented in 6.6% (95% confidence interval [CI]: 5.5-8.3) and 3.2% (95% CI: 2.3-4.8) of patients initiating therapy, respectively. There was significant improvement in CD4 counts over 2 years. Fourty-eight patients died, and 186 clinical events were documented in these patients. Tuberculosis was the most common cause of morbidity and mortality. Self-reported adherence was high. CONCLUSION: Fixed-dose formulations of NVP-based combination therapy are safe and produced durable clinical and immunologic benefit.     

Nepal mental health country profile

The Kingdom of Nepal is situated in the heart of Asia, between its two big neighbours China and India. Nepal is home to several ethnic groups. The majority of the 23 million population reside in the countryside. Although figures on many of the health and socio-economic indicators are non-existing, some existing ones show gradual improvement over the years. However the figures for illiteracy and infant mortality are still one of the highest in the world. As per GDP, and population living below the poverty line and per capita income, Nepal still remains one of the poorest countries in the world. Despite this, it provides shelter to thousands of Bhutanese refugees in its land. Frequent natural disasters and recent violent conflicts in Nepal have further added hardship to life. Less than 3% of the national budget is allocated to the health sector. Mental health receives insignificant attention. The Government spends about 1% of the health budget on mental health. There is no mental health act and the National Mental Health Policy formulated in 1997 is yet to be fully operational. Mental ill health is not much talked about because of the stigma attached. The roles of the legal and insurance systems are almost negligible. The financial burden rests upon the family. The traditional/religious healing methods still remain actively practiced, specifically in the field of mental health. The service, comprising little more than two-dozen psychiatrists along with a few psychiatric nurses and clinical psychologists (mainly practicing in modern health care facilities) has started showing its impact--however this is limited to specific urban areas. The majority of the modern health care facilities across the country are devoid of a mental health facility. The main contextual challenges for mental health in Nepal are the provision of adequate manpower, spreading the services across the country, increasing public awareness and formulating and implementing an adequate policy.     

Creating healthy communities,healthy homes,healthy people: initiating a research agenda on the built environment and public health

Mounting evidence suggests physical and mental health problems relate to the built environment, including human-modified places such as homes, schools, workplaces, parks, industrial areas, farms, roads and highways. The public health relevance of the built environment requires examination. Preliminary research demonstrates the health benefits of sustainable communities. However, the impact of mediating and moderating factors within the built environment on health must be explored further. Given the complexity of the built environment, understanding its influence on human health requires a community-based, multilevel, interdisciplinary research approach. The authors offer recommendations, based upon a recent conference sponsored by the National Institute of Environmental Health Sciences (NIEHS), for research and policy approaches, and suggest interagency research alliances for greater public health impact.     

A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit

Emergence agitation (EA) is a postanesthetic problem that interferes with a child's recovery and presents a challenge in terms of assessment and management. In this prospective cohort study, we sought to determine the incidence of EA, evaluate factors associated with and predictive of EA, and describe associated outcomes in healthy children. Children aged 3-7 yr who were undergoing general anesthesia for elective outpatient procedures were included. All perioperative care was documented, and postoperative behaviors in the postanesthesia care unit were recorded. Parents completed the Behavioral Style Questionnaire for 3- to 7-yr-olds. Five-hundred-twenty-one children were studied, of whom 96 (18%) had EA. Agitation lasted up to 45 min in some cases (range, 3-45 min; mean, 14 +/- 11 min), required pharmacologic intervention in 52% of children, and was associated with a prolonged postanesthesia care unit stay (117 +/- 66 min versus 101 +/- 61 min for nonagitated children; P = 0.02). Ten factors were found to be associated with EA, including age, previous surgery, adaptability, ophthalmology and otorhinolaryngology procedures, sevoflurane, isoflurane, sevoflurane/isoflurane, analgesics, and time to awakening. Of these, otorhinolaryngology procedures, time to awakening, and isoflurane were shown to be independent risk factors. IMPLICATIONS: Children may become agitated after general anesthesia. This study describes several factors that may increase the risk for agitation. These data are important in planning anesthesia care for young children.     

Prevention of caries by pulsed CO2 laser pre-treatment of enamel: an in-vitro study

The aim of the study was to assess the caries inhibitory potential of carbon dioxide laser and explore the effect of the number of pulses used to correlate caries inhibition. Caries free human mandibular molars were irradiated with carbon-dioxide laser of wavelength 10.6 microm at 5, 15, 25, 50 and 100 pulses. Simulated caries lesions were allowed to form by immersing the teeth in artificial caries medium for three weeks. Thin sections of 75 microns were obtained by using hard tissue microtome. These sections were observed under polarizing microscope, caries lesions were identified and their depth was measured. These values were subjected to statistical analysis. The results showed that carbon-dioxide laser irradiation can inhibit caries like lesion upto 82.7% and it was optimal at 25 pulses.     

Increased respiratory symptoms following surgery in children exposed to environmental tobacco smoke

OBJECTIVE: The aim of this study was to determine if children exposed to environmental tobacco smoke (ETS) via parental smoking (ETS+) developed more respiratory symptoms resulting in longer recovery times following surgical outpatient procedures compared with children of nonsmoking parents (ETS-). METHODS: One hundred and forty six children (4.9 +/- 3 years) undergoing inguinal hernia repair were prospectively studied. Parental smoking behaviour was determined by survey and urine analysis. Seven respiratory symptoms were evaluated during induction and emergence from anaesthesia and during the recovery room (RR) stay. RESULTS: Fifty-seven (39%) families admitted a smoking history while 89 (61%) denied it. This strongly correlated with the cotinine/creatinine ratio (Pearson correlation coefficient = 0.76; P = 0.01). ETS exposure was associated with an increased frequency of RR symptoms (ETS+: 56%; ETS-: 31%; P = 0.007). CONCLUSIONS: In children undergoing general anaesthesia for inguinal hernia repair, ETS exposure was associated with an increased frequency of respiratory symptoms during emergence from anaesthesia and during postoperative recovery.     

Endocapsular cellulomonas as a cause of persistent postoperative endophthalmitis

Sequestration of bacteria within the capsular fornices after cataract extraction with intraocular lens implantation can cause both acute and chronic inflammation. A case of persistent postoperative endophthalmitis caused by capsular sequestration of Cellulomonas is described. The patient underwent uncomplicated cataract extraction with intraocular lens implantation and subsequently developed acute postoperative endophthalmitis. Inflammation persisted despite several vitreous taps and the injection of intravitreal antibiotics. Definitive treatment required pars plana vitrectomy, intraocular lens explantation, capsular bag removal, and intravitreal and parenteral antibiotics. In patients with postoperative endophthalmitis, one must consider atypical organisms as the source and should consider explantation of the intraocular lens with capsular bag removal.     

Spontaneous bacterial peritonitis (SBP) in cirrhotic ascites: A prospective study in a tertiary care hospital, Nepal.

Background: Spontaneous bacterial peritonitis (SBP) is one of the potentially lethal complications of cirrhosis and is defined as infected ascites in the absence of any recognizable secondary cause of infection. Objective was to study the occurrence of SBP, clinical and laboratory characteristics and the response to antibiotics. Methods: We had prospectively evaluated 81 cirrhotic patients with ascites during one-year period. All SBP patients were treated with cefotaxime, 2gm IV, every 12h for 5days. Results: Of these 81 patients, 24.67% of patients (n=20) had SBP and its variants (classical SBP n= 4, CNNA n=13 and bacterascites n=3). There were thirteen males and 7 females in the study.85% of the cases had Child;s class C cirrhosis. UGI bleeding and abdominal pain were the most common presenting symptoms of SBP. Culture positives were 35% (n=7). The most frequent organisms were Escherichia coli (n=3) and Streptococcus pneumoniae (n=2). 94% of the patients responded to therapy after 48 hours of treatment. Total resolution after 5 days of therapy was 73% and in-hospital mortality was 15% (n=3). Conclusion: SBP, if diagnosed early can be treated with very good success rate up to 73%. Appropriate treatment of SBP with cefotaxime can help in reducing mortality and morbidity in patients with chronic liver disease. Key words: SBP, CNNA, Cirrhotic patients and Cefotaxime.     

Genetic diversity of noroviruses and sapoviruses in children with acute sporadic gastroenteritis in New Delhi, India

BACKGROUND: Human caliciviruses (HuCVs) cause gastroenteritis throughout the world. Limited information is available on molecular epidemiology of caliciviruses from developing countries including India. OBJECTIVES: Standardization and evaluation of a two-step multiplex RT-PCR assay for HuCVs and characterization of strains. STUDY DESIGN: Two hundred and twenty-six stool samples were collected from children with acute gastroenteritis (AGE) over a one and half year to study the prevalence and diversity of HuCVs in children with AGE in New Delhi, India. A multiplex two-step RT-PCR using 3 sets of external and 4 sets of internal primers from the RdRp gene was standardized for detection of NoVs and SaVs. Molecular characterization of some HuCV strains was done by sequencing followed by phylogenetic analysis. RESULTS: Fifty-nine HuCVs strains were detected in 54 (24%) of the samples; 5 samples had mixed infections. Of these 59 HuCVs, 36 (61%) were norovirus (34 were GGII; 2 were GGI) and 23 (39%) were sapovirus (22 were GGI; 1 was GGII). Phylogenetic analysis of partial RdRp gene of 12 HuCV strains identified three genotypes (GGI/4, GGII/3 and a newly identified GIIb/Hilversum cluster) in NoVs and one genotype (GGI/1) in SaVs. CONCLUSION: This is one of the few reports from India on detection and characterization of HuCVs by multiplex RT-PCR assay. This assay can be a useful tool for epidemiological studies of HuCV infections.