Background: Cytomorphological distinction between hepatocellular carcinoma and metastatic tumors to the liver may be difficult, especially when these have poor differentiation. The present study was done to assess the diagnostic utility of hepatocyte paraffin-1 (HepPar-1), CD10, and CD34 in differentiating hepatocellular carcinoma from metastatic carcinoma. Materials and Methods: Ultrasound-guided fine-needle aspiration was performed on 50 patients with space-occupying lesions of liver suspicious for malignancy on clinical/radiologic findings. The cytological assessment was done on smears stained with May–Grünwald–Giemsa and hematoxylin and eosin. Cell blocks were prepared, and immunostaining for HepPar-1, CD10, and CD34 was done. Results: In these 50 patients, hepatocellular carcinoma was diagnosed in 7 and metastatic tumors in 43 cases. The sensitivity of smears in diagnosing hepatocellular carcinoma was 100% and the specificity was 95.3%, while the sensitivity and specificity of cell block were 100%. A canalicular pattern of CD10 immunoreactivity had a 100% positive predictive value for diagnosing hepatocellular carcinoma. CD10 had a sensitivity of 57.1% and 41.9% in identification of HCC and metastatic tumors, respectively. For the diagnosis of hepatocellular carcinoma, the sensitivity of CD34 was 85.7% and the specificity of sinusoidal pattern of immunoreactivity was 100%. The sensitivity and specificity of granular cytoplasmic staining pattern of HepPar-1 were 100% in hepatocellular carcinoma. Conclusions: The staining patterns of HepPar-1, CD10, and CD34 are highly specific in distinguishing hepatocellular carcinoma from metastasis. These three immunomarkers should be included in the immunocytochemical panel for differentiating hepatocellular carcinoma from metastatic carcinoma to the liver.

Helicobacter pylori infection has been significantly linked to Peptic Ulcer Disease and Gastric Cancer. Metabolomic fingerprinting may offer a principal way of early diagnosis and to understand the molecular mechanism of H. pylori-induced pathogenicity. The rationale of the study is to explore the underlying distinct metabolic mechanisms of H. pylori-induced PUD and to identify potential biomarkers for disease diagnosis and associated risks using Gas chromatography/mass spectrometry. GC/MS-based analytical method was used to compare metabolic profiles of healthy controls (N = 20) and peptic ulcer patients (N = 45). Acquired metabolomic data were analyzed by constructing a diagnostic model using principal component analysis and a non-parametric two-tailed paired Wilcoxon analysis to identify disease-specific metabolic biomarkers. A total of 75 low-molecular-weight endogenous metabolites were detected during comparative metabolomic analysis of PUD vs. healthy gut tissues, among which 16 metabolites are being proposed to be diagnostic markers of Human PUD. Perturbations related to amino acids, carbohydrates, fatty acids, organic acids, and sterol metabolism were significantly revealed during this differential metabolomic profiling. Results convincingly suggest that metabolic profiles can contribute immensely in early diagnosis of the disease and understanding molecular mechanisms of disease progression for predicting novel drug targets for prophylactic and anaphylactic measures.

Helicobacter pylori is a major etiological agent responsible for several gastric diseases such as gastritis, peptic ulcer disease, and gastric cancer. From the last two decades, standard triple therapy is mostly recommended for H. pylori eradication; however, its efficacy is restricted by antibiotic resistance. Hence, the present study aimed at exploration for novel therapeutic agents being warranted to overcome antibiotic-associated limitations in the current H. pylori eradication regimens. H. pylori DSMZ 10242 was procured and maintained at standard conditions. Anti-microbial assays were performed (in triplicates) to determine the susceptibility of this gastric pathogen to the selected probiotic formulations (Darolac-Z, Pre-Pro, Sporlac, VSL#3, and Yakult) and commonly prescribed antibiotics. The study convincingly reports that Darolac-Z containing Lactobacillus rhamnosus and Saccharomyces boulardii possess stronger anti-H. pylori activity (24.17 mm in 20 h of incubation) in comparison to other probiotics and antibiotics (maximum inhibitory zone observed is 18.4 mm after 48 h of incubation in case of amoxicillin). The probiotic supplementation containing L. rhamnosus and S. boulardii has a synergistic effect on the inhibition of H. pylori growth due to competitive inhibition or production of certain compounds that may possess therapeutic potential as recorded in previous studies. Moreover, in the future, it might be quite interesting to study the role of metabolic by-products of these two strains in the treatment of H. pylori induced gastric disorders in-vivo.

BACKGROUND:Despite being the most commonly performed operations, sometimes cholecystectomy fails to relieve symptoms; this is now a well-recognised clinical entity termed 'post-cholecystectomy syndrome' (PCS). Very few studies from India deal with PCS, and the present study was carried out to find the incidence and risk factors for PCS in patients undergoing elective laparoscopic cholecystectomy (LC). MATERIALS AND METHODS:The records of 207 patients undergoing elective LC were prospectively maintained for 6 months after surgery. Persistence or appearance of new symptoms after surgery was documented and investigated only when they persisted beyond 30 days of surgery. RESULTS:There were 185 (89.4%) female patients and 22 (10.6%) male patients with a mean age of 44.4 years (age range: 12-79 years). Conversion to open cholecystectomy was done in 18 patients (8.69%), mainly due to adhesions and unclear anatomy. The incidence of symptoms was found to be 13% at 6 months follow-up, showing a reducing trend from 58% in the 1st week after LC; the most common symptom in symptomatic patients was dyspepsia (55.56%). On investigation, a cause for symptoms could be detected in only 0.97%. CONCLUSION:Symptoms are common after LC, but they settle over time. Very few patients have a detectable cause for symptoms after LC, and it is difficult to predict which patients will become symptomatic after LC; in the present series, previous attacks of cholecystitis and presence of co-morbid conditions were the only consistent risk factors for symptoms after LC.

To study the utility of glycated hemoglobin (HbA1c) in the diagnosis of diabetes in patients with cirrhosis as compared to the gold standard oral glucose tolerance test (OGTT) and to see the effect of anemia and severity of cirrhosis on its performance.

Background and Aims: Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are common conditions that affect millions of patients worldwide. NASH is commonly associated with increased liver related and all cause mortality. No effective treatment is yet available. In this study, the efficacy of saroglitazar, a novel PPARα/γ agonist, was assessed in the patients of NASH. Methods: An interventional study was conducted at the department of medicine at Government Medical College and Hospital Chandigarh. The study comprised of patients aged 18 to 75 yrs presenting in the Out-Patient Department with documented diagnosis of Non-alcoholic fatty liver disease (NAFLD) established either by imaging or liver biopsy showing Non alcoholic steato-hepatitis alongwith serum alanine aminotransferase levels (ALT) >1.5 times upper limit of normal. Patients with other causes of liver disease were excluded (alcohol consumption >3 units/d in males and >2 units/d in females:hepatitis B, C:known cirrhosis, score on fibroscan >7 KPa, TPN, starvation, use of drugs associated with NAFLD). The primary outcome was percentage change in baseline serum ALT levels after one month of receiving Saroglitazar 4 mg once daily after breakfast. Results: 20 patients received the drug for 1 month. 95%(19 out of 20) patients showed reduction in ALT levels. One patient was non compliant to the medication. A reduction of 17% to 61% from baseline was seen. In 5 patients (25%) ALT levels returned to normal. There was no reported incidence of hypoglycaemia. Conclusions: After a median follow up of one month the primary outcome occurred in 95% patients who received Saroglitazar. Based on the findings of the study it seems possible that Saroglitazar, a dual PPARα/γ agonist may improve serum ALT levels and can prevent adverse outcomes of other conditions associated with non alcoholic steato-hepatitis. The authors have none to declare.

We report the case of a 7-year-old unimmunized boy who presented with generalized anasarca for the first time, along with nephrotic-range proteinuria, hypoalbuminemia, microscopic hematuria and hypertension. Special investigations revealed ELISA test to be positive for hepatitis B surface antigen (HBsAg) and hepatitis B envelope antigen (HBeAg); hepatitis B viral DNA load (HBV DNA) level (real-time polymerase chain reaction) was 54 360 903 IU/ml. For hepatitis B virus (HBV)-related glomerulopathy, he was started on enalapril and lasilactone, and percutaneous renal biopsy was performed, which revealed membranous nephropathy (MN). A diagnosis of MN secondary to HBV infection contracted via horizontal transmission was made. The patient was started on peginterferon alfa-2b (50 μg/week) for 24 weeks. He failed to attain remission and seroconversion after interferon (IFN) therapy. Then, oral therapy with entecavir was started, and he attained remission as well as seroconversion after 3 months of therapy. He maintained his seroconversion status at his 6-month and the recent 12-month (quantitative HBV DNA level was 373 IU/ml) follow-up visit. Entecavir seems a promising drug for HBV-related glomerulopathy, especially in IFN-resistant cases.

OBJECTIVE:Till date, typical antipsychotic haloperidol is the treatment of choice for delirium. But, due to higher side effects with haloperidol, newer atypical antipsychotics (e.g., olanzapine) are increasingly being used in the treatment of delirious patients. The aim of the current research was to study the efficacy and tolerability of haloperidol and olanzapine in the treatment of delirium. MATERIALS AND METHODS:This was an open-label, randomized controlled study carried out in a tertiary care hospital at Chandigarh, India. A total of 100 patients admitted in medicine, surgery, and orthopedic wards and diagnosed as having delirium on Confusion Assessment Method scale were included in the study. Patients were given either haloperidol (1-4 mg/day either orally or by nasogastric tube) or olanzapine (2.5-10 mg/day either orally or by nasogastric tube). Severity of delirium and pattern of symptom improvement were assessed by Memorial Delirium Assessment Scale (MDAS). Extrapyramidal side effects were assessed by Simpson-Angus Scale. RESULTS:There was an improvement in delirium severity in both groups with treatment. Mean daily dose of haloperidol and olanzapine used per patient was 2.10 and 5.49 mg, respectively, and the mean duration of treatment in olanzapine group and haloperidol group was 3.57 days and 3.37 days, respectively. There was no significant difference in the mean duration of treatment in both groups. At the end of study period, the MDAS scores in olanzapine and haloperidol groups were 8.43 and 8.00, respectively, and the difference was not significant statistically with P = 0.765. Five patients experienced drug-related mild side effects. CONCLUSION:Low-dose haloperidol and olanzapine were equally efficacious and well tolerated in delirium.

Background & objectives: Multidrug-resistant Salmonellae have emerged worldwide as also in India. The aim of this study was to study the antimicrobial susceptibility pattern of Salmonella enterica serovars isolated at a tertiary care hospital in northern India. Methods: A total of 106 S. enterica serovars isolated from various clinical samples from January 2011 to June 2012 were tested for antimicrobial susceptibility by Kirby-Bauer disk diffusion method. The minimum inhibitory concentration (MIC) of ciprofloxacin, chloramphenicol and ceftriaxone was determined both by agar dilution method and E-test for all the isolates. Results: Salmonella Typhi (73.6%) was the predominant isolate followed by S. Paratyphi A (15.1%), S. Typhimurium (9.4%) and S. Enteritidis (1.9%). Of these, 34 (32.1%) were resistant to ciprofloxacin (MIC ≥1 μg/ml by agar dilution) with MIC90 of ciprofloxacin for S. Typhi, S. Paratyphi A and S. Typhimurium being 32, 4 and 1 μg/ml, respectively. All the isolates were sensitive to chloramphenicol (MIC ≤8 μg/ml) and ceftriaxone (MIC ≤1 μg/ml). Disk diffusion method showed high susceptibility rates to cefotaxime (100%), azithromycin (93.4%) and co-trimoxazole (97.2%). Nalidixic acid resistance was seen in 105 (99.1%) isolates. Of the nalidixic acid-resistant strains, only 34 (32.3%) were found to be resistant to ciprofloxacin (MIC ≥1 μg/ml). Interpretation & conclusions: This study showed an alarming increase in MIC to quinolones and re-emergence of susceptibility to conventional antibiotics among Salmonellae.

Objective: Published literature on the characteristics of prescribing medication to the Indian elderly is limited. This study aims to evaluate the prescription pattern among Indian elderly patients using WHO prescribing indicators. Methods: The prescriptions of 4005 outpatients aged sixty and above were evaluated prospectively using WHO prescribing indicators. Results: The average age of patients was 68.28±0.11 (±SEM) years. On an average, each patient had 2.01±0.01 diagnoses and was prescribed 6.45±0.04 drugs. The most common disorder which warranted a prescription was “diseases of circulatory system”. The patients were prescribed an average of 6.45±0.04 medications. Over half of the patients (57.9%) received more than five medications concurrently. Only 0.8% of the prescribed drugs had their generic names. Antibiotics were prescribed in 13% of the prescriptions, while 7.3% of patients were prescribed injections. Sixty six percent of the drugs prescribed were from National List of Essential Medicines 2003. Conclusions: The relatively small amount of prescription of antimicrobials and injections coupled with a higher number of prescriptions from essential drug list is a very positive reflection of rational prescribing among elderly outpatients. However, a high prevalence of polypharmacy, lower number of drugs prescribed by their generic name and from essential drug list indicated that prescribing need requires further refining. This study highlighted the fact that the number of co-morbidities increased with increasing age which resulted in increased number of medications prescribed. This, to the best of our knowledge, is the first set of published results on prescribing in a sample of 4005 Indian outpatients.

Antibiotic resistance has been an emerging concern for common bacterial infections worldwide.Helicobacter pylori, commonly associated with chronic bacterial infections, is also included in bacteria with drug resistant problems.Its infection, once considered curable, is now becoming a matter of grave concern with rising antibiotic resistant patterns reported worldwide.Resistance is mainly reported to the key antibiotics in the treatment of infection i.e. metronidazole and clarithromycin, and to a lesser extent to amoxicillin and tetracyclin, thereby decreasing the cure rates of the combination therapies used.Recently resistance to quinolones has also been reported.

The aim of the present study was to develop and evaluate an Adverse Drug Reaction Risk Score (ADR-risk score) to identify patients who are at increased risk to develop an adverse drug reaction (ADR). Data for the development of ADR-risk score were collected from a public teaching hospital of northern-India. Variables associated with ADRs were identified by a forward stepwise logistic regression analysis and used to compute the ADR risk score. The ADR risk score was then evaluated for performance by receiver operator characteristic (ROC) curve. Of 887 patients (mean [SEM] age, 44.6 [0.6] years) 99 (11.2%) experienced an ADR. The number of drugs and a cardiac disease condition were the strongest predictors of ADRs, followed by kidney disease, diabetes, and age ≥60 years. These variables were used to compute the ADR risk score. The area under the ROC curve, which assesses the accuracy of the risk score to predict ADRs, was 0.76 (95% confidence interval, 0.70- 0.81), and 76% of accuracy. The ADR risk score is likely to contribute to a better identification of ADRs and those at risk for ADRs. The present study proposes a method of identifying patients who are at increased risk for an ADR and who may be targeted at reducing drug-related illnesses.

Study of Parenteral Antimicrobial Therapy in ICUs of an Indian Public Teaching Hospital Using Glasgow Antimicrobial Audit Tool (GAAT) Pramil Tiwari1*, Bhanu Naga Sireesha Gudapati1, Satinder Gombar1, Sanjay D'cruz2 and Atul Sachdev2 1Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Department of Pharmacy Practice, Mohali, S.A.S Nagar, 160062, India 2General Medicine, Government Medical College and Hospital, GMCH-32, Chandigarh, 160030, India

BACKGROUND:Although several guidelines for appropriate prescribing are available, inappropriate drug prescription remains noteworthy problem among older adults. Indian older patients are also not spare from this issue and existing literature indicates a fair level of inappropriate drug use (IDU).OBJECTIVES:Identified potentially IDU and documented their reduction based on provided evidence-based information and also identified possible predictors of IDU in older inpatients.SETTING:Three years prospective study included 1510 inpatients aged 60 years or over, of both sexes. IDU identified using the Modified Updated AGS Beers Criteria 2012.RESULTS:The patients had an average age of 67.10 ± 0.23 years and on an average were prescribed 9.29 ± 0.11 medications. Using AGS Beers Criteria 2012, total IDU was found to be 21% (n = 325). Of total 287 patients received only one inappropriate drug whereas 38 patients received two or more inappropriate drug(s). According to first list of criteria long acting benzodiazepines, anticholinergics, nitrofurantoin and digoxin were most common IDU. Prescription of theophylline in insomnia followed by aspirin in gastric ulcer and calcium channel blocker in constipation were listed from second list of criteria. 31% reductions in IDU were observed based on evidence-based information regarding each identified inappropriate drugs.CONCLUSIONS:The findings of this study provide evidence that provision of unbiased evidenced based information is the best possible means for improvement of pharmacotherapy in older patients.

Studies on the characterization of prescription among Indian elderly are limited in literature. This study, therefore, aimed to evaluate the prescription pattern specifically among Indian elderly patients using WHO prescribing indicators. Prescriptions of 4005 outpatients, age 60 yrs or above, were evaluated prospectively using WHO prescribing indicators. The average age (±SEM) of patients was 68.28±0.11 yrs. On an average, each patient had 2.01±0.01 diagnoses & was prescribed 6.45±0.04 drugs. The most common disorder was ‘Diseases of circulatory system”. The patients were prescribed an average of 6.45±0.04 medications. Over half of the patients (57.9%) received more than five medications concurrently. The percentage of drugs prescribed by generic name was only 0.8%. Antibiotic usage was 13% while 7.3% of patients were prescribed injections. The percentage of drugs prescribed from National List of Essential Medicines 2003 was 66% of the drugs prescribed. The minimal prescription of antimicrobials and injections coupled with higher prescriptions from essential drug list is a very positive reflection of good prescribing among elderly outpatients. Studies on the characterization of prescription among Indian elderly are limited in literature. This study, therefore, aimed to evaluate the prescription pattern specifically among Indian elderly patients using WHO prescribing indicators.

Proteinuria is a common manifestation of renal disease. The present study was carried out to analyze the clinic-pathological correlation, assess the value of histopathology and immunofluorescence (IF) as well as note the spectrum of renal diseases in patients with significant proteinuria. Fifty consecutive patients having proteinuria >1 g/24 h underwent ultrasound-guided percutaneous renal biopsy. Clinical information was correlated with the pathological findings and the results were analyzed. The patients were in the age range of 12-79 years. Males (60%) outnumbered females (40%) in all the disease categories except lupus nephritis and IgA nephropathy. The most common clinical presentation was the nephrotic syndrome, seen in 31 cases (62%). Primary glomerular diseases (72%) were more common than secondary glomerular diseases (24%) and tubulointerstitial diseases (4%). Overall, the most common pathological diagnosis was focal and segmental glomerulosclerosis (FSGS) (20%), followed by membranous glomerulonephritis (MGN) (18%). In young patients (age <20 years), minimal change disease (36.4%) was the most common diagnosis while in adults it was MGN (23.5%) and in elderly patients (age >60 years) it was FSGS (60%). IF modified the diagnosis in 12% of the cases. The concordance between clinical diagnosis and pathological diagnosis was 66%. The difference between clinical diagnosis and final diagnosis was statistically significant. Our study further reinforces the knowledge that renal biopsy helps in accurate diagnosis and, thus, helps in appropriate management of the patients. IF provides additional information that can make the morphologic diagnosis considerably more precise.

Patients in the intensive care unit (ICU) have multiorgan dysfunction as well as altered pharmacokinetic parameters. Hence, they are more susceptible to adverse drug reactions (ADRs). The objective of the study was to identify the major class of drugs involved in causing ADRs in ICU patients of an Indian public teaching, tertiary care hospital. A prospective observational study was conducted in the ICUs of a public teaching hospital. All the relevant data was collected from the patients case records in a standard data collection format and the patients were followed until discharge or transferred from the ICUs. ADRs were identified based on the subjective findings, objective findings and spontaneous reporting. The drugs responsible for causing ADR were identified and classified using Anatomic, Therapeutic and Chemical(ATC) classification. The results of this 12 week study were based upon the data obtained from 70 patients(37 males, 33 females). Only 10 patients developed ADRs. The drugs causing ADRs were classified using the ATC classification. This showed that the most common ADR causing drugs belonged to the class of infections and infestations (30%), cardiovascular system(14%), endocrine system(14%), respiratory system (14%) and others (14%), followed by Brain and nervous system (7%), blood and blood forming agents (7%) accounting for least number of ADRs. In this pilot study, Antimicrobials was found to be the most common class of drugs causing ADRs. We studied small number of patients, it is suggested that future large scale studies should be done to further gain insight into the ADRs.