Haritha Sagili

Etiopathogenesis and Neurobiology of Narcolepsy: A Review

Narcolepsy is a chronic lifelong sleep disorder and it often leaves a debilitating effect on the quality of life of the sufferer. This disorder is characterized by a tetrad of excessive daytime sleepiness, cataplexy (brief loss of muscle tone following strong emotion), hypnogogic hallucinations and sleep paralysis. There are two distinct subgroups of Narcolepsy: Narcolepsy with cataplexy and Narcolepsy without cataplexy. For over 100 years, clinicians have recognised narcolepsy, but only in the last few decades have scientists been able to shed light on the true cause and pathogenesis of narcolepsy. Recent studies have shown that a loss of the hypothalamic neuropeptide Hypocretin/Orexincauses Narcolepsy with cataplexy and that an autoimmune mechanism may be responsible for this loss. Our understanding of the neurophysiologic aspect of narcolepsy has also significantly improved. The basic neural mechanisms behind sleepiness and cataplexy, the two defining symptoms of narcolepsy have started to become clearer. In this review, we have provided a detailed account of the key aspects of etiopathogenesis and neurobiology of narcolepsy, along with a critical appraisal of the more recent and interesting causal associations.We have also looked at the contributions of neuroimaging to the etiopathogenesis of Narcolepsy.

Pregnancy of unknown location: an evidence‐based approach to management

•  As women are presenting to early pregnancy assessment units at increasingly earlier gestations and are having earlier scans, the incidence of pregnancy of unknown location (PUL) is increasing. •  Although the vast majority will be failing PULs or intrauterine pregnancies, a small subset will be ectopic pregnancies; it is the detection of women in this group that poses the greatest challenge. •  Conservative management of PUL results in lower rates of unnecessary intervention, as the condition often resolves spontaneously; the difficulty is in determining which ones will not.

Modern management of miscarriage

• • Miscarriage has traditionally been treated by surgical evacuation, on the assumption that any retained tissue increases the risk of infection and haemorrhage. • • Over the last decade, effective non‐surgical alternatives have been advocated to minimise unnecessary surgical intervention while maintaining low rates of morbidity and mortality. • • Improved access to early pregnancy assessment units and greater awareness among women has led to increasing demand for more conservative management of miscarriage.

Comparison of different criteria for diagnosis of gestational diabetes mellitus.

Introduction: The International Association of Diabetes in Pregnancy Study Group (IADPSG) criteria for gestational diabetes mellitus (GDM) has been adopted by most associations across the world including the American Diabetes Association and World Health Organization (WHO). We conducted a study comparing the IADPSG and previous WHO criteria and their effects on neonatal birth weight. Methods: The study was carried out in Obstetrics and Gynaecology Department of a tertiary care institute in South India in collaboration with Endocrinology Department. Thousand two hundred and thirty-one antenatal cases with at least one risk factor for GDM and gestational age of more than 24 weeks were included in the study. Both criteria were compared on the basis of 75 g oral glucose tolerance test results. Results: The prevalence of GDM using IADPSG and previous WHO criteria were 12.6% and 12.4%, respectively. The prevalence of GDM was 9.9% when both criteria had to be satisfied. Both GDM criteria groups did not differ in neonatal birth weight and macrosomia rate. However, there was a significant increase in lower segment cesarean section in IADPSG criteria group. Elevated fasting plasma glucose alone picked up only one GDM in the previous WHO criteria group. Conclusions: A single 2 h plasma glucose is both easy to perform and economical. A revised WHO criterion using a 2 h threshold of ≥140 mg % can be adopted as a one-step screening and diagnostic procedure for GDM in our country.

Life-threatening complications following multidose methotrexate for medical management of ectopic pregnancy

A 25-year-old primigravida was diagnosed to be suffering from unruptured ectopic pregnancy. The serum β-human chorionic gonadotropin levels were 2851 mIU/l and the ectopic gestational sac was 2.7×2.7 cm without any fetal pole. It was decided to manage her by expectant therapy. But she received medical therapy with multidose methotrexate because of misinterpretation of expectant therapy as medical therapy. She suffered from methotrexate toxicity, which manifested as high-grade fever, vomiting, melena, oral ulcerations, pneumonitis, subconjunctival haemorrhages and skin pigmentation. She developed severe third space fluid collection and shock, which was mistaken for rupture ectopic gestation. Her haematological picture showed severe neutropaenia and thrombocytopaenia which confirmed the clinical picture to be due to methotrexate toxicity. She also developed septicaemia and candidal infection secondary to immunosuppression. She was managed in intensive care unit with ventilatory support, high-dose leucovorin and injection filgastrim. She responded well to the therapy with dramatic recovery in 4 days.

Hysteroscopic sterilisation with Essure®: a promising new alternative to tubal ligation?

The Essure (Conceptus Inc. San Carlos CA USA) contraceptive device consists of a nitinol (nickel/titanium alloy) coiled spring containing polyethylene fibres. It is a dynamic expanding microinsert placed under hysteroscopic visualisation in the proximal section of the Fallopian tube. The microinsert acts by inducing a tissue reaction that permanently blocks the tube within 3 months. It is recommended that an additional form of contraception be used until correct placement of the device is confirmed by an imaging procedure 3 months after the operation. Intrauterine devices (IUDs) cannot be used during this time period. Essure is becoming increasingly popular as a nonincisional permanent birth control device and has been licensed for use in the European Union since 2001. Approximately 501000 procedures have been performed worldwide of which 141000 have been carried out in Europe. National Institute for Health and Clinical Excellence (NICE) guidance concluded that current evidence on safety appeared adequate although evidence of the long-term efficacy did not appear adequate for the procedure to be used without special arrangements for consent and for audit or research. (excerpt)

Vaginal delivery after augmentation cystoplasty and Mitrofanoff's procedure for incontinence following traumatic bladder neck transection.

Urinary tract reconstruction surgery, particularly for congenital abnormalities, has increased considerably, especially in children and young women with reproductive potential. Procedures include e...

Incarcerated foreign body in the vagina - a metal bangle used as a pessary

Long-forgotten vaginal pessaries get incarcerated in the vagina and their removal poses problems. A 60-year-old postmenopausal woman presented with foul smelling purulent discharge per vaginum and stress incontinence. Speculum examination revealed foul smelling white discharge per vaginum and a friable vaginal wall which bled on touch. The anterior portion of a metal ring deeply embedded in the vagina was seen. The cervix appeared normal. Attempts of removal by traction under local infiltration failed and resulted in bleeding. Biopsy from the tissue covering the ring reported no evidence of malignancy. She was treated with broad-spectrum antibiotics for 1 week and the metallic ring was removed without any complications under general anaesthesia using electrocautery. It was found to be a metallic bangle with design. It is essential to gently cauterise and release the fibrosis over the incarcerated foreign body to achieve safe removal.

Intravenous Iron Sucrose and Oral Iron for the Treatment of Iron Deficiency Anaemia in Pregnancy

PURPOSE The aim of this study was to compare the efficacy and safety of intravenous iron sucrose and oral iron administration for the treatment of iron deficiency anaemia in pregnancy. MATERIALS AND METHODS Hundred women with gestational age between 30 and 34 weeks with established iron deficiency anaemia with Haemoglobin-6-8g/dL were randomised to receive either oral ferrous sulphate 200 mg thrice daily or required dose of intravenous iron sucrose 200 mg in 200 ml NS on alternate days. Haemoglobin, haematocrit, mean corpuscular volume, reticulocyte count were measured at recruitment and on 2(nd) week, 4(th) week and at 37 weeks. Adverse drug reactions were also noted in both the groups. RESULTS were analyzed by students t-test and Chi-square test. RESULTS Haemoglobin values varied significantly with time between the two groups at second week, 4(th) week and at term (p<0.005). The mean difference in mean corpuscular volume from the recruitment value was not significant at 2(nd) week. When compared to iron sucrose group, oral iron group had significant gastro-intestinal adverse effects. CONCLUSION Intravenous iron sucrose treated iron deficiency anaemia of pregnancy faster, and more effectively than oral iron therapy, with no serious adverse drug reactions.

Study of Tumour Cellularity in Locally Advanced Breast Carcinoma on Neo-Adjuvant Chemotherapy

BACKGROUND Breast cancer is the most common invasive malignancy which occurs in women worldwide. The advent of neoadjuvant chemotherapy has radically changed the management of locally advanced breast cancer and a complete response is reported to significantly improve disease free survival. Traditionally, clinical response is assessed on basis of tumour size. In this study, an attempt was made to check whether tumour cellularity could be a better prognostic factor and also to check as to what impact the correlation of tumour size with cellularity had on the response assessment in locally advanced breast cancer patients. MATERIALS AND METHODS Thirty seven patients with locally advanced breast cancer, who were treated by neoadjuvant chemotherapy during the period of December 2008 to May 2009, were selected for the study and from their case records, tumour size, clinical response and demographic details were gathered. Tumour cellularity was assessed prior to chemotherapy in core needle biopsy sections and it was matched with that seen in subsequent mastectomy specimens. Tumour size and cellularity were then correlated with the different treatment response groups and they were statistically analyzed by using the SPSS, version 13.0 software. RESULTS After neoadjuvant chemotherapy, the tumour size and cellularity were found to be significantly reduced in breast carcinomas (p<0.05, paired t-test). The relative changes in cellularity which were seen were highly variable between individual patients and different clinical response groups, particularly in the partial response and no response categories. The product of cellularity and size dramatically changed the distribution of residual tumour pathology, thus causing a shift towards a complete response. CONCLUSION The current study showed that the product of tumour size and cellularity may be a better prognostic indicator of clinical response in patients with neoadjuvant chemotherapy treated locally advanced breast cancer and that it would enable a new definition for clinical response in the future.