Shilpa Singla

A prospective randomized trial comparing the efficacy of Letrozole and Clomiphene citrate in induction of ovulation in polycystic ovarian syndrome

OBJECTIVES: To compare the efficacy of letrozole and clomiphene citrate (CC) in patients of anovulatory polycystic ovarian syndrome (PCOS) with infertility. MATERIALS AND METHODS: This prospective randomized clinical trial included 204 patients of PCOS. 98 patients (294 cycles) received 2.5–5 mg of letrozole; 106 patients (318 cycles) received 50–100 mg of CC (both orally from Days 3–7 of menstrual cycle). The treatment continued for three cycles in both the groups. Main outcome measures: ovulation rate, endometrial thickness, and pregnancy rate. Statistical analysis was done using SPSS 13 software. P value less than 0.05 was considered significant. RESULTS: The mean number of dominant follicles in letrozole groups and CC groups was 1.86±0.26 and 1.92±0.17, respectively (P=0.126). Number of ovulatory cycle in letrozole group was 196 (66.6%) versus 216 (67.9%) in CC group (P=0.712). The mean mid-cycle endometrial thickness was 9.1±0.3 mm in letrozole group and 6.3±1.1 in CC group, which was statistically significant (P=0.014). The mean Estradiol [E2] level in clomiphene citrate group was significantly higher in CC group (364.2±71.4 pg/mL) than letrozole group (248.2± 42.2 pg/mL). 43 patients from the letrozole group (43.8%) and 28 patients from the CC group (26.4%) became pregnant. CONCLUSION: Letrozole and CC have comparable ovulation rate. The effect of letrozole showed a better endometrial response and pregnancy rate compared with CC.

Severe hydrops in the infant of a Rhesus D-positive mother due to anti-c antibodies diagnosed antenatally: a case report

IntroductionRhesus haemolytic disease of the newborn is a prototype of maternal isoimmunisation and fetal haemolytic disease. There are other rare blood group antigens capable of causing alloimmunisation and haemolytic disease such as c, C, E, Kell and Duffy. In India, after the confirmation of a newborns blood group, antibodies are screened only if the mother is Rehsus D-negative negative and the father is Rhesus D-positive. Hydrops in Rhesus positive women are investigated along the lines of non-immune hydrops.Case presentationWe report the case of a patient from India where irregular antibodies were requested for an O-positive 26-year-old mother in order to investigate fetal hydrops. Anti-c antibody was revealed and the fetus was treated successfully with compatible O negative and c negative intrauterine blood transfusions. The baby was treated postnatally with double volume exchange transfusion with the same compatible blood, and was discharged 30 days after birth.ConclusionWe highlight the importance of conducting irregular antibody screening for women with significant obstetric history and fetal hydrops. This could assist in diagnosing and successfully treating the fetus with appropriate antigen negative cross-matched compatible blood. We note, however, that anti-c immunoglobulin is not yet readily available.

Postcoital vaginoperitoneal fistula after hysterectomy for gynecological malignancy.

A true incidence of postcoital fistula is not known as it is seldom suspected. It presents as acute pneumoperitoneum with signs and symptoms same as that of perforation of a hollow viscus. A 38-year-old parous woman presented with postcoital fistula 10 weeks after panhysterectomy for carcinoma ovary stage IIIc. Pneumoperitoneum was detected, with large amount of gas under the diaphragm on radiograph of the abdomen. A breach was found in the vaginal vault. All other causes of fistula were excluded. Fistula healed spontaneously on follow-up.

Virtual Pediatric Renal Grand Rounds: an innovative e-learning.

Sirs, With the availability of the newer web tools in Web 3.0, such as Blogs, Wikis, Twitter and Podcasts, physicians are able to interact and disseminate vital information to fellow physicians and patients much easier than has ever previously been possible. There is a need for the Pediatric Nephrology community to adopt these tools into their daily practice for efficient learning and continuing medical education [1]. The Pediatric Nephrology website (https://www.pediatricnephrology.com) was designed in November 2009 and incorporates the new tools of the web to facilitate interaction amongst pediatricians, fellow pediatric nephrologists and patients [1, 2]. The concept of ‘Virtual Pediatric Renal Grand Rounds’ was put in practice in December 2009. ‘Pediatric Renal Grand Rounds’ is a broadcast of information every second week that includes recent developments in the field, conference and book watches, commentary on a recent study, physician self-perspectives, patient self-experiences and learning cases for fellows and residents in pediatric nephrology. The ‘Grand Rounds’ were created to address the need for continuing education and to provide professional support to general pediatricians by bringing current evidence-based practice into their homes. The link to the current ‘Grand Rounds’ is delivered by e-mail to all the members of the website. An additional aim of the website and the ‘Grand Rounds’ is to serve as a free, user-friendly platform for pediatricians and pediatric nephrologists to quickly and easily seek diagnostic advice from the pool of expert consultants all over the world. Physicians can post their queries on the website, to which the experts can promptly respond [3]. The website was designed with the primary objectives of keeping the site as simple as possible—while maintaining a professional look—and making it accessible to all computers despite possible slow connections. Newer technologies, such as Twitter and text-sharing softwares, were incorporated (e.g. Facebook, Orkut, Delicious) for easy dissemination of the volumes. An e-mail list of pediatricians, fellows and pediatric nephrologists was generated, and they were invited to join the ‘Pediatric Renal Grand Rounds’ group. The ‘Pediatric Renal Grand Rounds’ became popular soon after its release, with more than 300 members on the website and a mailing list from all over the world, with more than 300,000 hits at the time of reporting. The majority of the views come from USA, Russia and India. The members include general physicians, pediatricians, pediatric nephrologists, fellows in nephrology, pathologists and patients. Nine volumes of the ‘Pediatric Renal Grand Rounds’ have been released to date. All ‘Grand Rounds’ can be accessed at https://www.pediatric-nephrology.com/pediatric-renal-grandrounds). Three ‘Grand Rounds’ with a special focus have also been released, namely, Acute Kidney Injury (https://www. pediatric-nephrology.com/home/2009/12/09/14-pgrone.html), Disasters (https://www.pediatric-nephrology.com/home/2010/ 01/30/88-pgriv.html), and Fellow’s special (https://www. S. K. Sethi (*) Division of Pediatric Nephrology, Department of Pediatrics, PGIMER and RML Hospital, New Delhi 110001, India e-mail: sidsdoc@gmail.com

Primary ovarian echinococcosis mimicking an ovarian carcinoma: an uncommon masquerade even in the developing world

Hydatid disease is a parasitic infection caused by Echinococcus granulosus. The disease is endemic in farming areas where animal husbandry is common, such as in Africa, Mediterranean region, the Middle East, Australia and parts of South America. The most common site is the liver (59–75%), followed in frequency by lung (27%), kidney (3%), bone (1–4%) and brain (1–2%). Rarely affected sites such as the heart, spleen, pancreas and muscle can cause diagnostic dilemma (1). Ovarian hydatid is very rare with few reported cases in literature (2). It may remain asymptomatic for long and may be discovered incidentally or may cause irritation or compression symptoms. A 56-year-old postmenopausal lady presented to a gynecology outpatient department with lower abdominal pain and distension for one and a half years and ultrasonic diagnosis of 7 8 cm bilateral ovarian cysts. She was referred to our institute for tertiary care with suspicion of malignancy. On examination, bilateral irregular lobulated masses with ill-defined margins could be appreciated in the iliac fossae. They were non-tender and had restricted mobility. There was no hepatosplenomegaly or finding suggestive of free fluid in abdomen. CA-125 and CEA were negative. Upper gastrointestinal endoscopy and sigmoidoscopy was normal. Ultrasound guided cyst aspiration was inconclusive on cytopathology. Detailed CT imaging showed large lobulated septate and hypodense cystic adnexal lesions of 8 11 cm on the right and 7 7 cm on the left side. There were multiple other small cystic lesions along the right hepatorenal region and in the bilateral paracolic gutters, but liver or omental deposits or ascites (Figure 1A,B). There was no history of contact with dogs or other pets. On suspicion of echinococcosis, anti-echinococcal IgG levels proved positive. The Casoni skin hypersensitivity test was positive. Preoperative albendazole was administered for 4 weeks, after which exploratory laparotomy was