REASSESSING THE ROLE OF HOMOCYSTEINE AND HOLOTRANSCOBALAMIN LEVELS IN DIAGNOSING VITAMIN B12 DEFICIENCY ANEMIA

Background: Vitamin B12 deficiency can lead to irreversible neurological damage, megaloblastic anemia, osteoporosis, cerebrovascular, and cardiovascular diseases, and thus, early diagnosis is essential. Objective: The objective of the study was to assess homocysteine (Hcy) and holotranscobalamine (HoloTC) levels among patients with Vitamin B12 deficiency and to see if Hcy and HoloTC level assay can help us in diagnosis of Vitamin B12 deficiency. Methods: We carried out a cross-sectional observational study on 60 patients of Sr. B12 deficient male and female patients between the ages of 18 and 65 years in IPD and OPD patients at multispecialty hospital. Data were collected from predefined pro forma and were asked about their diet, socioeconomic status, and history. Then, these patients further undergone anthropometric measurements and investigated for Hcy and HoloTC level. The statistical analysis was done using Statistical Package for the Social Sciences (SSPS) software (version 11). Results: About 60% of cases were vegetarian and 40% of cases were non-vegetarian. Mean age of study participants was 43.67 years, mean of mean cellular volume was 90.7 fl, mean of B12 was 138 pmol/L, mean of HoloTC was 60.84 pmol/L, and mean of Hcy was 34.17 umol/L. Out of 60 patients, 10 patients had anemia, 21 patients had neurological manifestation, and 29 patients had gastrointestinal (GI) manifestation. In male group, out of 32, 11 patients had HoloTC <8.9, 19 patients had value between 8.9 and 128, and two patients had HoloTC more than 128. In female group, out of 28, seven patients had HoloTC <8.9, 14 patients had value between 8.9 and 128, and seven patients had HoloTC >128. In group of 32 male patients, none of male patients showed Hcy value <5.9, four patients showed Hcy between 5.9 and 16, and 28 patients showed Hcy value >16. Out of 28 female patients, none of female patients showed Hcy <3.36, nine patients showed Hcy between 3.36 and 20.4, and 19 patients showed Hcy >20.4. p <0.001 is highly statistically significant. Conclusion: In our study, we found that 31.33% of cases also showed decreased HoloTC along with B12 deficiency, but this correlation was statistically insignificant. We also found that 78.33% of cases showed increased Hcy along with serum B12 deficiency, which was statistically significant, so we concluded that there is a strong association between serum B12 and Hcy. We found that all patients with elevated Hcy also had low HoloTC except in two cases, but this correlation was not found to be statistically significant

PLACENTA ACCRETA IN PRIMIGRAVIDA AT PERIPHERAL SETUP – A RARE CASE REPORT

One of the risk factors for maternal mortality is morbidly adherent placenta (MAP) and accounts for 7–10% of maternal mortality cases worldwide. Placenta accreta is the most common type of MAP, while the other two types are placenta increta and placenta percreta. Placenta accrete accounts for 75–80% of MAP. Here, we present a case of 22 years old, primigravida with no known antenatal risk factors, diagnosed to have placenta accreta intraoperatively after delivering health baby. It is extremely rare for MAP to occur in a patient with no prior risk factors in a primigravida. Peripartum hysterectomy is the only option in a limited care facility with a hemodynamically unstable patient without a proper full-fledged blood bank facility. It is once again reiterated that bleeding from the vagina that does not slow or stop, drop in blood pressure and signs of shock are early signs of blood loss and should be investigated with great concern

CORONAVIRUS DISEASE 2019 VACCINATION DRIVE: THE PERCEPTIONS AND ACCEPTANCE OF VACCINATION AMONG HEALTH CARE WORKERS

Objective: Coronavirus disease 2019 (COVID-19) infection evolved as a worst nightmare across entire humanity especially for health care workers along with all stakeholders of the society ever since the beginning of year 2020. Vaccination campaign is one of the most successful public health interventions and a cornerstone for the prevention of communicable infectious diseases. To have a baseline data and to form the basis for further vaccination drive, we carried out this study with an objective to understand the perception and COVID-19 vaccine hesitancy among health care workers (HCWs). Methods: A correctional study was carried out at one of the multispecialty hospital in North India where COVID-19 vaccination for HCWs was planned and 675 HCWs were taken into the study. Data were collected by means of personal interview using pretested semi-structured questionnaire and Epi Info version 6 was used for analysis. Results: The mean age of the participants was 32.78 years. Majority were male (89.48%), working in government sector (87.7%) and paramedic (88.15%). While 94.67% were accepting vaccine voluntarily while remaining were not confident enough on their own, only 26.96% were ready to take vaccine even on payment. The overall awareness scores of study participants were calculated and found that 79.56% of them had poor awareness level while only 20.44% had satisfactory awareness level. The association of awareness score was statistically significant with job profile (designation), gender, and prior COVID-19 positivity of study participants. Conclusion: The decision of vaccine prioritization to HCWs and frontline workers will boost the morale and spirit of warriors high in future. This study was a preliminary attempt to check any vaccine hesitancy factors among HCWs and act accordingly. Although almost all had volunteered for vaccine, the knowledge about vaccine was poor in majority of HCWs as the time period was recent to vaccine rollout and detailed research findings were not yet out about vaccine. All measures to be taken including intensive information education and communications activities targeting HCWs and general population on regular basis to upgrade the knowledge on vaccine issues. A strong communicating policy in an era of misinformation is highly recommended as social media plays an important role in spreading true as well as false messages jeopardizing the entire gains of successful vaccination and attainment of herd immunity. HCWs to act as role model for general public and patients which would in turn increase the vaccine acceptance among them

UTERUS DIDELPHYS IN NULLIPAROUS AND MULTIPAROUS WOMEN – A RARE ENTITY

Uterus didelphys is a rare congenital uterine abnormality in which the embryogenetic fusion of the Mullerian ducts fails to occur. It will lead to the formation of a double uterus with two separate cervices and most often a double vagina with a longitudinal septum as well. Here, we present two different cases of uterus didelphys with varied presentations. The first case is a nulliparous woman presented with post-coital bleeding. On examination, two cervical openings with a longitudinal complete vaginal septum were found, conservative management was done. Findings of didelphys uterus were confirmed on USG. The patient was counseled and discharged. The second case is a multiparous woman with previous cesarean delivery, rupture of membranes, and meconium in this pregnancy with term pregnancy taken up for emergency cesarean section. Dense adhesions and a mass on the right side of uterus were found intraoperatively, which on further inspection confirmed to be patent right horn of uterus. Diagnosis of uterus didelphys was made after doing per speculum and per vaginal examination post-cesarean

“EFFECT OF BODY MASS INDEX ON PREGNANCY OUTCOME” - A PROSPECTIVE STUDY

Background: Mothers who are overweight or obese during pregnancy and childbirth, are known to be at risk of significant antenatal, intrapartum, postpartum, and neonatal complications. Objectives: The objective of the study was to evaluate the impact of high pre pregnancy body mass index (BMI) (<12 weeks of gestation) on the occurrence of maternal pregnancy outcome. A longitudinal observational study was carried out in a tertiary care hospital. In Group I, 50 antenatal women with gestational age <12 weeks BMI 18.5–35 kg/m2 and having singleton pregnancies were included in the study, while 50 women with normal BMI formed the Group II. Both groups were followed up throughout pregnancy and post-natal to assess complication during pregnancy, labor, and puerperium. Results: The mean BMI in Group I and Group II was 27.516 kg/m2 and 21.433 kg/m2. The prevalence of anemia was 40% and 26% among two groups. Antenatal and post-natal complications were gestational diabetes mellitus (Group I - 28% and Group II - 6%), preeclampsia (Group I - 16% and Group II - 2%), required induction of labor (Group I - 26% and Group II - 6%), preterm labor (Group I - 4% and Group II - 16%), and meconium staining of liquor (GroupI-20% and GroupII-12%), and the difference was statistically significant among two groups. Newborn complications were weight ≥2.5 kg (Group I - 74% and Group II - 48%), neonatal intensive care unit admission requirement (Group I - 26% and Group II - 17%), and the difference was statistically significant among two groups. Other complications which were not statistically significant among two groups were oligohydramnios (Group I - 2% and Group II - 4%), polyhydramnios (Group I - 6% and Group II - 4%), and appearance, pulse, grimace, activity, and respiration score at 1 min <7 (Group I - 14% and Group II - 6%). Conclusion: Pregnancy complications related to maternal BMI is a growing problem. Both lean and obese mothers carry an increased risk of adverse perinatal outcome. Given the major economic and medical consequence of pregnancy in these women, all attempts should be made to maintain a normal BMI in women of childbearing age. Pre-pregnancy counseling, health programs and appropriate multidisciplinary management should be done

SECOND TRIMESTER UTERINE RUPTURE WITH PLACENTA PERCRETA IN PREVIOUS LOWER SEGMENT CESAREAN SCAR

Rupture of a pregnant uterus is a serious threat to the mother’s life and her unborn child. Most of the reported cases of uterine rupture in scarred uterus are due to dehiscence of previous cesarean scar or a rupture of myomectomy scar and usually occur in the third trimester. Spontaneous uterine rupture in first or second trimester is very rare. Here we report a case of second-trimester spontaneous uterine rupture with a particular emphasis on the etiological factors, discuss the course of events and difficulties in the diagnosis. The lesson learned from this case is that, although uterine rupture is very rare in the second trimester of pregnancy, it should be taken into consideration in the differential diagnosis of acute abdomen, especially if there is a predisposing factor such as previous lower segment caesarean section and fluid in the abdomen

PROFILE OF SURROGATE MARKERS OF MOLECULAR SUBTYPES USING THE EXPRESSION PATTERN OF ER, PR, AND HER2/NEU RECEPTORS IN OPERABLE BREAST CANCER

Objective: The present study was planned with an aim to study the profile of surrogate markers of molecular subtypes using the expression pattern of ER, PR, and HER2/NEU receptors in operable breast cancer so that most effective and advantageous treatment can be offered for better surgical outcomes. Methods: A cross-sectional observational study was carried out in one of the tertiary care centers in Central UP. All patients presenting to the center with early and locally advanced breast cancer with age bracket between 18 and 75 years during 2-year period and willing to participate in the study were included in the sample size. Clinical staging was done using the standard TNM criteria and all the specimens were subjected to immunohistochemical evaluation for surrogate molecular subtyping Results: Out of 94 cases enrolled in the study, a total of 32 (34.4%) were identified as luminal A, 3 (3.2%) were identified as luminal B, 35 (37.6%) were identified as HER2 positive, and remaining 23 (24.7%) were identified as triple negative. Statistically, there was no significant difference among groups with respect to age (p=0.958) and BMI (p=0.332). However, there was a significant difference among groups with respect to clinical stage (p=0.031), clinical nodal involvement (p=0.014), pathological staging (p=0.006), and pathological nodal involvement (p=0.023). Among those with nodal involvement, all the cases had involvement of one node except for one patient in Group I who had involvement of thrMost of the luminal A cases (81.3%) were clinically Stage 1 or 2. All the luminal B cases were clinically Stage 2 or 3 (100%). Almost half (48.8%) of Her2-negative cases were Stage 3 or 4. Majority of triple-negative cases were Stage 3 or 4 (65.2%). Clinically, nodal involvement was seen to be maximum in Her2-negative and triple-negative groups (54.3% and 52.2% of cases, respectively). Pathologically, most of the luminal A (83.9%), Her2 negative (81.8%), and all the luminal B cases were Stage 2. Pathologically, nodal involvement was seen in 16.1% of luminal A, 42.4% of Her2-negative, and 50% of triple-negative cases. Conclusion: The findings of the present study provided a glimpse of expression pattern of ER, PR, and HER2/NEU receptors in operable breast cancer based on which most effective and advantageous treatment can be offered for better surgical outcomes

A rare case of posterior wall uterovaginal rupture in a primigravida: points to ponder in a peripheral set up

Rupture of uterus in a primigravida lady is extremely rare and in most cases it is unalarmed or totally unexpected. The incidence of uterine rupture in general (primigravida or multigravida) is significantly higher in developing countries than in developed countries. Here we present a healthy 24-year-old primigravid woman presented in labor at 39 weeks of gestation with no known comorbidity. She had no significant past medical history and her antenatal care had been uneventful. Intraoperatively the patient was found to have posterior utero-vaginal tear which was repaired subsequently. This case of primigravida, is a rare one and important points to ponder in a periphery setup are discussed here.

Prevalence of underweight, stunting, wasting and obesity among urban school going children – Need for action

Background: The mental and physical growth, nutritional status, academic achievements of school-going children in the age group of 6-15 years are some of the important factors that would play a key role in shaping the future of our country in the coming years. Objectives: To assess the prevalence of underweight, stunting, wasting and obesity among urban school going children of Western Maharashtra, India so that corrective actions can be taken to improve the nutritional status. Methodology: We conducted a cross-sectional study on children aged 6-15 years studying in urban schools of Western Maharashtra. 2276 children were included in the study and a simple random sampling technique was used to select the sections of classes I to X standard. All children belonging to that section were included in the study. Institutional ethical clearance was taken, and informed consent was taken from all parents. Data was collected by the investigator himself by using a standard protocol and anthropometric measurements were taken using standard techniques. Results: In our study, according to WHO MGRS standards, the total prevalence of underweight was 3.57% among 5-9 years old children. Out of this, 0.4% of children were severely underweight. 3.3% boys and 3.87% girls were underweight. Stunting was observed in 1.4% of children. About 0.1% of children were severely stunted. Sex specific prevalence observed was 1.2% in boys and 1.8% in girls. Wasting was observed in 11.1% children. About 1.9% children were severely wasted. Among boys, 12.6% were wasted. As for girls, 9.3% were wasted. About 19.1% and 5.1% children were overweight and obese, respectively. Sex distribution for overweight was, 22.1% boys and 15.2% girls and that for obesity was, 6.4% boys and 3.4% girls. Conclusion: Although the prevalence of underweight, stunting, and wasting was less among the study participants, nutritional education should be imparted to children, regarding the type of food to be eaten, major food groups, nutritive value of various foods, and common nutritional problems and their effects. Overweight and obesity prevalence was high, hence requiring special emphasis to be given to these children. Health education should be imparted to parents during parent teacher meetings and IEC campaigns, regarding correct dietary practices such as food diversification and common nutritional problems in children and their consequences

Intussusception – A common entity but seldom diagnosed (lesson learnt from case series for family physicians)

Intussusception is one of the common causes of acute abdomen in paediatric age bracket with ileocolic type being the most prevalent. This happens when a proximal segment of bowel (intussusceptum) telescopes into the lumen of the adjacent distal segment (intussuscepiens). Here we report six cases of intussusception in which five were in paediatric age group and one was adult. All children were admitted, resuscitated well, USG abdomen was done to confirm the diagnosis, written and informed consent for surgery and anaesthesia, was taken from parents. However, all were managed successfully by hydrostatic saline reduction under sedation. Only one child had recurrence after one year who was again treated conservatively. Adult case was managed by means of laparotomy by excision of benign polyp being the pathological lead point. We present this case series to analyse the spectrum of presentation, diagnostic and therapeutic options available with review of literature. Since primary care providers and family physicians are first responders, this case series would help them for differential diagnosis and prompt referrals for further management