The medicinal leech, Hirudo medicinalis, is an excellent example of the use of invertebrates in the treatment of human disease. Utilized for various medical indications since the ancient times, the medicinal leech is currently being used in a narrow range of well-defined and scientifically-grounded clinical applications. Hirudotherapy is most commonly used in the setting of venous congestion associated with soft tissue replantations and free flap-based reconstructive surgery. This is a comprehensive review of current clinical applications of hirudotherapy, featuring a comprehensive search of all major medical search engines (i.e. PubMed, Google Scholar, ScientificCommons) and other cross-referenced sources. The authors focus on indications, contraindications, practical application/handling of the leech, and therapy-related complications.

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Hirayama's disease is a form of juvenile muscular atrophy affecting young individulas in their second to third decade. The underlying pathogenetic mechanism is believed to be an imbalanced growth between the individuals' vertebral column and the spinal canal contents, which causes abutment of the anterior spinal cord against the vertebral column and detachment of the posterior dura, leading to microcirculatory disturbances and ischemic changes in the cord. This mechanism is exiquisitely demonstrated on magnetic resonance imaging (MRI), but requires additional imaging, with the neck in the flexed position. Neurphysiological imaging studies have provided supporting evidence by demonstrating changes in the N13 potential, with neck flexion. Nonetheless, few studies have also reported contradictory findings with MRI and somatosensory evoked potentials, in Hirayamas Disease. This condition is underdiagnosed because most clinicians are not familiar with this disorder and do not request a flexion MRI. Early recognition of this entity and differentiation from other causes of focal cord atrophy is important, because limitation of neck flexion by using a simple neck collar can prevent its further progression. We report the classical MRI findings in a young patient with Hirayama's disease with neutral and flexion MRI.

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Background: Parents of children with specific learning disability (SpLD) undergo stress in coping up with their child's condition. Aims: To document the parenting practices of parents having a child with newly diagnosed SpLD and to analyze their impact on parent-child relationships. Settings and Design: Cross-sectional questionnaire-based study in our clinic. Materials and Methods: From May 2007 to January 2008, 150 parents (either mother or father) of children consecutively diagnosed as having SpLD were enrolled. Parenting practices and parent-child relationships were measured by the Alabama Parenting Questionnaire-Parent Form (APQ-PF) and the Parent Child Relationship Questionnaire (PCRQ), respectively. Statistical Analysis Used: Pearson correlation coefficients between subscales of APQ-PF and PCRQ were computed. Multiple regression analysis was carried out for statistical significance of the clinical and demographic variables. Results: Parents who were: (i) "involved" in parenting had a good "personal relationship and disciplinary warmth," (ii) practicing "positive parenting" had good "warmth, personal relationship and disciplinary warmth," (iii) "poorly supervising" their child's activities lacked "warmth and personal relationship," (iv) practicing "inconsistent discipline' had a higher "power assertion" and (v) practicing "corporal punishment" lacked "warmth" and had a higher "power assertion and possessiveness" in their relationships with their child. Parent being poorly educated or currently ill and child having all three types of SpLD present concomitantly or a sibling or a sibling with a chronic disability or being in class standard IX to XI were variables that independently predicted a poor parenting or parent-child relationship subscale score. Conclusions: The present study has identified parenting practices that need to be encouraged or excluded for improving parent-child relationships. Initiating these measures would help in the rehabilitation of children with SpLD.

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Heavy metal toxicity represents an uncommon but clinically significant medical condition, which if unrecognized or inappropriately treated results in significant morbidity and mortality. Among heavy metals, mercury is recognized as a potent and widely distributed toxicant having the ability to accumulate at various levels of food chain besides possessing ability to cross placental and blood-brain barrier. Symptom picture of mercury (Hg ²⁺ ) toxicity is characterized mainly by a series of renal disorders. Mechanism of inorganic mercury toxicity includes production of reactive oxygen species (ROS) capable of damaging lipids in membrane, proteins or enzymes in tissues, and DNA to induce oxidative stress as balance between generation, and elimination of ROS is essential for maintaining the functional integrity of a cell. Mitigation of endogenous mercury depends as a part on the presence of antioxidants such as glutathione - most abundant intracellular non-protein thiol that plays a central role in the maintenance of cellular redox status by quenching free radicals generated during oxidative stress. Ability of a cell to survive the threat posed by endogenous mercury represents a biological adaptation fundamental to survival. This review describes the current understanding and the mechanisms involved by different forms of mercury in eliciting their toxicity in kidney along with the knowledge of major intracellular reductant that plays important role in the mitigation of mercury toxicity for the maintenance of homeostasis within the body of living organisms.

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Background: Cardiovascular diseases are one of the leading causes of death in India. There is high prevalence of cardiovascular risk factors in urban Tamil Nadu. There are limited data on the prevalence of behavioral risk factors and overweight in rural Tamil Nadu. Aim: We estimated prevalence of behavioral risk factors, overweight and central obesity in a rural population in Tamil Nadu, India. Setting and Design: We conducted a cross-sectional survey in 11 villages in Kancheepuram/Thiruvallur districts, Tamil Nadu. Materials and Methods: Study population included 10,500 subjects aged 25-64 years. We collected data on behavioral risk factors and anthropometric measurements. Body mass index (BMI) was categorized using the classification recommended for Asians. Central obesity was defined as waist circumference ≥90 cm for men and ≥80 cm for women. We computed proportions for all risk factors and used trend chi-square to examine trend. Results: Among the 10,500 subjects, 4927 (47%) were males. Among males, 1852 (37.6%) were current smokers and 3073 (62.4%) were current alcohol users. Among females, 840 (15.1%) were smokeless tobacco users. BMI was ≥23.0 kg/m ² for 1618 (32.8%) males and 2126 (38.2%) females. 867 (17.6%) males and 1323 (23.7%) females were centrally obese. Most commonly used edible oil was palm oil followed by sunflower oil and groundnut oil. Conclusion: We observed high prevalence of tobacco use, alcohol use and central obesity in the rural population in Tamil Nadu. There is need for health promotion programs to encourage adoption of healthy lifestyle and policy interventions to create enabling environment.

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India is today facing a diabetes epidemic and has the maximum number of patients with diabetes in the world. People with diabetes are more prone to develop all types of infections. Pneumococcal infections are a common cause of morbidity and mortality, and people with diabetes are more prone to develop pneumococcal infections. With the availability of the pneumococcal vaccine, most international organizations now recommend that people with diabetes should be vaccinated against pneumococcal disease. This article tries to provide a balanced review of the place of pneumococcal vaccination in Indian diabetic patients.

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Idiopathic pulmonary hemosiderosis (IPH) is a rare disorder (triad of iron-deficiency anemia, hemoptysis, and alveolar infiltrates). A 3-year-old male presented with mild fever, breathlessness, dry cough, and bluish nail discoloration for 8 days. He had required five blood transfusions in the past 1 year (last transfusion was given 4 months ago). He had a respiratory rate of 58/min with respiratory distress, cyanosis, and grade III clubbing. Respiratory system examination was normal. Several previous reports of hemoglobin were as low as 3.6 g/dl with hypochromic and microcytic anemia. There were transient increases in the hemoglobin and normalization of red cell morphology with blood transfusions. Serum iron, G6PD enzyme assay, hemoglobin electrophoresis, the sickling test, Coomb's test, stool and urine analysis, and a Meckel's scan were normal. HIV antibody and dsDNA were negative. The chest radiograph revealed symmetrical patchy infiltrates sparing lung apices (confirmed on high-resolution computed tomography). Lung biopsy diagnosed pulmonary hemosiderosis (interstitial lung disease with hemosiderin-laden macrophages scattered in the alveoli and areas of fibrosis in the alveolar septa). The patient showed marked clinical improvement in 10 days of therapy with prednisolone. IPH should be listed in the differential diagnosis of a child presenting with unexplained hypochromic, microcytic anemia and respiratory symptoms.

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We herein report a patient with decompensated cirrhosis secondary to autoimmune hepatitis, who presented with pneumatosis intestinalis (PI) and portal venous gas. Mesenteric ischemia has been recognized as a common and life-threatening cause of PI which portends a grave prognosis. The patient was found to have bacterascites and recovered after appropriate antibiotic therapy. Spontaneous bacterial peritonitis/bacterascites with gas-forming organisms manifesting as PI has not been previously reported.

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Background: Antiphospholipid antibody syndrome (APAS) is regarded as the most frequently acquired risk factor for thrombophilia. The obstetric manifestations of APAS include early or late pregnancy losses and complications like preeclampsia and fetal growth restriction. Its timely diagnosis and treatment can improve maternal and neonatal outcome. Aims: To study the pregnancy outcome of patients with APAS treated with heparin and aspirin. Settings and Design: This was a retrospective study of pregnancy outcome in 42 consecutive women with APAS, treated with heparin and aspirin. Materials and Methods: The case records of 42 diagnosed cases of APAS with pregnancy, over a 3-year period, were studied. The pregnancy outcome in this group was compared before and after treatment with heparin and low-dose aspirin in terms of abortions, intrauterine deaths and live birth rate. The outcome of the present pregnancy in terms of fetal and maternal complications was analyzed. Results: The mean age and average parity of women with APAS were 30.1±4.1 years and 3.2±1.2, respectively. Among the treated patients of APAS, 13 (30.9%) had preeclampsia and 9 (21.4%) had intrauterine growth restriction (IUGR). There were 2 (4.7%) intrauterine deaths, 4 (9.5%) missed abortions and 3 (7.1%) abruptio placentae. Women with APAS had a live birth rate of 4.6% before treatment and 85.7% in the index pregnancy after treatment. Conclusion: Treatment of pregnant women with APAS results in marked improvement in the live birth rate (4.6-85.7%). However, complications like preeclampsia and IUGR occur even after treatment, requiring strict monitoring and timely delivery.

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Background: In developing countries, obesity is the most prevalent metabolic disease and leads to an important cardiovascular and global mortality rate, either directly or indirectly through cardiovascular risk factors. Aim: We sought to study the prevalence of impaired glucose tolerance (IGT), dyslipidemia, metabolic syndrome (MS), and cardiovascular risk (CVR) in a south Indian population. Setting and Design: A cross-sectional, single-center observational study in a cohort of 96 healthy male subjects. Materials and Methods: Age, body mass index (BMI), blood pressure (BP), total lipid profiles, fating plasma glucose (FPG), post lunch plasma glucose (PLPG), glycated hemoglobin (HbA1c), creatinine and insulin were measured by standard methods. Statistical Analysis: Student's t-test and Chi-square test were used to determine differences between mean and frequency values of continuous and categorical variables. Results: Significant differences were observed in the means of BMI (28.89 kg/m ² ) (P<0.0001), FPG (102.41 mg/dL) (P<0.0001), insulin (18.1 μU/L) (P<0.0001), PLPG (149.05 mg/dL) (P<0.0001), diastolic BP (84.41 mmHg) (P<0.01), total cholesterol (166.72 mg/dL) (P<0.001), low-density lipoprotein (90.65 mg/dL) (P<0.0001) in overweight subjects when compared to normal subjects . The prevalence of dyslipidemia, IGT, MS and CVR was significantly higher in younger (<45years) than middle-aged (46-55years) subjects. Conclusions: The condition of being overweight, expressed as BMI, appears to be a good indicator of risk for IGT, MS, and CVR, particularly in young non-obese subjects (BMI<30).

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Mediastinal widening in an adult is mostly nodal in origin. Occasionally vascular aneurysms may be the underlying cause, in which case the aorta or its branches are most frequently involved. Thoracic venous aneurysms, on the other hand, have been reported only in anecdotes, with fusiform aneurysm of the superior vena cava being the commonest. Isolated aneurysms involving the brachiocephalic/innominate vein are extremely rare. We describe detection of a saccular aneurysm of the innominate vein, as the underlying cause of mediastinal widening seen on a chest radiograph in a 42-year-old asymptomatic woman. The characteristic radiological findings of thoracic venous aneurysms are described with particular reference to the importance of multiplanar computed tomography in such settings. Also discussed is the role of imaging in the diagnosis and guiding the management of this rare entity.

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Kissing aneurysms are unusual and relatively rare types of multiple intracranial arterial aneurysms. When located on the anterior communicating artery (ACoA), kissing aneurysms pose considerable diagnostic difficulty on preoperative conventional angiogram. Special angiographic views or 3D rotational angiogram are needed to make the correct diagnosis and to avoid interpreting them as multilobed or bilobed saccular aneurysms on preoperative conventional angiogram. Treatment of these aneurysms, either by clipping or coiling, needs to be individualized. Unique problems which need to be addressed during surgical clipping are high risk of rupture due to dense adhesions between the kissing aneurysms, requirement of at least two clips in a narrow working area, the aneurysm that needs to be clipped first and interference of the first clip with application of subsequent clips. The authors present a case of a 63-year-old male who had kissing ACoA aneurysms managed successfully by clipping.

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Background: Computer usage capabilities of medical students for introduction of computer-aided learning have not been adequately assessed. Aim: Cross-sectional study to evaluate computer literacy among medical students. Settings and Design: Tertiary care teaching hospital in Mumbai, India. Materials and Methods: Participants were administered a 52-question questionnaire, designed to study their background, computer resources, computer usage, activities enhancing computer skills, and attitudes toward computer-aided learning (CAL). The data was classified on the basis of sex, native place, and year of medical school, and the computer resources were compared. The computer usage and attitudes toward computer-based learning were assessed on a five-point Likert scale, to calculate Computer usage score (CUS - maximum 55, minimum 11) and Attitude score (AS - maximum 60, minimum 12). The quartile distribution among the groups with respect to the CUS and AS was compared by chi-squared tests. The correlation between CUS and AS was then tested. Results: Eight hundred and seventy-five students agreed to participate in the study and 832 completed the questionnaire. One hundred and twenty eight questionnaires were excluded and 704 were analyzed. Outstation students had significantly lesser computer resources as compared to local students (P<0.0001). The mean CUS for local students (27.0±9.2, Mean±SD) was significantly higher than outstation students (23.2±9.05). No such difference was observed for the AS. The means of CUS and AS did not differ between males and females. The CUS and AS had positive, but weak correlations for all subgroups. Conclusion: The weak correlation between AS and CUS for all students could be explained by the lack of computer resources or inadequate training to use computers for learning. Providing additional resources would benefit the subset of outstation students with lesser computer resources. This weak correlation between the attitudes and practices of all students needs to be investigated. We believe that this gap can be bridged with a structured computer learning program.

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