Skin Discolouration Research Articles

Management of Kitibha Kushta w.s.r Chronic Plaque Psoriasis: A case report

In Ayurveda disorders of skin have been dealt under the heading Kushta which is having subtypes based on severity and Doshas involved. Skin being largest organ in human body there is many concerns for cosmetic purpose along with systemic involvement in disease prognosis. This is a case of Kitibha Kushta which is a variety of Kshudra Kushta involving the vitiation of Tridoshas which can be compared to chronic plaque psoriasis in modern science depending on its signs and symptomatology. This case was treated with Sadyo Vamana, Virechana and Shamana Aushadhis in SAMCH department of Panchakarma Bengaluru. Patient has found satisfactory improvements after the following therapies. The lesions have completely disappeared leaving behind only discolouration of skin. This proves us by repeated Shodhana and combination of Shamana Aushadhi gives better result.

P43 A complicated road to diagnosis: Auto inflammatory bone disease

Introduction/BackgroundAuto inflammatory bone disorders are characterized by chronic non-infectious osteomyelitis and inflammation-induced bone resorption. It results from aberrant activation of components of the innate immune system. The auto inflammatory bone disorder includes chronic non-bacterial osteomyelitis (CNO) and its severe form chronic recurrent multifocal osteomyelitis (CRMO); synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome; Majeed syndrome; deficiency of interleukin-1 receptor antagonist (DIRA) and cherubism. The most common among this is CRMO/CNO. The disease can affect any part of the body but the metaphyseal region of the long bones, clavicle, and vertebra are the most commonly affected site.Description/MethodA 9 year old girl presented with five month history of swelling over right periocular and temporal region, associated with skin discoloration and difficulty in opening her eyes. She also reported headache more in the right frontal region. She had on and off exacerbations of skin discoloration and headaches. There was no history of fevers, weight loss, night sweats, skin lesions or arthritic symptoms. She did not have a personal or family history of inflammatory or autoimmune disorders. She is under ophthalmology elsewhere since the age of 3 months with a right divergent squint and history of right squint surgery at 6 years.Physical examination revealed swelling involving right infraorbital and temporal region, which was soft and not tender to touch with associated erythema in the same site. There were no signs of meningism or altered mental status. Musculoskeletal examination was unremarkable.Her blood test results showed mild increase in platelets (476 * 109), CRP 8mg/L, ESR (18mm/hr). IgG4 titres were mildly raised (1.16g/L). Other immunologic markers including rheumatoid factor, human leukocyte antigen B27, antinuclear antibody and anti-neutrophil cytoplasmic antibody were normal.Histopathological examination of bone and soft tissue of her right orbital rim showed low grade non-specific chronic inflammation with extensive appositional remodelling of bone suggestive of CRMO/SAPHO. No evidence of malignancy/infection.Later whole body MRI was performed to identify the extent of disease. MRI whole body was performed which showed multiple areas of bone marrow oedema and periostitis within the appendicular and axial skeleton, bilateral gluteal enthesitis and sacroilitis. There are some features that are atypical for CRMO (asymmetrical involvement, transphyseal involvement including epiphyseal involvement of the left humerus). Also noted to have right-sided periorbital oedema, oedema of the right masticator muscles and temporalis. Further planned to do dedicated MRI of left humerus with contrast.Discussion/ResultsIt can be difficult to consider what the problem is when a health care provider is presented with a group of seemingly disparate signs and symptoms with a history and time course that do not match classic (or commonly atypical) disease presentations. Common things happen commonly, so when symptoms occur without the usual co-occurring symptoms, unusual symptoms or time courses, it can be challenging.The current patient presented with periocular swelling with headache and skin discolouration. The differentials can be Langerhans cell histiocytosis, IgG4-related disease, osteoblastoma, and osteosarcoma. There were no hepatosplenomegaly, lymphadenopathy, also the mass was soft to palpate, and hence the above differentials were unlikely. Patient was initially evaluated at tertiary oncology centre and malignancy ruled out. The histopathology slides were reviewed and reported as mentioned above. In view of no skin manifestations, CRMO was the likely diagnosis considered. Hence MRI whole body performed.Barrani et al reported a similar type of unusual case of a 12-year-old girl with CRMO arising with recurrent episodes of left supraorbital headache, followed by the appearance of a periorbital dyschromia. Magnetic resonance imaging (MRI) of the skull and orbits revealed an important subacute inflammatory process. However, a few months later, the child presented a painful swelling of the left clavicle; the histological examination of the related biopsy allowed us to establish the diagnosis of CRMO.The follow up with our patient is quite a short duration and she might evolve later in the disease course giving more clarity!Key learning points/ConclusionIn evaluating a diagnostic dilemma, starting the laboratory evaluation helps to begin the process of trying to find an answer and can also help the families as “something is being done.”Chronic recurrent multifocal osteomyelitis can present with unifocal lesions, atypical locations or absence of recurrence.A high level of suspicion is paramount to avoid unnecessary biopsies and repeated antibiotic regimens.Families will often be quite concerned and support for them is also necessary and close communication and follow up is appropriate.

The use of strain-gauge plethysmography in the functional assessment of chronic venous disease: five-year experience at a single centre.

Plethysmography can be used in the diagnosis and evaluation of chronic venous disease in the lower extremities. This study aimed to evaluate the applicability and reliability of strain-gauge plethysmography (SDP) in the functional assessment of chronic venous disease. This descriptive study was conducted between 2016 and 2021 at a single centre. Four hundred and thirty-two patients with symptomatic chronic venous disease were included in the study. All participants were diagnosed initially with Doppler ultrasonography. SGP was then performed to evaluate venous outflow capacity, venous reflux and muscle pump function. The average age was 45.16 ± 12.54 years (median age 46 years; range 20-78 years), and 239 (55.3%) women and 193 (44.7%) men were included in the study. The age groups, diagnosis, pathological distribution and risk factors were quantitatively determined according to gender. Localisation and lateralisation statistics of the pathologies are given. SGP measurements, including venous volume (V), venous emptying (VE), expelled volume ratio in four seconds (EV4/V), half refilling time (t½) and refilling volume (RV) of each lower extremity, were done individually to compare the involved extremity with the normal contralateral side. SGP measurements of each affected lower limb were also compared separately by gender, age group and disease onset. The correlation between t½ values and skin discolouration or oedema of the affected limb was examined. Finally, receiver operating characteristic curve analyses of the V, VE, EV4/V, t½ and RV values were done, and the cut-off values of each parameter were defined accordingly. High reliability and consistent results indicate that SGP is a practical and sensitive test for quantitative functional assessment of patients with chronic venous disease. It can be used as an effective method in diagnosing and following up chronic venous disorders. As there are no currently accepted cut-off values, we suggest that ours can be used as new reference values for SGP measurements.

Disease surveillance in England and Wales, June 2022.

Disease surveillance in England and Wales, June 2022.

Comparison of efficacy of bedaquiline and moxifloxacin in drug resistant pulmonary tuberculosis. A prospective observational study.

Drug-resistant tuberculosis remains a major public health concern in many countries. We compared the efficacy and safety of bedaquiline plus optimized background regimen (Bdq+OBR) with high dose moxifloxacin and optimized background regimen (Mfx(h)+OBR) for the treatment of patients with multidrug-resistant tuberculosis with additional resistance to fluoroquinolones. In this prospective observational study, newly diagnosed cases of multidrug-resistant tuberculosis with additional resistance to fluoroquinolone were enrolled. They received either Bdq+OBR or Mfx(h)+OBR and were followed up for six months. The sputum culture conversion rate at the end of six months and the time to culture conversion in each group were studied. The safety profile of both regimens was also studied. The sputum culture conversion was achieved in 41 patients (100%) in the Bdq+OBR group and 36 patients (87.8%) in the Mfx(h)+OBR group at the end of 6 months. The mean time to culture conversion was found to be 3.10±0.8 months in the Bdq+OBR group and 3.32±0.9 months in the Mfx(h)+OBR group. Mortality was 6.8% in the Bdq+OBR group and 10.8 % in the Mfx(h)+OBR group at 6 months. Raised serum lipase and dark discolouration of skin were significantly more common in the Bdq+OBR group while vomiting and ototoxicity were more common in the Mfx(h)+OBR group. Bdq+OBR was associated with higher success of sputum culture conversion at 6 months and faster sputum culture conversion rate as compared to the Mfx(h)+OBR.

Severity of scuffing injury of ‘Zesy002’ kiwifruit as influenced by maturity

ABSTRACT Kiwifruit (Actinidia chinensis var. chinensis ‘Zesy002’) have a relatively long harvest season, where fruit will change in maturity and hence attributes. Harvest may be followed by a long postharvest storage period. Scuffing is the discolouration of kiwifruit skin in response to an injury. This injury is observed throughout the supply chain to some extent and thus, it is of interest to identify possible reasons that predispose kiwifruit to skin discolouration. In this work, maturity, as influenced by harvest date and estimated by firmness and total soluble solids, was investigated as a potential descriptor of scuffing susceptibility. ‘Zesy002’ kiwifruit were sampled from 11 orchards in New Zealand on three occasions (ISO weeks 12, 18 and 20) during the 2020 harvest season. Upon arrival to the lab, 24 fruit from each grower were non-destructively assessed prior to a deliberately controlled scuffing treatment and subsequently stored for 2 weeks at 0°C, to allow symptom development. Of the at-harvest maturity indicators, firmness was found to be the strongest indicator of scuffing susceptibility and severity of the damage. Further work is required to understand the physical or physiological reasons that cause softer fruit to be more susceptible to scuffing.

Efficacy of Classical Siddha Formulations in the treatment of Peru Manjal Noi w.s.r to Jaundice

Background: Jaundice (Icterus) is a condition in which there is retention of bile pigments in the tissues as a result of liver disease, biliary obstruction, haemolysis or combination of all. In Yugi Vaithiya Chinthamani Jaundice can be correlated with Peru Manjal Noi with yellowish discolouration of urine, eyes, tongue, and body. Classical Siddha formulations were used in this study to reduce the biliary load, progression of disease as well as to provide symptomatic relief. Case presentation: A 52 years old male patient visited Outpatient department of Siddha Clinical Research Unit, Palayamkottai with the following complaints of Generalized weakness,Loss of appetite,Nausea on and off, Abdominal pain on and off, Yellowish discolouration of skin and eyes, Yellowish discolouration of urine since 15 days. Conclusion: Symptomatic relief was observed within 7 days of treatment and biochemical changes were observed within 16 days of treatment. A further randomized controlled clinical study has to be carried out to validate this study.

Arthritis glove provision in rheumatoid arthritis and hand osteoarthritis: A survey of United Kingdom rheumatology occupational therapists.

Hand pain and function limitations are common in rheumatoid arthritis (RA) and hand osteoarthritis (HOA). Provision of arthritis (compression) gloves to relieve hand symptoms is increasing in occupational therapy. Research evaluating arthritis gloves dates to the 1990s, focussing on night-wear of full-length finger gloves in RA. This survey examined glove provision in contemporary clinical practice in the United Kingdom. A survey of arthritis glove provision in RA was conducted with Royal College of Occupational Therapists Rheumatology Specialist Section members. A more detailed survey about glove provision in RA and HOA was conducted with rheumatology occupational therapists in North-West England. Response rates were good, with 60 (73%) therapists responding to the national and 24 (69%) to the regional surveys. Most therapists provided open-finger gloves (commonly IsotonerTM) to about a third of their RA and HOA patients, and to those with any arthritic condition causing significant hand pain and/or swelling. Day-wear was as common as night-wear, and patients were advised to wear these 'as and when' for hand symptom relief and support for hand function. They were advised not to wear gloves continually in the day, and regularly perform hand exercises and monitor for potential adverse effects, for example, skin discolouration. Therapists commonly provide replacement gloves as these are often used long-term. Prescription of arthritis gloves has changed considerably in the last 30 years, with open-finger gloves provided to a wider range of people with arthritis, for a broader range of clinical reasons.

A Laboratory Method to Measure Skin Surface Staining by Cigarette Smoke, Tobacco Heating Products and E-Cigarettes

Summary Exhaled or side-stream cigarette smoke (CS) may visually stain a consumer's skin over time. Tobacco heating products (THPs) and e-cigarettes (ECs) have reduced staining potential because they do not produce side-stream aerosols and their exhaled aerosols have significantly reduced levels of toxicants, particles and odour. Here we assess discolouration of porcine skin in vitro after exposure to particulate matter (PM) or aerosols from CS (3R4F), two THPs (glo and glo sens) and an EC (iSwitch Maxx). PM was prepared by capturing aerosols on Cambridge filter pads and eluting with dimethyl sulfoxide (DMSO). Abattoir-obtained porcine skin samples were incubated with PM or DMSO control at 37 °C between 0 and 6.0 h. For aerosol assessment, porcine skin samples were exposed to between 50 and 400 puffs of the products, or air control, using a smoking machine. Colour profiles and staining levels of each skin sample were measured at different timepoints and puff thresholds using a spectrophotometer. Staining increased with time and dose, the greatest changes being observed following exposure to aerosols and PM from CS. THP, EC and control values were significantly different from CS after 0.5 h exposure to PM or 50 puffs of aerosols. The minimal staining induced by THPs and EC was comparable to controls. These data suggest that THPs and ECs could offer hygiene benefits to consumers who switch from smoking cigarettes. Further studies are required to assess the longer-term effects of THPs and ECs on skin discoloration. [Contrib. Tob. Nicotine Res. 30 (2021) 158–166]

Advances in Nanotechnology towards Development of Silver Nanoparticle-Based Wound-Healing Agents.

Since antiquity, silver-based therapies have been used in wound healing, wound care and management of infections to provide adequate healing. These therapies are associated with certain limitations, such as toxicity, skin discolouration and bacterial resistance, which have limited their use. As a result, new and innovative wound therapies, or strategies to improve the existing therapies, are sought after. Silver nanoparticles (AgNPs) have shown the potential to circumvent the limitations associated with conventional silver-based therapies as described above. AgNPs are effective against a broad spectrum of microorganisms and are less toxic, effective at lower concentrations and produce no skin discolouration. Furthermore, AgNPs can be decorated or coupled with other healing-promoting materials to provide optimum healing. This review details the history and impact of silver-based therapies leading up to AgNPs and AgNP-based nanoformulations in wound healing. It also highlights the properties of AgNPs that aid in wound healing and that make them superior to conventional silver-based wound treatment therapies.

97 A Case Report: Necrotising Leukocytoclastic Vasculitis (NLV) Of the Breast Mimicking Necrotising Fasciitis (NF)

Leukocytoclastic vasculitis (LV) is an inflammation of the small vessels in the dermis characterised by the deposition of immunocomplexes in the involved vessel walls. It commonly manifests as palpable purpura, limited to the skin and predominantly of the lower limb. We report a rare case of necrotising LV (NLV) affecting bilateral breast, manifesting clinical features of necrotising fasciitis (NF), and emphasizes the potential diagnostic challenges that markedly influence the treatment and survival of patients.A 48-year-old female presented with an acute onset left breast skin necrosis and discolouration that rapidly progressed to the contralateral breast with surrounding erythema and oedema of the chest wall yet spared the intermammary cleft. Some non-blanching purpuric rash were also noted on upper abdomen and left lower limb. COVID-19 test was negative. CT scan showed extensive bilateral breast fat stranding and oedema. Patient became clinically septic with a moderately raised CRP and mild acute kidney injury. Radical mastectomies and chest wall excision were performed with intra-operative findings of cloudy fluid and easily peeled away subcutaneous tissue from fascia. Urgent gram stain and culture showed no organisms. Tissue biopsies subsequently showed the diagnosis of NLV. Chest wall defect was then reconstructed with split skin grafts, NLV treated with corticosteroids and patient made an uneventful recovery.This case highlights the incidence of a rare and aggressive manifestation of NLV on the breast that mimics NF, emphasizing the clinical differentiation that may lead to catastrophic results and significant cosmetic defect, if a differential diagnosis cannot be determined at the time.

Identification of the Causal Agent of Aqueous Spot Disease of Sweet Cherries (Prunus avium L.) from the Jerte Valley (Cáceres, Spain).

The pre and postharvest disease named ‘aqueous spot’ is an emerging risk for sweet cherries growing in Jerte Valley (Cáceres, Spain). Early stages of the disease appear in the tree, but it is usually detected after harvesting, during the postharvest period. Symptoms include the appearance of skin discolouration and translucency in the shoulder areas. At the most advanced stages, a mycelium of white colour partially or completely covers the fruit. This manuscript provides a detailed description of the microbes involved in this disease, such as bacteria, yeasts, and moulds. Microbes of different cherry cultivars were studied during two consecutive seasons (2019 and 2020). The counts of bacteria and yeast in damaged tissues were higher (7.05 and 6.38 log10 CFU/g for total aerobic mesophilic microbes and yeasts, respectively) than sound tissues (6.08 and 5.19 log10 CFU/g, respectively). The Enterobacterales order dominated the bacteria population. Among yeasts, Yarrowia lipolytica, in 2019, and Metschnikowia pulcherrima and Metschnikowia viticola, in 2020, were consistently isolated from all samples. The presence of moulds was inconsistently detected at the early stage of this disease by plate counts. However, microscopic observations revealed the presence of hyphae in cherry flesh. Different pathogenic moulds were identified, although white mycelium, identified as Botrytis cinerea by molecular methods, was consistently isolated at later stages. Inoculation tests confirmed the involvement of white-mycelium B. cinerea in the development of this new postharvest disease in the Jerte Valley. Its combination with Enterobacterales enhanced the evolution of rotting, whereas the combination with yeasts decreased and delayed the symptoms. This work presents the first report of a consortia of microorganisms implicated in the development of ‘aqueous spot’, an emerging disease in sweet cherry cultivars in the Jerte Valley.

Do facially disfiguring features influence attention and perception of faces? Evidence from an antisaccade task.

Facial disfigurements can influence how observers attend to and interact with the person, leading to disease-avoidance behaviour and emotions (disgust, threat, fear for contagion). However, it is unclear whether this behaviour is reflected in the effect of the facial stigma on attention and perceptual encoding of facial information. We addressed this question by measuring, in a mixed antisaccade task, observers’ speed and accuracy of orienting of visual attention towards or away from peripherally presented upright and inverted unfamiliar faces that had either a realistic looking disease-signalling feature (a skin discolouration), a non-disease-signalling control feature, or no added feature. The presence of a disfiguring or control feature did not influence the orienting of attention (in terms of saccadic latency) towards upright faces, suggesting that avoidance responses towards facial stigma do not occur during covert attention. However, disfiguring and control features significantly reduced the effect of face inversion on saccadic latency, thus suggesting an impact on the holistic processing of facial information. The implications of these findings for the encoding and appraisal of facial disfigurements are discussed.

A CLASSICAL REVIEW ON SNAYUKA ROGA WITH SPECIAL REFERENCE TO DRACUNCULIASIS

Snayuka roga is caused by a kapha-raktaja krimi, named Snayuka. In Ayurveda, reference of Snayuka roga is available in Bhavprakash, Sharangadhara Samhita, Madhava Nidana and Yogaratnakara. This disease is characterised by shotha (swelling), daha (severe burning sensation), discolouration of skin, blisters formation similar to visarpa (Erysipelas) and it further worsens the condition if the jivam (worm) crawls out of ulcer breaks further worsens the condition. On complete exit of worm from body through the wound, the symptoms get reduced. However, it can reoccur in other distant places. These symptoms and presentation of Snayuka roga resembles with Dracunculiasis in modern science, which was endemic in various countries in last century. Dracunculiasis, a vector-borne disease, commonly known as Guinea-worm disease, is caused by the parasite called Dracunculus medinensis, commonly called as "Guinea-worm". Its larvae migrate through the Cyclops containing water to the hosts by drinking and after degeneration of Cyclops in the stomach; they migrate to subcutaneous tissues, causing severe pain along with burning sensation followed by local swelling, blisters and finally an ulcer. In India the GWD was endemic in 89 districts in seven states. India was declared as guinea worm disease free country by WHO in 2000. But intestinal parasitic infection is a main public health problem in developing countries. There is need to create awareness among people about intestinal parasitic infections. Hence, here an effort has been made to understand and review Snayuka roga, caused by Snayuka krimi as explained in Ayurvedic texts, correlating Dracunculiasis (Guinea worm disease- GWD).

Computer Vision for Jaundice Detection in Neonates Using Graphic User Interface

TitlePhysiological jaundice occurs in the first week of life in newborns due to the increase in bilirubin level which in turn leads to yellowish discolouration of skin and sclera. Sever jaundice and toxic level of bilirubin can cause brain damage as bilirubin exists in the central nervous systems. Invasive blood sampling is the optimum method to measure bilirubin level; however, it is painful and stressful for the neonate, and it may cause blood loss and can lead to anaemia, especially when repeated blood tests are required. In addition, blood tests expose the infant to the risk of infections. Moreover, invasive tests are time-consuming as their results are not immediate. Due to all the problems mentioned earlier, this paper proposes a new system for jaundice detection that is based on skin colour analysis. The proposed system uses a digital camera as a colour based screening tool as it is affordable, objective, ubiquitous, and less painful to infants. Based on the analysis obtained from the captured images, jaundice was detected and estimated, opening the door for further case studies in medical applications, especially in diagnosis, monitoring patient’s health, and supplying active treatment.

EXPERIENCE OF EVALUATION OF PATIENTS OF OBSTRUCTIVE JAUNDICE BY SONOGRAPHY AND MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY AT A TERTIARY CARE CENTRE IN EASTERN INDIA

INTRODUCTION: Jaundice means yellow due to the yellowish discolouration of skin, sclera, and mucous membrane seen in jaundice caused by bilirubin pigment. It is divided in to two forms obstructive(surgical) and non- obstructive (non-surgical). AIM AND OBJECTIVE: To evaluate patients of obstructive jaundice by sonography and magnetic resonance cholangiopancreatography and compare the reporting and ndings by both the modalities. MATERIALS AND METHODS: Cross sectional observational study done from November 2018 to October 2020 and consists of 32 patients who had clinical jaundice and consented to being subjected to both ultrasound and MRCP. OBSERVATIONS:Both USG and MRCP were able to detect extrahepatic CBD dilatation equally in 25 patients. In 5(15.6%) patients USG and MRI both demonstrated intrahepatic mass causing obstruction at the level of conuence of right and left hepatic duct or CHD. Ultrasonography was able to detect the intrinsic mass of the extrahepatic common bile duct in 2(6.2%) patients out of 32 patients in our study population. MRCP could detect the same in 6(18.7%) patients. In our study narrowing of CBD with stricture formation and upstream dilatation of biliary tree was identied in 10(31.2%) patients on MRCP. Ultrasound could diagnose the same in one patient. Both USG and MRCP were able to detect pancreatic head mass as well as pseudocyst. CONCLUSION: The accuracy of MRCP was found to be comparable to that of ERCP for diagnosis of etiology for obstructive jaundice. MRCP allows better lesion characterization and assessment. However, the patchy availability of MR machines become the main achilles heel for the surgeons as well as the radiologists. Hence the valuable role of the omnipresent ultrasonography become immense.

Electrochemical Behaviour of Real-Time Sensor for Determination Mercury in Cosmetic Products Based on PANI/MWCNTs/AuNPs/ITO

Mercury is a common ingredient found in skin lightening soaps, creams, and makeup-cleansing products. It may cause skin rashes, skin discolouration, and scarring, as well as a reduction in the skin’s resistance to bacterial and fungal infections. By looking at this scenario, developing a sensor that involved a simple procedure and fasts for real-time detection without affecting mercury sensitivity is urgently needed. For that reason, a fast and sensitive electrochemical method was developed to determine mercury in cosmetic products with the composition of polyaniline/multi-walled carbon nanotubes/gold nanoparticles/indium tin oxide sheet using methylene blue as a redox indicator. The significantly enhanced electrochemical performance was observed using cyclic voltammetry (CV) and differential pulse voltammetry (DPV). In order to detect mercury qualitatively and quantitatively, deposition potential and deposition time were respectively optimised to be 0.10 V and 70 s. The modified sensor was revealed a wide detection range of mercury from 0.01 to 10.00 ppm with a limit of detection of 0.08 ppm. The modified sensor towards mercury with a correlation coefficient (r2) was of 0.9948. Multiple cycling, reproducibility, and consistency of different modified sensors were investigated to verify the modified sensor’s performance. The developed sensing platform was highly selective toward mercury among the pool of possible interferents, and the stability of the developed sensor was ensured for at least 21 days after 10 repeated uses. The proposed method is a fast and simple procedure technique for analysing the mercury levels in cosmetic products.

Thrombolytic strategies versus standard anticoagulation for acute deep vein thrombosis of the lower limb.

Standard treatment for deep vein thrombosis (DVT) aims to reduce immediate complications. Use of thrombolytic clot removal strategies (i.e. thrombolysis (clot dissolving drugs), with or without additional endovascular techniques), could reduce the long-term complications of post-thrombotic syndrome (PTS) including pain, swelling, skin discolouration, or venous ulceration in the affected leg. This is the fourth update of a Cochrane Review first published in 2004. To assess the effects of thrombolytic clot removal strategies and anticoagulation compared to anticoagulation alone for the management of people with acute deep vein thrombosis (DVT) of the lower limb. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries to 21 April 2020. We also checked the references of relevant articles to identify additional studies. We considered randomised controlled trials (RCTs) examining thrombolysis (with or without adjunctive clot removal strategies) and anticoagulation versus anticoagulation alone for acute DVT. We used standard methodological procedures as recommended by Cochrane. We assessed the risk of bias in included trials with the Cochrane 'Risk of bias' tool. Certainty of the evidence was evaluated using GRADE. For dichotomous outcomes, we calculated the risk ratio (RR) with the corresponding 95% confidence interval (CI). We pooled data using a fixed-effect model, unless we identified heterogeneity, in which case we used a random-effects model. The primary outcomes of interest were clot lysis, bleeding and post thrombotic syndrome. Two new studies were added for this update. Therefore, the review now includes a total of 19 RCTs, with 1943 participants. These studies differed with respect to the thrombolytic agent, the doses of the agent and the techniques used to deliver the agent. Systemic, loco-regional and catheter-directed thrombolysis (CDT) strategies were all included. For this update, CDT interventions also included those involving pharmacomechanical thrombolysis. Three of the 19 included studies reported one or more domain at high risk of bias. We combined the results as any (all) thrombolysis interventions compared to standard anticoagulation. Complete clot lysis occurred more frequently in the thrombolysis group at early follow-up (RR 4.75; 95% CI 1.83 to 12.33; 592 participants; eight studies) and at intermediate follow-up (RR 2.42; 95% CI 1.42 to 4.12; 654 participants; seven studies; moderate-certainty evidence). Two studies reported on clot lysis at late follow-up with no clear benefit from thrombolysis seen at this time point (RR 3.25, 95% CI 0.17 to 62.63; two studies). No differences between strategies (e.g. systemic, loco-regional and CDT) were detected by subgroup analysis at any of these time points (tests for subgroup differences: P = 0.41, P = 0.37 and P = 0.06 respectively). Those receiving thrombolysis had increased bleeding complications (6.7% versus 2.2%) (RR 2.45, 95% CI 1.58 to 3.78; 1943 participants, 19 studies; moderate-certainty evidence). No differences between strategies were detected by subgroup analysis (P = 0.25). Up to five years after treatment, slightly fewer cases of PTS occurred in those receiving thrombolysis; 50% compared with 53% in the standard anticoagulation (RR 0.78, 95% CI 0.66 to 0.93; 1393 participants, six studies; moderate-certainty evidence). This was still observed at late follow-up (beyond five years) in two studies (RR 0.56, 95% CI 0.43 to 0.73; 211 participants; moderate-certainty evidence). We used subgroup analysis to investigate if the level of DVT (iliofemoral, femoropopliteal or non-specified) had an effect on the incidence of PTS. No benefit of thrombolysis was seen for either iliofemoral or femoropopliteal DVT (six studies; test for subgroup differences: P = 0.29). Systemic thrombolysis and CDT had similar levels of effectiveness. Studies of CDT included four trials in femoral and iliofemoral DVT, and results from these are consistent with those from trials of systemic thrombolysis in DVT at other levels of occlusion. Complete clot lysis occurred more frequently after thrombolysis (with or without additional clot removal strategies) and PTS incidence was slightly reduced. Bleeding complications also increased with thrombolysis, but this risk has decreased over time with the use of stricter exclusion criteria of studies. Evidence suggests that systemic administration of thrombolytics and CDT have similar effectiveness. Using GRADE, we judged the evidence to be of moderate-certainty, due to many trials having small numbers of participants orevents, or both. Future studies are needed to investigate treatment regimes in terms of agent, dose and adjunctive clot removal methods; prioritising patient-important outcomes, including PTS and quality of life, to aid clinical decision making.

Assessment of determinants of polycystic ovarian syndrome in women in reproductive age group attending tertiary healthcare facility in southern Maharashtra

Introduction: Pathophysiology of PCOS reveals excessive ovarian and/or adrenal androgen secretion results in hyperandrogenism and is associated clinical manifestations ranging from hirsutism, acne, male-pattern baldness to irregular menses, infertility. This study aims at assessing the prevalence and clinical presentations of PCOS among women of the reproductive age group attending the OPD of a tertiary care centre. Materials and Methods: The study was carried women of reproductive age group (15-45yrs) attending Obstetrics and Gynaecology OPD of a tertiary care hospital presenting with relevant symptoms from July 2015 to July 2017. Results: In the present study, the average age of participant was 22.47 + 3.44 years, we also found that menstrual abnormalities were observed among all the study participants followed by skin discolouration (32.4%). Average BMI in kg/m2 was 22.22 + 2.22. Conclusions: PCOS in a common disorder among young women. Menstrual problems are the commonest reason for gynecological OPD consultation among adolescent girls. Evaluation of bleeding problems in adolescents is justified, before considering them as normal physiological transition. Keywords: Polycystic ovarian syndrome (PCOS), Menstrual abnormalities, Hyperandrogenism in women, Reproductive age women, Infertility.

A CASE STUDY: ROLE OF RAKTAMOKSHAN AND BAHYA LEPA IN MANAGE-MENT OF PSORIASIS

Psoriasis is an autoimmune skin disease characterized by red scaly patches over the skin. Broadly all the diseases of skin come under the umbrella of kustha. In ayurvedic text, Charaka samhita, kustha has been beautifully explained. Psoriasis is an immune mediated disease which mistakenly sends out faulty signals for a normal skin assuming it as a pathogen which causes overproduction of new skin cells. Fortunately, it is a non-contagious inflammatory skin disease. Psychological stress is one of the major triggering factors in the exacerbation of the disease. Ekkustha has similar features as like Psoriasis. Ayurveda is a holistic ap-proach particularly correcting the root cause through shodhana (panchakarma). While explaining the treatment for kustha, acharya chakarapani explains repetitive shodhana karma to be done on regular in-tervals to cure the disease. Hence a single case of ekkustha was given Raktamokshana followed by bahya lepa at regular interval to access the effect of the procedures. Different assessment criteria were used to monitor the improvements. There was significant relief in the scaling, discolouration of skin, elevated patches & redness of the skin lesion which explains that detoxification of the body reduces the inflamma-tory condition of the body by bringing back the normalcy of the dosha in the body