Showing papers in "Journal of Association of Physicians of India in 2006"

Vitamin B12 deficiency and hyperhomocysteinemia in rural and urban Indians.

Abstract: Background : Low vitamin B12 concentration in South Asian Indians is common, but the exact prevalence is not known. Aim : To investigate prevalence and associations of low vitamin B12 concentration and hyperhomocysteinemia in rural and urban Indian men living in and around Pune, Maharashtra. Method : We studied 441 middle-aged men (149 rural, 142 slum and 150 urban middle-class residents, mean age 39 y). Data on lifestyle, socio-economic status, nutrition and medical history were obtained. Circulating concentrations of vitamin B12, folate, ferritin, total homocysteine (tHcy), and haematological indices, and cardiovascular risk variables were measured. Results : Median plasma B12 concentration was low (110 pmol/L): Overall, 67% of men had low vitamin B12 concentration ( 15 µmol/L). Of the urban middle class, 81% had low vitamin B12 concentration and 79% had hyperhomocysteinemia. Low vitamin B12 concentration contributed 28% to the risk of hyperhomocysteinemia (population attributable risk) while low red cell folate contributed 2%. Vegetarians had 4.4 times (95%CI 2.1, 9.4) higher risk of low vitamin B12 concentrations and 3.0 times (95%CI 1.4, 6.5) higher risk of hyperhomocysteinemia compared to those who ate non-vegetarian foods frequently. Urban middle-class residence was an additional independent risk factor of hyperhomocysteinemia (odds ratio 7.6 (95%CI 2.5, 22.6), compared to rural men). Low vitamin B12 concentration was related to lower blood haemoglobin concentration and higher mean corpuscular volume, but macrocytic anemia was rare. Conclusion : Low vitamin B12 concentration and hyperhomocysteinemia are common in Indian men, particularly in vegetarians and urban middle class residents. Further studies are needed to confirm these findings in other parts of India. ©

Relevance of Weil-Felix test in diagnosis of scrub typhus in India

Abstract: Objective To study the relationship of Weil-Felix test and microimmunofluorescence test. Methods Sera of 21 patients with clinical diagnosis of scrub typhus were subjected to Weil-Felix and Microimmunofluorescence tests. Results On Weil-Felix test, 13 (62%) sera showed titers 1: > or = 40-320. 7 patients showed titers 1: > or = 320, 3 showed titers 1 : 160, 2 showed titers 1 : 80 and 1 patients showed titers 1 : 40, to Proteus OXK antigen. All 21 sera showed significant titers to O. tsutsugamushi on microimmunofluorescence. Conclusion Weil-Felix test is not a very sensitive test in diagnosis of scrub typhus but due to of lack of availability of definitive tests in India it canbe a useful tool when used and interpreted in the correct clinical context.

Gestational Diabetes Mellitus - Guidelines*

Abstract: The Diabetes In Pregnancy Study group India (DIPSI) is reporting practice guidelines for GDM in the Indian environment. Due to high prevalence, screening is essential for all Indian pregnant women. DIPSI recommends that as a pregnant woman walks into the antenatal clinic in the fasting state, she has to be given a 75g oral glucose load and at 2 hrs a venous blood sample is collected for estimating plasma glucose. This one step procedure of challenging women with 75 gm glucose and diagnosing GDM is simple, economical and feasible. Screening is recommended between 24 and 28 weeks of gestation and the diagnostic criteria of ADA are applicable. A team approach is ideal for managing women with GDM. The team would usually comprise an obstetrician, diabetes physician, a diabetes educator, dietitian, midwife and pediatrician. Intensive monitoring, diet and insulin is the corner stone of GDM management. Oral agents or analogues though used are still controversial. Until there is evidence to absolutely prove that ignoring maternal hyperglycemia when the fetal growth patterns appear normal on the ultrasonogram, it is prudent to achieve and maintain normoglycemia in every pregnancy complicated by gestational diabetes. The maternal health and fetal outcome depends upon the care by the committed team of diabetologists, obstetricians and neonatologists. A short term intensive care gives a long term pay off in the primary prevention of obesity, IGT and diabetes in the offspring, as the preventive medicine starts before birth.

Hypertension in pregnancy: hospital based study.

Abstract: Eighteen hundred two pregnant women consisting of 750 primigravida and 1,052 multigravida were screened for hypertension between July 2000 to June 2002. Hypertension was noted in 97 (5.38%) patients. Twenty five patients were lost to follow up and only 72 patients were included in the final study. The age of the patients ranged between 19 to 32 (mean +/- SD = 24.75 +/- 3.36) years. The majority of patients 41 (57%) were primigravida and 31 (43%) were multigravida. Of 31 multigravida, vast majority (84%) of patients were found to be hypertensive in the third trimester. Only 5 (16%) patient had hypertension in the first trimester. Stage I, II and III hypertension were noted in 18%, 50% and 32% of patients respectively as per JNC-VI criteria. Preeclampsia (PE) was seen in 44.44% (n=32), eclampsia in 40.28% (n=29), HELLP syndrome in 6.94% (n=5), chronic hypertension (HTN) with superimposed PE in 6.94% (n=5) and chronic HTN in 1.38% (n=1). Of the 6 patients with chronic hypertension 50% (3) had essential HTN. Acute renal failure (S. creat > 3 mg/dl) was seen in 7 patients and 4 required dialytic support. Maternal mortality was 5.55% (4) and perinatal death occurred in 37.5% (27) of deliveries. Low birth weight was seen in 66.66% (48) of births. Hypertension complicated 5.38% of all pregnancies in our study. Preeclampsia-eclampsia and its variants remain the major cause of hypertension in pregnant women. Hypertension during pregnancy is responsible for high fetal mortality and low birth weight.

Biological significance of essential fatty acids.

Abstract: Essential fatty acids (EFAs)--linoleic acid (LA) and alpha-linolenic acid (ALA) are critical for human survival. EFAs are readily available in the diet. But, to derive their full benefit, EFAs need to be metabolized to their respective long-chain metabolites. EFAs not only form precursors to respective prostaglandins (PGs), thromboxanes (TXs), and leukotrienes (LTs), but also give rise to lipoxins (LXs), resolvins, isoprostanes, and hydroxy- and hydroperoxyeicosatetraenoates. Certain PGs, TXs, and LTs have pro-inflammatory actions whereas LXs and resolvins are anti-inflammatory in nature. Furthermore, EFAs and their long-chain metabolites modulate the activities of angiotensin converting and HMG-CoA reductase enzymes, enhance acetylcholine levels in the brain, increase the synthesis of endothelial nitric oxide, augment diuresis, and enhance insulin action. Thus, EFAs and their metabolites may function as endogenous ACE and HMG-CoA reductase inhibitors, nitric oxide enhancers, beta-blockers, diuretics, anti-hypertensive, and anti-atherosclerotic molecules. In addition, EFAs and their long-chain metabolites react with nitric oxide (NO) to yield respective nitroalkene derivatives that exert cell-signaling actions via ligation and activation of peroxisome proliferator-activated receptors (PPARs). Thus, EFAs and their derivatives have varied biological actions that may have relevance to their involvement in several physiological and pathological processes.

Management Issues in the Metabolic Syndrome

Abstract: The metabolic syndrome or cardiovascular dysmetabolic syndrome is characterized by obesity, central obesity, insulin resistance, atherogenic dyslipidemia, and hypertension. The major risk factors leading to this syndrome are physical inactivity and an atherogenic diet and cornerstone clinical feature is abdominal obesity or adiposity. In addition, patients usually have elevated triglycerides, low HDL cholesterol, elevated LDL cholesterol, other abnormal lipid parameters, hypertension, and elevated fasting blood glucose. Impaired fibrinolysis, increased susceptibility to thrombotic events, and raised inflammatory markers are also observed. Given that India has the largest number of subjects with type-2 diabetes in the world it can be extrapolated that this country also has the largest number of patients with the metabolic syndrome. Epidemiological studies confirm a high prevalence. Therapeutic approach involves intervention at a macro-level and control of multiple risk factors using therapeutic lifestyle approaches (diet control and increased physical activity, pharmacotherapy - anti-obesity agents) for control of obesity and visceral obesity, and targeted approach for control of individual risk factors. Pharmacological therapy is a critical step in the management of patients with metabolic syndrome when lifestyle modifications fail to achieve the therapeutic goals. Anti-obesity drugs such as sibutramine and orlistat can be tried to reduce weight and central obesity and jointly control the metabolic syndrome components. Other than weight loss, there is no single best therapy and treatment should consist of treatment of individual components of the metabolic syndrome. Newer drugs such as the endocannabinoid receptor blocker, rimonabant, appear promising in this regard. Atherogenic dyslipidemia should be controlled initially with statins if there is an increase in LDL cholesterol. If there are other lipid abnormalities then combination therapy of statin with fibrates, nicotinic acid, or ezetimibe should be considered. For insulin resistance, drugs such as thiazolidinediones and renin-angiotensin system blockers are available. Available evidence suggests that angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) may be more beneficial for treatment of hypertension in patients with metabolic syndrome compared to others as these drugs also prevent development of diabetes. Patients with metabolic syndrome also have elevations in fibrinogen and other coagulation factors leading to prothrombotic state and aspirin may be beneficial for primary prevention in these patients. The new developments in the treatment of metabolic syndrome with drugs, such as peroxisome proliferator-activated receptor (PPAR) agonists and cannabinoid receptor-1 antagonists, will broaden the horizons of the current treatment options. Fixed-dose combination polypharmacy using a single pill is an interesting concept that needs to be evaluated in long-term prospective trials in such patients. ©

Correlation between timing of ASV administration and complications in snake bites.

Abstract: Aims of study: The present study was undertaken to study the relationship between the time of anti-snake venom (ASV) administration due to late arrival of patient at hospital and subsequent development of complications. Material and methods: All patients of snake bite that presented to our institution over a period of 1% years were included in the present study. A detailed clinical history, clinical examination and investigations were carried out. The patients were administered ASV within 10 minutes of presentation. The bite to needle time (time between the bite and start of ASV) was noted. The patients were then followed up to note any subsequent development of complications. The end-point of the study was normalization of haematological and neurological parameters. Results: Fifty patients became eligible for the study. Twenty patients (40%) had complications while remaining 30 patients (60%) were uncomplicated. An attempt was made to study relationship between bite to needle time and subsequent development of complications. It was found to be significant at 5% level of significance (p<0.05) by chi square test. Conclusion: Incidence of complications was directly proportional to the duration of venom in the blood prior to neutralization by ASV due to late arrival of patient at hospital. The early institution of ASV is beneficial in preventing complications however severe is the systemic envenomation.

Mortality rates due to diabetes in a selected urban south Indian population--the Chennai Urban Population Study [CUPS--16].

Abstract: Objective : The aim of this study was to determine the mortality rate in diabetic and non-diabetic subjects in urban south India. Methods : The Chennai Urban Population Study is an ongoing epidemiological study in Chennai [formerly Madras, in south India]. All individuals ≥ 20 years of age living in two residential colonies in Chennai were invited to participate in the study. Of the total 1399 eligible subjects, 1262 individuals responded [90.2%] at baseline, and of these, 1140 individuals [90.3%] could be followed annually from 1997 to 2003-04. Mortality rates and causes of death were the main outcome measures. Results : The median follow up period was six years. The overall mortality rate was higher in diabetic compared to non-diabetic subjects [18.9 vs.5.3 per 1000 person-years, p=0.004]. Mortality due to cardiovascular [diabetic subjects, 52.9%; non-diabetic subjects, 24.2%,p=0.042] and renal causes[diabetic subjects, 23.5%; non-diabetic subjects, 6.1%,p=0.072] was higher among diabetic subjects whereas mortality due to gastrointestinal [12.1%], respiratory [9.1%], lifestyle related [6.1%] and unnatural causes [18.2%] were observed only among non-diabetic subjects. Hazards ratio [HR] for all cause mortality for diabetes was 3.6, [95% Confidence Interval [CI]: 2.02-6.53, p<0.001] and this remained significant even after adjusting for age [HR:1.9, 95% CI:1.04-3.45, p=0.038]. Light grade physical activity was associated with higher mortality rate [p=0.008], but the significance disappeared when adjusted for age. Smoking was also associated with increased mortality. Conclusions : In urban India, mortality rates are two fold higher in people with diabetes compared to nondiabetic subjects. Cardiovascular and renal diseases are the commonest causes of death among diabetic subjects. ©

Study on clinico-epidemiological profile of HIV patients in eastern India.

Abstract: In this study, 438 HIV positive patients attending the HIV clinic of Sir Sundar Lal Hospital, IMS, BHU were enrolled. Of these 354 were males (mean CD4 count 179 +/- 9.3 cells/microl) and 84 were females (mean CD4 count 323 +/- 28.26 cells/microl). The mean age of the study subjects at the time of diagnosis was 32.6 years. Heterosexual contact was the commonest mode of transmission in 352 (80.4%) patients followed by blood transfusion in 2.5%. History suggestive of a risk factor for HIV transmission could not be elicited in 62 (14.1%) patients. Among male patients, 71.5% were migrant workers. Fever (70.6%), weight loss (53.3%), chronic diarrhea (43.9%) and cough (40.3%) were the common presenting symptoms. Out of the 438 patients, 66.4% had opportunistic infections at the time of reporting to the hospital. The most common opportunistic infection was tuberculosis (38.8%) followed by oropharyngeal candidiasis (20.3%) and diarrhea (12.7%). CD4 counts of the patients were significantly inversely correlated with the number of symptoms and the number of opportunistic infections (correlation coefficient were -.289 and -.236 respectively).

Prevalence of tobacco use and awareness of risks among school children in Jaipur.

Abstract: Background : Smoking and tobacco use is a major public health issue in developing countries. We performed an epidemiological study to determine the prevalence of smoking and tobacco-use and awareness of risks of tobacco use among school children. Methods : Students in randomly selected schools in Jaipur were studied. Students in classes 9-12 (age 13-18 years, boys 2866, girls 939) were enrolled. Medical social workers filled in information regarding presence of smoking and other forms of tobacco use among these children. Details of presence of tobacco use among family members, awareness of harms of tobacco and proactive role of children were also inquired. Results : Fifty nine boys (2.1%, 95% confidence interval1.5% to 2.6%) and 16 girls (1.7%, 0.9% to 2.5%) agreed to current tobacco use. Smoking cigarettes or bidis was present in 43 boys (1.5%, 72.8% of users) and 8 girls (0.8%, 50.0% of users). Smoking or tobacco use was present in immediate family of 1208 boys (42.1%) and 304 girls (32.4%) (p<0.001) but was significantly more in family of children who used tobacco (boys 51/59, 86.4%, girls 11/16, 68.8%). 2842 boys (99.2%) boys and 934 girls (99.5%) were aware that tobacco use is harmful and similar proportions disliked it. More than 90% students were aware of its importance in causing respiratory diseases and the majority of boys and girls, respectively, knew of its potential to cause general debility (55.7%, 54.1%), heart disease (56.8%, 58.3%), cancer (64.6%, 64.6%), impotence (40.9%, 23.2%), ulcer of stomach (48.1%, 46.4%) and death (68.2%, 68.1%). 76.4% boys and 75.7% girls considered quitting to smoke beneficial and 77.1% boys and 75.8% girls knew that passive smoking is bad. 75.7% boys and 75.0% girls would insist that no-one smokes in their presence. 1592 boys (55.5%) and 507 girls (54.0%) remembered seeing tobacco related advertisement in news-paper and could recall name of the brand. 57.2% boys and 62.4% girls agreed to participate in a tobacco-awareness and cessation program, however only 5.2% of the students had attempted tobacco-control among family or peers. Conclusions : There is low prevalence of smoking and tobacco use in school children in Jaipur. Awareness of harmful effects of tobacco is high. ©

Health problems and disability of elderly individuals in two population groups from same geographical location.

Abstract: Objective : To compare morbidity, disability (ADL-IADL disability) along with behavioral and biological correlates of diseases and disability of two elderly population groups (tea garden workers and urban dwellers) living in same geographical location. Methods : Two hundred and ninety three and 230 elderly from urban setting and tea garden respectively aged > 60 years were included in the study. Subjects were physical examined and activity of daily living instrumental activity of daily living (ADL-IADL) was assessed. Diagnosis of diseases was made on the basis of clinical evaluation, diagnosis and/or treatment of diseases done earlier elsewhere, available investigation reports, and electrocardiography. Hypertension was defined according to JNC-VI classification. BMI (weight/height 2 ) was calculated. Logistic regression analysis was performed to see the impact of important background characteristics on non-communicable diseases (NCD) and disability. Results : Hypertension (urban - 68% and tea garden - 81.4%), musculoskeletal diseases (urban - 62.5% and teagarden - 67.5%), COPD and other respiratory problems (urban - 30.4% and tea garden - 32.2%), cataract (urban 40.3% and tea garden - 33%), gastro-intestinal problems (urban - 13% and tea garden - 6.5%) were more commonly observed health problems among community dwellings elderly across both the groups. However in contrast to urban group, serious NCDs like Ischaemic Heart Disease (IHD), diabetes were yet to emerge as health problems among tea garden dwellers. Infectious morbidities, undernutrition and disability (ADL-IADL disability) were more pronounced among tea garden dwellers. Utilization of health service by tea garden elderly was very low in comparison to the urban elderly. Both tea garden men and women had very high rates of risk factors like use of non-smoked tobacco and consumption of alcohol. On the other hand, smoking and obesity was more common in urban group. Most morbidities and disabilities were associated with identifiable risk factors, such as obesity, tobacco (smoked and non-smoked) and alcohol consumption. Educational status was also found to be an important determinant of diseases and disability of elderly population. Age showed a J-shaped relationship with disability and morbidity. Sex difference in health status was also detected. Conclusion : This study highlights the physical dimension of health problems of elderly individuals. Social circumstances and health risk behaviours play important role in the variation of health and functional status between the two groups. Life-style modification is warranted to prevent onset of chronic diseases. To improve quality of life, rectification of poor health status through affordable health service for disease screening and better management of illness, nutritional improvement and greater health awareness are necessary particularly among low socio-economic group. Low-cost intervention like cataract surgery could make a difference in the quality of life of elderly Indian. ©

Prevalence of rheumatic heart disease in school children in Bikaner: an echocardiographic study.

Abstract: Objective: To determine prevalence of rheumatic heart disease (RHD) using clinical and echocardiographic criteria and to study influence of socioeconomic status (SES) we studied school children in a north-western Indian town. Methods : 3292 school children, age range 5-14 years, in two private schools, ten middle SES government schools and six low SES government schools were invited to participate in the study. 3002 (1837 boys, 1165 girls) were clinically examined (response 91%) of which 1042 were in private schools, 1002 in middle SES schools and 958 in low SES schools. Prevalence of cardiac murmurs and RHD based on clinical diagnosis was determined in school by a trained team of physicians. Those with a murmur were further evaluated by Doppler-echocardiography in the hospital. Group-specific and age-specific rates (prevalence/thousand) of murmurs and cardiac lesions were determined. Results : A significant cardiac murmur was observed in 55 subjects (18.3/1000) with similar prevalence in boys (20.7) and girls (14.6). The prevalence of murmur was significantly greater in children belonging to low SES schools (29.2/1000) as compared to middle SES (18.9) and higher SES schools (7.6). RHD prevalence based on clinical diagnosis was observed in 50 children (16.7/1000) and was similar in boys (19.1) and girls (12.9). Clinical RHD was more in the low SES school children (28.2/1000) as compared to middle (17.0) and high SES schools (5.8). RHD was demonstrated on echocardiography in 2 children (0.67/1000). Other prevalent cardiac lesions were congenital heart disease in 5 (1.66/1000) and mitral valve prolapse in 37 (12.3/1000). Conclusions: There is a low prevalence of RHD in school children in this region compared to previous Indian studies. Cardiac murmurs are more prevalent among low SES children.

Community empowerment--a successful model for prevention of non-communicable diseases in India--the Chennai Urban Population Study (CUPS-17).

Abstract: BACKGROUND AND OBJECTIVE: Randomized clinical trials have documented that lifestyle changes through physical activity can prevent diabetes. However there is no data whether such strategies are applicable at community level, that is, in a real life setting. This study demonstrates the first attempt in India, to our knowledge, of increasing physical activity through community empowerment in an attempt at primary prevention of non communicable diseases. METHODS: The Chennai Urban Population Study [CUPS] was conducted in the year 1996 in two residential areas: a middle income group the Asiad colony at Tirumangalam, and a low income group at Bharathi Nagar in T. Nagar. The Asiad colony was selected for this study. Of the 524 eligible individuals available at baseline in 1998 [age > or =20 years], 479 individuals consented for the study (response rate: 91.4%). After seven years, in 2004, the number of eligible individuals increased to 712 of whom 705 consented for the study (response rate:99%). Education regarding the benefits of physical activity was provided by mass awareness programmes like public lectures and video clippings. Both at baseline and during follow-up, details about the physical activity were collected using a validated questionnaire, which included job related and leisure time activities, and specific questions on exercise. Study individuals were then graded as having light, moderate and heavy physical activity using a scoring system. RESULTS: In response to the awareness programmes given by our research team, the colony residents constructed a unique public park with their own funds. Though the occupation grades did not change, there was a significant change in the pattern of physical activity. At baseline, only 14.2% of the residents did some form of exercise. more than three times a week, which presently increased to 58.7% [p < 0.001]. The number of subjects who walked more than three times a week increased from 13.8% at baseline to 52.1% during follow-up [p < 0.001]. CONCLUSION: This study is a demonstration of how community empowerment with increased physical activity could possibly lead to prevention of diabetes and other non communicable diseases at the community level. This study also highlights the importance of sharing the results of research studies with the community.

Pregnancy outcomes in pre-gestational and gestational diabetic women in comparison to non-diabetic women--A prospective study in Asian Indian mothers (CURES-35).

Abstract: Background and objective : Diabetes can complicate pregnancy but it is not the major complication of pregnancy. Though prevalence of diabetes is alarmingly high among Indians there have been very few studies assessing the effect of diabetes on pregnancy outcomes, particularly comparing pre-gestational diabetes mellitus [PGDM] and gestational diabetes [GDM] with non-diabetic mothers. Methods : Pregnant women attending the Dr. Mohan's Diabetes Specialities Centre, a tertiary care centre for diabetes in Chennai in southern India were selected for the study. PGDM and GDM were defined using standard criteria. Out of the 245 pregnant women with diabetes registered at the centre, follow up data was available for 225, which included 79 PGDM and 146 GDM subjects. Non-diabetic controls (n=30) were recruited from the ongoing population based study the Chennai Urban Rural Epidemiology Study (CURES). Details of outcome variables including abortions, mode of delivery, congenital anomalies and neonate’s birth weight were documented. Results : Women with PGDM had significantly higher fasting plasma glucose [p<0.001] and fructosamine [p<0.001] levels compared to GDM. Proportion of women who underwent abortions was 0% in non-diabetic controls, 10.1% in PGDM and 2.7% in GDM and the difference between PGDM and GDM was statistically significant [p = 0.04]. Prevalence of ‘low birth weight’ babies in the study groups were, 14.3% in non-diabetic mothers, 12.3% in PGDM and 8.2% in GDM. The prevalence of ‘large babies’ was higher in GDM [27.6%] and PGDM [19.2%] groups compared to non-diabetic controls [7.1%] but the differences reached statistical significance only in the GDM group [p = 0.04]. Prevalence of congenital anomalies was 0% among nondiabetic controls, 3.8% in PGDM and 1.4% in GDM but the differences did not reach statistical significance. A significant increase in frequency of abortions [trend chi square = 5.67, p = 0.017] and ‘low birth weight’ babies [trend chi square = 4.761,p = 0.029] was observed with increasing fructosamine levels in the diabetic mothers. Conclusion : Women with diabetes have worse pregnancy outcomes compared to non-diabetic mothers with and those with pre-gestational diabetes fare worse than those with gestational diabetes. The study emphasizes the fact that strict glycemic control is extremely important during pregnancy. ©

Subjective global assessment of nutritional status of patients with chronic renal insufficiency and end stage renal disease on dialysis.

Abstract: Objectives : (1)To assess the nutritional status of chronic renal insufficiency (CRI ) and dialysis patients using the subjective global assessment (SGA) method. (2) To validate SGA in assessing the nutritional status of this group of patients. Participants: The nutritional status of 81 patients was evaluated using dietary recall, anthropometry, biochemical parameters and SGA. There were 51 males and 30 females. Their mean µ SD age was 53.8 µ 14.3 years. There were 27 patients with (CRI) on conservative management, 38 patients with end stage renal disease (ESRD) on maintenance hemodialysis (HD) and 16 patients with ESRD on continuous ambulatory peritoneal dialysis (CAPD). Methods: SGA was done using seven variables derived from medical history and physical examination. Each variable was scored from 1-7 depending on the severity. The SGA scores were correlated with the standard methods. Results: Thirteen (48%) patients with CRI, 22 (58%) patients on HD and 8 (50%) patients on CAPD were malnourished. It was seen that the dietary protein & calorie intake and serum albumin level did not correlate well with the SGA scores. The anthropometric measures correlated with the SGA scores (Skinfolds and SGA r = 0.2, MAC and SGA r = 0.5 and MAMC and SGA r = 0.5). Conclusion : Malnutrition is an important complication in CRI patients and ESRD patients on dialysis. SGA is a reliable method of assessing nutritional status. Most important is the fact that it can detect the changing trend of nutritional status, which may be missed by one-time anthropometry and biochemical methods. ©

Tropical infections in the ICU.

Abstract: Certain arthropod-borne infections are common in tropical regions because of favorable climatic conditions. Water-borne infections like leptospirosis are common due to contamination of water especially during the monsoon floods. Infections like malaria, leptospirosis, dengue fever and typhus sometimes cause life threatening organ dysfunction and have several overlapping features. Most patients present with classicial clinical syndromes: fever and thrombocytopenia are common in dengue, malaria and leptospirosis; coagulopathy is frequent in leptospirosis and viral hepatitis. Hepatorenal syndrome is seen in leptospirosis, falciparum malaria and scrub typhus. The pulmonary renal syndrome is caused by falciparium malaria, leptospirosis, Hantavirus infection and scrub typhus. Fever with altered mental status is produced by bacterial meningitis, Japanese B encephalitis, cerebral malarial, typhoid encephalopathy and fulminant hepatic failure due to viral hepatitis. Subtle differences in features of the organ failure exist among these infections. The diagnosis in some of these diseases is made by demonstration of antibodies in serum, and these may be negative in the first week of the illness. Hence empiric therapy for more than one disorder may be justified in a small proportion of cases. In addition to specific anti-infective therapy, management of organ dysfunction includes use of mechanical ventilation, vasopressor drugs, continuous renal replacement therapy and blood products. Timely transfer of these patients to well-equipped ICUs with experience in managing these cases can considerably decrease mortality and morbidity.

Adipocytokines and the expanding 'Asian Indian Phenotype'.

Abstract: expenditure.13 In addition to adipocytokines, proinflammatory markers like tumour necrosis factor-α [TNFα] inhibit insulin signaling in human adipocytes,14 enhance insulin resistance and increase the risk for diabetes. Recent reports show that Indians have low levels of adiponectin compared to their Caucasian counterparts.15 In this issue of JAPI, Lele and Joshi16 report on interesting new information on the relation of adipocytokines with diabetes in urban western Indians. They show that adiponectin and leptin have a reciprocal association with diabetes. In a south Indian population, we showed that low adiponectin levels are associated with hypertriglyceridemia, low HDL cholesterol, insulin resistance and other components of the metabolic syndrome.17 As low levels of adiponectin have been demonstrated in migrant Indians, one could speculate that this could be one of the mechanisms for the increased diabetic tendency observed in Indians. It is of interest that in the study by Lele and Joshi,16 leptin had a positive association with obesity indices but a negative association with diabetes. This has been earlier documented in Caucasians.18 It is possible that adipocytokines secreted from different fat depots may have differential effects on diabetes.

Hypertension as a low-grade systemic inflammatory condition that has its origins in the perinatal period.

Abstract: Genetics, oxidative stress: superoxide anion (O2*-) and hydrogen peroxide (H2O2), endothelial nitric oxide (eNO), lipid peroxides, anti-oxidants, endothelin, angiotensin converting enzyme (ACE) activity, angiotensinII, transforming growth factor-beta (TGF-beta), insulin, homocysteine, asymmetrical dimethyl arginine, proinflammatory cytokines: interleukin-6 (IL-6), tumor necrosis factor-a (TNF-alpha), C-reactive protein (hs-CRP), and long-chain polyunsaturated fatty acids (LCPUFAs), and activity of NAD(P)H oxidase have a role in human essential hypertension. There is a close interaction between endogenous molecules: eNO, endothelin, cytokines, and nutrients: folic acid, L-arginine, tetrahydrobiopterin (H4B), vitamin B6, vitamin B12, vitamin C, and LCPUFAs. Statins mediate some, if not all, of their actions through LCPUFAs, whereas these fatty acids (especially omega-3 fatty acids) suppress cyclo-oxygenase activity and the synthesis of pro-inflammatory cytokines, and activate parasympathetic nervous system, actions that reduce the risk of major vascular events. Some LCPUFAs form precursors to lipoxins and resolvins that have anti-inflammatory actions. Low-grade systemic inflammation seen in hypertension seems to have its origins in the perinatal period and availability of adequate amounts of LCPUFAs during the critical periods of brain growth prevents the development of hypertension. This indicates that preventive strategies aimed at decreasing the incidence of hypertension and its associated conditions such as atherosclerosis, type 2 diabetes, coronary heart disease (CHD), and cardiac failure in adulthood need to be instituted during the perinatal period if they are to be effective.

Cytokine network and its manipulation in rheumatoid arthritis.

Abstract: Studies of the inflammatory process in the inflamed synovium from rheumatoid arthritis patients have shown an intricate network of molecules involved in its initiation, perpetuation and regulation trial balances the pro- and anti-inflammatory process. This system is self-regulating though the action of anti-inflammatory and pro-inflammatory cytokines cytokine receptor antagonists and naturally occurring antibodies cytokines. Inflammatory synovitis in rheumatoid arthritis (and possibly in other inflammatory arthritidies) appears to be the result of an imbalance in the cytokine network with either an excess production of pro-inflammatory cytokines or from inadequacy of the natural anti-inflammatory mechanisms. Using this knowledge the newer therapeutic approaches to RA and other inflammatory arthritides are being aimed at correcting this imbalance. Monoclonal antibodies to INF-alpha (humanised form of this is called infliximab), soluble TNF-alpha receptors (etanercept) are already in clinical use and adalimumab (humanised TNF-alpha antibody). IL-1Ra is undergoing clinical trials. Other promising therapeutic agents that could regulate the cytokine network are in various stages of laboratory and clinical evaluation. These studies promise to yield therapeutic targets that could dramatically change the way inflammatory diseases would he treated in the future. The now established efficacy of infliximab and etanercept in inflammatory arthritides could be considered just a glimpse of the exciting scenario of the future.

The natural history of complicated falciparum malaria--a prospective study.

Abstract: Objective : Despite a substantial disease burden, little is known about the natural history of complicated falciparum malaria. Therefore, the present prospective study was undertaken to assess the clinical course, outcome, and resolution time of various complications of falciparum malaria. Methods : This prospective study has been conducted in a tertiary health care institution with high prevalence of malaria. A cohort of 608 patients of complicated falciparum malaria with single and multiple complications were enrolled. After discharge, all patients were followed up for 1 month except patients with anaemia who were followed up for 3 months. The onset time, interval of progression of one complication to other, resolution time of complications and mortality were determined. Results : At the time of admission there were 288 (46.8%) patients with single complication (SC) and 320 (53.2%) patients with multiple complications (MC). Majority (n=214, 74.3%) of patients with SC had cerebral malaria, followed by jaundice (14.6%), anaemia (6.9%), hypoglycaemia (2.1%), and respiratory distress (2.1%). The multiple complications were found in various combinations and majority (n=136, 42.5%) had constellation of 3 different complications. Cerebral malaria, jaundice, and renal failure (102 of 136, 75.3%) were the most common combination. Regardless of number of complications, cerebral malaria was present in 91.6% (293 of 320) patients with MC. As the population of patients progressed from single to multiple complications, increasing proportions had jaundice, renal failure, and anaemia. 12.8% to 36.2% of patients in any category progressed from one complication to other complication within 72 hrs. There mortality rate was 14.6%, 21.3%, 30.9%, 38.5%, 100%, and 100% among patients with 1,2,3,4,5, and 6 complications respectively. Conclusion : This is the first prospective study that provides the clinical evidence that complicated malaria represents a hierarchical continuum of abnormalities resulting from malaria infection. All complications developed within 5 days (median 72 hrs, range-2 to120hrs.) of onset of fever. Pre-pernicious stage had been recognised in cases of cerebral malaria. Each complication is unique in its onset and recovery time. Not only the number but also the type of complication influences the outcome of complicated malaria. ©

Association of adipocytokines (leptin, adiponectin TNF-alpha), insulin and proinsulin with diabetes--the Mumbai Obesity Project [MOP].

Abstract: Asian Indians have a unique phenotype characterized by increased abdominal obesity and visceral fat despite low body mass index [BMI]. Though studies have indicated some adipocytokines to be associated with diabetes and obesity in Indians, there are virtually no studies relating adipocytokines and proinsulin with diabetes and obesity in Asian Indians. In this study we looked at adipocytokines- leptin, adiponectin and tumour necrosis factor-a [TNF-α] and insulin and proinsulin in subjects with diabetes and obesity. Thirty five diabetic subjects and 50 healthy controls were recruited for the study. Leptin [p=0.002] and adiponectin levels [p=0.011] were lower and proinsulin values higher [p<0.001] in diabetic subjects compared to non-diabetic subjects. In addition, leptin [p<0.001] and proinsulin [p<0.001] were higher and adiponectin [p<0.001] lower, in obese subjects compared to non-obese subjects. TNF-α failed to show any significant difference between the study groups. Leptin and proinsulin showed a significant and positive correlation with BMI [p<0.001] and waist circumference [p<0.001]. Adiponectin showed an inverse correlation with BMI [p=0.050] and waist circumference [p=0.002]. Proinsulin showed a significant negative association with adiponectin [p=0.002]. Logistic regression analysis revealed leptin to be negatively associated [Odds ratio [OR]: 0.864, 95% confidence interval [95% CI]: 0.775 -0.963, p=0.008] and proinsulin [OR: 1.567, 95% CI: 1.246-1.971, p<0.001] to be positively associated with diabetes even after adjusting for age, gender and BMI. Leptin [OR: 1.365, 95% CI: 1.170-1.592, p<0.001] and proinsulin [OR: 1.617, 95% CI: 1.218 -2.147, p=0.001] showed a significant positive association with obesity, while adiponectin [OR: 0.927, 95% CI: 0.865 – 0.995, p=0.035] had a significant inverse association. Linear regression analysis revealed that adiponectin is inversely associated with proinsulin even after the addition of age, gender and diabetes status [β= -0.61, p=0.033] into the model. In conclusion, in urban Asian Indians in western India, proinsulin levels showed a positive association, while leptin and adiponectin showed a negative association with diabetes. With regard to obesity, leptin and proinsulin had a positive association, while adiponectin had a negative association. Proinsulin levels showed an inverse association with adiponectin indicating a possible link between insulin secretion and insulin resistance. ©

Diagnosis of leptospirosis--role of MAT.

Abstract: ELISA/SAT MAT Interpretation +ve Single high titer Current infection +ve-ve Current infection-ve Single high titer Past infection ± Seroconversion/ Current infection 4 fold rise in titer We read the article by Dutta et al on " Leptospirosis-An Overview " with interest. 1 The problem in utilizing microscopic agglutination test (MAT) has been highlighted and we shall discuss briefly the current status of MAT. MAT is considered the gold standard test for diagnosis of leptospirosis. It has unsurpassed specificity, but its sensitivity is low compared to ELISA/SAT (Slide agglutination test). Angelo P Brendo et al from Brazil in their study of 108 cases of leptospirosis have stated that 65% of first sample where positive by SAT compared to 44% by MAT. 2 A four-fold rise in titer or seroconversion is the most definitive criteria for diagnosis of leptospirosis. Therefore a second sample is mandatory, which is difficult to obtain. In such circumstances, a single high titer in MAT can be taken as diagnostic criteria. As MAT titers peak and persist for a long time (5-10 yrs), they would interfere with current diagnosis. Therefore many workers use different criteria. 3 A titer of 1:100 is taken as significant criteria, but there is controversy on the single diagnostic titer as they depend on endemicity (Table 1). In endemic areas, a titer of 1/100 or 1/200 is considered low; while high titer is usually > 1/400 (some consider 1/800 or 1/1600 as diagnostic criteria). In non-endemic areas, 1/100 titer is taken as diagnostic criteria. It is preferable to do SAT/ELISA along with single high titers. Positive SAT/ELISA with high titers suggest current infection, while negative SAT/ELISA is probably due to past infection (Table 2). Therefore in the modified Faine's criteria, a four-fold rise in MAT has been given 25 points, while single high titer has been given 15 points along with SAT/ELISA. 2,4 In addition, low titers based on endemicity in the original Faine's criteria has been excluded as they complicate diagnosis. Serosurvey in the asymptomatic high risk group should be done with MAT only and a titer of > 1/50 can be taken as cut off titer. During an epidemic, the microbiology laboratories would be burdened with large number of samples (about 25 or more). It would be impossible to do MAT as it is complicated test. In addition the laboratories need to have all the 24 serogroups; otherwise, a negative MAT does …

Paget's disease from Western India.

Abstract: Aim and Objective: To prospectively study prevalence of Paget's disease from Western India. Methods and Materials: Seventeen consecutive cases from Western India from 1998 to 2005 are analysed for the clinical, biochemical, skeletal profile. Seventeen cases (15 males & 2 females) with mean age of 62 were diagnosed Results: The Western Indian cohort of Paget's disease has male preponderance with a mean age of 62 years at onset. Its clinical features are pain, fracture and typical skeletal involvement. It is a non-familial, polyostotic disease with pelvis, skull, spine and femur being the commonly affected bone sites. Elevated alkaline phosphatase is typical which responds well to bisphosphonate therapy in 6 months. Most cases do well with low dose alendronate (10-20mg/day). Conclusions: Paget's disease in western India is rare with classical clinical, radiological and biochemical features and responds well to low dose alendronate therapy. In eight years, seventeen cases of Paget's disease were seen from Western India indicating though still rare is present in this population of Western India.

Prevalence of cardiovascular risk factors in Indian patients undergoing coronary artery bypass surgery.

Abstract: Background : Conventional cardiovascular risk factors (CVRFs) are known to infl uence short-term and long-term outcome following coronary artery bypass graft surgery (CABG). There has been recent increase in prevalence of CVRFs in general population in India. However no information is available regarding the prevalence of same in patients undergoing CABG. Methods and Results : In this cross-sectional study, one thousand consecutive patients undergoing elective CABG were included and data on major CVRFs was obtained in them. Mean age of the patients was 59.73 ± 9.5 years and 884/1000 (88.4%) patients were males. 505/994 (50.8%) patients had BMI > 25.0 kg/m 2 and 747/ 994 (75.2%) had BMI > 23.0 kg/m 2 . Diabetes mellitus was present in 475/1000 (47.5%) patients (46.5% men and 55.2% women), hypertension in 709/1000 (70.9% overall; 70.8% men and 71.6% women) and dyslipidemia in 781/913 patients (85.6% overall; 84.5% men and 93.9% women). 213/913 (23.3%) patients had LDL > 100mg/dl, 662/913 (72.5%) patients had low HDL and 338/913 (37.0%) patients had elevated triglycerides. 199/1000 (19.9%) patients (18.7% men and 29.3% women) had family history of premature CAD and 545/1000 (54.5%) patients (53.4% men and 62.9% women) had at least one family member having CAD (irrespective of the age of onset). 94/1000 (9.4%) patients (10.4% men and 1.7% women) were current smokers and another 302/1000 (30.2% overall; 33.7% men and 3.4% women) had history of smoking in the preceding one year. 876/913 (95.9%) of all the patients had at least one of the fi ve major CVRFs and only 37/913 (4.1%) patients (4.1% men and 4.3% women) were free of all these risk factors. Sixty-one of the 1000 patients (6.1%) were younger than 45.0 years of age. As compared to older patients, dyslipidemia, family history of premature CAD and smoking were commoner in patients less than 45 years of age. In contrast, diabetes and hypertension were more prevalent in the older individuals. Conclusions : The present study showed high prevalence of most of the conventional CVRFs, esp. diabetes, hypertension and dyslipidemia in Indian population undergoing CABG. ©

Management of echinococcosis.

Abstract: Cystic echinococcosis is a zoonosis caused by larval forms of the tapeworm Echinocorccus granulosus and transmitted by dogs. In humans, the disease is characterized by slowly growing cyst commonly occurring in liver and lungs. Clinical features of hepatic hydatid cyst are mainly light upper quadrant pain, feeling of lump and enlarged tender liver. The cyst may be complicated by infection or rupture and may lead to anaphylactic reaction. Ultrasonography supported by serology is the main diagnostic modality. Treatment of univesicular cyst is predominantly medical or percutaneous. Percutaneous treatment (PAIR) is safe and effective and complications are infrequent. For multivesicular and complicated cyst surgery remains the mainstay of treatment.

Efficacy of species specific anti-scorpion venom serum (AScVS) against severe, serious scorpion stings (Mesobuthus tamulus concanesis Pocock)--an experience from rural hospital in western Maharashtra.

Abstract: BACKGROUND: Death caused by scorpion envenoming is a common event in the tropical and subtropical countries including many regions in India. Severe scorpion envenoming causes an autonomic storm producing multi-system organ-failure (MSOF) and death. OBJECTIVES: To determine the efficacy of Anti-scorpion venom serum (AScVS) in patients stung by scorpions (Mesobuthus tamulus concanesis Pocock--earlier called Buthus tamulus); to compare it with other modalities of therapy and to detect complications, if any, arising out of AScVS treatment. METHODS: Total 48 patients of severe, serious scorpion envenoming syndrome were studied during the period from 1992 to 2002. In 17 patients AScVS was the only mode of treatment. Others had received adjunctive therapy along with AScVS. RESULTS: 47 patients out of 48 scorpion sting victims recovered completely. Recovery period in patients given AScVS (10 hours) was faster than those who received alpha blockers (16-42 hours). No anaphylactic reaction with AScVS was observed. CONCLUSIONS: AScVS is effective and safe method of therapy in severe scorpion envenoming syndrome. Language: en

Cleistanthus collinus poisoning

Abstract: Cleistanthus collinus is an extremely toxic plant poison. Cleistanthin A and B, the toxins of Cleistanthus collinus, are diphyllin glycosides which produce cardiac arrhythmias, urinary potassium wasting, hypoxia, metabolic acidosis and hypotension. We report ARDS, distal renal tubular acidosis and distributive shock secondary to inappropriate vasodilatation in a case following ingestion of its leaves.

Thallium poisoning presenting as paresthesias, paresis, psychosis and pain in abdomen.

Abstract: Due to involvement of multiple systems, thallium poisoning is notorious for complexity and seriousness as symptoms of toxicity are non-specific and diverse. Alopecia and painful neuropathy are its cardinal features, others being gastrointestinal disturbances, encephalopathy, tachycardia, ataxia, hepatorenal and cardiac damage etc. We report a case of thallium poisoning who presented initially with gastrointestinal symptoms and later developed neurological features (peripheral neuropathy and delirium). Various diagnoses were entertained in this case and thallium poisoning was suspected only after he developed alopecia and neuropsychosis. He made a significant recovery by conservative management in spite of delay in diagnosis. We conclude that a high level of suspicion should be kept for thallium poisoning, especially in patients with painful, peripheral neuropathy and gastrointestinal symptoms which appear earlier than alopecia, since prognosis is more rewarding with early diagnosis, leading to complete recovery.

Quality of life in Parkinson's disease--Indian scenario.

Abstract: UNLABELLED The subjective sense of well being is central to the concept of quality of life (QoL) and a good QoL should be the ultimate goal to any therapeutic measure. In Parkinson's disease (PD), several rating scale are in vogue to measure the QoL, namely PDQ-39, PDQ-8, SF-36, Likert scale etc. Parkinson's Impact Scale (PIMS) has been used in this study to assess the QoL which includes 10 items. METHODOLOGY Thirty two patients of Parkinson's disease satisfying the UK Parkinson's disease brain bank diagnostic criteria, ranging from HY stage I to IV have been recruited. UPDRS was also administered to them. Statistical analysis was performed using Spearman rank correlation and multivariate stepwise regression analysis using SPSS for windows. RESULT Seventy two percents were male, all getting levodopa, 72% got anticholinergics. Monthly income varied from Rs.800 (US dollars 17.10) to Rs.15,000 (US dollars 320) pm. Eighty eight percent belonged to HY II-III. UPDRS score ranged from 3-85 (40.4 +/- 18.6). PIMS total score ranged from 1-22 (10.4 +/- 6.1). DISCUSSION AND CONSLUSION: The QoL deteriorates with H-Y staging, the UPDRS score, not with advancing age as seen in other studies. It is also significantly influenced by duration of the disease and financial security. Surprisingly, the family and community relations were not significantly affected with advancing disease, perhaps due the close family and social tie up among Indians. So, measurement of QoL should be made an essential part to the routine assessment of PD patients to get a complete scenario of the problem. PIMS can serve as a comprehensive tool for the same suitable for use in the OPD.

Outcome predictors for non-invasive positive pressure ventilation in acute respiratory failure

Abstract: Background: Noninvasive positive pressure ventilation (NIPPV) has emerged as a significant advancement in the management of acute respiratory failure. Objective: To identify factors, based on clinical and laboratory parameters, for predicting the outcome of NIPPV in patients with acute respiratory failure. Materials and Methods: Fifty patients were included in the study. Inclusion criteria were RR>30 breaths / min, PaO 2 <60mmHg, PaO 2 /FiO 2 <300, pCO 2 ≤45mmHg and signs of increased work of breathing. Baseline clinical parameters and arterial blood gas (ABG) were recorded before initiating NIPPV. Clinical parameters including heart rate, respiratory rate, oxygen saturation and ABG was revaluated at 1, 4, 12, 24 hrs after initiation of NIPPV. Change in these parameters and need for intubation was evaluated. Results: Of the 50 patients, 37 (74%) showed clinical and ABG improvement. Out of 13 (26%) patients who failed to respond, 7 (52%) needed endotracheal intubation within 1 hr. There was significant improvement in clinical and ABG parameters within 1 st hr in success group and these parameters continues to improve even after 4 hrs of NIPPV treatment (p<0.05). Failure group had higher baseline heart rate than success group (p<0.05). Conclusion: Determination of baseline clinical factors such as heart rate and respiratory rate, available at the time of initiation and after a short period, can predict the likelihood of success or failure of NIPPV. As a result, delay in intubation can be avoided which itself is associated with significant mortality.