Showing papers in "Journal of Postgraduate Medicine in 2017"

Psychiatric disorders and obesity: A review of association studies.

Abstract: Background: Inconsistent evidence exists regarding the strength, direction, and moderators in the relationship between obesity and psychiatric disorders. Aim: This study aims to summarize the evidence on the association between psychiatric illness and obesity with particular attention to the strength and direction of association and also the possible moderators in each postulated link. Materials and Methods: Systematic electronic searches of MEDLINE through PubMed, ScienceDirect, PsycINFO, and Google Scholar were carried out from inception till October 2016. Generated abstracts were screened for eligibility to be included in the review. Study designs that evaluated the strength of relationship between obesity and psychiatric disorders were included in the study. Quality assessment of included studies was done using the Newcastle–Ottawa checklist tool. Results: From a total of 2424 search results, 21 eligible articles were identified and reviewed. These included studies on obesity and depression (n = 15), obesity and anxiety (four) and one each on obesity and personality disorders, eating disorder (ED), attention deficit hyperactivity disorder, and alcohol use. Maximal evidence existed for the association between depression and obesity with longitudinal studies demonstrating a bidirectional link between the two conditions. The odds ratios (ORs) were similar for developing depression in obesity (OR: 1.21–5.8) and vice versa (OR: 1.18–3.76) with a stronger association observed in women. For anxiety disorders, evidence was mostly cross-sectional, and associations were of modest magnitude (OR: 1.27–1.40). Among other disorders, obesity, and EDs appear to have a close link (OR: 4.5). Alcohol use appears to be a risk factor for obesity and not vice versa but only among women (OR: 3.84). Conclusion: Obesity and depression have a significant and bidirectional association. Evidence is modest for anxiety disorders and inadequate for other psychiatric conditions. Gender appears to be an important mediator in these relationships.

Ketogenic diet in endocrine disorders: Current perspectives.

Abstract: Ketogenic diet (KD) is a high-fat, adequate-protein, and low-carbohydrate diet that leads to nutritional ketosis, long known for antiepileptic effects and has been used therapeutically to treat refractory epilepsy. This review attempts to summarize the evidence and clinical application of KD in diabetes, obesity, and other endocrine disorders. KD is usually animal protein based. An empiric vegetarian Indian variant of KD has been provided keeping in mind the Indian food habits. KD has beneficial effects on cardiac ischemic preconditioning, improves oxygenation in patients with respiratory failure, improves glycemic control in diabetics, is associated with significant weight loss, and has a beneficial impact on polycystic ovarian syndrome. Multivitamin supplementations are recommended with KD. Recently, ketones are being proposed as super-metabolic fuel; and KD is currently regarded as apt dietary therapy for “diabesity.”

Photokeratitis induced by ultraviolet radiation in travelers: A major health problem

Abstract: Ultraviolet (UV) irradiation is one of the several environmental hazards that may cause inflammatory reactions in ocular tissues, especially the cornea. One of the important factors that affect how much ultraviolet radiation (UVR) humans are exposed to is travel. Hence, traveling is considered to include a more acute UVR effect, and ophthalmologists frequently evaluate and manage the ocular manifestations of UV irradiation, including UV-induced keratitis. The purpose of this paper is to provide an evidence-based analysis of the clinical effect of UVR in ocular tissues. An extensive review of English literature was performed to gather all available articles from the National Library of Medicine PubMed database of the National Institute of Health, the Ovid MEDLINE database, Scopus, and ScienceDirect that had studied the effect of UVR on the eye and its complications, between January 1970 and June 2014. The results show that UVR at 300 nm causes apoptosis in all three layers of the cornea and induces keratitis. Apoptosis in all layers of the cornea occurs 5 h after exposure. The effect of UVR intensity on the eye can be linked to numerous factors, including solar elevation, time of day, season, hemisphere, clouds and haze, atmospheric scattering, atmospheric ozone, latitude, altitude, longitudinal changes, climate, ground reflection, and geographic directions. The most important factor affecting UVR reaching the earth's surface is solar elevation. Currently, people do not have great concern over eye protection. The methods of protection against UVR include avoiding direct sunlight exposure, using UVR-blocking eyewear (sunglasses or contact lenses), and wearing hats. Hence, by identifying UVR intensity factors, eye protection factors, and public education, especially in travelers, methods for safe traveling can be identified.

Effect of Vitamin D therapy on urinary albumin excretion, renal functions, and plasma renin among patients with diabetic nephropathy: A randomized, double-blind clinical trial.

Abstract: Background: Despite different management strategies, progression of proteinuria occurs in a sizable category of patients with diabetic nephropathy (DN). Increase in serum renin levels induced by the renin–angiotensin system (RAS) may contribute to this. Vitamin D therapy is found to have an inhibitory effect on the RAS. We aimed to study the effects of Vitamin D therapy on renal functions of patients with DN. Methods: This was a double-blind, randomized, placebo-controlled study. Patients with DN (urinary albumin [UA] >30 mg/g of creatinine) whose estimated glomerular filtration rate (eGFR) was more than 30 mL/min were selected and their plasma renin, parathyroid hormone, serum Vitamin D, serum calcium, serum creatinine, fasting blood sugar were done as baseline measurements. Subjects were randomized into two groups and treatment group was given Vitamin D, 50000 IU (0.25 ml) intramuscularly (IM) monthly for 6 months; control group received distilled water IM. Investigations were repeated after 6 months of therapy. Results: Of 155 patients invited, 85 were randomly assigned to two groups. After 6 months, mean reduction of UA to creatinine ratio in the treatment and control group was 51.8 mg/g (95% confidence interval [CI]; 66.1–−37.5, P ≤ 0.001); 22.4 mg/g (95% CI; −45.7–0.8, P = 0.06), respectively (between group difference P = 0.001). Significant increase in the eGFR observed in the treatment group while eGFR remained unchanged in the control group (P = 0.03 for the between-group difference). Mean reduction in plasma renin in treatment group and control group was 5.85 pg/mL (95% CI; −6.7–−4.6) (P

Does prehospital time affect survival of major trauma patients where there is no prehospital care

Abstract: Background: Survival after major trauma is considered to be time dependent. Efficient prehospital care with rapid transport is the norm in developed countries, which is not available in many lower middle and low-income countries. The aim of this study was to assess the effect of prehospital time and primary treatment given on survival of major trauma patients in a setting without prehospital care. Materials and Methods: This prospective observational study was carried out in a university hospital in Mumbai, from January to December 2014. The hospital has a trauma service but no organized prehospital care or defined interhospital transfer protocols. All patients with life- and/or limb-threatening injuries were included in the study. Injury time and arrival time were noted and the interval was defined as “prehospital time” for the directly arriving patients and as “time to tertiary care” for those transferred. Primary outcome measure was in-hospital death (or discharge). Results: Of 1181 patients, 352 were admitted directly from the trauma scene and 829 were transferred from other hospitals. In-hospital mortality was associated with age, mechanism and mode of injury, shock, Glasgow Coma Score <9, Injury Severity Score ≥16, need for intubation, and ventilatory support on arrival; but neither with prehospital time nor with time to tertiary care. Transferred patients had a significantly higher mortality (odds ratio = 1.869, 95% confidence interval = 1.233–2.561, P = 0.005) despite fewer patients with severe injury. Two hundred and ninety-four (35%) of these needed airway intervention while 108 (13%) needed chest tube insertion on arrival to the trauma unit suggesting inadequate care at primary facility. Conclusion: Mortality is not associated with prehospital time but with transfers from primary care; probably due to deficient care. To improve survival after major trauma, enhancement of resources for resuscitation and capacity building of on-duty doctors in primary centers should be a priority in countries with limited resources.

Acceptability and feasibility of mini-clinical evaluation exercise as a formative assessment tool for workplace-based assessment for surgical postgraduate students.

Abstract: Background: Despite an increasing emphasis on workplace-based assessment (WPBA) during medical training, the existing assessment system largely relies on summative assessment while formative assessment is less valued. Various tools have been described for WPBA, mini-clinical evaluation exercise (mini-CEX) being one of them. Mini-CEX is well accepted in Western countries, however, reports of its use in India are scarce. We conducted this study to assess acceptability and feasibility of mini-CEX as a formative assessment tool for WPBA of surgical postgraduate students in an Indian setting. Methods: Faculty members and 2nd year surgical residents were sensitized toward mini-CEX and requisite numbers of exercises were conducted. The difficulties during conduction of these exercises were identified, recorded, and appropriate measures were taken to address them. At the conclusion, the opinion of residents and faculty members regarding their experience with mini-CEX was taken using a questionnaire. The results were analyzed using simple statistical tools. Results: Nine faculty members out of 11 approached participated in the study (81.8%). All 16 2nd year postgraduate surgical residents participated (100%). Sixty mini-CEX were conducted over 7 months. Each resident underwent 3–5 encounters. The mean time taken by the assessor for observation was 12.3 min (8–30 min) while the mean feedback time was 4.2 min (3–10 min). The faculty reported good overall satisfaction with mini-CEX and found it acceptable as a formative assessment tool. Three faculty members (33.3%) reported mini-CEX as more time-consuming while 2 (22.2%) found it difficult to carry the exercises often. All residents accepted mini-CEX and most of them reported good to high satisfaction with the exercises conducted. Conclusions: Mini-CEX is well accepted by residents and faculty as a formative assessment tool. It is feasible to utilize mini-CEX for WPBA of postgraduate students of surgery.

Do high sensitivity C-reactive protein and serum interleukin-6 levels correlate with disease activity in systemic lupus erythematosuspatients?

Abstract: Introduction: Systemic Lupus Erythematosus (SLE) is an inflammatory autoimmune disease where an interplay between acute phase proteins and cytokines are involved in disease activation. Aim and Objectives: This case control study was performed to investigate interrelationship between high sensitivity C-reactive proteins (hs-CRP), Interleukin-6 (IL-6) levels and disease activity among SLE patients. Materials and Methods: One hundred forty one clinically diagnosed SLE cases were included and disease activity was noted by SLE Disease Activity Index (SLEDAI). Serum IL-6 levels were measure by cytokine multiplex assay. Serum hs-CRP, C3 and C4 levels were measure by nephelometer. The Pearson correlation test was used for correlation between hs-CRP, Il-6 and SLEDAI. Results: Based on SLEDAI, 126 patients (89.4 %) had active disease and 15 patients (10.6%) had inactive disease. Mean hs-CRP levels in SLE patients were significantly higher (12.1+ 11.5 mg/L) than controls (2.41+ 1.37 mg/L) (P < 0.0001). Hs-CRP levels among active SLE were significantly higher (13.5+ 11.4 mg/L) as compared with inactive SLE (4.4 + 2.9 mg/L) (P=0.0002). Similarly, IL-6 levels in SLE patients were significantly higher among active SLE (26.9 + 15.5 pg/ml) as compared with inactive SLE (13.9+ 10.2 pg/ml) (P=0.0001). An inverse correlation between Il-6 and hemoglobin levels between active and inactive SLE was noted (r=-0.46, P <0.0001). Conclusion: This study suggests a good correlation between hs-CRP, IL-6 and SLE disease activity indicating their direct involvement in inflammatory conditions associated with disease.

An epidemiological profile of chronic obstructive pulmonary disease: A community-based study in Delhi

Abstract: Background: Different definitions used for chronic obstructive pulmonary disease (COPD) preclude getting reliable prevalence estimates. Study objective was to find the prevalence of COPD as per standard Global Initiative for Chronic Obstructive Lung Disease definition, risk factors associated, and treatment seeking in adults >30 years. Methodology: Community-based cross-sectional study was conducted in Delhi, among 1200 adults, selected by systematic random sampling. Pretested questionnaire was used to interview all subjects and screen for symptoms of COPD. Postbronchodilator spirometry was done to confirm COPD. Statistical Analysis: Adjusted odds ratio (aOR) was calculated by multivariable analysis to examine the association of risk factors with COPD. Receiver operating characteristic (ROC) curve was developed to assess predictability. Results: The prevalence of COPD was 10.1% (95% confidence interval [CI] 8.5, 11.9%). Tobacco smoking was the strongest risk factor associated (aOR 9.48; 95% CI 4.22, 14.13) followed by environmental tobacco smoke (ETS), occupational exposure, age, and biomass fuel. Each pack-year of smoking increased 15% risk of COPD. Ex-smokers had 63% lesser risk compared to current smokers. Clinical allergy seems to preclude COPD (aOR 0.06; 95% CI 0.02, 0.37). ROC analysis showed 94.38% of the COPD variability can be assessed by this model (sensitivity 57.4%; positive predictive value 93.3%). Only 48% patients were on treatment. Treatment continuation was impeded by its cost. Conclusion: COPD prevalence in the region of Delhi, India, is high, and our case-finding population study identified a high rate of patients who were not on any treatment. Our study adds to creating awareness on the importance of smoking cessation, early diagnosis of COPD, and the need for regular treatment.

The impact of topical Saint John's Wort (Hypericum perforatum) treatment on tissue tumor necrosis factor-alpha levels in plaque-type psoriasis: A pilot study.

Abstract: Context: Psoriasis is an inflammatory disorder, formed by inappropriate interaction of T lymphocytes with keratinocytes, and consequent eruption of immune responses. High concentrations of tumor necrosis factor-alpha (TNFα) are found in the skin lesions and plasma of patients with psoriasis. Hypericum perforatum, a phytomedicine that has both anti-inflammatory and antiproliferative properties, has been recently reported to be clinically helpful for improvement of psoriatic lesions. Aims: The aim of the present study was to investigate the effects of topical H. perforatum on TNFα levels in psoriatic lesions for possible identification of the mechanism by which Hypericum reduces inflammation and modulates the disease in patients with plaque-type psoriasis. Settings and Design: A double-blind, placebo-controlled, pilot study with intraindividual comparison was conducted on twenty patients with mild to moderate plaque-type psoriasis. Subjects and Methods: TNFα levels in tissue samples were measured with immunohistochemistry method. Moreover, Psoriasis Area Severity Index (PASI) scores and histological and clinical changes were investigated after topical application of Hypericum extract. Statistical Analysis Used: The Wilcoxon signed-rank test was used to evaluate the possible differences between the drug and placebo group. Results: TNFα concentrations in dermis (p= 0.025), endothelial cells (p=0.033), and dendrite cells (p=0.014) were significantly reduced in lesions treated with drug and the reduction observed in epidermis was superior to placebo (p=0.046). Results of PASI scores showed that erythema, scaling, and thickness were significantly lower where the ointment had been applied compared to application of placebo (p=0.014, p=0.004, p=0.003, respectively). Moreover, significant improvement in clinical and histological features of treated lesions in comparison with untreated lesions was observed (P

Prevalence and risk factors of hypertension and diabetes in the Katkari tribe of coastal Maharashtra

Abstract: Background and Objectives: Urban and rural India are both going through health epidemiological transition and will soon face huge burden of noncommunicable diseases (NCDs). Information on the status of NCDs in tribals is limited. Although the prevalence of hypertension in scheduled tribes (STs) has been studied in several states by the National Nutrition Monitoring Bureau, tribe-specific data are very scanty. The objective of this study was to generate data on the status of hypertension and diabetes, the two objectively measurable NCDs in Katkaris, the dominant ST in the Raigad district of coastal Maharashtra. Methods: The study was conducted in 410 adult Katkaris (women 219) of both sexes of ≥18 years of age in three adjoining tehsils of the district. Using the Institution Review Board approved protocol; information was obtained on sociodemographic parameters, educational level, dietary pattern, and substance abuse. Prevalence of overweight, hypertension, and diabetes was measured using standard field-based procedures and techniques. Results: Katkaris, who are mostly landless manual laborers, subsist on a protein-poor, imbalanced diet. About half of women and one-third of men have body mass index (BMI) <18.5 kg/m2, an indication of undernutrition. On the other hand, about 2% of participants were obese (BMI ≥30 kg/m2). The overall prevalence of hypertension and diabetes was 16.8% and 7.3%, respectively. Hypercholesterolemia was recorded in about 3% of the participants. Interpretation and Conclusions: Prevalence of diabetes and hypertension in Katkaris is still lower than that of urban and rural populations, closer to the latter. This may be due to the absence of known risk factors such as obesity, sedentary lifestyle, and hyperlipidemia in this community. Fast acculturation of the STs suggests that NCDs will soon become a major health issue in them too. It is time to launch a multicentric national study to gather baseline information on the status of NCDs in STs.

Insomnia and risk of nonalcoholic fatty liver disease: A systematic review and meta-analysis.

Abstract: Aim: This sudy aims to investigate the association between insomnia or excessive daytime sleepiness (EDS) and risk of nonalcoholic fatty liver disease (NAFLD). Methods: We searched published studies indexed in MEDLINE and EMBASE database from inception to December 2015. Studies that reported odds ratios (ORs), risk ratios, hazard ratios or standardized incidence ratio with 95% confidence intervals (CI) comparing the risk of NAFLD among participants who had insomnia or EDS versus those without insomnia or EDS were included. Pooled ORs and 95% CI were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird. Cochran's Q test and I2 statistic were used to determine the between-study heterogeneity. Results: Our search strategy yielded 2117 potentially relevant articles (781 articles from MEDLINE and 1336 articles from EMBASE). After comprehensive review, seven studies (three cross-sectional studies and four case–control studies) were found to be eligible and were included in the meta-analysis. The risk of NAFLD in participants who had insomnia was significantly higher with the pooled OR of 1.13 (95% CI, 1.00–1.27). The statistical heterogeneity was moderate with an I2 of 62%. Elevated risk of NAFLD was also observed among participants with EDS even though the 95% CI was wider and did not reach statistical significance (pooled OR 2.21; 95% CI, 0.84–5.82). The statistical heterogeneity was moderate with an I2 of 62%. Conclusions: Our study demonstrated an increased risk of NAFLD among participants who had insomnia or EDS. Whether this association is causal needs further investigations.

Comparison of stress and burnout among anesthesia and surgical residents in a tertiary care teaching hospital in North India.

Abstract: Objective: The residents undergoing training at hospitals in our country face challenges in terms of infrastructure and high workload with undefined working hours. The aim of the study was to compare the stress and burnout levels in trainee doctors doing residency in surgical fields and anesthesia at a tertiary care academic center in North India. Materials and Methods: A comparative, observational study was conducted in a tertiary care teaching hospital in North India. After Ethics Committee approval, 200 residents (100 each from surgical branches and anesthesia) were required to fill a questionnaire with information about age, sex, year of residency, marital status, and the Perceived Stress Scale-10, and Burnout Clinical Subtype Questionnaire-12. Burnout and perceived stress were compared between residents of anesthesia and surgical specialties. Results: Residents of both surgical and anesthesia branches scored high in perceived stress, namely 21 and 18, respectively. The score was significantly higher in surgical residents (P = 0.03) and increased progressively with the year of residency. The majority of residents (90% surgical, 80% anesthesia) felt that they were being overloaded with work. However, only 20%–30% of respondents felt that there was lack of development of individual skills and still fewer (

Salmonella pyomyositis with concurrent sacroiliac osteomyelitis presenting as piriformis syndrome: A rare case

Abstract: A-21-year old male admitted with fever and piriformis syndrome, typically associated with gluteal region pain radiating down the thigh, was evaluated and found to have pyomyositis involving piriformis and osteomyelitis with sacroiliac joint affection on radiological imaging. Salmonella serotype typhi was isolated from blood culture. He was treated with intravenous Ceftriaxone for 6 weeks with signs of recovery documented clinically as well as on imaging studies. Salmonella pyomyositis with osteomyelitis in an immunocompetent patient with no previous hematological or endocrine disorder makes this case an unusual presentation.

Ischemic monomelic neuropathy.

Abstract: Ischemic monomelic neuropathy is an uncommon complication associated with the creation of arteriovenous (AV) fistula for hemodialysis. After placement of an arteriovenous fistula, there can be shunting of arterial blood away from the distal extremity resulting in damage to distal nerve fibers with acute neurologic symptoms. It can present with global muscle pain, weakness, and a warm hand with palpable pulses starting within the 1 st h after the creation of the AV fistula. It is a devastating complication and can result in permanent disability. We hereby report two cases of ischemic monomelic neuropathy associated with the creation of a brachiocephalic AV fistula for hemodialysis access.

Changing trend in bacterial etiology and antibiotic resistance in sepsis of intramural neonates at a tertiary care hospital.

Abstract: Background: Septicemia is an important cause of neonatal morbidity and mortality. However, organized data on causative organisms and their resistant pattern are scanty from developing countries. The changing trend in causative organisms and their antibiotic resistance is yet to be documented in India. The present study examines the trends in bacterial profile and antibiotic resistance of the organisms causing sepsis in hospitalized neonates. Materials and Methods: A retrospective laboratory-based analysis of blood cultures obtained from Neonatal Intensive Care Unit of a tertiary care hospital in New Delhi was done for the period of 1999–2014, divided into five phases. Results: A total of 4700 isolates were considered. Over time, Gram-negative organisms have replaced Gram-positives as frequent isolates. Initially, there was predominance of Klebsiella pneumoniae, then of Staphylococcus aureus which recently has been changed with coagulase negative-Staphylococcus and Acinetobacter. Growing resistance against the first and second line of drugs has been noted, including methicillin-resistant S. aureus and vancomycin-resistant Enterococcus. Conclusion: The etiological profile of neonatal sepsis has changed tremendously in the past 15 years. High resistance against common drugs necessitates continued surveillance and review of empirical antibiotic policy for neonatal sepsis. These steps are important to effectively curtail the surge of further antibiotic resistance.

Gossypibomas in India - A systematic literature review

Abstract: Purpose of Review: Gossypibomas remain a dreaded and unwanted complication of surgical practice. Despite significant interest and numerous guidelines, the number of reported cases remains sparse due to various factors, including potential legal implications. Herein, we review related data from India to ascertain if the problem is better or worse than that reported in world literature. Materials and Methods: A literature search was performed on PubMed and Google Scholar, to collect and analyze all case reports and case reviews regarding the condition in India. Results: On analysis of the results, there were 100 publications reporting a total of 126 events. The average patient age was 38.65 years. Average time to discovery was 1225.62 days. Forty-nine percent of reported cases were discovered within the 1 st year. The most common clinical features were pain (73.8%), palpable mass (47.6%), vomiting (35%), abdominal distention (26%), and fever (12.6%). Spontaneous expulsion of the gossypiboma was noted in five cases (3.96%). Transmural migration was seen in 36 cases (28.57%). Conclusions: Despite advancements in surgical approaches and preventive measures, gossypibomas continue to be a cause of significant morbidity. A safe working culture, open communication, teamwork, and an accurate sponge count remain our best defence against this often unpredictable complication of surgery.

Study of interleukin-6 and interleukin-8 levels in patients with neurological manifestations of dengue.

Abstract: Context: Pro-inflammatory markers play a key role in the pathogenesis of various Flavivirus infection. Aim: In this study, we evaluated the role of these markers in neurological manifestations of dengue. Settings and Designs: Consecutive dengue cases with different neurological manifestations who presented between August 2012 and July 2014 were studied in hospital-based case-control study. Materials and Methods: Interleukin (IL-6) and IL-8 level were measured in serum and cerebrospinal fluid (CSF) of dengue cases with different neurological manifestations and also in age- and sex-matched controls. Level was analyzed with various parameters and outcomes. Statistical Analysis: Statistical analysis was done using SPSS version 16.0 by applying appropriate statistical methods. P < 0.05 considered statistically significant. Results: Out of the 40 enrolled cases of dengue with neurological manifestations, 29 had central nervous system and 11 had peripheral nervous system (CNS/PNS) manifestations. In CNS group, both IL-6 and IL-8 (CSF and serum) were significantly elevated (P < 0.001), whereas CSF IL-6 (P = 0.008), serum IL-6 (P = 0.001), and serum IL-8 (P = 0.005) were significantly elevated in PNS group. CSF IL-6, serum IL-6, and IL-8 were significantly elevated in poor outcome patients in CNS group (P < 0.05). CSF IL-6 and IL-8 were significantly elevated in CSF dengue positive cases as compared to CSF negative patients (P < 0.05). Cytokine level was not significantly correlated with neuroimaging abnormality in CNS group. Nine patients died and the remainder recovered. Conclusion: Elevated level of IL-6 and IL-8 is associated with different neurological manifestations and poor outcome, but whether they are contributing to neuropathogenesis or simply a correlate of severe disease remains to be determined.

Rare disease heralded by pulmonary manifestations: Avoiding pitfalls of an "asthma" label.

Abstract: Pulmonary manifestations are seldom recognized as symptoms of storage disorders. The report describes the diagnostic journey in a 30-month-old male infant, born of a third-degree consanguineous marriage referred to our institute as severe persistent asthma. History revealed that the child had progressively worsening breathlessness and persistent dry cough not associated with fever but accompanied by weight loss. On physical examination, there was growth failure, respiratory distress, clubbing, hepatosplenomegaly, and occasional rhonchi. Blood gas revealed hypoxemia which improved with oxygen administration. Plain X-rays and high-resolution computed tomography of the chest showed perihilar alveolar infiltrates and patchy consolidation. The clinicoradiological features did not support a diagnosis of asthma but favored interstitial lung disease (ILD). Bronchoalveolar lavage was performed as a first-tier investigation. It showed periodic acid–Schiff-negative foamy macrophages. The clues of consanguinity, visceromegaly, ILD, and foamy macrophages in the bronchoalveolar fluid prompted consideration of lysosomal storage disorders as the likely etiology. Gaucher disease and Niemann–Pick disease A/B were ruled out by enzyme estimation. Niemann–Pick disease type C was suspected and confirmed by detecting a homozygous mutation in the NPC2 gene. This case serves to caution physicians against labeling breathlessness in every toddler as asthma. It emphasizes the importance of searching for tell-tale signs such as clubbing and extrapulmonary clues which point to a systemic disease such as lysosomal storage disorders as a primary etiology of chronic respiratory symptoms.

Assessment of healthcare measures, healthcare resource use, and cost of care among severe hemophilia A patients in Mumbai region of India.

Abstract: Background: In India, the low public health priority given to rare disorders such as hemophilia hinders their management and optimal care, leading to relatively poor health outcomes. This study aims to profile the multidimensional health status of patients with severe hemophilia A, and its association with the use of healthcare resources and the cost of care in Mumbai region of India. Subjects and Methods: A cross-sectional, single-center study was conducted during January–May 2011, among 160 patients diagnosed with severe hemophilia A in Mumbai region of India. Their health status was documented using the Hemophilia Utilization Group Study's validated instrument of Functional Health Status Measure (FHS) and a single item of Self-care Measure. Results: Of 160 patients, 55% (n = 88) scored on the lower side on the FHS, with an average score of 6.65 ± 2.85. The use of healthcare resources and cost of treatment were considerable for patients with a lower mean rank score on the FHS and a higher mean rank score on the self-care measure. The consumption of clotting factor concentrates (CFCs), number of visits to a health facility and incidence of inpatient episodes were significantly associated with a relatively low score on the FHS. Similarly, a higher cost of treatment, in terms of the cost of CFCs, direct cost, emergency room cost, and indirect cost, were significantly associated with a lower score on the FHS. Conclusion: The health status of patients with severe hemophilia A is compromised and has a significant impact on the use of healthcare resources and the cost of treatment.

Polyarteritis nodosa presenting as peripheral vascular disease and acute limb ischemia.

Abstract: Acute limb ischemia and peripheral vascular disease (PVD) are unusual presentations of polyarteritis nodosa (PAN). Here, we present a case with PVD of both lower limbs leading to foot claudication. Digital subtraction angiography showed narrowing, irregularity, and occlusion of both lower limb arteries with no involvement of the abdomen visceral arteries. Based on significant weight loss, diastolic blood pressure >90 mmHg, myalgia, testicular pain, and angiographic abnormalities in medium-sized arteries, he was diagnosed as having PAN. He was treated with corticosteroid and bolus intravenous cyclophosphamide following which he had prompt and near-complete recovery of the symptoms without any tissue loss.

Right atrial mural thrombi: An autopsy study of an under-diagnosed complication at an unusual site.

Abstract: Background: Right atrial mural thrombi (RAMT) are often seen in association with cardiac diseases or foreign bodies. Unusual locations at the flutter isthmus and the atrial appendage prompted us to evaluate our 2-year autopsy data on such thrombi. Materials and Methods: In the 2-year retrospective autopsy, the clinical and autopsy records of patients with RAMT were reviewed, with particular reference to the presence of central venous catheter (CVC), its site of insertion, its type, material and size, its duration of placement, and the drugs infused through the catheter. Results: Of the 940 autopsies performed in 2 years, RAMT was seen in 24 hearts and was related to an insertion of a CVC in 23 patients (95.8%). The risk and/or associated factors for this complication were tunneled and polyethylene catheters, Intensive Care Unit admission, infused drugs, underlying cardiac diseases, and pregnancy. A noteworthy feature was the location of the thrombi in the flutter isthmus in 16 hearts (66.7%) and atrial appendage in another six hearts. Localized endocarditis/myocarditis and pulmonary thromboembolism were observed in six and four patients, respectively.Conclusions: This autopsy study, which has a high incidence of catheter-related RAMT, does not reflect the true incidence but reiterates the importance of guided insertion of central venous and prompt recognition of thrombus formation.

Role of demographic and job-related variables in determining work-related quality of life of hospital employees.

Abstract: Background: Considering a huge working population in health sector faced with stressful work life, limited autonomy in work and declining work contentment calls for an overemphasis on evaluating and monitoring their satisfaction associated with work-related quality of life (WRQoL). This study evaluates WRQoL of hospital employees and validates the bilingual (English and Marathi) version of WRQoL scale. Methods: The study was conducted during March-April'2014 on employees of a corporate hospital of Pune, India after ethical approval and informed consent from employees. The bilingual WRQoL scale has been tested for reliability and validity, and WRQoL scores have been reported. Results: A total of 132 hospital employees (mean age 31 [±8] years, 55% males) who participated in the study reported overall moderate WRQoL scores. The scale showed high internal consistency (Cronbach's alpha = 0.82, P < 0.0001) and moderate to high validity. WRQoL did not significantly vary across marital status, family size, and gender. Stress at work score of WRQoL increased with age of employees. Higher work experience, employment at higher positions and those working in clinical and diagnostic departments reported a higher WRQoL. Conclusion: WRQoL scale is a reliable and valid instrument. Better WRQoL in employees placed in higher organizational positions indicates a need for focused measures to enhance WRQoL of employees in lower hierarchical levels, especially in control at work and home life interface domains. WRQoL needs regular monitoring for employees in lower positions and aging employees.

Adenosine monophosphate-activated protein kinase-based classification of diabetes pharmacotherapy

Abstract: The current classification of both diabetes and antidiabetes medication is complex, preventing a treating physician from choosing the most appropriate treatment for an individual patient, sometimes resulting in patient-drug mismatch. We propose a novel, simple systematic classification of drugs, based on their effect on adenosine monophosphate-activated protein kinase (AMPK). AMPK is the master regular of energy metabolism, an energy sensor, activated when cellular energy levels are low, resulting in activation of catabolic process, and inactivation of anabolic process, having a beneficial effect on glycemia in diabetes. This listing of drugs makes it easier for students and practitioners to analyze drug profiles and match them with patient requirements. It also facilitates choice of rational combinations, with complementary modes of action. Drugs are classified as stimulators, inhibitors, mixed action, possible action, and no action on AMPK activity. Metformin and glitazones are pure stimulators of AMPK. Incretin-based therapies have a mixed action on AMPK. Sulfonylureas either inhibit AMPK or have no effect on AMPK. Glycemic efficacy of alpha-glucosidase inhibitors, sodium glucose co-transporter-2 inhibitor, colesevelam, and bromocriptine may also involve AMPK activation, which warrants further evaluation. Berberine, salicylates, and resveratrol are newer promising agents in the management of diabetes, having well-documented evidence of AMPK stimulation medicated glycemic efficacy. Hence, AMPK-based classification of antidiabetes medications provides a holistic unifying understanding of pharmacotherapy in diabetes. This classification is flexible with a scope for inclusion of promising agents of future.

Hernia of the umbilical cord associated with a patent omphalomesenteric duct

Abstract: Congenital hernia of the cord is a different type of ventral abdominal wall defect in which the bowel usually herniates into the base of normally inserted umbilical cord through a patent umbilical ring. It is rare congenital anomaly with incidence of 1 in 5000. Although it was described as a distinct entity since 1920s it is often misdiagnosed as a small omphalocele. We present an unusal case of term male newborn with umbilical cord hernia associated with patent omphalomesenteric duct. The diagnose was made after birth despite antenatal ultrasound scans and it is managed successfully with uneventful recovery. If this is missdiagnosed, it could cause iatrogenic atresia of the ileum by clamping the umbilical cord after birth.

Outcomes of a conservative approach to management in amoebic liver abscess.

Abstract: Context: Unfortunately, there is confusion among the medical community regarding the management of amoebic liver abscess (ALA). Therapeutic options range from simple pharmacotherapy to use of interventions like a needle or catheter aspiration under ultrasound guidance to surgical intervention. There is a plethora of thresholds for parameters such as the maximum diameter of the abscess and volume on ultrasound examination suggested by various authors to serve as a criterion to help to decide when to use which modality in these cases. Aims: To assess the outcome of patients with uncomplicated ALA treated using a conservative approach. Moreover, to identify factors associated with its failure. Settings and Design: A prospective, observational study was carried out at a large municipal urban health care center over a period of 3-year (2011-2014) in India. Materials and Methods: Patients with uncomplicated ALA were recruited. All patients were managed with pharmacotherapy initially for a period of 72 h. Response to treatment was assessed by resolution of symptoms within the given time frame. Failure to respond was considered an indication for intervention. Needle aspiration was offered to these patients and response assessed within 72 h. Failure to respond to aspiration was considered an indication for catheter drainage. Statistical Analysis Used: Data recorded were entered in a Microsoft Office Excel Sheet and analyzed using the SPSS version 16.0 (IBM). Results: Sixty patients with ALA were included in the study over its duration. Forty-nine (81.67%) patients were managed conservatively, while 11 (18.33%) patients needed an intervention for relief. Patients who required intervention had deranged liver function at presentation, a larger abscess diameter (10.09 ± 2.23 vs. 6.33 ± 1.69 cm P 7.7 cm was found to be the optimal criterion to predict the need of intervention in cases of ALA. Conclusions: A conservative approach is effective in the management of ALA for a majority of patients. Failure of conservative management was predicted by the size of the abscess (maximum diameter >7.7 cm). Even in the cases of failure, a gradual step-up with interventions was found to be safe and effective.

Primary adrenal teratoma: An unusual tumor – Challenges in diagnosis and surgical management

Abstract: We report a rare case of a 25-year-old lady who presented with right hypochondriac pain associated with weakness for 3 months. Her hormonal evaluation was normal. Computed tomography scan revealed an adrenal mass for which a right open transperitoneal adrenalectomy was performed, and the lesion was diagnosed as mature teratoma on histopathological examination. Teratoma is an unusual neoplasm which arises from one or all the three germ layers. Extragonadal teratomas are rare in adults as compared to children and are mostly retroperitoneal in location, constituting only 4% of all primary teratomas. Primary adrenal teratomas are even rarer and to the best of our knowledge, only eight cases have been reported in adults in the past 10 years. Adrenal teratoma can pose a diagnostic challenge because radiologically it mimics myelolipoma, angiomyolipoma, liposarcoma, or pheochromocytoma. Mature teratomas are usually benign but may possess malignant potential, the chances of which are greater in adults as compared to children, making it an important entity requiring a proper diagnosis and management.

Association of anti-CLIC2 and anti-HMGB1 autoantibodies with higher disease activity in systemic lupus erythematosus patients

Abstract: Background: Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by numerous autoantibodies. In this study, we investigated the presence of anti-chloride intracellular channel 2 (anti-CLIC2) and anti-high mobility group box 1 (anti-HMGB1) autoantibodies in SLE patients (n = 43) versus healthy controls ([HCs] n = 43), and their association with serological parameters (antinuclear antibody [ANA], anti-double-stranded DNA [anti-dsDNA], and C-reactive protein [CRP]) and disease activity using Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score (active or inactive). Settings and Design: Case–control study at Rheumatology Clinic of Universiti Sains Malaysia Hospital. Subjects and Methods: The sera of SLE patients and HCs were tested for the presence of anti-CLIC2 and anti-HMGB1 autoantibodies using human recombinant proteins and ELISA methodologies. Other serological parameters were evaluated according to routine procedures, and patients' demographic and clinical data were obtained. Statistical Analysis: Mann–Whitney U-test, Chi-square test, Fisher's exact test, and receiver operating characteristic analysis. Results: Anti-CLIC2 autoantibody levels were significantly higher in SLE patients compared to HCs (P = 0.0035), whereas anti-HMGB1 autoantibody levels were not significantly elevated (P = 0.7702). Anti-CLIC2 and anti-HMGB1 autoantibody levels were not associated with ANA pattern, anti-dsDNA, and CRP. Interestingly, SLEDAI score (≥6) was associated with anti-CLIC2 (P = 0.0046) and with anti-HMGB1 (P = 0.0091) autoantibody levels. Conclusion: Our findings support the potential of using anti-CLIC2 autoantibodies as a novel biomarker for SLE patients. Both anti-CLIC2 and anti-HMGB1 autoantibody levels demonstrated potential in monitoring SLE disease activity.

Cytohistological correlation in pituitary tumor and immunological assessment with the help of Ki-67.

Abstract: Background: Tumors of the pituitary gland and sellar region represent approximately 10–15% of all brain tumors. Pituitary adenoma (PA), the most common pathology of the pituitary gland, can be effectively subclassified only with the help of immunohistochemistry (IHC). This is important and needed for individual patient management. Aims and Objectives: The objective of the study was to analyze the importance of intraoperative imprint smear cytology and correlating with final histopathological diagnosis. Furthermore, to classify the different types of PA with the help of IHC, prolactin (PRL), adrenocorticotropic hormone (ACTH), and growth hormone (GH) and to predict the benign, atypical, or malignant nature of the tumor with the help of prognostic marker Ki-67. Materials and Methods: A prospective study was done in 34 cases. The patients whose pituitary gland samples are referred from the endocrine and the neurosurgery department to the pathology department for histopathological examinations were selected. We have studied the clinical features, radiology and touch imprint cytology, histopathology, and IHC with the help of PRL, ACTH, GH, and Ki-67 of PA over 2 years. Results: In our study, we had 32 cases of PA of 34 cases over a span of 2 years. We have seen that there is a correlation between cytological and histological diagnosis of the subtypes of PA in 62% cases, and the Kappa statistics show a moderate extent of agreement (Kappa - 0.320, 95% confidence interval = 0.031–0.609). Ki-67 when compared to the radiological grading showed a high degree of comparability (Chi-square test: P P = 1.000) while in PRL-producing adenomas too this was not significant ( P = 0.269). Conclusion: PA can be effectively classified with the help of IHC. Intraoperative cytology is important in diagnosing PA, but histopathology remains the gold standard in diagnosing and differentiating PA from other pathologies of the pituitary gland. The radiological grading together with immunological classification and the prognostic markers of Ki-67 is important in deciding the benign or atypical nature of the adenomas thus helping in better patient management.

Postradiotherapy small cell neuroendocrine carcinoma of base of tongue: An unusual clinical and site presentation.

Abstract: Small cell neuroendocrine carcinoma (NEC) of the tongue is an extremely rare entity with only seven cases reported in literature till date. These are high-grade tumors with a dismal prognosis. There is much ambiguity regarding the classification, treatment protocols and prognostic factors of these tumors due to the paucity of studies. We describe an exceptionally rare and unusual case of small cell NEC of the base of tongue arising in an elderly man 6 years after receiving radiotherapy for the treatment of squamous cell carcinoma at the same site. The diagnosis was confirmed on histopathological examination and supported by immunohistochemical positivity for neuron-specific enolase, synaptophysin, chromogranin, pan-cytokeratin, and cytokeratin 7. To the best of our knowledge, this is the first case of intraoral NEC arising many years later within the irradiated field of the initial tumor.