Ceftriaxone-Induced Thrombocytopenia in a Patient with Bacterial Meningoencephalitis

Drug-induced thrombocytopenia is a rare and life-threatening condition. It is mainly caused by the initiation of drug-dependent platelet reactive antibodies that leads to the accelerated platelet destruction. Ceftriaxone is a third-generation cephalosporin, which has rarely reported cases of drug-induced immune thrombocytopenia. Here, we report a case of ceftriaxone-induced thrombocytopenia after the initiation of antibiotic therapy for bacterial meningoencephalitis based on the laboratory findings with the initiation and discontinuation of ceftriaxone.

In-vitro study of formulation and evaluation of nanosuspension of tamoxifen

Background: Nanosuspension technology has been developed as a promising candidate for efficient delivery of hydrophobic drugs. It could maintain the required crystalline state of the drug with reduced particle size, leading to an increased reporting on dissolution rate and therefore improved bioavailability.Methods: In this paper, we report on the preparation of Tamoxifen nanosuspension by high-pressure homogenization (HPH). The aim is to obtain a stable nanosuspension with an increased drug saturation solubility and dissolution velocity. The morphology and particle size distribution of the modified nanosuspensions were characterized by the means of several analyses that included: transmission electron microscopy (TEM), polarized light microscopy (PLM), scanning electron microscopy, differential scanning calorimetry (DSC) and powder X- ray diffractometry (XRD).Results: HPH was employed to produce aqueous drug nanosuspensions with fine solubility and dissolution properties, which render the produced particles stable up to one month. In addition, the prepared nanosuspensions possessed a high drug-loading efficiency (10%). The recoded zeta potential values (? -27 mV) indicated that the prepared nanosuspensions possess a higher degree of long-term stability. TEM data showed narrow size distribution with average size 322.7 nm. Morphologically, as indicated from results, the produced nanosuspensions have a homogenous distribution even after redispersion, indicating the stability of the product.Conclusions: It was possible to obtain Tamoxifen nanosuspensions with fine solubility and dissolution properties. Nanosuspensions possessed a high drug- loading (10%), which could reduce the dosage administration and gastrointestinal side effects. HPH can be employed to produce aqueous drug nanosuspensions that are stable up to one month. Aqueous nanosuspension can be converted to dry nanocrystals by lyophilization which offer superior physicochemical properties.

Combined approach to management of periocular arteriovenous malformation by interventional radiology and surgical excision

Periorbital arteriovenous malformations (AVMs) are congenital lesions that may cause significant morbidity such as amblyopia, cosmetic disfigurement, or chronic pain. Due to the rarity of these lesions, they are frequently misdiagnosed and treated inappropriately. We managed a 6-year-old girl with preseptal AVM by endovascular embolization followed by complete surgical excision after 2 days. She was previously diagnosed as capillary hemangioma and was being treated with intralesional steroid injections and oral propranolol. Neuroimaging revealed an AVM fed by the branches of both external and internal carotid arteries and drained by the superior ophthalmic vein. Endovascular embolization with glue followed by complete surgical excision of the lesion was done. The resultant cosmetic and functional outcome was gratifying. Diagnosis and management of periorbital AVM remain a challenge requiring a multidisciplinary approach involving interventional radiologist and trained oculoplastic surgeons. Combined endovascular embolization followed by surgical excision proved safe and effective.

Effect of a Comprehensive Training Programme for Tuberculosis Health Care Providers and Tuberculosis Patients on Diabetes – A Report from South India.

Aims: High prevalence of diabetes mellitus (DM) in TB patients demands that TB health care providers are sensitized and updated on risk factors, screening, diagnosis and management of DM. This study was designed to assess the impact of one day training programme on screening, detection and management of DM. Study Design: One group – pre and post test design. Place and Duration of Study: The one day training session with an inbuilt awareness programme was conducted for TB health care providers and TB patients with diabetes, over a period of 3 years, from since November 2010 involving 22 tuberculosis units of 3 districts in Tamil Nadu, India. Methodology: The impact was assessed using a pretested questionnaire pre and post training, based on the improvement in knowledge among physicians and other health care providers and awareness among patients. Similarly, using a separate questionnaire before and six months after the training programme, improvement in practice was assessed based on an increase in the proportion of staff involved in screening, educating and referring TB patients with diabetes. Appropriate statistical analysis was done using SPSS version 16. Results: There was a significant increase in the knowledge of physicians and other health care providers and in patient’s awareness on all components covered under the training and awareness session respectively. No significant improvement was noted in the knowledge of other TB health care providers, in diet category on the questionnaire. There was a significant improvement in practice based on the substantial increase in the proportion of tuberculosis unit staff conducting DM screening for TB patients using appropriate methods and in referrals for proper management of DM. Conclusion: The training session on DM with an inbuilt awareness campaign for TB patients had a significant impact on the knowledge and practice of TB health care providers.

Serum proteins, initial and follow-up lipid profile in children with nephrotic syndrome.

Background & Objectives: It has been noted that certain factors like diet, malnutrition, genetic traits etc., are known to alter the frequency and severity of lipid pattern. The Indian patient has a different dietary, constitutional and genetic background. Hence, we undertook a study to determine the spectrum of lipid abnormalities in children with nephrotic syndrome. An attempt was also made to correlate the degree of proteinuria and hypoproteinemia, with the rise in serum lipid values in cases of nephrotic syndrome. Methods: Twenty cases of Nephrotic Syndrome, 7 age and sex matched controls were studied. The samples were analysed for Protein profile and Lipid Profile. Lipid profile was measured 8-10 days after treatment of Nephrotic syndrome with initial levels measured within 24 hours of admission to the hospital. Results: There was a significant increase in Total cholesterol, LDLC, VLDL, Non-HDLC, serum phospholipids and triglycerides levels in Nephrotic syndrome patients when compared to normal controls (P<0.0001). There was significant decrease in Total protein, serum albumin and HDL-C in Nephrotic patients when compared to Controls. There was a significant difference between the initial and follow-up Lipid profile levels in these patients (p <0.001). Interpretation & Conclusion: Our study concludes that, in nephrotic syndrome, there is generalized hyperlipidemia (except HDL) and hypoalbuminemia. The serum cholesterol level in first episode nephrotic syndrome reaches normal at the end of steroid therapy. Hence there is a rationale for treatment.

Challenges in diabetes care in India: sheer numbers, lack of awareness and inadequate control.

With an estimated 40 million people suffering from the condition, the largest in any country in the world, diabetes has become a major health care problem in India. Recent epidemiological studies from India point to the great burden due to diabetes and its micro and macrovascular complications. This is primarily because the status of diabetes control in India is far from ideal. Based on the available data, the mean glycated hemoglobin levels are around 9% which is at least 2% higher than the goal currently suggested by international bodies. The IMPROVE study has helped identify the barriers to good control of diabetes both among patients as well as physicians in today's practice. However the recent ACCORD study points to the dangers of overaggressive treatment, especially in high risk in elderly patients. A balanced approach to improve awareness about diabetes and its control both among patients and the medical fraternity is urgent need of the hour in India. The associated risks of tight control in high risk groups should also be kept in mind.

Effect of methyl branching of C8H18 alkanes and water activity on lipase-catalyzed enantioselective esterification of ibuprofen

The purpose of this research was to study the effect of the methyl branching of a high log P alkane solvent and the water activity in the organic medium on the initial rate and the enantioselectivity of ibuprofen esterification catalyzed by Candida rugosa lipase. Resolution of ibuprofen is important because S-(+)-ibuprofen has the desired pharmacological activity, whereas the R-(-)-enantiomer causes much of the side effects. The Candida rugosa lipase-catalyzed reaction in isooctane at 40ºC and 0.73 water activity gave the best results, both in terms of the initial reaction rate and the enantioselectivity of the reaction. An increase in water activity allowed a higher reaction rate and enantiomeric excess in each of the four solvents. An increase in methyl branching did not necessarily increase the initial reaction rate, but it allowed a higher enantioselectivity, evidenced by an increase in the substrate enantiomeric excess.

Parental influence on the spectrum of type 2 diabetes in the offspring among Indians.

AIM: Familial aggregation of type 2 diabetes and its vascular complications is strong in Indians. In this study, we have analysed whether the age of the parent at birth of the offspring had any influence on the age at diagnosis of diabetes and age at onset of microvascular complications in the diabetic offspring. METHODS: Families with either a type 2 diabetic father or mother and a type 2 diabetic offspring, all of whom had been tested at our centre were included in this study (n = 300, father--122, mother--178, offspring male --201, female--99). Anthropometric details, age at diagnosis of diabetes, age at onset of complications and duration of diabetes were recorded. All relevant clinical and investigatory tests were done and appropriate statistical analyses were done. RESULTS: Age at onset of diabetes was lower in the offspring than in their parents at least by a decade. The age at diagnosis of diabetes in the offspring was determined inversely by the age of the parent at childbirth (p<0.001) and positively by the age of onset of diabetes and the presence of complications in the parents (both p<0.0001). Moreover, the age at diagnosis of complications in the offspring were determined inversely by the age of the parent at childbirth (p=0.0001) and positively by the age of onset of complications in the parents (p=0.0009). DISCUSSION: A younger parental age at childbirth was protective to the offspring in that the offspring developed diabetes and the complications at an older age.

Stress and undetected hyperglycemia in southern Indian coastal population affected by tsunami.

AIM: Natural calamities are known to result in higher stress conditions and also result in adverse health outcomes including development of non-communicable diseases. The impact of tsunami on mental stress and prevalence of hyperglycemic conditions was assessed in a population affected by the calamity in coastal populations of southern India. METHODS: Two populations similar in demography and physical characteristics, but, one affected by tsunami were selected for a comparative study. Subjects aged 20 years or above were randomly selected (control population n = 1176; tsunami population n = 1184). Details of stress were assessed using Harvard trauma questionnaire and scores were assigned. Glucose tolerance was assessed using 2h capillary blood glucose (75gms glucose load) and diagnosis was made using WHO criteria. RESULTS: Stress score was significantly higher in tsunami population. Although the total prevalence of diabetes was similar (control - 10.0 %; tsunami population - 10.5 %) prevalence of undetected diabetes (5.7 % vs. 3.8 %; Z = 9.54, P < 0.001) and impaired glucose tolerance (9.8 % vs. 8.3 %; Z = 12.83, P < 0.001) higher in the tsunami area. Stress score was higher in women and in the young in the tsunami area. CONCLUSION: Population affected by tsunami was under high stress and also showed a high prevalence of undetected diabetes and impaired glucose tolerance.

Development of a reliable and valid psychosocial measure of self-perception of health in type 2 diabetes.

OBJECTIVES: The aim was to develop a reliable and valid psychosocial measure of self-perception of health in type 2 diabetes. METHODS: Item analysis and factor analyses were done in order to stabilize and establish principal components of the questionnaire. Reliability (internal consistency aspect) was established using Chronbach's alpha method. Concurrent and discriminant validities were established using conventional methods. RESULTS: Factor analysis yielded 12 significant factors (eigen value > or =1), but first six components were retained based on Scree test. These six principal varimax factors explain 49.7% of variance of psychosocial measure of self-perception of health. CONCLUSIONS: The final version after all these psychometric procedures had 27 items with six principal components. They were appropriately named as follow: (I) Positive self-feeling; (II) Sociality; (III) Attention seeking; (IV) Feel healthy; (V) Worry about health; (VI) Dependence. Total variance explained is 49.7%.

Diffuse interstitial skeletal hyperostosis (DISH) in type 2 diabetes.

A 58 years type 2 diabetic woman, school teacher by profession, presented with backache, neck pain and generalised weakness since last few months. Pain was mild with stiffness and neck pain was particularly associated with extension of the neck towards back. There was no focal neurological deficit on central nervous system examination. X-ray of lumbo- sacral spine showed prolific osteophytes and new bone formation in the body of lumbar vertebrae. Cervical X-ray showed 'Melting candle-wax' appearance at the anterior to the cervical vertebrae. In view of clinical and radiological association the case was diagnosed as DISH syndrome. It is being presented for its rarity.

Detecting undiagnosed diabetes in urban Asian Indians--role of opportunistic screening.

BACKGROUND: The aim of the study was to determine the proportion of incidental to symptomatic diagnosis of diabetes and to compare the profile of symptomatic and incidentally diagnosed diabetic subjects. METHODS: One thousand newly diagnosed diabetic subjects (WHO criteria) were studied. Clinical, demographic, anthropometric details, blood pressure, glycaemic and lipid parameters were recorded. Reasons for medical check up were noted. RESULTS: Among the 1000 subjects, 29% were symptomatic for diabetes and 71% were incidentally diagnosed to have diabetes. Symptomatic subjects were younger, had higher glycaemia and prevalence of hypertension. CONCLUSION: The results show that majority of type 2 diabetic subjects remain asymptomatic and opportunistic screening for diabetes would be required for the early diagnosis of the disorder.

Use of glimepiride and insulin sensitizers in the treatment of type 2 diabetes--a study in Indians.

AIM: Short-term efficacy of glimepiride, metformin and pioglitazone in newly diagnosed type 2 diabetes was compared with a group treated with diet and exercise. Effects on insulin secretion and sensitivity were also assessed. METHODS: New type 2 diabetic subjects, aged 30-60 years with BMI < 30 kg/m2 were selected. Subjects having glycosylated haemoglobin (HbA1c) of < 8.5% were advised diet and exercise (control group). Others having HbA1c > or = 8.5 to 11.0% were randomized to receive glimepiride (group 2), metformin (group 3) and pioglitazone (group 4). At the final review between 12-14 weeks, changes in plasma glucose, HbA1c, lipid profile, HOMA insulin resistance (HOMA-IR), beta cell function (HOMA-BF) and insulinogenic index (delta I/G) were measured. Comparisons were made using appropriate statistical analyses. RESULTS: Seventy-seven of the 97 subjects randomized equally into four groups, were available for review. Glycaemic parameters improved in all groups. Mean cholesterol decreased significantly in groups treated with metformin and pioglitazone. HDL-cholesterol increased with pioglitazone. Insulin resistance decreased significantly with metformin and pioglitazone, beta cell fuhction also showed improvement CONCLUSIONS: Glycaemic control was seen in all study groups, the improvement was better in drug treated groups than in the control group. Glimepiride improved insulin secretion including the early phase secretion and reduced plasma triglycerides. Metformin and pioglitazone had beneficial effects on lipid levels, improved insulin sensitivity and improved insulin secretion also.

Age-specific prevalence and risk associations for impaired glucose tolerance in urban southern Indian population.

OBJECTIVES: A national survey of diabetes and impaired glucose tolerance (IGT) conducted in 2000 AD in six major cities of India showed a high prevalence of diabetes (12.1%) and IGT (14%). Prevalence of IGT was higher than that of diabetes in subjects with less than 40 years when compared with older subjects. This analysis was done to look for differences in the risk factors associated with IGT in the younger and older subjects. METHODS: Associations of body mass index (BMI), waist : hip ratio, physical activity, family history of diabetes and monthly income with IGT and with diabetes were tested in the age groups of < 40 and > or = 40 years separately. Multiple logistic regression analyses were done to test the associations. RESULTS: Prevalence of IGT was higher than diabetes in the younger group (13.1% Vs 5%, P < 0.001). Prevalence of obesity was higher in the older IGT subjects (38% Vs 30.5%, p < 0.003). Presence of positive family history of diabetes was similar in both the groups. In the > or = 40 year group age, BMI and family history of diabetes were common risk factors for diabetes and IGT. In the younger group, only BMI showed an association with IGT. The association of family history of diabetes with IGT was weaker than for diabetes even in the older subjects (Odds Ratio (OR) = 3.5 for diabetes, 1.33 for IGT). CONCLUSIONS: Prevalence of IGT was higher than diabetes in the age group < 40 years. Only BMI showed an association with IGT in them while the risk associations were similar to diabetes in the older group. Prospective studies will throw more light on the implications of these findings.

Quality of life and diabetes integration among subjects with type 2 diabetes.

Diabetes integration indicates that a person with diabetes makes an appropriate emotional adjustment to the requirements of diabetic way of life. Diabetes integration and a sense of well-being are expected to be correlated. The aim of diabetes treatment should be to enable a patient to adjust himself to his being a diabetic person. This should ensure a sense of well-being. Aims of this study was to assess the role of diabetes integration and psychological factors in patients with type 2 diabetes. METHOD: A sample of 227 type 2 diabetes patients participated in the study. They were all in the upper middle class social stratum. Diabetes integration scale yields one composite score of adjustment, has 19 items applicable to both type 1 and type 2 diabetic subjects. The psychological well-being scale has 22 items, measures depression (6 items), anxiety (6 items), energy (4 items), positive well-being (6 items) and a general sense of well-being score by the whole test of 22 items. RESULTS: The psychological well-being subscales and the whole scale scores significantly correlated with diabetes integration scale (all P values were < 0.0001). However, we found that diabetes integration and the psychological well-being subscales were not significantly correlated with metabolic and other medical indices. There were gender differences in depression (p < 0.04), anxiety (p < 0.0001), energy (p = 0.004), positive well-being. (p = 0.02) and general sense of well-being (p < 0.0001), men fared in a better than women subjects. No such gender differences were found in diabetes integration score. CONCLUSION: Diabetic patients who integrate themselves and emotionally adjust to diabetes experience a psychological sense of well-being.