Polyarticular charcot: A rare case report and a literature review in Indian context

Charcot or neuropathic arthropathies are a progressive form of destructive, erosive and generally painless arthropathies.Prevalence of neuropathic joints has decreased globally with reduction in the cases of leprosy and syphilis. However,syringomyelia and diabetes mellitus have emerged as the major causes for upper limb and lower limb Charcot jointsrespectively. Literature evidence shows lack of India data pertaining to these arthropathies. The present study describesa case of polyarticular Charcot in a patient with syrinx and Chiari malformation. The patient history revealed a provisionaldiagnosis of rheumatoid arthritis and Koch’s elbow, and was treated with anti-tubercular treatment (ATT) and diseasemodifying anti-rheumatic drugs (DMARDS). Nervous system examination would have easily led to the diagnosis ofsyringomyelia. The present study also provides a review of Indian literature on neuropathic joints from 2001 to 2019.Diabetes mellitus, syringomyelia, leprosy and syphilis are major etiologies for Charcot joints.

Validation of self-reported smoking status by measuring serum cotinine levels: An Indian perspective.

Background. Serum cotinine levels are a reliable marker of tobacco use. Few studies have validated questionnaires assessing smoking and exposure to environmental tobacco smoke (ETS) against serum levels. We undertook such a study in industrial workers in India. Methods. We chose 426 individuals by stratified random sampling from a database of 3397 individuals surveyed at New Delhi for the cardiovascular disease surveillance programme in a large industrial setting. Questionnaires assessing details of smoking practices and duration of exposure to ETS (if any) were administered. Cotinine levels were measured in the blood samples of these individuals. Results. The study population comprised 142 nonsmokers not exposed to ETS, 142 non-smokers exposed to ETS and 142 active smokers. Cotinine levels among nonsmokers not exposed to ETS were non-detectable; and for non-smokers exposed to ETS and active smokers, the median (interquartile range) levels were non-detectable (non-detectable to 46.1 ng/ml) and 336 ng/ml (204–500 ng/ml), respectively. The best combined sensitivity (91%) and specificity (87.2%) yielded a cotinine cut-off level of 40.35 ng/ml to differentiate active smokers from non-smokers not exposed to ETS and those exposed to ETS (area under the curve 0.902). The cut-off cotinine level was estimated at 10.95 ng/ml using a similar analysis (sensitivity 43%, specificity 82%; area under the curve 0.64) to distinguish non-smokers not exposed to ETS from those exposed to ETS. The misclassification rate was estimated at 19% and 57.1% among self-reported non-smokers not exposed to ETS and those exposed to ETS, respectively. Conclusions. Obtaining a history of tobacco use is an accurate method of detecting smokers in epidemiological studies whereas serum cotinine levels accurately differentiate smokers from non-smokers. However, a brief questionnaire assessing passive exposure to smoke has poor sensitivity in distinguishing non-smokers exposed to ETS from those not exposed to ETS.

Double burden of underweight and overweight among children (10–19 years of age) of employees working in Indian industrial units.

Background. Along with the existing problem of underweight, overweight in children is increasing in the developing world. However, there is little information on its magnitude and pattern in the Indian context. We aimed to study the pattern and correlates of overweight in Indian children and adolescents. Methods. A total of 3750 children in the age group of 10–19 years, who were family members of randomly selected employees from 10 different industrial sites in India, were surveyed using an interviewer-administered questionnaire. Results. The prevalence of underweight was highest in peri-urban areas (30.2% and 53.2% according to Indian and international criteria, respectively). In urban and highly urban areas, the prevalence of underweight was 14.1% and 9.8%, respectively, according to the Indian criteria, and 27.1% and 19.2%, respectively, according to international criteria. The proportion of overweight children was highest in the highly urban category (19.1% and 13.4% according to Indian and international criteria, respectively). The level of urbanization (OR 3.1 and 4.7 for overweight in urban and highly urban areas, respectively, compared with peri-urban areas, p<0.001), physical activity (OR 0.4, p<0.001, in children with physical activity score >75th percentile compared with a score <75th percentile) and frequency of meals outside the home (OR 12, p<0.001, if >25% weekly meals taken outside the home compared with <25% of weekly meals outside home) were significant predictors of overweight. Conclusion. There is a double burden of underweight and overweight among Indian children and adolescents.

Management of acute coronary syndromes in secondary care settings in Kerala: impact of a quality improvement programme.

BACKGROUND: Evidence-based therapies that have been shown to improve outcomes in acute coronary syndromes (ACS) are often underused in clinically eligible patients. We evaluated the impact, efficacy and acceptability of a quality improvement programme to manage ACS. METHODS: A well-defined geographical area was identified and a situational analysis done. All physicians in the area, who were actively involved in the detection and management of ACS, were invited to participate in the quality improvement programme. The programme involved the use of a service delivery package which consisted of standard admission orders and patient-directed discharge instructions. Concurrently, health education in the community to promote self-detection, self-administration of aspirin and self-referral were carried out. All participating physicians were asked to register consecutive cases of ACS (20 each) presenting to their clinics before and after the intervention programme. The pre- and post-intervention data were compared. RESULTS: The use of aspirin at discharge increased from 89.7% to 96.8% (p < 0.05) and that of heparin from 57.6% to 66.3% (p < 0.05). The use of beta-blockers increased from 48.6% to 63.4% (p < 0.05) and that of lipid-lowering therapy from 74.1% to 96.3% (p < 0.05). There was a significant reduction in the use of calcium channel blockers from 21.6% to 8.1% (p < 0.05). The time to thrombolysis decreased significantly (median difference of 54 minutes, p < 0.05) after the intervention programme. CONCLUSION: Structured quality improvement programmes aimed at both patients and providers can be successful in secondary care settings of developing countries.

Risk factors related to the development of diabetes in men working in a north Indian industry.

BACKGROUND: Epidemiological and lifestyle changes have been implicated in the high burden of diabetes in urban India. However, longitudinal data on the determinants for the development of diabetes in this population are not available. We investigated the determinants for the development of diabetes in workers in an Indian industrial organization. METHODS: Two cross-sectional surveys were done, using similar methodology (Survey 1 during 1995-98 [n=2548] and Survey 2 during 2002-03 [n=2800]) among all employees (age 20-59 years) of an industrial organization. A large majority of these were men (89.5% in Survey 1 and 92.8% in Survey 2). Men with no diabetes at baseline, who participated in both the surveys (n=942), constituted the study population. Development of new-onset diabetes was defined using history and fasting glucose concentrations > or =7 mmol/L. RESULTS: The mean (SD) age of the participants at baseline was 40 (2) years. Diabetes developed in 8% of the study population over 6.8 (1.7) years. Individuals who developed diabetes had significantly higher age, blood pressure, body mass index, waist circumference, fasting and post-prandial glucose, post-prandial insulin and fasting triglyceride levels at baseline. On multivariate regression analysis, only impaired glucose tolerance (OR 3.8, 95% CI: 2.1-6.8) and waist circumference (OR 1.09, 95% CI: 1.02-1.16) predicted the development of diabetes. Presence of the metabolic syndrome, as defined by the modified National Cholesterol Education Program Adult Treatment Panel (NCEP-ATP) III and WHO criteria, increased the odds (95% CI) of developing diabetes by 2.2 (1.3-3.6) and 4.5 (2.7-7.4) times, respectively. CONCLUSION: Impaired glucose tolerance, high waist circumference and the metabolic syndrome are powerful predictors for the development of diabetes among urban Indian men.

Congenital scaphoid megalourethera: A surgical experience with augmented Nesbitt's urethroplasty.

Congenital scaphoid megalourethera is described in two infants presented with abnormal large, flabby phallus and postvoiding dribbling of urine. MCU showed crescentric dilatation of penile urethra without any proximal or distal obstruction. A thorough evaluation suggested absence of any associated anomalies. Nesbitt's urethroplasty reinforced with dartos pedicle flap resulted in a satisfactory recovery. Authors review their experience with this modified surgical repair and the pertinent literature.

Sewing needle appendicitis in a child.

A six-year-old boy presented with abdominal pain and vomiting five days after accidental ingestion of a sewing needle. The presence of the needle in the right iliac fossa on plain roentgenogram along with signs of appendicular inflammation on clinical and laboratory evaluation provided a clue to the diagnosis. Surgical exploration revealed inflamed appendix with the ingested needle in its lumen. The child recovered after appendectomy, and is well six months later.

Post-traumatic retroperitoneal colonic injury presenting as gluteal abscess.

We report an 8-year-old boy who sustained blunt retroperitoneal right colonic injury in a vehicular accident and presented with gluteal abscess. Surgical exploration revealed perforated posterior wall of ascending colon with surrounding retroperitoneal abscess communicating with the gluteal region. Right hemicolectomy with drainage of retroperitoneal and gluteal collections resulted in satisfactory recovery.

Medical arthroscopy--emerging era of rheumatological intervention.

OBJECTIVE: To evaluate the safety and diagnostic value of arthroscopy performed by a rheumatologist. METHODS: Decisions for performing arthroscopy were taken when detailed clinical history-and relevant rheumatological investigations failed to arrive at a definite diagnosis. Arthroscopies were performed under local anesthesia as a daycare procedure. Synovial biopsies taken during procedures were subjected to histopathological examination (HPE). RESULTS: Of the 50 patients enrolled, 39 were males while 11 were females with mean age of 35.5 years. In lower limb oligoarthritis group of patients, three had macroscopic picture of crystal arthropathy, rest of the 29 patients revealed gross picture indicative of non-specific synovitis. While in polyarticular group of eight patients, three had macroscopic picture suggestive of crystal arthropathy (probably polyarticlar gout) while five were indicative of rheumatoid arthritis. In monoarticular disease pattern (n= 10) macroscopic picture findings were as follows- crystal arthropathy-two, tubercular-three, synovial chondromatosis-one and non-specific synovitis-two. HPE of synovium did not correlate in many cases. CONCLUSION: Arthroscopy using a 4 mm scope under local anesthesia in the hands of rheumatologists is a safe daycare procedure. In few cases arthroscopy helped in arriving at a final diagnosis but many patients remained undiagnosed. Both the rheumatologists and the pathologists require further experience in this field.

Epistaxis: study of aetiology, site and side of bleeding.

The present study comprises 300 cases of epistaxis. The analysis of these cases revealed a higher incidence in young males. Unilateral bleeding was seen in almost 60% each of indoor and outdoor cases. Litte's area was the most common site responsible for epistaxis in 28.8% of the indoor and 26.2% of the outdoor patients. Hypertension was the most common systemic cause among indoor patients (62.2%) and sickle cell disorder among the outdoor patients (37.5%). Atrophic rhinitis with myiasis was the local cause of epistaxis in maximum (27%) of the indoor patients and traumatic epistaxis was the commonest cause (33%) among outdoor patients-fingernail trauma in 75.9% of them. Idiopathic epistaxis contributed for 16.5% indoor and 26.1% of outdoor cases. Intractable epistaxis was seen in one case following accidental facial trauma.

Estimation & significance of serum & synovial fluid malondialdehyde levels in rheumatoid arthritis.

Serum and synovial fluid (SF) levels of malondialdehyde (MDA), a marker of free radical induced lipid peroxidation, were estimated in patients of rheumatoid arthritis (RA) and compared with healthy controls and patients of osteoarthritis (OA). While serum MDA levels were similar in healthy controls (0.24 +/- 0.10 nmol/ml) and OA (0.28 +/- 0.11 nmol/ml), the serum levels in RA (0.47 +/- 0.19 nmol/ml) were significantly higher as compared to both healthy controls and OA patients; and correlated with synovial fluid (SF) MDA levels. No difference was observed in SF-MDA levels in RA (0.17 +/- 0.07 nmol/ml) and OA (0.16 +/- 0.09). MDA levels did not correlate with markers of disease activity in RA like joint counts, duration of morning stiffness, erythrocyte sedimentation rate etc. Increased serum MDA levels in RA suggest the role of free radicals in the pathogenesis of this inflammatory arthropathy and support the need for further studies assessing the therapeutic role of free radical scavengers in RA.

Cervical spine involvement in rheumatoid arthritis: prevalence and relationship with overall disease severity.

Rheumatoid arthritis (RA) affects the cervical spine in 20-90% of patients in Western countries. We report the prevalence of cervical spine involvement in RA and its relationship with duration of disease, seropositivity, hand joint erosions and symptoms and signs suggestive of cervical spine involvement. 100 patients with RA criteria were included. Apart from clinical history and examination, study included X-rays of the cervical spine in AP, open mouth and lateral views and posteroanterior view of hands and rheumatoid factor estimation. All X-rays were read by a radiologist who was unaware of the clinical details. Cervical spine involvement was seen in 65% of patients. The commonest abnormality was erosions of the odontoid process (47%), followed by atlanto-axial dislocation and apophyseal joint involvement (24%). Only 5% of patients had abnormalities of spinous processes or vertebral bodies. Patients with abnormal cervical spine radiographs had higher prevalence of rheumatoid factor and erosions on hand radiographs. Severity of cervical spine changes was related to duration of disease (> 5 years). No correlation was seen between symptoms and radiological abnormalities except when neurological deficit was present. Patients with seropositivity, erosive disease and disease duration greater than five years should be screened for cervical spine disease.