Nutritional assessment in hospitalized elderly patients, its sociodemographic determinants and co-relation with activities of daily life.

Introduction: Present study was planned to identify various sociodemographic factors influencing nutritional status in elderly and impact of nutritional status on activities of daily living in them. Methods: Total of 177 patients were enrolled in a prospective observational study. Nutritional status was assessed at the time of discharge by using Mini Nutritional Assessment form (MNA). Kartz Activity of Daily Living was assessed at 3 months before admission, at the time of admission, at discharge and 3 months after discharge. After written informed consent and ethics clearance patients were enrolled in the study. Analysis was done using the SPSS version 23 and Chi Square test was used to find the association between different qualitative variables. Statistical significance was set at P < 0.05. Results: Mean age of the study participants was 68.64 ± 7.73 years. 40 patients (22.6%) were found to be malnourished. Higher age, living alone, high CCI score and low ADL at discharge were associated with malnutrition. Mean ADL score was 5.82 at - 3 months time point in well-nourished patients which decreased during admission and then increased to 4.94 at the 3 months after discharge. Mean ADL score was of 5.33 at -3 months time point which kept on decreasing during admission and at 3 months after discharge in malnourished group. All these changes were statistically significant (P < 0.001). Conclusion: Nutritional status is a modifiable risk factor in elderly so identifying and optimizing nutritional status of elderly will optimise their functional status and improve quality of life.

The assemblage of skin findings in the type 1 DM with incorrect injection technique: A case report.

Correct insulin administration technique, insulin type, and dose play a pivotal role in attaining glycemic control. An error in any of the steps may lead to poor glycaemic control, which affects the patient in the short and long term. We are presenting here unusual skin findings in children with the wrong injection technique. A 10-year-old male child already diagnosed with type 1 Diabetes Mellitus (DM), presented with poor glycemic control. On examination, we found skin rashes encircling most of his abdominal area circularly. Rashes were round to oval, well-circumscribed, hyperpigmented to hypopigmented to depigmented macules to papules surrounded by a hyperpigmented halo, 0.5 to 1 cm in diameter, painless varying in color from white to pinkish-red to light brown to brownish-black. On observing the administration technique of insulin, we found it was administered incorrectly as intradermal instead of subcutaneous. Proper Diabetes education and insulin administration techniques remain the cornerstone in the management of type 1 DM. We should ensure appropriate insulin administration on every visit.

Predictive Value of Frailty Index in Comparison to Traditional Markers of Sepsis in Predicting Mortality among Elderly Admitted in Tertiary Care Hospital.

INTRODUCTION: The frailty index's potential as a prognostic marker of sepsis is so far been untapped. Here we studied the predictive value of frailty index in the elderly with sepsis. METHODS: This prospective cohort study was conducted in a tertiary level hospital in North India. The duration of the study was 18 months starting from January 2020 to July 2021. The frailty index was calculated along with traditional markers of sepsis such as sequential organ failure assessment (SOFA), quick sequential organ failure assessment (qSOFA), and systemic inflammatory response syndrome (SIRS) within 24 hours of admission in elderly patients suspected to have sepsis. The area under the receiver operating characteristic (AUROC) of frailty index, SOFA, qSOFA, and SIRS was compared for in-hospital and 3-month mortality. RESULTS: There was no significant difference between the performance of the frailty index and SOFA (DeLong's test p = 0.242) in predicting in-hospital mortality, but there was a statistical difference between the AUROC of SOFA score (AUC = 0.548) and frailty in predicting 3-month mortality (DeLong's test p ≤0.001). CONCLUSION: The frailty index had greater sensitivity and negative predictive value among the other scores in predicting in-hospital mortality, whereas SOFA had higher specificity in predicting in-hospital mortality. The frailty index was superior to SOFA and the other prognostic markers of sepsis in predicting 3-month mortality.

Stroke Characteristics as Predictors of New-onset Seizure in Patients with Acute Ischemic Stroke.

INTRODUCTION: The current guidelines on diagnosis and management of new-onset seizures in stroke are not well defined, especially in the Indian setting. Our study aims at providing insight into the hospital prevalence risk of new-onset seizures following ischemic stroke and to correlate seizure risk with the characteristics of stroke and other clinical parameters. METHODS: A total of 127 patients were analyzed for the study where we assessed the clinical severity and the imaging severity of stroke using the National Institute of Health Stroke Scale (NIHSS) score and Alberta Stroke Program Early CT (ASPECT) score, respectively. Seizure-related variables including semiology, timing, and details of antiepileptic drugs (AEDs) were assessed under the domain of early and late poststroke seizures (PSSs). All patients were followed for 6 months for the seizure recurrence and change in Barthel index. In statistical analysis, quantitative variables were compared using the independent t-test/Mann-Whitney U test, and qualitative variables were correlated using Chi-square test/Fisher's exact test. Univariate and multivariate logistic regression was used to find out the significant risk factors of acute symptomatic seizure. RESULTS: The mean age of the study population was 59.72 years (±14.77), with a male predominance (60.63%). About 78.74% of the cases had an NIHSS score more than or equal to 6.24% had posterior circulation strokes and the rest had anterior circulation strokes. A cortical location of infarct was observed in 62.2% of cases and a subcortical location in 61.4% of cases. The prevalence of early PSSs observed in our study was 10.6%. Of those, 80% had generalized seizures, 13.3% had focal seizures, and 6.67% had focal seizures with secondary generalizations. No patient in the study group had late-onset seizures. Total leukocyte count, serum protein levels, serum uric acid levels, and erythrocyte sedimentation rate (ESR) values were associated with early seizures (p<0.05). Patients with early seizures were found to have a longer hospital stay (8 vs 6 days with p<0.05). In the Trial of Org 10,172 in Acute Stroke Treatment (TOAST) etiological classification, an acute stroke of undetermined etiology was found to have a significant association with the occurrence of early seizure in both univariate and multivariate analysis [p = 0.030; odds ratio (OR) 4.735 (1.160-22.576)]. There was no difference in change in the Barthel index among the two groups. CONCLUSION: There was no recurrence of seizures in those who defaulted for AED and one patient had a seizure even on AED. Prophylactic AEDs in stroke patients based on stroke characteristics could not be ascertained, but the sample size was small. Knowing the fact that antiepileptics cause sedation and increase the chance of aspiration, continuing AEDs in patients who develop acute symptomatic seizures should be judged judiciously.

Subconjunctival cysticercosis - Is surgery always indicated? Role of medical management-literature review and report of two cases.

Ocular cysticercosis is caused by the larval form of pork tapeworm for which humans and pigs are the intermediate hosts. Intense inflammation secondary to immunological reaction is the hallmark feature of the infection, which can affect almost any tissue of the host. Orbital imaging yields specific features suggestive of the diagnosis. Although medical management is the recommended treatment for extra-ocular and retro-orbital cysticercosis, surgical removal has also been suggested by several authors. Here, we report two cases of subconjunctival cysticercosis, successfully managed with medical treatment alone using oral steroid and albendazole. Surgical excision for subconjunctival cysticercosis is associated with complications which can be observed even with the most experienced hands. Through these two cases, we wish to sensitize the practicing physicians regarding the most common ocular infestation seen in the developing countries along with brief literature review on the management protocols to be followed before any surgical reference.

Rare but not Abdicated: Status of Haemophilia in foothills of Himalaya, Uttarakhand: A cross-sectional study.

BACKGROUND: Haemophilia is one of the bleeding disorders, which is inherited, in an xlinked recessive pattern. The diagnosis is by estimation of factor levels of 8 and 9. Timebound treatment for people living with Haemophilia (PWH) is factor replacement during bleeding manifestation. The prevalence of Haemophilia was mostly underestimated, and it is more so in hilly terrains like the state of Uttarakhand. MATERIALS AND METHOD: This is a crosssectional study by compiling the data of PWH visiting the tertiary care centre for Haemophilia in Uttarakhand. We collected data from the patients with bleeding disorder reporting to the Haemophilia centre from July 2017 to December 2018. In this manuscript, we try to describe the pattern of Haemophilia and the degree of severity and incidence of inhibitors among the sample population of PWH who represent the population of Uttarakhand. The magnitude of problems faced by PWH from this hilly terrain to assess basic treatment in case of emergency is also being depicted. RESULT: We reported Haemophilia A contributing about 80% of the PWH in our centre. Average distance a PWH has to travel to obtain treatment was about 131.5 km (SD ± 83.7 km). Incidence of inhibitors was about 5%. CONCLUSION: We infer from our study that Hemophilia A is more common than Hemophilia B. Through this manuscript we hope to spread awareness of the Haemophilia care that is ongoing, the role of prophylaxis therapy and the future role of primary care physicians that may change the care of PWH in future.

Child abuse: A social evil in Indian perspective.

Child abuse is a social evil which has existed in our society since a long time. The awareness regarding the same has been minimal in developing countries. Many a times, punitive measures taken by parents to discipline their children turn out to be painful scars in their childhood resulting in stunting of their mental and social growth. Doctors and other health care workers have a very important role in identifying and reporting such issues. Law has also evolved over the recent past in safeguarding the future of our children. However, awareness regarding this issue has remained to be the same as before. During the current era of COVID, parents and children have been restricted to their homes. Livelihood of many families have been at risk. These issues have burdened the caretakers at home and absence of teachers who were otherwise their guardian angels have impacted the minds of these children adversely. Hence in this article we intend to provide good clarity about this social evil, and the rights of our children. We also wish to stress upon the duties of parents, doctors, teachers in molding these tender minds so as to get the best out of them.

Pulmonary Embolism in Children: A Case Series.

BACKGROUND: Pulmonary embolism (PE) is a life-threatening event with a mortality of ~10%. It is relatively uncommon in children and literature regarding the condition is sparse. In adults, the classical clinical presentation is with pleuritic chest pain, hemoptysis, and dyspnea, whereas in children, the presentation is often nonspecific. MATERIALS AND METHODS: Clinical features, risk factors, and outcome of children with PE presenting to our unit between December, 19 and March, 2020 were recorded. RESULTS: Four children [mean age: 10 (6-16) years, 3 females], all presenting with tachycardia and dyspnea were diagnosed with PE. Different risk factors such as deep vein thrombosis, nephrotic syndrome, softtissue infection, and infective endocarditis (IE) were identified in all patients. One child died while others responded to anticoagulation. CONCLUSION: We aim to highlight the importance of timely recognition of PE in children with known risk factors for the same. Early recognition and timely treatment of PE are critical to save lives. HOW TO CITE THIS ARTICLE: Agrawal S, Shrivastava Y, Bolia R, Panda PK, Sharawat IK, Bhat NK. Pulmonary Embolism in Children: A Case Series. Indian J Crit Care Med 2020;24(12):1272-1275.

Malarial hepatopathy: a 6-year retrospective observational study from Uttarakhand, North India.

Background: Jaundice in malaria is multifactorial. Plasmodium falciparum causes malarial hepatopathy in around 2.5% of cases. The spectrum of hepatic dysfunction in patients with malaria varies from mild clinical and biochemical abnormalities to fulminant hepatic failure, although hepatic encephalopathy almost never occurs. We undertook this study in order to estimate the magnitude of hepatopathy in malaria, and study the associated clinical features, complications and outcome of patients. Methods: We retrospectively analyzed the data of patients with acute malaria hospitalized from between 2009 and 2015. We compared the clinical features, demographic parameters, laboratory findings, complications and outcome of patients with and without hepatopathy. Results: Hepatopathy was observed in 22% (215/978) (n=215) of those with acute malaria (n=978) due to mono-infection by Plasmodium vivax (56.7%) or P. falciparum (38.1%) and their co-infection (5.1%). The age of the patients ranged from 2 to 96 years, with male preponderance (63.2%). Bleeding events, thrombocytopenia, total leukocyte count, levels of transaminases (aspartate transaminases, alanine transaminases), serum bilirubin, serum albumin and serum creatinine, duration of hospitalization and mortality were significantly greater in patients with malarial hepatopathy (p<0.05). Also, hepatopathy and renal dysfunction were significantly associated (OR 5.35; p<0.001). Conclusion: Hepatopathy is a serious complication of malaria, and is associated with other organ dysfunction and greater mortality.

A Hospital-Based Retrospective Comparative Study of Complications, Outcomes, Clinical and Laboratory Parameters of Malaria with and without Neurological Involvement.

BACKGROUND & OBJECTIVES: Classically associated with Plasmodium (P.) falciparum, neurological complications in severe malaria is associated with increased morbidity and mortality. However, reports implicate the long considered benign P. vivax for causing severe malaria as well. We aimed to analyse the cerebral complications in malaria, and study if there is a species-related difference in the presentation and outcomes. METHODS: We retrospectively compared patients with malaria hospitalised from 2009-15, with (n=105) and without (n=1155) neurological involvement regarding outcomes, complications, demographic attributes, clinical features, and laboratory parameters. Subsequently, the same parameters were studied in those with cerebral malaria due to mono-infections of P. vivax or P. falciparum and their co-infection. RESULTS: Cerebral malaria was observed in 8.3% (58/696), 7.4% (38/513) and 17.6% (6/51) of P. vivax, P. falciparum and combined plasmodial infections respectively. Those with cerebral malaria had significantly (p<0.05) longer hospitalisation, delayed defervescence, required mechanical ventilatory support and dialysis despite comparable levels of azotemia and renal insufficiency, and adverse outcomes compared to non-cerebral malaria. Severe thrombocytopenia, respiratory distress and mechanical ventilation were significantly (p<0.05) associated with P. vivax cerebral malaria. CONCLUSIONS: The plasmodial species are comparable in clinical and laboratory parameters and outcomes in cerebral malaria in isolation and combination (p>0.05). P. vivax is emerging as the predominant cause of cerebral malaria, and its virulence is comparable to P. falciparum.

Dengue hepatitis sans dysfunction: experience of a single tertiary referral centre in the north Indian state of Uttarakhand.

Hepatic involvement is uncommon in dengue viral infections and is traditionally thought to be associated with severe disease in terms of morbidity and mortality. This study was conducted in order to assess the liver function in patients with dengue virus infection and to analyse its effect upon patient outcome. Three hundred and twenty-seven consecutive patients with dengue virus were categorized into groups A, B, C and D on the basis of elevation of either of the hepatic transaminases (normal, <3, 3-10 and >10 times, respectively). Primary and secondary outcome measures related to morbidity and mortality were studied. Hepatitis was seen in ∼3/4 patients; an increasing grade of liver involvement was significantly associated with fewer platelets (P < 0.001). Recovery of platelets, bleeding manifestations, renal dysfunction, platelet recovery and duration of hospitalization were similar in all groups. Among the patients with manifest bleeding, the platelet count did not differ significantly but the platelet recovery was significantly slower (P = 0.044) with increasing grade. Hepatic dysfunction is self-limited without any increase in morbidity and mortality.

Acute myocarditis in vivax malaria: an extremely rare complication.

We report on the occurrence of pulmonary oedema due to acute myocarditis in an adolescent girl, from the northern Indian state of Uttarakhand, with Plasmodium vivax infection after parasite clearance. Apart from pancytopenia, there were no other features of severe malaria. With the emergence of literature about the complications encountered in P. vivax, especially from this region, a high index of suspicion for unusual cardiovascular manifestations is necessary in cases with acute malaria.