Clinical Profile and Outcome of Snake Bite Patients from Tertiary Healthcare Center: In Sub-Himalayan Region: A Medical College-based Study.

OBJECTIVE: Snake bite is an emergency in tropical and subtropical countries. It is a neglected disease and is most commonly seen in rural setups, where people are ignorant about the venomous snake bites. It results in increased mortality and morbidity because precious time is wasted, either in consulting traditional healers or waiting for the development of signs and symptoms of envenomation. Then only the patient is shifted to a health center. Here we studied the clinical profile, management, and outcome of snake bite patients. MATERIALS AND METHODS: This study was done by retrieving the records of patients with snake bites admitted to the Department of Medicine, Indira Gandhi Medical College & Hospital, Shimla, from 1st January 2017 through December 2019. The recorded data was entered in a precoded performa, and analysis was done with respect to various variables. RESULT: We evaluated the records of 190 patients. The incidence of the bite was higher among females, 62.1% (n = 118). The commonest age group involved was 21-50 years, 70.1% (n = 34). In 55.8% (n = 106), the site of the bite was the upper limb. The daytime bite was present in 54.7% (n = 106). The maximum incidence of snake bites was found during the rainy season, 81.5% (n = 155). 28.4% (n = 54) of patients presented within 6 hours of the bite. Coagulopathy [whole blood clotting test (WBCT) of >20 minutes] and neurotoxicity were seen in 77.9 and 7.9% of patients, respectively. Anti-snake venom (ASV) was given to 87.8% (n = 167) of patients. In 80% (n = 152) of the cases, hospital stay was up to 3 days. Mortality was seen in only two (1.05%) cases. CONCLUSION: There is a need to create awareness among the community, particularly in rural areas, about snake bite envenomation and early transportation of victims to the nearest health center. Training of health professionals is also needed to manage cases of snake bites efficiently and judiciously, thereby reducing morbidity and morbidity.

Effect of internal migration on diabetes and metabolic abnormalities in India - The ICMR-INDIAB study.

AIMS: To assess the effect of migration (rural-to-urban and vice versa) on prevalence of diabetes and metabolic disorders in Asian Indians participating in the Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study. MATERIALS AND METHODS: The ICMR-INDIAB study is a national study on diabetes and associated cardiometabolic disorders in individuals aged ≥20 years from 28 states and 2 union territories of India. Individuals who moved to a different place from their place of birth and had resided in the new location for at least one year were considered as migrants. Anthropometric measurements, blood pressure estimation and a capillary oral glucose tolerance test were performed. RESULTS: Of the 113,043 participants, 66.4% were non-migrant rural dwellers, 19.4% non-migrant urban dwellers, 8.4% rural-urban migrants, 3.8% multiple migrants and 2.0% urban-rural migrants. Weighted prevalence of diabetes was highest in rural-urban migrants followed by urban dwellers, urban-rural migrants and rural dwellers [14.7%, 13.2%, 12.7% and 7.7% respectively (p < 0.001)]. Rural-urban migrants had highest prevalence of abdominal obesity (50.5%) compared to the other three groups. The risk for diabetes was 1.9 times higher in rural-urban migrants than among rural dwellers. Five risk factors [hypertension, abdominal and generalized obesity, physical inactivity and low fruit and vegetable intake] together explained 69.8% (partial population attributable risk) of diabetes among rural-urban migrants and 66.4% among non-migrant urban dwellers. CONCLUSIONS: Rural-to-urban migration is associated with increased risk of developing diabetes and other cardiometabolic abnormalities. Adoption of healthier lifestyle patterns among migrants could help prevent/delay onset of these abnormalities in this population.

Early Clinical Suspicion and Early Use of Doxycycline Reduces Scrub Typhus Associated Complications.

BACKGROUND: Scrub typhus has emerged as an important cause of febrile illness in this Himalayan region of the country. However, it is under considered in the differential diagnoses of febrile illnesses and is not treated and thus, patients often land up with complications in this tertiary care hospital. METHODOLOGY: It was a retrospective observational study done in department of Medicine from august 2013 to October 2013. All the patients more than or equal to 18 yrs of age admitted during this period with scrub typhus were analysed and their outcome followed. S. ELISA was used to detect scrub typhus. RESULTS: Total of 106 patients were observed out of which only 10 patients had received anti scrub antibiotics (doxycycline or azithromycin) prior to admission. Seven patients died (6.6%) and none had received anti scrub antibiotics prior to hospitalisation and presented late with average duration of illness of 9.2 days and had more severe form of complications at presentation.Those patients who had received prior anti scrub treatment had fewer and mild complications and none died among that group. CONCLUSION: Doxycycline or azithromycin (pregnancy or in child <8 years) should be included in the initial empirical antimicrobial therapy in febrile patients during tick season to treat scrub typhus. The goal is to begin anti-scrub therapy early to reduce the morbidity and mortality associated with this illness.

Prevalence of Psychiatric Comorbidity among Patients of Type 2 Diabetes Mellitus in a Hilly State of North India.

BACKGROUND: Psychiatric comorbidity with diabetes mellitus is common. Comorbidity of diabetes and psychiatric disorders can present in different patterns, which are associated with impaired quality of life, increased cost of care, poor treatment adherence, poor glycaemia control and increased emergency room visits. The present study was planned to assess the psychiatric comorbidity in type 2 diabetic patients at tertiary care hospital in a hilly state of North India. OBJECTIVES: To study the prevalence of psychiatric comorbidity among patients of type 2 diabetes mellitus and to study the association between psychiatric comorbidity, sociodemographic and clinical variables in such patients. MATERIALS AND METHODS: A cross-sectional study was conducted after enrolling the eligible diabetic patients attending outpatient department services of medicine department, Indira Gandhi Medical College, Shimla. The Brief Illness Perception Questionnaire was used to assess the cognitive and emotional aspects of illness, Hamilton Depression Rating Scale for assessment of depression, Hamilton Anxiety Rating Scale for assessing severity of anxiety and Mini-International Neuropsychiatric Interview 6.0 for screening all major Axis I disorders. RESULTS: Out of 320 patients of type 2 diabetes mellitus screened, 202 eligible patients were enrolled. Depression was the most common psychiatric comorbid illness present in (41.9%) patients. Depression was slightly higher in female patients and persons aged >50 years. Greater prevalence of depressive episodes was there in people with longer duration of diabetes. CONCLUSION: There were a significant percentage of diabetic patients having psychiatric illnesses. Their attitude towards these comorbidities may be changed by psychiatric counselling at regular intervals.

Clinical Profile and Outcome of Acute Pancreatitis: A Hospital-Based Prospective Observational Study in Subhimalayan State.

Background: Prospective and population-based studies on the incidence of acute pancreatitis (AP) are lacking. We aimed to determine the incidence, etiology, severity, and outcome of AP. Materials and Methods: This was an observational prospective study done on 123 patients with AP during one year period in IGMC, Hospital Shimla. Detailed Clinical history was recorded and examination and lab investigations were done. Severity of AP was assessed using modified Atlanta classification. Results: In this study, 123 patients were included- 89 men (72.35%) and 34 women (27.65%). Median age of presentation was 42 years. The most common presentation was abdominal pain followed by vomiting. The major etiological groups were as follows: alcohol 73 cases (59.3%), gallstones 40, (35.6%); postendoscopic retrograde cholangio-pancreatography 1 (0.8%), hypertriglyceridemia 3 (2.9%), autoimmune 1 (0.8%) and idiopathic 5 cases (4%). Alcohol was the most common cause of AP and followed by gallstone. Mortality was seen in 7(5.7%) patients. Out of seven patients who died in hospital, 5(71.42%) had severe pancreatitis and 2(28.57%) patients had moderately severe pancreatitis. When compared, patients with BMI ≥25, HCT≥44% and CRP ≥150mg/l had an increased risk of developing a severe form of AP. Conclusions: Alcohol and gallstones were the most common etiology of AP. HCT, CRP and BMI done at admission are useful predictors of severe pancreatitis.

Early Intensified Insulin Therapy in Newly Diagnosed Type 2 Diabetes Leads to Sustained Improvement in Glycemic Control and Improved Beta Cell Function.

AIM: Type 2 diabetes (T2D) is a progressive disease characterized by relentless deterioration of pancreatic ß-cell function. Traditionally, insulin is used in later stages of T2DM. This study looks at use of insulin at time of diagnosis of T2DM and its effect on glycemic control and beta cell function. METHODS: This is a prospective observational study conducted in symptomatic newly diagnosed type 2 diabetes adults (>18 years) who presented with glycated hemoglobin (A1C) levels > 9%. For the initial 8 weeks, patients were treated with pre-mix insulin after which they were changed over to oral agents, and followed up for next three years. RESULTS: Amongst 122 study participants, who completed the study, 50% were female and 90% were from rural areas. Average age of participants was 51.4 ± 9.6 years. Baseline mean fasting plasma glucose (FPG), post prandial plasma glucose (PPPG) and A1C were 267 ± 76 mg/dl, 408 ± 101 mg/dl and 11.5 ± 1.4% respectively. At the end of insulin therapy (8 weeks), the mean FPG, PPG and A1C reduced to 107 ± 10 mg/dl, 145 ± 24 mg/dl and 7.3 ± 0.8% respectively all of which were highly significant. The mean post-prandial C-peptide significantly increased from 1.8± 0.6 to 2.8± 0.9 ng/dl. An average of 1.7 kg weight gain and 0.97 episodes of mild to moderate hypoglycemia were observed. At the end of study (156 weeks), the mean FPG, PPG and A1C were 99 ± 14 mg/dl, 152 ± 12 mg/dl and 6.7 ± 0.4%. CONCLUSION: Early insulin therapy in treatment naïve patients with type 2 diabetes results in rapid improvement of glycaemia thus helps to maintain long term normoglycemia and improves ß-cell function.

Comparison of Safety and Efficacy of Glimepiride-Metformin and Vildagliptin- Metformin Treatment in Newly Diagnosed Type 2 Diabetic Patients.

OBJECTIVES: To compare the safety and efficacy of combination of Glimepiride - Metformin with Vildagliptin - Metformin in type 2 diabetic patients with HbA1c between 7.5to10. METHODS: A randomized, prospective, comparative and interventional study was conducted at Indira Gandhi Medical College, Shimla. The level of hemoglobin A1c (HbA1c), fasting blood sugar (FBS) and postprandial blood sugar (PP) were the primary outcomes, whereas, the evidence of hypoglycemia, quality of life and weight gain were recorded as secondary outcomes. 215 patients newly diagnosed with type 2 diabetes mellitus were randomized into Glimepiride-Metformin group (Group1) having 111 patients and Vildagliptin-Metformin group (Group 2) having 106 patients. Patients were followed up at 3 month, 12 month, 24 month and then after completion of 30 month of treatment. RESULTS: A comparable FPG, PPPG and HbA1c were observed from baseline at the end of 12 weeks in both groups. However, at the 130-week endpoint a significantly more pronounced reduction in HbA1c was observed in vildagliptin-metformin (1.96%) arm compared to Glimepiride-metformin (1.67%) arm. A similar significant more pronounced reduction was demonstrated in both FPG (48.25% vs. 41.70%) and PPPG (49.40% vs. 42.95%) in vildagliptin-metformin group compared to Glimepiride-metformin group. The proportion of patients who achieved an A1C < 7% at 130-weeks was 49% in the vildagliptin group and 41% in the Glimepiride group. Statistically significant more weight gain was observed in Glimepiride arm compared to vildagliptin arm (2.09 kg vs. 0.69 kg) and 8-fold lower incidence was observed in vildagliptin group. Conclusion: Vildagliptin -metformin represent a more effective combination in terms of number of patients achieving guidelines recommended A1C target of less than 7% at the end of 30 months, less weight gain, and a lower risk of hypoglycemia in newly diagnosed type 2 diabetic patients with moderate hypoglycemia. CONCLUSIONS: Vildagliptin -metformin represent a more effective combination in terms of number of patients achieving guidelines recommended A1C target of less than 7% at the end of 30 months, less weight gain, and a lower risk of hypoglycemia in newly diagnosed type 2 diabetic patients with moderate hypoglycemia.

Hemophagocytic Lymphohistiocytosis Secondary to Acute Hepatitis E Infection: A Rare Association.

Viral infections are commonest cause of secondar y hemophagoc ytic lymphohistiocytosis (HLH) and Ebstein Bar Virus is associated with majority of cases. We report a rare case of HLH associated with acute hepatitis E virus infection.

Diabetes Drug Prescription Pattern and Awareness Among Health Care Providers in Sub-Himalayan Region of India: A Population Based Study.

BACKGROUND: To determine the pattern of diabetic drug prescription and awareness about diabetes among primary health providers in the rural areas of Himachal Pradesh situated in the western Himalayas at an elevation range from 350 meters (1,148ft) to 6900 meters (22,966ft) above sea level. METHODS AND MATERIAL: Study was conducted in 20 rural areas of Himachal Pradesh, located 50 to 400 Km from state capital, at 2200 to 10,000 feet altitude. Non-pregnant diabetic adults were surveyed through 31 diabetic camps. Detailed history, weight, height, waist circumference, body mass index recorded. Fasting or random blood glucose, glycated hemoglobin, lipid profile measured and blood pressure recorded. RESULTS: 894 diabetic patients were included in the study (59.83% male) with the mean age of 52.94±6.78 years. Two in three patients were on oral hypoglycemic agents (OHAs), and one in three on alternative approaches for diabetes control. Among OHAs, sulphonylureas (SU) were the most commonly prescribed oral agents in 76.09% of patients followed by metformin in 23.87%. Glibenclamide was the most commonly prescribed SU in 44.60%. Amlodipine and atenolol was the commonest anti-hypertensive drug prescribed in 77.85% either in combination or as individual drug. Only 10.59% were on lipid lowering therapy. For primary care providers glycemic target was the mainstay of diabetes treatment with little emphasis on blood pressure control and no emphasis on lipid reduction. CONCLUSIONS: Sulphonylureas were the commonest anti-diabetic drug prescribed by the primary care providers followed by metformin. Insulin was prescribed to 2.23% only. Combination of amlodipine and atenolol was the commonest anti-hypertensive drugs prescribed and only 10% of patients were prescribed statin.

Prevalence of Cardiovascular Risk Factors among Diabetic Population and Awareness of Diabetes among Diabetic Patients: A Population Based Himalayan Study.

BACKGROUND: To determine the prevalence of modifiable cardiovascular risk factors among adults with diabetes in the remote Himalayan areas, at elevation range from 350 meters (1,148ft) to 6900 meters (22,966ft) above sea level, in the Indian state of Himachal Pradesh. MATERIAL AND METHODS: Study was conducted in 21 rural areas of Himachal Pradesh situated at 2200 to 10,000 feet altitude. Non-pregnant diabetic adults (>18years) were surveyed, through 32 diabetic camps. The date and place of the camp was decided one month in advance and advertised. Detailed history including smoking status, weight, height, waist circumference, body mass index recorded. Fasting or random blood glucose, glycated hemoglobin, lipid profile measured and blood pressure recorded. RESULTS: Total 909 eligible adult diabetics were surveyed (59.73% male) with a mean duration of disease 38.14±4.56 months.35.54% adults were smoker and 67.55% were either overweight or obese 54.04% males and 77.53% females had waist circumference above Indian standards. 78.35% had A1C >7% and 61.50% had blood pressure measurements above target (>140/80mmhg). 56.74% had elevated LDL and only 6.32% had all blood glucose, blood pressure and cholesterol at recommended levels. CONCLUSIONS: High prevalence of modifiable cardiovascular risk factors in addition to uncontrolled blood glucose is widespread, placing diabetics at higher risk for cardiovascular disease. Improved disease management system in addition to public awareness campaign is needed for people with diabetes in this region of the country.

High Prevalence of Hypovitaminosis D in Patients Presenting with Proximal Muscle Weakness: A Sub-Himalayan Study.

BACKGROUND: Hypovitaminosis D has emerged as a major public health problem and 25-50% of patients encountered in clinical practice are deficient in vitamin D. This study was conducted to estimate the prevalence of hypovitaminosis D among patients presenting with proximal muscle weakness. STUDY DESIGN: It was a cross-sectional study done on patients ≥18 years presenting in outdoor clinic from May 2008 to April 2013, with difficulty in standing and going up stairs/ diffuse musculoskeletal pains. Proximal muscle weakness due to other causes were excluded through investigations and those taking steroids and/or indigenous drugs were also excluded. Vitamin D levels measured by radioimmunoassay (RIA) in all eligible patients and individuals included in the study were those with hypovitaminosis D (<30ng/dl) and proximal muscle weakness. Patients reassessed after supplementation with vitamin D at 2 and 6 months. RESULTS: 99 patients with hypovitaminosis D associated proximal myopathy included in study. Of these 55 (55.55%) were males and 44 (44.44%) were females. Age ranged from 22 to 82 years with a mean of 52.84 ± 12.6 years. Of 99 patients, 55 (55.55%) were from the rural area and 44 (44.44%) from urban area. Mean duration of symptoms was 22.7 months (range 6-60 months). The level of 25(OH) Vitamin D ranged from 2.0 ng/dl to 35.7 ng/dl with the mean level of 13.18 ± 5.80 ng/dl (males = 12.76± 4.85ng/dl and females = 13.60±6.70ng/dl). Hypovitaminosis D was present in 98.98%. A direct relationship was found between the vitamin D levels (<10 ng/dl) and severity of weakness. Of 83 patients, who reported at the end of two and six months of treatment, 71 (85.54%) patients were able to stand-up from squatting position. CONCLUSION: Muscle weakness is common among vitamin-D deficient individuals. Our study indicates that more focus should be on muscle symptoms in at risk population groups. The vitamin D deficiency related myopathy should not be missed due to its potential reversibility with vitamin D supplementation.

Sheehan's Syndrome-The Most Common Cause of Panhypopituitarism at Moderate Altitude: A Sub-Himalayan Study.

Background: Panhypopituitarism is a rare disorder with varied clinical presentation having various etiologies. Sheehan's syndrome (SS) is decreasing in frequency worldwide and is a rare cause of panhypopituitarism in developed nations. Methodology: A retrospective study done between May 2011 and May 2015 in tertiary care hospital. We reviewed the records of patients with hypopituitarism. Clinical features, hormonal profile and radiological investigations noted. Results: Total 14 patients of panhypopituitarism included with average duration of symptoms 1.93± 1.96 years. four (28.57%) were males and ten (71.43%) were females with mean age of diagnosis 37.78± 13.68 years. Sheehan's syndrome (SS) was the most common cause of panhypopituitarism in 57.14%(8 patients), followed by post surgery in 14.28% (2 patients). 80% of women had SS with a mean duration of symptoms 2.39±1.54 years. Conclusion: Sheehan's syndrome is not uncommon in developing countries, High degree of clinical suspicion is desired as clinical features are most often subtle.

Clinical Profile and Outcome of Pregnant Patients with Acute HEV Hepatitis During Water Borne Epidemic in Himachal Pradesh: A Hospital Based Study.

Background: Recent outbreak of HEV hepatitis epidemic in Himachal Pradesh in Shimla caused significant morbidity and mortality especially among pregnant patients. Overall mortality is 0.5- 4% in patients developing acute hepatic failure (ALF) and is significantly higher in pregnant patients (20%). Present study conducted to observe clinical profile and outcome in pregnant patients. Methodology: this is a retrospective observational study done on admitted pregnant and post partum patients with acute HEV hepatitis during 3 months periods. History focussing on symptoms, duration, onset, progression, co morbidities, pregnancy outcome, complications noted. Confirmation of the HEV infection was done using HEV IgM ELISA. Results: Total 26 patients observed, among which 8 were pregnant and 18 were post partum Average age of presentation was 26.11±3.7 years and average duration of hospital stay 10.46 days. 8 (30.76%) patients required ICU care Presenting complaints were similar to typical presentation in viral hepatitis. All patients were icteric at presentation and 8 (30.76%) patients had hepatic encephalopathy (HE) and 8 (30.76%) patients had ALF, 20 (76.92%) sepsis and 7(26.92%) underwent preterm labour. Out of the total 14 patients who delivered, poor fetal outcome was seen in 5 patients died during this period (15.38%). Factors responsible for in hospital mortality were altered mental status at presentation (p0.018), edema (p 0.046), HE(0.018), acute liver failure(0.018). Conclusion: HEV infection has more morbidity and mortality among pregnant females and poor fetal outcome. Mortality is high (15.38%). Altered mental status at presentation, edema, HE, ALF have significant correlation (<0.05) with the mortality.

Cushing's Disease presenting as Suicidal Depression.

A case of Cushing disease, who presented with suicidal depression as the main complaint is reported. Prompt diagnosis and early management of the underlying cause of Cushing's disease, not only relieved features of hypercortisolaemia but also remitted depression fully.

A swinging heart.

We present a case of young female presenting with clinical features of cardiac tamponade. On initial investigation, the etiology of cardiac tamponade could not be made. The presence of bradycardia with cardiac tamponade prompted us to perform thyroid function test which lead to the diagnosis of hypothyroidism.

Diabetic muscle infarction: An unrecognised complication of diabetes - A case report from subhimalayan region of India.

A case of acute onset unilateral painful swelling of thigh is being presented where a high index of suspicion based on clinical presentation and characteristic MRI findings establish the diagnosis of DMI and avoided an inappropriate diagnosis and treatment.