Serpent strikes, sapien sways: A rare case of bilateral cerebellar infarct following viper bite.

Ischemic stroke following snake bite is rare. We report a posterior circulation infarct involving bilateral cerebellum and occipital lobe following Russell's viper bite in a previously healthy individual. A 50 years old healthy individual, soon after being bitten by the Russel viper on the left foot he developed pain and swelling followed by drooping of eyelids, slurring of speech and giddiness with multiple episodes of vomiting. The patient was administered ASV as well as neostigmine and atropine injections. Following this, the neurological manifestations resolved except dysarthria. CT brain study done was normal. On day 2 of hospitalization, he developed left cerebellar signs (positive finger nose finger test, rebound phenomenon, dysdiadochokinesia, a positive heel shin test). Subsequently, an MRI with MR angiogram was done which showed acute infarcts in bilateral cerebellar hemispheres, with the left superior cerebellar peduncle showing restricted diffusion and low ADC values. Ischemic infarction following viper envenomation has been described by only few authors. In majority of the cases reported, ischemic infarction involved the anterior circulation. The possible mechanisms of infarction in this scenario are discussed. Patient was treated with anti-snake venom and showed a good recovery. Early imaging and early treatment with anti-snake venom is important for a favourable outcome.

Résumé L'AVC ischémique consécutif à une morsure de serpent est rare. Nous rapportons un infarctus de la circulation postérieure impliquant le cervelet et le lobe occipital bilatéraux suite à une morsure de vipère de Russell chez un individu auparavant en bonne santé. Un individu en bonne santé de 50 ans, peu de temps après avoir été mordu par la vipère Russel au pied gauche, il a développé une douleur et un gonflement suivis d'un affaissement des paupières, d'un trouble de l'élocution et de vertiges avec de multiples épisodes de vomissements. Le patient a reçu de l'ASV ainsi que des injections de néostigmine et d'atropine. Suite à cela, les manifestations neurologiques ont disparu sauf la dysarthrie. L'étude cérébrale réalisée par TDM était normale. Au 2ème jour d'hospitalisation, il a développé des signes cérébelleux gauches (test doigt nez doigt positif, phénomène de rebond, dysdiadochokinésie, test talon tibia positif). Par la suite, une IRM avec angiographie IRM a été réalisée qui a montré des infarctus aigus dans les hémisphères cérébelleux bilatéraux, le pédoncule cérébelleux supérieur gauche montrant une diffusion restreinte et de faibles valeurs d'ADC. L'infarctus ischémique consécutif à une envenimation par vipère n'a été décrit que par quelques auteurs. Dans la majorité des cas rapportés, l'infarctus ischémique impliquait la circulation antérieure. Les mécanismes possibles de l'infarctus dans ce scénario sont discutés. Le patient a été traité avec du venin anti-serpent et a montré une bonne récupération. Une imagerie précoce et un traitement précoce avec du venin anti-serpent sont importants pour un résultat favorable. Mots-clés: Infarctus cérébelleux, étude cérébrale par imagerie par résonance magnétique, morsure de vipère.

The ambulatory blood pressure monitoring among obese and nonobese diabetes mellitus patients.

Background: Obesity and diabetes mellitus are two major factors related with the risk of metabolic syndrome and cardiovascular diseases. Co-existing hypertension with diabetes mellitus and obesity has poor prognosis for cardiovascular diseases. Ambulatory blood pressure monitoring (ABPM) correlates more closely to target organ damage than clinic blood pressure. Objectives: The objective of the study is to assess and compare ABPM pattern among obese and nonobese diabetes mellitus patients. Materials and Methods: A cross-sectional study was conducted among fifty obese and fifty nonobese diabetic patients who were classified based on their body mass index as per the WHO criterion. The clinical blood pressure measurements were measured on each subject using a digital sphygmomanometer, and 24 h ABPM was done and ABPM parameters such as dipping pattern, 24 h systolic blood pressure (SBP), diastolic blood pressure (DBP), Mean SBP, mean DBP, diurnal variability of SBP, DBP, Mean arterial pressure, pulse pressure, SD systole (Standard Deviation systole), SD diastole, white coat hypertension was derived and compared between the two groups. Results: Around 37 (74%) obese and 18 (36%) nonobese showed non dipping pattern in SBP and 28 (66.7%) of obese and 14 (33.3%) of nonobese showed a nondipping pattern in DBP and was found to be statistically significant (P < 0.001). On comparison between normotensive obese and normotensive nonobese, it was found that SBP non dipping pattern18 (67%) versus 9 (29%) and DBP nondipping pattern 12 (45%) versus 5 (16%) was statistically significant with P = 0.004, 0.016, respectively. Conclusion: Obese diabetes mellitus subjects had altered ABPM parameters and increased prevalence of nondipping status. In addition, obese diabetic patients who did not give prior history of hypertension were also found to have higher nondipping SBP and DBP patterns.

Comparison of prevalence of life style risk factors and 10 year risk of CVD event among rural and tribal population of Kollegal Taluk, Chamrajanagar district, South India.

CONTEXT: Cardiovascular diseases have been recognized as leading cause of death. Three-fourths of CVD deaths occur in low and middle income countries. Surveillance of CVD risk factors is a key strategy for effective CVD prevention. AIMS: To identify the extent of CVD risk factors and 10 year risk of developing Cardiovascular Disease events among rural and tribal population. SUBJECTS AND METHODS: This community based cross sectional study was conducted on a total of 482 rural and 415 tribal subjects aged above 30 years from Kollegal taluk, Chamrajanagar, Karnataka, India. Tobacco and alcohol consumption, BMI, blood pressure and capillary blood glucose were estimated. WHO/ISH risk prediction chart was used to predict 10 year risk of MI/stroke. RESULTS: Tobacco consumption was 15.4% (rural) and 90.8% (tribal). Alcohol consumption was 10.8% (rural) and 21.9% (tribal), Obesity was 40.2% (rural) and 14.0% (tribal). Prevalence of Hypertension was 49.8% (rural) and 32.2% (Tribal) and diabetes 8.3% (rural) and 2.9% (tribal). Nearly one fourth of the population are at moderate risk (10-30%) and one tenth are at high risk (30%) of MI/Stroke within 10 years. CONCLUSIONS: High prevalence of tobacco consumption among tribal and high prevalence of hypertension and diabetes among rural predisposes 10% of population to moderate to high risk of stroke/MI within 10 years.

Patient Self-reported quality of life assessment in Type 2 diabetes mellitus: A pilot study.

BACKGROUND: Quality of life (QoL) is an important outcome measure to assess the diabetic care and is increasingly replacing the traditional indicators of health. AIM: The aim is to evaluate the QoL in patients with type 2 diabetes mellitus (DM) using a third generation individualized QoL instrument like an audit of diabetes-dependent QoL (ADDQoL) questionnaire and to determine the predictors. MATERIALS AND METHODS: Patients who met the inclusion and exclusion criteria were recruited from a tertiary care hospital by convenience sampling. Sociodemographic and other relevant details were collected from the study patients, and ADDQoL questionnaire were administered to them. RESULTS: A total of 200 patients were included in the study among which 66% of patients had uncontrolled type 2 DM as suggested by their glycated hemoglobin (HbA1c) values. The mean QoL score was 0.07 (0.91) and diabetes-dependent QoL was -1.33 (0.58). Approximately 38% were associated with poor health-related QoL with a mean average weighted impact score of -0.51 (0.51). Most frequently affected life domain was the freedom to eat. A positive correlation was observed between QoL and gender, age, domicile, education status, occupation, family structure, duration of type 2 DM, HbA1c, insulin treatment, and the presence of comorbidities. CONCLUSION: The study highlights the impact of type 2 DM on QoL. Improving QoL of type 2 diabetic patients is important and knowledge of these preventable risk factors help to implement strategies to better management of type 2 DM and ultimately improve therapeutic outcome.

Diabetic self care practices in rural Mysuru, Southern Karnataka, India - A need for Diabetes Self Management Educational (DSME) program.

CONTEXT: Diabetes and its complications are the leading cause of morbidity and mortality in the world. Self care has emerged as a crucial element in the management of diabetes and a key factor associated with the quality of diabetic care. AIMS: The purpose of the study was to assess the self care activities of patients with Type II diabetes mellitus in a rural area of Mysuru district. SETTINGS AND DESIGN: A community based cross sectional descriptive study was carried out among 400 diabetic patients in rural Mysore. METHODS AND MATERIAL: Self care Activities (Diet, exercise, self blood glucose monitoring, medication, foot care, smoking) were assessed using a pre designed and tested questionnaire. STATISTICAL ANALYSIS USED: Relevant descriptive analysis like percentages is carried out using SPSS version 22.0. RESULTS: Most of the diabetic patients had good compliance for medication (92.5%), followed by 72% for diabetic diet. Only 27.75% of the diabetic patients participated in walking, 24.25% practised foot care, blood glucose monitoring by 24.75% and only 25.5% of them were current smokers. CONCLUSIONS: The rural diabetic patients are more adherent and compliant to medication and diabetic diet and less compliant to physical activity, foot care and self glucose monitoring.

Factors Contributing to Development and Reversal of LVH: A Pilot Study.

INTRODUCTION: Left Ventricular Hypertrophy (LVH) often reflects as a physiological adaptation to chronic pressure overload. It has been identified as a strong independent risk factor of all-cause mortality and adverse cardiac events. Since not all subjects with hypertension develop LVH, understanding the clinical factors contributing to the development of LVH and the appropriate diagnostic and treatment strategies may help clinicians in conducting more definitive evaluation and managing the disease effectively. AIM: To assess the incidence of LVH in hypertensive subjects and the factors influencing its development and reversal. The study also evaluated the most effective diagnostic technique and therapy that could improve the disease symptoms and prognosis. MATERIALS AND METHODS: The prospective study, conducted at Jagadguru Sri Shivarathreeshwara (JSS) Medical College JSS University, Mysore, India, included 50 patients with hypertension. Detailed history of the recruited subjects was collected from patient records and through physical examination. Demographic and clinical characteristics such as age, gender, BMI, and stage of hypertension (stage I HTN and stage II HTN) were also obtained. Funduscopic examination was done for all patients for evidence of hypertensive retinopathy. Echocardiography (ECHO), electrocardiography (ECG), and chest X-Ray were used for detection of LVH. The patients were reviewed after six months and reassessment of LVH was carried out. Statistical analysis was conducted using SPSS software and R 3.2 package. RESULTS: Angiotensin-Converting Enzyme (ACE) inhibitors were found to be more effective in the treatment of LVH when compared to calcium channel blockers and beta blockers. ECHO was found to be the best method to diagnose LVH. In patients with stage I HTN, 47.1% had normal LVM. Around 53% of the subjects with stage I HTN and all with stage II HTN had abnormal LVM. Retinal changes were noted in 96.2% of abnormal LVM patients and 50% of normal LVM patients. A positive association between BMI and LVH (OR: 1.39) was also noted. CONCLUSION: BMI may positively influence LVH regression. The presence of retinopathy, in addition to LVH, suggests an increased chance of regression with anti-hypertensive treatment.

Quality of diabetic care in an urban slum area of Mysore: A community based study.

MATERIALS AND METHODS: Community based cross sectional study was conducted in an urban slum of Mysore. Data was collected between July and August 2011. Known diabetics residing in this area were included in the study. Socio-demographic information of diabetic patients, history, physicians advice and the extent of compliance of patients towards treatment were assessed. Descriptive statistics, like percentages were calculated. RESULTS: Study comprised of 104 patients. Mean fasting and post prandial blood glucose was 163±70mg/dl and 239±89mg/dl respectively. Common co-morbid conditions were hypertension and obesity. Key process indicators of care, indicated that adherence to medication advice was maximum and less than one fourth of them had an annual Hba1c and lipid profile examinations. CONCLUSIONS: To prevent long term complications associated with diabetes, doctors must adhere to the guidelines. There is a need to improve the health system, in terms of developing facilities to provide annual eye examination, annual lipid profile, urea, creatinine testing for diabetic patient.

Sub-clinical Hypothyroidism in Type 2 Diabetes Mellitus Patients in a Tertiary Care Hospital, Mysore.

Thyroid diseases and type 2 diabetes mellitus are the two most common endocrine disorders encountered in clinical practice. Diabetes mellitus and thyroid disorders are shown to mutually influence each other. The present study was done to assess and compare the thyroid function tests in diabetes mellitus patients and normal healthy volunteers. This is a cross-sectional, age-matched, comparative, hospital based study. Type 2 Diabetes mellitus patients without hypothyroidism attending the medicine outpatient department (OPD) or admitted in the medicine wards were screened and then included as cases (30 patients). The normal healthy volunteers without diabetes mellitus or hypothyroidism were screened and included for control group (30 Patients). In this study the mean and standard deviation (S.D.) of thyroid stimulating hormone (TSH) was statistically, significantly higher in the diabetes mellitus group (5.48±2.32 mIU/dl), when compared to control group (2.91±1.44 mIU/dl). This sub clinical hypothyroidism leads to dyslipidemia. The results also showed elevated total cholesterol, low density lipoprotein (LDL) in diabetes mellitus group, when compared to control group. Thus, subclinical hypothyroidism in type 2 diabetes mellitus can aggravate the classical risk factors such as hypertension and dyslipidemia, arising from an undiagnosed thyroid dysfunction and can lead to an increased cardiovascular risk in these patients.

Physician's practices and perspectives regarding tobacco cessation in a teaching hospital in Mysore City, Karnataka.

CONTEXT: Tobacco is a leading cause of disease and premature death. Most of the smokers visit a doctor for various health related ailments and thus such clinic visits provide many opportunities for interventions and professional tobacco cessation advice. AIMS: The primary aim of the following study is to assess the physician practices, perspectives, resources, barriers and education relating to tobacco cessation and their perceived need for training for the same. The secondary aim is to compare the physician's cessation practices from patient's perspective. SETTINGS AND DESIGN: A descriptive study was conducted in a hospital attached to Medical College in Mysore city, Karnataka. MATERIALS AND METHODS: Information about doctor's practices, perspectives and their perceived need for training in tobacco cessation were collected using pre-structured self-administered Questionnaire, which were distributed in person. Patient's practices and perspectives were assessed using a pre-structured Oral Questionnaire. RESULTS: Almost 95% of physicians said that they ask patients about their smoking status and 94% advise them to quit smoking, but only 50% assist the patient to quit smoking and only 28% arrange follow-up visits. Thus, they do not regularly provide assistance to help patients quit, even though 98% of the physicians believed that helping patients to quit was a part of their role. Only 18% and 35% of the physicians said that Undergraduate Medical Education and Post Graduate Medical Education respectively prepared them very well to participate in smoking cessation activities. CONCLUSIONS: Tobacco cessation requires repeated and regular assistance. Such assistance is not being provided to patients by attending doctors. Our medical education system is failing to impart the necessary skills to doctors, needed to help patients quit smoking. Reforms in education are needed so as to prepare the physician to effectively address this problem.