Wernicke's Encephalopathy - 'Pushing the Envelope' of Patient's Profile: A Case Report.

Wernicke's encephalopathy (WE), an acute neuropsychiatric condition, is caused by thiamine deficiency. Traditionally, it has been associated with patients with a background of alcoholism. However, in the past few decades, with increasing trends in the incidence of WE among patients without a history of alcohol consumption, a pressing need was felt to examine the existing guidelines for the management of WE and its sequelae. The need for a revision was felt as the guidelines for the management of WE were developed around the premise that this affliction is observed mainly among alcoholics. In light of the opportunity presented to us by one of our patients who did not 'fit the bill' of a traditional case of WE, we decided to compare and contrast the management of WE among patients with and without a background of alcoholism. After analyzing the available data on WE among alcoholics and non-alcoholics, we concluded that a high degree of suspicion should be kept in mind if any of the classical features are observed, with a special emphasis on eliciting the underlying causes through a detailed history. Furthermore, thiamine supplementation at a lower dose of 100-200 mg should be initiated first, followed by laboratory and radiological investigations.

Assessment of cost of illness for diabetic patients in South Indian tertiary care hospital.

BACKGROUND: The impact of diabetes on health-care expenditures has been increasingly recognized. To formulate an effective health planning and resource allocation, it is important to determine economic burden. OBJECTIVE: The objective of this study is to assess the cost of illness (COI) for diabetic inpatients with or without complications. METHODOLOGY: The study was conducted in the medicine wards of tertiary care hospital after ethical approval by the Institutional Ethical Committee. A total of 116 each diabetic with or without complications were selected and relevant data were collected using COI questionnaire and data were analyzed using SPSS version 20. Mann-Whitney U test is used to assess the statistical significant difference in the cost of treatment of diabetes alone and with complications'. P ≤ 0.05 was considered statistically significant. RESULTS: Total COI includes the cost of treatment, investigation, consultation fee, intervention cost, transportation, days lost due to work, and hospitalization. The median of total COI for diabetic care without any complication was Rs. 22,456.97/- per patient per annum and with complication was Rs. 30,634.45/-. Patients on dialysis had to spend 7.3 times higher, and patients with cardiac intervention had to spend 7.4 times higher than diabetic patients without any complication. CONCLUSION: Treatment costs were many times higher in patients with complications and with cardiac and renal interventions. Complications in diabetic patients will increase the economic burden to family and also to the society.

Hypokalaemic Periodic Paralysis- A Prospective Study of the Underlying Etiologies.

BACKGROUND: Hypokalaemic periodic paralysis (HPP) is a rare muscular disorder characterised by episodic weakness associated with hypokalaemia. The disease can either be inherited or acquired and misdiagnosis of the disease is quite common. Most of the data available on the disease is from the western world. Studies reporting aetiological, clinical and metabolic profiles of Indian population are sparse. Hence we tried to provide insights of the disease among the Indian population. AIM: To study the aetiological, clinical and metabolic profile of patients diagnosed with Hypokalaemic Periodic Paralysis (HPP). MATERIALS AND METHODS: This is an observational and analytical study on HPP diagnosed patients, during September 2011 to September 2014 in Kasturba Hospital, Manipal. A total of 23 patients were studied. Detailed history, clinical evaluation and metabolic workup for secondary causes of HPP were analysed. RESULTS: Of the 23 patients, 57% had primary HPP while 43% had secondary HPP. The group of patients with primary HPP comprised of 92% males and 8% females with mean age of 28 years and the mean duration of symptoms of 18 hours. The group with secondary HPP comprised of 70% males and 30% females with mean age of 38.7 years and the mean duration of symptoms of 60 hours. The secondary causes of HPP were thyrotoxicosis (50%), infective diarrhea (20%), Crohn's disease (10%), renal tubular acidosis (RTA) Type I (10%) and Conn's syndrome (10%). CONCLUSION: In our study primary HPP was found to be more common than secondary HPP. Males were predominantly affected in both groups. HPP should be ruled out before starting therapy for Guillain-Barré Syndrome (GBS).

Association of Thyroid Function with Severity of Coronary Artery Disease in Euthyroid Patients.

INTRODUCTION: Thyroid hormone exerts multiple effects on the heart and vascular system. Variations of free T3 have been linked to coronary artery disease. We conducted a study to observe whether there is a relationship between the variation of the serum thyroid hormone levels (TSH, FT3 and FT4) and the presence and severity of CAD in the euthyroid patients. AIM: To study association of serum TSH, FT4 and FT3 levels within the normal range with presence and severity of coronary artery disease. MATERIALS AND METHODS: A total of 100 euthyroid patients with stable angina, who underwent coronary angiography were enrolled in the study. Coronary artery disease was defined as >50% stenosis in the luminal diameter in at least one major epicardial coronary artery. The Gensini scoring system was used to define the severity of the CAD and serum TSH, FT3 and FT4 levels were measured by the chemiluminescence method. RESULTS: Single vessel disease was found in 23%, double vessel disease in 15% and triple vessel disease in 17% of patients. TSH and FT4 levels were also comparable between the groups. Normal coronary group had significantly higher mean FT3 values than triple vessel disease (p=0.004) and FT3 levels showed an inverse relation with Gensini score (Pearson's correlation =- 0.30) (p =0.002). A level of FT3 ≤ 2.7 predicted the severity of CAD with a 70% sensitivity and 60% specificity (area under curve (AUC): 0.755, p=0.001). CONCLUSION: In the absence of primary thyroid disease and acute coronary syndrome, the occurrence of CAD is associated with lower serum levels of FT3. FT3 and not the FT4 and TSH levels may be used as an indicator of increased risk for severe CAD. The present study clearly shows the existence of a strong association between the reduction of biologically active T3 and severity of coronary artery disease. However, low T3 state could be at first interpreted as just a biological risk factor of severe coronary artery disease; only the demonstration of beneficial effects on cardiovascular, end points of long term T3 replacement in CAD patients with low T3 state can answer this fundamental issue.

Utility of total lymphocyte count as a surrogate for absolute CD4 count in the adult Indian HIV population: A prospective study.

BACKGROUND: Standard methods of CD4 counts and plasma viral load estimation require specialized equipment, highly trained personnel and are extremely expensive. This remains a major challenge for the initiation of anti-retroviral therapy for patients in resource-limited settings. OBJECTIVE: To assess the clinical utility of the total lymphocyte count (TLC) to serve as a surrogate marker for predicting a CD4 counts <350 cell/mm(3) in patients with HIV. MATERIALS AND METHODS: A prospective study of 200 consecutive newly detected highly active anti-retroviral therapy (HAART) naïve HIV patients admitted over a one year period was conducted. Linear regression, Pearson correlation and receiver operating characteristic (ROC) curves were used to calculate the relationship between TLC and CD4 counts. RESULTS: A significant correlation between TLC and CD4 count was observed (r = 0.682, P < 0.001). TLC cut off of 1200 cell/mm(3) as a predictor of CD4 count <350 cell/mm(3) had 73.1% sensitivity, 100% specificity, 100% positive predictive value (PPV) and 51.4% negative predictive value (NPV). Raising the cutoff to 1500 cells/mm(3) improved the sensitivity to 82.1% with 88.2% specificity, 96.5% PPV, 44.4% NPV. The ROC curve demonstrated highest area under curve (AUC = 0.8) for TLC of 1500 cell/mm(3). CONCLUSION: The study showed that TLC cutoff value of 1500 cells/mm(3) was a cost effective surrogate marker for CD4 counts <350 cells/mm(3) in resource-limited settings.

Quadrivalvular heart disease of mixed congenital and rheumatic aetiology with concomitant ostium secundum atrial septal defect and Ebstein's anomaly of the tricuspid valve.

We describe a 34-year-old man with an ostium secundum atrial septal defect, Ebstein's anomaly of the tricuspid valve with severe tricuspid regurgitation, congenital valvular pulmonary stenosis, rheumatic mitral stenosis and regurgitation with aortic regurgitation, who presented with decompensated heart failure after developing atrial fibrillation. The complex haemodynamic interplay of these lesions is also discussed.

Antihypertensive prescribing preferences in three South Indian Hospitals: cost analysis, physicians perspectives and emerging trends.

OBJECTIVES: The objectives of this study were i) to analyze the prescription pattern of antihypertensive agents in three South Indian hospitals ii) to perform cost-analysis of various antihypertensive treatment regimens iii) to examine the physicians' perspectives of antihypertensive prescribing. METHODS: A cross-sectional study was done on patients with essential hypertension (n = 2,100) by analyzing the medical records of the patients for the drugs prescribed and patient demographics. Cost comparisons were made for the most frequently prescribed agents for each class at the most frequently prescribed dose and regimen. A questionnaire was developed containing questions on familiarity with guidelines, diagnosis of clinical hypertension, an evaluation of patients and choice of drug, and was distributed to physicians in the three hospitals. RESULTS: About one-half of the patients received monotherapy where the remaining received combination therapy for their hypertension. Calcium channel blockers (CCBs) were the most preferred agents used, either as monotherapy or combination therapy in hypertensive patients with or without comorbidities. At the most frequently prescribed dose and dosage regimen, thiazide was the least expensive antihypertensives, followed by CCBs. Physician's responses favored the use of CCBs as first-line agent for uncontrolled hypertension and a two-drug combination approach. CONCLUSIONS: The preference of CCBs and combination-therapy over the traditionally used diuretics or beta-blockers is consistent with the outcomes of recent clinical trials that underscore the benefits of using combination therapy with CCBs as initial therapy for uncomplicated hypertension.

Native valve endocarditis and femoral embolism due to Granulicatella adiacens: a rare case report.

The fastidious Gram-positive cocci Granulicatella adiacens, previously known as nutritionally variant streptococci (NVS) are unusual but significant cause of endocarditis due to increased mortality and morbidity. Difficulties in reaching correct bacteriological identification, increased resistance to beta-lactam antibiotics and macrolides and complicated clinical course have contributed to problems in management of cases of infective endocarditis caused by this bacterium. We present the first Indian case of endocarditis with arterial embolus by G. adiacens in an elderly male with no preexisting cardiac abnormality.

False-positive widal in melioidosis.

Enteric fever is endemic in this part of the world, and Widal test is one of the time-honored laboratory tests that are being used for years to diagnose the disease. On the other hand, melioidosis is a newly emerging disease from this region, which is most often misdiagnosed or underdiagnosed by clinicians. It is well accepted that false-positive Widal reactions following certain non-typhoid Salmonella infections may occur commonly. Three cases of high titers of Widal test are described, where melioidosis was the actual diagnosis in every occasion and was never suspected until diagnosed microbiologically. All the patients had shown a partial response to ceftriaxone. Blood and pus cultures grew Burkholderia pseudomallei, whereas Salmonella typhi was not isolated from blood in any patient. With appropriate antibiotics, the patients showed clinical and microbiological improvement with lowering of Widal titers. These 3 cases show that high Widal titer in any patient may mislead the diagnosis of melioidosis, and further laboratory workup should always be done to rule out melioidosis, especially in cases with nonresponsiveness to treatment.

Validation of Liano score in acute renal failure: a prospective study in Indian patients.

AIM: To validate Liano score as a prognostic scoring system in acute renal failure (ARF): a prospective study in Indian patients. PATIENTS AND METHODS: Prospective study including 100 patients over a period of 1 year, from March 2006 to July 2007. Inclusion criteria were patients with no previous renal disease or any systemic disease known to affect the kidney and who presented with acute rise (hours to days) in serum creatinine. Exclusion criteria were patients with preexisting chronic renal failure, age younger than 12 years and ultrasound of the abdomen showing contracted kidneys. RESULTS AND CONCLUSIONS: In this study there were 68 males and 32 females. Peak incidence by age was in the fifth decade. There was no increased mortality in any age group (p = 0.278). A total of 19 patients had pre-renal ARF, 74 patients had intrinsic ARF, of which 46 were acute tubular necrosis (ATN); 7 patients had obstructive ARF. A total of 21 patients had Liano score greater than 0.9, of which 18 patients died and 3 were discharged against medical advice in a critical condition (and died later at home). Calculated sensitivity was 62.1%, specificity was 100% and positive predictive value was 100%. Sensitivity and specificity when calculated separately for intrinsic renal ARF (after excluding post renal ARF) were 60.7% and 100%, respectively. There was statistically significant correlation between Liano score and mortality (p < 0.001).

Insulin allergy.

A diabetic patient with a non-healing leg ulcer was found to be allergic to both conventional insulin and purified monocomponent insulin of porcine origin. He was successfully treated with human insulin.

Protease inhibitors in serum and urine of snakebite victims.

In victims of poisonous snakebites, serum total antichymotryptic activity but not the antitryptic activity was found to be increased. In addition, urinary antitryptic activity was found to be markedly elevated. In nonpoisonous snakebite cases, no such differences were noted. Ion-exchange chromatographic analysis of serum protease inhibitors revealed the absence of inhibitory activity in the alpha 2-macroglobulin fraction and elevation of alpha 1-antichymotrypsin in poisonous bite cases. In addition, there was a significant increase in the ratio of cationic to anionic fraction of alpha 1-protease inhibitor compared to normals. Urinary antitryptic activity could serve as a reliable index in assessing clinical improvement in snakebite victims during treatment and in differentiating poisonous from nonpoisonous cases.