George M. Abraham

Public Awareness of Warning Symptoms, Risk Factors, and Treatment of Stroke in Northwest India

Background and Purpose— This study assessed public awareness of warning symptoms, risk factors, and treatment of stroke in Ludhiana, Punjab, North West India. Methods— A hospital-based survey was conducted between February 2002 and September 2002 by the Stroke section of Christian Medical College. The study subjects were relatives of patients without history of stroke, attending the outpatient department of the hospital. Trained medical students, interns, and a nurse interviewed subjects using a structured, pretested, open-ended questionnaire. Results— Nine hundred forty-two individuals were interviewed during the study period (56.4% men, mean age 40.1 years, age range 15 to 80 years). Forty-five percent of the subjects did not recognize the brain as the affected organ in stroke. In the multivariate analysis, higher education (P<0.001; odds ratio 2.6; 95%, CI 1.8 to 3.8) and upper socioeconomic status (P<0.005; odds ratio 1.6; CI, 1.1 to 2.2) correlated with a better knowledge of which organ was affected in stroke. Twenty-three percent of the participants did not know a single warning symptom of stroke. Twenty-one percent of the subjects could not identify even a single risk factor for stroke. Seven percent of the study population believed that oil massage would improve stroke victims. A small proportion of subjects believed in witchcraft, faith healing, homeopathic, and ayurvedic treatment (3%). Conclusions— This hospital-based survey reveals a better awareness of stroke warning signs and risk factors. However, knowledge regarding the organ involved, etiology, and treatment of stroke is lacking. Considerable education is needed to increase public awareness in modern concepts of stroke treatment.

Spectrum of neurological manifestations in dengue virus infection in Northwest India.

Summary The objective of this study was to study the spectrum of neurological manifestations in patients with dengue infection. This was a prospective study undertaken at the Departments of Medicine and Neurology, Christian Medical College, Ludhiana, India. All patients diagnosed with dengue fever during an epidemic (1 September 2010–31 December 2010) were screened for neurological manifestations. There were a total of 799 patients with dengue infection. Neurological manifestations were present in 21 (2.63%),19 of whom were men with a mean age of 33.7 ± 13.9 years. The neurological diagnoses were hypokalaemia with: quadriparesis (7); myositis (4); encephalopathy (4); Guillain–Barre syndrome (2); acute disseminated encephalomyelitis (2); lumbosacral plexopathy (1); and intracranial haemorrhage (1). Three of these patients died. Clinicians should be aware that neurological manifestations in dengue fever are not uncommon.

Daptomycin-Induced Acute Renal and Hepatic Toxicity Without Rhabdomyolysis

Objective: To report a case of a patient who experienced acute renal and hepatic toxicity following administration of daptomycin and review previously published case reports of renal and hepatic dysfunction with daptomycin. Case Summary: A 35-year-old man receiving daptomycin 4 mg/kg (275 mg) intravenously once daily (started 5 wk prior to presentation for presumed osteomyelitis) presented to the emergency department with elevations in serum creatinine and hepatic transaminase levels. He did not experience creatine kinase (CK) elevation or rhabdomyolysis. Following discontinuation of daptomycin, his renal and hepatic function improved. Discussion: To our knowledge, this is the first case of daptomycin-induced hepatotoxicity with acute renal failure in the absence of rhabdomyolysis and CK abnormalities. Previously published case reports described patients with a variety of elevations in liver function tests, serum creatinine, and CK with daptomycin. In our patient, the acute renal and hepatic toxicity was probable according to the Naranjo probability scale. Conclusions: Although daptomycin is a well-tolerated antibacterial agent, clinicians should consider periodic monitoring of liver function and renal function tests to identify potential adverse effects.

Sofosbuvir in the Treatment of Chronic Hepatitis C: New Dog, New Tricks

The existing standard of care for chronic hepatitis C virus (HCV) infection includes the use of pegylated interferon and ribavirin as primary components of treatment, with the addition of a direct-acting antiviral for genotype 1 infection. Sofosbuvir, an oral nucleotide inhibitor of the HCV nonstructural protein 5B RNA-dependent RNA polymerase enzyme, was recently approved for use in combination with ribavirin and/or pegylated interferon for chronic HCV infection, depending on the genotype. Sofosbuvir is orally administered, and peak plasma concentrations are not affected by food. The drug is renally eliminated and does not require adjustment in mild to moderate renal insufficiency or in any degree of hepatic impairment. Sofosbuvir is not metabolized by cytochrome P450 isoenzymes, nor does it induce or inhibit the metabolism of agents that are substrates of these enzymes. Sofosbuvir demonstrates a high barrier to resistance and was well tolerated by patients in clinical trials. Overall efficacy rates vary between 70% and 90%.

Revising warfarin patient education materials to meet a National Patient Safety Goal

Anticoagulants are one of the drug classes most frequently cited in reports of medication errors or adverse drug reactions, and their improper use often results in emergency department visits, hospitalizations, or both.[1][1]–[3][2] In order to minimize the risks and standardize practices within

A multidisciplinary approach in travel medicine: the pharmacist perspective.

ecently, travel to underdeveloped and exotic desti-nations has increased substantially. Internationaltravel is a multi-billion dollar industry exceeding

Identification and review of mobile applications for travel medicine practitioners and patients.

900 billionUS dollars (600 euros) in 2008. By the year2020, it is expected that the number of internationaltravelers willexceed1 billion,halfbeingforleisurepur-posesandapproximately15%businessrelated.

Failed triple therapy in a treatment-experienced patient with genotype 6 hepatitis C infection

Advancements in technology have led to the development of medical applications (apps). Contents of 44 apps related to travel medicine were assessed demonstrating that many were updated infrequently and several developers had no medical background. There is an opportunity for healthcare professionals to develop apps in travel medicine.

A nail in the head

PURPOSE The first published report of the use of triple therapy in a patient with hepatitis C virus (HCV) genotype 6 infection-a treatment that was prescribed due to incorrect HCV genotyping and which ultimately failed-is presented. SUMMARY A 70-year-old male U.S. resident of Vietnamese descent requested treatment for chronic HCV infection acquired decades earlier. He reported experiencing hepatitis C treatment failures twice before-13 years prior (interferon alfa monotherapy for six months) and 7 years prior (standard dual therapy with pegylated interferon alfa-2b and ribavirin for nine months). Initial viral genotyping indicated infection with HCV genotypes 1a and 6c (a form of mixed HCV disease amenable to triple therapy), and treatment with pegylated interferon alfa-2a, ribavirin, and boceprevir was initiated. By week 8 of triple therapy, the patients viral load had decreased from 15,700,000 (7.20 log) to 462,882 (5.67 log) IU/mL, but the viral load subsequently rebounded to baseline levels, and treatment was discontinued at week 16. When repeat HCV genotyping was performed, it was discovered that initial genotyping was incorrect and that the mans infection involved not mixed genotypes but only genotype 6; he was not an appropriate candidate for triple therapy. The case emphasizes the need for clinicians to be cognizant of potential HCV genotyping errors, particularly with regard to patients of Southeast Asian descent. CONCLUSION Three courses of interferon-based treatment, including triple therapy with boceprevir, failed to produce a sustained therapeutic response in a 70-year-old ethnic Vietnamese man with genotype 6 HCV infection.

Recrudescence of Plasmodium falciparum in a Primigravida after Nearly 3 Years of Latency.

A 46-year-old man came to the emergency room with a nail in his head after the accidental fi ring of a nail gun at home. His only symptom was a mild frontal headache. Physical examination showed no focal neurological defi cits. A skull radiograph and CT scan of the brain revealed a 6·35 cm nail that had entered the calvarium through the right frontal bone with approximately 4·1 cm of parenchymal penetration, and a small intraparenchymal haemorrhage and air consistent with pneumocephalus (fi gure). The nail was removed successfully with minor bleeding in the tract seen on postoperative imaging. He had an uneventful recovery and was discharged home. An accidental foreign body insertion through the calvarium can have variable consequences, dependent on the velocity, chemical composition, shape, and location of the object. Frameless stereotactic systems greatly facilitate localisation of deep-seated intraparenchymal foreign bodies. Given the increasing use of pneumatic and cartridge-activated nail guns, the addition of a sequential trigger should be required in such equipment, especially for the protection of construction workers, who may be at highest risk for such injuries.