Jeffrey Pradeep Raj

Quantifying Burnout among Emergency Medicine Professionals

Background: Burnout is a syndrome explained as serious emotional depletion with poor adaptation at work due to prolonged occupational stress. It has three principal components namely emotional exhaustion(EE), depersonalization(DP) and diminished feelings of personal accomplishment(PA). Thus, we aimed at measuring the degree of burnout in doctors and nurses working in emergency medicine department (EMD) of 4 select tertiary care teaching hospitals in South India. Methods: A cross sectional survey was conducted among EMD professionals using a 30-item standardized pilot tested questionnaire as well as the Maslach burnout inventory. Univariate and Multivariate analyses were conducted using binary logistic regression models to identify predictors of burnout. Results: Total number of professionals interviewed were 105 of which 71.5% were women and 51.4% were doctors. Majority (78.1%) belonged to the age group 20-30 years. Prevalence of moderate to severe burnout in the 3 principal components EE, DP and PA were 64.8%, 71.4% and 73.3% respectively. After multivariate analysis, the risk factors [adjusted odds ratio (95% confidence intervals) for DP included facing more criticism [3.57(1.25,10.19)], disturbed sleep [6.44(1.45,28.49)] and being short tempered [3.14(1.09,9.09)]. While there were no statistically significant risk factors for EE, being affected by mortality [2.35(1.12,3.94)] and fear of medication errors [3.61(1.26, 10.37)] appeared to be significant predictors of PA. Conclusion: Degree of burn out among doctors and nurses is moderately high in all of the three principal components and some of the predictors identified were criticism, disturbed sleep, short tempered nature, fear of committing errors and witnessing death in EMD.

Euglycemic diabetic ketoacidosis: a diagnostic and therapeutic dilemma

Euglycemic diabetic ketoacidosis (EDKA) is a clinical triad comprising increased anion gap metabolic acidosis, ketonemia or ketonuria and normal blood glucose levels <200u2009mg/dL. This condition is a diagnostic challenge as euglycemia masquerades the underlying diabetic ketoacidosis. Thus, a high clinical suspicion is warranted, and other diagnosis ruled out. Here, we present two patients on regular insulin treatment who were admitted with a diagnosis of EDKA. The first patient had insulin pump failure and the second patient had urinary tract infection and nausea, thereby resulting in starvation. Both of them were aggressively treated with intravenous fluids and insulin drip as per the protocol for the blood glucose levels till the anion gap normalized, and the metabolic acidosis reversed. This case series summarizes, in brief, the etiology, pathophysiology and treatment of EDKA. Learning points: Euglycemic diabetic ketoacidosis is rare. Consider ketosis in patients with DKA even if their serum glucose levels are normal. High clinical suspicion is required to diagnose EDKA as normal blood sugar levels masquerade the underlying DKA and cause a diagnostic and therapeutic dilemma. Blood pH and blood or urine ketones should be checked in ill patients with diabetes regardless of blood glucose levels.

Splenic Infarct and Pulmonary Embolism as a Rare Manifestation of Cytomegalovirus Infection

Cytomegalovirus (CMV) is a type of herpes infection that has a characteristic feature of maintaining lifelong latency within the host cell. CMV manifestations can cover a broad spectrum from fever to as severe as pancytopenia, hepatitis, retinitis, meningoencephalitis, Guillain-Barre syndrome, pneumonia, and thrombosis. Multiple case reports of thrombosis associated with CMV have been reported. Deep vein thrombosis or pulmonary embolism is more common in immunocompetent patients while splenic infarct is more common in immunocompromised patients. However, here we report a female patient on low-dose methotrexate for rheumatoid arthritis who presented with both pulmonary embolism and splenic infarct.

Update in global trends and aetiology of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver responsible for an increasing number of cancer-related deaths, especially in developing economies of Asia and Africa. A plethora of risk factors have been described in the literature. Some of the important ones include chronic viral hepatitis, liver cirrhosis, environmental toxins such as aflatoxin, non-alcoholic fatty liver disease, lifestyle factors like alcohol consumption, smoking, and dietary factors, metabolic diseases like diabetes mellitus and obesity, and genetic and hereditary disorders. The development of HCC is complex involving sustained inflammatory damage leading to hepatocyte necrosis, regeneration, and fibrotic deposition. It also poses multiple challenges in diagnosis and treatment despite advances in diagnostic, surgical, and other therapeutic advancements. This is a narrative review of findings of multiple studies that were retrieved from electronic databases like PubMed, MEDLINE, Embase, Google Scholar, Scopus, and Cochrane. We summarise the current knowledge regarding the epidemiology and various risk factors for the development of HCC with a brief note on various prevention strategies.

Updated review of current pharmacological and non-pharmacological management of irritable bowel syndrome

ABSTRACT Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal tract that is usually associated with chronic abdominal pain and altered bowel habits. The two spectra of the disease include constipation‐predominant IBS and Diarrhea‐predominant IBS. Earlier it was thought to be an unexplained brain‐gut disorder, but of late, various underlying causes suggesting primary gut disturbance have been identified. The initial management primarily includes the non‐pharmacological measures such as dietary modifications, increasing physical activity, and psychological therapy. Pharmacological management is adjunct to non‐pharmacological management, and the drug is chosen based on the predominant symptom of bowel habit whether constipation or diarrhea. In this review, we aim to update the readers on the currently available management options in the treatment of IBS – both pharmacological and non‐pharmacological options. Further, for the various pharmacological treatments, we summarize the clinical pharmacology, indications, contraindications, adverse effects and use in pregnancy.

SLEep among diabetic patients and their GlycaEmic control (SLEDGE): A pilot observational study: Sleep and glycemic control

Recent cohort studies have proven the association between sleep deprivation and adverse glycemic control (GC). The aim of this study was to assess the prevalence of excessive daytime sleepiness (EDS), a subjective measure of sleep deprivation, among type 2 diabetic mellitus (T2DM) patients and its association with GC.

Prevalence of Obesity among Rehabilitated Urban Slum Dwellers and Altered Body Image Perception in India (PRESUME)

Background: An understudied risk factor for overweight/obesity in our population is distorted body image perception where studies from the west have proved a clear association between the two. We therefore aimed to evaluate the same and document the prevalence of overweight/obesity among rehabilitated slum dwellers. Materials and Methods: It was a cross-sectional study conducted during February 2015. The participants were recruited from among permanent residents of Tamil Nadu Slum Clearance Board residential apartment blocks. Systematic random sampling followed by cluster sampling was done. All consenting individuals above 18 years of age were included. Pregnant women, bed-ridden patients, and those who had an acute illness in the last 2 weeks were excluded. Data were collected using a semi-structured standardized pilot-tested questionnaire which included Stunkards figure rating scale. Results: Number of families included was 170 comprising 315 individuals. Prevalence of overweight was 36.5% and prevalence of obesity was 12.4%. Prevalence of body image dissatisfaction was 68.3% (women 68.9% and men 67%), and prevalence of body image distortion was 59% (women 57.5% and men 62.1%). Distorted body image (adjusted odds ratio [aOR]; 95% confidence interval [95% CI]: 1.927; 1.057, 3.514) and underestimating body image size (aOR; 95% CI: 8.001; 4.223, 15.159) were highly significant predictors of obesity as estimated by logistic regression. Conclusion: Although majority of population belonged to daily wage laborer workforce, prevalence of overweight is high. Distorted ideal and current body image perception is also significantly high and is a definite risk factor for obesity.

Methemoglobinemia: A Rare Entity Caused by Commonly Used Topical Anesthetic Agents, a Case Report

Benzocaine, a topical anesthetic agent, is widely used during short procedures like endoscopy, endotracheal intubation and likewise. Here we report a case of benzocaine spray-induced methemoglobinemia in an adult male patient during the transesophageal echocardiography (TEE) presenting as hypoxia and improved subsequently in the next 2 h on low-dose intravenous methylene blue. Causality assessment of the adverse event was probable, and preventability assessment was unpreventable. The patient was discharged with no further complications at good health. A relevant etiopathology and managing principles are summarized in this case report such that it serves as an awareness to all medical fraternity about this unexpected yet life-threatening adverse drug reaction to an otherwise safe local anesthetic.

Topiramate-induced acute liver injury: A rare adverse effect

Idiosyncratic drug-induced liver injury (DILI) is damage to liver occurring at recommended dose of a drug in contrast to toxic or predictable DILI. Although it is common in first-generation antiepileptic drugs (AEDs), it is rare in newer AEDs such as topiramate. Topiramate commonly causes neurological adverse effects such as psychomotor slowing and somnolence. Hepatotoxicity by topiramate is rare and has been previously reported in combination with other drugs such as valproate and carbamazepine. Here, we report a case of topiramate-induced asymptomatic elevation of liver enzymes in an adult man diagnosed with alcohol dependence syndrome and alcohol withdrawal complicated with seizures.

Doxycycline-Induced Acute Pancreatitis: A Rare Adverse Event

Doxycycline is a broad-spectrum antibiotic belonging to the tetracycline group which acts by inhibiting bacterial protein synthesis. It is considered to be a relatively safe drug. We report a case of doxycycline-induced acute pancreatitis (DIAP) in an adult female patient who was started on the usual therapeutic dose 1 week before for acne vulgaris. The WHO causality assessment was possible, and the Naranjo scale confirmed it as “definite” adverse drug reaction. A brief literature review on case reports previously reporting DIAP has also been summarized.