Kamal Kumar Sawlani

Prognostic Significance of Estimation of Pseudocholinesterase Activity and Role of Pralidoxime Therapy in Organophosphorous Poisoning

Background: Organophosphorous (OP) poisoning is one of the most common poisonings seen in India. OP compounds act through inhibition of enzyme acetylcholinesterase and estimation of pseudocholinesterase (PCE) activity strengthens the diagnosis in clinically uncertain cases of OP poisoning. The role of pralidoxime (PAM) therapy in OP poisoning has been controversial. Study Objectives: This study was aimed to determine the prognostic significance of estimation of PCE activity and also to assess the role of PAM therapy in OP poisoning. Materials and Methods: Patients of suspected OP poisoning of age >12 years admitted to emergency unit at a tertiary healthcare center of north India were enrolled. Patients were categorized into two groups; group A who were given intravenous atropine and group B who were given injectable PAM along with atropine. Serum PCE level was estimated at the time of admission in all patients and severity of OP poisoning was assessed according to PCE level. Requirement of atropine, oxygen inhalation, intubation and ventilatory support, total hospital stay, and mortality were compared between different classes of severity and also between Groups A and B. Results: This study included a total of 70 subjects, 35 in each group with mean age of 24.99 ± 8.7 years. Out of 70 subjects 49 (70%) were male and 21 (30%) were female. Forty nine patients (70%) of OP poisoning were with suicidal intent while 21 (30%) cases were accidentally poisoned. In all suicidal cases route of poisoning was ingestion whereas in all the accidental cases route of exposure was inhalational. PCE levels were reduced in all the cases and the mean level was 3,154.16 ± 2,562.40 IU/L. The total dose of atropine required, need for oxygen inhalation and need for intubation and ventilatory support, mean duration of hospital stay and mortality rate (P = 0.003) were higher in moderate to severe cases and did not have significant difference between Groups A and B. Conclusion: The study recommends estimation of PCE level at admission to classify severity of OP poisoning and to estimate prognosis. This study did not find any beneficial role of PAM therapy in reducing morbidity as well as mortality.

Snake bite-induced leucoencephalopathy

Snake bite is an important cause of mortality and morbidity in India with an estimated 35 000–50 000 fatal bites occurring annually. Neurological deficits following vasculotoxic snake bite are either due to intracranial haemorrhage or subarachnoid bleed as a result of consumption coagulopathy. However, ischaemic strokes and acute disseminated encephalomyelitis have been reported occasionally. We hereby report a case of snake bite leading to leucoencephalopathy.

Relation of glycated hemoglobin with carotid atherosclerosis in ischemic stroke patients: An observational study in Indian population

Context: Glycated hemoglobin A1c(HbA1c) indicates long-term uncontrolled hyperglycemia in the body, which in diabetic patients leads to various vascular complications as a part of generalized atherosclerosis culminating ultimately into ischemic stroke. Aims: Study aims to show the association between marker of uncontrolled long-term hyperglycemia HbA1c and marker of atherosclerosis (Carotid intima media thickness [CIMT] and carotid plaque) in ischemic stroke patients. Subjects and Methods: Carotid sonography using high resolution 7.5 MHz sonography technique was done in each patient to find the occurrence of increased CIMT and presence of plaque according to Mannheim CIMT Consensus (2004-2006). Levels of HbA1c measured in blood in both diabetic and non-diabetic patients and a comparison made between them. Finally an association sought between HbA1c levels with CIMT and plaque. Results: The average value of HbA1c of this cohort was 7.51 ± 1.75% with higher values in diabetic patients (9.29 ± 1.73%). The patients with high CIMT (>0.8 mm) had higher values of HbA1c then that of normal CIMT patients and this was nearly significantly (P = 0.06). However, HbA1c levels of blood were significantly associated with stroke patients with presence of carotid arteries plaque (P = 0.008). Conclusions: Prediction of future risk and prevention strategies for ischemic stroke could be formulated by utilizing HbA1c levels in both diabetic and non-diabetic population.

Effects of a standardized Ayurvedic formulation on diabetes control in newly diagnosed Type-2 diabetics; a randomized active controlled clinical study

OBJECTIVES The purpose of this study was to investigate the efficacy of a standardized polyherbal formulation consists of aqueous extracts from six herbs, in patients with Type-2 diabetes mellitus. DESIGN Randomized, active control study. INTERVENTIONS 93 patients, newly diagnosed with Type-2 diabetes mellitus were randomly allocated to group 1 (received polyherbal capsules 500 mg/day, up titrated weekly to a maximum of 3 g/day) and group 2 (received Metformin 500 mg/day, up titrated weekly to a maximum of 2 g/day). MAIN OUTCOME MEASURES The primary endpoint was effect on the change from baseline in blood glucose (Fasting blood Glucose and Postprandial blood glucose), and glycosylated hemoglobin (HbA1c). The secondary outcome includes the effect on lipid levels, liver enzymes and renal function test. RESULTS After 24 weeks, mean laboratory measured fasting and post prandial blood glucose showed a decrease of 25.52% and 24.22% in polyherbal formulation (PHF) treated group, compared to 31.46% and 24% decrease in Metformin treated group (estimated treatment difference -10.8; 95% CI -22.63 to 1.03 and -0.36; -12.1 to 11.38, respectively). Reduction in HbA1c was also similar for PHF and Metformin (estimated treatment difference 0.01; 95% CI -0.51 to 0.53). However, the decrease in the mean total cholesterol level was more pronounced in PHF treated group (estimated mean difference 61.3; 95% CI 55.32 to 67.28) than Metformin treated group (estimated mean difference 41.12; 95% CI 34.92 to 47.32). Also, there was statistical significance between the treatment groups in total cholesterol level at the end of six months treatment (estimated treatment difference 20.18; 95% CI 12.34 to 28.02). CONCLUSION The study demonstrated that daily intake of this PHF decreased the glycemic level and improved lipid homeostasis, while maintaining the other serum biochemical levels to the normal, and therefore it may be useful for the patients with Type-2 diabetes. This trial is registered in the Clinical Trials Registry - India (CTRI) (CTRI/2014/03/004490).

Native aortic valve fungal endocarditis

Infective endocarditis is the most common and dangerous form of endovascular infection. Fungal endocarditis especially of native valve is rare with Candida albicans being the causative organism in one-fourth of such cases. Diagnosis of such cases is further complicated if blood cultures are sterile, vegetations are not initially seen on echocardiogram and patient presents with non-specific symptoms. We hereby report a patient with native valve fungal endocarditis, treated successfully with voriconazole.

Atypical presentation of Lemierre syndrome: role of imaging.

A 51-year-old male patient presented with breathlessness for 10 days. Chest radiograph revealed bilateral moderate pleural effusion. Ultrasound-guided diagnostic pleural aspirate revealed sterile transudative fluid. CT thorax revealed bilateral moderate pleural effusion with partial collapse of both lower lobes and thrombus in right brachiocephalic vein. Two-dimensional-echo revealed circumferential pericardial effusion with mild pericardial thickening and moderate tricuspid regurgitation. Cardiolipin antibodies were within normal limits. d-Dimer assay and C reactive protein were markedly raised. During the period of investigations, the patient had developed mild swelling and pain in right upper limb for which colour Doppler ultrasonography of his right upper limb and neck regions were done. Thrombi in right internal jugular, subclavian and brachiocephalic veins were noted. CT angiography, CT abdomen and chest confirmed the above findings. However, extent of the thrombus and lung lesions was better delineated by CT angiography. We have highlighted the pathognomonic imaging findings of Lemierre syndrome.

Prevalence of psychiatric comorbidities in chronic obstructive pulmonary disease patients

Introduction: Psychiatric disorders, especially anxiety and depression have been reported to have an increased prevalence in chronic obstructive pulmonary disease (COPD) patients, but there is a paucity of data from India. Aims and Objectives: Aim of our study is to study the frequency of psychiatric comorbidities in COPD patients and their correlation with severity of COPD, as per global initiative for obstructive lung disease guidelines. Materials and Methods: This study was conducted in outpatient department of a tertiary care hospital (King Georges Medical University). A total of 74 COPD patients were included in this study and compared with 74 controls. The diagnosis and severity of COPD were assessed by spirometry. Psychiatric comorbidities were assessed using the Mini International Neuropsychiatric Interview questionnaire. Results: The frequency of psychiatric comorbidities was significantly higher (P < 0.05) in COPD patients (28.4%) as compared to controls (2.7%). As regards to severity, the frequency was significantly increased in severe and very severe COPD. The frequency of psychiatric comorbidities in COPD patients increased significantly with the increase in duration of symptoms being present in 67% of patients with duration of symptoms more than 10 years and only 23% of patients with duration of symptoms ≤5 years. Conclusion: The frequency of psychiatric comorbidities is increased in COPD patients as compared to controls. We recommend that all patients with COPD should be screened for psychiatric comorbidity, if any.

Dapsone-induced pure red cell aplasia and cholestatic jaundice: A new experience for diagnosis and management

Dapsone (4,4′- diaminodiphenylsulfone) is the parent compound of the sulfones, and it has potent antiparasitic, anti-inflammatory, and immunomodulatory effects. It is used in the treatment of leprosy, dermatitis herpetiformis, and prophylactically to prevent Pneumocystis pneumonia and toxoplasmosis in patients unable to tolerate trimethoprim with sulfamethoxazole. We hereby report a case of dapsone toxicity who developed pure red cell aplasia and cholestatic jaundice in a suspected case of dermatitis herpetiformis. Patient had an excellent response to corticosteroids after withdrawal of dapsone.

Pyopneumothorax following kerosene poisoning

Kerosene poisoning is a common poisoning in India especially in childhood, and clinical spectrum can range from meager chemical pneumonitis to grave complications such as hypoxia, pneumothorax, pneumomediastinum, and emphysema. Pyopneumothorax that may require aggressive management in the form of thoracotomy has not been reported in literature. We hereby report a 22-year young female who had developed series of respiratory complications including pyopneumothorax following ingestion of kerosene with suicidal intent and was treated successfully.

An unusual case of refractory metabolic acidosis.

Homeopathy is one of the most frequently used systems of complementary and alternative medicine. The patients who seek homeopathic treatment are primarily those suffering from long-standing, chronic diseases. These medicines may have considerable risk of severe side effects. Some homeopathic medicinal preparations use alcohol as a base and are frequently prescribed for common conditions. We hereby report an unusual case of refractory metabolic acidosis after homeopathic medicinal treatment.