Reginald Alex

Self‐harm and self‐poisoning in southern India: choice of poisoning agents and treatment

Objective  To record cases of suicide and attempted suicide among a population of 108 000 people living in a primarily rural area of southern India, with the aim of guiding policies and strategies to restrict access to poisonous compounds at community level.

Risk factors for foot ulcers in patients with diabetes mellitus - a short report from vellore, South India.

Diabetes mellitus, a metabolic disease, has a population prevalence of about 10-15%. The incidence of foot ulcers range from 8 to 17% in the cohort studies, with varying lengths of follow-up, and cause severe disability and possible hospitalization to patients and considerable economic burden to families.(1–4) A variety of foot lesions are seen in people with uncontrolled diabetes mellitus namely fissures, abscess, cellulites, ulcers, claw toes and Charcots joints. There is a risk of developing gangrene and of consequent amputation of the foot especially for people from the lower socioeconomic strata and for those living in rural areas. Clinical guidelines recommend that all patients with diabetes should be screened annually to establish their risk of foot ulceration.(2) Diagnostic tests and physical signs that detect peripheral neuropathy (biothesiometry, monofilaments and absent ankle reflexes), and those that detect excessive plantar pressure (peak plantar pressure and joint deformity) were all significantly associated with future diabetic foot ulceration. However, there was a paucity of evidence from India concerning the predictive value of symptoms and signs. This study aimed to examine the risk factors for foot ulcers in patients with diabetes mellitus attending the Community Health and Development (CHAD) Hospital, Christian Medical College, Vellore, a secondary care facility.

Foot care knowledge and practices and the prevalence of peripheral neuropathy among people with diabetes attending a secondary care rural hospital in southern India

Background: Diabetes mellitus is a multifaceted disease and foot ulceration is one of its most common complications. Poor foot care knowledge and practices are important risk factors for foot problems among people with diabetes. Aims: To assess the knowledge and practices regarding foot care and to estimate the proportion of people with peripheral neuropathy among people with diabetes. Settings and Design: The cross-sectional study was conducted in 212 consecutive diabetes patients attending the out-patient department of a rural secondary care hospital. Materials and Methods: A questionnaire which included demographic details, knowledge questionnaire, and Nottingham assessment of functional foot care was administered. The Michigan Neuropathy Screening Instrument was used to identify peripheral neuropathy. Statistical Analysis Used: Descriptive analysis with frequency distribution for knowledge and practice scores, univariate analysis, and multiple logistic regressions to find significant variables associated with good knowledge and practice scores. Results: About 75% had good knowledge score and 67% had good foot care practice score. Male gender (OR 2.36, 95% CI 1.16–4.79), poor education status (OR 2.40, 95% CI 1.19–4.28), and lesser duration of diabetes (OR 2.24, 95% CI 1.15–4.41) were significantly associated with poor knowledge on foot care. Poor knowledge was associated with poor foot care practices (OR 3.43, 95% CI 1.75–6.72). The prevalence of neuropathy was 47% (95% CI 40.14–53.85) and it was associated with longer duration of the disease (OR 2.18, 95% CI 1.18–4.04). Conclusion: There exist deficiencies in knowledge and practices regarding foot care. Male gender, low education, and lesser duration of diabetes are associated with poor knowledge scores. The prevalence of diabetic peripheral neuropathy is high.

Prevalence of musculoskeletal disorders among brick kiln workers in rural Southern India

Background: A variety of musculoskeletal disorders and discomfort are seen among brick kiln workers, where heavy physical work is associated with awkward working postures and manual handling of materials, leading to significant morbidity. Materials and Methods: This cross-sectional study was conducted in unorganized brick kiln industries in villages of Vellore district of Tamil Nadu and included 310 brick kiln workers. Modified Nordic Questionnaire was used to survey the prevalence of musculoskeletal disorders and the intensity of pain was assessed by the body pain discomfort scale. Results: The mean age of the workers was 37 ± 13.2 years with a range of 18-85 years. 62% (n = 192) had normal body mass index, whereas 27% (n = 85) were undernourished. The commonest posture adopted at work was squatting (67%) followed by standing (14%). Majority of workers (87%, n = 269) reported to having symptoms of pain currently of which 51% (n = 158) had pain during work. Chronic low back ache (LBA) (1 year prevalence -59%) and acute LBA (1 week prevalence-33%) were the commonest followed by chronic knee pain. More than 10 years of work was significantly associated (P < 0.05) with acute LBA and acute and chronic knee pain. Severity of the pain was also significantly (t statistic 2.476, P < 0.05) associated with job dissatisfaction. Conclusion: Long-term brick kiln workers, who adopt a specific posture for prolonged periods, have severe musculoskeletal pain that interferes with activities of daily living and reduces job satisfaction. Health education on frequent postural change, implementation and monitoring of laws among unorganized industries are recommended to bring down morbidity due to musculoskeletal disorders (MSD).

Malabsorption in wasting HIV disease: diagnostic and management issues in resource-poor settings.

In resource-poor countries with limited access to highly active antiretroviral therapy (HAART), the number of people dying from AIDS is expanding rapidly. The alarming death rates are a consequence of the combined effects of opportunistic infections, malnutrition and wasting in HIV disease. Several studies have shown that weight loss and wasting (usually defined as loss of at least 10% of body weight) is significantly associated with accelerated disease progression and increased mortality in HIV infection. In addition, with significant wasting, affected individuals are unable to carry out their normal activities which may worsen the stigma of already marginalized HIV-infected individuals. A significant risk factor for wasting in HIV disease is intestinal dysfunction and subsequent nutrient malabsorption. Malabsorption causes decreased appetite as a consequence of the ‘enterogastrone’ effects including dry mouth, decreased gastric acid secretion, decreased gastric emptying rate and slowed intestinal transit. Decreased appetite leads to poor intake of food that further jeopardizes maintenance of weight. We wish to draw the attention of clinicians treating HIV-infected individuals to malabsorption as a potential contributory cause of wasting in HIV disease. In HIV disease, the small intestine is typically affected either as a result of opportunistic enteric infections leading to intestinal dysfunction, or due to the direct effects of the HIV virus, causing malabsorption of most nutrients and subsequent wasting. Cryptosporidium, as well as Microsporidia and Isospora, are common opportunistic parasites that may cause serious gastrointestinal infections, intestinal damage and chronic malabsorption. Intestinal opportunistic infections are more common in patients with CD4 counts less than 180 cells/mm. Further studies have shown that fat malabsorption is the most frequent problem in HIV disease (seen in 25–90% of infected people) and the frequency of fat malabsorption increases as the disease progresses. Fat malabsorption impairs utilization of dietary fats which are food with a high calorie density. It causes abdominal symptoms such as diarrhoea and bloating which may further reduce food intake, and may be associated with micronutrient deficiencies from loss of fat-soluble vitamins. Micronutrient deficiencies further contribute to impaired immunity, rapid disease progression and increased mortality. It is imperative to prevent wasting in HIV-infected patients to reduce morbidity and mortality and improve the patient’s quality of life.. In resource rich countries, the physician would have access to sophisticated laboratory investigations to assess intestinal function and be able to administer the most appropriate treatments, whereas in resource-poor settings malabsorption is often not recognized due to the lack of diagnostic facilities. Even without specific diagnostic facilities, it is possible to treat the common causes of malabsorption, maintain energy balance and improve nutritional status by taking into consideration the loss of specific nutrients such as fat-soluble vitamins due to malabsorption. Every episode of diarrhoea should be carefully assessed with a detailed clinical history. If available, simple laboratory tests should be performed on stool samples including: examination for ova, cysts and parasites using wet saline mounts; a formol ether concentration method with Lugol’s iodine for the detection of cysts, ova, trophozoites and larvae of intestinal parasites; and a modified Ziehl-Nielsen staining of stool smears to identify Cryptosporidum parvum and Isospora belli. Nutritional therapy, including aggressive dietary counselling and oral supplements, are the mainstay in the management of wasting associated with HIV. An increase in energy intake of 500 kilocalories above the daily requirements will result in an average gain of 1 lb per week. The recommended dietary allowance of protein for persons aged 25–50 who are in good health is 0.8 g/kg body weight per day. For HIV-infected people with significant wasting, a protein intake up to 1.5 g/kg body weight may be advised. However, Carbonnel et al. demonstrated that what differentiates HIV-infected people with malabsorption from HIV negative patients with malabsorption is their inability to increase energy intake enough to overcome intestinal losses. Thus, an HIV-infected person may appear to consume an adequate amount of calories but still not increase his oral intake sufficiently to overcome intestinal losses. Those patients with inadequate oral intake may benefit from six or more small meals throughout the day, rather than three large ones. For those with diarrhoea, a lactose-free, low fibre, semi-solid diet should be recommended. In order for any person to maintain a stable weight, the energy intake must equal energy losses and total energy expenditure over time. However, HIV-infected patients in resource-poor countries commonly confront difficulties with access to sufficient good food because of financial constraints and poor social support. Issues relating to access to good food and social support should be addressed by individual countries with social and food security schemes for HIV-infected individuals. Micronutrient supplements are believed to protect the integrity of the gastrointestinal epithelia irrespective of whether the damage is caused by enteropathogens, or by HIV disease per se. Zinc plays a crucial role in maintaining the integrity of epithelial cells that line the intestine and preventing diarrhoea in HIV-infected individuals. In conclusion, nutrient malabsorption as a cause of wasting in the context of HIV infection should be addressed with close attention to treatment of opportunistic enteric infections, and to energy intake and weight gain. Addressing the underlying HIV infection and immunosuppression with appropriate antiretroviral therapy will further improve intestinal function, reduce the burden of disease and promote an improved quality of life in HIV-infected individuals.

Kikuchi-Fujimoto disease: Clinical and laboratory characteristics and outcome

Introduction: Kikuchi-Fujimoto disease is an uncommon disorder with worldwide distribution, characterized by fever and benign enlargement of the lymph nodes, primarily affecting young adults. Awareness about this disorder may help prevent misdiagnosis and inappropriate investigations and treatment. The objective of the study was to evaluate the clinical and laboratory characteristics of histopathologically confirmed cases of Kikuchis disease from a tertiary care center in southern India. Materials and Methods: Retrospective analysis of all adult patients with histopathologically confirmed Kikuchis disease from January 2007 to December 2011 in a 2700-bed teaching hospital in South India was done. The clinical and laboratory characteristics and outcome were analyzed. Results: There were 22 histopathologically confirmed cases of Kikuchis disease over the 5-year period of this study. The mean age of the subjects’ was 29.7 years (SD 8.11) and majority were women (Male: female- 1:3.4). Apart from enlarged cervical lymph nodes, prolonged fever was the most common presenting complaint (77.3%). The major laboratory features included anemia (54.5%), increased erythrocyte sedimentation rate (31.8%), elevated alanine aminotransferase (27.2%) and elevated lactate dehydrogenase (LDH) (31.8%). Conclusion: Even though rare, Kikuchis disease should be considered in the differential diagnosis of young individuals, especially women, presenting with lymphadenopathy and prolonged fever. Establishing the diagnosis histopathologically is essential to avoid inappropriate investigations and therapy.

A randomized non-inferiority clinical study to assess post-exposure prophylaxis by a new purified vero cell rabies vaccine (Rabivax-S) administered by intramuscular and intradermal routes

BACKGROUND Rabies is a 100% fatal disease but preventable with vaccines and immunoglobulins. We have developed a new purified vero cell rabies vaccine (Rabivax-S) and evaluated its safety and immunogenicity in post-exposure prophylaxis by intramuscular (IM) and intradermal (ID) routes. METHODS This was a randomized active-controlled non-inferiority study in 180 individuals (age 5years and above) with suspected rabies exposure (90 each with WHO Category II and Category III exposures). The participants received either Rabivax-S (1mL IM; five doses), Rabivax-S (0.1mL ID; eight doses) or purified chick embryo cell vaccine (PCEC, Rabipur®) (1mL IM; five doses). The IM doses were given on Day 0, 3, 7, 14 and 28 while the ID doses were given on days 0, 3, 7 and 28. Category III patients also received a human rabies immunoglobulin (HRIG) on Day 0. Adverse events (AEs) were recorded with diary cards till day 42. Rabies neutralizing antibody levels were measured on day 0, 7, 14, 28 and 42. RESULTS In both the category II and III patients, the geometric mean concentration (GMC) ratios of Rabivax-S IM and Rabivax-S ID groups to PCEC IM were more than 1, thus proving the non-inferiority. GMCs were similar or higher in Rabivax-S groups at all the time points. Seroresponse against rabies (RFFIT titre⩾0.5IU/mL) was achieved in all participants. Mostly mild local and systemic adverse events were reported across the three groups and all resolved without sequelae. CONCLUSIONS Rabivax-S was well tolerated and showed immunogenicity comparable to a licensed rabies vaccine by both IM and ID routes in post-exposure prophylaxis. Registry No.: CTRI/2012/11/003135.

Clinico-epidemiological Profile of Snake Bites over 6-year Period from a Rural Secondary Care Centre of Northern India: A Descriptive Study.

Estimated deaths due to snake bites are more than 46,000 annually in India. Ninety-seven percent bites occur in rural areas. Data on snake bites from Jharkhand rural area are sparse. This study describes 6 years profile of snake bite patients from January, 2007 to December, 2012 at Nav Jivan Hospital in Palamu district, Jharkhand.

Chronic pesticide exposure: Health effects among pesticide sprayers in Southern India

Background: Occupational health has never been a priority for policy makers in India, despite 63% of the Indian population being in the economically productive age group. Objectives: The study was designed to find out the morbidity as a result of long-term exposure to pesticides among professional pesticide sprayers in a rural block in Tamil Nadu. Subjects and Methods: A cross-sectional study was done in Kaniyambadi block of Vellore district, Tamil Nadu, during July to October 2013. A total of 70 professional pesticide sprayers and 66 people engaged in other occupations were enrolled into the study. The participants were administered a standardized questionnaire apart from measuring pulmonary function and peripheral sensations. Venous blood samples were collected for measuring serum cholinesterase. Results: The pesticide sprayers had higher prevalence of breathlessness on activities of daily living (odds ratio [OR]: 3.14, 95% confidence interval [CI]: 1.22–8.07), chronic cough/phlegm (OR: 3.53, 95% CI: 1.09–11.46), symptoms of peripheral sensory neuropathy (OR: 6.66, 95% CI: 2.53–17.51) and recurrent abdominal pain (OR: 3.05, 95% CI: 1.03–9.01), when compared to people engaged in other occupations. Pesticide sprayers also had significantly lower mean peak expiratory low rates and poor peripheral sensations. The serum cholinesterase levels were not statistically different between the groups. Conclusion: The pesticide sprayers had a higher morbidity when compared to people engaged in other occupations, and further research is needed to find out methods to prevent the same. Serum cholinesterase may not be a good marker for quantifying exposure to pesticide among sprayers, during a spraying season.

A study on morbidity among automobile service and repair workers in an urban area of South India.

Introduction: Service sector in Indian industrial growth has obtained significant numbers. Automobile service industry is one of the largest in the world with a majority of the workers in unorganized sector of the industry. This study was carried out among auto service industry workers in Vellore urban area to assess possible occupation related morbidity. Materials and Methods: A cross-sectional observation study was carried out among 106 automobile repair shop workers. Results: Half (47%) suffered work related stress, 32 (30.2%) reported exposure to dust, 81 (76%) to heat, and 50 (17%) to hazardous chemicals and heavy metals. More than 90% reported over exposure to petroleum products. A third reported cough for more than 2 weeks, more than a quarter reported gastrointestinal symptoms associated with work. Half of them reported musculoskeletal complaints associated with work with a quarter reporting un-intentional work place injuries. A tenth of them were found to have reduced pulmonary function on testing and nearly half had impaired sensory functions in peripheries. Reduced pulmonary function was found to be significantly associated with heavy metal exposure (P = 0.001). Peripheral neuropathy was significantly associated with years of occupation (P = 0.001), exposure to petroleum products (P = 0.03) and exposure to heavy metals (P = 0.018). Discussion: Half of the workers were unaware of health problems associated with their occupational exposures and thereby the use of personal protection is abysmally low. A very high proportion of workers had symptoms of cough, breathlessness, abdominal pain, abdominal discomfort and muscle aches. Almost a quarter of the workers had un-intentional occupational injuries in the last 6 months. Though they work in a high-risk environment with chances of fire hazard, falls and chemical exposures, none of the workshops had fire-extinguishers, first aid kits or any such safety devices.