Rushad Patell

Serotonin syndrome versus neuroleptic malignant syndrome: a challenging clinical quandary

Serotonin syndrome and neuroleptic malignant syndrome are two drug toxidromes that have often overlapping and confusing clinical pictures. We report a case of a young man who presented with alteration of mental status, autonomic instability and neuromuscular hyperexcitability following ingestion of multiple psychiatric and antiepileptic medications. The patient satisfied criteria for serotonin syndrome and neuroleptic malignant syndrome, and based on the characteristic clinical features, laboratory findings and clinical course it was concluded that the patient had both toxidromes. The patient was managed with cyproheptadine and supportive measures, and recovered over the course of 3 weeks. A brief review of literature highlighting the diagnostic clues as well as the importance of recognising and distinguishing the often missed and confounding diagnoses follows.

Cardiovascular disease and menopause.

AIM The aim of the study was to study the abnormalities in the cardiovascular profile in postmenopausal Indian women and to compare the same with the cardiovascular profile of pre menopausal Indian women belonging to the same age group; taken as controls. The goal was to throw some light on the cardiovascular risk in postmenopausal women of the Indian population as this population is thought to be at higher risk than their western counterparts and significant studies of the same kind in this population have been few. MATERIALS AND METHODS A cross-sectional comparative study on 100 women who were either postmenopausal or premenopausal and were between the age group of 40 to 55 years was carried out over a period of ten months at our hospital. The variations in the cardiovascular profile between both groups were studied. All the women were subjected to a detailed history, thorough examination, investigations and imaging studies. RESULTS The evaluation revealed that Coronary Artery Disease (CAD), hypertension, abnormal Body Mass Index (BMI) and abnormal Waist Hip Ratio (WHR) were significantly higher in the postmenopausal group as compared to the premenopausal group. The post menopausal women had significantly higher prevalence of abnormal lipid profiles as compared to their premenopausal counterparts. The postmenopausal women with a normal lipid profile also had increased prevalence of CAD and SAHT, which emphasizes the non-lipid cardiovascular benefits of estrogen. CONCLUSION Thus, we can conclude that cardiovascular disease was more common in postmenopausal women of age group 40-55 years as compared to those not yet achieved menopause in a population of western Indian women. And this risk was significantly associated with central obesity, an abnormal lipid profile and the postmenopausal state in itself.

Predicting Risk Of Venous Thromboembolism In Hospitalized Cancer Patients: Utility of A Risk Assessment Tool

Inpatient venous thromboembolism (VTE) is a priority preventable illness; risk in cancer varies and prophylaxis is inconsistently used. A previously validated tool (Khorana Score, [KS]) identifies VTE risk in cancer outpatients with 5 easily available variables but has not been studied in the inpatient setting. We evaluated the validity of KS in predicting VTE risk in hospitalized cancer patients. We conducted a retrospective cohort study of consecutive oncology inpatients at the Cleveland Clinic from 11/2012 to 12/2014 (n = 3531). Patients were excluded for VTE on admission (n = 304), incomplete KS data (n = 439) or other reasons (n = 8). Data collected included demographics, cancer type, length of stay (LOS), anticoagulant use, and laboratory values. Multivariate risk factors were identified with stepwise logistic regression, confirmed with bootstrap analysis. Of 2780 patients included, 106 (3.8%) developed VTE during hospitalization. Median age was 62 (range, 19‐98) years and 56% were male. Median LOS was 5 (range, 0‐152) days. High risk KS (≥ 3) was significantly associated with VTE in uni‐ and multivariate analyses (OR 2.5, 95% [confidence interval] CI 1.3‐4.9). Other significant variables included male gender (OR 1.67, 1.1‐2.53), older age (OR 0.86, 0.75‐0.99) and use of anticoagulants (OR 0.57, 0.39‐0.85). Recursive partitioning analysis suggested optimal cut point for KS is 2 (OR 1.82, 1.23‐2.69). This is the first report validating KS as a risk tool to predict VTE in hospitalized cancer patients. Using this tool could lead to more consistent and successful application of inpatient thromboprophylaxis.

Non-Alcoholic Fatty Liver Disease (NAFLD) in Obesity

BACKGROUND AND OBJECTIVES Limited studies have been undertaken to characterize Non-Alcoholic Fatty Liver Disease (NAFLD) in the Indian population. The main objective of our study was to document the prevalence of NAFLD amongst a cohort of obese Indian patients and demonstrate its relationship with other components of the metabolic syndrome. METHODS A total of 60 adult obese patients were subjected to a detailed history, clinical exam, anthropometric study and laboratory workup. Focus was on liver function and components of the metabolic syndrome like blood pressure, glycemic status and lipid profile. Subjects enrolled were divided into two groups Group A (n=48), with NAFLD and Group B (n=12) without NAFLD. The two groups were then compared amongst themselves as well as with data from previous similar studies. RESULTS A comparison of the anthropometric measurements revealed a statistically significant difference between the Body mass index (BMI) and Waist Hip Ratio of the two groups and in the mean triglyceride values between the two groups. Although the mean bilirubin levels measured in the serum were not statistically different the mean levels of SGOT and SGPT in the two groups was found to be statistically significant. On the contrary no significant difference in the values of alkaline phosphatase and synthetic liver functions could be discerned. A statistically highly significant difference in the mean liver span is seen. INTERPRETATION AND CONCLUSIONS NAFLD is common in Indian obese populations and is associated with significant differences in anthropometric, clinical, laboratory and ultrasonographic aspects as compared with obese individuals not affected with liver disease.

Paroxysmal Hemicrania: An Update

Paroxysmal hemicrania (PH) is an underreported and underdiagnosed primary headache disorder. It usually begins in the third or fourth decade of life. The recent observations indicate that it is equally prevalent in both males and females. PH is characterized by severe, strictly unilateral head pain attacks that occur in association with ipsilateral autonomic features. The attacks in PH are shorter and more frequent compared with cluster headache (CH) but otherwise PH and CH have similar clinical features. The hallmark of PH is the absolute cessation of the headache with indomethacin. However, a range of drugs may show partial to complete relief in certain groups of patients. Neuromodulatory procedures, such as greater occipital nerve blockade, blockade of sphenopalatine ganglion and neurostimulation of the posterior hypothalamus, are reserved for refractory PH.

Usefulness of CHADS2 and CHA2DS2-VASc Scores for Stroke Prediction in Patients With Cancer and Atrial Fibrillation

Stroke prediction scores have not been validated in patients with cancer and atrial fibrillation (AF). We aimed to identify unique risk factors and evaluate validity of CHADS2 and CHA2DS2-VASc scores to predict risk of stroke and mortality. A retrospective review of all patients with cancer with pre-existing AF presenting from 2008 to 2014 was performed. Outcomes included ischemic stroke and mortality. Prognostic factors were identified with Fine and Gray regression for stroke and Cox proportional hazards analysis for survival. After excluding patients with hemorrhagic strokes, 2,037 patients were analyzed. Genitourinary cancers were the most common (29%) followed by gastrointestinal cancers (18%). Overall, 52% had CHADS2 ≥2. At a median of 6.4 months, 74 patients (3.6%) developed an ischemic stroke. Increased CHADS2 score was associated with stroke (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.19 to 1.67; p <0.001).

Symmetrical Peripheral Gangrene Following Snake Bite

SPG (Symmetrical peripheral gangrene) is defined as symmetrical distal ischemic damage at two or more sites in the absence of large vessels obstruction. It has been ascribed to a number of infectious and non infectious conditions including connective tissue, cardiovascular, neoplastic and iatrogenic causes. We report a unique case of SPG in a 35-year-old Indian female who developed spontaneous gangrene of the distal phalanges of the right and left index, middle, ring and little fingers and the distal phalanges of all toes of the right and left foot following a snake bite. There have been very few cases of peripheral gangrene and acute renal failure associated with snake bite in literature.

A case report of Evans Syndrome.

Evans Syndrome (ES) is the rare simultaneous or subsequent development of immune thrombocytopenia purpura (ITP) and autoimmune hemolytic anemia (AIHA). It portends a poorer prognosis and a more aggressive line of management than either condition presenting alone. Here we report a case of a young female who presented with both bleeding and acute decompensated anemia. Although she was successfully treated, mystery still shrouds the etiology, pathophysiology, as well as line of management of this rare and enigmatic disease.

Identifying predictors for bleeding in hospitalized cancer patients: A cohort study

BACKGROUND Bleeding and thrombosis are both major complications of hospitalization in cancer patients. Concern regarding bleeding risk may reduce compliance with thromboprophylaxis. We assessed incidence of major and clinically relevant non-major bleeding (MCRNMB) and identified risk factors associated with in-hospital bleeding risk in hospitalized cancer patients. METHODS We conducted a retrospective cohort study of consecutive adults admitted to general oncology floor at Cleveland Clinic from 11/2012-12/2014 (n=3525). Patients were excluded for bleeding on admission (n=108), age<18 (n=1), non-malignant disease (n=2) and incomplete data (n=56). Data collected included demographics, body mass index (BMI), cancer type, length of stay (LOS), use of anticoagulants and baseline laboratory values (+48h). Univariate risk factors were identified with logistic regression analysis. Multivariable risk factors were identified with stepwise logistic regression and confirmed with bootstrap analysis. RESULTS The study population comprised 3358 patients of whom 69 (2.1%) developed MCRNMB. Median age was 62 (range, 19-98) years and 56% male. Median length of stay was 5 (range, 0-152) days. The majority of bleeding events were either gastrointestinal (GI) (N=23, 33%) or retroperitoneal (N=10, 14%). In multivariable analysis, anemia as the reason for admission (7.78, 95% CI 4.0-15.1, P<0.001), GI cancer site (2.96, 95% CI 1.7-5.2 P<0.001), BMI≥40 (3.08, 95% CI 1.3-2.9, P=0.008) and thrombocytopenia (1.7, 95% CI 1.0-2.9, P=0.05) were predictive. CONCLUSION The incidence of MCRNMB in a population of hospitalized cancer patients was 2.1%. Risk factors at admission included type of cancer and morbid obesity. Improved prediction of bleeding risk can assist physicians in optimizing selection of thromboprophylaxis in this population that is also at increased risk of VTE.

Awareness and Approach towards Hypertension Management among General Practitioners of Western Vadodara.

BACKGROUND Hypertension (HTN) is a major risk factor contributing to premature mortality from cardiovascular and cerebrovascular disease.To decrease morbidity and mortality from HTN, timely diagnosis of the disease and its complications, urgent treatment and referrals are required. General Practioners (GPs) are the first tier of the health care system in India and have a wide scope of practice. It is important to know the awareness and approach of primary care physicians to hypertension in their daily practice as compared to standard practice recommendations and guidelines, to identify targets for improvements. With this objective we decided to interview them personally and analyse their approach. MATERIALS AND METHODS We conducted a cross-sectional survey in 80 general practitioners (GPs) of the western part of Vadodara city with the use of a questionnaire prepared from JNC-7 guidelines and standard medical books. Seventy seven [97.55%] GPs completed the questionnaire and their responses were statistically analysed. RESULTS Twenty percent of GPs were not applying BP cuff properly for BP measurement. Only 18% and 16.6 % could diagnose isolated diastolic hypertension (IDH) and isolated systolic hypertension respectively (ISH) and 21% and 29% would have considered treatment of IDH and ISH respectively.48% consider treating pre-hypertension using non-pharmacological measures. Only 21% use thiazide diuretics for uncomplicated HTN and 50% use beta-blockers in coronary artery disease patients. CONCLUSION In our study, most of the GPs in western Vadodara are well aware and updated about the initial lab investigations,non-pharmacological measures and complications of HTN but lack an effective approach towards history taking for HTN,technique for measurement of blood pressure, diagnosis and treatment of IDH and ISH. Pre-hypertension and systolic and diastolic hypertension is under-treated and thiazide diuretics are underutilized. This study can be used to identify targets and approaches to improve hypertension management at the primary care level.