Sudha Vidyasagar

Nasal insulin gel as an alternate to parenteral insulin: Formulation, preclinical, and clinical studies

The objective of the present study was to formulate insulin gel for intranasal administration and to evaluate with respect to in vitro release studies and hypoglycemic activity in animal model and healthy human volunteers. The insulin gel was formulated using the combination of carbopol and hydroxypropyl methylcellulose as gelling agent. The in vivo efficacy of insulin gel administered intranasally was assessed by measuring the blood glucose levels and serum insulin levels at specified time intervals in rats and humans. The use of bioadhesive nasal gel containing insulin not only promoted the prolonged contact between the drug and the absorptive sites in the nasal cavity but also facilitated direct absorption of medicament through the nasal mucosa. Absorption of the drug through the nasal mucosa was high in the first 0.5 to 1.5 hours of the study with a sharp decline in blood sugar and rise in insulin values corresponding to that decline in blood sugar. This study further demonstrates that administration of insulin intranasally in gel form is a pleasant and painless alternative to injectable insulin.

Diagnostic validation of selected serological tests for detecting scrub typhus.

Clinical diagnosis of scrub typhus is often difficult because the symptoms are very similar to those of other febrile illness such as dengue, leptospirosis, malaria and other viral hemorrhagic fevers. Though better diagnostic tests are available for rickettsial diseases and scrub typhus elsewhere, the Weil–Felix test is still commonly used in India, mainly because microimmunofluorescence assays (M‐IFA) were not available in India till recently and relevant staff had insufficient training. The present study was performed to investigate the performance of M‐IFA, IgM ELISA, and Weil–Felix test on 546 non‐repeated serum samples from subjects suspected of having scrub typhus. One hundred and forty‐three of these 546 samples were positive by M‐IFA; these cases were also confirmed clinically to have scrub typhus based on their dramatic responses to doxycycline therapy. IgM ELISA was positive in 122 of the 143 M‐IFA positive cases and the Weil–Felix test in 96. Though the Weil–Felix test is a heterophile agglutination test, it was found in this study to have good specificity but far too little sensitivity to use as a routine diagnostic test. IgM ELISA can be a good substitute for M‐IFA. Incorporation of multiple prototype antigens on M‐IFA slides is likely one of the reasons for its superior performance. As newer and better diagnostic assays become available for scrub typhus diagnosis in developed countries, it will be imperative to also use such tests in other endemic countries to prevent over‐ or under‐diagnosis of scrub typhus.

Awareness of chronic disease related health benefits of physical activity among residents of a rural South Indian region: a cross-sectional study.

BackgroundPhysical activity trends for a lower-middle income country like India suggest a gradual decline in work related physical activity and no concomitant increase in leisure time physical activity. Perceived health benefits of physical activity and intention to increase physical activity have been established as independent correlates of physical activity status. In India, not much is known about peoples’ perceptions of health benefits of physical activity and their intention to increase physical activity levels. This study was performed to understand peoples’ perceptions and awareness about health benefits of physical activity in a rural South Indian region.MethodsThis cross-sectional study was conducted using a multistage cluster sampling design. A content validated, field tested questionnaire was administered in person by a trained interviewer in the participants’ native language. The questionnaire assessed the participants’ perceptions about their lifestyle (active or sedentary), health benefits of physical activity and need for increasing their physical activity. In addition, the participant’s physical activity was assessed using version 2 of global physical activity questionnaire. Frequencies and percentages were used to summarise perceived health benefits of physical activity and other categorical variables. Age and body mass index were summarised using mean ± SD, whereas physical activity (MET.min.wk −1) was summarised using median and interquartile range.ResultsFour hundred fifty members from 125 randomly selected households were included in the study, of which 409 members participated. 89% (364) of participants felt they lead an active lifestyle and 83.1% (340) of participants did not feel a need to increase their physical activity level. 86.1%, (352) of the participants were physically active. Though 92.4% (378) of participants felt there were health benefits of physical activity, majority of them (75.1%) did not report any benefit related to chronic diseases. None mentioned health benefits related to heart disease or stroke.ConclusionThere is low awareness of chronic disease related benefits of physical activity and participants do not see a need to increase their physical activity level. Public health awareness programs on importance and health benefits of physical activity would be useful to counter the anticipated decline in physical activity.

Leptospirosis and dengue fever: a predictive model for early differentiation based on clinical and biochemical parameters:

Leptospirosis and dengue fever are increasingly seen as causes of tropical febrile illness and often are clinically indistinguishable. This two-year prospective study from a tertiary care centre comprised 200 patients including 68 men (mean 34.8 years) with dengue and 73 (mean 46.19 years) with leptospirosis. Oliguria, icterus, muscle tenderness, anaemia, leukocytopenia, thrombocytopenia, elevated erythrocyte sedimentation rate (ESR), acute renal failure (ARF) and hypoalbuminaemia appeared more commonly in leptospirosis in comparison to dengue. Eighteen per cent mortality was observed in leptospirosis compared to one per cent in dengue. ARF, hyperbilirubinaemia, acute respiratory distress syndrome (ARDS), creatine kinase (CK) elevation and thrombocytopenia were predictors of death in leptospirosis and thrombocytopenia, ARDS and ARF predictors of death in dengue. On receiver operating characteristics (ROC) analysis, leucocytosis >11000/mm3, ESR >40 mm, serum creatinine >2 mg/dL, total serum bilirubin >2 mg/dL, CK >500 U/L and serum albumin <3 mg/dL were more likely to be an indication of leptospirosis at presentation compared to dengue.

Assessment of hematological adverse drug reactions to antiretroviral therapy in HIV positive patients at Kasturba Hospital Manipal

Background HIV-infected patients have a higher risk of developing hematological adverse drug reactions (ADRs) than the general population and have a significant impact on patients’ current and future care options. The study was to determine the causality, the incidence rate, severity pattern of occurrence of hematological ADRs associated with highly active antiretroviral therapy in HIV positive patients. Methods Prospective observational study conducted at medicine department, Kasturba Hospital over a period of 6 months. Enrolled HIV positive patients were intensively monitored for hematological ADRs associated with fixed dose of highly active antiretroviral therapy. Causality of adverse drug reactions was assessed by using WHO probability scale and also with Naranjo’s algorithm. Results Monitoring of 70 HIV positive patients (58 males and 12 females) with fixed dose drug combinations of antiretroviral therapy by active pharmacovigilance identified 47.3% cases of anemia, 15.7% cases of leucopenia, 21% cases of pancytopenia, 5.2% of eosinophilia, 10.5% cases of bicytopenia. The incidence rate of hematological adverse drug reactions was 37.9% and most of the reported ADR’s were definitely predictable and preventable. Fifty percent of these ADR’s were lead to hospitalization and seventy percent of these ADR’s were of moderate in severity. Hematological ADRs were highest with Zidovudine + Lamivudine + Nevirapine (68.4%) and Zidovudine + Lamivudine + Efavirenz (31.57%) combinations. Conclusion With the increasing access to use of highly active antiretroviral in India, clinician must focus for routine monitoring of hematological investigations for early detection and prevention of adverse effects associated with highly active antiretroviral therapy. Author details 1Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal – 576 104, Karnataka, India. 2Department of Medicine, Kasturba Medical College, Manipal University, Manipal – 576 104, Karnataka, India.

Community-Acquired Methicillin-Resistant Pyogenic Liver Abscess: A Case Report

Pyogenic liver abscesses are rare with an incidence of 0.5% to 0.8% and are mostly due to hepatobiliary causes (40% to 60%). Most are polymicrobial with less than 10% being caused by Staphylococcus aureus. Of these, few are caused by methicillin-resistant Staphylococcus aureus (MRSA) and fewer still by a community-acquired strain. Here we present a case study of a patient with a community-acquired MRSA liver abscess. The patient presented with fever since 1 month and tender hepatomegaly. Blood tests revealed elevated levels of alkaline phosphatase, C-reactive protein, erythrocyte sedimentation rate, and neutrophilic leukocytosis. Blood cultures were sterile. Ultrasound of the abdomen showed multiple abscesses, from which pus was drained and MRSA isolated. Computed tomography of the abdomen did not show any source of infection, and an amebic serology was negative. The patient was started on vancomycin for 2 weeks, following which he became afebrile and was discharged on oral linezolid for 4 more weeks. Normally a liver abscess is treated empirically with ceftriaxone for pyogenic liver abscess and metronidazole for amebic liver abscess. However, if the patient has risk factors for a Staphylococcal infection, it is imperative that antibiotics covering gram-positive organisms be added while waiting for culture reports.

Colistin-resistant Acinetobacter baumannii ventilator-associated pneumonia in a tertiary care hospital: an evolving threat

Ventilator-associated pneumonia (VAP) is the most frequently occurring nosocomial infection in mechanically ventilated patients. Acinetobacter infection has emerged as a frequent cause of VAP in recent decades and is characterized by rapid development of resistance to most of the antibiotics that would be clinically useful. Acinetobacter VAP (AVAP) poses grave implications in terms of high mortality and increased healthcare costs worldwide. Therefore, the present study was undertaken with the aim of studying the risk factors and outcome of patients developing AVAP. We performed a caseecontrol study for a period of one year (April 2012 to March 2013) in the medical intensive care unit (ICU) of a tertiary care hospital in south India. Cases were patients exposed to a ventilator who developed AVAP with a clinical pulmonary infection score (CPIS) 6. The isolates were identified as Acinetobacter baumannii by Vitek MS system (bioMérieux, Nürtingen, Germany). Ageand gender-matched patients exposed to a ventilator in the same ICU setting who did not develop VAP (CPIS <6) were taken as controls in the ratio of 1:2. Risk factors for developing AVAP such as prolonged ICU stay and duration of ventilation, antibiotic exposure, receipt of blood products, invasive procedures besides intubation and surgery were analysed. Samples from the AVAP patients’ humidifier or heat and moisture exchanger (HME) filter were sent for microbiological testing to find the source of acinetobacter infection. Institutional ethical clearance was obtained prior to carrying out the study. Informed consent was obtained from legally accepted representatives of the patients and details of the patients were kept confidential by giving them a coded identity. Statistical analysis was carried out using SPSS version 16. In all, 96 patients were included in our study with 32 cases and 64 controls. Mean age for the cases was 52.2 years and for the controls was 51.7 years. Median duration of ICU stay (cases: 21 days; controls: nine days) and mechanical ventilation (cases: 14 days; controls: five days) was significantly higher for

Secreted Frizzled-Related Protein 4 (SFRP4): A Novel Biomarker of β-Cell Dysfunction and Insulin Resistance in Individuals With Prediabetes and Type 2 Diabetes.

Studying biomarkers early could help to identify high-risk individuals who could be targeted for the prevention of type 2 diabetes (T2D). Secreted frizzled-related protein 4 (SFRP4) is highly expressed in the islets, and its levels are increased several years before diabetes diagnosis (1). We report here on the systemic levels of SFRP4 and its association with insulin resistance and β-cell dysfunction. Individuals with normal glucose tolerance (NGT; n = 100), impaired glucose tolerance (IGT; n = 60), and T2D ( n = 100) were recruited from a large tertiary diabetes center in Chennai and a medical college hospital at Manipal in southern India. NGT, IGT, and T2D were defined using World Health Organization consulting group criteria (2). β-Cell function and insulin resistance were calculated by the oral disposition index (DIo) and the HOMA of insulin resistance (HOMA-IR), respectively. SFRP4 levels were measured by ELISA. …

A prospective study on distribution of eschar in patients suspected of scrub typhus

Scrub typhus is an acute febrile illness caused by a tick bite infected with the bacteria Orientia tsutsugamushi. The clinical diagnosis is difficult as the symptoms are similar to other febrile illnesses such as dengue, typhoid, leptospirosis and so on. An eschar, if present, will narrow down the provisional diagnosis towards scrub typhus. There are no data on the preferential sites of tick bites in an Indian population. We present here the preferential sites of tick bites in a South Indian population of 123 cases positive for eschar. Geographically, clothing styles vary leading to the differences in the areas of skin exposed to the bite and thus the formation of eschars. Scrub typhus, if not treated, may lead to fatal complications. As scrub typhus is one of the most under-reported illnesses in the world, clinicians should look for the presence of an eschar in the preferential sites at least to narrow down the diagnosis and treatment.

Excellent and durable response to radiotherapy in a rare case of spinal cord compression due to extra-medullary hematopoiesis in β-thalassemia intermedia: Case report and clinicoradiological correlation

Spinal cord compression (SCC) is an unusual sequale of extra-medullary hematopoiesis (EMH). We report a patient diagnosed with β-thalassemia intermedia at the age of 7 years presenting as a 24-year-old with symptoms suggestive of paraparesis. MR imaging revealed long masses of EMH opposite T5-T11 and L5-S2 vertebrae with cord compression at T6 vertebrae. Patient was treated with external beam radiotherapy (EBRT) to a low dose of 20 Gy in 10 fractions over 2 weeks. The patient had symptomatic relief of paraparesis by the 5th fraction and nearly regained full power in bilateral lower limbs by EBRT conclusion. Patient was begun on hydroxyurea post EBRT and was symptom free at 2-month follow up. With a follow-up of 18 months so far, he remains asymptomatic and free of recurrence. MRI correlation of pre-EBRT, post-EBRT and at first follow-up showed a significant reduction in the size of EMH, increase in diameter of spinal canal post EBRT but a persistent edema which had no clinical manifestation. Though there was a 58% drop in leukocyte count by the end of EBRT, there was no leukocytopenia. We suggest that EBRT should be treatment of choice for SCC due to EMH as it produces as rapid and durable response with minimal acute hematological side-effects.