Ulhas Jajoo

Accuracy and Reliability of Pallor for Detecting Anaemia: A Hospital-Based Diagnostic Accuracy Study

Background Anaemia is a common disorder. Most health providers in resource poor settings rely on physical signs to diagnose anaemia. We aimed to determine the diagnostic accuracy of pallor for anaemia by using haemoglobin as the reference standard. Methodology/Principal Findings In May 2007, we enrolled consecutive patients over 12 years of age, able to consent and willing to participate and who had a haemoglobin measurement taken within a day of assessment of clinical pallor from outpatient and medicine inpatient department of a teaching hospital. We did a blind and independent comparison of physical signs (examination of conjunctivae, tongue, palms and nailbed for pallor) and the reference standard (haemoglobin estimation by an electronic cell counter). Diagnostic accuracy was measured by calculating likelihood ratio values and 95% confidence intervals (CI) at different haemoglobin thresholds and area under the receiver operating characteristic curve. Two observers examined a subset of patients (n = 128) to determine the inter-observer agreement, calculated by kappa statistics. We studied 390 patients (mean age 40.1 [SD 17.08] years); of whom 48% were women. The haemoglobin was <7 g/dL in 8% (95% confidence interval, 5, 10) patients; <9 g/dL in 21% (17, 26) patients and <12 g/dL in 64% (60, 70) patients. Among patients with haemoglobin <7 g/dL, presence of severe tongue pallor yielded a LR of 9.87 (2.81, 34.6) and its absence yielded a LR of 0. The tongue pallor outperformed other pallor sites and was also the best discriminator of anaemia at haemoglobin thresholds of 7 g/dL and 9 g/dL (area under the receiver operating characteristic curves (ROC area  = 0.84 [0.77, 0.90] and 0.71[0.64, 0.76]) respectively. The agreement between the two observers for detection of anaemia was poor (kappa values  = 0.07 for conjunctival pallor and 0.20 for tongue pallor). Conclusions/Significance Clinical assessment of pallor can rule out and modestly rule in severe anaemia.

Central retinal artery occlusion: an unusual complication of snakebite

Snakebites are endemic in some parts of India, being associated with a number of complications. Ocular disturbances are rare, except for injury to the cornea or conjunctiva when the eye is directly exposed to the venom. In this work, we present a case of central retinal artery occlusion caused by snakebite.

Prevalence of cardiovascular risk factors among rural population of elderly in Wardha district

BACKGROUND Cardiovascular diseases (CVD) are a leading cause of mortality among adults in India, and their risk factors (tobacco, hypertension, diabetes, overweight, and obesity) are common. Most risk-factor surveys have focused on young and middle aged adults. We measured the prevalence of risk factors for CVD among elderly (age 60 years or more) in rural India. METHODS AND RESULTS In a door-to-door cross-sectional survey we did a non-laboratory based assessment of risk factors (smoking or tobacco use in any form, diabetes mellitus, either known or newly detected hypertension, abnormal waist-hip-ratio, or a high body mass index) among elderly living in 23 villages in rural central India. Laboratory based assessment of risk factors was done in those who had two or more of the five measured conventional risk factors. We compared the distribution of risk factors between men and women. Among 2424 elderly included in the study (51% women, mean age 67), the prevalence of smokeless tobacco use was 50.8% (95% CI 48.1-52.8; smoking 10.5% (95% CI 9.3-11.8); and hypertension46.3% (95% CI 44.3-48.4). Only 10.2% participants were previously known to have had hypertension, and remaining 36.1% were detected to be hypertensive during the survey. A total of 8.2%(95% CI 7.0-9.5) participants were overweight and 4.1% (95% CI 3.3-4.9) had central obesity. The prevalence of dyslipidemia in those who underwent blood based tests was 40.6% (95% CI 36.5-44.9); and hyperglycemia 4.9% (95% CI 3.2-7.1). CONCLUSIONS Strategies to reduce the risk of cardiovascular disorders among elderly should be focused on reducing tobacco use and early detection and optimal control of hypertension.

Herpes zoster encephalitis presenting as multiple cerebral hemorrhages – a rare presentation: a case report

IntroductionAn infection by herpes zoster virus is a common and important cause of encephalitis. Herpes zoster virus encephalitis if not treated promptly can result in significant morbidity and mortality. The diagnosis of herpes zoster virus encephalitis is based on clinical history, examination, neuroradiological imaging (magnetic resonance imaging and/or computed tomography scan), cerebrospinal fluid analysis and identification of the pathogen in cerebrospinal fluid by polymerase chain reaction amplification and/or anti-herpes zoster virus immunoglobulin G antibody in cerebrospinal fluid. Although ischemic intracerebral infarcts in patients with herpes zoster virus encephalitis or vasculopathy are reported in the literature, multiple intracerebral hemorrhages as a complication of herpes zoster virus encephalitis in an immunocompetent individual are extremely rare.Case presentationA 40-year-old Indian man presented with an acute history of four episodes of seizures, fever, headache, drowsiness, focal neurological deficits and vesicular eruptions over the abdomen in a typical dermatomal distribution. His head computed tomography scan revealed multiple cerebral hemorrhages. Investigations (positive ratio between the cerebrospinal fluid/serum quotients for anti-herpes zoster virus immunoglobulin G and total immunoglobulin G antibodies) established its infective origin due to herpes zoster virus. He developed bilateral pneumonia during the hospital course. He had an excellent recovery following a 2 weeks’ course of intravenous acyclovir.ConclusionHerpes zoster virus encephalitis or vasculopathy is a rare cause of multiple intracerebral hemorrhages and must be considered in the differential diagnosis of patients presenting with an acute history of fever, altered consciousness, and focal neurologic deficits with history of a typical herpetic rash. Its prompt recognition and treatment could alter the course of illness.

Unusual presentation of orbital cysticercosis-ptosis, diminution of vision and medial rectus weakness: a case report

Cysticercosis is the most common parasitic disease of the nervous system. The disease occurs when humans become the intermediate host in the life cycle of Taenia solium by ingesting its eggs from contaminated food. The most common sites of involvement of cysticerci are soft tissue, eye and central nervous system. Unusual location of the cysts may result in uncommon manifestations. Ocular cysticercosis can involve both the intraocular and extra ocular muscle. Extra ocular muscle cysticercosis is rare. We are reporting the unusual manifestation of ptosis, proptosis, diminution of vision and medial rectus palsy due to cysticercosis. The patient was successfully treated with systemic steroids and albendazole.

Polyglandular autoimmune syndrome: We should entertain this possibility more than often

Polyglandular autoimmune syndrome (PGS) type III is a rare immune-mediated disorder. Common clinical presentation includes symptoms of hypothyroidism, diabetes, pernicious anemia, vitiligo, and autoimmune alopecia. Other autoimmune disorders associated with PGA syndrome III are celiac disease, hypogonadism, myasthenia gravis, sarcoidosis, rheumatoid arthritis, inflammatory bowel disease, gastric carcinoid tumor, and hepatitis C. We report a case of PGA syndrome type III in an 18-year-old male. Hashimotos thyroiditis was diagnosed when he was 13 years old. Clinical examination and laboratory findings revealed a PGS due to the presence of immune-mediated diabetes mellitus (DM) (type 1 DM), insufficient insulin hormone response, and thyroid autoimmunity. The patient had neither adrenal disease nor hyperparathyroidism. Therefore, we concluded that this patient has PGS type III A. When a patient presented with PGS, we should continue to consider other glandular hypofunction when evaluating patients with any type of endocrine hypofunction, as the risk of multiple glandular involvements is quite significant. Various therapeutic interventions if started early after diagnosis reduces the possible complications of the illness.

Effect of short term vitamin E supplementation on lipid peroxidation in acute myocardial infarction.

In view of sufficient body of evidence to substantiate the role of free radical mediated oxidative injury in myocardial infarction (M.I.), the utility of exogenous supplementation with antioxidant substance, vitamin E was studied. Forty patients of acute myocardial infarction were divided into two equal groups, one who received vitamin E and the other who did not. Plasma MDA levels showed a reduction in patients of M.I. who received vitamin E as well as in those who did not, however, the decrease was significantly more in the vitamin E treated subgroup.

Knowledge, attitude, and practice of foot care in patients with diabetes at central rural India

Introduction: Diabetic foot syndrome is one of the common and most devastating preventable complications of diabetes mellitus (DM). It is associated with morbidity and premature mortality due to long-term complications affecting foot. The American Diabetes Association recommends that people with diabetes should have a comprehensive foot examination once per year. Most of the foot problems can be prevented with careful foot care. It may take effort and time to build up good foot care habits, but self-care is essential. Aim: The main aim of the study is to analyze the knowledge, attitude, and practice of foot care in patients with DM in central rural India. Methodology: This study was conducted at a rural educational hospital in central part of India over 200 patients who have Type 1 and Type 2 diabetes. They were evaluated for their knowledge about foot care and footwear practices. A structured and validated questionnaire was administered to cases. Results: Around 82.9% of the patients were aware of the disease and 23.2% were aware of the complications of the DM. In 63% of the patients, foot care examination and education regarding foot complications were not suggested by their treating physicians. Annual examination of feet by the physician and self-examination were not known facts to the diabetic population. Conclusion: It is necessary to firstly develop awareness of diabetes mellitus and the related complications, one amongst which is foot care. Certain educational strategies should be established for both the consultant physician and also the common man to create awareness for effective foot care.

Prevalence of skin diseases in rural Central India: A community-based, cross-sectional, observational study

Aim: To identify prevalence of skin diseases and to determine the risk factors of skin diseases among the adult population of rural Central India. Materials and Methods: It was a community-based, observational study in which we prospectively recruited general population in and around Wardha beginning October 1, 2011, through March 2012. The main focus was to study population of 10 years and above. Results: Eczema was the most common dermatosis accounting for 22% participants and among them almost 60% sufferers were female. Fungal infection presented in 13.0% of all the affected participants and was found more in male participants (58%) than in female (42%) among those affected with fungal infection. Eczema, benign skin tumors, and pigmentary disorders were more common in participants aged 51 years and above accounting to 52.7%, 9.4%, and 6.3%, respectively. Fungal infection and acne were more in adolescent age group accounting to 17.4% and 30.4%, respectively. Conclusion: Hence, we concluded that of the entire study population prevalence of skin diseases was 60%. Our study brought a higher prevalence of eczema in female and fungal infection in male. Eczema, benign skin tumors, and pigmentary disorders were more common in participants aged 51 years and above, and fungal infection and acne were more in adolescent age group. Adolescents suffered predominantly from fungal infections and acne due to pubertal changes. Various causes such as environment, overcrowding, and poor living conditions are major factors and not only adolescents or old age group but also entire population between 21 and 50 years of age were found to be suffering more commonly from eczema and infective dermatoses.

Diagnostic Approach to a Case of Serositis

Effusions can be labeled as inflammatory (exudative) or non-inflammatory (transudative) depending upon the pathophysiological process involved. Various biomarkers (fluid glucose, fluid proteins, fluid albumin, protein ratio, protein gradient, albumin gradient) have been proposed for the same. In this study, we analysed all these biomarkers against the gold standard (cytology) and the practical utility of fluid adenosine deaminase (ADA) for diagnosing Tubercular serositis in a Tuberculosis prevalent area like that of ours. We found that albumin gradient proves its versatility in differentiating the pathophysiological nature of the effusion. We henceforth propose a minimum must step ladder diagnostic algorithm for a case of serositis, thereby cutting the costs of evaluation.