Vishakha Jain

Health-Related Quality of Life (Hr-Qol) in Patients with Type 2 Diabetes Mellitus

Background: Quality of life is an important aspect in diabetes because poor quality of life leads to diminished self-care, which in turn leads to worsened glycemic control, increased risks for complications, and exacerbation of diabetes overwhelming in both the short run and the long run. Aims: The aim of our study is to examine the health-related quality of life of diabetic patients in rural India. Materials and Methods: This case-control study was done among type 2 diabetes mellitus patients attending Medicine Outpatient department of a 780-bedded rural medical college located in central India. We used the World Health Organization Quality of Life Questionnaire — short version (WHOQOL-BREF) to assess quality of life. Results: The HRQOL among diabetics and non-diabetic controls is comparable to each other with bad physical health, bad psychological health, deteriorating social relationships, and bad environmental conditions affecting the HRQOL of both the groups equally. The overall HRQOL of the total study population (cases and controls) was poor. Conclusion: The finding of this study will help in health promotion in rural medical practice in India. It would beckon the much awaited avenue of holistic care of a diabetic patient with equal importance to the mental wellbeing and quality of life, as compared to physical well being.

Hypokalemia induced rhabdomyolysis.

An 18-year-old unmarried girl presented with a history of pain in the abdomen and nonbilious vomiting of 4-day duration. This was followed by painful muscle cramps and progressive proximal muscle weakness involving all four limbs. She had no history of diarrhea, diuretic intake, fever, arthralgia, and rash. She had a similar episode of abdominal pain, vomiting, and muscle weakness 2 months prior to this illness which recovered after receiving some IV injections in a private hospital. She had never passed any urine stones. She was normotensive and nondiabetic with a normal thyroid profile. There was no history of drug intake.

Unusual presentation of adult Gaucher's disease: A long and difficult road to diagnosis

Gauchers disease is the most frequent sphingolipid storage disease. We present a case of type 1 non-neuropathic type of adult Gauchers disease patient with atypical presentation.

A rare case of situs inversus with dextrocardia, lutembacher syndrome, and pericardial effusion.

Incidence of congenital cardiac anomalies in dextrocardia with situs inversus is low as compared to congenital cardiac anomalies in isolated dextrocardia. We describe the first ever case of situs inversus with dextrocardia, Lutembachers syndrome, and pericardial effusion. The pericardial effusion in our case was acquired and was tubercular in etiology.

Recurrent pneumothorax in a young female with pulmonary lymphangiomyomatosis: a case report and overview of literature.

Lymphangiomyomatosis (LAM) is a rare cystic interstitial lung disease that exclusively affects women of child bearing age and is associated with vascular proliferation of smooth muscle cells in the lung. We report a case of young female with pulmonary LAM presenting with recurrent pneumothorax.

Carotid intima-media thickness and apolipoproteins in patients of ischemic stroke in a rural hospital setting­ in central India: A cross-sectional study

Context: Carotid intima-media thickness (CIMT) and apolipoproteins have been found as a risk factor for ischemic stroke Objective: The objective was to study the carotid intima-media thickness, apolipoproteins, and their relation in patients of ischemic stroke in central rural India. Settings and Design: A cross-sectional study was performed in a rural hospital in central India. Materials and Methods: In all patients of ischemic stroke proven by computerized tomography (CT), CIMT, apolipoprotein A-I (ApoA-I), and apolipoprotein B(ApoB) were measured. Statistical Analysis Used: We used Students t-test to compare means, a chi-square test to compare proportions, and a Mann-Whitney test to compare medians. A P value <0.05 was considered significant. Results: The mean age of our study population (N=106) was 61 years. The mean CIMT was 0.83 mm ranging from a minimum of 0.45 mm to a maximum of 1.096 mm. Mean CIMT was significantly higher than expected 0.67 values, which was calculated according to the age of the study population. The association of decreased ApoA-I < 100 mg/dl and increased ApoB > 90 mg/dl with CIMT > 0.7 mm was statistically significant with P<0.001. Conclusions: The CIMT in computerized tomography-proven ischemic stroke was significantly higher than expected for the age of the study population. The relation of decreased ApoA-I and increased ApoB with CIMT > 0.7 mm was also statistically significant.

Massive acute intravascular hemolysis after platelet transfusion: An unrecognized entity

Sir, Transfusion of ABO-mismatched platelets is a common practice when ABO group specific platelet concentrates are unavailable. Acute intravascular hemolysis after platelet transfusion is a rarely encountered entity, but unfortunately a fatal event. We would like that this rare entity of acute hemolytic reactions after platelet transfusions be considered before any platelet transfusions. A 49-year-old, B Rh positive blood group, female was referred from a district hospital with a history of fever since 5–7 days. There was no history of jaundice, rash, bleeding tendencies, chest pain, dyspnea, or urinary complaints. She was treated at district hospital, was detected to have thrombocytopenia, and was transfused with Platelet rich plasma (PRPs). She received total of 8 PRPs (unmatched) over 2 days. Immediately after the last PRP, patient started complaining of increasing fever with chills, back ache, and started passing red colored urine. Subsequently over the next few hours, she started having jaundice and was referred to our hospital. She had not received any whole blood or packed cells. At admission to our hospital patient was febrile, jaundiced, no rashes, no evidence of any subcutaneous or submucosal bleed, with unremarkable systemic examination and red colored urine. Her blood which was drawn for investigation showed red coloured sera indicative of gross hemolysis. She was detected to have hemoglobin of 10 g/dl, high WBC counts of 48,470 with thrombocytopenia (platelets 73,000), spherocytes in peripheral smear, hyperglycemia (RBS 284), indirect hyperbilirubinemia, and acute kidney injury (urea 58 and serum creatinine 2.2). Her urine yielded high positive reaction for hemoglobin. Direct antiglobulin test was positive. Her reticulocyte count was 3.5. Serological tests for malaria and dengue were negative. Subsequently the patient continued to have fever, continued to pass red colored urine, and became tachypnoiec. Her kidney function had deteriorated with blood urea 107 and serum creatinine 5.7. She was immediately started on hemodialysis. Her subsequent reports showed that there was a fall in hemoglobin by 5 g/dl (Hb=5.7 g/dl), hematocrit 16.7, and platelets were 1 lakh. She was transfused 5 units of compatible packed cells. She continued to be tachypnoiec and was destaurating, with ensuing metabolic acidosis. She was intubated and supported by mechanical ventilation. Patient continued to deteriorate and finally died with refractory metabolic acidosis, hyperkalemia, and massive intravascular hemolysis. The clinical and biochemical scenario presented in this case is consistent with acute hemolytic reaction after PRP transfusions. Transfusion of ABO-mismatched platelets is a common practice when ABO group specific platelet concentrates are unavailable or a histocomapatibility leukocyte antigen (HLA) match is done. Minor ABO incompatibilities between donor’s plasma and recipient’s RBCs are low risk for hemolytic reactions. Blood and blood products from so-called “universal donors” prove catastrophic. These universal donors may have high titers of ABO isohemagglutinins either from vaccinations or other antigen exposures.[1] There has been evidence of acute hemolytic transfusions due to this ABO incompatibility and some authors have suggested that transfusion of group O components to group A or B patients should only be done if the titer of isohemagglutinins is less than the critical level. The most commonly cited titer is 200 when tested in saline.[2] In a 5-year review during which time nearly 1000 single-donor ABO incompatible plateletpheresis products were transfused to bone marrow transplant recipients, Shanwell et al. noted positive direct antiglobulin tests caused by passively absorbed anti-A and/or anti-B from the donor plasma, but found no cases of hemolysis.[3] In addition, a retrospective review by Mair and Benson showed no significant decrease in hemoglobin, as evidence of hemolysis, with transfusion of ABO-incompatible plateletpheresis products in 24 non-group-O bone marrow transplant patients.[4] At two separate large institutions, the incidence of hemolytic reaction from transfusion of ABO-incompatible single-donor apheresis products was only 0.01% over a 9–10-year period.[3,5] Nevertheless, many a time platelet transfusions are given to patient from out of their group and most of them are not guided or warranted by evidence-based practice guidelines. We would like that this rare entity of acute hemolytic reactions after platelet transfusions be considered before any platelet transfusions. Several ways to help minimize the risk may include the following: (1) limiting the quantity of platelet transfusions to what is clinically necessary; (2) continually evaluating those patients receiving large volumes of platelets; (3) whenever possible, transfusing ABO-compatible platelets; and (4) reducing the volume of incompatible plasma transfused for group A, B, or AB patients who must receive ABO-incompatible platelet products, particularly in children and patients with small plasma volume.

Visiting a “frail elderly”: A review on model of care and treatment strategies

Frail elderly are those who have less than normal physiological reserve which predisposes them to more severe adverse outcomes following a stressor compared to normal. As the number of elderly is increasing worldwide, there is increase in the problem of frailty. Frailty is a dynamic state in the sense that if interventions are directed to correct the state of frailty, then an elderly starts to shift toward normal side and if not then deteriorated even more. When it comes to managing a frail elderly, then the place of care can be patientfs home as well as health care facility. Comprehensive geriatric assessment and program for all.-inclusive care for the elderly are the concepts that advocate multidisciplinary approach for the management of frail elderly. There is increasing evidence in favor of the management of these patients at their home and delaying the transfer to health care facility till these patients cannot be managed at home. Apart from the specific treatment of the acute illness and the underlying chronic illness, there are other interventions cum life style modification which can help in improving a frail state. These includes increasing content of whey protein, essential amino acids in the diet, combination of resistance and endurance exercises, Vitamin D supplementation, and pharmacotherapy such as testosterone, ghrelin, and growth hormone.

Apoplexy in pituitary macroadenoma presenting with total ophthalmoplegia and preserved vision: A rare entity

Pituitary macroadenoma is a rare tumor with varied presentation. It can present acutely due to apoplexy. Here, we present a rare presentation of total ophthalmoplegia with normal vision in a case of pituitary macroadenoma with apoplexy.

A comparative study of the C-reactive protein and the ST-score (ECG) as prognostic indicators in acute myocardial infarction in a rural resource-constrained hospital setting in central India: A cross-sectional study

Context: The electrocardiogram remains a crucial tool in identification of acute myocardial infarction (AMI). High sensitivity C-reactive protein (hs-CRP) has been found to be strong predictor of coronary artery disease (CAD) and future cardiovascular events. Aims: The aim of the present study was to compare hs-CRP and ST-Score (STS) as prognostic indicator in acute ST segment elevated myocardial infarction (STEMI) in central rural India. Settings and Design: Cross sectional study, rural hospital in central India. Material and Methods: In all patients of STEMI, STS, ST index and hs-CRP were measured on admission and serially. The Primary outcome was all cause mortality at 30 days. Secondary outcome were heart failure, life threatening arrhythmia, cardiogenic shock, re-infarction, hospital stay and re-admission. Statistical analysis used: We used Students t test to compare means, Chi-square test to compare proportions and Mann Whitney test to compare medians. P value <0.05 will be considered significant. Crude odds ratios were computed to assess the strength of association between risk factors and independent variable along with 95% confidence intervals. Results: STS was significantly higher in patients with poor outcome, when compared with good outcome (20.27mm vs.12.47mm, P = 0.002). On multivariate regression model STS was significant predictor of composite outcome events (OR = 2.74; 95% [CI], 1.46 to 5.17; P = 0.002). The area under the ROC curve was 0.70, with sensitivity of 73.5%, specificity of 58.7%; PPV of 68.3% and NPV of 64.2%. hs-CRP in patients with poor outcome vs. good outcome (6mg/L vs. 3.74mg/L, P = 0.003) and (P = 0.06, 0.85 and 0.12) respectively. Conclusions: STS on admission is independent predictor while hs- CRP is not in resource constrained settings.