Diagnostic Signs and Symptoms of Cyanocobalamin Deficiency at Rural Setting in India: Novel Method of Supplementation.

BACKGROUND: Cyanocobalamin or B12 deficiency is common in the Indian population, and responsible for anemia. Various clinical manifestations include central nervous system and cardiovascular manifestations, secondary to a rise in serum homocysteine levels. METHOD AND PATIENTS: In a routine outpatient department at Bawaskar Hospital and Clinical Research Centre, Mahad, patients with suspected clinical signs and symptoms suggestive of cyanocobalamin deficiency were studied in detail regarding their dietary habits, serum hemoglobin, B12, and homocysteine levels. FINDINGS: A total of 1,992 (female 1,009, 50.75%) were clinically examined in detail. Of these, 945 (49.94%), 999 (50.17%), and 48 (2.40%) were strict vegetarians, both vegetarian and nonvegetarian, and strict nonvegetarians, respectively. Common occupations associated with B12 deficiency include 666 (33.4%) housewives, 396 (19.9%) service workers, 316 (15.9%) businesspeople, 180 (9%), and 198 (9.9%) retired and industrial populations, respectively. Clinical manifestations include recurrent scalp hair loss in 268 (13.5%), poor memory in 240 (12%), tingling and numbness in 200 (10%), and generalized weakness in 387 (19.4%) patients. Additionally, 541 (27.15%) patients had pigmentation of the nail bed, knuckles, oral mucosa, and tongue, while 237 (10.81%) suffered from hypertension and ischemic heart disease. During the process of preparation of vegetarian and nonvegetarian food, there is a 30-48% reduction in vitamin content. Supplementation of vitamin by adding table salt to food on a plate at the time of eating improves the vitamin level in the blood. CONCLUSION: In the absence of laboratory investigations in rural settings, clinical signs and symptoms are helpful in detecting B12 deficiency. Directly adding vitamin powder, similar to table salt, to cooked food on the plate improved blood vitamin levels.

Dermatological Conundrum: Puzzling Pigmentation in Vitamin B12 Deficiency and Addison's Disease.

We report a case series of two patients who had similar skin pigmentation but were caused by vitamin B12 deficiency and Addison's disease. We further discuss the pathophysiology of skin hyperpigmentation in both of these disorders and the response to treatment. Our case report highlights the importance of the identification of simple bedside clinical signs to diagnose reversible causes of skin pigmentation.

Imparting knowledge is no more considered a paramount contribution.

I have been practising medicine in an under-served rural setting since 1976, and have published around 109 papers in PubMed-indexed journals - including The Lancet, BMJ, NEJM and several tropical medicine journals - on scorpion and snakebite cases causing acute life-threatening conditions. I have researched in detail, with restricted resources, the acute clinical effects of envenomation and management of scorpion and snakebite cases [1, 2]. In Mahad, the fatality rate due to refractory heart failure arising from autonomic storm evoked by scorpion venom was previously 30% [3]. Since the advent of prazosin and scorpion antivenom, it has dropped to less than 1% [4]. Similarly, fatalities due to snakebite poisoning have been reduced from 18% to 5.

Newer onset of diabetes mellitus and thyroid dysfunction in COVID-19: Study from rural India.

Background: Cytokine and bardykine storm plays important role in then pathogenesis of COVID-19 diseses, as result there are raised inflammatory markers and blood sugar. Patients and Method: Patient with RTPCR positive with signs and symptoms of COVID-19 were investigated for fasting and postprandial blood sugar and glycoted hemoglobin percentage, inflammatory markers TSH and Covid antibodies. Result: All the 17 cases detected newly onset of diabetes with normal HBA1c and raised thyroid stimulating hormones in five cases. Significant raised levels of inflammatory markers and D-diamer. All cases showed bilateral pneumonias in the lungs. Conclusion: Newer onset of diabetes mellitus due to COVID-19 disease should be mangled with insulin therapy.

Stung to the Heart.

A 48-year-old woman with a history of scorpion sting was admitted with cardiogenic shock. Electrocardiogram showed ventricular tachycardia which reverted with magnesium sulphate after failed attempts with electrical cardioversion. Postcardioversion electrocardiogram showed Brugada pattern. (Level of Difficulty: Advanced.).

Blood lead level among fuel station workers, Ganesh idol painters, persons with routine daily application lead containing black pigment to eyes and Garage workers.

BACKGROUND AND AIMS: The aim of this study is to determine the lead level in blood, workers expose to lead. METHODS: 42 subjects blood was analyzes for Lead. 21,14,2,5 persons are from fuel station workers, idol painters, application of lead containing pigment to eyes and garage workers respectively. Studied from January 2012 to 2017. Analysis blood by method of inductivity coupled atomic emission spectroscopy. RESULTS: 21 fuel outlet works 11 (45.83%) Lead levels in blood were from 35.4 to 190 (mean 72.77) mcg/dl, remaining 10 lead levels were <10 mcg/dl. Out of 14 idol painters 9 (64.28%) persons blood Lead levels were 10.06 to 18.57 (12.57) mcg/dl, remaining 5 it was <10 mcg/dl. 2 Surma application to eyes their Lead levels were 29.22 and 10.93 respectively. 5 garage workers Lead levels were 13.54 to 46.75 (mean23.52) mcg/dl. CONCLUSION: Occupation exposure to lead containing fuel, paints, surma and garage workers blood levels of lead is significant.

From quarantine room: Physician perspective.

This write-up is a brief reflection of a rural doctor couple, Dr. Himmatrao Saluba Bawaskar (HSB) and Dr. Pramodini Himmatrao Bawaskar (PHB), working in the remote area of Maharashtra state of India during COVID-19 pandemic. During the pandemic, rural doctors are routinely exposed to symptomatic COVID-positive cases in the outpatient as well as indoor setting. The authors, both husband and wife, were in compulsory quarantine for twice at home and experienced social stigmas attached to a positive case. Here is a report the details of COVID-19 pattern and its management learned from the published scientific papers on COVID-19, and severe acute respiratory syndrome due to SARS-CoV-2 from December 2019 and their own experience in rural setting and the current literature shared in the form of personal narration. Apart from the personal experience of patients experience regarding quarantine period, COVID-19 is discussed in detail for the benefit of rural practitioners.

Response to "Casteism in a medical college: A reminiscence".

I was a student of the Government Medical College (GMC), Nagpur, from 1970 to1975. Based on my own experiences, I agree completely with Anurag Bhargava's comments regarding casteism at GMC Nagpur (1). Caste stigma gets attached to you early in life and stays with you till you reach the grave. I am still afraid to visit my so-called alma mater and I will explain why in this letter.

Can doctors advise beyond the purely professional?

A 25-year-old woman, six-months pregnant, came to me in great distress. She said she had been happily married for five years. Unexpectedly, a minor accidental injury to her husband had revealed that he had been suffering from a brain tumour since 2012. He had been operated on at the time but the tumour had subsequently metastasised and had required further surgery. His condition had not been revealed to the wife either at the time of the marriage or later. The husband and his family were unapologetic about the non-disclosure. When the wife confronted her husband's regular attending neurosurgeon, asking why he had not counselled the patient against marriage, he had argued that it was not his responsibility to do so. The issue this case raises is: Is it not the duty of a responsible treating doctor towards a patient with a life-threatening condition and his parents, to counsel them regarding marriage? A doctor occupies the position of a respected adviser and his counsel would surely be considered seriously.