Cost of screening, out-of-pocket expenditure & quality of life for diabetes & hypertension in India

Background & objectives: The Government of India has initiated a population based screening (PBS) for noncommunicable diseases (NCDs). A health technology assessment agency in India commissioned a study to assess the cost-effectiveness of screening diabetes and hypertension. The present study was undertaken to estimate the cost of PBS for Type II diabetes and hypertension. Second, out-of-pocket expenditure (OOPE) for outpatient care and health-related quality of life (HRQoL) among diabetes and hypertension patients were estimated. Methods: Economic cost of PBS of diabetes and hypertension was assessed using micro-costing methodology from a health system perspective in two States. A total of 165 outpatients with diabetes, 300 with hypertension and 497 with both were recruited to collect data on OOPE and HRQoL. Results: On coverage of 50 per cent, the PBS of diabetes and hypertension incurred a cost of ? 45.2 per person screened. The mean OOPE on outpatient consultation for a patient with diabetes, hypertension and both diabetes and hypertension was ? 4381 (95% confidence interval [CI]: 3786-4976), ? 1427 (95% CI: 1278-1576) and ? 3932 (95% CI: 3614-4250), respectively. Catastrophic health expenditure was incurred by 20, 1.3 and 14.8 per cent of patients with diabetes, hypertension and both diabetes and hypertension, respectively. The mean HRQoL score of patients with diabetes, hypertension and both was 0.76 (95% CI: 0.72-0.8), 0.89 (95% CI: 0.87-0.91) and 0.68 (95% CI: 0.66-0.7), respectively. Interpretations & conclusions: The findings of our study are useful for assessing cost-effectiveness of screening strategies for diabetes and hypertension.

Prevalence of Antineutrophil Cytoplasmic Antibodies and Antinuclear Antibodies in Patients with Pulmonary Tuberculosis: A Tertiary Care Center Experience from North India

Background: Tuberculosis (TB) can have manifestations closely mimicking autoimmune diseases. The prevalence of autoantibodies in TB varies among different populations. Objectives: To study the prevalence of anti-neutrophilic cytoplasmic antibodies (ANCA) and antinuclear antibodies (ANA) in pulmonary tuberculosis (PTB). Methods: This was a cross-sectional, observational study. Subjects with microbiologically confirmed PTB, either via smear or culture positivity on sputum or bronchoalveolar lavage (BAL) fluid, or positive rapid diagnostic tests were included. ANCA against proteinase-3 (PR3), myeloperoxidase (MPO), lactoferrin, and elastase were tested using an enzyme-linked immunosorbent assay (ELISA). ANA was detected using indirect immunofluorescence (IIF). Results: Eighty-nine subjects with a median [interquartile range (IQR)] age of 28 (20–46) years, 67.4% males, were recruited. Eighty-one subjects had microbiological confirmation on sputum examination, and eight required examination of BAL fluid. Sera were drawn from 62 treatment-naïve subjects, the rest (27) were on antitubercular therapy (ATT). Eighty-six (96.6%) subjects tested positive for anti-elastase antibody, seven of which were also positive for anti-PR3. None were positive for anti-MPO and anti-lactoferrin. Six (6.7%) subjects tested positive for ANA. None of the subjects had features of underlying connective tissue disease or vasculitis. Conclusion: PTB patients showed a high prevalence of anti-elastase and a low prevalence of ANA and anti-PR3 antibodies. ANCA positivity should be interpreted with caution in TB endemic areas. The role of anti-elastase antibodies in differentiating TB from ANCA-associated vasculitis (AAV) needs further research.

Uric acid as a predictor of endothelial dysfunction in patients with metabolic syndrome

ABSTRACT Objective: We conducted a study to examine the association of endothelial dysfunction and oxidative stress with uric acid levels in patients of metabolic syndrome. Subjects and methods: One hundred and two patients of Metabolic Syndrome (International Diabetes Federation definition) were included in the study. Anthropometric measurements, serum uric acid levels, fasting blood sugar levels and lipid levels, as well as malondialdehyde and reactive nitrogen intermediates were measured after an 8-hour fasting period. Flow mediated vasodilation (FMD) of the brachial artery was measured and endothelial dysfunction was defined as an increase in diameter < 10% post compression. Results: A total of 102 patients were included in the study. Mean uric acid level was 5.49 ± 1.61 mg%. A total of 59 patients in the study had endothelial dysfunction, defined by an abnormal FMD. Patients with an abnormal FMD had higher levels of serum uric acid which was statistically significant (p value = 0.010). Serum RNI and MDA levels were negatively correlated with uric acid, but did not reach statistical significance. Patients with an abnormal FMD had a lower RNI level, but this did not reach statistical significance. Serum MDA levels were significantly higher in patients with an abnormal FMD (p value = 0.038). Conclusions: Uric acid was significantly associated with endothelial dysfunction in patients with metabolic syndrome in our study. It was inversely correlated with serum RNI and MDA levels, but this did not reach statistical significance.

Clinico-pathological study of locally advanced breast cancer and their hormone receptor analysis

Background: Breast carcinoma is one of the most common malignant tumor of women. Determination of estrogen receptors (ER) and progesterone receptors (PR) status, prior to therapeutic intervention has become standard practice. Survival and response to hormone therapy are most favorable among women who are receptor positive. The aim of this study is to assess the hormone receptor status in locally advanced breast carcinomas and correlate this reactivity pattern with tumor stage, clinical stage and lymph node metastasis. Objective of the study was to co-relate the locally advanced breast cancer and their hormone receptor analysis.Methods: Patients who visited Department of General Surgery, Hamidia Hospital, Bhopal were assessed clinically, radiologically and histopathologically and then ER and PR study was done, for a total of 50 cases were done.Results: In our study majority of the cases were locally advanced breast cancer (50%) which may be due to the low socio economic status, late presentation, pain tolerance, illiteracy and availability of the resources. Majority of cases were in postmenopausal, clinical stage 3 and histological grade 2. ER positivity 50% and PR positivity 44% and it was found that hormone receptor positivity was high in locally advanced breast cancers 63.5%.Conclusions: Hormone receptor analysis should be an integral part of initial workup of carcinoma breast, as the percentage of hormone receptor positivity is increasing in our population in locally advanced breast cancer. So locally advanced breast cancer can be diagnosed at an early stage by screening and conducting breast awareness programs.

Association And Determinants Of Clinical And Subclinical Hypothyroidism In Patients With Diabetic Retinopathy: A Clinic Based Study From North India

Introduction: The association of type 2 diabetes mellitus and thyroid dysfunction is well known. Thyroid dysfunction especially subclinical hypothyroidism has been reported to be a risk factor for sight threateningdiabetic retinopathy. Therefore, it is of importance to investigate the determinants of clinical and subclinicalhypothyroidism in patients with diabetic retinopathy. This study was aimed to investigate the effect of hypothyroidism on diabetic retinopathy and the determinants of hypothyroidism.Aims: To study the association of hypothyroidism and diabetic retinopathy and its effect on severity of retinopathy in type 2 diabetes and investigate the determinants of hypothyroidism in patients with diabetic retinopathy.Subjects and methods: A cross sectional study conducted on one hundred patients of type 2 diabetes withdiabetic retinopathy. They were evaluated for status of diabetes control, thyroid function, lipid profile andretinopathy grade. Those found to have clinical and subclinical hypothyroidism were analyzed for variousclinical and biochemical parameters for possible determinants of thyroid dysfunction.Results: There were seventy-four euthyroid patients and eighteen with subclinical hypothyroidism and five withclinical hypothyroidism. Patients with subclinical hypothyroidism had severe form of retinopathy (61.11%versus 32.43%). The odds of having a subclinical hypothyroidism in patients with severe form of diabeticretinopathy was found to be significant (OR 3.23; p=.048 CI=1.10-9.88). High HBA1c was an independent determinant of abnormal thyroid function.Conclusions: About one fourth of type II diabetes patients with retinopathy have thyroid dysfunction. Thesepatients are also likely to have severe form of the retinopathy especially those having subclinical hypothyroidism. Thus, we recommend thyroid function test should be done in all patients with type II diabetes mellitus withretinopathy. Those identified as having subclinical hypothyroidism should be closely followed so as, to detectand prevent vision threatening complications

To Study Predictors For Withdrawal Seizures In Patients Of Alcohol Withdrawal Syndrome

Introduction– The alcohol withdrawal seizure(WS) occurs during the early phase of withdrawal and is characterized by reduction in the seizure threshold and it emerges within 48 hours of cessation of prolonged drinking (Brathen G et al,1999;Victor M et al,1967.)The appearance of a withdrawal seizure represents a strong risk factor for progression into a severe withdrawal state with following development of DT in up to 30% of cases(Victor M et al,1967). Aim– The purpose of the current study is to identify the most parsimonious collection of risk factors present at the time of hospital admission that were predictive for the development of WS. METHODOLOGY– 102 subjects admitted at deaddiction centre, SMS hospital were selected using a screening performa which was followed by a comprehensive assessment of alcohol use followed by relevant laboratory investigations with blood pressure and pulse rate recording. Severity of alcohol withdrawal syndrome (AWS) was determined in analogy to the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA–Ar) scale. Patients were put on standard treatment based upon institute guidelines and withdrawal was assessed for 1 week. Patients were monitored for withdrawal seizure and diagnosis was made as per criteria of ICD 10. RESULTS– Age of onset of drinking, duration of alcohol abuse and daily ethanol intake were found to be significantly correlated to the development of WS. Systolic BP, Diastolic BP, Heart rate had significant correlation to the occurrence of WS which can be attributed to the autonomic hyperactivity during the withdrawal state. CIWA–Ar score also came out to be a significant risk factor to the development of WS.Previous history of seizures, delirium tremens, previous alcohol withdrawal syndrome and previous detoxification episodes were also a significant risk factor for the occurrence of WS . CONCLUSION– The various variables that were found to be significantly correlated to the occurrence of WS are mentioned as follows: age, duration of abuse, daily alcohol intake, CIWA–Ar score>15, systolic & diastolic BP, previous history of WS and DT, previous history of alcohol withdrawal syndrome and previous detoxification episodes.

Cancer treatment associated cardiac toxicities

Cardiovascular disease remains the leading cause of mortality and morbidity in men and women both in the US and worldwide. With increased access to healthcare, it is predicted that life expectancies in developed countries will continue to rise and thus, lead to an increase in both cardiovascular disease and cancer. Similarly, improved survival rates in cancer patients have led to an increased awareness of the presence and potential worsening of cardiovascular disease in these patients. Cardiovascular complications due to side effects from cancer therapy or from cancer progression can be a common occurrence. Although recent advances in cancer therapeutics have led to improved survival rates and quality of life, the increase in life expectancy may be counteracted by the increased morbidity and mortality from progressive cardiac pathology. Examples of such complications include local invasion or distant metastatic spread, which can lead to superior vena cava syndrome, cardiac tamponade, or hyperviscosity syndromes. In addition, many chemo and radiation therapies can be directly toxic to the cardiovascular system. This review aims to discuss the potential cardiac toxicities of the most commonly used chemotherapeutics along with some strategies to manage these complex patients.

Study of Efficacy of Tramadol as an Adjuvant to Lignocaine in Intravenous Regional Anesthesia at a Tertiary Care Teaching Centre

Introduction: Tramadol is a central analgesic with an opioid agonistic activity with some selectivity for µ-receptors. Several studies showed that tramadol is beneficial as an additive to local anesthetics in different regional nerve blocks including infiltration, caudal block, brachial plexus block and IVRA. However, the existing data on its role as an additive for IVRA are conflicting. Therefore, a prospective, randomized controlled trial was conducted to determine efficacy of Tramadol (100mg) as an intra-operative, post-operative and pre-emptive analgesic as an adjuvant to lignocaine in IVRA. Materials and Methods: Present study was   carried   out   in   80   patients   undergoing   upper arm orthopedic surgery at Sharda Hospital, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India. All patients selected were planned for forearm surgeries, of ASA Grade I or II, aged 16-60 years. Patients received 0.5% lignocaine 40 ml in one group and we added Tramadol 100 mg in the other group. All the patients were monitored for onset of effect, quality of anesthesia, post op analgesia after deflation of tourniquet, time of first analgesic drug and number of analgesic drug required in first 24 hrs. Results: Onset of sensory analgesia was significantly earlier in group B (59.7±23.8 sec v/s 196.3±42.7) while onset of motor paralysis was similar in both groups. The post-operative analgesia was significantly longer in group B (304.7 ± 87.9 mins) then group A (12.6 ± 5.1 mins). Accordingly the number of analgesics consumed in post-operative first 24 hours was significantly less in group B (1.2±0.6) then group A (2.9±0.8). Conclusion: Tramadol has favorable effects as an adjuvant to lignocaine for IVRA. Tramadol substantially shortens the onset of sensory block, improves patient’s tolerance of tourniquet, prolongs the duration of analgesia after deflation of tourniquet and reduces the postoperative analgesic consumption.

An Adolescent with Kawasaki Disease.

Kawasaki disease is an acute vasculitis of unknown etiology that predominantly affects children <5 years of age. The incidence and the severity of myocarditis in this disease is variable and depends upon the stage of the disease, acute or chronic. Acute-stage Kawasaki disease shows relatively high incidence of myocarditis, but almost all cases are clinically mild. We describe teenage boy presenting with atypical/incomplete manifestations of Kawasaki disease and developing fulminant myocarditis within a week of illness resulting in death. The case underscores the importance of suspecting Kawasaki disease in a young child presenting with features of myocardial ischemia.

Urinary bladder paraganglioma – A rare dreaded tumor.

Catecholamine-secreting tumors that arise from chromaffin cells of the adrenal medulla and t sympathetic ganglia are referred to as pheochromocytomas and extra adrenal catecholamine secreting paragangliomas (extra adrenal pheochromocytomas), respectively. Bladder paragangliomas are rare entities with initial non-specific presenting symptomatology. Differentitaion of urinary bladder pheochromocytomas from other bladder tumors has important treatment implications. We have presented here the case of a 55 year old female who presented to our outpatient urology clinic with complains of hematuria for 3 months and headache for 1 month. Cystoscopy revealed diffusely thickened bladder wall with a well circumscribed smooth surfaced mass protruding from the right lateral wall of the bladder. Multiple biopsies were taken and sent for histopathology. After cystectomy, diagnosis of paraganglioma of bladder was done by histopathology and immunohistochemistry.

Aquasomes: A novel drug carrier.

Aquasomes are one of the most recently developed delivery system for bioactive molecules like peptide, protein, hormones, antigens and genes to specific sites. Aquasomes are spherical in shape with 60–300 nm particles size. These are nanoparticulate carrier systems but instead of being simple nanoparticles these are three layered self assembled structures, comprised of a solid phase nanocrystalline core coated with oligomeric film to which biochemically active molecules are adsorbed with or without modification. These structures are self assembled by non covalent and ionic bonds. The solid core provides the structural stability, while the carbohydrate coating protects against dehydration and stabilizes the biochemically active molecules. The delivery system has been successfully utilized for the delivery of insulin, hemoglobin, and enzymes like serratiopeptidase etc. This reviews the principles of self assembly, the challenges of maintaining the conformational integrity and biochemical activity of immobilized surface pairs, the convergence of these principles into a single functional composition and its application in various fields of pharmacy.

Gastrointestinal toxicity due to bitter bottle gourd (Lagenaria siceraria)-a report of 15 cases.

Traditional medicine is widely practiced in tropical countries. Bottle gourd (Lagenaria siceraria) fruit juice is advocated as a part of complementary and alternative medicine. If the bottle gourd juice becomes bitter it is considered toxic. We report 15 patients, who developed toxicity due to drinking bitter bottle gourd juice. Patients presented with abdominal pain, vomiting, hematemesis, diarrhea and hypotension within 15 min to 6-h after ingestion of bottle gourd juice. Endoscopy showed esophagitis, gastric erosions, ulcers and duodenitis. Hypotension was treated with crystalloids and inotropic support. All patients recovered in 1–4 days. Endoscopically the lesions healed in 2 weeks. Bitter bottle gourd can cause gastrointestinal toxicity with hematemesis and hypotension. Supportive management is the treatment and all patients recover within 1 week.

Trichophyton rubrum onychomycosis in an 8-week-old infant.

An 8-week-old infant presented with 7 weeks history of nail involvement and discoloration. Lesions started over the middle fingernail of right hand at 1 week of age, spreading over to other nails within 2 weeks. Only two nails of the feet were spared. On KOH examination, fungal hyphae were seen and culture showed growth of Trichophyton rubrum. The purpose is to report the earliest case of onychomycosis having multiple nail involvement of fingers and toes (18 nails).

In vitro study to compare sensitivity of amoxicillin+clavulanic acid and cefpodoxime+clavulanic acid among beta-lactamase positive clinical isolates of gram-positive and gram-negative pathogens.

The present study was carried out to compare the in vitro sensitivity of cefpodoxime + clavulanic acid and amoxicillin + clavulanic acid against 55 Gram-positive and 123 Gram-negative beta-lactamase positive clinical isolates. Micro-organisms isolated from different clinical specimens were tested for beta-lactamase/ESBL by using nitrocefin disc test and for metallo beta-lactamase by using double disc synergy test. A total of 299 (93 Gram-positive and 206 Gram-negative) clinical isolates were tested for beta-lactamase. Among 93 Gram-positive clinical isolates 25 (78.12%) out of 32 coagulase positive S. aureus, 23 (60.52%) out of 38 coagulase negative S aureus, 7 (63.63%) out of 11 enterococci and 0 (0%) out of 12 Strept pneumoniae were positive for beta-lactamase /ESBL. Notably Strept pneumoniae was found to be beta-lactamase/ESBL negative. Among 206 Gram-negative clinical isolates, 25 (69.44%) out of 36 acinetobacter spp, 20 (41.66%) out of 48 Branhamella catarrhalis, 24 (64.86%) out of 37 E. coli, 7 (46.66%) out of 15 H influenzae and 22 (62.85%) out of 35 proteus were positive for beta-lactamase/ ESBL/metallo beta-lactamase. Positive strains were tested for comparative sensitivity to amoxicillin+ clavulanic acid and cefpodoxime+clavulanic acid by Kirby Bauer disc diffusion method. As regards comparative sensitivity among beta-lactamase/ESBL positive Gram-positive strains, 84% and 92% strains of coagulase positive S aureus, 65.21% and 86.95% strains of coagulase negative S. aureus, 83.33% and 100% strains of Strept pneumoniae and 71.42% and 100% strains of enterococci were found sensitive to amoxicillin +clavulanic acid and cefpodoxime + clavulanic acid respectively. Sensitivity to amoxicillin+ clavulanic acid and cefpodoxime +clavulanic acid among beta lactamase/ESBL positive Gram-negative strains of acinetobacter spp, Branhamella catarrhalis, E. coli, H. influenzae and proteus spp were found to be 20% and 28%, 100% and 100%, 50% and 75%, 71.42% and 100%, 50% and 68.18% respectively. This study demonstrated that cefpodoxime +clavulanic acid combination has more potent in vitro activity in comparison to amoxicillin+ clavulanic acid combination against beta-lactamase producing strains of Gram-positive and Gram-negative bacteria. Given this broad spectrum of activity, cefpodoxime+clavulanic acid appears well suited for use in the treatment of a variety of healthcare-associated infections.

Cardiovascular disease risk management in a primary health care setting of north India.

OBJECTIVE: This study was primarily carried out to assess the feasibility of an adapted WHO CVD risk management package in a primary care setting. METHODS: A community intervention trial was conducted in eight health posts located in rural, urban, and slum areas of northern India. After a 4 day training, eight health workers implemented the package among 1010 adults > or =30 years of age from a randomly chosen cluster of households. Locally adapted scenario 1 WHO protocol was used for the assessment of CVD risks. The health workers inquired about smoking, alcohol, diet, physical activity, symptoms of angina, and transient ischaemic attacks; and measured systolic blood pressure (SBP7), height, and weight. Those with a risk were counseled and referred to a physician. Hypertensives were followed at 1, 3, and 5-month interval to reinforce risk prevention and adherence to treatment. In a 20% random sub sample, in the study and control area before and after the intervention, WHO STEPS instrument was used to evaluate effectiveness of the package. FINDINGS: After training, the knowledge of health workers regarding risk factors and symptoms of CVDs increased from 47% to 92.5%, and their performance in detection of risks was comparable to the investigator. All health workers could pay scheduled home visits regularly. They referred 279 (27.6%) individuals having raised systolic blood pressure (SBP), and 74.5% contacted the doctor. Significant decrease in mean SBP (8.8 mm Hg) was observed during follow-up. Significantly higher reports of intention to quit tobacco (60.3% vs 25.5%) and regular intake of anti-hypertensive medication (58.3% vs 34.8%) were observed in the intervention area compared to the control area. CONCLUSION: Adapted WHO CVD risk management package can be implemented through primary care system.

Retinal arterial occlusion in Takayasu's arteritis.

Takayasu's arteritis is an auto-immune disorder of the large and medium-sized arteries, commonly involving the heart and its main vessels. It is now recognised that the inflammatory process of the large arteries affects regions of the walls supplied by the vasa vasorum, suggesting that primary small vessel involvement may contribute to the development of the clinico-pathological features of Takayasu aorto-arteritis. Classical ophthalmic features of the disease result from reduced ocular perfusion, which manifests as hypoxic retinal changes such as microaneurysms, arterio-venous anastomosis and non-perfused areas. Branch retinal artery occlusion has not been previously described in this condition. This case illustrates retinal arterial occlusion as the presenting feature of Takayasu's arteritis.

Pancreatic calculus impacted at Ampulla of Vater causing severe cholangitis and septic shock.

Patients with chronic pancreatitis may have varied complications including common bile duct stenosis, cholangitis, pseudocyst or fistula formation and secondary biliary cirrhosis. Common bile duct obstruction due to disimpaction of a pancreatic calculus into the ampulla of Vater leading to severe cholangitis and septic shock is a rare phenomenon. We are reporting such a case here.