Inertia in Adaptation of Healthcare System to Biologics and Biosimilars.

Biologics and biosimilars are underused. Different manufacturing, regulatory and social barriers, and clinical inertia prevent its adequate usage despite indications. Awareness of clinicians, patient education, reduction of costs, regulatory easing, and simplification of manufacturing processes will help in the earlier adaptation of biologics in the healthcare system. Further advancement of technologies will help to generate biologics and biosimilars of greater safety, better efficacy, lesser immunogenicity, and good interchangeability.

Spectrum of Disorders associated with Tetany.

INTRODUCTION: Awareness regarding the etiological spectrum of tetany is poor among physicians. Because of poor awareness, tetany is underdiagnosed and undertreated. MATERIALS AND METHODS: Databases like PubMed, PubMed Central, Scopus, and Google Scholar are searched to identify peer-reviewed articles on tetany. Case reports, case series, and original articles are analyzed to identify different causes of tetany prevalent in the community. Different causes found are analyzed and tabulated, and finally, a flowchart is made on the approach for diagnosing different underlying pathologies of tetany. RESULTS: Both metabolic and respiratory alkalosis are important causes of tetany because of reduced ionized calcium levels. Gitelman syndrome (GS) is associated with metabolic alkalosis, hypokalemia, hypomagnesemia and hypocalciuria, and frequently causes normocalcemic tetany. Recurrent vomiting and primary hyperaldosteronism also cause tetany due to metabolic alkalosis. Hyperventilation syndrome (HVS) leads to respiratory alkalosis and is a frequent cause of tetany. Hyperventilation-induced tetany is also seen after spinal anesthesia and in respiratory disorders like asthma. Vitamin D deficiency (VDD), primary hypoparathyroidism, and pseudohypoparathyroidism (PHP) (1a, 1b, and 2) cause hypocalcemic tetany. Hypomagnesemia causes hypocalcemia and tetany due to peripheral parathyroid hormone resistance and impaired parathyroid hormone secretion. Drugs causing tetany include bisphosphonates, denosumab, cisplatin, antiepileptics, aminoglycosides, diuretics, etc. Tetany is also seen in acute pancreatitis, dengue, falciparum malaria, hyperemesis gravidarum, tumor lysis syndrome (TLS), massive blood transfusion, etc. Conclusion: The spectrum of disorders associated with tetany is diverse. Awareness of different causes will help early and proper diagnosis of tetany.

A clinico-epidemiological Study of acute Self-poisoning by different Types of herbicidal Substances used in agricultural Fields: A Study from Patients admitted in a Tertiary Care Hospital in West Bengal.

INTRODUCTION: Herbicides are the chemical compounds used to control the growth of unwanted plants or to eliminate them. The common poisonous herbicides available in India are paraquat, glyphosate, pretilachlor, etc. Ingestion of herbicides with suicidal intention is common in rural India and West Bengal but very scanty literature is available. METHODOLOGY: We conducted a unicentric, hospital-based, noninterventional, cross-sectional study comprising 50 consecutive patients to estimate the morbidity, case fatality, and clinical features of acute suicidal poisoning of different herbicides used in agricultural fields. Data were collected from history, clinical features, and laboratory findings. Proper statistical method was used for data analysis. RESULTS: Most of the study population were from 26 to 40 years age group (48%), followed by 13-25 years age group (34%). Paraquat was ingested by 64%, followed by pretilachlor (20%) and glyphosate (16%). Common symptoms were vomiting (60%), abdominal pain (40%), throat discomfort (26%), oral ulcer (24%), decreased urination (50%), and respiratory distress (30%). In laboratory investigation, 64% patients had deranged liver enzymes, 58% patients had acute kidney injury, and 30% patients had alveolar damage. A total of 62% patients were discharged after recovery and 38% patients died. Case fatality rate of paraquat was 56.2%, glyphosate was 12.5%, and pretilachlor was nil (0%). CONCLUSION: Herbicides like paraquat and glyphosate are associated with high morbidity and case fatality. Paraquat has the highest case fatality rate. Pre-emergent herbicide pretilachlor is relatively safe.

Yoga and the Need of Its Integration in Modern Medicine.

INTRODUCTION: Growing evidences of the health benefits of yoga are available in the literature. But physicians are not aware of it. METHODOLOGY: Databases like PubMed, PubMed Central, Google Scholar, and Scopus are searched for the articles on preventive, therapeutic, and rehabilitation potential of yoga. Scientific evidences available are analyzed and incorporated into the article. RESULT: Yoga provides relief from stress, anxiety, depression, and obsessive thoughts. It promotes better sleep. It relieves psychosomatic disorders. Yoga helps to cope with post-traumatic stress disorder (PTSD). Pranayama appears to alter autonomic responses by breath-holding that increases vagal tone and decreases sympathetic discharge and causes relaxation. Yoga increases GABAergic activity that has an anxiolytic effect. Yoga reduces stress-induced cortisol release and reduces hyperglycemia. Yoga reduces seizure frequencies, prevents rapid cognitive decline in Alzheimer's disease, and helps in poststroke rehabilitation. Reduction of blood pressure and heart rate are seen with yoga. Yoga increases heart rate variability (HRV) and reduces health consequences of allostatic overload. Pranayama improves the vital capacity of lungs. Yoga improves musculoskeletal flexibility and enhances the ability of sustained isometric muscle contraction. Yoga is proved to be a viable adjunct of drug therapy for depression and anxiety. It is a promising alternative to psychoanalysis and cognitive behavior therapy. Yoga prevents lifestyle disorders. CONCLUSION: Yoga is safe and affordable. Integration of yoga in modern medicine needs intensification because of its various health-promoting, disease-preventing, therapeutic, and rehabilitative effects.

Gitelman-like Syndrome with Kanamycin Toxicity.

A 22 year-old lady with multi-drug-resistant pulmonary tuberculosis was on Kanamycin, Cycloserine, Ethionamide, Pyrazinamide and Moxifloxacin since more than two months. She presented with muscle cramps and carpopedal spasm. Investigation revealed hypokalemia and metabolic alkalosis. She also had hypomagnesemia, hypochloremia and hypocalciuria. Serum urea and creatinine levels were normal. Patient was treated with intravenous and oral potassium chloride. Kanamycin was stopped. Metabolic alkalosis and hypokalemia improved gradually over one month. Biochemical parameters were like Gitelman's syndrome but it reversed with stoppage of Kanamycin. Gitelman-like syndrome with Kanamycin toxicity has not been reported in literature previously.

Ebstein's Anomaly with Paradoxical Embolism to Lower Limb.

Ebstein's anomaly (EA) is a rare congenital heart disease. Paradoxical embolism (PDE) may occur in EA due to associated atrial septal defect (ASD). An 18 year old male with EA presented with left lower limb ischemia due to PDE to the limb. No features of cerebral embolism was present. PDE is a potential complication of EA. High level of awareness is needed for early diagnosis of PDE in EA to save a limb in case of embolism to the extremity.

Disabling Osteopetrosis in an Young Lady.

Osteopetrosis is a rare disorder of osteoclastic bone resorption leading to hyperostosis. Albers-Schonberg disease, an autosomal dominant variant of osteopetrosis occurs in young adults and has a benign course. A 17 year old female presented with generalized weakness and pallor for last two months. She had insidious onset and gradually progressive loss of vision and hearing for last two years. Plain x-ray of skull revealed increased radio-opacity of skull bones specially in the base, severe under-pneumatization of frontal and sphenoidal sinuses. Maxillary and ethmoid sinuses were also opaque and under-pneumatised. Bone scintigraphy with technetium-99m methylene diphosphonate showed diffusely increased uptake in whole skull. Bone marrow biopsy revealed a reactive marrow with areas of fibrosis without any evidence of granuloma or malignancy. The case had cranial entrapment neuropathies and severe anaemia due to osteopetrosis. High level of awareness is needed to diagnose the case properly and to help the patient to cope with the disabling features of the disease.

Systemic Lupus Erythematosus Presenting as Neuroretinitis.

Neuroretinitis is the inflammation of retina and optic nerve. It is associated with optic disc edema accompanied by peripapillary or macular hard exudates. A 17 yr old female presented with headache and nausea of five days duration. She had periorbital edema and mild splenomegaly. Neurological assessment was non-contributory. She was found to have pancytopenia, albuminuria and a high ESR. Thereafter she developed blurring of vision of both eyes. Opthalmological examination showed it to be due to bilateral neuroretinitis. ANA and anti-ds DNA were strongly positive. Renal biopsy with immunofluorescence study revealed diffuse global proliferative lupus nephritis with active lesions [class IV-G (A)]. She was diagnosed as a case of SLE presenting with neuroretinitis.

Anorexia Nervosa with Obsessive-Compulsive Disorder.

We report the case of an adolescent female, previously nonobese, belonging to educated average socioeconomic Muslim family. She stopped taking food, developed a perception of distorted body image with occasional episodes of binge eating and forced vomiting. She became amenorrheic and emaciated with loss of secondary sexual characters. She satisfied the criteria for anorexia nervosa with obsessive-compulsive disorder.

Assessment of adherence to cardiovascular medicines in rural population: An observational study in patients attending a tertiary care hospital.

INTRODUCTION: Nonadherence to cardiovascular medicines is a major concern. It increases the morbidity and mortality of cardiovascular patients. The work was conducted to evaluate the adherence to cardiovascular medicines in patients of rural India. METHODS: The study was conducted in the Department of Medicine involving rural patients with essential hypertension (HTN), congestive cardiac failure (CCF), and ischemic heart disease (IHD) over 12 months period. Patients were prescribed with cardiovascular medicines at the initial visit and adherence to medicines was assessed in the subsequent visit. Four items Morisky's Medication Adherence Scale (MMAS-4) was used for assessing medication adherence. Patients were considered adherent to medication if they answered negatively to all four questions. RESULTS: Overall adherence to medication was 20.83%, 28.37% and 32% in HTN, CCF, and IHD patients, respectively. Nonadherence was highest in patients of HTN. Among the four reasons of nonadherence assessed by MMAS-4, carelessness was the most common and forgetfulness was the least common cause of nonadherence in all the three groups of patients. CONCLUSION: Patients of rural India adhere poorly to cardiovascular medicines. Nonadherence should be considered as a public health problem. Strategies for detecting the level of adherence of cardiovascular medicines, its barriers, and subsequent interventions should be developed by policy-makers to reduce morbidity and mortality due to cardiovascular disorders.

Hyperventilation of pregnancy presenting with flaccid quadriparesis due to hypokalaemia secondary to respiratory alkalosis.

Hyperventilation in pregnancy is a cause of chronic respiratory alkalosis. Alkalosis either metabolic or respiratory may cause intracellular shift of potassium ions that may lead to hypokalaemia. However, the resultant hypokalaemia in respiratory alkalosis is usually mild and does not cause much clinical features. A five-months-pregnant female of the age 25 years presented with sudden onset flaccid weakness of both lower limbs associated with thigh muscle pain followed by weakness of both upper limbs within three days. Subsequent investigation revealed severe hypokalaemia due to acute exacerbation of chronic respiratory alkalosis secondary to hyperventilation of pregnancy, other causes of hypokalaemia being ruled out. Respiratory alkalosis causes tetany and other clinical manifestations. But hypokalaemia and such weakness is rarely found. Thisis probably the first report of this type from India.

Generalised hyperpigmentation in vitamin B12 deficiency.

In developing countries like India, nutritional deficiencies are prevalent and hyperpigmentation due to protein energy malnutrition, zinc deficiency and pellagra are common. Indian women, especially vegetarian are prone to vitamin B12 deficiency. Vitamin B12 deficiency can present as anaemia, neurological defect, gastrointestinal symptoms or dementia. Hyperpigmentation as the first presentation of Vitamin B12 deficiency is rare. Our patient, a 45 year-old Hindu vegetarian female presented to us with generalized hyperpigmentation. Examination revealed associated anaemia and peripheral neuropathy. Laboratory investigation confirmed vitamin B12 deficiency. Clinical features along with hyperpigmentation improved with vitamin B12 supplementation. We report this case to highlight this rare manifestation of vitamin B12 deficiency. A high index of clinical suspicion is warranted to diagnose the case. Since India is a country with a large number of potential vitamin B12 deficiency cases, the physicians need to be aware of all the varied manifestations of this vitamin deficiency. In case of hyperpigmentation, nutritional aspect must be ruled out as it is reversible. Early replacement therapy may also help to prevent morbidities like dementia and neuropathy.