Assessment of Heart Failure Post-discharge Management Strategies, Needs and Acceptance of Mobile Application-based Remote Patient Management in South India.

The demand for digital platforms in managing heart failure (HF) is expected to increase with promising effects on readmission and health expenditure. The study aims to explore current post-discharge management strategies and identify the need and acceptance of digital platforms, to ensure the development of a user-friendly mobile application for HF patients. Using a cross-sectional analytical research design, 90 consecutive patients diagnosed with HF who were discharged from a Tertiary Care Center were enrolled. Tele-interview was conducted using a self-developed and validated tool. The mean age of participants was 55.54 ± 10.33 years. The participants' adherence to HF management strategies was low in terms of physical exercise and weight monitoring. More than one-third were willing to self-record their measurements and use a mobile application. The common mobile application features requested were medication information/reminder (88.6%), health education (84.3%), chat with nurses (84.3%), physical activity (81.4%), symptoms (78.6%), diet (78.6%) and weight management (72.9%). The findings from this initial phase of mobile development are expected to help leverage better development of digital interventions for HF patients.

Down referral and assessing comprehensive diabetes care in primary care settings: An operational research from India.

BACKGROUND AND AIMS: In this study, we aimed to refer eligible (patients with stable blood sugar and without any history of cardiovascular events or proliferative retinopathy) and willing persons with diabetes (PwDs) to primary healthcare centers (PHCs) from tertiary care and to compare the care indicators. METHODS: This before-after interventional study was conducted among PwDs aged ≥18 years at a tertiary care hospital in South India. Care indicators (regularity to the clinic, waiting time, and blood sugar control status) were assessed before down referral and after three months of follow-ups at PHCs. RESULTS: Of 204 PwDs referred to PHCs. Among them, 88% (n = 180) registered at PHCs for care and 46% (n = 94, 95% CI 39.1-53.2%) were lost to follow-ups at PHCs. The main reason for loss to follow-ups was the unavailability of medicines at PHCs(n = 41, 44%). Among those who were on regular follow-ups at PHCs, there was no significant difference in fasting blood glucose (FBG) control status compared to tertiary (52%-64.6%, p = 0.083). However, there was a significant improvement in the regularity of clinic visits (75% vs. 100%, p < 0.001), consultation waiting time (90 vs. 60 min, p = 0.028), and waiting time at pharmacy queues (120 vs. 30 min, p < 0.001) between tertiary care and PHCs. However, among those registered at PHCs, only 40.6% (n = 73, 95% CI 33.3-48.1) were willing to continue care at PHCs for their diabetes management. CONCLUSION: Primary care was better than tertiary care in terms of PwD's regularity of clinic visits and waiting time for care.

Decentralizing diabetes care from tertiary to primary care: how many persons with diabetes can be down-referred to primary care settings?

BACKGROUND: In a cohort of persons with diabetes (PWDs) seeking care at a tertiary care center, we aimed to determine the proportion of PWDs eligible and willing for down referral to primary health centers (PHCs). METHODS: We conducted a cross-sectional analytical study among PWDs on treatment for at least 1 year. PWDs with stable blood sugar, no history of cardiovascular events and proliferative retinopathy were considered as 'eligible' for primary care management. RESULTS: Of the total 1002 PWDs, mean (SD) age was 56 (12) years; 62% were male and 81% were from rural areas. About half (49%) of them were on insulin, and 52% had comorbidities. In total, 45.6% (95% CI: 42.3-48.8%) were eligible to be managed at PHCs. Among those who were eligible, 46.6% were willing to go back to PHCs. Males (APR = 1.16), people with diabetes for more than 10 years (APR = 1.23), and the presence of comorbidities (APR = 1.13) were significantly associated with unwillingness. Quality of medicines (46%) and poor facilities (40%) at PHCs were the main reasons for unwillingness. CONCLUSIONS: About half of the PWDs availing care at tertiary hospitals can be managed at primary care settings; of those, only half were willing to receive care at PHCs.

Neurological Outcomes Following Suicidal Hanging: A Prospective Study of 101 Patients.

CONTEXT: Survivors of suicidal hanging can have variable neurological outcomes - from complete recovery to irreversible brain damage. Literature on the neurological outcomes in these patients is confined to retrospective studies and case series. Hence, this prospective study was carried out. AIMS: The aim is to study the neurological outcomes in suicidal hanging. SETTINGS AND DESIGN: This was a prospective observational study carried out from July 2014 to July 2016. SUBJECTS AND METHODS: Consecutive patients admitted to the emergency and medicine wards were included in the study. Details of the clinical and radiological findings, course in hospital and at 1 month postdischarge were analyzed. STATISTICAL ANALYSIS USED: Statistical analysis was performed using IBM SPSS advanced statistics 20.0 (SPSS Inc., Chicago, USA). Univariate analysis was performed using Chi-square test for significance and Odd's ratio was calculated. RESULTS: Of the 101 patients, 6 died and 4 had residual neuro deficits. Cervical spine injury was seen in 3 patients. Interestingly, 39 patients could not remember the act of hanging (retrograde amnesia). Hypotension, pulmonary edema, Glasgow coma scale (GCS) score <8 at admission, need for mechanical ventilation, and cerebral edema on plain computed tomography were more in those with amnesia as compared to those with normal memory and these findings were statistically significant. CONCLUSIONS: Majority of patients recovered without any sequelae. Routine imaging of cervical spine may not be warranted in all patients, even in those with poor GCS. Retrograde amnesia might be more common than previously believed and further studies are needed to analyze this peculiar feature.

Prehospital delay and time to reperfusion therapy in ST elevation myocardial infarction.

BACKGROUND: Despite efforts aimed at reducing the prehospital delay and treatment delay, a considerable proportion of patients with ST elevation myocardial infarction (STEMI) present late and receive the reperfusion therapy after unacceptably long time periods. This study aimed at finding out the patients' decision delay, prehospital delay, door-to-electrocardiography (ECG), door-to-needle, and door-to-primary percutaneous coronary intervention (PCI) times and their determinants among STEMI patients. MATERIALS AND METHODS: A cross-sectional study conducted among 96 patients with STEMI admitted in a tertiary care center in South India. The data were collected using interview of the patients and review of records. The distribution of the data was assessed using Kolmogorov-Smirnov test, and the comparisons of the patients' decision delay, prehospital delay, and time to start reperfusion therapy with the different variables were done using Mann-Whitney U-test or Kruskal-Wallis test based on the number of groups. RESULTS: The mean (standard deviation) and median (range) age of the participants were 55 (11) years and 57 (51) years, respectively. The median patients' decision delay, prehospital delay, door-to-ECG, door-to-needle, and door-to-primary PCI times were 75, 290, 12, 75, 110 min, respectively. Significant factors associated (P < 0.05) with patients' decision delay were alcoholism, symptom progression, and attempt at symptom relief measures at home. Prehospital delay was significantly associated (P < 0.05) with domicile, difficulty in arranging money, prior consultation at study center, place of symptom onset, symptom interpretation, and mode of transportation. CONCLUSIONS: The prehospital delay time among the South Indian population is still unacceptably high. Public education, improving the systems of prehospital care, and measures to improve the patient flow and management in the emergency department are essentially required. The time taken to take ECG and to initiate reperfusion therapy in this study points to scope for improvement to meet the American Heart Association recommended timings.

Wilson's disease - A rare cause of renal tubular acidosis with metabolic bone disease.

We report a 16-year-old boy who presented with weakness of lower limbs. He was diagnosed to have Wilson's disease, renal tubular acidosis and osteoporosis. Screening of siblings showed that his younger sister was also affected by the disease.

Escobar syndrome in three male patients of same family.

We describe three male individuals from a consanguineous south Indian family affected with the multiple pterygium syndrome (Escobar syndrome). Common clinical features included short stature, multiple pterygium, skeletal anomalies, and normal intelligence. The first report of this condition was made in 1902 from this same place (Pondicherry) and the disease received its present popular name Escobar syndrome in 1982. The genetic defect for this condition was identified in 2006 as mutation in the fetal acetylcholine receptor.

Influence of CYP2C9 gene polymorphisms on response to glibenclamide in type 2 diabetes mellitus patients.

PURPOSE: The antidiabetic drug glibenclamide is metabolized by the enzyme cytochrome P450 2C9 (CYP2C9) encoded by the polymorphic gene CYP2C9. Previous studies involving healthy volunteers have shown a significant influence of variant CYP2C9 genotypes on glibenclamide metabolism. The aim of this study was to investigate the influence of genetic polymorphisms of CYP2C9 on the response to glibenclamide and on glibenclamide plasma levels in type 2 diabetes mellitus patients. METHODS: The study cohort consisted of type 2 diabetes mellitus patients (n = 80) on regular therapy with glibenclamide either alone or with concomitant metformin. Plasma levels of glibenclamide were estimated by reverse phase high pressure liquid chromatography. The variant alleles of CYP2C9, namely CYP2C9 *2 and *3, were identified by PCR-restricted fragment length polymorphism. The plasma levels of glibenclamide and occurrences of hypoglycemic adverse effects with their severity were compared between the genotype groups. RESULTS: Of the 80 patients (61 males, 19 females), 78 were on concomitant treatment with two drugs, namely, glibenclamide and metformin, and two were on monotherapy with glibenclamide. There was a significant association (p < 0.001) between genotype status of CYP2C9 and the control of diabetes in patients receiving treatment with glibenclamide. There were no statistically significant differences in hypoglycemic adverse effects between the genotype groups. CONCLUSION: The type 2 diabetes mellitus patients participating in this study with variant genotypes of CYP2C9 were found to respond better to treatment with glibenclamide than those with the normal genotype. The variant genotype CYP2C9 *1/*3 did not significantly influence the hypoglycemic adverse effects among those patients on long-term glibenclamide treatment.

Imidacloprid poisoning: a case report.

Imidacloprid is a systemic, chloronicotinyl insecticide. It is generally considered nontoxic to humans based on available literature. Its effects are mediated through acetylcholine receptor blockade. We report a patient with such poisoning who had respiratory arrest, for which he had to be mechanically ventilated, and who subsequently recovered. This is only the second such case report.

Alkyl succinate poisoning.

A case of alkyl succinate poisoning is being reported. Oral ingestion of this compound led to gastrointestinal tract involvement and central nervous system manifestatations suggestive of parkinsonism. The patient recovered completely following conservative management without any sequelae.

A clinical and laboratory profile of Cleistanthus collinus poisoning.

AIMS: 1. To study the clinical features in patients with Cleistanthus collinus poisoning, 2. To study in them the effect of Cleistanthus collinus poisoning on the various organ systems and metabolic parameters using standard laboratory investigations. METHODS: All patients admitted to the hospital between September 1998 and April 2000 were studied. Statistical analysis of the results was done using chi-square test, Fisher's exact test and Student's 't' test. RESULTS: Forty six cases were studied, 15 (32%) of whom died. Eighty percent of the patients were in the second to third decade. The female:male ratio was 3:2. Ingestion of the poison as a decoction prepared from the leaves and ingestion of a large number of leaves otherwise were associated with a poor outcome. While survivors remained relatively asymptomatic, fatally poisoned patients presented with significant clinical signs and symptoms, however, laboratory abnormalities such as hypokalaemia, hyponatremia, an elevated AST/LDH/CPK/CPK-MB, nonspecific ST-T changes and QTc prolongation on ECG, metabolic acidosis and hypoxia with widened alveolar-arterial oxygen difference (A-aDO2) were seen in both groups. CONCLUSION: It is a poisoning seen in the young with significant mortality. Cause of death appears to be mainly due to its cardiac and respiratory effects. Metabolic disturbances especially hypokalaemia was a prominent feature. Most deaths occurred on the 3rd day and all within a week. No specific antidote is available.