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   2011| July-September  | Volume 57 | Issue 3  
    Online since September 22, 2011

 
 
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REVIEW ARTICLES
Status epilepticus: Why, what, and how
PP Nair, J Kalita, UK Misra
July-September 2011, 57(3):242-252
DOI:10.4103/0022-3859.81807  PMID:21941070
Status epilepticus (SE) is an important neurological emergency with high mortality and morbidity. The first official definition of SE was the product of 10 th Marseilles colloquium held in 1962 which was accepted by International League Against Epilepsy in 1964. There are as many types of SE as of seizures. SE is supposed to result from failure of normal mechanisms that terminate an isolated seizure. In half of the cases, there is no history of epilepsy and SE is precipitated by some intercurrent infection. In children, it is often infection, whereas in adults, the major causes are stroke, hypoxia, metabolic derangements, and alcohol intoxication or drug withdrawal. The treatment of SE aims at termination of SE, prevention of seizure recurrence, management of precipitating causes, and the management of complications. The extent of investigations done should be based on the clinical picture and cost benefit analysis. The first line antiepileptic drugs (AED) for SE include benzodiazepines, phenytoin, phosphenytoin, and sodium valproate. Mortality of SE ranges between 7 and 39% and depends on underlying cause and response to AEDs.
  26,784 88 14
A framework for healthcare quality improvement in India: The time is here and now!
P Varkey, A Kollengode
July-September 2011, 57(3):237-241
DOI:10.4103/0022-3859.85222  PMID:21941069
Healthcare in India has been undergoing rapid changes in the last decade. As demand outpaces supply, quality improvement (QI) initiatives and tools can be beneficial to enhance safe, effective, efficient, equitable and timely care. Healthcare quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. This article discusses the framework for QI and reviews the Plan-Do-Study-Act (PDSA), Lean and Six Sigma methodologies, and briefly discusses key patient safety and quality measurement concepts. The PDSA cycle assists in testing the ideas through small tests of change or "pilots". Six Sigma aims at reducing variations in processes, and the Lean methodology predominantly focuses on enhancing process efficiency and eliminating non-value added steps in the process. It is likely that such structured problem solving approaches will provide an objective and systematic method of enhancing quality in healthcare institutions across India. As increasing attention being is paid on enhancing the quality of life through the Quality Council of India and accreditation of hospitals in India through the International Organization for standardization and National Accreditation Board for hospitals and healthcare providers, a focus on QI by institutional leaders and healthcare providers is key to enhancing the safety and quality of healthcare in India. Central to this also will be leadership buy-in, identification of a core faculty or team that will be the initiators of change, a respect for the need for faculty training and education in QI, measurement of issues to identify key priorities to focus on, and enhanced information systems where resources permit the same.
  9,810 18 2
ORIGINAL ARTICLES
Knowledge, attitude and practice of pediatric critical care nurses towards pain: Survey in a developing country setting
PJ Mathew, JL Mathew, S Singhi
July-September 2011, 57(3):196-200
DOI:10.4103/0022-3859.85203  PMID:21941056
Background : Nurses' knowledge, sensitivity and attitudes about pain in children and its management affect their response and therefore management of pediatric pain. Children in critical care units undergo more painful procedures than those in general wards. Aims : To study the knowledge, attitude and practice of nursing personnel catering to critically ill children in a developing country. Settings and Design : Prospective questionnaire-based survey. Materials and Methods : The survey was carried out in a tertiary care teaching hospital on nursing personnel in three pediatric/neonatal intensive care units. The domains studied were: i. Training and experience, ii. Knowledge of pediatric pain, iii. Individual attitude towards pain in children, iv. Personal practice(s) for pain alleviation, v. Pain assessment, and vi. Non-pharmacological measures adopted. Statistical Analysis : Descriptive statistics and logistic regression. Results : Of the 81 nursing personnel working in the three critical care units, 56 (69.1%) responded to the questionnaire. Only one-third of them had received formal training in pediatric nursing. Fifty percent of the respondents felt that infants perceive less pain than adults. Training in pediatric nursing was a significant contributing factor in the domain of knowledge (P=0.03). Restraint and distraction were the common modalities employed to facilitate painful procedures. Scientific approaches like eutectic mixture of local anesthetic and the judicious use of sedatives were not adopted routinely. Observing a child's face and posture were widely used parameters to assess pain (83%). None of the three critical care areas used a scoring system to assess pain. Conclusions : There are several lacunae in the knowledge and practice of nurses in developing countries which need to be improved by training.
  9,101 44 5
CASE SNIPPETS
Ginkgo biloba: An ancient tree with new arrhythmic side effects
V Russo, A Rago, GM Russo, R Calabṛ, G Nigro
July-September 2011, 57(3):221-221
DOI:10.4103/0022-3859.85214  PMID:21941062
  7,035 27 -
CASE REPORTS
A rare diagnosis of multiple hemorrhagic metastases in brain
A Kumar, CE Deopujari, VS Karmarkar
July-September 2011, 57(3):214-217
DOI:10.4103/0022-3859.85210  PMID:21941060
A 30-year-old female presented with an episode of generalized tonic-clonic convulsions. The imaging revealed multiple hemorrhagic lesions in the brain. There was no significant past history except for a cardiac surgery two years ago, for a benign atrial myxoma. The diagnosis of probable metastases was thought of and a thorough workup was planned, to determine the primary. Surprisingly, no primary lesion was detected, and therefore, as a histological diagnosis was required, she underwent navigation-guided excisional biopsy of one of the lesions. The histopathology proved that it was a myxomatous lesion. Thus, a rare diagnosis of atrial myxoma presenting as hemorrhagic metastases of the brain was formed. Atrial myxoma is a benign tumor of the heart. It can embolize distally and can present with known embolic/ischemic manifestations. However, presentation as hemorrhagic mass lesions, involving multiple areas of the brain, after many years of complete surgical excision, is quite rare and is rarely considered as a differential diagnosis. Hence, such a possibility should be kept in mind and careful primary cardiac intervention, with preventive measures to minimize the chances of distal embolization should be undertaken. As only few such cases have been reported worldwide, no treatment protocol has been devised at present, and a close follow-up of these patients is warranted.
  6,170 23 1
ORIGINAL ARTICLES
Frequency and nature of adverse drug reactions in elderly in-patients of two Indian medical college hospitals
A Harugeri, G Parthasarathi, M Ramesh, S Guido, H Basavanagowdappa
July-September 2011, 57(3):189-195
DOI:10.4103/0022-3859.85201  PMID:21941055
Background : Adverse drug reactions (ADRs) are a major public health problem in the elderly. Although the Indian elderly represent 12.8% of the entire global elderly population, data on prevalence and predictors of ADRs in elderly Indians is extremely limited. Aim : To determine the prevalence, severity, preventability, length of hospital stays, and risk factors for ADRs in hospitalized Indian elderly. Setting : Medicine wards of two tertiary care teaching hospitals. Design : Prospective study was conducted between July 2007 and December 2009. Materials and Methods : In-patients of either sex and aged ≥60 years were included and monitored for ADRs throughout their hospital stay. Severity (Hartwig et al. scale), preventability (Shumock and Thornton criteria) and increased length of stay (considering underlying disease, ADR, and discussion with clinicians) were assessed. Statistical Analysis : Bivariate analysis and subsequently multivariate logistic regression were used to determine the risk factors for developing ADRs. Results : Over the study period, among the 920 patients monitored, 296 patients (32.2%) experienced 419 ADRs. Among all ADRs, 48.4% (203) were preventable. Majority of ADRs [226 (53.9%)] were moderate in severity. Therapeutic classes of drugs frequently associated with ADRs were the drugs used in diabetes [76 (18.1%)] and antibacterials for systemic use [54 (12.9%)]. ADRs increased the hospital stay in 5.9% (54) of patients. Female gender [Odds Ratio: 1.52, 95% Confidence Interval:1.04-2.22, P=0.03] was observed as the influential risk factor for ADRs. Conclusion : One third of hospitalized elderly experienced ADRs. Interventions focused at preventable ADRs should be developed and implemented to reduce their implications.
  6,020 27 6
Relationship of body fat with insulin resistance and cardiometabolic risk factors among normal glucose-tolerant subjects
K Gokulakrishnan, M Deepa, F Monickaraj, V Mohan
July-September 2011, 57(3):184-188
DOI:10.4103/0022-3859.85200  PMID:21941054
Background : The amount of body fat, rather than the amount of excess weight, determines the health risks of obesity, type 2 diabetes mellitus, and cardiovascular disease. Aims : To look at the association of body fat percentage with cardiometabolic risk factors in subjects with normal glucose tolerance (NGT). Settings and Design : Cross-section study from the Chennai Urban Rural Epidemiology Study. Materials and Methods : Body fat was measured by Beurer body fat analyzer. Metabolic syndrome (MS) was diagnosed based on modified ATPIII guidelines. Statistical Analysis : Student's t test or one-way ANOVA (with Tukey's HSD) was used to compare groups for continuous variables. Results : Body mass index, waist circumference, systolic and diastolic blood pressure, HOMA IR, serum cholesterol, and LDL cholesterol increased significantly with increasing tertiles of body fat (P<0.001). There was a linear increase in the percentage of body fat with increase in number of components of MS (no metabolic abnormality: 25±11, one metabolic abnormality: 28±10, two metabolic abnormalities: 33±8, and three and more metabolic abnormalities: 35±7) (P<0.001). Regression models showed significant association of body fat with MS after adjusting for age, gender, insulin resistance, and glycated hemoglobin (Odds ratio: 1.04, 95% confidence interval: 1.04 - 1.08, P<0.001). In linear regression analysis, body fat showed a significant association with insulin resistance after adjusting for age, gender, and glycated hemoglobin (β=0.030, P<0.001). Conclusions : A significant association exists between body fat, MS, and cardiometabolic risk factors even among subjects with NGT.
  5,093 23 1
A study of drug-drug interactions in cancer patients of a south Indian tertiary care teaching hospital
G Kannan, R Anitha, Vanitha N Rani, P Thennarasu, J Alosh, J Vasantha, JR Martin, MRC Uma
July-September 2011, 57(3):206-210
DOI:10.4103/0022-3859.85207  PMID:21941058
Background : Drug interactions in oncology are of particular importance owing to the narrow therapeutic index and the inherent toxicity of anticancer agents. Interactions with other medications can cause small change in pharmacokinetics or pharmacodynamics of chemotherapeutic agents that could significantly alter their safety and efficacy. Aim : To identify and document the potential drug-drug interactions in prescriptions of patients receiving cancer chemotherapy. Settings and Design : A tertiary care teaching hospital based prospective study. Materials and Methods : Patients admitted in the medical oncology wards with different types of malignancies and receiving cancer chemotherapy during the period of June 2009 to November 2009 were included in the study. A detailed data collection was done in a specially designed proforma with ethical approval and consent of patients and their prescriptions were subjected to drug-drug interaction screening using Drug Interaction Fact Software Version-4 and standard references. Incidence of drug-drug interactions, their types, correlation between age, cancer type, number of drugs prescribed and incidence of drug interactions were analyzed. Statistical Analysis : Logistic regression analysis and Odds ratio were performed to identify the incidence of drug-drug interactions and their correlation with the factors above mentioned. Results : A total of 75 patients (32 males and 43 females; median age 56 years, age range 23-74) were enrolled in the study and their prescriptions were screened. 213 interactions were identified of which, 21 were major, 121 were moderate and 71 were minor. There were 13 (6.1%) clinically significant interactions between anticancer drugs and 14 (6.5%) drug-drug interactions between anticancer drugs and other drugs prescribed for co-morbidities. There was a positive correlation between number of drugs prescribed and drug interactions (P=0.011; OR 0.903). Conclusion : Though there was not any life threatening interactions, the potential interactions were brought to the oncologist purview for ensuring patients safety and to avoid undesirable effects.
  4,929 22 8
LETTERS
Large cavernous hemangioma of the skull base associated with an angular artery aneurysm
X Wang, J Li, G Li, C You
July-September 2011, 57(3):258-259
DOI:10.4103/0022-3859.85228  PMID:21941076
  4,598 12 -
GRAND ROUND CASE
A young adult with progressive limb shaking and slowness
RT Chakor, GC Rajadhyaksha
July-September 2011, 57(3):231-236
DOI:10.4103/0022-3859.85221  PMID:21941068
  4,419 21 -
ORIGINAL ARTICLES
Resistance pattern in drug-resistant pulmonary tuberculosis
C Nagaraja, BL Shashibhushan, C Sagar, M Asif, PH Manjunath
July-September 2011, 57(3):181-183
DOI:10.4103/0022-3859.85197  PMID:21941053
Background : Drug-resistant tuberculosis is an important issue for public health. There is a rise in the trend of drug-resistant tuberculosis, especially multi drug resistance (MDR), in different parts of world, India being one of the high burden countries. This study is undertaken to assess the various patterns of resistance among confirmed drug resistant pulmonary tubercular patients and to initiate second line anti tubercular treatment. Aims and Objectives : To assess various resistance patterns among confirmed drug resistant pulmonary tubercular patients and for the initiation of appropriate drug regimens in our setup. Study Design : An observational prospective study. Materials and Methods : This study was conducted at Rajiv Gandhi Institute of Chest Diseases, Bangalore between January 2005 and November 2010. A total of 309 drug resistant tuberculosis cases were studied. Sputum culture and drug sensitivity were carried out at National Tuberculosis Institute. Drug sensitivity testing done for all first line drugs, except pyrazinamide, by using LJ media. Results : In this study, out of 309 patients, MDR pattern was observed in 224 (72%), of which 20 (6.47%) had resistance only to isoniazid (INH) and rifampicin (RMP), 58 (18.7%) had resistance to INH, RMP, and either of the other first line drugs streptomycinor ethambutol and 146 (47.25%) had resistance to all first line drugs. Poly drug resistance pattern was observed in 72 (23.3%) and Mono drug resistance in 13 (4.2%). Conclusion : In the present study the most common pattern observed is MDR with predominant resistance to INH. There is a rise in the number of drug resistant tuberculosis cases, especially MDR. Hence close monitoring of drug resistant pattern is required to formulate designs of different regimens in the treatment of drug resistant tuberculosis; especially MDR-TB based on accredited laboratory reports, in a specialized center which is very much essential for the betterment of the patients and the community.
  4,389 28 1
LETTERS
A curious case of chylothorax
AA Karnik, NP Patel
July-September 2011, 57(3):259-261
DOI:10.4103/0022-3859.85229  PMID:21941077
  4,014 13 -
A giant mesocolic lipoma - presenting as an irreducible sliding inguinal hernia: A case report of a rare clinical presentation
AB Pachani, A Reza, RV Jadhav, S Mathews
July-September 2011, 57(3):253-255
DOI:10.4103/0022-3859.85224  PMID:21941071
  3,950 14 -
Bloodletting - An Ayurvedic perspective
HS Sathish, DB Vaghela
July-September 2011, 57(3):253-253
DOI:10.4103/0022-3859.85223  PMID:21941072
  3,818 19 -
CASE SNIPPETS
Uncommon manifestation of organophosphorus poisoning
R Lohiya, S Sangle
July-September 2011, 57(3):224-225
DOI:10.4103/0022-3859.85218  PMID:21941065
  3,567 15 2
CASE REPORTS
Severe intestinal pseudo-obstruction following withdrawal from over-the-counter steroid abuse
A Sharma, V Naraynsingh, R Goalan, ST Teelucksingh
July-September 2011, 57(3):218-220
DOI:10.4103/0022-3859.85212  PMID:21941061
Relative adrenal insufficiency (RAI) is commonly diagnosed in critically ill patients failing to maintain a pressor response and/or with electrolyte abnormalities. We report a case of a 59-year-old man who presented with diverticular bleeding and developed prolonged ileus postoperatively. After observing arthritic joints on examination, further questioning revealed long-term, high-dose steroid use for analgesic effect. Failure to produce an effective cortisol response was due to adrenal suppression from continuous steroid use. Immediate improvement of his ileus was seen after steroid replacement. Unreported self-medication is a frequent problem encountered in developing countries. RAI can be easily missed and requires a high index of suspicion in any patient who fails to respond to conventional treatment or with long-term steroid use.
  3,388 19 2
IMAGES IN PATHOLOGY
Ectopic liver tissue in umbilical cord
P Vaideeswar, D Yewatkar, R Nanavati, P Bhuiyan
July-September 2011, 57(3):229-230
DOI:10.4103/0022-3859.85220  PMID:21941067
  3,168 20 3
CASE SNIPPETS
An unusual oral mass
PA Sathe, RK Ghodke, BM Kandalkar
July-September 2011, 57(3):222-223
DOI:10.4103/0022-3859.85215  PMID:21941063
  3,157 16 -
ORIGINAL ARTICLES
Polymorphisms of the gamma crystallin A and B genes among Indian patients with pediatric cataract
S Mehra, S Kapur, AR Vasavada
July-September 2011, 57(3):201-205
DOI:10.4103/0022-3859.85205  PMID:21941057
Background : Previous familial studies have reported co-segregation of mutation in gamma crystallin A and B CRYGA and CRYGB genes with childhood cataract. Aim : We investigated association of nucleotide variations in these genes in subjects with and without pediatric cataract from India. Settings and Design : The study included 195 pediatric subjects including healthy children with no ocular defects and pediatric cataract cases. Materials and Methods : Subjects were genotyped by PCR-RFLP method for exonic and intronic genetic variations in CRYGA and CRYGB. Statistical Analysis : The association of these polymorphisms with cataract was estimated by two way contingency tables and the risk allele was also analyzed for their functional impact using in silico tools. Results : No significant difference was observed between cases and control subjects for the frequencies of SNPs G198A (Intron A), T196C (Exon 3) of CRYGA and G449T (Exon 2) of CRYGB gene. -47C allele of rs2289917 in CRYGB showed the strongest association with cataract (Odd Ratio-OR=3.34, 95% Confidence Interval-CI 95% =1.82-6.12, P=0.00007). In silico analyses revealed that this polymorphism lies in a phylogenetically conserved region and impacts binding of a transcription factor, viz. progesterone receptor (PR) to CRYGB promoter. Conclusion : rs2289917 risk allele showed a strong association with increased vulnerability for pediatric cataract. The findings suggest that this association may be a secondary phenomenon related to genetic variation playing critical role in lens development during perinatal and/or pediatric growth. Present exploratory study provides a basis for further defining the role of PR as a regulator of CRYG locus in lens formation/transparency.
  2,969 18 1
CASE SNIPPETS
Face to face: Misplaced intrauterine device and abdominal ectopic pregnancy
SV Parulekar
July-September 2011, 57(3):223-224
DOI:10.4103/0022-3859.85217  PMID:21941064
  2,919 16 -
LETTERS
How honest is the h-index in measuring individual research output?
BK Patro, AK Aggarwal
July-September 2011, 57(3):264-265
DOI:10.4103/0022-3859.85233  PMID:21941081
  2,817 15 5
VIEW POINT
Perennial impression of an emerging arbovirus on the epidemiology of rheumatic diseases in South India: Insights from the COPCORD study
A Rahim, AJ Mathew
July-September 2011, 57(3):226-228
DOI:10.4103/0022-3859.85219  PMID:21941066
Are rheumatic musculoskeletal diseases (RMSD) given their due recognition by the medical fraternity and policy makers in India today? Focus on lifestyle diseases has taken away the importance of morbidity caused by musculoskeletal pain, which is one of the commonest ailments in the community. Poor awareness in general regarding the upcoming field of rheumatology and lack of proper data regarding these diseases in the country are the primary causes for this debacle. The epidemiology of RMSD in the country is fast changing, especially in the wake of viral epidemics, which leave their mark for months and years together. This view point emphasizes the burden of RMSD by highlighting the findings of two Community Oriented Programme for the Control of Rheumatic Diseases studies conducted to study the prevalence of RMSD in rural communities in the southern state of Kerala, which inadvertently captured the burden of RMSD following Chikungunya viral epidemics in the regions. Both the studies have reported a high prevalence of RMSD following the epidemics. The value of including RMSD in a national programme to combat the morbidity caused and to improve the health related quality of life of patients has been stressed upon, in the background of altering epidemiology of these disorders in the country.
  2,813 18 1
CASE REPORTS
Unusual case of isolated biventricular non-compaction presenting with stroke
S Mageshkumar, D Patil, D Samuel, D Muthukumar
July-September 2011, 57(3):211-213
DOI:10.4103/0022-3859.85209  PMID:21941059
Prominent ventricular trabeculations are seen in a fetal heart. Isolated ventricular non-compaction (IVNC) is a rare form of primary cardiomyopathy. It usually presents with heart failure, arrhythmias and very rarely with thrombo-embolic manifestation. The left ventricle is involved in the majority of the cases. Echocardiography is the principal modality for the diagnosis of this condition. IVNC may be misdiagnosed as dilated or hypertrophic cardiomyopathy wherein the prognosis and management do differ significantly. We report a case of a 38-year-old male with IVNC involving both the ventricles, who presented very unusually as stroke resulting from a cardiogenic embolus.
  2,762 12 3
LETTERS
Altered sensorium in scrub typhus
B Remalayam, S Viswanathan, V Muthu, S Mookappan
July-September 2011, 57(3):262-263
DOI:10.4103/0022-3859.85231  PMID:21941079
  2,663 13 2
A fluke occurrence of paramount significance
D Gude, DP Bansal
July-September 2011, 57(3):255-256
DOI:10.4103/0022-3859.85225  PMID:21941073
  2,429 12 -
An uncommon catastrophe associated with methotrexate
D Gude, GS Chinnam, DP Bansal
July-September 2011, 57(3):261-262
DOI:10.4103/0022-3859.85230  PMID:21941078
  2,261 16 1
Nonalcoholic fatty liver disease in South India
R Pellicano, S Fagoonee
July-September 2011, 57(3):257-258
DOI:10.4103/0022-3859.85227  PMID:21941075
  2,078 17 -
Reporting of outcomes in drug promotional materials distributed by pharmaceutical companies
C Jaykaran, D Saxena, P Yadav, ND Kantharia
July-September 2011, 57(3):256-257
DOI:10.4103/0022-3859.85226  PMID:21941074
  2,010 15 -
Postgraduate entrance test reforms
SV Parulekar
July-September 2011, 57(3):263-264
DOI:10.4103/0022-3859.85232  PMID:21941080
  1,881 17 -
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