Professional Documents
Culture Documents
Japi 07.2015
Japi 07.2015
63 July 2015
11
editorial
h e s e e - s a w b a t t l e b e t we e n
humans and microbes
con t i nues. Ex t ended Spectrum
Beta-lactamases (ESBLs) in Gramnegative Bacteria (GNB) emerged
in the past two decades as a major
public health challenge. They
spelt disaster for 3 rd generation
Cephalosporins and Aztreonam.
Organisms harbouring them
were frequently co-resistant to
Fluoroquinolones (FQN) and
Aminoglycosides further curtailing
treatment choices. Although
ESBL producing organisms were
susceptible to Carbapenems and
Beta-lactam plus Beta-lactamase
inhibitor combinations (BL-BLI)
it was recommended to use
Carbapenems in preference to
BL-BLI due to the perceived
inferiority of the BL-BLI. This was
attributed to the inoculum effect,
co-existence of other resistance
mechanisms that are not inhibited
by inhibitors, animal data and
some human observational studies
showing poor outcomes.1 The
preferential use of Carbapenems
would have been reasonable
w h e n E S B L o r g a n i s m s we r e a
rarity and confined to the hospital.
H o we ve r t h e y r a p i d l y s p r e a d
through the networks of bacterial
populations so that a large
proportion of even communityacquired infections were due to
ESBL producing organisms.
Consultant Internal Medicine and Infectious Diseases, 2Consultant Microbiologist, PD Hinduja Hospital and
Medical Research Centre, Mumbai, Maharashtra
12
References
1.
3.
4.
6.
7.
8.
14
Original Article
Editorial Viewpoint
G r a m - n e g a t i v e b a c i l l i
(GNBs) are adding to
the menace by causing
carbapenem resistance as
supported by this study.
Introduction
to carbapenem is commonly
seen in non-fermenting Gramnegative bacilli (GNB); emergence
of carbapenem resistance in
A d d i t i o n o f c o l i s t i n
or tigecycline with
carbapenem are the
current treatment options
for curbing infections
caused by GNBs.
The study needs further
validation by the
multicentric reporting.
Enterobacteriaceae has also been
observed. The later raises an added
risk of its dissemination in the
community.2-4 Very few therapeutic
options are available for treatment
of carbapenem-resistant GNB
blood stream infection (BSI), and
are basically limited to colistin
and tigecycline. 1 However, the
low plasma concentrations of
tigecycline and the toxicity
associated with colistin make
these less appealing options for
use in BSI. In addition to these
concerns, there is limited literature
on the clinical consequences of
such infections. 5 This study aims
to describe the epidemiology
and clinical outcome of bloodstream infections associated with
Sr. Technical Officer, 2Consultant, Microbiology Department, Kokilaben Dhirubhai Ambani Hospital and Medical
Research Institute, Mumbai, Maharashtra
Received: 01.04.2015; Accepted: 20.04.2015
Phenotypic method
Study location
Results
A total of 42 clinically significant
carbapenem-resistant Gramnegative bacilli were isolated from
blood cultures during the study
period of 4 months. Epidemiology
Table 1: Epidemiology of
carbapenem-resistant Gramnegative bacilli from bloodstream infection
Carbapenem-resistant isolates
from BSI
Acinetobacter baumannii
Enterobacteraiceae spp.
Klebsiella pneumoniae
Escherichia coli
Enterobacter cloacae
Citrobacter freundii
Pseudomonas aeruginosa
Total
Total
15
15
1
2
1
8
42
15
of carbapenem-resistant isolates
in BSI is depicted in (Table 1).
Antimicrobial susceptibility of
all isolates is shown in (Table
2). Kirby Baur disk diffusion
method confirmed the carbapenem
resistance amongst all the isolates
and did not show any discrepancy
in results of susceptibility for
imipenem and meropenem. Except
three isolates of Pseudomonas
aeruginosa all other (92.9%) isolates
were positive for carbapenemase
production by MHT.
The medical records of patients
included in study cohort were
reviewed. Their characteristics are
given in (Table 3).
The source of bacteremia
included central venous catheter
(71.5%), respiratory tract infection
(7.1%), urinary tract infection
(2.4%), and uncertain in eight cases
(19%). In these eight cases patients
were diagnosed with bacteremia
from the blood culture collected on
the first day of admission and were
known to have previous history
of hospitalisation. Eleven (26%)
patients died within 48 hours from
the day of initial blood culture,
of which four did not receive any
effective antimicrobial therapy
and seven received effective
clinical therapy for less than 24
hours. These were not included in
further analysis. In one of the cases
patient suffered from secondary
bacteremia caused by colistinresistant Klebsiella pneumonia (MIC
of colistin 8 mg/l) while the patient
wa s o n c o l i s t i n m o n o t h e r a p y .
Patient died within 24 hours from
the time of collection of blood
culture. Antimicrobial regimen
received by 31 patients having BSI
and their clinical outcome is given
in (Table 4).
Discussion
Carbapenem-resistant Gramnegative bacilli pose a serious
threat to current medical practices.
Carbapenem has been the treatment
of choice for serious infections
(MDR infections) caused by
16
MIC90
16
16
64
16
16
0.5
8
4
% Sensitivity
5.3
5.3
47.4
5.3
15.8
94.7
36.8
0
MIC90
16
16
16
0.5
8
4
32
64
% Sensitivity
0
0
0
6.7
0
100
46.7
0
6.7
13.3
MIC90
% Sensitivity
Imipenem
1 to 16
16
12.5
Meropenem
1 to 16
16
16
12.5
Amikacin
64
64
64
Tobramycin
16
16
16
Gentamycin
16
16
16
Colistin
0.5
0.5
0.5
100
Tigecycline
NA
1 to 4
12.5
Ciprofloxacin
Note: MIC, Minimum inhibitory concentration in mg/l; MIC50, MIC required to inhibit the growth
of 50% isolates of this study; MIC90, MIC required to inhibit 90% isolates of this study; MICs were
determined by broth dilution method; ND Not Done; NA Not Applicable.
Total
Successful
Colistin therapy
(mono and
25
20 (80)
combination)
Colistin
6
monotherapy
5 (83)
Colistin
combination
therapy
19
15 (79)
Colistin +
carbapenem
12
12 (100)
Colistin
+noncarbapenem
7
3 (43)
Colistin +
Tigecycline
5
1 (20)
Colistin +
Amikacin
1
1 (100)
Colistin +
Sulbactam
1
1 (100)
4
4 (100)
Carbapenem*
1
1 (100)
Tigecycline*
Tigecycline +
carbapenem
1
0 (0)
Total
31
25 (81)
Note: *Catheter removal associated with
antimicrobial regimen
17
18
8.
References
1.
9.
2.
3.
6.
20
Original Article
Editorial Viewpoint
L e i s u r e t i m e p h y s i c a l
activity has an association
with progress of
diastolic dysfunction in
hypertension.
Methods: Total 301 patients of age 30-60 year old with essential
hypertension were included in prospective observational study. Patients
were classified according to their leisure time physical activity and
subjected for echocardiography and color Doppler.
Results: Out of 301 patients, 149 (49.66%) were sedentary during leisure
time, out of which 114 (76.5%) were having diastolic dysfunction and
35 (23.5%) were normal, while 104 (34.66%) were having moderate
physical activity in which 66 (63%) were normal. Twenty-nine (60%) of
48 vigorously active were found to be normal. By using Fishers exact
test p-value was < 0.05.
Conclusion: In this study, a sedentary lifestyle is found to be associated
with a rapid decline of ventricular compliance.
Physical activity in any form has definite protective role in prevention of
degenerative changes occurring inside the body.
Introduction
S e d e n t a r y l i f e s t y l e
is associated with
deterioration in diastolic
dysfunction.
More prospective studies
with long-term follow-up
required to strengthen
this association.
preventable causes of death in all
over the world. 4
Physical activity i.e. exercise has
been shown to have beneficial effects
on glucose metabolism, skeletal
muscle function, ventilator muscle
strength, bone stability, locomotor
coordination, psychological wellbeing, and other organ functions. 5
The hypertension and
cardiovascular disease burden is
ever increasing globally. The World
Health Organization attributes
hypertension, as the third leading
cause of cardiovascular morbidity
and mortality. 6 As estimated 17.3
million people i.e. 30% of all
global deaths are attributed to
cardiovascular disease in 2008. 7
In Indian scenario it is 29 % of all
deaths.
Nearly one billion people
are affected by hypertension
Methodology
A written informed consent was
taken from all patients, complete
history and clinical examination
was done according to a proforma.
Blood pressure was measured as
a mean of two readings recorded
on the right arm, measured under
standardized conditions with the
participant seated (after 5 min rest).
In all the patients of essential
hypertension information
regarding the leisure time physical
activity was gathered.
Then patients were subjected
to detailed clinical examination
routine hematological and
biochemical examination and ECG
to rule out secondary hypertension
and IHD.
Patients who were detected or
diagnosed as essential hypertension
as per JNC VII criteria were
included.
Definitions
Essential Hypertension
JNC 7
Normal
Prehypertension
Hypertension
Stage 1
Stage 2
21
Diastole9
22
Diastolic dysfunction
Present
Sedentary
114(76.5%)
Moderate
38(37%)
Vigorous
19(40%)
Diastolic dysfunction
Absent
35(23.5%)
66(63%)
29(60%)
E a r l y d i a s t o l i c wa ve E i . e .
E p r i m e o r E m wa ve a n d l a t e
diastolic wave A at the time of atrial
contraction we recorded and E/A
and E/E ratio were calculated.
Results
Distribution of patients
with respect to age (years) and
occurrence of diastolic dysfunction
is shown in Figure 1.
A n a l y s i s wa s p e r f o r m e d b y
using PHILIPS HD 7 and following
parameters were measured.
Assessment of Diastolic Function Using
Doppler12
Total
p-value
149
104
48
< 0.001
Discussion
The study included 301 cases
fulfilling inclusion criteria, found
171 (55.70%) were having abnormal
diastolic function.
Slama et al 14 demonstrated that
diastolic dysfunction preceded
the left ventricular hypertrophy.
Also Ike et al in a study found that
prevalence of diastolic dysfunction
in the hypertensive group to be
82.86%. 15
In our study the majority i.e. 137
(74%) patients out of 301, were from
the age group of 51 60 years. As
the age advances the leisure time
activity decreases. 16
Similar to this Redfield et al
in cross-sectional survey found
diastolic dysfunction common
above 65 years. 17
Among 167 males 98 (58.68%)
were having diastolic dysfunction,
out of 134 females 73 (54.47 %)
were found to having diastolic
dysfunction. It seems that females
have more sedentary lifestyle than
males. 16 Similar to this Masoudi, et
al in a cross-sectional study using
data from retrospective medical
chart abstraction of a national
Identification of a sedentary
lifestyle in females increases the
probability of diagnosing diastolic
dysfunction. 22
Similarly, Arbab-Zadeh et al in
twelve healthy sedentary seniors
and 12 masters athlete found that
sedentary lifestyle during healthy
aging is associated with decreased
left ventricular compliance,
leading to diminished diastolic
performance. 23
Prolonged, sustained endurance
t r a i n i n g p r e s e r ve s ve n t r i c u l a r
compliance with aging and may
help to prevent heart failure in the
elderly.
Kitzman et al reported the first
single-center, single-blind RCT on
exercise training in older patients
with diastolic dysfunction. The
benefits of exercise training in
patients with heart failure include
an improvement in exercise
tolerance as assessed not only
by exercise duration but more
importantly by peak VO 2. 24
Leisure-time physical activity
is associated with longer lifeexpectancy, even at relatively low
levels of activity and regardless of
body weight, according to a study
by a team of researchers led by the
National Cancer Institute (NCI),
part of the National Institutes of
Health. The study, which found
that people who engaged in leisuretime physical activity had lifeexpectancy gains of as much as 4.5
years. 25
In conclusions, our study
suggests that urban population
is more susceptible for diastolic
dysfunction as compared to rural
population. This is definitely linked
with leisure time physical activity.
It is shown that there is definite
cardioprotection with a leisure time
physical activity which is feasible,
safe, and effective in patients with
diastolic dysfunction.
Leisure time physical activity
delays the development of
ventricular diastolic dysfunction.
A sedentary lifestyle is definitely
23
References
1.
2.
3.
4.
5.
6.
7.
8.
G u p t a R . Tre n d s i n hy p e r te n s i o n
epidemiology in India. J Human Hypertens
2004; 18:7378.
9.
24
27
Original Article
Abstract
Objective: To evaluate the efficacy, safety and tolerability of fixed dose combination of Rabeprazole (enteric-coated,
EC) 20mg + Domperidone (sustained release, SR) 30 mg for treatment of laryngopharyngeal reflux disease (LPRD).
Design: A prospective, single centre, open-label, non-comparative, observational study
Setting: The study was conducted at an otolaryngology clinic in India between May2012 and November2012.
Patients: Patients (>18 yrs) with suspicious LPR-related symptoms, reflux symptom index (RSI) score >13 and reflux
finding score (RFS) >7, willing to undergo rigid laryngoscopy and requiring fixed dose combination of Rabeprazole
(enteric-coated, EC) 20 mg + Domperidone (sustained release, SR) 30 mg capsule treatment according to the
investigators discretion were eligible for enrolment in the study.
Methods: Fixed dose combination of Rabeprazole (enteric-coated, EC) 20 mg + Domperidone (sustained release,
SR) 30 mg capsule treatment was given for a total duration of 90days and efficacy was assessed by the change
in RFS and RSI score at Day90. The safety and tolerability of the study drug was assessed by monitoring adverse
events, vital signs and physical examination.
Results: Overall, 50 patients were enrolled and completed the study. After 12 weeks of fixed dose combination
of Rabeprazole (enteric-coated, EC) 20 mg + Domperidone (sustained release, SR) 30 mg capsule treatment there
was a significant change in mean RSI scores [mean (SD) RSI: 19.18 (3.24) at baseline to 2.52 (2.31) at end of study;
(p<0.0001)] as well as mean RFS score [mean (SD) RFS: 12.62 (1.48) at baseline to 0.30 (0.51) at end of study;
(p<0.0001)]. No adverse event was reported by any patient during the study period.
Conclusion: Twelve weeks of treatment with combination of fixed dose combination of Rabeprazole (entericcoated, EC) 20 mg + Domperidone (sustained release, SR) 30 mg capsule significantly improved reflux symptoms
in patients with LPR. The combination was found to be safe and well tolerated.
Editorial Viewpoint
Laryngopharyngeal reflux disease (LPRD) is diagnosed in 10% of ENT OPD patients.
Combination of gastroesophageal reflux disease (GERD) and LPRD seems to be common.
Combination of rabeprazole and domperidone for 12 weeks effectively reduced LPRD symptoms.
1
Director, Selvam ENT Clinic, Chennai, Tamil Nadu; 2Medical Director, 3Chief Manager, Medical Services Division, Abbott Healthcare Private Limited, Mumbai, Maharashtra
Received: 03.07.2014; Revised: 29.10.2014; Re-revised: 25.11.2014; Accepted: 29.11.2014
28
Introduction
Methods
This was a prospective,
single centre, open-label, noncomparative, observational study
conducted between May2012 and
November2012 at an ENT clinic in
India. The primary objective of the
study was to evaluate the efficacy,
safety and tolerability of fixed
dose combination of Rabeprazole
(enteric-coated, EC) 20 mg +
Domperidone (sustained release,
SR) 30 mg for treatment of LPRD.
The study was approved by an
independent ethics committee and
was conducted in compliance with
the guidelines of the World Medical
Association declaration of Helsinki
in its revised edition (Seoul, 2008),
the guidelines of GCP (CPMP/
ICH/135/95) as well as the Schedule
Y (2005). All patients were given a
detailed description of the study
and their written informed consent
was obtained prior to study.
The patients who visited the
ENT clinic with suspicious LPR
symptoms and requiring Fixed
dose combination of Rabeprazole
(enteric-coated, EC) 20 mg +
Domperidone (sustained release,
SR) 30 mg treatment according to
the investigators judgement were
eligible for enrolment for the study.
Rigid laryngoscopy was performed
to document the laryngeal findings
and determine the RFS scores.
Specific inclusion criteria for
LPR patients in the present study
included the following: patients
with more than 18 years of age,
LPR-related symptoms (hoarseness
of voice, dry throat, throat itchiness,
sudden onset of coughing with loss
of breath), having RSI score greater
than 13 and RFS score greater than
7 and those willing to undergo rigid
laryngoscopy. Patients who had
29
Results
A t o t a l o f 6 5 p a t i e n t s we r e
screened to enrol 50 in the
study. All the enrolled patients
successfully completed the study.
The demographic details of the
enrolled patients are presented in
Table 1. The mean age was found
to be 45.3 years old and 56% of the
patient population in the study
were females.
The pre-treatment RSI score was
19.18 3.24 (mean SD) which
significantly decreased to 10.20
3.22 and 2.52 2.31 at Day 30 and
Day 90 of Fixed dose combination
of Rabeprazole (enteric-coated, EC)
20 mg + Domperidone (sustained
release, SR) 30 mg treatment,
respectively (p<0.0001). There was
a 46.82% reduction in RSI score at
Day 30 and 86.86% reduction at Day
90 (Table 2). The nine individual
30
22
Table 2: Change in of reflux symptom index (RSI) and reflux finding score (RFS) scale
from baseline (n=50)
%
Scores
44.00
Female
28
56.00
Mean SD
Age (yrs.)
45.30 9.90
Height (cm) 163.16 5.54
Weight (kg) 65.50 9.38
BMI
24.62 3.34
Min.
24
151
48
18.59
Max.
66
175
85
31.25
Discussion
The importance of diagnosis of
LPRD is developing progressively
in the otolaryngological practice.
RSI
RFS
Screening
Day 30
Day 90
Screening
Day 30
Day 90
Mean
SD
19.18
10.20
2.52
12.62
1.74
0.30
3.24
3.22
2.31
1.48
1.24
0.51
Change from
baseline
Mean
%
change change
-8.98
-46.82
-16.66
-86.86
-10.88
-86.21
-12.62
-97.62
95% CI for
change
Paired t test
Lower
Upper
-9.02
-17.15
-8.94
-16.17
449.00 <0.0001
68.91 <0.0001
-11.29
-12.72
-10.47
-11.92
53.51
61.33
<0.0001
<0.0001
RSI: Reflux Symptom Index; RFS: Reflux Finding Score; SD: Standard Deviation; CI: Confidence
Interval
Table 3: Changes of reflux symptom index (RSI) before and after 30 and 90 days
of fixed dose combination of Rabeprazole (enteric-coated, EC) 20 mg +
Domperidone (sustained release, SR) 30 mg treatment
Reflux symptom index (RSI)
RSI components
Screening
Day 30
Day 90
Hoarseness of voice
Throat clearing
Excess throat mucus / post-nasal drip
Difficult swallowing
Coughing after eating or lying down
Breathing difficulties or choking episodes
Troublesome or annoying cough
Sticky/lump sensation in throat
Heartburn /chest pain / indigestion /reflux
2.120.87
2.060.65
2.040.57
1.840.62
2.000.61
2.180.69
2.480.54
2.300.54
2.160.74
1.120.87
1.060.65
1.040.57
0.860.57
1.000.61
1.180.69
1.480.54
1.300.54
1.160.74
0.360.63
0.220.42
0.180.39
0.100.30
0.200.45
0.300.46
0.500.51
0.340.48
0.320.55
Friedman test
p
2
95.15 <0.0001
96.14 <0.0001
96.50 <0.0001
93.48 <0.0001
92.98 <0.0001
96.88 <0.0001
99.51 <0.0001
99.03 <0.0001
96.50 <0.0001
Table 4: Changes of reflux finding score (RFS) before and after 30 and 90 days
of fixed dose combination of Rabeprazole (enteric-coated, EC) 20 mg +
Domperidone (sustained release, SR) 30 mg treatment
Reflux finding score (RFS)
Friedman test
P
Screening
Day 30
Day 90
2
Infraglottic edema (pseudosulcus vocalis) 2.000.00
0.000.00 0.000.00 100.00 <0.0001
Ventricular obliteration
2.000.00
0.000.00 0.000.00 100.00 <0.0001
Erythema / hyperemia
2.080.57
0.120.48 0.000.00 96.16 <0.0001
Vocal fold edema
1.260.49
0.260.49 0.020.14 94.37 <0.0001
Diffuse laryngeal edema
1.180.39
0.200.40 0.000.00 93.89 <0.0001
Posterior commissure hypertrophy
2.220.58
1.160.62 0.280.45 97.28 <0.0001
Granuloma / granulation
0.520.89
0.020.14 0.000.00 25.40 <0.0001
Thick endolaryngeal mucus
1.360.94
0.000.00 0.000.00 68.00 <0.0001
RFS components
A l l p a t i e n t s we r e f o u n d t o b e
compliant to the study medication,
i.e. took more than 80% of study
medication during the therapy
period. The high percentage of
compliance could be attributed to
the fixed dose combination (FDC)
of PPI and prokinetic drug. It is
a well-known fact that there is
an inverse correlation between
the complexity of a drug regimen
and medication adherence. FDC
therapies are hypothesised to
enhance compliance by decreasing
the number of required pills and
simplify dosing which could result
in better patient adherence to
therapy.28
RSI and RSF scores have been
used for many years in centres
worldwide and are believed
to be valid and reliable in the
documentation of patient treatment
outcomes. 13,14 Patients identified by
positive results of these tests have
a high probability of responding
to 8-12 weeks of PPI treatment. By
implementation of RFS and RSI,
most patients may not require costintensive diagnostic examinations
in the first-line assessment of
LPR and these examinations can
be reserved for non-responders
o f P P I t r e a t m e n t . 29 I n t h i s
study, the RSI and RFS scores
wa s f o u n d t o b e s i g n i f i c a n t l y
reduced after 30 (46.82% and
86.21%) and 90 days (86.86% and
97.62%) respectively. In addition
to significant improvement in total
RSI and RFS scores, individual
components of both the scores
showed significant improvement
after 90 days of therapy (p<0.0001).
This is consistent with the findings
of similar studies conducted by
other authors. 30,31 The investigators
rated global assessment of efficacy
of the combination at the end of
the study as very good in 80%
of patients and global assessment
f o r t o l e r a b i l i t y o f t h e p r o du c t
as good in 98% of patients.
Approximately, 82% patients rated
global assessment of efficacy as
very good and 98% patients rated
global assessment for tolerability
31
as good.
The results of two previous
meta-analysis based on Western
literature failed to show any
significant clinical benefit for PPI
over placebo. 7 However most of
the studies included in the metaanalysis had limitations of either
having a small sample size or of
using a non-standardised rating
for documentation of LPR-related
symptoms and laryngeal findings.
Most of the studies did not use RSI
score in the documentation of LPRrelated symptoms. 31
The stringent inclusion criteria
followed for enrolling the patients
in this study could be one of
the main reasons for obtaining
encouraging results. Patients with
a RSI score less than 13 and RFS
less than 7 were excluded from
our study population. A study
reported by Reichel et al showed
significant improvement in RSI
and RFS with esomeprazole 20 mg
twice daily for 12 weeks duration
c o m p a r e d w i t h p l a c e b o . 32 T h e
authors recruited 62 patients
with RFS greater than 7 and RSI
greater than 13 in the study. Similar
results observed in our study thus
might underline the importance
of stringent inclusion criteria for
enrolment of participants in further
randomized controlled trials for
different treatments of LPRD.
The combination of Rabeprazole
(EC) 20 mg + Domperidone (SR)
30mg studied on Indian population
was found to be safe and well
tolerated. No adverse events were
reported by any of the patients
and no concomitant drugs were
reported to be consumed by the
patients during the study period.
These findings were comparable
to studies conducted with similar
combinations on patients with
GERD. 20,21,24,26
This observational study was
marked by limitations of being
open-label and non-comparative
in design. Despite the constraints
of this study, this is one of the first
study conducted on evaluating
32
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Medication on Laryngopharyngeal Reflux.
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prokinetic drug in gastroesophageal reflux
disease. Acta Med Indones 2011; 43:233-6.
21. Ezzat WF, Fawaz SA, Fathey H, El Demerdash
A. Virtue of adding prokinetics to proton
pump inhibitors in the treatment of
lar yngophar yngeal reflux disease:
prospective study. J Otolaryngol Head
Neck Surg 2011; 40:350-6.
22. Chun BJ, Lee DS. The effect of itopride
combined with lansoprazole in patients
with laryngopharyngeal reflux disease. Eur
Arch Otorhinolaryngol 2013; 270:1385-90.
23. Handa KK. Laryngopharyngeal reflux:
Current opinion. Indian J Otolaryngol Head
Neck Surg 2005; 57:267-70.
24. M iyamoto M, Haruma K , Takeuchi
K, Kuwabara M. Frequency scale for
symptoms of gastroesophageal reflux
disease predicts the need for addition
of prokinetics to proton pump inhibitor
therapy. J Gastroenterol Hepatol 2008;
23:746-51.
25. A r a i K , Ta k e u c h i Y, Wa t a n a b e H ,
Tsukurimichi A, Uchida N, Imawari M.
Prokinetics influence the pharmacokinetics
of rabeprazole. Digestion 2008; 78:67-71.
26. Shahani S, Sawant P, Dabholk ar P.
Rabeprazole plus domperidone: the
answer for gastro-oesophageal reflux
disease. J Indian Med Assoc 2008; 106:264,
266, 268.
27. Friedman M, Maley A, Kelley K, Pulver T,
Foster M, Fisher M, et al. Impact of pH
monitoring on laryngopharyngeal reflux
treatment: improved compliance and
symptom resolution. Otolaryngol Head
Neck Surg 2011; 144:558-62.
28. Pan F, Chernew ME, Fendrick AM. Impact
of fixed-dose combination drugs on
adherence to prescription medications. J
Gen Intern Med 2008; 23:611-4.
29. Habermann W, Schmid C, Neumann
K , Devaney T, Hammer HF. Reflux
symptom index and reflux finding score
in otolaryngologic practice. J Voice 2012;
26:e123-7.
30. Lee YS, Choi SH, Son YI, Park YH, Kim SY,
Nam SY. Prospective, observational study
using rabeprazole in 455 patients with
laryngopharyngeal reflux disease. Eur Arch
Otorhinolaryngol 2011; 268:863-9.
31. Lam PK, Ng ML, Cheung TK, Wong BY, Tan
VP, Fong DY, et al. Rabeprazole is effective
in treating laryngopharyngeal reflux in a
randomized placebo-controlled trial.Clin
Gastroenterol Hepatol 2010; 8:770-6.
32. Reichel O, Dressel H, Wiedernders K, Issing
WJ. Double-blind, placebo-controlled trial
with esomeprazole for symptoms and signs
associated with laryngopharyngeal reflux.
Otolaryngol Head Neck Surg 2008; 139:41420.
33
Original Article
Editorial Viewpoint
F e a r o f i n j e c t i o n a n d
hypoglycemia, social
stigma and lack of
education are major
factors for psychological
insulin resistance (PIR).
Introduction
Director, 2Sr. Diabetes Educator, 3Associate Consultant, 7Diabetes Nurse Educator, Institute of Endocrinology
Diabetes and Metabolism, Max Healthcare Inst. Ltd., New Delhi; 4Diabetes Educator, RG Diabetes and Healthcare
Centre, Varanasi, Uttar Pradesh; 5Diabetes Nurse Educator, Kalazar Research Center, Muzaffarpur, Bihar; 6Diabetes
Nurse Educator, Institute of Endocrinology, Max Healthcare, Gurgaon, Haryana; 8Sr. Medical Writer, Medical
and Scientific Writing Dept., Max Neeman International, New Delhi
Received: 14.05.2013; Revised: 22.01.2014; Accepted: 29.01.2014
1
34
Methods
T h i s wa s a c r o s s - s e c t i o n a l ,
retrospective, non-interventional
survey of 206 patients with T2DM.
Of these, data of 198 patients
were analyzed and the incomplete
data of remaining 8 patients was
excluded.
The study protocol was
approved by the ethics committee
of Max Healthcare. To gather
data from varying socioeconomic
groups, patients were recruited
from different healthcare set upsgovernment organizations, tertiarycare private hospitals and private
c l i n i c s . T h e s t u d y d e s i g n wa s
based on the previous literature. 11
T h e s t u d y wa s c a r r i e d o u t i n
accordance with the principles
of the Declaration of Helsinki as
revised in 2000.
Patients who met all the inclusion
criteria and none of the exclusion
criteria were enrolled in the study.
The inclusion criteria were age
18 years, diag nosis of t y pe 2
diabetes, treatment with the oral
hypoglycemic agents, ability to
communicate in English/Hindi, and
ability to provide written informed
c o n s e n t . Pa t i e n t s w i t h t y p e 1
diabetes, severe psychiatric disease
(e.g., active schizophrenia and
drug dependency) or on current/
previous insulin treatment were
excluded from the study. The study
was conducted in co-ordination
with the local physicians. Besides
medical and socioeconomic history,
the patients data was obtained
by mostly face-to-face interaction
and incomplete information was
collected telephonically using 5
different validated questionnairesDiabetes Attitude Scale (DAS-3
which assessed patients diabetes
attitude), Diabetes Knowledge
Test (DKT which assessed patients
diabetes knowledge), Diabetes
Self-Efficacy Scale (DSES which
assessed patients self-efficacy
and how confident a patient feels
while doing certain activity/ies),
Interpersonal Processes of Care
Survey- 29 (IPC-29 which assessed
an understanding of how a patient
feels while talking to doctors
and their staff ) and Barriers to
Insulin Treatment (BIT which
assessed patients barriers to
insulin treatment). 17-21 BIT score
was considered as a direct measure
of PIR and other 4 scores (DKT,
D S E S , I P C - 2 9 a n d D A S ) we r e
compared against BIT; serving as
an indirect measure of PIR.
To identify potential risk
factors leading to PIR, different
demographic variables viz. age,
height, weight, body mass index
(BMI), blood pressure; different
categories of patients based on
their annual family income,
level of education, glycosylated
haemoglobin (HbA1c) level,
occupation and the type of
healthcare setup were compared
with overall scores of validated
questionnaires. Four categories of
patients were constructed based
on their annual family income:
> Rs1000000 (18,260.00 USD),
Rs1000000-Rs500000 (9,130.00
USD),Rs500000-Rs100000 (1,826.00
USD),and< Rs100000 (1833.52
USD); 3 categories were based on
the education level- graduates
Value
Results
Of 198 patients, 63% (n=125)
were males, 52% (n=104) had
HbA1c <7 % (<53 mmol/mol),
32% (n=63) were in service, 35%
(n=70) had the annual family
income between Rs 100000-500000
and 50% (n=98) were graduates.
Approximately 81% (n=161) of the
patient population were enrolled
from private healthcare set ups
(Table 1).
Following factors were
considered as obstacles in the use of
insulin treatment: fear of injections,
fear of pain while injecting insulin,
fear of pain during regular blood
checks, low expectations regarding
positive outcome of the treatment
35
36
Table 2: Correlation of DAS subscales with BIT, DKT, DSES and IPC score
DAS subscales
Mean
Need for special Seriousness of
Value of
Psychosocial
Patient
BIT
training
NIDDM
tight control impact of DM
autonomy
*
*
*
*
0.40
0.53
0.81
-0.09
Need for special
1.0
0.39
training
Seriousness of
1.0
0.59*
0.43*
0.30*
-0.003
NIDDM
0.20*
-0.08
Value of tight
1.0
0.35*
control
-0.08
Psychosocial
1.0
0.46*
impact of DM
Patient
1.0
-0.08
autonomy
Parameters
BIT subscales
Mean
BIT
Fear of injection
Expectation
Expected Stigmatization
Fear of
positive outcome hardship
hypoglycemia
Fear of injection
1.0
0.001
0.18*
0.22*
0.17*
0.65*
Expectation
1.0
0.04
-0.004
0.09
0.40*
positive outcome
Expected
1.0
0.3*
0.04
0.6*
hardship
Stigmatization
1.0
0.23
0.64*
Fear of
1.0
0.47*
hypoglycemia
Parameters
Mean
DAS
Mean
DSES
Mean
IPC
DKT
total
score
0.75*
0.14
0.21*
-0.3*
0.06
0.12
0.02
0.02
-0.08
-0.04
-0.1
0.05
0.16*
-0.02
0.07
-0.06
0.67*
0.15
0.18*
-0.34*
Mean
DAS
Mean
DSES
Mean
IPC
DKT
total
score
-0.1
-0.01
-0.16
0.24*
0.19*
-0.16
0.07
0.01
-0.01
-0.23*
0.003
0.09
-0.08
0.04
-0.03
0.11
0.06
0.22*
0.08
0.14
*Statistical significant correlation; negative sign denotes a negative correlation between PIR scale
Mean
BIT
1.0
Mean
DAS
-0.09
1.0
PIR scales
Mean
DSES
-0.07
0.23*
1.0
Mean
IPC
0.1
0.04
0.28*
1.0
DKT total
score
0.07
-0.09
-0.05
0.02
1.0
*
Statistical significant correlation; negative sign denotes a negative correlation between PIR
scale
Discussion
This was a first major
observational, non-interventional,
a n d c r o s s - s e c t i o n a l s u r ve y i n
Northern India determining
factors for psychologically induced
barriers in initiating and complying
with insulin treatment based on
37
Fear of
injection
BIT variables
Expectations
Expected
Fear of
positive
Stigmatization
hardship
hypoglycemia
outcome
Average
BIT
DKT
DAS
DSES
IPC
5.7 (2.9)
4.6 (2.4)
6.5 (2.4)
5.5 (2.6)
6.7 (2.5)
6.8 (2.7)
6.0 (1.5)
5.1 (1.6)
16.6 (3.7)
16.7 (3.2)
3.5 (0.4)
3.5 (0.5)
6.8 (1.9)
7.0 (1.8)
2.6 (0.5)
2.8 (0.5)
5.5 (2.9)
4.7 (2.5)
4.8 (2.4)
6.3 (2.5)#
4.9 (2.5)
5.9 (2.5)
6.9 (2.5)
6.4 (3.0)
6.6 (2.5)
5.8 (1.4)#
5.0 (1.8)
5.3 (1.5)
16.2 (3.9)
16.1 (2.8)
17.8 (3.6)
3.5 (0.5)
3.7 (0.4)*
3.4 (0.6)
6.8 (1.9)
7.0 (1.9)
6.6 (1.7)
2.8 (0.5)
2.7 (0.5)
2.8 (0.5)
6.3 (2.2)
7.0 (1.5)
7.6 (1.2)
6.5 (0.7) $
14.3 (2.3)
3.3 (0.4)
6.0 (1.8)
2.8 (0.5)
5.0 (2.9)
4.6 (2.5)
6.5 (2.0)
5.4 (2.9)
6.4 (3.0)
7.0 (2.5)
5.6 (1.5)
5.2 (1.7)
16.5 (3.2)
17.0 (3.4)
3.5 (0.5)
3.5 (0.41)
5.6 (2.6)
7.0 (1.8)
2.9 (0.5)
2.7 (0.5)
4.7 (2.5)
7.1 (1.7)
7.6 (2.0)
5.6 (1.2)
15.4 (4.5)
3.3 (0.6)
5.9 (2.0)
2.7 (0.5)
5.6 (2.9)
6.1 (2.4)
6.4 (2.5)
5.5 (1.6)
16.0 (3.2)
3.5 (0.4)
6.7 (1.9)
2.8 (0.5)
4.6 (2.5)
5.1 (2.4)
6.9 (2.6)
5.3 (1.5)
17.5 (3.1)
3.6 (0.4)
7.1 (1.8)
2.7 (0.5)
4.9 (2.3)
7.0 (2.8)
7.4 (3.1)
5.9 (1.9)
17.8 (3.6)
0.7 (0.7)
7.8 (1.4)
2.8 (0.6)
4.66 (2.6)
6.46 (2.0)
5.77 (2.6)
6.22 (2.1)
6.67 (2.8)
7.02 (1.7)
5.23 (1.6)
6.46 (1.2)
7.24 (1.8)
5.82 (1.5)
2.84 (0.5)
2.56 (0.5)
5.1 (2.6)
4.9 (2.7)
4.6 (2.4)
5.8 (2.5)
5.7 (2.6)
6.1 (2.5)
6.8 (2.6)
7.0 (2.4)
6.3 (2.8)
5.4 (1.4)
5.6 (1.5)
5.3 (1.9)
6.9 (1.9)
7.1 (1.7)
6.9 (1.9)
2.7 (0.5)
3.0 (0.4)
2.9 (0.4)
3.6 (0.4)
3.4 (0.5)
3.4 (0.6)
a
P-value calculated using independent T-test; bP-value calculated by Tukeys studentized range test; Statistically significant higher in: female versus
male; at home versus service; #at home versus business; *business versus service; high school versus graduate; $no formal education versus graduates;
no formal education versus high school; 500000-1000000 and >1000000 versus <100000 and private versus government; <7 versus 7-9
38
Conclusion
In conclusion, in India, the
major contributing factors to PIR
are fear of injection or fear of pain
during injection including fear of
hypoglycemia. Social stigma and
lack of education are other major
factors presenting PIR to Indian
diabetic patients. However, PIR
in Indian diabetes patients could
be lowered by good and effective
interpersonal interactions with
healthcare providers.
References
1.
2.
3.
4.
6.
7.
8.
9.
22. http://www.diabeteseducator.org/export/
sites/aade/_resources/pdf/Definition_
Diabetes_Educator.pdf
23. Rema M, Premkumar S, Anitha B, et
al. Prevalence of Diabetic patients
Retinopathy in Urban India: The Chennai
Urban Rural Epidemiology Study (CURES)
Eye Study-1. Invest Ophthalmol Vis Sci 2005;
46:2328-33.
24. Murugesan N, Snehalatha C, Shobhana R,
39
41
Review Article
Introduction
Influence of Ventilation on
Cardiac Function
Changes in intrathoracic
pressures are transmitted to the
heart and pericardium, the great
arteries and viens. Spontaneous
Hemodynamic Changes
During Weaning
Cardiac-related weaning
failure can be assessed by
echocardiography. High risk
weaning failure can be detected
by low ejection fraction (LVEF),
diastolic dysfunction and elevated
LV filling pressures. LV filling
Junior Consultant Cardiologist, Fortis Escorts Heart Institute, Okhla, New Delhi
Received: 31.10.2013; Accepted: 30.12.2013
42
Va r i a b i l i t y i n d e x i s r a t i o o f
Dmax-Dmin /Dmean expressed in
percentage.
Assessment of Right
Ventricle in Mechanically
Ventilated Patients
Fig. 2: Dilatation and absent collapse in Inferior vena cava (IVC) in subcostal
view (arrows) in a patient on mechanical ventilation.
Echocardiographic
Assessment of Fluid
Responsiveness During
Mechanical Ventilation
Cardiac Output
Cardiac output varies by 50%
with respiration in mechanically
ventilated patients. Therefore, endexpiratory phase measurements
should be taken into account.
Maintaining a high CO has not
shown to improve any outcomes but
Invasive haemodynamic
monitoring
PAC invasive arterial waveform
analysis semi-invasive
Generally not portable
No
Yes
Yes
Less user dependent, some
methods require calibration
Invasiveness
Transthorcic vs.
Transesophageal Echo in
MV Patients
T r a n s e s o p h a g e a l
echocardiography (TEE) is
performed when TTE does not
solve clinical problems and when
TTE has shown some unsuspected
fin di n g s wh i ch req uir ed t o b e
confirmed and therapeutic decision
needs to be taken. TEE is well
tolerated imaging technique in
MV patients for assessment of LV
function and pericardial effusion,
h o we ve r T T E c o n t i n u e s t o b e
excellent diagnostic tool even when
PEEP is present.
Advantages vs
Disadvantages: Echo vs
Invasive Monitoring
The advantages and
disadvantages of echocardiography
comparing invasive monitoring are
discussed in Table 1.
cardiac echo)
43
Conclusion
Hemodynamics in patient
on MV are much different
from physiological state.
Echocardiography can help in both
prognosis and follow up of patients
on MV. Fluid responsiveness, CO,
LV systolic and diastolic parameters
with patients on positive pressure
ventilation can well be followed
up by a non-invasive method using
echocardiography.
I. What is LV function?
References
1.
2.
3.
4.
5.
6.
7.
F A T E
( f o c u s e d
assessed transthoracic
echocardiography)
I.
Observations
A larger left atria (LA) size has
been observed in patients with
repeated weaning failures. Patients
w i t h s u c c e s s f u l we a n i n g h a ve
smaller sized cardiac chambers. Not
much difference has been observed
in echocardiographic parameters
in patients with pressure support
ve n t i l a t i o n ( P S V ) a n d T - p i e c e
breathing. Unlike spontaneous
breathing patient, IVC diameter
an d response t o respirat ion is
unvalidated in MV patients and
44
Art of Writing
Writing Introduction:
Laying the Foundations of a Research Paper
Sandeep B Bavdekar
Abstract
The Introduction section explains the rationale for undertaking the study
and clearly describes the main purpose of conducting it. It should be
focused, succinct and crisp. Providing an extensive and detailed literature
review, not stating the hypothesis of the objectives with clarity and not
providing focused information are some of the common mistakes that
the authors should steer clear of.
Professor and Head, Department of Pediatrics, TN Medical College and BYL Nair Charitable Hospital, Mumbai,
Maharashtra
Received: 05.05.2015; Accepted: 15.05.2015
45
46
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
52
Pictorial CME
2 ye a r s o l d l a d y p r e s e n t e d
with complaints of painful
blisters on the right lower face,
ulcers in the mouth and severe
right otalgia of 24 hours duration.
She had burning sensation in the
skin near the lower lip two days
prior to the appearance of the
blisters. Examination revealed
vesicular eruptions with clear fluid
on right half of face involving the
cheek, chin and lower lip (Figure
1 ) . o r a l e x a m i n a t i o n r e ve a l e d
multiple shallow mucosal ulcers
3.
References
1.
54
Abstract
Organising pneumonia is a histopathological entity characterised by
intra-alveolar buds of granulation tissue, intermixed myofibroblasts
and connective tissue. Cryptogenic organising pneumonia (COP) is
characterised by this particular histopathological pattern, along with
typical clinical and imaging features, when no other underlying aetiology
is found. COP (previously known as bronchiolitis obliterans organising
pneumonia [BOOP]) is one of the rare variants of interstitial pneumonias.
This condition is characterised by a rapid clinical and radiological
improvement with steroid treatment. Here we are reporting a case of COP
in adult female with discussion on approach and basic pathophysiology
of this type of pneumonia.
Introduction
Departments of 1Internal Medicine, 3Radio-diagnosis, 4Pathology, All India Institute of Medical Sciences,
New Delhi; 2Intern, Sir Ganga Ram Hospital, New Delhi
Received: 20.05.2015; Accepted: 27.05.2015
55
56
Chlamydia pneumoniae
Coxiella burnetii
Legionella pneumophila
Mycoplasma pneumoniae
Nocardia asteroides
Pseudomonas aeruginosa
Serratia marcescens
Staphylococcus aureus
Streptococcus
2. Viral
Herpes virus
Influenza virus
Parainfluenza virus
3. Fungal
Cryptococcus neoformans
Pneumocystis carinii
Drugs
Amiodarone
Bleomycin
Carbamazepine
Cocaine
Interferon alpha
Minocycline
Phenytoin
Sulfasalazine
Tacrolimus
Sotalol
Systemic inflammatory diseases
Rheumatoid arthritis
Polymyositis/dermatomyositis
Polymyalgia rheumatic
Solid organ malignancies
Colon
Breast
Haematological malignancies
Non- Hodgkin lymphoma
Renal transplant
Post-radiation
Aspiration pneumonia
Parameter
pH
Pretreatment
7.40
Posttreatment
7.42
PaO2 (mmHg)
55.6
66.5
PaCO2 (mmHg)
30.8
32.5
FiO2
ESR (mm/hr)
D(A-a)O2 (mmHg)
0.4
102
194
0.21
40
44
Fig. 4: Chest radiograph (A) and HRCT thorax (B) showing marked clearing of
bilateral lung consolidation after treatment
Conclusion
57
References
1.
2.
3.
4.
5.
6.
58
Case Reports
Introduction
Case Report
A 2 2 ye a r o l d m a l e M u s l i m
patient presented with history of
an episode of fever 2 days prior.
He had a single episode of vomiting
on the day before presentation
following which he had developed
generalized muscle weakness. He
had been previously apparently
well, except that he did not have
II
III
This patient
IV
15 years
4 years 6 months
Ex-Asst. Professor, 2Ex-Senior Resident, Dept. of Medicine, MP Shah Medical College and GG Hospital, Jamnagar,
Gujarat
Received: 15.10.2010; Revised: 15.04.2015; Accepted: 23.04.2015
Investigation
Admission Discharge
Hb (g%)
12.4
RBC Count
4.53
PCV (%)
37.7
83.4
MCV (m3)
MCH (pg/cell)
27.4
MCHC (g/dL)
32.9
RDW (%)
12.9
WBC Count
8100
DC N/L/E/M/B
70/27/2/1/0
PS for MP
- ve
RBS (mg/dL)
122
Blood urea
78
Serum creatinine
1.77
Serum sodium
123
120
Serum potassium
1.3
1.6
Serum chloride
92.6
Arterial pH
7.399
7.502
Urine R/M
NAD
Urine Na+ (mEq/L)
58
random
+
Urine K (mEq/L)
16.6
random
Investigation
Admission Discharge
Serum creatinine
2.7
Serum sodium
105
124
Serum potassium
0.9
2.8
Serum chloride
91
Serum bicarbonate
23
Serum calcium
8.8
Serum magnesium
1.96
Arterial pH
7.500
Venous pH
7.324
Urine sodium
124.23
(mEq/day)
Urine potassium
56.52
(mEq/day)
Urine chloride
357.96
(mEq/day)
Urine bicarbonate
66.64
(mEq/day)
Urine calcium
122.4
(mg/day)
T h e p a t i e n t f o l l o we d u p o n
8 th day after discharge. He had
no acute symptoms at follow
up. Arterial blood gas analysis
at the time of follow up showed
metabolic alkalosis, hypokalemia
and hyponatremia (pH 7.537,
serum sodium 117 mEq/L, serum
potassium 1.2 mEq/L and serum
bicarbonate 29.4 mEq/L). He was
continued on the same medications
and was asked to follow up a week
later. 56 days after his 1 st follow
up, he stopped all his medications.
Further 56 days later, he had
a few episodes of vomiting and
was readmitted. At the time of 2 nd
admission, he had hypotension (BP
70/60 mmHg). This was quickly
restored to normal by 1 liter of
normal saline. At this admission,
drugs which affect the renal
sodium and potassium handling
we r e a v o i d e d . H e wa s t r e a t e d
with potassium chloride (infusion
and oral) till all other work-up
was completed. His investigations
during 2 nd admission are tabulated
in Table 2.
These investigations confirmed
that the patient was having
hypokalemia, metabolic alkalosis,
renal sodium and potassium
wasting and normal to low blood
pressure without hypomagnesemia
and without hypocalciuria. Urinary
59
60
Fig. 2: Starch iodide test showing complete absence of sweating. (Upper row: Testing on palms. Lower row: Testing on axilla.)
Images in each row from left to right Before application of iodine, after application of iodine, after application of
starch and after application of moisture
Discussion
2 months
1.7
135
4.1
3 months
1.6
135.7
3.7
7.500
5 months
1.5
137.5
4.28
19 months
1.4
133
3.23
7.460
References
1.
2.
61
3.
4.
5.
Abstract
Pulmonary hypoplasia (PH), a rare congenital anomaly is observed
with incomplete development of the lung, and may be associated with
anomalies in other body systems. The clinical presentation varies with the
extent of hypoplasia and the patient may be asymptomatic or may present
with severe respiratory distress in the neonatal, infancy or childhood
period. A six year old girl suffering from right sided hypoplasia was
hospitalized with common presenting chest symptoms. She had taken
antituberculosis treatment for past three years and was thought to be
an MDR suspect. The child was thoroughly investigated was diagnosed
to be a case of PH and is under followup.
Introduction
Case Report
A six years old girl was treated
by private medical practitioners/
h o s p i t a l s a n d wa s r e f e r r e d t o
the department of Pulmonary
Medicine, Rohilkhand Medical
College and Hospital, Bareilly (UP)
as a case of suspected MDR-TB
for establishing the diagnosis and
management with the complaints
of breathlessness increased on
exertion, cough with expectoration,
mild chest pain, cold, fever off
and on and loss of appetite for
t h r e e ye a r s . T h e r e wa s n o h / o
haemoptysis. The h/o recurrent
infection (LRTI) since 6 months
of age was noticed. There was no
h/o jaundice, seizure etc. The child
had not been fully immunized
except oral Polio vaccine. The
child was given antituberculosis
treatment for past three years. The
family history was unremarkable.
Professor, 2Assistant Professor, 3Resident, Department of Pulmonary Medicine, Rohilkhand Medical College
and Hospital, Bareilly, Uttar Pradesh
Received: 23.09.2013; Accepted: 20.05.2014
61
Abstract
Pulmonary hypoplasia (PH), a rare congenital anomaly is observed
with incomplete development of the lung, and may be associated with
anomalies in other body systems. The clinical presentation varies with the
extent of hypoplasia and the patient may be asymptomatic or may present
with severe respiratory distress in the neonatal, infancy or childhood
period. A six year old girl suffering from right sided hypoplasia was
hospitalized with common presenting chest symptoms. She had taken
antituberculosis treatment for past three years and was thought to be
an MDR suspect. The child was thoroughly investigated was diagnosed
to be a case of PH and is under followup.
Introduction
Case Report
A six years old girl was treated
Professor, 2Assistant Professor, 3Resident, Department of Pulmonary Medicine, Rohilkhand Medical College
and Hospital, Bareilly, Uttar Pradesh
Received: 23.09.2013; Accepted: 20.05.2014
62
Fig. 2: X-ray whole spine revealed kyphoscoliosis and hemivertebra (at the level
of T3)
Discussion
Pulmonary hypoplasia is the
failure of the development of the
lung in the utero, which is often
u n i l a t e r al a n d can range from
hypoplasia to aplasia resulting
in an abnormally low number
and size of bronchopulmonary
segments or alveoli. The lungs
are abnormally small and the
hypoplastic lung doesnt have
enough tissue and blood flow to
allow the individual to breathe on
his/her own. This condition can be
grave and sometimes fatal. 1,2
Monaldi categorizes
developmental disorders of the lung
in four groups . 4 l. No bifurcation
of trachea; ll. Rudimentary main
bronchus only; lll. Uncompleted
development after bifurcation of
main bronchus; lV. Incomplete
development of small segment
and subsegmental bronchi of
corresponding lobe. According
to Boyden, 5 the developmental
disorders are seen in three different
extents: (1) agenesis: complete
absence of lung tissue, (2) aplasia:
no lung tissue but rudimentary
bronchus, (3) hypoplasia:
all lung tissues exist but are
underdeveloped. The present case
belongs to fourth group of Monaldi
Fig. 3: CECT thorax showed right sided markedly reduced lung volume
associated with hypoplastic right pulmonary artery
classification.
The causes of PH are multiple
and include (a) Thoracic:
Congenital diaphragmatic hernia,
extra lobar sequestration, agenesis
of diaphragm, mediastinal
mass(es), teratoma, decreased
p u l m o n a r y va s c u l a r ( a r t e r i a l )
perfusion from a congenital
cardiovascular anomaly e.g. Fallots
tetralogy or unilateral absence of
pulmonary artery (b) Extrathoracic:
oligohydramnios, Potter sequence,
renal abnormalities, preterm
premature rupture of membrane
(PPROM); skeletal dysplasias
causing narrow fetal thorax,
Jeune syndrome asphyxiating
thoracic dystrophy, thanatophoric
dysplasia, achondrogenesis,
osteogenesis imperfecta, short rib
polydactyly syndrome, campomelic
dysplasia, Klippel Feil syndrome,
63
4. M o n a l d i V . M a l f o r m a t i v e
bronchopulmonary diseases caused by
anatomical defects. Minerva Medica 1960;
51:3474 3478.
5.
References
6.
1.
3.
63
Introduction
Case Report
A 75 year old man non-diabetic,
non-hypertensive was admitted
with the complaints of urinary
retention and constipation since
last 24 hours. There was no history
of urinary complaints in the past.
There was history of rash and
burning sensation on his lower
back and lower abdomen on
the right side, 8 days prior to
admission. He was diagnosed as
a case of herpes zoster infection at
government medical college and
was put on symptomatic treatment.
Otherwise there was no significant
Discussion
The most common presentations
were paresthesias, pain and
itching. 2 In a study conducted
on 205 patients of herpes Abdul
et al found that only 4.8% had
sacral involvement while 42% had
thoracic involvement. 1
There are three syndromes
of zoster associated bladder
dysfunction. They are zoster
cystitis, zoster retention of urine
and zoster myelitis. Retention is
caused by spread of infection from
dorsal root ganglion into the sacral
motor neurons, roots or peripheral
nerves causing interruption of
bilateral detrusor reflex to manifest
as atonic bladder. 2
Involvement of the sacral nerve
roots (S2-S4) in herpes zoster is
uncommon. The virus involves
not only the ipsilateral nerve root
ganglion but also the meninges
and contralateral root involvement
partially. Thus herpes zoster may
cause bilateral pelvic nerve root
involvement eventhough the skin
eruption is unilateral. 3
Symptoms of sacral and lumbar
radiculopathy in herpes cause
dull or tingling pain in the lower
back, buttocks or anogenital area,
sciatica-like pain down the thighs,
weakness of the lower limb and
inability to walk on tip toes. In
Associate Professor, 2Lecturer, Department of Medicine, S.D.K.S.D.C. and Hospital, Nagpur, Maharashtra
Received: 04.12.2014; Revised: 03.04.2014; Accepted: 26.05.2014
64
References
1.
2.
3.
4.
65
Abstract
Presence of multiple cardiovascular manifestations of the Marfan
syndrome in the same patient is not commonly encountered. We present a
49 year-old lady with this syndrome who presented with decompensated
heart failure. Evaluation revealed presence of extensive Stanford type
A aortic dissection alongwith severe aortic and mitral incompetence.
However, the patient declined surgery and was discharged on medical
management. At a years follow-up, she had dyspnea of NYHA class II
with persistent cardiovascular findings.
Case Report
66
Discussion
The Marfan syndrome is
a disorder of connective tissue
caused by mutations in the fibrillin1 gene, a major component of
extracellular microfibrils, with
Fig. 4: CT Aortogram- views showing aortic dissection extending from the root and involving right brachiocephalic trunk,
extending down to the abdominal aorta, involving renal arteries)
References
1.
2.
67
4.
5.
6.
7.
67
Introduction
Takotsubo cardiomyopathy or
stress cardiomyopathy, also called
transient left ventricular apical
ballooning syndrome or broken
heart syndrome was first described
in Japan in 1991 and named
a s Ta k a t s u b o a s i t r e s e m b l e s
a n o c t o p u s t r a p . Pa t h o g e n e s i s
postulated are catecholamine
excess, coronary artery spasm
o r m i c r o va s c u l a r s p a s m , f o c a l
myocytolysis and myocarditis.
It is usually seen in elderly and
postmenopausal women and seen
after acute emotional stress. It is also
mentioned after an acute medical
conditions such as septicaemia,
lactic acidosis, acute abdominal
surgery, hypoglycemia, pneumonia
and adult respiratory distress
syndrome. Electrocardiogram
may reveal ST segment elevation
or depression, T wave changes,
prolonged QT interval and abnormal
Q waves. Cardiac enzymes may be
mildly elevated. Transthoracic
echocardiogram typically shows
akinesis of apical and distal
anterior wall, left ventricular apical
ballooning and hypercontractile
basal walls giving typical shape
of Takatsubo. Coronary arteries
are normal on angiography. These
echocardiographic changes show
complete resolution of apical
wall motion abnormality and also
resolution of impaired systolic
function.
Case Report
An 11 years old boy was admitted
68
Discussion
T h i s wa s a c a s e o f d e n g u e
f e ve r w i t h t h r o m b o c y t o p e n i a ,
hypotension, mild cerebral
edema and transient regional
left ventricular wall motion
abnormality that normalized
without any specific treatment as
the patient improved.
The literature search showed
va r i e d c a r d i a c i n v o l ve m e n t i n
severe dengue fever. Many case
reports are of severe myocarditis
and cardiogenic shock. There are
References
1.
2.
3.
4.
69
5.
6.
7.
8.
9.
13. Neo HY, Wong RC, Seto KY, Yip JW, Yang H,
Ling LH. Noncompaction cardiomyopathy
presenting with congestive heart failure
during intercurrent dengue viral illness :
importance of phenotypic recognition. Int
J Cardiol 2006; 107:123-5.
14. Chuah SK. Transient ventricular arrhythmia
as a cardiac manifestation in dengue
haemorrhagic fever a case report.
Singapore Med J 1987; 28:569-72.
70
Abstract
Tracheobronchial foreign body (TFB) aspiration is rare in adults, although
incidence rates increases with advancing age. We report a case of foreign
body in left main bronchus in an adult female who had no risk factor. She
was successfully treated with removal of betel nuts by bronchoscopy.
Unusual presentation and high index of suspicion can help in proper
management.
Introduction
Case Report
A 45 year old female presented
with complaints of breathlessness
and cough since 2 months,
fever since 5 days. She started
developing breathlessness which
was progressive and more in lying
down position associated with
dry cough. She also gave history
o f 4 - 5 e pi so de s o f fever along
with above symptoms. She took
treatment in form of oral antibiotics
from local practitioners. She was
admitted in private hospital for
the same complaints 15 days
Associate Professor, 2Senior Resident, 3Professor and Head, Dept. of Medicine, Dr. V.M. Govt. Medical College,
Solapur, Maharashtra
Received; 24.01.2013; Revised: 26.12.2013; Accepted; 02.07.2014
Discussion
Unlike foreign-body aspiration
in young children and in the elderly,
this occurrence is uncommon in
adults. In the adult population,
such aspiration is most commonly
secondary to unconscious
accidental ingestion during general
anaesthesia, sedation, intoxication,
seizures or neurologic disorders
affecting the oropharynx. 1 The
foreign bodies can be dietary or
non-dietary but are associated with
similar sequelae. 2 The symptoms
of foreign-body aspiration range
from coughing, wheezing and
dyspnoea to haemoptysis and
choking. 1 Computed tomography
of the chest may be valuable in
identifying small aspirated objects
or when associated chest disease
is suspected. Bronchoscopy is
frequently both diagnostic and
therapeutic. 1,2 The availability of
both rigid and flexible bronchoscopy
should be emphasized since larger
71
References
Fig. 4: Normal HRCT thorax after
removal of foreign bodies
1.
2.
3.
4.
5.
6.
72
Introduction
IV continues to account
for a significant burden
of worldwide disease. While
much work remains to be done
in earlier disease diagnosis and
enhancing access to treatment,
the introduction of increasingly
sophisticated antiretroviral
therapies over the last two
decades has saved countless lives.
Antiretroviral treatment allows for
the reestablishment of the immune
system, resulting in enhanced
ability to fight off organisms
responsible for opportunistic
infections in immunocompromised
individuals.
accompanied by a paradoxical
flare of underlying inflammatory
diseases, recurrence of dormant
infections, or worsening of prior
treated opportunistic infections;
this constellation of occurrences,
in association with rising CD4
counts or decreasing HIV viral
R N A l e ve l s , h a s b e e n t e r m e d
the immune reconstitution
inflammatory syndrome (IRIS). A
postulated molecular mechanism of
IRIS invokes a treatment-induced
dysregulation of effector and
regulatory T-cells in the process
of immune recovery, leading to an
imbalance of cells for particular
pathogen-related antigens. 2 The
resulting inflammation that
is observed is thought to be a
manifestation of specific immune
response targeted at a given
pathogen. 2
Systematic reviews indicate
IRIS is more likely to present in
individuals with lower CD4 counts
at the time of initiation and may
affect up to 22% of individuals
started on antiretroviral treatment.3
Other potential risk factors for
the development of IRIS include
male sex and higher HIV viral
load level at time of antiretroviral
initiation. 4 While any organ system
may be affected by IRIS, cutaneous
manifestations are seen in more
than half of individuals with
IRIS. 5-8 Frequently encountered
skin findings in IRIS include
infectious (e.g., primary herpes
simplex, herpes zoster, genital
warts, molluscum contagiosum,
cutaneous mycobacterial
infections), inflammatory (e.g. acne
vulgaris, eosinophilic folliculitis),
and malignant etiologies (e.g.
Kaposis sarcoma, non-Hodgkins
lymphoma). 9 IRIS can occur de
novo or unmask or exacerbate
underlying condition in individuals
with HIV.
Pyoderma gangrenosum
is an inflammatory dermatosis
characterized by sterile neutrophilic
ulceration with an increased
Department of Medicine, Brigham and Womens Hospital, Boston, MA USA; 2Harvard Combined Dermatology
Residency Program, Boston, MA, USA; 3Department of Medicine, Weill Cornell Medical College, New York, NY
USA; 4Department of Dermatology, Weill Cornell Medical College, New York, NY USA; 5Department of HIV
Medicine, Jaslok Hospital, Mumbai, Maharashtra, India; 6Department of Dermatology, University of California
at San Francisco, San Francisco, CA USA
Received: 28.07.2014; Revised: 05.03.2015; Accepted: 09.03.2015
1
Co-morbidities
Case 1
40 Years
Male
Asian
India
14
1,28,000
TDF + FTC + EFV
Case 2
46 Years
Male
Asian
India
171
1,67,500
ZDV + 3TC + NVP
Case 3
39 Years
Female
African American
USA
33
46,434
ENF (T20) + 3TC + DRV/r
Alcoholic,
Frailty syndrome
Diabetes mellitus,
Eczema
p r e va l e n c e a m o n g i n d i v i d u a l s
with underlying inflammatory
conditions such as autoimmune
arthritis and inflammatory bowel
disease, as well as in association
with hematologic malignancies.
Etiopathologically, pyoderma
gangrenosum is postulated to reflect
disrupted innate immune regulation
causing altered neutrophil
chemotaxis. 10,11 It is uncommonly
reported in association with HIV.
In this case series, we present
three cases of IRIS-associated
development and worsening of
pyoderma gangrenosum in patients
with HIV. None of the patients
had any of the characteristic risk
factors for pyoderma gangrenosum
such as autoimmune arthritis,
(a)
(b)
Case Reports
Summary information regarding
the three patients with pyoderma
gangrenosum is presented in Table
1.
Case 1
The first patient was a 40-yearold male from India with HIV
presenting with a CD4 count of
14. His comorbidities included
diabetes mellitus and dyslipidemia.
He was initiated with triple
antiretroviral treatment with a
73
(c)
(d)
Fig. 1: Vegetative pyoderma gangrenosum in a 40 year old Indian male after initiation of antiretroviral treatment for AIDS. (a,
b) Vegetative lesions on the dorsal and lateral aspects of the penis. (c) Dense mixed inflammation of neutrophils and
eosinophils in the epidermis and perifollicularly; hematoxylin and eosin stain. (d) Dense dermal inflammation with a
neutrophil predominance; hematoxylin and eosin stain
74
(a)
(b)
(c)
(d)
Fig. 2: Superficial erosive pyoderma gangrenosum in a 46 year old Indian male after initiation of antiretroviral treatment
for AIDS. (a) Superficial ulcerative lesions on the buttocks. (b) Improvement in the buttock lesion after treatment with
dapsone, clofazimine, and topical tacrolimus. (c,d) Multiple recurrences of superficial erosive pyoderma gangrenosum
on the back and scalp
Discussion
(a)
(b)
Systemic immunosuppression
w i t h c o r t i c o s t e r o i d s, d a p so n e ,
azathioprine, and several biologic
agents has been tried with varying
success in patients refractory
to local treatments. Treatment
of pyoderma gangrenosum in
the context of HIV presents a
special therapeutic challenge,
given the balance between immune
reconstitution and medical
immunosuppression. In all three
patients, clinical improvement
wa s n o t e d w i t h s o m e f o r m o f
immunomodulatory therapy in
contrast to immunosuppression,
raising consideration for a
protective inflammatory role in
keeping pyoderma gangrenosum
controlled.
While mild or superficial
pyoderma gangrenosum will
often respond to treatment
with corticosteroids alone, the
deep ulcerations as seen in our
patients often require a multiagent immunosuppressive or
immunomodulatory approach. 11
The slow healing of deep ulcerations
in response to immunosuppressive
or immunomodulatory treatment,
as seen in Case 3, are in keeping with
the clinical history of pyoderma
gangrenosum. The chronic
relapsing course with development
of new lesions, as seen in Case 2,
is not uncommon for patients with
pyoderma gangrenosum as well.
I n o u r p a t i e n t s w i t h H I V,
treatment of their underlying
immunocompromised condition
with antiretrovirals and the resulting
IRIS may have paradoxically led to
the development or worsening of
pyoderma gangrenosum. Other
inflammatory conditions such as
sarcoidosis have been noted to
flare in association with IRIS, at
times even greater than 1 year after
antiviral initiation. 14 As one of our
patients presented here developed
pyoderma gangrenosum more
than two years after antiretroviral
initiation, the timeline is still
in keeping with other reported
IRIS-associated worsening of
inflammatory disease. Pyoderma
75
gangrenosum is a diagnosis of
exclusion which may be seen in
the setting of other underlying
systemic diseases such as
hematologic malignancies or
inflammatory bowel disease. None
of the patients presented in this
report demonstrated any history
or physical findings suggestive
of these conditions, and as such
invasive diagnostic procedures
such as bone marrow biopsies or
endoscopies were not performed in
the absence of such findings.
Initiation of antiretrovirals
targeting the HIV virus results
i n s e ve r a l c h a n g e s w i t h i n t h e
immune system; most notable is the
restoration of CD4+ T-lymphocyte
counts and function. However,
antiretroviral therapy has also been
noted to impact neutrophil numbers
and function as well. The incidence
of neutropenia in individuals with
HIV is estimated to be as high as
44% based on large population
studies. 13 Neutrophil function is
also markedly reduced in advanced
HIV. 15 The start of antiretroviral
therapy has been demonstrated to
increase neutrophil counts, as well
as result in enhanced neutrophil
chemotaxis and antimicrobial
activity. 13,16 The exact mechanism
of such neutrophil enhancement
by antiretrovirals remains to be
fully elucidated. In our patients,
this neutrophil activation may have
served to catalyze the development
of pyoderma gangrenosum as a
manifestation of IRIS.
These cases raise several
important lessons for
dermatologists and other clinicians
caring for patients with HIV who
d e ve l o p c u t a n e o u s u l c e r a t i o n .
First and foremost, in addition
t o r a i s i n g a wa r e n e s s o f I R I S associated idiopathic pyoderma
gangrenosum, we hope to stress the
importance of ruling out infectious
etiologies in patients with HIV. As
pyoderma gangrenosum does have
the potential to exhibit pathergy,
we would caution against vigorous
surgical debridement, as this has
the potential to worsen the disease.
76
Immunosuppressive medications
in patients with HIV may present
particular challenges, both from
the basic immune physiology as
well as in the form of drug-drug
interactions or side effects (such
as the impact of cyclosporine on
renal failure in individuals on
antiretroviral medications, seen
in Case 3). Antibiotic agents used
for their inflammatory properties,
such as minocycline, may have a
useful therapeutic role here, as seen
in our series of patients. Finally,
immunomodulatory drugs that
have been explored for the treatment
of pyoderma gangrenosum such
as anti-TNF biologic agents may
n o t b e a s r e a d i l y a va i l a b l e o r
easily dispensed globally in areas
w i t h h i g h p r e va l e n c e o f H I V
(such as in India and sub-Saharan
A f r i c a ) a n d t h e p r e va l e n c e o f
significant infectious diseases
such as tuberculosis and hepatitis
B may limit their utility in such
settings. Future work dedicated
to better understanding the
molecular mechanisms underlying
o u r o b s e r va t i o n i s n e c e s s a r y
to fully characterize this rare
occurrence and shed light on future
diagnostic and therapeutic options
for pyoderma gangrenosum
presenting as a manifestation of
HIV associated IRIS.
References
1.
2.
3.
4.
5.
6.
7.
8.
78
VIEWPOINT
Abstract
Postgraduate medical education has undergone drastic changes in
the developed and developing countries on par with advancements in
technology.
The Indian examination system which we imbibed from the British
requires a rethinking and restructuring to keep pace with the changing
trends shown by the Federation of the Royal Colleges of UK. In this
manuscript we look at the strengths and weaknesses of different
examination systems. We suggest changes in the theory examination
which should be objectively based rather than the outdated essay and
short notes.
We discuss positive and proactive changes to reform our clinical
examination system to enable a just and fair assessment of the candidate
in a strictly time bound fashion.
Prof. of Medicine, Pondicherry Institute of Medical Sciences, Puducherry; 2Jr. Consultant in Medicine, Christian
Medical College and Hospital, Vellore, Tamil Nadu
Received: 07.01.2015; Accepted: 20.02.2015
79
80
How we as an Academic
Community should Rise Up
S o we b e l i e ve t h a t i t i s o u r
role as teachers of tomorrows
physicians to structure a more
robust post graduate education
system - from start to finish, that
we are made aware of our role
in their mentoring, that we guide
them in the different domains of
competence, continually gauge,
motivate improvement, that we
finally asses with standards and
that this cycle continues on and
improves.
We p r o p o s e t h e f o l l o w i n g
recommendations for restructuring
the examination:
References
1.
http://www.census2011.co.in/.
83
drug corner
Introduction
Fondaparinux
Fondaparinux is a synthetic,
factor Xa inhibitor which is
structurally similar to the
antithrombin binding site of
heparin and low-molecular-weight
heparin (LMWH). 3 The inhibition
of factor Xa is mediated by plasma
Major Pharmacokinetic
and Pharmacodynamic
Properties
Fondaparinux can be
administered by intravenous
or subcutaneous route.2
Subcutaneously administered
fondaparinux sodium 2.5 mg
has been shown to be rapidly
and completely absorbed in
healthy volunteers 1 with 100%
bioavailability.5 The mean
maximum plasma concentration
i s a c h i e ve d i n a m e a n t i m e o f
1.7 hours.1 With intravenous
dosage, the maximum plasma
concentration of fondaparinux is
achieved even faster as compared
to subcutaneous administration,
without any effect on the half-life. 6
The mean elimination half-life of
fondaparinux is 17.2 hours, which
allows once daily administration 1
and also result in maintenance
of significant, 2 predictable and
1
Chief Medical Manager, Abbott Healthcare Pvt. Ltd., Mumbai, Maharashtra; 2Director, Delhi Heart and Lung
Institute, Delhi; 3Consultant Clinical and Interventional Cardiologist, Jupiter Hospital, Thane, Maharashtra
Received: 09.09.2014; Revised: 20.11.2014; Accepted: 27.12.2014
84
5.8%
16.00%
5.7%
14.00%
6.0%
11.20%
12.00%
5.0%
8.90%
10.00%
4.0%
8.00%
3.0%
6.00%
2.0%
4.00%
1.0%
2.00%
0.0%
14.80%
13.40%
0.00%
Fondaparinux
Enoxaparin
Dose of Fondaparinux
The recommended dose of
fondaparinux for the treatment
of ACS is 2.5 mg. 8 The dose of
fondaparinux 2.5 mg once daily
subcutaneously is selected based
on the dose-ranging study. In the
Pentasaccharide in Unstable Angina
(PENTUA) study, fondaparinux
was administered subcutaneously
in four different dosages 2.5, 4, 8,
or 12 mg once daily and efficacy
of different dosages was compared
with enoxaparin 1 mg/kg twice
9.70%
7.40%
Fondaparinux
Control group
Day 9
Day 30
End of study
(3-6 month)
d a i l y g i ve n f o r t h r e e t o s e ve n
days, in ACS without persistent
ST-segment elevation. The results
o f t h i s s t u d y s h o we d n o d o s e
response. 11
Efficacy of Fondaparinux
The efficacy and safety of
fondaparinux has been evaluated
in many clinical studies. It has
been found to be effective and well
tolerated in prevention of various
thromboembolic conditions.
Place of Fondaparinux in
the Management of ACS
In the European Society of
C a r d i o l o g y ( E S C ) 1 3 a s we l l a s
American College of Cardiology/
American Heart Association (ACC/
AHA) Practice Guidelines 14 on
the management of patients with
NSTE-ACS, use of an anticoagulant
drugs has class IA recommendation.
Thus, fondaparinux has class
I recommendation in both the
ESC and ACC/AHA NSTE-ACS
guidelines. As per ESC guidelines,
in case of pending decision between
e a r l y i n va s i ve o r c o n s e r va t i ve
strategy, fondaparinux was
Efficacy in Patients
Undergoing Percutaneous
Coronary Intervention
(PCI)
Factor Xa is a target for treatment
of arterial thrombosis because of its
Fondaparinux in Other
Conditions
The efficacy and safety of
fondaparinux in preventing venous
thromboembolism (VTE) during
orthopedic surgery has been proved.
Fondaparinux is at least as effective
and safe as body-weight-adjusted
85
Fondaparinux in
Pregnancy
Heparin is considered as the
drug of choice for the treatment
or prevention of thromboembolic
e v e n t s d u r i n g p r e g n a n c y . 24
Fondaparinux does not cross the
placenta. It belongs to pregnancy
class B. It can be used in outpatients
without need for monitoring. 25
Though fondaparinux has been
shown to be successfully used in
case of severe allergic reactions
to heparin, its use in pregnancy,
should be limited to the patients
with severe allergic reactions to
heparin or those with heparininduced thrombocytopenia, till
larger studies are available. 24
Safety
As fondaparinux does not
cross-react with heparin-induced
antibodies, the monitoring of
platelet count may not be
required. 7 Similarly, it has been
used successfully in cases with
hypersensitivity to unfractioned
86
4.1%
4.5%
4.0%
3.5%
3.0%
2.2%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Fondaparinux
Enoxaparin
Bleeding complications
a r e t h e m o s t c o m m o n a d ve r s e
events associated with the use
of fondaparinux. Mild local
adverse events may occur after
the injection. Other reported
adverse events include anaemia,
insomnia, increased wound
drainage, hypokalemia, dizziness,
hypotension, confusion, hematoma,
purpura etc. Fondaparinux is
contraindicated in patients with
serious hypersensitivity to the
product, creatinine clearance
<30 mL/min in prophylaxis/
treatment of VTE, active major
bleeding, bacterial endocarditis,
thrombocytopenia (associated
with a positive anti-platelet
antibody in vitro test in presence
o f f o n da p a r i n u x ) a n d p at i en t s
with body weight <50 kg (VTE
References
1.
2.
3.
4.
Approval Status
5.
6.
7.
8.
Summary
9.
prophylaxis only). 27
Extreme caution is required
while using fondaparinux during
spinal or epidural anesthesia to
avoid possibility of spinal and
epidural hematoma. Indwelling
catheters should not be used when
patient is on fondaparinux. 28
10. Fa a i j R A , B u rg g r a a f J, Co h e n A F.
Lack of pharmacok inetic (PK ) and
pharmacodynamic (PD) interaction
between the first synthetic factor Xa
inhibitor and warfarin in human volunteers
87
89
Consultant Physician and infectious Diseases Specialist, 2Consultant Microbiologist, 3Consultant Microbiologist
and Chairperson Infection Control, PD Hinduja National Hospital and MRC, Mumbai
89
he milestones of progress
in microbiology from
conventional to molecular diagnosis
involved contributions of many
scientists who devoted their lives
to revolutionize microbiology.
Clinical Assistant in Microbiology, 3Consultant Microbiologist and Chairperson Infection Control, 4Consultant
Physician and Infectious Diseases Specialist, PD Hinduja National Hospital and MRC, 2Associate Consultant
Microbiologist, Sir HN Reliance Foundation Hospital, Mumbai, Maharashtra
1
90
Walther Hesse
(1846 1911)2
References
1.
2.
3.
4.
92
Medical Philately
Professor of Medicine (Retd.), T.N. Medical College, Hon. Physician, Bhatia Hospital, Mumbai, Maharashtra
93
94
Correspondences
Splenic Infarction in
Polycythemia Vera:
Can the Spleen be
Saved?
VD Charan1
Clinical Hematologist, Pune, Maharashtra
Sir,
I read the above article ( JAPI
Mar 2014, Vol 62, pg 64-66) with the
great intrest. Patient was detected
to be hypertensive 10 years back,
that is at the age of 35 yrs, in all
probability it was manifestation of
polycythemia vera (PV), as is almost
50% of PV present with sencondary
hypertension.Hypertension is
caused by rise in hematocrit and
resultant hyperviscosity leading to
increase in intraarterial pressure.
Since the patient had no fever,
tachycardia, leucocytosis or tender
spleen on admission thereby
suggesting that most likley he had
infarction 2 months back when he
References
1.
2.
94
Correspondences
Successful
Management of
Highly Drug-Resistant
Tuberculosis with
Individualized Drug
Susceptibility Testing
Bharat Purandare1
Consultant in Infectious Diseases, Deenanath
Mangeshkar Hospital and Medical Research Institute,
Pune, Maharashtra
Sir,
I read with interest the original
article Successful management of
highly drug-resistant tuberculosis
with individualized drugsusceptibility testing by Soman
et al in July 2014 issue of JAPI. I
have following comments to make.
Multi-drug resistant tuberculosis
(MDR-TB) cases are on the rise 1
and our tertiary care hospitals are
reporting up to 20-25% of TB isolates
as MDR (personal communication).
The article puts forth real-life
scenario that a physician faces
while managing such complex
cases. Large number of regimens
used to treat the patients in this
case-series reflects the differences
in drug-susceptibility of MDR-TB
strains as well as patient tolerance
to various drugs. Single regime
(like in DOTS PLUS program) is less
likely to work in this heterogeneous
population. Rapid molecular tests
like Gene Xpert MTB/RIF or Line
Injectable aminoglycosides
given for several months (minimum
6 months or sometimes even
longer ) appear to be the key
to successful treatment. Short
duration courses run the risk of
TB relapse. Injection site pain and
fibrosis, hearing loss, tinnitus,
and renal function abnormalities
are common adverse effects which
limit patient compliance. Use of
fluoroquinolones (FQ), wherever
possible, increase the chances of
t h e r a p e u t i c su c c e s s . H o we ve r ,
rates of FQ resistance found in this
study are >40%, way beyond PETTS
study which reported around 13%
resistance to FQ,3 indicating serious
situation that we face in India.
PAS, cycloserine, ethionamide,
linezolid, high-dose isoniazid and
clofazimine are useful agents but
have their own range of side effects
on long-term use. Newer and safer
anti-MDRTB drugs are therefore
urgently required.
In extrapulmonary TB cases,
judging the response to antiMDR-TB treatment is difficult
as follow-up cultures are not
easily possible. Good outcome
was reported in 49/52 patients in
this study, which is encouraging.
Competent microbiology support,
References
1.
2.
3.
4.