Hepatocellular Carcinoma Evaluation and Management for Physicians: Joint Gastroenterology Research Society and Association of Physicians of India Guidelines

Hepatocellular carcinoma (HCC) is the most common cause of, and accounts for almost 90% of all liver cancers. Data from India is limited especially due to cancer not being a reportable disease and in view of wide variation in diagnostic modalities. This document is a result of a consensus meeting comprising Hepatologists, Interventional Radiologists, Hepatobiliary surgeons, medical and surgical Oncologists nominated by the Association of Physicians of India and Gastroenterology Research Society of Mumbai. The following Clinical Practice Guidelines for practicing physicians is intended to act as an up to date protocol for clinical management of patients with hepatocellular carcinoma. The document comprises seven sections with statements and sub-statements with strength of evidence and recommendation.

A longitudinal study of antibody responses to selected host antigens in rheumatic fever and rheumatic heart disease

Introduction. Group A streptococci can trigger autoimmune responses that lead to acute rheumatic fever (ARF) and rheumatic heart disease (RHD).Gap Statement. Some autoantibodies generated in ARF/RHD target antigens in the S2 subfragment region of cardiac myosin. However, little is known about the kinetics of these antibodies during the disease process.Aim. To determine the antibody responses over time in patients and healthy controls against host tissue proteins - cardiac myosin and peptides from its S2 subfragment, tropomyosin, laminin and keratin.Methodology. We used enzyme-linked immunosorbent assays (ELISA) to determine antibody responses in: (1) healthy controls; (2) patients with streptococcal pharyngitis; (3) patients with ARF with carditis and (4) patients with RHD on penicillin prophylaxis.Results. We observed significantly higher antibody responses against extracellular proteins - laminin and keratin in pharyngitis group, patients with ARF and patients with RHD when compared to healthy controls. The antibody responses against intracellular proteins - cardiac myosin and tropomyosin were elevated only in the group of patients with ARF with active carditis. While the reactivity to S2 peptides S2-1-3, 8-11, 14, 16-18, 21-22 and 32 was higher in patients with ARF, the reactivity in the RHD group was high only against S2-1, 9, 11, 12 when compared to healthy controls. The reactivity against S2 peptides reduced as the disease condition stabilized in the ARF group whereas the reactivity remained unaltered in the RHD group. By contrast antibodies against laminin and keratin persisted in patients with RHD.Conclusion. Our findings of antibody responses against host proteins support the multistep hypothesis in the development of rheumatic carditis. The differential kinetics of serum antibody responses against S2 peptides may have potential use as markers of ongoing cardiac damage that can be used to monitor patients with ARF/RHD.

Impact of Autoantibodies to Complement Components on the Disease Activity in SLE

INTRODUCTION

Systemic Lupus Erythematosus (SLE) is a chronic multi-system autoimmune disease with varied clinical presentations. Complement components are the major players in disease pathogenesis. This retrospective cross-sectional study was aimed at assessing the role of autoantibodies to these complement components and their association disease activity in newly diagnosed SLE patients from India.

METHOD

Clinically diagnosed SLE patients (n=57) classified as per 2015 ACR/SLICC revised criteria were enrolled between November 2016 to April 2017. Patients' sera were tested for C3 and C4 by nephelometry, while serum levels of factor H, factor P (properdin) as well as autoantibodies to C3, C4, factor H and factor P were detected by ELISA. GraphPad Prism Version 6.01 was used for statistical analysis. Mean, SD, SEM were calculated. Mann Whittney U-test, ANOVA, Chi-square test, Odd's Ratio were calculated. Pearson's correlation was used to study relativeness of the study parameters.

RESULTS

Among the 57 SLE patients, low C3 were seen in 51% patients, low C4 in 49%, low factor H in 19% and low factor P in 49% patients. Positivity for autoantibodies against complement components, anti-C3 were seen in 42% patients, anti-C4 in 7%, anti-factor H in 19% and anti-factor P in 28% patients. Serum levels of C3 (p=0.0009), C4 (p=0.0031) and anti-C3 autoantibodies (p=0.0029) were significantly associated with ACR/SLICC 2015 scores.

CONCLUSION

Hypocomplementemia was found to be associated with higher disease damage score in newly diagnosed SLE patients. This study adds novel arguments for the importance of the anti-C3 autoantibodies as a marker of SLE.

API-ISG Consensus Guidelines for Management of Gastrooesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common problem in the community. The Indian Society of Gastroenterology and Association of Physicians of India have developed this evidence-based practice guideline for management of GERD in adults. A modified Delphi process was used to develop this consensus containing 43 statements, which were generated by electronic voting iteration as well as face-to-face meeting, and review of the supporting literature primarily from India. These statements include 4 on epidemiology, 9 on clinical presentation, 11 on investigations, 18 on treatment (including medical, endoscopic, and surgical modalities), and one on complications of GERD. The statement was regarded as accepted when the proportion of those who voted either to accept completely or with minor reservation was 80% or higher. The prevalence of GERD in large population-based studies in India is approximately 10% and is probably increasing due to lifestyle changes and increase in obesity. The diagnosis of GERD in the community should be mainly based on presence of classical symptoms like heartburn and sour regurgitation, and empiric treatment with a proton pump inhibitor (PPI) or H2 receptor antagonist should be given. All PPIs in equipotent doses are similar in their efficacy in the management of symptoms. Patients in whom symptoms do not respond adequately to PPI are regarded as having PPIrefractory GERD. Invasive investigations should be limited to patients with alarm symptoms and those with refractory GERD.

Expression of the matrix metalloproteinases MMP-2 and MMP-9 and their inhibitors TIMP-1 and TIMP-2 in systemic lupus erythematosus patients

BACKGROUND

The study aimed to look at alterations in expression of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) and their potential use as biomarkers in the pathogensis of SLE.

METHODS

SLE patients (n = 41) and healthy controls (n = 50) were recruited. Quantitative RT-PCR/ELISA assays were performed for expression of MMP and TIMP mRNA in whole blood and PBMC; and corresponding serum protein levels. Intracellular levels of MMP-2 and MMP-9 proteins were analysed by flow cytometry.

RESULTS

Based on SLEDAI scores patients were grouped into active (SLEDAI ≥ 10) and inactive cases (SLEDAI < 10). In active cases, MMP-2 expression significantly increased and TIMP-2 expression was decreased (p < 0.0001) both at serum secretion (p = 0.0003) and mRNA (p < 0.0001) levels as compared to inactive cases. MMP-9 and TIMP-1 showed significantly reduced serum secretion and mRNA expression (p < 0.0001) in active cases as compared to inactive cases. Intracellular concentration of MMP-9 was reported to be higher in neutrophils, while MMP-2 was mainly found in lymphocytes of SLE patients as compared to controls. MMP/TIMP ratio profile was altered as SLE disease progresses.

INTERPRETATION & CONCLUSIONS

Findings suggest disturbed MMP and TIMP levels have a role in the pathogenesis of SLE.

Role of MMP-2 and its inhibitor TIMP-2 as biomarkers for susceptibility to systemic lupus erythematosus

Aim: To investigate the possible association between MMP-2 (-1575 G/A, -1306 C/T) and its inhibitor TIMP-2 (-418 G/C) functional polymorphisms with development of severity in systemic lupus erythematosus (SLE) patients. Materials & methods: 150 SLE patients and matched healthy controls were recruited. Polymorphisms were detected by PCR-RFLP and serum levels by ELISA. Results: Mean MMP-2 and TIMP-2 serum level and mRNA expression were significantly increased in SLE cases as compared with controls (p < 0.0001). The concomitant presence of both MMP-2 1575A and its inhibitor TIMP-2 418C alleles synergistically increased the risk of SLE by 3.25-fold (CI: 1.44-7.34, p = 0.003). Conclusion: MMP-2, TIMP-2 and MMP-2/TIMP-2 ratios may act as biomarkers for susceptibility to SLE.

The 2019 Novel Coronavirus Outbreak - A Global Threat

The 2019 Novel Corona virus infection (COVID 19) is an ongoing public health emergency of international significance. There are significant knowledge gaps in the epidemiology, transmission dynamics, investigation tools and management. In this article, we review the available evidence about this disease. Every decade has witnessed the evolution of a new coronavirus epidemic since the last three decades. The varying transmission patterns, namely, nosocomial transmission and spread through mildly symptomatic cases is an area of concern. There is a spectrum of clinical features from mild to severe life threatening disease with major complications like severe pneumonia, ARDS, acute cardiac injury and septic shock. Presence of bilateral ground glass opacity and consolidation on imaging in appropriate clinical background should raise a suspicion about COVID 19. Poor prognostic factors include Multilobular infiltration on chest imaging, Lymphopenia, Bacterial co-infection, Smoking history, Chronic medical conditions like Hypertension and age >60 years (MuLBSTA score). Diagnosis is confirmed with PCR based testing of appropriate respiratory samples. Management is primarily supportive, with newer antivirals (lopinavir ritonavir and Remdesivir) under investigation. Role of steroids is still inconclusive. Standard infection control and prevention techniques should be followed. Vigilant screening of suspected cases and their contacts is important. Isolation of symptomatic cases and home quarantine of asymptomatic contacts is recommended. To conclude, controlling this highly transmissible disease requires international co-ordination.

Clinical Benefits of Fixed Dose Combinations Translated to Improved Patient Compliance

Pharmacotherapy with fixed dose combination (FDC) drugs is becoming popular as evidence-based clinical guidelines recommend using multiple therapeutic agents in complex regimens for many chronic diseases including type 2 diabetes mellitus (T2DM). FDC formulations have unique advantages such as complementary mechanism of action, synergistic effects, better tolerability, elongated product life-cycle management, and cost savings. Polypharmacy is a frequent problem in T2DM patients having hypertension, dyslipidemia, and other comorbidities. Use of FDCs is a rational approach for achieving optimal therapeutic benefits while minimizing pill-burden. Greater convenience with decreased pill-burden leads to improved adherence, resulting in superior clinical outcomes and greater cost-effectiveness. However, the general guidance for the clinical development and approval of FDC drugs in India is not much standardized. For rationale approval, the central and state regulators must harmonize their procedures for licensing FDCs. Because regulatory approval of FDCs is based on bioavailability data, similar to the way generic medications are approved, the lack of prospective, randomized controlled trials directly comparing FDCs with their component drugs administered as separate pills should not be considered a limitation to their use. Nevertheless, all new and existing FDC products should be subjected to submission of longterm safety surveillance through closely monitored national level postmarketing studies.

Fibrotic Cytokine Interplay in Evaluation of Disease Activity in Treatment Naïve Systemic Sclerosis Patients from Western India

BACKGROUND

: Systemic sclerosis (SSc) is a demyelinating disease of skin, subcutaneous tissue, muscles and internal organs, with fibrosis as an important pathological event.

AIM

: To understand cytokine interplay of IL-1β, IL-4 and IL-6 and their association with disease activity in treatment naïve active cases of systemic sclerosis from Western India.

METHODS

Twenty-five SSc patients as per ACR-EULAR 2013 criteria (classified based on pulmonary fibrosis and generalized fibrosis) and 25 age-sex matched controls were enrolled. Serum cytokine levels of IL-1β, IL-4 and IL-6 were assessed by multiplex bead based immunoassay.

RESULTS

Ten patients had Interstitial lung disease (ILD), whereas, 16 patients had generalized fibrosis. Anti-nuclear antibodies were seen in 22 patients (88%); antiScl70 in 15 patients (60%) and anti-Centromere antibodies in 5 patients (20%). Serum levels of IL-1β in patients were significantly higher than healthy controls (p=0.0006). IL-4 levels in all SSc patients were marginally raised (p=0.0102), while IL-6 levels were significantly raised (p<0.0001). IL-4 was found to be significantly raised in SSc patients with ILD (p=0.021) as compared to patients without ILD. IL-1β (p=0.0293) and IL-4 (p<0.0001) were significantly higher in SSc patients with fibrosis. On the contrary, IL-6 levels in patients with fibrosis were found to be lower than in patients without fibrosis.

CONCLUSION

Significantly raised cytokine levels among treatment naïve systemic sclerosis patients were found to be associated with higher disease severity in our study. Higher levels of IL-1β and IL-6 indicated an active inflammatory status, whereas significantly raised IL-4 levels indicated at higher fibrotic activity.

Association of Physicians of India: Position Statement on Role of Chirally Pure Molecules in Clinical Practice

Chirally pure molecules or enantiomers are non-superimposable mirror images of each other with a chiral center (such as carbon, sulphur, nitrogen or phosphorous atom). An equimolar mixture of enantiomers forms a racemate. Chirally pure molecules (single enantiomers) are important in the field of drug discovery as the drug targets such as enzymes and receptors are enantioselective in nature. Clinical studies have demonstrated that chirally pure drugs exhibit different pharmacokinetic and metabolic profiles, reduced adverse events, improved safety profiles and similar therapeutic activity at lowered drug dosage as compared with the racemate in many therapeutic areas. However, since there is a low level of awareness on the advantages of chirally pure molecules among clinicians, pharmacists and patients in India, the Association of Physicians of India (API) developed this position statement to increase awareness on the concept of chirality and the associated advantages of using chirally pure drugs in certain therapeutic areas to maximize patient outcomes. This includes the clinical evidence associated with single enantiomers such as S-metoprolol, S-amlodipine, esomeprazole, escitalopram, levobupivacaine, cisatracurium, S-etodolac, dexketoprofen, levofloxacin in terms of efficacy and safety as compared with their racemates. In addition, the API also provides some tactical recommendations for clinicians, pharmacists, patients, regulatory body and pharmaceutical companies to increase awareness on chirally pure drugs and puts forth the need for expedited availability of chirally pure drugs in the Indian market.

Indian College of Physicians Position Statement: Addictive Disorders Among Persons with Diabetes Mellitus

OBJECTIVES

Migraine, a common primary headache disorder which can be severely disabling, associated with poor health-related quality of life (HRQoL) amongst affected patients. The present study was performed to provide adequate clinical data on migraine and the management practices in India.

MATERIAL AND METHODS

A cross-sectional study was designed to assess disease burden, HRQoL, symptom profile, management trends and comorbidities associated with migraine patients across ten centres in India. This study assessed HRQoL using Migraine Specific Quality of life (MSQ) and Migraine Disability Assessment Scores (MIDAS) questionnaire. Categorical variables were summarized as frequency, and percentage and continuous variables as mean and standard deviation respectively.

RESULTS

A total of 705 patients were enrolled with a mean age of 35.2 years. Hypertension (7.0%) was the highest co-morbid illness associated with migraine. A higher MSQ score was observed in females as compared to males (39.3±12.4 and 37.4±11.6) while MIDAS showed a comparable score (27.7±47.6 and 27.2±35.4). Majority of migraine patients were unemployed (61.6%) and in profession, females had poor HRQoL than males by MIDAS and MSQ. Majority of patients had pulsating, bilateral attacks for the duration of 4h to 72 h. Paracetamol (47.1%) and propranolol (50.9%) was most commonly prescribed drugs for acute attack and prophylaxis, respectively.

CONCLUSION

The quality of life was superior in males as compared to females amongst migraine patients in India. Hypertension was the commonest comorbidity associated with migraine.

KEY MESSAGES

Migraine is associated with substantial disability with higher prevalence in females and older people (age >40 years). NSAIDs and propanol was widely prescribed drug in acute attacks and prophylaxis of migraine respectively. Cardiovascular diseases, diabetes mellitus and anxiety were common comorbidities associated with migraine.

Glucose-6-Phosphate Dehydrogenase Deficiency Unveiled by Diabetic Ketoacidosis: A Dual Dilemma

An 18 year old male, known case of Type 1 Diabetes Mellitus was admitted in view of diabetic ketoacidosis. With normalization of blood sugars patient developed gross reddish discoloration of urine. Urine routine microscopy did not reveal RBCs or RBC casts. Peripheral blood smear revealed bite cells, Heinz bodies and spherocytes. Thus a diagnosis of hemolytic anemia with hemoglobinuria was made. Patient's glucose-6-phosphate dehydrogenase (G6PD) levels were below the normal range. G6PD, an enzyme of the HMP shunt, is the most common enzyme defect causing hemolytic anemia. G6PD deficiency related hemolytic crisis is most commonly precipitated by infection, drugs or fava beans. Its association with DKA has been seldom reported.

Indian College of Physicians (ICP) Position Statement on Pharmacovigilance

Pharmacovigilance is the art and science of detection, understanding and prevention of adverse drug reactions and not merely a critical analysis of prescriptions and errors. This field starts with reporting by clinicians of a suspected adverse drug reaction (ADR) to the pharmacologist followed by joint causality analysis and ends at the application of new information by a clinician for benefit of patients. There are a number of ways, which can be utilised for reporting adverse effects using pen and paper format to software applications for smart phones. Varied types of activities spreading from systematic reviews to the mechanistic evaluation of ADR can be performed under the umbrella of pharmacovigilance. It is of utmost importance for clinicians to understand how to identify, communicate and understand adverse effects of drugs with an aim to prevent harm to patients.

Mesenteric Vasculitis in a Case of Systemic Lupus Erythematosus

We present a case of mesentric vasculitis with systemic lupus erythematosus who relapsed after high dose steroids but achieved subsequent remission after starting pulse cyclophosphamide therapy. 38 years old female who had earlier polyserositis and cerebral venous thrombosis was admitted with provisional diagnosis of SLE and developed acute abdominal pain during hospital stay. She was diagnosed as mesenteric vasculitis and initially responded to pulse methylprednisolone. However, she had relapse which subsequently responded to pulse cyclophosphamide and steroids. During the ward course she also developed acute thyroiditis and was diagnosed to have class IV lupus nephritis on renal biopsy.

Recommendations for Vaccination Against Seasonal Influenza in Adult High Risk Groups: South Asian Recommendations

Influenza is a global public health problem and concern especially in high risk people. Prevention plays a key role in avoiding complications of influenza related illnesses. Despite the existing prevalence of influenza, and documented importance of vaccination, the uptake of influenza vaccine is very poor. This document provide recommendations for influenza vaccination in high-risk individuals and help implement best practices in the South Asian region and improve coverage of influenza vaccination to achieve better outcomes in this population.

Association of Serum Ferritin Levels with Hematological Manifestations in Systemic Lupus Erythematosus Patients from Western India

OBJECTIVE

To identify the hematological manifestations and its association with serum ferritin levels in SLE patients from Western India.

METHODS

Ninety clinically diagnosed SLE patients fulfilling ACR criteria were included. Disease activity was assessed at the time of evaluation using Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Sera were tested for serum ferritin levels by ELISA (Calbiotech, USA). Autoantibodies such as ANA, anti-dsDNA by indirect immunofluorescence test (IFA- Bio-Rad, USA) and anti-cardiolipin antibodies (ACA) to IgG and IgM isotypes and Anti-β2 GP antibodies to IgG and IgM isotypes were detected by ELISA using commercially available kits (Euroimmun, Lubeck, Germany).

RESULTS

Out of 90 SLE patients studied, 41 patients (45.6%) showed hematological abnormalities, where anemia (82.9%), leucopenia (26.8%), autoimmune hemolytic anemia (AIHA) (14.6%) and idiopathic thrombocytopenic purpura (ITP) were noted in (34.1%) patients. Mean±SD serum ferritin levels among SLE patients were 270.2±266.0 ng/ml as compared to 29.0±15.8 ng/ml healthy normal controls (p<0.0001). A positive correlation between serum ferritin levels and SLEDAI scores (r= 0.2640, p=0.0124) and anti-dsDNA positivity was noted (r=0.32, p<0.0001). Serum ferritin levels were negatively correlated with hemoglobin levels (r=-0.5964, p=0.0001), WBC count (r=-0.1705, p=0.2316), platelet count ((r=-0.1701, P=0.2375), C3 levels (r=-0.4417, p=0.0034) and C4 levels (r=-0.0363, p=0.8215).

CONCLUSIONS

Serum ferritin is an excellent marker of SLE which can be used for an evaluation of disease activity particularly in active stage of the disease mainly in patients having hematological and renal manifestations.

Myasthenia Gravis with Amyotropic Lateral Sclerosis: A Rare Co-existence

The co-occurrence of myasthenia gravis with motor neurone disease is not a very common association and may pose problem and confusion in the minds of the treating physician because of the gamut of neurological symptoms. This case intends to highlight these dilemmas.

Zika Virus Infection, the Recent Menace of the Aedes Mosquito

Mosquito-borne infections and viral outbreaks have bewildered physicians and population at large from time to time, there seems to be a constant cat and mouse race between the medical fraternity and these mosquito menaces. Zika virus and its vector Aedes aegyti are currently bothering the world population, this infection has affected pregnant women causing microcephaly in their new-borns and also has caused GBS-like manifestations in affected individuals. Currently the outbreak is concentrated in the countries of South American continent, but the omnipresence of its vector has made the world community cautious about the potential of its spread; thus the great emphasis is on prevention and vector control strategies to counter Zika virus attack. Consequently, Ministry of Health, Government of India has also taken cognizance of this and issued guidelines to tackle this problem.

Guillain Barré Syndrome, Systemic Lupus Erythematosus and Acute Intermittent Porphyria – A Deadly Trio

Peripheral nervous system involvement occurs in 3-18% patients of systemic lupus erythematosus (SLE) cases. American College of Rheumatology (ACR) includes 19 neuropsychiatric syndromes for diagnosis of SLE divided into neurological syndromes of central, peripheral and autonomic nervous systems along with the psychiatric syndromes. Sensorimotor quadriparesis in a suspected case of SLE could be due to a Guillain Barré (GBS)-like illness, mononeuritis multiplex presenting as plexopathies, an anterior spinal artery syndrome or it can present like an acute transverse myelitis or hypokalemic periodic paralysis related to Sjogren’s syndrome with renal tubular acidosis. We here report a case of a fulminant quadriparesis due to a SLE flare which subsequently was also found to be a case of Acute Intermittent Porphyria.

Clinical Profile of Patients Requiring Prolonged Mechanical Ventilation and their Outcome in a Tertiary Care Medical ICU

INTODUCTION

An increasing number of patients require mechanical ventilation and there has been a proportional increase in patients needing prolonged mechanical ventilation (ventilated for ≥ 21 days, for atleast 6 hours per day). It accounts for about 10% of all mechanically ventilated patients. Although these patients represent a smaller proportion of intensive care unit (ICU) patients, they consume substantial ICU resources. We studied etiology, metabolic and clinical profile, complications and outcome of these patients.

METHODS

This was a prospective observational study in the medical ICUs of a tertiary hospital over 18 months. All patients above 12 years of age requiring prolonged invasive mechanical ventilation were recruited. Detailed clinical and laboratory records were noted. Sequential Organ Failure Assessment (SOFA) score was calculated on admission.

RESULTS

Of a total 1150 patients who were admitted in ICU during study duration, 34.5% (n= 397) needed mechanical ventilation and 3.91% (n=45) required prolonged mechanical ventilation. Most common patient subsets were: acute inflammatory demyelinating polyneuropathy (AIDP) 28.50% (n=13), cerebro-vascular accident (CVA): 17.30% (n=8), tetanus 8.60% (n=4) and acute respiratory distress syndrome (ARDS) 6.50% (n=3). The mean age of patients was 32 years. Electrolyte imbalances observed were hypocalcaemia (84.44%), hypomagnesaemia (40.9%), hypokalemia (31.11%) and hypophosphatemia (23.8%). Ventilator-associated pneumonia (VAP) (53.33%) was the most frequent complication, followed by decubitus ulcers (40%) and deep vein thrombosis (8.89%). Mean duration of ICU stay was 57.02 days ± 44.73 days. Twenty six out of 45 patients (57.75%) were successfully weaned off ventilator support and discharged from the hospital. The SOFA score of patients who survived (mean 2.15) was lesser than that of patients who expired (mean 2.89) (p= 0.36, ns).

CONCLUSIONS

The incidence of prolonged mechanical ventilation in our study was 3.91% of total 1150 ICU admissions and 11.3% of the 397 patients requiring invasive mechanical ventilation. AIDP, CVA, tetanus and ARDS were the most common diagnoses. Survival in the study population was 57.75%. VAP was the most common complication. High incidence of hypocalcaemia, hypomagnesaemia, hypokalemia and hypophosphatemia was noted in patients requiring prolonged mechanical ventilation.

Recurrent Hypoglycaemia due to Insulin Autoimmune Disease (Hirata Disease) Associated with Monoclonal Gammopathy of Unknown Significance

Hirata disease is a rare disease characterised by recurrent episodes of hypoglycaemia due to anti-insulin antibody. In most of these cases causative agents were sulfhydryl containing compounds like Penicillamine, Glutathione, and Methimazole. The presentation of disease closely mimics insulinoma. We report 52 years female patient presenting with recurrent episodes of hypoglycaemia due to anti-insulin antibody. On evaluation, underlying cause of antibody was found to be monoclonal gammopathy of unknown significance (MGUS).

Codeine: A Relook at the Old Antitussive

Cough is the most frequent complaint of patients seeking medical attention in general and hospital practice. Cough is controlled by treating the cause, however, when no cause can be found, symptomatic relief of cough must be considered. Treatment of dry cough resulting from increased sensitivity of the cough reflex remains a challenge in some subjects. Codeine in combination with other medicines has been a mainstay for the effective short-term symptomatic relief of dry or nonproductive cough in clinical practice. This article focuses on the current status of codeine as an antitussive formulation in the treatment of dry cough. Codeine is one of the centrally acting narcotic opioids approved for use as an antitussive, a prodrug that is bioactivated by CYP2D6 into morphine in the liver. The opioid effects of codeine are related to plasma morphine concentrations. Codeine is one of the most frequently used antitussive in clinical practice and has been widely regarded as the standard cough suppressant against which newer drugs are being evaluated. Codeine has an advantage as an antitussive because of its multifaceted effect as an analgesic and sedative along with cough suppression. However, codeine may have efficacy to suppress cough in humans only in specific situations. Caution is also needed to limit its use only when and as long as it is clinically necessary, particularly in children.

Ebola Virus: Another Challenge from the Deadly Viral Brigade

Ebola viruses are the causative agents of a severe form of viral haemorrhagic fever in man, designated Ebola haemorrhagic fever, and are endemic in regions of central Africa. The recent west African outbreak of Ebolavirus has brought this filoviral infection again in limelight, Indian government has issued guidelines to various airports to screen travelers coming from Africa and middle east Haj pilgrims to keep a check on this highly virulent infection. This viral hemorrhagic disease has remained confined majorly to Africa but its high outbreak potential makes it essential for all infectious disease clinicians and people dealing with travel medicine to be cautious. Management of these patients with symptomatic therapy is the current strategy which is followed. There is absence of any effective vaccine so further research is warranted in this direction.

Biologics in SLE: the current status

Systemic lupus erythematosus (SLE) can be a severe and potentially life-threatening disease that often represents a therapeutic challenge because of its heterogeneous organ manifestations. Only glucocorticoids, hydroxychloroquine, mycophenolate mofetil, azathioprine, cyclophosphamide, and very recently belimumab have been approved for SLE therapy. Dependence on glucocorticoids and resistance to the approved therapeutic agents, as well as substantial toxicity, are frequent. B-cells abnormalities leading to autoantibody production play a central role in Systemic Lupus Erythematosus (SLE) pathogenesis. The targets of these biological therapies are directed toward the B cell depletion, interference in the co-stimulation signals and the blockade of cytokines. Biologic agents targeting specific pathways (i.e. T-B lymphocyte interaction, cytokines and complement) have been also proposed as new tools for SLE treatment. B-cell targeted therapies, including anti-B lymphocyte stimulator (BLyS) and anti-CD20 monoclonal antibodies are at forefront of new SLE treatment. Results from randomized trials in systemic lupus erythematosus (SLE) have been very disappointing, with lack of efficacy for some drugs and development of severe side-effects such as infections for others. Fortunately, as more and more trials of biologics in the treatment of lupus are being performed, the first promising results have been achieved. Today, belimumab is expected to become the first approved drug for use in lupus in several decades. In this review we will focus on biological drugs whose potential efficacy have been evaluated in open-label and randomized clinical trials. Biologics provide encouraging results that represent a possible option in the treatment of refractory lupus. Thus we review recent clinical trials in patients with systemic lupus erythematosus (SLE), with emphasis on outcomes and on mechanisms by which the biological agents suppress autoimmunity.

Clinical profile of severe Plasmodium vivax malaria in a tertiary care centre in Mumbai from June 2010-January 2011

BACKGROUND

Plasmodium vivax is the most widely distributed human malaria parasite with an at risk population of 2.5 billion persons. With the implementation of molecular diagnosis, it has become evident that P. vivax monoinfection could also result in multiple organ dysfunction and severe life-threatening disease as seen in P. falciparum infection.

AIMS AND OBJECTIVES

To note the clinical profile of patients with severe vivax malaria with regards to demographic, clinical and biochemical profile and its outcome. To compare the profile of falciparum malaria with vivax malaria.

METHOD AND MATERIAL

We recruited 711 patients fulfilling the criteria for severe malaria during the study period from June 2010 to Jan 2011. Detailed history and examination findings were noted in all the patients. All the patients were subjected to routine haematological and biochemical investigations. The end points were discharge from wards or death due to malaria.

RESULTS

We had 711 patients with severe malaria of which 488 (68.53%) patients had severe vivax and 223 (31.32%) had severe falciparum malaria. Amongst vivax group, 351 (71.92%) were males and 137 (28.07%) females. Thrombocytopenia (89.13%) was the most common complication followed by renal (31.96%), hepatic (19.46%) cerebral (8.19%) and pulmonary (1.63%) involvement. Most patients were in the age group of 21-30 years and mortality increased with increasing age. The mortality observed in severe vivax malaria was 9.01% (44/488), as compared to falciparum malaria where it was 16.14% (80/223).

CONCLUSIONS

Severe vivax malaria is now very common with increasing mortality. The mortality in vivax malaria increases with increasing age. Thrombocytopenia is very common in severe vivax infection. Also, renal, hepatic, lung and cerebral involvement are also occur with increasing frequency. Along with age, severe metabolic acidosis is an independent risk factor for fatal outcome.

Study of patient characteristics/profile and factors determining the (immediate) outcome in spontaneous subarachnoid hemorrhage

AIMS AND OBJECTIVES

The aims of the study were to delineate the risk factors, type and location of underlying pathology, outcome and the determinants of outcome in patients with spontaneous subarachnoid hemorrhage.

MATERIAL AND METHODS

Forty consecutive patients with spontaneous subarachnoid hemorrhage on neuroimaging scan were recruited over a period of 1 year. Risk factors profile, site and type of pathology seen on angiography were assessed in all patients. Patient outcome at the end of hospital stay was assessed using the Glasgow Outcome Scale (GOS) and was analysed with respect to demographic factors, premorbid risk factors, initial WFNS scoring, neuroimaging findings and complications during in-hospital stay.

RESULTS

Of the total 40 patients in the study, 43% were males and 57% were females. The mean age in study group was 49.63 yrs (SD 13.12). Fifty percent patients were hypertensive, 22.5% were smokers and alcohol intake was reported by 17.5%. Saccular aneurysms were seen in 80% patients and arteriovenous malformations in 7.5%. Aneurysms were more common in the anterior circulation than in the posterior circulation. Poor outcome was associated with higher age, hyponatremia, higher World Federation of Neurosurgeons (WFNS) grade on admission, presence of vasospasm on angiography, fever any time during the course in hospital and requirement of ventilatory support.

CONCLUSION

Gender, site of aneurysmal bleeding (anterior/posterior circulation) and procedure performed (coiling/clipping) do not influence the immediate outcome of patients with subarachnoid hemorrhage. Further studies on Indian subset of patients are necessary to determine the patient characteristics and factors influencing the long-term outcome in spontaneous subarachnoid hemorrhage.

Crimean Congo hemorrhagic fever: requires vigilance and not panic

Crimean Congo hemorrhagic fever (CCHF) has been in the news with reports of its outbreak in India from Gujarat. CCHF is caused by a virus which is a member of the Nairovirus genus of the family Bunyaviridae. All of these viruses are transmitted by either ixodid or argasid ticks. Humans get this infection after a bite of an infected tick or from one infected human to another by contact with infectious blood or body fluids. Workers in livestock and agriculture industry, slaughterhouses, and veterinary practice are most prone to this infection. In severe cases after 3-6 days of the onset of symptoms hemorrhagic manifestations occur. IgG and IgM antibodies may be detected in serum by ELISA from about the sixth day of the illness. The mainstay of treatment in CCHF is supportive. Management of DIC, sepsis, shock and MODS should be undertaken. The antiviral drug Ribavirin has shown benefits. Benefits of treatment with ribavirin outweigh the fatal risks, and ribavirin may therefore be recommended. People at risk should use effective personal protective measures against tick bites. Acaricide treatment of livestock in CCHF virus endemic areas is effective in reducing the population of infected ticks.

Migraine: pitfalls in the diagnosis

Although the understanding of the pathophysiology and the pharmacology of migraine has exploded there are still many pitfalls that may occur in the clinical assessment and management of migraine. This may prevent the patient from receiving optimal treatment. A diagnosis of migraine may be missed in the presence of other headache types that occur more frequently than migraine. Also, migraine may be misdiagnosed when treating physicians inappropriately interpret specific symptoms and co-morbid conditions as indicators of the presence of a non-migraine headache type such as sinus headache or tension headache. Migraine and tension-type headache share common triggers and this also contributes to the difficulty in their differential diagnosis. The non-availability of any diagnostic laboratory investigation only makes this job further difficult.

Cardiac amyloidosis

We present a 54 year old male who presented with congestive cardiac failure and was diagnosed as restrictive cardiomyopathy with mild mitral regurgitation on 2D echocardiography. Cardiac amyloidosis was diagnosed in view of renal biopsy revealing amyloid deposition. Patient did not have any obvious etiology for secondary amyloidosis.

Tumefactive demyelination

We present a case of 22 year old female who had pulmonary tuberculosis followed by tuberculous meningitis and tuberculomas in past. This time she presented to us with right hemiparesis and altered sensorium. Diagnosis of tumefactive demyelination was made on the basis of typical MRI findings. Patient showed good response to steroids.

Serum uric acid in acute myocardial infarction

BACKGROUND

There is evidence that high uric acid is a negative prognostic factor in patients with mild to severe heart failure. A study showed a close correlation between serum uric acid concentration and Killip classification in patients of acute myocardial infarction.

MATERIAL AND METHODS

We studied 100 patients with acute myocardial infarction and 50 controls. Serum uric acid level was measured on day 0, 3 & 7 of MI.

RESULTS

There was a statistically significant higher level of serum uric acid concentration in patients of MI on day of admission as compared to controls. Patients with history of MI in the past had higher serum uric acid levels. On all the days serum uric acid levels were higher in patients who were in higher Killip class. All the five patients who died after 3 days of hospital stay had serum uric acid level more than 7.0 gm/dL and all of them were Killip class IV.

CONCLUSIONS

Serum uric acid levels are higher in patients of acute myocardial infarction correlated with Killip class. Combination of Killip class and serum uric acid level after acute myocardial infarction is a good predictor of mortality after AMI.

Evaluation of efficacy and tolerability of dothiepin hydrochloride in the management of major depression in patients suffering from rheumatoid arthritis

Several studies have shown that 20 to 66.2% of patients with rheumatoid arthritis have associated psychiatric comorbidity especially depression. Dothiepin hydrochloride is a well-established and effective antidepressant in patients with depressive symptoms of varying severity and co-existing anxiety. To document the efficacy and tolerability of dothiepin hydrochloride in the management of major depressive disorder (MDD) in rheumatoid arthritis patients a phase IV, open, single arm, prospective study was initiated with dothiepin hydrochloride in the dose of 75 mg/day, duration of therapy was 6 weeks. Twenty-five rheumatoid arthritis patients suffering from co-morbid MDD completed the 6-week dothiepin hydrochoride treatment and were considered for final analysis. There was significant reduction (p < 0.05) in mean HAM-D scores at week 2 (13.92 +/- 5.45), week 4 (9.28 +/- 4.13) and week 6 (5.72 +/- 3.26) compared to baseline (21.64 +/- 5.93). There was significant reduction (p < 0.05) in mean HAM-A scores at week 2 (6.52 +/- 3.34), week 4 (4.0 +/- 2.25) and week 6 (2.76 +/- 1.59) compared to baseline (10.68 +/- 3.68). The global impression of efficacy at the end of 6 weeks of dothiepin hydrochloride treatment was rated by the clinician (psychiatrist) as marked and moderate improvement in 20 (80%) and 5 patients (20%) respectively. Only 2 patients reported dry mouth as an adverse event in the study. The overall assessment of tolerability at the end of 6 weeks of dothiepin hydrochloride treatment was rated by the clinician (psychiatrist) as good and fair in 19 (76%) and 6 patients (24%) respectively. Dothiepin hydrochloride was found to be an effective and well-tolerated drug in the management of MDD and anxiety in patients suffering from rheumatoid arthritis.

Idiopathic hypereosinophilic syndrome manifesting as pulmonary oedema

Idiopathic hypereosinophilic syndrome is a progressive and fatal disease if not treated effectively. We report this case since hypereosinophilia is an uncommon cause of pulmonary oedema.

Neuropathy in rheumatoid arthritis

BACKGROUND

Paucity of Indian literature on rheumatoid neuropathy creates a lacuna in the critical evaluation and discussion of the subject. We did this study to find out the incidence and pattern of neuropathy and to correlate it with disease parameters and other extra-articular involvement.

MATERIAL AND METHODS

We studied 31 patients of rheumatoid arthritis (RA) classified by ACR criteria. Electromyography and nerve conduction studies (EMG/NCV) were done in all the patients apart from routine laboratory and radiological investigations. Electrocardiograph (ECG), pulmonary function tests (PFT) and ophthalmological examination were also carried out to ascertain extra-articular involvement.

RESULTS

Ten out of 31 RA patients had neuropathy of which five each were overt and subclinical respectively. Only one patient had entrapment neuropathy. Four of the ten patients had pure motor neuropathy whereas the other six were sensori-motor neuropathies. Four patients had mononeuritis multiplex and five had symmetrical peripheral neuropathy. Nine of the ten neuropathic patients had RA for more than 2 years. Seven patients had other extra-articular features along with neuropathy.

CONCLUSIONS

One-third of patients with RA have evidence of neuropathy. Disease parameters such as activity, rheumatoid factor and functional and radiological grade do not correlate with neuropathy. Non-entrapment sensori-motor type of neuropathy is the most common type.

Relationship between osteoarthritis of knee and menopause

AIM

To study the difference in the onset of osteoarthritis (OA) between males and females with respect to age and to note the relationship between OA of the knees and menopause and hysterectomy in females.

MATERIAL AND METHODS

One hundred consecutive patients (50 males and 50 females) were studied for the onset of OA and compared for the statistical difference. In females the relationship between onset of OA and menopause and hysterectomy, if done, was noted.

RESULTS

Fifty eight percent of females had onset of symptoms of OA of knees before 50 years of age as compared to only 20% in males (p < 0.05). Sixty four percent of females with OA of knees had the onset of symptoms either perimenopausally or within five years of natural menopause or hysterectomy.

CONCLUSION

There is a definite early peaking of the incidence of OA of knees in women in the fifth decade of life as compared to males. There is an association between OA of knees and menopause and we suggest correlating it with the levels of sex hormones.

Leprosy: a close mimic in a rheumatology clinic

Cutaneous and neurological manifestations of leprosy are readily diagnosed. However, physicians sometimes fail to recognize that leprosy may present with a rheumatic symptoms. A plethora of rheumatic manifestations are associated with leprosy, particularly with lepra reactions. A diligent examination for skin lesions/nerve involvement may uncover the diagnosis of leprosy in a patient referred for a rheumatological disorder. To highlight the fact that leprosy can mimic several rheumatological disorders, we have discussed a few representative cases seen over the past two years at our rheumatology clinic in a teaching hospital. In all these cases, a diagnosis of leprosy was made when the patient was referred for a rheumatic complaint.