Alcohol Withdrawal Presenting with Cut Throat Injury during COVID-19 Lockdown: Case Reports from Nepal

Background

The relationship between alcohol dependence and suicidal tendency is well recognized. Self-harm by cut throat is an uncommon but is potentially life-threatening when attempted. We present a description and discussion of a series of three cases of alcohol dependence syndrome who presented with self-inflicted cut throat wounds during the lockdown period from 24th March to 7th July 2020 due to the COVID-19 pandemic at the largest tertiary care hospital in Nepal. Case description. During the three and a half months of COVID-19 lockdown, we had three cases of alcohol dependence syndrome presenting to emergency services with a self-inflicted cut throat injury. Two cases were diagnosed as having alcohol withdrawal delirium and one case as alcohol-induced psychotic disorder (alcoholic hallucinosis) as per the international classification of mental and behavioral disorders diagnostic criteria for research. All three cases were alcohol dependent for more than a decade, but with no prior self-harm attempts. Necessary surgical interventions were done by the Department of Otorhinolaryngology, and in liaison with the Department of Psychiatry, appropriate psychiatric management was done. All three cases had uneventful outcomes in regard to wound care and mental disorder.

Conclusion

Suicidal precautions should be taken in alcohol dependence during phases of consumption and abstinence. Screening for alcohol dependence and withdrawal should be a standard process in all self-harm cases that present to the emergency department during a crisis.

AB0281 THE 2016 REVISED ACR FIBROMYALGIA CRITERIA IDENTIFY A HIGHER PREVALENCE OF FIBROMYALGIA IN RHEUMATOID ARTHRITIS PATIENTS: A CROSS-SECTIONAL STUDY FROM INDIA

Background

Fibromyalgia (FM) prevalence in rheumatoid arthritis (RA) is reported around 5-50% as per older American College of Rheumatology (ACR) FM Criteria, while in India reported around 15% (1). The Revised 2016 ACR FM criteria has greater sensitivity and specificity of 94% and 91% respectively compared to older criteria (2). To best of our knowledge, no study has evaluated presence of FM in RA as per revised 2016 ACR FM criteria.

Objectives

1) To study prevalence of FM as per revised 2016 ACR FM criteria in RA patients.

2) To compare Disease activity, Disability status, Quality of life, Anxiety and Depression in RA with and without FM.

Methods

This cross-sectional study included 200 RA patients and equal number of controls. FM was diagnosed using revised 2016 ACR FM Criteria. Disease activity, quality of life and functional disability in RA patients was assessed using disease activity scores (CDAI, SDAI, DAS-28 CRP, WHO-Qol BREF and Health Assessment Questionnaire CRD HAQ-DI). Presence of depression and anxiety was determined using validated Hospital Anxiety and Depression Scale (HADS).

Results

FM was present in 31% and 4% of RA patients and healthy controls respectively in our study using 2016 ACR FM criteria. This is significantly higher compared to the 15% and 2.5% in RA and healthy control populations respectively of the study by Dhir V. et studying a similar population of Indian patients, using 1990 ACR FM criteria. RA patients with FM were older, predominantly females, had longer disease duration, were more on steroids, had higher disease activity and more functional disability. In a multivariable linear regression analysis, FM was important predictor of DAS28 score & CDAI, even after adjusting for other independent variable like disease duration, CRP, SJC, functional disability. RA patients with FM had a poorer quality of life and had higher prevalence of anxiety and depression. No difference was noted in use of disease modifying agents, biological or ts-DMARDs in RA patients with or without FM.

Table 1.

Characteristics of RA with FM and RA without FM patients.

RA without FM (n=138)RA WITH FM (n=62)P VALUEMean ± sdMean ± sdAge, yrs.,47.17±12.4451.37±12.330.028Duration of RA4.1±3.596.46±6.090.006TJC, 0-284.57±2.866.87±3.08<0.001SJC,0-282.3±2.373.37±2.870.011Pain VAS,0-10036.38±16.1655.24±11.18<0.001ESR39.01±20.6746±20.390.028CRP11.61±11.1516.43±15.720.032CDAI14.6±6.6919.68±6.71<0.001SDAI15.74±7.3321.34±7.48<0.001DAS-28 CRP4.1±1.14.85±0.84<0.001PDS,0-318.68±3.2216.27±2.33<0.001Physical score*, 0–10054.83±12.1634.37±9.41<0.001Psychological score, 0–10059.78±14.3439.84±12.74<0.001Social score, 0–10060.68±12.7551.5±12.76<0.001Environmental score, 0-10059.21±11.0449.35±9.73<0.001CRD HAQ-DI1.04±0.641.8±1.03<0.001Anxiety, n (%)23(17%)53(85%)<0.001Depression, n (%)44(32%)59(95%)<0.001

TJC: tender joint count (28 joints); SJC: swollen joint count (28 joints); CDAI: Clinical disease activity index; SDAI: Simplified disease activity index; DAS 28: disease activity score (28 joints); PDS: Polysymptomatic distress score of fibromyalgia; *Domain scores of quality of life (WHO-Qol BREF).

Conclusion

The prevalence of FM in RA patients is significantly higher with 2016 ACR FM Criteria as compared to older criteria in similar population of RA patients. A significant number of patients had anxiety and depression that needs to be clinically attended. The presence of FM in RA adversely affects the Disease activity, quality of life, functional disability.

References

[1]Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016 Dec 1;46(3):319–329.

[2]Dhir V, Lawrence A, Aggarwal A, Misra R. Fibromyalgia is common and adversely affects pain and fatigue perception in North Indian patients with rheumatoid arthritis. J Rheumatol. 2009 Nov;36(11):2443–2448.

Disclosure of Interests

None declared

Internalized stigma in patients with schizophrenia: A hospital-based cross-sectional study from Nepal

Introduction

The aim of this study was to examine the internalized stigma of mental illness in patients with schizophrenia visiting psychiatry outpatient in a tertiary level hospital in Kathmandu, Nepal, and to explore the associated sociodemographic and clinical factors.

Methods

This was a cross-sectional study, where participants were selected by purposive sampling from the outpatient department of psychiatry in Tribhuvan University Teaching Hospital, Kathmandu, Nepal. One hundred and fourteen patients were selected and given the Internalized Stigma of Mental Illness scale to complete to assess the level of stigma. A semi-structured sociodemographic form was used to get information on sociodemographic and clinical factors. Simple descriptive analysis was done followed by multivariate analysis to explore the sociodemographic and clinical correlates of stigma in these patients.

Results

A total of 114 patients were included in the study. Moderate to high levels of internalized stigma was reported in almost 90% of patients with schizophrenia. The subscale with the highest mean score was stereotype endorsement and that with the lowest mean score was stigma resistance. Duration of illness was the only clinical variable associated with stigma while occupation was the only sociodemographic variable related to stigma.

Conclusion

Moderate to high levels of internalized stigma were reported across all subscales of stigma in patients with schizophrenia and the prevalence was high. Further, duration of illness was associated with stigma. Stigma reduction should therefore be a component of the overall management of patients diagnosed with schizophrenia.

Impact of Albendazole Therapy on Clinical and Radiological Outcomes at One Month in Patients with Active Solitary Neurocysticercosis Patients

Background Cerebral neurocysticerosis is a common parasitic disease of human nervous system but evidence on duration of albendazole therapy and their outcomes in this condition is inadequate Objective To evaluate the impact of varying duration of albendazole therapy on the clinical and radiological outcomes at one month in patients with active solitary neurocysticercosis. Method This is an interventional study conducted at Upendra Devkota Memorial National Institute of Neurological and Allied sciences, Bansbari over 1 year (2017 March - 2018 February). One hundred eighteen patients with new onset seizure secondary to active solitary cysticercal granuloma either received albendazole therapy for 1, 3, 9 or 21 days with the usual care or only received the usual care. Clinical and radiological outcomes were observed at one month follow-up. The difference in the proportion of the outcome measures between intervention and control groups were assessed using chi-square test. Result Our study included 118 patients with male predominance of 61.9%. Albendazole therapy for 3, 9 and 21 days reduced headache by 57.2%, 70.0% and 63.1% respectively which was higher than those with 1-day therapy or without the therapy. This difference in the proportion was statistically significant at p=0.001. Though seizure recurrence also declined but the difference was not significant (p=0.406) between groups. However, at one-month follow-up, majority of patients who received albendazole for 9 days (14, 70%) and 21 days (14, 73.7%) had normal lesion, while most calcified lesion (21, 67.7%) was observed in those who did not receive albendazole therapy. The difference between lesion among the groups was significant (p < 0.001). Conclusion Albendazole therapy in patients with active solitary neurocysticercosis for 9 days is as effective as 21 days and better than 3 days in headache control and lesion dissolution but seizure control could be achieved irrespective of the treatment.

AB0447 PREVALENCE OF PRIMARY BILIARY CIRRHOSIS IN SYSTEMIC SCLEROSIS AND SJÖGREN’S SYNDROME OVER TIME: A SYSTEMATIC REVIEW

Background:

Primary biliary cirrhosis (PBC) is a rare slowly progressive autoimmune disease characterized by inflammatory destruction and fibrosis of intrahepatic bile ducts. It is known to coexist together with rheumatological conditions such as Sjögren’s syndrome (SS) and systemic sclerosis (SSc). There is a wide range in reported prevalence of disease overlap with these entities; however, the exact prevalence rates remain unclear.

Objectives:

The objectives were to determine the prevalence of: 1) PBC in patients with SS and SSc (and the subsets of limited cutaneous SSc (lcSSc) and diffuse cutaneous SSc (dcSSc)), 2) SSc and SS in patients with PBC, and 3) to analyze changes in frequency over time. SSc occurs in 3/10,000 and PBC in 4-40/10,000 but these rare autoimmune diseases are known to coexist together. We speculated that there could be more cases diagnosed due to increasing availability of standardized antibody tests such as ANA, centromere antibodies, ENA and mitochondrial antibodies.

Methods:

A systematic review of the literature was performed using Medline, EMBASE, CINAHL, and the Cochrane Library databases up till June 16, 2020. Only full text articles in the English language with at least 40 patients were included. Cohorts, case series, cross-sectional studies, correspondences and registries with reported prevalence rates of both PBC in patients with SS and SSc as well as SSc and SS in patients with PBC were included. Data on frequency of co-existent diseases was studied by year of publication to determine if prevalence changed over time using linear regression. We used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist to assess the quality of the studies.

Results:

Of 2876 citations identified, 67 were included in the analysis (n=33 for PBC, 15 for SSc, 18 for SS and 1 for SSc/SS). STROBE checklist scores ranged from 7-21. The prevalence of PBC was 5% in patients with SSc. Within the subsets, the prevalence of PBC in lcSSc was 8% and in dcSSc was 1%. In patients with SS, the prevalence of PBC was 4%. The prevalence of SSc overall in those with PBC was 5% and, within the subsets was 6% in lcSSc and 0% in dcSSc. The prevalence of SS in PBC was 18%. There was also no significant association between year of publication and prevalence. There was a lack of standardized definitions so misclassification may have occurred.

Conclusion:

PBC is increased in SSc but mostly in the lcSSc subset. SS in PBC is common at nearly 1 in 5. Over the years, there was no change in the prevalence of PBC in SSc indicating stability over time.

Acknowledgements:

Meagan Stanley, Western University Librarian.

Disclosure of Interests:

None declared.

Neuropsychiatric manifestations in General Paralysis of Insane (GPI)

General paralysis of insane is a form of neurosyphilis which brings parenchymatous changes in the central nervous system. Its manifestations include a variety of neuropsychiatric symptoms ranging from cognitive impairment to overt psychosis. Clinicians face difficulties in proper diagnosis as variety of symptoms changes from one form to other within a short period of time. Rarity of the disease at this modern era of penicillin is also another factor in timely diagnosis and management of such cases. Here we present a case of general paralysis of insane who presented with variety of neuropsychiatric symptoms and have had great difficulties to reach into the diagnosis.

Screening for vision-threatening diabetic retinopathy in South India: comparing portable non-mydriatic and standard fundus cameras and clinical exam

PurposeTo evaluate the sensitivity and specificity of a portable non-mydriatic fundus camera to diagnose vision-threatening diabetic retinopathy (VTDR).Patients and methodsA prospective, single-site, comparative instrument validation study was undertaken at the Aravind Eye Care System. Overall, 155 subjects with and without diabetes were recruited. Images from 275 eyes were obtained with the (1) non-mydriatic Smartscope, (2) mydriatic Smartscope, and (3) mydriatic table-top camera of the macular, nasal, and superotemporal fields. A retina specialist performed a dilated fundus examination (DFE), (reference standard). Two masked retina specialists graded the images. Sensitivity and specificity to detect VTDR with the undilated Smartscope was calculated compared to DFE.ResultsGraders 1 and 2 had a sensitivity of 93% (95% confidence interval (CI): 87-97%) and 88% (95% CI: 81-93%) and a specificity of 84% (95% CI: 77-89%) and 90% (95% CI: 84-94%), respectively, in diagnosing VTDR with the undilated Smartscope compared to DFE. Compared with the dilated Topcon images, graders 1 and 2 had sensitivity of 88% (95% CI: 81-93%) and 82% (95% CI: 73-88%) and specificity of 99% (95% CI: 96-100%) and 99% (95% CI: 95-100%).ConclusionsRemote graders had high sensitivity and specificity in diagnosing VTDR with undilated Smartscope images, suggesting utility where portability is a necessity.

Level of awareness of lung cancer risk factors, signs, symptoms and safe practices among college teachers of different states in India: Do awareness programmes have an impact on adoption of safe practices?

Lung cancer is the one of the most common cause of cancer mortality among men in India where incidence rates are increasing although they are largely preventable diseases. In India, late presentation is generally responsible for high mortality and morbidity rates and early detection is one of the best ways to control it. The purpose of this study is to measure the level of awareness on lung cancer among women represented by a sample of college teachers in India and the impact of awareness programs in changing or adopting safer practices and the prevention and early detection of the disease.

MATERIAL AND METHODS

The assessment was conducted during a Pink Chain Campaign on cancer awareness in 2011 in various women colleges in India. Pre-test related to lung cancer was followed by awareness programs. Posttest using the same questionnaire was conducted at the end of interactive session, at 1 year and 6 months.

RESULTS

A total of 156 out of 182 teachers participated in the study (overall response rate was 85.7%). Mean age of the study population was 42.4 years (range- 28-59 yrs). There was a significant increase in level of knowledge regarding lung cancer at 6 months and this was sustained at 1 year. Magazines and newspapers were the primary source for information regarding risk factors, signs and symptoms of lung cancer in more than 60% of teachers whereas more than 30% teachers were educated by doctors. At post-awareness after 1 year and 6 months, there was a significant change in alcohol and smoking habits. The main reasons for not undergoing screening tests are: ignorance (50%), lethargic attitude (44.8 %) and lack of time (34.6 %).

CONCLUSION

Knowledge about lung cancer was very low among teachers. Overall awareness of risk factors, signs and symptoms, and screening modalities of lung cancer have improved after 1 year along with practices related to smoking and alcohol consumption. There was a significant improvement in people undergoing regular check-up's. Improved means of communication, access to information and effective warnings about cigarette smoking are necessary to increase public awareness. To ensure the adoption of safe practices in the lifestyle of people who smoke and consume alcohol, awareness programmes such as the pink chain campaign should be conducted regularly, frequently and more widely in various areas of India.

Management of traumatic atlanto-axial instability: A retrospective study of eight cases

BACKGROUND

C1 lateral mass-C2 transpedicular fixation is an accepted surgical procedure of choice in a large number of cases with traumatic atlanto-axial instability. However, bony and vascular anomalies can predispose to unacceptably high risk with this procedure, And hence are the contraindications for this procedure. The purpose of this study is to analyze the clinical and radiological results in such cases for which only unilateral fixation has been performed in cases where bilateral fixation could not be performed due to various reasons.

MATERIALS AND METHODS

Eight patients (7 males, 1 female) with a mean age of 41.12 years (range 12-68 years), who presented with traumatic atlanto-axial instability and in whom bilateral fixation could not be performed, were treated with unilateral C1 lateral mass-C2 transpedicular fixation. Of these cases, preoperative vertebral artery occlusion was noted in one case, iatrogenic vertebral artery injury in two cases and bony anomalies or fractures in the remaining of five cases. All patients were evaluated clinically with the American Spinal Injury Association (ASIA) scale and radiologically with computed tomography scans and serial X-ray using criteria to evaluate stability.

RESULTS

All cases were evaluated at 6 months followup with mean followup of 2 years and one month (range 6 months to 4 years). All eight patients showed adequate stability and fusion at 6 months; clinically there was no significant restriction of neck movement in any of the patient. There was no neurological deterioration in any of the patient at their last follow-up.

CONCLUSION

Unilateral C1 lateral mass-C2 transpedicular fixation could be considered a viable option in cases of traumatic atlanto-axial instability where vascular and osseous anomalies contradict a bilateral fixation.

A comparative study on adult mortality of Nepal

BACKGROUND

Adult mortality (15-49 years) is one of the major public health issues which remains neglected in many developing counties like Nepal. Only limited data are available which is insufficient to identify the cause and level of mortality among adults.

OBJECTIVES

The aim of the study is to explore and compare the adult mortality rate of Nepal between 1996, 2001 and 2006 surveys.

MATERIALS AND METHODS

This is comparative study conducted by using secondary data extracted from Nepal Family Health Survey (NFHS, 1996), National Census Report 2001 and Nepal Demographic and Health Survey (NDHS, 2006). Statistical analysis was done using Microsoft excel soft ware. The adjusted mortality rates were computed using 2001 census population as standard population.

RESULT

This studied showed there was statistical evidence of declining age specific mortality rate between 1996 and 2006 survey for both men and women respectively (p<0.05). Annually adult men mortality rate and adult women mortality rate was found to be declining by 1% and 3. 2% respectively. Women mortality rate declined by 2.26 times as compared to men mortality rate over ten year's period.

CONCLUSION

There is a need of in-depth analysis of adult mortality in the developing countries like Nepal.

Complement and cell mediated cytotoxicity by antiendothelial cell antibodies in Takayasu's arteritis

OBJECTIVE

To study complement and cell mediated cytotoxicity by antiendothelial cell antibodies (AECA) in Takayasu's arteritis (TA).

METHODS

Complement dependent cytotoxicity (CDC) and antibody dependent cellular cytotoxicity (ADCC) of AECA positive/negative TA sera were investigated by colorimetric MTT and 51Cr release assays, respectively, using human umbilical vein endothelial cells (HUVEC) as targets.

RESULTS

Seven of 12 (58%) sera positive for IgG and/or IgM AECA exhibited CDC in comparison to none of the 13 AECA negative sera (p = 0.0052). The median value of CDC of the AECA positive group was 14% (range 13-21%) and that of the AECA negative group was 1% (p = 0.0012). Interleukin 1beta (10 U/ml) treatment of HUVEC resulted in enhancement in CDC of 6 of the 7 AECA positive cytotoxic sera, the median enhancement being 17% (range 7-29%). Tumor necrosis factor-alpha (100 U/ml) treatment of the targets resulted in a median enhancement by 36% (range 25-55%) in the CDC of 3 of these 7 sera. No sera exhibited ADCC at any of the effector:target ratios tested (10:1 to 100:1).

CONCLUSION

AECA in TA mediate CDC against endothelial cells and may have a pathogenic role in the perpetuation of vascular damage in this disease.

Developing an information pack for the Asian carers of people with autism spectrum disorders

An investigation is described which forms the basis for the development of an information package for the Asian carers of people with autism spectrum disorders (ASD) and learning disabilities. The results of semi-structured interviews and planning for questionnaires with three different linguistic Asian groups (Urdu, Gujarati and Bengali) are presented. The views, attitudes and awareness of autism, knowledge of support services and perceived priority of needs are analysed for the three different communities. The investigation concludes with recommendations as to whether separate information is needed by each culture or whether a single information pack can be used and presented in each language format. The possible presentation format in which the information can be produced is also discussed.

4-substituted cubylcarbinylamines: a new class of mechanism-based monoamine oxidase B inactivators

Cubylcarbinylamine (1a), (4-cyclopropylcubyl)carbinylamine (1b), and (4-phenylcubyl)carbinylamine (1c) were synthesized and shown to be time-dependent, irreversible inactivators of monoamine oxidase B (MAO B). Substrate protects the enzyme from inactivation, but beta-mercaptoethanol does not, suggesting that these compounds are mechanism-based inactivators. All three compounds were also substrates for MAO B with partition ratios ranging from 152 to 536. The 4-substituted analogues were more potent inactivators than the unsubstituted analogue, indicating a benefit to 4-substitution in this class of inactivators.

Isolation of fungi from local bread of Chhindwara

In the present paper, fungi isolated from bread samples are being reported. Out of 150 samples of bread, only 20 samples appeared to be infected but when cultured all the samples could not give positive results, except, A. fumigatus. Ten fungi including Aspergillus fumigatus, A. niger, A. flavus, A. glaucous, A. carnous, A. terreus, A. ochraceous, Rhizophus stolonifer, Trichoderma harrianua, and Trichothecium roseum were recovered from the bread samples. Among these A. fumigatus and A. niger were dominant which are known to cause toxicity and pulmonary aspergillosis in human beings.