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Jul22
STUDY OF NEUROPSYCHIATRIC MANIFESTATIONS IN PATIENTS OF FALCIPARUM MALARIA
AIM:
To study incidence of neuropsychiatric manifestations and post malarial neurological sequelae in patients of falciparum malaria.

MATERIALS AND METHODS:
Patients with fever and MP (slide, QBC) showing PFR positive were enrolled for this study and detail history, general examination, neurological examination and psychiatric evaluation including mini mental score, routine examination, CT scan of brain were done at the time of admission, during hospital stay, after recovery and during follow up.

OBSERVATION AND DISCUSSION:
Fourty (40) patients were enrolled in this study, of which 32(80%) were male and 8 (20%) female. The clinical presentation at the time of admission was fever (100%), anemia (77.5%), impaired consciousness(32.5%), psychosis (25%), convulsion (17.5%), , hypotension (13%), only 12.5% patients were deeply comatose with GCS score  7, out of which one (1) patient died.During hospital stay, 2.5% patients developed focal neurological deficit 12.5% patients depression, 5% patients speech disorder in the form of dysarthria, 5% patients memory loss & 5% patients developed acute cerebellar syndrome. Mini mental score (MMS) examination of patients after completion of antimalarial treatment revealed two (2) patients with MMS  21 i.e., they were showing cognitive impairment. Heavy parasitemia was observed, particularly in more numbers of patients with coma and depression. High blood urea (> 49 mg%) was seen to be correlated with impaired consciousness, psychosis, depression and memory loss with p value < 0.005. Three (3) of the patients developed post malarial neurological syndrome in the form of psychosis(1), delayed cerebellar ataxia (1) and memory loss (1).

CONCLUSION:
Neuropsychiatric manifestations are important aspects of clinical features of falciparum malaria, because of it unique characteristics leading to micro vascular involvement. Heavy parasitemia and high blood urea were well correlated with most neuropsychiatric manifestations of falciparum malaria which needs further discussion. So proper anti-malarial treatment needs to be instituted promptly to avoid these complications and postmalarial neurological syndrome to a minimum.


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Jul22
VALIDITY OF CEREBROSPINAL FLUID AND SERUM C-REACTIVE PROTEIN (CRP) IN DIAGNOSIS OF MENINGITIS IN ADULTS
AIM OF THE STUDY:
Validity of C.S.F. and Serum CRP in the diagnosis of meningitis in adults.

MATERIALS AND METHODS:
Fifty cases of meningitis were taken for study in the Department of Medicine form June 2004 to May 2006. Detailed clinical history, physical examinations and routine laboratory investigations were done including mandatory serum and CSF CRP estimation by semi-quantitative method. Clinical diagnosis of pyogenic (bacterial) and TB meningitis (TBM) was determined by history, physical examination, Routine CBC, CSF cytological and biochemical studies.

OBSERVATION AND DISCUSSION:
Out of 50 cases of meningitis 58% were males, 42% were females. Among the bacterial meningitis group maximum number of cases 8 (53.3%) were adults (26-40 years) and in TBM maximum number of cases 12 (37.5%) are in the age group 26-40 years. Fever and headache were the commonest symptoms in all type of meningitis (100%). Meningeal signs were more marked in bacterial (100%) than in TBM (62.5%) and viral cases. Majority of bacterial meningitis were conscious well oriented (66.6%) or at best confused (20%). Altered level of consciousness was more common among TBM cases (87.5%). CSF cell count in pyogenic meningitis varied from 2000/cmm to 63/cmm and 11(73.3%) cases were predominantly polymorphic whereas 4(26.6%) were dimorphic. Among 32 TBM cases the cell count varied from 150/cmm to 20/cmm . 6(18.7%) were dimorphic and rest 26 (81.25%) were predominantly mononuclear. CSF sugar level was reduced more in bacterial meningitis (<20mg/dl) than in TBM cases whereas it was nearly normal in cases of viral meningitis. The CSF protein levels both in bacterial and TBM are high (> 100 mg/dl) whereas it was nearly normal in viral meningitis. The CSF CRP test was positive in 14 (93.3%) out of 15 bacterial meningitis and 2(6.25%) out of 32 cases of TBM. Serum CRP test was positive in all cases of bacterial and tubercular meningitis (100%).

Type of Meningitis No. of Cases Positive serum CRP Positive CSF - CRP
Bacterial meningitis 15(30%) 15(100%) 14(93.3%)
TB meningitis 32(64%) 32(100%) 2(6.25%)
Viral Meningitis 3(6%) - -
Total 50 47 16

CONCLUSION:

Clinical features, cytological and biochemical study of CSF did not differentiate accurately pyogenic from TBM. It was observed that CSFCRP test was positive in almost all cases of bacterial and partially treated bacterial meningitis. The serum CRP test did not discriminate different meningitis whereas CSF CRP positive indicates pyogenic meningitis with greater validity and CSF CRP negatitivity validates tubercular meningitis


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Jul22
COMPARATIVE STUDY OF LOSARTAN WITH ENALAPRIL IN MILD TOMODERATE HYPERTENSION
AIMS AND OBJECTIVES:
To study the efficacy, beneficial and adverse effects of losartan in comparison to enalapril in cases of mild to moderate hypertension during the period of January 2003 to January 2005.

MATERIALS AND METHODS:
In the present study 48 patients of stage 1 and II hypertension without any other complications were included from the Department of General Medicine. They are divided into two groups 'A' & 'B'. The group 'A' was subjected to losartan potassium 50 - 100'nig/day and group 'B' to enalapril maleate 5-10 mg/day to maintain the BP below 140/90 mmHg.

All the patients were subjected to detailed history and clinical examination at the time of presentation. Baseline investigations like nemogram, urine for albumin, sugar and microscopic examination, FBS, serum urea, creatinine, sodium, potassium , uric acid, total cholesterol and HDL cholesterol, LFT, ECG, X-ray chest and USG abdomen were done. All cases were critically evaluated at the time of discharge and were followed up fortnightly for 3 months. During each visit patient is enquired for any adverse effect, BP measured and was investigated for FBS, serum urea, creatinine , sodium , potassium and cholesterol. At the end of 3 months all investigation were repeated.

OBSERVATION:
In the present study it was observed that response rate to BP control is 90.9% with losartan group and 86.5% with enalapril group. Higher doses were required in 20% cases of losarton group and 30% cases of enalapril group. BP reduction was more .with losartan group.

There was no significant alteration in FBS, serum urea, creatinine, sodium and potassium, lipid profile, LFT and hemogram.

In losartan treated group a significant reduction in uric acid level (from 4.75±0.7 mg% to 3.24±0,48 mg%) in comparison to enalapril (4.5±0.71 mf% to 4.03 ±0,47 mg%) was seen.

No serious side effects were seen in both groups. However 10% cases of enalapril group developed dry cough. Overall incidence of adverse effects like weakness, dizziness were less with losartan (15%) than enalapril (25%). However due to small number of cases included in the present study the incidence of adverse effects may not represent the true incidence.

CONCLUSION:
The present study shows that losartan is a potent, safe antihypertensive agent along with uric acid lowering effect and is an useful adjunct to the antihypertensive therapeutic armamentarium.


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Jul22
CATION (CALCIUM & MAGNESIUM) STATUS IN ESSENTIAL HYPERTENSION AND RESPONSE TO
AIM:
1. To study the divalent cation status in essential hypertension and to observe the response to different antihypertensive drugs based on divalent cation status.
2. To emphasize the importance of calcium and magnesium status in essential hypertension to serve as surrogate markers of plasma rennin activity and to initiate antihypertensive drugs accordingly as close as physiological antidote.

MATERIALS AND METHODS:
The present study was conducted among essential hypertensive patients, aged >18years with SBP  140 mmHg and DBP  90 mmHg after exclusion of severe essential hypertension and secondary hypertensions in the department of Medicine. V.S.S. Medical College & Hospital, Burla from January 2004 to January 2006. There were 50 patients included in the study without any complication or morbidity. Detailed clinical and laboratory examination were performed. Patients with serum ionized calcium values were grouped into three groups i.e., Group 1 with 2.09  0.03, Group 2 with 2.24  0.03 and Group 3 with 2.34 0.03 mEq/L of ionized calcium and similarly three groups of patients with serum magnesium values i.e., Group 1 with 2.07 0.03 , Group 2 with 1.94 0.03 and Group 3 with 1.830.02 mEq/L magnesium according to Laragh et al. These groups represent surrogate of low rennin, normal rennin and high rennin activity status of essential hypertension respectively. Again these patients were divided into two groups i.e, Group A having surrogate of low renin and normal renin activity - surrogate (LREH/NREH) and constituted 40 patients and Group B surrogate of high rennin activity status of essential hypertension (HREH) and constituted 10 patients. Initially Group A patients were treated with Amlodipine and the cross over to Ramipril for 12 weeks with a washout interval of one month between the two treatments. Group B patients were similarly initially treated with Ramipril and the cross over to Amlodipine after a washout period of one month for 12 weeks respectively.

OBSERVATION:
1. By using the divalent cation status as surrogate of rennin activity incidence of low renin, normal renin and high renin essential hypertension was 36%, 44% and 20% respectively.
2. Incidence of low renin essential hypertension (LREH) was 55% in females and high renin essential hypertension (HREH) was 80% in males.
3. Most patients in Group –A (LREH) were in the age group between 56-60 years while in Group –B (HREH) the average age were between 42-45 years.
4. 82.5%(33) cases of Group A responded well to a dose of 5mg of Amoldipine, while 17.5% (7) responded well to 10mg. In comparison with Ramipril 95% (38) cases responded well to 5mg of Ramipril and 5%(2) cases with 2.5 mg of Ramipril.
5. In Group B 90% patients responded to 2.5 mg Ramipril, 10%(1) cases responded to 5 mg Ramipril. In comparison of response to Amlodipine 80% patients required 10 mg dose of Amlodipine.
6. Average SBP, DBP, MAP fall of the end of 12 weeks in Group–A with Amlodipine was 19.8, 13.7 and 15.8 mmHg respectively. While with Ramipril the average falls were 16.45, 7.79 and 10.72 mmHg respectively.
7. The average fall of SBP, DBP, MAP and Ramipril in Group–B were 18, 15.79 and 15.98 mmHg & 14.6, 8.8 and 10.23 mmHg respectively with Amlodipine.

CONCLUSION:
Measurement of serum ionized calcium and serum magnesium levels and according to their level which serve as surrogate marker of plasma renin activity can be classified into low renin, normal renin and high renin status of essential hypertension patients. From the above study, the low renin status patients best responded to calcium channel blocker Amlodipine, while high renin status patients best responded to ACE inhibitor Ramipril. This new innovative approach can help initiate antihypertensive drugs like a physiological antidote in the treatment of essential hypertension and may help to control hypertension and retard or prevent complications in the absence of costly, bothersome and non-availability of plasma renin activity study. SBP- Systolic Blood Pressure, DBP- Diastolic Blood Pressure, MAP- Mean Arterial Pressure, LREH- Low Renin Essential Hypertension, HREH- High Renin Essential Hypertension, NREH- Normal Renin Essential Hypertension.


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Jul22
STUDY OF L-ARGININE THERAPY IN SICKLE CELL DISEASE PATIENTS
Objective of the Study :
To study the effect of L-Arginine in sickle cell pain crises.
Methodology:
Sixty consecutive known patients of sickle cell disease (ss) with vasoocclusive pain crisis admitted to general medical ward were taken into study. Routine relevant haematological and other study were done for every patients. L-Arginine 8 gm/day in divided doses 8 hourly was given orally to 30 patients of trial group with consent of patients or their relatives along with current therapy of controlled gentle hydration. Oxygen and analgesic. Control group patients were managed with same current conservative therapy but without L-Arginine . Rating of pain scale was done daily 8 hourly.

Observation:
There were 22 male and 8 females on trial group and 24 male and 6 female in control group. Age range was between 15-35 years. 17 cases (56.7%) were age range between 15-20 years in trial group and 18 cases (60%) in control group. At presentation patients were classified in 3 group according to pain scale (0-10) into mild, moderate and severe pain . Trial group has mild pain in 2 cases (6.6%), moderate pain in 14 cases (46.7%), severe pain in 14 Cases (46.7%) and in control group mild pain in 2 cases (6.6%), moderate pain in 15 (50%) and severe pain in 13 cases (43.4%). There was no adverse effects due to L-arginine in this study in short term.

Resolution of pain after giving L-arginine in trial group with mild , moderate and severe pain was 48 hours , 60 hours and 88 hours respectively in comparison to control group with mild moderate and severe pain, which was 72, 96 and 128 hours respectively. There was a difference of decreased pain duration in trial group by 24 hour , 36 hours and 40 hours respectively.

Conclusion:
From this study it is concluded that administration of L-arginine in sickle cell pain crisis along with conventional conservative therapy can lessen the duration of pain crisis in comparison to conservative therapy alone. Patients having severe pain at the time of admission took longer time to pain resolution in both groups. However randomized double blind placebo controlled intention to treat trial should be done in large number of patients in multicentre to conclude its effectiveness.


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Jul22
AN OBSERVATION ON NEUROCYSTICECOSIS
AIMS AND OBJECTIVES:
The study has been undertaken to identify the incidence, clinical presentation and response to treatment of nerurocysticercosis (NC) in Western Orissa.

MATERIALS AND METHODS:
150 patients presenting with convulsion were investigated for NC with CT scan and ELISA and confirmed cases of NC were given albendazole, steroid and anticonvulsant and were followed up at regular interval for 3 months.

RESULT:
Out o f150 patients with convulsion 40(26.6%) were diagnosed to have NC. Out of 40 patients of NC 8 (20%) were vegetarian and 32(80%) were non-vegetarian including 5 pork eaters. 24 (60%) cases had presented with focal convulsion. In 32 (80%) cases CT showed single ring enhancing lesion (SSEL) and 8 (20%) showed multiple enhancing and non-enhancing lesions.

The common site of lesion is in parenchyma. In 30(75%) cases the lesion were found in the parietal lobe, ELISA for IgG NC was found 32(80%) and 24(60%) cases in CSF and serum respectively. Repeat CT Scan 3 month after treatment with albendazole (15 mg/kg/day fro 28 days) steroid and anticonvulsant, showed complete resolution in 36 (90%) cases. Remaining 4 (10%) cases those not resolved were calcified lesion.

CONCLUSION:
NC is a common cause of late onset focal convulsion in this part of country. As very few 5(12.5%) cases consumed pork, transmission fo NC through raw vegetable is a strong possibility, which may be due to contamination through the bio-fertilizer commonly used in this part of the country


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Jul22
STUDY OF THYROID FUNCTION STATUS IN PATIENTS OF CHRONIC RENAL FAILURE
AIMS OF THE STUDY:
To estimate Serum T3, T4TSH in patients of Chronic Renal failure with special reference to (a) Biochemcial abnormalities of thyroid functions in CRF(b) To correlate between severity of CRF and alteration of thyroid indices (c) Effect of conservative management vs haemodialysis on thyroid indices.

MATERIALS AND METHODS:
Twenty cases of CRF patients admitted to Department of Medicine and Nephrology, V.S.S. Medical College Hospital Burla from January 2003-December 2003 were taken for the study. CRF was diagnosed by the criteria given by “Harrison’s Principles of Internal Medicine, Edn 15th. Individuals with known thyroid disease and those on antithyroid drugs, iodine intake were not included in the study. Serum T3, T4, TSH and free T3, T4 was done in all patients on admission and repeated at 3rd , 6th and 12th months during follow up and results were compared. Severity of renal failure was grouped according to GFR and the value of T3, T4, TSH was compared between groups.

OBSERVATION:
Out of 20 CRF patients in this study, male (80%) commonest presenting features anorexia (80%), puffiness on face (70%), oliguria (50%). All patients were anaemic , 70% had hypertension. Commonest vause of CRF was diabetes (50%), hypertension (20%), chronic glomerulonephritis (10%), chronic pylonephritis (5%). No cause found in 15%. TSH was normal in 17 cases. Only 3 cases had increased TSH. 16 cases had low T3, 13 cases normal T4, only 7 cases had increased T4. No significant improvement in T3, T4, TSH was seen in aptietns receiving conservative management. However haemodialysis reverted the abnormality partially. Severity of renal failure and thyroid dysfunction with respect to T3 was found to be significant.

CONCLUSION:
From the study it can be presumed that, there occurs a state of biochemical hypothyroidism in patients of CRF and extent of thyroid dysfunction depends upon the severity of renal failure. The low T3 is not due to increased T3 degradation or decreased T3 secretion, but as a result of impaired extrathyroidal T4 to T3 conversion. The reduction in T4 s due to presence of circulating inhibitors which impair binding of T4 to thyroxin binding globulin. Conservative management does not improve thyroid status through haemodilysis partially reverts back the abnormality.


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Jul22
STUDY OF DYSLIPIDEMIA IN CORONARY ARTERY DISEASE PATIENTS WITH TYPE - 2 DIABETES MELLITUS
Aims and Objective:
Dyslipidemia is associated with 50% of all diabetic people and contributes to substantial increased risk (3-4 fold) of premature, extensive and accelerated atherosclerosis leading to CAD, PVD and MI etc. It remains silent in majority of patients with diabetes. This peculiarity makes CAD in diabetes the single most important cause of premature mortality accounting for 60-65% of all deaths. The aims of the present study was to determine the pattern of dyslipidemia in patients of CAD with type – 2 DM so as to initiate anti-lipidemic therapy for secondary prevention.

MATERIALS AND METHODS:
We studied 100 cases of type 2 DM with CAD and without CAS admitted to V.S.S. Medical College and Hospital, Burla, Orissa. The mean age group of the study was 30-69 years from both the sexes. The FBS and 2 hour PPBG was done by glucose oxidase method and serum lipid profile was estimated by enzymatic methods and compared to study the pattern of dyslipidemia.

Results:
In the present study dyslipidemia was found in 92% of diabetic patients with LDL hyperlipoproteinemia in 76% (LDL > 100mg%)HDL dydlipidemia in 64% (HDL < 40 mg%), hypertriglyceridemia in 925 (TG > 150 mg%) and hypercholesterolemia (56%) (> 200,g%). The lipid profile was significantly altered in patients with coronary artery disease compared to patients without coronary artery diseases.

Conclusion:
The major concern in the present study highlights the high percentage of LDL and TG dydlipidemia. However TC and HDL levels were of less significance. In the present study more than 90% of patients were smokers and alcoholics, LDL dyslipidemia is more significant from prognostic and therapeutic point of view, hence pharmacotherapy in the form of statins and TG dyslipidemia can be brought down by blood glucose control itself. Glycemic control should be the first priority followed by fibric acid derivatives or high dose statins.


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Jul22
MICROALBUMINURIA IN DIABETES MELLITUS AND ITS PROGNOSTIC SIGNIFICANCE
AIM OF THE STUDY:
Microalbuminuria is well established as the earliest detectable marker of nephropathy in Diabetes. Persistent microalbuminuria leads to nephropathy, cardiovascular changes and other complications. The present study was undertaken to correlate microalbuminuria in both type of Diabetes with complications.

METHODOLOGY:
One hundred cases of DM were studied during the period of January 2003 to December 2003. Urine samples of all cases were subjected to boiling test for detection of albumin (Microalbuminuria). Negative samples were subjected to micral test for microalbuminuria. Cases having definite previous history of Renal, Thyroid and Hepatic disease and Nephrotoxic drugs exposure were excluded from the study. All cases were subjected to detailed history, clinical and laboratory examination.

OBSERVATION:
In the present study out of 36 cases of Type 1 DM , 5 had microalbuminuria(13.8%) and out of 64 cases of type – 2 DM, 11 cases had microalbuminuria(17.1%). In both groups there was male preponderance (Type I, 17.3:7.6%; Type 2 21.5:12.5%). The 24 hour protein excretion was 14956.5 mg% in microalbuminuria cases. The mean systolic blood pressure was 145 19.95mm of HG in micral positive cases compared to 12622.83 mm of Hg in negative cases. The mean Blood pressure was 105.213.5mm of Hg in micral positive groups as compared to 91.312.63 mm of Hg in control group. The FBS and 2 hours PGBS was higher in micral positive groups. The creatinine clearance was 14712.9ml/min in micral group as compared to 12613.10 ml/min in negative groups indicating a significant increase in GFR in microalbuminuria cases. The serum cholesterol was high i.e 202.334.45 mg% in microalbuminuria cases indicating association of dyslipidemia specially in Type – 2 DM. Peripheral neuropathy, retinopathy and cardiovascular diseases were larger in patient with microalbuminuria <100 mg/24 hours suggesting renal hypertrophy is an early feature of diabetic renal disease and GFR was more in these patients. Renal biopsy showed basement membrane thickening in 11 cases and mesangial cell proliferation in 9 cases.
CONCLUSION:
In the present study microalbuminuria was correlated with different complications irrespective of the type of DM the systolic, diastolic and mean blood pressure was high. Neuropathy, retinopathy and cardiovascular complications were more in microalbuminuria cases and directly correlated with the duration of diseases. Renal hypertrophy was an early feature if nephropathy. Renal hisopathology was found to have a direct correlation with duration of disease and severity of microalbuminuria.


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Jul21
CORRELATION OF ECG CHANGES IN HYPOKALEMIC PERIODIC PALSY WITH SERUM POTASSIUM LEVEL
Aims and Objective:
To study the correlation of ECG changes in hypokalemic periodic palsy with serum potassium level.
Material and Method:
Thirty five cases of clinically diagnosed hypokalemic periodic palsy were included in this study admitted to medicine wards of VSS Medical College Hospital, Burla during the period of February 2004 to June 2004. Correlation between electrocardiographic changes i.e PR – interval , QRS – duration, QTc – interval, ST- Segment depression, flattening of T-wave and presence of U-wave and AV block with corresponding serum potassium level was studied.

Secondary causes of hypokalemia were excluded in this study.

Observation:
ECG Changes of 35 cases are tabulated below with serum potassium level
Se. K+ level in mEq/L Total Cases Prolonged PR interval Presence of U-wave
Mild (3.1 – 3.5) 1 0 1
Moderate (2.6-3) 14 1 14
Severe (<2.5) 20 05 20

There were one (2.9%) cases of mild, 14(40%) cases of moderate and 20(57.1%) cases of severe hypokalemia. At the time of admission all 35 (100%) cases showed flattering of T-wave with presence of U-wave in ECG and prolonged QTc – interval in 32(91.4%) cases. ST –depression was found only 20 (57.1%) cases. Out of 10 cases of AV – block, 6(17.1%) cases had first degree AV-block with prolonged PR interval and 4(11.4%) cases had second degree AV – block.

Out of 10 cases of AV- block 9 (90%) cases had AV-block with serum potassium level 2.5 mEq/L and 1(10%) case had AV block with serum potassium 2.8 mEq/L.

Conclusion:
Various types of ECG changes occur in moderate to sever hypokalemia and do not specify level of hypokalemia. However AV – block was present in majority cases of severe hypokalemia and presence of AV – block with other features of hypokalemic ECG changes preclude immediate potassium supplementation before the availability of serum potassium level reports.


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