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Presented by DR.SREEKALA.M

JOURNAL REVIEW

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CLINICAL PROCEEDINGS
PUBLISHED BY DEPARTMENT OF MEDICINE CALICUT MEDICAL COLLEGE JANUARY- FEBRUARY 2010 VOL.6 ISSUE NO:1

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EDITORIAL BOARD
EDITOR IN CHIEF DR.P.K.SASIDHARAN HOD EXECUTIVE EDITORS- DR.SREEJITH.R, DR.SHIJI.P.V MEMBERS- DR.N.K.THULASEEDHARAN, DR.V.UDHAYABHASKARAN, DR.P.MOHAMMED, DR.BINOY.J.PAUL, DR.JAYESH KUMAR, DR.K.G.SAJEETHKUMAR
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All communications may be addressed to

DR.P.K.SASIDHARAN Editor in chief Department of internal medicine Medical college, calicut Pin 673 008, ph- 0495-2352065 e-mail sdharanpk@yahoo.com drsreejith41@gmail.com
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CONTENTS
REVIEW ARTICLES ORGINAL ARTICLES DRUG REVIEW CASE REPORTS X-RAY, ECG,PHOTOQUIZ GENERAL ARTICLE

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FROM THE EDITORS DESK

DR.P.K.SASIDHARAN

Various problems in healthcare system

Lack of comprehensive health care policy Consequent elimination of family doctors and even generalist doctors Unchecked proliferation of single system specialists Lack of referral system

Various problems in medical education

Against new modern medicine(BRMS) course offered by government Importance of society oriented research and patient care

About articles in the journal

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Original articles
Sl.no : 1 2 SLE & BLOOD A SIMPLE URINE TEST FOR DIAGNOSIS& DAY TO DAY MANAGEMENT OF DIABETES MELLITUS ARTICLE AUTHORS P.K.SASIDHARAN M.V.IMBICHI MAMMI

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SLE & BLOOD

Hematological manifestation is the most common presenting problem in SLE In many cases investigations may be negative early on and finally during follow up other features come up and diagnosed as SLE The manifestations are in the following order of decreasing frequency: hematological>skin>renal>endocrine>eye>joint involvement>CNS involvement These observations are based on more than 300 proven SLE, all of whom came as diagnostic problems, not as established cases
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 The observations have given us better insight into the etiology of the disorder Some case histories are given to highlight the key observations Suggests that the criteria used to diagnose SLE needs revision A practical guide line to diagnose SLE is suggested at the end of the discussion

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etiology
It is possible to postulate that females or males with genetic background, with probable predisposing genes on X chromosomes, develop the disease due to their abnormal lifestyles and dietary habits, combined with lack of protective elements in diet or some environmental problems

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1. 2. 3. 4. 5. 6.

Indian criteria forconsistent with SLE One clinical problem/autoimmune disorder

SLE(eg. ITP, AIHA,APLA,MDS,ADEM,skin lesion, hypothyroidism) Rule out other causes for that disorder- by clinical reasoning and investigations Another co-existing autoimmune disorder/evidence of autoimmunity ANA positive Anti ds DNA positive Sustained and definite response to treatment with steriod & immune suppresents 1+2 are essential + any two of the remaining 3 to 6 is diagnostic 1+2+any one of 3-6 is almost always SLE

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conclusion
SLE/ ITP is only a manifestation, and the most important investigation to find out etiology is clinical skill+observation Observe and study the diet , life style and environment

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 This simple urine test for diagnosis and day today management of DM which empowers the patient is the first step towards an efficient management of diabetes

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Diagnosis of DM
SYMPTOMS PRESENCE OF ANTS AT THE SITE OF URINATION TASTING

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Gold standard for diagnosis of DMblood estimation by(GOD/POD)-enzymatic calorimetric method

To 1ml of GOD/POD reagent solution 10L of plasma is added, incubated at 37C for 10 minutes a pink color develops if glucose is present Merits Accurate result possible Hypoglycemia can be detected

Demerits
Time consuming Patient has to go to lab Blood has to be taken by vein puncture Costly Inconvenient for the patient to do the test many times a day and when required
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Hexokinase method
Not at all patient friendly as the color developed is below the ultra violet range and cannot be detected by human eyes

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 Even 1mg% of glucose could be detected by an autoanlyser 10-15% of benedicts negative cases were shown to be positive The intensity of pink colour developed was proportional to the glucose concentration Test standardised to overcome limitationsstandard color charts This method was tested and studied in thousands of diabetic patients during the last 12 years
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Application of results of lab to real life situations

Camps conducted in northern kerala With following instructions to patients
Take 3-4L of water everyday for 7 days prior to the camp To come to the campus coming for a fasting blood glucose To pass urine to the last drop just before starting to the camp
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Blood & urine samples tested by 4 methods 1.Benedicts test 2.Urine test strip method 3.GOD/POD method 4.Modified GOD/POD method

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Results of positive cases in the first 1000 cases analysed

Urine tests 1 2 3 4 Positive out of 1000 Benedicts test urine test strip method GOD/POD method Modified GOD/POD method % positive 730 810 870 870 73% 81% 87% 87%

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Color chart with the corresponding blood glucose values and no: of patients in each group
Vial no: Con: of glucose in each vial Color developed with known con: of glucose Corresponding range of blood glucose No: of +ve cases in each group 146160mg% 50 175195mg% 650 210-225mg % 100 235265mg% 45 275300mg % 20(+5) 1 10 mg% 2 25mg% 3 50 mg% 4 75mg% 5 100mg %

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Main observations
Renal threshold for glucose is around 150 mg % and not the old 180 mg% Superior sensitivity

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Other advantages of new test

Cheap and simple. It costs only Indian rupees2/- per test, hassle free and risk free No chance of false positive and false negative results Hypoglycemia?/hyperglycemia?/ - can be quickly solved by one drop of urine Best suited for conducting mass screening camps Pricks can be avoided in diabetic keto acidotic coma with indwelling catheter No pricks are required for type1 (IDDM)patients except for insulin delivery No GTT or frequent blood estimation is necessary for pregnancy diabetes Single testing process to quantify glucose level both in urine & blood
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 Single color chart is easier for the patients to monitor the changes themselves. Non-invasive and can be done many times a day by the patients themselves Empowers the patient to regulate their food physical activity and medication to maintain normal blood glucose level. If a test becomes negative , the same solution can be used again To sum up it can be said that the painful and invasive blood glucose estimation need not be done in future except when there is raised renal threshold, renal glycosuria or when the patient is unable to provide one drop of proper urine.
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REVIEW ARTICLES
SL.NO: 1 2 ARTICLE CHIKUNGUNYA DIABETES IN ELDERLY AUTHOR RAVEENDRAN.A.V K. CHANDINI

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Case definition
Clinical criteria
Acute onset of fever > 38.50C Severe arthralgia/ arthritis Not explained by other medical condition

Epidemological criteria
Residing or having visited epidemic areas Within 15 days prior to the onset of symptoms www.similima.com

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 Laboratory criteria

POSSIBL CASE: meeting clinical criteria PROBABLE CASE: meeting clinical +epidemological criteria CONFIRMED CASE: meeting lab criteria irrespective of clinical presentation
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Virus isolation Presence of viral RNA by RT-PCR Presence of virus specific Ig M antibody Four fold increase in Ig G values in samples collectedatleast 3 weeks apart

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 By 2026,almost every 6th individual in kerala is expected to be a senior citizen Diabetes is a highly prevalent, and expanding chronic health problem for older people. We as clinicians confronted with an elderly diabetic in his clinical practice must understand the similarities & differences in the pathophysiology and management of diabetes in older vs middle aged adults
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INTRODUCTION
Leptospirosis ia very common disease in kerala especially during rainy season Little data is available regarding the relation between nutritional status of patients & outcome of the illness There are no studies conducted to assess the life style disorders like alcoholism and smoking on the mortality & morbidity of leptospirosis Myalgia & muscle tenderness are important clinical features of leptospirosis along with fever for which NSAIDS are widely prescribed. The adverse effects of this drug group which cause renal & hepatic dysfunction in a patient with a disease like leptospirosis are under recognised
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objectives
To evaluate the clinical spectrum, outcome of the patients and biochemical parameters with leptospirosis To assess the influence of diet, lifestyle and NSAIDS on the outcome of leptospirosis To study the epidemological profile of leptospirosis To look for the dignostic predictability of clinical features in comparison with investigation

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Materials & methods

150 patients with selected leptospirosis who presented between may 1st & october 31st of 2009, were selected for study A detailed history and physical examination along with relevant investigations were done in suspected cases History was taken with special emphasis on of diet and lifestyle, history of medication especially NSAIDs blood count,ESR,renal, liver function tests, IgM leptospiral antibody test were done in all cases Number of days as inpatient treatment & outcome were analysed in different groups as with patients with NSAIDs and without NSAIDs Diet Lifestyle Body mass index

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observations

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conclusions

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format

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CASE REPORTS
Sl.no: 1 2 3 4 5 6 7 8 9 10 11 TITLE thymoma with pure red cell aplasia A case of young stroke due to CNS Tuberculosis An unusual cause of hypokalemic paralysis A case of chronic progressive external opthalmoplegia A case of pheochromocytoma A case of polycythemia rubra vera A case of cerebral venous thrombosis A case of pophyria A case of plasma cell lukemia A case of essential thrombocytemia presenting as digital gangrene A case of APLA syndrome presenting as young stroke
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Sl.no: 12 13 14 15 16 17 18 19 20 21 22 23 24

TITLE A rare complication of chikungunya fever A case of biphenotypic lukemia presenting as prolonged fever Successful medical treatment of a large hydatid cyst A case of dermatomyositis presenting as muscle weakness A case of tuberculous liver abscess A case of sub acute cutaneous erythematosis A case of Budd Chiari syndrome due to secondary polycythemia A case of idiopathic intracranial hypertension A case of tuberculous constrictive pericarditis Bernard soulier syndrome presenting as hemorrhagic cyst of ovary Leptomeningeal metastasis from adenocarcinoma lung A case of wilsons disease
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ABSTRACT
18 yearold female presented with 4 days history of fever with sore throat, vomiting & loose stools followed by weakness of both upper& lower limbs associated with pain. Examination revealed symmetric flaccid paralysis with areflexia. Investigations revealed hypokalemia with type 1 RTA. ANA profile done showed a serological positivity for sjogrens syndrome. Here we report a case of hypokalemic paralysis due to type 1 RTA lacking the typical sicca syndrome, but with serology suggestive of sjogrens.
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General article
Why swine flu and what we should be doing?

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