Morbid Conditions Research Articles

Patterns of psychiatry morbidity in referred patients attending psychiatry out patient department in a tertiary centre

Background: Consultation-liaison psychiatry is an important part of psychiatry dealing with cases having co morbid general medical conditions. Psychiatrists need to be involved in evaluation of patients referred from other specialties.Objectives: To assess the patterns of psychiatry morbidity in referred patients attending psychiatry out patient department of Kathmandu Medical College.Methods: A total of 200 patients were referred to the department of psychiatry from different out patient departments during a period of six months. Each of them underwent a detailed psychiatric evaluation.Results: The mean age of the patients evaluated was 36.03 years; most of them were females (66.5%), married (67%), educated up to class seven (28%) and housewives (32.5%) living in a nuclear family (62.5%) coming from a middle income socio-economic status (75%). More than half (52%) referrals were from Medical ward coming with the chief complaint of headache (18.5%) followed by disturbance in sleep pattern (17%) and pain in more than three sites (17%). The most common psychiatric diagnosis was depression (49%) followed by anxiety (35.5%). A majority of the patients (55%) perceived their illness to be neurological and had received alternative treatment from a faith healer (26%) before being referred to the psychiatric out patient department.Conclusion: Psychiatric consultation was sought mostly by medical out patient department that had maximum number of patients. The commonest diagnosis seen in the referred out-patients was depression and anxiety disorder. Patients mostly presented with vague somatic complaints such as headache, disturbance in sleep pattern and pain over morethan three sites of the body.

TOTAL KNEE ARTHROPLASTY;

Objectives: We aim to evaluate the level of satisfaction after total knee arthroplastyprocedure in the patient population at a tertiary care hospital in Karachi, Pakistan, and to assessthe relationship between patient satisfaction and the outcome based on traditional scores.Methods: Study Design: Case series for determination of patient satisfaction. Period: Oneyear duration from April 2015 to May 2016. Setting: Tertiary care centre in Karachi, Pakistan.The inclusion criteria was all the patients with late stage osteoarthritis of the knee joint andunderwent total knee arthroplasty at our institute. Data was analyzed using SPSS version 22.Results: A total of n= 102 patients were included in the study while n= 109 knee surgerieswere done in total (n= 95 patients had unilateral surgery, while n= 7 patients had bilateralsurgeries on both the knee joints) n= 58 patients were females while n= 44 patients weremales, the median age was 60 years, patients had a mean body mass index (BMI) of 27kg/m2. Of the total surgeries performed n= 100 were in the satisfaction group while n= 9 were inthe dissatisfaction group. The majority of the patients reported that they would recommend theprocedure. The co morbid conditions did not affect the patient’s level of satisfaction having ap value of 0.678. In the dissatisfied group, there was no significant difference when it comes togender, the mean age of patients in the dissatisfaction group was higher than the mean age ofpatients in the satisfaction. We found that WOMAC scores for functioning and the final WOMACscores were correlated with patient satisfaction and that was statistically significant, similarlySF-36 form patients were satisfied about the improvement in the physical health while they didnot improve the mental health aspect of their disease. Conclusion: According to our studytotal knee arthroplasty is an effective treatment for osteoarthritis of the knee, patient satisfactionis correlated with post-operative WOMAC function and overall scores, and SF-36 physicalcomponent. It is important to keep patients expectations in check through proper counseling.

English

Objectives: We aim to evaluate the level of satisfaction after total knee arthroplastyprocedure in the patient population at a tertiary care hospital in Karachi, Pakistan, and to assessthe relationship between patient satisfaction and the outcome based on traditional scores.Methods: Study Design: Case series for determination of patient satisfaction. Period: Oneyear duration from April 2015 to May 2016. Setting: Tertiary care centre in Karachi, Pakistan.The inclusion criteria was all the patients with late stage osteoarthritis of the knee joint andunderwent total knee arthroplasty at our institute. Data was analyzed using SPSS version 22.Results: A total of n= 102 patients were included in the study while n= 109 knee surgerieswere done in total (n= 95 patients had unilateral surgery, while n= 7 patients had bilateralsurgeries on both the knee joints) n= 58 patients were females while n= 44 patients weremales, the median age was 60 years, patients had a mean body mass index (BMI) of 27kg/m2. Of the total surgeries performed n= 100 were in the satisfaction group while n= 9 were inthe dissatisfaction group. The majority of the patients reported that they would recommend theprocedure. The co morbid conditions did not affect the patient’s level of satisfaction having ap value of 0.678. In the dissatisfied group, there was no significant difference when it comes togender, the mean age of patients in the dissatisfaction group was higher than the mean age ofpatients in the satisfaction. We found that WOMAC scores for functioning and the final WOMACscores were correlated with patient satisfaction and that was statistically significant, similarlySF-36 form patients were satisfied about the improvement in the physical health while they didnot improve the mental health aspect of their disease. Conclusion: According to our studytotal knee arthroplasty is an effective treatment for osteoarthritis of the knee, patient satisfactionis correlated with post-operative WOMAC function and overall scores, and SF-36 physicalcomponent. It is important to keep patients expectations in check through proper counseling.

Epidural Anaesthesia Saved A Patient With Multiple Co-Morbid Condition

Epidural anaesthesia has been routinely used for many years and widely accepted as an effective mathod of pain relief . The procedure is commonly performed as a sole anaesthesic or in combination with spinal or general anaesthesia. In our case Md. Alauddin, 59 years old male was admitted in KYAMCH with complaints of diabetic gangrene of right foot with features of septicemia and he has a long history uncontrolled diabetes mellitus and hypertension leading to developed ischemia heart disease and CRF. After proper evaluation patient's physical status was graded as ASA (American society of Anesthesiologists) class-IV, and selected for above knee amputation of right lower limb but patient was unfit for anesthesia due to his co morbid conditions. As a life saving procedure the operation was done under epidural anesthesia and per- operative and postoperative recovery was uneventful.KYAMC Journal Vol. 7, No.-1, Jul 2016, Page 729-730

Prevalence and pattern of co morbidity among type2 diabetics attending urban primary healthcare centers at Bhubaneswar (India).

ObjectiveIndia has the second largest diabetic population in the world. The chronic nature of the disease and high prevalence of co-existing chronic medical conditions or “co morbidities” makes diabetes management complex for the patient and for health care providers. Hence a strong need was felt to explore the problem of co morbidity among diabetics and its dimensions in primary health care practices.MethodThis cross sectional survey was carried out on 912 type 2 diabetes patients attending different urban primary health care facilities at Bhubaneswar. Data regarding existence of co morbidity and demographical details were elicited by a predesigned, pretested questionnaire“Diabetes Co morbidity Evaluation Tool in Primary Care (DCET- PC)”. Statistical analyses were done using STATA.ResultsOverall 84% had one ormore than one comorbid condition. The most frequent co morbid conditions were hypertension [62%], acid peptic disease [28%], chronic back ache [22%] and osteoarthritis [21%]. The median number of co morbid conditions among both males and females is 2[IQR = 2]. The range of the number of co morbid conditions was wider among males [0–14] than females [0–6]. The number of co morbidities was highest in the age group > = 60 across both sexes. Most of the male patients below 40 years of age had either single [53%] or three co morbidities [11%] whereas among female patients of the same age group single [40%] or two co morbidities [22%] were more predominantly present. Age was found to be a strong independent predictor for diabetes co morbidity. The odds of having co morbidity among people above poverty line and schedule caste were found to be[OR = 3.50; 95%CI 1.85–6.62]and [OR = 2.46; CI 95%1.16–5.25] respectively. Odds were increased for retired status [OR = 1.21; 95% CI 1.01–3.91] and obesity [OR = 3.96; 95%CI 1.01–15.76].ConclusionThe results show a high prevalence of co morbidities in patients with type 2 diabetes attending urban primary health care facilities. Hypertension, acid peptic disease, chronic back ache and arthritis being the most common, strategies need to be designed taking into account the multiple demands of co morbidities.

Defining definitions: a Delphi study to develop a core outcome set for conditions of severe maternal morbidity.

Develop a core outcome set of international consensus definitions for severe maternal morbidities. Electronic Delphi study. International. Eight expert panels. All 13 high-income countries represented in the International Network of Obstetric Surveillance Systems (INOSS) nominated five experts per condition of morbidity, who submitted possible definitions. From these suggestions, a steering committee distilled critical components: eclampsia: 23, amniotic fluid embolism: 15, pregnancy-related hysterectomy: 11, severe primary postpartum haemorrhage: 19, uterine rupture: 20, abnormally invasive placentation: 12, spontaneous haemoperitoneum in pregnancy: 16, and cardiac arrest in pregnancy: 10. These components were assessed by the expert panel using a 5-point Likert scale, following which a framework for an encompassing definition was constructed. Possible definitions were evaluated in rounds until a rate of agreement of more than 70% was reached. Expert commentaries were used in each round to improve definitions. Definitions with a rate of agreement of more than 70%. The invitation to participate in one or more of eight Delphi processes was accepted by 103 experts from 13 high-income countries. Consensus definitions were developed for all of the conditions. Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process. These should be used in national registrations and international studies, and should be taken up by the Core Outcomes in Women's and Newborn Health initiative. Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process.

A community based study on perceived knowledge of diabetes on cause, control, prevention and complications among diabetic patients in Bengaluru city

Background: The numbers of diabetes mellitus cases are increasing among all sections of Indian population. The knowledge about the disease, associated complications and co-morbidities are not satisfactory among the public including diabetic patients. The objective of the study was to assess the perceived knowledge and determining factors on onset, control, prevention and complications of diabetes mellitus in urban area of Bengaluru.Methods: A cross sectional, descriptive and community based study with a sample size 770 randomly selected known diabetics was conducted during May to July 2016 in Bengaluru city by direct interviewing them at their doorsteps using pretested questionnaire. The data contained information about the socio-demographic profile, knowledge about the warning signs, complications, controllability, consequences and co morbidities. Data was analysed in SPSS version 18.Results: There were 43.7% and 57.5% of males and females respectively. Seventy percent of females were homemakers and two third were literates. The maximum numbers of subjects were in the age group of 41-60 years with mean age of 56±11.6 years. Family history of diabetes was present among 40%. The median duration of diabetes was 48 months (range 1 to 360) and 38% of the subjects had co morbid conditions related to cardiovascular diseases and other systems. The perceived knowledge related to prevention, complications, consequences and controllability of diabetes was not adequate in relation to their literacy status, family history and duration of diabetes. The overall perceived knowledge was better among females than male subjects.Conclusions: The perceived knowledge about the different aspects of diabetes care at the personal level of diabetics were inadequate and needs periodic counselling as intervention measures.

Convulsions in pregnancy-not always eclampsia role of neuro-imaging in diagnostic dilemma

Background: Convulsions in pregnancy is always considered and treated as Eclampsia unless otherwise proved. Eclampsia is associated with increased risk of maternal death varying from 1.8 % to 14 % in developed countries. Despite availability of Intensive care units and improved antenatal care, some women still die from Eclampsia. Cerebral complications are the major cause of death in eclampsia patients. Hypercoagulopathy of pregnancy is a high risk factor for these patients in respect to development of cerebro vascular thrombosis and ischaemic strokes. Eclampsia patients who are refractory to the routine treatment have been found to have various Central Nervous System pathological conditions amenable to the medical treatment.Objective: To study the neuro pathophysiology behind a seizure in pregnancy and to reduce the morbidity associated with it. To study the role of neuro-imaging in patients with convulsions in pregnancy not responding to treatment with magnesium sulphate (MgSo4).Methods: It was a prospective study design which included 50 antenatal mothers. All patients were admitted in the eclampsia room with history of convulsions and all of them were put on MgSo4 therapy and Antihyperertensives. The patients who were refractory to the treatment such as having recurrent convulsions despite therapy with MgSo4 were selected for neuro- imaging with Computed Tomography scan. Neuro-imaging was done using Phillips Tomoscan CT scanner where slices of 10-mm thickness were taken through the entire brain in the trans-axial plane. Abdomen shielding was done with lead shield to prevent radiation hazard in the antenatal period.The results were documented and analysed using appropriate statistical method.Results: The CT scanning report revealed: Cerebral oedema (30/50), Encephalopathy (10/50), Intra Cranial Haemorrhage (02/50) Cerebral infarction (01/50), Cortical venous sinus thrombosis (01/50), Tuberculomas (01/50), Neurocysticercosis (01/50) and Hydrocephalus (01/50). Three patients out of 50 had normal CT scan report. Conclusion: Patients with convulsions in pregnancy who were refractory to the treatment with MgSo4 and Antihypertensives have been found to have very significant and morbid CNS pathological conditions. Neuro imaging in these patients have done a pivotal role in identifying the abnormality and rectifying it with medical means which had definitely improved patients conditions and have reduced morbidity and mortality. Health Renaissance 2015;13 (3): 144-151

Severe maternal morbidity: A population-based study of an expanded measure and associated factors.

Severe maternal morbidity conditions such as sepsis, embolism and cardiac arrest during the delivery hospitalization period can lead to extended length of hospital stays, life-long maternal health problems, and high medical costs. Most importantly, these conditions also contribute to the risk of maternal death. This population-based observational study proposed and evaluated the impact of expanding the Centers for Disease Control and Prevention (CDC) measure of severe maternal morbidity by including additional comorbidities and intensive care admissions during delivery hospitalizations and examined associated factors. A New York State linked hospitalization and birth record database was used. Study participants included all New York State female residents, ages 10 to 55 years, who delivered a live infant in a New York acute care hospital between 2008 and 2013, inclusive. Incidence trends for both severe maternal morbidity measures were evaluated longitudinally. Associations between covariates and the two severe maternal morbidity measures were examined with logistic regression models, solved using generalized estimating equations and stratified by method of delivery. The New York expanded severe maternal morbidity measure identified 34,478 cases among 1,352,600 hospital deliveries (estimated incidence 2.55%) representing a 3% increase in the number of cases compared to the CDC measure. Both estimates increased over the study period (p<0.001). Covariates with an odds ratio > 1.5 included most measured comorbidities (e.g., pregnancy-induced hypertension, placentation disorder), multiple births, preterm birth, no prenatal care, hospitalization prior to delivery, higher levels of perinatal care birthing facilities and race/ethnicity. Expanding the measure for severe maternal morbidity during delivery to capture intensive care admissions provides a more sensitive estimate of disease burden. Perinatal regionalization in New York appears effective in routing high risk pregnancies to higher levels of perinatal care birthing facilities.

Effects of caregiving status and changes in depressive symptoms on development of physical morbidity among long-term cancer caregivers.

Cancer caregiving burden is known to vary across the survivorship trajectory and has been linked with caregivers' subsequent health impairment. Little is known, however, regarding how risk factors during long-term survivorship relate to vulnerability to caregivers' health during that period. This study examined effects of caregiving status and depressive symptoms on development of physical morbidity by 5 years postdiagnosis. Family caregivers (N = 491; Mage = 55.78) completed surveys at 2 (Time 1 [T1]) and 5 years (T2) after their care recipients' cancer diagnosis. Demographic and caregiving context variables known to affect caregivers' health were assessed at T1. Self-reported depressive symptoms and a list of physical morbid conditions were assessed at T1 and T2. Caregiving status (former, current, or bereaved) was assessed at T2. Hierarchical negative binomial regression revealed that current caregivers at T2 (p = .02), but not those bereaved by T2 (p = .32), developed more physical morbid conditions between T1 and T2 compared with former caregivers, controlling for other variables. Independently, caregivers reporting either newly emerging or chronically elevated depressive symptoms at T2 (ps < .03), but not those whose symptoms remitted at T2 (p = .61), showed greater development of physical morbidity than did those reporting minimal depressive symptoms at both T1 and T2. Results highlight the roles of long-term caregiving demands and depressive symptoms in cancer caregivers' premature physical health decline. Clinical attention through the long-term survivorship trajectory should be emphasized for caregivers of patients with recurrent or prolonged illness and to address caregivers' elevated depressive symptoms. (PsycINFO Database Record

Abstract 278: The Sister Study: Morbid conditions at enrollment in a breast cancer cohort

Abstract The Sister Study is a prospective cohort of 50,884 unaffected sisters of women diagnosed with breast cancer; given that participants were at increased risk of developing breast cancer, we wanted to investigate the prevalence of other conditions at enrollment. We compared demographic, lifestyle, and selected self-reported morbid conditions between Sister Study participants and women in NHANES, a representative sample of the US population, using age-adjusted prevalence, overall and by race/ethnicity. Demographically, women in the Sister Study are more likely than women in NHANES to be non-Hispanic white, well-educated and to have had higher household incomes. They were also somewhat more likely to have been post-menopausal at enrollment and have ever used hormonal birth control or hormone replacement therapy. The Sister Study has a lower prevalence of current smokers and a higher prevalence of alcohol consumption than among women in NHANES. BMI was lower in the Sister Study. Sister Study participants generally had a lower age-adjusted prevalence of self-reported chronic morbid conditions at baseline than did women in NHANES. For cardio- and cerebrovascular conditions, for example, heart attack and stroke were lower in the Sister Study (0.9% vs. 2.4%; 0.6% vs. 3.1%, respectively) as were self-reported hypertension and high cholesterol (22.8% vs. 34.5%; 28.6% vs. 40.7%). This pattern was similar across all race/ethnicity groups with the exception of angina, which was similar to NHANES overall (2.1% vs. 2.2%). Prevalence of diabetes was lower in the Sister Study (4.9% vs. 9.5%) as were cancers other than breast or non-melanoma skin (4.4% vs. 8.1%) and rheumatoid arthritis (3.3% vs. 6.2%). Again, this was similar across race/ethnicity groups. A few conditions had a higher prevalence in the Sister Study: uterine fibroids, endometriosis, osteoporosis, and allergies (22.0% vs. 13.7%; 12.2% vs. 7.7%; 17.0% vs. 8.6%; and 54.1% vs. 44.2%). Thyroid disease (excluding cancer), asthma, Crohn’s disease, and ulcerative colitis were similar in the Sister Study and NHANES (19.4% vs. 18.5%; 14.6% vs. 15.0%; 0.5% vs. 0.4%; and 1.4% vs. 1.3%). Two or more morbid conditions were reported by just over one third of Sister Study participants. After restriction to college graduates, differences between the Sister study and NHANES were no longer apparent. The few exceptions were differences that would be expected, given Sister Study participants’ ability to participate in a long-term study, healthy behaviors and access to care: lower prevalence of hypertension and high cholesterol; higher prevalence of self-reported fibroids, osteoporosis, and allergies. Although Sister Study participants do differ in a few respects from the NHANES population, the cohort is a unique and well characterized resource, well-suited for research on the incidence of number of chronic conditions, in addition to breast cancer. Note: This abstract was not presented at the meeting. Citation Format: M. Elizabeth Hodgson, Whitney D. Arroyave, Sandra Deming-Halverson, Aimee A. D'Aloisio, Dale P. Sandler. The Sister Study: Morbid conditions at enrollment in a breast cancer cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 278. doi:10.1158/1538-7445.AM2017-278

CONTINUOUS MONITORING OF TURNING MOBILITY IN PATIENTS WITH ALZHEIMER’S DISEASE: A PILOT STUDY

Patients with Alzheimer's Disease (AD) frequently have impairments with spatial orientation and navigation. These deficits in spatial cognition are thought to contribute to the increased risk of falls and wandering in AD, which are highly morbid conditions for these patients. Recent studies using continuous activity monitoring in cognitively-normal older adults observed that reduced spatial cognitive skills was associated with poorer turning mobility. The goal of this study was to investigate the preliminary feasibility of continuous monitoring of turning mobility in AD patients, with the broader goal of developing an objective measure of spatial cognitive skills in AD patients. We recruited four AD patients into the study. The patients wore an Opal sensor (APDM, Portland, OR) on a belt on the lower back during normal daily activity and were instructed to wear the device for 4 consecutive days. An algorithm identified periods of walking from the 3D accelerations (>10 sec) and calculated the following turning metrics that occurred while walking: 1) number of turns occurring in each 30 min period, 2) turn angle amplitudes, 3) turn durations, 4) turn velocities (mean and peak). We were able to successfully record from all 4 patients (mean age 77.3 years, 75% male, MMSE range 13–24). The number of days of use ranged from 2–5 days, and the number of hours of use ranged from 16.5–45.5 hours. Data on turning mobility were generated for all 4 patients. The only quantity that differed substantially between data from healthy older adults and the AD patients was mean turn angle which was higher in the older adults (96° vs. 75°). In this pilot study, AD patients (even with an MMSE of 13) tolerated the Opal continuous monitoring device and provided evaluable data on turning mobility. We determined that 4 days of monitoring (yielding at least 36 hours of data) would be needed to provide sufficient data for estimation of turning mobility parameters. The next steps of this study are to complete recruitment of a total of 25 patients, and evaluate whether turning mobility is associated with MMSE and spatial cognition in AD patients.

Estilo de vida e intervenções não farmacológicas no tratamento e na prevenção das síndromes geriátricas: uma revisão integrativa

As grandes síndromes geriátricas — insuficiência cognitiva, instabilidade postural, incontinência urinária, iatrogenia e imobilidade — estão associadas ao declínio da capacidade funcional de importante parcela da população idosa. Esta revisão faz uma compilação e análise de estudos que abordam a importância do estilo de vida, da alimentação, de exercícios físicos, e de outras medidas não farmacológicas, na prevenção e no tratamento dos chamados “gigantes da geriatria”, condições de alta prevalência e morbidade na população idosa.

Revisiting Interdialytic Weight Gain and Mortality Association With Serum Albumin Interactions: The Japanese Dialysis Outcomes and Practice Pattern Study

The dialysis practice guideline in Japan sets a limit on the allowed interdialytic weight gain (IDWG) <6%. However, the effects of relative gain of fluid volume to body weight may differ in presence of morbid conditions. Here, we examined whether or not the associations between IDWG and mortality differ by serum albumin (sAlb), a nutritional and illness marker. The study type used was prospective cohort study. Patients who participated in the Japan Dialysis Outcomes and Practice Pattern Study (phase 1-4 [1999-2011]) and received thrice-weekly hemodialysis. IDWG was the exposure of interest and was collected every 4 months, divided into 7 categories as follows: <2%, 2% to 3%, 3% to 4% (reference), 4% to 5%, 5% to 6%, 6% to 7%, and >7%. sAlb was treated as both an effect modifier and confounder and dichotomized into ≥3.8g/dL and <3.8g/dL segments, according to the protein-energy wasting criteria proposed by the International Society of Renal Nutrition and Metabolism. The outcome in this study was all-cause mortality. A total of 8,661 patients were analyzed. Time-varying Cox regression analyses revealed that, when sAlb was ≥3.8g/dL, an IDWG >7% was associated with greater risk of mortality (adjusted hazard ratio [AHR] 2.74; 95% confidence interval [CI], 1.49-5.05). When sAlb was <3.8g/dL, however, IDWGs <2% (AHR 1.89; 95% CI, 1.50-2.39) and 4% to 5% (AHR 0.75; 95% CI, 0.58-0.96) were associated with mortality (P for interaction=.001). Cubic spline analyses showed that the mortality increased when IDWG exceeded 6% for patients with sAlb ≥3.8g/dL; in contrast, for patients with sAlb <3.8g/dL, the mortality increased when IDWG was <3% and decreased when IDWG was between 4% and 6%. The main limitation was possible residual confounding. The direction and magnitude of the associations between IDWG and mortality were modified by sAlb. Dialysis experts should take these results into account when revising the clinical practice guidelines.

Clinical Profile and Outcome of Necrotizing Fasciitis

Background: Necrotizing fasciitis is soft tissue infection which spreads through the facial planes. It is a surgical emergency with its rapid onset and varied occult characteristic can cause diagnostic delays resulting in high mortality and morbidity.Objectives: To study the clinical profile and evaluate the determinants of outcome in patients with necrotizing fasciitis.Methods: A descriptive study of patients admitted and operated in the surgical units of Nepalgunj Medical College and Teaching Hospital Kohalpur with a diagnosis of necrotizing fasciitis from January 2013 to December 2015.Results: Total of 45 patients were included in the study. There were 27(60%) male and 18(40%) female, male to female ratio being 1.5: 1. The patient's age ranged from 2 to 76 years with mean age being 48.04±19.62 years. 38(84.44%) patients had no predisposing factor however trauma was the triggering factor in 4(8.89%) cases followed by surgery and insect bite. Diabetes mellitus 26(57.78%) and alcohol dependence 5(11.11%) cases were the most common co morbid condition associated with the disease. The lower limb 28(62.22%) was the most common site followed by upper limb, scrotum, perineum, trunk and abdomen. The growth was polymicrobial in 24(53.33%), mono microbial in 16(35.56%) and sterile in 5(11.11) cases . Staphylococcus aureus was predominant in 24(53.33%) cases followed by Streptococcus, E coli, Klebsiella, Enterococcus. The main procedure was debridement with secondary suturing 23(51.11%) and debridement with grafting in 18(40%) patient. Amputation was done in 2(4.44%) and secondary wound healing was observed in 2(4.44%) patients. 39(86.67%) cases improved with the above management while mortality was observed in 3(6.67%). 3(6.67%) cases left against medical advice so outcome was unknownConclusion: On the basis of our study we concluded that high index of suspicion and awareness of the clinical presentation is required to diagnose this condition early. Diabetes mellitus is the most common co-morbid condition associated with necrotizing fasciitis. The presence of multiple co morbid conditions and delayed presentation reduces the survival rate. Early diagnosis and debridement, broad spectrum antibiotics with organ supportive intensive care will improve morbidity and mortality.JNGMC Vol. 14 No. 1 July 2016

Long-term use of proton pump inhibitors among community-dwelling persons with and without Alzheimer's disease.

The aim of this study is to determine the prevalence of use and long-term use (≥180days) of proton pump inhibitors (PPIs) and associated factors among community-dwellers with and without Alzheimer's disease (AD). MEDALZ cohort encompassed all persons who received a verified diagnosis of AD in Finland during the years 2005-2011 and their age-, sex-, and region of residence-matched comparison persons, including 69,353 persons with and 69,353 persons without AD. Data was derived from several Finnish administrative registers. A mathematical modelling method, PRE2DUP, was used for converting dispensing data to drug use periods (when regular PPI use started and ended). Morbid conditions and concomitant drugs associated with use and long-term use of PPIs were assessed with logistic regression models. Use of PPIs was more common among comparison persons than persons with AD (39.0 and 35.8%, respectively, p<0.001), whereas long-term use of PPIs was more frequent among persons with than without AD (20.3 and 17.9%, respectively, p<0.001). Factors related to long-term use of PPIs were female sex, history of gastrointestinal bleedings, AD, rheumatoid arthritis, cardiovascular disease, asthma/COPD and use of bisphosphonates, SSRIs and antithrombotic agents. Median follow-up time was 2.6years among persons with AD and 3.5years among persons without AD. Median duration of the first long-term PPI use was similar in both groups (1.4years). Long-term use of PPIs was common among persons with and without AD. Due to possible adverse events associated with the long-term use of PPIs, need for PPIs should be assessed regularly.

Cardiac Surgery in Developing Countries

This literature review summarizes recommendations and challenges encountered when establishing cardiac surgery centers in developing countries and common heart diseases encountered abroad. Cardiac surgery is not widely available in most developing countries, and most patients have no choice but to live in morbid conditions. The ideal continuous treatment for these patients would be provided by a local, sustainable cardiac surgery center. A collaborative effort from international volunteers, nongovernmental organizations, local governments, and private benefactors is necessary to facilitate adequate cardiac care in developing countries.

Describing Transitional Palliative Nursing Care Using a Standardized Terminology

We used a standardized terminology to describe patient problems and the nursing care provided in a pilot study of a transitional palliative care intervention with patients and caregivers. Narrative phrases of a nurse's documentation were mapped to the Omaha System (problem, intervention, and target). Over the course of the intervention, 109 notes (1473 phrases) were documented for 9 adults discharged home (mean age, 68 years; mean number of morbid conditions, 7.1; mean number of medications, 15.4). Thirty-one of the 42 Omaha System problems were identified; the average number of problems per patient was 13. Phrases were mapped to all 4 problem domains (environmental, 2.6%; health-related behaviors, 52.3%; physiological, 30.8%; and psychosocial, 14.3%). Surveillance phrases were the most frequent (72.4%); case management phrases were at 20.9%, and teaching, guidance, and counseling phrases were at 6.7%. The number of problems documented per patient correlated with the time between the first and last notes (ρ = 0.76; P = .02) but not with the number of notes per patient (ρ = 0.51; P = .16). These results are the first to describe nursing interventions in transitioning palliative care from hospital to home with a standardized terminology. Linking interventions to patient problems is critical for describing effective strategies in transitioning palliative care from hospital to home.

Memory and Learning Complaints in Relation to Depression among Elderly People with Multimorbidity.

Although current models of care are generally well-suited to providing treatment for individual medical conditions, the emergence of multimorbidity is becoming a serious concern for practitioners and policy researchers, particularly in developing countries. The challenges of tackling multimorbidity are further compounded when the multimorbidity co-occurs with psychiatric conditions such as cognitive and depressive disorders. Understanding the relationships between multimorbidity and psychiatric illnesses is therefore of considerable clinical importance. In the present study, we cross-sectionally examined whether multimorbidity has an association with perceived cognition—including memory, learning complaints, and depression—among elderly population in South Africa. Study subjects were 422 men and women aged 50 years and older. The prevalence of arthritis, asthma, cancer, diabetes, heart disease, chronic lung disease, hypertension, and stroke was respectively 31.5, 7.3, 1.7, 10.2, 1.2, 1.7, 52.1, and 31.5%, and that of multimorbidity was 30.8%. In the multivariate analysis, women with multimorbidity were 4.33 times (OR = 4.33, 95%CI = 2.96–14.633) more likely to report memory complaints. The odds of diagnosed depression were 1.4 times (OR = 1.4, 95%CI = 1.045–5.676), and the odds of self-reported depression were 1.7 times (OR = 1.7, 95%CI = 1.41–2.192) higher among women who had multimorbidity compared with those who had no morbid conditions. However, the association was not significant among men. Overall, the findings suggest that the occurrence of multimorbidity warrants special attention, especially regarding its compounding effects on psychological health. The findings need to be replicated through longitudinal studies that consider a broader range of chronic conditions.

Clinical and Biochemical Profile of Women Presenting with Hirsutism and It’s Treatment Outcome-A Prospective Study

INTRODUCTION: Hirsutism is a disorder which affects about 10 to 15 percent of women. Hirsutism is the most frequent androgen excess disorder in women1. Hirsutism is defined as the excessive growth of terminal hair in androgen dependent areas of a woman’s body. The sites affected include; The upper lip, Chin, Chest, Upper abdomen, Lower abdomen, Upper back, Lower back, Upper Arm, Thighs. Each of the nine areas is given a score of 0 to 4 depending upon the grade 1 –mild, 2-moderate, 3-complete light coverage and 4 for complete heavy coverage. A score of more than 15 is considered as severe hirsutism2. Occasionally, hirsutism may signal more serious pathology. Therefore, clinical evaluation should differentiate benign causes from tumours and other conditions that require specific treatment. Hirsutism should be differentiated from hypertrichosis. Hypertrichosis is defined as a diffuse increase in vellus hair growth and is not androgen dependent. The congenital causes of hypertrichosis include Hurlers syndrome, trisomy 18, fetal alcohol syndrome etc. The other causes include hypothyroidism, porphyrias, epidermolysis bullosa, anorexia nervosa, malnutrition, dermatomyositis, severe head injury and trauma. AIM OF THE STUDY: There are not many studies that look at the causes of hirsutism, their clinical profile and hormonal changes .Therefore, this study was undertaken to analyse the clinical profile, biochemical profile, various causes of hirsutism and the response to treatment. MATERIALS AND METHODS: Study Design: This is a prospective study. Period of Study: The period of study was from August 2010 to September 2011. Place of Study: Subjects were taken from Endocrinology clinic and Fertility Research centre, Institute of Obstetrics and Gynaecology, Govt Hospital for Women and Children, Egmore. Inclusion Criteria: Females with modified Ferriman-Gallwey scoring >8 were included in the study. After getting an informed consent from the subjects, they were subjected to clinical and biochemical evaluation after history taking. Exclusion Criteria: Women who were 60 years and above and pregnant women were excluded from the study. SUMMARY: In this study, 52 had ovarian causes, (46 – PCOS, 4- ovarian tumour, 2- premature ovarian failure), one had adrenal cause (late onset CAH), systemic cause (hypothyroid -6) for hirsutism.• Majority of cases of hirsutism in this study fall in the 21 – 30 years age group. • In addition to hirsutism, menstrual irregularity is the chief complaint. • Majority had hirsutism scoring of 9 to 11. Severe hirsutism (Scoring more than > 15) was seen in androgen secreting ovarian tumour and PCOS (4 cases). • Virilization features commonly were seen in all the 4 ovarian tumors and late onset CAH . Highly elevated free testosterone levels were seen in androgen secreting ovarian tumours and late onset congenital adrenal hyperplasia. • Subjects with hirsutism were either overweight or obese except ovarian tumours and CAH. • Co morbid conditions like hyperlipidemia, diabetes mellitus, hypertension were seen in few PCOS and few non PCOS subjects. • Level of the testosterone did not correlate with the severity of hirsutism in the PCOS group. CONCLUSION: This study evaluates the various causes of hirsutism, their clinical and biochemical profile and their outcome after treatment. Although PCOS is the most common cause for hirsutism, other causes should also be thought of. The treatment should be individualised depending upon the cause of hirsutism. We should have a high suspicion of virilizing tumours if features of virilization are present. Hirsutism has a response to OCP containing cyproterone acetate but the reduction in severity of hirsutism is mild. They might need increase in the duration of treatment and dosage of cyproterone acetate. Free testosterone and DHEAS may or may not be elevated in PCOS. Majority have normal levels. Free testosterone is highly elevated in androgen secreting ovarian tumours. This study has highlighted the importance of evaluating the other causes of hirsutism such as androgen secreting ovarian tumours and adrenal hyperplasia. Hirsutism causes cosmetic problem and psychological upset on a woman. It can also be a manifestation of an underlying health problem. Hence it should be properly treated so that a favourable outcome can be obtained.