The National medical journal of India最新文献

Background Thrombotic thrombocytopenic purpura (TTP) is a multisystem disorder characterized by widespread microthrombosis that can predispose to multiple organ failure. The literature is sparse on the outcomes of critically ill patients with TTP managed in intensive care units (ICUs). We aimed to determine the mortality of ICU patients admitted with TTP and evaluate the predictors of survival. We also compared the incidence of nosocomial infection among those who did or did not receive plasma exchange (PE). Methods We conducted a retrospective study in a tertiary ICU. Two authors screened patients for eligibility from the hospital information system based on peripheral smear reports. Adult critically ill TTP patients managed in ICU were included. Patients with a diagnosis of haemolytic uraemic syndrome, autoimmune causes of haemolysis and pregnancy-related conditions, etc. were excluded. Two authors extracted data from medical charts. No imputation of missing variables was done. Non-parametric statistics were used to report data. Statistical analyses were performed using Stata version 16. Results Of the 535 records that were screened, 33 patients were deemed eligible. Mortality among TTP patients was 14 (42%). The women to men ratio was 7:3. At admission, greater degree of anaemia, thrombocytopenia, and higher lactate dehydrogenase levels were observed in non-survivors compared to survivors (5.4 g/dl [4.8-7.1] v. 7.6 g/dl [6.1-8.9], p=0.05; 17x103 μl v. 21x103 μl, p=0.63; and 2987 (1904-3614) U/L v. 2126 U/L (1941-3319), p=0.71; respectively]. Nineteen (57%) patients had acute kidney injury (AKI), of which 11 survived: 6 recovered completely from renal failure and 5 progressed to end-stage renal disease. Nosocomial infection rates were not different among those receiving and not receiving PE therapy (7 [33%] v. 3 [25%], respectively). Conclusion TTP is more common in women and has a high mortality. Older age, low haemoglobin and higher platelet transfusions are predictors of poor survival. Nosocomial infection rates were similar irrespective of receiving PE therapy.

Background Infertility and its treatment are frequently associated with psychological distress. We assessed the prevalence of anxiety and depression in couples undergoing treatment for infertility with assisted reproductive techniques (ARTs). Methods We included 160 married couples undergoing treatment for infertility at an ART centre. The prevalence of anxiety and depression was assessed using the hospital anxiety and depression scale. Results The prevalence of anxiety and depression was 46.2% and 40.9%, respectively. Women had higher mean (SD) anxiety (10.76 [2.69]) and depression (9.86 [2.06]) scores; however, this gender difference was statistically significant only with respect to anxiety (p=0.02). The mean anxiety scores were highest among both genders when the cause of infertility was attributed to both partners and during the first year and 10 years after treatment. Men in the age groups of 20-24 years and 40-44 years and those with no prior treatment had a statistically significant association with the highest anxiety scores. The mean depression scores showed a statistically significant decline in both genders with increasing age. Among men, the mean depression scoreswere significantly higher in those with no prior treatment, male cause of infertility and during the first year and after 10 years of treatment. Conclusion The prevalence of anxiety and depression among infertile couples undergoing treatment with ART was almost twice as high as that in the general population. The mean anxiety scores were significantly associated with duration of treatment and gender-based attribution in both genders; however, age and prior treatment were associated with only men. The mean scores of depression were significantly associated with age in both genders, while duration of treatment, gender-based attribution and prior treatment were significantly associated only with men.

Background Fundus examination is an integral part of the clinical evaluation of patients with medical emergencies. It is done at the bedside using a portable direct ophthalmoscope. Smartphone fundus photography (SFP) is a novel technique of retinal imaging. We evaluated the use of SFP by a physician in medical emergencies and compared it with direct ophthalmoscopy (DO) findings of the ophthalmologist. Methods We did a prospective study on patients admitted with medical emergencies with an indication for fundus examination. The SFP was done by the physician, and its findings were noted. These were compared with the DO findings of the ophthalmologist. Results Of the 182 patients studied, 111 (61%) had fundus findings by SFP and 95 (52.5%) by DO. Papilloedema (21.4%), haemorrhages (20%) and Roth spots (12.5%) were most common. DO missed early papilloedema and findings in the peripheral retina. Conclusions SFP is as effective as DO, in detecting retinal findings in patients with medical emergencies and can be performed at the bedside by the physician.

We report a 26-year-old girl who was diagnosed with diabetes mellitus in her childhood and was treated with insulin. With a history of visual disturbances during her childhood and anaemia, which was partially evaluated; the possibility of syndromic diabetes was considered. Genetic analysis was done and revealed a mutation in the SLC19A2 gene, confirming the diagnosis of thiamine-responsive megaloblastic anaemia. She was supplemented with thiamine, which dramatically improved her haemoglobin levels and glucose control. However, her vision could not be salvaged as the rod-cone dystrophy is a permanent damage.

Background Various clinical conditions can cause troponin elevation in the absence of myocardial ischaemia. Elevated troponin represents the likely occurrence of myocardial necrosis and does not itself provide any indication of the aetiology. Identifying the cause for troponin elevation and its sensitivity and specificity in predicting acute coronary syndrome (ACS) and cardiac mortality is an important step in determining the optimal management for these patients. Methods We retrospectively collected data of inpatients who had troponin I (TnI) testing as part of their clinical assessment, either in the emergency department, medical wards, coronary care unit (CCU) or intensive care unit (ICU) with their final diagnosis. TnI was used as the index test of sensitivity to diagnose ACS and either echocardiography or coronary angiogram in those available as the reference gold standard. They were classified into two groups of normal and elevated TnI, and further divided into those with ACS and no ACS. Data on clinical parameters and aetiology of elevated TnI in patients without ACS were analysed. Results Of the 254 patients studied, 114 patients (45%) had normal TnI and 140 (55%) had elevated TnI. Seventy-eight patients had ACS, 66 (84.6%) of whom had elevated TnI and 12 (15.38%) had normal TnI. Seventy-four (52.85%) of 140 patients with elevated TnI had alternate causes of TnI elevation; the most common being sepsis, acute kidney injury (AKI) and heart failure without ACS. All-cause mortality was significantly higher in patients with elevated TnI with or without ACS. There was no cardiac mortality among patients with ACS with normal TnI. Sensitivity and specificity of TnI for predicting ACS was 84.6% (95% CI 74.7%-91.8%) and 58% (95% CI 50.3%-65.3%), respectively. Conclusion A variety of conditions apart from myocardial infarction can lead to elevated TnI. Hence, caution should be exercised while diagnosing a patient with ACS based on TnI value in the absence of other supporting evidence given its low specificity. Elevated TnI portends a worse prognosis regardless of the aetiology and has a role in predicting all-cause and cardiac mortality.

Background In general surgery, a clinician is commonly required to break bad news. However, training in communication is not a part of the formal curriculum either in medical school or in surgical residency and there is a paucity of data on awareness of the SPIKES (Setting up the interview, Perception, Invitation, Knowledge sharing, Emotion, Strategy and Summary) protocol among practising surgeons and residents in India. Methods We did a cross-sectional study in the Department of General Surgery at our institution. Junior residents were invited to take part in a one-on-one interview. Descriptive statistics were used to describe the findings of the study. Comparison for categorical data was done using Fisher exact test or chi-square test (whichever was applicable). Results A total of 82 residents with mean (SD) age of 27 (2.5) years (range 23-37 years) participated in the study. Only 31 (37.8%) had ever received training for breaking bad news, though 80 (97.6%) had broken bad news at least once. Twenty-one (26.3%) participants had a bad experience while breaking bad news. Seventy-seven (93.9%) participants felt the need for training in breaking bad news and 76 of them were willing to attend the same. Although the complete SPIKES protocol was followed only by 25 (31.3%) residents, 46 (56.1%) felt that it was practically possible to follow the SPIKES protocol. Conclusion Resident doctors in general surgery face situations of breaking bad news and adherence to the SPIKES protocol is poor. Formal training at every level may enhance their communication skills and enable better healthcare delivery.