Publications

Functional neurological disorders (FNDs) are altered voluntary symptoms incompatible with recognized medical or neurological conditions, causing significant distress to the patient. It is not a diagnosis of exclusion, but positive signs must be used to make a confident diagnosis and initiate appropriate management at the earliest. The understanding of FNDs has evolved over decades from supernatural power in the Mesopotamian age to the current neurocircuitry dysfunction and yet continues to be an area of active research. The evolution of various theories and terminologies for these disorders has been highlighted in this article in addition to key clinical signs for the diagnosis of various subsets of these disorders. In this article, FNDs are grouped into functional limb weakness, functional seizures, functional movement disorders, functional gait disorders, functional pseudosyncope, and functional cognitive dysfunction, and important clinical clues of diagnosis are discussed. FNDs contribute to about 5-10% of outpatient neurological consultations, and identification of appropriate positive clinical signs plays a key role in early diagnosis and judicious use of investigations (Bennett et al., 2021).1 Management of these disorders involves a multidisciplinary approach ranging from effective communication of the diagnosis and management of psychiatric comorbidities to individually tailored counseling and therapy sessions.

BACKGROUND: Healthcare practitioners (HCPs) face high stress levels at work due to the demanding nature of their profession, making them more susceptible to burnout. The objective of the study is to assess the prevalence of burnout among HCPs in India and to examine its relationship with age, gender, and working hours.

MATERIALS AND METHODS: A descriptive cross-sectional, pan India study was conducted from October 6 to 26, 2022. A total of 763 Indian HCPs participated in the study. The prevalence of burnout among HCPs was assessed using the Copenhagen Burnout Inventory (CBI). The CBI is a validated instrument that measures three dimensions of burnout: personal, work-related, and patient-related burnout. Data collected from the survey responses were analyzed using the Statistical Package for the Social Sciences (SPSS) version 18. Descriptive statistics were calculated to summarize the participants' demographic characteristics and burnout levels, including means, standard deviations (SD), frequencies, and percentages. A Chi-squared test was employed to examine associations and predictors of burnout among Indian HCPs.

RESULTS: Out of the 763 HCPs, 577 (76%) were males and 186 (24%) were females. The average age of the HCPs was 43.4 years. The prevalence of personal, work-related, and patient-related burnout was 47, 31, and 35%, respectively, with 24.9% experiencing all three types of burnout. Burnout was more common among female and younger practitioners. HCPs who spent longer hours a day treating patients and those with night duties and night calls reported higher burnout levels. A larger proportion of smokers reported work-related burnout. Regular exercise of at least 45 minutes and 6 hours of sleep was associated with lower burnout levels. Additionally, HCPs with anxiety as a medical condition were more likely to experience all three types of burnout.

CONCLUSION: This study reveals a significant prevalence of burnout among HCPs, with approximately 25% experiencing all three types of burnout. This raises concern, as burnout can have negative implications for the healthcare system. Further research is necessary to understand the impact of physician burnout on healthcare delivery and outcomes.

BACKGROUND: Systemic lupus erythematosus (SLE) is an autoimmune disorder with heterogeneous phenotypes. The symptoms range from mild to life-threatening features. Azathioprine (AZA) is a routinely used immunosuppressive agent in mild to moderate SLE. Although bone marrow suppression is reported in AZA usage, severe alopecia is not very common with AZA.

CASE DESCRIPTION: We report a 45-year-old female with stable clinical and serological lupus maintained on mycophenolate mofetil 500 mg twice per day and hydroxychloroquine 200 mg once per day. She was lost to follow-up with us for >1 year. Since her disease was stable, we switched to AZA 25 mg twice per day to start with and escalated to 50 mg in the morning and 25 mg at night after 2 weeks, with an advice for 4-week follow-up after starting AZA. Hydroxychloroquine was continued at 200 mg once per day. No corticosteroids were used at this time as it was not deemed necessary. Monitoring blood tests for AZA were planned at 4 weeks. She presented at 6 weeks with severe leukopenia as summarized in the table of investigations below and the graph summarizing the trend in leukocyte counts after AZA usage. She was managed in the hospital with intravenous dexamethasone, antibiotic prophylaxis, and hematology consultation, who opined as AZA-induced severe bone marrow suppression and severe alopecia due to AZA. Bone marrow examination was not deemed necessary by the hematologist. AZA was stopped in the hospital and mycophenolate mofetil was prescribed in the immediate follow-up after discharge, as she had previously responded to this drug. Hydroxychloroquine continued throughout her hospital stay. Although her blood counts responded very well after AZA withdrawal, it took nearly 3 months for her to have her normal scalp hair. One of the major differentials that was considered was SLE flare-up, but her clinical features and serology did not support a lupus flare.

CONCLUSION: Bone marrow suppression is a severe complication of AZA in SLE. Leukopenia and hair loss are the major adverse effects reported during the therapy of AZA. It is sensible to recognize this relationship as prompt diagnosis and treatment is crucial.

Maturity-onset diabetes of the young (MODY) was first described by Tattersall and Fajans in their classic paper published in 1975.1 At that time, the classification of diabetes was based purely on the age at onset of diabetes. Those diagnosed with diabetes below 40 years of age were labeled as "growth onset diabetes," while those with onset at or above the age of 40 years were referred to as "maturity onset diabetes." At that time, these types were believed to be equivalent to what are known as type 1 diabetes (T1D) and type 2 diabetes (T2D) today.

BACKGROUND: Iron deficiency anemia (IDA) is the most common cause of anemia and represents a significant global health problem. While the role of endoscopy in diagnosing IDA is well-established, the frequency and types of lesions identified vary widely across different regions. Factors such as symptomatology, complications, age, and geographic location significantly influence diagnostic outcomes. This study was conducted to evaluate the diagnostic yield of various endoscopic techniques in patients with IDA in an Indian cohort.

METHODS: This retrospective analysis included all patients evaluated for IDA in the Department of Gastroenterology and Hepatology from January 2016 to March 2023. Data collection included patient demographics, clinically significant endoscopic findings, and laboratory parameters such as hemoglobin levels, serum ferritin, total iron-binding capacity, and serum iron concentrations.

RESULTS: A total of 554 patients were initially enrolled, of whom 435 underwent upper gastrointestinal (GI) endoscopy, and 309 underwent colonoscopy after applying exclusion criteria. The diagnostic yield for detecting clinically significant lesions via upper endoscopy was 43.6%, while colonoscopy demonstrated a yield of 52.4%. Dual lesions were identified in 2.4% of all patients. The most common finding on upper endoscopy was peptic ulcer disease (13.3%), followed by esophageal varices (8.3%). On colonoscopy, colonic ulcers were the most prevalent finding (25.24%), followed by colonic malignancies (12%). Symptom presence was significantly associated with higher endoscopic diagnostic yield (p < 0.05).

CONCLUSION: GI endoscopy should be considered an essential diagnostic tool for all patients with IDA. The selection of the initial endoscopic modality should be guided by the presence of symptoms. Given the favorable risk-benefit ratio, GI evaluation is recommended across all age groups, including premenopausal women.

INTRODUCTION: In recent times, neutrophil-to-lymphocyte ratio (NLR) has garnered interest from all over the world as a multisystemic marker for ongoing inflammatory processes. It has been found to be independently related to poor clinical outcomes among patients with liver cirrhosis due to any cause.

AIM: To determine any significant correlation between NLR with Child-Turcotte-Pugh (CTP) score and model for end-stage liver disease (MELD)-Na score among patients with decompensated liver cirrhosis in a tertiary referral center in Ahmedabad, India.

MATERIALS AND METHODS: The cross-sectional study involved patients diagnosed with liver cirrhosis at SMS Multispeciality Hospital, Dr. M.K. Shah Medical College and Research Centre in March 2023. The study enrolled 16 cirrhotic patients, regardless of the etiologic agent. The CTP score was fulfilled by using two methods; bilirubin, albumin and international normalized ratio (INR) were noted from medical record registry, while ascites and encephalopathy were assessed using interview and physical examination on the day of patient admission. MELD-Na score was calculated by an online calculator after collecting data on all the patient's serum bilirubin, creatinine, sodium levels, and INR on the day of admission. The Spearman correlation test was performed to determine the correlation between two sets of variables, while the demographic characteristics were presented in a single table with mean or median and standard deviations.

RESULTS: A significant correlation between NLR and CTP score was obtained (p = 0.002), and it was positively correlated (r = 0.722). No significant correlation between NLR and MELD-Na could be established with a p-value = 0.149 and r = 0.378.

CONCLUSION: The NLR ratio may be used as an independent parameter to prognosticate the severity of decompensated liver disease. However, it still needs further study to acknowledge its potential.

BACKGROUND: The diagnosis of hypertension (HTN) is best achieved by ambulatory blood pressure monitoring (ABPM) as it helps differentiate sustained hypertension (SH) from white coat hypertension (WCH).

AIM: To diagnose SH and WCH in newly diagnosed hypertensive patients.

MATERIALS: All newly diagnosed hypertensive patients with office blood pressure measurement (OBPM) ≥140/90 mm Hg, attending the medical outpatient department and not on any antihypertensive treatment, were included in the study.

OBJECTIVES: To evaluate the clinical utility of ABPM in newly diagnosed hypertensive subjects by comparing OBPM with ABPM readings.

METHODS: This descriptive cross-sectional study was carried out on 196 newly diagnosed HTN patients over a period of 18 months. All hypertensive patients were subjected to ABPM. Patients with persistent HTN on ABPM were labeled as SH, whereas those with normal blood pressure on ABPM were labeled as WCH.

RESULTS: SH was diagnosed in 143 out of 196 (73%) patients. WCH was detected in 53 patients (27%). Patients with SH had a significant family history of HTN compared to patients with WCH (82.5 vs 45.3%, p = 0.00), higher office diastolic blood pressure (DBP) compared to WCH (96.56 ± 4.63 vs 94.13 ± 3.23, p = 0.000), and significant nondipping pattern compared to WCH (37.1 vs 18.9%, p = 0.015).

CONCLUSION: ABPM should be performed in all newly diagnosed hypertensive patients, especially if they have no family history of HTN and DBP is <95 mm Hg, to rule out WCH.

BACKGROUND: Edaravone is recommended for amyotrophic lateral sclerosis (ALS) based on a study showing an effect on a defined subset of patients.

AIM: To document the effect of edaravone in a cohort of ALS patients from India to find out if, after starting edaravone, there is a plateau period or significant slowing from baseline to compare results with existing literature.

METHODS: This was a single-center, prospective observational study with no control arm (due to ethical reasons). ALS patients >18 years of age, not requiring respiratory support or tube feeding, were included. All patients were given edaravone infusion in addition to standard of care and oral riluzole 50 mg twice daily. This consisted of giving the drug in monthly cycles over 6 months. The first cycle consisted of daily infusion of the drug for 14 days followed by a drug-free interval for the remaining part of the month. From cycle 2 to cycle 6, the patients received the drug for the first 10 days of the month followed by a drug-free interval for the remaining part of the month. The primary outcome was a significant change in Revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) score from baseline at 6 months. Secondary outcomes were monthly change in ALSFRS-R scores when compared with the previous month and baseline, change in the first 3 months compared to the change in the next 3 months, adverse drug effects, and number of deaths. The study was registered with the Indian Council of Medical Research Clinical Trial Registry of India with the trial number CTRI/2019/11/021838. Paired t-test was used for statistical analysis.

RESULTS: Thirty patients received the drug along with riluzole. Twenty-three patients completed all six monthly infusions. Two died (3 months), two developed adverse reactions (3 months) and did not want further infusions (one had breathing difficulty and the other had hypotension during infusion). Two withdrew consent due to perceived poor effectiveness of the drug. The mean ALSFRS-R at baseline was 35.17 [standard deviation (SD) 8.01; range 20-46]. The primary outcome showed a significant decline in the mean last available ALSFRS-R score 6 months by -4.9 (SD 1.21) (p < 0.01). For the secondary outcome measure, mean monthly ALSFRS-R score was calculated before each infusion after excluding dropouts. There was a significant monthly decline in ALSFRS-R score: -0.93 (SD 0.58), -1.0 (-0.52), -0.90 (SD 0.71), -0.87 (SD 0.61), -0.82 (SD 0.57), -0.95 (SD 0.63), respectively (p < 0.001). There was also a progressive monthly decline when compared to baseline. The rate of decline in the first 3 months was the same as in the remaining 3 months: -2.5 (SD 0.73) vs -2.6 (SD 0.98) (p = 0.3).

CONCLUSION: Edaravone infusion does not stop or significantly slow progression of disease from baseline but is safe.

INTRODUCTION: Fever and pain are natural body responses to infections and inflammation. This study aims to collect real-world data and compare the safety and effectiveness of nimesulide (100 mg), ibuprofen (400 mg) + paracetamol (325 mg), and paracetamol (650 mg) in individuals with fever or fever-related pain.

METHODS: A prospective, multicenter, comparative, and observational study was conducted in four centers across India with male and female subjects aged 18-60 years with fever or fever with pain. Fever reduction was assessed using a thermometer, and pain intensity was measured with the visual analog scale (VAS) at multiple intervals, up to 10 days.

RESULTS: The study enrolled 303 subjects, divided into three groups: (1) group I (nimesulide), (2) group II (ibuprofen + paracetamol), and (3) group III (paracetamol). Remarkable fever and pain reduction were exhibited in the nimesulide group. Its effect on fever reduction was observed within 15 minutes of administration, with a significant improvement in VAS scores. Patients on nimesulide showed greater fever reduction at 1, 2, 4, and 6 hours, continuing through day 8, and greater improvements in VAS, especially by day 1 (p < 0.0001). No serious adverse events or deaths were reported.

CONCLUSION: Nimesulide (100 mg) was superior to ibuprofen (400 mg) + paracetamol (325 mg) and paracetamol (650 mg) in managing fever or fever with pain, with a comparable safety profile.

BACKGROUND: The growing threat of antimicrobial resistance (AMR) poses a significant challenge globally in the treatment of respiratory tract infections (RTIs). The PERCEPT survey aimed to capture Indian healthcare practitioners' (HCPs) perspectives on the prevalence of RTIs, AMR patterns, AMR diagnosis, and clinical evaluation of cefpodoxime and its combination with clavulanic acid in managing RTIs.

MATERIALS AND METHODS: A structured questionnaire was used to conduct a cross-sectional survey among 1,000 healthcare professionals (HCPs) who manage RTIs in Indian adults and children, with 842 participants responding. The collected data were compiled and thoroughly analyzed.

RESULTS: Most HCPs reported RTIs in 26-50% of adult and pediatric patients, with the most common RTIs including pharyngitis/tonsillitis, bronchitis, and common cold. Streptococcus pneumoniae and Staphylococcus aureus were reported as the prevalent antibiotic-resistant microorganisms causing upper respiratory tract infections (URTIs) and lower respiratory tract infection (LRTIs). Antibiotic susceptibility testing (AST) is a common method to detect AMR in patients with RTIs. Among antibiotics, amoxicillin was the most common linked with resistance to microorganisms causing RTIs. Cefpodoxime alone or in combination with clavulanic acid was the most preferred drug for managing RTIs due to its high efficacy, broad-spectrum activity, safety, and better tolerability.

CONCLUSION: Indian practitioners find cefpodoxime monotherapy and its combination with clavulanic acid effective in managing RTIs compared to earlier-generation cephalosporins and amoxicillin.