Almotriptan versus ibuprofen in migraine: A randomised placebo-controlled trial

80 Pages·2016·1.57 MB·English

C O N T E N T S
Journal, Indian Academy of Clinical Medicine  Vol. 17, Number 2, April-June, 2016
Contains 84 pages from 85 to 164 (inclusive of all advertisements)
View Point Quantum world view 90
BM Hegde
Original Articles Acute malarial nephropathy – A complication less recognised 92
Sushma Trikha, Neelima Singh, Pradeep Prajapati, Archana Kansal, Navneet Agrawal
Profile of medical illness, hypertension, diabetes mellitus, cerebrovascular accident,
chronic renal failure, and coronary artery disease in patients attending a geriatric OPD 95
YK Gupta, HS Bhardwaj, BL Bhardwaj, H Singh, S Aggarwal, GK Bedi
Role of cardiac biomarkers in assessing risk in chronic kidney disease 99
Nimi Bharathan, Biju K Gopinath, Sajna MV, Suchithra ET, Pushpalatha M
Vitamin D status in patients of congestive heart failure 102
Sanjay Agrawal,Vishakha Mittal, Sandeep Bansal, BC Kabi
A study of CSF C-reactive protein levels in patients of meningitis 105
S Aharwar, S Trikha, A Kansal, K Verma, OP Jatav
Almotriptan versus ibuprofen in migraine: A randomised placebo-controlled trial 111
Ramakant Yadav, TP Singh, Archana Verma, SK Shukla
Review Article Spontaneous bacterial empyema (SBEM) 115
R Kumar, S Prasad, R Manocha
Case Reports Noonan syndrome – Clinical diagnosis of a rare case 119
Gouranga Santra
An unusual presentation of dapsone hypersensitivity syndrome 123
Indra Kishor Singh, Sujay Srinivas, BK Tripathi
Sudden bilateral vision loss in a patient of fibrous dysplasia due to ruptured
sphenoid sinus mucocoele 125
Mayank Arora, Saurabh Gupta, Shafali Nandwani, SK Virmani, Moneet Agarwal, Avinash Munshi
Cutaneous presentation of chronic lymphocytic leukaemia 128
Kavita Paul, Harbans L Kazal, Jasmine Kaur
Intradural extramedullary tuberculoma causing compressive myelopathy in
a patient with human immunodeficiency virus infection 130
SB Devi, N Robinson, R Akshay, P Obang, K Jaya
Spinocerebellar ataxia type-2 presenting with signs of amyotrophy 133
Nitya Nand, Sameer Aggarwal, Virender Chauhan, Nisha Batra
Journal, Indian Academy of Clinical Medicine  Vol. 17, No. 2  April-June, 2016 85
C O N T E N T S
Journal, Indian Academy of Clinical Medicine  Vol. 17, Number 2, April-June, 2016
Contains 84 pages from 85 to 164 (inclusive of all advertisements)
Case Reports Left bundle branch block – A rare hyperkalaemic ECG manifestation 135
M Venkata Madhav, G Anvesh, KV Seshaiah, G Eswar, Ajith Mohammad
An unusual case of misplacement of internal jugular double lumen dialysis
catheter into ipsilateral subclavian vein in reverse direction 139
Rohit Rungta
Atelectasis with acute liver failure in a patient of scrub typhus 142
Ratan Ram, Robinson Ningshen, S Kenny Singh, S Bhagyabati Devi
Pituitary apoplexy in vivax malaria with thrombocytopenia 145
Rajesh Deshwal
Short Communication An attempt to develop the management guidelines of vitamin D supplementation in
patients with primary hyperparathyroidism and co-existent vitamin D deficiency in
a district general hospital in the United Kingdom 148
I Talapatra, IPM O’Connell
Pictorial CME Arcus juvenilis – A sign not to be missed 152
PS Sreejith, M Mahesh, CR Venkatesh
Announcements Advertisement Tariff of the Journal, Indian Academy of Clinical Medicine (JIACM) 101
Invitation for Papers (Platform/Poster) for IACMCON-2016, Gwalior, M.P. 138
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Journal, Indian Academy of Clinical Medicine  Vol. 17, No. 2  April-June, 2016 89
V I E W P O I N T JIACM 2016; 17(2): 90-91
Quantum world view
BM Hegde*
“Religion and natural sciences have a point of contact in Heisenberg were wiser. Newton’s Laws of deterministic
the issue concerning the existence and nature of a predictability and Einstein’s laws of relativity together
supreme power ruling the world, and here the answers founded a world view of “space-time”constraints where
given by them are to a certain degree at least everything else out with this space time module was
comparable.” rejected. They, along with others, tried to split an atom to
study the subatomic particles, which in itself was another
– Max Planck (1950).
big business resulting in the atomic bomb! I still remember
Science is the biggest enterprise that man ever created. Of the words of Max Planck following the bomb blast. “I am
all the living things on this planet man is the only one that proud of my students’ cleverness in splitting an atom but
seems to have started thinking about how this world works. am wondering if that atom that they have split might teach
To understand that, he started this new venture, called mankind a bitter lesson one day which might be too costly
science, which was originally meant just to understand how for mankind” According to the Space Time world view the
this world works. Some exceptionally brilliant minds did speed of light should be the fastest.
accidentally tumble upon some understanding of the
When this group had some confusion they would call for a
world’s laws, like gravity, buoyancy, and others in the west
Copenhagen Conference where the problems would be
while the Indian sages had realised this much earlier. The
discussed and “settled”! They did not look beyond their
next step was to find out how the world works by doing
noses. They patted each other’s back either by their Nobel
some experiments. At this stage the western churches
Prizes or their Fellowships of Newton’s Royal Society.
started obstructing their work as this kind of scientific
Buoyed up by the successful technological advances of
enquiry, they thought, might interfere with the religious
their initial scientific laws like the aeroplane,
belief. That is where the first conflict between religion and
communications’ facilities, infrastructure, industrial growth,
science started. The fall out was that the scientists
atom bomb, space travel, weapons of mass destruction, hi-
subconsciously developed an aversion to the God concept
tech medical quick-fixes, etc., scientists also became money
in religion and thus God was kept out of the scientific realm.
wise. Money spoils man. This scientific world view makes
Now that has become a fad and fashion with the young man to be arrogant with some scientific authority. They are
budding scientists to call themselves as atheists. To cap it, a bound to sell their souls, which in fact, is a sordid boon. They
young brilliant mathematical brain of Rene Descartes embarked on some funny experiments to split the particles
assumed all power to himself by declaring “Cogito ergo further by colliding them at the speed of light in large
sum” (I think, therefore, I am). If he were a lot more submerged reactors at an enormous cost like the CERN
experienced and wise, he would have realised that was his scientists looking for the building blocks of this universe.
perception and not the world view. There is no perception Along with particle physics other natural sciences like
without a perceiver. In short, we do not have a universe but chemistry and biology also adopted this reductionist mind
a multiverse of perceptions, otherwise called the concept set. Evolution was said to be genetic based on Darwin-
of biocentrism. Each one of us, including animals, has his or Mendel hypothesis forgetting the vital role the whole
her own perception which is different from others. The environment plays on evolution, initially put forward by
world does not run because of that. The real thing should Lamarck. New Evolutionary biologists like Elisabet Sahtouris
have been “I am, therefore, I am able to think.” Let us have tried to revolutionise the field of evolutionary biology
therefore, think from hereafter. where the world view in totally new.
More and more people started dabbling in science as the Some thinking physicists started wondering about the
world had enough to eat and exist. Finding one’s next meal behaviour of subatomic particles not confined to the Space
was not that difficult. Science then was more of a hobby for time constraints. The particle wave distinction also died down
the well-to-do. The leading lights of that generation were gradually when they could easily discern that both the waves
Isaac Newton and Albert Einstein. There were a host of and particles are but the two faces of the same coin. In his
others, but less illustrated than the above two, and so are article for lay people, Hans Peter Durr, a former Emeritus
not mentioned here; although some of them like Werner Director of the Max Planck Institute, wrote “my job was to
*Padma Bhushan; Former Vice-Chancellor, Manipal University; Editor-in-Chief, The Journal of the Science of Healing Outcomes
(JSHO); Chairman, State Health Society’s Expert Committee, Govt. of Bihar, Patna; Visiting Professor of Cardiology, The Middlesex
Hospital Medical School, University of London, U.K.; Affiliate Professor of Human Health, Northern Colorado University, U.S.A.
look at matter at its subtlest level and going down the line at without chemistry one cannot understand biology and life.
one stage I found that there is no matter at all. Was I surprised? Schrödinger and Heisenberg created a universe based on
– not at all! I expected that!” Starting from Max Planck, de superimposed inseparable waves of probability amplitudes,
Broglie, Paul Deric, Heisenberg, Schrödinger and many others the sea of waves, and a view consistent with the Vedic
went ahead with the new ideas and we have now reached a concept of All in One.” One could argue that the parallels or
stage where physics took a quantum jump into this new analogies between Vedanta and quantum theory are merely
field of quantum physics which has created a new world coincidental. But one can certainly say that Vedanta did not
view which comes closer to reality compared to the old follow (plagiarise) quantum logic!
“Space-Time conundrum.” For a novice it is a bit confusing as
The earlier science gave an impression that man is the one
this new world view is more of a possibility than actuality.
who can make this world run as per the laws of deterministic
This comes into view when we look at it and we do not
predictability within the constraints of space time, with speed
know what happens when we do not look. However, no
limited to the speed of light. The Indian concept of manovega,
more doubt remains as most of the new concepts are proven
the speed of the mind, is a reality in the quantum world.
by experimentation. Werner Heisenberg, Niels Bohr, Max Born
Quantum world view teaches us that we are all the same
and Wolfgang Pauli finally resolved the paradox of this
wave energy and, therefore, interconnected. Once this world
“quantum physics” in 1925 with a radical re-interpretation of
view gets currency, all negative human thoughts like hatred,
the dynamics. “It demanded a revolution in what had been
anger, jealousy and greed will have to be replaced by universal
the classical view of the world, with the surprising recognition
compassion making wars and terrorism look foolish and non-
that matter is not really material at all, but a web of
productive. When we harm someone else whom are we
relationships, a kind of gestalt, or in a certain way ‘information’
harming but ourselves? Diseases take a back seat as all of
without any carrier.” Hans Peter Durr had a better word in
them start in the human mind in negative thoughts. The
German, the Wirklichkeit.
human mind was confined to the human brain in the earlier
Experimental physicists have shown that a particle, like in world view but quantum world view brings it out in the open
the double slit experiment, could be directed to go through as a part of this big universal wave (consciousness). The world
the path that the experimenter wants it to take – mind at can now be compared to the wide sea where we, as
work! Non-locality, a concept that Albert Einstein did not individuals, are but a small wave. We ARE a part of that sea.
agree till his last breath, is a reality now. Einstein called it This should make man humble and, consequently, educated.
“spooky action at a distance – God playing dice”, etc. This The earlier world view with all its prizes and awards used to
reality was a well-known entity in Eastern philosophy, make man arrogant and sick. “But man, proud man, Dress’d in
especially Indian Vedanta. Teleportation, transfer of a little brief authority, Most ignorant of what he’s most assur’d
knowable or known entity from one place to another — His glassy essence — like an angry ape Plays such fantastic
without loss of time, and with no communications facilities, tricks before high heaven As makes the angels weep.”The word
has brought spirituality closer to science. When one tries to “I” used to dominate (starting illness). Now the word is WE
understand the new quantum physics, one is struck by the (meaning wellness). In the Quantum world view your award
existence of a superior intelligence (consciousness) at work is your capacity to be compassionate. This new science opens
in this world. Consciousness has now become a scientific the flood gates to quantum healing, a limitless field. This also
concept and has revolutionised medical science in a big leads to the inner development of man for the good of
way. That is why I am into this field. Non locality brings in mankind.
telepathy, a well know concept in Vedanta. Non locality
That said, I must hasten to add that there will not be too
shows that there is the possibility of a particle having its
many to buy this truth as this is not a good business
counterpart active at a distance simultaneously. Quantum
proposition and might not allow us to make money like the
entanglement brings us together. Many other concepts like
reductionist world view of the past. My good friend, Amit
quantum Tunnelling, etc., take this science nearer to
Goswami, a bright Bengali professor of Theoretical Physics
mysticism. Mystics were able to transfer their powers to
at the Oregon University, USA is trying his level best to spread
others. Experiments now have shown how induced brain
the message of quantum physics to the world. He is doubly
waves could be simultaneously seen in other brains in
qualified as he is a scholar in Indian Vedanta as well. My
contact with the first one psychologically. Are you reminded
hope is that this scientific truth of quantum reality would
of telepathy, not an unusual experience in thinkers?
bring man and man together “To Give without Remembering
Physics still has to grapple with 95% of dark matter and energy. and Receive without Ever Forgetting.”
This is possible with Indian Vedanta. The autobiography of
“I don’t argue things being spiritual versus scientific,
one of the founder fathers of quantum world, Erwin
because I’ve never met anyone who knows enough about
Schrödinger, claimed that he obtained his central intuition
either to be convincing—including myself.”
from the Vedas. This is a singular credit because without
quantum mechanics one cannot understand chemistry, and – S. Kelley Harrell.
Journal, Indian Academy of Clinical Medicine  Vol. 17, No. 2  April-June, 2016 91
O R I G I N A L A R T I C L E JIACM 2016; 17(2): 92-94
Acute malarial nephropathy – A complication less recognised
Sushma Trikha*, Neelima Singh**, Pradeep Prajapati**, Archana Kansal*, Navneet Agrawal***
Abstract
Malaria induced acute renal failure is a complication less well known than anaemia and cerebral malaria, but the mortality in this
subgroup is high, especially when the disease is not diagnosed early. It may present as a part of a multi-organ dysfunction, or as a
lone complication. This study was aimed to find-out the incidence of acute renal failure in patients with malaria, association with
various complications, and the outcome with the management offered in our set-up. Cerebral malaria, anaemia, hepatic
involvement, and acute respiratory distress were common in patients with malaria-induced acute renal failure.
Keywords: Acute renal failure, anaemia, cerebral malaria.
Introduction Material and methods
Malarial acute renal failure (ARF) is emerging as an important Material
problem in tropical countries, and carries a high mortality,
This is a prospective study which was conducted over a
especially when the disease is not diagnosed early. Acute
period of one year from September 2008 to August 2009
renal failure (ARF) is seen mostly in Plasmodium falciparum
in JA Hospital, G. R. Medical College, Gwalior. All patients
infection, but P. vivax and P. malariae can occasionally
positive for malarial parasite were included as subjects.
contribute towards renal impairment1,2,3. Malarial ARF is
Patients with pre-existing renal disease were excluded.
commonly found in non-immune adults and older children
with falciparum malaria4,5. However, recently it has been
Method
reported more often in semi-immune African children with
associated morbidity and mortality6. Several factors including All the patients with confirmed malaria were subjected to a
various chemical mediators, catecholamine release, detailed clinical and biochemical examination as per a pre-
cytoadherence of parasitised erythrocytes, dehydration, structured proforma. Patients were grouped into two
intra-vascular haemolysis, intra-vascular coagulation, sepsis, categories on the basis of renal failure (i.e., those with and
hyperbilirubinaemia, and hyperparasitaemia have been these without renal failure). Those patients with acute renal
implicated in the pathogenesis of ARF in malaria. failure were grouped into three categories on the basis of
Haemodynamic alteration, haematologic change, and RIFLE Criteria. RIFLE defines 3 grades of increasing severity
immunologic response are among the major of ARF on the basis of change in serum creatinine: R – risk
pathophysiologic mechanisms in the pathogenesis of the (serum creatinine 1.5 times the normal), I – injury (serum
disease. Disturbances in the renal microcirculation are creatinine 2 times the normal), F – failure serum creatinine
responsible for acute renal failure; massive intravascular 3 times the normal); and 2 outcome variables: L – loss, E –
haemolysis causes haemoglobinuria with or without renal end-stage kidney disease. Patients with established end-
failure; and immunologic reaction to parasites accounts for stage renal kidney disease and chronic kidney disease on
glomerular lesions. Risk factors for poor outcome were maintenance dialysis were excluded from the study. Clinical
anaemia, jaundice, cerebral malaria, disseminated profile and biochemical profile of patients with acute renal
intravascular coagulation7. failure was studied. The mangement included appropriate
anti-malarial, fluids, electrolytes, and dialysis if indicated.
Aims and objectives Data was analysed to find-out the incidence of acute renal
failure in malaria, and the outcome. The association between
1. To study the incidence and outcome of acute renal various complications and acute renal failure was assessed
failure in cases of malaria. using univariate analysis, odd ratio.
2. To study the relation of acute renal failure with various
complications of malaria. Results
This study was conducted with an objective to highlight the A total number of 1,145 patients positive for malarial parasite
occurrence of acute nephropathy in patients with malaria. were enrolled as subjects. Females (53.53%) out-numbered
*Associate Professor, **Assistant Professor, ***Post-Graduate Student, Department of Medicine,
Gajra Raja Medical College, Katora Tal Road, Lashkar, Gwalior - 474 009, Madhya Pradesh.
males (46.46%). Most of the patients (51.87%) were in the (4.84 - 12.64) p value 0.00016, ARDS 6.53 (1.18 - 36.20) p
age group 21 - 40 years. Falciparum malaria was found to value 0 .00001.
be positive in 607 (53.01%) patients, vivax malaria in 497
Overall mortality was 78 (6.8%). Mortality was 64 (6.02%) in
(43.40%), and mixed infections (falciparum and vivax) in
those without acute renal failure, and 14 (16.86%) in those
41 (3.59%) patients.
with acute renal failure.
83 (7.24%) patients developed acute renal failure. Out of
Table I: Showing severity of acute renal failure in
83 patients with ARF, 47 (56.6%) were males, and 36 (43.3%)
different types of malaria.
females. 41 (49.39%) patients were in the age group 21 -
40 years. 67 (11.03%),10 (2.01%), and 6 (14.63%) patients (n = 83)
with falciparum malaria, vivax malaria, and mixed malaria
S. No Severity of ARF Falciparum malaria Vivax malaria Mixed malaria
respectively developed acute renal failure.
1. At risk (n = 6) 6 (7.22%) 0 0
Clinical profile of patients with acute renal failure was as
2. Acute kidney injury 19 (22.89%) 7 (8.43%) 3 (3.61%)
follows: fever - 77 (92.77%), altered sensorium - 27 (32.5%),
(n = 29)
oedema - 39 (46.98%), dyspnoea - 23 (27.71%), diarrhoea
- 7 (8.43%), pain abdomen - 4 (4.81%), convulsions - 2 3. Acute renal failure 40 (48.1%) 5 (6.02%) 3 (3.61%)
(n = 48)
(2.40%), pallor - 32 (38.55%), icterus - 30 (36.14%),
hepatomegaly - 33 (39.75%), and splenomegaly in 31
Table II: Association between various complications
(37.34%).
of malaria in patients with and without acute renal
Significant biochemical profile in patients with acute renal failure.
failure revealed anaemia in 31 (37.3%), hyponatraemia in
S. Complications With ARF Without ARF Univariate p value
30 (35.7%), hyperkalaemia in 5 (5.9%), hyperbilirubinaemia
No 83 cases 1,062 cases Analysis < 0.05
in 33 (39.3%), and elevated liver enzymes in 30 (35.7%) Odd ratio significant
patients.
1. Cerebral malaria 23 (27.38%) 192 (17.96%) 1.74 (1.06 - 2.22) 0.00001
Urinalysis in patients of malarial ARF showed microscopic
2. Anaemia 31 ( 37.3%) 535 (50.04%) 0.59 (.37 - 0.93) 0.0003
haematuria in 10 (11.9%), granular casts in 24 (28.57%),
3. Hepatic 37 (39.2%) 99 (9.26%) 7.82 (4.84 - 12.64) 0.00016
and albumin in 38 (45.23%).
involvement
On the basis of RIFLE criteria, patients were divided into 3
4. Acute respiratory 2 (4.76%) 4 (.37%) 6.53 (1.18 - 36.20) 0.00001
groups. Those at risk were only 6 (7.22%) cases with
distress syndrome
falciparum malaria; those with acute kidney injury (AKI)
were 19 (22.6%) patients with falciparum malaria, 7
Discussion
(8.33%) with vivax malaria, and 3 (3.57%) with mixed
malaria; and those with acute renal failure were 40 (47.6%)
83 (7.24%) patients developed acute renal failure. Overall
with falciparum malaria, 5 (5.95%) vivax malaria, and 3
mortality in malaria was 78 (6.8%). Comparing patients with
(3.57%) with mixed malaria. Non-oliguric acute renal
renal failure and those without, mortality was (16.86% vs
failure was observed in 19 (20.23%) patients. All the 14
6.02%).
(16.86%) patients who expired were those with ARF. None
in the risk category or with acute kidney injury succumbed 67 (11.03%), 10 (2.01%), and 6 (14.63%) patients with
to malaria. falciparum malaria, vivax malaria, and mixed malaria
respectively developed acute renal failure ( Table I). Out of
58 (69.87%) patients were managed conservatively while
14 patients with ARF who expired 12 patients had P.
25 (30.12%) required dialysis. Out of 25 patients who were
falciparum and 2 patients had P. vivax. This means that the
dialysed, 22 (88%) improved; and 3 (12%) patients expired.
benign tertian malaria is not always benign. P. vivax malaria
Associated complications of malaria in patients with ARF
has the propensity to cause ARF, which occurs more
were anaemia in 31 (37.3%), hepatic involvement (raised
commonly in P. falciparum malaria1,2,3. Renal involvement
serum bilirubin, and elevated liver enzymes) in 37 (39.2%),
varies from mild proteinuria, haematuria, to severe
cerebral malaria in 23 (27.38%), and acute respiratory
azotaemia.
distress in 2 (4.76%) patients. Univariate analysis showed
significant association of various complications of malaria Acute nephropathy (ARF/AKI) may present as a component
with ARF (Table II). Univariate analysis Odd ratio for cerebral of multi-organ dysfunction (MOD), or as a lone
malaria 1.74 (1.06 – 2.22) p value - 0 .00001, anaemia 0.59 complication. In this study, complications like cerebral
(0.37 - 0.93) p value - 0 .0003, hepatic involvement 7.82 malaria, anaemia, hepatic involvement, acute respiratory
Journal, Indian Academy of Clinical Medicine  Vol. 17, No. 2  April-June, 2016 93
distress syndrome (ARDS) emerged as an important management can reduce morality, and enhance recovery
association in simple univariate analysis in those with acute of renal function12.
renal failure (Table II). These associations may have a role
to play in prognosticating the outcome. Cerebral malaria Conclusion
was seen in 23 (27.38%) patients, and 31 (37.3%), 37 (
39.2%), 2 (4.76%) had anaemia, hepatic, and respiratory Incidence of malarial ARF was 7.24% in this study. Renal
involvement. ARF necessitating dialysis was seen in 25 failure in malaria appears to be a complication less well
(30.12%) cases. 69 (83.1%) patients with ARF recovered, known. Complications like cerebral malaria, anaemia,
and 14 ( 16.86%) patients expired. Associated hepatic involvement, acute respiratory distress syndrome
complications might have contributed to mortality. Low are common in patients with malarial ARF. The presentation
haemoglobin, hyperbilirubinaemia, cerebral malaria, and of renal failure associated with malaria needs to be
high serum creatinine were the main predictors of recognised globally in order to reduce mortality.
mortality7.
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“The Earth has rights too, to live without pollution.
What mankind must know is that human beings cannot live without Mother Earth,
but the planet can live without humans.”
– EVO MORALES.
94 Journal, Indian Academy of Clinical Medicine  Vol. 17, No. 2  April-June, 2016