Methaemoglobinaemia and a Heinz-body haemolytic anaemia are uncommon but potentially treatable complications of aniline poisoning. Management of aniline poisoning is mainly removing the source of aniline exposure and management of methaemoglobinaemia. Management of methaemoglobinaemia is guided by blood methaemoglobin levels and patient symptoms. Blood methaemoglobin level <30% requires only supplemental oxygen while for methaemoglobin level >30%, intravenous methylene blue is the mainstay of treatment. All patients treated with methylene blue should be observed for delayed haemolysis, acute renal failure and cardiac complications. In patients with contraindication to methylene blue, exchange transfusion can be used while haemodialysis is reserved for complicated cases. We successfully managed 6 patients of methaemoglobinaemia due to aniline poisoning by methylene blue. Two of these patients who developed Heinz-body haemolytic anaemia with acute renal failure as a complication also required exchange transfusion.

Abstract Background The Guillain-Barre Syndrome (GBS), also known as acute idiopathic polyneuritis, is a critical acquired condition associated with preceding nonspecific infection or triggering factors like trauma, surgery, or vaccination. GBS is currently the most frequent cause of acute flaccid paralysis in India. This study evaluates the short-term and in-hospital outcomes in different subtypes of GBS. Methods A prospective observational study was conducted at V.S. Hospital, Ahmedabad, from September 2015 to December 2017. Patients above the age of 12 were included. Patients having other underlying neurological conditions, as well as immunodeficiency disorders, were excluded. The patients were classified into different subtypes of GBS, and functional outcomes were recorded on admission and discharge according to Hughes Scoring System. All statistical analyses were performed by using SPSS software. Results Out of 50 patients, 35 (70%) were males. The mean age was of 37.18 +/− 18.35 years. 25 (50%) patients had a preceding infection. 88% of patients presented with cranial nerve (CN) involvement had a Hughes Score of >/= 3 (p = 0.0087). They had less improvement of Hughes Score on discharge (0.13 +/− 0.04) as compared to the patients without cranial nerve involvement (0.38 +/− 0.08) (p = 0.008). Respiratory involvement was associated with a higher Hughes Score (p = 0.005) on admission. 85% of patients diagnosed with an axonal subtype of GBS had a Hughes Score of >/= 3 (p = 0.06) compared to 74% patients with demyelinating subtype. Axonal subtype required double period (11 +/− 2.34) to show improvement as compared to demyelinating subtype (6 +/− 1.2) (p = 0.020). Irrespective of the subtypes, in two different treatment cohorts (PLEX vs IVIG), there was no difference in short term functional outcomes measured by improvement in the Hughes scores (p = 0.89). Conclusions Early cranial nerve and respiratory involvement in patients presenting with GBS are associated with poor outcomes warranting immediate critical care involvement. In our study, amongst all the subtypes, axonal had poor clinical outcomes. Further clinical trials on the Indian subpopulation will help us evaluate the impact of different treatment modalities on this disease.

The intraoperative administration of Hyperthermic Intraperitoneal Chemotherapy is a novel treatment strategy that tries to provide similar therapeutic effects while avoiding some of the limitations of traditional treatment. The purpose of this analysis is to systemically review the available clinical studies to determine the infection rates postoperatively as complication of HIPEC with CRS procedure. As there are currently evolving guidelines for clinical application of this intervention this study helps in evaluating the safety of combined CRS and HIPEC for rates of infection. A detailed comprehensive search for all relevant studies was conducted through PubMed, MEDLINE and Google scholar using search words as (((“Cytoreduction Surgical Procedures/adverse effects”[Mesh]) AND “Hyperthermic Intraperitoneal Chemotherapy/adverse effects”[Mesh]) AND “Infections”[Mesh]) AND “Neoplasms”[Mesh]. Extracted data was analysed using Rev Man software and random effect model using self-designed tables. Out of 41 studies included, 24 were retrospective, while 17 were prospective studies. These studies matriculated a total of 10303 procedures of CRS with HIPEC; out of which, 2704 (26.24%) episodes of infections were observed while no infection was noted in 7675 (74.49%) procedures. Random effect model was used for outcome analysis which showed significant heterogeneity (I2 = 97%) but overall effect size was significant (p<0.00001). The funnel plot of infection vs no infection was asymmetrical on visual inspection. Risk ratio was 0.37 (0.30, 0.49) for development of infectious complications. The most common infections were SSI (1075, 39.8%) followed by sepsis (519, 19.2%). Mortality rate was recorded in 35 (out of 41)studies and found highest (42.1%) in study by Elgendy et al. Increased stay in hospital was reported, (minimum 1 – maximum 177 days) in patients developing infections. CRS with HIPEC is a safe and effective treatment procedure under trained supervision, with no increased risk of infection. Infectious complications can be effectively managed with a multi-disciplinary approach involving oncosurgeons and infectious disease specialists for optimal patient outcomes. As a result of the possible survival advantages CRS and HIPEC provide, it would be prudent to study the complications associated with this novel surgical technique in an appropriately designed prospective study.

A 40-year old male, was presented with complaint of difficulty in walking with inability to flex foot and toes in bilateral feet (“foot drop”), which was acute at the onset and gradually progressive since the past 7 days. The patient’s wife and their 2 children had similar complaint with the same period of onset. At home, his family used cottonseed oil as cooking oil with wheat grain mixed with castor oil. On neurological examination, he was found to have lower motor neuron weakness with spasticity. After ruling out other common causes of polyneuropathy and lower motor weakness; due to high suspicion of poisoning by food adulterant, RBC acetyl cholinesterase (AChE) and plasma cholinesterase (BuChE) were tested at National Institute of Occupational Health (NIOH), which came low and confirmed diagnosis of Organophosphorus (OP) poisoning. Nerve conduction study was done; which showed decreased amplitude of conduction in bilateral peroneal and right tibial nerve along with decreased mean nerve conduction velocity of bilateral median nerve. Thus patient was diagnosed with organophosphorus agent induced delayed axonal type of polyneuropathy and physiotherapy was started as treatment. OP compounds are a diverse group of chemicals which are principally used as insecticides in agriculture. Following organophosphate poisoning (OPP), 3 well-defined neurological syndromes are recognised: cholinergic crisis, intermediate syndrome and delayed polyneuropathy. Some organophosphates, particularly triorthocresyl phosphate (TOCP) and tricresyl phosphate (TCP), produce delayed neuropathy. On ingestion, they do not produce significant cholinergic crisis, but 7 to 20 days later it leads to a pure motor axonal neuropathy with wrist and foot drop. The mechanism may involve inhibition of neuropathy target esterase (NTE), which is found in the brain, peripheral nerves, and lymphocytes. This form of toxicity has been seen occasionally in small epidemics in India due to adulteration of cooking oil with TOCP.

Background: Stress testing is a simple, reliable and excellent non-invasive method for diagnosing coronary artery disease in asymptomatic patient and predicting future coronary events, particularly in patient with coronary risk factors. A risk factor is a feature of individual or population that is present early in life and is associated with increased risk of developing disease in future. Risk factor of interest for coronary artery disease may be hypertension, diabetes mellitus, smoking, hyperlipidaemia, obesity and physical inactivity.Methods: A clinical survey of 50 cases of patient with coronary risk factor was carried out at Civil Hospital, Ahmedabad. These patients were subjected to tread mill stress testing after proper preparation.Results: In the present study modifiable risk factors like hypertension have 81% positive test; diabetics with hypertension have 91% positive test; smokers have 80% positive test; obese patients have 67% positive test and those with physical inactivity have 78.12% positive test.Conclusions: Most patients with modifiable risk factors are unaware of their condition and Coronary Artery Disease can be reduced efficiently if these patients are made aware of the risk and proper action is taken to control the risk factors.

Background: In an ischaemic stroke, a strong correlation exists between the stroke severity and the level of arterial occlusion. Patients with major or proximal artery occlusion tend to have worst clinical picture and poor outcomes; and they are most benefited by revascularization interventions. These patients can be identified early before angiography by clinical scoring methods like National Institute of Health Stroke Scale (NIHSS) score. The NIHSS score (range 0-42) is a 15 item neurological examination stroke scale used to evaluate the effects of acute cerebral infarction on levels of consciousness, visual field loss, extra ocular movements, motor strength, ataxia, sensory loss, language, dysarthria and neglect.Methods: A prospective study of 50 patients, who were admitted to the hospital with an acute ischaemic stroke within 12 hours of onset, was carried out to evaluate the relationship of NIHSS score and MR angiographic (MRA) findings.Results: We found that majority of patients (38%) belonged to 6th decade with mean age of 59 years. Out of various risk factors, hypertension (64%) and smoking (48%) were most prevalent. Highest numbers of patients (40%) were in NIHSS score group 07 to 15. Out of 50 patients, 29 (58%) patients showed visible arterial occlusion on MRA. Median NIHSS score was 16 in occlusion group and 6 in non-occlusion group (p<0.01). In the same way, median NIHSS score in central occlusion group (20) was higher than distal occlusion group (11) (p<0.01). At NIHSS score 10, sensitivity and specificity to detect arterial occlusion in MRA was 86%. Positive predictive value (PPV) for arterial occlusion at >10 NIHSS score was 89% and PPV for detecting central occlusion at >12 NIHSS score was 87%.Conclusions: In summary, a significant association was found between the NIHSS score and the presence and the location of a vessel occlusion in acute ischaemic stroke. In this era of reperfusion therapy where time is the most critical element, simple bedside score like NIHSS can greatly help in selecting patients requiring urgent treatment and improve patient disease outcome.

Sir, Crimean-Congo haemorrhagic fever (CCHF) is a tick-borne viral disease with average mortality rate of 30-50 per cent1. In India, presence of CCHF was first time confirmed in Gujarat State during a nosocomial outbreak in 20112,3. Since then, numerous outbreaks and sporadic cases of this disease have been reported from different districts of Gujarat State4,5,6. Studies conducted at the National Institute of Virology (NIV), Pune, had reported the presence of anti-CCHF IgG antibodies in domestic animals from Sirohi district, Rajasthan State. However, in the last four years none of the referred human samples were found positive3,4,5,6. On March 18, 2014, blood sample of a suspected CCHF case was referred to NIV, Pune, for aetiology confirmation. This suspected CCHF case was a 45 yr old male, shepherd by profession, residing at Veravilapur village, Sirohi district, Rajasthan. He was presented on March 14, 2014, with complains of abdominal discomfort since last six days and vomiting since one day along with history of intermittent fever since 15 days. He had moderate fever without chills and was associated with arthralgia, generalized body ache, constipation, decreased urine output, bleeding from nose, haematuria and bleeding per rectum. He was a known case of HBsAg reactivity, and was transferred from Rajasthan State to Civil hospital, Ahmadabad, Gujarat. On admission, patient had thrombocytopenia (20,000/μl). Serum creatinine was 1.2 mg/dl, prothrombin time 15.3 sec, International Normalized Ratio (INR) 1.15, and activated partial thromboplastin time (APTT) was 50.0 sec (Table). There was impairment of liver function test in the form of markedly elevated liver enzymes of serum glutamic-pyruvic transaminase (SGPT: 2620 U/l) with normal serum total bilirubin (0.40 mg/dl) and normal renal function. Parameters of complete blood count were in the normal range (Table). Table Day-wise clinical laboratory findings of Crimean-Congo haemorrhagic fever (CCHF) case in 2014 The differential diagnosis of CCHF at the pre-haemorrhagic stage is more difficult. As the disease progresses, clinical features become clearer and diagnosis becomes easier. The sample was differentially tested for some aetiological agents (hepatitis viruses, Leptospira and dengue viruses) which are endemic in the region and mimic the clinical illness of CCHF. Apart from HBsAg, patient was negative for viral markers (i.e. anti-HEV IgM, anti-HAV IgM, anti-HCV IgM). Anti-HIV antibodies, anti-Leptospira IgM and IgG antibodies, dengue IgM antibody, blood and urine culture were negative. The patient did not have any recent travel history to Gujarat State; but had close contact with livestock. Whole blood of the patient was collected on March 15, 2014 (2nd day of admission) and March 19, 2014 (6th day of admission). On day 19, urine sample was also collected. The patient's serum and urine samples were processed for CCHF virus specific real-time RT-PCR5,7. Anti-CCHF IgM antibodies were tested in serum samples using commercial CCHF IgM ELISA Kit (Vector-Best, Novosibirsk, Russia). Real-time RT-PCR results were found positive for both serum samples collected on day 15th [threshold cycle (Ct) =27] and on 19th day (Ct=34)]. On 19th day urine sample showed Ct=38. Both serum samples (of 15th and 19th days) were positive for IgM antibodies against CCHF virus. Real-time reverse-transcription RT-PCR data showed high CCHF viral copy number. On 19th post illness day, the urine sample also showed low level of CCHF viral RNA. As soon as the sample was laboratory confirmed as CCHF case, the patient was put in strict isolation. For treatment, oral ribavirin was administered on day 3 after admission on clinical suspicion at the dosage recommended by the World Health Organization8,9,10, along with the supportive and replacement therapy with blood products. The patient responded to the treatment and recovered completely, and was discharged on request on March 27, 2014 (14th day of admission). Livestock trade and movements of domestic animals infested with infected ticks might be the reason in distribution of infected ticks to newer areas, and eventually spread of CCHFV. As CCHF mimics a wide range of common illnesses caused by different aetiological agents which are endemic in India, differential diagnosis should be done based on clinical biochemical, haematological, bacteriological and virological findings. These include Kyasanur forest disease, hepatitis, Neisseria meningitidis infection, leptospirosis, borreliosis, typhoid, rickettsiosis, dengue and malaria. However, malaria diagnosis can be excluded in cases of suspected viral haemorrhagic fever (VHF)11. In conclusion, there is a need to initiate active serosurvey of CCHF among human population, and domestic animals in Rajasthan. This will be helpful in understanding the prevalence of this disease in Rajasthan State which eventually will alert the State health authorities.