Status epilepticus (SE) is an important neurological emergency with high mortality and morbidity. The first official definition of SE was the product of 10 ^th Marseilles colloquium held in 1962 which was accepted by International League Against Epilepsy in 1964. There are as many types of SE as of seizures. SE is supposed to result from failure of normal mechanisms that terminate an isolated seizure. In half of the cases, there is no history of epilepsy and SE is precipitated by some intercurrent infection. In children, it is often infection, whereas in adults, the major causes are stroke, hypoxia, metabolic derangements, and alcohol intoxication or drug withdrawal. The treatment of SE aims at termination of SE, prevention of seizure recurrence, management of precipitating causes, and the management of complications. The extent of investigations done should be based on the clinical picture and cost benefit analysis. The first line antiepileptic drugs (AED) for SE include benzodiazepines, phenytoin, phosphenytoin, and sodium valproate. Mortality of SE ranges between 7 and 39% and depends on underlying cause and response to AEDs.

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Healthcare in India has been undergoing rapid changes in the last decade. As demand outpaces supply, quality improvement (QI) initiatives and tools can be beneficial to enhance safe, effective, efficient, equitable and timely care. Healthcare quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. This article discusses the framework for QI and reviews the Plan-Do-Study-Act (PDSA), Lean and Six Sigma methodologies, and briefly discusses key patient safety and quality measurement concepts. The PDSA cycle assists in testing the ideas through small tests of change or "pilots". Six Sigma aims at reducing variations in processes, and the Lean methodology predominantly focuses on enhancing process efficiency and eliminating non-value added steps in the process. It is likely that such structured problem solving approaches will provide an objective and systematic method of enhancing quality in healthcare institutions across India. As increasing attention being is paid on enhancing the quality of life through the Quality Council of India and accreditation of hospitals in India through the International Organization for standardization and National Accreditation Board for hospitals and healthcare providers, a focus on QI by institutional leaders and healthcare providers is key to enhancing the safety and quality of healthcare in India. Central to this also will be leadership buy-in, identification of a core faculty or team that will be the initiators of change, a respect for the need for faculty training and education in QI, measurement of issues to identify key priorities to focus on, and enhanced information systems where resources permit the same.

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Background : Nurses' knowledge, sensitivity and attitudes about pain in children and its management affect their response and therefore management of pediatric pain. Children in critical care units undergo more painful procedures than those in general wards. Aims : To study the knowledge, attitude and practice of nursing personnel catering to critically ill children in a developing country. Settings and Design : Prospective questionnaire-based survey. Materials and Methods : The survey was carried out in a tertiary care teaching hospital on nursing personnel in three pediatric/neonatal intensive care units. The domains studied were: i. Training and experience, ii. Knowledge of pediatric pain, iii. Individual attitude towards pain in children, iv. Personal practice(s) for pain alleviation, v. Pain assessment, and vi. Non-pharmacological measures adopted. Statistical Analysis : Descriptive statistics and logistic regression. Results : Of the 81 nursing personnel working in the three critical care units, 56 (69.1%) responded to the questionnaire. Only one-third of them had received formal training in pediatric nursing. Fifty percent of the respondents felt that infants perceive less pain than adults. Training in pediatric nursing was a significant contributing factor in the domain of knowledge (P=0.03). Restraint and distraction were the common modalities employed to facilitate painful procedures. Scientific approaches like eutectic mixture of local anesthetic and the judicious use of sedatives were not adopted routinely. Observing a child's face and posture were widely used parameters to assess pain (83%). None of the three critical care areas used a scoring system to assess pain. Conclusions : There are several lacunae in the knowledge and practice of nurses in developing countries which need to be improved by training.

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A 30-year-old female presented with an episode of generalized tonic-clonic convulsions. The imaging revealed multiple hemorrhagic lesions in the brain. There was no significant past history except for a cardiac surgery two years ago, for a benign atrial myxoma. The diagnosis of probable metastases was thought of and a thorough workup was planned, to determine the primary. Surprisingly, no primary lesion was detected, and therefore, as a histological diagnosis was required, she underwent navigation-guided excisional biopsy of one of the lesions. The histopathology proved that it was a myxomatous lesion. Thus, a rare diagnosis of atrial myxoma presenting as hemorrhagic metastases of the brain was formed. Atrial myxoma is a benign tumor of the heart. It can embolize distally and can present with known embolic/ischemic manifestations. However, presentation as hemorrhagic mass lesions, involving multiple areas of the brain, after many years of complete surgical excision, is quite rare and is rarely considered as a differential diagnosis. Hence, such a possibility should be kept in mind and careful primary cardiac intervention, with preventive measures to minimize the chances of distal embolization should be undertaken. As only few such cases have been reported worldwide, no treatment protocol has been devised at present, and a close follow-up of these patients is warranted.

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Background : Adverse drug reactions (ADRs) are a major public health problem in the elderly. Although the Indian elderly represent 12.8% of the entire global elderly population, data on prevalence and predictors of ADRs in elderly Indians is extremely limited. Aim : To determine the prevalence, severity, preventability, length of hospital stays, and risk factors for ADRs in hospitalized Indian elderly. Setting : Medicine wards of two tertiary care teaching hospitals. Design : Prospective study was conducted between July 2007 and December 2009. Materials and Methods : In-patients of either sex and aged ≥60 years were included and monitored for ADRs throughout their hospital stay. Severity (Hartwig et al. scale), preventability (Shumock and Thornton criteria) and increased length of stay (considering underlying disease, ADR, and discussion with clinicians) were assessed. Statistical Analysis : Bivariate analysis and subsequently multivariate logistic regression were used to determine the risk factors for developing ADRs. Results : Over the study period, among the 920 patients monitored, 296 patients (32.2%) experienced 419 ADRs. Among all ADRs, 48.4% (203) were preventable. Majority of ADRs [226 (53.9%)] were moderate in severity. Therapeutic classes of drugs frequently associated with ADRs were the drugs used in diabetes [76 (18.1%)] and antibacterials for systemic use [54 (12.9%)]. ADRs increased the hospital stay in 5.9% (54) of patients. Female gender [Odds Ratio: 1.52, 95% Confidence Interval:1.04-2.22, P=0.03] was observed as the influential risk factor for ADRs. Conclusion : One third of hospitalized elderly experienced ADRs. Interventions focused at preventable ADRs should be developed and implemented to reduce their implications.

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Background : Drug interactions in oncology are of particular importance owing to the narrow therapeutic index and the inherent toxicity of anticancer agents. Interactions with other medications can cause small change in pharmacokinetics or pharmacodynamics of chemotherapeutic agents that could significantly alter their safety and efficacy. Aim : To identify and document the potential drug-drug interactions in prescriptions of patients receiving cancer chemotherapy. Settings and Design : A tertiary care teaching hospital based prospective study. Materials and Methods : Patients admitted in the medical oncology wards with different types of malignancies and receiving cancer chemotherapy during the period of June 2009 to November 2009 were included in the study. A detailed data collection was done in a specially designed proforma with ethical approval and consent of patients and their prescriptions were subjected to drug-drug interaction screening using Drug Interaction Fact Software Version-4 and standard references. Incidence of drug-drug interactions, their types, correlation between age, cancer type, number of drugs prescribed and incidence of drug interactions were analyzed. Statistical Analysis : Logistic regression analysis and Odds ratio were performed to identify the incidence of drug-drug interactions and their correlation with the factors above mentioned. Results : A total of 75 patients (32 males and 43 females; median age 56 years, age range 23-74) were enrolled in the study and their prescriptions were screened. 213 interactions were identified of which, 21 were major, 121 were moderate and 71 were minor. There were 13 (6.1%) clinically significant interactions between anticancer drugs and 14 (6.5%) drug-drug interactions between anticancer drugs and other drugs prescribed for co-morbidities. There was a positive correlation between number of drugs prescribed and drug interactions (P=0.011; OR 0.903). Conclusion : Though there was not any life threatening interactions, the potential interactions were brought to the oncologist purview for ensuring patients safety and to avoid undesirable effects.

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Background : The amount of body fat, rather than the amount of excess weight, determines the health risks of obesity, type 2 diabetes mellitus, and cardiovascular disease. Aims : To look at the association of body fat percentage with cardiometabolic risk factors in subjects with normal glucose tolerance (NGT). Settings and Design : Cross-section study from the Chennai Urban Rural Epidemiology Study. Materials and Methods : Body fat was measured by Beurer body fat analyzer. Metabolic syndrome (MS) was diagnosed based on modified ATPIII guidelines. Statistical Analysis : Student's t test or one-way ANOVA (with Tukey's HSD) was used to compare groups for continuous variables. Results : Body mass index, waist circumference, systolic and diastolic blood pressure, HOMA IR, serum cholesterol, and LDL cholesterol increased significantly with increasing tertiles of body fat (P<0.001). There was a linear increase in the percentage of body fat with increase in number of components of MS (no metabolic abnormality: 25±11, one metabolic abnormality: 28±10, two metabolic abnormalities: 33±8, and three and more metabolic abnormalities: 35±7) (P<0.001). Regression models showed significant association of body fat with MS after adjusting for age, gender, insulin resistance, and glycated hemoglobin (Odds ratio: 1.04, 95% confidence interval: 1.04 - 1.08, P<0.001). In linear regression analysis, body fat showed a significant association with insulin resistance after adjusting for age, gender, and glycated hemoglobin (β=0.030, P<0.001). Conclusions : A significant association exists between body fat, MS, and cardiometabolic risk factors even among subjects with NGT.

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Background : Drug-resistant tuberculosis is an important issue for public health. There is a rise in the trend of drug-resistant tuberculosis, especially multi drug resistance (MDR), in different parts of world, India being one of the high burden countries. This study is undertaken to assess the various patterns of resistance among confirmed drug resistant pulmonary tubercular patients and to initiate second line anti tubercular treatment. Aims and Objectives : To assess various resistance patterns among confirmed drug resistant pulmonary tubercular patients and for the initiation of appropriate drug regimens in our setup. Study Design : An observational prospective study. Materials and Methods : This study was conducted at Rajiv Gandhi Institute of Chest Diseases, Bangalore between January 2005 and November 2010. A total of 309 drug resistant tuberculosis cases were studied. Sputum culture and drug sensitivity were carried out at National Tuberculosis Institute. Drug sensitivity testing done for all first line drugs, except pyrazinamide, by using LJ media. Results : In this study, out of 309 patients, MDR pattern was observed in 224 (72%), of which 20 (6.47%) had resistance only to isoniazid (INH) and rifampicin (RMP), 58 (18.7%) had resistance to INH, RMP, and either of the other first line drugs streptomycinor ethambutol and 146 (47.25%) had resistance to all first line drugs. Poly drug resistance pattern was observed in 72 (23.3%) and Mono drug resistance in 13 (4.2%). Conclusion : In the present study the most common pattern observed is MDR with predominant resistance to INH. There is a rise in the number of drug resistant tuberculosis cases, especially MDR. Hence close monitoring of drug resistant pattern is required to formulate designs of different regimens in the treatment of drug resistant tuberculosis; especially MDR-TB based on accredited laboratory reports, in a specialized center which is very much essential for the betterment of the patients and the community.

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Relative adrenal insufficiency (RAI) is commonly diagnosed in critically ill patients failing to maintain a pressor response and/or with electrolyte abnormalities. We report a case of a 59-year-old man who presented with diverticular bleeding and developed prolonged ileus postoperatively. After observing arthritic joints on examination, further questioning revealed long-term, high-dose steroid use for analgesic effect. Failure to produce an effective cortisol response was due to adrenal suppression from continuous steroid use. Immediate improvement of his ileus was seen after steroid replacement. Unreported self-medication is a frequent problem encountered in developing countries. RAI can be easily missed and requires a high index of suspicion in any patient who fails to respond to conventional treatment or with long-term steroid use.

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Background : Previous familial studies have reported co-segregation of mutation in gamma crystallin A and B CRYGA and CRYGB genes with childhood cataract. Aim : We investigated association of nucleotide variations in these genes in subjects with and without pediatric cataract from India. Settings and Design : The study included 195 pediatric subjects including healthy children with no ocular defects and pediatric cataract cases. Materials and Methods : Subjects were genotyped by PCR-RFLP method for exonic and intronic genetic variations in CRYGA and CRYGB. Statistical Analysis : The association of these polymorphisms with cataract was estimated by two way contingency tables and the risk allele was also analyzed for their functional impact using in silico tools. Results : No significant difference was observed between cases and control subjects for the frequencies of SNPs G198A (Intron A), T196C (Exon 3) of CRYGA and G449T (Exon 2) of CRYGB gene. -47C allele of rs2289917 in CRYGB showed the strongest association with cataract (Odd Ratio-OR=3.34, 95% Confidence Interval-CI _95% =1.82-6.12, P=0.00007). In silico analyses revealed that this polymorphism lies in a phylogenetically conserved region and impacts binding of a transcription factor, viz. progesterone receptor (PR) to CRYGB promoter. Conclusion : rs2289917 risk allele showed a strong association with increased vulnerability for pediatric cataract. The findings suggest that this association may be a secondary phenomenon related to genetic variation playing critical role in lens development during perinatal and/or pediatric growth. Present exploratory study provides a basis for further defining the role of PR as a regulator of CRYG locus in lens formation/transparency.

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Are rheumatic musculoskeletal diseases (RMSD) given their due recognition by the medical fraternity and policy makers in India today? Focus on lifestyle diseases has taken away the importance of morbidity caused by musculoskeletal pain, which is one of the commonest ailments in the community. Poor awareness in general regarding the upcoming field of rheumatology and lack of proper data regarding these diseases in the country are the primary causes for this debacle. The epidemiology of RMSD in the country is fast changing, especially in the wake of viral epidemics, which leave their mark for months and years together. This view point emphasizes the burden of RMSD by highlighting the findings of two Community Oriented Programme for the Control of Rheumatic Diseases studies conducted to study the prevalence of RMSD in rural communities in the southern state of Kerala, which inadvertently captured the burden of RMSD following Chikungunya viral epidemics in the regions. Both the studies have reported a high prevalence of RMSD following the epidemics. The value of including RMSD in a national programme to combat the morbidity caused and to improve the health related quality of life of patients has been stressed upon, in the background of altering epidemiology of these disorders in the country.

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Prominent ventricular trabeculations are seen in a fetal heart. Isolated ventricular non-compaction (IVNC) is a rare form of primary cardiomyopathy. It usually presents with heart failure, arrhythmias and very rarely with thrombo-embolic manifestation. The left ventricle is involved in the majority of the cases. Echocardiography is the principal modality for the diagnosis of this condition. IVNC may be misdiagnosed as dilated or hypertrophic cardiomyopathy wherein the prognosis and management do differ significantly. We report a case of a 38-year-old male with IVNC involving both the ventricles, who presented very unusually as stroke resulting from a cardiogenic embolus.

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