Pellagra induced psychosis: a rare presentation

Pellagra is a nutritional deficiency disease associated with low levels of niacin (vitamin B3). Neuropsychiatric symptoms are rare and are difficult to be diagnosed by clinicians in a timely manner. A 35 years old male was brought with complaints of generalized weakness, decreased appetite and work impairment since past 4 years. Scaly and itching skin rashes have also been present since 3 months followed by hearing voices, suspiciousness and agitated behaviour since one month. On examination, he had pruritic skin rashes over hands which extended over face and neck. His diet comprised mainly of jowar and maize and had history of occasional alcohol use. With an initial diagnosis of psychosis, the patient was started on oral olanzapine. Laboratory and imaging investigations were within normal limits. Dermatology referral confirmed pellagra clinically. The patient was started on injectable multivitamins for 14 days and later shifted to oral multivitamins. Patient showed significant improvement in his skin and neuropsychiatric symptoms. Present case suggests that physicians need to remain vigilant because it is easy to overlook such patients. Pellagra has an insidious onset and psychiatric symptoms appear rare and late in the course when disease is allowed to progress

A rare case of mixed connective tissue disease presenting with central nervous system glioma, vasculitis and polymyositis

Mixed connective tissue disease (MCTD) was first recognized by Sharp and Colleagues in 1972 among a group of patients with overlapping clinical features of systemic lupus erythematosis (SLE), scleroderma and myositis, with the presence of distinctive antibodies against, what now is known to be U1-ribonucleoprotein (RNP). We report an unusual case of a 23-year old female with MCTD characterized by the coexistence of signs, symptoms and immunological features of 3 defined autoimmune diseases SLE, systemic sclerosis (SSc), polymyositis (PM) and an unusual presence of central nervous system (CNS) Glioma

A cohort evaluation of clinical use and performance characteristics of Ambu® AuraGain™: A prospective observational study

Background and Aims: Ambu® AuraGain™ (AG) (Ambu, Ballerup, Denmark) is a supraglottic device which has a design facilitating its use as a conduit for intubation. We designed this prospective observational study to assess the ease of AG placement in paralysed patients, determine its position and alignment to the glottis and assess its utility as a conduit for intubation. Methods: One hundred patients, aged 18–60 years, American Society of Anesthesiologists physical status I–II, undergoing elective surgery under general anaesthesia were included in the study. The ease and number of attempts for successful insertion, ease of gastric tube insertion, leak pressures, fibre-optic grade of view, number of attempts and time for tracheal intubation, time for AG removal and complications were recorded. The mean, standard deviation (SD), interquartile range (IQR) and range were calculated. The upper limit of confidence interval for overall failure rate was calculated using Wilson's score method. Results: AG was successfully inserted in all patients. The mean (SD) time taken for insertion was 17.32 (8.48) s. The median [IQR] leak pressures were 24 [20–28] cm of H2O. Optimal laryngeal view for intubation was obtained in 68 patients. Eighty-eight patients could be intubated in the first attempt. Five patients could not be intubated. The overall failure rate of device was 9%. Conclusion: AMBU® AuraGain™ serves as an effective ventilating aid, but caution is suggested before using it as a conduit for endotracheal intubation

A prospective randomized double-blind study comparing dexmedetomidine vs. combination of midazolam-fentanyl for tympanoplasty surgery under monitored anesthesia care

Background: Analgesia and sedation are usually required for the comfort of the patient and surgeon during tympanoplasty surgery done under local anesthesia. In this study, satisfaction scores and effectiveness of sedation and analgesia with dexmedetomidine were compared with a combination of midazolam-fentanyl. Materials and Methods: Ninety patients undergoing tympanoplasty under local anesthesia randomly received either IV dexmedetomidine 1 μg kg -1 over 10 min followed by 0.2 μg kg -1 h -1 infusion (Group D) or IV midazolam 0.06 mg kg -1 plus IV fentanyl 1 μg kg -1 over 10 min (Group MF) followed by normal saline infusion at 0.2 ml kg -1 h -1 . Sedation was titrated to Ramsay sedation score (RSS) of three. Vital parameters, rescue analgesics (fentanyl 1 μg kg -1 ) and sedatives (midazolam 0.01 mg kg -1 ), patient and surgeon satisfaction scores were recorded. Results: Patient and surgeon satisfaction score was better in Group D than Group MF (median interquartile range (IQR) 9 (8-10) vs. 8 (6.5-9.5) and 9 (8.5-9.5) vs. 8 (6.75-9.25), P = 0.0001 for both). Intraoperative heart rate and mean arterial pressure in Group D were lower than the baseline values and the corresponding values in Group MF ( P 0.17). Seven patients in Group D had dry mouth vs. none in Group MF ( P = 0.006).One patient in Group D had bradycardia with hypotension which was effectively treated. Conclusion: Dexmedetomidine is comparable to midazolam-fentanyl for sedation and analgesia in tympanoplasty with better surgeon and patient satisfaction. Hemodynamics need to be closely monitored