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Acute kidney injury (AKI) is common in hospitalized patients and is an important cause of mortality. This is a descriptive study of AKI in patients from Himachal Pradesh, India, located in Western Himalayan region. Over a period of 1 year, 102 patients with clinical and laboratory evidence of azotemia were included. Out of 102 patients, 84.3% had community acquired AKI and 15.7% had hospital acquired AKI. Medical causes were leading contributors (85.3%), with septicemia being the main factor (33.3%). Multiorgan failure was present in 59.8% patients. The overall mortality was 29.2%, and community acquired AKI was associated with higher mortality as compared to hospital-acquired AKI (22.5% vs 6.7%). AKI is still common in community and associated with high mortality. Septicemia, volume depletion and nephrotoxins were the leading cause of AKI in our study. Our study highlights the presence of hypotension, multiorgan failure and oliguria with mortality. Community-acquired AKI had higher mortality than hospital-acquired AKI.

Background: Pulmonary artery hypertension is a disorder with limited treatment options and poor prognosis. We studied the effect of tadalafil, a selective phosphodiesterase type 5 inhibitor, in patients with this disease., Methods and Results: In thirteen patients (5 males, 8 females) aged 15-70 years, with pulmonary artery hypertension (7 with congenital heart disease, 4 with chronic pulmonary thromboembolism and 2 with primary pulmonary hypertension), tadalafil was added to their baseline therapy at 10 mg OD for two weeks and if tolerated well, increased to 20 mg OD for the next two weeks. After four weeks of therapy, all thirteen patients had subjective improvement in the form of overall well being and objective improvement as measured by duration of exercise on treadmill following Bruce protocol from a baseline of 350.54+/-255.06 seconds to 479.54+/-195.00 seconds (p<0.01). There was improvement in NYHA functional class in eleven patients. Two patients, though showed no improvement in functional class, had subjective improvement in effort tolerance and objective improvement as measured by duration of exercise on TMT. Hemodynamic parameters showed a trend towards improvement, mean pulmonary artery mean pressure decreased from 63.5+/-26.2 mmHg to 62.2+/-24.8 mmHg (p>0.05), mean pulmonary blood flow increased from 3.26+/-1.04 L/min to 3.44+/-1.26 L/min (p>0.05), mean total pulmonary vascular resistance decreased from 1858.6+/-1138.9 dyne-sec.cm-5 to 1737.3+/-1017.2 dyne-sec.cm-5 (p>0.05)., Conclusion: Oral tadalafil was well tolerated and had a beneficial effect in patients with pulmonary artery hypertension irrespective of age, sex and underlying etiology. Patient had improved effort tolerance and a trend towards improved pulmonary hemodynamics.

A case of multifactorial symmetrical peripheral gangrene due to viral gastroenteritis, shock, dopamine infusion, exposure to low temperature and nonlactose fermenters septicaemia is presented for its rarity and devastating consequences.

Availability of a large number of drugs/remedies for the management of hiccups suggests that all the available drugs are not effective in all the patients. Baclofen was successful in relieving the intractable hiccups where all other known drugs of hiccup were unable to provide relief.

Objectives: To evaluate the radiological miliary shadows in the high landers of a Himalayan desert for the presence of silicosis., Methods: Seventeen high landers attending the Medicine OPD of a multi-speciality medical camp at Kaza in Himalayas (height 12,500 feet above sea level) having radiological miliary shadows were included in the study. A detailed life time work place history was taken. In the laboratory workup their hemogram, repeat chest skiagram, peak expiratory flow rate, urinalysis and electrocardiogram were undertaken. Their localities were looked for the presence of industries particularly for silicosis prone work place. The silica contents of upper strata of soil were estimated., Results: Silicosis--chronic simple variety was present in nine males and eight females. The youngest person was 43 years of age and oldest person was of 65 years of age. There was no silicosis prone industry in their locality. Four had taken repeated courses of anti-tubercular treatment in adequate doses for these miliary shadows without any change in the radiological shadows. Three had silicosis prone work history. Seven were smokers and two had hypertension. The miliary shadows were 2-4 mm in size and hilar lymphadenopathy was in 11 and fine calcification of lymph nodes in two. Peak expiratory flow rate was reduced. Upper strata of soil had a silica content of 36.8 percent., Conclusion: Silicosis developed in high landers of the Himalayas even without working in silicosis prone work place. They were exposed to silica from the non-work place silica rich environment.

Objective: To study the incidence of koilonychia in the residents of high altitude., Methods: Nails of all the patients attending the Medical Outpatient Department (MOPD) of a multispeciality medical camp at Kaza in Himalayas (height 12,500 feet above sea level) were looked for the presence of koilonychia and were included for the study. Those residing below 10,000 feet were excluded from the study. A detailed history was taken and a thorough physical examination was made in each. Routine laboratory investigations were undertaken. Serum ferritin levels were estimated in seven., Results: Koilonychia was present in 6.99% of the patients (67 out of the 986). There were 29 males and 37 females within the age range of 37 to 78 years. Sixty four were high landers since generations and three were high landers from 2nd generation onward. All were right handed. Koilonychia was in the nails of both upper and lower limbs in 14, in the nails of upper limbs in 49 and in the nails of lower limbs in 18. In the upper limbs it was in all the fingers in 42, in thumb, index and middle fingers of right hand in 12 and of left hand in nine. In the lower limbs it was bilateral in the first three toes in nine. Chronic obstructive pulmonary disease was in 29, ulcer like dyspepsia in 24, osteoarthritis of knee in 17, hypertension in 14, pulmonary tuberculosis in eight, anxiety neurosis in five, pneumoconiosis in two and squamous cell carcinoma of lung in one. The haemoglobin in all was normal and serum ferritin level of the seven patients estimated was also normal., Conclusions: Koilonychia at high altitude is present in 6.99%. It is due to retardation of nail plate growth and is more common in upper limbs.

A case of vivax malaria with neurological symptoms is described.

A prospective double blind cross over study compared the anti-ischemic effect of 20 mg of isosorbide-5-mononitrate (IS-5-MN), 60 mg of diltiazem and 100 mg of metoprolol by performing serial treadmill tests (TMTs) following oral administration of single dose of each drug in 28 patients of ischemic heart disease with positive exercise TMT. The anti-ischemic effect of IS-5-MN, diltiazem and metoprolol was evaluated by assessing the time to onset of ischemia (400.8 +/- 41.1 vs 394.1 +/- 36.0 vs 412.7 +/- 36.6 secs respectively, all p > or = 0.05), duration of ischemia (390.9 +/- 58.5 vs 447.6 +/- 65.9 vs 419.4 +/- 58.7 secs respectively, all p > or = 0.05), duration of exercise 464.0 +/- 32.9 vs 476.8 +/- 32.5 vs 502.6 +/- 31.3 secs respectively, all p > or = 0.05) and severity of ischemia by scoring system (10.0 +/- 1.5 vs 10.7 +/- 1.4 vs 9.8 +/- 1.5 respectively, all p > or = 0.05). Thus, the present study suggests that there is no significant difference in the anti-ischemic effect of IS-5-MN, diltiazem and metoprolol and also suggests that the anti-ischemic effect of metoprolol is primarily by decreasing the heart rate while IS-5-MN and diltiazem exert anti-ischemic effect probably by decreasing oxygen demand and improving coronary blood flow.

Five patients of hyperthyroidism with Motor Neurone Disease like picture seen over a span of five years are described. The illness was of over 3 years duration and all patients were males. One patient had even the diagnosis of "MND'. It took 1 to 3 months for disappearance of MND picture with antithyroid drugs. In MND like disease every effort should be made to exclude hyperthyroidism.

Four patients of pure gouty nephropathy are presented. Gout was of over five years duration and asymptomatic nephropathy manifested as non-oliguric acute renal failure. Diseases commonly associated with it like uric acid stones, urinary tract infections, hypertension, diabetes mellitus, hyperlipidemid, obesity and nephrosclerosis were absent. Reduction in serum uric acid level resulted in prompt improvement in renal functions. Early detection and control of hyperuricemia may help in restoration of renal functions.

The role of real-time ultrasonography was evaluated in 50 randomly selected cases with a strong clinical suspicion of gallbladder diseases and normal oral cholecystogram. Of these, 13(26%) cases showed abnormalities on ultrasonography.

Neurological complications like type II paralysis are well described in organophosphorus poisoning. Sphincteric involvement is not described. We report two patients of organophosphorus poisoning who had sphincteric involvement as an unusual manifestation of type II paralysis.

Electrocardiographic monitoring of a 24 year old male, who sustained household electric current injury, showed low voltage ECG complexes, varying degrees of atrioventricular (AV) blocks, and ventricular fibrillation. The low voltage ECG complexes and varying AV blocks disappeared spontaneously and ventricular fibrillation reverted to normal after cardioversion.

A patient with Lyme disease is described. He presented with meningitis-like picture, arthritis, and carditis (congestive cardiac failure and variable AV blocks without valvular lesions). Borrelia was present in the peripheral blood smear.

Two cases with severe hypoglycaemia following zinc phosphide poisoning are reported. Both patients succumbed to toxic myocarditis.