A case of anti-LGI-1 encephalitis presented as acute psychosis

Anti-leucine-rich glioma inactivated protein-1 (LGI-1) encephalitis is a rare autoimmune disease with a varied neuropsychiatric clinical manifestation and have potential for reversal with immunotherapy. Early identification and treatment are therefore of paramount importance. We present the case of a 43-year-old man admitted for acute psychosis with facio-brachial dystonic seizures not responding to anti-epileptic drugs (AEDs). His symptoms started approximately 5 months prior admission to the hospital and associated with progressive cognitive impairment (particularly verbal and visio-spatial domains) followed by altered behavior, irrelevant talk, and disturbance in daily activities of living and facio-brachial dystonic seizures. There was history of allergic reaction to valproate, carbamazepine and levetiracetam, and serum sample tested strongly positive for LGI-1 (leucine rich glioma inactivated-1) antibodies. He was treated with injection methylprednisolone (1 gm intravenous) brief pulse therapy for 7 days and then underwent four sessions of plasma exchange followed by oral steroids and immunosuppressant therapy. Treatment was successful and patient returned to his previous baseline functioning but patient develops steroid induced hypomania and diabetes mellitus in the due course of time. Patient was discharged after successful resolution of symptoms. Patient did not come up for follow-up. He was contacted telephonically and we get to know that he relapsed after 2 weeks and consulted at higher center where he died while on treatment. Prognosis of anti-LGI-1 encephalitis is usually good but our patient died.

Prevalence of depression in patients of type 2 diabetes mellitus: A cross sectional study in a tertiary care centre

AIMS

The present study aims to study the prevalence of depression in patients with uncomplicated type II diabetes mellitus and to find its association with various socio-demographic factors in the same.

MATERIALS AND METHODS

A cross-sectional, single interview study was performed in an outpatient department of an endocrinology institute. Total 80 type II DM patients without any associated complications of diabetes were included in this study. To diagnose Depressive Episode, structured clinical interview for DSM V was applied. Severity of depression was assessed by Hamilton Rating Scale for Depression (HAM-D). To assess socio-demographic characteristics of the patients, all of them were evaluated with a semi-structured socio-demographic performa.

RESULTS

38.75% patients (N=31) were found to be suffering from depression. Among them 48.38% were moderately depressed and none were suffering from very severe depression. Significant association was not found between depression and socio-demographic factors of age (p=0.920), gender (p=0.251), economic profile (p=0.583), local background of the patient (p=0.646), educational qualification (p=0.935) and marital status (p=0.644). Similarly no association was found with duration of diabetes, HbA1c and BMI.

CONCLUSION

Exclusion of complicated cases didn't seem to influence overall prevalence of depression, although reduction in severity was apparent. Thus even in those diabetic patients who are leading a complication free life, a detailed psychiatric analysis to rule out depression is mandatory.

Barriers and facilitators to starting insulin in patients with type 2 diabetes: a systematic review

AIM

To identify the barriers and facilitators to start insulin in patients with type 2 diabetes.

METHOD

This was a systematic review. We conducted a systematic search using PubMed, EMBASE, CINAHL and Web of Science (up to 5 June 2014) for original English articles using the terms 'type 2 diabetes', 'insulin', and free texts: 'barrier' or 'facilitate' and 'initiate'. Two pairs of reviewers independently assessed and extracted the data. Study quality was assessed with Qualsyst.

RESULTS

A total of 9740 references were identified: 41 full-text articles were assessed for eligibility. Twenty-five articles (15 qualitative, 10 quantitative) were included in the review. Good inter-rater reliability was observed for the Qualsyst score (weighted kappa 0.7). Three main themes identified were as follows: patient-related, healthcare professional and system factors. The main patient-related barriers were fear of pain and injection (n = 18), concerns about side effects of insulin (n = 12), perception that insulin indicated end stage of diabetes (n = 11), inconvenience (n = 10), difficulty in insulin administration (n = 7), punishment (n = 7) and stigma and discrimination (n = 7). Healthcare professionals' barriers were as follows: poor knowledge and skills (n = 9), physician inertia (n = 5) and language barriers (n = 4). System barriers included lack of time (n = 5). The most common facilitators were understanding the benefits of insulin (n = 7), not being afraid of injections (n = 5), and patient education and information (n = 5).

CONCLUSION

Major barriers to insulin initiation persist despite availability of newer and safer insulin. Healthcare professionals should explore and address these barriers. Targeted interventions should be developed to overcome these barriers.

Factitious disorder-a case report

A case of factitious illness in a young village woman is described. She presented with multiple physical and psychiatric symptoms and had interpersonal and sexual problems. A simple behavioural approach was successful in ameliorating her symptoms.