1

RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE.

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1.NAME OF THE CANDIDATE
AND ADDRESS / DR. CHANDRAKANT S JAVALI
C/o - P. S. JIDAGI PlotNo. 55,
14thCross, Vidyagiri,
Bagalkot-587103
Karnataka
2.NAME OF THE
INSTITUTION / BANGALOREMEDICALCOLLEGE AND RESEARCH INSTITUTE, BANGALORE.
3.COURSE OF STUDY AND
SUBJECT / M.D. GENERAL MEDICINE
4.DATE OF ADMISSION TO
THE COURSE / 28-04-10
5.TITLE OF THE TOPIC / A STUDY OF CLINICAL PROFILE OF COMPLICATED MALARIA WITH SERUM LACTATE LEVELS AS A PROGNOSTIC MARKER.

6. BRIEF RESUME OF THE INTENDED WORK

6.1 NEED FOR THE STUDY

Patients exhibiting a disorder of lactate metabolism are typically significantly ill and are at risk for developing multiple organ failure. Patients suffer a hospital mortality rate that increases nearly linearly with the concentration of serum lactate. Several studies have shown that vigilant correction of hyperlactemia is associated with decreased morbidity and mortality. The mortality rate of patients with a serum lactate level greater than 2 mmol/L persisting after 24 hours with an associated acidemia approaches 70%.1

Hyperlactatemia commonly co-exists with hypoglycemia.2Acidaemic patients had a slower mean respiratory rate and a higher incidence of respiratory rhythm abnormalities than other patients3.Acidotic breathing is often followed by circulatory failure refractory to volume expansion or inotropic drugs & ultimately by respiratory arrest.

The study addresses the impact of lactic acidosis as a prognostic indicator of complicatedmalaria patients.

6.2 REVIEW OF LITERATURE

Study conducted by TA Taylor2 et al The strong association of altered acid-base statuswith disease severity and mortality was independent of other previously identifiedpredictors of illness and death in malaria

A study by M. English4et al demonstrated that Severemalaria caused a predominantly

high-anion gapmetabolic acidosis in at least 43% of children.Children with coma and

respiratory distress(CM+RD) had greater evidence of renal dysfunction, lower mean pH

and higher meanplasma osmolalitythan those with respiratory distress (RD) or coma.

In a study conducted by Maitland K5 et al demonstrated metabolic acidosis as a central

feature of severe malaria and is the best independent predictor of a fatal outcome in both

adults and children.

Piero Olliaro6showed that, despitethe diversepresenting syndromes across the different

age groups, depth of coma and severityof acidosis were the most important prognostic

factors, independent of age.

Andrej Trampuz 7et al showed in their study that metabolic acidosis and hypoglycemia

are common systemic complications of severe malaria.

Tsiri Agbenyega 8et al in their study demonstrated the positive correlation between

duration of coma and the lactate disposalrates is consistent with the hypothesis that

microvascular obstruction,due to sequestration of infected erythrocytes, is an underlying

mechanism that is common to the development of both cerebral malariaand lactic

acidosis.

Tim Planche9et al in their study suggested that severe malaria has many manifestations,

of which coma and lactic acidosis are the best independent predictors of a fatal outcome.

6.3AIMS & OBJECTIVES OF THE STUDY :

To analyse the clinical significance of measuring serum lactate levels as prognostic indicator in complicated malaria

.

  1. MATERIALS AND METHODS :

7.1 SOURCE OF DATA:

The cross-sectional study will be conducted from October 2010toseptember 2012 in

Patients attending hospitals affiliated to BMCRI.

.

7.2METHOD OF COLLECTION OF DATA:Subjects will be 40 patients of complicated malaria diagnosed as per WHO guidelines.

7.3 INCLUSION CRITERIA:40 patients who will meet the criteria of complicated malaria are included.

7.4EXCLUSION CRITERIA:

  1. Diabetic patients on metformin therapy
  2. HIV patients on Anti Retroviral Therapy
  3. Chronic Renal Failure patients
  4. Congestive Cardiac Failure patients
  5. Chronic liver disease
  6. Acute febrile illness mimicking malaria(MP-ve) as in Leptospirosis , Dengue fever & sepsis
  7. Known patients with G-6 P D deficiency

7.5 STUDY DESIGN: Descriptive study

7.6 STATISTICAL METHOD: Chi-square test and regression study

7.7DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO DESCRIBE BRIEFLY- YES

INVESTIGATIONS REQUIRED

  1. Complete hemogram
  2. Thick & thin blood smears / QBC for MP
  3. Random blood sugar
  4. Serum lactate levels & arterial blood gas analysis (if neded)
  5. Liver Function Test & Renal Function Test
  6. Urine routine, 24 hrs urine output , benzidine test
  7. Bleeding Time , Clotting Time , Prothrombin Time in patients with bleeding disorder
  8. Peripheral Smear for broken & fragmented RBC’S
  9. CSF examination in patients with meningitis signs & Focal Neurological Deficits

7.8HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.7:YES

8.LIST OF REFERENCES

8.1JOURNALS

  1. Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA.Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial.JAMA.Feb 242010;303(8):739-46.[Medline].
  2. Krishna S, Waller DW, ter Kuile F, D.Kwiatkowski,J.Crawley, C.F.C.Craddocket al. Lactic acidosis and hypoglycaemia in children with severe malaria: pathophysiological and prognostic significance. Trans R Soc Trop Med Hyg. 1994;88:67–73
  3. Taylor T, Borgstein A, Molyneux M. Acid Base Status in Paediatric Plasmodium Palciparum Malaria. Q J Med 1993; 86:99–109.
  4. M. english, R. Sauerwein,, C. waruiru, M. mosobo, J. obiero,B. Lowe et al.Acidosis in severe childhood malaria,Q J Med 1997; 90:263–70
  5. Maitland K, Marsh K. Pathophysiology of severe malaria in children. Acta Trop. 2004;90:131–140
  6. Piero Olliaro CID 2008; 47:158-60.
  7. Andrej Trampuz, Matjaz Jereb, Igor Muzlovic and Rajesh M Prabhu.Critical CareAugust 2003; volume7(4):315-23.
  8. Tsiri agbenyega ,CharlesR.J.C.Newton,ClarissaValim,Sanjeev Krishna, David Wypij,Christopher Olola clin infect dis. 2005 october 1;41(7):948-57.
  9. Tim Planche. Trends in Parasitology, Volume 21(12), 562-67, 1 December 2005
  10. TEXTBOOKS
  1. White NJ. Malaria. In : Garden C,. Manson’s Testbook of Tropical Diseases. 21st edition. London : WB Saunders.2010; 1087-1164.
  2. White NJ. Malaria. Fauci et al. Harrison’s text book of internal medicine. 17th edition.Mc Graw Hill.2008;1280-94.

9. SIGNATURE OF THE CANDIDATE:

Dr. CHANDRAKANT S JAVALI

10REMARKS OF THE GUIDE:

With resurgence of malarial epidemic, we are seeing increasing number of cases of

complicated malaria. There are several clinical as well as biochemical prognostic

indicators ofsevere malaria. There are only few studies in the literature conducted

on adults predicting severityof malaria. Plasma concentration of lactate &

bicarbonate are the best prognosticators in severecomplicated malaria. Hence this

study addresses the clinical profile as well as serum lactate levelas a prognostic

indicator of severe malaria.

11. Name and designation of

Guide : PROF.GOVINDAPPA D.

Professor of medicine

Department of medicine

Bangaloremedical college & research

institute Bangalore

11.2 Signature:

11.3 Co-guide (if any) – No

11.4HEAD OF THE DEPARTMENT:

DR.VASANTHA KAMATH MBBS MD FICP

Professor & head of the department

Department of medicine,

Bangalore medical college & research institute

Bangalore

11.5: Signature -

12.1 Remark of chairman and principal

12.2 Signature -