To date, a lack of role exclusivity in a small and confined speciality field with multiple potential competitors has resulted in surprisingly little role conflict. Financial constraints within the National Health Service are considered likely to favour a privately funded service model of delivery, and this may have implications for dietitians specialising in this field. Dietitians also perceived an increase in professional status as a result of extended roles.

COPD was associated with an increased risk of vitamin D deficiency, and there was a significant association between vitamin D levels and Combined COPD stage severity. Also, a higher pack year and a low BMI are associated with lower levels of vitamin D.

Sitagliptin is a newer oral hypoglycemic drug of the dipeptidyl peptidase-IV inhibitor class. It appears to be a promising newer oral hypoglycemic agent. The advantages are the absence of hypoglycemia when used as monotherapy and they cause less gain weight. We report a case of sitagliptin-induced hemolysis, a rare side effect, not reported in the literature. As sitagliptin is widely used in type 2 diabetes mellitus physicians should be aware of the possibility of this rare but potentially serious adverse drug reaction.

Context. Ability of SAAG to differentiate malignant ascites from other aetiologies like tubercular peritonitis is a major problem. Alternate screening test is needed for differentiating ascites due to malignancy from those due to tubercular peritonitis. Aims. To study the diagnostic utility of serum ascites lipid gradients and serum ascites protein gradients in pathophysiological differentiation of ascites. Settings and Design. The present study is a prospective, descriptive, hospital-based, cross-sectional study. Methods and Material. The study was conducted on patients with ascites who were admitted to General Medicine Department, Kasturba Hospital, Manipal. The study included 60 patients with ascites of different etiologies (liver cirrhosis, tubercular peritonitis, and malignant ascites). All of them had undergone clinical, laboratory, and imaging investigations and were treated as per standard of care. All patients underwent abdominal paracentesis, and fluid samples were sent for analysis. Statistical Analysis Used. ANOVA, Kruskal-Wallis H test, and ROC curve analysis. Results. Among the gradients, only SAPG and SAAG had over all statistical significance (<0.005) among the groups, but no significance between malignancy and tubercular peritonitis had been observed. Similarly all the ascitic fluid parameters measured had an overall statistical significance (<0.005), but there was no significant difference observed between malignancy and tubercular peritonitis groups. However, ascitic fluid and serum HDL cholesterol had a statistical significance (<0.05) between malignancy and tubercular peritonitis. Conclusions. With a cut-off value of 4, SAPG is one of best screening tests in differentiation of cirrhotic with noncirrhotic ascites when compared with SAAG, whereas it is a poor parameter with high sensitivity and very low specificity in differentiation of malignant with nonmalignant ascites. Also the present study reveals HDL cholesterol levels in ascitic fluid to be a valuable marker with higher sensitivity and specificity in differentiation of malignancy and tuberculosis peritonitis (i.e., differentiation of low SAAG ascites).

Necrotising fasciitis is one of the fatal skin and soft tissue infections. Vibrio vulnificus is a rare cause of necrotising fasciitis; however, the disease is one of the major manifestations of the bacteria. Here, we report one such case in a middle-aged male patient. He presented with the signs of bilateral lower limb cellulitis and altered sensorium. V. vulnificus was isolated from blood culture and also from debrided tissue. Though the organism is well characterised, it is a rare causative agent of necrotising fasciitis. This case is a re-emphasis on active look out for this bacterium in patients presenting with necrotizsing fasciitis.

Multiple acyl-CoA dehydrogenase deficiency (MADD) is a rare metabolic disorder of oxidation of amino acids and fatty acids with an autosomal recessive inheritance. Patients usually present symptoms of MADD in the neonatal period, though it can also be diagnosed in the late adulthood. We present a 36-year-old male with MADD who had sensory axonal neuropathy, rhabdomyolysis metabolic acidosis, lactic acidosis, hypoglycemia and low ketone bodies and renal failure. Early diagnosis and prompt management with carnitine and riboflavin supplements can help in better management of this rare metabolic disorder.

Tropical pyomyositis is an underdiagnosed condition. We reported a 35 year old male farmer, who presented with septicemia and acute respiratory distress syndrome due to pyomyositis involving the paraspinal muscles. Culture of the pus grew methicillin sensitive Staphylococcus aureus, and the patient recovered after surgical drainage and antibiotic treatment. Diagnostic delays can be avoided if tropical pyomyositis is considered as a differential diagnosis in patients with septicemia.

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