Comparison of a Novel Score "NOD-ACLF" to Other Established Prognostic Scores for Prediction of Mortality in APASL-ACLF Patients: A Cohort Study from a Tertiary Care Center of North India.

Background: Commonly used prognostic scores for acute on-chronic liver failure (ACLF) have complex calculations. We tried to compare the simple counting of numbers and types of organ dysfunction to these scores, to predict mortality in ACLF patients. Methods: In this prospective cohort study, ACLF patients diagnosed on the basis of Asia Pacific Association for Study of the Liver (APASL) definition were included. Severity scores were calculated. Prognostic factors for outcome were analysed. A new score, the Number of Organ Dysfunctions in Acute-on-Chronic Liver Failure (NOD-ACLF) score was developed. Results: Among 80 ACLF patients, 74 (92.5%) were male, and 6 were female (7.5%). The mean age was 41.0±10.7 (18-70) years. Profile of acute insult was; alcohol 48 (60%), sepsis 30 (37.5%), variceal bleeding 22 (27.5%), viral 8 (10%), and drug-induced 3 (3.8%). Profiles of chronic insults were alcohol 61 (76.3%), viral 20 (25%), autoimmune 3 (3.8%), and non-alcoholic steatohepatitis 2 (2.5%). Thirty-eight (47.5%) were discharged, and 42 (52.5%) expired. The mean number of organ dysfunction (NOD-ACLF score) was ->4.5, simple organ failure count (SOFC) score was >2.5, APASL ACLF Research Consortium score was >11.5, Model for End-Stage Liver Disease-Lactate (MELD-LA) score was >21.5, and presence of cardiovascular and respiratory dysfunctions were significantly associated with mortality. NOD-ACLF and SOFC scores had the highest area under the receiver operating characteristic to predict mortality among all these. Conclusion: The NOD-ACLF score is easy to calculate bedside and is a good predictor of mortality in ACLF patients performing similar or better to other scores.

Culture-independent identification of bloodstream infections from whole blood: prospective evaluation in specimens of known infection status.

Sepsis caused by bloodstream infection (BSI) is a major healthcare burden and a leading cause of morbidity and mortality worldwide. Timely diagnosis is critical to optimize clinical outcome, as mortality rates rise every hour treatment is delayed. Blood culture remains the "gold standard" for diagnosis but is limited by its long turnaround time (1-7 days depending on the organism) and its potential to provide false-negative results due to interference by antimicrobial therapy or the presence of mixed (i.e., polymicrobial) infections. In this paper, we evaluated the performance of resistance and pathogen ID/BSI, a direct-from-specimen molecular assay. To reduce the false-positivity rate common with molecular methods, this assay isolates and detects genomic material only from viable microorganisms in the blood by incorporating a novel precursor step to selectively lyse host and non-viable microbial cells and remove cell-free genomic material prior to lysis and analysis of microbial cells. Here, we demonstrate that the assay is free of interference from host immune cells and common antimicrobial agents at elevated concentrations. We also demonstrate the accuracy of this technology in a prospective cohort pilot study of individuals with known sepsis/BSI status, including samples from both positive and negative individuals. IMPORTANCE: Blood culture remains the "gold standard" for the diagnosis of sepsis/bloodstream infection (BSI) but has many limitations which may lead to a delay in appropriate and accurate treatment in patients. Molecular diagnostic methods have the potential for markedly improving the management of such patients through faster turnaround times and increased accuracy. But molecular diagnostic methods have not been widely adopted for the identification of BSIs. By incorporating a precursor step of selective lysis of host and non-viable microorganisms, our resistance and pathogen ID (RaPID)/BSI molecular assay addresses many limitations of blood culture and other molecular assay. The RaPID/BSI assay has an approximate turnaround time of 4 hours, thereby significantly reducing the time to appropriate and accurate diagnosis of causative microorganisms in such patients. The short turnaround time also allows for close to real-time tracking of pathogenic clearance of microorganisms from the blood of these patients or if a change of antimicrobial regimen is required. Thus, the RaPID/BSI molecular assay helps with optimization of antimicrobial stewardship; prompt and accurate diagnosis of sepsis/BSI could help target timely treatment and reduce mortality and morbidity in such patients.

KGHeBTA (King George's Medical University Hepatitis B Therapeutic Algorithm): A New Diagnostic and Therapeutic Algorithm and Clinico-epidemiological Spectrum of Hepatitis B.

Background: Diagnostic and therapeutic algorithms given by various societies for hepatitis B are fragmented and complex. The clinico-epidemiologic spectrum of hepatitis B is not studied with large-scale data from our region. We aimed to develop a comprehensive algorithm for the treatment of hepatitis B and study its clinico-epidemiological spectrum. Methods: From 2014-2019, the clinico-laboratory data of hepatitis B surface antigen (HbsAg)-positive patients were prospectively recorded. King George's Medical University hepatitis B therapeutic algorithm (KGHeBTA) was developed on the basis of the standard existing guidelines. The prevalence of different clinical stages of HBsAg-positive patients was calculated and their treatment records reviewed. Testing circumstances and risk factors were noted. Results: Among 1,508 data record sheets, 421 were complete. According to the KGHeBTA algorithm, 221 had detectable hepatitis B virus DNA. 21% were cirrhotic and 79% non-cirrhotic. 72% were incidentally detected asymptomatic hepatitis B, 7% were hepatitis B with acute symptoms, 0.7% were acute hepatitis B, and 22% were chronic hepatitis B. 20% patients were eligible for antivirals and 80% patients were not eligible. 32% patients were actually treated with antivirals due to the inclusion of some special indications as pregnancy and family history. Screening during various medical illnesses (40%) was the most common and during health camps (0.2%), the least common testing approach. Road-side shaving (52%) was the most common and intravenous drug abuse (0.2%) and the least common risk factor for the detection of hepatitis B in our data pool. Conclusions: HBsAg-positive patients can be easily worked up and treated based on the proposed algorithm (KGHeBTA). About one fourth to one fifth of all HBsAg-positive patients were eligible and treated with oral antivirals. Most of the patients were incidentally detected asymptomatic hepatitis B screened during medical illnesses. Roadside shaving and intravenous drug abuse were the most and the least common risk factors.

Fetal Epicardial Fat Thickness: Its Role as Marker for Gestational Diabetic Mellitus.

Background There are very few studies on the association between fetal epicardial fat thickness (EFT) and gestational diabetes mellitus (GDM). Aims To evaluate the role of fetal epicardial fat thickness as a marker and use it in pregnancies to screen for GDM. Settings and Design A cross-sectional analytical study was conducted in the Department of Radiodiagnosis and Imaging at Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, after the due clearance from the institutional research and ethics committee. Materials and Methods The study included pregnant patients at 24 + 0/6 to 28 + 0/6 weeks of gestation scheduled for a 75 g oral glucose tolerance test from December 1, 2020 to March 30, 2022. Antenatal ultrasound was performed on Voluson E8 Expert BT12 (Wipro GE) ultrasound machine. Out of 180 patients, 60 patients were selected, that is, 30 patients with raised 75 g OGTT results (cases of GDM) and 30 patients with normal 75 g OGTT results. Statistical Analysis The collected data were transformed into variables, coded, and entered into Microsoft Excel. Data were analyzed using the Shapiro-Wilk normality test, student's t -test or Mann-Whiney U test, chi-square test, or Fisher's exact test and statistically evaluated using the SPSS-PC-25 version. Results Fetal EFT was found to be significantly more in the GDM group in comparison to controls without GDM, and the increased fetal EFT was positively associated with 2-hour OGTT serum glucose values. The mean fetal epicardial fat thickness (EFT) in mothers with GDM was significantly larger, i.e., 0.17 ± 0.02 cm than in mothers without GDM, i.e., 0.12 ± 0.01 cm ( p < 0.001). The receiver operating characteristic (ROC) curve plotted from values calculated from our results shows high sensitivity (i.e., 96.67%) and specificity (i.e., 90%) of fetal EFT as a predictor for GDM with an AUROC value of 0.96 and 95% confidence interval of 0.92 to 1.0. Conclusions EFT was significantly higher in fetuses of diabetic versus nondiabetic mothers. The mean difference in EFT of GDM cases and controls was relatively small but was statistically significant. The study concluded that measuring the epicardial fat thickness in fetuses can serve as a novel marker in GDM.

Obstructive Sleep Apnea in Hypertension.

Introduction About one-half of patients who have essential hypertension have obstructive sleep apnea (OSA), and about one-half of patients who have obstructive sleep apnea have essential hypertension. OSA can cause even resistant hypertension if left untreated. These two entities often co-exist and are seen as a continuum of the same process. Eighty percent to 90% of OSA cases are undiagnosed mostly because of a lack of awareness. Material and methods This was a cross-sectional study done over a period of one year in a tertiary care hospital. After taking informed consent, 179 hypertensive patients of >18 years were included in the study. All patients were screened for OSA by the STOP-BANG questionnaire. Patients having scores of ≥3 were subjected to overnight polysomnography to confirm the diagnosis of OSA (AHI ≥5). Patients with a STOP-BANG score ≤2 or score ≥3 with AHI <5, were considered non-OSA. Results More than half (53.1%) of the patients enrolled in the study had OSA. Their age ranged from 18 to 78 years and the mean age was 52.07±11.40 years. The mean age of OSA cases was found to be slightly higher than that of non-OSA. The majority of OSA cases were males (73.7%). There was an increase in the prevalence, as well as the severity of OSA, with an increase in BMI. Most of the cases had snoring and a history of tiredness. Triglyceride (TG) and low-density lipoprotein (LDL) levels of the OSA group were found to be significantly higher and high-density lipoprotein (HDL) levels were significantly lower than that of the non-OSA group. Conclusion More than half of our hypertensive patients had OSA. These two conditions often co-exist and are known as a dangerous pair. Physicians ought to have increased suspicion for early diagnosis and treatment to improve cardiovascular outcomes, reduce road traffic accidents, and improve quality of life.

Nontubercular bacterial and fungal infections in patients of chronic obstructive pulmonary disease.

Introduction: Acute exacerbation of chronic obstructive pulmonary disease (COPD), frequently due to respiratory tract infection is the major cause of morbidity and mortality, and estimate suggests that it is currently the third leading cause of death worldwide. Aims and Objectives: This study aims to study the prevalence of nontubercular bacterial and fungal infections in patients of COPD. Materials and Methods: It is an observational study done for 1-year period from August 2017 to July 2018. A total of 100 COPD patients who fulfilled the inclusion and exclusion criteria were analyzed in the present study. These cases were classified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) combined assessment criteria and subjected to sputum or in some cases Bronchoalveolar lavage (BAL) fluid examination for nontubercular bacterial and fungal pathogens. Serum galactomannan assay, bronchoscopy, and computed tomography chest were done in selected cases. Results: The age of the study population ranged from 40 to 85 years and the mean age was 60.01 ± 9.85 years. Majority of the patients were male (81.0%) and most (78.0%) of them were smokers. Most of the patients belonged to GOLD Grades 2 and 3. Forty-six percent of the patients did show pathogenic organisms in sputum examination. Out of these, 80.4% were bacterial, mainly Gram-negative organisms (Acinetobacter, Pseudomonas, Escherichia coli, Enterobacter, Proteus, and Citrobacter) and 19.6% of cases were having fungal infections (Candida and Aspergillus). Conclusions: Increasing patient age, smoking habit, and severity of COPD were related to an increasing frequency of bacterial and fungal infections. Early detection and proper treatment could help in preventing the morbidity and mortality related to COPD.

Résumé Introduction: L'exacerbation aiguë de la maladie pulmonaire obstructive chronique (MPOC), souvent en raison de l'infection des voies respiratoires, est la principale cause de morbidité et de mortalité, et l'estimation suggère qu'il s'agit actuellement de la troisième cause de décès dans le monde. Objectifs et objectifs: Cette étude vise à étudier la prévalence des infections bactériennes et fongiques non tubulaires chez les patients de la MPOC. Matériaux et méthodes: Il s'agit d'une étude d'observation réalisée pour une période de 1 an d'août 2017 à juillet 2018. Un total de 100 patients atteints de MPOC qui remplissaient les critères d'inclusion et d'exclusion ont été analysés dans la présente étude. Ces cas ont été classés selon l'initiative globale des critères d'évaluation combinés chroniques obstructifs (OR) et soumis à des expectorations ou dans certains cas examen des liquides de lavage bronchoalvéolaire (BAL) pour les agents pathogènes bactéries et fongiques non tubulaires. Le test de galactomannane sérique, la bronchoscopie et le poitrine de tomodensitométrie ont été effectués dans certains cas. Résultats: L'âge de la population d'étude variait de 40 à 85 ans et l'âge moyen était de 60,01 ± 9,85 ans. La majorité des patients étaient des hommes (81,0%) et la plupart (78,0%) d'entre eux étaient des fumeurs. La plupart des patients appartenaient à GOLD GRADES 2 et 3. Quarante-six pour cent des patients ont montré des organismes pathogènes à l'examen des expectorations. Parmi ceux-ci, 80,4% étaient des organismes bactériens, principalement à Gram - négatifs (Acinetobacter, Pseudomonas, Escherichia coli, Enterobacter, Proteus et Citrobacter) et 19,6% des cas avaient des infections fongiques (Candida et 23 aspergillus). Conclusions: L'âge croissant du patient, l'habitude du tabagisme et la gravité de la MPOC étaient liés à une fréquence croissante des infections bactériennes et fongiques. La détection précoce et le traitement approprié pourraient aider à prévenir la morbidité et la mortalité liées à la MPOC. Mots-clés: Maladie pulmonaire obstructive chronique, infection fongique, initiative mondiale pour la maladie pulmonaire obstructive chronique, infection bactérienne non tuberculeuse.

Amphotericin B induced pancytopenia.

Amphotericin B (AMB) has been the irreplaceable drug of choice for countless fungal and protozoal infections. One of the lesser-known adverse effects of AMB is Pancytopenia - very rare with very few cases reported - most commonly observed following prolonged administration. We report the case of a patient suffering from visceral leishmaniasis, who developed worsening pancytopenia four to five days after being administered a single bolus dose of Liposomal Amphotericin B (L-AMB). The diagnosis was clinical and management involved supportive care, and granulocyte-macrophage colony-stimulating factor (GM-CSF). AMB is an effective drug, but is also associated with numerous side effects. Physicians are well-versed with the more frequently seen adverse drug reactions and their management. However, pancytopenia, being a rare adverse reaction to AMB, is less known and can be easily overlooked. This case report aims to ensure that the physicians must be aware of such possibilities in the first place to make swift diagnoses and management. The condition itself is seemingly self-limiting, although GM-CSF may be needed in refractory cases. It's true that few previous case reports have indicated pancytopenia in association with prolonged AMB exposure, but we believe certain conditions may predispose a patient to a more acute presentation - as seen in our case.

Obstructive sleep apnea in hypothyroidism.

Introduction: Obstructive sleep apnea (OSA) and hypothyroidism are closely linked as hypothyroidism has been shown to lead to the development of OSA through multiple mechanisms. With the changing lifestyle patterns worldwide and increased prevalence of obesity, the burden of OSA has substantially increased. The association of OSA with hypothyroidism is essential to establish. If identified early, treatment of OSA and associated hypothyroidism can be done timely to minimize the potential harmful complications of OSA on all aspects of the patient's health. Aims: This study was done to find out the prevalence of OSA in hypothyroidism patients. Setting and Designs: It was a cross-sectional study, done over a period of 1 year in a tertiary care hospital. Materials and Methods: A total of 100 hypothyroidism patients were enrolled after taking written consent. All patients were subjected to STOP-Bang questionnaire and patient falling in intermediate-high risk (score3-8), were taken for overnight polysomnography to confirm the diagnosis of OSA (AHI ≥5). Statistical Analysis Used: The Statistical Package for the Social Sciences version 21.0 statistical analysis software. Results: Out of 100 patients, who underwent polysomnography, 74 (74%) cases had OSA (AHI ≥5). Out of total 74 OSA cases, 29 (39.2%) cases had mild OSA (AHI 5-14), 15 (20.3%) cases had moderate OSA (AHI 15-30), and 30 (40.5%) cases had severe OSA. The age of the study population ranged between 24 and 78 years and the mean age was 58.28 ± 11.22 years. The mean age of the patients in the OSA group (59.27 ± 11.17 years) was higher than the non-OSA group (55.46 ± 11.09 years). Majority (64%) of our cases were male, and the proportion of males was found to be higher than females in both the groups (OSA/non-OSA). The body mass index (BMI) of the OSA group was found to be statistically higher as compared to that of the non-OSA group (P = 0.040). The BMI was found to be higher in severe OSA, but it was not statistically significant (P = 0.128). The mean value of FT4 was lower and thyroid-stimulating hormone (TSH) was higher in the OSA group as compared with the non-OSA group. However, no significant association was found between FT4 and TSH values in both the groups. Out of 100 cases, 41 patients were treatment naïve with mean TSH value of 13.1 ± 7 and 59 were on treatment with mean TSH of 8.3 ± 4. Treatment-naïve patients had a statistically higher number (85.3%) of OSA cases in comparison to patients on treatment (66.1) (P = 0.030). Conclusions: Prevalence of OSA is quite high in hypothyroidism. Patients with hypothyroidism should be screened for OSA for early diagnosis, especially in individuals with higher BMI. Treatment of hypothyroidism reduces the prevalence of OSA.

Résumé Introduction: L'apnée obstructive du sommeil (OSA) et l'hypothyroïdie sont étroitement liées car l'hypothyroïdie s'est avérée conduire au développement de l'AOS à travers de multiples mécanismes. Avec l'évolution des modèles de style de vie dans le monde et une prévalence accrue de l'obésité, le fardeau de l'AOS a considérablement augmenté. L'association de l'AOS avec l'hypothyroïdie est essentielle à établir. S'il est identifié tôt, le traitement de l'AOS et de l'hypothyroïdie associée peuvent être effectués en temps opportun pour minimiser les complications nocives potentielles de l'AOS sur tous les aspects de la santé du patient. Aims: Cette étude a été réalisée pour découvrir la prévalence de l'AOS chez les patients hypothyroïdiennes. Cadre et conception: C'était une étude transversale, réalisée sur une période de 1 an dans un hôpital de soins tertiaires. Matériaux et méthodes: Un total de 100 patients hypothyroïdiennes ont été inscrits après avoir pris consentement écrit. Tous les patients ont été soumis à un questionnaire d'arrêt de bang et à la chute des patients à risque élevé (score3-8), ont été pris pour la polysomnographie d'une nuit pour confirmer le diagnostic de l'AOS (AHI ≥5). Analyse statistique utilisée: Le logiciel Statistical Package for the Social Sciences Version 21.0 Analyse statistique. Résultats: Sur 100 patients, qui ont subi une polysomnographie, 74 (74%) cas avaient une OSA (AHI ≥5). Sur le total de 74 cas d'ASA, 29 (39,2%) avaient des cas légers de l'ASA (AHI 5­14), 15 (20,3%) avaient des cas d'ASA modérés (AHI 15-30), et 20 (40,5%) avaient une OSA sévère. L'âge de la population d'étude variait entre 24 et 78 ans et l'âge moyen était de 58,28 ± 11,22 ans. L'âge moyen des patients du groupe OSA (59,27 ± 11,17 ans) était plus élevé que le groupe non-OSA (55,46 ± 11,09 ans). La majorité (64%) de nos cas étaient des hommes, et la proportion d'hommes s'est révélée plus élevée que les femmes dans les deux groupes (OSA / non-OSA). L'indice de masse corporelle (IMC) du groupe OSA s'est avéré statistiquement plus élevé par rapport à celui du groupe non-OSA (P = 0,040). L'IMC s'est avéré être plus élevé dans l'OSA sévère, mais il n'était pas statistiquement significatif (p = 0,128). La valeur moyenne de FT4 était inférieure et l'hormone stimulante thyroïdienne (TSH) était plus élevée dans le groupe OSA par rapport au groupe non-OSA. Cependant, aucune association significative n'a été trouvée entre les valeurs FT4 et TSH dans les deux groupes. Sur 100 cas, 41 patients étaient naïfs de traitement avec une valeur TSH moyenne de 13,1 ± 7 et 59 étaient sous traitement avec une TSH moyenne de 8,3 ± 4. Les patients naïfs de traitement avaient un nombre statistiquement plus élevé (85,3%) des cas d'AOS par rapport à patients sous traitement (66,1) (p = 0,030). Conclusions: La prévalence de l'AOS est assez élevée en hypothyroïdie. Les patients atteints d'hypothyroïdie doivent être dépistés pour l'AOS pour un diagnostic précoce, en particulier chez les personnes atteintes d'IMC plus élevée. Le traitement de l'hypothyroïdie réduit la prévalence de l'AOS. Mots-clés: Indice d'apnée - hypene, indice de masse corporelle, hypothyroïdie, apnée obstructive du sommeil, polysomnographie, ronflement, fatigue pendant la journée, apnée observée et hypertension, indice.

Serum kallistatin as a marker of severity of liver fibrosis in cirrhosis: A cross-sectional observational study.

Background: Liver cirrhosis is among the leading causes of morbidity and mortality worldwide. Although liver biopsy is the gold standard for the assessment of liver fibrosis in cirrhosis, it has its own limitations. Therefore, noninvasive methods to detect liver fibrosis are widely preferred. However, they also have their own limitations. Thus, there is always a need to extend the battery of serum-based assays. Kallistatin is a protein synthesized primarily in the liver. As it is a negative acute-phase protein, its blood level decreases with a decline in liver function. In our study, we explored the relationship between serum kallistatin and radiological evidence of liver fibrosis by transient elastography to determine if kallistatin levels can be used as a diagnostic marker of liver fibrosis. Materials and Methods: A cross-sectional study of 1-year duration was conducted at a leading tertiary care hospital in northern India. Patients between 15 and 75 years of age having evidence of chronic liver disease were enrolled. All enrolled patients were evaluated by detailed history, physical examination, and relevant investigations. Serum kallistatin levels were quantified using the ELISA method. Grading of liver fibrosis was done using transient elastography. A FibroScan scoring card was used to convert FibroScan results measured in kPa into the Metavir scale F1-F4. Results: A total of 128 subjects, including 64 patients with cirrhosis and 64 healthy controls, were enrolled. Our study suggested that FibroScan values were significantly higher in cases as compared to controls. The kallistatin level of cases was significantly lower than that of controls. An inverse correlation was found between FibroScan value and kallistatin level among cases. Conclusion: We conclude that serum kallistatin levels are low in patients with liver fibrosis and can be used as a potential marker of liver fibrosis.

Scrub Typhus and its co-infection with Leptospirosis at a tertiary care hospital in Uttar Pradesh.

The diagnosis of Scrub Typhus is now improving with the availability of an array of serological tests at the majority of diagnostic centres and of molecular tests at advanced laboratories. Our study focuses on evaluating the spectrum of Scrub Typhus and its coinfection with Leptospirosis in patients presenting with acute febrile illness. A total of 1743 blood samples were collected from both In and Out Patient Department (OPD) patients and analyzed for anti Orientia tsutsugamushi and anti-Leptospira IgM antibodies. Our study showed the presence of Scrub Typhus IgM antibodies in 20.7% of all the cases of acute febrile illness. We also found an interesting correlation of Scrub Typhus with Leptospirosis owing to the presence of co-infection in 8.4% of Scrub Typhus cases paving a way for future research in this regard.

COVID-19 cases and their outcome among patients with uncommon co-existing illnesses: A lesson from Northern India.

Introduction: Newer coexisting conditions should be identified in order to modify newer risk factors. Aim was to identify patients with non-classical or less common coexisting conditions in patients infected of COVID 19. Method: Single centred study from June 2020 to May 2021 at a tertiary centre in North India. A preformed questionnaire was used to record clinical and laboratory parameters and to identify cases which are in addition to CDC list and Indian data. Results: 0.67% (46) cases out of 6832 patients were identified to have non-classical coexisting illness. It was divided into 2 groups-infections A (60.1%) and non-infections B (39.9%). Group A included-tuberculosis- pulmonary (14.3%) & extra pulmonary (32.9%), bacterial (25.0%) viral infections [dengue, hepatitis B & C] (14.3%), HIV disease (10.7%) and malaria (3.6%). Group B included- organ transplant (27.8%), autoimmune [myasthenia gravis, polymyositis, psoriasis] (22.6%), haematologic [Haemophilia, ITP, Aplastic anaemia, APML, CML] (27.8%), uncommon malignancies [disseminated sacral chordoma and GTN] (11.1%) and snakebite (11.1%). Serum Procalcitonin was not helpful for diagnosis of bacterial infection in COVID-19 disease. Group A had significantly longer duration of illness, hepatitis and elevated CRP. The mortality in group A & B were 32.1% and 43.8% respectively. Death in non-severe COVID cases was in tetanus and snakebite. 30.7% death among tuberculosis patients. More than 70% of deaths were attributable to COVID 19 in both the groups. Conclusion: In Indian settings, comorbidities like tuberculosis and bacterial infections can precipitate severe COVID 19 unlike other parts of the world where tuberculosis is relatively uncommon.

Prevalence of obstructive sleep apnea in diabetic patients.

Context: Obstructive sleep apnea (OSA)-related hypoxemia stimulates release of acute-phase proteins and reactive oxygen species that exacerbate insulin resistance and lipolysis and cause an augmented prothrombotic and proinflammatory state which can leads to premature death. Aims: This study aims to study the prevalence of OSA in diabetic patients. Setting and Design: It was a cross-sectional study, done over a period of 1 year in a tertiary care hospital. Materials and Methods: A total of 149 type 2 diabetic patients were enrolled after taking written consent. All patients were subjected to STOP BANG questionnaire and patients falling in intermediate-high risk (score 3-8), were taken for overnight polysomnography to confirm the diagnosis of OSA (apnea hypopnea index ≥ 5). Statistical Analysis Used: Statistical Package for Social Sciences (SPSS) Version 21.0 statistical analysis software. Results: Fifty-five percent of our diabetic population were having OSA. The age of patients enrolled in the study ranged between 30 and 86 years and prevalence increases with an increase in age groups. Majority (61.7%) of our cases were males. Incremental trend in weight, body mass index (BMI), neck circumference, and waist circumference of OSA cases were found with increasing in severity of OSA. Mean levels of raised blood sugar and HbA1c were higher in severe OSA cases. Conclusions: OSA has a high prevalence in patients with type 2 diabetes mellitus. Patients with type 2 diabetes should be screened for OSA, even in the absence of symptoms, especially in individuals with higher waist circumference and BMI.

RésuméContexte: L'hypoxémie liée à l'apnée obstructive du sommeil (AOS) stimule la libération de protéines de phase aiguë et d'espèces réactives de l'oxygène qui exacerber la résistance à l'insuline et la lipolyse et provoquer un état prothrombotique et pro-inflammatoire accru qui peut conduire à un décès. Objectifs: Cette étude vise à étudier la prévalence de l'AOS chez les patients diabétiques. Cadre et conception: il s'agissait d'une étude transversale, réalisée sur une période d'un an dans un hôpital de soins tertiaires. Matériels et méthodes: Un total de 149 patients diabétiques de type 2 ont été recrutés après avoir pris consentement écrit. Tous les patients ont été soumis au questionnaire STOP BANG et les patients à risque intermédiaire-élevé (score 3-8), ont été prise pour une polysomnographie nocturne pour confirmer le diagnostic d'AOS (index d'apnée hypopnée ≥ 5). Analyse statistique utilisée: statistique Package for Social Sciences (SPSS) Version 21.0 du logiciel d'analyse statistique. Résultats: Cinquante-cinq pour cent de notre population diabétique étaient souffrant d'AOS. L'âge des patients inclus dans l'étude variait entre 30 et 86 ans et la prévalence augmente avec l'augmentation des tranches d'âge. La majorité (61,7 %) de nos cas étaient des hommes. Tendance progressive du poids, de l'indice de masse corporelle (IMC), du tour de cou et du tour de taille des cas d'AOS ont été trouvés avec une augmentation de la sévérité de l'AOS. Les taux moyens de glycémie élevée et d'HbA1c étaient plus élevés dans les cas graves d'AOS. Conclusions: L'AOS a une prévalence élevée chez les patients atteints de diabète de type 2. Les patients atteints de diabète de type 2 doivent subir un dépistage de l'AOS, même en l'absence de symptômes, en particulier chez les personnes ayant un tour de taille et un IMC plus élevés.

Reference values for the cross-sectional area of the normal sciatic nerve using high-resolution ultrasonography.

AIM: High-resolution ultrasonography is a new and promising technique to evaluate peripheral and spinal nerves. Its validity as a diagnostic tool in neurological diseases has been demonstrated in adults. The aims of study were to establish the reference values for the cross-sectional area of the normal sciatic nerve on high-resolution ultrasonography, and to determine the relationship between the cross-sectional area of the normal sciatic nerve and the subjects' age, gender, height (in cm), weight (in kg), and body mass index. MATERIAL AND METHODS: Two hundred subjects of both genders and above 18 years of age were studied with high-resolution ultrasonography. The subjects had no history of peripheral neuropathy or trauma to the lower limb. The cross-sectional areas of the normal sciatic nerves were obtained at two different levels in both lower limbs. The mean cross-sectional areas of the sciatic nerves were measured at two different levels, one located at 1 cm above the bifurcation of the sciatic nerve into the tibial and common peroneal nerves, and the other 4 cm above the bifurcation of the sciatic nerve into the tibial and common peroneal nerves. RESULTS: A positive correlation of the mean cross-sectional area was established with height, weight, and body mass index. Women had smaller cross-sectional areas of the normal sciatic nerves than men at both measuring sites. No significant relationship was established with the age of the subjects. CONCLUSIONS: The established reference values of the cross-sectional area of the sciatic nerve can facilitate the analysis of pathological nerve conditions.

Reference values for the cross-sectional area of normal radial nerve at two levels using high-resolution ultrasonography.

AIM OF THE STUDY: High-resolution ultrasound is less often used to evaluate the radial nerves. The radial nerve is often involved in entrapment syndromes. The aim of the study is to establish the reference values for the cross-sectional area of the normal radial nerve on high-resolution ultrasonography, and to identify relationships between the cross-sectional area and the subject's age, gender, height, weight, body mass index, and hand dominance. MATERIAL AND METHODS: The study was conducted on 200 subjects of both sexes, between 18 and 75 years of age, who did not have history of peripheral neuropathy or trauma to the upper limb. High-resolution real-time sonographic examination of the radial nerves was performed in both arms at two different levels. Level 1 was taken just proximal to the nerve bifurcation, and level 2 just after the nerve exits the spiral grove. RESULTS: The mean cross-sectional area measured at level 2 (4.3 ± 0.4 mm2) was greater than that measured at level 1 (2.3 ± 0.3 mm2). No significant relationship was seen with age and hand dominance (p >0.05), but the cross-sectional area values at above mentioned levels were larger in males than in females (p <0.05). In addition, the cross-sectional areas of the radial nerves showed a positive correlation with height, weight, and body mass index (p <0.05). CONCLUSION: The established ultrasonographic reference values along with basic clinical data will aid in the diagnosis, response to treatment, and prognostic evaluation of peripheral neuropathies.

Clinical and biochemical profile of scrub typhus patients at a tertiary care hospital in Northern India.

BACKGROUND: Scrub typhus is a neglected rickettsial disease in India. Every year, we are facing outbreaks of Scrub typhus after Monsoon season. Patients present with a wide clinical spectrum ranging from pyrexia of unknown origin to multiple organ dysfunction. Some of these clinical features overlap with presentation of other tropical infections prevalent in Indian subcontinent, which leads to diagnostic dilemma and delay in diagnosis. Hence, we planned this study to know the demographic, clinical and biochemical profile of scrub typhus patients. METHODS: This was an observational study conducted in department of Medicine, King George's Medical University Lucknow, India a leading tertiary care hospital of Northern India. All scrub typhus patients were evaluated by detailed history, examination and laboratory tests. RESULTS: We enrolled 52 patients in our study. The mean age of the patients was 35.17 ± 16.90 years with majority (82.7%) of patients from rural background. All the patients had fever with an average duration of 9.6 ± 2 days. Most of the patients developed hepatitis (69.2%) followed by acute encephalitis syndrome (47%), acute kidney injury (23.1%) and acute respiratory failure (19.2%). Eschar was found in 11 patients (21.2%). CONCLUSION: Scrub typhus is often misdiagnosed or diagnosed late due to its wide clinical spectrum overlapping with clinical presentation of other commonly prevalent tropical diseases. One should always consider the differential diagnosis of scrub typhus while evaluating a young febrile patient of rural background, with features of single or multiple organ dysfunction and laboratory findings of leucocytosis, thrombocytopenia and elevation of transaminases.

Serological and molecular study of Leptospira in pediatric patients at a tertiary care centre of northern India.

Leptospirosis is considered as one of the most neglected zoonotic tropical diseases. Animals and humans acquire this infection through direct contact with contaminated urine or body fluids of infected animals. This prospective study was undertaken to know the proportion of leptospirosis in pediatric patients presented with acute febrile illness at the Post Graduate Department of Microbiology, King George's Medical University, Lucknow, Uttar Pradesh. Blood samples were collected over a period of one year from January to December 2018 from 70 pediatric patients aged up to 0-12 years presented with febrile illness for 3-14 days. Out of the 70 samples, 7 (10%) samples were found positive by IgM ELISA, 4 (5.7%) samples were positive by MAT and 3(4.3%) were found positive by PCR. Risk factors such as contact with infected animals and contaminated environment were highly associated with seropositivity of leptospirosis. Clinical symptoms such as fever, chills, myalgia, headache, abdominal pain and cough were significantly associated (p < 0.05) with the seropositivity of leptospirosis.

A learning experience of pandemic COVID-19 management at our medical institute.

BACKGROUND: Coronavirus disease-19 (COVID-19) pandemic caused by Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) is a novel disease. OBJECTIVES: Our healthcare sector is at the epicentre of this unprecedented global pandemic challenge and we are not fully aware of it's management. Here we have discussed our learning experience in managing and tackling the COVID-19 pandemic at our institute which will set an example for other hospitals as well as instill confidence in our primary care physicians who are the frontline warriors. METHODS AND RESULTS: For combating COVID-19, dedicated teams for its management including logistic support was streamlined. Our capacity was built up for 200 isolation beds including 40 ventilator equipped beds and 645 defined quarantine rooms, to be implemented in phased manner. Till date more than 200 COVID-19 patients have been admitted here. Fever and cough were common presentations. Mortality was high in patients with advanced age or who had multiple co-morbid conditions. Efficient training and infection prevention control have resulted in a satisfactory outcome. CONCLUSION: In the wake of this pandemic all hospital setup, with collective responsibility should follow a specified protocol so that our hospital is not converted to the hotspot. COVID-19 has imposed a new challenge where not only patients have to be managed but our health care workers also need to be protected. Telemedicine and our primary care physicians will play a crucial role. Here at a medical institute, medical teaching, and learning atmosphere has to be created amidst the pandemic apprehension for our budding medicos.

High-resolution ultrasonography of the sural nerve in diabetic peripheral neuropathy.

Aim of the study: To study the cross-sectional area, the maximum thickness of the nerve fascicle and the thickness/width ratio of the sural nerve in patients with diabetes mellitus and non-diabetic subjects using high-resolution ultrasonography and to correlate the results with nerve conduction studies. Material and methods: This prospective study was conducted among 60 patients divided into two groups: A and B. Group A consisted of 30 patients >18 years of age with a history of type 2 diabetes mellitus, and Group B consisted of 30 non-diabetic patients >18 years of age. High-resolution ultrasonography was performed using a linear transducer with the frequency of 5-18 MHz in all the patients in the prone position with the transducer placed in a transverse position at the junction of the middle and lower thirds of the calf. Nerve conduction studies were performed using Aleron 201 (RMS) in all the patients. Results: As compared to the control group, the sural nerve in the diabetic group showed increased cross-sectional area, maximum thickness of the nerve fascicle and thickness/width ratio (p <0.05). Nerve conduction studies showed decreased amplitude, increased latency and decreased velocity in the cases as compared to controls (p <0.05). The cross-sectional area, maximum thickness of the nerve fascicle and thickness/width ratio showed statistical significance when compared with amplitude, latency and velocity in the cases as well as controls (p <0.001). Conclusion: This study suggests that high-frequency ultrasound of the sural nerve is a useful tool for evaluating changes typical of peripheral neuropathy in patients with diabetes mellitus.Aim of the study: To study the cross-sectional area, the maximum thickness of the nerve fascicle and the thickness/width ratio of the sural nerve in patients with diabetes mellitus and non-diabetic subjects using high-resolution ultrasonography and to correlate the results with nerve conduction studies. Material and methods: This prospective study was conducted among 60 patients divided into two groups: A and B. Group A consisted of 30 patients >18 years of age with a history of type 2 diabetes mellitus, and Group B consisted of 30 non-diabetic patients >18 years of age. High-resolution ultrasonography was performed using a linear transducer with the frequency of 5­18 MHz in all the patients in the prone position with the transducer placed in a transverse position at the junction of the middle and lower thirds of the calf. Nerve conduction studies were performed using Aleron 201 (RMS) in all the patients. Results: As compared to the control group, the sural nerve in the diabetic group showed increased cross-sectional area, maximum thickness of the nerve fascicle and thickness/width ratio (p <0.05). Nerve conduction studies showed decreased amplitude, increased latency and decreased velocity in the cases as compared to controls (p <0.05). The cross-sectional area, maximum thickness of the nerve fascicle and thickness/width ratio showed statistical significance when compared with amplitude, latency and velocity in the cases as well as controls (p <0.001). Conclusion: This study suggests that high-frequency ultrasound of the sural nerve is a useful tool for evaluating changes typical of peripheral neuropathy in patients with diabetes mellitus.

Influence of Lactitol and Psyllium on Bowel Function in Constipated Indian Volunteers: A Randomized, Controlled Trial.

Psyllium and lactitol have been reported to increase fecal volume, moisture content and bowel movement frequency (BMF). However, the benefits of their combined use on constipation has not been examined. The aim of this study was to evaluate the effects of a 4-week intervention with lactitol and/or psyllium on bowel function in constipated volunteers. Adults (N = 172) who were diagnosed with functional constipation per Rome III criteria were randomized to four treatment groups: 10 g lactitol, 3.5 g psyllium, a combination of 10 g lactitol and 3.5 g psyllium, or placebo. The primary endpoint was change in BMF from Day 0 to 28 as compared to placebo. Secondary endpoints were assessed by inventories, including stool consistency, patient assessment of constipation symptoms and quality of life, relief of constipation, 24-h food recall, physical activity, product satisfaction and adverse events (AE). BMF increased by 3.0 BMs with lactitol, by 2.9 with psyllium, and by 3.1 with the combination, but was not different from placebo (3.7 BMs). Other clinical endpoints were similar between treatments. No serious AEs were reported. In conclusion, this study showed a similar effect on relief of constipation in all treatment groups. The treatments that were administered to the volunteers were well tolerated.

Prevalence of thyroid dysfunction in chronic obstructive pulmonary disease patients in a tertiary care center in North India.

INTRODUCTION: Thyroid dysfunction can cause inspiratory and expiratory muscle weakness in patients with or without chronic obstructive pulmonary disease (COPD) Thyroid dysfunction in COPD results in increased frequency of exacerbation thus lead to poor quality of life. It may further increase cardiovascular disease risk thereby increasing mortality. AIMS AND OBJECTIVES: This study was conducted to evaluate the prevalence of thyroid dysfunction and hence that the quality of life of COPD can be improved. MATERIALS AND METHODS: This is a cross-sectional - prevalence study. The study was conducted over a period of 1 year from August 2015 to July 2016. The study group was consists of male and female COPD patients diagnosed with spirometry and severity was determined according to the global initiative for chronic obstructive lung disease classification criteria. The patients were enrolled in this study from medicine outpatient department (OPD), respiratory OPD and those admitted to indoor wards of Medicine Department. Patients were screened for thyroid dysfunction. RESULTS: Out of 171 patients, thyroid dysfunction was present in 43 patients. All of them were hypothyroid. The prevalence of thyroid dysfunction was 25%. In Stage A it was 20.5%, Stage B 25.7%, Stage C 23.4%, and in Stage D 30.4%. Thyroid dysfunction was associated with more frequent exacerbation. CONCLUSION: Thyroid dysfunction is a common extrapulmonary manifestation in COPD patients. It is associated with frequent exacerbations which affect the quality of life in these patients. Early detection and proper management can improve the quality of life in these patients.