Thyroid Disorders among Type 2 Diabetes Mellitus: A Cross-sectional Study from a District Hospital in West Bengal.

INTRODUCTION: The coexistence of diabetes mellitus (DM) (both type 1 and type 2) and thyroid dysfunction, two common endocrine problems, is scientifically predictable. The prevalence of thyroid disorders among type 2 diabetics (more prevalent in India) was studied among patients visiting the outpatient department (OPD) of a district hospital in West Bengal to assess its relation with different characteristics of type 2 DM. MATERIALS AND METHODS: A total of 120 patients suffering from type 2 DM (already diagnosed and on treatment) were randomly selected from the OPD (irrespective of their glycemic status). The thyroid status of all those patients was assessed. All diabetic patients were studied with a predesigned schedule and lab investigations for the prevalence of thyroid dysfunction and its association with pertinent variables from January to December 2019. RESULTS: This study found a 28.3% prevalence of thyroid dysfunction among diabetics. It was significantly associated with poor glycemic control [rising hemoglobin A1c (HbA1c) level] (actual p-value for HbA1c vs abnormal thyroid status = 2.4 E-21) but not with other variables, including the duration of diabetes. CONCLUSION: Screening for thyroid dysfunction among diabetic persons should be routine, and strict glycemic control is essential.

Association of Physicians of India: National Expert Opinion and Clinical Practice Recommendations for Primary Care Cough Management in India.

INTRODUCTION: Pathological cough in primary care is a significant concern. With a prevalence ranging from 5 to 10% in India, cough is the second most common symptom seen by general practitioners (GPs). The existing algorithms and tools that are available are generally meant for cough categorization in specialized fields; their limited adoption by GPs results in insufficient screening and categorization of cough, which results in the use of irrational fixed drug combination formulations. OBJECTIVES: Formulation of recommendations for GPs to enable them to appropriately screen and categorize cough for efficient management and avoid irrational treatments. METHODS: An expert panel (seven experts specializing in pulmonology and internal medicine) held a virtual discussion to assess the necessity for cough categorization and develop user-friendly tools, along with a simplified format for history taking in cough evaluation and management. Panel discussions were based on a questionnaire that contained items related to the categorization of cough, assessment tools, and approaches to treating cough. RESULTS: After deliberations, simplified clinical practice recommendations and assessment tools were developed by the experts to facilitate the categorization of cough into wet or dry categories, thereby helping in the symptom-based management of cough. CONCLUSION: By adhering to these principles and using assessment tools, primary care practitioners can optimize cough management, avoid irrational drug combinations, minimize potential risks, and improve patient well-being.

Effect of α-blockers on Handgrip Test Response of Diastolic Blood Pressure in Hypertensive, Benign Hypertrophy of Prostate Patients in a Therapeutics Clinic, Kolkata: A Cross-sectional Study.

BACKGROUND: The isometric handgrip (IHG) test is commonly used to detect sympathetic autonomic dysfunction. Tamsulosin, approved for the management of symptomatic benign prostatic hyperplasia (BPH), acts as an antagonist for α1-adrenergic receptors (α1-AR), whereas prazosin, an α1 receptor blocker, being less selective than tamsulosin, is used as an antihypertensive agent clinically. Our objective was to investigate if there is a distinction in blood pressure (BP) increase during IHG exercise between individuals with essential hypertension taking tamsulosin compared to those taking prazosin. MATERIALS AND METHODS: A cross-sectional observational study was performed on 50 subjects receiving tablet prazosin and 47 subjects receiving tamsulosin, who were asked to undergo an IHG test. Pre- and posttest BP was recorded for both the groups, and the difference in diastolic BP (DBP) (delta DBP) was compared between the groups and to their respective baseline values. RESULTS: Post-IHG test, mean DBP was found to be 93.98 ± 9.13 mm Hg in the prazosin group and 101.00 ± 12.05 mm Hg in the tamsulosin group, respectively. The change of delta DBP in the tamsulosin group was significant, but the prazosin group showed an insignificant rise in DBP. CONCLUSION: Prazosin, being less selective than tamsulosin in terms of α1 receptor antagonism, showed suppression of BP during IHG. Tamsulosin demonstrates high selectivity for prostatic receptors while showing minimal affinity for vascular receptors. As a result, its impact on BP is expected to be minimal.

Association of Physicians of India Expert Recommendations on Oral Fluid, Electrolytes, and Energy Management during Transition Care and Discharge for Hospitalized Patients with Nondiarrheal Illnesses.

Acute nondiarrheal illnesses (NDIs) involve overt or subclinical dehydration, requiring rehydration and electrolyte repletion. Dehydration is frequently under-recognized and under-managed, both in outpatient departments (OPDs) and inpatient departments (IPDs). Postadmission dehydration is associated with longer hospital stays and higher inhospital mortality rates. Recognizing and understanding dehydration in hospitalized patients is necessary due to the adverse outcomes associated with this condition. In this article, we aimed to develop practical consensus recommendations on the role of oral fluid, electrolyte, and energy (FEE) management in hospitalized patients with FEE deficits in NDI. The modified Delphi consensus methodology was utilized to reach a consensus. A scientific committee comprising eight experts from India formed the panel. Relevant clinical questions within three major domains were formulated for presentation and discussion: (1) burden and factors contributing to dehydration in hospitalized patients; (2) assessment of fluid and electrolyte losses and increased energy requirements in hospitalized patients; and (3) management of FEE deficits in hospitalized patients [at admission, during intravenous (IV) therapy, IV to oral de-escalation, and discharge]. The consensus level was classified into agreement (mean score ≥4), no consensus (mean score <4), and exclusion (mean score <4 after the third round of discussion). The questions that lacked agreement were discussed during the virtual meeting. The experts agreed that the most common factors contributing to dehydration in patients with NDI hospitalized in IPDs include decreased oral fluid intake, increased fluid loss due to the illness, insensible fluid loss, and a lack of awareness among doctors about dehydration, which can result in poor fluid intake. Time constraints, discontinuity of care, lack of awareness of the principles of fluid balance, lack of formal procedures for enforcing hydration schemes, and lack of adequate training are most often barriers to the assessment of hydration status in hospital settings. Experts used hydration biomarkers, such as changes in body weight, serum, or plasma osmolality; fluid intake; and fluid balance charts; along with urine output, frequency, quantity, and color, to determine hydration status in hospital settings. Experts agreed that appropriate FEE supplementation in the form of ready-to-drink (RTD) fluids can restore FEE deficits and shorten the length of hospital stays in hospitalized patients at admission, during de-escalation from IV to oral therapy, and at discharge. RTD electrolyte solutions with known concentrations of electrolytes and energy are good choices to avoid taste fatigue and replenish FEE in hospitalized patients during transition care and at discharge.

Sympathetic Neurofunction Testing in Gestational Hypertension and Relationship with Developing Preeclampsia and Eclampsia: Real-world Evidences from Clinical Pharmacology Clinics.

BACKGROUND: Gestational hypertension carries a high-risk for adverse maternal and fetal outcomes, and it can also develop into preeclampsia. A relative decrease in parasympathetic and increase in sympathetic activity has been seen in normal pregnancy which returns to baseline after delivery. The present study aimed to detect any abnormality in sympathetic neurofunction in gestational hypertension and to identify its possible association with the development of preeclampsia/eclampsia. METHODS: A prospective, observational study was carried out among gestational hypertensive patients between 24 and 26 weeks of gestation, who were sent to clinical pharmacology clinics for autonomic neurofunction testing, along with their 24-hour urinary protein testing reports. Preisometric handgrip (IHG) and post-IHG differences in diastolic blood pressure (DBP) were noted. The association between Δ DBP and the development of eclampsia/preeclampsia was probed. RESULTS: A total of 52 pregnancy-induced hypertension (PIH) participants, both multigravida (n = 15) and primigravida (n = 37) were included in one arm (PIH arm), and 52 matched (age and gravida) pregnant women, those do not have PIH included in another arm for comparative analysis. On comparing the PIH arm and normal arm, prehand grip DBP (p ≤ 0.0001), posthand grip DBP, and Δ DBP were significantly higher in the PIH arm. Correlation between Δ DBP and 24 hours' proteinuria was observed in the PIH arm, with a significant positive correlation. CONCLUSION: A high-rise in DBP post-IHG exercise is associated with gestational hypertensive mothers and this rise is strongly correlated with the development of preeclampsia and eclampsia, which suggests that addressing sympathetic hyperactivity could be a potential area to target therapeutics while managing gestational hypertension.

Loop Diuretics: An Overview of Its History and Evolution.

The loop of Henle plays a key role in kidney function, especially in retaining solutes and concentrating urine. Diuretic agents, crucial for managing fluid overload and related conditions like hypertension and heart failure (HF), enhance water and electrolyte excretion. The history of diuretics dates back to 1775 with the discovery of Digitalis, evolving significantly with the introduction of chlorothiazide in 1957, which revolutionized diuretic therapy. Loop diuretics, developed in the 1950s and including drugs like torsemide, furosemide, and ethacrynic acid, are potent agents acting on the loop of Henle. They are vital for treating severe fluid overload conditions and require careful monitoring to manage potential side effects.

Management of Hypertension in Patients with Type 2 Diabetes Mellitus: Indian Guideline 2024 by Association of Physicians of India and Indian College of Physicians.

In India and the Southeast Asian population, hypertension and type 2 diabetes mellitus (T2DM) are the leading lifestyle-related diseases, responsible for a majority burden of morbidity and mortality. Multiple population-spanning studies have revealed the staggering prevalence of both diseases in India, and the prevalence of both will only increase further due to factors such as an aging population, rapid urbanization, increased obesity, and sedentary lifestyles. More than 50 percent of hypertensive patients in India are also diagnosed with T2DM, and a detailed management protocol for the same is required, especially when a major portion of the disease is managed at the primary care level. The Association of Physicians of India (API) guidelines for the management of hypertension in patients with T2DM have been formulated based on consultation with leading physicians, cardiologists, diabetologists, and endocrinologists of India and Southeast Asia, keeping in mind the challenges faced by the patients in these countries and the appropriate management protocols that will be beneficial. While standard office-based blood pressure (BP) measurement forms the cornerstone of hypertension diagnosis and demands a uniform methodology to be followed, home blood pressure monitoring (HBPM) is recommended for long-term follow-up with validated devices. Ambulatory blood pressure monitoring (ABPM) offers comprehensive insights crucial for cardiovascular (CV) risk stratification. The complications of diabetic hypertension can span from increased CV risk, heart failure (HF), and renal dysfunction, and nonpharmacological and pharmacological management should be aimed toward not only control of the BP values but also protecting the end organs. While nonpharmacological measures include a focus on nutrition and diet, they also focus on approaches to weight loss, including a novel section covering the benefits of yoga. The guideline also focuses on a novel section of factors influencing CV risk, especially in the Indian population. For the pharmacological management, the guidelines address each of the categories of antihypertensive drugs, emphasizing the significance of combination therapies in the management of diabetic hypertension. In line with leading global guidelines for the management of hypertension in T2DM, for diabetic patients who often struggle with BP management and carry a high CV risk, the recommended dual combination antihypertensive therapy is particularly crucial and should be considered as first-line management therapy. While angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) play a highly beneficial role in the management of diabetic hypertension, a combination of ACEi or ARB with dihydropyridine calcium channel blockers (DHP-CCBs) is recommended to reduce the risk of complications and enhance patient adherence. To achieve the target of effective BP control and end-organ protection, it is beneficial and recommended to include newer CCBs (e.g., cilnidipine) in the management protocol in combination with ACEi/ARBs. Combination therapy including ARBs and DHP-CCBs should be preferred over ß-blockers and thiazides. Among the CCBs, cilnidipine, a novel molecule, is a more effective and safer option for diabetic hypertensive patients in India. ß-blockers should be used if there is a history of myocardial infarction (MI), HF, coronary artery disease (CAD), or stable angina along with the initial hypertensive regimen. The guideline also focuses on the novel reno- and cardioprotective molecules such as finerenone and sodium-glucose cotransporter 2 inhibitors (SGLT2i) and their benefits in the management of diabetic hypertension.

A Prospective Study to Evaluate the Possible Role of Cholecalciferol Supplementation on Autoimmunity in Hashimoto's Thyroiditis.

A Prospective Study to Evaluate the Possible Role of Cholecalciferol Supplementation on Autoimmunity in Hashimoto's Thyroiditis Biva Bhakat1 , Jyotirmoy Pal2 , Sukdeb Das3 , Sumit Kr Charaborty4 1,3Nil Ratan Sircar Medical College, Kolkata, 2 RG Kar Medical College and Hospital, 4 North Bengal Medical College, Siliguri Introduction: Hashimoto thyroiditis (HT) is an autoimmune disease that destroys thyroid cells by antibody and call-mediated immune processes. Hashimoto thyroiditis is the commonest cause of goitre in iodine-sufficient regions.[1] The aetiology of Hashimoto disease is very poorly understood. Most patients develop antibodies to a variety of thyroid antigens, the most common of which is anti-thyroid peroxidase (anti-TPO). Many also form antithyroglobulin (anti-Tg) and TSH receptor blocking antibodies (TBII). These antibodies attack the thyroid tissue, eventually leading to inadequate production of thyroid hormone. There is a small subset of the population, around 10-15% with the clinically evident disease, that are serum antibody-negative.[2][3] The mechanisms underlying the assumption that vitamin D is linked with autoimmunity are not clear but probably are associated with its anti-inflammatory and immunomodulatory functions. The dendritic cells are antigen-presenting cells originating from bone marrow and also a primary target for the immunomodulatory activity of vitamin D. 1,25[OH]2D has direct immunomodulatory effects at the level of the T cell vitamin D receptor. Together, these immunomodulatory effects can lead to the protection of target tissues, such as thyroid cells in autoimmune diseases. Considering that in HT, a disorder of T cell-mediated immunity, immunologic attack is triggered when thyrocytes express MHC class II surface HLA-DR antigens, a process induced by the production of Th1 type inflammatory cytokines (especially IFN-γ). Moreover, at another stage, after being activated by T cells, B cells' ongoing proliferation might be inhibited and apoptosis might be induced by 1,25[OH]2D. Thus, 1,25[OH]2D might decrease antibodies that react with thyroid antigens. The exact levels of vitamin D that are sufficient to improve the immune regulatory function and lead to an effective immune response, should be investigated. Several clinical studies have reported a low vitamin D status in AITD or HT, indicating an association between vitamin D deficiency and thyroid autoimmunity. If supplementation of the Vitamin D decreased thyroid antibody titres in Vitamin D deficient subjects, in the future Vitamin D may become a part of AITDs' treatment, especially in those with Vitamin D deficiency. [4] So, our study tries to assess any potential therapeutic role of vitamin D in the management of patients with Hashimoto's thyroiditis. AIMS AND OBJECTIVES: Most studies have shown an association between low vitamin D status and pathogenesis of AITD, especially HT. However, there are only few preliminary interventional studies for HT. whether vitamin D supplementation is beneficial for AITD or HT, should be evaluated. Treatment of HT mainly based on thyroid hormone supplementation, so if a beneficial role of vitamin D supplementation is identified/ confirmed, it will be helpful in the treatment of patients with HT and may be a part of treatment of HT patients. AIMS AND OBJECTIVES: Evaluating the role of vitamin D on an excessive thyroid immune response. MATERIALS AND METHODS: Study area: N.R.S. Medical college and hospital, Kolkata (Department of General Medicine). STUDY PERIOD: 1 year (January,2019 to December,2019 Sample size: 100 patients both male and female. Sample Design: Patients attending outpatient dept in N.R.S medical college. STUDY DESIGN: Prospective, hospital based, single centre study. INCLUSION CRITERIA: Newly diagnosed patients (age >18 years and of both sexes) with HT and vitamin D deficiency. EXCLUSION CRITERIA: Patients suffering from: Other autoimmune diseases. Chronic illnesses like diabetes mellitus, chronic kidney disease, chronic liver disease, malignancy. Pregnancy Study tools: Estimation from serum: TSH. Free thyroxine (FT4) 25 hydroxy vitamin D Anti-thyroid peroxidase (anti-TPO) antibody' Study techniques: This is a prospective study conducted in N.R.S Medical college, Kolkata, India. Total 100 adult patients of both sexes diagnosed with HT and vitamin D deficiency (vit D<30 ng/ml)12, having none of the exclusion criteria and getting treatment on out-patient department basis, who gave informed consent were included in our study. Blood samples drawn for anti TPO antibody and 25hydroxy vitamin D from all the participants. The correlations between serum Vit D and anti TPO antibody were measured and presented by correlation coef ficient (r2). Study participants are randomly assigned into two groups by random permuted block. Cholecalciferol supplement given in the dose of 60,000 IU weekly for 8 weeks in one group (n = 50). Another group (n = 50) were given placebo (empty soft gelatine capsule). At the onset of the study, patients were requested to keep their habitual diet and routine level of physical activity throughout the study period and not to take any medication that might affect their reproductive physiology. Compliance to the consumption of supplement and placebo was examined by empty blister packets. However, 2 patients from cholecalciferol group and 1 patient from control group lost to follow up. After 8 weeks blood anti TPO antibody level measured in both the groups (n = 48 & 49 in 2 group). The change in the mean value of anti TPO antibody measured and statistical significance of the change checked. Results considered significant or non-significant when P> or < 0.05, respectively. TSH, T4 measurement Performed with chemiluminescence using ADVIA Centaur XP Immunoassay System. Work plan: Study was done over 12 months. Data collected and compilation done and then statistical analysis done by standard statistical method. STATISTICAL ANALYSIS: For statistical analysis data were entered into a Microsoft excel spreadsheet and then analyzed by SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism version 5. p-value ≤ 0.05 was considered for statistically significant. The Negative Correlation was found between Serum 25 hydroxy vitamin D (ng/ml) vs Serum TSH (mU/L) which was statistically significant. Distribution of mean serum anti-TPO antibody level (IU/ml) [mean±SD] in both groups before and after intervention Reduction of serum anti-TPO antibody level in cholecalciferol group is 30.5% and reduction of serum anti-TPO antibody level in placebo group is 16.5%. DISCUSSION: This study is carried out with the total no. of 100 outdoor based patients of diagnosed Hashimoto's Thyroiditis (elevated Anti-thyroid peroxidase antibody) and vitamin D deficiency (vit D < 30 ng/mL)12 in Nil Ratan Sircar medical college and hospital within the mentioned study period. The study focussed on evaluating the role of vitamin D on an excessive thyroid immune response i.e. the effect of vitamin D supplementation on thyroid autoimmunity and that low vitamin D levels and the risk of HT are closely associated and the potential application of vitamin D in the treatment of AITD. The result demonstrates a negative Correlation between Serum 25 hydroxy vitamin D (ng/mL) vs anti TPO antibody (IU/ml) which was statistically significant. Pearson Correlation Coefficient (r)= -0.775, p value = 0.0001. Goswami et al. conducted a community-based survey on 642 adults to investigate the relationship between serum vitamin D concentrations and thyroid autoimmunity. Their results highlighted a significant inverse association between 25(OH)D3 and TPO Ab levels [40]. This inverse correlation was substantiated in the following studies.[5-8] As regards thyroid function in the context of HT, Mackawy and co-workers demonstrated a strong negative association between serum vitamin D concentrations and TSH levels, leading to speculate that vitamin D deficiency in HT patients could be associated with a progression towards hypothyroidism (TSH > 5.0 m UI/L) [45]. Our study also demonstrates negative Correlation between Serum 25 hydroxy vitamin D (ng/mL) vs Serum TSH (mU/L) and the result was statistically significant. Pearson Correlation Coefficient (r) = -0.301, p value = 0.003. So, the results indicate that vitamin D deficiency is a risk factor of Hashimoto's thyroiditis. Mean (mean± s.d.) Serum anti TPO antibody (IU/ml) before intervention was 545.06± 230.82 and after cholecalciferol supplementation the mean value decreased to 378.6± 160.49. So, there is a 30.5% reduction in the mean value of anti TPO antibody level. Difference of mean Serum anti TPO antibody (IU/mL) was statistically significant (p < 0.0001). In the placebo group the mean Serum anti TPO antibody (IU/ml) (mean ± s.d.) of patients was 686.97± 290.19 and after 8 weeks of placebo the mean value was 573.1 ± 254.09. So, in the placebo group the reduction is only 16.5%. Difference of mean Serum anti TPO antibody (IU/ml) was statistically significant (p < 0.0001). Therefore, in line with the hypothesis the data contributes clearer understanding that vitamin D supplementation results in a reduction of thyroid autoimmunity. This result also supports the previous research. Simsek et al. prospectively evaluated 82 patients with HT randomized in two groups: the first group treated with cholecalciferol for one month and the second group without vitamin D replacement. Their results showed that TPO Ab and Tg Ab levels were significantly decreased by the vitamin D replacement therapy in the first group [46]. These findings were also confirmed by other prospective studies and randomized controlled trials.[9-11] So, the result of our study clearly indicates that vitamin D supplementation could exert a positive effect on thyroid function as well as thyroid autoimmunity Limitations: Vitamin D status is not measured at the end of 8 weeks because of economic constraints. So, it is difficult to determine the optimal level of vitamin D needed for improving the evolution of this immunological disorder. Cholecalciferol is used in HT patients in our study, although active form calcitriol might be more beneficial as vitamin D binding protein level may affect the conversion of inactive vitamin D form and thus alters its function on immune cells. HT patients with normal vitamin D level have been excluded from the study, so from our study we cannot comment on beneficial effect of vit D supplementation in HT patient with normal vit D level. As we used empiric dose of levothyroxine in both the groups instead of a fixed dose, we could not analyze the potential role of vitamin D supplementation in reduction of serum TSH in HT There is still a gap in the knowledge regarding the potential of vitamin D supplementation in the treatment of HT patients whether vitamin D supplementation will help in decreasing the replacement dose of levothyroxine or whether it will stop the need of levothyroxine replacement if used in early stages of HT. CONCLUSIONS: The 8 weeks randomized; double-blind, placebo-controlled clinical trial demonstrates a negative correlation between Serum 25 hydroxy vitamin D vs anti TPO antibody level. Treatment with 60,000 IU cholecalciferol weekly for 8 weeks, is associated with significant decrease in antithyroid antibody titers. It also improved serum TSH level compared with the placebo, i.e. supplementary treatment with cholecalciferol seems to have beneficial effects on AITD. However, large multicentre studies are needed to investigate the impact of vitamin D supplementary treatment on meaningful long-term clinical end points in AITD. References Dana L. Mincer; Ishwarlal Jialal. StatPearls [Internet]. Hashimoto Thyroiditis. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Leung AKC, Leung AAC. Evaluation and management of the child with hypothyroidism. World J Pediatr 2019;15(2):124-134. Yuan J, Sun C, Jiang S, et al. The pevalence of thyroid disorders in patients with vitiligo: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2018;. Front Endocrinol (Lausanne). 2018; 9:803. Yoo WS, Chung HK. Recent advances in autoimmune thyroid diseases. Endocrinol Metab (Seoul) 2016;31(3):379-385. Ke W, Sun T, Zhang Y, et al. 25-Hydroxyvitamin D serum level in Hashimoto's thyroiditis, but not Graves' disease is relatively deficient. Endocr J 2017;64(6):581-587. Shin D, Kim KJ, Kim D, et al. Low serum vitamin D is associated with anti-thyroid peroxidase antibody in autoimmune thyroiditis. Yonsei Med J 2014; 55:476-481. ElRawi HA, Ghanem NS, ElSayed, N.M.; et al. Study of vitamin D level and vitamin D receptor polymorphism in hypothyroid egyptian patients. J Thyroid Res 2019. Kim CY, Lee YJ, Choi J, et al. The association between low vitamin d status and autoimmune thyroid disease in korean premenopausal women: the 6th korea national health and nutrition examination survey, 2013-2014. Korean J Fam Med 2019;40:323-328. Chaudhary S, Dutta D, Kumar M, et al. Vitamin D supplementation reduces thyroid peroxidase antibody levels in patients with autoimmune thyroid disease: An open-labelled randomized controlled trial. Indian J Endocrinol Metab 2016;20:391-398. Krysiak R, Szkróbka W, Okopie´n, B. The effect of vitamin D on thyroid autoimmunity in levothyroxine-treated women with Hashimoto's thyroiditis and normal vitamin D Status. Exp. Clin. Endocrinol. Diabetes 2017;125:229-233. Krysiak R, Kowalcze K, Okopie´n B. Selenomethionine potentiates the impact of vitamin D on thyroid autoimmunity in euthyroid women with Hashimoto's thyroiditis and low vitamin D status. 2018;71:367-373. Mazokopakis EE1, Papadomanolaki MG, Tsekouras KC, et al. Is vitamin D related to pathogenesis and treatment of Hashimoto's thyroiditis? Hell J Nucl Med. 2015;18(3):222-7.

Clinical Practice Guidelines for Management of Pain, Agitation, Delirium, Immobility, and Sleep Disturbance in the Intensive Care Unit: The ABCDEF Bundle.

It is crucial to prevent and manage intensive care unit (ICU) distress caused by a pentad of pain, agitation, delirium, immobility, and sleep disturbance (PADIS) to optimize immediate and longterm recovery and outcomes of critically ill patients. This clinical practice guideline provides an update on the prevention, management, and liberation of PADIS in adult ICU patients using an integrated, evidence-based, multidisciplinary ICU protocol: the ABCDEF bundle. ABCDEF bundle incorporates assessment, prevention, and management of pain; both spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT); choice of sedation and analgesia; delirium: assessment, prevention and management, and early mobility and exercise; family involvement and empowerment (ABCDEF) together as a PADIS care bundle. This is a multidimensional ICU liberation bundle which is a patient-oriented, holistic team approach to the management of critically ill patients aimed at reducing ICU distress and immediate and long-lasting consequences of PADIS.

Spectrum of Neurological Illnesses in Pregnancy - An Observational Study from a Tertiary Care Centre of Eastern India.

INTRODUCTION: Neurological disorders in pregnancy may be observed in patients with a pre-existing neurological disorder; patients developing a primary neurological disorder during the course of pregnancy or puerperium; and in patients with primary medical disorders presenting with neurological manifestations. OBJECTIVES: The objectives of the study were to find out the magnitude of neurological disorders in pregnancy in a tertiary care hospital along with assessment of proportion of women with particular disorders among total number of neurological disorders during the course of pregnancy or puerperium (6 weeks after child birth) and also to elicit the effect of neurological disorders on pregnancy outcome, if any. METHODS: A prospective observational longitudinal study was carried out in a tertiary care centre of Eastern India from July 2018 to June 2020 including all pregnant women attending the department of Obstetrics and Gynaecology. We screened 886 pregnant women, out of which 91 cases were identified and investigated. For the purpose of comparison of fetal and maternal outcome, 91 control subjects were chosen from the screened patients in a randomized fashion, so that the baseline characteristics of the two groups were comparable Results: In our study, 10.3% population had neurological disorders, among which 30.8% had primary headache, 3.2% had secondary headache, 8.5% had neurological low back pain, 19.1% had epilepsy, 6.4% had cerebrovascular disorders, 27.6% had peripheral neuropathy, 4.2% had other disorders such as neuropsychiatric Wilson's disease, myasthenia gravis and compressive myelopathy. Moreover, 10.2% of the total study population was hypertensive and 2.9% were diabetic. CONCLUSION: 10.3% mothers did have some neurological disorder, the commonest of which was migraine (primary headache) followed by carpal tunnel syndrome (peripheral neuropathy) and neurological low back pain. Overall fetomaternal outcomes were favorable barring cerebro-vascular disorder and Posterior reversible encephalopathy syndrome (PRES). We recommend screening for neurological disorder from early pregnancy for early detection and appropriate management of that condition.

An Observational Study on Metabolic Derangements in People Living with HIV.

BACKGROUND: HIV infection is a global pandemic. The adult HIV prevalence in India is 0.22%. Successful therapy is transforming HIV into a chronic medical condition, and there are many metabolic complications. This study aimed to evaluate the metabolic abnormalities in people living with HIV (PLHIV) who were on antiretroviral therapy (ART) for at least 2 years and compare it with ART-naïve patients as well as the effect of protease inhibitor-based (PI-based) and non-protease inhibitor-based (non-PI-based) ART was assessed. METHODOLOGY: Adult HIV-positive patients both ART-naïve and on ART for more than 2 years were included. Detailed history and clinical examination, including blood pressure and anthropometric measurements were done. This was followed by investigations like lipid profile including total cholesterol, triglyceride, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), fasting plasma glucose, and hemoglobin A1c (HbA1C) estimation. Standard statistical tools were utilized to assess derangements and association to therapy. RESULTS: The study was conducted for 1.5 years in a tertiary care hospital. A total of 70% of the study population was male with mean age of participants being 43.2 years, 40% were ART-naïve, 37% received non-PI-based ART, and 23% PI-based ART. The mean total cholesterol level and mean triglyceride value were significantly higher in the PI-based ART group than in the therapy-naïve group. The ART-naïve group was seen to have more subjects with abnormally low HDL-C values. The PI-based ART study subjects were found to have a greater number of cases of glucose intolerance in relation to the rest of the two groups significantly (p-value <0.001). The LDL-C systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI), and waist circumference had no association with the different ART regimens or with the HIV infection itself. CD4 T cell count at diagnosis in the three study groups was compared with all the variables of metabolic syndrome and no association was found. CONCLUSION: Total cholesterol, triglycerides, and glucose levels are the main parameters found to be affected in PLHIV on therapy.

Deprescribing for Better Patient Outcomes in Chronic Long Term Care and Role of Clinical Pharmacological Review.

Prescribing is always a risky proposition with a varied degree of vulnerability embedded in the act. It is therefore important to do a perfect balancing in favor of benefit against harm. Deprescribing is the planned and supervised process of dose reduction or stopping of prescribed medications, aimed at correcting inappropriate polypharmacy and improving patient outcomes. Informed reconciliation for potential deprescribing need should be a norm in all patients receiving many medications for multiple chronic comorbidities and is best done in partnership with the prescribing physician. Judicious deprescribing through clinical pharmacological review ensures better patient outcomes. We present here a case series from our experience in clinical pharmacology outpatients' department (OPD), highlighting how de-prescribing helps achieving better patient outcomes.

COVID Associated Mucormycosis: A Study on the Spectrum of Clinical, Biochemical and Radiological Findings in A Series of Ten Patients.

BACKGROUND: There is more than twofold rise in prevalence of mucormycosis cases in India during the COVID-19 pandemic which needs to be evaluated. AIMS: The study aimed to document the spectrum of cases of mucormycosis seen at our Institute during COVID-19 times. METHODS: The study is a retrospective observational study carried out at our Institute from May 2021 to mid-June 2021. All patients with biopsy-proven mucormycosis were enrolled in the study. The patients were subjected to complete history taking, ophthalmological examination, and imaging studies. The patients were treated with a multidisciplinary approach with antifungal therapy as well as surgical intervention when needed. RESULTS: Ten patients (n=10) were seen, with a mean age of 50.3 years. The major risk factors included recent use of steroids, uncontrolled diabetes, and CKD. The most common presentation was swelling of unilateral eye and ptosis, followed by loss of vision. Inflammatory marker (CRP) and d-dimer were raised at presentation in all cases. Imaging showed the spread of infection from paranasal sinus to orbit and brain via cavernous sinus, which was a poor prognostic factor. Intravenous Amphotericin-B was given to all patients for at least 4 weeks. Two patients were discharged after completion of treatment and mortality was seen in three patients. CONCLUSION: We present an array of COVID-associated-mucormycosis (CAM) cases from Eastern India. CAM is presenting with rhino-orbito-cerebral involvement. There is poor outcome with cerebral involvement and high incidence of adverse effects with deoxycholate formulation of amphotericin-B. The causal association of COVID-19 with mucormycosis needs to be unearthed but possible preventive role of anticoagulation should be evaluated.

Effect of Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers on COVID-19 outcome: A Record Based Observational Study in West Bengal.

BACKGROUND: Since its first identification in December 2019, in WUHAN (CHINA), SARS-COV-2, causative agent of Corona virus pandemic, has affected millions of people worldwide, causing thousands of death. There is much speculation about the interplay between ACEI/ARB and Corona virus infection, as for internalization into host cell SARS-COV-2 binds through S spike protein to ACE-2, aided TMPRSS2. METHODS: A record based observational study has been conducted (data obtained from the clinics of fourteen physicians) in two worst affected districts of West Bengal, to find out the association of ACEI/ARB on patients, suffering from Corona virus infection. The study-protocol has already been approved by Clinical Research Ethics Committee of Calcutta School of Tropical Medicine. (IEC Ref. No: CREC-STM/2020-AS-37) Results: Increasing age, male sex and presence of co-morbidities (viz. Diabetes, COPD) are significantly associated with the occurrence of moderate and severe disease. Drugs (viz. ACEI/ARB), though are associated with less severe disease, have not achieved statistical significance, in the present study. CONCLUSION: Drugs, like ACEI/ARB, should be continued in patients suffering from COVID-19 infection, (if they are already on these drugs).

Adherence to anti-hypertensive medications and its determinants: A study among hypertensive stroke patients in a tertiary care government hospital of West Bengal.

There is a paucity of antihypertensive drug adherence studies among stroke patients in West Bengal. With an aim to identify antihypertensive drug adherence and its determinants, this descriptive cross-sectional study was conducted for 2 months among a calculated sample of 133 study participants using predesigned and pretested schedule, the metric "Proportion of days covered (PDC)," and the Morisky, Green, and Levine (MGL) Scale. Data were compiled and analyzed using SPSS software (version 20.0). Adherence rates were 31.6% and 44.4% based on the MGL scale and PDC method, respectively. Higher adherence was significantly associated with increased age (P = 0.006), higher literacy (P = 0.013), increased interval between diagnosis of hypertension and present symptom (P = 0.001), a greater gap between antihypertensive treatment initiation and present symptom (P = 0.003), receiving advice on regular drug intake (P = 0.000), and registered medical practitioner prescribing the medication (P = 0.007).

Risk Benefit Analysis in Reference to use of LMWH in COVID-19.

Venous thromboembolism (VTE) and disseminated intravascular coagulation (DIC) are frequent cardiovascular and/or respiratory complications among hospitalized patients of COVID-19 infection. A relatively high mortality of severe coronavirus disease 2019 (COVID-19) is worrying, and the application of heparin in COVID-19 has been assessed and recommended with some expert consensus because of the risk of DIC and venous thromboembolism. However, "Risk Benefit Analysis" on the aspect of safety in using low molecular weight heparin (LMWH) in COVID-19 patients for thrombosis prophylaxis has been explained below with a few case studies and detailed information from various clinical evidence. COVID-19 infection has been associated with inflammation and a prothrombotic state, with increase in fibrin, fibrin degradation products, fibrinogen, and D-dimers. Heparin treatment including unfractionated and low molecular weight heparin appears to be associated with better prognosis in severe COVID-19 patients with coagulopathy. Major studies since the onset of this pandemic, found better prognosis in severe COVID-19 patients meeting SIC criteria or with markedly elevated D-dimer, by approaching thrombosis prophylaxis with LMWH.