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.

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 studyclearly 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.

Association between Polypharmacy and Cardiovascular Autonomic Function among Elderly Patients in an Urban Municipality Area of Kolkata, India: A Record-Based Cross-Sectional Study.

We assessed the association between polypharmacy and cardiovascular autonomic function among community-dwelling elderly patients having chronic diseases. Three hundred and twenty-one patients from an urban municipality area of Kolkata, India were studied in August 2022. The anticholinergic burden and cardiac autonomic function (Valsalva ratio, orthostatic hypotension, change in diastolic blood pressure after an isometric exercise, and heart rate variability during expiration and inspiration) were evaluated. Binary logistic regression analysis was performed to find out the association of polypharmacy and total anticholinergic burden with cardiac autonomic neuropathy. A total of 305 patients (age, 68.9 ± 3.4; 65.9% male) were included. Of these patients, 81 (26.6%) were on polypharmacy. Out of these 81 patients, 42 patients were on ninety-eight potential inappropriate medications. The anticholinergic burden and the proportion of patients with cardiac autonomic neuropathy were significantly higher among patients who were on polypharmacy than those who were not (8.1 ± 2.3 vs. 2.3 ± 0.9; p = 0.03 and 56.8% vs. 44.6%; p = 0.01). The presence of polypharmacy and a total anticholinergic burden of > 3 was significantly associated with cardiac autonomic neuropathy (aOR, 2.66; 95% CI, 0.91−3.98 and aOR, 2.51; 95% CI, 0.99−3.52, respectively). Thus, polypharmacy was significantly associated with cardiac autonomic neuropathy among community-dwelling elderly patients.

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.

Evaluation of respiratory manifestations in systemic lupus erythematosus with special reference to pulmonary interstitial involvement.

Different respiratory manifestations in systemic lupus erythematosus (SLE) are not uncommon. We lack sufficient Indian data in this regard. Forty diagnosed cases of SLE were evaluated, to find out the prevalence of respiratory manifestations in SLE, as also to correlate the findings as observed by different diagnostic methods. It was a single centre cross-sectional observational study conducted at rheumatology clinic, IPGME&R, Kolkata. Patients suffering from chronic airways obstruction, upper airway diseases, left ventricular failure and lung cancer were all excluded from the study. After clinical evaluation and routine testing of organ specific parameters, patients underwent spirometry and chest x-ray in all cases and pleural fluid study, pleural biopsy and high resolution CT scan of thorax selectively as required. Mean age at presentation was 26.8 years and female to male ratio was 39:1. Commonest respiratory symptom was dyspnoea and commonest respiratory manifestation was pleural effusion. Pleural effusion was bilateral in 80% of cases. Interstitial lung disease (ILD) was found in 10% of cases presented either subacutely or chronically. High resonance CT was found to be more sensitive to diagnose ILD, as in 50% of ILDs diagnosed by scan, chest x-rays were normal. Pleuropulmonary infections (7.5%) were next most common manifestation and tuberculosis was found to be the commonest cause. Lupus pneumonitis was found in one only (2.5%). Screening lung function test as done by spirometry, could pick up some abnormality in 50% cases and restrictive change was the major abnormality (47%). None showed evidence of bronchial hyper-responsiveness. No case was detected to have neuromuscular disease, acute respiratory distress syndrome or pulmonary thrombo-embolism. All the respiratory manifestations as noted appeared in variable period after the onset of SLE.

Immune reconstitution inflammatory syndrome associated with acquired immunodeficiency syndrome-related gastrointestinal limited Kaposi's sarcoma presenting as acute intestinal obstruction: a case report.

INTRODUCTION: Immune reconstitution inflammatory syndrome during anti-retroviral treatment of acquired immunodeficiency syndrome (AIDS) -associated gastrointestinal Kaposi's sarcoma has rarely been reported. CASE PRESENTATION: A 36-year-old Asian Indian male, newly diagnosed with AIDS and treatment naïve, was started on highly active antiretroviral therapy (HAART). He developed acute intestinal obstruction after four weeks of therapy. A laparotomy was done with excision and adhesiolysis leading to relief of symptoms. A histology report revealed the lesion to be Kaposi's sarcoma. Our patient was diagnosed to be having immune reconstitution inflammatory syndrome associated with AIDS-associated gastrointestinal limited Kaposi's sarcoma, which presented as acute intestinal obstruction. Our patient was treated with paclitaxel post-operatively and HAART was continued. Our patient responded to therapy. CONCLUSION: Immune reconstitution inflammatory syndrome involving Kaposi's sarcoma may occur in HAART-naïve individuals with AIDS-related Kaposi's sarcoma. Gastrointestinal Kaposi's sarcoma may present with sudden increase in size or inflammation leading to acute intestinal obstruction. This does not indicate failure of HAART or a need for changes in anti-retroviral regimen.

Dermatomyositis associated with acute myelocytic leukemia.

Polymyositis (PM) and dermatomyositis (DM) are inflammatory myopathic diseases characterized by symmetric, proximal myopathy with or without a distinct cutaneous eruption. They have long been recognized to be associated with cancer. The common cancers associated with DM/PM include ovarian, lung, pancreatic, breast, and stomach cancer. PM/DM associated with hematological disorders and especially with acute myelocytic leukemia (AML) is extremely rare with very few cases being reported till date. In our review of literature we could find only seven such reported cases. We present here a case presenting with DM and diagnosed to be suffering from AML on admission. This happens to be the second reported case of DM and AML with no latent period between the two diseases.

Opportunistic infections of central nervous system in AIDS.

HIV/AIDS is a new epidemic in current century. Predominant route of transmission is sexual. Virtually all systems are affected either directly by virus or by oppurtunistic infections or by malignancy. Neurological complications may occur at any stage of disease. Clinical manifestations may be acute, subacute or chronic. Presentation and diagnosis are often confusing. Central nervous system toxoplasmosis and tuberculous meningitis are commonest opportunistic infections in advanced HIV patients. Patients frequently present with focal neurodeficit. Mortality is high i.e., 13 (54%) out of 24 cases of opportunistic infectious in the study carried out at the SSKM Hospital during the period January 2005 to December 2006.