Clinical and nerve conduction study correlation in patients of diabetic neuropathy.

AIMS AND OBJECTIVES: 1) To study types of neuropathy in Type 2 diabetes. 2) To correlate clinical features of peripheral neuropathy with nerve conduction study in Type 2 diabetes. MATERIAL: A total of 50 diabetics, whose onset of diabetes after the age of 30 years were studied from Dr. D. Y. Patil hospital and research centre. Type 2 Diabetes mellitus with symptom suggestive of peripheral neuropathy were studied and included. Chronic alcoholic, peripheral neuropathy due to any other known cause were excluded. METHOD OF COLLECTION OF DATA: History of symptoms like paraesthesia like tingling sensation, burning feet, hyperaesthesia, foot ulcer, history of weakness and gait abnormality was noted. Complete central nervous system examination was performed to look for signs such as diminished ankle jerk, diminished power. Sensory examination for loss of light touch, superficial pain, temperature sense, vibration and joint position was done. Nerve conduction studies were performed using Clarity Octopus NCV/EMG machine. Written and informed consent from patient were taken. RESULTS: 1) 46 patients i.e. 92% presented with complaints of tingling sensation and 32 patients i.e. 64% had burning feet. 2) 29 patients i.e. 58% have diminished ankle jerk, 29 patients i.e. 58% have diminished or loss of vibration sense, in 21 patients i.e. 42% patients have diminished light touch and 20 patients i.e. 40% patients have loss of joint position senses. 3) NCV performed on 50 patients of diabetic neuropathy out of which all patients i.e. 100% had involvement of lower limb and only 24 patients i.e. 48% had involvement of upper limb also. 4) Involvement of tibial and sural nerve is more common i.e. 86% and 82% respectively. 5) 42 patients i.e. 84% found to have distal symmetrical polyneuropathy, 2 patients i.e. 4% had isolated tibial nerve involvement, 4 patients i.e. 8% had pure sensory sural nerve involvement, and only 1 patient each of isolated medial and plantar nerve involvement. CONCLUSION: Distal symmetrical polyneuropathy is most common form of diabetic neuropathy. Involvement of tibial and sural nerve is more common in diabetic neuropathy.

Subdural haematoma in an adult due to hypernatraemia.

Neurological manifestations are quite common in hypernatraemia but subdural haematoma due to hypernatraemia is very rare in adult population. We report a case of 50 year old female patient who presented with acute acalculus cholecystitis who subsequently developed persistent hypernatraemia with multiple subdural haematomas and patient died. Patient died because of persistently raised intracranial tension, before she could be taken up for surgical evacuation of subdural haematoma.

Echocardiographic assessment of cardiac dysfunction in patients of end stage renal disease on haemodialysis.

OBJECTIVE: To assess the prevalence of systolic and diastolic dysfunction in patients of end stage renal disease (ESRD) on haemodialysis. METHODS: Seventy patients with ESRD were subjected to two-dimensional and M mode echocardiography for determination of systolic and diastolic dysfunction. All patients were evaluated clinically, biochemically and radiologically and were diagnosed as chronic kidney disease (CKD). The left ventricular ejection fraction (LVEF) and fractional shortening (FS) were taken as measures of left ventricular (LV) systolic function. Diastolic function was determined by measuring E/A ratio by spectral doppler LV inflow velocity. Echocardiographic findings of hypertensive and normotensive patients were compared. RESULTS: Out of 70 patients studied, there were 53 males (75.7%) and 17 females (24.3%). Hypertension (37.1%) was leading cause of ESRD. Echocardiography showed that left ventricular hypertrophy (LVH) was present in 74.3%. Systolic dysfunction as measured by reduced fractional shortening (<25%) and decreased LVEF (< 50%) was present in 8.6% and 24.3% respectively. Diastolic dysfunction as denoted by E/A ratio of less than 0.75 or more than 1.8 was present in 61.4% of patients. Regional wall motion abnormality (RWMA) was present in 12.9%. Pericardial effusion was noted in 14.3% of patients. Valvular calcification was noted in 7.1% of ESRD patients. Mean left ventricular internal diameter in diastole was 45.55 +/- 6.03 mm. Mean Interventricular septum diameters in systole was 12.2 +/- 1.71 mm. Mean left atrium diameter was 33.01 +/- 4.11 mm. Normotensive group was compared to hypertensive group. Statistically significant difference was noted in LVH and E/A ratio in hypertensive group as compared to normotensive group. CONCLUSION: Patients with hypertensive ESRD had higher prevalence of diastolic and systolic dysfunction as compared to normotensive counterparts.

Viral load, antibody titers and recombinant open reading frame 2 protein-induced TH1/TH2 cytokines and cellular immune responses in self-limiting and fulminant hepatitis e.

OBJECTIVES: Hepatitis E virus (HEV) is the predominant cause of water-borne epidemics, sporadic acute viral hepatitis (AVH) in adults and fulminant hepatic failure (FHF) among pregnant women and other adults in India. This preliminary study was designed to examine the association of viral load and certain host immune responses with uneventful recovery or progression to FHF. METHODS: Viral load, anti-HEV antibody titers, rORF2p-induced Th1/Th2 cytokines levels and cellular immune responses were assessed in 47 patients with self-limiting hepatitis E and 14 FHF-E cases. The controls included 16 anti-HEV-IgM and IgG-negative healthy individuals. RESULTS: In AVH category, the viral load was 2.4 x 10(4) +/- 1.92 x 10(4) copies/ml while except for one, all FHF patients were negative for HEV RNA; anti-HEV-IgM and IgG titers were higher in the FHF group. Lymphocyte proliferative response to rORF2p was comparable in both groups. As compared to AVH, significantly higher levels of both Th1 (IFN-gamma, IL-2 and TNF-alpha) and Th2 (IL-10) cytokines were recorded in FHF patients. Analysis of sequential samples differentiated FHF recovered and fatal patients with respect to IFN-gamma and IL-12. CONCLUSION: The results document increased Th1/Th2 responses and anti-HEV titers in FHF patients that warrant in-depth immunological studies.

Urinary Albumin Excretion, Estimated Glomerular Filtration Rate, and Prevalence of Microalbuminuria in Obese Nondiabetic and Nonhypertensive Adults: A Cross-Sectional Study.

CONTEXT: Obesity even in absence of diabetes and hypertension increases the risk for microalbuminuria (MAU), glomerular hyperfiltration, and therefore nephropathy. AIMS: This study aims to assess the urinary albumin excretion (UAE), prevalence of MAU, and values of estimated glomerular filtration rate (eGFR) in obese nondiabetic and nonhypertensive patients, vis a vis thin healthy subjects, and attempts to correlate anthropometric measurements with UAE and eGFR. SETTING AND DESIGN: Cross-sectional analytical study on 60 cases who were obese according to Asia Pacific guidelines and 60 nonobese controls. Patients with diabetes, hypertension, ischemic heart disease, and established renal disease were excluded. METHODS AND MATERIAL: Albuminuria was assessed in each patient by quantitative immunoturbidimetry method on a spot urine sample. eGFR was calculated by Cockcroft-Gault formula. STATISTICAL ANALYSIS: Data was analyzed using SPSS (2015 version). Mann-Whitney U-test, Fisher Exact test, and Spearman's correlation coefficient was used for various variables. RESULTS: The mean age of cases was 31.90 ± 6.32 years. About 78.33% were in class 1 and 21.66% in class 2 obese groups. The mean UAE at 21.20 ± 26.82 mg/g creatinine was higher in the case group. The prevalence of MAU was 11.66% and 3.33% in case and control groups, respectively. The cases had a significantly higher mean eGFR of 123.29 ± 20.49 mL/min/kg as compared with controls who had a mean eGFR of 106.59 ± 10.15 mL/min/kg. There was moderate correlation between anthropometric measurements and eGFR. CONCLUSION: Younger, class 1 obese patients had a higher UAE, eGFR, and three times higher MAU prevalence, even in absence of diabetes and hypertension, with a correlation between anthropometry and eGFR as compared with nonobese individuals.

Platelet volume indices in patients with coronary artery disease and acute myocardial infarction: an Indian scenario.

AIMS: To study platelet volume indices (PVI) in the spectrum of ischaemic heart diseases. METHODS: A total of 210 cases were studied; 94 patients had unstable angina (UA) or acute myocardial infarction (AMI) diagnosed on the basis of history, characteristic electrocardiographic changes, and increased cardiac enzyme activities. Seventy patients had stable coronary artery disease (stable CAD) or were admitted for a coronary angiography or coronary artery bypass graft procedure. The third group comprised 30 age and sex matched healthy controls with no history of heart disease and a normal electrocardiogram. RESULTS: All PVI-mean platelet volume (MPV), platelet distribution width (PDW), and platelet large cell ratio (P-LCR)-were significantly raised in patients with AMI and UA (mean MPV, 10.43 (SD, 1.03) fL; mean PDW, 13.19 (SD, 2.34) fL; mean P-LCR, 29.4% (SD, 7.38%)) compared with those with stable CAD (mean MPV, 9.37 (SD, 0.99) fL; mean PDW, 11.35 (SD, 1.95) fL; mean P-LCR, 22.55% (SD, 6.65%)) and the control group (mean MPV, 9.2 (SD, 0.91) fL; mean PDW, 10.75 (SD, l.42) fL; mean P-LCR, 20.65% (SD, 6.14%)). CONCLUSIONS: Larger platelets are haemostatically more active and are a risk factor for developing coronary thrombosis, leading to myocardial infarction. Patients with larger platelets can easily be identified during routine haematological analysis and could possibly benefit from preventive treatment. Thus, PVI are an important, simple, effortless, and cost effective tool that should be used and explored extensively, especially in countries such as India, for predicting the possibility of impending acute events.

Profile of bone marrow examination in HIV/AIDS patients to detect opportunistic infections, especially tuberculosis.

Morphological evaluation of 140 bone marrow aspirations received in haematopathology laboratory with serologically established HIV infection, along with other relevant special haematological tests, was done during 1st Jan 1999 - 31st Dec 2002 at state government run tertiary care General Hospital in Maharashtra state, India. Out of 140 cases: 118 (84.28%) patients had anaemia, 25 (17.86%) had leukopenia, while 13 (9.28%) were thrombocytopenic. Dyserythropoiesis was present in 18 (12.86%) cases, dysmyelopoiesis 37 (26.43%) and micromegakaryocytes were noted in 44 (31.43%) cases. Haemophagocytosis was evident in 8 (5.71%) cases. Plasmacytosis encountered in 120 (85.71%) cases was a common feature. Based on clinical profile and results of other investigations 56 (40%) patients were clinically diagnosed to be of Mycobacterium tuberculosis (TB). Of these, 18 (12.86%) bone marrow aspirates were positive for AFB, Mycobacterium tuberculosis. In 4 cases cryptococci were demonstrated (Mucicarmine stain). There was one case each of Histoplasma capsulatum and leishmaniasis. One patient showed dense parasitemia with Plasmodium falciparum. One patient had immunoblastic lymphoma and showed bone marrow infiltration. Findings in this study strongly indicate that in HIV/AIDS, AFB stain should be done on each marrow aspirate to rule out tuberculosis in countries like India; where TB and AIDS are marching together.

Vasculitis with digital gangrene in a patient with HIV infection.

A case of polyarteritis nodosa (PAN) like systemic necrotizing vasculitis in an HIV infected individual, who presented with digital ischaemia is reported. The pathogenesis of PAN in HIV infected patients is not well understood and whether HIV or other agents are directly involved in the vascular injury remains to be established.

Evaluation of clinical criteria for the diagnosis of leptospirosis.

OBJECTIVES: Leptospirosis has a wide range of clinical presentation and therefore, clinical suspicion of the infection is often difficult. The objective of this study is to find out the usefulness of the clinical and epidemiological criteria in the diagnosis of leptospirosis and its comparison with microagglutination test (MAT). METHODS: A total of 118 patients with undiagnosed fever of more than seven days duration were included in the study. Their clinical presentation was scored on the basis of a clinical criteria. Sera of the patients were tested for antibodies against leptospira with the help of microagglutination test using a battery of antigens. The usefulness of the criteria was evaluated and compared with microagglutination test. RESULTS: A total of 44 out of 118 (37.28%) patients could be provisionally diagnosed as cases of leptospirosis on the basis of the clinical criteria. Eighteen of these 44 (40.9%) patients had serological evidence of leptospirosis. The criteria had a sensitivity of 81.81%, specificity of 72.91%, a positive predictive value of 40.9% and a negative predictive value of 94.59% when compared with microagglutination test. CONCLUSIONS: The criteria had a moderate sensitivity and specificity. Considering the non-specific signs and symptoms of this infection, the positive predictive value is significantly high. The criteria has a high negative predictive value and this would help the clinicians exclude the diagnosis of leptospirosis with precision.