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.

Dengue Encephalitis Versus Japanese Encephalitis in Cases of Dengue Fever With Altered Sensorium: A Diagnostic Dilemma.

Dengue and Japanese encephalitis (JE) are diseases that often conquer the top headlines in the leading newspapers during epidemics. Although recovery is the rule in most dengue cases, some unfortunately land up with multiple organ dysfunction syndromes, get critical, and even succumb to death. The main risk here is bleeding due to thrombocytopenia and platelet dysfunction. On the other hand, JE often presents with acute encephalitis syndrome (AES). We report a confirmed case of dengue (NS1 reactive, IgM dengue positive) by enzyme-linked immunosorbent assay (ELISA) who developed sudden onset altered sensorium. Non-contrast computed tomography (NCCT) head was done, which showed an infarct in the right gangliocapsular region with normal-sized ventricles. The patient had deteriorated in the past four days, which warranted a repeat NCCT head, revealing dilated ventricles and hemorrhagic transformation in the old infarct with surrounding edema. CSF viral markers were suggestive of IgM anti-JE virus positive. An MRI brain was planned but could not be done due to the deteriorating condition of the patient. Unfortunately, the patient landed up with multiple organ dysfunction syndrome and succumbed to death.

Type 2 Diabetes Mellitus in a Young Female Later Diagnosed as​​​​ Pancreatogenic Diabetes: The Dilemma in Classifying Diabetes Mellitus.

Diabetes mellitus type 3c (DM3c) is a diabetes caused by pancreatic pathology. It occurs due to the destruction of the endocrine islet cells. Diabetes diagnosed at the age of 20-30 years share a common dilemma in segregating between the type of diabetes the patient has, as its management varies depending on the type of diabetes the patient is harboring. However, insulin remains the treatment of choice in later decades as the pancreatic reserves of beta cells exhaust, although it takes decades to happen. We report a case of a woman who was diagnosed with diabetes mellitus at the age of 26, was on oral hypoglycemic agents (OHA), and was shifted to insulin therapy as she became non-responsive to OHA in a short span of six years, which was alarming. The patient presented to us with the chief complaints of recurrent abdominal pain that aggravated on taking meals and was associated with multiple episodes of vomiting for two months. Blood gas analysis on admission had no evidence of metabolic acidosis, urine ketones were negative, and a random blood sugar test (RBS:202) excluded the possibility of diabetic ketoacidosis. Serum amylase and serum lipase were within normal limits. Contrast-enhanced computed tomography (CECT) of the abdomen was suggestive of the atrophic pancreas with the non-dilated main pancreatic duct. Magnetic resonance cholangiopancreatography (MRCP) was done to rule out the congenital anomalies of the pancreas responsible for chronic pancreatitis, which showed no structural abnormalities. During our clinical workup, we postulated that the diabetes she was diagnosed with at the age of 26 was DM3c, i.e., pancreatogenic diabetes. The rapid shift of patients from OHA to subcutaneous insulin in a short span must be alarming to the physician managing diabetes and needs extensive workup to look upon the etiology of the same.

Serum Ammonia Levels as a Non-invasive Predictor of the Presence and Severity of Esophageal Varices in Chronic Liver Disease Patients.

Background Portal hypertension leads to the formation of portosystemic collateral veins, of which esophageal varices (EV) are the most severe complications and have the greatest clinical impact. The possibility of identifying cirrhotic patients with varices by non-invasive tests is appealing, as they can lead to reduced healthcare costs and can be done in resource-limited settings. In this study, we investigated ammonia as a potential non-invasive predictor of EV. Methods This was a single-center cross-sectional observational study that was done at a tertiary health care hospital in north India. It included 97 chronic liver disease patients irrespective of etiology after excluding patients with portal vein thrombosis and hepatocellular carcinoma to participate in endoscopic screening for the presence of EV and correlate it with various non-invasive markers like serum ammonia levels, thrombocytopenia and aspartate aminotransferase to platelet ratio index (APRI ). On the basis of endoscopy, enrolled patients were divided into two groups, i.e., group A consisting of large varices (grade III and grade IV) and group B consisting of patients with low-grade varices and no varices (grade II, grade I, and no varices). Results This study included 97 patients, out of which 81 patients have varices on endoscopy, and mean serum ammonia levels were found to be significantly higher in cases with varices (135 ±69.70 ) vs. those without varices (94±43) (p value=0.026). Further, on comparing serum ammonia values between patients with large varices (Grade III/IV) (Group A) with a mean value of 176 ± 83 vs. Grade I/II/No varices (Group B) with a mean value of 107±47, which were significantly higher in Group A patients (<0.001). In our study, we also found a correlation between blood urea level as a non-invasive predictor of varices, but no statistically significant relation was found between thrombocytopenia and APRI. Conclusion This study found that serum ammonia can be used as a useful marker for the prediction of EV and can also be used to determine the severity of varices. Apart from ammonia, serum urea levels can also prove to be a good non-invasive marker for the prediction of varices although further multicentric studies are warranted to reach this conclusion.

The COVID-19 Clinical Spectrum and the Effect of Associated Comorbidities on Illness Severity in the North Indian Population: A Cross-Sectional Study.

BACKGROUND: The activity level of the 2019 novel coronavirus (2019-nCoV) or coronavirus disease 2019 (COVID-19), as it is now called, is considered low. Despite early preventive lockdown measures and a massive vaccination drive, almost the entire adult population in India will have been vaccinated at least once by the beginning of 2022 (2,072,946,593 till 11 August 2022). There is still concern about a pan-India outbreak and threat due to newly emerging pathogenic strains. The goal of this study is to find out how common various presenting complaints are in COVID-19 patients as well as how comorbidities affect the severity of the illness. METHODS: This cross-sectional observational study was conducted from December 2020 to January 2021 at a tertiary care hospital's department of internal medicine in North India. The study included 237 patients who were COVID-19-positive and were admitted to our hospital after providing informed consent. They were classified into three groups: mild, moderate, and severe. RESULTS: Fever was the most common presenting symptom, affecting 84.4% of the population, while diarrhoea was the least common, affecting only 3.4% of the population. Fever, cough, sore throat, headache, and breathlessness were significantly correlated with the severity of the illness. Gastrointestinal symptoms like diarrhoea did not have any significant correlation with the severity of the illness. The severity of illness was statistically related to comorbidities such as hypertension, diabetes, coronary artery disease, chronic kidney disease, and chronic obstructive pulmonary disease. CONCLUSION:  Males were more likely to develop more serious illnesses. However, the correlation was not statistically significant. The number of comorbid conditions and the severity of the illness were found to have a fair and significant relationship. None of the diarrhoea symptoms were related to the severity of the illness.