Acute kidney injury in obstetrics: Hospital-based cohort study.

Obstetric acute kidney injury (AKI) is a serious unsolved global health-care problem and is a significant contributor to the overall burden of AKI resulting in devastating maternal and foetal outcomes. We studied the characteristics of obstetric AKI and the factors related to its unfavourable outcome. A total of 110 patients developed AKI among 10,138 admission giving a frequency of 1.08%. The commonest risk factor was pre-eclampsia followed by haemorrhage and sepsis. Complete recovery of renal function occurred in 40.9%. However, 9.1% were left with end-stage renal disease. AKI due to sepsis, delayed referral and deranged renal function on admission was associated with unfavourable outcome. AKI in pregnancy merits special attention because it involves risk to two lives, mother and foetus. Early identification of risk factors coupled with timely and efficient management will result in reducing obstetric AKI and associated maternal morbidity and mortality.

Clinical profile, etiology, and outcome of acute pancreatitis: Experience at a tertiary care center.

Background: Acute pancreatitis (AP) is an inflammatory process of the pancreas with varying degree of involvement of regional tissues. This was a population-based study on the incidence of AP. We aimed to determine the incidence, etiology, and outcome of AP. Materials and Methodology: This prospective study was conducted in the Department of Medicine, King George's Medical University, Lucknow, India, on 120 patients of AP. Clinical history, examination, and laboratory investigations were done. Severity of AP was assessed using the modified Atlanta classification. Results: A total of 120 patients comprising of 88 men (73.33%) and 32 women (26.66%) were recruited. The mean age of study participant was 36.96 ± 13.44 years. The most common presentation was abdominal pain followed by vomiting. The leading etiological factors were alcohol in 85 patients (70.8%) and gallstones in 25 (20.8%). It was idiopathic 5 patients (4.1%). Mortality was seen in three (2.5%) patients, all of which had severe pancreatitis. Patients with body mass index (BMI) ≥25 kg/m2, Hematocrit (HCT) ≥44% and C-reactive protein (CRP) ≥150 mg/l had an increased risk of developing a severe AP. Conclusions: Alcohol and gallstones were the most common etiological factors of AP, whereas HCT, CRP, and BMI were the useful predictors of severe pancreatitis.

RésuméContexte: La pancréatite aiguë (PA) est un processus inflammatoire du pancréas avec divers degrés d'implication des tissus. Il s'agissait d'une étude basée sur la population sur l'incidence de la PA. Nous visions à déterminer l'incidence, l'étiologie et le résultat de la PA. Matériaux et méthodologie: Cette étude prospective a été menée au Département de médecine de l'Université de médecine du roi George, Lucknow, Inde, sur 120 patients atteints de PA. Les antécédents cliniques, les examens et les analyses de laboratoire ont été effectués. La gravité de la PA a été évaluée en utilisant la classification modifiée d'Atlanta. Résultats: Un total de 120 patients comprenant 88 hommes (73,33%) et 32 femmes (26,66%) ont été recrutés. L'âge moyen des participants à l'étude était de 36,96 ± 13,44 ans. La présentation la plus courante était une douleur abdominale suivie de vomissements. le Les principaux facteurs étiologiques étaient l'alcool chez 85 patients (70,8%) et les calculs biliaires chez 25 (20,8%). Il s'agissait de patients idiopathiques 5 (4,1%). Mortalité a été observée chez trois (2,5%) patients, tous atteints de pancréatite sévère. Patients ayant un indice de masse corporelle (IMC) ≥ 25 kg / m2, HCT ≥ 44% et La protéine C-réactive (CRP) ≥ 150 mg / l avait un risque accru de développer une PA sévère. Conclusions: L'alcool et les calculs biliaires étaient les plus facteurs étiologiques communs de la PA, tandis que la HCT, la CRP et l'IMC étaient les prédicteurs utiles de la pancréatite sévère. Mots-clés: pancréatite aiguë, profil clinique, étiologie, issue.

Evaluation of Serum Cystatin C as an Early Biomarker of Acute Kidney Injury in Patients with Acute Pancreatitis.

INTRODUCTION: Acute pancreatitis (AP) is an inflammatory process of pancreas with varying degree of involvement of regional tissues. The aim of this study was to investigate the potential use of serum cystatin C (Cys-C) for the early and accurate diagnosis of acute kidney injury (AKI) in patients of AP. MATERIALS AND METHODS: This was a prospective study conducted in 1 year. Total of 215 cases of AP fulfilling the inclusion criteria were enrolled in this study. Patients suffering from chronic pancreatitis, neoplasm, chronic liver disease, and chronic kidney disease were excluded from the study. Diagnosis of AP was based on the Atlanta classification 2012. All patients were classified into a non-AKI group (n = 152) and an AKI group (n = 38) according to the dynamic changes in serum creatinine levels. Serum Cys-C was measured by particle-enhanced immune nephelometric assay. RESULTS: By univariate logistic regression analysis, body mass index (BMI) (OR = 1.44, 95% CI: 1.23-1.68; p < 0.001), blood urea (OR = 1.15, 95% CI: 1.06-1.23; p < 0.001), Cys-C (OR = 1.04, 95% CI: 1.01-1.07; p < 0.05), serum calcium (OR = 0.59, 95% CI: 0.41-0.86; p < 0.05), and serum lactate dehydrogenase (LDH) (OR = 1.001, 95% CI: 1.0-1.001; p < 0.05) were the significant indicators for AKI in patients with AP. Using multivariate logistic regression analysis, urinary albumin and Cys-C were independent and significant indicators of AKI in patients with AP (OR = 1.026, 95% CI: 1.01-1.07; p < 0.01). Receiver operating characteristic (ROC) curve of serum Cys-C, for AKI in patient with AP could be identified with a sensitivity of 92.06% at specificity of 96.0% [area under the curve (AUC) = 0.96, 95% CI: 0.92-0.98] by baseline serum Cys-C (cutoff value = >32.32 mg/L). CONCLUSION: Increase of baseline serum Cys-C was associated with AKI in patients with AP. HOW TO CITE THIS ARTICLE: Patel ML, Shyam R, Bharti H, Sachan R, Gupta KK, Parihar A. Evaluation of Serum Cystatin C as an Early Biomarker of Acute Kidney Injury in Patients with Acute Pancreatitis. Indian J Crit Care Med 2020;24(9):777-782.

Early weight loss in a standalone mHealth intervention predicting treatment success.

OBJECTIVE: Early weight loss is a strong predictor of longer-term and clinically meaningful weight loss but has not been studied in the context of mobile health ('mHealth') interventions. METHODS: GoalTracker was a randomized trial among adults (21-65 years) with overweight or obesity comparing three 12-week standalone mHealth interventions for weight loss. All arms received a free commercial mobile app (MyFitnessPal) for daily self-monitoring of diet and/or weight and a goal to lose 5% of weight by 3 months. Collapsing across arms, this analysis examined participants with a 1-month weight (n = 84), categorizing them as either early responders (≥2% weight loss at 1 month) or early non-responders (<2% weight loss at 1 month). RESULTS: Early responders - 36% of participants - had greater per cent weight change at 3 months (-5.93% [95% confidence interval: -6.82%, -5.03%]) than early non-responders (-1.45% [-2.15%, -0.75%]), which was sustained at 6 months (-5.91% [-7.33%, -4.48%] vs. -1.28% [-2.37%, -0.19%]; ps < 0.0001). Over half (57%) of early responders achieved ≥5% weight loss at 3 months vs. 11% of early non-responders. At 4 weeks, self-monitoring frequency (weight/diet) was significantly greater among early responders, which continued across 12 weeks. CONCLUSION: Responding early to an mHealth treatment is associated with higher engagement and greater likelihood of achieving clinically meaningful weight loss.

Prevalence of pulmonary artery hypertension in patients of chronic obstructive pulmonary disease and its correlation with stages of chronic obstructive pulmonary disease, exercising capacity, and quality of life.

BACKGROUND: Pulmonary arterial hypertension (PAH) is a complication of chronic obstructive pulmonary disease (COPD) in advance stages, and its presence indicates poor prognosis. AIMS AND OBJECTIVE: The present study was design to know the prevalence of PAH in patients with COPD and its correlation with stages of COPD, exercising capacity, and quality of life. MATERIALS AND METHODS: It is a cross-sectional prevalence study over a period of 1 year from August 2015 to July 2016. The study included 109 COPD patients, diagnosed by spirometry, and severity was determined according Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification criteria. Screening two-dimensional echocardiography was done to determine pulmonary arterial hypertension and exercising capacity assessed by 6 min walk test (6MWT) while the quality of life was assessed by St George respiratory Questionnaire for COPD (SGRQ-C) Questionnaires. RESULTS: Out of 109 patients, PAH was present in 68 (62.4%) cases consisting of mild grade 41 (37.6%), moderate grade 11 (10.1%), and severe grade 16 (14.7%). In GOLD A stage, there were 20 cases of mild PAH and Stage B included 18 cases of mild and 3 cases of moderate PAH. Stage C had 3 cases of mild and 8 cases of moderate PAH while Stage D had 16 cases of severe PAH. In 6MWT, patients with severe grade PAH fail to perform the test while patients with mild to moderate PAH walked short distance. In SGRQ-C Questionnaires symptom, activity, impact, and total score were high with the severity of PAH. CONCLUSION: The prevalence of PAH in COPD was significant. Therefore, every COPD patient should be evaluated for PAH.

Uncovering Metabolic Syndrome among Chronic Obstructive Pulmonary Disease Patients in a Tertiary Care Hospital, India.

INTRODUCTION: Chronic Obstructive Pulmonary Disease (COPD) is known to cause various systemic problems including Metabolic Syndrome (MetS). MetS is a group of cardiovascular risk factors. By assessing MetS, one can assess the cardiovascular disease risk. There is increasing evidence of MetS in COPD patients. However, the frequency of MetS and its individual components are not still been clearly shown which is likely to vary in different population. AIM: To know the extent of association of metabolic syndrome and its components in patients with COPD. MATERIAL AND METHODS: This study was designed as an analytical case control study. Ninety cases of COPD satisfying the inclusion criteria and 45 healthy volunteer subjects as controls were recruited over 18 months duration. Simple random sampling method was used to select all cases attending outdoor and indoor medicine department. All subjects (cases and controls) were matched for age, sex, occupation and socioeconomic status. Prior to participation in the study, written informed consent was taken from all subjects. All included subjects underwent a detailed history, clinical examination and laboratorial analysis. All subjects were assessed for MetS by using National Cholesterol Education Program-Third Adult Treatment Panel (NCEP ATP III) and International Diabetic Federation (IDF) criteria. RESULTS: The present study demonstrated Metabolic Syndrome (MetS) in COPD according to NCEP ATP III and IDF criteria as 14 (15.56%) and 30 (33.33%) while there was no association of MetS with controls. The frequency of its component such as abdominal obesity, systolic blood pressure, diastolic blood pressure, elevated triglyceride, reduced HDL-C and elevated fasting glucose respectively was 71 (78.89%), 25 (26.67%), 12 (13.33%), 18 (20%), 23 (25.56%) and 17 (18.78%) respectively. Dyslipidemia was found in 36 (40%) cases of COPD including 16 (17.78%) cases of elevated LDL cholesterol. CONCLUSION: Our study concluded that MetS is frequent in COPD patients as compared to general population. Therefore, a comprehensive medical approach to screen all COPD patients for MetS should be done there to lower the significant risk of cardiovascular events in patients with COPD.

Acquired Bartter syndrome following gentamicin therapy.

Aminoglycoside nephrotoxicity may manifest as nonoliguric renal failure or tubular dysfunction, such as Fanconi-like syndrome, Bartter-like syndrome (BS), or distal renal tubular acidosis. We report a case who developed severe renal tubular dysfunction on the the 7th day of gentamicin therapy, resulting in metabolic alkalosis, refractory hypokalemia, hypocalcemia, hypomagnesemia, and polyuria. The patient was diagnosed as a case of transient BS associated with gentamicin exposure. The patient recovered with conservative management.

Symmetrical peripheral gangrene: Unusual complication of dengue fever.

Symmetrical peripheral gangrene (SPG) is a rare clinical entity, infective, and noninfective both types of etiologies are responsible. The basic underlying pathology in SPG is being disseminated intravascular coagulation and carries a high mortality. Here, we describe a 52-year-old male with dengue fever, who developed bilateral symmetrical dry gangrene of both hand and feet. His dengue IgM antibody was positive. All the peripheral pulses of the affected limbs were palpable. Color Doppler study of upper and lower limb vessels showed normal flow. The patient was managed with intravenous fluids, low molecular weight heparin, and fresh frozen plasma. His general condition was improved within 72 h with no further progression of gangrene. Clinician should suspect the possibility of SPG while dealing a case of dengue fever presenting as peripheral gangrene.

Neutrophil gelatinase-associated lipocalin as a biomarker of disease progression in patients with chronic kidney disease.

Chronic kidney disease (CKD) is associated with early mortality, decreased quality of life and increased health care expenditures. The aim of this study was to determine whether or not urinary NGAL (uNGAL) level is associated with renal damage and kidney disease progression in patients with CKD and to evaluate the predictive value of uNGAL in progression of CKD. Totally, 91 cases of CKD stage II, III, IV, and 50 age-matched healthy controls were enrolled. The follow-up end-point was 18 months; end-point of the study was progression to an estimated glomerular filtration rate (eGFR) of <15 ml/min and/or CKD stage V. Forty-five cases (49.4%) were progressors and 46 were nonprogressors. uNGAL levels were significantly higher in CKD subjects as compared to healthy controls (log 1.09 ± 0.22 µg/ml in controls versus log 1.22 ± 2.08 µg/ml in stage II, log 3.34 ± 2.74 µg/ml in stage III and log 3.70 ± 0.18 µg/ml in stage IV). Univariate Cox proportional hazards model showed that only eGFR (hazard ratio [HR]: 0.95; 95% confidence interval [CI]: 0.93-0.96; P < 0.001) and uNGAL (HR: 1.11; 95% CI: 1.01-1.20; P < 0.001) were significantly associated with end-point of CKD stage V, but multiple Cox proportional regression model showed significant association of uNGAL (HR: 1.11; 95% CI: 1.01-1.20; P < 0.001) and eGFR (HR: 0.962, 95% CI: 0.95-0.98; P < 0.001) with end-point of CKD stage V. This suggests that uNGAL would not be a simple surrogate index of baseline eGFR, but a marker of CKD progression beyond the information provided by eGFR estimation.

Reduction of microalbuminuria in type-2 diabetes mellitus with angiotensin-converting enzyme inhibitor alone and with cilnidipine.

The aim of our study was to find out the antiproteinuric effect of enalapril angiotensin-converting enzyme (ACE inhibitor) alone or in combination with cilnidipine in patients with type-2 diabetes mellitus. The study was conducted on 71 patients with type-2 diabetes mellitus patients with hypertension and microalbuminuria. They were divided into two groups randomly as follows: Group I (enalaprilalone, n = 36) and Group II (enalapril with cilnidipine, n = 35). In both the groups, baseline 24 h urinary albumin was estimated and was repeated every 3 months upto 1-year. After 1-year follow-up, reduction in microalbuminuria was found to be greater in Group II. In Group I microalbuminuria came down by 25.68 ± 21.40 while in Group II it reduced by 54.88 ± 13.84 (P < 0.001). We conclude that in diabetic population, cilnidipine has an additive effect in microalbuminuria reduction over and above the well-proven effect of ACE inhibitors.

Complete axial torsion of pregnant uterus with leiomyoma.

Uterine torsion is defined as a rotation of the uterus of more than 45° along its long axis. It is a rare complication during pregnancy; a common cause of torsion can be uterine myoma. Here we describe the case of a 27-year-old G2P1+0 woman at 15 weeks 3 day pregnancy, who presented to our outpatient department as a case of acute abdomen, in a state of shock. Clinical findings did not correlate with investigation. On lapratomy she was diagnosed as a case of complete axial torsion of pregnant uterus with fundal myoma with massive abruption. Early diagnosis and timely intervention would help in improving both maternal and fetal outcome.

Cervical tuberculosis masquerading as cancer cervix: a report of three cases.

Tuberculosis is still frequently observed in third world countries like Africa and Asia. Here we report three cases of genital tuberculosis with variable presentations. First case was a lady of reproductive age group who presented with polymenorrhea and post-coital bleeding with unhealthy cervix. Histopathology of cervical tissue revealed tubercular cervicitis. Second and third cases presented with different complaints like discharge per vaginum, post-coital bleeding and pain in lower abdomen with growth over the cervix. Cervical biopsy was inconclusive of tuberculosis but endometrial tissue sampling for TB PCR was positive. This shows that newer diagnostic marker test can help us to detect secondary genital tuberculosis.

Two unusual cases of hypothyroidism with renal dysfunction.

We describe two cases in which the initial finding of renal impairment guided further investigation leading to the diagnosis of hypothyroidism. In the first case, a 40-year-old female patient presented with a complaint of facial puffiness. On investigation, her serum creatinine was 1.86 mg/dl, glomerular filteration rate (GFR) by Cockcroft-Gault equation was 40 ml/min, free throxine (FT4) was <1 mg/dl and a thyroid stimulating hormone (TSH) concentration >80 µ/l. In the second case, a 45-year-old male patient presented with complains of indigestion, weight gain and lethargy. On examination, his blood pressure was 160/100 mm Hg and there was facial puffiness and mild pedal oedema. On investigation, her serum creatinine was 1.5 mg/dl and estimated GFR by Cockcroft-Gault equation was 55 ml/min. Thyroid function was abnormal, FT4 2.99 mg/dl and TSH 80 µ/l. In both the cases, thyroid hormone replacement therapy brought about complete recovery of renal function.