Delhi Model: A New Tool for Predicting Response to Terlipressin in Hepatorenal Syndrome-Acute Kidney Injury.

Background and objectives: International club of ascites (ICA) has introduced revised criteria for hepatorenal syndrome-acute kidney injury (HRS-AKI) with an aim to improve the response rate to treatment. We lack prospective trials to assess its positive impact on the response rate and factors influencing response rate. Thus, we conducted this study with the primary aim of identifying independent factors that predict treatment response to terlipressin. Methods: We prospectively included patients of HRS-AKI as per the revised ICA criteria. All were treated with terlipressin and albumin according to the defined protocol and were followed for 90 days, death or liver transplantation. Baseline parameters, as well as delta serum creatinine (sCr) at day 4 (DCD4), were investigated as predictive factors influencing response to terlipressin (primary endpoint). Secondary endpoints were the overall response rate to terlipressin, response in various subgroups of acute-on-chronic liver failure (ACLF) patients, need for readmission, and 90 days survival. Results: The study included 114 patients with a median age of 52 years (83% males). 70 (61%) patients responded to terlipressin. Response rate among ACLF1, ACLF2, and ACLF3 were 62%, 48%, and 35%, respectively. On multivariate analysis, baseline creatinine (odds ratio [OR] 7.889, 95% confidence interval [CI] 3.335, 18.664), Child Turcotte Pugh (CTP) score (OR 1.470, 95% CI 1.026, 2.106), and the DCD4 (OR 0.048, 95% CI 0.015, 0.158) were independently predicting response. We also created a Delhi Model (DM) with an excellent predictive ability for response prediction at day 4 with an AUROC of 0.940 (95% CI 0.897, 0.982). Among responder group, 50% of patients required readmission within three months. The 90-days survival among responder and non-responder groups were 68.5% and 9% (P value < 0.01), respectively. Conclusions: Baseline creatinine, CTP score, and DCD4 independently predict response to terlipressin in HRS-AKI. The DM may guide terlipressin treatment in HRS-AKI but need further validation.

Safety and efficacy of the novel motorized power spiral enteroscopy: A single-center experience.

Objective: Evaluation and management of small bowel disorders have always been challenging due to the limitations of the existing technology. Motorized power spiral enteroscopy (PSE) is an innovative new technique that offers easier, faster, and more complete small bowel evaluation with the ability to perform therapeutics. We aimed to evaluate the safety and efficacy of PSE in various indications. Methods: Retrospective analysis of prospectively collected data of consecutive patients, who underwent PSE at a tertiary care center. Primary outcome measures were technical success rate, pan-enteroscopy rate, diagnostic and therapeutic yield, and the secondary outcomes measures were the depth of maximal insertion, median insertion time, and adverse events. Results: Fifty-four patients (mean age of 49.38 ± 16.26 years) underwent PSE for small bowel evaluation. Technical success rate was 95.55% (antegrade route) and 93.10% (retrograde route).  Pan-enteroscopy rate is 46.29% and antegrade enteroscopy to the cecum was achieved in eight patients.  Overall diagnostic and therapeutic yields were 85.18% and 30.76%, respectively. The most common findings were ulcero-stricturing lesions (51.92%) followed by vascular lesions (9.61%). The most common histopathologic diagnosis was Crohn's disease in 29.62%. Median depth of maximal insertion was 400 cm (range 150-550 cm; antegrade route) and 180 cm (range 50-350 cm; retrograde route). The median insertion time to depth of maximal insertion was 70 min (range 30-110 min; antegrade route) and 45 min (range 20-70 min; retrograde route).  PSE-associated major adverse events occurred in one patient and minor adverse events were seen in 48.14%. Conclusion: PSE is a safe and effective modality for the evaluation of small bowel disorders with a high diagnostic yield.

Disseminated histoplasmosis in India presenting as addisonian crisis with epiglottis involvement.

Histoplasmosis is caused by Histoplasma capsulatum. Like most fungal infections, histoplasmosis is common in immunocompromised patients. In immunocompetent patient, infection is generally asymptomatic and rarely turns into a disseminated form. Addisonian crisis as presentation of disseminated form has been reported in present. Here, we report a case of disseminated histoplasmosis leading to life threatening adrenal crisis and hypercalcemia in an elderly immunocompetent Indian patient. Appropriate diagnosis and anti fungal and steroid treatment lead to dramatic improvement in patient. Histoplasmosis should be considered in a immunocompetent hosts with adrenal involvement.

2,4-D poisoning: a review with illustration of two cases.

2,4-D (2,4-dichlorphenoxyacetic acid) is a chlorphenoxy group pesticide. Its relative safety and broad leaf selectivity makes it a favourite herbicide of many home gardeners and agricultural workers. Severe systemic toxicity requiring hospital admission and intensive care usually occurs following intentional oral ingestion. 2,4-D poisoning is an under-recognised cause of a potentially lethal toxic syndrome, especially in low- and middle-income countries, where such compounds are widely used in farming and readily available in households. It warrants close monitoring and high-quality supportive care along with plasma alkalinisation or extracorporeal removal of the toxin. We present a short review on 2,4-D poisoning and describe two illustrative cases with significant oral ingestion resulted in early and rapidly developing systemic toxicity. Both patients were admitted to the intensive care unit; one patient was managed with alkaline diuresis and other case required three sessions of haemodialysis.

Mean paltelet volume (MPV) the neglected marker of cardiovascular risk and glycosylated hemoglobin in diabetic patient.

INTRODUCTION: Platelets activation and aggregation play fundamental role in thrombotic events in diabetes. MPV marker of platelet activity determines this cardiovascular risk. So by using simple parameter like MPV we can indirectly assess vascular complication in diabetic patient in periphery. AIMS AND OBJECTIVES: Determining MPV of both T1DM and T2DM with their controls and Relation between HbA1C and MPV in Diabetes Mellitus (DM). METHODOLOGY: This cross-sectional study was conducted in department of medicine, SPMC Bikaner from June 2014 - December 2014, included 100 patients attending medical outdoor and 100 healthy matched controls. Diabetics were divided into 3 GROUPS: HbA1c <6.5%, >6.5 but =< 8% and >8%. Groups were compared with regards to MPV and HbA1c. RESULTS: MPV was found significantly higher in both T1DM and T2DM compare to control groups (9.606±1.03 and 8.968±1.23 vs 7.85±0.680, p=0.0001). The mean age of diabetic groups were 40.50±5.08 years, 42.26±6.42 years and 44.56±8.25 respectively The mean MPV among diabetic groups were 8.18±0.99, 9.08±1.01, 9.54±1.268 respectively. On statistical comparison the difference was significant (p value-0.001).we also statistically significant difference on comparing HbA1C and MPV in T1DM and T2DM with p=0.006 r- 0.4968 and p=0.013 and r- 0.316 respectively. CONCLUSION: This shows that the MPV is significantly higher in patients with high HbA1C levels. Key Words: Glycosylated hemoglobin (HbA1c), Mean platelet volume (MPV).

Neuropsychiatric Profile in Malaria: An Overview.

INTRODUCTION: Malaria is the most important parasitic disease of humans causes clinical illness over 300-500 million people globally and over one million death every year globally. The involvement of the nervous system in malaria is studied in this paper, to help formulate a strategy for better malaria management. AIM: To study the Neuropsychiatric manifestation in malaria. MATERIALS AND METHODS: This was a prospective observational study in 170 patients with a clinical diagnosis of malaria admitted in various medical wards of medicine department of PBM Hospital, Bikaner during epidemic of malaria. It included both sexes of all age groups except the paediatric range. The diagnosis of malaria was confirmed by examination of thick and thin smear/optimal test/strip test. Only those cases that had asexual form of parasite of malaria in the blood by smear examination or optimal test were included in the study. RESULTS: Out of total 170 patients 104 (62%) reported Plasmodium falciparum (PF), Plasmodium vivax (PV) were 57 (33.5%) followed by mixed (PF+PV) 9 (5.3%) cases. The total PBF-MP test positivity was 84.5%. Maximum patients were belonging to the age range of 21-40 year with male predominance. Neuropsychiatric manifestation seen in falciparum malaria (n=111) as follow: altered consciousness 20 (18.01%), headache 17 (15.32%), neck rigidity 5 (4.5%), convulsion 5 (4.55%), extra pyramidal rigidity 2 (1.8%), decorticate rigidity 1 (0.90%), decerebrate rigidity 1 (0.90%), cerebellar ataxia 3 (2.7%), subarachnoid haemorrhage 1 (0.90%), aphasia 2 (1.8%), subconjunctival haemorrhage 1 (0.90%), conjugate deviation of eye 1 (0.90%) and psychosis 6 (5.40%). Twenty one patients presented with cerebral malaria out of 111 patients. Most patients of cerebral malaria presented with altered level of consciousness followed by headache and psychosis. Acute confusional state with clouding of consciousness was the most common presentation of psychosis (50%). CONCLUSION: Neuropsychiatric manifestations are not an uncommon presentation of malaria. Most commonly caused by PF malaria. Malaria should be thought as a differential diagnosis in pyrexia with neuropsychiatric manifestation. Observation obtained in the study will be highly useful for the diagnosis and management of patients suffering from malaria.

Pulmonary cryptosporidiosis in an immunocompetent host treated successfully with nitazoxanide.

Cryptosporidium parvum is an intracellular spore-forming protozoa which predominantly causes intestinal diseases. It causes severe and life-threatening diarrheal diseases in immunocompromised hosts and usually self-limiting disease in immunocompetent hosts. Extra-intestinal manifestations of cryptosporidium infection are very rare. Herein, we report a case of pulmonary cryptosporidiosis in a 35-yrs-old immunocompetent host, who presented with fever, cough and breathlessness which was soon followed by diarrhea and vomiting, had lung consolidation, and treated successfully with nitazoxanide.