The Correlation of the Neutrophil-to-Lymphocyte Ratio With Microvascular Complications in Patients With Diabetes Mellitus.

Background High neutrophil-to-lymphocyte ratio (NLR) may be used as a reliable measure of vascular complications and an indicator of poor outcomes in cases of diabetes mellitus (DM). Methods A prospective analytical cross-sectional observational study was conducted at the Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India. A total of 100 patients with DM who met the inclusion and exclusion criteria were included in the study. A pre-tested and semi-structured questionnaire was given to the patients. IBM SPSS software version 26 (IBM Corp., Armonk, NY, USA) and MedCalc trial version 20.114 (MedCalc Software Ltd., Ostend, Belgium) were used for data analysis. Logistic regression analysis was performed to determine the association of the NLR with microvascular complications. Results In our study, the male-to-female ratio was 1.78:1 (male: 64 (n)%, female: 36 (n)%). The mean age of our study population was 56.28 ± 13.24 years. Of 58 patients with microvascular complications, 34 had a high NLR, and 24 patients had a normal NLR. Of 42 patients without microvascular complications, only 14 had a high NLR, and the remaining 28 patients had a normal NLR (p = 0.012). Logistic regression was performed to analyze the association between the NLR and microvascular complications, which demonstrated a significant association (odds ratio (OR): 2.833, 95% confidence interval (CI): 1.238-6.481; p = 0.013). Conclusions Our study demonstrated the higher odds of having microvascular complications among diabetics with a high NLR compared with non-diabetics. Therefore, the NLR may be used as a measure of microvascular complications in the diabetic population.

Serum Lipase Amylase Ratio as an Indicator to Differentiate Alcoholic From Non-alcoholic Acute Pancreatitis: A Systematic Review and Meta-Analysis.

A lipase/amylase (L/A) ratio of more than three may be a tool for differentiating alcoholic pancreatitis from non-alcoholic pancreatitis. We conducted a systematic literature review to identify published studies. A thorough data search of various databases was conducted using keywords. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 survey. Data were extracted under the following headings: country, sample size, baseline characteristics, specificity, and sensitivity of the L/A ratio. Studies were analyzed using a bivariate random-effects model, and the sensitivity and specificity of the L/A ratio were pooled separately. Summary receiver operating characteristic (SROC) curves were plotted using the hierarchical method. A total of nine studies with 1,825 patients were identified for inclusion. SROC showed estimates of the area under the curve to be 0.75 (confidence interval (CI) = 0.71-0.79). Forest plots for sensitivity and specificity showed pooled estimates of sensitivity to be 74% (95% CI = 62-83%) while that of specificity was 63% (95% CI = 47-77%). The pooled diagnostic odds ratio was estimated to be 5 (95% CI = 3-9), the pooled positive likelihood ratio was estimated at 2.0, and the pooled negative likelihood ratio was estimated to be 0.41. We concluded that an L/A ratio of more than 3 has moderate accuracy for the diagnosis of alcoholic pancreatitis.

Association of Fibrinogen With Ischemic Stroke: A Systematic Review and Meta-Analysis.

Validation of a risk factor in a multifactorial disease like ischemic stroke is necessary to practice precision medicine. Many risk factors have been attributed to causing ischemic stroke but contribute very little to it. There are many risk factors that need to be validated, and fibrinogen is one such risk factor. Using a meta-analysis technique, we investigated fibrinogen as a risk factor for ischemic stroke. We searched the computerized databases such as PubMed, Google Scholar, and Cochrane to explore articles on ischemic stroke. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random effects model. A total of 10 case-control studies with 6877 cases and 7219 controls were included in the study that match inclusion and exclusion criteria. The Asiatic population was portrayed in four studies, whereas the Caucasian population was portrayed in six studies. Under the recessive model, an elevated level of serum fibrinogen is linked to an increased risk of ischemic stroke as shown by pooled odds ratio (OR: 1.47, 95% CI: 1.19-1.76, I2 = 78.3%, P = 0.000). Our meta-analysis concluded that a high level of fibrinogen is associated with an increased risk of ischemic stroke.

Fibrinogen as a Predictor of Early Neurological Deterioration in Acute Ischemic Stroke - Evidence From the Indian Population.

Background: Early neurological deterioration (END) is a common occurrence in ischemic stroke and contributes significantly to poor outcomes. Although multiple factors that predict END have already been identified, the role of fibrinogen - a key component of the coagulation pathway, is controversial. Objective: To assess the role of fibrinogen in predicting END and poor hospital outcome in patients with acute ischemic stroke. Design: Single-centre prospective observational study. Methods: 141 patients with acute ischemic stroke were analyzed in this prospective observational study from a single tertiary-care hospital in East India. END was defined as a worsening of ≥2 points on the National Institutes of Health Stroke Scale (NIHSS) within 7 days of admission. A score of 3-5 on the Modified Rankin Scale (mRS), a stroke recurrence event or death during hospital stay was considered poor hospital outcome. We performed univariate analysis using age, sex, body-mass index (BMI), hypertension, diabetes, NIHSS scores, stroke etiology, blood glucose and lipid parameters and plasma fibrinogen to develop a logistic regression model to establish the independent predictors of END and poor outcome. Results: Age (Odds Ratio (OR) 1.034 [95% CI 1.001-1.069], P = .046), NIHSS score at admission (OR 1.152 [95% CI 1.070-1.240], P < .001) and fibrinogen (OR 1.011 [95%CI 1.006-1.015], P < .001) were independent predictors of END in patients with acute ischemic stroke. Factors independently associated with poor outcome were NIHSS score at admission (OR 1.257 [95% CI 1.150-1.357], P < .001), fasting plasma glucose (OR 1.007 [95% CI 1.001-1.013], P = .020), and fibrinogen [OR 1.004 [95% CI 1.000-1.007], P = .038). Conclusion: The significant role of fibrinogen in determining neurological worsening and subsequent poor outcomes in patients with acute ischemic stroke may help in early prognostication and guided therapeutic interventions.

Serum gamma-glutamyl transferase level as a risk factor in acute stroke.

Background: Worldwide stroke is the second major cause of mortality and the fourth prominent cause of disease load after coronary heart disease and all types of malignancy. Greater than 3/4th of these cases are in low-priced and middle-priced nations. Several epidemiological studies have shown that alcohol consumption is a risk factor for stroke. The correlation between alcohol consumption and stroke involves various processes. For excessive alcohol consumption, GGT (gamma glutamyl transferase) is used as a marker. The study aims to see whether serum GGT level is an independent risk factor for stroke in young and elderly patients who do not have a history of alcohol intake. Material and Method: The study is an analytical cross-sectional comparative hospital-based study done in the Department of Medicine, RIMS, Ranchi from November 2019 to April 2021. A total number of 100 cases including both sexes who presented with the first episode of stroke have been compared with 100 age-sex-matched healthy control subjects without any cerebrovascular or cardiovascular disease meeting inclusion and exclusion criteria. Analysis of data is done by SPSS software and R studio software. Result: Serum GGT is lower in the age group of 40-60 years (24-hour GGT mean 50.70 U/L+SD 16.86) than the age group of 60-80 years (24-hour GGT 65.89 U/L+SD59.04) with a P value of 0.005. This is also true in 48-hour GGT (48.02 U/L+SD16.02) in 40-60 years compared to 57.94 U/L+SD42.81 in 60-80 years with a P value of 0.001 and 72-hour GGT (44.80 U/L+SD16.98) in 40-60 years compared to the mean (56.16 U/L+SD43.82) in 60-80 years with a P value of 0.001. This suggests that serum GGT level is significantly lower in the 40-60 years age group with a P value < 0.01. The serum GGT level in the case population is mean 58.30 (U/L) + SD43.87, and that in the control group is mean 17.48 (U/L) + SD4.32 with P value < 0.001. This implies an increased level of serum GGT level in stroke patients. Conclusion: Serum GGT level is independently correlated with stroke even in the presence of other risk factors for stroke such as diabetes mellitus, hypertension, and dyslipidemia. Serum GGT level is more in hypertensive, dyslipidemic, and ischemic stroke patients than in non-hypertensive, non-dyslipidemic, non-ischemic stroke patients, but serum GGT level cannot predict the outcome (survival or death) in stroke patients.

Excessive and Unreliable Health Information and Its Predictability for Anxiety: A Cross-Sectional Observational Study.

INTRODUCTION: Being ignorant or unaware is not expected in a situation like the pandemic of COVID-19 with modern internet connectivity and the era of social media. However, information overload may itself lead to health anxiety. AIMS AND OBJECTIVES: This study investigated the predictability of health anxiety with information overload and sociodemographic profiles during the COVID-19 pandemic. MATERIALS AND METHODS: A cross-sectional study was done among 400 caretakers of non-covid patients in a tertiary healthcare medical college. The consenting participants provided their sociodemographic details and responded to the short health anxiety inventory (SHAI), Beck anxiety inventory (BAI) and Information overload scale (IOS) for COVID-19. RESULTS: A total number of 400 participants aged 35.58 ± 10.57 years participated and out of which 88.2% acknowledged health-related anxiety and 56.8% for excessive use of social media. BAI measured anxiety was mild for 19.8%, moderate for 3.5% and severe for 3%. The linear regression analysis predicted health anxiety by three variables only: total anxiety as measured by the Beck anxiety inventory [ß = 0.416, t = 9.318, p = 0.000], information overload (rejection of information) [ß = 0.171, t = 3.126, p = 0.002], and excessive use of social media [ß = 0.124, t = 2.888, p = 0.004]. CONCLUSION: Information overload, its rejection and excessive use of social media were found to be predictive of health-related anxiety.

Association of Glycosylated Haemoglobin (HbA1c) Level With Left Ventricular Diastolic Dysfunction in Patients With Type 2 Diabetes.

Background Some literature has shown a high prevalence of pre-clinical diastolic dysfunction in subjects with type 2 diabetes mellitus. The current study was carried out to determine the association of glycosylated hemoglobin (HbA1c) levels with left ventricular diastolic dysfunction (LVDD) in patients with type 2 diabetes. Methods An observational cross-sectional study was conducted in a tertiary health care center in Jharkhand. A total of 100 subjects diagnosed with type 2 diabetes mellitus who gave informed consent and fulfilled the inclusion and exclusion criteria were studied in our center from April 2019 to September 2020. Logistic regression was carried out to determine the association of potential variables with outcomes. Multivariable logistic regression analysis was conducted to determine the independent effects of variables for LVDD prediction. Results The mean HbA1c of the population with LVDD was found to be higher (11.07 ± 3.66%) as compared to the population with normal LVDD (9.11 ± 2.95%), which was found statistically significant (probability value (P) =0.004). This signifies that a higher level of HbA1c in a patient with diabetes will have a higher incidence of LVDD. On applying multivariate analysis to determine the independent effect of variables for LVDD, HbA1C was found to be significant with an odds ratio (OR) of 1.26, 95% CI 1.08-1.48. The duration of diabetes was also found to be significant with OR 1.48 and CI 95 % (1.20-1.82) P <0.001. On plotting the receiver operating characteristic curve (ROC), the area under the ROC curve to predict the left ventricular function with the model was 0.8137. Conclusions Patients who have higher HbA1C are linked to a higher risk of left ventricular diastolic dysfunction in patients with type 2 diabetes. The combination of diabetes and left ventricular dysfunction can lead to increase morbidity and mortality in those patients in whom it is not identified timely and appropriate measures are not taken. Our work emphasizes the requirement of screening intermittently symptomless diabetic patients for diastolic dysfunction through a Doppler echocardiography so that timely action can be taken.

Correlation between chest CT and RT-PCR testing in India's second COVID-19 wave: a retrospective cohort study.

OBJECTIVES: To assess the diagnostic accuracy of chest CT in clinically suspected patients with COVID-19 using reverse transcriptase PCR (RT-PCR) as the reference standard and establish the correlation between CT Severity Score (CTSS) and RT-PCR results. DESIGN AND SETTING: Retrospective cohort study. Single-centre tertiary care hospital-based study. PARTICIPANTS: We enrolled 112 clinically suspected patients with COVID-19 between 1 April 2021 and 31 May 2021. Chest CT and RT-PCR tests were performed for all patients at a time interval of no longer than 7 days between the two tests. Patients with prior chronic respiratory illnesses were excluded. The diagnostic performance of chest CT was evaluated using RT-PCR as the reference standard. The CTSS was calculated for all patients with positive chest CT findings, and it was correlated with results of the RT-PCR assay. MAIN OUTCOME MEASURES: The primary outcome measures were determination of the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of chest CT using RT-PCR as the standard of reference. The correlation between CTSS and RT-PCR was the secondary outcome. RESULTS: 85/112 (76%) patients tested positive on the RT-PCR whereas 91/112 (81%) had chest CT findings typical of SARS-CoV-2 infection. Chest CT had a sensitivity of 90.6% (95% CI 82.3% to 95.8%), a specificity of 48.1% (95% CI 28.7% to 68.0%), a PPV of 84.6% (95% CI 79.2% to 88.8%), an NPV of 61.9% (95% CI 43.0% to 77.8%) and an accuracy of 80.4% (95% CI 71.8% to 87.3%). There was a significant correlation between the CTSS and RT-PCR positivity (p value=0.003). CONCLUSION: In our experience, chest CT has a good sensitivity and provides a reliable diagnostic tool for moderate-to-severe COVID-19 cases in resource limited settings.

Cerebral salt wasting induced hyponatraemia presenting as catatonia.

Cerebral salt wasting (CSW) is an important cause of hyponatraemia in the background of a central nervous system disease. It causes hypovolaemic hyponatraemia and is associated with polyuria and high urine sodium levels. It is important to distinguish it from the more common syndrome of inappropriate antidiuretic hormone and this is primarily based on the volume status. Although CSW has been known to present with confusion, stupor, abnormal behaviour and seizures, its association with catatonia is yet to be reported. We report a case in which the patient developed CSW and hyponatraemia as a sequela of tuberculous meningitis and presented with catatonia. Prompt correction of hyponatraemia resulted in complete reversal of catatonia. This highlights the importance of evaluating all patients with catatonia for electrolyte abnormalities, especially hyponatraemia as its correction leads to excellent outcomes.

Clinical profile and prognostic factors of alcoholic cardiomyopathy in tribal and non-tribal population.

OBJECTIVE: Alcoholic cardiomyopathy (ACM) is a leading cause of non-ischaemic dilated cardiomyopathy (DCM) in tribal and non-tribal population. However, no study has been done depicting the correlation between clinical profile and prognosis of ACM in tribal and non-tribal population. This study also defines the long-term outcome and prognostic markers of ACM. METHODS: We studied 290 patients with ACM who were evaluated in our institute between January 2013 and December 2016. The primary endpoint of the study was all-cause mortality. Statistical analysis was done by using Kaplan-Meier survival curves for the assessment of all-cause mortality and Cox regression for the assessment of risk factors. RESULTS: After a median follow-up period of 3.75 years (IQR: 3-4 years), 50 patients with ACM (37.3%) died among tribal population while 14 patients (9%) died among non-tribal population. Independent predictors of all-cause mortality in ACM identified by Cox regression were left ventricular ejection fraction (LVEF) (HR: 0.883; 95% CI 0.783 to 0.996; p=0.043), QRS duration (HR: 1.010; 95% CI 1.007 to 1.017; p=0.005) and Child-Turcotte-Pugh (CTP) Scoring (HR: 12.332; 95% CI 6.999 to 21.728; p<0.001) at admission. The Kaplan-Meier survival probability estimate was 95.1% at 1 year and all-cause mortality was found to be higher in patients with QRS>120 ms, LVEF ≤35%, CTP Grade B/C than patients with QRS≤120 ms, LVEF >35% and CTP Score A, respectively (log-rank χ²=55.088, p<0.001; log-rank χ²=32.953, p<0.001; log-rank χ²=139.764, p<0.001, respectively). CONCLUSION: Our study indicated increased morbidity and mortality in tribal population. LVEF, QRS duration and CTP Scoring at the time of presentation were found to be the independent prognostic markers of patients with ACM.

Intramuscular pyrethroid with organophosphorus (cypermethrine 3% + quinolphos 20%) mixed poisoning, its clinical presentation and management.

Organophosphorus compounds are absorbed by any route including intramuscular injection. Pyrethroid compounds are less toxic for human but in combination with organophosphates, its toxic effect potentiates due to inhibition of its metabolism. In this case report, a 40-year-old female patient presented with acute onset of pain abdomen, recurrent vomiting, and excessive salivation followed by altered mental status, on evaluation her clinical findings were suggestive of organophosphorus poisoning. Her treatment was started with injection atropine, anti-emetics, and adequate parenteral rehydration. After regaining consciousness, the patient confessed that she had taken herself intramuscular injection of pesticide which contained 3% cypermethrine plus 20% quinolphos. It was further confirmed by a very low level of plasma cholinesterase level. Intramuscular injection acted as a depot that leads to prolong intoxication and in the due course of illness, she also developed delayed onset intermediate syndrome that was managed appropriately.

Cerebral venous sinus thrombosis-A primer for emergency physician.

Cerebral venous sinus thrombosis (CVT) is notoriously known for its varied presentations and extremely high risk of mortality, if remains undetected and untreated. On the other hand, life can be saved with full functional recovery if CVT can be identified with high index of clinical suspicion with supportive imaging and treatment with appropriate anticoagulation. It is important for clinicians to be meticulous to screen for both the potential reversible and heritable causes of CVT so that appropriate measures can be taken to prevent such catastrophe. Here we report a case of CVT involving right sigmoid and transverse sinuses presenting with acute onset left sided hemiplegic without antecedent headache or seizures. Patient was successfully treated with anticoagulants with nearly full functional recovery. Multiple predisposing factors were identified. As per our knowledge, this is the first case of CVT with underlying conglomeration of multiple acquired (lactation, folate deficiency, hyperhomocysteinemia, depot medroxyprogesterone acetate injection) and hereditary risk factors (deficiency of protein C, protein S and antithrombin-III) in a single patient.

COVID-19: the endocrine opportunity in a pandemic.

The 2019 Coronavirus disease (COVID-19) pandemic has disrupted the social, economical and medical system worldwide. Although it is strictly an infectious disease, its intricate bidirectional relationship with various non-communicable metabolic diseases and endocrinological factors has been observed. While diabetes, hypertension, obesity have been found to be independent risk factors for COVID-19 disease severity and mortality, more inclination towards sedentary lifestyle, psychosocial stress at this critical time may be the harbingers of metabolic syndrome. Thus, endocrinologists have a great opportunity to play their role to combat this pandemic. This paper examines how various endocrinological disorders influence the dynamics of COVID-19 and vice versa. Moreover, it also intends to review the clinical guidelines to be adopted in practice of endocrinology in this trying time.

A rare case of Rhupus syndrome with Hashimoto's thyroiditis, associated adverse effect of drugs and incidental findings.

The term Rhupus is coded for the individuals who have rheumatoid like arthritis with erosions and fulfil the criteria for both rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Abnormal Th2 cell plays a central role in SLE while Th1 participate in RA. Thus the overlap of SLE and RA has a very low incidence (0.01%-0.2%) in patient with arthritis. This 40-year-old male patient presented with complains of severe multiple joint pain with progressive deformities, diminished vision from last 2 months, redness on back, headache and swelling over scalp. As this patient had history of severe trauma that was considered as a precipitating factor for ongoing chronic inflammatory disorder. Posterior subcapsular cataract was explained by prolong use of systemic steroid and rashes on the lower back due to sulfasalazine. Radioimaging study revealed arachnoid cyst and calcified projection arising from outer table of skull, which was kept under observation.

Report on a rare single coronary artery anomaly: Need for comprehensive investigations.

Single coronary artery anomaly (SCAA) is a very rare disorder with an incidence of about 0.024%-0.066% which presents with the diverse feature but is mostly asymptomatic. It has found to be one of the pathological states to cause sudden death. We report a case of R-III type of SCAA as classified by Lipton et al. which is only about 15% of all the cases of SCAA which makes it even rarer. Hypoxic environment is thought to be an important cause for the development of such anomalies which gives us clues to determine the predisposing factors to be ruled out in patient's history. Coronary angiography is the key toward definitive diagnosis which can be later supported by computed tomography scan and determination of its subtypes. Depending on the findings and physical state of the patient, medical or surgical treatment can be defined but only after correct diagnosis by comprehensive investigations.

A suspected case of olanzapine induced hyponatremia.

Here we report a case of a 63-year-old male diagnosed with recurrent depressive disorder and current episode of severe depression with psychotic symptoms, developed hyponatremia soon after addition of olanzapine and increasing the dose of escitalopram. A possible causality association was established with olanzapine, and the possible etiological reasons of this clinically significant risk were discussed.