Effect of Disease-related Variables on Bone Mineral Density in Patients with Rheumatoid Arthritis.

OBJECTIVE: Rheumatoid arthritis (RA) is a chronic inflammatory disease that affects the bony architecture. Nevertheless, it remains uncertain whether these effects are due to disease progression, limited mobility, or medication. We conducted this study to analyze changes in bone mineral density (BMD) in patients with RA and its relationship with various disease parameters, such as demographic factors, disease activity, functional disability, duration since onset of symptoms, cumulative steroid dose, and titers of rheumatoid factor (RF). MATERIALS AND METHODS: This cross-sectional study was conducted at the Rheumatology Clinic of the Tertiary Care Hospital of Mumbai. We included 96 consecutive patients diagnosed with RA using the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria. Demographic, clinical, and biochemical data were also collected. Disease severity was assessed using the Disease Activity Score 28 with Erythrocyte Sedimentation Rate (DAS28-ESR) score, and physical disability was assessed using the Health Assessment Questionnaire (HAQ) score. BMD was calculated using dual-energy X-ray absorptiometry (DEXA). Significant variations among continuous variables were examined using the t-test, while disparities between categorical variables were evaluated using the Chi-squared test. Statistical significance was set at p < 0.05 within the 95% confidence interval (CI) range. RESULTS: Of the 96 patients, 77 were female, and 19 were male. The mean age of the study population was 45.28 ± 10.15 years. As the age of patients increased, BMD was found to decrease in the total lumbar spine, neck of the femur, and total hip region (p < 0.05). Sex did not seem to affect BMD. In all three regions, a decrease in BMD with increasing duration since the onset of RA symptoms was observed. Disease severity, measured using the DAS28-ESR score, did not decrease BMD. There was an increase in functional disability, calculated using the HAQ score, with a decrease in BMD at all sites. RF positivity was associated with decreased BMD at the neck of the femur and total hip region but not the total lumbar spine. Long-term use of steroids (≥30 days) decreased BMD at all three sites. CONCLUSION: Our study reiterates the effect of RA on the BMD of patients. Advanced age, duration since symptom onset, physical disability, RF positivity, and long-term corticosteroid use are disease-related factors affecting BMD in patients with RA.

Deranged Biochemical Markers As Early Predictors for the Development of Hepatorenal Syndrome in Patients With Alcoholic Liver Cirrhosis.

Objective To investigate predictive biomarkers correlated with the onset of hepatorenal syndrome (HRS) in individuals with alcoholic liver cirrhosis using various factors, including age, sex, and laboratory indicators such as serum sodium, bilirubin, PT/INR, and albumin levels. Additionally, we sought to establish a correlation between the occurrence of hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), and the model for end-stage liver disease (MELD) score at the time of diagnosis and the development of HRS in cirrhotic patients. Methods This cross-sectional study spanned 12 months and included a total of 83 patients as its sample size. This study was conducted at the Department of Internal Medicine, a tertiary care hospital situated in Mumbai, India. Two distinct groups were formed: one consisted of patients diagnosed with HRS, and the other group comprised patients with alcoholic liver cirrhosis but without HRS. This study aimed to investigate potential relationships with the suggested risk factors. To discern statistically meaningful distinctions among categorical variables, the chi-square test was employed, whereas for continuous variables, analysis of variance (ANOVA) was used. Only patients who provided written informed consent were included in this study. Results No correlation was found between patients with and without HRS with respect to age (p=0.056) and sex (p=0.067). The presence of HE (p<0.001), SBP (p=0.021), hyponatremia (p=0.0001), hypoalbuminemia (p<0.0001), higher PT/INR (p=0.03), and higher MELD score (p=0.0002) were found to be correlated with an increased risk of developing HRS. Hyperbilirubinemia was not correlated with an increased risk of developing HRS (p=0.157). Conclusions HRS is a severe and potentially avoidable complication associated with advanced liver cirrhosis, characterized by a notably high mortality rate. By closely monitoring key biomarkers, such as serum sodium, PT/INR, and albumin levels, in addition to assessing the presence of SBP and HE during the initial presentation of patients with alcoholic cirrhosis, medical professionals may be able to identify those at a heightened risk of developing HRS. This, in turn, enables the swift diagnosis and implementation of aggressive treatment strategies. Such measures not only hold the potential to reverse HRS but also enhance survival rates among individuals with alcoholic liver cirrhosis, thereby increasing the pool of candidates eligible for liver transplantation, which remains the cornerstone of treatment.

Short-Term Efficacy and Adverse Effects of Sulfasalazine in the Management of Axial Spondyloarthropathy.

INTRODUCTION: Ankylosing spondylitis (AS) is an inflammatory spondyloarthropathy that involves the sacroiliac joints and the axial skeleton. Sulfasalazine's efficacy in treating the axial symptoms of AS has been a subject of controversy. METHODS: This prospective observational study recruited AS patients and categorized them into two groups: the first group had AS for less than or equal to four years and the second group had AS for more than four years. Erythrocytic sedimentation rate (ESR) and C-reactive protein (CRP) levels were recorded at baseline and at six-month follow-up. Disease severity was assessed using the ankylosing spondylitis disease activity score (ASDAS), Bath ankylosing spondylitis disease activity index (BASDAI) score, and Bath ankylosing spondylitis functional index (BASFI) score. RESULTS: A total of 33 patients diagnosed with AS were recruited in this study, mostly males (88%) and within 21-30 years of age. ESR and CRP values were measured at baseline and at six months post-treatment with sulfasalazine. Mean ESR and mean CRP values showed a statistically significant reduction of 43.5% (p=0.001) and 58.45% (p=0.0012) respectively, at the 6-month follow-up. Four patients (12.12%) reported gastrointestinal intolerance. The mean reduction in the ASDAS score was 24% (p=0.002), the BASDAI score was 40.08% (p=0.001), and the BASFI score was 39.54% (p=0.01). Additionally, the duration of symptoms did not appear to influence with efficacy of sulfasalazine. DISCUSSION: Sulfasalazine is a safe alternative therapy for patients with AS who cannot afford biologics, due to its reasonable short-term efficacy, good tolerability, cost-effective nature, and low incidence of adverse effects.

Predictors of Outcome in Acute Respiratory Distress Syndrome in Acute Febrile Illness in Medical Intensive Care Unit.

AIMS: Acute Respiratory Distress Syndrome (ARDS) is a known complication of acute febrile illness (AFI). The in-hospital mortality rate of ARDS is between 35-44%. Our study aimed to identify the different parameters that could be used to detect patients at higher risk of poor outcome in AFI complicated by ARDS. METHODS: 130 patients with AFI complicated by ARDS as per Berlin definition, admitted at the Medical Intensive Care Unit of Seth GS Medical College KEM Hospital Mumbai, were studied over a period of 18 months. Investigations done during the course of MICU stay were noted. From the reports, SOFA score, delta SOFA score, Lung Injury Score (LIS), Disseminated Intravascular Coagulation (DIC) score (by ISTH scoring system) were also calculated. Main outcome was recorded as transfer out from the MICU or death. RESULTS: Etiology of the 130 patients of AFI with ARDS was as follows-dengue 32 patients (24.6%), H1N1 -31(23.8%), undifferentiated fever -30 (23.1%), leptospirosis-22 (16.9%), malaria-15 (11.5%). Our study had a mortality rate of 25.4 %( n=33). 40.8% of the study population required invasive ventilation at admission. SOFA score at admission and 48 hours, delta SOFA score, PaO2/ FiO2 ratio at admission and 48 hours, Blood Urea Nitrogen (BUN), creatinine, bicarbonate and albumin were the significant predictors of overall outcome. Hemoglobin, platelets and leukocyte counts, pH, pO2 , pCO2 at admission and 48 hours, Lung Injury Score (LIS) and DIC score were not significant predictors of outcome. CONCLUSION: SOFA score at admission and 48 hours, delta SOFA score and PaO2 / FiO2 ratio were significant predictors of outcome in patients of acute febrile illness with ARDS. LIS and DIC score were not significant predictors of outcome.

Clinical Study of Use of Remdesivir and Tocilizumab in Severely Ill COVID-19 Patients.

Introduction: Remdesivir and Tocilizumab are two experimental drugs used in severely ill COVID-19 patients. Various clinical trials studying these drugs are giving conflicting results. Our aim is to study these two drugs and share the experience in our setting. Methods: Our Study is a retrospective analysis of Clinico-laboratory details and outcome of three groups of patients who were given either (i) Remdesivir or (ii) Tocilizumab or (iii)both Remdesivir and Tocilizumab . We compared the outcome of these patients with other patients who did not receive either of these drugs, when it was not available or not introduced as experimental drugs earlier in treatment guidelines. Results: Out of a total of 521 patients, in the above three groups who received either or both Remdesivir or Tocilizumab, 334 survived. Out of 214 patients who did not receive any of the two drugs only 74 survived. The outcome was better individually for all the three groups of patients receiving either or both of the drugs as compared to neither of the drugs.(p <0.01) Conclusion: Remdesivir and Tocilizumab were useful drugs in treatment of severely ill covid -19 patients as compared with the patients who did not receive any of the above drugs.

Guillain-Barre Syndrome as Presenting Feature in a Patient with Systemic Lupus Erythematosus.

Guillain-Barré syndrome. GBS as initial manifestation of lupus is exceedingly rare and has been reported in a few cases in the literature. We report here a 35 year old woman who presented with 10 day history of progressive muscle weakness and paraesthesias in all four limbs. She was diagnosed as SLE with renal involvement and was treated with steroids and cyclophosphamide.

Cardiovascular Manifestations in Newly Diagnosed Hyperthyroid Patients and their Outcome with Anti-Thyroid Treatment.

OBJECTIVE: To evaluate the incidence of cardiovascular abnormalities in newly identified hyperthyroid patients and their outcome with anti-thyroid therapy. METHODS: A total of 96 patients who were newly diagnosed to have hyperthyroid disease were screened and out of them, 40 patients who presented with cardiovascular symptoms and sign were included in study (30 females, 10 males). Hyperthyroid patients were re-evaluated after antithyroid therapy. Findings in patients were compared at presentation, and after 3 month of treatment. All had undergone a structured cardiovascular history and examination, including measurements of blood pressure (BP) and pulse rate. All had resting 12-lead electrocardiogram and 2D ECHO. RESULTS: Cardiovascular symptoms and signs, as well as abnormal hemodynamic and dysrhythmias, especially supraventricular, were frequent among patients with hyperthyroidism. Palpitation and atrial fibrillation (AF) were more recurrent in overt hyperthyroid subjects than those with subclinical hyperthyroidism and remained more prevalent after 3 month of antithyroid treatment in that subject who had persistently high serum T3 and T4 level. CONCLUSION: Cardiovascular abnormalities are one of the most common presentations in patients with hyperthyroidism and they respond very well to treatment before the structural changes occur in the cardiovascular system.

Comparison of Rifaximin Plus Lactulose with the Lactulose Alone for the Treatment of Hepatic Encephalopathy.

INTRODUCTION: Hepatic encephalopathy is challenging complication of liver dysfunction. Therapeutic treatment options for hepatic encephalopathy are currently limited and have appreciable risks and benefits associated with their use. Rifaximin is a novel anti microbiological agent with wide spectrum of activity that has shown promise as an alternative option for hepatic encephalopathy. AIMS AND OBJECTIVE: The present study was undertaken to compare the effectiveness of Rifaximin and Lactulose as a combination vs Lactulose alone, to compare the adverse effects and to study the rapidity of therapeutic effects of Rifaximin and Lactulose. METHODS: It was a prospective observational study. 60 patients suffering from hepatic encephalopathy (HE) were studied. Patients were investigated and treated as per treating physician's decision. At the time of analysis, patients were divided into 2 groups, Rifaximin group who received Rifaximin+Lactulose (R+L) and Lactulose group(L), who received Lactulose only. Parameters such as mental status grade, Asterixis grade, Serum Ammonia grade, Number Connection Test grade (NCT grade), Hepatic Encephalopathy Index (HE index) were evaluated and compared in both groups. Clinical efficacy was determined using HE index improvement. Primary end points were decrease in HE index and reversal of HE grades. Secondary end points were mortality from HE or any other cause, decrease in mental status grade, asterixis grade, serum Ammonia grade, NCT grade. RESULTS: Out of 60 patients, 32 received Rifaximin+Lactulose combination and 28 patients received Lactulose alone. Mean Child-Turcotte-Pugh score (CTP score) was 10.6 in R+L group and 10.32 in L group. There was statistically significant improvement in mental status grade, Asterixis grade, Serum Ammonia grade, NCT grade, Hepatic encephalopathy index in both groups, p value <0.05 but no statistically significant difference between improvement in mental status grade, Asterixis grade, Serum Ammonia grade, NCT grade, HE index between the two groups. Rifaximin + Lactulose combination was effective in 31 out of 32 i.e.96.87% and Lactulose alone in 24 out of 28 patients, i.e. in 85.71%, which is not statistically different, p=0.3251. DISCUSSION: Rifaximin+ Lactulose combination is not superior to Lactulose alone in treatment of refractory hepatic encephalopathy. Addition of Rifaximin may help in the treatment of refractory hepatic encephalopathy. CONCLUSIONS: Rifaximin + Lactulose combination is effective, but not superior to Lactulose alone in treatment of hepatic encephalopathy.

Artery of Percheron Infarction in a Patient with Atrial Fibrillation: A Rare Stroke Syndrome.

The artery of Percheron uncommon anatomic variant that provides bilateral arterial supply to the paramedian thalami and the rostral midbrain. Occlusion of this artery results in bilateral thalamic and mesencephalic infarctions. The clinical diagnosis is difficult because of the large clinical variability. We report the clinical and MR imaging findings in a patient who developed infarction in the typical distribution of the artery of Percheron.

Congenital Adrenal Hyperplasia with 11-Beta Hydroxylase Deficiency with Testicular Adrenal Rest Tumour.

Congenital adrenal hyperplasia refers to the non-malignant enlargement of adrenal gland tissue as a result of deficiency of one of several enzymes involved in adrenal hormone synthesis, secondary to a genetic mutation. 11 - Beta hydroxylase is one such enzyme, and its deficiency is a rare cause of Congenital Adrenal Hyperplasia. We describe the case of an 18-year old man who presented to us with an acute right ganglio-capsular bleed, hypertension and bilateral scrotal swelling. Investigations revealed hypokalemia, and normal renal and cardiac functions. Furthermore, sex hormone levels were found to be markedly raised, and Renin to Aldosterone ratio was also deranged. CT imaging of the adrenals confirmed hyperplasia, and ultrasound of the testes confirmed Testicular Adrenal Rest tumour, a rare finding. His condition improved significantly with treatment, and he is currently undergoing physical and occupational rehabilitation. Our case highlights the importance of evaluation of hypertension in young patients and a high degree of suspicion for rarer causes.

Evaluation of the Association between CD4, CD8 and CD25 Cell Counts and SLE in Active Disease and in Remission.

AIM: To evaluate the correlation between the levels of CD4, CD8 and CD25 cells and SLE disease in active phase and in remission. METHODS: A total of 25 SLE patients, aged between 18-60 years, and fulfilling the ACR criteria with preferential Renal and CNS involvement were included in this study. Baseline CD4/CD8 and CD25 counts, lab parameters etc were conducted. Approximately at the end of 6 months with the settlement of the disease activity blood sample was drawn for the CD4, CD8 and CD25 counts and other lab parameters. RESULTS: ESR showed a statistical significant decrease while the SLEDAI score and proteinuria showed a decreasing trend as the patients underwent remission. The C3 showed an increasing trend, while the C4 showed more or less a stable pattern. Rise in %CD4 and %CD25 count was statistically significant. There was negative correlation between % CD4 count and SLEDAI score, while positive correlation between % CD25 count and SLEDAI score. CONCLUSIONS: %CD4 count is a sensitive, specific, reliable and valid marker of active disease in SLE and can be used to follow disease activity. %CD25 count can also be used as a marker to follow disease activity.

Oculo-otological Manifestations in a Case of Granulomatosis with Polyangiitis.

A 44 year old lady presented with acute onset of loss of vision in the right eye and cough with mucopurulent expectoration for two months. Ophthalmic examination revealed central retinal artery occlusion (CRAO). Chest radiograph showed multiple cavitatory nodules with fluid levels. Sputum was negative for AFB and ANCA was strongly positive suggestive of a diagnosis of Granulomatosis with Polyangiitis (GPA). Within the next few weeks the patient had rapid detenoration due to left eye CRAO, progressive bilateral hearing loss, facial palsy and retro orbital mass. The aggressive disease responded well to steroids and cyclophosphamide.

Recurrent Seizures Due to Pancreatic Insulinoma.

We present the case of a 70 year old man who was admitted with history of generalized tonic clonic seizures on and off since 6 years in spite of being on regular therapy with anticonvulsants. Patient was found to have hypoglycemia and was evaluated for same. He was diagnosed to have endogenous hyperinsulinemia due to pancreatic insulinoma. Patient underwent enucleation of tumor and was relieved of his symptoms.

A case report of hemophagocytic lymphohistiocytosis (HLH).

Hemophagocytic lymphohistiocytosis (HLH), is an uncommon, life-threatening hyperinflammatory syndrome caused by severe hypercytokinemia with excessive activation of lymphocytes and macrophages due to a highly stimulated but ineffective immune process. We report a case of Hemophagocytic Lymphohistiocytosis in a 15 year old boy presenting with fever, lymphadenopathy and pancytopenia due to infection caused by Klebsiella Pneumoniae and Acinetobacter.

Rickettsial fever presenting with isolated third nerve palsy.

Rickettsial fevers are known to have neurological involvement, mostly in the form of meningoencephalitis. Focal neurodeficits, including isolated cranial nerve palsies have been rarely reported. We hereby report a case of a 25 year old man who presented to us with high grade fever caused by rickettsia and left sided partial third cranial nerve palsy. He responded to doxycycline.

Disseminated melioidosis presenting as septic arthritis.

Melioidosis is an infection caused by Burkholderia pseudomallei. The disease is known as a remarkable imitator due to the wide and variable clinical spectrum of its manifestations. Septic arthritis is rare but well-recognized manifestation of this disease. We report a case of melioidosis in a 52 year male with uncontrolled diabetes mellitus (DM) presenting with a rare combination of septic arthritis and abscesses in the chest wall, liver and subcutaneous tissue. The patient responded to prolonged treatment of intravenous ceftazidime followed by oral co-trimoxazole.

A prospective observational study to assess quality of life and prescription pattern in osteoarthritis patients at tertiary health centre in Mumbai.

BACKGROUND: Osteoarthritis (OA) is a major cause of disability and is focused in "Bone and Joint Decade" declared by WHO which substantially affect different dimensions of quality of life. The aim of present study was to find the disease pattern in OA patients, monitoring prescription pattern to assess prognosis of osteoarthritis by WOMAC index. MATERIALS AND METHODS: An observational study on prospective data collected for the evaluation of Quality of Life (QOL) in OA was conducted at tertiary health care centre in Mumbai. Patients with a diagnosis of OA were enrolled. The patient's history and clinical examination was based on classification criteria of the American College of Rheumatology; drugs prescribed were noted on case record form. Same procedure was carried out for the first and second follow-ups at 6 th and 12 th weeks respectively. RESULTS: The patients belong to primary OA (84%) as compared to secondary OA (16%). Females (70.56% and 10%) were affected more commonly than males (13.44% and 6%). Knee Joint was worst affected in 76%, followed by hip joint in 16% and shoulder, ankle, wrist, elbow joint each having 2% (n=1) involvement. NSAIDs continued to dominate prescriptions given to 84% of patients followed by antiarthritic drugs and calcium supplements in 54% cases. The WOMAC score was higher in most of patients. After medication hydroxy chloroquine sulfate has shown maximum reduction in average WOMAC sore followed by paracetamol, indomethacin and diclofenac sodium. CONCLUSION: Osteoarthritis has a significant impact on quality of life, only partly ameliorated by anti-arthritic drugs, as assessed by the WOMAC scale in this study population. Further, a study with larger sample size is needed to further support our findings.

Mycotic aneurysm of the popliteal artery due to infective endocarditis.

Mycotic aneurysm (MA) is an infrequent complication of infective endocarditis (IE), reported in 3 to 15% of the patients with IE. The commonest site for such aneurysm is intracranial vessels (65%) followed by abdominal and then the peripheral vessels. We describe a case of 32 year old man with recently diagnosed rheumatic heart disease and mitral regurgitation. He had infective endocarditis (IE) and developed a large mycotic popliteal artery aneurysm (MPAA) and a small profunda femoris arterial aneurysm (PFAA) while he was on antibiotic therapy. The patient was successfully treated with prolonged antibiotic therapy and embolisation of the MPAA while PFAA was managed conservatively.