Clinical profile of patients and sensitivity of troponin I in patients with and without acute coronary syndrome: An observational study.

Background Various clinical conditions can cause troponin elevation in the absence of myocardial ischaemia. Elevated troponin represents the likely occurrence of myocardial necrosis and does not itself provide any indication of the aetiology. Identifying the cause for troponin elevation and its sensitivity and specificity in predicting acute coronary syndrome (ACS) and cardiac mortality is an important step in determining the optimal management for these patients. Methods We retrospectively collected data of inpatients who had troponin I (TnI) testing as part of their clinical assessment, either in the emergency department, medical wards, coronary care unit (CCU) or intensive care unit (ICU) with their final diagnosis. TnI was used as the index test of sensitivity to diagnose ACS and either echocardiography or coronary angiogram in those available as the reference gold standard. They were classified into two groups of normal and elevated TnI, and further divided into those with ACS and no ACS. Data on clinical parameters and aetiology of elevated TnI in patients without ACS were analysed. Results Of the 254 patients studied, 114 patients (45%) had normal TnI and 140 (55%) had elevated TnI. Seventy-eight patients had ACS, 66 (84.6%) of whom had elevated TnI and 12 (15.38%) had normal TnI. Seventy-four (52.85%) of 140 patients with elevated TnI had alternate causes of TnI elevation; the most common being sepsis, acute kidney injury (AKI) and heart failure without ACS. All-cause mortality was significantly higher in patients with elevated TnI with or without ACS. There was no cardiac mortality among patients with ACS with normal TnI. Sensitivity and specificity of TnI for predicting ACS was 84.6% (95% CI 74.7%-91.8%) and 58% (95% CI 50.3%-65.3%), respectively. Conclusion A variety of conditions apart from myocardial infarction can lead to elevated TnI. Hence, caution should be exercised while diagnosing a patient with ACS based on TnI value in the absence of other supporting evidence given its low specificity. Elevated TnI portends a worse prognosis regardless of the aetiology and has a role in predicting all-cause and cardiac mortality.

Usability and feasibility assessment of a smartphone application (Suhriday) for heart failure self-care remote monitoring in an Indian tertiary health care setting: a pilot mixed-methods study.

BACKGROUND/OBJECTIVES: Remote monitoring as a component of chronic heart failure (CHF) management programmes has demonstrated utility in reducing the risk of rehospitalisation and mortality. There is little evidence on mobile health app facilitated remote monitoring in India. We conducted a pilot usability and feasibility assessment of a smartphone-based application (Suhriday) to remotely monitor patients with CHF. METHODS: We used a mixed-methods design. Usability testing consisted of the think-aloud approach followed by semistructured in-depth interviews (SSIs) and a satisfaction questionnaire. Feasibility testing was done using acceptability and user satisfaction questionnaires in addition to SSIs. We trained five purposively sampled patients with CHF (based on health literacy and gender) and their caregivers (n=10) in self-care monitoring and app use. Usability was assessed using metrics such as task completion, time required for task completion and user satisfaction using Brooke's System Usability Scale (SUS). Content analysis of the transcripts with deductive coding was performed for both usability and feasibility interviews. The number and types of medical alerts transmitted through the app were captured and escalated to the treating team. RESULTS: Critical tasks involving (1) opening the app and identifying task list, (2) reporting blood pressure, weight, heart rate and fluid intake and (3) reporting symptoms were completed within 60 s by four patients. Median (IQR) SUS score was 85 (75-92.5) indicating high level of usability. There were 62 alerts from four patients over 4 weeks, with 36 (58.1%) excess fluid intake alerts and 16 (25.8%) blood pressure variations being the most frequent. One participant had challenges using the app and was monitored through active phone calls. CONCLUSION: Overall usability and satisfaction with Suhriday were good and we were able to remotely manage patients. However, patients with limited health literacy and those facing technological challenges required active structured telephone support.

Dengue and HELLP: Beware of the Masquerade.

HELLP is a syndrome characterized by hemolysis, elevated liver enzymes, and low platelets. It is a rare complication of pregnancy and is usually associated with pre-eclampsia. However, 10-20% cases of HELLP can present without hypertension. Dengue fever is an arboviral-borne tropical illness that is characterized with fever, thrombocytopenia, and bleeding manifestations. We present a case of a primigravida with HELLP syndrome masquerading in the background of dengue fever. Unique features to this case report include delayed presentation of HELLP syndrome with normotension which can have overlapping features with dengue fever, especially in term pregnancy. This case highlights the need of strict vigilance in cases of dengue fever with pregnancy. How to cite this article: Patnaik R, Kulkarni S, Karan N. Dengue and HELLP: Beware of the Masquerade. Indian J Crit Care Med 2022;26(5):639-640.

Diabetic Nephropathy and Proton Pump Inhibitors - Pilot Case-Control Study.

Introduction: Proton pump inhibitors (PPIs) are liberally used over the counter medication and is largely considered safe. Off late, there are many reports that suggest increased incidence of chronic kidney disease with long-term PPI use. PPIs are often prescribed in patients with diabetes mellitus (DM) and one of the well-known complications of DM is diabetic nephropathy (DN). Thus, the aim of our study was to evaluate association between PPI use and DN. Methods: It was a case-control study conducted over a 2-year period (April 2017-March 2019). Cases were outpatients with type II DM and associated DN. Controls were age and sex-matched type II DM without DN. Results: A total of 200 participants, 100 each in the case and control group, were recruited. The proportion of participants using PPI was 62% in the cases and 42% in the controls (P = 0.005). The most common PPI used was pantoprazole. Increased duration of PPI use was significantly associated with DN [adjusted odds ratio: 1.171; 95% confidence interval: 1.022, 1.341; P = 0.023]. Conclusion: There is a significant association between the use of PPIs and DN in patients with type II DM. Since PPIs have other beneficial effects in patients with DM such as glycaemic control and relief from gastro-oesophageal symptoms, need for risk benefit assessment for long-term use of PPIs in DM is warranted.

Combination chemotherapy versus temozolomide for patients with methylated MGMT (m-MGMT) glioblastoma: results of computational biological modeling to predict the magnitude of treatment benefit.

BACKGROUND: A randomized trial in glioblastoma patients with methylated-MGMT (m-MGMT) found an improvement in median survival of 16.7 months for combination therapy with temozolomide (TMZ) and lomustine, however the approach remains controversial and relatively under-utilized. Therefore, we sought to determine whether comprehensive genomic analysis can predict which patients would derive large, intermediate, or negligible benefits from the combination compared to single agent chemotherapy. METHODS: Comprehensive genomic information from 274 newly diagnosed patients with methylated-MGMT glioblastoma (GBM) was downloaded from TCGA. Mutation and copy number changes were input into a computational biologic model to create an avatar of disease behavior and the malignant phenotypes representing hallmark behavior of cancers. In silico responses to TMZ, lomustine, and combination treatment were biosimulated. Efficacy scores representing the effect of treatment for each treatment strategy were generated and compared to each other to ascertain the differential benefit in drug response. RESULTS: Differential benefits for each drug were identified, including strong, modest-intermediate, negligible, and deleterious (harmful) effects for subgroups of patients. Similarly, the benefits of combination therapy ranged from synergy, little or negligible benefit, and deleterious effects compared to single agent approaches. CONCLUSIONS: The benefit of combination chemotherapy is predicted to vary widely in the population. Biosimulation appears to be a useful tool to address the disease heterogeneity, drug response, and the relevance of particular clinical trials observations to individual patients. Biosimulation has potential to spare some patients the experience of over-treatment while identifying patients uniquely situated to benefit from combination treatment. Validation of this new artificial intelligence tool is needed.

A qualitative, grounded theory exploration of the determinants of self-care behavior among Indian patients with a lived experience of chronic heart failure.

BACKGROUND: Prior reports have documented extremely poor adherence to evidence-based medications among South Asian patients with established chronic cardiovascular diseases. Treatment adherence is now considered a part of the 'self-care' process, the determinants of which have not been adequately explored or explained among South Asian patients with chronic heart failure (CHF). Our objective was to qualitatively ascertain the determinants of the self-care process among Indian patients with a lived experience of heart failure. METHODS: We conducted in-depth interviews (audio-recorded) among 22 purposively sampled patients living with chronic heart failure, diagnosed at least 4 weeks prior to the interview and 17 caregivers (n = 39) in a tertiary care teaching hospital in Southern India. We employed an inductive analytical approach using Charmaz's constructivist grounded theory. Initial line-by-line coding and categorization was followed by memo writing, reflexive analysis after interviewing and analyzing four, eight and twelve patients, and at each stage further theoretical sampling was carried out until we reached thematic saturation. We used NVivo ver. 12 to analyze and organize data. RESULTS: The mean age of our patients was 61 years and they represented 5 Indian states and spoke seven languages, distributed across socio-economic strata and literacy levels. We classified self-care determinants into 3 broad, simple categories and defined underlying themes namely, negative determinants (passivity, entrenched beliefs, negative affect, lack of knowledge, financial difficulties, and fatalism), intermediate factors (patient expectations, provider/hospital hopping) and facilitators or positive self-care determinants (intrinsic and extrinsic facilitators). Gender and the cultural background of patients' upbringing appear to shape these determinants, thereby affecting self-care decision making in chronic heart failure. CONCLUSION: We have empirically described a unique set of self-care determinants among Indian chronic heart failure patients, which in turn are shaped by economic and socio-cultural factors. Assessing for and addressing these determinants during clinical interactions through multi-factorial approaches may help improve self-care among Indian CHF patients, thus improving treatment adherence and clinical outcomes.

Effect of intensive lifestyle modification & metformin on cardiovascular risk in prediabetes: A pilot randomized control trial.

BACKGROUND & OBJECTIVES: Prediabetes is associated with increased prevalence of cardiovascular disease (CVD). In participants with prediabetes, the effects of exercise and metformin were evaluated on high-sensitivity C-reactive protein (hsCRP) and carotid intima-media thickness (CIMT), surrogate markers of atherosclerosis and CVD compared with standard care. METHODS: In a pilot randomized control trial, the participants were randomized in to three arms: standard care (STD), intensive lifestyle modification (ILSM) or ILSM and metformin (ILSM+Met) and followed up for six months. Monitoring of ILSM was done by a trained healthcare facilitator. hsCRP, CIMT and other relevant parameters were measured before and after intervention. RESULTS: A total of 103 participants were randomized into three arms and followed up for six months. At six months, there was a reduction from baseline in weight and fasting blood sugar (FBS) (P <0.01) in all three arms and a reduction in haemoglobin A1c (P =0.03) only in the ILSM+Met arm. The differences in hsCRP over six months within the STD, ILSM and ILSM+Met arms were -0.12 (95% confidence interval, -1.81, 2.08), -0.58 (-2.64, 0.43) and -0.11 (-1.84, 1.56), respectively. There was no difference in hsCRP, CIMT (right) or CIMT (left) between the three arms at six months. INTERPRETATION & CONCLUSIONS: There was a reduction in weight and FBS from baseline in all three arms. There was, however, no difference seen in hsCRP and CIMT in the two intervention arms compared to standard care. Larger studies with long-term follow up need to be done to detect differences in risk markers for CVD in prediabetes.

Secondary metabolites extracted from marine sponge associated Comamonas testosteroni and Citrobacter freundii as potential antimicrobials against MDR pathogens and hypothetical leads for VP40 matrix protein of Ebola virus: an in vitro and in silico investigation.

The current study explores therapeutic potential of metabolites extracted from marine sponge (Cliona sp.)-associated bacteria against MDR pathogens and predicts the binding prospective of probable lead molecules against VP40 target of Ebola virus. The metabolite-producing bacteria were characterized by agar overlay assay and as per the protocols in Bergey's manual of determinative bacteriology. The antibacterial activities of extracted metabolites were tested against clinical pathogens by well-diffusion assay. The selected metabolite producers were characterized by 16S rDNA sequencing. Chemical screening and Fourier Transform Infrared (FTIR) analysis for selected compounds were performed. The probable lead molecules present in the metabolites were hypothesized based on proximate analysis, FTIR data, and literature survey. The drug-like properties and binding potential of lead molecules against VP40 target of Ebola virus were hypothesized by computational virtual screening and molecular docking. The current study demonstrated that clear zones around bacterial colonies in agar overlay assay. Antibiotic sensitivity profiling demonstrated that the clinical isolates were multi-drug resistant, however; most of them showed sensitivity to secondary metabolites (MIC-15 µl/well). The proximate and FTIR analysis suggested that probable metabolites belonged to alkaloids with O-H, C-H, C=O, and N-H groups. 16S rDNA characterization of selected metabolite producers demonstrated that 96% and 99% sequence identity to Comamonas testosteroni and Citrobacter freundii, respectively. The docking studies suggested that molecules such as Gymnastatin, Sorbicillactone, Marizomib, and Daryamide can designed as probable lead candidates against VP40 target of Ebola virus.

Vitamin D Supplementation in Adults with Vitamin D Deficiency and Its Effect on Metabolic Syndrome - A Randomized Controlled Study.

BACKGROUND: Inverse relationship between metabolic syndrome (MetS) and 25-hydroxyvitamin D (25(OH) D) levels is controversial. Hypovitaminosis-D has long been suspected as a risk factor for glucose intolerance. AIM: A randomized double blind placebo controlled study to evaluate effects of vitamin D supplementation on insulin resistance in subjects with hypovitaminosis-D and MetS. MATERIALS AND METHODS: Subjects were randomized to receive either oral 25(OH) D3 supplement (60000 (IU) per week for 8 weeks followed by 60,000 IU monthly for 4 months) or a placebo for six months. The parameters measured were blood pressure, vitamin D, fasting blood sugar (FBS), insulin, homeostasis model assessment (HOMA), quantitative insulin sensitivity check index (QUICKI), body mass index (BMI), and waist circumference (WC). RESULTS: There were no significant changes in parameters of vitamin-D group compared to placebo group except serum vitamin-D was significantly increased in vitamin-D group (p < 0.0001). In vitamin-D group, mean WC at baseline was 95.9 ± 6.66, which significantly changed to 94.6 ± 7.47 (p = 0.001). Mean BMI at baseline was 29.1 ± 4.06 which significantly changed to 28.5 ± 4.16 (p = 0.001). The mean vitamin-D concentration at baseline was 15.4 ± 9.03 which significantly (p < .0001) increased to 26.1 ± 11.8. In placebo group mean insulin levels was 10.7 ± 4.81IU / L which increased significantly (p = 0.03) to 15.4 ± 14.0. Mean QUICKI at baseline was 0.34 ± 0.03 which decreased significantly (p = 0.02) to 0.32 ± 0.03. CONCLUSION: In this study the relationship between vitamin D supplementation and MetS or IR was not established. Whether achieving vitamin D sufficiency in large population-based trials with a longer duration would produce more favorable results needs to be assessed.

Markers of renal function tests.

BACKGROUND: The markers of renal function test assess the normal functioning of kidneys. These markers may be radioactive and non radioactive. They indicate the glomerular filtration rate, concentrating and diluting capacity of kidneys (tubular function). If there is an increase or decrease in the valves of these markers it indicates dysfunction of kidney. AIM: The aim of this review is to compare and analyze the present and newer markers of renal function tests which help in diagnosis of clinical disorders. MATERIAL #ENTITYSTARTX00026; METHODS: An extensive literature survey was done aiming to compare and compile renal function tests makers required in diagnosis of diseases. RESULTS: Creatinine, urea, uric acid and electrolytes are makers for routine analysis whereas several studies have confirmed and consolidated the usefulness of markers such as cystatin C and ß-Trace Protein. CONCLUSION: We conclude that further investigation is necessary to define these biomarkers in terms of usefulness in assessing renal function.

A review on laboratory liver function tests.

Laboratory liver tests are broadly defined as tests useful in the evaluation and treatment of patients with hepatic dysfunction. The liver carries out metabolism of carbohydrate, protein and fats. Some of the enzymes and the end products of the metabolic pathway which are very sensitive for the abnormality occurred may be considered as biochemical marker of liver dysfunction. Some of the biochemical markers such as serum bilirubin, alanine amino transferase, aspartate amino transferase, ratio of aminotransferases, alkaline phosphatase, gamma glutamyl transferase, 5' nucleotidase, ceruloplasmin, α-fetoprotein are considered in this article. An isolated or conjugated alteration of biochemical markers of liver damage in patients can challenge the clinicians during the diagnosis of disease related to liver directly or with some other organs. The term "liver chemistry tests" is a frequently used but poorly defined phrase that encompasses the numerous serum chemistries that can be assayed to assess hepatic function and/or injury.