Association of C-peptide level with peripheral neuropathy in type 2 diabetes: An observational cross-sectional preliminary study.

BACKROUND AND AIMS: Peripheral neuropathy is the most common microvascular complication of diabetes mellitus. In subjects with type 1 diabetes (T1D) relationship of C-peptide levels and neuropathy has been observed in several studies, however, there are very few studies in type 2 diabetes (T2D) subjects. In this study we aim to assess the association of C-peptide levels with peripheral neuropathy in Indian subjects with T2D. METHOD: One hundred patients of T2D were included in this study. Clinical and laboratory parameter was assessed for all participants. The C-peptide level was measured by fluorometric enzyme immunoassay method. Assessment of diabetic peripheral neuropathy was based on diabetic neuropathy symptom score and the diabetic neuropathy examination scores. RESULTS: Total 100 patients completed the study. Mean age of subjects was 60.03 years and male: female ratio was 1.17. Peripheral neuropathy was detected in 47% of subjects evaluated. Subjects were further divided in to neuropathy group and no-neuropathy group for analysis. Age in neuropathy group was significantly higher than no-neuropathy group [65.62 ± 10.5 vs 55.08 ± 9.41 yrs (p-value <0.0001)] and similarly duration of T2D was significantly higher in neuropathy group [10.11 ± 6.13 vs 4.16 ± 3.7 yrs (p-value <0.0001)]. Importantly mean fasting C-peptide (2.27 ± 0.98 vs 3.12 ± 0.84 ng/ml) and mean post meal C-peptide (4.27 ± 1.34 vs 5.33 ± 0.89 ng/ml) were significantly lower in neuropathy group compared to no-neuropathy group. An association of HbA1c level and neuropathy was statistically not significant (p = 0.793). CONCLUSION: Serum C-peptide concentrations are associated with peripheral neuropathy in T2DM patients, independent of the degree of glycemic control.

Severe Thrombocytopenia in Dengue Fever and Vitamin B12 Level.

OBJECTIVE: To document correlation between vitamin B12 deficiency and severity of thrombocytopenia, platelate recovery and duration of hospital stay in dengue fever patients. METHODS: This prospective observationl study was done in dengue fever patient with severe prolonged thrombocytopenia (<20,000 µl and > 2 days duration). Patient with underlying malignancy, hematological disorders, septicemia, or use of any drug which may cause thrombocytopenia, were excluded. Standard statistical methods were used. RESULTS: Total 40 subjects were included in current study. Twenty one were male and mean age was 25±12 years. Forty percent sujects were having B12 level < 200 pg/L and mean B12 level was 336.9±362.36 pg/L. SDP requirement was highest in B12<100 pg/L group was (3±1.41) as compmared to other groups Time required for recovery of platelates to 20000/µl thresold, was also highest in B12<100 pg/L group (5.75±0.95days) as compmared to other groups. Duration of hospital stay was also highest in B12<100 pg/L group (5.25±1.25days) as compmared to other groups. There was no relation between B12 levels and other complications of dengue like bleeding, serositis, and shock. CONCLUSION: Our study suggests that B12 deficiency may responsible for severe thrombocytopenia; slower platelates count recovery and prolonged hospitalisation in dengue fever patients.

Predictive prognostic value of neutrophil-lymphocytes ratio in acute coronary syndrome.

OBJECTIVE: To assess the relationship between neutrophil-lymphocytes ratio (NLR) at admission and patient outcome over a period of six month in subjects with acute coronary syndrome (ACS). METHODS: A total of 435 consecutive patients presenting with ACS were enrolled and 400 patients completed the study. Patients were categorized into 2 groups: the NLR group 1 (NLR≤5.25; n=265, 66.25%) and the NLR group 2 (NLR>5.25; n=135, 33.75%). The primary outcomes were in-hospital and 6 months mortality. RESULTS: Forty-seven (11.8%) patients died during 6 months follow up. Higher mortality was seen in NLR group 2 (42/135, 34.1%) compared to NLR group 1 (5/265, 1.9%) with p value <0.001. CONCLUSION: Our study suggest that elevated NLR (>5.25) is independently associated with higher all-cause mortality rate up to 6 months period irrespective of ACS type.

Aconite poisoning with arrhythmia and shock.

A 55-year-old male presented with history of nausea, vomiting, palpitation paresthesis and profuse sweating in emergency department 2h after ingestion of "Bachnaag" (Aconite) root. Examination revealed shock with irregular pulses. Initial ECG showed frequent multifocal ventricular ectopics (VE), which later turned to short runs of ventricular tachycardia (VT). Immediate gastric lavage was done and activated charcoal given. Patient was treated with fluid resuscitation without any improvement in blood pressure. Patient was started on nor-adrenaline infusion with gradual recovery from hypotension over a period of 6h, but support was continued for 48h. Amiodarone was started to control ventricular excitability, which persisted over 72h with gradual decrease in frequency of VT and VE. Patient was discharged with normal sinus rhythm on oral amiodarone on 5th day of hospitalization. On follow-up after 2 weeks patient was totally asymptomatic and amiodarone was stopped.

A Case of Autoimmune Polyglandular Syndrome (APS) Type II with Hypothyroidism, Hypoadrenalism, and Celiac Disease - A Rare Combination.

Autoimmune Polyglandular syndrome (APS) are rare condition characterised by presence of immune dysfunction of two or more endocrine glands and other non-endocrine organs. APS is divided into 2 major subtypes based on age of presentation, pattern of disease combinations and mode of inheritance. APS 1(juvenile) usually manifest in early adolescence or in infancy. It is characterised by multiple endocrinal deficiency with mucocutaneous candidiasis and ectodermal dystrophy. Of the endocrine diseases, hypoparathyroidism form an important component followed by Addison's disease, type 1A diabetes, hypogonadism and thyroid disease. On the other hand APS II usually manifest in 3rd or 4th decade of life with female preponderance. Endocrine diseases commonly include autoimmune thyroid disease (graves or autoimmune thyroiditis), type 1A diabetes, and Addison's disease. Hypoparathyroidism is of rare occurrence and there is no mucocutaneous candidiasis. We report here a case of APS type II in a 29-year-old male who initially presented with hypothyroidism, which was soon followed by Addison's disease. The involvement of thyroid gland preceding the involvement of adrenal is of rare occurrence. The patient also had celiac disease which makes the combination further uncommon.

Acute hepatitis after starting pinaverium bromide in a patient taking mirtazapine.

A 56-year-old man presented with chronic abdominal pain. He had been evaluated extensively in the recent past undergoing upper gastrointestinal endoscopy, colonoscopy and CT scan of the abdomen with normal results. The provisional diagnosis of irritable bowel syndrome was performed and pinaverium bromide was started. The patient had pre-existing hypertension, a major depressive disorder and gastro-oesophageal reflux disease. He had been taking nebivolol and pantoprazole for several years and mirtazapine for the last 1 year. The patient developed nausea, vomiting and anorexia after 5 days of starting pinaverium bromide. Investigations revealed marked elevation of liver enzymes and bilirubin. He was negative for HIV, HBSAg, anti-hepatitis C virus, IgM for hepatitis A virus, hepatitis E virus, antinuclear antibody and antimitochondrial antibody. An ultrasound showed mild hepatomegaly with hypoechoic echo texture; the rest of scan was normal. Pinaverium and mirtazapine were stopped immediately. The patient was treated symptomatically and his liver profile returned to normal after 4 weeks.

Peripheral embolisation after an abdominal massage.

A 65-year-old man presented with a history of acute onset pain in toes of the right foot immediately after an abdominal massage by a 'local healer'. General physical examination and systemic examination were normal except for discolouration of the fourth and fifth toes and cold toes. Investigations including complete blood count, erythrocyte sedimentation rate, renal function tests, liver profile, lipid profile, antinuclear antibody, antineutrophil cytoplasmic antibody, ECG, chest X-ray, ultrasound abdomen, cardiac echocardiography, lower limb Doppler and CT scan of the abdomen were normal. The patient was treated with regular heparin infusion, aspirin and tramadol. Recovery was complete in 5 days.

Lower extremity deep vein thrombosis after heavy exertion.

A young woman leading a sedentary life, travelled on foot for a distance of 25 km in a day. The following day she noticed pain and swelling of left foot and left leg. She got no relief with analgesics and her orthopaedic evaluation was normal. Her clinical examination was normal except for local swelling, oedema and tender calf. Her haematological and biochemical examination was normal except for mild elevation of creatine phosphokinase. A Doppler ultrasound revealed the thrombosis of anterior tibial vein and popliteal vein.

A randomized, comparative, multicentric clinical trial to assess the efficacy and safety of zileuton extended-release tablets with montelukast sodium tablets in patients suffering from chronic persistent asthma.

Leukotriene (LT) modifiers are anti-inflammatory drugs that are useful as an add-on therapy with first-line asthma-controller medications. This group includes LT synthesis inhibitors (eg, Zileuton) and receptor antagonists (eg, Montelukast), whose direct comparative clinical data are not available. This study was conducted to assess the comparative efficacy and safety of orally administered Zileuton extended-release (ER) with Montelukast sodium in patients suffering from chronic persistent asthma. Patients of 18-65 years of age with mild to moderate chronic stable asthma were randomized to treatment with Zileuton ER 2400 mg/d or Montelukast 10 mg/d for 12 weeks. Peak expiratory flow rate (PEFR) and asthma symptoms (cough, wheeze, chest tightness, and shortness of breath each on a 4-point scale) were assessed on monthly scheduled out-patient visits. Safety assessments by clinical and laboratory parameters were carried out during the course of the study. Among 210 patients eligible for efficacy assessment, PEFR improved by 64.8 ± 52.8 (95% confidence interval: 54.8-74.7) L/min with Zileuton ER (n = 109) and 40.6 ± 47.5 (31.3-49.9) L/min with Montelukast (n = 101; P < 0.001), whereas percent improvements were 27.0% (22.6%-31.5%) versus 18.4% (14.1%-22.7%), respectively (P = 0.006). Zileuton ER lead to ≥12% PEFR improvements in 74 of 109 [67.9% (59.1%-76.7%)] patients, whereas the same was noted in 52 of 101 [51.5% (41.7%-61.2%)] patients receiving Montelukast (P = 0.015). The reduction in the mean overall symptom intensity score was also significantly better with Zileuton ER [-5.0 ± 2.1 (4.6-5.4) versus -4.2 ± 2.3 (3.8-4.7)] (P = 0.018); however, the same was not observed for the decline in the individual symptom scores. A lesser but not significantly different adverse event rate was reported in the Zileuton ER group than the Montelukast group with the commonest events being headache and gastrointestinal effects in both the groups. Thus, Zileuton ER seems to be more efficacious than Montelukast and well tolerated for the treatment of mild to moderate chronic persistent asthma in adult patient population. Further studies can elucidate the comparative treatment benefits of these LT modifiers in asthma management.