Long-Term Persistence of COVID-Induced Hyperglycemia: A Cohort Study.

Although the short-term mortality of patients with COVID-19 infection and hyperglycemia has been well documented, there is little available data regarding longer-term prognosis. The presence of diabetes has not only influenced disease severity but has also impacted its transmission dynamics. In this study, we followed a historical cohort of patients without previous history of diabetes who presented with moderate to severe COVID-19 and were found to have hyperglycemia (random blood glucose > 140 mg/dL) at the time of admission. We evaluated the need for antidiabetic therapy in these patients at the end of 6 months and the risk factors associated with persistent hyperglycemia determined by monthly values of self-monitored blood glucose. Of the seventy participants who were followed telephonically, 54 (77%) continued to receive antidiabetic therapy or have persistent hyperglycemia (> 140 mg/dL) at the end of 6 months. Persistent hyperglycemia at the end of follow-up, was found to be associated with a higher blood glucose at presentation.

High level of psychological stress in COVID-19 recovered individuals: role of copeptin as a potential biomarker.

Background: Study aimed to assess stress in COVID-19 recovered individuals using a validated questionnaire PSS-10 score and stress biomarkers - salivary cortisol and serum copeptin. Methods: A total of 83 subjects of which 54 subjects (66.3%) who were hospitalized were recruited 8-20 weeks following recovery from COVID-19. Stress was assessed by PSS-10 stress-scale after a mean duration of 14.5 weeks after recovery. Sixty-eight subjects (81.9%) had new or persistent symptoms after recovery. Subjects were divided into two groups on the basis of PSS score; mild stress (PSS:0-13) and moderate to severe stress (PSS:>14) and levels of biomarkers (serum copeptin, DHEAS and salivary cortisol) were compared in the two groups. Results: Forty-four subjects (53%) had moderate to severe stress and 39 subjects (47%) had mild stress. Subjects with post COVID symptoms had significantly higher stress levels as compared to subjects who were asymptomatic [15 vs. 9; p = 0.003]. Serum copeptin levels were significantly higher among subjects with moderate to severe stress as compared to those with mild stress [0.41 vs. 0.67 ng/mL; p = 0.031]. Subjects with moderate to severe stress had higher median salivary cortisol compared to subjects with mild stress [1.03 vs. 1.44 nmol/L; p = 0.448]. Conclusion: Our study demonstrated moderate to severe stress in over half and some level of stress in nearly all COVID recovered individuals even after 3 months. Serum copeptin was found to be a useful biomarker to objectively measure stress in these subjects.

The increasing presence of the internet in the lives of patients and doctors: threat or opportunity?

The conventional sharing of information and education between doctor and patient is no longer what it used to be prior to Dr. Google's entry into the mix with voluminous data, not only transforming but often threatening the patient-doctor relationship. While patients no longer seek basic information from their physicians since they've already consulted Dr. Google, the wise physician accepts that patients are now more aware, more involved in their own care, and more empowered with information. The good old doctor who knew everything is now more a myth that exists largely in folklore. While doctors may be well versed in a variety of fields, they have often narrowed down their areas of specialisation, while they continue to apply what they learn from their daily encounters with patients, establishing a stronger relationship over time. The challenge arises when a patient, having consulted Dr. Google, starts to question their doctor with the little knowledge gained from the internet. Biased opinions based on prior knowledge, have lately placed the doctor-patient relationship in jeopardy.

Isoniazid and rifampicin heteroresistant Mycobacterium tuberculosis isolated from tuberculous meningitis patients in India.

BACKGROUND: Heteroresistant Mycobacterium tuberculosis (mixture of susceptible and resistant subpopulations) is thought to be a preliminary stage to full resistance and timely detection, initiation of correct treatment is vital for successful anti tubercular therapy. The aim of this study was to detect multi drug resistant (MDR) and heteroresistant M. tuberculosis with the associated gene mutations from patients of tuberculous meningitis. METHODS: A total of 197 M. tuberculosis isolates from 478 patients of TBM were isolated from July 2012 to July 2015 and subjected to drug susceptibility testing (DST) by BACTEC MGIT and Genotype MTBDR line probe assay (LPA). Heteroresistance was defined as presence of both WT and mutant genes in LPA. RESULTS: Of 197 M. tuberculosis isolates, 11 (5.6%) were MDR, 23 (11.6%), 1 (0.5%) were mono resistant to isoniazid (INH) and rifampicin (RMP) respectively. Heteroresistance was detected in 8 (4%), 2 (1%) isolates to INH and RMP respectively. INH heteroresistant strains had WT bands with mutation band S315T1 whereas RMP heteroresistant strains had WT bands with mutation band S531L. CONCLUSION: The prevalence of MDR M. tuberculosis was 5.6% in TBM patients with the most common mutation being ΔWT band with S315T1 for INH and ΔWT band with S531T for RMP. MGIT DST was found to be more sensitive for detecting overall resistance in M. tuberculosis but inclusion of LPA not only reduced time for early initiation of appropriate treatment but also enabled detection of heteroresistance in 8 (4%), 2 (1%) isolates for INH and RMP respectively.

Recurrent Hypokalemia leading to Flaccid Quadriparesis: A Renal or Connective Tissue Disorder.

Hypokalemic periodic paralysis (hypoKPP) is a clinical entity characterized by recurrent skeletal muscle paralysis due to a decrease in serum potassium levels; hypoKPP can have either a primary (familial) or a secondary cause. One of the secondary causes of hypoKPP is distal renal tubular acidosis (dRTA). Distal renal tubular acidosis (dRTA) is diagnosed when the urinary pH is greater than 5.3 and in the presence of hyperchloremic metabolic acidosis and hypokalemia, with one of the causes being primary Sjögren's syndrome (pSS). PSS can have both glandular and extra glandular manifestations, with dryness of the eyes and mouth being the most common presenting symptoms. DRTA arising from pSS is very unusual, occurring in fewer than 2% of the cases of Sjogren's syndrome (SS). Here, we report on a case of recurrent flaccid quadriparesis that appears to have been caused by distal RTA, resulting in hypokalemia; upon further investigation and clinical evaluation, the patient was diagnosed with pSS.

Predictors of adverse outcome in patients of tuberculous meningitis in a multi-centric study from India.

INTRODUCTION: This study aimed to investigate the factors which may predict mortality and neurological disability at one year follow up in patients of tuberculous meningitis (TBM) in India. METHODOLOGY: Patients with TBM were prospectively enrolled from July 2012 to September 2014 from four tertiary care hospitals of Delhi. The demographic characteristics, clinical features and laboratory findings were collected and patients were followed up till 1 year. These were analyzed by univariate and multivariate multinomial logistic regression analysis to identify predictors of adverse patient outcome at 1 year follow up. RESULTS: Out of 478 patients enrolled, 391 patients could be followed up to 1 year. Sixty-four patients (16.3%) died and 150 patients (39%) survived with one or more neurological disability. Altered sensorium, motor deficit, cranial nerve palsy, seizures, isolation of M. tuberculosis and presence of multi-drug resistance were independently associated with any adverse outcome (death or disability) but by multivariate analysis only motor deficit, altered sensorium and isolation of M. tuberculosis on culture produced a statistically significant model for prediction of patient outcome. CONCLUSION: The three-predictor model with motor deficit, altered sensorium and isolation of M. tuberculosis produced a statistically significant model with correct prediction rate of 60.4%. These three variables predicted death with odds ratio of 39.2, 6.7 and 2.1 respectively in comparison to recovery whereas only motor deficit and isolation of M. tuberculosis predicted neurological disability at 1 year with odds ratio of 3.9, 2.4 respectively.

Dyslipidaemia & oxidative stress in patients of psoriasis: Emerging cardiovascular risk factors.

BACKGROUND & OBJECTIVES: Psoriasis is a recurrent hyper-proliferative skin disease which is often associated with free radical generation, abnormal lipid metabolism and increased inflammatory secretion that induce cardiovascular risk in these patients. The present study was intended to evaluate serum lipids, lipoprotein and oxidants-antioxidants status and to establish their relationship with atherogenic risk markers [oxidized low-density lipoprotein (oxLDL) and high-sensitivity C-reactive protein (hsCRP)] in patients with psoriasis. METHODS: The study was conducted on 150 psoriasis patients and 150 age- and sex-matched healthy controls. Overnight fasting blood samples were obtained for lipids, lipoproteins, lipid oxidation and peroxidation products [oxLDL, malondialdehyde (MDA)], antioxidant enzymes [reduced glutathione (GSH) and total antioxidant status] levels and hsCRP estimations. RESULTS: The mean levels of atherogenic lipids [total cholesterol (P<0.001), triacylglycerol (P<0.01)], lipid peroxidation products (P<0.001) and oxLDL and hsCRP (P<0.001) levels in patients with psoriasis were found to be significantly higher than those of healthy controls. On the other hand, ferric-reducing ability of plasma (FRAP, P<0.001) and antioxidant enzyme activities (reduced GSH, P<0.01) were significantly lower when compared to healthy controls. The plasma oxLDL was positively correlated to LDL cholesterol (P<0.001) and MDA (P<0.001) and negatively associated with antioxidant status in these patients. Serum MDA, FRAP and oxLDL were correlated with risk of atherosclerosis in the patients with psoriasis; however, no significant association was found between reduced GSH and hsCRP. INTERPRETATION & CONCLUSIONS: The study results suggest that LDL oxidation and reactive oxygen species in addition to inflammatory markers may play a pivotal role in inducing atherosclerosis in patients of psoriasis.

Nonketotic Hyperglycemia Presenting as Monoballism.

BACKGROUND: Monoballismus is rarely seen clinically, but when observed, it is usually a manifestation of an acute cerebrovascular accident (CVA). We report a case of monoballismus observed in a patient without evidence of a CVA. CASE REPORT: We observed a case of monoballismus in a 60-year-old diabetic patient who had not had a stroke. The movement disorder resolved with improvement of the patient's hyperglycemia. Nonketotic hyperglycemia is an uncommon cause of ballismus. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should include the movement disorder of ballismus among the potential clues that a patient may be suffering an acute CVA. However, noncerebrovascular causes of ballismus exist. The movements manifest by a patient with ballismus should also lead the physician to consider the possibility not only of a CVA, but also neuroleptic malignant and serotonin syndromes.

Newer perspectives of coronary artery disease in young.

Coronary artery disease (CAD) occurring in less than 45 years of age is termed as young CAD. Recent studies show a prevalence of 1.2% of CAD cases in this age group. Ethnic wise south Asians especially Indians are more vulnerable to have CAD in young age group with a prevalence of 5% to 10%. Conventional risk factors such as smoking, diabetes, hypertension, obesity and family history seems to be as important as in older CAD subjects. But the prevalence of these risk factors seems to vary in younger subjects. By far the most commonly associated risk factor is smoking in young CAD. Several genes associated with lipoprotein metabolism are now found to be associated with young CAD like cholesterol ester transfer protein (CETP) gene, hepatic lipase gene, lipoprotein lipase gene, apo A1 gene, apo E gene and apo B. Biomarkers such as lipoprotein (a), fibrinogen, D-dimer, serum Wnt, gamma glutamyl transferase, vitamin D2 and osteocalcin are seems to be associated with premature CAD in some newer studies. In general CAD in young has better prognosis than older subjects. In terms of prognosis two risk factors obesity and current smoking are associated with poorer outcomes. Angiographic studies shows predominance of single vessel disease in young CAD patients. Like CAD in older person primary and secondary prevention plays an important role in prevention of new and further coronary events.

Glycated apolipoprotein B-A surrogate marker of subclinical atherosclerosis.

AIMS: Sustained hyperglycemia is a causative factor for glycation of proteins. Glycated low-density lipoprotein (LDL) is strongly associated with an increased risk of CAD (Coronary Artery Disease) in diabetics. Hence, we planned to evaluate the association of glycated apo B with subclinical atherosclerosis. METHOD: Forty-five non obese and 45 obese diabetics were recruited. Glycated hemoglobin (HbA1c) levels were estimated by HPLC (High Pressure Liquid Chromatography) and small dense low-density lipoprotein (sdLDL) was calculated using standard formula. Plasma Insulin was done by RIA. Insulin resistance was calculated using homeostatic model assessment insulin resistance (HOMA-IR) model. Glycated apo B in serum was estimated using ELISA. Carotid intimal media thickness (CIMT) was estimated using B mode USG of carotid arteries. RESULTS: Glycated apo B levels were correlated significantly with fasting blood glucose (FBG) (p=0.001), post prandial glucose (PPG) (p=0.001), HbA1c (p=0.013). The percent glycated apo B levels correlated significantly with FBG (p=0.032), PPG (p=0.004) in obese diabetic group. Multivariate regression analysis of glycated apo B and percent glycated apo B, showed that glycated apo B (p=0.009) and percent glycated apo B (p=0.006) were significantly correlated to FPG in diabetic population. The percent glycated apo B was also significantly correlated to PPG (p=0.003) and sdLDL (p=0.009). CIMT levels were higher in obese diabetics with 2 plaques positive when compared to obese non diabetic controls; however levels were not statistically significant. CONCLUSION: Persistent hyperglycemia and sdLDL are independently associated with glycation of apo B. Presence of plaques and increased thickness of intima indicates that glycated apo B predisposes diabetics to atherosclerosis.

Evaluation of Geno Type MTBDRplus Line Probe Assay for Early Detection of Drug Resistance in Tuberculous Meningitis Patients in India.

BACKGROUND: Molecular methods which allow for rapid and reliable detection of drug resistance have yet not been sufficiently evaluated for timely management of patients with tuberculous meningitis. AIMS: We aimed to evaluate Geno Type MTBDRplus line probe assay for early detection of drug resistance in Mycobacterium tuberculosis isolates and CSF samples of confirmed tuberculous meningitis patients. SETTINGS AND DESIGN: This was a multicentric prospective study carried out from July 2011 to December 2013 in tertiary care hospitals of Delhi. MATERIALS AND METHODS: The assay was performed on 89 M. tuberculosis isolates and 31 direct CSF samples from microbiologically confirmed tuberculous meningitis patients. The sensitivity and specificity of this assay was calculated in comparison to drug susceptibility testing by BACTEC MGIT 960 system. RESULTS: The sensitivity, specificity for detection of resistance to Isoniazid was 93%, 97% and to Rifampicin was 80%, 98.8%, respectively by this assay in comparison with the phenotypic drug susceptibility testing. The line probe assay could detect M. tuberculosis in 55% of CSF samples from patients with microbiologically confirmed tuberculous meningitis. Only 5/89 isolates (5.6%) were resistant to both Isoniazid and Rifampicin while 9/89 (10%) isolates were additionally resistant to Isoniazid. Resistance to any of the drugs, namely Isoniazid, Rifampicin, Streptomycin or Ethambutol, was seen in 24.7% of strains. CONCLUSION: The line probe assay has a good sensitivity and specificity for detection of drug resistance to Isoniazid and Rifampicin in M. tuberculosis culture isolates. However, this assay has limited role in detection of M. tuberculosis and drug resistance from direct samples with confirmed diagnosis of tuberculous meningitis.

Helicobacter pylori: Does it add to risk of coronary artery disease.

Helicobacter pylori (H. pylori) is a known pathogen implicated in genesis of gastritis, peptic ulcer disease, gastric carcinoma and gastric lymphoma. Beyond the stomach, the organism has also been implicated in the causation of immune thrombocytopenia and iron deficiency anemia. Although an area of active clinical research, the role of this gram negative organism in causation of atherosclerosis and coronary artery disease (CAD) remains enigmatic. CAD is a multifactorial disease which results from the atherosclerosis involving coronary arteries. The major risk factors include age, diabetes mellitus, smoking, hypertension and dyslipidemia. The risk of CAD is believed to increase with chronic inflammation. Various organisms like Chlamydia and Helicobacter have been suspected to have a role in genesis of atherosclerosis via causation of chronic inflammation. This paper focuses on available evidence to ascertain if the role of H. pylori in CAD causation has been proven beyond doubt and if eradication may reduce the risk of CAD or improve outcomes in these patients.

An Unusual Presentation of Dengue Fever: Association with Longitudinal Extensive Transverse Myelitis.

Association of dengue fever with transverse myelitis in the form of extensive spinal cord involvement is a rare entity described in the literature. We describe a middle-aged man who presented with dengue fever and in whom weakness of the bilateral lower limbs and urinary incontinence developed on the third day of fever. Magnetic resonance imaging confirmed the diagnosis of longitudinally extensive transverse myelitis. Over a four-week course of corticosteroids with supportive management, the patient recovered without any residual neurologic deficit.

Acute viral hepatitis E presenting with haemolytic anaemia and acute renal failure in a patient with glucose-6-phosphate dehydrogenase deficiency.

The association of acute hepatitis E viral (HEV) infection with glucose-6-phosphate dehydrogenase (G6PD) deficiency leading to extensive intravascular haemolysis is a very rare clinical entity. Here we discuss such a patient, who presented with acute HEV illness, developed severe intravascular haemolysis and unusually high levels of bilirubin, complicated by acute renal failure (ARF), and was later on found to have a deficiency of G6PD. The patient recovered completely with haemodialysis and supportive management.

Splenic abscess: Plasmodium vivax with secondary Escherichia coli infection.

Splenic abscess is a rare clinical entity as described in literature. The incidence is in the range of 0.14-0.7% and it has a high mortality rate. Hence, it is important to know its clinical presentation and complications, so that it can be treated early. We report a 40-year-old diabetic man who presented with fever with chills and rigor for the last 9 days and heaviness in the left hypochondrium for the last 6 days. He was initially diagnosed as having splenomegaly due to Plasmodium vivax (P. vivax), but was later found to have a splenic abscess due to Escherichia coli (E. coli). This was successfully managed by catheter drainage (CD) and antibiotic treatment.

Cardiovascular Risk Factors in Young Patients of Coronary Artery Disease: Differences over a Decade.

INTRODUCTION: Studies evaluating temporal trends of Coronary artery disease (CAD) in young patients, from the India, are still lacking. The aim of this study was to evaluate temporal differences in risk factors of young patients of CAD over a decade. METHODS: This is a single centre retrospective study performed in a tertiary care teaching institution in North India. Case records of young patients (≤40 years) with acute coronary syndrome between January 2000 to December 2001 and January 2009 to December 2010 were obtained. Records were sought for active smoking, family history, waist size, blood pressure, hypertension, fasting and postprandial blood sugar and lipid profile for both groups and analyzed using SPSS v.17. For the purpose of the study, p value <0.05 was considered statistically significant. RESULTS: Medical records of a total of 79 and 83 patients with young CAD (≤40 years) were obtained for 2000-01 and 2009-10 period respectively. An increase in proportion of female patients, hypertension (p=0.004), dysglycemia (p<0.001), family history (p=0.01), metabolic syndrome (p<0.001), low high density lipoprotein (HDL) (p=0.07) and mean waist size (0.03) was noted over the years. Among males, increase in number of dysglycemics (p=0.0002), positive family history (p<0.0001) and mean waist size (0.032) was statistically significant. CONCLUSION: Over a decade the patients with young CAD in our study, there was an increase in proportion of patients with metabolic syndrome, dysglycemia and low HDL.