Can glycated haemoglobin (HbA1c) be used as a predictor of left ventricular diastolic dysfunction in non-hypertensive patients with newly diagnosed type 2 diabetes mellitus: a cross-sectional study at a tertiary care centre in Eastern India.

OBJECTIVES: This study was conducted to establish the association between glycated haemoglobin (HbA1c) and left ventricular diastolic dysfunction (LVDD) in non-hypertensive patients with newly diagnosed type 2 diabetes mellitus (DM) and determine the cut-off value of HbA1c for detecting LVDD. DESIGN: Cross-sectional study. SETTING: This study was conducted in General Medicine Department in collaboration with the Cardiology Department at All India Institute of Medical Sciences, Patna. PARTICIPANTS: The study population comprised patients with newly diagnosed type 2 DM within the past 3 months, aged between 18 years and 80 years, who were not hypertensive and without any systemic diseases and who presented to the General Medicine Department. PRIMARY AND SECONDARY OUTCOME MEASURES: The presence of LVDD was the primary outcome measure. RESULTS: Among the total of 60 participants, it was observed that age (adjusted odds ratio (AOR): 1.169, 95% CI: 1.066 to 1.283) and HbA1c (AOR: 2.625, 95% CI: 1.264 to 5.450) were found to be independent predictors for the presence of LVDD. Receiver operating characteristic analysis identified a cut-off value of HbA1c at 9.5% (80 mmol/mol) for detecting LVDD, with a specificity of 96.43%, a sensitivity of 37.5% and a positive predictive value (PPV) of 91.62%. CONCLUSIONS: This study demonstrated that age and HbA1c levels are independent predictors of LVDD in patients with newly diagnosed type 2 DM without hypertension. A cut-off value of 9.5% for HbA1c was identified with a high specificity and PPV for predicting LVDD in patients with newly diagnosed type 2 diabetes. This underscores the importance of conducting echocardiography in patients with newly diagnosed asymptomatic type 2 diabetes with HbA1c 9.5% or more to assess LVDD, allowing for prompt interventions if necessary and to decelerate the progression towards heart failure.

Classic paroxysmal nocturnal haemoglobinuria presenting with intestinal malabsorption syndrome, acute abdomen and acute kidney injury.

A male patient in his 30s presented with complaints of acute abdominal pain, black stools and red-coloured urine. CT revealed thrombi in the splenic and left renal veins, leading to infarctions. An endoscopy displayed scalloping of the duodenal folds, indicative of intestinal malabsorption syndrome (IMS). Histopathological examination confirmed IMS. Due to the presence of intravascular haemolysis, haemoglobinuria and thrombotic complications, paroxysmal nocturnal haemoglobinuria (PNH) was suspected and subsequently confirmed by flow cytometry. Thus, a diagnosis of classic PNH with IMS and thrombotic complications was established. This unique case highlights the coexistence of PNH and IMS, resembling the complement hyperactivation, angiopathic thrombosis and protein-losing enteropathy disease, suggesting potential shared pathophysiology.

Secondary Hemophagocytic Lymphohistiocytosis: A Series of Three Cases.

Hemophagocytic lymphohistiocytosis (HLH) is a disease of abnormal activation of the immune system, either due to a familial cause or a sporadic cause, in relation to various triggering agents. Secondary HLH is a complication of various diseases, such as infections, malignancies, and autoimmune disorders. In our case series, we present three cases of secondary HLH with varied etiologies. Case 1 involved an 18-year-old male with a history of pulmonary tuberculosis, presenting with fever, hepatosplenomegaly, and elevated inflammatory markers. HLH was treated with steroids alongside antitubercular therapy (ATT). In case 2, a 17-year-old male presented with dengue fever, fever, hepatosplenomegaly, and elevated inflammatory markers. HLH was managed with steroids and etoposide. In case 3, a 29-year-old female with systemic lupus erythematosus (SLE) presented with fever, hepatosplenomegaly, and a positive antinuclear antibody (ANA) test. Steroid therapy was initiated for HLH. The prognosis depends on various factors. The management of such cases necessitates expeditious treatment of the underlying disease in conjunction with amelioration of the cytokine storm with the immunosuppressive agents precipitated by the secondary conditions. Once the underlying cause of the cytokine storm is treated, the lethal progression of the disease may come to a halt.

High-Resolution Computed Tomography and Intraoperative Correlation in Cholesteatoma: Enhancing Preoperative Evaluation and Surgical Management.

INTRODUCTION: Cholesteatoma, a hazardous non-neoplastic lesion of the temporal bone, is prevalent in socio-economically disadvantaged groups in developing nations like India. Timely detection and surgical intervention are essential for effective management. High-resolution computed tomography (HRCT) has revolutionized the assessment of temporal bone pathology, though its role in preoperative evaluation remains debated. This study aimed to validate HRCT's utility in diagnosing cholesteatoma, compare its findings with intraoperative observations, and assess sensitivity and specificity. METHODS: This diagnostic accuracy study was conducted at a tertiary care center in Western India, from March 2021 to November 2022. HRCT findings of 54 cholesteatoma patients were evaluated and compared with intraoperative findings. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and Cohen's kappa coefficient were calculated. RESULTS: HRCT demonstrated a sensitivity exceeding 90% in identifying scutum erosion, mastoid sclerosis, and abnormalities in the tympanic membrane, along with a specificity surpassing 90% in detecting various conditions, including facial canal erosion, sinus plate erosion, lateral semicircular canal erosion, erosion of the posterior wall of the external auditory canal, and abnormalities in the tympanic membrane. Furthermore, HRCT exhibited an accuracy of over 90% in detecting most pathologies. There was a perfect or near-perfect agreement observed for abnormal tympanic membrane, sinus plate erosion, mastoid sclerosis, and erosion of the posterior wall of the external auditory canal (with kappa values > 0.8). Moderate to fair agreement was noted for other pathologies. CONCLUSION: HRCT offered precise detection of the majority of pathologies, thereby facilitating surgical planning. However, the presence of limitations in distinguishing specific abnormalities highlights the significance of utilizing HRCT in tandem with other diagnostic modalities to ensure meticulous diagnosis and effective treatment planning.

Efficacy of Interventions Based on WHO Multimodal Hand Hygiene Improvement Strategy in a Tertiary Care Hospital in Eastern India: A Quasi-Experimental Study.

The study aimed to evaluate the efficacy of the World Health Organization (WHO) multimodal hand hygiene improvement (WHO-5) strategy in enhancing hand hygiene compliance among health care workers at a tertiary care hospital. The interrupted time series study included preintervention, intervention, and postintervention phases, with 2 points of observation each during the pre- and postintervention phases. The baseline hand hygiene compliance was 16%, which improved to 43.9% after the intervention. Health care workers were 4 times more likely to adhere to proper hand hygiene postintervention (odds ratio [OR], 4.117). Independent predictors of hand hygiene compliance included the week of observation (week 3: adjusted odds ratio [AOR], 0.872; week 5: AOR, 3.427; and week 7: AOR, 4.713), health care worker type (consultants: AOR, 0.964; residents: AOR, 2.187; and interns: AOR, 6.684), daytime (AOR, 1.232), and "after" type of hand hygiene opportunity (AOR, 1.577). No significant differences were found in knowledge, attitude, and practices pre- and postintervention, and the interventions' effect was sustained and increased over time, supporting implementation in hospitals across India.

The Prevalence of Thyroid Abnormalities in Patients With Chronic Kidney Disease: A Cross-Sectional Study at a Tertiary Care Hospital.

Background and objective Chronic kidney disease (CKD) is a clinical syndrome characterized by the irreversible loss of kidney function. It is a widespread condition affecting populations worldwide. The kidneys play a crucial role in the metabolism, breakdown, and elimination of thyroid hormone and thyroid-stimulating hormone (TSH). Consequently, thyroid dysfunction can occur as an endocrine manifestation in CKD patients. Previous studies investigating thyroid abnormalities and the severity of CKD have yielded diverse outcomes. In light of this, this study aimed to determine the prevalence of thyroid dysfunction in CKD patients and explore the association between different thyroid dysfunctions and markers of kidney function. Methods A total of 140 CKD patients who met the inclusion criteria were recruited, and their demographic details and routine investigations were recorded. Blood samples were collected for kidney function tests and thyroid function tests. The primary outcome measures included markers of kidney function [urea, creatinine, and estimated glomerular filtration rate (e-GFR)] and thyroid profile [TSH, free thyroxine (FT4), and free triiodothyronine (FT3)]. Mean and standard deviation (SD) were calculated for continuous variables, while frequencies were calculated for categorical data. Fisher's exact test was employed to evaluate the association between two categorical variables, and p-values below 0.05 were considered statistically significant. Results The mean (± SD) urea, creatinine, and e-GFR were found to be 139 (± 81.1) mg/dL, 5.33 (± 4.1) mg/dL, and 20.1 (± 15) ml/min/1.73 m2, respectively. Of note, 133 (95%) patients had elevated urea levels, with the majority (n = 109, 77.8%) having urea levels between 40 and 199 mg/dL; 70 (50%) patients had creatinine levels less than 4 mg/dL, and 107 (76.4%) had e-GFR of less than 30 ml/min/1.73 m2. The mean (± SD) TSH, FT4, and FT3 levels were found to be 6.64 (± 11.2) mIU/ml, 13.6 (± 4.54) pmol/L, and 2.65 (± 1.89) pmol/L, respectively. It was observed that 18 (12.9%, 95% CI: 8.29-19.4%) of the CKD patients had hypothyroidism and 21 (15%, 95% CI: 10.02-21.8%) had subclinical hypothyroidism (SCH), while only two (1.4%, 95% CI: 0.39-5.05%) and five (3.6%, 95% CI: 1.5-8.08%) had hyperthyroidism and subclinical hyperthyroidism, respectively. Thirty-nine (27.9%, 95% CI: 21.1-35.8%) patients had low FT4 levels, whereas a considerable majority (n = 123, 87.9%, 95% CI: 81.41-92.28%) of the patients suffering from CKD were found to have low FT3 levels. The associations of urea levels with SCH, low FT4, and FT3 status were found to be statistically significant with p-values of 0.002, 0.033, and <0.001, respectively. The association between e-GFR and low FT3 status was also statistically significant, with a p-value of 0.014. Conclusion Nine out of 10 patients with CKD were discovered to have low FT3 levels, whereas one in four patients had low FT4 levels. The study participants also exhibited a significant presence of SCH and hypothyroidism, with prevalence rates of 15% and 12.9%, respectively. Urea levels and e-GFR, indicating the severity of CKD, showed a significant association with the presence of various thyroid abnormalities. Hypothyroidism in CKD patients can complicate disease progression, impact mortality rates, and affect overall quality of life. Therefore, routine screening for thyroid abnormalities should be conducted in all CKD patients.

Hemophagocytic Lymphohistiocytosis With Obstructive Jaundice as a Rare Presentation of Disseminated Tuberculosis in an Adult.

Tuberculosis (TB) is a disease of global concern due to its varying clinical presentations and outcomes. Hemophagocytic lymphohistiocytosis (HLH) syndrome, along with obstructive jaundice, is one of the rarest presentations of tuberculosis involving immune activation and has a very high mortality rate. Thus, on-time diagnosis becomes crucial for the management of the disease. Prompt treatment with anti-tubercular therapy (ATT) can limit the morbidity and mortality associated with it. We report the case of a 28-year-old male who presented with fever, yellowish discoloration of the skin, features of bicytopenia, jaundice with hepatosplenomegaly, and ascites. The liver function test (LFT) was suggestive of obstructive jaundice. TB was confirmed on the analysis of lymph node aspirates, and the contrast-enhanced computed tomography (CECT) of the thorax and abdomen was suggestive of disseminated tuberculosis. Upon investigation, the criteria for HLH were fulfilled. Bone marrow aspiration smears revealed multiple hemophagocytic histiocytes in the background of a hypercellular marrow, erythroid hyperplasia, and myeloid-to-erythroid ratio of 1:1. Thus, a diagnosis of disseminated TB with HLH and obstructive jaundice was established. A modified ATT regimen was started, keeping in mind the deranged LFT of the patient, but no immunosuppressive therapy was initiated as it could make the TB worse. This case demonstrates the fact that in cases of hemophagocytic syndrome with tuberculosis as an underlying cause, just starting ATT without immunosuppression could be rewarding and lifesaving.

Comparison of Biochemical and Hematological Profiles in Patients of Extrapulmonary and Pulmonary Tuberculosis at a Tertiary Care Center.

Background Tuberculosis (TB) is a disease of global concern, especially in countries like India. Pulmonary TB (PTB) and extrapulmonary TB (EPTB) differ a lot when it comes to presentations, treatment, and outcomes. The biochemical and hematological test can serve as a marker reflecting the response to treatment in various types of TB, resulting in a better prognosis. Therefore, this study was conducted to compare the biochemical and hematological profiles in patients of extrapulmonary and pulmonary tuberculosis in adults and children. Methods TB cases were divided into four categories: PTB adult, EPTB adult, PTB pediatrics, and EPTB pediatrics. Forty-nine patients in each category were selected, resulting in a total of 196 patients. The sample size was met via convenience sampling. A total of 27 parameters were compared. Mann-Whitney U tests were used for statistical analysis. Results It was observed that serum calcium levels in PTB cases (11.65, 1.15; median and inter-quartile range (IQR), respectively) were significantly different from those in EPTB cases (9.18, 1.03; p<0.001). The median serum sodium levels in EPTB cases (139.49, 6.86) were higher than in PTB cases (130.10, 5.77; p<0.001). For total platelet count levels, a significant difference was observed between PTB (337.00, 180.75) and EPTB cases (278, 159.25; p=0.006). In EPTB cases, the total red blood count (RBC) count levels (4.47, 0.96) were higher than in PTB cases (4.24, 0.89; p=0.036). Biochemical and hematological parameters between pediatrics and adult age groups were compared, and it was observed that the median values (IQR) of serum phosphorus, total white blood cells (WBC), and platelet count in pediatric cases were 5.16 (1.09), 14.75 (6.03), and 350.00 (155.75), respectively, and were higher from those in adult cases 3.78 (0.97); 8.35 (6.66) and 264 (181.5), respectively (p<0.001). For serum creatinine levels, a significant rise was observed between PTB 0.54 (0.19) and EPTB cases 0.57 (0.16) (p<0.001). It was also observed that alanine transaminase (ALT) levels were higher in adults (18.90 (17.83)) than in the pediatric age group (24.70 (28.67); p=0.042) while alkaline phosphatase (ALP) was higher in the pediatric age group (108.95 (78.37)) than in adults (94.25 (47.92); p=0.003). Conclusion Serum calcium levels and total WBC counts were higher in PTB cases, while the levels of serum sodium and total RBC counts were higher in EPTB cases. ALT, serum phosphorus, total WBC counts, and total platelet counts were higher in the pediatric age group, while ALP, serum urea, and creatinine levels were higher in adults. Increased tissue damage and severity of disease in the pediatric age group, reactive thrombocytosis due to biogenesis in lungs, and abnormal anti-diuretic hormone secretion in PTB cases may be possible explanations for these findings. These findings may help clinicians in the early identification of potential complications, and further studies on these parameters should be conducted.

Wernekink Commissure Syndrome With Bilateral Cerebellar Signs and Holmes Tremor in a Patient With a Preexisting Movement Disorder.

Wernekink commissure syndrome (WCS) is an extremely rare midbrain syndrome, in which there is the selective destruction of the decussation of the superior cerebellar peduncle, which commonly presents with bilateral cerebellar signs. We describe a case of WCS with Holmes tremor in a patient having an undiagnosed involuntary movement disorder since childhood following an undocumented case of meningitis. The patient presented with sudden onset gait instability with bilateral cerebellar signs (more prominent on the left side), Holmes tremor in bilateral limbs, slurred speech, and marked dysarthria. No ophthalmoplegia or palatal tremors were noted. The patient was conservatively managed along the lines of a stroke, and there was a marked improvement in cerebellar signs and Holmes tremor with time but no evolution (improvement or worsening) was observed in the involuntary movements of limbs and face that were present before the onset of WCS.