Outcome measures in pediatric chronic inflammatory demyelinating polyradiculoneuropathy.

INTRODUCTION/AIMS: Objective outcome measures in children undergoing treatment for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are lacking. The aim of the study was to record serial grip strength and motor nerve conduction studies to assess interval change. METHODS: This was a retrospective review of 16 children (8 females and 8 males; median age, 9.7 years; interquartile range, 6-13 years) with CIDP followed at a tertiary children's hospital from 2013 to 2021. Subjects were treated with intravenous immunoglobulin (IVIG). Right and left grip strength measurements were obtained at each clinic visit using a handheld dynamometer. Annual right median motor nerve conduction study data were recorded during the study period. RESULTS: Mean duration of follow-up was 2.9 years. Grip strength (right: 0.19 kg/month, p < 0.001; left 0.23 kg/month, p < 0.001) and median F-wave latencies (-0.23/month, p = 0.015) showed significant improvement over time. Akaike information criterion showed time + IVIG frequency <21 days as best fit for grip strength and distal compound muscle action potential amplitude. DISCUSSION: Our study results indicate serial grip strength measurements are a feasible and objective way to assess motor strength improvement in children with CIDP receiving immunotherapy.

Serum Levels of Activin A: Predictor of Insulin Resistance and Atherosclerosis in Prediabetics.

BACKGROUND: Pathological effects of dysglycemia and insulin resistance on atherosclerosis and cardiac remodeling starts as early as in the prediabetic state before the onset of overt diabetes. Activin A is a molecule with multiple functions, including an important part in glucose homeostatic mechanisms as well as inflammatory processes and is therefore being researched as a useful novel biomarker for prompt recognition of the risk of cardiovascular disease (CVD) in prediabetic individuals, thereby helping in disease prognostication and early institution of therapeutic measuresObjective: The study aimed to measure serum levels of activin A in prediabetic patients and evaluate them in comparison to normoglycemic controls. The association of activin A with carotid intima media thickness (CIMT), left ventricular diastolic dysfunction (LVDD), and homeostatic assessment of insulin resistance (HOMA-IR) was also studiedMaterials and methods: A total of 60 prediabetic cases and 60 normoglycemic control subjects [matched as per age, gender, and body mass index (BMI)] were recruited. Measurement of serum glucose levels (fasting and postprandial) and fasting insulin levels and glycated hemoglobin (HbA1c) levels were done in all the subjects. The values of HOMA-IR were computed using established formulae. Enzyme-linked immunosorbent assay (ELISA) kits were used for the evaluation of serum levels of activin A in both groups. Parameters for the two groups were compared. In the cases, CIMT (using B-mode ultrasound) and LVDD (using two-dimensional (2D) echocardiography) were measured and correlated with activin A levelsResults: Serum fasting insulin (mIU/L) was considerably higher in cases than in the controls (p < 0.001). HOMA-IR median [interquartile range (IQR)] was 4 (3.25-4.93) in some cases, and that in the control group was 1.2 (0.88-1.5) (p < 0.001). Serum activin A levels in the cases group had a median (IQR) of 263.55 (227.1-279.5) ng/mL, which was substantially greater as compared to the control group 159.9 (150.7-178.7) ng/mL (p < 0.001). A significant positive association of serum activin A levels with HOMA-IR (ρ = 0.75, p < 0.001) and CIMT (ρ = 0.50, p < 0.001) was found. In LVDD grade I and II groups, the serum levels of activin A were 257.86 (219.3-271.2) ng/mL and 269 (244.19-291.5) ng/mL, respectively (p = 0.12)Conclusion: A substantial proportion of morbidity and mortality related to dysglycemic states can be attributed to cardiovascular complications. Elevated levels of activin A in prediabetes can act as an indicator of subclinical CVD leading to early diagnosis and intervention.

A prospective real-world study evaluating serum levels of arginine and cysteine in women with chronic telogen effluvium: do we really need blanket prescription of amino acid supplementation?

Amino acids form a major component of hair fibres and are prescribed routinely in the form of nutritional supplements in patients with chronic telogen effluvium (CTE). Such a practice is based on assumption of a nutritional deficiency state in such patients. In this prospective study, we evaluated the serum levels of cysteine and arginine in 30 women with CTE and in healthy controls. We found no significant difference between the two groups in terms of serum arginine levels. Cysteine levels were higher in patients with CTE (P < 0.001). No correlation was found between levels of serum amino acids (cysteine and arginine) and either diet type (vegetarian or not) or body mass index, and no significant correlation between levels of the two amino acids and severity of disease. Our work suggests that arginine and cysteine deficiency is not present in women with CTE. Supplementation is unlikely to be of any benefit in nutrient-replete populations and only adds to the cost of therapy.

Comparative diagnostic utility of different urinary biomarkers during pre-albuminuric stages of non-hypertensive type 2 diabetic nephropathy.

Background & objectives: Activation of renin-angiotensin system and tubulointerstitial damage might be seen in pre-albuminuria stage of diabetic nephropathy (DN). Here, diagnostic utility of four urinary biomarkers [Angiotensinogen (Angio), Interleukin (IL)-18, Neutrophil Gelatinase-Associated Lipocalin (NGAL) and Cystatin] during pre-albuminuria stages of non-hypertensive type 2 diabetes patients was studied. Methods: A total of 952 type 2 diabetes mellitus (T2DM) patients were screened for nephropathy [estimated glomerular filtration rate (eGFR) ≥120 ml/min and albumin-creatinine ratio (ACR) ≥30], and 120 patients were followed up for one year. At one year, they were classified into hyperfiltration (43), normoalbuminuria (29) and microalbuminuria (48) groups. Another 63 T2DM patients without nephropathy were included as controls. Hypertension, patients on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, eGFR <60 ml/min/1.73 m2 and all proteinuric conditions were excluded. All were subjected to testing for urine protein, ACR, HbA1C, eGFR, along with urinary biomarkers (IL-18, cystatin-C, NGAL and AGT). Comparative analysis of all the diagnostic tests among different subgroups, correlation and logistic regression was done. Results: Urinary IL-18/Cr, cystatin/creatinine (Cr) and AGT/Cr levels were higher in groups of hyperfiltration (13.47, 12.11 and 8.43 mg/g), normoalbuminuria (9.24, 11.74 and 9.15 mg/g) and microalbuminuria (11.59, 14.48 and 10.24 mg/g) than controls (7.38, 8.39 and 1.26 mg/g), but NGAL/Cr was comparable. The area under receiver operating characteristic curve (AUC) and sensitivity of AGT to detect early CKD were higher than ACR and eGFR (0.91 and 90.4%, 0.6 and 40% and 0.6 and 37%, respectively). AUC values of other biomarkers, namely IL-18/Cr, cystatin/Cr and NGAL/Cr, were 0.65, 0.64 and 0.51, respectively. Angio/Cr and IL-18/Cr showed correlation with log albuminuria (r=0.3, P=0.00, and r=0.28, P=0.00, respectively). NGAL showed correlation with log eGFR (r=0.28 P=0.00). Multivariate logistic analysis showed that odds ratio of developing nephropathy was 7.5 times with higher values of log Angio/Cr. Interpretation & conclusions: Urinary AGT showed a higher diagnostic value than ACR and eGFR followed by IL-18 and cystatin to diagnose DN during pre-albuminuric stages.

Effect of a Biopsychosocial Intervention or Postural Therapy on Disability and Health Care Spending Among Patients With Acute and Subacute Spine Pain: The SPINE CARE Randomized Clinical Trial.

Importance: Low back and neck pain are often self-limited, but health care spending remains high. Objective: To evaluate the effects of 2 interventions that emphasize noninvasive care for spine pain. Design, Setting, and Participants: Pragmatic, cluster, randomized clinical trial conducted at 33 centers in the US that enrolled 2971 participants with neck or back pain of 3 months' duration or less (enrollment, June 2017 to March 2020; final follow-up, March 2021). Interventions: Participants were randomized at the clinic-level to (1) usual care (n = 992); (2) a risk-stratified, multidisciplinary intervention (the identify, coordinate, and enhance [ICE] care model that combines physical therapy, health coach counseling, and consultation from a specialist in pain medicine or rehabilitation) (n = 829); or (3) individualized postural therapy (IPT), a postural therapy approach that combines physical therapy with building self-efficacy and self-management (n = 1150). Main Outcomes and Measures: The primary outcomes were change in Oswestry Disability Index (ODI) score at 3 months (range, 0 [best] to 100 [worst]; minimal clinically important difference, 6) and spine-related health care spending at 1 year. A 2-sided significance threshold of .025 was used to define statistical significance. Results: Among 2971 participants randomized (mean age, 51.7 years; 1792 women [60.3%]), 2733 (92%) finished the trial. Between baseline and 3-month follow-up, mean ODI scores changed from 31.2 to 15.4 for ICE, from 29.3 to 15.4 for IPT, and from 28.9 to 19.5 for usual care. At 3-month follow-up, absolute differences compared with usual care were -5.8 (95% CI, -7.7 to -3.9; P < .001) for ICE and -4.3 (95% CI, -5.9 to -2.6; P < .001) for IPT. Mean 12-month spending was $1448, $2528, and $1587 in the ICE, IPT, and usual care groups, respectively. Differences in spending compared with usual care were -$139 (risk ratio, 0.93 [95% CI, 0.87 to 0.997]; P = .04) for ICE and $941 (risk ratio, 1.40 [95% CI, 1.35 to 1.45]; P < .001) for IPT. Conclusions and Relevance: Among patients with acute or subacute spine pain, a multidisciplinary biopsychosocial intervention or an individualized postural therapy intervention, each compared with usual care, resulted in small but statistically significant reductions in pain-related disability at 3 months. However, compared with usual care, the biopsychosocial intervention resulted in no significant difference in spine-related health care spending and the postural therapy intervention resulted in significantly greater spine-related health care spending at 1 year. Trial Registration: ClinicalTrials.gov Identifier: NCT03083886.

Prevalence of recreational substance use in patients presenting with seizures to a tertiary care hospital.

RATIONALE: Recreational substance use (RSU) has been associated with seizure. There is limited knowledge on prevalence of seizures in patients with concomitant RSU in U.S. Thus, we aimed to investigate the prevalence of concomitant RSU in patients with seizures at a university based tertiary healthcare system. METHODS: We conducted a retrospective observational study from 01/01/2013 to 02/28/2021. Data from patient cohort explorer (a de-identified database) were used to select patients with seizure and a positive drug test (either urine or serum) obtained during the same encounter. The prevalence of RSU for individual substance was reported as percentage of number of encounters. RESULTS: There were 226,613 encounters with seizure(s) for a total of 40,459 subjects. Of the total, 5787 (2.5%) encounters with 4,342 subjects concomitantly tested positive for RSU. Mean age was 40.1 (±16.9) years, 58.4% were males, 59.1% were African Americans, and 38.3% were Caucasians. Gender and race of subjects with concomitant RSU for individual drug class was studied for all age groups and for subjects older than 16 years. CONCLUSIONS: Overall, the most common concomitantly positively tested RSU during seizure encounters was cannabinoid (40.7%) followed by benzodiazepine (38.7%). There was a higher proportion of males' encounters with concomitant seizure and RSU regardless of type of drug class. Amphetamine use was more common in Caucasians, while the remaining studied RSU were more common in African Americans. Similar trends were seen in the subgroup of subjects older than 16 years.

Transthyretin - A Novel Biomarker for Insulin Resistance and Atherosclerosis Risk in Prediabetics.

OBJECTIVE: The aim of the study was to compare serum levels of Transthyretin in prediabetics and controls and to correlate levels of same with HOMA-IR and mean CIMT Method: It was a case control study in which 60 prediabetic patients and 60 controls (age, sex, BMI matched) were employed. Plasma levels of glucose (fasting and postprandial), glycated hemoglobin (HbA1c), and serum levels of insulin (fasting) were measured in both cases and controls. HOMA-IR values in both the groups were calculated using fasting plasma glucose and serum insulin levels. Serum Transthyretin levels were measured using ELISA. The values obtained were compared between cases and controls. In cases, obtained serum levels of Transthyretin were correlated with HOMA-IR values and mean CIMT (measured in cases only using B-mode ultrasonography). RESULTS: Median (IQR) of serum levels of insulin (fasting in µIU/ml) in cases {11.3 (10.175-13.505)} was significantly higher than that of controls {5.73 (4.3-7.1)}. HOMA-IR median (IQR) in cases and controls was 3.12 (2.73-3.595) and 1.21(0.918- 1.505) respectively. Median (IQR) for serum levels of Transthyretin was also significantly higher in cases as compared to controls [46.74 (30.43-81.225) and 22.38 (16.628-27.89) respectively]. Significant positive correlations were observed between serum levels of Transthyretin with both HOMA-IR and mean CIMT (with correlation coefficients being 0.288 and 0.536 respectively). Univariate linear regression analysis showed that with increase in serum Transthyretin by 1 mg/ dl, mean CIMT increases by 0.001 mm. CONCLUSION: Individuals with impaired glucose tolerance have been found to have increased risk of atherosclerosis as compared to normoglycemics after excluding other risk factors. Assessment for the risk of same with the help of novel markers can help in diagnosis and intervention at an early stage and thereby preventing risk of further complications.

Serum Retinol Binding Protein-4 Levels in Prediabetics - Novel Biomarker of Insulin Resistance and Atherosclerosis.

BACKGROUND: Atherosclerotic cardiovascular diseases are the leading cause of morbidity and mortality in both diabetics and prediabetics. In insulin resistant states, increased levels of various adipose derived cytokine (adipokine) have been found to have an important role in the process of atherosclerosis. One such novel adipokine is RBP4, (belonging to lipokalin family) which also by exerting an inflammatory process has a role in the pathogenesis of insulin resistance and CVD.. Early detection of all these inflammatory cytokines may immensely help us in prognosticating the pace of disease besides instituting early interventional manuevers. OBJECTIVE: The aim of the study was to compare serum levels of RBP4 in prediabetics and controls and to correlate levels of RBP4 with HOMA-IR and CIMT. METHODS: 60 prediabetic patients and 60 age, sex, BMI matched controls were employed in the case control study. In both cases and controls serum levels of fasting and postprandial blood glucose, glycated hemoglobin (HbA1c) and fasting insulin levels were measured. HOMA-IR values in both the groups were calculated using fasting glucose and insulin levels. Serum RBP4 levels were measured using ELISA. The values obtained were compared between cases and controls. CIMT was only measured in cases using B-mode ultrasonography. RESULTS: Median (IQR) of fasting plasma insulin levels (uIU/ml)in cases was 11.3 (10.175-13.505) versus that of controls which was 5.73 (4.3-7.1). HOMA-IR median (IQR) in cases and controls was 3.12 (2.73-3.595) and 1.21(0.918-1.505) respectively. Median (IQR) for RBP4 in cases was 67.4 (46.166-111.088) which was significantly higher as compared to controls 33.92 (23.902-52.45). Significant positive correlation was seen between RBP4 with both, HOMA-IR and mean CIMT with correlation coefficients of 0.3693 and 0.621 respectively. On performing univariate linear regression analysis it was found that with increase in serum RBP4 levels by 1 mg/L, HOMA-IR and mean CIMT significantly increased by 0.007 units and 0.001 mm respectively. METHODS: 60 prediabetic patients and 60 age, sex, BMI matched controls were employed in the case control study. In both cases and controls serum levels of fasting and postprandial blood glucose, glycated hemoglobin (HbA1c) and fasting insulin levels were measured. HOMA-IR values in both the groups were calculated using fasting glucose and insulin levels. Serum RBP4 levels were measured using ELISA. The values obtained were compared between cases and controls. CIMT was only measured in cases using B-mode ultrasonography. CONCLUSION: Prediabetics have been found to have more risk of cardiovascular events as compared to normoglycemics. Early assessment of the same with the use of novel biomarkers like RBP4 can be considered for early detection of atherosclerosis in prediabetic individuals. It may further help in early intervention and thus prevention from future complications.

Serum Heart Type Fatty Acid Binding Protein Levels in Prediabetes-An Invaluable Cardiovascular Biomarker.

BACKGROUND: The pathophysiological effects of diabetes on the heart and the rest of the cardiovascular system begins much earlier in its precedent stage of prediabetes and one major underlying defect is insulin resistance. Heart-type fatty acid binding protein (H-FABP) is a recently studied molecule inherent to the cardiac myocytes found to rise in both coronary and non-coronary heart diseases. The utility of the molecule in prediabetes and its relationship with insulin resistance is being studied. OBJECTIVE: The aim of the study is to compare serum levels of H-FABP in prediabetics and controls and correlate them with Homeostatic model assessment - insulin resistance (HOMA-IR). METHODS: 50 prediabetic patients and 50 age, sex and BMI matched controls were employed in the case control study. Serum fasting and postprandial blood sugars, glycosylated hemoglobin (HbA1c), fasting insulin levels were measured in cases and controls. HOMA-IR index was calculated from fasting glucose and insulin values. Serum H-FABP was measured in both cases and controls using Immunoturbidimetric method with anti- H-FABP coated latex reagent kits. The values were compared between both the groups. RESULTS: The mean serum fasting insulin level among cases was 12.22mIU/ml and that of the control group was 5.37mIU/ml (p value <0.0001). HOMA- IR mean values were 3.31 ± 1.56 and 1.16 ± 0.44 in cases and controls respectively (p- <0.001). The mean serum levels of H-FABP among cases and controls were 6.38± 2.76ng/ml and 3.24 ± 2.47 ng/ml respectively (p <0.0001). The correlation between the two variables, HOMA-IR and H-FABP was also found to be strongly positive (r=0.675). Linear regression analysis showed that for 1 unit increase in HOMA-IR, H-FABP increased by 1.095 and for 1 unit increase in Fasting insulin, H-FABP increased by 0.038. CONCLUSION: Prediabetics have a higher risk of cardiovascular morbidity when compared to normoglycemics with insulin resistance being the single most important contributor. Serum H-FABP levels are elevated in prediabetes representing a marker of subclinical cardiovascular disease (CVD).

Calcium Homeostasis Comparison in Thermal Burn Patients-Early Tangential Excision and Grafting versus Conservative Management.

Introduction With the advent of better burn wound management protocols, early excision and grafting, increased number of burns patients are surviving and entering the struggle of prolonged rehabilitation. Calcium homeostasis and its influence on bone mineralization plays an important role, but it is adversely influenced by the proinflammatory state in burns, leading to hypocalcemia and paradoxical hypercalciuria which, in turn, leads to excessive bony resorption and pathological fractures. The role of early excision in the overall metabolism of calcium is being investigated in the study. Method This study was undertaken in a tertiary level government-run hospital from February 2018 to August 2019. A total of 28 patients with second degree thermal burns were included. For all patients, fasting serum parathormone levels along with various serum electrolytes like Ca 2+ , Mg 2+ , PO 4 3- and urinary calcium levels were serially measured from day of admission to 2 months. The first group of 14 patients (Group A) underwent early tangential excision and skin grafting, whereas another 14 patients (Group B) underwent conservative management. All categorical variables were analyzed with the help of Chi square test. A p value of < 0.05 was considered statistically significant. Result There was a statistically significant improvement in serum parathormone and other electrolytes' levels in the tangential excision group. Similarly, urinary excretion of calcium also showed favorable results in the group. Conclusion Early tangential excision and grafting in burns plays an important role in maintaining serum parathormone and calcium levels, leading to prevention of hypercalciuria and optimization of other factors affecting calcium homeostasis.

Neuropathy in Prediabetics: Is Oxidative Stress to Contribute?

OBJECTIVE: To assess the association of oxidative stress and serum vitamin D levels in sensory neuropathy in prediabetes. METHODS: Serum and urine levels of 8-OHdG (a marker of oxidative stress) and serum levels of vitamin D were compared in prediabetic patient having sensory neuropathy to those who did not have sensory neuropathy as determined by VPTs measured by Digital Biothesiometer and MNSI (Michigan Neuropathy Screening Instrument). RESULT: A total of 60 prediabetic cases between 35 years to 60 years were included in this study. Among all the prediabetic subjects, 43.3 % subjects had neuropathy according to VPTs measured by Biothesiometer. T-test analysis suggested that serum levels of 8-OHdG were significantly higher in subjects with neuropathy than subjects without neuropathy (1006.58 ± 511.8 vs 688.6 ± 607.3, p value = 0.035). Urinary levels of 8-OHdG were also significantly higher in subjects with neuropathy than subjects without neuropathy (699.35 ± 419.5 vs 474.57 ± 402.5, p-value = 0.04). No such significant difference however was present in serum levels of vitamin D between neuropathic and non-neuropathic prediabetics (20.13 ± 18.44 vs 16.96 ± 11.72, p value = 0.419. VPTs were found to have statistically significant positive correlation with serum 8-OHdG {, Pearson Correlation Coefficient= 0.317(R), 0.307(L); p-value=0.014(R),0.017(L)} and urine 8-OHdG levels{Pearson Correlation Coefficient= 0.288(R), 0.255(L); p-value=0.026(R), 0.049(L),}. According to MNSI physical assessment score (> or = 2), 38.3 % subjects (23 subjects) had neuropathy. MNSI score is positively correlated with serum 8-OHdG (Pearson Correlation Coefficient = 0.308; p-value = 0.017). Correlation with urine 8-OHdG was not statistically significant (Pearson Correlation Coefficient= 0.687; p value = 0.06). Correlations of MNSI scores {Pearson Correlation Coefficient=0.14, p-value=0.287} and VPTs{Pearson Correlation Coefficient= 0.058(R), 0.189(L); p-value=0.660(R), 0.148(L)} with serum vitamin D levels were not statistically significant. CONCLUSION: Oxidative stress, as confirmed by the biomarker, 8-OHdG, has a important role in the development of this sensory neuropathy.

Hepcidin and proinflammatory markers in children with chronic kidney disease: A case-control study
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BACKGROUND: Hepcidin is the main regulator of hepcidin-ferroportin axis and is elevated in children with chronic kidney disease (CKD). Anemia of CKD and its relation to hepcidin, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and high-sensitivity C-reactive protein (hs-CRP) in iron- and erythropoietin (EPO)-naïve, non-dialyzed children with CKD is under-studied. MATERIALS AND METHODS: This case-control study aimed to study the levels of hepcidin and other proinflammatory markers (IL-6, TNF-α, hs-CRP) and their relation with anemia in iron- and erythropoietin-naïve, non-dialysis CKD (stage 3 - 5) patients. 32 pediatric CKD stage 3 - 5 patients aged 2 - 18 years without previous iron or EPO therapy were compared with 32 gender- and age-matched healthy controls. The CKD cases were also divided into three categories based on their serum ferritin levels and transferrin saturation (%TSAT): true iron deficiency, impaired iron trafficking, and no iron deficiency. The baseline iron status was then correlated with the serum hepcidin levels. RESULTS: Serum hepcidin, IL-6, and TNF-α levels were significantly elevated compared to controls. As CKD stage progressed, hemoglobin levels decreased, while serum hepcidin, IL6, TNF-α and hs-CRP levels increased significantly. Serum hepcidin levels correlated positively with IL-6 (r = 0.57, p = 0.001), TNF-α (r = 0.34, p = 0.05), hs-CRP (r = 0.36, p = 0.03), and ferritin (r = 0.07, p = 0.001), while being inversely correlated with Total iron binding capacity (TIBC) (r = -0.50, p = 0.003), hemoglobin (r = -0.52, p = 0.001), and glomerular filtration rate (GFR) (r = -0.71, p = 0.000). Serum hepcidin levels were highest in those with impaired iron trafficking, followed by those with no iron deficiency, followed by those with absolute iron deficiency (55.16 vs. 49 vs. 11.8, p = 0.005). Amongst those with no iron deficiency, hepcidin correlated negatively with hemoglobin (r = -0.752, p-value = 0.007). CONCLUSION: A positive correlation between hepcidin and other inflammatory biomarkers in non-dialyzed, iron- and EPO-naïve pediatric CKD patients suggests a role of these markers in higher hepcidin production and its contribution to iron-restricted erythropoiesis across the spectrum of CKD. Median hepcidin levels were highest in those with impaired iron trafficking, followed by those with no iron deficiency, followed by those with absolute iron deficiency, suggesting that in an iron-replete state, high hepcidin levels inhibit iron absorption from the gut and release from iron storing cells, thus restricting erythropoiesis leading to anemia.
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Protean Neurological Manifestations in Chikungunya.

Unplanned urbanization and secondary migration has caused increased spurt in arboviral diseases especially Dengue and Chikungunya. With this exponential rise in these illness, now we are beginning to notice uncommon presentations of these common illnesses. Here we present two interesting cases: one of paraparesis and another of quadriparesis with respiratory involvement secondary to Chikungunya, although the mechanism in one is hypokalemia and the other is GBS secondary to Chikungunya. Just the magnitude of cases presenting in metros and major cities of our country warrant sensitizing the physicians about these uncommon manifestations..

Delayed presentation of toxic epidermal necrolysis-like cutaneous acute graft-versus-host disease in the setting of recent immunosuppressant discontinuation.

Acute graft-versus-host disease (GvHD) is a process that classically has been defined as occurring less than 100 days after stem cell transplant. When Stage IV cutaneous acute GvHD occurs outside this window, it can be difficult to distinguish clinically from toxic epidermal necrolysis (TEN). A 50-year-old man with diffuse large B-cell lymphoma who had undergone an allogeneic stem cell transplant 20 months previously was admitted for neutropenic septic shock. He developed a slowly progressing macular/papular eruption with multiple tender bullae found to be consistent with TEN-like Stage IV cutaneous acute GvHD on biopsy. It was discovered that the patient's maintenance immunosuppression had been completely discontinued one month prior to admission in preparation for clinical trial enrollment, causing a late presentation of cutaneous acute GvHD. This case provides particular insight into the diagnosis and management of late-presenting acute GvHD given that it is the first reported case of Stage IV cutaneous acute GvHD more than 12 months after stem cell transplant. In the setting of decreased immunosuppression in a patient with a history of a stem cell transplant, acute graft-versus-host disease must be considered regardless of the time that has elapsed since transplant.

Subclinical non-autoimmune hypothyroidism in children with steroid resistant nephrotic syndrome.

BACKGROUND: Thyroid status has not been studied well in children with steroid resistant nephrotic syndrome (SRNS). METHODS: In this cross sectional study we recruited 20 children aged 1-16 years with SRNS and similar number of controls. Serum levels of FT3, FT4 and TSH were measured in all the subjects. Overt hypothyroidism was defined as low FT4 (normal values: 0.7-2.0 ng/mL) and elevated serum TSH above reference values (0.45-4.5 mIU/L). Subclinical hypothyroidism (SH) was defined as an elevation in serum TSH with a normal serum FT4 concentration. The primary outcome measure was serum levels of FT3, FT4 and TSH in children with SRNS. RESULTS: Thirty per cent of the children (n = 6) with SRNS had non-autoimmune subclinical hypothyroidism (2 children each with grade I, II and III). Children with SRNS had a median TSH value [3.9 mIU/L (0.5-13)] within normal range, but levels were high as compared to controls. Out of 6 children with SH, 3 were in partial remission, 3 were in complete remission. The TSH levels normalized on thyroxine supplementation in grades II and III subclinical hypothyroidism. CONCLUSION: Subclinical non-autoimmune hypothyroidism is present in a significant proportion of children with SRNS despite partial or complete remission. Thyroid profile should be evaluated routinely in this subset of patients.

Hepcidin Levels in Response to Oral Iron Therapy in Children with Anemia.

OBJECTIVE: To estimate the change in serum hepcidin levels and its correlation with change in hemoglobin (Hb) level during the initial two weeks of oral iron therapy in children with iron deficiency anemia (IDA). METHODS: A prospective observational study was carried out in children aged 2-12 years with IDA. Children with severe anemia (Hb < 7 g/dL), those with fever, infections, history of oral iron intake or blood transfusion within the preceding three months, or intolerant to oral iron were excluded. Serum hepcidin-25 was assessed using ELISA-based kits on day 0 (pre-therapy), after 24 hours and 14 days of starting oral iron therapy. RESULTS: Out of 78 children who were screened, we included 64 children with IDA with a mean (SD) hemoglobin of 8.81 (1.22) g/dL. The baseline mean (SD) serum hepcidin-25 levels [7.81 (4.88) ng/mL] increased significantly to 8.38 (4.96) ng/mL at 24 hours and 9.51 (5.2) ng/mL on day 14 of oral iron therapy (P < 0.001). 63 children showed a good response to oral iron therapy. No significant correlation was observed between baseline hepcidin levels with change in hemoglobin on day 1 (r = -0.10, P = 0.40) or day 14 (r = -0.10, P = 0.43) of therapy. CONCLUSION: Serum hepcidin levels rise significantly as early as 24 hours after starting oral iron therapy and should be explored to assess response to oral iron therapy in children with anemia.

Doxycycline-associated acute pancreatitis: a rare adverse effect of a commonly prescribed antibiotic.

In this case, a woman in her 80s presented to the emergency department with signs and symptoms of acute pancreatitis that began after starting a course of doxycycline. Common aetiologies of acute pancreatitis, including alcohol use, gallstones and hypertriglyceridaemia were ruled out. Less common aetiologies, including recent Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure, hypercalcaemia, malignancy, infection and trauma, were also ruled out, making drug-induced acute pancreatitis the most likely aetiology. After consideration of her medication list, doxycycline was determined to be the offending medication. On discontinuation and treatment with fluids and analgesics, her condition slowly improved.This case illustrates a rare but severe complication of doxycycline use. Determining the aetiology of drug-induced acute pancreatitis is more difficult in older patients due to high rates of polypharmacy. Recognition of doxycycline as an aetiology of drug-induced pancreatitis may allow earlier recognition and intervention in cases of suspected pancreatitis without a clear common aetiology in older patients with polypharmacy.

Sebaceous carcinoma of the trunk and extremities: Epidemiology and treatment patterns in the United States.

Background: Sebaceous carcinoma is a rare cancer, and little is known about its current epidemiology and treatment. This is particularly true for sebaceous carcinomas of the trunk and extremities. Objective: We present a database analysis of sebaceous carcinoma cases to further delineate demographics, location, tumor characteristics, and treatment modalities among patients diagnosed with these tumors. Methods: The National Cancer Database was queried for cases of sebaceous carcinoma between 2004 and 2016. 3211 cases were analyzed for descriptive and comparative statistics. Results: Twenty-six percent of sebaceous carcinomas were found on the trunk and extremities. Tumors on the trunk and extremities were more likely to be larger than tumors on the head and neck, with 8% being greater than 50 mm (P < .001). Tumors on the trunk and extremities were more likely to be well differentiated (P < .001) and have fewer lymph node metastases (P < .001). Surgery was the primary treatment modality for tumors, followed by radiotherapy and rarely chemotherapy. Conclusions: Sebaceous cancer is a poorly understood entity. We demonstrated that trunk and extremity tumors tend to be larger and more differentiated than those of the head and neck. Treatment practices are varied at this time, but surgery is the primary modality.

Risk stratification analysis of recurrent myocardial infarction in Indian population using inflammatory, lipid, thrombotic and extracellular matrix remodeling markers.

OBJECTIVE: Atherosclerosis is a chronic condition characterized by impaired lipid homeostasis and chronic inflammatory pathology in large and mid-sized arteries. Myocardial infarction is caused by coronary artery thrombosis in a ruptured or unstable atherosclerotic plaque. Despite the emphasis on known triggering factors, such as hypertension and dyslipidemia, adverse events following MI, such as recurrence and mortality, are still high. Therefore, it is imperative to assess potential determinants of plaque instability. We evaluated markers of inflammation, extracellular matrix (ECM) remodeling, thrombosis, and lipids in first-time and recurrent MI (RMI). METHODS: Two hundred patients diagnosed with MI within the first 24 h of the event were included in the study and categorized as first-time or recurrent MI. Serum levels of NF-κB, hs-CRP, TNF-α, IFN γ, IL-6, VCAM-1,MMP-9, stromelysin, TIMP-1, MCP-1, PAPP-A, vWF, D-dimer, PLA2, PON-1, Apo-B, Apo-A1, ox-LDL, and anti-oxidized LDL antibodies were analyzed by ELISA. We performed a multivariate logistic regression analysis for risk stratification. RESULTS: The mean age of first-time MI patients was 52.4 ± 25 years and that of recurrent MI patients was 55.9 ± 24.6 years. RMI patients showed significant (p¡0.05) upregulation of markers of inflammation (TNF-α), endothelial adhesion (VCAM-1), ECM remodeling (MMP-9, PAPP-A), and antioxidant PON-1 enzyme. First-time MI patients had significantly higher serum IL-6 and D-dimer levels than RMI patients. Risk categorization for RMI was determined at 0.5 cut-off utilizing proteomic indicators at 95% confidence interval. CONCLUSION: Non-lipid factors provide substantial insights into plaque instability. Multiple markers of inflammation, thrombosis, extracellular matrix remodeling, and paroxonase-1 are reliable indicators of recurrent myocardial infarction.