Urinary Neutrophil Gelatinase-associated Lipocalin as a Diagnostic and Prognostic Marker for Acute Kidney Injury in Hospitalized Cirrhotic Patients: A Study from North Indian Population.

Background: A serious problem in cirrhosis is acute renal injury. The study aimed to examine the urinary neutrophil gelatinase-associated lipocalin (uNGAL) as a diagnostic and prognostic marker of acute kidney injury (AKI) in cirrhotic patients. Methods: A prospective study was carried out over a period of 1 year. A total of 490 patients suffering from cirrhosis who visited an indoor hospital were screened, and after the exclusion, a total of 90 subjects admitted to the medicine intensive care unit (MICU) fulfilling inclusion criteria were enrolled. Those having a history of renal diseases, on nephrotoxic drugs, in septic shock, peritonitis, UTI, and no urine output were excluded. On admission, for the estimation of uNGAL, urinary levels of sodium, creatinine, fresh urine samples were obtained, and blood samples were taken for serum creatinine estimation. Results: Out of 90 patients, 33.3% did not develop AKI, and 66.7% developed AKI. Urinary neutrophil gelatinase-associated lipocalin levels were six times higher in patients with acute tubular necrosis (259.08 ± 118.41 ng/mL) and three times higher in Hepatorenal syndrome (HRS)-AKI (124.97 ± 16.38) as compared with patients with normal kidney function (39.76 + 5.7). Those who died had a higher uNGAL (171.6 ng/mL) in comparison to those who survived (133.7 ng/mL). At a cutoff value of ≥114.9 (ng/mL), urinary NGAL represents a sensitivity of 86.92% and specificity of 100% to diagnose AKI and AUC 0.966 (95% CI: 0.919-0.990) in cirrhotic patients. Conclusion: Urinary NGAL is good for diagnosing AKI and is a marker to distinguish the types of AKI in liver cirrhosis. How to cite this article: Patel ML, Shyam R, Chaudhary A, Sachan R, Ali W. Urinary Neutrophil Gelatinase-associated Lipocalin as a Diagnostic and Prognostic Marker for Acute Kidney Injury in Hospitalized Cirrhotic Patients: A Study from North Indian Population. Indian J Crit Care Med 2023;27(8):545-551.

Correlation of C-reactive Protein with Delirium in Obstetrics Intensive Care Unit: A Tertiary Center Experience.

Background: Delirium is a neuropsychiatric illness. It affects critically ill patients on ventilator and increases mortality. The aim of this study was to evaluate the association of C-reactive protein (CRP) level with delirium in critically obstetrics women and its role in prediction of delirium. Materials and methods: Arospective observational study was conducted in the intensive care unit (ICU), and the duration of study was one year. Total 145 subjects were recruited, 33 patients were excluded, and 112 subjects were studied. For study, group A (n = 36) includes critically ill obstetric women who had delirium on admission; group B (n = 37) includes critically ill obstetric women who developed delirium within 7 days; and group C (n = 39) that includes critically ill obstetric women who did not develop delirium after follow-up of 7 days was served as control. Disease severity was assessed by using acute physiologic assessment and chronic health evaluation (APACHE) II score, and Richmond Agitation-Sedation Scale (RASS) was used to assess awakeness. In awake patients (RASS of ≥3), delirium was assessed by the use of confusion assessment method for ICU tools. C-reactive protein measured by particle enhanced turbidimetric immunoassay-two point kinetic method. Results: The mean ages of group A, B, and C were 26.44 ± 4.72, 27.46 ± 4.97, and 28.26 ± 5.67 years, respectively. C-reactive protein levels on the day of delirium development (group B) were found to be significantly higher than day 1 CRP levels of groups A and C. The mean Global Attentiveness Rating (GAR) was significantly lower in groups A and B as compared to that in group C (p < 0.001). On evaluating the correlation of CRP with GAR, it was found to be inverse and mild in strength for the correlation between CRP and GAR (r = -0.403, p < 0.001). At a cut-off value of >181 mg/L, CRP had sensitivity of 93.2% and specificity of 69.2%. The positive predictive value was 85% and the negative predictive value was 84.4% that differentiate delirium from non-delirium. Conclusion: C-reactive protein is a useful tool for screening and prediction of delirium in critically ill obstetric patients. How to cite this article: Shyam R, Patel ML, Solanki M, Sachan R, Ali W. Correlation of C-reactive Protein with Delirium in Obstetrics Intensive Care Unit: A Tertiary Center Experience. Indian J Crit Care Med 2023;27(5):315-321.

Study of Pulmonary Function Test Abnormalities in Metabolic Syndrome.

INTRODUCTION: Metabolic Syndrome (MetS) is defined as a constellation of an interconnected physiological, biochemical, clinical, and metabolic factors that directly increases the risk of atherosclerotic cardiovascular disease and T2DM. Although the link between impaired lung function and cardiovascular events and T2DM has been recognized, the association between impaired lung function and MetS has not been comprehensively assessed. MATERIAL AND METHODS: A cross sectional prevalence study was done in tertiary care hospital in northern India on 100 patients of the age between 25-65 years who fulfilled the IDF criteria for MetS to evaluate pulmonary function test (Spirometry) abnormalities. RESULTS: Maximum number of patients were in 31-40 years of age group (45%) followed by those aged 41-50 year (26%), < 30 years (15%), >50 years (14%). Mean age of patients was 39.59±8.67 year. In this cross-sectional study, patients with Metabolic Syndrome showed significantly lower FVC % predicted (P< 0.001), FEV1 % predicted (P< 0.001) as compared to the group without Metabolic Syndrome. There was a strong linear decrease in FVC and FEV1 % predicted as the number of components of MetS increases. We observed that 28% of the male and 46.6% of female patients showed restrictive ventilatory pattern and 7% of male and 13.4% of female patients showed mixed pattern. CONCLUSION: All MetS components were associated with pulmonary function impairment. As the number of MetS components increases, patients had more severe decline in pulmonary functions.

A Study of Cardiovascular Abnormalities in HIV Positive Patients in a Tertiary Care Hospital in Northern India.

Introduction: Cardiovascular illness is common in patients with HIV infection, particularly in the later course of disease. Cardiovascular abnormalities in people living with HIV disease (PLHIV) often go unrecognized or untreated resulting in increased cardiovascular related morbidity and mortality and reduced quality of life. The prevalence of cardiac involvement in PLHIV has been reported to range between 28 to 73%. However, the incidence of symptomatic heart failure in HIV positive patients is 8-10%. Aims and Objectives: The present study had been undertaken to study the prevalence of cardiovascular manifestation in HIV positive patients in north Indian population and its association with HAART, CD4 count and WHO stages of the disease. Material and Methods: This study was conducted in the department of Medicine, KGMU, Lucknow. A total of 75 HIV positive patients of age >15 years, admitted to the hospital were enrolled, out of which 32 were on ART. The cardiovascular evaluation in the form of chest x-ray, ECG, 2D echocardiography and NT-ProBNP was done and their correlations with CD4 count was studied. Two rheumatic heart disease patients were excluded during analysis. Results: Cardiovascular manifestations were found in around 52.1% of HIV positive patients. Chest x-ray showed cardiomegaly in 8 out of 73 patients. ECG abnormalities were found in 49.3% while 2 D echocardiography was abnormal in 52.1% of the patients. Though NT-Pro BNP was abnormal in 26.7% of the patients, no statistical correlation was found with CD4 counts. Conclusion: The prevalence of cardiovascular abnormalities in our study population was 52.1%. Our study did not show any statistical correlation with CD4 counts but showed correlation with the WHO clinical staging of the disease. We suggest a study with larger sample size to see the exact prevalence of cardiovascular disease in HIV positive patients.

Role of Urinary Neutrophil Gelatinase-associated Lipocalin as a Biomarker of Acute Kidney Injury in Patients with Circulatory Shock.

BACKGROUND: The early prediction of acute kidney injury (AKI) by the current clinical and laboratory methods remains inadequate. Neutrophil gelatinase-associated lipocalin (NGAL) has emerged as a promising noninvasive biomarker of kidney injury in shock. The aim of this study was to assess the ability of urinary NGAL (uNGAL) to predict AKI in adult Intensive Care Unit (ICU) patients. MATERIALS AND METHODS: We prospectively studied 70 patients with circulatory shock admitted to the ICU over a period of 1 year. uNGAL was analyzed at ICU admission and after 24 h. Risk, injury, failure, loss, and end-stage kidney criteria were calculated at admission and for consecutive 4 days. The primary outcome was AKI defined as an increase in creatinine of at least 50% from baseline or a reduction in urine output to <0.5 ml/kg/h for 6 h. RESULTS: uNGAL was a good diagnostic marker for AKI development; at day 1, the cutoff value 48.54 ng/mL had a sensitivity and specificity of 79.49 and 73.14, respectively, and the area under the curve (AUC) of 0.82 (95% confidence interval [CI], 0.75-0.87) for predicting AKI. At day 2, the cutoff value 190.92 ng/mL had a sensitivity and specificity of 90.0 and 64.66, respectively, and the AUC of 0.76 (95% CI, 0.70-0.88) for predicting AKI. CONCLUSION: uNGAL could be a good early predictor biomarker of AKI following circulatory shock.

A Comparative Study of Community-acquired Acute Kidney Injury and Hospital-acquired Acute Kidney Injury from a Tertiary Care Hospital in North India.

BACKGROUND: In this observational study, clinical characteristics, etiologies, and outcomes of patients admitted to the hospital with community-acquired acute kidney injury (CAAKI) have been compared in contrast to those who hospital-acquired Acute Kidney Injury (HAAKI). METHODS: This was a prospective study of adults aged 18 years or above diagnosed with acute kidney injury (AKI) over a period of 17 months at a tertiary care hospital. RESULTS: 230 patients had AKI with the mean age of the study population being 45.33 ± 12.68 years. 178 (77.4%) patients were enrolled from medical unit, 25 (10.7%) from surgical unit, and 27 (11.7%) from obstetrical unit. The observed incidence of AKI was 15/1000 admissions. About 58.2% had CAAKI and 96 (43.7%) had HAAKI. Out of 230 patients, 170 (73.9%) patients were male and 60 (26.1%) were female. Sepsis was the most common (52.1%) etiology of AKI among the medical cases. Urosepsis, scrub typhus, and pneumonia were the most common causes of AKI. Sixty percent of AKI was Kidney Disease Improving Global Outcomes Stage 1 or 2 and 40% was in Stage 3. Oliguria was seen in 56.5%, hyperkalemia in 34.7%, fluid overload in 6.1%, and metabolic acidosis in 22.6%. The majority of patients had multiple organ involvement (52.1%) at the time of enrollment. About 116 (50.4%) had lung injury requiring mechanical ventilation and 95 (41.3%) were on inotropes. Mortality occurred in 19.5%. Anemia, the use of vasopressor drugs, and the need for intensive care support were independent predictive factors for mortality. CONCLUSION: AKI was common in hospitalized patients and leads to significant inhospital mortality. AKI is largely a CAAKI, and the lesser extent is due to HAAKI. Many causes are potentially preventable. Early fluid resuscitation, effective antibiotics, appropriate antidotes, and timely referral of established AKI patients to centers with dialysis facilities can improve AKI outcomes.

Résumé Contexte:Dans cette étude observationnelle, les caractéristiques cliniques, les étiologies et les résultats des patients admis à l'hôpital pour des affections aiguës d'origine communautaire. les lésions rénales (CAAKI) ont été comparées à celles qui ont contracté une lésion rénale aiguë à l'hôpital (HAAKI).Méthodes:Il s'agissait d'une étude prospective portant sur des adultes âgés de 18 ans ou plus ayant reçu un diagnostic d'insuffisance rénale aiguë (IRA) sur une période de 17 mois dans un hôpital de soins tertiaires.Résultats:230 patients avaient une IRA, l'âge moyen de la population étudiée étant de 45,33 ± 12,68 ans. 178 (77,4 %) patientes ont été recrutées dans l'unité médicale, 25 (10,7 %) dans l'unité chirurgicale et 27 (11,7 %) dans l'unité obstétricale. L'incidence observée de l'IRA était de 15/1 000 admissions. Environ 58,2 % avaient CAAKI et 96 (43,7 %) avaient HAAKI. Sur 230 patients, 170 (73,9 %) étaient des hommes et 60 (26,1 %) étaient des femmes. Le sepsis était l'étiologie d'IRA la plus courante (52,1 %) parmi les cas médicaux. L'urosepsie, le typhus des broussailles et la pneumonie étaient les causes les plus fréquentes d'AKI. Soixante pour cent des AKI étaient des maladies rénales améliorant les résultats globaux de stade 1 ou 2 et 40 % étaient au stade 3. Une oligurie a été observée dans 56,5 %, une hyperkaliémie dans 34,7 %, une surcharge hydrique dans 6,1 % et une acidose métabolique dans 22,6 %. La majorité des patients présentaient une atteinte de plusieurs organes (52,1 %) au moment de l'inscription. Environ 116 (50,4 %) souffraient de lésions pulmonaires nécessitant une ventilation mécanique et 95 (41,3 %) prenaient des inotropes. La mortalité est survenue dans 19,5%. L'anémie, l'utilisation de médicaments vasopresseurs et la nécessité d'un soutien en soins intensifs étaient des facteurs prédictifs indépendants de mortalité.Conclusion:L'IRA était fréquente chez les patients hospitalisés et entraîne une mortalité hospitalière significative. AKI est en grande partie un CAAKI, et dans une moindre mesure est dû au HAAKI. De nombreuses causes sont potentiellement évitables. Une réanimation liquidienne précoce, des antibiotiques efficaces, des antidotes appropriés et une orientation rapide des patients atteints d'IRA établis vers des centres dotés d'installations de dialyse peuvent améliorer les résultats de l'IRA.

Diagnostic Accuracy of Serum Glycosylated Fibronectin in Prediction of Preeclampsia: A Nested Case-Control Study.

BACKGROUND: Preeclampsia is a life-threatening complication of pregnancy that occurs in approximately 7% of all pregnancies. In India, the incidence of preeclampsia is 8%-10% and the prevalence is 5.4%, whereas the prevalence of hypertensive disorders of pregnancy is 7.8%. AIM AND OBJECTIVES: This study was aimed at evaluating the diagnostic accuracy of serum glycosylated fibronectin (S. GlyFn) in the prediction of preeclampsia. METHODS: A nested case-control study was carried out for 16 months in the department of obstetrics and gynecology. A total of 240 women were recruited and followed after written consent and ethical clearance. Six were lost to follow-up, 15 had second-trimester abortions (excluded from the study), and 32 women developed hypertensive disorders of pregnancy (cases), out of which 1 woman developed antepartum eclampsia, 10 women developed preeclampsia with severe features, and 21 women developed preeclampsia without severe features. One hundred and eighty-seven women remained normotensive throughout the pregnancy until 6 weeks postpartum. After randomization, out of these samples, 54 were analyzed and considered controls. Levels of S. GlyFn were estimated using an ELISA kit using the ELISA technique. RESULTS: The mean S. GlyFn level was significantly higher at the time of enrollment among those women who later developed preeclampsia (127.59 ± 27.68 ng/m) as compared to controls (107.79-53.51 ng/mL). GlyFn at a cutoff value of 126.70 ng/mL significantly (P = 0.034) discriminates cases of preeclampsia with severe features from healthy controls with a sensitivity of 90.00%, a specificity of 63.00%, a 31.03% positive predictive value, and 97.14% negative predictive value. CONCLUSION: S. GlyFn, at a cutoff value of 126.70 ng/mL, had good sensitivity to discriminate PE from normotensive and was also a good prognostic marker.

Résumé Contexte:La prééclampsie est une complication potentiellement mortelle de la grossesse qui survient dans environ 7 % de toutes les grossesses. En Inde, l'incidence de la prééclampsie est de 8 % à 10 % et la prévalence est de 5,4 %, alors que la prévalence des troubles hypertensifs de la grossesse est 7,8 %. But et objectifs : Cette étude visait à évaluer la précision diagnostique de la fibronectine sérique glycosylée (S. GlyFn) chez la prédiction de la prééclampsie.Méthodes:Une étude cas-témoin nichée a été menée pendant 16 mois dans le service d'obstétrique et gynécologie. Au total, 240 femmes ont été recrutées et suivies après consentement écrit et autorisation éthique. Six ont été perdus de vue, 15 avaient avortements au deuxième trimestre (exclus de l'étude), et 32 femmes ont développé des troubles hypertensifs de la grossesse (cas), dont 1 femme a développé une éclampsie antepartum, 10 femmes ont développé une prééclampsie avec des caractéristiques sévères et 21 femmes ont développé une prééclampsie sans traits sévères. Cent quatre-vingt sept femmes sont restées normotendues tout au long de la grossesse jusqu'à 6 semaines après l'accouchement. Après randomisation, sur ces échantillons, 54 ont été analysés et considérés comme témoins. Les niveaux de S. GlyFn ont été estimés à l'aide d'un kit ELISA en utilisant la technique ELISA.Résultats:Le niveau moyen de S. GlyFn était significativement plus élevé au moment de l'inscription chez les femmes qui ont développé plus tard une prééclampsie (127,59 ± 27,68 ng/m) par rapport aux témoins (107,79­53,51 ng/mL). GlyFn à une valeur seuil de 126,70 ng/mL de manière significative (P = 0,034) discrimine les cas de prééclampsie avec des caractéristiques sévères des témoins sains avec une sensibilité de 90,00 %, un spécificité de 63,00 %, une valeur prédictive positive de 31,03 % et une valeur prédictive négative de 97,14 %.Conclusion:S. GlyFn, à une valeur seuil de 126,70 ng/mL, avait une bonne sensibilité pour distinguer l'EP du normotendu et était également un bon marqueur pronostique.

Prognostic significance of estimation of pseudocholinesterase activity and role of pralidoxime therapy in organophosphorous poisoning.

BACKGROUND: Organophosphorous (OP) poisoning is one of the most common poisonings seen in India. OP compounds act through inhibition of enzyme acetylcholinesterase and estimation of pseudocholinesterase (PCE) activity strengthens the diagnosis in clinically uncertain cases of OP poisoning. The role of pralidoxime (PAM) therapy in OP poisoning has been controversial. STUDY OBJECTIVES: This study was aimed to determine the prognostic significance of estimation of PCE activity and also to assess the role of PAM therapy in OP poisoning. MATERIALS AND METHODS: Patients of suspected OP poisoning of age >12 years admitted to emergency unit at a tertiary healthcare center of north India were enrolled. Patients were categorized into two groups; group A who were given intravenous atropine and group B who were given injectable PAM along with atropine. Serum PCE level was estimated at the time of admission in all patients and severity of OP poisoning was assessed according to PCE level. Requirement of atropine, oxygen inhalation, intubation and ventilatory support, total hospital stay, and mortality were compared between different classes of severity and also between Groups A and B. RESULTS: This study included a total of 70 subjects, 35 in each group with mean age of 24.99 ± 8.7 years. Out of 70 subjects 49 (70%) were male and 21 (30%) were female. Forty nine patients (70%) of OP poisoning were with suicidal intent while 21 (30%) cases were accidentally poisoned. In all suicidal cases route of poisoning was ingestion whereas in all the accidental cases route of exposure was inhalational. PCE levels were reduced in all the cases and the mean level was 3,154.16 ± 2,562.40 IU/L. The total dose of atropine required, need for oxygen inhalation and need for intubation and ventilatory support, mean duration of hospital stay and mortality rate (P = 0.003) were higher in moderate to severe cases and did not have significant difference between Groups A and B. CONCLUSION: The study recommends estimation of PCE level at admission to classify severity of OP poisoning and to estimate prognosis. This study did not find any beneficial role of PAM therapy in reducing morbidity as well as mortality.

S100B as a predictor of delirium in critically ill obstetric patients: A nested case-control study.

Background: Delirium is a neuropsychiatric illness that lasts for a short period of time. The incidence of delirium in the intensive care unit (ICU) varies from 20% to 80%. Methods: A nested case-control study was carried out in the obstetric ICU. Individuals were divided into three groups: critically ill obstetric women who had delirium on admission (Group A), women who developed delirium within follow-up of 7 days (Group B), and women who did not develop delirium after follow-up of 7 days (Group C). The APACHE II score was used to assess critical illness severity. The Richmond Agitation-Sedation Scale was used to assess the alertness or sedation level of patients, and the Confusion Assessment Method (ICU scale) was used to assess the presence of delirium. S100B was measured by human S100B calcium-binding protein B ELISA kit (Elabscience Biotechnology, Houston, USA). Results: Severe preeclampsia and antepartum eclampsia were significantly associated with delirium. S100B levels in Group B were found to be significantly higher than those in Group C. S100B levels were higher in patients with >2 morbidities in comparison to patients with two morbidities. At a cutoff value of >169.25 pg/ml, S100B had a sensitivity of 74% and a specificity of 87.2% to discriminate cases of delirium from nondelirium. Conclusion: The rise in S100B levels was approximately three times greater in those who developed delirium as compared to those who did not. It is a more specific predictor of delirium.

Diagnostic Accuracy of Plasma Cystatin C and Renal Resistive Index for Acute Kidney Injury in Critically Ill Patients: A Prospective Observational Study.

Background: Acute kidney injury (AKI) is a quite common problem in critically ill patients. Serum cystatin C has emerged as a marker of AKI. This study was aimed to evaluate the diagnostic ability of serum Cystatin-C and Renal Resistive Index in prediction of AKI among critically ill patients. Methodology: This prospective observational study was carried out in the department of Medicine, over a period of one year. After informed consent and ethical clearance total 120 critically ill patients suffering from sepsis were enrolled, out of which 70 patients developed AKI while 50 did not develop AKI during treatment in Intensive care unit (ICU). Serum cystatin C was measured on day 1 by particle-enhanced immune nephelometric assay, Renal resistive index (RRI) calculated by ratio of the velocities of arterial perfusion throughout the cardiac phase and glomerular filtration rate was measured on days 1, 3, and 7 respectively. Results: S. cystatin C value was significantly higher(>3times) in AKI patients (14.07±4.8 mcg/ml) as compared to those who did not develop AKI (4.28±3.27 mcg/ml) (p<0.001). After ROC analysis it was found that day1, S. cystatin C, at cut off value of ≥9.29 mcg/ml had diagnostic accuracy 90% with sensitivity 91%, specificity89% and PPV 95.5%. While RRI value on day 7, at cut-off value of ≥0.72, had diagnostic accuracy 98%, sensitivity (98.6%) and specificity (96.7%) for AKI with 98.6% PPV, 96.7% NPV. Conclusion: Serum cystatin C appears to be a promising bio- markers for early diagnosis of AKI in critically ill patients. Whereas, RRI although non-invasive had good diagnostic accuracy but it diagnosed AKI after few days thus diagnosis of kidney injury delayed.

ROC-Analysis Derived Immunohistochemical P53 Cut-Off Scores as an Adjunct to Routine Histopathology for Better Diagnostic Compartmentalisation of Cervical Lesions.

Objective: The aim of this study was to evaluate the predictive value of Immunohistochemical p53 cut-off scores as an adjunct to routine histopathology for better diagnosis of cervical lesions. Materials and Methods: Prospective study carried out for 1 year. After ethical approval and informed consent, a total of 100 cervical tissue samples were analyzed; chronic cervicitis (CC)-15, cervical intraepithelial neoplasia (CIN)-40, and squamous cell carcinoma cervix (SCC)-45 (FIGO 2018 clinical staging). After routine processing of tissue specimen, hematoxylin and eosin (HE) staining was done. Grading of cervical precancerous lesions (CIN) was done as per World Health Organisation criteria as CIN 1,2 or 3. Broder's grading was assigned for every SCC sample. Results: Mean p53 scores of CC, CIN, and SCC cases were 0.0, 1.70, and 4.38, respectively, CIN 1, 2, and 3 were 1.07, 1.63, and 2.22, respectively. SCC was differentiated from CIN3 with p53 ≥4.5 as predictor for SCC, sensitivity and specificity were 57.8% and 88.9%, respectively. Overall diagnostic accuracy of the proposed scoring system for differentiating CC, CIN, and SCC was 61%, while the accuracy of previous methods of interpreting p53 immunoreactivity as immunoscore >2 or arbitrary cut-off of >10% cells with nuclear positivity was only 48%. Conclusion: ROC-derived immunoscore cut-offs can provide the much-needed objectivity and optimal decision thresholds to immunohistochemistry interpretation.

Single step "See and Treat" strategy might be replacing the "conventional three step strategy" in management of preinvasive cervical lesions at tertiary center: A North Indian study.

Introduction: The aim of this study was to compare overtreatment rates of see and treat colposcopy-based single step protocol with cytology and colposcopy-guided biopsy-based conventional three-step protocol using loop electrosurgical excision procedure (LEEP) for treatment of preinvasive lesions of cervix. Materials and Methods: Prospective interventional study was carried out over a period of 1 year. Recruitment of cases was done from the 664 diagnostic colposcopies performed for various gynecological indications. Among 496 colposcopies performed exclusively for unhealthy cervix on per speculum examination, 74 women had high-grade colposcopy (Swede score ≥5). Subsequently, 50 women were enrolled under the see and treat arm, arm 1 and underwent LEEP. In study arm 2, conventional three-step strategy, concurrently 22 women with abnormal cytology. ≥ Atypical squamous cells of undetermined significance and unhealthy cervix were enrolled for colposcopy and if indicated, guided biopsy was obtained and tissue was sent for histopathology. Only 12 such women having HPE reports of cervical intraepithelial neoplasia (CIN) 2 or 3 were subjected to LEEP. Overtreatment was defined as CIN 1 or less on final LEEP tissue histopathology. Results: The overtreatment rate in See and Treat protocol was 44% when colposcopy Swede score cutoff was considered 5, which fell down to 0% when Swede score cutoff was taken 7. Conventional three step protocol had an overtreatment rate of 8.3%. Incidentally diagnosed high-grade CIN or invasive cancer was found in 24%. Discrepancy between biopsy tissue and LEEP tissue histopathology was 50% in conventional arm. Conclusion: Women with unhealthy cervix having high-grade colposcopy (Swede score ≥7) can be directly subjected to LEEP without waiting for results of any initial screening modality. Advantages include minimal over treatment coupled with reduced patient visits and interventions.

Role of renal replacement therapy in pregnancy related acute kidney injury and its outcome.

Background: Pregnancy-related acute kidney injury (PRAKI) has bimodal distribution. The rates of maternal mortality and perinatal mortality in patients with PRAKI have increased. The aim of this study was to evaluate magnitude of PRAKI in North Indian women and to assess morbidity, mortality, and outcomes in patients who received renal replacement therapy. Materials and Methods: This prospective observational study was carried out in the Department of Obstetrics and Gynaecology, in collaboration with nephrology. A total of 150 women suffering from PRAKI were recruited and total 98 obstetrics AKI, requiring renal replacement therapy, classified as per KDIGO guidelines 2012 were enrolled for dialysis. Six patients were lost to follow up before final analysis. Haemodialysis was carried out by B. Brawn machine. Results: Approximately 82% cases of PRAKI diagnosed in postpartum period. Mean cycles of dialysis was 9.06 ± 7.75 approximately half of the females required 1-5 cycles of dialysis. Higher percentages of maternal deaths were observed within 1-5 cycles of dialysis. Women received dialysis after 72 h showed increased chances of partial recovery. After 3 months of follow-up, rate of complete recovery was significantly higher in Stage I (100%) and Stage II (84.6%) PRAKI while rate of partial recovery and deaths were significantly higher in Stage III PRAKI (37.3%). Stage of AKI, baseline K+ levels, treatment modality, duration of ICU stay and use of Vasopressure showed significant association with adverse outcome. Conclusion: Higher percentages of deaths were observed in those who referred late and delay in initiation of dialysis and it was observed within 1-5 cycles of dialysis.

Role of platelet count and mean platelet volume and red cell distribution width in the prediction of preeclampsia in early pregnancy.

INTRODUCTION: Mean platelet volume (MPV), platelet count (PC), and red cell distribution width (RDW) are various blood indices that play important role in preeclampsia. This study aimed to evaluate the role of MPV, RDW, and PC for the prediction of preeclampsia in the early second trimester of pregnancy and to observe its correlation with disease severity. MATERIAL AND METHODS: A prospective case-control study was conducted for 1 year in the Department of Obstetrics and Gynecology. A total of 543 healthy pregnant women were recruited, after obtaining informed consent and ethical clearance and followed till 6 weeks postpartum, 43 were lost to follow-up. Out of 500 women, nonsevere preeclampsia (NSPE) occurred in 16 women and severe preeclampsia (SPE) in 34 women. Around 51 healthy normotensive pregnant women were recruited after systematic randomization from the same cohort, who had not developed the disease, served as controls. NSPE and SPE were defined as per ACOG 2013b guideline. MPV, RDW, and PC were measured two times by the Siemens Advia analyzer; the first samples were withdrawn at the time of enrolment and the next sample was taken after the development of the disease, and both samples were analyzed. RESULTS: MPV was increased with the severity of preeclampsia, diagnostic accuracy was 69.4%, at a cutoff value of ≥9.05 fl and MPV discriminated controls and NSPE with 50.0% sensitivity and 82.4% specificity. To discriminate between controls and SPE, diagnostic accuracy was 74.6% at a cutoff value of ≥9.05 fl, with a sensitivity of 50%. For control versus SPE, MPCs at the cutoff value of ≥2.085 lac/mm3 had sensitivity 52.9% and specificity 66.7%, and diagnostic accuracy 61.2%. For RDW NSPE, at a cutoff value of ≥11.5%, it discriminated against controls and NSPE with 85.3% sensitivity and 49.0% specificity. CONCLUSION: NSPE, MPV, RDW, and PCs had good discriminatory value with the severity of the disease.

Detection of undiagnosed and inadequately treated high blood pressure in dentistry by screening.

BACKGROUND: Worldwide, hypertension is considered as an important health issue due to its unbearable complication of cardiovascular, renal, and nervous system diseases. AIMS AND OBJECTIVE: The aim was to find the prevalence and inadequately treated undiagnosed hypertension in the general population attending the Outpatient Department (OPD) of the Department of Oral and Maxillofacial Surgery, King George's Medical University, Lucknow. MATERIALS AND METHODS: A total of 2500 patients were enrolled in the study within the age group of 20-60 years, attending dental clinics. For every patient, blood pressure (BP) was taken three times, and all the readings were grouped into four categories including normal, prehypertensive stage, Stage 1, and Stage 2 of hypertension. In the dental clinic, the BP assessment was done considering parameters such as sex, smoking and alcohol, the effect of local anesthesia, gutkha chewing, age group, and regular exercise. RESULTS: About 24.39% of undiagnosed hypertensive patients were found among all who attended the OPD of the department of oral and maxillofacial surgery. It was observed that the rise in BP was 16.71% and 2.35% in Stage 1 and Stage 2, respectively, after giving the local anesthesia. CONCLUSION: This study reveals that early diagnosis of undiagnosed and inadequately treated hypertension among general people notified by dentists is an important role, and this should be promoted and emphasized to restrict fatal life complications.

The prognostic value of neutrophil gelatinase-associated lipocalin in sepsis-associated acute kidney injury: A prospective observational study.

BACKGROUND: Sepsis is one of the most common triggering factors for acute kidney injury (AKI). The aim of the study is to evaluate the outcome in sepsis with AKI and determine the prognostic value of urinary neutrophil gelatinase-associated lipocalin (NGAL) in septicemic AKI. MATERIALS AND METHODS: This prospective follow-up study was carried out over a period of 1 year after ethical clearance from the Institutional Ethics committee, a total 165 cases of septicemia were recruited, of which 15 patients were dropped out, 150 patients were identified suffering from septicemia defined as per the organ dysfunction criteria (according to third international consensus 2016) and patients of AKI defined as per the Kidney Disease Improving Global Outcomes 2012 criteria). RESULTS: Out of 150 patients of septicemia enrolled in the study, only 38 (25.33%) suffering from AKI were classified as Group I and rest 112 (74.67%) patients of septicemia not suffering from AKI were classified as Group II. In total, 60.0% (90) patients were discharged from the hospital, rest of the patients (40%) expired. Mean duration of survival was higher in Group II (21.29 ± 1.89 days) as compared to Group I (13.67 ± 1.06 days). Cases with ≥121.90 urine NGAL, rate of mortality (41.7%), were higher as compared to alive patients discharged (34.4%). CONCLUSION: Sequential organ failure assessment score, hospital stay, and mortality were high in septicemic patients with AKI as compared to sepsis without AKI. Survival of patients also not good with septic AKI, those patients who had high NGAL value had poor prognosis.

Assessment of subclinical atherosclerosis and endothelial dysfunction in chronic kidney disease by measurement of carotid intima media thickness and flow-mediated vasodilatation in North Indian population.

BACKGROUND: Chronic kidney disease (CKD) predisposes to accelerated atherosclerosis that is measured by carotid artery intima media thickness (CIMT) and brachial artery flow-mediated dilation (FMD). The aim of this study was to assess the noninvasive risk markers of subclinical atherosclerosis and endothelial dysfunction and their correlation with disease severity. METHODS AND RESULTS: This was a cross-sectional study conducted in 62 patients with CKD: 38 predialysis and 24 on hemodialysis and 50 age- and gender-matched controls. In both the patients and controls, high-sensitivity C-reactive protein (CRP) levels, %FMD, and CIMT were measured. Patients with CKD had increased CRP levels {[5.8 (1.0-6.0)] mg/L vs [1.0 (0.5-2.20)] mg/L; P < 0.001}; %FMD was significantly lower in patients on hemodialysis (5.51%) compared with stage IV (7.62%) and stage III (15.02%) and 17.95% in control subjects (P < 0.001); and CIMT values in hemodialysis patients (0.88 ± 0.06 mm) were significantly higher compared with stage IV (0.67 ± 0.10) and stage III (0.61 ± 0.12) (P < 0.001). Increased CIMT values were seen in patients with CKD (0.82 ± 0.21 mm) than in the healthy controls (0.55 ± 0.16 mm). In patients with CKD, a significant negative correlation was found between CRP levels and FMD responses (r = -0.315; P < 0.001), while a significant positive correlation was found between CRP and CIMT values (r = 0.327; P < 0.001). Compared with predialysis, hemodialysis subjects had significantly lower FMD and higher CRP and IMT values. CONCLUSION: CKD confers a higher inflammatory status when compared with apparently healthy general population. Abnormal FMD responses and CIMT values are more commonly found in dialysis patients. Our findings suggest that CIMT and FMD can be used as noninvasive markers for early risk assessment and stratification in various stages of CKD.

A Study on Cervical Cancer Screening Using Pap Smear Test and Clinical Correlation.

OBJECTIVE: The objective of the study is to evaluate the use of the Pap smear screening method for detection of precancerous lesions. METHODS: All women who visited the outpatient gynecology clinic of the Department of Obstetrics and Gynaecology at King Georges Medical University, Lucknow, UP, India, over 1 year for different clinical problems were recruited for the study. A total of 1650 women who were sexually active and over 21 years of age were enrolled in the study. A clinical examination, an examination per speculum, and a vaginal examination were performed and a history taken for all women. A Pap smear was used for all women to screen for cervical cancer. The smear was obtained using an Ayre spatula and spread over a marked glass slide, which was placed in 95% ethyl alcohol and sent to the Department of Pathology for cytopathological examination. All data were recorded using a predetermined pro forma. Women who had visible malignant cervical lesions were excluded from the study. RESULTS: Most women were in the age range of 30-50 years and multiparous. Vaginal discharge was the most common complaint, occurring in 36.96% of the women. An irregular menstrual cycle was the complaint of 12.78% and abdominal pain of 25.63% of women, while 15.15% were asymptomatic. The Pap smear test of 93.57% of the women was adequately taken, while 6.42% of the individuals had an inadequate sample. The test was negative for malignancy in 48.84%, and 42.66% had infection or inflammation. Atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), and high-grade squamous intraepithelial lesion (HSIL) were detected in 2.90%, 5.09%, and 0.48%, respectively. Women with Pap tests positive for ASCUS, LSIL, and HSIL underwent a colposcopy and guided biopsy. CONCLUSIONS: Women with an abnormal Pap test should undergo a colposcopy, and those with abnormal colposcopy findings should be advised to undergo a biopsy. A Pap smear is simple, noninvasive, cost-effective, and easy to perform for detection of precancerous lesions in a gynecological patient.

Diagnostic accuracy of spot albumin creatinine ratio and its association with fetomaternal outcome in preeclampsia and eclampsia.

INTRODUCTION: Hypertensive disorders in pregnancy are one of the leading causes of maternal and perinatal mortality. Proteinuria is one of the common and important features of preeclampsia. To evaluate the diagnostic accuracy of albumin-creatinine ratio (ACR) in woman with preeclampsia and eclampsia and examine the association between ACR and fetomaternal outcome. MATERIALS AND METHODS: Prospective study carried out over a period of 1 year in the Department of Obstetrics and Gynaecology, after informed consent and ethical clearance total ninety pregnant women from gestational age 20 to 40 weeks were enrolled, including, thirty preeclampsia, thirty antepartum eclampsia, considered as cases and thirty normotensive pregnant women as controls. Preeclampsia was defined as per National High Blood Pressure Education Program 2000 working group. All patients were asked for a spot midstream urine sample, followed by 24 h urine collection. Urinary protein was estimated by the sulfosalicylic acid method and creatinine by the Jaffe's method. The urinary ACR was determined by automated analyzer. RESULTS: Mean value of urinary ACR of controls was significantly lower (0.103 ± 0.037) as compared to both groups. On comparing between groups the difference was significant (<0.001), a strong correlation between urinary ACR levels and 24 h urinary proteins was observed. CONCLUSION: In our study, an association of raised ACR values with severity of disease as well as with adverse fetomaternal outcome was observed.

Self Mutilating Behaviour in Severe Meningococcal Infection; An Interesting Association.

Neisseria meningitidis most commonly manifests as asymptomatic colonization in the nasopharynx of healthy adolescents and adults. It may rarely present as invasive disease which may be either bacterial meningitis or meningococcal septicaemia. Hereby we report a case presented with fever and rashes, irritability followed by self mutilating behaviour who was diagnosed as a case of invasive meningococcal infection. He responded well to treatment with intravenous ceftriaxone and self mutilating behaviour was subsided completely after treatment. Necrosed tissues of fingers were amputated. With best of our knowledge, no similar case of self-mutilation associated with meningococcal infection has been reported yet.