Postural fall in systolic blood pressure is a useful warning sign in dengue fever

Background

Capillary leak is the hallmark of development of severe dengue. A rise in haematocrit has been a major warning sign in WHO guidelines. Postural hypotension, which could reflect the intravascular volume reduction in capillary leak has been noted as warning sign in CDC and Pan American Health Organisation guidelines. We evaluated the diagnostic accuracy of postural hypotension as a marker of development of severe dengue.

Methods

150 patients admitted with dengue fever were recruited in this prospective observational study. Diagnostic accuracy of conventional warning signs (abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, liver enlargement, increasing hematocrit with decreasing platelets) and postural hypotension was evaluated.

Results

23 (15.3%) subjects developed severe dengue. Multiple logistic regression analysis showed that ascites/pleural effusion and postural fall in systolic blood pressure of >10.33% had odds ratio of 5.024(95%CI:1.11 - 22.75) and 11.369 (95% CI:2.27 - 56.87), respectively. Other parameters did not reach statistical significance. Sensitivity and specificity of ascites/pleural effusion were 82.6% and 88.2% for development of severe dengue whereas postural fall in systolic blood pressure had sensitivity and specificity of 87% and 82.7%.

Conclusions

These findings present a strong case for including postural hypotension as a warning sign in patients with dengue fever, especially in resource limited settings.

Erythrocyte miRNA-92a-3p interactions with PfEMP1 as determinants of clinical malaria

Based on the recently added high throughput analysis data on small noncoding RNAs in modulating disease pathophysiology of malaria, we performed an integrative computational analysis for exploring the role of human-host erythrocytic microRNAs (miRNAs) and their influence on parasite survival and host homeostasis. An in silico analysis was performed on transcriptomic datasets accessed from PlasmoDB and Gene Expression Omnibus (GEO) repositories analyzed using miRanda, miRTarBase, mirDIP, and miRDB to identify the candidate miRNAs that were further subjected to network analysis using MCODE and DAVID. This was followed by immune infiltration analysis and screening for RNA degradation mechanisms. Seven erythrocytic miRNAs, miR-451a, miR-92a-3p, miR-16-5p, miR-142-3p, miR-15b-5p, miR-19b-3p, and miR-223-3p showed favourable interactions with parasite genes expressed during blood stage infection. The miR-92a-3p that targeted the virulence gene PfEMP1 showed drastic reduction during infection. Performing pathway analysis for the human-host gene targets for the miRNA identified TOB1, TOB2, CNOT4, and XRN1 genes that are associated to RNA degradation processes, with the exoribonuclease XRN1, highly enriched in the malarial samples. On evaluating the role of exoribonucleases in miRNA degradation further, the pattern of Plasmodium falciparum_XRN1 showed increased levels during infection thus suggesting a defensive role for parasite survival. This study identifies miR-92a-3p, a member of C13orf25/ miR-17-92 cluster, as a novel miRNA inhibitor of the crucial parasite genes responsible for symptomatic malaria. Evidence for a plausible link to chromosome 13q31.3 loci controlling the epigenetic disease regulation is also suggested.

A novel method for measuring sublingual temperature using conventional non-contact forehead thermometer

Background: Sublingual temperature measurement is a quick and accurate representation of oral temperature and corresponds closely with core temperature. Sub-lingual temperature measurement using non-contact infrared thermometers has not been studied for this purpose and if accurate they would be a reliable and convenient way of recording temperature of a patient very quickly. The aim of the study was to evaluate the utility of recording sublingual temperature using an infrared non-contact thermometer and establish its accuracy by comparing the readings with tympanic thermometer recordings.

Methods: This cross-sectional study was carried out in 29 patients (328 paired recordings from sublingual and tympanic sites simultaneously). Subjects were requested to keep their mouth closed for five minutes before recording the temperature. Sublingual recordings were performed for each patient at different times of the day using an infrared thermometer. The infrared thermometer was quickly brought 1cm away from the sublingual part of the tongue and the recordings were then done immediately. Readings were compared with the corresponding tympanic temperature.

Results: The non-contact sublingual temperature correlated very closely with tympanic temperature (r=0.86, p<0.001). The mean difference between the infrared sublingual and tympanic temperature was 0.21°C (standard deviation [SD]:0.48°C, 95% confidence interval [CI] of 0.16-0.27). The intra-class correlation co-efficient (ICC) between core and sublingual temperatures was 0.830 (95% CI: 0.794 to 0.861) p<0.001. The sensitivity of sublingual IR (infrared) temperature of 37.65°C was 90% and specificity was 89% for core temperature >38°C.

Conclusions: This innovative modification of using the forehead infrared thermometer to measure the sublingual temperature offers an accurate, rapid and non-contact estimation of core temperature.

Serum soluble interleukin-2 receptor (sIL-2R) is an accurate biomarker for dengue-associated hemophagocytic lymphohistiocytosis syndrome diagnosed by Hscore

Objective

Hemophagocytic lymphohistiocytosis is a potentially fatal complication of severe dengue fever. Here we evaluated the serum soluble IL-2R levels as potential biomarker for identifying HLH in patients with dengue fever.

Methods

In this cross-sectional study conducted in a tertiary care center of a teaching hospital, subjects with dengue and fever of more than 5 days, leukopenia/thrombocytopenia and/or hepatosplenomegaly were studied. Data were collected to compare sIL-2R values and serum ferritin with Hscore and Histiocyte Society 2004 criteria. Relevant statistical methods were used.

Results

80 subjects with severe dengue fever were analyzed with relevant investigations. Mean H score was 219.2 ± 17.6 in 18 dengue patients with HLH v/s 166.2 ± 11.2 in 62 patients without HLH (p =  < 0.001). Serum ferritin (11,230.5 v/s 7853.5, p = 0.013) and sIL-2R (32,917.5 v/s 6210, p = < 0.001) were significantly higher in those patients with HLH. sIL-2R correlated very well with HScore (r = 0.98, p < 0.001) compared to ferritin (r = 0.51, p < 0.001) with an AUROC of 1.00 compared to 0.694 (95% CI 0.557–0.831) of serum ferritin for diagnosing HLH. A cut-off value of 10,345 pg/ml for sIL-2R had a sensitivity and specificity of 100% for HLH, whereas, a ferritin value of 8613 ng/ml had only 67% sensitivity and 55% specificity.

Conclusion

sIL-2R could be a single most useful biomarker to differentiate dengue fever patients who are likely to progress to HLH, from those that are not. Full workup for HLH could be limited only to those patients with elevated sIL-2R, especially in resource limited settings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-022-01906-8.

Fever Time Series Analysis Using Slope Entropy. Application to Early Unobtrusive Differential Diagnosis

Fever is a readily measurable physiological response that has been used in medicine for centuries. However, the information provided has been greatly limited by a plain thresholding approach, overlooking the additional information provided by temporal variations and temperature values below such threshold that are also representative of the subject status. In this paper, we propose to utilize continuous body temperature time series of patients that developed a fever, in order to apply a method capable of diagnosing the specific underlying fever cause only by means of a pattern relative frequency analysis. This analysis was based on a recently proposed measure, Slope Entropy, applied to a variety of records coming from dengue and malaria patients, among other fever diseases. After an input parameter customization, a classification analysis of malaria and dengue records took place, quantified by the Matthews Correlation Coefficient. This classification yielded a high accuracy, with more than 90% of the records correctly labelled in some cases, demonstrating the feasibility of the approach proposed. This approach, after further studies, or combined with more measures such as Sample Entropy, is certainly very promising in becoming an early diagnosis tool based solely on body temperature temporal patterns, which is of great interest in the current Covid-19 pandemic scenario.

Massive hemoptysis: A rare case with uncommon presentation and rapid response - A case report

We report an unusual case of massive haemoptysis in young patient with mass lesion in left upper lobe. Bronchoscopic biopsy, percutaneous CT guided biopsy & serum marker confirmed the lesion to be granulomatous with polyangiitis (GPA). Rarity of the case was endoluminal bronchial lesion in GPA and radiographic presentation of mass lesion on the Computed Tomography. Also this case highlights that massive haemoptysis can be a sole and initial manifestation of GPA. Prompt diagnosis & pulse therapy led to dramatic symptomatic, clinical & radiological improvement, emphasizing the fact that GPA can present as acute emergency and rapid diagnosis with early treatment initiation with pulse steroid therapy & rituximab can be life saving measure.

Plasmapheresis in Sepsis-induced Thrombotic Microangiopathy: A Case Series

Introduction

Cytokines and granulocyte elastase produced in sepsis cleave a disintegrin and metalloprotease with thrombospondin type I motif 13 (ADAMTS13) and deplete its levels. By this mechanism, sepsis results in microangiopathic hemolytic anemia (MAHA) with thrombocytopenia. Hence, the hypothesis is that plasmapheresis may help in sepsis-induced thrombotic microangiopathy (sTMA), by removing the factors responsible for low levels of ADAMTS13. In tropical countries like India, the contribution of sepsis to intensive care unit (ICU) mortality is high; and hence, it is essential to look out for newer modalities of sepsis treatment. There is abundant literature on the use of plasmapheresis in sepsis but data on its use in sTMA are limited, thus necessitating further research in this field.

Case description

This case series studies the outcomes of five patients admitted with sTMA in the ICU and attempts to evaluate the effectiveness of plasmapheresis in improving their outcomes. All patients diagnosed with sTMA and treated with plasmapheresis, between January 2016 and August 2018 at our tertiary care center, were selected for the study. The diagnosis of sepsis was based on sepsis-3 definition.

Results

Four different gram-negative organisms were found to have caused MAHA, with the commonest source being either urinary tract infection (UTI) or lower respiratory tract infection. Three of five patients required hemodialysis and two had disseminated intravascular coagulation (DIC). All five had good outcome and recovered well from the acute episode post plasmapheresis.

Discussion

In two of five patients, the initial smear was negative and hence the need for repeated examination of the peripheral blood smear should be kept in mind in cases of sTMAs. The median of the number of plasmapheresis sessions required in sTMA is six, which is lesser than that required for primary thrombotic thrombocytopenic purpura (TTP). Hence, the duration of central line placement and the risk of catheter-related complications are low. Based on the observations made in this case study, further exploratory studies are required to evaluate the efficacy of plasmapheresis in sTMA secondary to tropical infections.

How to cite this article

Upadhya SRS, Mahabala C, Kamat JG, Jeganathan J, Kumar S, Prabhu MV. Plasmapheresis in Sepsis-induced Thrombotic Microangiopathy: A Case Series. Indian J Crit Care Med 2020;24(3):195–199.

Asymptomatic malaria carriers and their characterization in hotpops of malaria at Mangalore

Objective:

This study aimed to identify asymptomatic malaria carriers and study the differences in local and migrant population in Mangalore.

Materials and Methods:

This study was conducted using two-stage cluster sampling. In the first stage, wards were randomly selected. The sample size for each cluster (wards) was determined using the probability proportionate to size method. In the second stage, required number of households was selected using a simple random sampling technique from each cluster. From the selected clusters, samples from 140 participants were collected.

Results:

Of the 140 cases, 106 (75.7%) were male and 34 (24.3%) were female. Six cases (4.3%) of the 140 cases were positive for malarial parasites, of which gametocytes of Plasmodium falciparum were noted in three cases and schizonts of Plasmodium vivax in three cases. From the total number of cases, 56 (40%) constituted the migrant population and the remaining 84 (60%) were the local population. All the six patients with asymptomatic carriers belonged to the migrant population.

Conclusion:

A more sound malaria elimination strategy needs to be implemented, for which active surveillance for cases would form a backbone. This study shows that the migrant population seems to show a predilection for asymptomatic malaria, thus targeting malaria elimination programs to areas with a high migrant population would help.

MiRNA-146a Polymorphism Was Not Associated with Malaria in Southern India

Micro-RNAs (miRNAs) play a crucial role in immune regulation, and a common miRNA-146a polymorphism (rs2910164) increased the odds of falciparum malaria in pregnant African women. Here, we examined whether this association holds true in a different population, that is, 449 mainly male and adult malaria patients and 666 community controls in southwestern India. Plasmodium vivax malaria (67%) predominated over falciparum malaria (11%) and mixed species infections (22%). Overall, 59% of the study participants carried the miRNA-146a polymorphism. However, it was not associated with the odds of malaria, irrespective of parasite species. This underlines the importance of considering the complexities of clinical manifestations of malaria, genetic background, and parasite species when disentangling the role of human genetic variation, including those of miRNAs in malaria.

Classification of fever patterns using a single extracted entropy feature: A feasibility study based on Sample Entropy

Fever is a common symptom of many diseases. Fever temporal patterns can be different depending on the specific pathology. Differentiation of diseases based on multiple mathematical features and visual observations has been recently studied in the scientific literature. However, the classification of diseases using a single mathematical feature has not been tried yet. The aim of the present study is to assess the feasibility of classifying diseases based on fever patterns using a single mathematical feature, specifically an entropy measure, Sample Entropy. This was an observational study. Analysis was carried out using 103 patients, 24 hour continuous tympanic temperature data. Sample Entropy feature was extracted from temperature data of patients. Grouping of diseases (infectious, tuberculosis, non-tuberculosis, and dengue fever) was made based on physicians diagnosis and laboratory findings. The quantitative results confirm the feasibility of the approach proposed, with an overall classification accuracy close to 70%, and the capability of finding significant differences for all the classes studied.

Duffy antigen receptor for chemokines gene polymorphisms and malaria in Mangaluru, India

Background

Duffy blood group antigens serve as receptors for Plasmodium vivax invasion into erythrocytes, and they are determined by polymorphisms of the Duffy antigen receptor for chemokines (DARC), also known as Fy glycoprotein (FY). Duffy negativity, i.e., absence of the antigens, protects against P. vivax infection and is rare among non-African populations. However, data on DARC polymorphisms and their impact on Plasmodium infection in India are scarce.

Methods

In a case–control study among 909 malaria patients and 909 healthy community controls in Mangaluru, southwestern India, DARC polymorphisms T-33C (rs2814778), G125A (rs12075), C265T (rs34599082), and G298A (rs13962) were genotyped. Associations of the polymorphisms with the odds of malaria, parasite species and manifestation were assessed.

Results

Among patients, vivax malaria (70%) predominated over falciparum malaria (9%) and mixed species infections (21%). DARC T-33C was absent and C265T was rare (1%). FYB carriage (deduced from DARC G125A) was not associated with the risk of malaria per se but it protected against severe falciparum malaria (P = 0.03), and hospitalization (P = 0.006) due to falciparum malaria. Vice versa, carriage of DARC 298A was associated with increased odds of malaria (aOR, 1.46 (1.07–1.99), P = 0.015) and vivax malaria (aOR, 1.60 (1.14–2.22), P = 0.006) and with several reported symptoms and findings of the patients.

Conclusion

This report from southern India is the first to show an independent effect of the DARC 298A polymorphism on the risk of malaria. Functional studies are required to understand the underlying mechanism. Moreover, FYB carriage appears to protect against severe falciparum malaria in southern India.

Molecular Evidence for Plasmodium falciparum Resistance to Sulfadoxine-Pyrimethamine but Absence of K13 Mutations in Mangaluru, Southwestern India

In most of India, sulfadoxine-pyrimethamine (SP) plus artesunate serves as first-line treatment for uncomplicated falciparum malaria. In 112 clinical Plasmodium falciparum isolates from Mangaluru, southwestern India, we sequenced molecular markers associated with resistance to SP, lumefantrine, and artemisinin (pfdhfr, pfdhps, pfmdr1, and K13). The pfdhfr double mutation 59R-108N combined with the dhps 437G mutation occurred in 39.3% and the pfdhfr double mutation plus the pfdhps double mutation 437G-540E in additional 24.1%. As for pfmdr1, the allele combination N86-184F-D1246 dominated (98.2%). K13 variants were absent. No evidence for artemisinin resistance was seen. However, the antifolate resistance alleles compromise the current first-line antimalarial sulfadoxine-pyrimethamine plus artesunate, which may facilitate the emergence of artemisinin resistance. Artemether-lumefantrine, introduced in northeastern parts of the country, in the study area faces the predominant pfmdr1 NFD genotype, known to impair lumefantrine efficacy. Further monitoring of resistance alleles and treatment trials on alternative artemisinin-based combination therapies are required.

Characterization of Plasmodium vivax pvmdr1 Polymorphisms in Isolates from Mangaluru, India

India accounts for approximately half of the global Plasmodium vivax cases, but information as to the presence of chloroquine (CQ) resistance is scarce. In an observational study in Mangaluru, south-western India, of 116 vivax malaria patients analyzed, 89.5% (102/114) had cleared parasitemia on days two or three of CQ treatment. Two remaining patients presented on days four and five without parasitemia. One hundred eight isolates of these 116 patients were successfully sequenced for pvmdr1 polymorphisms. Eight non-synonymous polymorphisms but no wild-type isolate were detected. Ten pvmdr1 haplotypes were observed with mutations T958M and F1076L occurring in all isolates, whereas the candidate CQ resistance marker Y976F was present in one isolate only. Pvmdr1 polymorphisms were not associated with early parasite clearance. The high proportion of early parasite clearance and the virtual absence of pvmdr1 Y976F and of sextuple pvmdr1 mutants suggest that CQ in the study area is still sufficiently effective. However, the abundance of pvmdr1 mutations in the local parasite population warrants monitoring.

Classification of Infectious and Noninfectious Diseases Using Artificial Neural Networks from 24-Hour Continuous Tympanic Temperature Data of Patients with Undifferentiated Fever

Fever is one of the major clinical symptoms of undifferentiated fever cases. Early diagnosis of undifferentiated fever is a challenging task for the physician. The aim of this study was to classify infectious and noninfectious diseases from 24-hour continuous tympanic temperature recordings of patients with undifferentiated fever using a machine learning algorithm (artificial neural network). This was an observational study conducted in 103 patients who presented with undifferentiated fever. Twenty-four-hour continuous tympanic temperature was recorded from each patient. Features were extracted from temperature signals and classified into infectious and noninfectious diseases using an artificial neural network (ANN). The ANN classifier provided the highest accuracy at 91.3% for differentiating infectious and noninfectious diseases from undifferentiated fever cases. Significant kappa agreement (κ = 0.777) was found between the final diagnosis as determined by the physician and the classification obtained using an ANN classifier. Based on our results, we conclude that the continuous 24-hour temperature monitoring and application of an ANN classifier provides a simple noninvasive and inexpensive supplementary diagnostic method to differentiate infectious and noninfectious diseases.

Unique temperature patterns in 24-h continuous tympanic temperature in tuberculosis

Body temperature monitoring in most healthcare institutions is limited to checking the presence or absence of fever. Our present study evaluated the 24h continuous tympanic temperature pattern in patients with fever in order to detect typical patterns seen in tuberculosis (TB). This observational study was conducted on 81 undifferentiated fever patients whose recordings were stored using the TherCom device. Unique temperature patterns were analysed and compared. TB patients exhibited a unique temperature pattern, namely a slow temperature elevation followed by slow temperature fall seen in 78.5% (22/28) compared to 24.52% (13/53) of non-TB patients. Recognition of this pattern may therefore be useful as a valuable diagnostic aid in the early diagnosis of TB.

Manifestation of malaria in Mangaluru, southern India

BACKGROUND

Severe and fatal vivax malaria is increasingly reported from India. In Mangaluru, southern India, malaria is focused in urban areas and associated with importation by migrant workers. In Wenlock Hospital, the largest governmental hospital, the clinical, parasitological and biochemical characteristics of malaria patients were assessed.

METHODS

During the peak malaria season in 2015 (June to December), outpatients were interviewed and clinically assessed. Malaria was ascertained by microscopy and PCR assays, concentrations of haemoglobin, creatinine and bilirubin, as well as thrombocyte count, were determined, and severe malaria was defined according to WHO criteria.

RESULTS

Among 909 malaria patients, the vast majority was male (93%), adult (median, 26 years) and of low socio-economic status. Roughly half of them were migrants from beyond the local Karnataka state, mostly from northern and northeastern states. Vivax malaria (69.6%) predominated over mixed Plasmodium vivax-Plasmodium falciparum infection (21.3%) and falciparum malaria (9.0%). The geometric mean parasite density was 3412/µL. As compared to vivax malaria, patients with falciparum malaria had higher parasite density and more frequently showed impaired general condition, affected consciousness and splenomegaly. Also, they tended to more commonly have anaemia and increased creatinine levels, and to be hospitalized (7.3%). Mixed-species infections largely assumed an interim position. Severe malaria (3.5%) was not associated with parasite species. No fatality occurred.

CONCLUSION

In this study, uncomplicated cases of malaria predominated, with P. falciparum causing slightly more intense manifestation. Severe malaria was infrequent and fatalities absent. This contrasts with the reported pattern of manifestation in other parts of India, which requires the analysis of underlying causes.

Analysis of Long-Term Temperature Variations in the Human Body

Body temperature is a continuous physiological variable. In normal healthy adults, oral temperature is estimated to vary between 36.1°C and 37.2°C. Fever is a complex host response to many external and internal agents and is a potential contributor to many clinical conditions. Despite being one of the foremost vital signs, temperature and its analysis and variations during many pathological conditions has yet to be examined in detail using mathematical techniques. Classical fever patterns based on recordings obtained every 8-12 h have been developed. However, such patterns do not provide meaningful information in diagnosing diseases. Because fever is a host response, it is likely that there could be a unique response to specific etiologies. Continuous long-term temperature monitoring and pattern analysis using specific analytical methods developed in engineering and physics could aid in revealing unique fever responses of hosts and in different clinical conditions. Furthermore, such analysis can potentially be used as a novel diagnostic tool and to study the effect of pharmaceutical agents and other therapeutic protocols. Thus, the goal of our article is to present a comprehensive review of the recent relevant literature and analyze the current state of research regarding temperature variations in the human body.

Manipal diabetes coronary artery severity score

AIMS

To develop a risk score, for identifying severe and complex CAD in patients with type 2 diabetes mellitus.

METHODS

In this cross sectional study, 179 patients with type 2 diabetes mellitus undergoing coronary angiogram for the evaluation of suspected coronary artery disease (CAD) were recruited at a tertiary-care hospital. Patients were divided into developmental (n=124) and validation (n=55) cohorts. Biochemical and anthropometric parameters were analysed. Predictors of severe and complex CAD (SYNTAX Score>22) were identified by multiple logistic regression analysis.

RESULTS

Insulin resistance>3.4 (OR: 21.26, 95% CI: 5.71-79.09), duration of diabetes>5years (OR: 13.50, 95% CI: 3.13-58.25), total cholesterol/HDL-C ratio>5 (OR: 2.75, 95% CI: 0.66-11.55) and waist circumference>96cm (OR: 5.08, 95% CI: 1.27-20.42) were independent predictors of severe and complex CAD, and Manipal Diabetes Coronary Artery Severity Score was developed.

CONCLUSIONS

The prediction of severe and complex CAD was achieved with this simple score, and thus enabling effective identification of patients beforehand, who are not likely to be suitable for angioplasty.

Basal hyperinsulinemia beyond a threshold predicts major adverse cardiac events at 1 year after coronary angiogram in type 2 diabetes mellitus: a retrospective cohort study

BACKGROUND

There is a substantial reduction in cardiovascular related morbidity and mortality in the general population attributed to improved treatment of cardiac risk factors and disease, the same magnitude of benefit has not been observed in those with diabetes mellitus. The aim of the present study was to evaluate factors associated with the cardiac outcome at 1 year after coronary angiogram in patients with type 2 diabetes mellitus and to compare the outcomes with nondiabetics.

METHODS

A retrospective cohort study was carried out in subjects who underwent coronary angiogram for an evaluation of CAD, with follow-up data available for period of 12 months. The data consisted of 208 type 2 diabetic and 75 non-diabetic patients. Clinical, anthropometric and other biochemical risk factors of the study participants were recorded. Univariate and multivariate cox proportional hazard regression analyses were performed to evaluate the relation between the cardiovascular risk factors and major adverse cardiac events (MACE).

RESULTS

At 1 year, MACE was observed in 50 (24.04%) type 2 diabetic subjects, which included non-fatal myocardial infarction 24 (11.54%), target vessel revascularization 15 (7.21%) and death 11 (5.29%). The area under the curve for insulin in predicting MACE was found to be 0.81 (95% CI 0.73-0.88) with sensitivity and specificity of 88% (95% CI 0.71-0.96) and 74% (95% CI 0.65-0.81) respectively. After adjustment for potential confounders hyperinsulinemia (>20 µIU/ml) was significantly associated with MACE [adjusted hazard ratio (HR): 3.03, 95% CI 1.41-6.54, p = 0.005]. Interestingly, the MACE rate in type 2 diabetics with insulin levels <20 µIU/ml (10.2%) and non-diabetics (12%) (p = 0.676) appears to be same.

CONCLUSIONS

In addition to severity of the CAD at the baseline, basal hyperinsulinemia beyond a threshold strongly predicts adverse cardiac events at 1 year in type 2 diabetes mellitus. Those below the threshold, appears to be having a risk equivalent to non-diabetics.

Correlation between serum ferritin and bone marrow iron stores

Bone marrow aspirate examination is a gold standard to assess bone marrow iron stores. The correlation between serum ferritin and bone marrow iron has not been established in detail, as the cutoff value for iron stores have not been uniformly established. Ours was a cross-sectional study. Perl's Prussian blue stain was used to stain bone marrow, assessed by Gale's grading. Receiver operating characteristic curve analysis and Spearman's correlation coefficient calculated. Gale's grading revealed iron store deficiency in 26 and sufficiency in 13. Spearman's correlation coefficient of 0.90 showed a significant relation between serum ferritin and bone marrow iron stores. A serum ferritin of 228 pmol/L had high sensitivity and specificity for iron deficiency; our study suggests that this level be taken as the cutoff value to predict iron store deficiency in bone marrow.

Comparison of Conventional Mercury Thermometer and Continuous TherCom® Temperature Recording in Hospitalized Patients

INTRODUCTION

Detection of accurate body temperature fluctu-ations in hospitalized patients is crucial for appropriate clinical decision-making. The accuracy and reliability of body temperature assessment may significantly affect the proper treatment.

AIM

To compare the conventional and continuous body temperature recordings in hospitalized patients.

MATERIALS AND METHODS

This cross-sectional study was carried out at a tertiary care centre and study included 55 patients aged between 18-65 years with a history of fever admitted to a tertiary care hospital. A noninvasive continuous temperature recording was done using TherCom^® device through tympanic temperature probe at tympanic site at one-minute intervals for 24 hours. The conventional temperatures were recorded in the axilla using mercury thermometer at specific time intervals at 12:00 noon, 8:00 PM and 5:00 AM. Peak temperature differences between continuous and conventional methods were compared by applying Independent sample t-test. Intra class Correlation Coefficient (ICC) test was performed to assess the reliability between two temperature-monitoring methods. A p<0.05 was considered as significant.

RESULTS

The average peak temperature by non-invasive continuous recording method was 39.07°C ±0.76°C while it was 37.55°C ±0.62°C by the conventional method. A significant temperature difference of 1.52°C [p<0.001;95% CI(1.26-1.78)] was observed between continuous and conventional temperature methods. Intra class Correlation Coefficient (ICC) between continuous and conventional temperature readings at 12:00 noon was α= 0.540, which had moderate reliability. The corresponding coefficients at 8:00 PM and 5:00 AM were α=0.425 and 0.435, respectively, which had poor reliability.

CONCLUSION

The conventional recording of temperature is routinely practiced and does not reflect the true temperature fluctuations. However, the continuous non-invasive temperature recording is simple, inexpensive and a better tool for recording the actual temperature changes.

Carbon monoxide exposure among police officers working in a traffic dense region of Southern India

Currently, in India, air pollution is widespread in urban areas where vehicles are major contributors. The aim of this study was to investigate the level of exposure in traffic police officers exposed to vehicle exhaust for less than 8 h/day. The specific objective of the study was to determine the levels of carboxyhaemoglobin (COHb) in these officers. The effect of exposure for 8 h/day is known, but shorter durations of chronic exposure need to be investigated, and there is a need to explore the policy options in this exposed population. This cross-sectional study, included non-smoking traffic police officers between 30 and 50 years of age working for more than 2 years in busy traffic junctions. The cases were sex matched with controls of same age group, working in offices at a teaching hospital. Venous blood was collected at the end of 3 h of duty for estimation of COHb among both the groups. The COHb levels were expressed as percentage values. Differences between the COHb levels among the traffic police officers and office workers were analysed using the Mann-Whitney U test and considered significant at p < 0.05. Traffic police officers had significantly elevated COHb levels compared with the controls; 76.5% of traffic police officers had COHb >2.5% compared with no office workers at this level and 41.2% of the police officers had COHb levels >4%. Overall, 53.8% of officers with COHb >2.5% reported headaches compared with 15.8% of officers with COHb <2.5%.

Severity of coronary artery disease in type 2 diabetes mellitus: Does the timing matter?

AIM

The aim of our study was to compare the angiographic changes in 53 nondiabetic patients, 54 type 2 diabetic patients of less than 5 years of duration, 41 patients with 5-10 years of diabetes, and 27 with more than 10 years of diabetic duration.

METHODS

In this cross-sectional study, 175 patients, who underwent coronary angiogram for the evaluation of the coronary artery disease (CAD), were recruited. Based on the angiographic findings, syntax score, vessel score, and coronary collaterals grading were analyzed. The biochemical analysis was done by using the auto analyzer.

RESULTS

A significant increase in the mean syntax score (p=0.019), vessel score (p=0.007), and coronary collateral grade (p=0.008) was observed in the patients with 5-10 years of diabetes when compared to those with less than 5 years of diabetic duration. There was no significant difference in the mean syntax score (p=0.979), vessel score (p=0.299), and collateral grade (p=0.842) between the patients with 5-10 years and more than 10 years of diabetes. The difference in the mean syntax score (p=0.791), vessel score (p=0.098), and collateral grade (p=0.661) between the nondiabetic and the patients with less than 5 years of diabetes was not significant.

CONCLUSION

A significant structural change in the coronary arteries was found among the patients with 5-10 years of diabetes.

Factors associated with no apparent coronary artery disease in patients with type 2 diabetes mellitus for more than 10 years of duration: a case control study

BACKGROUND

Type 2 diabetes mellitus is an important risk factor in the development of coronary artery disease (CAD) and is often associated with severe disease. However, this risk is not uniform, some patients remain free of CAD even after many years of treatment for diabetes. The present study was aimed to identify the factors that are associated with a favorable CAD profile.

METHODS

A case-control study of 76 patients with type 2 diabetes mellitus who were on treatment for more than 10 years duration and undergoing a coronary angiogram for the evaluation of clinically suspected CAD at a tertiary care hospital were recruited for the study. The presence and absence of significant CAD was determined after a coronary angiogram. Clinical history, and anthropometric and biochemical parameters were analyzed. Insulin resistance was determined by the Homeostasis Model Assessment. Multiple logistic regressions were done to find out the factors associated for a favorable CAD profile.

RESULTS

The difference in HOMA-IR (2.37 ± 0.69 VS 3.77 ± 1.64, p < 0.001) and urine microalbumin (24.15 ± 32.16 VS 82.72 ± 117.70, p = 0.004) were found to be statistically significant among those who did not have CAD when compared to those who had CAD. The difference in lipid profile, HbA1C, fasting blood sugar, BMI, waist hip ratio, waist and hip circumference was not significant. The adjusted odds ratio for insulin resistance less than 2.5 (OR 9.09, 95 % CI 1.91-41.83, p = 0.005), females (OR 7.91, 95% CI 1.55-40.38, p = 0.013) and microalbumin <20 mg/l (OR 4.57, 95% CI 1.17-17.85, p = 0.029) were independently associated with normal coronaries. The adjusted odds ratio for lipid profile, BMI, blood pressure and HbA1C were not significant.

CONCLUSIONS

HOMA-IR less than 2.5, microalbuminuria less than 20 mg/l and females are the factors appear to be associated with no apparent CAD.

Acute eosinophilic ascites: An unusual form of an unusual case

Eosinophilic gastroenteritis (EGE) is an uncommon disease characterised by eosinophilic infiltration in the gastrointestinal tract. EGE may involve more than one layer of the gastrointestinal tract. Clinical features depend on the layer and location which is involved. We report an unusual case of eosinophilic ascites associated with antinuclear antibody positivity, which is an unusual variety of serosal form of EGE.

Correlation of severity of coronary artery disease with insulin resistance

BACKGROUND

Insulin resistance (IR) has known to be associated with coronary artery disease (CAD), but the assessment of severity of the CAD based on IR in type 2 diabetes mellitus has not been established in detail.

AIMS

The aim of our study was to establish the correlation between IR and the severity of CAD in type 2 diabetes mellitus.

MATERIALS AND METHODS

In a cross-sectional study design, 61 consecutive patients with type 2 diabetes mellitus who underwent coronary angiogram for the evaluation of CAD were recruited. Fasting blood glucose, fasting insulin levels, systolic blood pressure and total cholesterol/high density lipoprotein-cholesterol ratio were determined. Homeostasis model assessment-IR (HOMA-IR) was correlated with severity of CAD, which was measured by modified Gensini Score.

RESULTS

There was a significant correlation between log HOMA-IR and severity of CAD (r = 0.303, P = 0.009) in diabetic patients. Correlation of the Gensini Score with other known risk factors was not significant.

CONCLUSIONS

The results of our study indicate that we might able to predict the severity of CAD by measure of IR.

Antihypertensive therapy: nocturnal dippers and nondippers. Do we treat them differently?

Hypertension is a major independent risk factor for cardiovascular diseases. Management of hypertension is generally based on office blood pressure since it is easy to determine. Since casual blood pressure readings in the office are influenced by various factors, they do not represent basal blood pressure. Dipping of the blood pressure in the night is a normal physiological change that can be blunted by cardiovascular risk factors and the severity of hypertension. Nondipping pattern is associated with disease severity, left ventricular hypertrophy, increased proteinuria, secondary forms of hypertension, increased insulin resistance, and increased fibrinogen level. Long-term observational studies have documented increased cardiovascular events in patients with nondipping patterns. Nocturnal dipping can be improved by administering the antihypertensive medications in the night. Long-term clinical trials have shown that cardiovascular events can be reduced by achieving better dipping patterns by administering medications during the night. Identifying the dipping pattern is useful for decisions to investigate for secondary causes, initiating treatment, necessity of chronotherapy, withdrawal or reduction of unnecessary medications, and monitoring after treatment initiation. Use of this concept at the primary care level has been limited because 24-hour ambulatory blood pressure monitoring has been the only method for documenting dipping/nondipping status so far. This monitoring technique is expensive and inconvenient for routine usage. Simpler methods using home blood pressure monitoring systems are evolving to document basal blood pressure in the night, which would help in greater acceptance and use of the concept of dipper/nondipper in managing hypertension at the primary care level.

Atypical Manifestations of Dengue Fever (DF) - Where Do We Stand Today?

BACKGROUND AND OBJECTIVES

Dengue fever (DF) is transmitted by Aedes aegypti mosquitoes. With growing population, rapid urbanization and lack of appropriate sanitary measures, proliferation of mosquitoes and subsequent dengue infections have increased rampantly with an estimated 30-fold increase in incidence over last five decades. With rising disease burden, atypical manifestations have increased as well, which are missed most often due to lack of awareness. Our aim was to look for the atypical manifestations of dengue fever.

MATERIALS AND METHODS

A prospective hospital based observational study was conducted at hospitals of Kasturba Medical College in Mangalore over a period of two years (June-2010 to May-2012). One-hundred fifty ELISA confirmed IgM-dengue sero-positive cases satisfying WHO criteria were examined clinically and laboratory data assessed till they got discharged from hospital after ruling out other causes of fever. Atypical manifestations in dengue fever were noted and analyzed.

RESULTS

Most common symptoms noticed were myalgia, headache, rash, arthralgia, pain in abdomen and nausea. More than half of the study group had one or the other atypical manifestation. Liver function test derangement was most often seen. Most common atypical manifestation was hepatitis found in 40.6% patients. Febrile diarrhea, renal failure, Acalculous cholecystitis and conduction abnormalities of heart were among other common manifestations. Three patients died of multi-organ dysfunction, disseminated intravascular coagulation and shock. Platelet count did not correlate well with severity of bleeding. Overall recovery rate was good.

CONCLUSION

Some of the atypical manifestations of dengue fever are no more a rare entity. Clinical vigilance for these manifestations is important for timely detection and management as some of them could be fatal.

Cutaneous mucormycosis with necrotising fasciitis in a young immunocompetent individual

Primary cutaneous mucormycosis is uncommon and is extremely rare in immunocompetent young individuals. Here we report a case of necrotising fasciitis due to mucormycosis in an immunocompetent young individual following minor trauma. Mucormycosis must be suspected in any wound that is worsening despite appropriate treatment even in immunocompetent individuals.

Tuberculous retropharyngeal abscess

Chronic retropharyngeal abscess caused by tuberculosis is rare. It should be suspected in a person who presents with a destructive lesion of the vertebra and a retropharyngeal mass. Early diagnosis and treatment are necessary to prevent the serious complications of the disease. We present the case of a patient who came to our clinic with collapse of the C5-C6 vertebrae and retropharyngeal abscess. We were able to avoid any complications by initiating early surgical drainage and antituberculous therapy.

Tuberculous Retropharyngeal Abscess

Chronic retropharyngeal abscess caused by tuberculosis is rare. It should be suspected in a person who presents with a destructive lesion of the vertebra and a retropharyngeal mass. Early diagnosis and treatment are necessary to prevent the serious complications of the disease. We present the case of a patient who came to our clinic with collapse of the C5-C6 vertebrae and retropharyngeal abscess. We were able to avoid any complications by initiating early surgical drainage and antituberculous therapy.