Spectrum of Skin Manifestations in CKD: A Tertiary Care Center Experience from North India

Introduction: Dermal manifestations in chronic kidney disease (CKD) patients may range from mild ones, like xerosis, skin pallor, pruritus, coated tongue, superficial infections and hair and nail changes, to severe life-threatening ones, like nephrogenic systemic fibrosis, which is a rare entity in current times. The present study was done to evaluate the spectrum of mucocutaneous manifestations in patients with CKD and to look for an association between them and various biochemical parameters and inflammatory markers. Material and methods: This study was a 1 year prospective, observational study conducted on adult patients with CKD who presented to the Nephrology clinic in Pt. BD Sharma PGIMS, Rohtak. Patients between the ages of 17 and 75 years with CKD stages II or more with dermatological conditions were included in this study. Each participant was subjected to detailed clinical, biochemical, radiological and dermatological examination by same consultants in order to avoid interpersonal variations. Various skin, mucosal, nail and hair manifestations along with cutaneous infections were analyzed across the spectrum of CKD. Results: Among cutaneous infections, fungal infections predominated, amongst which, onychomycosis was the most common. Xerosis was the most common dermatological disease and the prevalence of xerosis, skin pallor and pruritus was found to increase significantly from Stage II to Stage V and VD of CKD in a statistically significant manner. An association was found between xerosis and decreasing levels of hemoglobin and while ferritin was not different between patients with and without xerosis, high-sensitivity C-reactive protein (hs-CRP) was significantly higher in patients with xerosis. Similarly, hs-CRP levels were significantly elevated in patients with xerostomia and nail pallor as compared with those who did not have these conditions. Lastly, patients with nail pallor had significantly lower albumin. Conclusion: It was observed in our study that in CKD patients on hemodialysis and on conservative management, xerosis, pruritus, pigmentation, nail changes, oral mucosa changes and cutaneous infections were the predominant cutaneous manifestations. In patients with CKD, mucocutaneous manifestations progressively worsened as renal function deteriorated.

Association of Non-Alcoholic Fatty Liver Disease and Type 2 Diabetes Mellitus- An Analytical Cross-Sectional Study

Nonalcoholic fatty liver disease (NAFLD) is a common liver disorder but is often ignored especially in diabetes mellitus and thus carries serious complications in the long run. We aim to study the association of NAFLD with type 2 diabetes mellitus.METHODSA prospective observational case control study of diabetic patients was done in a tertiary care teaching hospital. A total of 50 diabetic patients fulfilling the inclusion criteria were selected as cases while 50 age sex matched non-diabetic patients were included as controls. Complete clinical, laboratory and radiological data was collected from each patient and analyzed. Data was analyzed using statistical software SPSS ver. 21.RESULTSMean value of age in cases was 52.42 ± 10.24 years and in control was 54.04 ± 10.16 years (p>0.05). There were 56% males and 44% females in both the groups. Among the cases, majority (84%) of the patients were on Oral Hypoglycemic Agents (OHA). As compared to controls, cases had significantly higher SGOT and SGPT but significantly lower total bilirubin levels (p<0.05). In the lipid profile, cases had significantly higher TG, LDL and VLDL levels (p<0.05). Significant difference was seen in the USG findings between cases and controls. Majority (66%) of the patients in cases had abnormal USG findings showing liver thickness, as compared to 30% in controls.CONCLUSIONSType 2 diabetes was strongly found to be associated with development of NAFLD, and since most patients of NAFLD remain asymptomatic, all diabetic patients must be screened for development NAFLD.

Diferentes sistemas de pontuação na pancreatite alcoólica aguda: qual a seguir? Um dilema em curso / Different scoring systems in acute alcoholic pancreatitis: which one to follow? an ongoing dilema

ABSTRACT BACKGROUND: Acute pancreatitis is a common disorder in medical practice. In recent times, management has changed drastically with majority of decisions like intravenous antibiotics, negative suction with Ryle's tube and surgical interventions like necrosectomy etc based on severity of the disease. There are different scores in use to assess severity of disease but the relative efficacy has remained a debatable subject. OBJECTIVE: The present study was thus done to investigate the predictive accuracy of different scoring systems in acute pancreatitis. METHODS: Fifty patients of acute pancreatitis admitted in medicine ward of Pt. B.D. Sharma PGIMS, Rohtak, India, were taken for study after fulfilling eligibility criteria. These patients were investigated at admission and followed up prospectively. The severity of pancreatitis was classified for each of these patients as per Revised Atlanta System of Classification. Commonly used scoring systems pertaining to acute pancreatitis, viz, BISAP, Ranson, APACHE II and modified computed tomography severity index (CTSI) were calculated. Subsequently these scores were then correlated with severity, presence of organ failure, occurrence of local complications and final outcome of the patients. RESULTS: Out of 50 patients, etiology was chronic alcohol intake in all but one with idiopathic pancreatitis. The mean age of the study population was 42.06±13.27 years. 32% of these patients had pancreatic necrosis, 40% had peripancreatic collections. 56% of them had mild acute pancreatitis, 24% had moderately severe acute pancreatitis, while 20% had severe acute pancreatitis. APACHE II had the highest accuracy in predicting severity, organ failure and fatal outcomes. As far as these parameters were concerned, the negative predictive values of BISAP score were also considerable. Modified CTSI score was accurate in predicting local complications but had limited accuracy in other predictions. CONCLUSION: APACHE II emerged as most reliable scoring system followed by BISAP and Ranson in management of the patients with acute pancreatitis. But in constraints of time and resources, even BISAP score with its significant negative predictive values served as a valuable tool for assessing and managing these patients.

RESUMO CONTEXTO: A pancreatite aguda é uma desordem comum na prática médica. Nos últimos tempos, sua gestão mudou drasticamente com a maioria das decisões tomadas baseadas na gravidade da doença, como administração de antibióticos intravenosos, sucção negativa com o tubo de Ryle ou intervenções cirúrgicas como necrosectomia, etc. Há diferentes escores em uso para avaliar a gravidade da doença, mas a eficácia relativa manteve-se um assunto discutível. OBJETIVO: O presente estudo foi assim realizado para investigar a acurácia preditiva de diferentes sistemas de pontuação na pancreatite aguda. MÉTODOS: Foram selecionados 50 pacientes com pancreatite aguda admitidos na enfermaria de medicina de Pt. B.D. Sharma PGIMS, Rohtak, Índia, e foram considerados para estudo após o cumprimento dos critérios de elegibilidade. Estes pacientes foram investigados na admissão e seguidos prospectivamente. A severidade da pancreatitie foi classificada para cada um destes pacientes pelo sistema de classificação Atlanta revisado. Os sistemas de pontuação comumente usados pertencentes à pancreatite aguda, ou seja, BISAP, Ranson, APACHE II e CTSI modificado foram calculados. Posteriormente, esses escores foram correlacionados com a severidade, presença de falência de órgãos, ocorrência de complicações locais e desfecho final dos pacientes. RESULTADOS: Dos 50 pacientes, a ingestão crônica de álcool foi a etiologia em todos, exceto em um com pancreatite idiopática. A média de idade da população estudada foi de 42,6±13,27 anos. Destes pacientes, 32% apresentavam necrose pancreática, 40% apresentavam coleções peripancreáticas, 56% apresentavam pancreatite aguda leve, 24% apresentavam pancreatite aguda moderadamente grave, enquanto 20% apresentavam pancreatite aguda grave. O APACHE II teve maior precisão em prever a severidade, a falha do órgão e resultados fatais. No que diz respeito a esses parâmetros, os valores preditivos negativos do escore BISAP também foram consideráveis. A contagem modificada de CTSI foi exata em prever complicações locais, mas teve a exatidão limitada em outras predições. CONCLUSÃO: O APACHE II emergiu como o sistema de pontuação mais confiável seguido por BISAP e Ranson na gestão dos pacientes com pancreatite aguda. Mas em condicionantes do tempo e dos recursos, mesmo a Pontuação do BISAP com seus valores preditivos negativos significativos, serviu como uma ferramenta valiosa para avaliar e administrar esses pacientes.

Comparative Analysis Of Various Electrophysiological Methods For The Diagnosis Of Carpal Tunnel Syndrome

BACKGROUND:Patients with Mild Carpal tunnel syndrome (CTS) may not be picked up by routine nerve conduction methods. So, this study was performed to identify the most sensitive way to detect mild to moderate Carpal tunnel syndrome and to evaluate the sensitivity of different methods for diagnosis of carpal tunnel syndrome.MATERIALAND METHOD: We included sixty clinically confirmed CTS patients in our study. We recorded the clinical characteristics and laboratory features in a proforma. We also included sixty healthy age and sex-matched asymptomatic individuals as controls in our study. We excluded patients with underlying peripheral neuropathy. We included Median distal motor latency, Median distal sensory latency, Median-versus-ulnar 2nd Lumbrical-interossei comparison study, Median-versus-ulnar wrist-to-digit four comparison study, Median -versus- Radial thumb sensory study, Median-versus-ulnar motor distal latency difference, and Median-versus-ulnar sensory latency difference tests in our study.RESULTS:Out of sixty patients, female: male ratio was 2.3:1, and the mean age was 44.28±11.41 years. The mean symptom duration was 0.76±0.03 years. Out of 42 females, 38(90.4%) were engaged in daily household activities. In patients group median nerve distal motor latency was 5.024±2.05 ms, whereas sensory latency was 3.53±0.75 ms. We found maximum sensitivity in Median-versus-ulnar wrist-to-digit four comparison study (90.19%). In Median-versus-Radial thumb sensory study sensitivity was 88.23%, followed by Median-versus-ulnar 2nd Lumbrical- interossei comparison study (86.27%). We found lowest sensitivity (72.55%) in Median distal motor latency test.CONCLUSION:Electrophysiological tests including Median-versus-ulnar wrist-to-fourth digit comparison study, and comparative study of Median-versus-ulnar 2nd Lumbrical- interossei should be included to diagnose mild CTS patients with normal Median distal motor latency, and median distal sensory latency tests

Dot-in-circle Sign of Mycetoma on Magnetic Resonance Imaging

Mycetoma is a chronic granulomatous disease prevalent in tropical countries, but it also occurs in Europe and the United States.Early diagnosis is important as it has therapeutic implications. Although biopsy and microbiological culture provide the definitivediagnosis, these are difficult to achieve in many instances. The dot-in-circle sign is a recently proposed magnetic resonanceimaging (MRI) sign of mycetoma, which is likely to be highly specific. We present a case of mycetoma of the left calcaneumwith characteristic MRI features.

Role of Diffusion-weighted Imaging, Perfusion Magnetic Resonance Imaging, and Magnetic Resonance Spectroscopy in Evaluating Histopathologically Confirmed Brain Tumors in 3-Tesla Magnetic Resonance Imaging

Objective: Our aim was to evaluate the diagnostic capabilities of physiological magnetic resonance imaging (MRI) in differentiatingtype and grades of tumor and correlation with prospective histopathology results.Materials and Methods: We evaluated 70 patients in 3-tesla MRI preoperatively using conventional and physiological MRsequences (diffusion, perfusion, and spectroscopy) of common brain tumors who were prospectively confirmed by histopathology.Post-imaging analysis was done by available software and ratio was calculated. Data were expressed as mean ± standarddeviation and median (range) and Kolmogorov–Smirnov analysis was used to check distribution. Multiple statistical tests wereapplied and receiver operating characteristic (ROC) curve was plotted wherever feasible.Results: We obtained a significant difference in spectroscopic parameters, relative cerebral blood volume, and apparent diffusioncoefficient values between different tumor groups and also between different tumor grades. ROC curve plotted among groupsshowed sensitivity and specificity of diagnostic capability. Time-intensity curve showed a significant difference between differenttumor groups and correlation with grades of tumor.Conclusion: We propose an algorithm for differentiating different types and grades of common brain tumor using physiologicalMRI in addition to conventional MR sequences.

Bioanalytical Method Development and Validation for the Determination of Levocetirizine in Pharmaceutical Dosage Form and Human Plasma by RP-HPLC.

This study describes the development of a rapid, selective, precise and sensitive reverse phase high-performance liquid chromatography method for the quantitative determination of Levocetirizine Dihydrochloride (LCD) in human plasma and pharmaceutical dosage form. Extraction of drug from plasma was done by employing optimized liquid-liquid extraction procedure. The sample was analyzed using Acetonitrile: Methanol: 20mM Ammonium Acetate Buffer pH-5 (25:55:20 % v/v/v) as mobile phase. Chromatographic separation was achieved on Prontosil C-18 column (4.6 x 250mm, 5μ particle size) as stationary phase using isocratic elution (at a flow rate of 1 mL/min). The peak was detected using UV-PDA detector set at 232 nm and retention time was found to be 8 min for LCD. The calibration curve obtained was linear (r2= 0.9998) over the concentration range of 2-10 μg/mL. Method was validated for precision, robustness and recovery. The limit of detection (LOD) and limit of quantitation (LOQ) was 0.0057 and 0.174 µg/mL respectively. There was no significant difference between the amount of drug spiked in plasma and the amount recovered and plasma did not interfere in estimation. Thus, the proposed method is suitable for the analysis of LCD in tablet dosage forms and human plasma.

Venous Thrombosis Complicating Acute Pancreatitis.

Most cases of pancreatitis are mild and self limited. On the other hand, approximately one quarter of patients with pancreatitis may develop vascular complications. Pancreatitis in combination with vascular complications is dangerous and potentially lethal. The survival of patients with pancreatitis and vascular complications depends on the early diagnosis of these complications. We report a case of an elderly male patient who had recurrent pancreatitis. On radiological imaging, patient was found have portal vein, splenic vein and superior mesenteric vein thrombosis. Patient recovered after emergent and timely management. The article focuses on the aspects of etiology, pathogenesis, diagnosis and management of acute pancreatitis with venous thrombosis.

De La Chapelle Syndrome: A rare case of male infertility / Journal of the ASEAN Federation of Endocrine Societies

@#<p style="text-align: justify;">A 25-year-old Indian male presented to Endocrine Outpatient Department of PGIMS Rohtak with chief complaints of inability to father a child in spite of 2 years of unprotected sexual intercourse. Patient had a normal male phenotype, however seminal fluid analysis was suggestive of azoospermia. Karyotyping chromosomal analysis showed 46, XX chromosomes. The frequency, etiology and diagnosis of this syndrome are reviewed here.</p>

Comparative Study to Assess Diagnostic Reliability of Ultrasound and 3T-MRCP in Patient of Obstructive Jaundice.

Background: Evaluation of jaundice patients should include proper history and examination, laboratory investigation and imaging investigations (non invasive like Ultrasound (U\S), CT and MRI or invasive like ERCP and PTC). Aim of Study: The aim of this prospective study is to evaluate the diagnostic reliability of U\S and MRI-MRCP in patients of obstructive jaundice in clinical practice. Materials and Methods: This is a prospective study performed on 60 patients (31 male and 29 female) with an average age of 55.53 +/- 17.57 years presented with obstructive jaundice for whom abdominal ultrasound (U\S) and magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) on 3 Tesla was performed in the departments of radiology in Max super speciality teaching hospital, saket, Delhi, India from May 2012 to May 2013. The final diagnosis was achieved by endoscopic retrograde cholangiopancreatography (ERCP) and \or surgery and confirmed by histopathology. Results: The most common cause of obstructive jaundice in our study was common bile duct stones (51.65%) followed by tumors (33.3%) then benign strictures (10.0%), choledochal cyst (3.33%). In this study, MRI-MRCP could differentiate surgical from medical jaundice in all cases, while U\S could differentiate surgical from medical jaundice in 91.25% of cases. MRI-MRCP correctly defines the level of obstruction in all cases (100%). While U\S correctly define the level of obstruction in only 78% of the total cases. MRI-MRCP correctly suggests the most possible cause of obstruction in 96.25% of cases. While USG is correctly suggests the most possible cause in only 76.3%. Conclusion: So that USG as a screening modality is useful to confirm or exclude biliary dilatation & to choose patients for MRCP examination. MRI-MRCP is a useful non-invasive and essential method in the preoperative evaluation of patients with obstructive jaundice. In addition MRI-MRCP was superior to U\S or ERCP in studying the extent & staging of malignant lesions.

Radial nerve palsy with fracture shaft of the humerus treated with early limited nerve exploration and internal fixation.

Background and Objective: Radial nerve injuries associated with fractures of the humerus are the most common peripheral nerve injuries in long bone fractures. Management of these injuries remains controversial. Strong convictions for and against either line of treatment - conservative or operative can be drawn from the literature. This study evaluates the role of early limited exploration in these injuries. Methods: Sixteen patients with radial nerve palsy with fracture shaft of humerus treated with open reduction and internal fixation with plates were studied. Follow up of the patients was done with regard to intraoperative findings and pattern of recovery. Results: Radial nerve continuity with spontaneous clinical recovery was seen in all of our cases. The average time for onset of recovery in our study was two weeks for neurapraxia and 22 weeks for axonotmesis. The average time for complete recovery was five weeks for neurapraxia and 30 weeks for axonotmesis. 88% of our cases showed excellent and 12% showed good results. Conclusions and interpretation: Limited early nerve exploration of radial nerve is a reliable option while performing internal fixation for both primary as well as secondary radial nerve palsy with fracture of shaft of humerus.

Eco friendly spectrophotometric method for quantitative estimation of lomefloxacin using hydrotropic approach.

The present work describes a novel, accurate, sensitive and economic safe spectrophotometric method was developed by application of hydrotropy, using 8 M Urea solution as hydrotropic solubilizing agent, for the quantitative determination of poorly watersoluble lomefloxacin HCl in tablet dosage form. There were more than 43 times enhancements in the solubility of lomefloxacin HCl increases in hydrotropic solution as compared to solubilities in distilled water. Lomefloxacin HCl shows maximum absorbance at 281 nm. Urea and other tablets excipents did not show any absorbance above 230 nm, and thus no interference in the estimation was seen. Lomefloxacin HCl was obeyed Beer,s law in the concentration range of 5 to 25μg/ml (r2= 0.9998) in hydrotropic solvent with mean recovery ranging from 98.03±0.65 to 98.59±0.32%. Proposed method is new, simple, economic, safe, rapid, accurate and reproducible. The developed methods were validated according to ICH guidelines and values of accuracy, precision and other statistical analysis were found to be in good accordance with the prescribed values. The method can be used for routine analysis in both research laboratories, and pharmaceutical and chemical industries to analyze the drugs without the use of organic solvents thus make the environment eco-friendly.