Screening Parameters for COPD-OSA Overlap Syndrome in COPD Patients: Indian Perspective

Introduction: As Indian patients have different predisposing morphological characteristics, we undertook this study to evaluate the clinical profile of overlap syndrome and compare them with COPD patients to find out the screening tools for obstructive sleep apnea (OSA) in Indian chronic obstructive pulmonary disease (COPD) patients. Aims and objectives: • To study the clinical profile of patients with overlap syndrome. • To compare them with COPD patients. • To develop screening tools for overlap syndrome in COPD. Materials and methods: A prospective case-control study was carried out in a tertiary care center. Overnight pulse oximetry was carried out for all COPD patients. Those having snoring or saw-tooth pattern on overnight oximetry were subjected to level 1 polysomnography. About 30 patients of overlap syndrome were compared with 65 COPD patients. Results: The mean age in overlap syndrome group (56.9 ± 6.86 years) was significantly lower (p < 0.01). The daytime PaO2 and lowest nocturnal saturation were significantly lower in overlap group. PaCO2 and forced expiratory volume at 1 second (FEV1) were significantly higher. For diagnosing overlap syndrome, the positive and the negative predictive values of snoring were 84.42 and 100%; of body mass index (BMI) ?25 kg/m2 were 86.67 and 98.88%; and of excessive daytime sleepiness were 37.57 and 97.86%, respectively. Conclusion: Absence of snoring and BMI <25 kg/m2 virtually rules out overlap syndrome. The EDS has a high false-positive rate for predicting OSA. Patients having overlap syndrome have poor daytime and nocturnal oxygenation despite good lung functions.

Obstructive Sleep Apnea with Insomnia Overlap: An Under-recognized Entity

Introduction: The association between obstructive sleep apnea (OSA) and insomnia is relatively common but is underrecognized. There are important diagnostic and therapeutic implications of comorbid OSA杋nsomnia overlap but there is no data available from India. Objectives: (1) To find out the prevalence of insomnia among patients with OSA; (2) To compare the demographic characteristics, Epworth sleepiness scale (ESS) scores and the presence of comorbidities among patients of OSA with insomnia vs OSA without insomnia. Materials and methods: It was a prospective observational study involving 250 patients with suspected OSA. A total of 189 patients had OSA based on type I polysomnography and were further analyzed. Insomnia was diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria. Results: The prevalence of insomnia among OSA was 15.34% (29/189). Overlap was seen in 22.45 and 12.86% of women and men respectively among patients with OSA. The prevalence of overlap increased with decreasing severity of obesity and OSA. Those with OSA杋nsomnia overlap had significantly lower ESS scores as compared to OSA without insomnia (12.31 vs 15.24; p = 0.019). A total of 10.34% (3/29) of patients of overlap had depression whereas none from OSA alone had depression. Conclusion: There is a high prevalence of insomnia among patients with OSA (15.34%), similar to findings worldwide. Insomnia is more common among women with OSA. Overlap patients have lower ESS scores and are likely to be depressed.

Isolated Index Finger Dactylitis with Hilar Adenopathy

Dactylitis due to tuberculosis (TB) is an extremely uncommon manifestation of TB. We report a unique case of isolated index finger dactylitis with right hilar adenopathy due to TB in a 15-year-old immunocompetent student. High index of clinical suspicion, radiological findings and histological confirmation helped in the diagnosis. Anti-tuberculous therapy remains the cornerstone for the management of these cases.

Prevalence of thyroid dysfunction in patients with type 2 diabetes

 Background: Diabetes mellitus, a leading cause of death worldwide, is the most common endocrine disorder. Type 2 Diabetes (T2D) and Thyroid Dysfunction (TD) often present together and complicate each other at many levels. Recent studies find out the prevalence of TD in T2D in Malwa Region. Objective of the purpose of this study was to find out the prevalence of TD in patients with T2D.Methods: A match cross-sectional study design was conducted at Department of Medicine, Sri Aurobindo Medical College, from March 2018 to April 2019. Source populations were all patients who live in Malwa Region, Indore. A total of 150 cases were enrolled in this study, 75 cases (TD in T2D) and 75 controls were taken into study.Results: There was no significant difference in age and body mass index (BMI) between groups. The average duration of diabetes was 7.76±5.57 years and mean Hemoglobin A1c (HBA1c) was 8.17±1.66%. Only 29(38.6%) of patients had HbA1c below 7%. There was significant difference (p=0.001) in HbA1c. Prevalence of TD in T2D was significantly more in females. Out of TD in T2D patients, sub-clinical hypothyroid was present in 14.6% hypothyroidism was present in 8% patients and sub-clinical hyperthyroidism and hyperthyroidism was present in 1.3% patients.Conclusions: This study reveals about one in four people living with T2D are suffering from TD in Malwa Region. TD is common in T2D patients and can produce significant metabolic disturbances.

Evaluate the differences in serum magnesium levels and lipid profile with correlation of hemoglobin A1C levels in type 2 diabetes patients: a case control study

Background: Magnesium deficiency is a common problem in diabetic patients. Magnesium deficiency may increase the incidence of Type 2 Diabetic (T2D) and occurrence complications. Objective of this study aimed at determining the differences in serum magnesium levels and lipid profile among patients newly diagnosed with T2D and normoglycemic individuals.Methods: The cross sectional observation study design was conducted at Sri Aurobindo Medical College, from March 2018 to April 2019. Source populations were all patients who attending to the OPD, Department of General Medicine. A total of 75 patients were enrolled in this study. This study was divided in two group’s cases group (T2D) and second control group (Non-diabetic). First group not initiated on any oral-hypoglycaemic, anti-hypertensive or lipid lowering drugs, and healthy patients were included in control group.Results: Triglycerides (TG), Total Cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C) showed significantly (p<0.001) higher mean levels in T2D compared to the controls. The Magnesium and High-Density Lipoproteins-cholesterol (HDL-C) levels were significantly (p<0.001) lower among the T2D group compared to the control group. There was a significant inverse correlation (r2= 0.567, p<0.001) between Hemoglobin A1C (HbA1c) levels and serum magnesium.Conclusions: Serum magnesium levels and lipid profile were significantly different in T2D patients compared to control group.

Evaluate the relation between microalbuminuria and with other biochemical parameters related to complications of type 2 diabetes

Background: Type 2 Diabetes (T2D) with microalbuminuria have increased risk of progression to overt proteinuria, and after some time, renal failure. It is the leading cause of end-stage renal disease as a sequalae of Diabetic Nephropathy (DN) and an independent risk factor for Cardio-Vascular Diseases (CVD). Initial finding for microalbuminuria can prevent long-term complications. The objective of the present investigation was to study the relation between microalbuminuria and with other biochemical parameters related to complications of T2D.Methods: This observational study was conducted among 150 T2D patients attending to the OPD, Department of General Medicine during the time period March 2018 to April 2019. The patients were interviewed for socio-demographic details, history and clinical examination and subjected to blood investigations and Electrocardiogram (ECG).Results: Microalbuminuria was present in 47(31.3%) of the diabetics. The age group 48-63 years 18(38.3%), male gender 33(70.2%) duration of diabetes >5 years 11(23.4%). The smokers, Diabetic Retinopathy, Peripheral Neuropathy, Ischemic Heart Disease, SBP 160-170 mmHg, DBP 95-100 mmHg and 100-105 mmHg, BMI 30-35 Kg/m2, TG >250 mg/dl, LDL >110 mg/ dl and HbA1c 7.5-9 % showed a greater odds ratio and significant association (p<0.001) with microalbuminuria.Conclusions: There was an increased prevalence of microalbuminuria among patients with T2D. It also showed a significant association of major microvascular and macrovascular complications of T2D and microalbuminuria

The prevalence and assessment of chronic kidney disease with diabetes: single center study

Background: The prevalence of chronic kidney disease (CKD) and Type 2 diabetes (T2D) is increasing worldwide, information on Indian populations regarding the CKD patients with T2D is lacking. In this study, we examined the association of gender and age on the prevalence of other complications in CKD with T2D patients.Methods: A cross-sectional study was conducted at Sri Aurobindo Medical College, from March 2018 to April 2019. Source populations were all patients who came our medicine department for routine check-up.Results: A total of 163 CKD patients were included in the study. All the patients were randomly divided in two groups 61(37.4%) patients in CKD with T2D case group and 102 (62.5%) patients in CKD control group. Out of this 107 were males (65.6%) and 56 were females (34.3%). Male-to-female ratio and mean age were higher in the CKD with T2D group. The clinicopathological characteristics of CKD patients with T2D are even more complicated and severe disease in many ways.Conclusions: A male presents was higher as compare to female in CKD with T2D and control group. In present study there is significant difference in older and younger age in CKD with T2D and control group. Age, HNT, CVD, smoking, BMI, and 24-h urinary protein level were identified as possible contributors’ factors of CKD patients with T2D

Lymph node metastasis: A bearing on prognosis in squamous cell carcinoma.

Nodal status is a significant predictor for survival of patients with oral squamous cell carcinoma (SCC), sentinel lymph node (SLN) biopsy, step sectioning of SLNs, and immunohistochemistry have changed the detection of tumor deposits in lymph nodes (LNs). The extent of LN metastasis is a major determinant for the staging and the prognosis of most human malignancies and often guides therapeutic decisions. Metastasis to regional lymph node (RLN) is a complex process. It is often associated with several clinical and pathological characteristics. The involvement of RLN is often, a harbinger for increased risk of metastasis. New knowledge in this area can enable the clinicians and pathologists to study and treat tumors in a more directed fashion. A molecular approach to factors that predicts the likelihood of RLN metastasis could eliminate the reoccurrence of the tumor in the form of “micrometastasis” and “skip” metastasis. The aim of this review is to discuss different modes of spread of metastasis in SCC.

Commitment of Measles Elimination by 2020: Challenges in India.

The eleven member states of World Health Organization South-East Asia Region committed to eliminate measles by 2020. In phased manner, Government of India is working on this goal, and has introduced two-dose strategy for measles vaccine in the routine immunization. Molecular epidemiology of measles in India has been considerably growing that would be useful for understanding the circulation of wild type measles in pre- and post-elimination period. However, importations of cases from other countries may be likely. This article describes major challenges to achieve the measles elimination goal in India.

Pyogenic granuloma: A diagnostic dilemma.

Pyogenic granuloma (lobular capillary hemangioma) is a common acquired vascular lesion of the skin and mucous membranes in the pediatric age group. Pyogenic granuloma and hemangioma of oral cavity are well- known benign lesions. The clinical diagnosis and differentiation of these lesions is at times difficult. The purpose of this article is to report an unusual case of benign tumor occuring on hard palate which was clinically diagnosed as pyogenic granuloma and hiatopathologically as capillary hemangioma.

Developing an evaluation system for undergraduate teaching.

Many teachers teach with very little concern about their own teaching skills. Thus they miss the opportunity to identify the lacunae in their teaching. Hence the present study was undertaken to develop an evaluation system for undergraduate teaching and to test its acceptability and workability. The evaluation system was aimed to identify lacunae in teaching and encourage the teachers to overcome them. An objective type questionnaire which could evaluate the teaching skills like set induction, content, presentation, student teacher interaction was designed. Five randomly selected teaching sessions of each teacher were evaluated. The anonymity on the part of students and teachers was maintained. The lacunae noticed in teaching and ways to overcome them were discussed with each teacher individually and confidentially. The teachers were encouraged to overcome them. The evaluation system was found to be workable, acceptable and easy to implement. It was useful and effective for evaluation and improvement of the faculty. It was also found to be inexpensive and less time consuming. The students’ feedback can form a workable and inexpensive system to evaluate and improve the faculty. Such a study is beneficial for the teachers, students as well as the institution. Such a regular system of evaluation can help considerably to develop the faculty as well as to improve the standards of teaching. When coupled with peer evaluation, the system established in this study can be used to assess and improve the individual / departmental teaching.

Evaluation of anti-atherosclerotic and vasculoprotective effect of long acting nifedipine in patients after PTCA.

The anti-atherosclerotic and vasculoprotective effect of long acting nifedipine (nicardia retard 20) was evaluated on patients undergoing percutaneous transluminal coronary angioplasty (PTCA). This was a randomised, controlled, prospective clinical trial. A total of 30 patients fulfilling inclusion criteria were divided randomly in 2 groups of 15 each. One group was given long acting nifedipine while other group did not receive long acting nifedipine. The rest of the treatment was similar for both the groups. Clinical and angiographic parameters were evaluated regularly for a period of one year. The group receiving long acting nifedipine showed 20% restenosis as against 33% in group not receiving long acting nifedipine. Thus, from this trial, it can be concluded that long acting nifedipine can reduce the progress of reocclusion and thus demonstrates the anti-atherosclerotic and vasculoprotective action.

Relationship between osteoarthritis of knee and menopause.

AIM: To study the difference in the onset of osteoarthritis (OA) between males and females with respect to age and to note the relationship between OA of the knees and menopause and hysterectomy in females. MATERIAL AND METHODS: One hundred consecutive patients (50 males and 50 females) were studied for the onset of OA and compared for the statistical difference. In females the relationship between onset of OA and menopause and hysterectomy, if done, was noted. RESULTS: Fifty eight percent of females had onset of symptoms of OA of knees before 50 years of age as compared to only 20% in males (p < 0.05). Sixty four percent of females with OA of knees had the onset of symptoms either perimenopausally or within five years of natural menopause or hysterectomy. CONCLUSION: There is a definite early peaking of the incidence of OA of knees in women in the fifth decade of life as compared to males. There is an association between OA of knees and menopause and we suggest correlating it with the levels of sex hormones.

Sports sponsorship by cigarette companies influences the adolescent children's mind and helps initiate smoking: results of a national study in India.

To estimate the effect of large scale tobacco sponsorship of cricket, a study was conducted on children's knowledge and perceptions about smoking and their impact on subsequent smoking uptake. Twelve nations played 36 matched in the Wills World Cup-1996 cricket series over one month during which Wills (a cigarette brand) was extensively advertised by live broadcast to a 2-billion viewers with WILLS logo on the players' T-shirts and playground, newspapers, magazines, and hoardings. An anonymous structured questionnaire including 4 knowledge based questions about tobacco, 4 about perceptions directly promoted by Wills and 10 questions related to wrong perceptions about smoking was administered by class teachers six months after the series. A total of 5822 children (65% boys and 35% girls) in Grade 10, aged 13-17 years (median 14) were selected. Smokers increased from 137 (2.4%) before the series to 649 (11.1%) after the series. The smoking initiation rate was 2.04% (13/636) in children with full knowledge and no wrong perceptions, 7.8% (48/618) among those with less knowledge and no wrong perceptions. Among those with less knowledge but believing in at least 2 of Wills related perceptions and 3 of the smoking related perceptions the rate for smoking initiation was 20.55% (127/618). The sponsorship appeared to have a similar effect on initiation rates in both sexes despite the strong social taboo against girls smoking in India. Wrong perceptions about smoking promoted by tobacco sponsorship increases smoking initiation amongst both boys and girls even when they are aware of the risks involved. The study suggests that education, without bans on advertisements is unlikely to stop initiation of smoking among children.

Leprosy: a close mimic in a rheumatology clinic.

Cutaneous and neurological manifestations of leprosy are readily diagnosed. However, physicians sometimes fail to recognize that leprosy may present with a rheumatic symptoms. A plethora of rheumatic manifestations are associated with leprosy, particularly with lepra reactions. A diligent examination for skin lesions/nerve involvement may uncover the diagnosis of leprosy in a patient referred for a rheumatological disorder. To highlight the fact that leprosy can mimic several rheumatological disorders, we have discussed a few representative cases seen over the past two years at our rheumatology clinic in a teaching hospital. In all these cases, a diagnosis of leprosy was made when the patient was referred for a rheumatic complaint.

Combining aspirin with angiotensin converting enzyme inhibitors in heart failure: how safe is it?

The above discussion on the interaction of aspirin and ACE inhibitors seems to suggest that aspirin in high doses may have adverse interaction with ACE inhibitors in patients with heart failure but the data obtained is not sufficient or conclusive to recommended omission of aspirin in patients with heart failure. This raises a query in the mind of the physician whether to use a combination or not? The role of aspirin in the early period after myocardial infarction is well established so is the role of ACE inhibitors. Hence in patients with myocardial infarction and preserved left ventricular function it would not be wrong to administer combination of ACE inhibitors and aspirin. Albeit at a lower dose. In patients with large myocardial infarction or heart failure, warfarin may be an option but still needs to be documented in large trials. As suggested long term use of aspirin after infarction is still ambiguous and may be harmful in patients with heart failure with its anticedent side effects. But long term benefits of ACE inhibitors in heart failure are well documented. Hence if a choice has to be made whether to discontinue either of the two drugs it would be preferable to stop the aspirin. To answer the issue of use of aspirin in patients with heart failure it would be essential to conduct a double blind randomized trial comparing known anti-thrombotic treatment, aspirin and anti-coagulants on mortality in patients with heart failure, especially caused by coronary artery disease. Such a trial is underway at the present and till the results are available it should be left to clinical judgement of the physician whether to administer aspirin in patients with heart failure after weighing the benefits versus risk.

Molybdenum, xanthine oxidase and riboflavin levels in tamoxifen treated postmenopausal women with breast cancer.

40 cases postmenopausal women with breast cancer constituted the study group and 20 sex and age matched formed the control group. The study group of untreated patients showed nonsignificant decrease in molybdenum but significant decrease in blood xanthine oxidase and riboflavin levels. Tamoxifen treated patients showed nonsignificant increase in molybdenum, after 3 months, significant increase after 6 months and significant increase in xanthine oxidase and riboflavin levels. Thus tamoxifen when given in breast cancer helps in amelioration of the diseased condition.