Retino-Renal Dissociation in Type 2 Diabetes Mellitus: An Observational Cross Sectional Study at a Tertiary Care Center of Sub-Himalayan Region.

INTRODUCTION: Diabetic retinopathy, the diabetes-specific long-term microvascular complication is an important predictor of diabetic nephropathy. Diabetes induced retinopathy mostly proceeds nephropathy in patients with Type1 diabetes; however, this sequence is not consistent in patients with Type 2 diabetes and has significant discordance. METHODS: It was a hospital-based prospective, observational study conducted at Indira Gandhi Medical College, Shimla Himachal Pradesh a tertiary care center in the sub-Himalayan region of India from July 2016 to June 2017. A total of 141 patients were recruited in this study period. RESULTS: 141 patients with type 2 diabetes, 83(58.9%) males,58(41.1%) females were recruited in the study. The mean duration of diabetes in this study was 5.78±6.21 years. Mean HbA1C in our study was 9.66±3.04%. 79(56.0%) patients in our study had HbA1C more than 9.0% while 39(27.7%) had HbA1C between 7.0- 9.0%. only 23 (16.3%) patients had HbA1C less than 7.0%. A total of 118 (83.7%) patients had poor glycaemic control. Out of a total of 141 patients, DKD (albuminuria and/or reduced eGFR) was present in 67 (47.52%) patients. 33 had diabetic retinopathy. CONCLUSION: The relationship between retinopathy and nephropathy in type 2 diabetic patients is not as clear as in type 1 diabetic patients. Patients with type 2 diabetes do not have diabetic nephropathy always and non-diabetic renal disease is also quite common. The absence of retinopathy, rapid progression diabetes, presence of RBC, and cast are some of the atypical findings, and patients presenting with them should be subjected to renal biopsy to rule out non-diabetic renal disease (NDRD).

Clinical Profile, Severity and Outcome of Acute Upper Gastrointestinal Bleeding in Elderly Patients Compared to Non-elderly Patients: A Prospective Observational Study.

AIM: To determine the clinical profile, severity and outcome of acute upper gastrointestinal bleeding (UGIB) in elderly subjects (>60 years) compared to the non elderly ones (<60 years). METHODS: In a prospective observational study, 380 consecutive adult patients presenting with acute UGIB were enrolled. Patients were divided into two groups: elderly (≥60 years) and non-elderly (<60 years). RESULTS: Out of 380 patients, 254(66.84%) patients were non-elderly and 126(33.15%) patients were elderly. The proportion of patients with co-morbidity and consumption of non-steroidal anti-inflammatory drugs was higher among elderly patients. The commonest mode of presentation was hematemesis and melena in the both groups, while isolated hematochezia (29% vs. 1.9%, p<0.01) was more common in elderly group. The variceal bleeding was significantly higher among non-elderly group (38.1% vs. 18.2%, p<0.01) and bleeding from gastric or duodenal ulcer was the predominant cause of bleeding among elderly group (65% vs. 43% p<0.01). The proportion of patients with tachycardia (68.2% vs. 20%, p<0.01), postural hypotension (29.3% vs. 14.9%, p<0.01) and blood transfusion requirement of 4 units or more (20.2% vs. 10.1%, p<0.01) was significantly higher among elderly group than in non-elderly group. Despite similar re-bleeding rates, mortality rate was significantly higher in elderly patients compared to the non-elderly patients (10.32% vs. 1.94%, p<0.01). CONCLUSION: Nearly 33% of the patients with acute UGIB are over 60 years old. The severity of bleeding and mortality rates was higher in elderly in comparison to non-elderly patients.

Factors for Severe Outcome in Scrub Typhus: A Hospital Based Study in Sub Himalayan Region.

Background: Scrub typhus is a re-emerging zoonotic rickettsial infection. Mortality is approximately 15% in some areas due to missed or delayed diagnosis. There had been only few studies on the markers for the severity of the disease, so this study has been planned to provide the knowledge regarding various aspects of scrub typhus in adult age group to detect early signs of severity . Methods: All the patients more than 18 years of age admitted with febrile illness with positive IgM ELISA for scrub typhus with or without eschar were included in the study. The clinical profile was observed. The predictors of mortality were explored using univariate and multivariate analysis. Results: On linear regression analysis and logistic regression analysis altered sensorium, low serum albumin, hepatic dysfunction, renal dysfunction, septic shock, MODS, ARDS, duration of fever > 7 days, day of receiving treatment > 7 days at presentation were significantly associated with high in- hospital mortality. Conclusions: Early treatment with doxycycline should be instituted at the clinical suspicion of scrub pending investigation as it is life saving. Close follow up of the patient should be done to indentify subtle signs of organ dysfunction to start early supportive treatment.

Bone Marrow Disease Profile in Geriatric Patients: An Institutional Experience.

Bone marrow examination is integral to the diagnosis of hematological and many non-hematologic disorders. With increase in the elderly population, rise in the incidence of age-related health conditions is being observed. There are few published studies on the disorders involving the bone marrow exclusively in the geriatric age group. We studied the bone marrow profile in the elderly age group (60 years and above) over a period of 1 year using bone marrow aspiration and biopsy. Anemia was the most frequently diagnosed entity followed by multiple myeloma and non-Hodgkin lymphoma. Cases of leukemia, primary myelofibrosis and metastatic carcinoma were also encountered. Bone marrow aspiration and biopsy were found to be complementary.

Frequency of Macro Vascular Complications in Patients of Newly Diagnosed Type 2 Diabets Mellitus and its correlation with Major Cardiovascular Risk Factors; A Hospital Based Study.

OBJECTIVE: Frequency of macrovascular complications in newly diagnosed patients of type 2 diabetes mellitus and its correlation with major cardiovascular risk factors; A Hospital Based Study. METHOD: All consecutive newly diagnosed type 2 diabetics were enrolled and evaluated for the presence of cardiovascular risk factors and macro vascular complications i.e. Coronary Artery disease (CAD), Cerebrovascular Disease (CVD) and peripheral vascular disease (PVD). RESULTS: 105 newly diagnosed subjects with diabetes with a mean age of 56.55±7.43 years were enrolled in the study amongst them 53 were male and 52 were females. The mean plasma glucose of these patients was 178.40±52.05 mg%, out of 105 patients enrolled in the study 20 (19.05%) of the patients had macro vascular complications at the time of diagnosis of type 2 diabetes. CONCLUSION: Type 2 diabetes mellitus can present with or without symptoms and with chronic vascular complications at the time of diagnosis, opportunistic screening for diabetes should be done in high risk patients along with screening for the vascular complications.

Hemophagocytic Lymphohistiocytosis Secondary to Acute Hepatitis E Infection: A Rare Association.

Viral infections are commonest cause of secondar y hemophagoc ytic lymphohistiocytosis (HLH) and Ebstein Bar Virus is associated with majority of cases. We report a rare case of HLH associated with acute hepatitis E virus infection.

Safety and efficacy of therapeutic membrane plasmapheresis in the treatment of Guillain-Barré syndrome: A study from a tertiary care hospital from India.

BACKGROUND: Reports on therapeutic plasma exchange (TPE) with the standard hemodialysis equipment are scarce, particularly from developing countries. MATERIALS AND METHODS: A retrospective analysis of safety and efficacy of membrane-based TPE with a standard hemodialysis equipment for the treatment of severe Guillain-Barré syndrome (GBS) was conducted. RESULTS: A total of 120 TPE sessions were performed in 31 GBS patients over a period of 5½ years. Each patient underwent a mean of 3.8 ± 1.5 TPE sessions. One (3.2%) patient died. Thirty (96.8%) patients survived and recovered. At 2 weeks, there was a significant improvement in the grade of power in both the upper and lower extremities (P = 0.001) and a significant decrease in the GBS disability grade (P = 0.001). Twenty four (77.4%) patients were able to walk unaided. Complications observed were: hypotension in 12 (10%), accelerated hypertension in 3 (2.5%), chills and rigors in 5 (4.2%), bleeding in 5 (4.2%), and filter clotting in 6 (5%) sessions. One patient experienced an anaphylactoid reaction and 1 patient survived a cardiorespiratory arrest. Two patients developed aspiration pneumonia and 1 patient developed catheter site infection. CONCLUSIONS: Membrane-based TPE can be conveniently delivered with the standard hemodialysis equipment. It is a safe, effective, and comparatively less expensive treatment option for GBS.

Sheehan's Syndrome-The Most Common Cause of Panhypopituitarism at Moderate Altitude: A Sub-Himalayan Study.

Background: Panhypopituitarism is a rare disorder with varied clinical presentation having various etiologies. Sheehan's syndrome (SS) is decreasing in frequency worldwide and is a rare cause of panhypopituitarism in developed nations. Methodology: A retrospective study done between May 2011 and May 2015 in tertiary care hospital. We reviewed the records of patients with hypopituitarism. Clinical features, hormonal profile and radiological investigations noted. Results: Total 14 patients of panhypopituitarism included with average duration of symptoms 1.93± 1.96 years. four (28.57%) were males and ten (71.43%) were females with mean age of diagnosis 37.78± 13.68 years. Sheehan's syndrome (SS) was the most common cause of panhypopituitarism in 57.14%(8 patients), followed by post surgery in 14.28% (2 patients). 80% of women had SS with a mean duration of symptoms 2.39±1.54 years. Conclusion: Sheehan's syndrome is not uncommon in developing countries, High degree of clinical suspicion is desired as clinical features are most often subtle.

Clinical Profile and Outcome of Pregnant Patients with Acute HEV Hepatitis During Water Borne Epidemic in Himachal Pradesh: A Hospital Based Study.

Background: Recent outbreak of HEV hepatitis epidemic in Himachal Pradesh in Shimla caused significant morbidity and mortality especially among pregnant patients. Overall mortality is 0.5- 4% in patients developing acute hepatic failure (ALF) and is significantly higher in pregnant patients (20%). Present study conducted to observe clinical profile and outcome in pregnant patients. Methodology: this is a retrospective observational study done on admitted pregnant and post partum patients with acute HEV hepatitis during 3 months periods. History focussing on symptoms, duration, onset, progression, co morbidities, pregnancy outcome, complications noted. Confirmation of the HEV infection was done using HEV IgM ELISA. Results: Total 26 patients observed, among which 8 were pregnant and 18 were post partum Average age of presentation was 26.11±3.7 years and average duration of hospital stay 10.46 days. 8 (30.76%) patients required ICU care Presenting complaints were similar to typical presentation in viral hepatitis. All patients were icteric at presentation and 8 (30.76%) patients had hepatic encephalopathy (HE) and 8 (30.76%) patients had ALF, 20 (76.92%) sepsis and 7(26.92%) underwent preterm labour. Out of the total 14 patients who delivered, poor fetal outcome was seen in 5 patients died during this period (15.38%). Factors responsible for in hospital mortality were altered mental status at presentation (p0.018), edema (p 0.046), HE(0.018), acute liver failure(0.018). Conclusion: HEV infection has more morbidity and mortality among pregnant females and poor fetal outcome. Mortality is high (15.38%). Altered mental status at presentation, edema, HE, ALF have significant correlation (<0.05) with the mortality.

Clinical Profile of Scrub Typhus in Pregnancy in Sub-Himalayan Region.

BACKGROUND: Scrub typhus is rare in pregnancy, but it has now become an important cause of febrile illness in pregnancy in sub-Himalayan region of India. Only a few case reports have been published so far, and they show adverse maternal and fetal outcomes. No consensus has been reached till now regarding treatment. METHODOLOGY: All the pregnant patients irrespective of period of gestation admitted with febrile illness with positive IgM ELISA for scrub typhus with or without eschar were included. The clinical profile was observed using a detailed history of symptoms, travel, recreation, agricultural activities, treatment record prior to admission, and a detailed examination, and the treatment outcome was noted. Fever workup including cultures, CXR, CSF analysis, serology for scrub was done. IgM scrub typhus was done by kit method manufactured by InBios Intertational, Inc. RESULTS: We observed in total 14 pregnant patients out of which eight were in the the second trimester and six were in the third trimester. The clinical features of the disease observed for pregnant females were the same as for nonpregnant females. There was no difference in the severity of scrub typhus between pregnant and nonpregnant women. No mortality was found in these patients. On follow-up, they had normal peripartum and postpartum periods. All were treated with azithromycin 500 mg once a day for 5 days. CONCLUSION: Although rare, scrub typhus should be considered in differential diagnosis of fever in pregnant patients especially in scrub season. Azithromycin should be the drug of choice in pregnancy as it has no adverse effect on fetus and pregnancy outcome.

Clinical Profile and Complications of Scrub Typhus: Hospital-Based Study in Sub-Himalayan Region.

BACKGROUND: Scrub typhus is a documented disease in Himachal Pradesh, but there have been no clinico-epidemiological studies in this area. The present study is done with IgM ELISA as a diagnostic test which has higher sensitivity and specificity as most of previous studies had used Weil Felix test as a diagnostic test. METHODOLOGY: This was a prospective observational study. All the patients more than 18 years of age with positive IgM ELISA for scrub typhus with or without eschar were included. The clinical profile was observed. IgM scrub typhus was done by kit method manufactured by InBios International, Inc. RESULTS: Total 330 patients were observed. Maximum patients were observed in August, September, and October. Fever was the most common presenting complaint. Eschar was present in 40.61% patients. Complications were seen in 71.2 %. CONCLUSIONS: The general physicians should be sensitized for the early diagnosis to reduce mortality.

Subclinical atherosclerotic vascular disease in chronic obstructive pulmonary disease: Prospective hospital-based case control study.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is an important non-communicable disease worldwide with a rising global incidence. COPD is associated with multiple co-morbidities. Patients with COPD are at increased risk of atherosclerosis and other cardiovascular events. Cardiovascular diseases are an important cause of morbidity and mortality in COPD. The present case-control study was designed to assess the relationship between sub-clinical atherosclerotic vascular diseases with COPD. METHODS: It was a prospective case-control blinded observational study. There were 142 COPD patients and 124 age-and sex-matched controls without COPD and cardiovascular diseases. Frequency of sub-clinical atherosclerosis was assessed by the carotid B-mode duplex ultrasonography assessment of carotid wall intima medial thickness (IMT). Plaque was defined as IMT of more than 1.2 mm. RESULTS: Prevalence of carotid plaqing was significantly higher amongst patients of COPD (38.7%) compared to controls (13.7%, odds ratio 3.9, P < 0.0001). Multinomial logistic regression analysis revealed COPD as an independent predictor of carotid plaqing (r = 0.85, P < 0.023). CONCLUSION: The frequency of carotid plaqing is high in COPD patients. Carotid plaqing may be due to shared risk factors or the presence of low-grade systemic inflammation. Presence of increased CIMT and carotid plaqing in COPD patients identifies early atherosclerotic changes and future cardiovascular risk. Hence screening of CIMT should be a part of cardiovascular assessment in patients with COPD.

Prevalence of metabolic syndrome among newly diagnosed hypertensive patients in the hills of Himachal Pradesh, India.

To study the prevalence of metabolic syndrome (MS) among newly diagnosed hypertensive patients in a tertiary care hospital in the northern hilly state of Himachal Pradesh, India, located in western Himalayas at a moderate altitude of 2200 m above mean sea level. One hundred and eighteen newly diagnosed hypertensive patients above the age of 20 years were studied in a hospital-based cross-sectional study. MS prevalence was estimated by International Diabetes Federation (IDF) criteria and modified National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) criteria. Student's t-test was used to compare the mean of the continuous variables. Chi-square test was used to compare discrete variables. The prevalence of MS in hypertensive patients was 68.6% (modified NCEP-ATP III) and 63.6% (IDF criteria). The most common phenotype of MS with the component of hypertension was the coexistence of waist circumference (90.1%), low high-density lipoprotein (HDL; 70.4%), and high triglycerides (67.9%) as per the modified NCEP-ATP III criteria, and low HDL (76.2%) and high triglycerides (66.4%) as per the IDF criteria. Fasting blood glucose (33.2% as per the modified NCEP-ATP III criteria and 32.6% as per the IDF criteria) was the least significant factor having an association with MS. The prevalence of MS among hypertensive patients was high and indicates the need for metabolic screening in all hypertensive patients at the first diagnosis.

Scrub typhus associated acute kidney injury--a study from a tertiary care hospital from western Himalayan State of India.

OBJECTIVE: To report the clinical profile of acute kidney injury (AKI) associated with scrub typhus. METHODS: Retrospective study of hospitalized patients of acute febrile illness who were diagnosed scrub typhus and had AKI. RESULTS: 174 (35%) patients (75.9% female), mean age (41.4 ± 15.9 years) were studied. The laboratory abnormalities were: anemia (63.2%), leukocytosis (44.3%), thrombocytopenia (61.5%), hyponatremia (35.6%), hypernatremia (2.9%), and hypokalemia (12.1%), hyperkalemia (11.5%), hypoalbuminemia (56.9%), hepatic dysfunction (70%) and metabolic acidosis (28.7%). The complications of hypotension (5.7%), septic shock (3.4%), pneumonia (10.9%), acute respiratory distress syndrome (ARDS) (11.5%), meningoencephalitis (6.9%), encephalopathy (5.2%), gastrointestinal bleed (1.3%), myocarditis (3.4%), disseminated intravascular coagulation (2.9%) and multi organ failure (MOF) (10.3%) developed during course of hospitalization in these patients. Twenty-five (14.4%) patients required intensive care support (ICU) support and seven (4%) patients were dialyzed. 146 (83.9%) patients survived. Twenty-eight (16.1%) patients died. There was a significant difference in the age, various hematological & biochemical abnormalities, complications and need for ICU support in the non-survival group as compared the survival group. CONCLUSION: This study shows that AKI in scrub typhus is common and a severe disease. Age, a shorter hospital stay, severities of leukocytosis, thrombocytopenia, azotemia, hypoalbuminemia, hepatic dysfunction and the complications of ARDS, encephalopathy, MOF and need for ICU support are the factors associated with mortality.

Atrial myxoma: a rare cause of ischemic stroke.

Arial myxoma can present as stroke and should be considered as a differential diagnosis of stroke in young individuals. We present here a 42 years female who presented with sudden loss of conciousness. After extensive work up for young stroke, left atrial myxoma was detected and tumor was removed surgically and histopathological report was consistent with the atrial myxoma.

Subcutaneous emphysema secondary to pulmonary cavity in absence of pneumothorax or pneumomediastinum.

Subcutaneous emphysema is a common condition occurring after chest injury. It may also be observed in association with pneumothorax or pneumomediastinum as a result of pathological changes in the respiratory tract. Spontaneous subcutaneous emphysema in absence of pneumothorax or pneumomediastinum is rare. We report a case of spontaneous subcutaneous emphysema in isolation secondary to fibrocavitatory lesion in the chest along with review of the literature.