Avinash Agarwal

Correlation of shock index and modified shock index with the outcome of adult trauma patients: A prospective study of 9860 patients

Background: Triage at emergency department is performed to identify those patients who are relatively more serious and require immediate attention and treatment. Despite current methods of triage, trauma continues to be a leading cause of morbidity and mortality. Aims: This study was to evaluate the predictive value of shock index (SI) and modified shock index (MSI) for hospital mortality among adult trauma patients. Materials and Methods: In this prospective longitudinal study, all adult patients who sustained trauma enrolled as per as inclusion/exclusion criteria. After the collection of data, SI and MSI were calculated accordingly. All parameters were again recorded hourly and calculations were done at six-hour intervals. Further, to achieve a value that can be analyzed, we determined threshold value for vital signs, which set the threshold values as heart rate at 120 beats per minute, systolic blood pressure at less than 90, and SI at cut-off 0.5-0.9 and MSI at less than 0.7 to more than 1.3. Results: We analyzed 9860 adult trauma patients. Multivariate regression analysis demonstrated that heart rate more than 120 beats per minute, systolic blood pressure less than 90 mmHg, and diastolic blood pressure (DBP) less than 60 mmHg correlate with hospital stay and mortality rate. MSI <0.7 and >1.3 had higher odds of mortality as compared to other predictors. Conclusions: MSI is an important marker for predicting the mortality rate and is significantly better than heart rate, systolic blood pressure, DBP and SI alone. Therefore, modified SI should be used in the triage of serious patients, including trauma patients in the emergency room.

Hypokalemic quadriparesis: An unusual manifestation of dengue fever

Dengue is the most important mosquito-borne, arboviral infection found in tropical and sub-tropical climates. Clinical presentation varies from a severe flu-like illness to a potentially lethal dengue hemorrhagic fever. Dengue has been regarded as a nonneurotropic virus. However, there are reports describing neurological involvements in dengue virus infection. The neurological involvement in dengue virus infection includes encephalitis, acute disseminated encephalomyelitis, transverse myelitis, and Guillain-Barre syndrome. The neurological spectrum of dengue patients has been limited because of small number of case reports, paucity of imaging, and neurophysiologic studies. There are only a few isolated case reports and case series documenting acute pure motor quadriparesis in dengue fever. We report acute pure motor reversible quadriparesis due to hypokalemia. Clinicians in the endemic area should be aware of such association of acute pure motor reversible quadriparesis with dengue fever

Prognostic Significance of Estimation of Pseudocholinesterase Activity and Role of Pralidoxime Therapy in Organophosphorous Poisoning

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

Oxidative stress determined through the levels of antioxidant enzymes and the effect of N-acetylcysteine in aluminum phosphide poisoning.

Introduction: The primary objective of this study was to determine the serum level of antioxidant enzymes and to correlate them with outcome in patients of aluminum phosphide (ALP) poisoning and, secondly, to evaluate the effect of N-acetylcysteine (NAC) given along with supportive treatment of ALP poisoning. Design: We conducted a cohort study in patients of ALP poisoning hospitalized at a tertiary care center of North India. The treatment group and control group were enrolled during the study period of 1 year from May 2011 to April 2012. Interventions: Oxidative stress was evaluated in each subject by estimating the serum levels of the enzymes, viz. catalase, superoxide dismutase (SOD) and glutathione reductase (GR). The treatment group comprised of patients who were given NAC in addition to supportive treatment (magnesium sulfate and vasopressors, if required), while in the control group, only supportive treatment was instituted. The primary endpoint of the study was the survival of the patients. Measurements and Results: The baseline catalase (P = 0.008) and SOD (P < 0.01) levels were higher among survivors than non-survivors. Of the total patients in the study, 31 (67.4%) expired and 15 (32.6%) survived. Among those who expired, the mean duration of survival was 2.92 ± 0.40 days in the test group and 1.82 ± 0.33 days in the control group (P = 0.043). Conclusions: This study suggests that the baseline level of catalase and SOD have reduced in ALP poisoning, but baseline GR level has not suppressed but is rather increasing with due time, and more so in the treatment group. NAC along with supportive treatment may have improved survival in ALP poisoning.

Prognostic Factors in Patients Hospitalized with Diabetic Ketoacidosis

Background Diabetic ketoacidosis (DKA) is characterized by a biochemical triad of hyperglycemia, acidosis, and ketonemia. This condition is life-threatening despite improvements in diabetic care. The purpose of this study was to evaluate the clinical and biochemical prognostic markers of DKA. We assessed correlations in prognostic markers with DKA-associated morbidity and mortality. Methods Two hundred and seventy patients that were hospitalized with DKA over a period of 2 years were evaluated clinically and by laboratory tests. Serial assays of serum electrolytes, glucose, and blood pH were performed, and clinical outcome was noted as either discharged to home or death. Results The analysis indicated that significant predictors included sex, history of type 1 diabetes mellitus or type 2 diabetes mellitus, systolic blood pressure, diastolic blood pressure, total leukocyte count, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, blood urea nitrogen, serum creatinine, serum magnesium, serum phosphate, serum osmolality, serum glutamic oxaloacetic transaminases, serum glutamic pyruvic transaminases, serum albumin, which were further regressed and subjected to multivariate logistic regression (MLR) analysis. The MLR analysis indicated that males were 7.93 times more likely to have favorable outcome compared with female patients (odds ratio, 7.93; 95% confidence interval, 3.99 to 13.51), while decreases in mean APACHE II score (14.83) and serum phosphate (4.38) at presentation may lead to 2.86- and 2.71-fold better outcomes, respectively, compared with higher levels (APACHE II score, 25.00; serum phosphate, 6.04). Conclusion Sex, baseline biochemical parameters such as APACHE II score, and phosphate level were important predictors of the DKA-associated mortality.

Thyroid functions and serum lipid profile in metabolic syndrome

Background Thyroid hormones are known to affect energy metabolism. Many patients of metabolic syndrome have subclinical or clinical hypothyroidism and vice versa. To study the correlation of thyroid profile and serum lipid profile with metabolic syndrome. Method It is a hospital based cross sectional case-control study carried out in tertiary care health center, we studied thyroid functions test and serum lipid profile in 100 metabolic syndrome patients according to IDF criteria and a similar number of age, gender and ethnicity matched healthy controls. Result We found that serum HDL was significantly lower (p < 0.001) in cases (41.28 ± 8.81) as compared to controls (54.00 ± 6.31). It was also found that serum LDL, VLDL, triglyceride levels and total cholesterol were found to be significantly higher (p < 0.001) in cases than controls. Serum TSH levels of subjects in cases group (3.33 ± 0.78) were significantly higher (p < 0.001) than that of controls (2.30 ± 0.91) and significantly lower levels of T4 (p < 0.001) in the patients of metabolic syndrome (117.45) than in controls (134.64) while higher levels of T3, although statistically insignificant in the patients of metabolic syndrome. Conclusion Thyroid hormones up-regulate metabolic pathways relevant to resting energy expenditure, hence, obesity and thyroid functions are often correlated.

Nonnutritive sweeteners: Pros and cons

Nonnutritive sweeteners (NNSs) are the substances having an intense sweet taste with no or very low calories and are used as substitutes for simple sugars for reduction of energy intake. The consumption of NNSs is increasing at an alarming rate because of the ever evolving pandemic of obesity and Type 2 diabetes mellitus. NNSs have various positive and negative metabolic consequences on the health of the consumers. There are misconceptions and myths regarding the use of NNSs for which various professional bodies have issued guidelines. However, the overall long-term effects of the NNSs are still an area of debate and discussion.

Study of oxidative stress biomarkers in chronic obstructive pulmonary disease and their correlation with disease severity in north Indian population cohort

Background: Oxidant-antioxidant imbalance forms a prime component in pathogenesis of chronic obstructive pulmonary disease (COPD). Studies of oxidative stress markers in South Asians were sparse. Methods: One hundred and eighty COPD patients and eighty healthy nonsmokers were enrolled in the study. Serum malondialdehyde (MDA) and iron levels were estimated for oxidative stress. Three antioxidant markers evaluated-catalase, superoxide dismutase (SOD), and serum copper. Patients on antioxidant therapy and with sepsis and chronic illness were excluded from the study. Results: The mean age of COPD patients was 59.29 ± 10.3 years. Serum levels of MDA and iron were significantly higher in COPD patients compared to controls (5.21 ± 1.9 vs. 0.71 ± 0.29 nmol MDA/ml, P = 0.0001 and 69.85 ± 85.49 vs. 79.32 ± 24.39 μg/dl, P = 0.0001, respectively). Mean level of all antioxidant enzymes catalase, SOD, and copper were significantly diminished in cases when compared to control population (P = 0.001). Levels of MDA and iron were found to be significantly elevated in higher Global Initiative for Chronic Obstructive Lung Disease (GOLD) classes (III, IV) when compared to lower GOLD Classes (I, II). The levels of serum antioxidants were significantly depleted in higher GOLD grades too. COPD patients who were male and smoked had significantly higher levels of oxidants and depleted antioxidant levels compared to female and nonsmoking compatriots. Serum MDA levels negatively correlated with forced expiratory volume 1 s and forced vital capacity (r = −0.19 and r = −0.21, P ≤ 0.01). The presence of a cough significantly correlated with higher levels of MDA and iron (P = 0.001). The levels of MDA negatively correlated with SOD and catalase levels. Conclusion: Oxidative markers (MDA and iron) are higher whereas antioxidants (catalase, copper, and SOD) are significantly reduced in patients of COPD. Serum MDA levels correlate with lung functions and disease severity.

Unusual Manifestations Associated with Primary Hypothyroidism: Experience from A Tertiary Care Health Center

Hypothyroidism is a commonly diagnosed endocrine disorder. Typical signs and symptoms of hypothyroidism include lethargy, cold intolerance, hoarseness, dry skin, constipation, delayed relaxation phase of deep tendon reflexes, and bradycardia. However, some patients may present with unusual signs and symptoms of hypothyroidism which can result in diagnostic confusion. Besides the usual clinical manifestations of primary hypothyroidism, some signs are very unusual and not commonly recorded. The treating physician may not be familiar with them. Hence, timely identification of these unusual presentations is very important for early intervention and treatment.

Gemigliptin: Newer promising gliptin for type 2 diabetes mellitus

The dipeptidyl peptidase-4 (DPP-4) inhibitors have facilitated the management of type 2 diabetes mellitus (T2DM) owing to their superior efficacy and safety with low incidence of adverse effects. Gemigliptin is a new member of this family of drugs, and studies have revealed certain advantages of gemigliptin use compared to its previous congeners. Besides, this drug has also been studied for the treatment of T2DM as monotherapy, in combination with metformin or other oral antidiabetic drugs and in T2DM with moderate-to-severe renal failure. In this review, we explore the published data highlighting the pharmacology, efficacy, and safety of gemigliptin along with its recommendations for use in patients with T2DM.