Mrinal Pal

Study of Vitamin B 12 deficiency and peripheral neuropathy in metformin-treated early Type 2 diabetes mellitus

Background: Long-term therapy with metformin was shown to decrease the Vitamin B12 level and manifested as peripheral neuropathy. Aim: The aim of this study is to define the prevalence of Vitamin B12 deficiency in early Type 2 diabetic patients (duration ≤5 years or drug treatment ≤3 years) and the relationship among metformin exposure and levels of cobalamin (Cbl), folic acid, and homocysteine (Hcy) with severity of peripheral neuropathy. Methodology: This is a cross-sectional study involving randomly selected ninety patients (male 56, female 34) between age groups of 35 and 70 years, comparing those who had received >6 months of metformin (Group A) (n = 35) with those without metformin (Group B) (n = 35) and patients taking metformin with other oral hypoglycemic agent (Group C) (n = 20). Comparisons were made clinically, biochemically (serum Cbl, fasting Hcy, and folic acid), and with electrophysiological measures (nerve conduction studies of all four limbs). Comorbidities contributing to neuropathy were excluded from the study. Results: Group A patients (54.28%) were prone to develop peripheral neuropathy comparing Group B (28.57%) and Group C (35%). There was significantly low plasma level of Cbl in Group A (mean 306.314 pg/ml) than in Group B (mean 627.543 pg/ml) and Group C (mean 419.920 pg/ml). There was insignificant low-level plasma folic acid in Group A (16.47 ng/ml) than in Group B (16.81 ng/ml) and Group C (22.50 ng/ml). There was significantly high level of Hcy in Group A (mean 17.35 µmol/L) and Group C (mean 16.99 µmol/L) than in Group B (mean 13.22 µmol/L). Metformin users even for 2 years showed evidence of neuropathy on nerve conduction velocity though their body mass index and postprandial blood sugar were maintained. There was significant difference in between groups regarding plasma Cbl, folic acid, and Hcy level as significance level <0.05 in all three groups (F [2, 87] = 28.1, P = 0.000), (F [2, 87] = 7.43, P = 0.001), (F [2, 87] = 9.76, P = 0.000). Post hoc study shows significant (P < 0.05) lowering of Cbl and Hcy level in Group A (mean = 306.314, standard deviation [SD] = 176.7) than in Group C (mean = 419.92, SD = 208.23) and Group B (mean = 627.543, SD = 168.33). Discussion: Even short-term treatment with metformin causes a decrease in serum Cbl folic acid and increase in Hcy, which leads to peripheral neuropathy in Type 2 diabetes patients. A multicenter study with heterogeneous population would have increased the power of the study. We suggest prophylactic Vitamin B12 and folic acid supplementation or periodical assay in metformin user.

The dengue fever and its complication: A scenario in a tertiary-level hospital of greater Kolkata

Background: India experienced a massive outbreak of dengue fever in the 2012-2013 period and this outbreak shows significantly different distribution across India. It also envisaged the hidden weakness of prevention and control program of vector-borne diseases. Aim and Objective: This study was designed to characterize the clinical and demographical profiles of this outbreak in a tertiary-level hospital of greater Kolkata. Materials and Methods: A descriptive hospital-based observational study was conducted among diagnosed dengue fever patients admitted at a tertiary-level hospital during the dengue outbreak in the 2012-2013 period. The clinical, biochemical, and demographic data of those patients were collected and recorded in a planned structured format. Results: The data of a total 382 dengue patients were analyzed. Out of these 382 patients, 67.8% are males and 42.1% belongs to 20-40 years age group. The mean and median ages of the study group were 37.39 (±17.70) years and 35 years, respectively. The mean (±SD) duration of hospital staying was 4.9 (±1.90) days. Out of these patients, 19.4% had hemorrhagic rash throughout the body, 13.2% presented with hemorrhage, and 8.6% were comorbid with typhoid immunoglobulin M (IgM) positive. Clinical shock, peripheral edema, and pulmonary edema were documented in 6.3%, 2.6%, and 5.3% of the patients, respectively. Ultrasonography (USG) abdomen test revealed that 15% of the patients had thick-walled gallbladder, while 11.27% had ascites. Out of the 382 patients, 26.3% (101) presented with pleural effusion, and 10.5% patient′s platelet count went below 35,000. The alanine transaminase (ALT), alkaline phosphatase, and lipase level were abnormally increased in 82.7%, 17.1%, 29.6% patients, respectively. Conclusion: Suburban as well as rural area′s people, mainly the young males, were mostly affected in this outbreak. Enteric fever was found with comorbid infection among a few dengue patients. Some patients documented with deferent complications, which were managed by early diagnosis and supportive treatment.

Validation of leiden score in predicting progression of rheumatoid arthritis in undifferentiated arthritis in Indian population

Background: Leiden Score, is a very useful tool for predicting future development of rheumatoid arthritis (RA), among undifferentiated arthritis (UA) patients. This score has been validated in various western studies but rarely among south east Asian patients. Aims: To validate the Leiden early arthritis prediction rule in an Indian cohort of patients for predicting rheumatoid arthritis (RA) in undifferentiated arthritis (UA) patients and to formulate any simpler version of prediction score taking only clinical variables of original Leiden prediction rule. Subjects and Methods: In a group comparative longitudinal study model, 58 patients with early symmetrical polyarthritis were enrolled and baseline evaluation was done according to Leiden prediction rule and then 3 monthly. After 1 year, Leiden prediction score and chance of evolving into RA were calculated. Patients were divided into two groups: Those who developed RA and who did not. They were selected on random sampling process. Tender joint count (TJC), duration of morning stiffness, and duration of arthritis were selected as clinical variables for linear discriminant analysis with disease outcome being the dependent variable. Discriminant scores (D) for each patient was calculated. A receiver operating characteristic (ROC) curve was constructed with the discriminant score and compared with Leiden prediction score. Results: About 54% (27/50) of patients were diagnosed with RA and 46% (23/50) developed other rheumatologic condition or viral inflammatory arthritis or remained undifferentiated or attained complete remission. None of the patients with UA, who scored the regression coefficients 4 or less progressed to RA, and those who scored 7 or more, almost certainly progressed to RA. Unstandardized canonical discriminant coefficients for TJC (T), duration of morning stiffness (M), and duration of arthritis (A) were calculated. ROC curve was plotted with the formula: D = 0.164 × T + 0.066 × M + 0.012 × A − 2.838. Area under curve (AUC) at 95% confidence interval for our discriminant function was 0.845 (standard error [SE] 0.054). In comparison, AUC of Leiden prediction score was 0.897 (SE 0.043). Conclusions: Leiden prediction rule is highly applicable to UA patients to predict progression of RA in Indian patients and larger multi-center study with larger cohorts is needed to validate the formulation we derived to predict RA.