Narinder Pal Singh

Unusual complications of heroin abuse: transverse myelitis, rhabdomyolysis, compartment syndrome, and ARF.

Introduction. Heroin overdose can cause various rare neurological complications like spongiform leukoencephalopathy, seizures, stroke, toxic amblyopia, transverse myelopathy, mononeuropathy, plexopathy, acute inflammatory demyelinating polyradiculoneuropathy, rhabdomyolysis, compartment syndrome, fibrosing myopathy, and acute bacterial myopathy. We report here the simultaneous presentation of multiple complications of heroin toxicity. Case report. A young heroin addict was found unarousable lying in the lotus posture. Examination showed quadriplegia and left leg gangrene. He subsequently developed heroin-induced transverse myelitis, rhabdomyolysis, left leg compartment syndrome, and myoglobin-induced acute renal failure. Discussion. This case leads us to consider a common linked or systemic mechanism of injury rather than a local mechanism when multiple simultaneous organ failure occurs complicating heroin abuse.

Effect of addition of either sitagliptin or pioglitazone in patients with uncontrolled type 2 diabetes mellitus on metformin: A randomized controlled trial

Objective: To compare and study the dipeptidy1 peptidase-4 (DPP-4) inhibitors in combination with metformin against established combination therapies. Materials and Methods: This 16-week study was designed to compare sitagliptin versus pioglitazone as add-on therapy in patients of type 2 diabetes mellitus inadequately controlled with metformin alone. Fifty-two patients were randomized into two groups to receive either sitagliptin 100 mg (group 1) or pioglitazone 30 mg (group 2) in addition to metformin. The primary efficacy end point was change in HbA1c. Secondary end points included change in fasting plasma glucose (FPG), body weight and lipid profile. Treatment satisfaction was assessed using the Diabetes Treatment Satisfaction Questionnaire. Both the groups had a significant decrease in HbA1c. Results: There was no significant difference between mean reductions in FPG in both the groups. There was a significant decrease in the mean body weight and body mass index in group 1 in contrast to the significant increase in the same in group 2. Both the treatment groups reported a significant decrease in High-density lipoprotein (HDL-C) and Triglyceride. Conclusion: Sitagliptin was well tolerated without any incidence of hypoglycemia. It was concluded that sitagliptin as an add-on to metformin is as effective and well tolerated as pioglitazone.

Antimicrobial dosing in critically ill patients with sepsis-induced acute kidney injury

Severe sepsis often leads to multiple organ dysfunction syndromes (MODS) with acute kidney injury (AKI). AKI affects approximately, 35% of Intensive Care Unit patients, and most of these are due to sepsis. Mortality rate of sepsis-induced AKI is high. Inappropriate use of antimicrobials may be responsible for higher therapeutic failure, mortality rates, costs and toxicity as well as the emergence of resistance. Antimicrobial treatment is particularly difficult due to altered pharmacokinetic profile, dynamic changes in patients clinical status and, in many cases, need for renal replacement therapy. This article aims to describe the appropriate antimicrobial dosing and reviews the factors contributing to the difficulties in establishing precise guidelines for antimicrobial dosing in sepsis-induced AKI patients. Search strategy: Text material was collected by systematic search in PubMed, Google (1978–2013) for original articles.

Does angiotensin-converting enzyme-1 (ACE-1) gene polymorphism lead to chronic kidney disease among hypertensive patients?

Abstract Background: Hypertension is one of the important contributing factors linked with both causation and development of kidney disease. It is a multifactorial, polygenic, and complex disorder due to interaction of several risk genes with environmental factors. The present study was aimed to explore genetic polymorphism in ACE-1 gene as a risk factor for CKD among hypertensive patients. Methods: Three hundred patients were enrolled in the study. Ninety were hypertensive patients with CKD taken as cases, whereas 210 hypertensive patients without CKD were taken as controls. Demographic data including age, sex, Body mass index (BMI), and other risk factors were also recorded. DNA was extracted from blood by salting out method. Genotyping of ACE gene was done by PCR technique. All the statistical analysis was done by using Epi Info and SPSS version 16 software (SPSS Inc., Chicago, IL). Results: Mean age was higher in the control group (pu2009<u20090.05). Variables among two groups were compared out of which age, BMI, hemoglobin (Hb) was found to be statistically significant whereas other variables like systolic blood pressure, triglyceride and low-density lipoprotein were not. Blood urea and serum creatinine levels were statistically significant in the two genotypes (pu2009<u20090.05). Total and HDL cholesterol were statistically significant for DD genotype of ACE gene (ORu2009=u20091.42, 95% CIu2009=u20090.72–2.81). Similarly, the risk for CKD among hypertensive patients was also associated with D allele of ACE gene (ORu2009=u20091.25, 95% CIu2009=u20090.86–1.79). Conclusion: It is concluded that ACE-DD genotype may be a risk factor for the causation and development of chronic kidney failure among hypertensive patients.

Attenuation of angiotensin converting enzyme inhibitor induced cough by iron supplementation: role of nitric oxide

The present study examined whether (1) the cough associated with angiotensin converting enzyme inhibitor therapy is attenuated by oral intake of iron and anti-oxidants, and (2) nitric oxide (NO) has any role in this attenuation. Of the 100 patients under investigation, cough occurred in 28 of them with preponderance in females. All the 28 patients were followed up for six weeks: the first two weeks were the observation period and the remaining four weeks the experimentation period. After the observation period, 11 patients received a single oral dose of ferrous sulphate (200 mg), eight received vitamin E (200 mg, o.d.) and vitamin C (150 mg, o.d.) and nine were given placebo during the experimentation period. Cough scoring, serum NO and malondialdehyde (MDA) levels were determined during both the periods. While there were significant decreases in cough scores, NO and MDA levels between these two periods in the iron group, cough scores and MDA level decreased significantly in the anti-oxidant group. None of these parameters changed in the control group. NO level was found to be increased significantly in patients who developed cough (n = 28) compared with those who did not cough (n = 72). These results suggest that iron supplementation suppresses cough in patients on ACE-I therapy through its effect on NO generation.

Bone Histo-Morphology in Chronic Kidney Disease Mineral Bone Disorder

Chronic Kidney Disease-Mineral Bone Disorder(CKD-MBD) is a systemic disorder of the mineral and bone metabolism seen in patients with Chronic Kidney Disease(CKD). It is manifested by either one or a combination of the following: (a) Abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism. (b) Abnormalities in bone turnover, mineralization, volume, linear growth, or strength. (c) Vascular or other soft- tissue calcification. Renal osteodystrophy measures the skeletal component of CKD-MBD. To study the histomorphology of bone marrow biopsy in patients with CKD-MBD and correlate the histological features of bone biopsy with the clinicobiochemical parameters. 32 cases of diagnosed CKD-MBD formed the study group. Detailed clinical history and biochemical analysis was done for them. Bone marrow trephine biopsies were conducted and the histology was studied. The clinicobiochemical and the histomorphological findings were correlated. Based on the bone biopsy findings, Hyperparathyroid bone disease consisted of-14 cases (44%), Mixed uremic osteodystrophy of-16 cases (50%) and one case (3%) each of Low turnover disease (Adynamic bone disease) and Normal histology. The mean blood urea, S. Creatinine, S Phosphate and the S. Vit D3 were found to be statistically significant between the two major subgroups. The area of the bone trabeculae and the osteoid percentage was found to be more in the MUO group and was found to be statistically significant. Conclusion: A trephine biopsy helps us in understanding the skeletal symptoms of the CKD when the clinical and biochemical parameters are not conclusive. A biopsy in unexplained bone pain/fractures, unexplained hypercalcemia and elevated phosphate levels helps in guiding the proper management of the patient.

An Uncommon Cause of Postpartum Renal Failure—Bilateral Emphysematous Pyelonephritis

Peripartum acute renal failure is an important complication related to pregnancy leading to significant morbidity and mortality. Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the renal parenchyma, with formation of gas within the collecting system, renal parenchyma, or perirenal tissues. EPN is common in persons with diabetes or urinary tract obstruction. Herein we report a case of bilateral emphysematous pyelonephritis in a postpartum lady who had no evidence of diabetes or urinary tract obstruction. Management of this condition has traditionally been aggressive, and surgery has been considered mandatory. Our patient was managed successfully with antibiotics and supportive measures alone.