Baseline Laboratory Investigations Research Articles

Relationship between NT-proBNP, echocardiographic abnormalities and functional status in patients with subclinical siabetic cardiomyopathy

IntroductionPersons with diabetes are at risk for developing a cardiomyopathy through several pathophysiological mechanisms independent of traditional risk factors for heart failure. Among those with diabetic cardiomyopathy (DbCM), the relationship between natriuretic peptides, cardiac structural abnormalities and functional capacity is largely unknown.MethodsIn this prespecified subgroup analysis of the Aldose Reductase Inhibition for Stabilization of Exercise Capacity in Heart Failure (ARISE-HF) trial, 685 participants with asymptomatic DbCM underwent baseline echocardiography data, laboratory investigations, and functional assessments. Participants were stratified by N-terminal pro-B type natriuretic peptide (NT-proBNP) quartiles, and correlation with echocardiographic and functional parameters were assessed using Spearman correlation test.ResultsThe median NT-proBNP was 71 (Q1, Q3: 33, 135) ng/L. No association was observed between NT-proBNP concentrations and echocardiographic parameters of either diastolic or systolic dysfunction including global longitudinal strain, left ventricular ejection fraction, left ventricular mass index, left atrial volume index, E/E’, or right ventricular systolic pressure. In contrast, NT-proBNP was significantly correlated with overall Kansas City Cardiomyopathy Questionnaire score (rho = − 0.10; p = 0.007), the Physical Activity Scale in the Elderly (rho = − 0.12; p = 0.004), duration of cardiopulmonary exercise testing (rho = − 0.28; p < 0.001), peak VO2 (rho = − 0.26; p < 0.001), and ratio of minute ventilation/carbon dioxide production (rho = 0.12; p = 0.002). After adjustment for known confounders, the correlation with Physical Activity Scale in the Elderly and overall Kansas City Cardiomyopathy Questionnaire score was no longer significant.ConclusionAmong patients with subclinical DbCM, elevated NT-proBNP concentrations are associated with worse health status, lower activity levels, and reduced functional capacity, but not with cardiac structural abnormalities. These findings suggest that regardless of cardiac structural abnormalities, biomarker concentrations reflect important deterioration in functional capacity in affected individuals.Trial registrationARISE-HF, NCT 04083339 Date Registered August 23, 2019.Graphical abstractAbnormal ECHO defined as Myocardial Global Longitudinal Strain < − 16 or left ventricular mass index > 95 for females or > 115 for males or E/e’ >13 or left atrial volume index > 34. †Normal ECHO is defined as the absence of these abnormalities. Low NT-proBNP is defined as < 71 ng/L while high NT-proBNP is defined as ≥ 71 ng/L.

(108) Evaluation the Efficacy and Safety of Hyperbaric Oxygen Therapy in Sildenafil Citrate Non Responder Organic Erectile Dysfunction Patients: a Randomized Double Blinded Controlled Clinical Trial

Abstract Introduction Although the phosphodiesterase 5 inhibitors (PDE5i) are the first-line oral agents for erectile dysfunction (ED) treatment, there is growing number of PDE5i- non responder patients. Management of those patients is challenging and one of the new suggested regenerative therapies is the hyperbaric oxygen therapy (HBOT). HBOT is the application of oxygen under pressure to increase tissue oxygen levels. Few clinical reports were published about HBOT and ED. Objective To evaluate the efficacy and safety of HBOT in sildenafil citrate non- responder organic ED patients. Methods The current study included 30 sildenafil citrate non-responder ED patients. Patients were divided into two groups (randomly assigned and comparably cross-matched for age). Both patients and the investigators were blinded as regards the treatment until the end of the study. Group 1: Patients assigned to the HBOT group (20 patients) were treated with (30) sessions in 5 days/week (90 minutes of 100% oxygen at 2.2 ATA); Group 2: Patients assigned to the control group (10 patients) were exposed to (30) sessions of air oxygen tension at 1 ATA with room oxygen. Baseline laboratory investigations were done (random blood sugar, lipid profile, total &amp; free testosterone). All patients were evaluated with the sexual health inventory for men (SHIM), erection hardness score (EHS), the sexual health encounter profile (SEP), and penile color Doppler initially, at 1 &amp; 3 months after the end of treatment. Results The age mean ± SD in the HBOT group was 56.35±7.43 years and in the control group was 61.7±7.14 years. The current study showed that sildenafil citrate non-responders ED patients with 30 sessions of HBOT in 5 days/week, demonstrated a significant improvement of the total SHIM score, EHS, and SEP after 1 month of stoppage of treatment as compared to the control group. Also, penile color Doppler evaluation showed a significant improvement of 10 &amp;20 minutes peak systolic velocity (PSV) between patients receiving HBOT compared to the control after 1 month of stoppage of treatment. More interestingly, the improvement of the total SHIM score, EHS, and SEP continued after 3 months of stoppage of the HBOT treatment as compared to the baseline evaluation. In addition, 10 &amp;20 minutes PSV with penile color Doppler evaluation demonstrated maintained improvement after 3 months of stoppage of the HBOT treatment as compared to the baseline evaluation. In addition, the linear regression analysis was done for factors affecting SHIM score improvement (1 month/baseline) in the HBOT treatment group, revealing that hypertension was an independent predictor for SHIM score improvement. Hypertensive patients showed 4.6 times more SHIM score improvement as compared to non-hypertensive patients. As regards HBOT safety, there was no significant difference in adverse effects between the HBOT treatment group and the control group. Conclusions HBOT might be a potential therapeutic modality for sildenafil citrate non-responder ED patients especially in hypertensive patients with good safety profile. Further a multi-centric trial with a larger sample size and a longer follow-up period is recommended. Disclosure No.

Clinical presentations and complications of parapneumonic effusion and pleural empyema in children presenting in a tertiary care setup.

Objective: To evaluate the clinical presentations and complications of parapneumonic effusion (PPE) and pleural empyema (PE) in children presenting in a tertiary care setup in Karachi. Study Design: Cross-sectional study. Setting: Medical Units of National Institute of Child Health, Karachi, Pakistan. Period: July 2022 to June 2023. Material &amp; Methods: Hospitalized children of either gender, aged between 1 month and 12 years diagnosed with PPE or PE on the basis of radiological findings were analyzed. Baseline laboratory investigations were done. Complications of PPE/PE were noted. Outcome was observed in the form of discharged, referred or mortality. Results: In a total of 86 with PPE/PE, 61.6% were boys while the overall mean age was 4.35±3.17 years. Common clinical symptoms included fever (100%), decreased air entry (86%), cough (75.6%), and respiratory difficulty (74.4%). Blood cultures revealed bacterial infections in 10.5% of cases, while most common isolates were Staphylococcus aureus and Pseudomonas. Positive pleural fluid cultures noted in 39.5% of cases while pseudomonas and staphylococcus aureus were the most common bacterial isolates. Most commonly used antimicrobials were Vancomycin, Ceftriaxone, Tazobactum+Piperacillin, and Linezolid. Tube thoracostomy was performed in 96.5% of patients. Most frequent complications of PPE/PE included residual organized empyema (36%), pneumothorax (9.3%), and sepsis (9.1%). Overall, the mortality was noted in 5.8% cases. Conclusion: Most frequent clinical presentations of PPE/PE include fever, cough, respiratory difficulty, and abdominal pain, with fever being universal. Staphylococcus aureus and Pseudomonas were the most common bacterial isolates. The most common complications were residual organized empyema, pneumothorax, and sepsis.

A rare case of juvenile primary lateral sclerosis

Primary lateral sclerosis (PLS) is a rare, neurodegenerative disorder, which affects the upper motor neurons (UMN), predominantly the large pyramidal cells of corticospinal and corticobulbar tracts, common during fourth to fifth decade of life. Juvenile PLS is an autosomal recessive form with ALS2 gene mutation on 2q33.2 chromosome affecting infants and children. A 6-year-old girl presented with complaints of difficulty in walking and climbing stairs noticed by parents in the last 2 months and frequent falls associated with stiffness of lower limbs for 15 days with no other significant history. Central nervous system (CNS) examination was normal except for spasticity in bilateral lower with exaggerated lower limb reflexes with spastic gait. Baseline laboratory investigations were normal. Magnetic resonance imaging (MRI) brain and spine showed symmetrical signal abnormality along corticospinal tracts bilaterally. Diagnosis of primary lateral sclerosis was made after ruling out possible causes.

Study of the Urinary TGF-β1 Profile in Diabetic Nephropathy: A Single-Center Experience From India.

Background Diabetic nephropathy is one of the important causes of end-stage kidney disease (ESKD). Of the various cytokines playing a role in the pathogenesis of diabetic nephropathy, transforming growth factor beta-1 (TGF-β1) is an important one. Its major role is to mediate extracellular matrix deposition. Increased renal expression of TGF-β1 is found in diabetic nephropathy and its urinary excretion can serve as a useful marker of outcomes. Material and methods A prospective observational study was conducted, which included 10 cases of diabetic nephropathy in group A with age ≥ 18 years and a urinary protein creatinine ratio (UPCR) value of > 0.5 mg/mg and 10 healthy controls in group B. Patients with active urinary tract infection, chronic kidney disease (CKD) stage Vd patients on maintenance hemodialysis, and renal transplant recipients were excluded from the study. Urinary TGF-β1 level estimation in a 24-hour urine sample, 24-hour urine protein, and other baseline laboratory investigations were done. Results In diabetic nephropathy cases (group A), the mean value of urinary TGF-β1 levels was 88.33± 12.44 ng/24 hours. In the control group (group B), the mean value of urinary TGF-β1 was 29.03 ± 3.23 ng/24 hours. Urinary TGF-β1 levels were significantly elevated in group A as compared to group B (p<0.001). There was no significant correlation between urinary TGF-β1 levels andestimated glomerular filtration rate (eGFR) (r=0.376, p= 0.285) as well as the urinary TGF-β1 levels and 24-hour urine protein levels (p = 0.334, r = 0.341) in diabetic nephropathy cases. Glycosylated hemoglobin (HbA1c) levels didn't correlate with the urinary TGF-β1 levels (r = -0.265, p = 0.46). Conclusion The urinary TGF-β1 levels were significantly elevated in diabetic nephropathy patients as compared to healthy controls. There was no significant correlation between urinary TGF-β1 levels and proteinuria,eGFR, or HbA1c levels in diabetic nephropathy patients.

Clinical Outcomes of Patients with Type II Diabetes Mellitus and Hypothyroidism undergoing Percutaneous Coronary Revascularization

Background: Diabetes mellitus (DM) and hypothyroidism are independently associated with coronary artery disease (CAD) severity with poor percutaneous revascularization outcomes. However, the influence of Type II diabetes mellitus (T2DM) with hypothyroidism on the clinical outcomes of patients undergoing percutaneous coronary intervention (PCI) has not been evaluated. Aim: The aim of the study is to assess the clinical outcomes of CAD patients with T2DM and hypothyroidism undergoing PCI. Materials and Methods: Consecutive patients who underwent PCI from September 2020 to March 2021 at our institution were enrolled in the study. Patients were categorized into four groups: Group I-Patients with euglycemia and euthyroid, Group II- patients with T2DM and euthyroid, Group III- patients with hypothyroidism and euglycemic, and Group IV- Patients with T2DM and hypothyroidism. Baseline demographics, laboratory investigations, procedural details, and in-hospital major adverse cardiovascular events were assessed. The continuous and normally distributed data were presented as mean ± standard deviation and were analysed using ANOVA. Categorical data were presented as the frequency with percentages and analysed using the Chi-square test. Result: In the total of 605 patients, 36% (n=220), 54% (n=325), 3% (n=19), and 7% (n=41) were in Group I, Group II, Group III, and Group IV respectively. The mean age of the population was 56.1 ± 11.6 vs 59.6 ± 9.8 vs 60.4 ± 9.9 vs 56.9 ± 12.1 (p = 0.002). Males were predominant 89.5% (n=197) in Group I and females were predominant 47.4% (n=9) in Group III. The prevalence of hypertension and dyslipidemia were high in Group II and Group IV respectively. Higher triglyceride levels (159.6 ± 109.6 Vs 166.2 ± 83.2 Vs 136.7 ± 72.3 Vs 222.2 ± 161.9, p = 0.03) and glycosylated hemoglobin A1c (HbA1C) levels (6.2 ± 1.2 Vs 8.5 ± 1.9 Vs 6.6 ± 2.1 Vs 9.2 ± 1.8, p&lt;0.001) were noted in Group IV. Single vessel disease was high (59.1% Vs 45.5% Vs 57.8% Vs 48.7%, p=0.02) among Group I patients whereas left anterior descending (LAD) artery involvement was more in Group IV (64.5% Vs 57.8% Vs 36.8% Vs 70.7%, p=0.03) and in-stent restenosis was high among Group III (0.9% Vs 3.7% Vs 10.5%, p=0.02). Incidence of bleeding was high in Group III (0.5% Vs 1.2% Vs 10.5%, p= 0.001). There was no significant difference in In-hospital mortality between groups. Conclusion: Patients with T2DM and hypothyroidism had significantly higher levels of triglycerides, HbA1C and more LAD involvement but there was no significant difference in in- hospital mortality.

Inflammatory phenotypes may be more important than age and comorbidities in predicting clinical outcomes in hospitalised patients with COVID-19

ObjectivesIn critically ill patients with COVID-19, distinct hyperinflammatory and hypoinflammatory phenotypes have been described, with different outcomes and responses to therapy. We investigated if similar phenotypes exist in non-severe illness. MethodsConsecutive patients with polymerase chain reaction (PCR) confirmed SARS-CoV-2 were examined. Baseline demographics and laboratory investigations were tabulated, including serum C-reactive protein. Patients were divided into those who were hyperinflammatory (defined as C-reactive protein >17 mg/l) or hypoinflammatory. Adverse outcomes, defined as requiring oxygenation, intensive care, or death, were recorded during the hospital stay. Clinical characteristics and outcomes were compared. ResultsOf the 1781 patients examined, 276 (15.5%) had a hyperinflammatory phenotype. They were older (51.8 ± 17.2 vs 40.3 ± 13.8 years, P <0.001), had a lower PCR cycle threshold (PCR cycle threshold value 19.3 ± 6.3 vs 22.7 ± 15.4, P = 0.025) at presentation, and more medical comorbidities. The hyperinflammatory phenotype was independently associated with adverse clinical outcomes, even after adjusting for age, medical history and viral load on multivariable analyses (adjusted odds ratio 5.78, 95% confidence interval 2.86-11.63). ConclusionEven in non-severe COVID-19, there are distinct hyper- and hypoinflammatory phenotypes, with the hyperinflammatory phenotype strongly associated with adverse clinical outcomes, that could be distinguished with a simple biomarker.

PA14 Aquagenic palmar wrinkling in a 15-year-old swimmer

Abstract A 15-year-old girl presented with a 1-year history of recurrent palmar wrinkling on contact with water. This was associated with a burning sensation within minutes of water exposure and progressive persistent thickening of the palmar skin. She was otherwise well, with no family history of note, including cystic fibrosis (CF). She had no regular medication or newly introduced medications before the onset of wrinkling. Moderate improvement in hyperkeratosis was seen with twice-daily use of urea 10% and salicylic acid 10% creams; however, the discomfort experienced in water was negatively affecting her ability to continue competitive swimming. On examination, there was palmar hyperlinearity with focal hyperkeratosis over the thenar and hypothenar eminences. Immersion of the hands in lukewarm water resulted in wrinkling within 2 min and peaking at 3 min, at which point the patient reported a burning sensation. Wrinkling resolved within 30 min of drying her hands. Baseline laboratory investigations were normal. Biopsy of the palm in the wrinkled state showed subtle prominence and dilation of sweat gland ducts. A diagnosis of aquagenic syringeal keratoderma (ASK) was made. At the 3- and 6-month reviews, the patient reported spontaneous resolution of wrinkling on contact with water, which was confirmed clinically. Residual hyperkeratosis had similarly resolved, although subtle palmar hyperlinearity persisted. She was able to resume competitive swimming activities without symptoms. The ASK is a rare condition, classically affecting the palms of young women, in which palmar wrinkling occurs within minutes of immersion in water. It may be asymptomatic or associated with stinging, burning or paraesthesia. Palmar wrinkling typically resolves after drying of the hands without persisting signs. The mechanism for this phenomenon is unclear, with theories including acquired abnormalities in eccrine glands, an underlying primary keratoderma, or potential induction by cyclooxygenase. Aquagenic palmar wrinkling is also recognized in association with CF, both in individuals with the disease and carriers, with more rapid onset of wrinkling in the former. In this case, there was no suggestion of personal or family histories of CF, and hyperkeratosis persisted for months at a time until liberal regular use of keratolytic topical agents was introduced. Hereditary papulotranslucent acrokeratoderma, a differential diagnosis in this case, was considered; however, in this condition once papules and wrinkling appear, they typically remain and are further exacerbated by water exposure. For this patient, a diagnosis of atypical ASK was favoured due to the persisting sequelae, with probable mild atopic dermatitis reflected by palmar hyperlinearity. This case serves to highlight this rare dermatological phenomenon and its impact on a teenage swimmer.

Neurological consequences and short–term outcome of children with diagnosis of cyanotic congenital heart diseases at a Tertiary Care Cardiac Setup of Pakistan: A single center study.

Objective: To determine the neurological consequences and short–term outcome of children with diagnosis of cyanotic congenital heart diseases (CHDs) at a tertiary care cardiac setup of Pakistan. Study Design: Single Center Observational Cohort study. Setting: Department of Pediatric Cardiology, National Institute of Cardiovascular Disease (NICVD), Karachi, Pakistan. Period: November 2021 to October 2022. Material &amp; Methods: A total of 80 children of both genders, aged between 1 month to 12 years with known cyanotic CHD as per 2D transthoracic echocardiography were admitted in Pediatric Cardiology Department of NICVD, Karachi and were considered. At the time of enrollment, demographic characteristics along with presenting complaints were noted. Necessary baseline laboratory and radiological investigations were ordered and clinical neurological examination was done. Children were discharged and short term outcomes were labeled after 3 months follow up. Results: In a total of 80 children with cyanotic CHDs, most common underlying diagnosis was tetralogy of fallot, found in 41 (51.3%) children. The CT brain revealed ischemic infarct, brain abscess and gross oedema as the most frequent observations revealed in 47 (58.8%), 40 (50.0%) and 37 (46.3%) children. Surgical management of underlying neurological abnormality was advised in 23 (28.8%) children. After 3 months follow-up, complete recovery was observed among 43 (53.8%) children. CT findings at the time of enrollment as haemorrhagic infarct (p&lt;0.001), brain abscess (p=0.001) and atrophic changes (p=0.032) were significantly associated with incomplete recovery. Surgery as a mode of treatment for the underlying neurological disease was associated with good recovery outcomes (p&lt;0.001). Conclusion: Most common underlying diagnosis among children with cyanotic CHDs was tetralogy of fallot. CT findings at the time of enrollment as haemorrhagic infarct, brain abscess and atrophic changes, as well as hypotonia, down going plantars and developmental delay at the time of presentation were significantly linked with incomplete recovery.

Etiological study of short stature in children and role of insulin like growth factor-1 and insulin like growth factor binding protein-3 as screening markers for growth hormone deficiency.

To determine aetiological factors in children with short stature, and to evaluate the role of insulin like growth factor-1 and insulin like growth factor binding protein-3 as screening markers for growth hormone deficiency. The cross-sectional study was conducted at the Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from August 2020 to July 2021, and comprised children with short stature. Evaluation protocol included complete history and examination, baseline laboratory investigations, X-ray for bone age and karyotyping. Growth hormone status was assessed using growth hormone stimulation tests, and serum insulin like growth factor-1 and insulin like growth factor binding protein-3 levels were also assessed. Data was analysed using SPSS 25. Of the 649 children, 422(65.9%) were boys and 227(34.9%) were girls. The overall median age was 11 years (interquartile range: 11 years). Of the total, 116(17.9%) children had growth hormone deficiency. Familial short stature was present in 130(20%) children and constitutional delay in growth and puberty in 104(16.1%). There was no significant difference in levels of serum insulin like growth factor-1 and insulin like growth factor binding protein-3 in children who had growth hormone deficiency and those who had other causes of short stature (p>0.05). Physiological variants of short stature were found to be more common in the population followed by growth hormone deficiency. Serum insulin like growth factor-1 and insulin like growth factor binding protein-3 levels alone should not be used to screen children with short stature for growth hormone deficiency.

Clinical Audit of Methotrexate Therapy in Psoriasis at a Tertiary Care Teaching Hospital in Western India

Background: Methotrexate (MTX) is one of the most useful drugs in the treatment of psoriasis. It is like a double-edged sword; beneficial when given under strict medical supervision and harmful when standard guidelines are not followed. Objective: The present study was a process audit done with the aim to improve quality of care in patients of psoriasis with MTX therapy and to minimize the errors. Materials and Methods: The study was a clinical audit assessing patients of psoriasis who were given MTX therapy. Patients were selected on a random basis from hospital data records from January 2018 to August 2019. To assess the patients on MTX therapy, a pro forma was filled which included demographic details, psoriasis area severity index (PASI) scores, baseline investigations carried before starting MTX and at regular intervals afterward, dosage of MTX, its tapering schedule, and cumulative dose. The data were analyzed using descriptive statistics. Ratios, proportions, and percentages were used to describe the data. Results: A total of 30 psoriasis patients on MTX therapy were selected randomly, of which 25 (83.3%) participants had record of proper history and clinical assessment. PASI >10 was observed in 24 (80%) and was calculated by the 1st-year residents in 15 (50%) participants. Before starting MTX therapy, baseline laboratory investigations (CBC, LFT, and RFT) were done in all 30 (100%) participants. Initial dose of MTX (2.5–5 mg/week) was given in 6 (20%) participants. Supplementary medications such as folic acid in proper dosage were given to 28 (93.3%) participants. Twenty-nine (96.6%) participants were investigated for CBC and LFT every 2 weekly in the first 3 months, while only 16 (53.3%) participants were investigated for RFT. After reduction of 75% of PASI, MTX was tapered in 21 (70%) participants. Conclusion: The study reveals some pitfalls in following the guidelines in patients on MTX. Educational interventions in the form of training among dermatologist and resident doctors should be carried out.

Glucose to lymphocyte ratio predicts prognoses in patients with colorectal cancer.

Colorectal cancer (CRC) is characterized by high morbidity and mortality. Inflammatory, metabolic, and immune factors are closely related to survival of patients with CRC, but their combined impact is unknown. Hence, we chose and evaluated the prognostic value of glucose to lymphocyte ratio (GLR) and a nomogram that include GLR for patients with CRC. A total of 1448 patients with CRC were included in our study, and their baseline clinicopathological characteristics and laboratory investigations were collected for analysis. We used Cox proportional hazard regression analyses (both univariate and multivariate) to determine prognostic values of clinical indicators. A nomogram was constructed, and concordance index (C-index) was used to assess the predictive power. Multivariate analyses demonstrated GLR as an independent prognostic factor (hazard ratios 1.060; 95% confidence interval 1.030-1.091; p < .001). A nomogram was constructed integrating factors with clinical significance (sex) and those with independent prognostic value (age, body mass index, tumor stage, and GLR), and the model showed a C-index of .778 (.757-.799), which was higher than that of .738 (.717-.759) for tumor stage. GLR can independently predict the prognoses of patients with CRC, and our nomogram provides more accurate prediction than TNM staging.

Risk Factors and Predictors of Variceal Re-bleeding in Schistosomal Portal Hypertension Patients at the Bleeding Center in Ibn Sina Specialized Hospital

Background: Bleeding varices is a common complication of portal hypertension. It occurs secondary to schistosomal portal hypertension in the majority of our patients. The aim of this study is to determine the factors possibly affecting risk of recurrent variceal bleeding. Methods: This study is a descriptive cross sectional hospital based study which was carried out in Ibn Sina Specialized Hospital Bleeding Center during the period from July 2019 to January 2020. A total of 201 (n= 201) patients suffering from bleeding varices due to schistosomal portal hypertension were included. Any patients bleeding from other causes were excluded. Baseline laboratory investigations were done (CBC, RFT, and INR). Patients underwent upper GI endoscopy. Results: Males were predominant (78.6 %, n= 158), while 21.4 % of patients were females (n=43). Male: Female ratio was 4:1. Age ranged from &gt; 20 to &lt; 70 years, mean age being (52.15 ± 15.7) years. At presentation 44.7% of patients (n= 90) had both hematemesis and melena, 28.8% of patients (n= 46) had only melena and 32.2% (n= 65) had only hematemesis. Forty three percent of patients (n= 87) had Hemoglobin of less than 8 g/dl. Comorbidities were present in 19.9 %. Previous attacks of hematemesis were found in (88.6%) of patients (n= 178) and previous attacks of melena were found in 56.7% (n= 114). Endoscopy showed grade 3 esophageal varices in 50.7% (n= 102). Band ligation was done to 48.9 % (n= 97), while 29.4 % (n= 59) received sclerotherapy. One hundred and twenty two patients (60.7%) recovered and discharged from the hospital after one day and 38.3% (n= 77) stayed for more than 2 days. Unfortunately 7 Patients expired (3.5%). The correlations between the occurrence of re-bleeding and the level of hemoglobin at presentation (P= 0.014), grade of the varices, chronicity of schistosomiasis (P= 0.03 for both) and hypertension (P= 0.04) were statistically significant. Smoking was significantly associated with risk of re-bleeding (P=.05

Presence of diarrhea associated with better outcomes in patients with COVID-19 – A prospective evaluation

PurposeGastrointestinal (GI) manifestations have been well documented in patients with coronavirus disease 2019 (COVID-19), but its clinical impact on the course of the disease is debatable. Majority of the available data is retrospective, and hence this prospective study was planned to study the impact of GI symptoms on COVID-19 outcome. MethodsAll COVID-19 patients admitted in a tertiary care centre from August–October 2020 were screened and patients without pre-existing GI diseases were included. A detailed history of the various symptoms including duration was documented. Various baseline laboratory investigations and inflammatory markers were conducted as per the protocol. Patients with and without diarrhea were compared for the various disease outcome parameters. ResultsOf the 244 patients screened, 203 patients (128 males; 63.1%) were included. Respiratory symptoms alone were present in 49 (24.1%), GI symptoms alone in 20 (9.9%) and 117 (57.6%) had both. Overall GI symptoms was noted in 137 (67.5%) cases with the commonest being diarrhea (61; 30.0%). Patients with both respiratory and any GI symptoms showed a lower trend towards need for mechanical ventilation (12.2% vs 7.7%; p ​= ​0.35) and mortality (10.2% vs 4.3%; p ​= ​0.14) compared to respiratory symptoms alone, although not statistically significant. Patients with diarrhea (n ​= ​61) had no mortality (0% vs 7.7%; p ​= ​0.036) or need for mechanical ventilation and shorter hospital stay compared to those who did not have diarrhea. ConclusionGI symptoms are frequent in patients with SARS-CoV-2 infection and the commonest is diarrhea. Diarrhea is a harbinger of better outcome with lower mortality among COVID-19 positive patients.

A rare case of unilateral acute posterior multifocal placoid pigment epitheliopathy with features of Vogt-Koyanagi-Harada disease

The purpose of this study is to report a rare case of unilateral acute posterior multifocal placoid pigment epitheliopathy (APMPPE) with features of Vogt-Koyanagi-Harada (VKH) disease. Both the diseases have their own unique presentations and can lead to vision loss in the affected eye. Overlapping features of both diseases in the same eye is rare. A 28-year-old healthy female presented with loss of vision in her right eye for 10 days duration. Visual acuity in the affected eye was 20/200, N36. Fundus examination revealed numerous creamy yellow lesions overlying the posterior pole with subretinal fluid. Further investigations including fundus fluorescein angiography and optical coherence tomography were suggestive of overlapping features of both APMPPE and VKH disease. Baseline laboratory investigations and markers for Sarcoidosis, Tuberculosis, and Syphilis were normal. The patient was treated with tapering doses of oral steroids. One month following initiation of treatment, the vision had improved to 20/20, N6 with complete resolution of subretinal fluid in the right eye. The overlapping clinical and imaging features suggest that both diseases may be a part of a common inflammatory process that secondarily damages the outer retinal structures.

The Index Case of Covid-19 in Delta State, Nigeria: A Case Report

Background: Coronavirus disease (COVID-19) is a fatal respiratory infection that has spread rapidly around the world since it was first discovered in China in late 2019. Several management options and experiences have been observed across health systems globally including Nigeria. We report the progression and evolving clinical scenario of the first case of COVID-19 in Delta State, Nigeria.Methods: We reviewed the hospital admission case record of the first case of COVID- 19 in a 50-year-old male managed at the isolation centre of the Delta State University Teaching Hospital, Oghara, Delta State. All relevant information about the patient’s clinical characteristics, investigations, treatment and outcome were obtained and documented.Results: The patient was positive for COVID-19 and was placed on a wide-range of medications and supportive therapy. No baseline laboratory investigations were done throughout the period due to lack of a designated infectious disease laboratory to provide services at the time. Patient’s overall wellbeing was based on physical assessment and monitoring of vital signs: temperature, pulse rate, respiratory rate, blood pressure and oxygen saturation (SPO2). Although he became symptom-free by the 12th day of admission, the laboratory report was persistently positive for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) until the 35th day of admission when he became negative.Conclusion: This report showed that the patient had complete resolution of clinical symptoms without concomitant viral clearance. Also, intensive supportive care contributed to a favourable outcome in this patient. The need for improved surveillance and response systems to ensure better patient outcome is recommended.&#x0D; Keywords: COVID-19; Case Report; Index Case; Coronavirus; Delta State

POS-092 SGLT2 INHIBITOR – INDUCED EUGLYCEMIC DIABETIC KETOACIDOSIS IN GUILLAIN-BARRE SYNDROME: A CASE REPORT

Introduction: Euglycemic diabetic ketoacidosis (EuDKA) is a rare but increasingly reported serious adverse effect of SGLT2 inhibitors. There is not much published literature on the incidence of EuDKA and the factors associated with it. Though SGLT2 inhibitors were introduced as glucose lowering agents, recent trials have demonstrated their favourable cardiovascular outcome in heart failure and ability to retard progression of proteinuric kidney disease, including in non-diabetics. Hence use of this class of drugs is anticipated to increase exponentially, given the combined high global burden of diabetes, coronary artery disease and chronic kidney disease. As we embark to use the SGLT2 inhibitors in different clinical scenarios, it becomes imperative to report their adverse effects encountered in uncommon clinical conditions as well. Case history: A 42-year-old gentleman with history of type 2 diabetes mellitus for 15 years and coronary artery disease, presented with difficulty in climbing stairs and walking for 5 days with progressive difficulty in getting up from bed. He did not have past history of covid infection and had been immunised with 1 dose of covid vaccine. On examination, patient had normal hemodynamics. There was flaccid quadriparesis with areflexia and truncal muscle weakness. Nerve conduction study confirmed acute demyelinating polyradiculoneuropathy. His baseline laboratory investigations revealed normal renal parameters but metabolic acidosis was noted at the time of admission. Patient was started on iv immunoglobulin 2mg/kg and the motor weakness improved from grade 2/5 to 4/5. However, the high anion gap metabolic acidosis worsened over the next 4 days and patient developed acidotic breathing. His sugars were within normal limits and the patient was on metformin, glimeperide, vildagliptin, voglibose and dapagliflozin. As blood lactate levels were normal with urine acetone positivity, euglycemic diabetic ketoacidosis secondary to SGLT2 inhibitor was suspected and all the oral hypoglycemic agents were stopped. He was started on hydration and insulin infusion. After 48 hours of stopping dapagliflozin, acidosis resolved completely and the patient was reintroduced back on the other 4 class drugs. At follow-up, there was no recurrence of acidosis and patient was able to walk with support and physiotherapy. Discussion: SGLT2 inhibitors cause glycosuria and directly induce glucagon release from pancreas. Combined with insulin deficiency, this results in lipolysis, fatty acid oxidation and ketogenesis. They also cause increased renal reabsorption of ketone bodies. The precipitating factors for EuDKA identified so far include abrupt reduction in insulin dosage, reduced oral intake, infections, surgery, excess alcohol use, volume depletion, type 1 diabetes and heavy physical exercise. This is the first reported case of SGLT2 inhibitor-induced EuDKA in a patient with Guillain-Barre syndrome. As symptoms of dehydration may not be significant due to lack of hyperglycemia in EuDKA, there may be a delay in the diagnosis of this complication. Conclusion: The possibility of EuDKA to be kept in mind while evaluating metabolic acidosis in a diabetic patient on SGLT2 inhibitors. Temporarily withholding the SGLT2 inhibitors during an intercurrent illness will prevent the occurrence of the above serious adverse effect.

Role of Oxidative Stress as a Marker of Cardiovascular Risk in Children on Regular Hemodialysis

Introduction: Chronic kidney disease (CKD) is a major public health problem worldwide, and its main consequences include loss of renal function leading to end-stage renal disease (ESRD), increased risk of cardiovascular disease (CVD), significant increase in morbidity and mortality, and a decrease in health-related quality of life.&#x0D; Aims and Objectives: The basic aim of the study is to analyze the oxidative stress and total antioxidant capacity as a biomarker of cardiovascular risk in those children who are on regular hemodialysis.&#x0D; Materials and Methods: This cross sectional study was conducted at DHQ hospital, Faisalabad during July 2020 to January 2021. The data were collected from the age of less than 18 years children of both sexes. There were 50 children who was selected for this study. At the time of the study, all the patients were on regular three HD sessions per week. In HD patients, venous blood samples were drawn immediately before and after hemodialysis session. Baseline laboratory investigations were carried out for all patients and controls including complete blood count, serum urea and creatinine, arterial pH, arterial blood gases and infection screening, which included blood and urinary cultures by standard methods. &#x0D; Results: The data were collected from 50 dialysis patients. The mean age of this study is 15years. We collected all the demographic data of patients. The mean value of Urea is 64.34±2.44 mg/dl). At before-dialysis session, duration of disease positively correlated with TPX (r = 0.969, P &lt;0.001), but, negatively correlated with TAC (r = −0.469, P &lt;0.002). At after-dialysis session, HIF-1α negatively correlated with each of TPX (r = −0.529, P &lt;0.001) and OSI (r = −0.459, P &lt;0.003); while, OSI positively correlated with TPX (r = 0.944, P &lt;0.001).&#x0D; Conclusion: It is concluded that HD patients, the clinical and prognostic significance of oxidative status associated with cardiovascular risk factors is very different from the general population. Although a direct causality cannot be inferred from such kind of correlative investigations.

The Impact of Diabetes Mellitus and Hyperglycemia on the Severity and Outcome of Patients with COVID-19 Disease: A Single-Center Experience.

PurposeDiabetes mellitus (DM) has been reported to be associated with a worse outcome of COVID-19 infection. The evidence is scarce in the Middle East and Saudi Arabia. We aimed to evaluate the impact of diabetes mellitus and hyperglycemia in non-diabetic individuals on the severity and outcome of COVID-19 infection.MethodsThis is a retrospective observational study, which included patients with confirmed COVID-19 infection [RT-PCR positive for SARS-CoV2] who were admitted to King Fahd Hospital of the University-Khobar-Eastern Province-Saudi Arabia from March to September 2020. Baseline demographic data, laboratory investigations, and markers of the severity of COVID-19 were analyzed. The collected data were categorized according to the Saudi Arabian Ministry of Health COVID-19 infection severity criteria. Patients were divided into three groups as follows: patients in Group 1 had pre-existing DM, patients in Group 2 did not have DM but were documented to have hyperglycemia at presentation, and patients in Group 3 were neither diabetics nor hyperglycemics at presentation and served as the control group. The severity and outcome of the control group were compared with the other two groups. The effect of risk factors on the severity and outcome of COVID-19 infection was studied in the DM group.ResultsA total of 414 patients were included (70.5% males and 29.5% females). The mean age (SD) of patients was 52.3 (±15.5) years. Compared to the control group, pre-existing DM was found to be significantly associated with severe (OR 3.61), critical disease (OR 4.32), intensive care unit (ICU) admission (OR 2.0), and death (OR 2.0) from COVID-19 infection. Hyperglycemia without known DM was also found to be associated with critical COVID-19 pneumonia (P 0.001), and had longer duration of hospitalization (P 0.014), higher ICU admission, mechanical ventilation, and death from COVID-19 infection (P < 0.0001).ConclusionDiabetes mellitus and hyperglycemia at presentation, even in the absence of pre-existing DM, are independent risk factors for disease severity and worse outcome of COVID-19 infection. These patients should be identified and managed accordingly. The COVID-19 vaccination program should also target those populations to improve their outcomes.

Novel Predictive Model for Adrenal Insufficiency in Dermatological Patients with Topical Corticosteroids Use: A Cross-Sectional Study.

PurposeThis study aimed to identify predictive factors and to develop a predictive model for adrenal insufficiency (AI) related to topical corticosteroids use.MethodsThe research was conducted using a cross-sectional design. Adult patients with dermatological conditions who had been prescribed topical steroids for at least 12 months by the dermatology outpatient departments of the Faculty of Medicine, Chiang Mai University from June through October 2020 were included. Data on potential predictors, including baseline characteristics and laboratory investigations, were collected. The diagnoses of AI were based on serum 8AM cortisol and low-dose ACTH stimulation tests. Multivariable logistic regression was used for the derivation of the diagnostic score.ResultsOf the 42 patients, 17 (40.5%) had AI. The statistically significant predictive factors for AI were greater body surface area of corticosteroids use, age <60 years, and basal serum cortisol <7 µg/dL. In the final predictive model, duration of treatment was added as a factor based on its clinical significance for AI. The four predictive factors with their assigned scores were: body surface area involvement 10–30% (20), >30% (25); age <60 years old (15); basal serum cortisol of <7 µg/dL (30); and duration of treatment in years. Risk of AI was categorized into three groups, low, intermediate and high risk, with total scores of <25, 25–49 and ≥50, respectively. The predictive performance for the model was 0.92 based on area under the curve.ConclusionThe predictive model for AI in patients using topical corticosteroids provides guidance on the risk of AI to determine which patients should have dynamic ACTH stimulation tests (high risk) and which need only close follow-up (intermediate and low risk). Future validation of the model is warranted.