Profile of Patients Admitted with Acute-on-Chronic Liver Disease in a Tertiary Care Hospital Bal Kishan Gupta, Shyam Lal Meena, Vijay Kumar Meena; Jigyasa Gupta

Introduction: Chronic liver disease (CLD) and cirrhosis of liver are 12th leading cause of death. Acute-on-chronic liver failure (ACLF) is an increasingly recognized entity encompassing an acute deterioration of liver function in patients with cirrhosis and it is associated with high mortality. Methodology: A total of 100 consecutive patients admitted with ACLF were studied. Chronic liver disease was defined as per 2014 ICD-10 CM Diagnosis Code K 76.9. ACLF was defined as per the Asian Pacific Association for the Study of the Liver (APASL) criteria. Grading of severity of ACLF was done as per the CANONIC study. Prognostic scores including Child- Pugh scoring system were also calculated. Results: Out of 100 patients 84 were males (mean age 44.31±13.58 years) and 16 females (mean age 40.19±19.11 years). Underlying etiology of CLD was alcoholic (76 cases), Hepatitis B virus (HBV) (10 cases), cryptogenic (seven cases), autoimmune (four cases) and Heapatitis C virus (HCV) in (three cases). There were 74% from rural area, 51% illiterate and 82% belonged to the low socio-economic status. Most common presentation of ACLF was hemetemesis (36%) followed by melena (30%), vomiting (30%), sepsis (28%), pain abdomen (27%), hepatic encephalopathy (17%) and hepato-renal syndrome (16%). Mortality rate in our study was 9% and all belonged to the alcoholic group. Severe anemia, hypoalbuminemia, hyperbilirubinemia, renal dysfunction, sepsis, hyponatremia, high PT-INR and high Child Pugh score 10-15 were associated with poor prognosis. Conclusion: Knowledge and early recognition of various risk factors may help in prevention of acute- on- chronic liver failure and early identification of various prognostic features may help in decreasing the mortality in patients of acute-on-chronic liver failure

Educational status-related disparities in awareness, treatment and control of cardiovascular risk factors in India

ObjectiveTo determine association of socioeconomic status, defined by educational status (ES), with awareness, treatment and control of cardiovascular risk factors.MethodsWe performed an epidemiological study at 11 cities in India using cluster sampling. 6198 subjects (3426 men, 2772 women, response 62%, age 48±10 years) were evaluated for sociodemographic, lifestyle, anthropometric and biochemical factors. ES was categorised according to years of schooling into low (≤10 years), medium (11-15 years) and high (>15 years). Risk factors were diagnosed according to current guidelines. Awareness, treatment and control status were determined for hypertension, diabetes and hypercholesterolaemia. For smoking/tobacco use, quit rate was determined. Descriptive statistics are reported.ResultsAge-adjusted and sex-adjusted prevalence (%) of various risk factors in low, medium and high ES subjects was hypertension 31.8, 29.5 and 34.1, diabetes 14.5, 15.3 and 14.3, hypercholesterolaemia 24.0, 23.9 and 27.3, and smoking/tobacco use 24.3, 14.4 and 19.0. Significantly increasing trends with low, medium and high ES were observed for hypertension awareness (30.7, 37.8, 47.0), treatment (24.3, 29.2, 35.5) and control (7.8, 11.6, 15.5); diabetes awareness (47.2, 51.5, 56.4), treatment (38.3, 41.3, 46.0) and control (18.3, 15.3, 22.8); hypercholesterolaemia awareness (8.9, 22.4, 18.4), treatment (4.1, 6.2, 7.9) and control (2.8, 3.2, 6.9), as well as for smoking/tobacco quit rates (1.6, 2.8, 5.5) (χ(2) for trend, p<0.05).ConclusionsLow ES subjects in India have lower awareness, treatment and control of hypertension, diabetes and hypercholesterolaemia and smoking quit rates

Geographic epidemiology of cardiometabolic risk factors in middle class urban residents in India: cross–sectional study

Objective: To determine epidemiology of cardiovascular risk factors according to geographic distribution and macro-level social development index among urban middle class subjects in India. Methods: We performed cross-sectional surveys in 11 cities in India during years 2005–2009. 6198 subjects aged 20–75 years (men 3426, women 2772, response 62%) were evaluated for cardiovascular risk factors. Cities were grouped according to geographic distribution into northern (3 cities, n=1321), western (2 cities, n=1814), southern (3 cities, n=1237) and eastern (3 cities, n=1826). They were also grouped according to human social development index into low (3 cities, n=1794), middle (5 cities, n=2634) and high (3 cities, n=1825). Standard definitions were used to determine risk factors. Differences in risk factors were evaluated using χ2test. Trends were examined by least squares regression. Findings Age–adjusted prevalence (95% confidence intervals) of various risk factors was: low physical activity 42.1% (40.9–43.3), high dietary fat 49.9% (47.8–52.0), low fruit/vegetables 26.9% (25.8–28.0), smoking 10.1% (9.1–11.1), smokeless tobacco use 9.8% (9.1–10.5), overweight 42.9% (41.7–44.1), obesity 11.6% (10.8–12.4), high waist circumference 45.5% (44.3–46.7), high waist–hip ratio 75.7% (74.7–76.8), hypertension 31.6% (30.4– 32.8), hypercholesterolemia 25.0% (23.9–26.9), low HDL cholesterol 42.5% (41.3–43.7), hypertriglyceridemia 36.9% (35.7–38.1), diabetes 15.7% (14.8–16.6), and metabolic syndrome 35.7% (34.5–36.9). Compared with national average, prevalence of most risk factors was not significantly different in various geographic regions, however, cities in eastern region had significantly lower prevalence of overweight, hypertension, hypercholesterolemia, diabetes and metabolic syndrome compared with other regions (P<0.05 for various comparisons). It was also observed that cities with low human social development index had lowest prevalence of these risk factors in both sexes (P<0.05). Conclusions Urban middle–class men and women in eastern region of India have significantly lower cardiometabolic risk factors compared to northern, western and southern regions. Low human social development index cities have lower risk factor prevalences

Oliguric and non-oliguric acute renal failure in malaria in west zone of rajasthan, India-A comparative study

Objective: To report a comparative clinical and histopathological study on oliguric and non-oliguric acute renal failure (ARF) in malaria. Method: 311 consecutive cases of malaria out of which 74 (23.79%) had ARF as per WHO criteria were conducted. Mean age was 32.58 (range 15–60 years) and male: female was 2:1. Result: Most of the cases developed ARF within 10 d of onset. 18 cases (11 falciparum, 2 mixed, 5 vivax) presented with oliguric and 56 (41 falciparum, 6 mixed, 9 vivax) with non-oliguric renal failure. Associated major manifestations were jaundice (75.68%), cerebral malaria (41.89%), bleeding manifestations (32.43%), severe anemia (27.03%), hypotension (25.68%), multi-organ failure (18.92%), severe thrombocytopenia (12.16%), and ARDS (8.11%). Kidney biopsy (n=20) showed acute tubular necrosis (n=7), Mesangioproliferative glomerulonephritis (n=4) or both (n=9). Hemodialysis was done in 8 cases of oliguric renal failure out of which 4 survived (average no. of session 2.9). Conclusion: Most of the cases recovered within 3 weeks. Total mortality was 28.38% (n=21) and mortality was more in oliguric renal failure (72.22%) as compare to non-oliguric renal failure (14.29%)

Acute abdomen presentation in dengue fever during recent outbreak

Objective: To evaluate the etiology, clinical profile and outcome of acute abdomen presentation in Dengue Fever (DF).Methods: This clinical prospective study was done on confirmed cases of DF admitted in the department of medicine during recent epidemic (September 2015 to November 2016). All patients were evaluated clinically and by laboratory and imaging investigations and followed-up during hospital stay till discharge. The cause of pain abdomen was ascertained by blood tests (amylase, lipase and liver function test etc), radiology (Flat plate abdomen-erect, Ultrasonography of abdomen, CECT abdomen) and/or endoscopy.Results: Out of the 501 patients diagnosed as DF, 165 (32.93%) presented with acute abdomen. Some patients presented in other departments like surgery, gastroenterology and emergency, were later diagnosed as DF on laboratory evaluation. Various causes of acute abdomen in our study were nonspecific severe pain abdomen (67 cases), acute hepatitis (46) one had acute fulminant hepatitis, acute acalculous cholecystitis (31), ascitis (12), acute hyperemic gastritis with malena (5), acute pancreatitis (2), and 1 case each of acute appendicitis and acute jejuno-ileal intussuception. All patients were managed conservatively. One patient of acute pancreatitis died of multi-organ failure.Conclusion: Our study concludes that clinical vigilance about such type of presentations is important as timely recognition can influence outcome and may prevent unwanted surgery

Clinical Profile and Prognostic Indicators in Adults Hospitalized with Severe Malaria Caused by Different Species

Introduction Severe malaria remains a major cause of death and morbidity among adults in the Asiatic tropics. This study was planned to evaluate clinical profile and prognostic indicators of severe malaria in adults so as to improve insight into this highly prevalent disease. Materials and Methods This prospective observational study was conducted on 60 confirmed cases of malaria. Cases were divided into two groups: (a) study group: suffering from severe malaria and (b) control group: no severe manifestations. All cases were thoroughly studied for clinical features, laboratory evaluation, and outcome. Prognostic evaluation was also done by different score systems. Results In all, 40 cases suffer from severe malaria (study group), while 20 cases belong to the control group. The majority of our cases were males of age 21–40 years. The most common species of malaria in the study group was vivax (52.5%), followed by falciparum (25%) and mixed malaria species (22.5%). The clinical predictors for severe malaria were rural habitat, longer duration of fever, marked chills, tiredness, giddiness, nausea, vomiting, decreased urine output, jaundice, and altered sensorium. Extreme weakness (80%), jaundice (55%), renal failure (50%), and severe anemia (27.5%) were the most common presenting features in severe malaria. Two patients died of severe mixed malaria. The mortality rate was significantly associated with lower hemoglobin level ( P = 0.002); higher total leukocyte count ( P = 0.006), blood urea ( P < 0.001), serum creatinine ( P < 0.001), SGOT ( P = 0.001), SGPT ( P < 0.007), serum bilirubin ( P = 0.003), and parasite density ( P = 0.033); lower platelet count ( P = 0.043); and those who had more APACHE II score ( P = 0.003), SOFA score ( P = 0.04), and Multiple Organ Dysfunction Score ( P < 0.001) and lower Glasgow Coma Scale ( P < 0.001). Conclusions Manifestations of severe malaria is becoming increasingly more prevalent specifically in vivax and mixed malaria cases. Our study proposes that there are certain clinical predictors and prognostic indicators that should be kept in mind for better management of severe malaria

Evaluation of Clinical Significance of Vitamin D3 Status in Hospitalized Cases of Acute Febrile Illness with Thrombocytopenia in North-West Zone of Rajasthan

Introduction: Thrombocytopenia is an important haematological manifestation of acute febrile illness caused by a variety of infections. Besides the role of vitamin D3 in bone homeostasis, its significance in infections, inflammation, and immune response has also been documented. This study aimed to evaluate clinical significance of vitamin D3 status in patients of acute febrile illness with thrombocytopenia. Methodology: The present cross-sectional study was conducted on 400 patients of fever with thrombocytopenia admitted between May 2022 to October 2022. Laboratory evaluation including vitamin D3, complete blood count (CBC), renal function test (RFT), liver function test ( LFT), blood sugar, lactate dehydragenase (LDH), rapid diagnostic test for malaria, peripheral blood smear (PBS) for malaria parasite (MP), test for dengue, HBsAg, HCV, HIV, blood culture, D dimer, test for scrub typhus and leptospirosis, ultrasonography, and chest X-ray was also done in all the cases. Results: Out of 400 patients, 227 were males (mean age 5.46±15.63 years) and 173 females (mean age 39.75±17.36 years). Dengue fever was found to be the commonest cause (29.5%) followed by malaria, COVID-19 infection (0.75%), and one case each of HIV and Hepatitis B. Low level of vitamin D3 was found in 73.5% cases as compared to 17.5% in control subjects (p 0.2089), residence (p>0.97), comorbidities (p>0.248), and etiology (27.70±14.0, 27.45±11.96, 34.13±6.36, 28.79±26.04, respectively for dengue, malaria, COVID-19, and undiagnosed; p>0.609). Longer duration of illness at the time of hospitalization (p<0.02) and longer duration of hospital stay (p<0.04) was associated with lower vitamin D3 status. Low D3 status was associated with increased incidence of bleeding manifestations (p <0.05) and more requirement of platelet transfusion (p <0.017)