A Study on LFT Monitoring in ATT and the Spectrum of Anti-Tuberculous Drug induced Liver Injury

INTRODUCTION : Drug reactions are often under reported and majority of drug reactions are minor. Some cases of adverse drug reactions may be major events like hepatotoxicity or nephrotoxicity. DILI is one of the leading causes of acute liver failure in the US, accounting for 13% of cases of acute liver failure; these events pose a major challenge for drug development and safety. Antimicrobials and agents for the central nervous system are the most common causes of DILI and health foods or dietary supplements account for 7% of cases of DILI in the US. In India and other developing countries, ATT is the most important drug implicated in DILI. Anti Tuberculous drug induced liver injury is mostly due to inadequate evaluation of risk factors and “inappropriate dosing”. Worldwide, incidence of Anti Tuberculous DILI, between 5 to 33%. This wide variation may be due to the predilection of TB towards developing count 1ries than West. Even developed nations have a recent surge after the global HIV pandemic of HIV during 80s. In India, a nation contributing significant proportion of TB cases, the incidence of ATT DILI ranges between 33 to 35%. AIM OF THE STUDY : Primary Aim : 1. To identify DILI even before onset of symptoms, which may prevent serious drug induced Acute Liver failure. 2. To identify the risk factors for DILI due to Anti Tubercular Treatment. 3. To formulate the way of monitoring for DILI in patients who are started ATT. Secondary : 1. To study the Prevalence of ATT DILI in patients with deranged baseline LFT values. 2. To study the Incidence of Hepatic adaptation and its significance in monitoring patients on ATT. MATERIALS AND METHODS : This is a prospective study from our Institute, Department of Digestive Health and Diseases. Government peripheral Hospital Anna Nagar., a tertiary care Centre, fed by a chest clinic and many DOTS (Directly Observed Short Term Chemotherapy) centers. The study period is from January 2014 to January 2015. THE STUDY GROUP : The Study population is patients who are registered under dots and started on ATT, at chest clinic, Govt. Kilpauk Medical College. They were patients diagnosed with TB, pulmonary or extra pulmonary. Also, they were not on previous anti-TB chemotherapy higher than two weeks . All patients were followed till the end of their ATT COURSE and LFT was monitored. EXCLUSION CRITERIA : 1. HIV Positive and on HAART, 2. Pregnant Females, 3. Postpartum 3 Months, 4. Patients on Cancer Chemotherapy, 5. Age Less Than 18 Years, 6. Moribound State. LFT and clinical monitoring in patients who are selected under the inclusion criteria in the study were followed up till the end of their therapy by serial LFTs. Patients were divided into two groups according to their baseline LFT as follows., 1. GROUP 1 –Patients With Normal Baseline LFT Values. 2. GROUP 2- Patients With Baseline Altered LFT Values. LFT was done baseline and every week for the first month, then fortnightly for the next 2months and then monthly until the end of therapy. Patients with clinical and lab evidence of DILI were evaluated for risk factors. All results were analysed for both groups. Patients with referred with ATT DILI to this tertiary care were analyzed for Risk factors and the Demographic profile of DILI. Finally the incidence of DILI in both groups was analysed. The incidence of hepatic adaptation was analysed Also, the mortality rate in patients taking ATT and significance of risk factors in, mortality of DILI was analysed. An ATT DILI criterion is taken according to American Thoracic Society Guidelines-2006, when any one of these three criteria was met ATT was stopped. 1. S.Transaminases >3 ULN with Symptoms, 2. S.Transaminases >5ULN without Symptoms, 3. Any increase in Bilirubin. RESULTS: The incidence of Drug induced liver injury in Group 1 & 2 Both is 11.7%. Incidence of DILI in Group 1 is 9.48%. Incidence of DILI in Group 2 is 20.7%. Patients with normal baseline LFT had stastically significant incidence of DILI of 9.4%(p<0.001). Mortality Rate : a.Mortality due to ATT, among the total study population is 4.1%.(n=145) Mortality due to ATT among Group 1 is 2.5%. Mortality due to ATT in Group 2 is 10.3%. The cause specific mortality rate for Group 1 patients with DILI-27.2%. The cause specific mortality rate fort Group 2 patients with DILI- 50%. Mortality among Group 2 (n=25). The mortality rate in Patients on ATT in Group 2 is 10.3%. There is stastical significance between patients recovered and not recovered in Group 2. (p<0.001). Mortality in females - Group 1. Females have higher Odds for DILI deaths compared to males. Since there were no females died of DILI in Group 2, p value and odds ratio was not applicable. Diabetics have higher Odds in DILI related mortality than Non Diabetics in Group 1. Since there were no diabetics, who died in Group 2, p value and Odds ratio was not applicable. CONCLUSION : 1. There is increased incidence of DILI in patients with Altered Baseline LFT values. 2. Females with Normal baseline LFT have higher Odds for DILI deaths than Males. 3. Diabetics with Normal baseline LFT, have higher Odds for DILI deaths than Non Diabetics. 4. The patients with altered baseline LFT values have higher mortality with ATT. 5. Periodic monitoring of LFT prevents mortality in DILI

Study of thyroid function in patients admitted in intensive care unit

Background: The thyroid gland produces two related hormones, tetraiodothyronine (T4) and triiodothyronine (T3) play a critical role in cell differentiation during development and maintain thermogenic and metabolic homeostasis in the adult. Critically ill patients have been defined as those that by dysfunction or failure of one or more organ system depend on survival from advanced instruments monitoring and therapy. The objective was to study the thyroid dysfunction in critically ill patients admitted in intensive care units and its relation to the mortality and severity of disease.Methods: This is a cross sectional study carried out in Dr. Pinnamaneni Siddhartha institute of medical sciences and research foundation, Chinoutpalli, Andhra Pradesh from 1st January 2022 to 30th September 2022 involving 100 patients. Patients of age above 18 years, both sexes, admitted to intensive care units with critical illness were analyzed and approved by institutional ethics committee of Dr. PSIMS and RF data were entered in MS-excel and analyzed in SPSS V22 software. Descriptive statistics, Mann-Whitney U test, logistic regression, ROC curves were applied. P values were reported for all statistical tests and a value of&lt;0.05 was considered to be significant.Results: Out of 100 critically ill patients out of which 17 patients had sepsis, 18 had acute renal failure, 19 patients had acute respiratory failure, 19 patients had diabetic ketoacidosis, 16 patients had congestive cardiac failure, and 11 patients had stroke and their correlation with t3 hormone decrement showed positive correlation.Conclusions: Thyroid profile can be used in predicting the mortality in ICU patients

A Path Difficult to Tread: Pure Autonomic Failure, A Case Report

Introduction - Pure autonomic failure is a rare disorder characterized by orthostatic hypotension, absence of a compensatory rise in heart rate, and abnormal autonomic functions. In most cases, supine hypertension is seen coupled with orthostatic hypotension, making the management of these patients a big challenge. We present the case of a 74-year-old gentleman, who presented to the ED with altered mental status for a day; weakness, and falls for 3 weeks. The patient had a past medical history of Hypertension, alcoholism, and REM sleep disorder. He was being treated for erectile dysfunction for the last 10 years and had a family history of Parkinson\u27s disease in his mother and sister. The patient was compliant with Lisinopril 40 mg, Amlodipine, and Rosuvastatin, Tamsulosin 0.4 mg. His blood pressure(BP) on presentation was ranging between 109/74-194/76 mm of Hg. Systolic BP dropped by 30mmHg after tilting the angle of the bed to 45 degrees for 1 minute with no change in HR and the patient became symptomatic in this position. Orthostatic vitals showed a dramatic drop in Systolic BP of \u3e80mmHg with no change in heart rate. MRA and MRI showed chronic microvascular changes. The Echocardiogram, Cortisol, and TSH levels were all normal. All anti-hypertensives were discontinued and supportive treatment was started with Midodrine, Droxidopa, and Pyridostigmine, thigh-high TED hose and abdominal binders at bedtime, and Nitroglycerin patch at night for hypertension. The patient was started on fludrocortisone as he continued to drop his BP by 80 mmHg on standing. The use of TED stockings and bed tilting improved the issue of uncontrolled supine hypertension at night. Conclusion- Treatment of autonomic dysfunction continues to be challenging. There are no definitive guidelines and management is largely individualized. Both pharmacological and non-pharmacological measures are used

Structural Progression in Patients with Definite and Non-Definite Arrhythmogenic Right Ventricular Cardiomyopathy and Risk of Major Adverse Cardiac Events

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare inherited disease characterised by early arrhythmias and structural changes. Still, there are limited echocardiography data on its structural progression. We studied structural progression and its impact on the occurrence of major adverse cardiovascular events (MACE). In this single-centre observational cohort study, structural progression was defined as the development of new major or minor imaging 2010 Task Force Criteria during follow-up. Of 101 patients, a definite diagnosis of ARVC was made in 51 patients, while non-definite ‘early’ disease was diagnosed in 50 patients. During 4 years of follow-up (IQR: 2–6), 23 (45%) patients with a definite diagnosis developed structural progression while only 1 patient in the non-definite (early) group gained minor imaging Task Force Criteria. Male gender was strongly associated with structural progression (62% of males progressed structurally, while 88% of females remained stable). Patients with structural progression were at higher risk of MACE (64% of patients with MACE had structural progression). Therefore, the rate of structural progression is an essential factor to be considered in ARVC studies

A Machine learning Classification approach for detection of Covid 19 using CT images

Coronavirus disease 2019 popularly known as COVID 19 was first found in Wuhan, China in December 2019. World Health Organization declared Covid 19 as a transmission disease. The symptoms were cough, loss of taste, fever, tiredness, respiratory problem. These symptoms were likely to show within 11 –14 days. The RT-PCR and rapid antigen biochemical tests were done for the detection of COVID 19. In addition to biochemical tests, X-Ray and Computed Tomography (CT) images are used for the minute details of the severity of the disease. To enhance efficiency and accuracy of analysis/detection of COVID images and to reduce of doctors' time for analysis could be addressed through Artificial Intelligence. The dataset from Kaggle was utilized to analyze. The statistical and GLCM features were extracted from CT images for the classification of COVID and NON-COVID instances in this study. CT images were used to extract statistical and GLCM features for categorization. In the proposed/prototype model, we achieved the classification accuracy of 91%, and 94.5% using SVM and Random Forest respectively

Effects of green tea and chamomile tea on plaque pH, salivary pH, Streptococcus mutans count

Aim: Green tea is healthy beverage and is a part of our day to day life. Similarly, chamomile tea is known for its aspirin like properties. Beneficial effects of these tea includes protection against dental caries, periodontal disease and tooth loss and found that can a decrease in streptococcus mutans count as well as increase in pH. Hence the present study was to compare the pH of saliva and plaque, before and after the intake of green tea and to evaluate the role of green tea and chamomile tea on growth of s.mutans in culture using saliva. Material and Methods: Salivary samples were collected from 30 healthy individuals aged 20-30 years with certain criteria. The pH of saliva was determined by collecting samples before, immediately after and 15 min, 30 min after drinking tea using pH meter. Similarly the microbial colonies were also counted. The Data obtained were analyzed using Wilcoxon’s, Friedman's and Mann Whitney test. Results: There was statistically no significant difference between salivary streptococcus mutans count before and after (p 0.001) intake of green tea and chamomile tea. Conclusion: The result of the present study has proved that consumption of green tea and chamomile tea inhibit salivary Streptococcus mutans count and cause reduction of pH in saliva. So, it is advisable to encourage the regular consumption of this widely available, tasty and inexpensive beverage as an interesting alternative to other drinks

Choroidal Structural Changes Correlate With Neovascular Activity in Neovascular Age Related Macular Degeneration.

Purpose To correlate changes in choroidal thickness and vascularity index with disease activity in patients with neovascular age-related macular degeneration (nAMD). Methods Eyes diagnosed with AMD that had two sequential visits within 12 months and that had no choroidal neovascularization (CNV) or had inactive CNV at the first visit were included. Those that had active CNV at follow-up were enrolled as cases. Eyes that did not developed a CNV or that were still inactive at the second visit were enrolled as controls. Disease activity was based on optical coherence tomography (OCT) and fluorescein angiography findings. Subfoveal choroidal thickness (SCT), mean choroidal thickness (MCT), and choroidal vascularity index (CVI) were assessed on enhanced depth imaging OCT and compared between the baseline and follow-up visit. Subgroup analysis accounting for lesion type and previous treatment, if any, were performed. Results Sixty-five eyes from 60 patients (35 females) and 50 age- and sex-matched controls were included. At the active visit, cases had an increase from 164 ± 67 μm to 175 ± 70 μm in mean ± SD SCT and from 144 ± 45 μm to 152 ± 45 μm in MCT (both P < 0.0001). The mean CVI also increased at from 54.5% ± 3.3% to 55.4% ± 3.8% (P = 0.04). Controls did not show significant changes in choroidal measurements between the two visits. Mean SCT, MCT, and CVI values were similar for previously treated and treatment-naive eyes. Conclusions Choroidal thickness and CVI significantly increased with active disease in nAMD eyes. Changes in choroidal thickness may predict CNV development or recurrence before they are otherwise evident clinically