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  Access statistics : Table of Contents
   2021| July-September  | Volume 9 | Issue 3  
    Online since July 16, 2021

 
 
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EDITORIAL
Biomarkers in assessing the severity of stroke
Girish Baburao Kulkarni
July-September 2021, 9(3):137-138
DOI:10.4103/ajim.ajim_57_21  
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REVIEW ARTICLES
Arterial stiffness – A measurable vascular marker in clinical practice
Nagaraj Desai, CR Venkatesh, Prabhakar Koregol
July-September 2021, 9(3):146-152
DOI:10.4103/ajim.ajim_95_20  
Arterial stiffness results from the changes in the walls of the large vessels and aorta. It has been incriminated in the pathogenesis of cardiovascular disorders. Its association with the major risk factors and atherosclerosis has been explored. Pulse wave velocity (PWV) is generally measured to evaluate it. Noninvasive methods of its measurement, which have been found to be satisfactory inaccuracy, make it a very attractive tool for cardiovascular risk assessment. In clinical practice, probe-based or cuff-based systems are commonly used to measure arterial stiffness. It may well be suited for the detection of vascular abnormality of an intermediate clinical phenotype and has been shown to be a marker of poorer prognosis in some diseases like chronic kidney disease. It has also been found to be reversible in clinical studies, although in the early stages. Given the global burgeoning cardiovascular diseases, it may serve as an attractive clinical screening tool that may be applied to a large population to implement early preventive strategies and utilize the limited resources to those with abnormal findings. Region-specific guidelines do recommend measurement of PWV. However, in the real world, the measurement of arterial stiffness remains underutilized as yet.
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Nonalcoholic fatty liver disease: New epidemic
Rajkumar P Wadhwa, Deven Shrikant Gosavi, Aathira Ravindranath
July-September 2021, 9(3):139-145
DOI:10.4103/ajim.ajim_59_20  
The global obesity epidemic has dramatically increased the prevalence of nonalcoholic fatty liver disease (NAFLD), such that it is the most common cause of chronic liver disease in Western nations. NAFLD is an important cause of liver disease in India also. The prevalence of NAFLD in India is around 9%-32% of general population with higher prevalence in those with overweight or obesity and those with diabetes or prediabetes. NAFLD is an important cause of unexplained rise in hepatic transaminases, cirrhosis, and hepatocellular carcinoma. The spectrum of abnormalities which the term NAFLD encompasses is isolated fatty liver, nonalcoholic steatohepatitis (NASH), and cirrhosis. The pathogenesis of NAFLD/NASH is complex and includes the development of insulin resistance, accumulation of excess lipids in the liver, mitochondrial dysfunction, and cell damage, and development of necroinflammation. Diagnosis is usually incidental during the evaluation for unrelated abdominal symptoms, elevated transaminases without any other explanation. Imaging modalities such as ultrasound are useful to diagnose the presence of excessive fat deposition in the liver but are not useful in differentiating simple steatosis from NASH. Liver biopsy may be useful in making this distinction, especially in those with risk factors for significant liver disease. Treatment modalities include weight reduction and exercise, metformin, Vitamin E, pentoxifylline, and saroglitazar and are effective in normalizing transaminases or in improving hepatic steatosis and inflammation in Indian patients with NAFLD. Randomized controlled treatment trials involving large number of patients with histological end point are required to assess the efficacy of different modalities.
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ORIGINAL ARTICLES
Study of delayed treatment perspective of snake bites and their long-term effects in a tertiary care hospital in balgalkot district of Karnataka
M Mahendra, Mohammed Mujtaba, CN Mohan, Madhumathi Ramaiah
July-September 2021, 9(3):153-158
DOI:10.4103/ajim.ajim_78_20  
Background: Snakebite is an acute life-threatening and time limiting medical emergency. Alternative and traditional methods of cure are barriers to early treatment which results in considerable delay in coming to the hospital. This study was done to assess the clinical profile and to identify long-term perspective of snake bites in patients who presented to the hospital beyond 6 h of snake bite. Methodology: This descriptive study was conducted over 18 months that included 45 patients with alleged history of snake bite of which 15 had delayed presentation, 6 h after snake bite. A detailed history, clinical examination and investigations were monitored for any complications during treatment and follow-up to look for delayed complications. Results: The clinical profile and outcome were different among patients presenting beyond 6 h and within 6 h, cellulitis (46.66% vs. 33.33%), bleeding manifestations (46.66% vs. 50%), neurological manifestations (33.33% vs. 33.33%), AKI (33.33% vs. 16.66%), respiratory failure requiring ventilatory support (33.33% vs. 10%), and mortality (20% vs. none). Delayed complications observed in patients with delayed presentation on long-term follow-up were ulceration including knee amputation, chronic kidney disease, psychiatric disturbances, and musculoskeletal symptoms. Conclusion: The acute complications were significantly higher with delayed presentation and delayed complications that are often overlooked which contributes to significant morbidity and suffering. The general population needs to be educated regarding the available treatment strategies and significance of seeking early medical attention for better treatment outcome and to reduce morbidity and mortality both short term and long term.
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Assessment of symptoms and complications in treatment naive newly diagnosed type 2 diabetes mellitus and their correlation with glycemic parameters: A cross-sectional study from kalyana Karnataka
Swaraj Waddankeri, SW Meenakshi, B Mangshetty
July-September 2021, 9(3):159-166
DOI:10.4103/ajim.ajim_97_20  
Background and Objectives: The Assessment of symptoms in newly diagnosed type 2 diabetes mellitus (T2DM) and determine its correlation with glycemic parameters such as General random blood sugar (GRBS) Fasting blood sugar (FBS), Post prandial blood sugar (PPBS), and Glycated hemoglobin (HbA1c) at diagnosis. Methodology: Cross-sectional, observational, single-arm study of 73 consecutive cases of treatment naïve, newly diagnosed T2DM with a baseline HbA1c >9. Hyperglycemic symptoms and complications were assessed at diagnosis and evaluated for their association with glycemic parameters (FBS, PPBS, and HbA1c). Results: Nocturia and weight loss were positively correlated (P < 0.05) to FBS, PPBS, and HbA1c. The most frequently observed symptoms in patients with complication were weight loss (16/18, 88.9%), followed by nocturia (14/18, 77.8%), polyuria (12/18, 66.6%), and balanitis (10/18, 55.5%). Furthermore, nocturia was associated with higher GRBS and polyuria/polyphagia with higher HbA1c at diagnosis. The mean General Random Blood Sugar (GRBS) was 335.4 mg/dl. The mean FBS and PPBS were 272 mg/dl and 397.1 mg/dl, respectively. The mean of HbA1c at diagnosis was 12.6%. Conclusions: Hypertension was the most common comorbidity. Chronic kidney disease and nonproliferative diabetic retinopathy were the commonly observed complications. In newly diagnosed T2DM patients, nocturia, polyuria, and weight loss were the most common symptoms associated with higher glycemic levels at presentation. Hypertension with higher creatinine at diagnosis is one of the ominous signs of harboring one or more underlying complication.
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A study of neutrophil-to-lymphocyte ratio in patients with metabolic syndrome
Manjushree Mohan, ST Kavya, HR Sanjay Kumar
July-September 2021, 9(3):167-170
DOI:10.4103/ajim.ajim_102_20  
Background and Aim of the Study: Numerous studies have shown an association of metabolic syndrome (MS) and insulin resistance with inflammation. The prevalence of MS as defined by the National Cholesterol Education Programme, Adult Treatment Panel III (NCEP, ATP), and other criteria indicates ranges from 11% to 41% in India. Neutrophil-lymphocyte ratio, which is calculated from a routine complete blood count with differential, is an easily obtained, inexpensive, can be used as a widely available marker of inflammation. This ratio can also aid in the risk stratification of patients with various cardiovascular diseases in addition to the traditionally used markers. Materials and Methodology: In this cross-sectional study, 210 patients with and without MS were included after detailed history and examination. Patients were considered as cases based on the NCEP, ATP III criteria for MS. Both groups of patients were subjected to routine investigations which included complete blood counts, total white blood counts, neutrophil and lymphocyte levels, HbA1c levels, serum glucose levels, fasting lipid profile, and electrocardiography. Logistic regression analysis was done to look for the association of neutrophil-lymphocyte ratio with MS. P < 0.05 was considered as statistically significant. Results: It was seen that the neutrophil-lymphocyte ratio in participants without MS was found to be 1.57 ± 0.728 and the ratio in participants with MS fulfilling 3 out of the 5 criteria, 4 out of 5 and 5 out of 5 criteria were, respectively, 2.65 ± 1.003, 3.59 ± 1.258, and 4.79 ± 2.143. This association was statistically significant with a P = 0.00. Conclusion: Participants with MS had increased neutrophil-lymphocyte ratio when compared to participants without MS. Participants fulfilling higher criteria of MS had higher neutrophil-lymphocyte ratio suggesting increasing inflammatory state.
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A study to assess diabetic distress and other factors which affect glycemic control in patients with type 2 diabetes mellitus
Amruthavarshini Nagabhushana, Madhumathi Ramaiah, Mumtaz Ali Khan, Siddesh Nijaguna
July-September 2021, 9(3):176-179
DOI:10.4103/ajim.ajim_8_21  
Objective: The objective of the study was to assess diabetes distress and other factors, which affect glycemic control in patients with type 2 diabetes mellitus (T2DM) and to assess the relation between hemoglobin A1c (HbA1c) and diabetes distress, duration of illness, educational status and treatment modalities, and body mass index (BMI). Methodology: A cross-sectional study conducted at Bangalore Medical College and Research Institute included T2DM patients attending outpatient departments between November 2018 and February 2019, 280 patients were screened for diabetic-related distress using Diabetes Distress Screening Scale (DDS), the patients with diabetes distress were subjected to DDS 17 Questionnaire to determine the type of diabetes distress, and based on score divided into (0–2) little/no distress, (2–2.9) moderate distress, and (3 and more) severe distress. Results: Among 280 patients, 184 patients had diabetic distress and among them, 58.2% had severe distress, 7.5% had moderate distress, 34.3% had little/no distress, 83.1% had emotional burden, 59.2% had physician-related distress, 60.4 had regimen-related distress, and 83% had interpersonal distress. The diabetes distress was significantly associated with age (P = 0.032) and medication adherence (P = 0.00) with educational status. 51.4% had poor glycemic control with HbA1c of >7. The factors significantly associated with poor glycemic control included duration of diabetes with P = 0.008, diabetic distress with P = 0.00, and no significant association with educational status, age, BMI, and treatment modalities. Conclusion: Among type 2 diabetes patients, diabetic distress is a serious problem and needs to be addressed for better glycemic outcome.
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CASE REPORTS
When pulmonary embolism mimics pneumonia: An interesting case report
CS Sooraj, Vasantha Kamath, Shreyashi Ganguly
July-September 2021, 9(3):183-186
DOI:10.4103/AJIM.AJIM_3_20  
The classic presentation of pulmonary embolism is rather uncommon. The lack of pathognomonic signs and symptoms makes the diagnosis of PE difficult. Here, we report a patient presented with symptoms suggestive of pneumonia and ultimately diagnosed as PE. A 75 years old male patient with no known co-morbidity, presented with of breathlessness for 1 week, cough for one week, productive in type, with scanty sputum, chest pain since one week, sharp, aggravated on coughing. His respiratory system examination revealed increased VF/VR in right mammary and left infrascapular areas, equal air entry with normal vesicular breath sounds, crepitations in the right mammary and left infrascapular areas. He was initially treated as pneumonia but did not respond. His chest X-ray PA view showed probable mass lesion in the right para cardiac region, ECG– sinus tachycardia with right axis deviation and RV strain pattern. CECT Thorax- Intraluminal thrombus in Rt and Lt pulmonary artery consistent with acute pulmonary thromboembolism.The patient was lysed with Inj. Streptokinase and subsequently improved over the next 6 days. Whilst established criteria aid in ruling in or out the diagnosis in a setting, the gestalt of a clinician is the most appropriate defence against a missed diagnosis especially in settings of confounded presentation. Therefore, until conclusively proven with the help of imaging and lab-work, PE should be a diagnosis that needs be considered in any case of atypical pneumonia who is not responding to first line therapies.
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ORIGINAL ARTICLES
A study of human carcinoembryonic antigen as a biomarker for assessing the severity of stroke
Vishwanath Krishnamurthy, Sonia Srinivas, Sujatha K Jayaram, Arun Narayan, Megha Reddy, Arun Patted
July-September 2021, 9(3):171-175
DOI:10.4103/ajim.ajim_110_20  
Background and Objectives: Human carcinoembryonic antigen (CEA) is widely used as a tumor marker. Striking similarities have been reported between process of tumor genesis and atherosclerotic diseases. CEA levels have also been associated with development of atherosclerosis; there are not many studies on the use of CEA as a biomarker in prognostication of stroke. This study was aimed at evaluating the role of CEA as a marker of severity and as a prognostic marker in patients with acute ischemic stroke. Materials and Methods: A hospital-based case–control study was conducted at a tertiary care hospital in Bangalore. Sixty-eight individuals above 18 years of age were divided into two groups with 34 individuals each: Group A (ischemic stroke) and Group B (age- and sex-matched healthy controls). Exclusion criteria for Group A included diabetes mellitus, heavy smoking, and recent cerebrovascular or myocardial events. The blood sample was taken not later than 24 h of onset of stroke in Group A. CEA levels were estimated using double-sandwich ELISA method. CEA was compared in both the groups. Data were analyzed using statistical software SPSS version 21. Results: The mean standard error serum CEA levels in ischemic stroke patients (cases) and healthy controls were 5.67 ± 1.64 and 0.973 ± 0.21 ng/mL, respectively (P < 0.001). This was significant even after adjusting for confounders. The cases were further divided into three quartiles based on CEA levels. The mean duration of hospital stay, mortality and higher National Institutes of Health Stroke Scale scores, and poor improvement in grade of power were seen in cases under higher CEA quartile (>7 ng/ml) group. The difference was statistically significant. Conclusion: Patients with ischemic stroke have raised level of CEA. CEA is a promising novel biomarker for assessing the severity of acute ischemic stroke.
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CASE REPORTS
Ellis–van creveld syndrome: A rare autosomal recessive genetic disorder
K Ravi, Suraj S Hegde
July-September 2021, 9(3):180-182
DOI:10.4103/AJIM.AJIM_91_19  
Ellis–van Creveld syndrome is a rare genetic disorder with autosomal recessive inheritance, mainly affecting the Amish population living in Pennsylvania, USA, with an incidence of 1:244,000 for the general population. This syndrome consists of characteristic features such as bilateral postaxial polydactyly, chondroectodermal dysplasia, congenital heart defects, and hypoplastic nails and teeth. There have been few case reports of this syndrome published mainly in dental literature. We report a case of a 40-year-old male presenting with typical features of this syndrome.
  169 20 -
Nivolumab-Induced Thyroid Dysfunction
Lohit Kumbar, Chitra Selvan, YP Ganavi
July-September 2021, 9(3):191-193
DOI:10.4103/AJIM.AJIM_25_20  
Nivolumab is one of human IgG4 monoclonal antibody belonging to the family of immune checkpoint inhibitors which acts by blocking ligand activation of programmed Cell death 1 receptor on T cells. Nivolumab has been approved for the management of patients with metastatic melanoma, metastatic squamous nonsmall cell lung carcinoma, renal cell carcinoma, and metastatic urothelial carcinoma. Associated side effects include increased risk of severe immune-mediated reactions involving the respiratory and gastrointestinal tracts, liver, kidney, and thyroid gland. Its effects on thyroid gland can result in hypothyroidism (7%), hyperthyroidism (1%), and thyroiditis (<1%), mostly developing around week 12 after the start of therapy with nivolumab. Here, we report a case of nivolumab-induced thyroid dysfunction
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ECG DIAGNOSIS
The mystery of the “Fainting Patient”
Raghavendra Bhat
July-September 2021, 9(3):195-196
DOI:10.4103/ajim.ajim_39_21  
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CASE REPORTS
Transfusion of Incompatible Blood
P Sandesh, Damodar Shenoy, SA Deepa Adiga
July-September 2021, 9(3):186-189
DOI:10.4103/AJIM.AJIM_18_20  
Transfusion of incompatible blood is mostly accidental rather than therapeutic. However, at times, we are faced with challenges wherein we need to transfuse incompatible blood. Once such situation arise in autoimmune hemolytic anemia (AIHA) if it leads to severe anemia. Here, we report a case of AIHA with hypoxia and hemodynamic instability requiring urgent transfusion and later diagnosed to have systemic lupus erythematosus. In AIHA, typing and crossmatching are very difficult. Therefore, one should use the least incompatible blood if transfusion is indicated for the risk of hemolysis.
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OBITUARY
Obituary
Rajesh M Honnutagi
July-September 2021, 9(3):194-194
DOI:10.4103/ajim.ajim_60_21  
  116 12 -
CASE REPORTS
A case of bilateral lower motor neuron facial palsy in cerebral venous sinus thrombosis
Vaishal Shah, Vijay Sardana
July-September 2021, 9(3):189-191
DOI:10.4103/AJIM.AJIM_19_20  
Cerebral venous thrombosis commonly presents with headache, seizure, and motor weakness. Among cranial nerves, the abducens nerve is common to get involved. We report a patient who had cerebral venous sinus thrombosis involving superior sagittal sinus, right lateral sinus, and right internal jugular vein and presented with bilateral lower motor neuron (LMN) facial palsy besides bilateral abducens nerve palsy and bilateral optic nerve involvement in the form of papilledema. A few cases of cerebral venous thrombosis involving lateral sinus with ipsilateral LMN facial nerve palsy have been reported. Our case highlights the rare occurrence of bilateral LMN facial palsy with unilateral lateral sinus involvement.
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