Publications

BACKGROUND: Tropical coinfections (CI) are the simultaneous occurrence of two or more vector-borne diseases in a single host. The prevalence of such illnesses is not uncommon among tropical and subtropical regions such as India; however, these CIs have not been systematically studied prospectively. Mixed infections can prove potentially detrimental if underdiagnosed or undertreated. We undertook this study to estimate the prevalence and compare the clinical profile, laboratory characteristics, and various outcomes among the patients with tropical CI who presented with acute undifferentiated febrile illness (AUFI).

MATERIALS AND METHODS: A prospective, observational study was conducted on adult patients hospitalized with tropical CIs. As per the clinical suspicion, a panel of tests for dengue fever (D), malaria (M), scrub typhus (S), leptospirosis (L), chikungunya (C), and brucella (B) was carried out. Statistical analysis was done using standard methods.

RESULTS: The mean age of the population was 39.4 ± 17.3 years. Among 986 patients presenting with AUFI, 8.1% of the patients had CIs. Of these CIs, 95% had dual infections, and 5% had CIs with three tropical pathogens. We observed 17 diverse tropical CI combinations; four predominant being D + L, D + S, D + C, and S + L with a prevalence of 26.2, 25, 15, and 13.8%, respectively. 16.25% of the patients with tropical CIs died, mostly those suffering from D + S and D + L. Coinfection with D + S had predominant acute kidney injury (AKI), whereas acute transaminitis was highest in the D + L category. Acute respiratory distress syndrome (ARDS) was clinically significant in S + L, and multiorgan dysfunction was highest in the D + S combination. Using logistic regression, AKI, hepatitis, ARDS, shock, gastrointestinal bleeding, and myocarditis were independent risk factors for mortality.

CONCLUSION: Our study identified 17 different combinations of CIs. Four groups, i.e., D + L, D + S, D + C, and S + L-accounted for 80% of CIs. Despite significant organ involvement in certain CI combinations, we conclude that a clinical bedside differentiation of tropical CIs from monomicrobial infections is often difficult. Hence, optimal treatment for a possible CI may well be commenced empirically and early, bearing in mind an 8% probability of a concurrent tropical coinfection.

OBJECTIVE: Risk estimation tools have been developed to predict coronary heart disease (CHD) in type 2 diabetes (T2D). To evaluate augmentation following the addition of lipoprotein(a) [Lp(a)] to risk calculation, we performed a pilot study.

METHODS: A total of 90 successive T2D patients were included. Details of clinical and biochemical features were obtained. Lp(a) was determined using ELISA. CHD risk estimation was performed using Framingham, QRISK-3, SCORE-2D, INTERHEART, and European Atherosclerosis Society (EAS) algorithms with and without Lp(a). Descriptive statistics are reported.

RESULTS: Mean age of patients was 55.0 ± 8 years, BP systolic/diastolic 133.7 ± 12/95.0 ± 9 mm Hg, body mass index (BMI) 26.0 ± 1.9 kg/m2, waist-hip ratio 0.96 ± 0.08, fasting glucose 198.0 ± 38 mg/dL, HbA1c 9.3 ± 1.3%, total cholesterol 197.0 ± 26 mg/dL, LDL cholesterol 114.2 ± 25 mg/dL, non-HDL cholesterol 153.8 ± 27 mg/dL, and triglycerides 197.8 ± 44 mg/dL. Lp(a) was mean 23.1 ± 9.7 mg/dL and median 22.0 (25-75 IQR 15.9-29.5) mg/dL. Mean risk scores were Framingham 11.2 ± 8.7, QRISK-3 28.6 ± 15.3, INTERHEART 21.0 ± 6.0, SCORE-2D 14.9 ± 8.3, and EAS 29.2 ± 15.2. Patients with raised Lp(a) >30 mg/dL had higher levels of total, LDL, and non-HDL cholesterol and triglycerides (p < 0.01). Spearman's correlation of Lp(a) with risk scores was Framingham 0.127, QRISK-3 0.174, INTERHEART 0.137, SCORE-2D 0.050, and EAS 0.320, while EAS-Lp(a) was 0.397. In different risk algorithms, high risk for CHD were: Framingham 14.4%, QRISK-3 64.4%, INTERHEART 45.6%, SCORE-2D 30.0%, EAS 71.1%, and EAS with Lp(a) 74.4%. Area under the curve (AUC) for Lp(a) with various scores were Framingham 0.53 (CI: 0.39-0.68; p = 0.644), QRISK-3 0.57 (CI: 0.42-0.71), INTERHEART 0.55 (CI: 0.39-0.69), SCORE-2D 0.47 (CI: 0.32-0.61), EAS 0.65 (CI: 0.50-0.79), and EAS-Lp(a) 0.68 (CI: 0.54-0.83). In addition, adding Lp(a) to the EAS risk calculator increased risk reclassification by a range of 4.6-19.3%.

CONCLUSION: Substantial variation in coronary artery disease (CAD) risk prediction using various clinical algorithms is observed in T2D. The EAS algorithm provides the most robust estimate. The addition of Lp(a) to the risk algorithms augments risk stratification significantly. The results of this pilot study need confirmation with larger prospective studies.

INTRODUCTION: Our study assesses human immunodeficiency virus (HIV) drug resistance (HIVDR) in patients failing first-line (1L) antiretroviral therapy (ART) with dual nucleoside analog reverse transcriptase inhibitor (NRTI) and non-nucleoside reverse transcriptase inhibitor (NNRTI) regimens in India.

METHODS: In this cross-sectional study, consecutive HIV-1-infected patients aged 13 years or older, failing 1L ART after at least 12 months exposure, underwent HIV genotyping and drug resistance testing (DRT) using the ViroSeq™ HIV-1 Genotyping System and the Stanford HIV-1 Database, with HIVDR classification based on a penalty score of ≥30.

RESULTS: Among 115 eligible participants, 110 underwent DRT, revealing efavirenz (EFV) or nevirapine (NVP) resistance rates of 85.3% (n = 93/109) and 87.2% (n = 95/109), respectively, and substantial cross-resistance to rilpivirine (RPV) (37.6%, n = 41/109), etravirine (ETV) (30.3%, n = 33/109), and doravirine (DOR) (60.5%, n = 66/109). The cohort was categorized into 3 groups based on their previous ARV drug exposure: group A (36.4%, n = 40) with prior TA exposure (AZT or d4T) but no TFV exposure; group B (19.1%, n = 21) with prior nonconcomitant exposure to both TAs and TFV; and group C (44.5%, n = 49), exposed to TFV only. Despite group B's 1L ART regimen failure with TFV, the prevalence of AZT resistance was similar (difference in proportions, ∇P: 14.6%, p = 0.277) between group A [57.5% (n = 23/40)] and group B [42.9% (n = 9/21)]. TFV resistance was comparable (∇P: 0.8%, p = 0.947) between group A (32.5%, n = 13/40) and group B (33.3%, n = 7/21), despite group A's lack of TFV exposure, and was also similar to the TFV-only-exposed group (group C: 38.8%, n = 19/49). Regarding distinct DRM patterns, the prevalence of K65R DRM was higher (∇P: 22.4%, p = 0.060) among TFV-only-exposed patients (group C: 36.7%, n = 18/49) compared with PLH exposed to both TAs and TFV (group B: 14.3%, n = 3/21), whereas multiple TAMs occurred at similar rates (∇P: 12.1%, p = 0.367) among TA-exposed patients [group A: 55.0% (n = 22/40) vs group B: 42.9% (n = 9/21)].

CONCLUSION: The research provides insights into the complexities of HIVDR, emphasizing the interplay of resistance patterns and the role of drug exposure history, especially in the context of resistance to TFV and second-generation NNRTIs.

CLINICAL SIGNIFICANCE: Ensuring adequate drug exposure history in patients can prevent poor outcomes in PLH being treated with ART due to resistance. Resistance profiling is especially relevant following first-line ART failure.

INTRODUCTION: Acute kidney injury (AKI) is a well-known serious complication of cardiopulmonary bypass (CPB) surgery and one of the significant risk factors for mortality, prolonged hospital stay, and additional cost. Patients having preexisting kidney dysfunction are more likely to develop AKI in the perioperative period. The complexity of CPB surgery often leads to AKI. Mechanisms of AKI include kidney hypoperfusion due to low-pressure blood flow. The nonpulsatile perfusion of the kidney, hypothermia, and inflammatory milieu, which causes afferent arteriolar constriction, contribute to AKI. The early postoperative period is characterized by a low cardiac output state, which gradually surpasses kidney compensatory mechanisms and filtration reserve. Various indigenous and infused vasopressors cause markedly elevated afferent arteriolar resistance, leading to a drop in glomerular filtration rate (GFR). Several studies have assessed the value of risk factors and their association with AKI after cardiac surgery. The evidence was mixed, with some showing a positive association. With an aim to clarify this relationship further, especially in the Indian population, we tried to study the incidence and clinical profile of AKI and its correlation with functional and clinical outcomes. We also tried to look for any diagnostic markers of AKI in the setting of cardiac surgery.

METHODOLOGY: The study was conducted among patients attending the Department of General Medicine and Cardiology at a tertiary care hospital in Delhi. It was a prospective longitudinal observational study conducted between March 2022 and February 2024. Around 200 patients underwent cardiac surgery using a cardiopulmonary bypass machine at the study center during the study period. History, including comorbidities such as transient ischemic attacks, previous stroke, coronary artery disease, diabetes mellitus, hypertension, chronic obstructive pulmonary disease (COPD), and complete physical examination, were recorded. Patients were followed up preoperatively and postoperatively up to day 28. Preoperative details such as hemoglobin, serum creatinine, blood transfusion, and urine output were recorded. Intraoperative details such as duration of surgery, ACC (aortic cross-clamp) duration, hypotension, vasopressor use, and re-exploration were recorded. Postoperative findings such as urine output and serial kidney function tests on day 3, day 7, and day 28 were documented.

RESULTS: Among 200 subjects, 99 patients had hypertension, and 70 patients developed AKI. Older age (>60 years) was significantly associated with AKI (p-value 0.04367). Comorbid conditions such as T2DM, hypertension, dyslipidemia, and COPD were significantly associated with AKI as compared to those without comorbidities (Chi-squared test, p-value < 0.0001). In the study, there was no association between the type of surgery and the development of AKI (Chi-squared test, p-value 0.07). There was no relationship between AKI severity and cardiopulmonary bypass (CPB) duration. Similarly, there was no association between the severity of AKI and ACC duration. Intraoperative hypotension was significantly associated with AKI. About 53% of hypotensive patients developed AKI during surgery as compared to 19.44% of normotensive patients (p-value < 0.0001, Chi-squared test). AKI was linked with a significantly prolonged hospital stay. A prolonged stay of >3 weeks was seen in 8.5% (6 out of 70) of patients who developed AKI as compared to 2.3% (3 out of 130) of patients without AKI. Most patients with AKI (57%) recovered within 1 week, and 24.28% recovered between 1 and 4 weeks. In the study, 8 patients (11.2%) developed acute kidney disease (AKD), and 5 patients (7%) died.

CONCLUSION: This prospective study concluded that AKI is a common complication in the perioperative period of cardiopulmonary bypass surgery. Older age, comorbid conditions, and intraoperative hypotension were significantly associated with AKI. AKI was linked with extended hospital stay and longer recovery times. Severe grades of AKI were associated with progression to AKD, need for dialysis, and higher mortality. It is imperative to focus on interventions to minimize and address the risk factors to reduce morbidity and mortality associated with AKI in CPB surgery.

BACKGROUND: Diabetics often develop vitamin B12 deficiencies, which are crucial for blood, nerve, cognitive, and cardiovascular functions. The impact of metformin on vitamin B12 levels, leading to complications such as peripheral neuropathy and anemia, is well-known; yet no studies focus on deficiency status at diabetes diagnosis or the start of treatment.

METHODS: A cross-sectional study was conducted at 2 tertiary care institutions in India, Command Hospital (Western Command), Haryana, and Civil Hospital in Sirsi, Karnataka, from July 2022 to November 2023. The study included 326 newly diagnosed type II diabetes mellitus (DM) patients and prediabetes individuals attending outpatient and inpatient departments, collecting data on substance use, dietary practices, fasting blood sugar, random blood sugar, HbA1c, and vitamin B12 levels (CLIA method).

RESULTS: The study population of 326 individuals showed significant regional differences in mean age, gender distribution, and dietary preferences. Vitamin B12 deficiency (<200 pg/mL) was prevalent in 43.4% of prediabetic and 51.9% of type II DM patients. Significant differences in fasting blood sugar, postprandial blood sugar, and HbA1c levels were observed between regions. However, no significant correlation was found between vitamin B12 levels and HbA1c, age, or fasting glucose levels. Vegetarian individuals exhibited significantly higher vitamin B12 deficiency.

CONCLUSION: This study revealed a high prevalence of vitamin B12 deficiency in newly diagnosed diabetes patients, emphasizing the need for early identification and treatment to prevent complications such as neuropathy. The study recommends incorporating initial vitamin B12 assessment into the diagnosis protocol for newly detected diabetes patients to improve patient care and prevent complications in the Indian population.

INTRODUCTION: India harbors the second-largest population with diabetes, with over 100 million, and type 2 diabetes mellitus (T2DM) constitutes the major share. Metformin remains the first-line pharmacotherapy for T2DM due to its safety profile, cost-effectiveness, and beneficial metabolic effects.

MATERIALS AND METHODS: The aim of the study was to assess the frequency of vitamin B12 deficiency in patients with T2DM on metformin therapy and compare it with their cohabiting family members who are not on metformin but share similar dietary habits.

RESULTS: This study included 180 participants with 90 cases and controls each, and we enrolled 89 females (49.4%) and 91 males (50.6%). The mean age was 57 (± 4.88) years, and overall gender distribution and dietary pattern were nearly balanced among cases and controls. The mean duration of diabetes among cases was 7.69 ± 4.35 years, and duration of metformin use was 5.22 ± 3.77 years, ranging from 1-16 years. The mean daily dose of metformin was 1238.89 ± 586.50 mg/day, with a median dose of 1000 mg/day. The mean serum vitamin B12 level in metformin users was significantly lower than in controls (206.66 ± 59.09 pg/mL vs 301.44 ± 72.28 pg/mL, p < 0.001). Vitamin B12 deficiency was present in 40.0% of metformin users versus 11.1% of controls, yielding an odds ratio of 5.33 (95% CI: 2.44-11.65), which was a highly significant difference between the two groups (t = -9.631, p < 0.001), strongly suggesting an association between metformin use and reduced B12 levels. Neurological symptoms were observed in 14.4% of cases (OR 4.896, 95% CI: 1.345-17.827; p = 0.009).

CONCLUSION: Long-term metformin use in T2DM patients is strongly associated with both biochemical vitamin B12 deficiency and an increased likelihood of neurological symptoms.

BACKGROUND: Understanding Indian healthcare professionals' (HCPs) perceptions of beta (β)-blockers is critical, given the high burden of hypertension (HTN) and cardiovascular (CV) diseases in the country.

MATERIALS AND METHODS: A cross-sectional survey was conducted among 1,000 Indian HCPs, including consulting physicians, cardiologists, and specialists in diabetes/metabolism experienced in managing adult patients across the HTN and CV disease continuum. Conducted between April 2023 and March 2024, the survey employed a 26-item structured questionnaire, developed through literature review and expert consultation, to assess β-blockers utilization patterns, prescribing preferences, and perceived barriers.

RESULTS: Responses from 855 HCPs were analyzed. Consulting physicians (431; 50.4%) and cardiologists (342; 40.0%) formed the majority. β-blockers were prescribed to 25-50% of patients with HTN by 489 (57.2%) HCPs. Approximately 429 (50.2%) observed a systolic BP reduction of 10-15 mm Hg, while 465 (54.4%) reported a diastolic BP reduction of 5-10 mm Hg. β-blockers were commonly prescribed for heart failure (381; 44.6%), postmyocardial infarction (214; 25%), and chronic coronary syndrome (309; 36.1%). Metoprolol was the preferred BB in 75% of HTN, post-MI, chronic coronary syndrome (CCS), and AF cases, and in 66.2% for HF management.

CONCLUSION: This survey highlights real-world prescribing patterns and perceptions of β-blockers in India, with metoprolol emerging as the most preferred agent across multiple CV indications, reflecting its strong clinical acceptance and perceived efficacy.

How to cite this article: Saibaba J, Chandra N, Amalnath D, et al. "The Cancer that Carried the Chalk"-NXP2+ Paraneoplastic Dermatomyositis Unleashing Calcinosis Cutis and Peripheral Neuropathy. J Assoc Physicians India 2026;74(2):102-103.

OBJECTIVES: (1) To know the contributions of bronchoscopy in intensive care units (ICUs) in terms of therapeutic benefits and diagnostic purposes. (2) To know the safety of the bronchoscopy procedure in ICUs in critically ill patients.

MATERIALS AND METHODS: This is a retrospective observational study that included 41 patients who underwent bronchoscopy in the ICU of a tertiary care center. Data collected included the patient's clinical profile, vitals, cause of ICU admission, indication for bronchoscopy, and complications.

RESULTS: There were 41 ICU patients who required and underwent bronchoscopy. A number of 15 patients (36.5%) were on mechanical ventilation, and 10 patients (24.3%) were on noninvasive ventilation (NIV) support. The most common indication was lung collapse in 23 (56%) patients. Out of 41 patients who underwent the procedure, 28 patients (68.2%) showed postprocedure improvement, which shows the utility of the procedure. Minor complications occurred in 18 patients (43%) and included hypoxia, bleeding, and bronchospasm. Zero mortality was reported during or after the procedure.

CONCLUSION: Bronchoscopy provides excellent diagnostic yield and therapeutic benefits in ICU patients with respiratory conditions, and it is relatively safe even in high-risk patients when done by trained consultants.