搜索结果：The Journal of the Association of Physicians of India

The morbidity and mortality burden of the COVID-19 pandemic was high in socioeconomically deprived areas. Identifying the factors associated with in-hospital mortality in such settings will help physicians prioritize the scarce resources for the more needy individuals. To study the demographic, clinical, and biochemical factors associated with in-hospital mortality in COVID-19 patients in Wayanad, Kerala, India. We also report the incidence of post-COVID symptoms and the mortality rate in the survivors of COVID-19 pneumonia. The study design was a record-based retrospective cohort, and the study participants were 402 patients admitted with moderate to severe COVID-19 at the secondary care hospital of Wayanad, Kerala, India, during late 2020 and early 2021. In-hospital mortality was the major outcome variable, and we expressed the mortality risk in terms of relative risks (RRs). Factors associated with the same were assessed using Chi-square, Fisher's exact tests, and t-tests depending upon the type of exposure variable. Dose-response relationships were assessed using Chi-square for trend. A subgroup of consented survivors (n = 156) was followed to study the post-COVID symptoms and mortality rate outside the hospital. We constructed binary logistic models to find out the independent predictors of mortality. The patient group (n = 402) was composed of individuals aged 18-95 years, and two-thirds (n = 258) were men. The in-hospital mortality rate was 17.7%. The risk of mortality increased with age, multimorbidity, and extent of hypoxia, peripheral oxygen saturation/fraction of inspired oxygen [SpO2/FiO2 (SF)] ratio, D-dimer, serum glutamic-oxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), serum creatinine, and blood urea. The case fatality rate (CFR) had a dose-response relationship with the number of comorbidities. Out of the individual comorbidities analyzed, systemic arterial hypertension [RR = 1.5 (1.16-1.83)], cancer [RR = 4.7 (1.38-15.6)], and neurological disorders [RR = 5.8 (1.6-21.16)] were significantly associated with mortality in the hospital. According to the binary logistic regression analysis, age, hypoxia at the time of admission, intensive care unit (ICU) admission, serum creatinine, and SF ratio were the significant predictors of mortality. Most of the patients (73%) complained of some symptoms during follow-up. Easy fatigability and tiredness were the most common post-COVID symptoms, followed by exertional breathlessness, myalgia, decreased sleep, weight loss, and cough. The physician should prioritize patients with multimorbidity and markers of organ involvement to save lives in resource-poor settings during pandemics and large infectious disease outbreaks affecting the community. The early diagnosis and management of comorbidities should be included in pandemic or outbreak preparedness to reduce morbidity and mortality.

We present a rare case of Poncet's disease, a sterile reactive arthritis associated with active tuberculosis (TB), mimicking seronegative spondyloarthritis in a young diabetic male. We aim to highlight the diagnostic challenges and emphasize the importance of considering Poncet's disease in patients with inflammatory arthritis, especially in the context of subclinical TB. We present a detailed case report of a 28-year-old male with poorly controlled diabetes mellitus type 2 [glycated hemoglobin (HbA1c) 13.9%] who presented with a 3-week history of bilateral ankle pain, swelling, and redness. The pain progressed to involve multiple small joints of the hands, wrists, elbows, and knees, significantly impacting his mobility, with no history of trauma, fever, rash, or urinary symptoms. Physical examination revealed tenderness and swelling in the affected joints with limited range of motion. Laboratory investigations showed an elevated erythrocyte sedimentation rate (ESR) of 74 mm/hour and C-reactive protein (CRP) of 104 mg/L. Chest X-ray revealed bilateral hilar lymphadenopathy, and computed tomography (CT) scan confirmed multiple enlarged lymph nodes in the mediastinum and bilateral hilar regions, suggestive of pulmonary TB. Despite the absence of acid-fast bacilli in bronchoalveolar lavage (BAL), the clinical presentation, imaging findings, exclusion of other causes of reactive arthritis, and a dramatic response to anti-TB therapy within days of initiation strongly supported the diagnosis of Poncet's disease. The patient completed 6 months of anti-TB therapy and achieved complete resolution of joint pain and swelling, regaining his full range of motion. The patient's symptoms, including joint pain, swelling, and inflammatory markers, significantly improved within weeks of starting anti-TB therapy. Serial CRP and ESR readings showed a downward trend, confirming the response to treatment. This case report highlights the importance of considering Poncet's disease in the differential diagnosis of seronegative spondyloarthritis, particularly in patients with underlying TB. A high index of suspicion and prompt initiation of anti-TB therapy can lead to rapid improvement in symptoms and prevent unnecessary investigations and potentially harmful immunosuppressive medications.

Thyroid dysfunction is a frequently overlooked yet clinically significant comorbidity in human immunodeficiency virus (HIV)-infected individuals. The introduction of antiretroviral therapy (ART) has improved life expectancy but has also been associated with metabolic and endocrine disturbances, including thyroid abnormalities. Thyroid dysfunctions such as subclinical hypothyroidism, sick euthyroid syndrome, and overt hypothyroidism are increasingly recognized in both treatment-na&#xef;ve and ART-experienced patients. However, limited data are available on thyroid function at the time of HIV diagnosis and its evolution following ART initiation, especially in the Indian population. This prospective observational study was conducted at Moti Lal Nehru Medical College, Prayagraj, including 100 newly diagnosed HIV patients aged &#x2265;18 years. Baseline free T3, free T4, TSH, and CD4 were measured prior and 3 months after the start of ART. Statistical analysis was performed using SPSS version 27.0, with paired t-tests, analysis of variance (ANOVA), and Pearson correlation test to assess the changes and associations between thyroid parameters and ART, CD4 count, and demographic variables. The study focused on measuring serum free T3, free T4, and TSH levels at baseline and after ART initiation and analyzing their relationship with immunological status as indicated by CD4 count. The study population consisted of 100 individuals with a mean age of 37.29 &#xb1; 13.01 years, predominantly male (70%). At baseline, 62% of patients were euthyroid, while the remaining 38% showed thyroid dysfunction, primarily subclinical hypothyroidism and subclinical hyperthyroidism. Following 3 months of ART, the prevalence of thyroid dysfunction increased: euthyroid patients decreased to 41%, and cases of subclinical hypothyroidism, clinical hypothyroidism, and subclinical hyperthyroidism rose noticeably. This shift in thyroid status distribution was statistically significant (Chi-squared test, p = 0.028), suggesting a potential impact of ART on thyroid physiology. In terms of hormone levels, the study observed a statistically significant increase in mean TSH values (from 4.23 &#xb1; 4.13 &#xb5;IU/mL to 7.50 &#xb1; 7.85 &#xb5;IU/mL, p < 0.001) and a significant decrease in free T3 levels (from 2.92 &#xb1; 0.88 pg/mL to 2.45 &#xb1; 1.00 pg/mL, p = 0.005) post-ART. Free T4 levels did not show a significant change (p = 0.337). These results align with existing literature suggesting that ART may unmask or exacerbate subclinical thyroid dysfunction, possibly through immune reconstitution or direct effects on thyroid metabolism. Correlation analysis demonstrated a significant negative association between CD4 count and TSH levels both before and after ART (&#x3c1; = -0.28 and -0.34, respectively), and a positive correlation between CD4 and both free T3 and free T4. This study establishes that ART is associated with significant changes in thyroid hormone profiles, particularly an increase in TSH and a decline in free T3 levels, reflecting emerging thyroid dysfunction. The results underscore the importance of regular thyroid function monitoring in HIV patients, particularly after initiating ART, to facilitate early detection and management of evolving endocrine disturbances.

Tobacco use and its smoke produces oxidative stress in the body, which eventually triggers cell damage by lipid peroxidation. Smokers report lower levels of omega-3 fatty acids (FAs) in their serum as compared to nonsmokers. Omega-3 deficiency impairs neurotransmission, resulting in hypofunctioning of the mesocortical system, which is a reward and dependency system that can raise tobacco cravings, disrupting tobacco quitting efforts. Omega-3 polyunsaturated fatty acid (PUFA) regulates stress, anxiety, and negative emotions that are associated with tobacco urges. Limited research has assessed the supplementation effect of omega-3 PUFA [in the form of alpha-linolenic acid (ALA)] on tobacco craving. We aimed to explore the effects of omega-3 PUFA (ALA) on the frequency of tobacco use per day, tobacco dependence, and tobacco craving when compared to placebo in regular tobacco users. Regular tobacco users (n = 83) recruited from the Tobacco Cessation Clinic were randomly allocated to two groups. Group I was the omega-3 PUFA group, supplemented with 10 mL/day of omega-3 PUFA in the form of ALA (5.1 gm) for 180 days, and the other group received a placebo for the same duration. The outcome was evaluated by means of a case record form (for demographic parameters), self-reports of tobacco use (for frequency of tobacco use per day), as well as psychometric measures (for tobacco dependence and tobacco craving). The evaluations were carried out at baseline and after 180 days of intervention. The frequency of tobacco use per day, tobacco dependence, and tobacco craving were found to be significantly decreased (p < 0.0001) in the group receiving omega-3 PUFA (ALA) at the end of supplementation. This is a novel approach that ALA supplementation reduces tobacco cravings in regular tobacco users in comparison to a placebo. Thus, omega-3 FAs may be an adjuvant tool in quitting tobacco use by reducing nicotine dependence and tobacco craving. Further studies are necessary with large samples to understand the possible association and explore the probable nonpharmacological approaches for tobacco cessation.

Takotsubo cardiomyopathy (TCM) is a type of disorder of cardiomyocytes in which there is apical akinesia and ballooning, whereas the base is hyperkinetic. Reverse Takotsubo cardiomyopathy (rTCM) is a rare variant of TCM in which the base of the heart is akinetic and ballooned out rather than the apex, which is hyperkinetic. Takotsubo cardiomyopathy is usually seen in postmenopausal women, but a rising number of cases of the reverse variant are being reported in peripartum women. We present a case of a 24-year-old primigravida at 37 weeks of gestation, who presented with an acute onset of breathlessness just after cesarean delivery. A 2D echocardiogram revealed changes of rTCM with an overall ejection fraction of 40%. She was treated for the same, and a 2D echocardiogram repeated after 1 week showed improvement in the ejection fraction to >60%, which supported our diagnosis of peripartum rTCM. Another important objective of this study is to differentiate TCM occurring in the peripartum period from peripartum cardiomyopathy (PPCM), both of which are clinically indistinguishable but have different etiopathogenesis, treatment, and prognosis. While rTCM treatment mostly includes the management of heart failure, such as oxygen supplementation, diuretics, and noninvasive mechanical ventilation, the management of PPCM also includes bromocriptine, along with treating heart failure. The outcome of rTCM is excellent, with recovery of left ventricle function in almost all cases, while a few patients of PPCM have irreversible heart failure, making it imperative to differentiate between the two clinical entities.

Prostate cancer (PCa) is one of the most common malignancies in men worldwide. Androgens influence both prostate growth and hair patterns. Androgenic alopecia (male-pattern baldness) and excessive male-pattern body hair (hypertrichosis) have been hypothesized as clinical markers of long-term androgen exposure. Previous Western studies have reported mixed results on whether early-onset or severe androgenic alopecia correlates with increased prostate cancer risk. Data in South Indian (Dravidian) populations is lacking. To examine the association between androgenic hypertrichosis, androgenic alopecia, and prostate cancer in Dravidian men from the Cauvery Delta region of Tamil Nadu, India. We conducted an age-stratified, population-based case-control study among men in the Cauvery Delta. The cases consisted of 117 men with pathologically confirmed adenocarcinoma of the prostate (diagnosed 2010-2015). Controls were 123 men with benign prostatic hyperplasia (BPH) from the same hospital registries, frequency-matched by age. Individuals with incomplete data or non-Dravidian (North Indian) ancestry were excluded. Trained investigators performed face-to-face interviews, directly observing and recording postpubertal body hair growth (indicative of androgenic hypertrichosis) and scalp hair loss (androgenic alopecia classified by the Norwood scale). Statistical analysis included multivariate discriminant analysis (Wilks' Lambda), one-way ANOVA for continuous variables, chi-square cross-tabulation, and computation of Cramer's V statistic to assess association strength. A two-tailed p-value of <0.05 was considered statistically significant. The age distributions of cases and controls were comparable. The prevalence of androgenic hypertrichosis and alopecia did not differ significantly between prostate cancer cases and BPH controls. Cramer's V analysis showed that prostate cancer status accounted for only 1.1% of the variance in hypertrichosis (Cramer's V &#x2248; 0.011) and 1.5% of the variance in alopecia (Cramer's V &#x2248; 0.015). In this case-control study of Dravidian men from Tamil Nadu, we observed no significant association between androgenic alopecia or hypertrichosis and prostate cancer. These findings contrast with data from Western cohorts, suggesting that interethnic variation in androgen receptor polymorphisms, follicular sensitivity, and environmental exposures may modulate prostate cancer risk differently. Further research is needed to elucidate how androgenic traits influence prostate carcinogenesis across different ethnic groups.

Neuropathic pain, characterized by nerve damage, can significantly impact quality of life. Traditional treatments often fall short, prompting the exploration of topical therapies such as capsaicin. This systematic review aims to evaluate the efficacy, safety, and tolerability of topical capsaicin in treating neuropathic pain. A systematic review of clinical studies assessing the topical use of capsaicin for neuropathic pain of different etiologies, including painful diabetic peripheral neuropathy (DPN) and postherpetic neuralgia (PHN), was conducted. Data were extracted regarding pain relief and adverse effects. A systematic review of literature identified through database searches, including PubMed and ScienceDirect, was conducted using the search term "topical capsaicin." A total of 22 studies were included (placebo-controlled: n = 13; active-controlled: n = 4; uncontrolled: n = 4; comparison of two capsaicin formulations: n = 1). Topical capsaicin demonstrated significant efficacy in reducing pain intensity and improving quality of life across various neuropathic pain conditions. Localized adverse effects were reported but were generally tolerable and occurred more often in the first week of treatment. Comparisons between 0.025% and 0.075% formulations indicated that the higher concentration is generally more effective. The development of a new roll-on formulation of capsaicin retains efficacy while reducing adverse effects. Topical capsaicin 0.075% is a promising and effective option for neuropathic pain management, providing meaningful pain relief and improved quality of life with a manageable and favorable safety profile. Further research is needed to evaluate long-term efficacy and explore combination treatment approaches.

There are a number of guidelines on how to manage obesity, but inconsistencies in healthcare access, varying infrastructure, resource constraints, and diverse local practices restrict their global applicability. This underscores the need for universal recommendations that address the unique challenges faced by patients and healthcare providers worldwide. Our Global Guidelines emphasize the incorporation of novel therapies while integrating standards of care with the most up-to-date evidence to enable clinicians to optimize obesity management. Context-specific recommendations tailored to individual patient needs are highlighted, providing a thorough evaluation of the risks, benefits, and overall value of each therapy, aiming to establish a standard of care that improves patient outcomes and reduces the burden of hospitalization in this susceptible population. These Global Guidelines provide evidence-based recommendations that represent a group consensus considering the many other published guidelines that have reviewed many of the issues discussed here, but they also make new recommendations where new evidence has recently emerged, and-most importantly-also provide recommendations on several issues where resource limitations may put constraints on the care provided to patients living with obesity. Such "economic adjustment" recommendations aim to guide situations when "Resources are somewhat limited" or when "Resources are severely limited." Hence, this document presents a comprehensive update to obesity management guidelines, thereby aiming to provide a unified strategy for the pharmacological, non-pharmacological, and invasive management of this significant global health challenge that is applicable to the needs of healthcare around the globe.

Dermatophytes, primarily Epidermophyton spp., Trichophyton spp., and Microsporum spp., are responsible for superficial cutaneous mycoses, estimated to affect 20-25% of the people worldwide. The rise of antifungal resistance, especially to terbinafine, has made treating dermatophytosis increasingly difficult. This study aims to assess the clinical and mycological characteristics of dermatophytosis cases and evaluate the in vitro susceptibility of dermatophyte isolates to terbinafine and griseofulvin. A total of 118 samples were studied from patients with clinical suspicion of dermatophytosis. The samples were processed for KOH mount and fungal culture for further speciation. Susceptibility to terbinafine and griseofulvin was assessed using the microbroth dilution technique, following the guidelines established by the Clinical and Laboratory Standards Institute (CLSI). Tinea corporis (57.6%) appeared as the leading symptomatology in our study, followed by tinea cruris (10.2%). KOH positivity was higher (70.3%) compared to positivity by culture (16.9%). Trichophyton mentagrophytes was the predominant species (85%) isolated, followed by Trichophyton violaceum (10%) and Microsporum gypseum (5%). Terbinafine resistance was observed in over 60% of T. mentagrophytes isolates, with moderate resistance detected in T. violaceum. Griseofulvin showed moderate resistance in T. mentagrophytes and higher resistance in T. violaceum. This study highlights the increased resistance of T. mentagrophytes to terbinafine and T. violaceum to griseofulvin, stressing the critical role of routine susceptibility profiling. The findings highlight the growing challenge of antifungal resistance in dermatophytes and the importance of optimizing diagnostic and treatment strategies to improve patient outcomes.

It is not a rare occurrence where a patient who has been declared dead in the hospital comes alive either during transport back home or while performing the last rites. But in recent times we are witnessing a steady rise in such incidences.1-4 Though it is a global phenomenon, in our country it has brought a lot of negativity and adverse publicity against medical professionals and hospitals. These incidences are casting serious doubt in the minds of the public about the ability and knowledge of medical professionals in declaring someone dead and have eroded the public trust in doctors. On many occasions it is being perceived as serious negligence or total irresponsibility on the part of a medical professional. A patient who has been declared dead but comes alive could put medical professionals under serious mental stress with long-lasting emotional trauma as well. Beyond the medical realm, such cases raise legal and ethical dilemmas. Families go through unnecessary mental trauma, funeral services are disrupted, and, in some cases, patients wake up in morgues or coffins-an unimaginable horror. In India we have neither any data on such occurrences nor a well-accepted protocol or guidelines for the determination and declaration of death. While cases of the "dead" coming back to life remain rare, they highlight the gaps in medical practices that need urgent attention, and there is a pressing need for a foolproof protocol for pronouncement of death that is acceptable legally and medically and with a pan-India application.

Gastric cancer (GC) is a leading cause of cancer-related mortality worldwide. Perioperative chemotherapy improves tumor downstaging and survival rates. The FLOT regimen was proven superior in the FLOT4-AIO trial, establishing it as the standard care for resectable gastric adenocarcinoma. Despite these encouraging results from randomized controlled trials, real-world data on the feasibility and outcomes of FLOT in diverse patient populations, particularly in low- and middle-income settings, remain limited. This study aimed to assess the feasibility, safety, and clinical outcomes of perioperative FLOT chemotherapy in patients with resectable gastric adenocarcinoma at a tertiary care center. We conducted a retrospective review of the medical records of patients diagnosed with resectable gastric adenocarcinoma who received perioperative FLOT chemotherapy between April 2019 and April 2025. The primary outcomes were the feasibility of perioperative FLOT chemotherapy and pathological complete response (pCR). The secondary outcomes were surgical outcomes, treatment adherence, and adverse events (AEs). The results showed that 64.4% of patients completed at least four cycles of neoadjuvant FLOT, while only 24.4% underwent surgical resection. No pathological complete responses were observed. Grade 3-4 AEs occurred in 18.1% of patients, primarily cytopenias. A high rate of loss to follow-up (45.4%) was noted in the preoperative phase. While FLOT demonstrated an acceptable safety profile, the lower-than-expected surgical resection rate and high attrition highlight the challenges in managing locally advanced gastric cancer in real-world settings. This study emphasizes the need for strategies to improve treatment adherence and optimize patient selection to maximize the benefits of perioperative chemotherapy for gastric cancer.

Low or abnormal plasma concentrations of anti-tuberculosis drugs can be a major reason for treatment failure or the emergence of drug resistance. Acetylator status, which affects drug metabolism, plays a key role in determining drug bioavailability. This study aimed to perform therapeutic drug monitoring (TDM) of rifampicin and isoniazid and to evaluate the correlation between plasma drug concentrations and acetylator status among Indian patients receiving first-line antituberculosis therapy. Plasma concentrations of rifampicin and isoniazid were measured using in-house standardized high-performance liquid chromatography methods, while acetylator status was determined by conventional PCR of NAT2 gene. Peak concentrations were estimated from 125 patients on first-line tuberculosis (TB) treatment. Among these, 56% exhibited subtherapeutic rifampicin concentrations and 28% had subtherapeutic isoniazid concentrations. Conversely, above normal (potentially toxic) concentrations were seen in 2% and 21% for rifampicin and isoniazid, respectively. Despite receiving the standard TB treatment regimen, only 62% of patients improved clinically, while 38% of patients continued harboring TB signs and symptoms, among which 6 patients (5%) developed rifampicin resistance during the treatment course. About 44% were slow acetylators, followed by 40% intermediate and 16% rapid acetylators. The acetylator status significantly influenced the plasma concentrations of both drugs. Slow acetylators had significantly higher isoniazid concentrations (p = 0.004) and lower rifampicin concentrations (p = 0.01) as compared to rapid acetylators. Abnormal concentrations of rifampicin and isoniazid are prevalent and a major concern. Acetylator status influences plasma concentrations of rifampicin and isoniazid. Hence, determining acetylator status and performing TDM could be instrumental in optimizing and improving TB outcomes.

Pigment nephropathy is an underrecognized cause of acute kidney injury. Data from northern India is scarce. The present study aims to assess the clinical characteristics and outcomes of pigment nephropathy in this region. We analyzed the demographics, etiology, and outcomes of 20 patients with biopsy-proven pigment nephropathy. The mean age was 27.75 years (range: 13-52), with a male-to-female ratio of 18:2. The average peak serum creatinine was 12.09 mg/dL (range: 0.84-22.3). Rhabdomyolysis was identified in 14 (70%) and hemolysis in 6 patients (30%). The rhabdomyolysis was attributed to hypokalemia, infection, strenuous exercise, physical trauma, inflammatory myositis, neuroleptic malignant syndrome, and heat stroke. The hemolysis was caused by paroxysmal nocturnal hemoglobinuria, thrombotic microangiopathy, transfusion reaction, rifampicin, and physical stress. The majority of patients (85%) required hemodialysis, with a mean of 6 sessions (range: 3-17). The mean duration of hospitalization was 15.3 days (range: 4-30), and the average time to renal recovery was 3.1 weeks (range: 2-6). All 20 patients survived and achieved complete renal recovery. Of the 20 patients, 13 completed at least 1 year of follow-up, 4 were lost to follow-up, and 3 remain under observation. At 1 year, all 13 patients had normal serum creatinine. None progressed to chronic kidney disease. Of 20 patients (4.1%) with pigment-induced acute kidney injury (AKI), 70% had myoglobin- and 30% hemoglobin-induced nephropathy. Common causes included hypokalemia, infection, strenuous activity, and paroxysmal nocturnal hemoglobinuria. Hemodialysis was required in 85%, with an average hospital stay of 15.3 days. Among 13 patients with a 1-year follow-up, none developed chronic kidney disease. Overall prognosis appears favorable; however, larger studies with extended follow-up are needed to better characterize long-term outcomes in pigment nephropathy.

Transverse myelitis (TM), a rare inflammatory condition affecting the spinal cord, presents with a rapid onset of bilateral motor and sensory symptoms with or without bladder/bowel and sexual dysfunction. Recent studies are attempting to identify its improvement, worsening, or conversion to multiple sclerosis, and the factors that determine these outcomes. The present study aims to assess the immediate and long-term outcomes of TM and to determine the factors associated with them. The study involved a retrospective review of hospital records of 30 patients diagnosed with TM between 2018 and 2022, followed by a telephonic interview to assess their present outcomes. Median age of the patients was 40 years [Interquartile range (IQR) = 30-48.5], with 53% males. About 76.7% had longitudinally extensive transverse myelitis (LETM). Onset was acute in 63.3%. Half (50%) of the patients had paraparesis. MRI spine showed involvement of the long segment in 65.5% and the short segment in 24.1%. At the end of treatment, 43.3% patients improved partially, and 16.7% improved completely. At follow-up, nearly 30% of the respondents reported complete recovery, while 8.3% reported worsening. One patient (3.33%), with an acute onset of TM, quadriparesis, bowel involvement, sexual dysfunction, and long spinal segment involvement, converted to multiple sclerosis at follow-up. 25% of patients with initial partial improvement showed complete improvement at follow-up. Acute onset LETM cases can potentially convert to multiple sclerosis. Patients who show early improvement, whether partial or complete, have higher chances of complete recovery at follow-up.

Intracranial hemorrhage, most often intraparenchymal hemorrhage, is an increasingly common and fatal complication of warfarin-induced coagulopathy. Warfarin remains the anticoagulant of choice in valvular atrial fibrillation. However, warfarin has a narrow therapeutic index. Extra axial hemorrhage due to warfarin-induced coagulopathy is a rare adverse event. We present a rare case of right vestibulocochlear and lower motor neuron (LMN) facial palsy secondary to an intracranial bleed along the cerebellopontine angle. A 36-year-old woman presented with headache, giddiness, sudden onset of right-sided hearing loss, and left-sided deviation of the angle of the mouth. Symptoms had developed acutely over 4 hours. She was diagnosed with mitral stenosis at 8 years of age and had undergone mitral valve repair 2 years before presentation, after which she was started on warfarin. She was lost to follow-up for over a year and on presentation had right-sided sensorineural hearing loss along with features such as difficulty raising her right eyebrow, inability to close her right eye, and water drooling from the right side, all consistent with a right LMN facial palsy and vestibulocochlear nerve palsy. MRI brain showed an extra-axial hemorrhage at the right cerebellopontine angle cisterns. Warfarin-induced intracranial bleeds without involving the parenchyma are a rare event, and through this case, we would like to highlight the importance of timely monitoring of the international normalized ratio (INR) of patients on warfarin therapy.

The thyrotropin controversy in subclinical thyroid disorders (STDs) is among the most common endocrine disorders globally. In India, approximately 42 million people suffer from thyroid disorders, with subclinical hypothyroidism (SCH) affecting about 9.4% of the population. SCH is more prevalent in females (11.4%) compared to males (6.2%). The diagnosis and treatment of SCH and subclinical hyperthyroidism (SHT) are controversial. SCH is often diagnosed based on biochemical markers, as patients may be asymptomatic or exhibit vague symptoms. Thyrotropin (TSH) levels may be elevated or decreased, while triiodothyronine (T3) and thyroxine (T4) remain within the normal reference range or near the lower or upper limits. STDs refers to an abnormal TSH with normal thyroxine (FT4) and free triiodothyronine (FT3) levels. It includes STDs and individuals at high risk for disease progression or adverse outcomes, with unclear prognosis. Progression of SCH to overt hypothyroidism depends on initial serum TSH levels, thyroid peroxidase antibodies (TPO), family history of thyroid disorders, previous radiation, and smoking. Controversies surround SCH and its association with cardiovascular diseases (CVD), pregnancy outcomes, neuropsychiatric issues, metabolic syndrome, dyslipidemia, and diabetes. Assay interference is a problem in interpreting thyroid function tests (TFTs), occurring in 1% of cases. The health package investigation systems often overlooks the impact of drug intake and assay interference. Various methods for measuring TFTs, such as radioimmunoassay, immunometric assay, and ELISA, differ in sensitivity, specificity, and standardization, leading to methodological variability. Common causes of assay interference include human antimurine antibodies (HAMA), thyroid hormone autoantibodies (THAAbs), rheumatoid factor, antistreptavidin, and antiruthenium antibodies. When diagnosing SCH, it is crucial to rule out other causes of elevated TSH, such as autoantibodies, goiter, and rare conditions such as thyroid hormone resistance (THR), diagnosed by serum glycoprotein alpha subunit (&#x3b1;-GSU) and family history. Biotin, a common supplement, can affect TFT assays, leading to spurious results. It can cause falsely high T4 and T3 levels and low TSH, leading to misdiagnosis of SCH. The timing of TFTs, whether fasting, postprandial, or random, remains a debated issue. Assay interference and biotin intake should be considered when analyzing TFTs. The role of iodine and iodine supplementation during pregnancy and its impact on STDs are not yet fully conceptualized. Large randomized clinical and epidemiological studies are needed to establish a consensus on the diagnostic threshold for TSH. These studies should include diverse populations and medical conditions to improve our understanding of the disease and patient outcomes. In practice, avoid rushing to treat elevated TSH levels between 4 and 10 mIU/L or low TSH between 0.5 and 0.1 mIU/L without confirming the diagnosis with additional tests (T3, T4, FT4, FT3, and TPO). TSH alone should not be the sole decision-maker; consider other TFTs and sequential testing from the same laboratory and time to make more informed decisions. While TSH levels can be affected by time and prandial state, FT3 and FT4 levels remain stable, suggesting all three TFTs may aid in accurate diagnosis and treatment decisions.

Tuberculosis (TB) is a global health concern caused by Mycobacterium tuberculosis, primarily affecting the lungs. In addition to TB, chronic respiratory conditions like Chronic Obstructive Pulmonary Disease (COPD) and asthma are becoming more prevalent globally. Inhaled corticosteroids (ICS) are commonly used for COPD and bronchial asthma management, but some recent studies suggest a potential association between ICS usage and an increased risk of TB, raising concerns that they may lower lung immunity and enhance tuberculosis infection. This research study was performed with an aim to investigate whether there is a link between inhaled corticosteroids (ICS) use and the risk of developing tuberculosis (TB) in COPD patients. The primary objective is to study whether the use of inhaled corticosteroids increases the risk of tuberculosis infection. The secondary objective is to compare the risk of TB in vulnerable populations with underlying comorbidities using inhaled corticosteroids. This is an observational, analytical study conducted over 2 months in patients with COPD who have been receiving inhaled corticosteroids for more than 2 years. A total of 97 COPD patients on ICS were recruited and categorized into TB (n = 4) and non-TB (n = 93) groups based on final outcomes. The mean ICS duration for the non-TB and TB groups was 24.8 and 48.0 months, respectively. Despite being on ICS for more than 2 years, there was no significant correlation between ICS usage and TB infection. However, the study highlighted the significance of a prior TB history as a risk factor for increased reactivation (p < 0.001). Additionally, anemia was observed in reactivated TB cases, suggesting potential implications for identifying underlying chronic diseases in COPD patients.

With the rise of irrational drug prescriptions, leading to polypharmacy, increased health care costs, drug interactions, and risks of adverse drug reactions, irrational antibiotic prescribing, overuse of injections, and hospitalization, it has become important to monitor drug use patterns. With the objective to assess the drug use indicators of a government teaching hospital of Assam using WHO Core Drug Use Indicators, 700 prescriptions from OPDs of various specialties were assessed prospectively from the hospital dispensary and details of core drug use indicators were noted and analyzed for each in a proforma as per WHO recommendation on investigating drug use in health care facilities. Descriptive statistics were used thereafter to express the results. The WHO core prescribing indicators analysis revealed that the average number of drugs per encounter was 3.6. The percentage of drugs prescribed by generic name was 37%, with only 6% being injectable drugs; however, 39.14% of prescriptions included one or more antibiotics. Only 37% of the drugs prescribed were from the NLEM. This study highlights that only prescriptions involving injectable drugs were in accordance with WHO recommendations, while the other parameters exceeded the WHO-recommended values.

Global efforts to reduce tuberculosis (TB) are severely hampered by stigma. With a high number of TB infections, India struggles with the widespread stigma surrounding the illness, which makes it difficult to diagnose and treat patients promptly. To shed light on an important but often ignored component of TB management, we calculate the prevalence of TB-related stigma and variability in the manifestation in different groups. After calculating the sample size, we stratified them into different groups: patients with TB, healthcare workers providing TB services, and family members living with the patients. A validated, predesigned questionnaire was employed to assess stigma across various domains. MS Excel was used to compile the data, and Epi Info 7 to analyze it. Health professionals made up the largest percentage of those who experienced stigma (11.78%), followed by family members (8.91%), and patients (6.05%). The association of stigma with different groups of study participants was statistically significant, implying that stigma exists variably in the other groups. The majority of the patients (3.50%) perceived stigma at their home, whereas the majority of the family members faced stigma in the community (5.41%). Healthcare workers face stigma majorly in the community (7.96%). Stigma related to TB lays its foundation in varied perceptions by society. Societal norms determine acceptable and undesirable behaviors. Our study reveals major roadblocks on the way to TB eradication in the country and reveals a picture that can be extrapolated to most communities throughout. Aiming to reduce stigma will, in turn, improve treatment-related outcomes in TB and pave the way for smoother management and eradication.