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   Table of Contents - Current issue
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October-December 2017
Volume 29 | Issue 4
Page Nos. 149-203

Online since Monday, December 4, 2017

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EDITORIAL  

Medicine in Islamic Egypt p. 149
Nevine Abd El-Gawad Ali Hasan
DOI:10.4103/ejim.ejim_47_17  
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ORIGINAL ARTICLES Top

CD4 cell counts, complete blood picture and lipid profile in HIV infected and AIDS patients in a specific populace from South India p. 151
MVR Ratnam, Abhishek S Nayyar, B Kalivara Prasad, SVN Sashikiran, G Upendra, Debasis Sahu
DOI:10.4103/ejim.ejim_59_17  
Context AIDS is caused by a retrovirus known as HIV which breaks down the body’s immune system leaving the patient vulnerable to a host of life-threatening opportunistic infections, neurological disorders, or unusual malignancies. According to estimates by WHO and UNAIDS, 35 million people were living with HIV globally at the end of the year 2013. The first AIDS case in India was detected in the year 1986. Seldom studies have been conducted correlating these parameters in the Indian population. Aim The present study was carried out to evaluate the CD4 cell counts, complete blood picture, and lipid profile in HIV-infected patients and those with AIDS and correlate these parameters with those obtained in the sero-negative controls. Materials and methods This was a cross-sectional, hospital-based study. The included participants were divided into three groups: group A consisted of 500 patients who were without any systemic illness as healthy controls, group B consisted of 500 patients who were diagnosed as having HIV infection, and group C consisted of 500 patients diagnosed as having AIDS depending on their CD4 cell counts. Permission from the Ethical Committee of the Institution as well as Superintendent of Government Hospital was taken to conduct the study. Evaluation of CD4 cell counts in patients with HIV infection and AIDS was done using CyFlow counter, whereas complete blood picture, hemoglobin (Hb), packed cell volume, red blood cell and white blood cells (WBCs) and platelet counts, were analyzed using Sysmex XP 100, a compact, fully automated analyzer. Lipid profile was evaluated using an automated analyzer, Erba EM 360 powered by a diffraction grating photometer. Results The results were found to be statistically significant, with the P-value being less than 0.001, for the CD4 cell counts, Hb, WBCs, and platelet counts. The levels of total cholesterol and low-density lipoproteins (LDLs) were significantly decreased whereas triglycerides and very LDLs were significantly increased in patients with AIDS when compared with the control group and patients with HIV infection. Conclusion CD4 cell counts, Hb, WBCs and platelet counts as well as total cholesterol, LDLs, triglycerides and very LDLs were significantly altered in patients with HIV infection and those with AIDS when compared with the controls.
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Microscopic colitis in Egyptian population: study of some contributing factors and role of chromogranin A as a diagnostic marker p. 164
Mohamed S Gomaa, Ahmad S Elsawaby, Emad A Awad, Magdy G Abdel Rahman
DOI:10.4103/ejim.ejim_36_17  
Background Microscopic colitis (MC) and irritable bowel syndrome (IBS) have similar symptoms and a normal endoscopic appearance, as well as normal radiologic findings. Several studies have shown that MC can be mistakenly diagnosed as IBS. Over recent decades, MC has emerged as a common cause of diarrhea, especially in middle-aged or older women, and the disease is regarded as a subgroup within inflammatory bowel disease. The prevalence of MC in Egyptian patients with chronic watery nonbloody diarrhea is high when compared with that in developed countries. MC mainly affects young and middle-aged patients, and it is more commonly of the lymphocytic type. Chromogranin A is a common marker for endocrine cells, and the present finding suggests that colonic hormones are involved in the pathophysiology of lymphocytic colitis (LC). The chromogranin cell density seems to be a good diagnostic marker with high sensitivity and specificity in both the right and left colon; thus, sigmoidoscopy can be used in the diagnosis of LC using this marker. Aim The aim of the current work is to study the prevalence of MC among patient presented with symptoms of IBS. In addition, it is to determine whether chromogranin A cell density is increased in patients with MC and to examine the possibility of using it as a marker for the diagnosis of LC and collagenous colitis. Patients and methods The study was conducted initially on 100 patients presented with symptoms of IBS according to Rome IV criteria. Overall, 50 patients were excluded after finding an organic cause for their symptoms by diagnostic studies. Results A total of 37 cases were diagnosed as having nonspecific colitis, five cases were diagnosed as having MC (10% of the total cases studied), four cases were found to have ulcerative colitis, three cases was found to have eosinophilic colitis, and one case was found to have melanosis coli. Conclusion The initial results of our study revealed that MC is not an uncommon disease, and there was a significant correlation between using NSAID and proton pump inhibitor and smoking, with cases proved to have MC.
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Urinary netrin-1 predicts early ischemic acute kidney injury after cardiopulmonary bypass p. 170
Mohammad H Aly, Alsayed Alnahal, Goerge Emad, Abdel A.M Jumaa, Mohammad M El Shaarawy
DOI:10.4103/ejim.ejim_39_17  
Background Serum creatinine is an unreliable early biomarker for the diagnosis of acute kidney injury (AKI) after cardiac surgery. We need to search for a rapid and dependable marker for the detection of AKI. Aim of work This study was designed to test urinary netrin-1 (Ntn1) as a marker of early kidney injury post cardiac surgery. Our study included 39 patients with preoperative normal creatinine. We measured serum creatinine and urinary Ntn1 at 0, 6, and 24 h after cardiac surgery, AKI was defined according to the KDIGO 2012 definition. Results Fourteen patients developed AKI after cardiac surgery. There was statistically significant elevation in urinary Ntn1 at 6 and 24 h after cardiopulmonary bypass (CPB) surgery in the AKI group, while serum creatinine failed to show any statistically significant elevation at 6 h after CPB in the same group. No statistically significant change was seen in the level of creatinine or urinary Ntn1 at 6 and 24 h after CPB surgery in the non-AKI group. The sensitivity and specificity of urinary Ntn1 to detect AKI at 6 h after CPB surgery was 86.7 and 91.7%, respectively, at a cutoff value of 107.3 pg/ml. Combined urinary Ntn1 and serum creatinine had the same sensitivity and specificity. Conclusion Urinary Ntn1 may be considered as an early sensitive biomarker of AKI at 6 h after cadiopulmonary bypass surgery instead of serum creatinine that rises only 24 h after CPB surgery in patients with cardiac surgery-associated acute kidney injury.
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Relationship between subclinical hypothyroidism and serum osteoprotegerin level in type 2 diabetic patients p. 176
Eman H El-Adawy, Gehan A Shaker, Amal Seleem
DOI:10.4103/ejim.ejim_40_17  
Background Subclinical hypothyroidism (SCH) and osteoprotegerin (OPG) are associated with higher risks of cardiovascular disorders in patients with type 2 diabetes mellitus (T2DM). It is unknown whether diabetic patients with SCH have elevated OPG compared with those with euthyroid and, if so, whether SCH independently associated with OPG level. Objective The objective was to study the association between SCH and serum OPG level among Egyptian adults with newly diagnosed T2DM. Patients and methods One hundred and fifty patients with newly diagnosed T2DM and 150 healthy controls matched for sex and age were included in the study. Serum OPG, thyroid-stimulating hormone (TSH), free thyroxine, free triiodothyronine, blood glucose, lipid profile, fasting insulin, homeostasis model assessment of insulin resistance (HOMA-IR), and anthropometric measurements were assessed for all participants. Results The prevalence of SCH and elevated level of OPG in the diabetic patients were higher than healthy controls (17.3 vs. 4%, P<0.001; and 14 vs. 4.7%, P=0.02; respectively). Diabetics with SCH demonstrated significantly higher HOMA-IR, serum TSH, and OPG compared with diabetics without SCH. Serum TSH was significantly correlated with total cholesterol (P=0.05), fasting insulin (P=0.01), HOMA-IR (P=0.01), and OPG (P=0.005). Moreover, serum OPG was correlated with waist circumference (P=0.01), fasting insulin (P=0.05), and HOMA-IR (P=0.02). Multiple logistic regression analysis revealed that SCH was associated with serum level of OPG independently of the other significant variables (β=2.49, P=0.01). Conclusion T2DM patients with SCH demonstrate higher level and independent association with serum OPG than those with euthyroid. This result might add new information about the causal relationship between SCH and cardiovascular disorders in such a population.
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Assessment of left ventricular functions in patients with type 2 diabetes mellitus using tissue Doppler imaging and its correlation with a novel cardiac biomarker p. 181
Ebtissam Zakria, Naglaa M Elsayed, Nashwa S Ghanem, Elham Youssif, Mervat M Kalaf, Safaa ElGabarty
DOI:10.4103/ejim.ejim_48_17  
Introduction Cardiovascular diseases account for about 65% of diabetes-related mortality. Objective Noninvasive assessment of left ventricular functions in asymptomatic nonhypertensive nonischemic type 2 diabetics using echo heart and tissue Doppler imaging (TDI) for detecting structural and functional cardiac abnormalities, and correlating them with levels of Brain natriuretic peptide (BNP) for early planning of management before passing into overt heart failure (HF) were the objectives of this study. Patients and methods We studied 55 patients with type 2 diabetes and classified them into two groups: 26 patients with less than 10 years diabetes duration and 29 patients with more than 10 years duration. Full history, fasting blood glucose, postprandial blood glucose, glycated hemoglobin, creatinine, lipid profile, BNP, ECG, conventional echo, and TDI were performed for all patients. Results In all, 45 (80%) patients out of 55 patients have diastolic dysfunction, classified as 15 (27%) with type 1 diastolic dysfunction, 26 (47%) with type 2 pseudonormal diastolic dysfunction, and four (7%) patients with type 3 diastolic dysfunction. Systolic dysfunction (ejection fraction <55) was present in nine (16%) patients despite absent HF. BNP was significantly high in patients with longer diabetes duration (P=0.008). There was a statistically significant difference in the BNP level between those with diminished systolic function and those with normal systolic function, P=0.001; yet no statistically significant difference was found between BNP and different groups of diastolic dysfunction (P=0.7). Conclusion Diabetic cardiomyopathy is an important diabetes complication. It varies from subclinical ventricular dysfunction to overt HF. Echocardiography is the standard diagnostic tool for diabetic cardiomyopathy. TDI can be used to quantitatively assess global, regional, systolic, and diastolic myocardial functions. Plasma BNP can be a prognostic rather than diagnostic test.
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Does brain natriuretic peptide have a significant diagnostic value in subclinical peripheral atrial disease type 2 diabetic patients? p. 189
Eman M Fahmy, Ahmed M El Mahdi, Marwa A Gaber, Mohamed A Monem Saeed
DOI:10.4103/ejim.ejim_58_17  
Background Peripheral arterial disease (PAD) is a serious complication of diabetes mellitus (DM); it is also correlated with increase in the morbidity and mortality in diabetics owing to cardiovascular disease. Ankle–brachial index (ABI) is an established method to detect PAD. Patients and methods This is a cross-sectional study to detect brain natriuretic peptide (BNP) level in patient with type-2 DM with PAD using ABI. Results This study revealed 11 patients diagnosed with low ABI. Patients with low ABI showed statistical significance regarding mean age (P=0.038), duration of DM (P=0.004), concentration of glycated hemoglobin (P=0.044), BNP (P=0.013), and microalbuminurea (P=0.007). Moreover, patients with low ABI were significantly associated with nephropathy (P=0.001) and retinopathy (P=0.007). BNP at cutoff value of 360 pg/ml had sensitivity and specificity of 27.27 and 95.9, respectively. The BNP level was negatively correlated with the ABI (r=−0.183, P=0.162). BNP showed statistical significance with fasting blood sugar, postprandial glucose, nephropathy, retinopathy, and albumin/creatinine ratio in urine. Conclusion BNP is a potential and a promising biomarker for PAD screening in patients with type-2 DM.
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CASE REPORTS Top

Thyrotoxicosis associated with severe hypoalbuminemia and hyperbilirubinemia p. 196
Mert Evlice, Zekeriya Aksoz
DOI:10.4103/ejim.ejim_7_17  
Thyrotoxicosis is a known cause of nonspecific abnormalities in liver function tests: most commonly mild elevations in serum bilirubin and liver enzymes, and rarely decreases in serum albumin levels. We report a case of severe hyperbilirubinemia and hypoalbuminemia secondary to thyrotoxicosis in a 64-year-old woman who presented to our emergency department with complaints of jaundice, pruritis, and chronic diarrhea. In our case, the symptoms and signs of various abnormalities in liver function tests such as serum albumin and bilirubin normalized after euthyroid state. We think that these findings are related to thyroid dysfunction. Every hyperbilirubinemia and hypoalbuminemia, which can be seen in many serious diseases, may unexpectedly appear in the long-term progression of thyrotoxicosis. Whether thyrotoxicosis is present in patients with hyperbilirubinemia and hypoalbuminemia should be evaluated.
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An interesting case of encephalitis Highly accessed article p. 199
A.V. Raveendran, Kariampuzha Chacko George, Mohammed Shafi Pilavullakandy
DOI:10.4103/ejim.ejim_57_17  
Autoimmune encephalitis is an emerging clinical entity/medical emergency. Psychiatric symptoms can be a presenting feature of this condition, causing diagnostic confusion. Early and appropriate treatment is essential for complete recovery and to prevent relapse.
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Glucocorticoid hypersensitivity syndrome resulting from inhaled corticosteroid: a case report p. 201
Ejiofor T Ugwu
DOI:10.4103/ejim.ejim_49_17  
The term ‘glucocorticoid hypersensitivity syndrome’ is very sparse in the literature. It describes a very rare entity characterized by the appearance of typical Cushingoid features in the presence of normal or low serum cortisol levels. It is also known as cortisol hyper-reactive syndrome or normocortisolemic Cushing’s syndrome. This report illustrates this unusual phenomenon accompanied by metabolic syndrome-like manifestations in a young Nigerian man who was receiving inhaled corticosteroid for bronchial asthma and who experienced a significant improvement following withdrawal of the steroid treatment.
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