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Pannu AK, Chand D, Bhalla A, Dhibar DP. Efficacy of a low dose of antivenom for severe neuroparalysis in Bungarus caeruleus (common krait) envenomation: a pilot study. Toxicol Res (Camb) 2024; 13:tfae023. [PMID: 38450179 PMCID: PMC10913380 DOI: 10.1093/toxres/tfae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/26/2023] [Accepted: 02/15/2024] [Indexed: 03/08/2024] Open
Abstract
Introduction Despite the widespread use of antivenom for the treatment of snakebite envenoming in the Indian subcontinent, the ideal dose of antivenom has been a point of contention. Low-dose regimens can economize on a scarce resource in low- and middle-income countries. This study assessed the effectiveness of a low-dose (10 vials) antivenom regimen compared to the usual 20 vials in patients with krait bite neuroparalysis requiring mechanical ventilation. Methods This study was a prospective controlled pilot study conducted in a tertiary-care hospital in north India. Participants were eligible if they were ≥12 years old, had krait bite neurotoxicity, showed severe paralysis requiring mechanical ventilation, and had access to antivenom therapy within 24 h of the bite. The primary outcome was the duration of mechanical ventilation, and the secondary outcomes were the length of hospital stay and in-hospital survival. Results Fifteen patients received 10 vials of antivenom, and 25 received 20 vials. The two treatment groups had similar baseline demographics, clinical and laboratory features, snakebite severity scores, and median time from snakebite to initiation of antivenom therapy. The low-dose regimen was as effective as the standard dose concerning the median duration of mechanical ventilation (41 h vs. 55 h, P = 0.094), the median length of stay (78 h vs. 85.5 h, P = 0.360), and in-hospital deaths (1 vs. 3, P = 1.000). The incidence of ventilator-associated pneumonia was similar between the two groups (1 vs 3, P = 1.000). Conclusion A low dose of antivenom effectively treats patients with severe krait bite neuroparalysis.
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4 Floor, F Block, Nehru Hospital, Chandigarh 160012, India
| | - Duni Chand
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4 Floor, F Block, Nehru Hospital, Chandigarh 160012, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4 Floor, F Block, Nehru Hospital, Chandigarh 160012, India
| | - Deba Prasad Dhibar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4 Floor, F Block, Nehru Hospital, Chandigarh 160012, India
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Divyashree K, Pannu AK, Saroch A, Angrup A, Sharma N. Changing spectrum of primary pyomyositis in North India. Trop Doct 2024; 54:91-97. [PMID: 38083802 DOI: 10.1177/00494755231219775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
Recent data have demonstrated the changing epidemiology of primary pyomyositis worldwide. Our hospital-based retrospective study investigated the clinical and microbiological spectrum of primary pyomyositis between 2013 and 2021 in PGIMER (Chandigarh), India. Over a quarter had predisposing conditions, mainly diabetes mellitus and immunosuppressive therapy. Fever, muscle pain, local swelling and breathlessness were the usual presentations, with quadriceps, iliopsoas and gluteal muscles commonly affected. Staphylococcus aureus was the predominant cause, with c.50% methicillin-resistant strains. Almost two-thirds presented with metastatic infection (stage 3 pyomyositis), frequently with septic lung emboli. Patients with methicillin-sensitive and resistant Staphylococcus aureus had a similar incidence of metastatic infection. In-hospital mortality was c.10% and was strongly associated with a high international normalised ratio. Primary pyomyositis remains a significant problem, with a dramatic increase in community-associated methicillin-resistant Staphylococcus aureus.
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Affiliation(s)
- Krishna Divyashree
- Senior Resident, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Ashok Kumar Pannu
- Associate Professor, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Atul Saroch
- Associate Professor, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Archana Angrup
- Associate Professor, Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research Block A, Chandigarh, India
| | - Navneet Sharma
- Professor, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
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Soni D, Pannu AK, Saroch A, Bhatia V, Ahluwalia J, Singh R, Jain A. The Utility of Quantitative D-Dimer Assay as a Biomarker in the Diagnosis and Exclusion of Cerebral Venous Sinus Thrombosis. Indian J Hematol Blood Transfus 2024; 40:122-129. [PMID: 38312171 PMCID: PMC10831008 DOI: 10.1007/s12288-023-01677-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 06/16/2023] [Indexed: 02/06/2024] Open
Abstract
The utility and sensitivity of quantitative D-Dimer assay to rule out the diagnosis of deep vein thrombosis is well established. We extrapolated this principle to evaluate the utility of D-Dimer assay in exclusion of cerebral venous sinus thrombosis (CVST). As advanced imaging modalities required for the diagnosis of CVST might not be available everywhere, it is important to have a sensitive biomarker and a clinical decision rule which can assist in the diagnosis. Patients undergoing CT/MR Venography of the brain with the suspicion of CVST were enrolled. Quantitative D-Dimer assay was performed in those who had CVST on CT/MR Venography and was compared with those who did not. A Clinical decision rule for the diagnosis of CVST was formulated using logistic regression analysis. Receiver operating characteristic analysis evaluating the diagnostic accuracy of D Dimer for patients with CVST as compared to those who did not revealed an AUROC of 0.694. D-Dimer levels of < 300 ng/mL had a sensitivity of 90% for the exclusion of CVST. After logistic regression analysis, a clinical decision rule with a total score of 16 and individual components of Female gender (2 points), Headache (7 points), D-Dimer levels of ≥ 792 ng/mL (7 points) was proposed. D-Dimer had a poor diagnostic accuracy for differentiation of patients who had CVST from those who did not, however, had a high sensitivity at values < 300 ng/mL. The proposed clinical decision rule with a score of ≥ 9 had a good diagnostic accuracy in prediction of CVST (AUROC = 0.809).
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Affiliation(s)
- Dipesh Soni
- Department of Internal Medicine, PGIMER, Chandigarh, India
| | | | - Atul Saroch
- Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Vikas Bhatia
- Department of Radiodiagnosis PGIMER, Chandigarh, India
| | | | | | - Arihant Jain
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, India
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Selvam S, Simha A, Nawaz RS, Sarmin A, Gangadharappa RC, Pannu AK. Occult paraquat poisoning causing pneumomediastinum and organizing pneumonia. Trop Doct 2024; 54:66-68. [PMID: 37674474 DOI: 10.1177/00494755231200042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Pneumomediastinum is not an uncommon manifestation of lung toxicity in acute paraquat ingestion. The condition is almost invariably seen with other lung parenchymal abnormalities such as consolidations, ground-glass opacities and interlobular septal thickening. The diagnosis may be challenging in cases with no history of toxin exposure, presentation with a subacute illness and/or absence of typical local or systemic features of paraquat toxicity.
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Affiliation(s)
- Suresh Selvam
- Senior Resident, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amar Simha
- Senior Resident, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rana Sadaqat Nawaz
- MD Resident, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Aziza Sarmin
- MD Resident, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Ashok Kumar Pannu
- Associate Professor, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Pannu AK, Kiran R, Kumar A, Sharda SC, Bhatia M, Saroch A, Dutta P, Sharma N. Comparative study of diabetic ketoacidosis in the elderly and non-elderly patients: A nine-year experience from an academic hospital in North India. Diabetes Metab Syndr 2023; 17:102903. [PMID: 37988830 DOI: 10.1016/j.dsx.2023.102903] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND AND AIMS Despite an increasing prevalence of the aged population with diabetes in low-middle-income countries, there is limited literature on geriatric hyperglycemic emergencies. The present study aimed to compare the spectrum and outcomes of diabetic ketoacidosis (DKA) between elderly and non-elderly adult patients in India. METHODS Seventy-seven elderly patients (≥60 years) were compared to 477 non-elderly patients (13-59 years) with DKA admitted to the medical emergency, Postgraduate Institute of Medical Education and Research, Chandigarh, India, between January 2014 and December 2022. Clinical features, laboratory parameters, precipitating factors, and in-hospital outcomes were reviewed. RESULTS Elderly patients less commonly had vomiting and abdominal pain than non-elderly patients (31.3 % vs. 66.2 %, 27.3 % vs. 60.1 %, respectively) and typically presented with dyspnea (48.5 %), altered mental status (47.8 %), and fever (46.3 %). Ketonemia and metabolic acidosis were significantly more marked in non-elderly patients, whereas elderly patients frequently had anemia, hypoalbuminemia, and renal dysfunction. The most common precipitations of geriatric DKA were infections (70.1 %), followed by treatment non-adherence (66.2 %) and non-infectious disorders (35.1 %). Infections and non-infectious disorders were significantly more frequent in elderly patients than in non-elderly patients. Respiratory and urinary tract infections were prevalent in both age groups. In-hospital survival was 74.9 % (n = 415) and remained lower in older patients (48.1 % vs. 79.2 %, P-value <0.001). The independent prognostic factors were age (OR 1.030, 95 % CI 1.006-1.054, P = 0.014), Glasgow coma scale (OR 0.789, 95 % CI 0.717-0.869, P <0.001), and infection trigger (OR 6.635, 95 % CI 2.852-15.441, P <0.001). CONCLUSION Older patients with DKA present atypically, frequently have precipitation with infections and noninfectious disorders, and have poor outcomes.
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Ravindran Kiran
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Abhishek Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Saurabh Chandrabhan Sharda
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Mandip Bhatia
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Atul Saroch
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Pinaki Dutta
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
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Pannu AK, Kumar A, Kiran R, Bhatia M, Sharda SC, Saroch A, Angrup A, Dutta P, Sharma N. Diagnostic utility of procalcitonin for bacterial infections in diabetic ketoacidosis. Clin Exp Med 2023; 23:5299-5306. [PMID: 37634230 DOI: 10.1007/s10238-023-01169-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/10/2023] [Indexed: 08/29/2023]
Abstract
Procalcitonin is a widely used infection biomarker; however, its utility in identifying bacterial infection in diabetic ketoacidosis (DKA) is unclear. We aimed to evaluate its diagnostic performance for detecting DKA cases triggered by bacterial infections. We reviewed 303 case records of patients aged ≥ 13 years with DKA admitted to the emergency department, PGIMER (Chandigarh), between 2017 and 2022. Baseline procalcitonin was measured by electrochemiluminescence immunoassay, and a value > 0.5 ng/mL was considered elevated. Both microbiological reference standard (MRS) and composite reference standard (CRS) were used to evaluate the diagnostic performance of procalcitonin. 151/303 (49.8%) DKA cases had infection precipitations. Bacterial infections were present in 98 patients (53 microbiologically confirmed), of which urinary tract infection (n = 42), pneumonia (n = 19), skin and soft-tissue infection (n = 13), and bacteremia (n = 11) were common. The median value of procalcitonin was higher with bacterial infections than in patients without (3.68 vs. 1.00, P-value < 0.001). An elevated procalcitonin to detect bacterial infections in DKA had sensitivity 84.69%, specificity 34.15%, positive likelihood ratio (LR +) 1.29, and negative likelihood ratio (LR -) 2.44, against CRS. Against MRS, both LR + and LR - further decreased to 1.23 and 1.81, respectively. Using the receiver-operating-characteristic curve, an optimal cut-off of procalcitonin was calculated at 1.775 ng/ml against both CRS (area under curve 0.655, sensitivity 68.37%, specificity 59.02%, LR + 1.67, LR - 1.86, Yoden's index 0.274) and MRS (area under curve 0.616, sensitivity 67.92%, specificity 59.02%, LR + 1.66, LR - 1.84, Yoden's index 0.269). Procalcitonin does not help detect bacterial infections in patients with DKA at admission.
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
| | - Abhishek Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
| | - Ravindran Kiran
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
| | - Mandip Bhatia
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
| | - Saurabh Chandrabhan Sharda
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
| | - Atul Saroch
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India.
| | - Archana Angrup
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research Block A, Sector 12, Chandigarh, 160012, India
| | - Pinaki Dutta
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Nehru Hospital Extension, Sector 12, Chandigarh, 160012, India
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India
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Kumar A, Pannu AK, Kumar M, Angrup A, Dutta P, Sharma N. Sepsis screening tools for predicting infection triggers and outcomes in diabetic ketoacidosis. Biomark Med 2023; 17:947-958. [PMID: 38214173 DOI: 10.2217/bmm-2023-0574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
Background: An early prediction of infection is challenging in diabetic ketoacidosis (DKA). Methods: This prospective cohort study aimed to assess effectiveness of various sepsis screening tools in predicting infections and prognosis in DKA. Results: Among 141 cases, infection (44.0%) was the commonest precipitating factor. A Sequential Organ Failure Assessment score ≥4 showed high specificity (82.28%) and high positive likelihood ratio (2.64) but limited sensitivity (46.77%). Conversely, Systemic Inflammatory Response Syndrome ≥2 exhibited good sensitivity (95.16%) but a high false-positive rate (84.28%). National Early Warning Score ≥7 and Quick Sequential Organ Failure Assessment ≥2 had low sensitivity and specificity. These sepsis tools also demonstrated low prognostic accuracy for mortality. Conclusion: Sepsis screening tools have limited predictive accuracy for infections and mortality in DKA.
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Affiliation(s)
- Abhishek Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, 160012, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, 160012, India
| | - Mohan Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, 160012, India
| | - Archana Angrup
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research Block A, Chandigarh, 160012, India
| | - Pinaki Dutta
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Nehru Hospital Extension, Chandigarh, 160012, India
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, 160012, India
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Shaji A, Parvez M, Chirumamilla NK, Sharma N, Pannu AK. Severe pulmonary-renal syndrome in honeybee sting envenomation - A case report. Turk J Emerg Med 2023; 23:246-249. [PMID: 38024185 PMCID: PMC10664193 DOI: 10.4103/tjem.tjem_138_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 12/01/2023] Open
Abstract
Honeybee stings with features of envenomation (either local or allergic and rarely systemic toxicity) are often seen in agriculture workers. An initial presentation with severe diffuse alveolar hemorrhage or pulmonary-renal syndrome is rare and only confined to a few case reports. Herein, we describe a case of a 45-year-old male who presented with multiple bee stings and subsequently developed acute kidney injury and pulmonary hemorrhage. He was managed with hemodialysis, invasive mechanical ventilation, red-cell transfusion, and pulse methylprednisolone. However, he developed cardiac arrhythmias with ventricular tachycardia and died.
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Affiliation(s)
- Alan Shaji
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Malik Parvez
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naresh Kumar Chirumamilla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nalin Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Pannu AK, Singla V, Suri V, Kumar R, Mathur Y, Mohindra R, Jain S. Adult-onset Still's disease and fever of unknown origin in India. Clin Exp Med 2023; 23:1659-1666. [PMID: 36178600 PMCID: PMC9523624 DOI: 10.1007/s10238-022-00903-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/20/2022] [Indexed: 11/27/2022]
Abstract
Despite an essential differential diagnosis for fever of unknown origin (FUO) in young adults, adult-onset Still's disease (AOSD) is infrequently considered and remained underdiagnosed in low-middle-income countries. The present study analyzed the clinical, serological, radiological, and pathological characteristics of AOSD presented as FUO in India. A hospital-based retrospective study of patients aged > 13 years admitted with FUO and later diagnosed with AOSD in Postgraduate Institute of Medical Education and Research, Chandigarh (India), was conducted between January 2014 and December 2020. Petersdorf and Beeson's criteria were used to define FUO. The diagnosis of AOSD was made based on Yamaguchi's criteria. Twenty-seven patients (median age 26 years, 14 females) were enrolled. All presented with intermittent fever with a median duration of 10 weeks. The typical features of AOSD at admission were arthralgia (n = 24), hepatosplenomegaly (n = 21), spiking fever ≥ 39 °C (n = 19), lymphadenopathy (n = 18), typical rash (n = 17), and sore throat (n = 11). Leukocytosis (n = 25) and neutrophilia (n = 19) were frequent. Hyperferritinemia was universal (range, 700-145,003 ng/ml; ≥ 2000, n = 23). At admission, AOSD was suspected in only nine FUO cases, while tuberculosis (n = 16), undifferentiated connective tissue disorder (n = 14), and lymphoproliferative disorder (n = 11) were common diagnostic possibilities. Crispin et al. clinical scale detected AOSD in only 15 (55.5%) FUO patients. Whole-body imaging (n = 27), including fluorodeoxyglucose positron emission tomography (n = 12), demonstrated reticuloendothelial organ-system involvement and serositis. Seventeen (63%) patients had macrophage activation syndrome at the time of AOSD diagnosis. AOSD FUO presents with typical but nonspecific features; thus, early differentiation from common causes (e.g., tuberculosis, lymphoma) is difficult. Macrophage activation syndrome is common in AOSD with FUO presentation.
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, 4th floor, F block, Chandigarh, 160012 India
| | - Vidhi Singla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, 4th floor, F block, Chandigarh, 160012 India
| | - Vikas Suri
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, 4th floor, F block, Chandigarh, 160012 India
| | - Rajender Kumar
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012 India
| | - Yamini Mathur
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012 India
| | - Ritin Mohindra
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, 4th floor, F block, Chandigarh, 160012 India
| | - Sanjay Jain
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, 4th floor, F block, Chandigarh, 160012 India
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Sharma N, Seal R, Teja DU, Pannu AK. Cystic Pneumocystis pneumonia. BMJ Case Rep 2023; 16:e255853. [PMID: 37479492 PMCID: PMC10364152 DOI: 10.1136/bcr-2023-255853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023] Open
Affiliation(s)
- Neha Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Ratul Seal
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Devarakonda Uday Teja
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
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Sharda SC, Bhatia MS, Jakhotia RR, Behera A, Saroch A, Pannu AK, Kumar HM. Efficacy and safety of the Arctic Sun device for hypoxic-ischemic encephalopathy in adult patients following cardiopulmonary resuscitation: A systematic review and meta-analysis. Brain Circ 2023; 9:185-193. [PMID: 38020958 PMCID: PMC10679624 DOI: 10.4103/bc.bc_18_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/30/2023] [Accepted: 07/18/2023] [Indexed: 12/01/2023] Open
Abstract
AIM The principal objective of this study was to carry out a comprehensive and thorough analysis to compare the safety and effectiveness of the Arctic Sun, a servo-controlled surface cooling device, with conventional cooling techniques for providing therapeutic hypothermia in adult patients who had experienced hypoxic-ischemic brain injury following cardiopulmonary resuscitation. METHODS In order to achieve our goal, we conducted an extensive search of multiple databases including PubMed, Embase, Cochrane, and ClinicalTrials.gov up to the date of July 30, 2021. We only included studies that compared the safety and efficacy of the Arctic Sun surface cooling equipment with standard cooling approaches such as cooling blankets, ice packs, and intravenous cold saline for treating comatose adult patients who had recovered after experiencing cardiac arrest. We evaluated various outcomes, including all-cause mortality, good neurological outcome at 1 month, and the occurrence of adverse effects such as infections, shock, and bleeding. We employed a random-effects meta-analysis to estimate the odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous outcomes. RESULTS One hundred and fourteen records were identified through our search; however, only three studies met our eligibility criteria, resulting in overall 187 patients incorporated in the meta-analysis. The findings indicated no significant difference in mortality rates among the Arctic Sun device and conventional cooling techniques (OR: 0.64; 95% CI: 0.34-1.19; P = 0.16; I2 = 0%). In addition, we found no significant difference in occurrence of good neurological outcomes (OR: 1.74; 95% CI: 0.94-3.25; P = 0.08; I2 = 0%) between the two cooling methods. However, the application of the Arctic Sun device was associated with increased incidence of infections compared to standard cooling methods (OR: 2.46; 95% CI: 1.18-5.11; P = 0.02; I2 = 0%). While no significant difference occurred in the incidence of shock (OR: 0.29; 95% CI: 0.07-1.18; P = 0.08; I2 = 40%), the use of the Arctic Sun device was linked to significantly fewer bleeding complications compared to standard cooling methods (OR: 0.11; 95% CI: 0.02-0.79; P = 0.03; I2 = 0%). CONCLUSIONS After analyzing the results of our meta-analysis, we concluded that the use of the Arctic Sun device for targeted temperature management following cardiopulmonary resuscitation did not result in significant differences in mortality rates or improve neurological outcomes when compared to standard cooling techniques.
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Affiliation(s)
- Saurabh C. Sharda
- Department of Internal Medicine, Division of Acute Care and Emergency Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandip Singh Bhatia
- Department of Internal Medicine, Division of Acute Care and Emergency Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit R. Jakhotia
- Department of Medicine, Chaitanya Hospital, Pune, Maharashtra, India
| | - Ashish Behera
- Department of Internal Medicine, Division of Acute Care and Emergency Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Atul Saroch
- Department of Internal Medicine, Division of Acute Care and Emergency Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Division of Acute Care and Emergency Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - H Mohan Kumar
- Department of Internal Medicine, Division of Acute Care and Emergency Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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12
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Bolla T, Pannu AK. Splenomegaly in scrub typhus. Trop Doct 2023:494755231173737. [PMID: 37151040 DOI: 10.1177/00494755231173737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Affiliation(s)
- Tukaram Bolla
- Senior Resident, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar Pannu
- Associate Professor, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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13
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Pannu AK. Optimal empirical antimicrobial therapy in infective endocarditis. QJM 2023; 116:156-157. [PMID: 35353184 DOI: 10.1093/qjmed/hcac086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/27/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- A K Pannu
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, 4th floor, F block, Chandigarh 160012, India
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14
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Shankar JA, Kaur A, Tyagi L, Selvam S, Hans R, Pannu AK. Severe copper sulphate poisoning: A case rescued with plasmapheresis. Trop Doct 2023; 53:327-328. [PMID: 36628444 DOI: 10.1177/00494755231151256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Acute copper sulphate poisoning is associated with multi-organ failure and high mortality. Patients typically present with gastrointestinal symptoms, haemolysis, methaemoglobinaemia, acute liver injury, rhabdomyolysis and renal failure. Management is usually supportive, and the role of chelation therapy has not been established. Copper is not dialysable. Plasmapheresis has been shown to remove protein-bound copper, reducing plasma and intracellular concentrations. We present a case of severe copper sulphate poisoning, who did not improve with chelation therapy with D-penicillamine and supportive care, but with therapeutic plasma exchange (four cycles) showed rapid clinical recovery.
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Affiliation(s)
- Jandhyala Anand Shankar
- Department of Internal Medicine, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anterpreet Kaur
- Department of Internal Medicine, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Lakshay Tyagi
- Department of Internal Medicine, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Suresh Selvam
- Department of Internal Medicine, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rekha Hans
- Department of Transfusion Medicine, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
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15
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Kanneganti V, Divyashree K, Pannu AK. Role of bone marrow examination in pyrexia of unknown origin. Trop Doct 2022; 53:338-339. [PMID: 36452975 DOI: 10.1177/00494755221142940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
A stepwise approach is essential to evaluating pyrexia of unknown origin (PUO). When other investigations are negative, bone marrow examination is a valuable diagnostic tool in PUO. It is particularly helpful in patients with involvement of reticuloendothelial organs (e.g. cytopenia, splenomegaly), immunodeficiency states, or older age.
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Affiliation(s)
- Vineetha Kanneganti
- Junior Resident, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Krishna Divyashree
- Senior Resident, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Ashok Kumar Pannu
- Associate Professor, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
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16
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Pannu AK. Response to: Palla's sign and the challenge of optimizing the imaging strategy in patients with high pretest probability of pulmonary embolism. QJM 2022; 115:778-780. [PMID: 34918160 DOI: 10.1093/qjmed/hcab323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- A K Pannu
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, 4th Floor, F Block, Sector 12, Chandigarh 160012, India
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17
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Grewal TS, Soni D, Nada R, Sharma N, Pannu AK. A young boy with severe pulmonary-renal syndrome: Will you suspect IgA nephropathy? Turk J Emerg Med 2022; 23:52-56. [PMID: 36818945 PMCID: PMC9930386 DOI: 10.4103/2452-2473.357334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/23/2022] [Accepted: 02/15/2022] [Indexed: 11/04/2022] Open
Abstract
IgA nephropathy is a renal-limited form of systemic vasculitis, and pulmonary manifestations are uncommon. An initial presentation with severe diffuse alveolar hemorrhage (DAH) or pulmonary-renal syndrome is rare and only confined to a few case reports. Herein, we present a young male admitted with acute-onset dyspnea, hemoptysis, and rapidly progressive renal failure. With an initial diagnosis of an immune-mediated pulmonary-renal syndrome, he was treated with high-dose corticosteroids and therapeutic plasmapheresis along with intensive organ support (including hemodialysis, red cell transfusion, and high-flow oxygen). After a detailed laboratory evaluation and kidney biopsy, IgA nephropathy was diagnosed. The patient continued to worsen with persistent DAH and died. IgA nephropathy-associated severe DAH or pulmonary-renal syndrome is rare but increasingly recognized. The condition is difficult to diagnose early and has no proven disease-targeted therapy.
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Affiliation(s)
- Tejinderpal Singh Grewal
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Dipesh Soni
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Dr. Ashok Kumar Pannu, 4th Floor, F Block, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail:
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18
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Bhatia MS, Sharda SC, Attri R, Pannu AK, Dahiya N. Correlation of mortality with Pro-BNP and precipitating factors of acute heart failure in patients presenting to a medical emergency of tertiary care hospital: an observational study from north India. Eur Rev Med Pharmacol Sci 2022; 26:6459-6468. [PMID: 36196696 DOI: 10.26355/eurrev_202209_29745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Acute heart failure is a syndrome defined as the new onset de novo heart failure or worsening [acutely decompensated heart failure (ADHF)] leading to symptoms and signs of HF, mostly related to systemic congestion as based on the European Society of Cardiology (ESC) definition. India has a huge burden of heart failure patients. Several factors have been identified as precipitating acute HF hospitalizations. These include myocardial ischemia, no adherence to medications, arrhythmias, infection, uncontrolled hypertension (HTN), anemia, renal impairment, and diet. However, there is a dearth of studies assessing their effect on mortality in patients admitted with acute heart failure. Many previous studies have shown that BNP and NT-pro-BNP are independent predictors of mortality and other cardiac outcomes in patients with heart failure (HF) and ADHF. However, no studies have provided any clear direction with respect to the critical cut-off values that suggest high mortality. Comprehensive knowledge of the correlation of Pro-BNP and precipitating factors of heart failure with mortality can help in prognostication and clinical management of AHF patients. PATIENTS AND METHODS This was a prospective observational cross-sectional study conducted in the Emergency Department of the Postgraduate Institute of Medical Education and Research, Chandigarh which is a teaching and research hospital located in North India. Patients were enrolled from 1st August 2021 to 28th February 2022. Patients who met inclusion criteria were enrolled; they were followed for 5 days. After 5 days outcomes were recorded. Various precipitating factors for hospitalization were identified and their clinical impact on mortality was noted. Pro-BNP values were obtained at admission and their correlation with mortality and patient outcome after 5 days was noted. Values of Pro-BNP were compared among those who survived after 5 days vs. those who had fatal outcomes. RESULTS The most common precipitating factor for AHF was poor medical compliance which did not affect mortality. It was followed by sepsis which significantly increases mortality in patients of AHF. ACS was also an important precipitating factor for AHF, though it had no effect on mortality. The mortality in the group of patients with very high Pro-BNP levels ≥ 2000 pg/ml was significantly higher than in the group of patients who had moderately elevated Pro-BNP < 2000 pg/ml. The median value of Pro-BNP was significantly higher in patients who had fatal outcomes [3670 (IQR- 2745 to 3980)] as compared to patients who survived after 5 days of hospitalization [1340 (IQR- 987 to 1670)]. CONCLUSIONS Poor compliance with medications and sepsis are the most common precipitating factors for acute heart failure in north Indian patients. Sepsis as a precipitating factor is a significant risk factor for in-hospital mortality in acute heart failure patients presenting to the emergency department. Pro-BNP values above 2000 pg/ml in patients with acute heart failure requiring emergency admission are associated with a poor prognosis.
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Affiliation(s)
- M S Bhatia
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (P.G.I.M.E.R.), Chandigarh, India.
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Reddy SP, Phadnis SA, Kumari P, Sharma N, Sethi J, Pannu AK, Sharma N. Thrombotic microangiopathy in Russel's viper envenomation. QJM 2022; 115:486-487. [PMID: 35323969 DOI: 10.1093/qjmed/hcac081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- S P Reddy
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S A Phadnis
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - P Kumari
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - N Sharma
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - J Sethi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - A K Pannu
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - N Sharma
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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20
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Anbalagan LC, Pannu AK. Multiple Myeloma or AL amyloidosis? QJM 2022; 116:403-404. [PMID: 35792862 DOI: 10.1093/qjmed/hcac165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- L C Anbalagan
- Department of Internal Medicine, Postgraduate Institute of Medical, Education and Research, Nehru Hospital, Sector 12, Chandigarh (India) (160012)
| | - A K Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical, Education and Research, Nehru Hospital, Sector 12, Chandigarh (India) (160012)
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21
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Chhabria B, Arora N, Chahal S, Kumar Pannu A, Muthu V, Kumar M. SARS-CoV-2 infection, pulse oximetry, and interpretive caveats. Trop Doct 2022; 52:593-595. [PMID: 35775134 PMCID: PMC9253519 DOI: 10.1177/00494755221094983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypoxaemia in COVID-19 does not necessarily imply COVID pneumonia or post-COVID
lung fibrosis, and the caveats of finger pulse oximetry should be remembered.
Drug-induced methaemoglobinemia should be considered in individuals with
unexplained cyanosis, refractory hypoxaemia, or the presence of a saturation
gap. Here, we share our recent encounter of ‘spurious hypoxia’ in a patient with
COVID-19 and methaemoglobinemia.
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Affiliation(s)
| | | | | | | | | | - Mohan Kumar
- Mohan Kumar H, Assistant Professor,
Department of Internal Medicine, Post Graduate Institute of Medical Education
and Research, Chandigarh, India.
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Abstract
OBJECTIVE Although the elderly population remains at high risk for tuberculosis, studies addressing tuberculous meningitis (TBM) in this age group are scarce. The present study aimed to evaluate the spectrum and outcome of geriatric TBM and document differences between older and young patients. METHODS A prospective cohort study was conducted in the adult TBM patients admitted at PGIMER, Chandigarh (India). Consecutive older patients aged 60 years and above were enrolled from January 2019 to December 2020, and young adults aged 18-59 years were enrolled from July 2019 to December 2019. RESULTS Fifty-five older patients with a mean age of 66.6 years and 73 young patients with a mean age of 35.1 years were enrolled. At admission, older patients were more likely to have altered mental status (96.4% vs. 78.1%, P = 0.003) and advanced disease with British medical research council staging 2 or 3 (98.2% vs. 89.0%, P = 0.043); however, headache (38.2% vs. 67.1%, P = 0.001), vomiting (18.2% vs. 35.6%, P = 0.030) and fever (80.0% vs. 91.8%, P = 0.052) were less common. Cerebrospinal fluid (CSF) abnormalities were less marked in older patients, with a significant difference in median total cells (70 vs. 110/µl, P = 0.013). Hydrocephalous and infarct were common neuroimaging abnormalities in both groups; however, tuberculomas were significantly less in the elderly (15.1% vs. 35.2%, P = 0.012). Older patients had a significantly low survival rate (56.4% vs. 76.7%, P = 0.021). CONCLUSION Significant differences in clinical, CSF and radiological characteristics exist between elderly and young TBM patients, with survival remains dismal in the elderly.
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Affiliation(s)
- N Rahman
- From the 1Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, 4th floor, F block, Sector 12, Chandigarh 160012, India
| | - A K Pannu
- From the 1Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, 4th floor, F block, Sector 12, Chandigarh 160012, India
| | - R Yadav
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research Block A, Sector 12, Chandigarh 160012, India
| | - S Sethi
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Research Block A, Sector 12 , Chandigarh 160012, India
| | - A Saroch
- From the 1Department of Internal Medicine , Postgraduate Institute of Medical Education and Research, Nehru Hospital, 4th floor, F block, Sector 12, Chandigarh 160012, India
| | - M Garg
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh 160012, India
| | - D Kumar
- From the 1Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, 4th floor, F block, Sector 12, Chandigarh 160012, India
| | - A Bhalla
- From the 1Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, 4th floor, F block, Sector 12, Chandigarh 160012, India
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, 4th floor, F block, Chandigarh, 160012, IndiaAddress: , Mobile: +91 8264786277; +91 9914291115
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24
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Pannu AK. Coinfection of tuberculosis and cryptococcosis: a one-two punch. QJM 2022; 115:336-337. [PMID: 34185086 DOI: 10.1093/qjmed/hcab181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- A K Pannu
- From the Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, 4th floor, F block, Sector 12, Chandigarh 160012, India
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25
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Pannu AK. Diagnosis of Acute Intermittent Porphyria in Emergency Department. QJM 2022; 116:317-318. [PMID: 35482526 DOI: 10.1093/qjmed/hcac111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ashok Kumar Pannu
- Address: 4th floor, F block, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector, 12, Chandigarh (India) (160012)
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26
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Affiliation(s)
- S Suresh
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, 4th floor, F block, Chandigarh, India
| | - A K Pannu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, 4th floor, F block, Chandigarh, India
| | - N Arora
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, 4th floor, F block, Chandigarh, India
| | - M Chabra
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, 4th floor, F block, Chandigarh, 160012 India
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Abstract
Although recent data have shown a declining trend in mortality in diabetic ketoacidosis (DKA), the outcomes are likely to be different during the coronavirus (COVID-19) pandemic. We conducted a prospective cohort study to evaluate the spectrum and outcomes of adult DKA during the pandemic and document differences in DKA patients with or without COVID-19. A total of 169 patients (mean age 44 years) were admitted at the Emergency Department of PGIMER, Chandigarh (India), from January 2020 to June 2021. The precipitating factors were noncompliance with antidiabetic therapy (77.5%), infections (62.7%), and noninfectious conditions (21.3%). Thirty-nine (23.1%) patients had COVID-19, including 31 with severe infection. DKA severity and resolution, ventilator requirement, hospital stay, and mortality were similar in the patients with or without COVID-19. In-hospital mortality was 39.6% (n = 67). The independent mortality predictors were ventilator requirement (p-0.000), an infection trigger (p-0.049), and hyperosmolarity (p-0.048). DKA mortality is increased significantly during the pandemic.
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Affiliation(s)
- Ravindran Kiran
- Department of Internal Medicine, Postgraduate Institute of Medical
Education and Research, Nehru Hospital, Sector 12, Chandigarh, India
| | - Atul Saroch
- Department of Internal Medicine, Postgraduate Institute of Medical
Education and Research, Nehru Hospital, Sector 12, Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical
Education and Research, Nehru Hospital, Sector 12, Chandigarh, India
- Dr Ashok Kumar Pannu MD, Associate
Professor, Department of Internal Medicine, PGIMER, 4th floor, F block,
Department of Internal Medicine, Postgraduate Institute of Medical Education and
Research, Nehru Hospital, Sector 12, Chandigarh (India) (160012).
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical
Education and Research, Nehru Hospital, Sector 12, Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, Postgraduate Institute of Medical
Education and Research, Nehru Hospital Extension, Sector 12, Chandigarh, India
| | - Mohan Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical
Education and Research, Nehru Hospital, Sector 12, Chandigarh, India
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Divyashree K, Gupta R, Chandana VS, Pannu AK. Hydroxyurea-induced lunular hyperpigmentation. BMJ Case Rep 2022; 15:e249123. [PMID: 35292553 PMCID: PMC8928243 DOI: 10.1136/bcr-2022-249123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2022] [Indexed: 11/04/2022] Open
Affiliation(s)
- Krishna Divyashree
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Raghav Gupta
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vinayan Sajitha Chandana
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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29
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Shaji A, Rajpurohit HC, Shankar JA, Saroch A, Bhatia M, Pannu AK. Clinical triad of fat embolism syndrome. QJM 2022; 115:105-106. [PMID: 34893890 DOI: 10.1093/qjmed/hcab311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A Shaji
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - H C Rajpurohit
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - J A Shankar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - A Saroch
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - M Bhatia
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - A K Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
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30
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Chaudhary D, Aggarwal T, Pannu AK. Staphylococcus aureus pyomyositis and septic lung emboli. CMAJ 2022; 194:E126. [PMID: 35101872 PMCID: PMC8900776 DOI: 10.1503/cmaj.210782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
- Deepak Chaudhary
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Tanushi Aggarwal
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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31
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Bhalla A, Pannu AK. Are Ayurvedic medications store house of heavy metals? Toxicol Res (Camb) 2022; 11:179-183. [PMID: 35237422 PMCID: PMC8882783 DOI: 10.1093/toxres/tfab124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/25/2021] [Accepted: 12/09/2021] [Indexed: 01/17/2023] Open
Abstract
Ayurvedic formulations are widely used and perceived as safer medicine and subjected to be self-prescribed. However, recent reports have demonstrated adulterating these drugs with toxic quantities of heavy metals. To study the magnitude of the problem in Indian-manufactured Ayurvedic medications, we randomly collected common over-the-counter Ayurvedic preparations from the licensed Ayurvedic shops in the local markets of Chandigarh in 2017. The samples were analyzed to identify and quantify eight metal ions, including mercury, arsenic, lead, cadmium, zinc, iron, copper, and chromium, using inductively coupled plasma mass spectrometry in Postgraduate Institute of Medical Education and Research, Chandigarh. The permissible limit set by the Food and Agriculture Organization/World Health Organization (FAO/WHO) for herbal medicines was followed to define the high metal concentrations. Out of 43 Ayurvedic preparations, 42 were analyzed. Heavy metals were detected in all formulations. The median (range) concentrations (in μg/g or mg/kg) of the metals were quantified as follows- mercury, 13.52 (0.00-61 095.99); arsenic, 0.00 (0.00-1038.83); lead, 1.40 (0.00-57.09); zinc, 84.2200 (26.48-22 519.03); iron, 1356.21 (128.24-136 835.25); copper, 17.1450 (0.00-12 756.86) and chromium, 20.9050 (0.00-2717.58). The metal contents above the FAO/WHO-mandated limit for zinc, mercury, arsenic, and lead were detected in 35, 29, 6, and 2 formulations, respectively. All medications contained detectable quantities of zinc and iron. Copper was detected in all except one. Cadmium was not found in any sample. Ayurvedic medications have a high prevalence of heavy metals. An evaluation of the sources of contamination and the necessary drug safety regulations are required.
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Affiliation(s)
- A Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - A K Pannu
- Correspondence address. Ashok Kumar Pannu, Room no. 26, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh, 160012, India. Tel: +919914291115, +918264786277; E-mail:
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Pannu AK, Saroch A, Kumar M, Behera A, Nayyar GS, Sharma N. Quantification of chronic diseases presenting in the Emergency Department and their disposition outcomes: A hospital-based cross-sectional study in north India. Trop Doct 2022; 52:276-279. [PMID: 34994260 DOI: 10.1177/00494755211069450] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A knowledge of the extent and distribution of chronic comorbidity plays an essential role in providing appropriate care, and allocating health resources to the patients admitted to the emergency department. We performed a cross-sectional study to quantify the chronic diseases presenting in the Emergency Department of PGIMER, Chandigarh (India). Out of 205 patients, 133 (64.9%) had pre-existing comorbidity. Common were chronic kidney disease (29, 14.1%), chronic liver disease (23, 11.2%), diabetes mellitus (21, 10.2%), malignancy (20, 9.8%), cardiac diseases (17, 8.3%), and chronic obstructive pulmonary disease (9, 4.4%). The median Charlson comorbidity index score was 2 (range, 0-9). In-hospital mortality was 43 (21%) and was predicted by older age (median, 60 v. 50 years; p-value, 0.017). Deaths with previous stroke (66.6%), chronic obstructive pulmonary disease (55.6%), and diabetes (28.6%) were higher than cardiac (2.3%) and renal (6.9%) comorbidity. Increasing comorbidity requires a shift in existing models of emergency care.
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, 29751Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Atul Saroch
- Department of Internal Medicine, 29751Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Mohan Kumar
- Department of Internal Medicine, 29751Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Ashish Behera
- Department of Internal Medicine, 29751Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Gursimran Singh Nayyar
- Department of Internal Medicine, 29751Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, 29751Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
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Pannu AK, Jhuria L, Bhalla A, Sharma N. OUP accepted manuscript. Toxicol Res (Camb) 2022; 11:361-366. [PMID: 35510238 PMCID: PMC9052320 DOI: 10.1093/toxres/tfac015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/15/2022] [Accepted: 02/19/2022] [Indexed: 11/14/2022] Open
Abstract
Introduction We recently derived a simplified 3-point PGI score (representing blood pH < 7.25, Glasgow coma scale [GCS] score < 13, and impaired systolic blood pressure [SBP] < 90 mm Hg), which accurately predicted in-hospital case fatality ratio (CFR) in acute aluminum phosphide poisoning. The present study aimed to validate the PGI score and compare it with Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score, Sequential Organ Failure Assessment score (SOFA), and Simplified Acute Physiology Score (SAPS) II scores. Patients and Methods We performed a prospective cohort study in adult patients with aluminum phosphide ingestion admitted in PGIMER, Chandigarh (India), from April 2013 to August 2014. A univariant analysis detected the association of various baseline variables with CFR. Correlation of the PGI score with SOFA, SAPS-II, and APACHE-II scores was performed using Spearman's correlation (rs , range -1 to +1) and scatter plots. Results Seventy-six patients were enrolled (mean age, 28.3 years; 41 males). CFR was 60.5%. PGI score variables-pH, GCS, and impaired SBP predicted CFR (P-value <0.001). Among patients with a total PGI score of 3 or 2, 100% died, compared with 50% in score 1 and 10.7% in score 0. Baseline PGI, SOFA, SAPS-II, and APACHE-II scores predicted CFR (P-value <0.001). There was a positive correlation between the PGI score and SOFA score (rs , 0.855), SAPS-II score (rs , 0.861), and APACHE-II score (rs , 0.883). The P-value for all rs values was <0.001. Conclusion The PGI score is a validated toxidrome-specific and simplified risk-stratification tool. Validation in other populations is warranted to confirm its routine use.
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Affiliation(s)
| | | | | | - N Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Pannu AK, Garg S, Bhalla A, Dhibar DP, Sharma N. Lipid emulsion for the treatment of acute organophosphate poisoning: an Open-Label randomized trial. Clin Toxicol (Phila) 2021; 60:602-608. [PMID: 34928182 DOI: 10.1080/15563650.2021.2013496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Many organophosphate (OP) pesticides are lipid-soluble; therefore, intravenous lipid emulsion (ILE) has been evaluated as a possible treatment for acute poisoning. A single bolus dose of 100 ml of 20% ILE was found safe in a pilot observational study. This randomized trial aimed to assess the effectiveness and safety of an extended dose of ILE in acute OP poisoning. METHODS This was an investigator-initiated, parallel-group, open-label, randomized controlled trial conducted at PGIMER, Chandigarh (India), from January 2019 to June 2020, in patients aged above 13 years with acute OP poisoning. The primary efficacy outcome was to study the change in atropine dose requirement (total and over the first 24 h) for cholinergic crisis after giving an initial bolus dose of 100 ml of 20% ILE followed by an infusion of 100 ml of 20% ILE over 6 h in addition to the standard care. The secondary efficacy outcomes were to detect the effects on hemodynamic variables, length of hospital stay, and duration of mechanical ventilation required. The incidence of adverse events was evaluated. RESULTS A total of 45 patients were assigned to receive either ILE (intervention group, n = 23) or normal saline (control group, n = 22) in addition to standard treatment. Baseline variables in both groups were comparable. The median dose of atropine (in mg) in the first 24 h and at complete resolution in the ILE group were similar to the control group (124.0 versus 141.8, p-value 0.916; and 150.8 versus 175.0, p-value 0.935). Hemodynamic variables (systolic and diastolic blood pressures, mean arterial pressure, and pulse rate) over 24, 48, and 72 h of treatment, length of hospital stay, and duration of mechanical ventilation were also unaffected by ILE. Case fatality was 4 and not statistically different between intervention and control groups (1 versus 3, p-value 0.346). There was no excessive fever, dyspnea, elevation of serum amylase, or pancreatitis from ILE. CONCLUSION ILE has no apparent benefit in acute OP poisoning. However, an extended dose appears safe for the indication.
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahil Garg
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deba Prasad Dhibar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Arora N, Panda PK, Cr P, Uppal L, Saroch A, Angrup A, Sharma N, Sharma YP, Vijayvergiya R, Rohit MK, Gupta A, Sihag BK, Gupta H, Dahiya N, Bahl A, Singh P, Mehrotra S, Barwad P, Pannu AK. Changing spectrum of infective endocarditis in India: An 11-year experience from an academic hospital in North India. Indian Heart J 2021; 73:711-717. [PMID: 34861981 PMCID: PMC8642647 DOI: 10.1016/j.ihj.2021.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/24/2021] [Accepted: 09/08/2021] [Indexed: 11/17/2022] Open
Abstract
Objective Several studies have demonstrated a shift in the spectrum of infective endocarditis (IE) in the developed world. We aimed to investigate whether demographic and microbiologic characteristics of IE have changed in India. Design A retrospective analysis of patients with in north India between 2010 and 2020. Methods The clinical and laboratory profiles of 199 IE admitted to an academic hospital patients who met the modified Duke criteria for definite IE were analysed. Results The mean age was 34 years, and 84% were males. The main predisposing conditions were injection drug use (IDU) (n = 71, 35.7%), congenital heart disease (n = 46, 21.6%), rheumatic heart disease (n = 25, 12.5%), and prosthetic device (n = 19, 9.5%). 17.1% of patients developed IE without identified predispositions. Among 64.3% culture-positive cases, the most prevalent causative pathogens were Staphylococcus aureus (46.1%), viridans streptococci (7.0%), enterococci (6.0%), coagulase-negative staphylococci (5.5%), gram negative bacilli (5.5%), polymicrobial (5.5%), and Candida (1.0%). The tricuspid (30.3%), mitral (25.6%), and aortic (21.6%) valves were the most common sites of infection, and 60.3% had large vegetations (>10 mm). Systemic embolization occurred in 55.3% of patients at presentation. Cardiac surgery was required for 13.1%. In-hospital mortality was 17.1% and was associated with prosthetic devices (p-value, 0.001), baseline leucocytosis (p-value, 0.036) or acute kidney injury (p-value, 0.001), and a microbial etiology of gram negative bacilli or enterococci (p-value, 0.005). Conclusion IDU is now the most important predisposition for IE in India, and S. aureus has become the leading cause of native valve endocarditis with or without IDU.
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Affiliation(s)
- Navneet Arora
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Prashant Kumar Panda
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Pruthvi Cr
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Lipi Uppal
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Atul Saroch
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Archana Angrup
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Yash Paul Sharma
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Rajesh Vijayvergiya
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Manoj Kumar Rohit
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Ankur Gupta
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Bhupinder Kumar Sihag
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Himanshu Gupta
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Neelam Dahiya
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Ajay Bahl
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Parminder Singh
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Saurabh Mehrotra
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Parag Barwad
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Affiliation(s)
- L C Anbalagan
- Department of Internal Medicine, 4th Floor, F Block, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - K Khanna
- Department of Internal Medicine, 4th Floor, F Block, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - R Aggarwal
- Department of Internal Medicine, 4th Floor, F Block, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - A Saroch
- Department of Internal Medicine, 4th Floor, F Block, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - M Kumar
- Department of Internal Medicine, 4th Floor, F Block, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - A K Pannu
- Department of Internal Medicine, 4th Floor, F Block, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Kumar H M, Sharma P, Rudramurthy SM, Sehgal IS, Prasad KT, Pannu AK, Das R, Panda NK, Sharma N, Chakrabarti A, Agarwal R, Muthu V. Serum iron indices in COVID-19-associated mucormycosis: A case-control study. Mycoses 2021; 65:120-127. [PMID: 34743358 PMCID: PMC8662179 DOI: 10.1111/myc.13391] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Whether dysregulated iron metabolism is associated with COVID-19-associated mucormycosis (CAM) remains unknown. Herein, we compare the serum iron indices in COVID-19 subjects with and without mucormycosis. METHODS We conducted a case-control study enrolling COVID-19 participants with and without mucormycosis. We compared the baseline serum iron indices (iron, ferritin, total iron-binding capacity [TIBC], unsaturated iron-binding capacity and percentage transferrin saturation) between CAM cases and COVID-19 controls. Additionally, we performed a multivariate logistic regression analysis to assess whether any iron indices are associated with CAM. RESULTS We enrolled 28 CAM cases (mean age 53.6 years old; 78.6% men) and 26 controls (mean age 57.2 years old; 73.1% men). Rhino-orbital (±cerebral) mucormycosis (85.7%) was the most clinical presentation. Diabetes mellitus was more frequent in the cases than controls (75% vs. 42.3%; p = .015). Hypoxaemia during COVID-19 illness was more common in controls than cases. The mean serum iron values (33 vs. 45 μg/dl, p = .03) and TIBC (166.6 vs. 201.6 μg/dl, p = .003) were significantly lower in CAM cases than controls. On multivariate analysis, we found a lower TIBC (odds ratio [OR] 0.97; 95% confidence interval [CI], 0.95-0.99) and diabetes mellitus (OR 5.23; 95% CI, 1.21-22.68) to be independently associated with CAM after adjusting for serum iron, ferritin and glucocorticoid therapy. The case fatality rate of CAM was 73.9%. The iron indices were not significantly different between CAM survivors and non-survivors. CONCLUSIONS The CAM is associated with lower TIBC levels than COVID-19 subjects without mucormycosis, suggesting dysregulated iron metabolism in its pathogenesis. Further studies are required to confirm our preliminary observations.
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Affiliation(s)
- Mohan Kumar H
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Prashant Sharma
- Department of Hematology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Reena Das
- Department of Hematology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Naresh K Panda
- Department of Otolaryngology and Head and Neck Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Yadav BK, Pannu AK, Kumar R, Rohilla M, Kumari S. Fever of Unknown Origin in Older Adults: A Prospective Observational Study from North India. J Assoc Physicians India 2021; 69:11-12. [PMID: 34781653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Fever of unknown origin (FUO) has different etiology in different age groups. We aimed to determine the spectrum of FUO in older patients and to establish the underlying etiology. METHODS This was a hospital-based prospective observational study conducted between January 2018 to June 2019 at Postgraduate Institute of Medical Education and Research, Chandigarh, India. Fifty-one consecutive patients aged 60 years and above met the qualitative criteria of FUO. RESULTS The etiological distribution was infections in 21 patients (41.2%), malignancies in 16 (31.4%) and noninfectious inflammatory disorders in 8 (15.7%). Six patients (11.8%) remained undiagnosed. Among infections, 15 patients (29.4%) had tuberculosis, and 10 had an extrapulmonary disease. Twelve out of 16 cases with malignancies had a hematological cause, and eight had lymphoma. ;Regarding decisive methods of diagnosis, 18F-fluorodeoxyglucose positron emission tomography was diagnostic in 17 out of 27 patients (63%) and computed tomography in 21 out of 42 cases (50%). Imaging or endoscopy-guided procedures provided a diagnostic clue in 12 out of 14 patients (85.7%), and bone marrow examination results were useful in 9 out of 19 (47.4%). CONCLUSIONS Infections and malignancies contributed to about three-fourths of cases, with tuberculosis and lymphoma being the commonest etiologies.
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Affiliation(s)
- Bipin Kumar Yadav
- Resident, Post Graduate Institute of Medical Education and Research, Chandigarh
| | | | - Rajender Kumar
- Assistant Professor, Post Graduate Institute of Medical Education and Research, Chandigarh
| | - Manish Rohilla
- Assistant Professor, Post Graduate Institute of Medical Education and Research, Chandigarh
| | - Savita Kumari
- Professor, Post Graduate Institute of Medical Education and Research, Chandigarh
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Muthu V, Kumar M, Paul RA, Zohmangaihi D, Choudhary H, Rudramurthy SM, Panda NK, Pannu AK, Sharma N, Sharma S, Chakrabarti A, Agarwal R. Is there an association between zinc and COVID-19-associated mucormycosis? Results of an experimental and clinical study. Mycoses 2021; 64:1291-1297. [PMID: 34420245 PMCID: PMC8661931 DOI: 10.1111/myc.13365] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The enormous increase in COVID-19-associated mucormycosis (CAM) in India lacks an explanation. Zinc supplementation during COVID-19 management is speculated as a contributor to mucormycosis. We conducted an experimental and clinical study to explore the association of zinc and mucormycosis. METHODS We inoculated pure isolates of Rhizopus arrhizus obtained from subjects with CAM on dichloran rose Bengal chloramphenicol (DRBC) agar enriched with (three different concentrations) and without zinc. At 24 h, we counted the viable colonies and measured the dry weight of colonies at 24, 48 and 72 h. We also compared the clinical features and serum zinc levels in 29 CAM cases and 28 COVID-19 subjects without mucormycosis (controls). RESULTS We tested eight isolates of R arrhizus and noted a visible increase in growth in zinc-enriched media. A viable count percentage showed a significantly increased growth in four of the eight isolates in zinc-augmented DRBC agar. A time- and concentration-dependent increase in the mean fungal biomass with zinc was observed in all three isolates tested. We enrolled 29 cases of CAM and 28 controls. The mean serum zinc concentration was below the reference range in all the subjects and was not significantly different between the cases and controls. CONCLUSIONS Half of the R arrhizus isolates grew better with zinc enrichment in vitro. However, our study does not conclusively support the hypothesis that zinc supplementation contributed to the pathogenesis of mucormycosis. More data, both in vitro and in vivo, may resolve the role of zinc in the pathogenesis of CAM.
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Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary MedicinePost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Mohan Kumar
- Department of Internal MedicinePost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Raees A. Paul
- Department of Medical MicrobiologyPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Deepy Zohmangaihi
- Department of BiochemistryPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Hansraj Choudhary
- Department of Medical MicrobiologyPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | | | - Naresh K. Panda
- Department of Otolaryngology and Head and Neck SurgeryPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Ashok Kumar Pannu
- Department of Internal MedicinePost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Navneet Sharma
- Department of Internal MedicinePost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Sadhna Sharma
- Department of BiochemistryPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Arunaloke Chakrabarti
- Department of Medical MicrobiologyPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Ritesh Agarwal
- Department of Pulmonary MedicinePost Graduate Institute of Medical Education and ResearchChandigarhIndia
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Pannu AK, Jangpangi G, Chhabria B, Suri V, Bhalla A, Kumari S. Acute febrile illness with choreoathetosis: a rare presentation of brucellosis. Postgrad Med J 2021; 98:e25-e26. [PMID: 37066559 DOI: 10.1136/postgradmedj-2021-140351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/21/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Ashok Kumar Pannu
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gauri Jangpangi
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Bharath Chhabria
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Suri
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Savita Kumari
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Saini MK, Kumar H, Saini K, Behera A, Pannu AK, Soundappan K, Kumar H M. Impact of lockdown on medical emergency visits during the COVID-19 pandemic in India. Postgrad Med J 2021; 98:e112-e114. [PMID: 37066539 DOI: 10.1136/postgradmedj-2021-140850] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Mandeep Kaur Saini
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Hemendra Kumar
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Komal Saini
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Behera
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar Pannu
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kathirvel Soundappan
- Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mohan Kumar H
- Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Jindal A, Suresh S, Dhakal P, Pannu AK. Hyperkalaemia and cardiac conduction block: an initial presentation of chronic kidney disease mimicking cardiac emergency. BMJ Case Rep 2021; 14:e245019. [PMID: 34479902 PMCID: PMC8420690 DOI: 10.1136/bcr-2021-245019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 11/03/2022] Open
Affiliation(s)
- Ashish Jindal
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Selvam Suresh
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Prashiddha Dhakal
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Pal S, Sharma N, Singh SM, Kumar S, Pannu AK. A prospective cohort study on predictors of mortality of delirium in an emergency observational unit. QJM 2021; 114:246-251. [PMID: 32483589 DOI: 10.1093/qjmed/hcaa183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/16/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Delirium is often an underdiagnosed and underestimated neuropsychiatric syndrome, especially in low- and middle-income countries. AIM To document the prevalence and clinical profile of delirium and to detect the baseline parameters associated with in-hospital mortality. DESIGN A prospective cohort study conducted between January 2016 to December 2016 at an adult medical emergency observational unit of an academic hospital in north India. METHODS Confusion Assessment Method for the intensive care unit was used for screening and diagnosis of delirium. Subtypes of delirium and severity were defined with the Richmond agitation-sedation scale and Delirium Rating Scale-Revised-98 (DRS-R-98). RESULTS Out of 939 screened patients, 312 (33.2%) had delirium, including 73.7% unrecognized cases. The mean age was 49.1 ± 17.3 years (range 17-90), and only 33.3% of the patients were above 60 years. The prevalence of hypoactive, mixed and hyperactive delirium was 39.1, 33.7 and 27.2%, respectively. Usual predisposing factors were alcohol use disorder (57.4%) and hypertension (51.0%), and infections remain the most common precipitating factors (42.0%). In total, 96.1% of patients received midazolam before delirium onset, and physical restraints were used in 73.4%. Mortality was higher in delirium (19.9% vs. 6.4%). The independent predictors of death in delirium were low diastolic blood pressure (P-value = 0.000), Glasgow coma scale score <15 (P = 0.026), high Acute Physiology and Chronic Health Evaluation II score (P = 0.007), high DRS-R-98 severity score (P = 0.000) and hyperactive delirium (P = 0.024). CONCLUSION Rapid screening with Confusion Assessment Method for the intensive care unit detected a high prevalence of delirium (even in young patients), and it associated with high mortality.
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Affiliation(s)
- S Pal
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
| | - N Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
| | - S M Singh
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, 3rd Floor, Cobalt Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
| | - S Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
| | - A K Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, Sector 12, Chandigarh, India (160012)
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Affiliation(s)
- Navneet Arora
- Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Devender Kumar
- Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ravindran Kiran
- Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar Pannu
- Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Rahman N, Yadav R, Sethi S, Saroch A, Behera A, Bhalla A, Garg M, Pannu AK. Clinical spectrum and outcomes of geriatric tuberculosis emergencies in North India. Turk J Emerg Med 2021; 21:91-97. [PMID: 34377864 PMCID: PMC8330606 DOI: 10.4103/2452-2473.320800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/28/2020] [Accepted: 10/27/2020] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES: Despite the acute and life-threatening repercussions that tuberculosis (TB) may have on the burgeoning older population in endemic countries like India, the spectrum of geriatric TB emergencies is not adequately understood. METHODS: We performed a prospective observational study at the emergency department of an academic hospital in north India between January 2019 and June 2020, investigating the clinical and laboratory features and outcomes of active TB in older patients aged 60 years and above. RESULTS: Out of 71 geriatric TB emergencies, central nervous system disease predominated (n = 41, 57.7%), followed by pulmonary (n = 16, 22.5%), pleural TB (n = 8, 11.3%), and multisite involvement (n = 6, 8.4%). Nearly 71.8% were male, and 77.4% belonged to low socioeconomic status (lower-middle or lower class). Usual predisposing factors were tobacco smoking (38.0%), chronic alcohol use (27.0%), and diabetes mellitus (23.9%). Atypical features were more frequent with extrapulmonary TB. Only 28.2% were microbiologically confirmed cases, and rifampicin resistance was seen in only one case. The mortality rate was considerably high (24.0%), highest with pulmonary TB (37.0%). CONCLUSION: Older patients with TB emergencies have atypical presentations, diagnostic difficulties, and high mortality.
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Affiliation(s)
- Nadim Rahman
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Rakesh Yadav
- Department of Medical Microbiology, Postgraduate Institute of Medical Educationand Research, Chandigarh, India
| | - Sunil Sethi
- Department of Medical Microbiology, Postgraduate Institute of Medical Educationand Research, Chandigarh, India
| | - Atul Saroch
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Ashish Behera
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
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Bolla T, Kanneganti V, Aggarwal T, Singh S, Chaudhary S, Pannu AK. Fire-breather's lung: hydrocarbon pneumonitis. Postgrad Med J 2021; 98:e50. [PMID: 37066578 DOI: 10.1136/postgradmedj-2021-140543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/30/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Tukaram Bolla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vineetha Kanneganti
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Tanushi Aggarwal
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shubham Singh
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Swapnil Chaudhary
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Pannu AK, Bhalla A, Vishnu RI, Garg S, Dhibar DP, Sharma N, Vijayvergiya R. Cardiac injury in organophosphate poisoning after acute ingestion. Toxicol Res (Camb) 2021; 10:446-452. [PMID: 34141158 DOI: 10.1093/toxres/tfab036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Sparse data and conflicting evidence exist on the prevalence and prognosis of organophosphate (OP)-related cardiac toxicity. We aimed to characterize the cardiac abnormalities of OP after an acute cholinergic crisis in adults without previous cardiovascular conditions. Patients and Methods We did a prospective observational study in a tertiary-care hospital of north India (Postgraduate Institute of Medical Education and Research, Chandigarh) in 74 patients aged ≥ 13 years admitted with acute OP poisoning after self-ingestion. A systemic evaluation, including clinical characteristics, electrocardiography, and echocardiography, was performed to estimate the prevalence and prognosis of cardiac injury. A rate-corrected QT interval was calculated using Bazett's method, and >440 milliseconds was used to define prolongation. Results Chlorpyrifos was the most commonly ingested OP (n = 29). The patients had a similar occurrence of hypotension (n = 10) and hypertension (n = 9) at admission, and electrocardiography demonstrated sinus tachycardia in 38 (51.3%) and sinus bradycardia in one case. During the hospital stay, 3 out of 74 patients had a prolonged rate-corrected QT interval (457, 468, and 461 milliseconds), and one patient developed supraventricular tachycardia. Eight (10.8%) patients developed the intermediate syndrome, and six (8.1%) died. None of the hemodynamic or electrocardiographic abnormalities was associated with in-hospital mortality or intermediate syndrome development on univariant analysis. Baseline echocardiography at hospital discharge was performed in 27 patients (admitted during 2018) and normal in all except mild tricuspid regurgitation in one. At a 6-month follow-up, 23 cases were available for cardiovascular screening (including echocardiography) and had a normal evaluation. Conclusion Cardiac toxicity is uncommon after acute OP self-ingestion and lacks prognostic significance.
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Affiliation(s)
- Ashok Kumar Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - R I Vishnu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - Sahil Garg
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - Deba Prasad Dhibar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, 4th Floor, F Block, Nehru Hospital, PGIMER, Chandigarh 160012, India
| | - Rajesh Vijayvergiya
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, 3rd Floor, Block - C, Advanced Cardiac Center, PGIMER, Chandigarh 160012, India
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Pannu AK, Sharma R, Sharma N, Kaur J, Walia R, Kumar S. Stewart (physicochemical) approach versus conventional anion gap approach for resolution of metabolic acidosis in diabetic ketoacidosis. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-021-00927-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Pannu AK, Bhalla A, Vishnu RI, Dhibar DP, Sharma N, Vijayvergiya R. Organophosphate induced delayed neuropathy after an acute cholinergic crisis in self-poisoning. Clin Toxicol (Phila) 2020; 59:488-492. [PMID: 33078989 DOI: 10.1080/15563650.2020.1832233] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Despite organophosphate pesticide is the most prevalent cause of acute poisoning in low- and middle-income countries, data on organophosphate induced delayed neuropathy (OPIDN) are limited. We aimed to characterize organophosphates' long-term effects on the peripheral nervous system after an acute cholinergic crisis in adults. METHODS We performed a prospective observational study in an academic hospital of north India in patients aged 13-40 years with acute organophosphate ingestion. After resolving the cholinergic crisis, the patients were followed for six months with neurologic assessments, including history, neurologic examination, and nerve conduction study (NCS). RESULTS Twenty-three patients were recruited to the study. All but one had normal neurological examination and NCS at discharge from hospital a median duration of six days (interquartile range, 3-10) after self-poisoning. Eight (34.8%) developed OPIDN during the six-month follow-up. Three patients had symptomatic neuropathy, and NCS detected subclinical peripheral nerve involvement in five. All cases were associated with chlorpyrifos ingestion (8/17 total chlorpyrifos cases). Two OPIDN cases had foot drop and gait ataxia at three-month which persist at six-month. One patient had distal paresthesia at three months, which improved at a six-month follow-up. NCS in OPIDN cases invariably revealed axonal degeneration, injury to motor fibers more than sensory fibers, and frequent peroneal nerve involvement. None of the baseline characteristics, including the ingested amount, predicted clinical or subclinical OPIDN in chlorpyrifos self-poisoned patients on a univariant analysis. CONCLUSION Peripheral nerve involvement is not uncommon after recovery from a cholinergic crisis in chlorpyrifos self-poisoning and debilitating in some patients. Detection of subclinical injury on NCS may provide an early window to prevent severe symptomatic neuropathy.
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Affiliation(s)
- A K Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - A Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R I Vishnu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - D P Dhibar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - N Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R Vijayvergiya
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kumar D, Pannu AK, Dhibar DP, Singh R, Kumari S. The epidemiology and clinical spectrum of infections of the central nervous system in adults in north India. Trop Doct 2020; 51:48-57. [PMID: 33019910 DOI: 10.1177/0049475520959905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Infections of the central nervous system (CNS) are a leading cause of mortality in low- and middle-income countries. We studied the spectrum, aetiology and outcome of CNS infections in 401 consecutive patients aged ≥12 years admitted at the medical emergency centre of PGIMER, Chandigarh, India. An aetiological diagnosis was made in 365 (91.0%) patients, with 149 (40.8%) microbiologically confirmed cases. CNS tuberculosis was the most prevalent cause (51.5%), followed by viral meningoencephalitis (13.9%), community-acquired bacterial meningitis (9.7%), cryptococcal meningitis (6.2%), scrub typhus meningoencephalitis (1.7%), neurocysticercosis (1.7%) and fungal brain abscess (1.7%). Human immunodeficiency virus (11.0%) and diabetes mellitus (6.2%) remained the usual predisposing conditions. We found a mortality rate of 27.9%, highest in cases without an aetiology (64.5%). Tuberculosis remained the most common cause; however, an increasing number of scrub typhus, dengue, fungal infections and non-classical bacterial pathogens may indicate a change in the epidemiology of community-acquired CNS infections in India.
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Affiliation(s)
- Devender Kumar
- Resident, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Ashok Kumar Pannu
- Assistant Professor, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Deba Prasad Dhibar
- Assistant Professor, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Rajveer Singh
- Assistant Professor, Department of Neurology, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
| | - Savita Kumari
- Professor and Head, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India
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