Diagnostic Accuracy of Drop Hydrogen Peroxide Test as a Novel Bedside Diagnostic Test to Differentiate Transudative and Exudative Pleural Effusion Against Light's Criteria

Background Diagnostic evaluation of pleural fluid according to Light's criteria to differentiate between exudative and transudative fluid takes 1 or 2 working days. For rapid clinical management, especially in critically ill patients, a simpler bedside diagnostic test can be done which has similar diagnostic accuracy as that of Light's Criteria. Objective To determine the diagnostic accuracy of Drop Hydrogen Peroxide test to differentiate exudative and transudative pleural effusion in comparison to Light's criteria. Method A concurrent validity test was performed using a convenient sampling technique including patients presenting to the Department of Internal Medicine from January to September 2021, who had pleural effusion. Two milliliters of tapped pleural fluid of patients who underwent aseptic thoracocentesis was collected in a test tube to which one to two drops of 20% hydrogen peroxide was added. Presence of bubbles suggested an exudative type of fluid. Rest of the tapped pleural fluid was sent to the laboratory for further evaluation by Light's criteria, which was compared with the results by Drop Hydrogen Peroxide Test. Result There were 83 patients who had pleural effusion, of them a total of 43 patients had transudative pleural effusion while 40 patients had exudative pleural effusion based on Light's criteria and 37 patients had transudative pleural effusion while 46 patients had exudative pleural effusion based on drop hydrogen peroxide test. Conclusion The drop hydrogen peroxide test allows cost effective and prompt evaluation of the type of pleural effusion is exudative or transudative, thereby making it a convenient diagnostic bedside test.

Urinary B cell activating factor (BAFF) and a proliferation-inducing ligand (APRIL): potential biomarkers of active lupus nephritis

B cell activating factor (BAFF) and a proliferation-inducing ligand (APRIL) help in B cell activation, maintenance and plasma cell survival. B cell infiltration has been demonstrated in kidneys of patients with lupus nephritis (LN). Serum levels of BAFF and APRIL have shown inconsistent relationships with lupus disease activity. We evaluated urinary levels of BAFF and APRIL as biomarker for LN. Thirty-six patients with proliferative lupus nephritis (AN), 10 with active lupus without nephritis (AL) and 15 healthy controls (HC) were studied. APRIL and BAFF levels were measured in both serum and urine using enzyme-linked immunosorbent assay (ELISA). Urine levels were normalized for urinary creatinine excretion. Urine levels were correlated with conventional disease activity markers and histology. Levels were reassessed in 20 AN patients at 6 months after treatment with cyclophosphamide. Urinary APRIL (uAPRIL) and BAFF (uBAFF) levels were raised significantly in AN. uAPRIL, but not uBAFF, correlated moderately with renal Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) in AN (r = 0·36, P < 0·05). On receiver operator curve (ROC) analysis, uBAFF and uAPRIL showed an area under the curve (AUC) of 0·825 and 0·781, respectively, in differentiating between nephritis and non-nephritis, which performed better than low C3, C4 and raised anti-dsDNA antibodies. There was no correlation of serum levels with uBAFF (r = 0·187, P = 0·261) and uAPRIL (r = 0·114, P = 0·494). uAPRIL levels reduced after treatment (mean 125 pg/mg to 36 pg/mg, P < 0·05). uBAFF levels reduced in 16 responders while two of four non-responders had increase in levels. Thus, uBAFF and uAPRIL are potential biomarkers of proliferative lupus nephritis.

Recombinant Salmonella typhimurium outer membrane protein A is recognized by synovial fluid CD8 cells and stimulates synovial fluid mononuclear cells to produce interleukin (IL)-17/IL-23 in patients with reactive arthritis and undifferentiated spondyloarthropathy

In developing countries, one-third of patients with reactive arthritis (ReA) and undifferentiated spondyloarthropathy (uSpA) are triggered by Salmonella typhimurium. Synovial fluid mononuclear cells (SFMCs) of patients with ReA and uSpA proliferate to low molecular weight fractions (lmwf) of outer membrane proteins (Omp) of S. typhimurium. To characterize further the immunity of Omp of Salmonella, cellular immune response to two recombinant proteins of lmwf, OmpA and OmpD of S. typhimurium (rOmpA/D-sal) was assessed in 30 patients with ReA/uSpA. Using flow cytometry, 17 of 30 patients' SF CD8(+) T cells showed significant intracellular interferon (IFN)-γ to Omp crude lysate of S. typhimurium. Of these 17, 11 showed significantly more CD8(+) CD69(+) IFN-γ T cells to rOmpA-sal, whereas only four showed reactivity to rOmpD-sal. The mean stimulation index was significantly greater in rOmpA-sal than rOmpD-sal [3·0 (1·5-6·5) versus 1·5 (1·0-2·75), P < 0·005]. Similarly, using enzyme-linked immunospot (ELISPOT) in these 17 patients, the mean spots of IFN-γ-producing SFMCs were significantly greater in rOmpA-sal than rOmpD-sal [44·9 (3·5-130·7) versus 19·25 (6-41), P < 0·05]. SFMCs stimulated by rOmpA-sal produced significantly more proinflammatory cytokines than rOmpD-sal: IFN-γ [1·44 (0·39-20·42) versus 0·72 (0·048-9·15) ng/ml, P < 0·05], interleukin (IL)-17 [28·60 (6·15-510·86) versus 11·84 (6·83-252·62) pg/ml, P < 0·05], IL-23 [70·19 (15-1161·16) versus 28·25 (> 15-241·52) pg/ml, P < 0·05] and IL-6 [59·78 (2·03-273·36) versus 10·17 (0·004-190·19) ng/ml, P < 0·05]. The rOmpA-sal-specific CD8(+) T cell response correlated with duration of current synovitis (r = 0·53, P < 0·05). Thus, OmpA of S. typhimurium is a target of SF CD8(+) T cells and drives SFMC to produce increased cytokines of the IL-17/IL-23 axis which contribute to the pathogenesis of Salmonella-triggered ReA.

Unusual extensive physiologic melanin pigmentation of the oral cavity: a clinical presentation

Pigmented lesions are commonly found in the oral cavity. Oral pigmentations may be physiological or pathological in nature. It may represent as a localized anomaly of limited significance or the presentation of potentially life threatening multisystem disease. Oral pigmentation has a multifactorial etiology. Most of the oral pigmentations are physiologic. Evaluation of a patient with pigmented lesions should include a full medical and dental history, extraoral and intraoral examinations. In this article, we report a case of extensive physiologic pigmentation of the oral cavity in a 12 year old female patient, posing a diagnostic challenge.

Endothelial keratoplasty in the management of irido-corneal endothelial syndrome

PURPOSE

To describe the results of endothelial keratoplasty (EK) in the management of irido-corneal endothelial (ICE) syndrome.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

Eight eyes of seven patients underwent EK for corneal edema owing to ICE syndrome. Simultaneous cataract surgery was performed in five eyes. The charts were reviewed for demographics, clinical findings, and outcomes after EK.

RESULTS

Mean age was 50.4 years (range 35-59 years). Mean follow-up was 12.5 months (range 6-24 months). Corneal clarity was restored in all eyes and was maintained till the last follow-up. Four patients had acute rise in the intraocular pressure in the post-operative period, which was well controlled on medical treatment. One patient who was non-compliant with medications and regular follow-up advice had progression of glaucomatous disc changes and visual field loss. The best-corrected visual acuity ranged from 20/50-20/30.

CONCLUSIONS

EK is a viable option in ICE syndrome. Adequate control of glaucoma is the paramount factor in maintaining good visual acuity in these eyes.

Interaction of Strychnos nux-vomica-products and iron: with reference to lipid peroxidation

In this paper, it has been investigated that strychnine, the major active principle in the alcoholic extract of the seeds of Strychnos nux-vomica, is responsible for its antilipid peroxidative property. The mechanism of action of this drug is through the chelation of the free iron in the system. It has also been observed that strychnine does not have any pro-oxidant-property, because it does not convert Fe3+ to Fe2+ and vice versa in the reaction system, as has been observed with several other antioxidants.

Bacopa monniera Linn. as an antioxidant: mechanism of action

Bacopa monniera, Linn. (Brahmi: Scrophulariaceae) an Ayurvedic medicine is clinically used for memory enhancing, epilepsy, insomnia and as mild sedative. For the first time the effect of alcohol and hexane fraction of Brahmi has been studied on FeSO4 and cumene hydroperoxide induced lipid peroxidation. Alcohol fraction showed greater protection with both inducers. Results were compared with known antioxidants tris, EDTA and a natural-antioxidant vitamin E. The effect of Brahmi was also examined on hepatic glutathione content. The mechanism of action could be through metal chelation at the initiation level and also as chain breaker. The results suggested that Brahmi is a potent antioxidant. The response of Brahmi was dose dependent. Tris, an hydroxyl trapper did not show any protection in comparison to Brahmi where as EDTA and vitamin E did protect against FeSO4. In experimental conditions 100 micrograms Brahmi extract (alcoholic) was equivalent to 247 micrograms of EDTA (0.66 microM) and 58 micrograms of vitamin E. Interestingly Brahmi only slightly protected the autooxidation and FeSO4 induced oxidation of reduced glutathione on lower doses 100 micrograms/ml and below, but on higher concentrations it enhanced the rate of oxidation.

Antioxidant and anti-inflammatory property of Sandhika: a compound herbal drug

The present study was envisaged to assess the rationality for the use of "Sandhika", a popular Ayurvedic drug in rheumatoid arthritis. This drug, when tested against carrageenan induced paw oedema and cotton pellet granuloma, showed significant anti-inflammatory activity at the dose of 0.25 g/kg body weight. The antioxidant property was assessed by determining cumene hydroperoxide (CHP) induced lipid peroxidation and reduced glutathione content in rat liver homogenate (in vitro). Experiments show the significant protection against lipid peroxidation at the dose of 80 micrograms/ml, measured as reduction in the level of malondialdehyde (MDA) induced by 1.5 mM cumene hydroperoxide (CHP). This effect was accompanied by the maintained reduced glutathione (GSH) content in drug treated rats. Oral treatment of drug up to 2 g/kg body weight for 15 days did not show any rise in serum transaminases (SGOT and SGPT). The results suggest that "Sandhika" which is an indigenous drug for inflammation with no detectable adverse effect, might be acting through scavenging the free radicals.

Comparative study of Inula Racemosa and Saussurea Lappa on the glucose level in Albino rats

Inula racemosa and Saussurea lappa have been used in ayurvedic system for the management of diabetes. The result of this communication concludes that I. racemosa reduces the blood glucose earlier as compared to S. lappa. Maximum response in case of I. racemosa is noted between 2 to 4 hours after drug administration while for S. lappa while for S. lappa, it is 4 to 8 hours. S. lappa can be used as substitute for I. racemosa for the management of diabetes, but it should not be taken for granted that this substitution should be applicable to all other systems, where I. racemosa has been recommended as a drug of choice.