Role of Combined CT Pulmonary Angiography and Indirect CT Venography in Diagnosing Venous Thromboembolism in COVID-19 Patients - Experience From an Indian Quaternary Centre

OBJECTIVES

To study the role of combined CTPA and indirect CT venogram to diagnose venous thromboembolism (VTE) in patients with COVID-19 pneumonia and to compare the clinical characteristics, laboratory parameters, CT findings and clinical outcomes between the VTE positive and negative groups.

METHODS

In this retrospective study, 131 patients with COVID-19 pneumonia who underwent CTPA and venogram between August 2020 and January 2021 were included. Relevant demographical, clinical and laboratory data and CT images were collected. Two thoracic radiologists independently reviewed the CTPA and venogram images.

RESULTS

VTE was identified in 29 patients (22% of the study population). CT venogram identified DVT in 9 patients. No statistical difference was observed between the two groups with respect to age, gender, BMI and presence of comorbidities. There was a significant difference in the hospital stay duration, which is increased in the VTE positive group. The number of patients who were dependent on oxygen and mortality were also high in the positive group. There was statistically significant difference in the mean D-dimer value and the mean Neutrophil/lymphocyte ratio, which were higher in the VTE positive group.

CONCLUSION

Combined CTPA and venogram can be used as a one-stop investigation for diagnosing PE and DVT of lower limbs in patients with COVID-19 pneumonia. CTPA with venogram should be performed in patients with D-dimer value in the range of 1000 - 1200 μg/L and above to rule out VTE as the hospital stay duration and final outcomes vary between the positive and negative groups.

Newly proposed classification of celiac artery variations based on embryology and correlation with computed tomography angiography

PURPOSE

We studied the prevalence of celiac trunk and its anatomical variations on diagnostic computed tomography angiography (CTA) studies and have proposed a new classification to define the celiac artery (CA) variations based on embryology.

MATERIAL AND METHODS

We retrospectively assessed the celiac trunk variations in 1113 patients who came to our department for diagnostic CTA for liver and renal donor workup. The patient data were acquired from the Picture Archiving and Communication System of our institutions. We analysed the celiac trunk's origin and branching pattern, including the superior mesenteric artery (SMA) and inferior phrenic artery (IPA).

RESULTS

We evaluated the CTA studies of 1050 patients. A normal trifurcation pattern, the most common type, was observed in 39% of cases. Variation with CA + left IPA was the most common subtype. Other variations noted in the study and their incidences are listed in the table below. We attempted to propose a new classification based on embryo-logy, which comprises 6 main types and their subtypes. We also analysed previous studies from the literature, including cadaveric, post-mortem, CTA, and digital subtraction angiography studies and compared them with the present study.

CONCLUSIONS

Because variations of CA classifications reported to date do not encompass all CA branching pattern variants, we have proposed a new classification that incorporates most of the variants. We reiterate the clinical importance of anatomical variants of CA, IPA, and SMA in surgical and interventional radiology procedures.

Salmonella Bacteremia Causing Mycotic Pseudoaneurysm of Right Common Iliac Artery Complicated by Septic Caval Thrombosis

Mycotic pseudoaneurysm (MPA) is a blind, saccular outpouching of the arterial lumen of infective origin. MPA is a rare life-threatening condition and if not treated early, has a 67% mortality rate due to sepsis and hemorrhage. Major predisposing factors are diabetes mellitus, chronic renal failure, malignancy, steroids, and intravenous drug use. Imaging modalities include Doppler ultrasound, contrast-enhanced computed tomography, and digital subtraction angiography. We report a unique case of Salmonella bacteremia-related MPA of the right common iliac artery complicated by septic inferior vena cava (IVC) thrombosis in a patient with uncontrolled diabetes. Such transcompartmental involvement of IVC has hitherto not been described in the literature and hence makes for interesting documentation. This case ponders upon the aggressiveness of the invasive nontyphoidal Salmonella infection pathogen and the need for early imaging of suspicious patients to reduce morbidity and mortality.

Tacrolimus-induced Central Pontine Myelinolysis in a Pediatric Liver Transplant Recipient

Central pontine myelinolysis (CPM) is a rare neurological complication reported in liver transplant recipients. A 16-year-old boy with Wilson disease underwent a living donor liver transplant for acute-on-chronic liver failure. On postoperative day 7, he was noted to have diplopia, dysphagia, and bilateral lower limb weakness with wide base gait with gradual progression to akinetic mutism. Magnetic resonance imaging (MRI) brain was performed which was suggestive of CPM, and it was attributed to tacrolimus. We stopped tacrolimus, and he was started on ciclosporin. His neurological symptoms started improving after 72 hours and he had a complete clinical recovery by 6 weeks. Repeat MRI brain at 16 weeks after liver transplantation showed complete radiological resolution of the pontine lesion.

COVID-19 Associated Acute Necrotizing Pancreatitis with Normal Serum Amylase and Lipase Levels: Report of an Unusual Finding

Coronaviruses are a large family of single-stranded RNA viruses infecting humans and animals, causing a multitude of symptoms. COVID-19 is not only known to affect the respiratory system, but shows unusual gastrointestinal complications. Pancreatitis can be caused by biliary stones, alcohol abuse, viruses, drug intake, metabolic syndromes, or trauma. Diagnosis of acute pancreatitis requires any two of the three criteria: acute onset of severe upper abdominal pain, consistent with pancreatitis; elevation of serum amylase or lipase, three times the upper limit of normal; and/or characteristic imaging findings. COVID-19 associated pancreatitis is thought to be mediated by the angiotensin-converting enzyme-2 receptor on the host cells, which are highly expressed in the pancreatic cells. Here, we report a unique case of acute necrotizing pancreatitis caused by COVID-19 with hyperglycemia and normal amylase and lipase levels.

Optimal diagnostic tool for surveillance of oesophageal varices during COVID-19 pandemic

AIM

To study the diagnostic accuracy and utility of triphasic abdominal computed tomography (CT) in the diagnosis and grading of oesophageal varices (OVs) as an alternative to endoscopy during the COVID-19 pandemic.

MATERIALS AND METHODS

A prospective analysis was undertaken of retrospective data from cirrhotic patients who underwent oesophago-gastro-duodenoscopy (OGD) and a triphasic abdominal CT from January to December 2019. Endoscopists and radiologists provided their respective independent assessment of OV grading after being blinded to the clinical details. Performance of CT grading of OVs was compared with the reference standard endoscopic grading using weighted kappa (k). Non-invasive scores such, as aspartate transaminase (AST)-to-platelet ratio index (APRI), Fibrosis-4 (FIB-4) Index, platelet: spleen (PS) ratio were correlated between the two techniques.

RESULTS

OV grading between endoscopists and radiologists showed 81.73% agreement (85 out of 104 patients) in the comparative analysis of 104 cirrhotic patients, of which no varices (57.1%, n=4), small (85.1%, n=23), medium (72.2%%, n=26), and large varices (94.1%, n=32) with a weighted k score of 0.88 (95% confidence interval 0.82-0.94). Overall, the sensitivity of CT in the diagnosis of no, small, medium, and large OVs was 66.6%, 79.3%, 89.6%, and 94.1%, respectively, with an area under the receiver operating curve (AUROC) score of 0.775, 0.887, 0.839, and 0.914. Performance of APRI, FIB-4, and PS ratio correlated well with the severity of OVs with no difference between OGD and CT grading.

CONCLUSION

Triphasic abdominal CT can be an invaluable tool in the diagnosis and grading of OVs during the COVID-19 pandemic.

Systemic arterio-venous thrombosis in COVID-19: A pictorial review

Coronavirus disease 2019 (COVID-19) is caused by the novel coronavirus severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Systemic complications include cardiovascular, neurological, hepatic, renal and altered coagulation. Derangements in haemostasis with SARS-CoV-2 infection have been termed COVID-19 associated coagulopathy (CAC). CAC is postulated to be one of the significant causes for sudden deaths in this pandemic, with infection of endothelial cells and subsequent endotheliitis through angiotensin-converting enzyme-2 receptors playing a key role in the pathogenesis. In this pictorial review, we describe the imaging findings in a multitude of extrapulmonary arterial (aorta, cerebral, mesenteric, renal and peripheral arterial system) and venous thrombotic phenomena detected on contrast-enhanced computed tomography and magnetic resonance imaging of COVID-19 patients which could not be attributed to any other causes. Knowledge of incidence of these complications, lowering the threshold for diagnostic imaging in symptomatic patients and timely radiological detection can play a vital role in subsequent management of these critically ill patients.

High frequency of occupied attB regions in Norwegian Staphylococcus aureus isolates supports a two-step MRSA screening algorithm

Rapid nucleic acid amplification tests for methicillin-resistant Staphylococcus aureus (MRSA) diagnostics commonly target the mec resistance gene, genes specific for S. aureus, and the integration site for the SCCmec resistance cassette, orfX. Due to poor specificity when these target genes are used individually, additional culture is required to verify positive results. The combination of these targets is useful, but the optimal algorithm may depend on the presence of the genetic markers in S. aureus isolates, as well as the prevalence of MRSA in a population. The aim of the present study was to identify a rapid, low-cost, and functional screening algorithm in order to reduce the response time for MRSA diagnostics. An in-house orfX-SCCmec polymerase chain reaction (PCR) assay was established and evaluated. The results were compared with an existing mec/nuc PCR assay and traditional culture. Methicillin-sensitive S. aureus (MSSA) that tested false-positive in the orfX-SCCmec PCR assay were further investigated with full genome sequencing using the Ion PGM™ System to verify results and causality. Based on these data, a two-step screening algorithm with initial mec/nuc PCR followed by orfX-SCCmec PCR on positive samples was suggested and tested on 1443 patient samples. 22.5 % of MSSA isolates tested false-positive with the orfX-SCCmec PCR. Full genome sequencing of these isolates identified genetic variation in the attB region of S. aureus, including empty cassette variants and non-mec SCC. The suggested two-step MRSA screening algorithm allowed us to report MRSA results for 95.6 % of all samples and 99 % of MRSA-negative samples after one day.

Biosynthesis and Characterization of Titanium Dioxide Nanoparticles Using Pithecellobium Dulce and Lagenaria Siceraria Aqueous Leaf Extract and Screening their Free Radical Scavenging and Antibacterial Properties

The recent development and implementation of new technologies have led to new era, the nanorevolution which unfolds role of plants in bio and green synthesis of nanoparticles which seem to have drawn quite an unequivocal attention with a view of synthesizing stable nanoparticles. In this present work, we have compared titanium dioxide nanocrystals synthesized by both chemical method and biological method from Titanium tetra isopropoxide as precursor. The biological method was performed by using the aqueous plant extract of Pithecellobium dulce and Lagenaria siceraria. The synthesized nanocrystals were characterized by FTIR Spectroscopy, Scanning Electron Microscopy (SEM), Energy Dispersive Xray (EDAX), Transmission Electron Microscope (TEM) and X-ray diffraction (XRD) techniques and also Antioxidant assay and antimicrobial test were performed to evaluate its biological behaviour. The nanocrystals synthesized by biological method were found to have higher antioxidant potential, antimicrobial activity than chemically synthesized.

Stigma of mental illness: An interventional study to reduce its impact in the community

BACKGROUND

Research literature has documented the nature of stigma associated with mental illness (MI) and its consequences in all spheres of life of ill persons and their families. It is also suggested that there is a need to develop intervention strategies to reduce stigma. However, very little is reported about these initiatives in the Indian context.

AIM

To understand the nature of stigma associated with MI in a rural and semi-urban community in India and to develop an intervention package and study its impact.

MATERIALS AND METHODS

The study adopted a pre- and post-experimental/action research design with a random sample of community members including persons with chronic MI and their caregivers from rural and semi-urban areas. A semi structured interview schedule was used to assess the nature of stigma. An intervention package, developed on the basis of initial findings, was administered, and two post assessments were carried out.

RESULTS

Stigmatized attitude related to various aspects of MI were endorsed by the respondents. Caregivers had less stigmatizing attitude than the members of the community. Postintervention assessments (PIAs) revealed significant changes in attitudes towards some aspects of MI and this improved attitude was sustained during the second PIA, that is, after 3 months of intervention.

CONCLUSION

People in the rural and semi-urban community have stigmatizing attitude toward MI. Intervention package focusing on the relevant aspect of MI can be used for reducing stigma of MI.

Pre-clinical toxicity & immunobiological evaluation of DNA rabies vaccine & combination rabies vaccine in rhesus monkeys (Macaca mulatta)

BACKGROUND & OBJECTIVES

Pre-clinical toxicology evaluation of biotechnology products is a challenge to the toxicologist. The present investigation is an attempt to evaluate the safety profile of the first indigenously developed recombinant DNA anti-rabies vaccine [DRV (100 μg)] and combination rabies vaccine [CRV (100 μg DRV and 1.25 IU of cell culture-derived inactivated rabies virus vaccine)], which are intended for clinical use by intramuscular route in Rhesus monkeys.

METHODS

As per the regulatory requirements, the study was designed for acute (single dose - 14 days), sub-chronic (repeat dose - 28 days) and chronic (intended clinical dose - 120 days) toxicity tests using three dose levels, viz. therapeutic, average (2x therapeutic dose) and highest dose (10 x therapeutic dose) exposure in monkeys. The selection of the model i.e. monkey was based on affinity and rapid higher antibody response during the efficacy studies. An attempt was made to evaluate all parameters which included physical, physiological, clinical, haematological and histopathological profiles of all target organs, as well as Tiers I, II, III immunotoxicity parameters.

RESULTS

In acute toxicity there was no mortality in spite of exposing the monkeys to 10XDRV. In sub chronic and chronic toxicity studies there were no abnormalities in physical, physiological, neurological, clinical parameters, after administration of test compound in intended and 10 times of clinical dosage schedule of DRV and CRV under the experimental conditions. Clinical chemistry, haematology, organ weights and histopathology studies were essentially unremarkable except the presence of residual DNA in femtogram level at site of injection in animal which received 10X DRV in chronic toxicity study. No Observational Adverse Effects Level (NOAEL) of DRV is 1000 ug/dose (10 times of therapeutic dose) if administered on 0, 4, 7, 14, 28 th day.

INTERPRETATION & CONCLUSIONS

The information generated by this study not only draws attention to the need for national and international regulatory agencies in formulating guidelines for pre-clinical safety evaluation of biotech products but also facilitates the development of biopharmaceuticals as safe potential therapeutic agents.

Efficacy of psychosocial rehabilitation program: The RFS experience

BACKGROUND

People with severe and persistent mental illness need help in most aspects of their lives, as the disability associated with these diseases can be debilitating. Psychosocial rehabilitation interventions aim to help them relearn skills that would reduce disabilities so that they can be reintegrated into society.

OBJECTIVE

To study the efficacy of the rehabilitation program at the Richmond Fellowship Society (RFS) 'ASHA' half-way home.

SUBJECTS

Fifty-four clients diagnosed with either schizophrenia or affective disorder who stayed at the half-way home for more than 6 months.

MATERIALS AND METHODS

A retrospective evaluative approach was followed. An evaluation checklist was developed for the purpose and this was used to assess the level of functioning of the clients. A paired sample t-test was used to score changes in client progress between admission and discharge.

RESULTS

Significant improvement ( P≤.05 level) was noticed on all the parameters from baseline to discharge.

CONCLUSION

The psychosocial rehabilitation program at the RFS half-way home has a beneficial effect.

Nonclinical toxicology study of recombinant-plasmid DNA anti-rabies vaccines

The absence of standard guidelines from National and International regulatory agencies for the safety evaluation of biotechnology products challenges the ingenuity of toxicologists. At present, the development of standard pre-clinical toxicology protocols for such products is on an individual case basis. The present investigation is an attempt to evaluate the safety profile of the first indigenously developed DNA based anti-rabies vaccine in India. The test compounds were DNA rabies vaccine [DRV (100 microg)] and combination rabies vaccine (CRV (100 microg DRV and 1/50 dose of cell culture vaccine)), intended for clinical use by intramuscular route on 1, 7, 14 and 28 day. As per the regular mandatory requirements, the study has been designed to undertake acute (single dose--10 days), sub-chronic (repeat dose--28 days) and chronic (intended clinical dose--120 days) toxicity tests using three dose levels viz. therapeutic, average (2 x therapeutic dose) and highest dose (10 x therapeutic dose) exposure in Swiss Albino mice. The selection of the rodent model viz. Swiss Albino mice is based on affinity and rapid higher antibody response during the efficacy studies. Apart from physical, physiological, clinical, hematological and histopathology profiles of all target organs, the tier-I immunotoxicity parameters have also been monitored. There were no observational adverse effects even at levels of 10x therapeutic dose administration of DRV and CRV. The procedure also emphasizes on the designing of protocols for the products developed by recombinant technique.

Family support group in psychosocial rehabilitation

BACKGROUND

Support groups for families of persons with mental illness are emerging as significant components in psychosocial rehabilitation programmes.

AIM

To ascertain the expectations of family members who attend family support group meetings and to find out the efficacy of such programmes.

METHODS

The data were collected from support group members using a semi-structured interview schedule. The study sample (n=20) was drawn from family members who attended the support group meetings regularly for a minimum period of 6 months. Data analysis was done using percentile.

RESULTS

Analysis of the data revealed that members attending the support group meetings expected to get more information about the illness, develop skills to cope with problems at home and learn skills to deal with the ill person. An important finding of the study was that the members developed a 'feeling of togetherness' as a result of being a member of a group with common aims.

CONCLUSION

Participation in a support group meeting positively affects key variables in the participant's adaptation to mental illness in a relative.

Coacervate microspheres as carriers of recombinant adenoviruses

The therapeutic utility of recombinant adenoviruses (rAds) is limited in part by difficulties in directing the viruses to specific sites and by the requirement for bolus administration, both of which limit the efficiency of target tissue infection. As a first step toward overcoming these limitations, rAds were encapsulated in coacervate microspheres comprised of gelatin and alginate followed by stabilization with calcium ions. Ultrastructural evaluation showed that the microspheres formed in this manner were 0.8-10 microM in diameter, with viruses evenly distributed. The microspheres achieved a sustained release of adenovirus with a nominal loss of bioactivity. The pattern of release and the total amount of virus released was modified by changes in microsphere formulation. Administration of the adenovirus-containing microspheres to human tumor nodules engrafted in mice showed that the viral transgene was transferred to the tumor cells. It is concluded that coacervate microspheres can be used to encapsulate bioactive rAd and release it in a time-dependent manner.

The Yelandur study: a community-based approach to epilepsy in rural South India--epidemiological aspects

Data on the epidemiology of epilepsy in a rural community in a developing country would be of value in planning a decentralized management of this malady in its early stages commensurate with available local resources. A detailed screening instrument covering various seizure types was used by trained paramedical workers in a door-to-door survey of a population of 64,963 in rural South India. The prevalence period was from 1 April 1990 to 31 March 1991. The crude prevalence rate per 1000 for active epilepsy was 4.38 for males, 3.40 for females and 3.91 for both. The minimum and maximum prevalence rates, the latter computed from a validation sample, were 3.91 and 4.63 for active epilepsy; 0.28 and 0.77 for inactive epilepsy and 4.19 and 5.41 for life-time prevalence. In addition, corresponding figures for hot-water epilepsy, a type of reflex epilepsy peculiar to this area, were 2.49 and 2.99 for active phase; 0.35 and 0.85 for inactive phase and 2.85 and 3.83 for life-time prevalence. The incidence rate for epilepsy was 49.3 per 100,000, the same as in developed countries. These data do not support the concept that the prevalence of epilepsy in developing countries is twice that in the developed world. However, the role of local/regional variations should be borne in mind before extrapolating the figures to an entire country.

A finite element model for predicting the distribution of drugs delivered intracranially to the brain

Drug therapy to the central nervous system is complicated by the presence of the blood-brain barrier. The development of new drug delivery techniques to overcome this obstacle will be aided by a clear understanding of the transport processes in the brain. A rigorous theoretical framework of the transport of drugs delivered locally to the parenchyma has been developed using the finite element method. Magnetic resonance imaging has been used to track the transport of paramagnetic contrast markers in the brain. The information obtained by postprocessing spin-echo, T1-weighted, and proton density images has been used to refine the mathematical model that includes realistic brain geometry and salient anatomic features and allows for two-dimensional transport of chemical species, including both diffusive and convective contributions. In addition, the effects of regional differences in tissue properties, ventricular boundary, and edema on the transport have been considered. The model has been used to predict transport of interleukin-2 in the brain and study the major determinants of transport, at both early and late times after drug delivery.

Utilization of tyrosine and tryptophan for protein synthesis by undernourished developing rat brain

Incorporation of tracer doses of radiolabeled tryptophan and tyrosine into brain proteins was investigated in rats malnourished during gestation and lactation. Age and time dependent increases in the radioactivity was observed in the whole homogenate and in the TCA insoluble fraction. Protein malnourished rats showed increased incorporation of tryptophan and tyrosine. However the diet restricted (Pair-fed) animals showed increased incorporation of tyrosine only. The increased incorporation may probably be due to changes in the pool size of the amino acids and effective recycling of the amino acids. The enhanced utilization in protein synthesis may also probably offer a mechanism for conservation of these amino acids.

Comparison of electroconvulsive therapy with imipramine in endogenous depression: a double blind study

Electroconvulsive therapy was compared with imipramine in the treatment of endogenous depression in a double blind randomized controlled trial. Both treatments produced equally significant improvement which was equally maintained till the end of six months. However ECT produced its effects quicker with lesser subjective side effects to the patient. ECT did not cause any organic brain dysfunction as assessed at the end of three and six months.

Free amino acid levels in undernourished developing rat brain

Free amino acid levels in the brains of young ones born to mothers fed a 20% protein diet ad libitum (well nourished), 7.5% protein diet ad libitum (protein restricted) and a 20% protein diet in restricted amounts (pair-fed) were investigated during brain development in the present study. The dietary protein was obtained from a cereal-legume mixture. Protein restricted animals showed increases in the levels of taurine, glycine and glutamic acid and decreases in the concentrations of methionine, leucine, isoleucine, and GABA. The pair-fed animal showed increases only in glutamic acid and glycine and a decrease only in the levels of GABA. The significance of these observations is discussed.

Single daily dose chlorpromazine therapy in psychosis. An evaluation

A double blind study was undertaken to compare the efficacy of a single bedtime dose of chlorpromazine (300 mg) with divided doses of the same drug (100 mg, thrice daily). Brief Psychiatric Rating Scale (BPRS) and Nurses' Observation Scale for Inpatient Evaluation (NOSIE) were administered to 80 acutely psychotic patients who took part in the study. Thirty-one patients in the experimental and 29 in the control group completed this 3-week trial. It was observed that there were no statistically significant differences between the two modes of treatment. Drowsiness was seen more often in the single bedtime schedule. Postural hypotension was observed in both patient groups. The implications of single night-time medication in psychotics is discussed.

Effect of undernutrition on tryptophan and tyrosine hydroxylases in the developing rat brain

Rats born to well-fed mothers (20% protein diet ad libitum), protein-restricted mothers (7.5% protein diet ad libitum) or pair-fed with protein-restricted mothers were killed on days 0, 7, 14, 21, 28 and 35 and activities of the two enzymes of neurotransmitter synthesis, tryptophan-5-hydroxylase (EC 1.14.16.4) and tyrosine hydroxylase (EC 1.14.16.2) were assayed. Enzyme activities in normal animals were low at birth and progressively increased to reach adult levels by day 15. Protein-restricted and pair-fed animals also showed a similar pattern. However, significantly higher activities were observed from day 15 onwards in both experimental groups.

Effect of dietary protein and calorie deficiency on tryptophan levels in the developing rat brain

The pattern of development of brain tryptophan in the rat was studied in the progeny of mothers fed a 7.5% protein diet ad lib., a 20% protein diet ad lib. and those fed a 20% protein diet pair-fed with mothers who received the 7.5% protein. The pattern of development was similar in all three groups. Starting with a high brain tryptophan content at birth, all animals showed a progressive reduction during the next 3 weeks. However, tryptophan levels at birth were several fold higher in the brains of pups born to mothers receiving either the low protein diet fed ad lib. or those born to mothers who received the 20% protein diet in restricted amounts. From the 14th day after birth, tryptophan concentration of brain in undernourished pups was significantly lower until the 35th day. The implications of this finding are discussed.