Mercury air, urine monitoring and health effects on occupationally exposed dental healthcare workers in Delhi, India

BACKGROUND

Mercury (Hg) is a toxic heavy metal with multiple uses in various medical devices. Hg is used in dentistry as a restorative material. Such use creates significant exposure to dental practitioners. Hence, it is important to assess the risk created by Hg use in healthcare.

OBJECTIVE

To quantify airborne Hg vapour exposure and Hg levels in dental healthcare workers, and determine the association of various symptoms and diseases to Hg exposure.

METHODS

Air monitoring of Hg vapours were conducted in dental clinics and amalgam rooms. Urine samples were collected from occupationally exposed dental healthcare workers and urine Hg levels were measured. A cross-sectional health survey was conducted in 23 healthcare units of Delhi to determine an association between Hg exposure and various health effects.

RESULTS

Hg vapour concentration ranged from 0.96μg/m3 to 15μg/m3, the highest concentration was recorded in the amalgam room (15μg/m3). Urine Hg levels in healthcare workers (0.51±0.17μg/L) were higher than the control (0.29±0.05μg/L). A cross-sectional health survey revealed a significant prevalence of confusion, forgetfulness, muscle spasm, and tremors by the respondents.

CONCLUSION

Hg concentration in dental clinics may hover above the prescribed safe levels posing a definitive health risk to healthcare workers. Urinary Hg measurements did not reveal an excess of body burden except in one case. Since Hg bio accumulates, it is probable as these workers grow older, they may end up with a higher body burden of Hg that may lead to a variety of adverse health outcomes.

Systemic inflammatory response syndrome criteria (SIRS) and sepsis 3 criteria for assessing outcomes in sepsis: A prospective observational study

Background

Sepsis is a major cause of death in hospitalised patients worldwide. Most studies for assessing outcomes in sepsis are from the western literature. Sparse data from Indian settings are available comparing the systemic inflammatory response syndrome (SIRS), Sequential Organ Failure Assessment (SOFA) and quick SOFA (qSOFA) (sepsis 3 criteria) for assessing outcomes in sepsis. In this study, we aimed to compare the SIRS criteria and sepsis 3 criteria to assess disease outcome at day 28 (recovery/mortality) in a North Indian tertiary care teaching hospital.

Methods

A prospective observational study was performed in the Department of Medicine from 2019 to early 2020. Patients admitted to the medical emergency with clinical suspicion of sepsis were included. Systemic inflammatory response syndrome, qSOFA and SOFA scores were calculated at the time of presentation to the hospital. Patients were followed through the course of their hospital stay.

Results

Out of 149 patients, 139 were included in the analysis. Patients who died had significantly higher mean SOFA, qSOFA scores and mean change in SOFA score than patients who survived (P value <0.01). There was no statistical difference between recovery and deaths at similar SIRS scores. A 40.30% fatality rate was recorded. Systemic inflammatory response syndrome had low Area Under Curve (AUC) (0.47) with low sensitivity (76.8) and specificity (21.7). SOFA had the maximum AUC (0.68) compared to qSOFA (0.63) and SIRS (0.47). SOFA also had the maximum sensitivity (98.1) while the qSOFA score had the maximum specificity (84.3).

Conclusion

SOFA and qSOFA scores had superior predictive ability as compared to the SIRS score in assessing mortality in sepsis patients.

Can Sublingual Nitrate Improve Visualization of Lower Limb Arteries on Computed Tomography Angiography?

OBJECTIVE

The aim of the study is to evaluate the role of sublingual nitrate in improving vessel visualization on peripheral computed tomography angiography (CTA).

METHODS

Fifty patients clinically diagnosed with peripheral arterial disease of the lower limb were prospectively included in this study: Twenty-five underwent CTA after sublingual nitrate administration (nitrate group) and 25 without (non-nitrate group). Two blinded observers qualitatively and quantitatively assessed the data thus generated. The mean luminal diameter, intraluminal attenuation, site, and percentage of stenosis were evaluated in all segments. Assessment of collateral visualization at sites of significant stenosis was also done.

RESULTS

Patients in the nitrate and non-nitrate groups were similar in age and sex characteristics (P > 0.05).On subjective evaluation, there was significantly improved visualization of the femoropopliteal and tibioperoneal vasculature of the lower limb in the nitrate group compared with the non-nitrate group (P < 0.05). Quantitative evaluation showed a statistically significant difference in the measured arterial diameters for all evaluated segments in the nitrate group versus the non-nitrate group (P < 0.05). Intra-arterial attenuation was significantly greater for all segments in the nitrate group resulting in better contrast opacification in these studies. Collateral visualization around segments with more than 50% stenosis/occlusion was also better in the nitrate group.

CONCLUSIONS

Our study suggests that nitrate administration before peripheral vascular CTA can improve visualization, especially in the distal segments by increasing the vessel diameter and intraluminal attenuation along with better delineation of the collateral circulation around stenotic areas. It may also improve the number of evaluable segments of vasculature in these angiographic studies.

Evaluation of Water Quality, Urinary Mercury & Arsenic Investigation and Survey of Diseases Associated with Drinking Water Sources

Background: Contamination of freshwater sources can be caused by both anthropogenic and natural processes. WHO reported that 1.1 billion people worldwide consume contaminated water, and the majority of diarrheal diseases (88%) are caused by it. According to Central Pollution Control Board (CPCB), Maharashtra along with two other states contribute 80% of hazardous waste, including heavy metal pollution in India. Certain dissolved heavy metals are easily absorbed by aquatic organisms and can enter the body through drinking water, skin absorption, and biological chains, posing a health risk. Hence, the main objectives of the study were, (1) surface and groundwater quality assessment, (2) to determine the association of diseases/symptoms with different sources of drinking water used, and (3) urinary Mercury (Hg) and Arsenic (As) levels investigation in the study population. Methods: The cross-sectional study was conducted in the industrialized city of Solapur, Maharashtra, India. The study area was limited to 25 km around the industrial hub. A total of 557 people were randomly selected for the survey, with consumers from all four types of water sources i.e., surface, handpump, wells, and municipal water. Spot urine samples were collected for estimating Hg and As levels after considering inclusion and exclusion criteria. People under treatment for tuberculosis, cancer, and chronic heart, lung, or kidney ailments were excluded. Also, pregnant and lactating women were not included. One surface water, one municipal water, and five handpump water samples were collected for evaluating water quality. Samples were analyzed for pH, Total Dissolved Solids (TDS), Dissolved Oxygen (DO), Biological Oxygen Demand (BOD), Chemical Oxygen Demand (COD), Fluoride, Ammonia, Mercury, Arsenic, Cadmium, Lead, Nickel, Copper, Zinc, Chromium, and Manganese. Results: The water samples were observed to be neutral to slightly basic. TDS was between 410 to 1898 mg/L for groundwater whereas for surface water was 378 & 450 mg/L. F concentration ranged between 0.4 to 0.9 mg/L, Zn from 0.32 to 0.57 mg/L, and NH3 was found to be <0.1 mg/L. Out of 557 people, 43 (7.7%) used surface water, 194 (34.8%) used handpump, 64 (11.5%) used well, and 256 (46%) used municipal water. Among surface water users, 14 (32.5%) people reported frequent loose stools (p-value <0.05), and 11 (25.5%) people reported frequent abdominal pain. Handpump and well water users majorly reported frequent abdominal pain and gastric discomfort (p-value <0.05) respectively. 47 people were selected for estimating urinary Hg and As levels after considering exclusion and inclusion criteria. The mean value of urinary Hg & As are 4.91 ± 0.280 & 42.04 ± 2.635 µg/L respectively.  Conclusion: In our study frequent loose stools, abdominal pain, and gastric discomfort were associated with the various sources of drinking water. Urine Hg levels were above the permissible reference value set by NHANES (USA) Survey. Additionally, it is advised that frequent drinking water monitoring be implemented in the vicinity of the industrial hub since metal accumulation may be dangerous to consumers when it is present in excess, and if found higher, necessary action should be taken to reduce exposure.

Human Health Risk Assessment due to Heavy Metals in Ground and Surface Water and Association of Diseases With Drinking Water Sources: A Study From Maharashtra, India

BACKGROUND

Contamination of freshwater sources can be caused by both anthropogenic and natural processes. According to Central Pollution Control Board, Maharashtra along with 2 other states, contribute 80% of hazardous waste generated in India, including heavy metal pollution. Hence, it is important to quantify heavy metal concentrations in drinking water sources in such areas.

MATERIALS AND METHODS

Water samples were analyzed for toxic elements (F, As, Cd, Hg, Pb, Ni, Cu, Zn, Mn, and Cr) using Inductively Coupled Plasma-Mass Spectrometry (ICP-MS) Agilent 7500. Health risks due to ingestion and dermal contact was assessed. A total of 557 people were randomly selected, with consumers from all 4 types of water sources that is surface water, hand pump, wells, and municipal water. Spot urine samples were collected from 47 people after considering inclusion and exclusion criteria. Urine was collected for estimating mercury and arsenic levels in the study participants.

RESULTS

Arsenic contributes the most health risk from ingestion from water. Among surface water users, 14 people (32%) reported frequent loose stool (P-value < .05) (OR 2.5), and 11 people (23%) reported frequent abdominal pain (OR 1.9). Hand pump and well water users reported frequent abdominal pain (27%) (OR 1.4) and gastric discomfort (31%) (P-value < .05) (OR 3) respectively. The mean value of urinary Hg and As were 4.91 ± 0.280 and 42.04 ± 2.635 µg/L respectively.

CONCLUSION

Frequent loose stool, gastric discomfort, and frequent abdominal pain were associated with the various sources of drinking water. Urine Hg levels were found higher than the NHANES (USA) Survey. It is recommended that frequent monitoring of drinking water should be enforced around the industrial hub, so that appropriate actions can be taken if present in excess.

Diffusion-weighted magnetic resonance imaging of abdominal tuberculosis: a new take on an old disease

Abdominal tuberculosis is a major cause of mortality and morbidity in developing countries also re-emerging in western world due to the AIDS epidemic and population migration. Large proportion of the patients are young and hence radiation exposure is of concern. In addition, in some patients, contrast may be contraindicated or repeat studies may be required, where MR especially DWI may be useful. The aim of the study is to describe MRI features in abdominal tuberculosis including DWI in the involved bowel, lymphadenopathy, omental, and peritoneal thickening. Nodes being especially easy to appreciate on DWI, thus DWI in conjunction with routine noncontrast MR sequence can be useful technique to identify abdominal tubercular lesions in patients with contraindication to contrast.

Sewer gas poisoning causing transient and focal ST-segment elevation in the ECG: Case report

In India, a large number of sanitary care workers are involved in manual scavenging. This exposes them to sewer gas mainly consisting of hydrogen sulphide. Sewer gas toxicity primarily causes neurological injury, followed by cardiac and respiratory involvement. A few cases of diffuse ST-segment elevation in the electrocardiogram (ECG) following hydrogen sulphide poisoning are known in the literature. Here, we report a case of acute sewer gas poisoning in a 45-year-old man with transient and focal ST-segment elevation in the anteroseptal leads of the ECG mimicking acute anterior wall myocardial infarction.

Heavy Metal Accumulation in Fruits and Vegetables and Human Health Risk Assessment: Findings From Maharashtra, India

BACKGROUND

Vegetables are consumed enormously by humans all over the world. Consumption of contaminated fruits and vegetables is the most likely route of heavy metal exposure. Hence, it is important to quantify heavy metal concentration in frequently consumed fruits and vegetables.

MATERIALS AND METHODS

The main aim of our study is to investigate heavy metal (Pb, Cd, As, and Hg) contamination in 24 different kinds of vegetables and fruits grown in the industrialized city of Solapur, Maharashtra, India. Potential health risks due to the consumption of fruits and vegetables were assessed. Heavy metal concentration and quality of native soil were also determined. Vegetable and fruit samples were analyzed using Inductively Coupled Plasma-Mass Spectrometry (ICP-MS) Agilent 7500.

RESULTS

The mean concentrations of selected heavy metals in fruits and vegetables analyzed were: Lead (0.17 ± 0.38 mg/kg) > Mercury (0.06 ± 0.09 mg/kg) > Cadmium (0.02 ± 0.007 mg/kg) > Arsenic (0.002 ± 0.003 mg/kg). Among them, garlic showed the highest heavy metal accumulation followed by potato.

CONCLUSION

Overall, vegetables showed higher metal accumulations than fruits. Some vegetables showed alarming levels of human health risk indices such as the Metal Pollution Index (MPI), Health Risk Index (HRI) and Hazard Index (HI), suggesting that reducing the intake amount of these vegetables may lower the adverse health effects.

Effect of Supplementation of Vitamin C and Thiamine on the Outcome in Sepsis: South East Asian Region

INTRODUCTION

The global burden of sepsis is overwhelming and novel therapeutic agents is the need of the hour. The present study was designed to understand the role of Malondialdehyde as a marker of the oxidative stress in sepsis, as well as the effect of supplementation of Vitamin C and Thiamine in patients of sepsis.

METHODS

80 patients of sepsis were randomly divided into 4 groups of 20 each. Twenty age-sex matched healthy volunteers were chosen as controls. The first group received Vitamin C, the second group received Thiamine, the third group received both and the fourth group received neither. Vitamin C (2g 8 hourly) and Thiamine (200 mg 12 hourly) were given intravenously for five days. The outcome was recorded in terms of mortality in the various groups as well as by the improvement in SOFA scores (ΔSOFA). The serum levels of Vitamin C, Thiamine and Malondialdehyde were estimated.

RESULTS

Among the 80 patients, 17 (21%) were in septic shock. The mortality rate was 10% overall, and 47% among patients of septic shock. No additional mortality benefit was observed in the groups supplemented with Vitamin C and Thiamine. However, the ΔSOFA score in patients who received both Vitamin C and Thiamine was significantly higher as compared to the other groups. The mean malondialdehyde level was higher in patients of sepsis (1.81±1.18 µmol/l) as compared with healthy controls (0.78 ± 0.36 µmol/l). The Vitamin C level and Thiamine level (estimated indirectly by TPP effect), at presentation were 5.14±4.19 ng/ml and 52.99±28.45 % in patients of sepsis, which was significantly lower than that in healthy controls, in whom the levels were 14.64±5.51 ng/ml and 27.55±13.67% respectively.

CONCLUSION

Vitamin C and Thiamine supplementation is a cost-effective approach with a good safety profile. Additional studies including a larger population is required to study the mortality benefits and reaffirm our findings.

Clinicopathological Parameters of Haemolytic Anaemia in COVID-19 Infection: A Series of Three Cases

Coronavirus Disease 2019 (COVID-19) patients show various haematological abnormalities like cytopenia and coagulation disorders. Corona virus can induce an inflammatory state, leading to extensive coagulation manifestations. Association between COVID-19, Autoimmune Haemolytic Anaemia (AIHA) and thrombotic state is still the subject of extensive research. In this study, three cases of haemolytic anaemia are discussed. First case was a 28-year-old female with a history of abruptio placentae who presented with complaints of generalised weakness and oliguria for five days. She was diagnosed as thrombotic microangiopathy based on peripheral smear finding of schistocytes and spherocytes and few polychromatophils and normal prothrombin time (International Normalized Ratio (INR)) with very high D-dimer levels on coagulation profile. Second case was of a 25-year-old female who presented with complaints of fatigue, rashes, dark urine, nausea and abdominal pain. She was diagnosed as a case of AIHA based on peripheral smear finding of Red Blood Cells (RBC) clumping and positive direct coomb test. Third case was of a two-month-old child who presented with respiratory distress and pallor. He was diagnosed as a case of haemolytic anaemia either due to direct effect of COVID-19 infection or Cytomegalovirus (CMV) and mycoplasma infection. Thus, COVID-19 infection can directly or indirectly lead of a wide spectrum of haemolytic manifestations and every patient with anaemia should be thoroughly investigated for early detection and treatment.

Drug utilization, rationality, and cost analysis of antimicrobial medicines in a tertiary care teaching hospital of Northern India: A prospective, observational study

BACKGROUND:

The burden of bacterial infections is huge and grossly under-represented in the current health-care system. Inappropriate use of antimicrobial medicines (AMMs) poses a potential hazard to patients by causing antibiotic resistance. This study was conducted to assess the: (i) AMM consumption and use patterns in patients attending the outpatients and inpatients of Medicine and Surgery departments of the hospital. (ii) Appropriateness of the AMM in the treatment prescribed, and (iii) cost incurred on their use in admitted patients.

MATERIALS AND METHODS:

An observational, prospective study was conducted among inpatients and outpatients of the Medicine and Surgery departments of a tertiary care hospital of northern India. Analysis of 2128 prescriptions and 200 inpatient records was performed using a predesigned format. The use of AMMs was reviewed using anatomical therapeutic chemical classification and defined daily doses (DDDs). To evaluate the expenditure incurred on AMMs, ABC analysis was performed.

RESULTS:

AMMs were prescribed to 37.9% outpatients and 73% of admitted patients. The percentage encounters with AMMs was 40.6% (medicine) and 25.6% (surgery) outpatients. The total DDDs/100 patient days of AMMs in medicine and surgery were 3369 and 2247. Bacteriological evidence of infection and AMM sensitivity was present in only 8.5% of cases. Over 90% of AMMs were prescribed from the hospital essential medicines list. Most of the AMMs were administered parenterally (64.9%). Multiple AMMs were prescribed more to inpatients (84.2% vs. 4.2% outpatients). Overall, expenditure on AMM was 33% of the total cost of treatment on medicine. ABC analysis showed that 74% of the expenditure was due to newer, expensive AMM, which constituted only 9% of the AMM used. The AMM therapy was found to be appropriate in 88% of cases as per Kunin's criteria for rationality.

CONCLUSION:

AMMs are being commonly prescribed without confirmation of AMM sensitivity in the hospital. A large proportion of expenditure is being incurred on expensive AMM used in a few number of patients. There is a need for developing a policy for rational use of AMM in the health facility.

Critical care practice in India: Results of the intensive care unit need assessment survey (ININ2018)

BACKGROUND

A diverse country like India may have variable intensive care units (ICUs) practices at state and city levels.

AIM

To gain insight into clinical services and processes of care in ICUs in India, this would help plan for potential educational and quality improvement interventions.

METHODS

The Indian ICU needs assessment research group of diverse-skilled individuals was formed. A pan- India survey "Indian National ICU Needs" assessment (ININ 2018-I) was designed on google forms and deployed from July 23^rd-August 25^th, 2018. The survey was sent to select distribution lists of ICU providers from all 29 states and 7 union territories (UTs). In addition to emails and phone calls, social medial applications-WhatsApp™, Facebook™ and LinkedIn™ were used to remind and motivate providers. By completing and submitting the survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status.

RESULTS

There were total 134 adult/adult-pediatrics ICU responses from 24 (83% out of 29) states, and two (28% out of 7) UTs in 61 cities. They had median (IQR) 16 (10-25) beds and most, were mixed medical-surgical, 111(83%), with 108(81%) being adult-only ICUs. Representative responders were young, median (IQR), 38 (32-44) years age and majority, n = 108 (81%) were males. The consultants were, n = 101 (75%). A total of 77 (57%) reported to have 24 h in-house intensivist. A total of 68 (51%) ICUs reported to have either 2:1 or 2≥:1 patient:nurse ratio. More than 80% of the ICUs were open, and mixed type. Protocols followed regularly by the ICUs included sepsis care, ventilator- associated pneumonia (83% each); nutrition (82%), deep vein thrombosis prophylaxis (87%), stress ulcer prophylaxis (88%) and glycemic control (92%). Digital infrastructure was found to be poor, with only 46 % of the ICUs reporting high-speed internet availability.

CONCLUSION

In this large, national, semi-structured, need-assessment survey, the need for improved manpower including; in-house intensivists, and decreasing patient-to-nurse ratios was evident. Sepsis was the most common diagnosis and quality and research initiatives to decrease sepsis mortality and ICU length of stay could be prioritized. Additionally, subsequent surveys can focus on digital infrastructure for standardized care and efficient resource utilization and enhancing compliance with existing protocols.

Clinical Profile of nCOVID-19 Cases in Andaman and Nicobar Islands: A Case Series

nCOVID-19 (2019 novel corona virus) is a naive infective virus that brought the whole world to standstill. The clinical features attributing to its infection have a broad spectrum, ranging from minimally symptomatic to respiratory failure and death. The aim of present case series was to assimilate data regarding the clinical characteristics of first 11 cases of COVID-19 infection in the local population of Andaman and Nicobar Islands. Various clinical features, biochemical and individual parameters were compiled that may affect the disease evolution and then, subjected to descriptive analysis. Out of 11 patients, six patients had a definitive known source of their infection and four patients had history of close contacts with first six ones. Only one patient had unknown source of the infection. Majority of the patients remained asymptomatic to pauci-symptomatic. Mean duration of symptomatic period was less than seven days (5.6 days). In this series, out of 11 patients, 2 (18%) were females and rest all were males (82%). Four of the patients had fever, four had cough and four had weakness and fatigue, two had malaise, three had anorexia, one had dyspepsia and one diarrhea. None of the patient landed in Intensive care unit (ICU). Patients were treated with empirical combination therapy including Azithromycin (500 mg OD) and Oseltamivir (75 mg BD) irrespective of their symptoms. Additionally, Hydroxychloroquine (200 mg BD) was given to symptomatic ones. Conclusively, less dreadful clinical presentation of this infection was faced in this population.

Correlation of CAT, CCQ and mMRC Scores in Patients of COPD with Exacerbation and after Treatment

Introduction: Chronic Obstructive Pulmonary Disease (COPD), a globally prevalent disease holds a huge stake among all pulmonary patients being admitted throughout the year. Various disease specific and health related quality of life questionnaires such as the Constructed Response Question (CRQ) and St. George’s Respiratory Questionnaire (SGRQ) are readily available, although, attributing to their complex structure, they can’t be used in a widespread manner. Some new scores like COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ) were developed to ease-off this dilemma. However, there is a need to justify usage of these patient-friendly simplified scores by objectifying their inter-score reliability and correlation with disease severity and progression using statistical analysis. Aim: To analyse efficacious use of CAT, CCQ score and modified Medical Research Council (mMRC) scale in assessing health status of COPD with exacerbation. Additionally, it was also targeted to assess the inter-score correlation and reliability. Materials and Methods: A total of 180 confirmed cases of COPD with exacerbation were included in this study and subjected to requisite biochemical parameters, assessment scores at their admission, after 1 week and then after 4-6 week (at stabilisation) and spirometry. 136 patients were followed-up to 4-6 weeks and studied. Quantitative and qualitative variables thus obtained were compared statistically to find out correlation, if any. A p-value of <0.05 was considered significant. Results: Mean difference between CAT score at exacerbation and at 1 week and CAT score at exacerbation and at 4-6 weeks were statistically significant. The changes in CCQ scores from exacerbation to 1 week and 6 weeks were also found to be statistically significant. Similar pattern was also observed in assessing timescale variability of mMRC score. There was good correlation between CAT, CCQ and mMRC scores at exacerbation, 1 week and it continually intensified as patients progressed towards a more stable state (4-6 weeks). Similar pattern was also observed with significant progressive positive correlation between change in CAT, CCQ and mMRC scores from exacerbation to 1 week and from exacerbation to 4-6 weeks. Conclusion: These score have a high correlative reliability when used to assess health status among various stages of disease from exacerbation towards a stable state. Similarly, correlation between change of individual score from exacerbation towards recovery state was also high.

Management and Therapeutic Options for COVID-19: A Review

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the causative organism for Coronavirus Disease 2019 (COVID-19), originated in Wuhan, China and has now spread to most parts of the world. A pandemic of this magnitude has not been witnessed in more than 100 years since the Spanish flu in 1918. The major challenge for scientists and doctors worldwide has been to find a therapeutic intervention to prevent the spread and development of this disease. As more research is being done, the pathophysiology of COVID-19 has been explained, although no effective therapy has been found. Multiple drugs and therapies are under trials and a few have shown inconclusive results. The attempts have ranged from repurposing drugs to trying to develop new vaccines. Formulation of guidelines pose another challenge to the government and international agencies owing to the lack of data. These agencies have constantly released and updated guidelines based on new research and growing knowledge. In this review, we aim to compare and bring out the different international guidelines for management of COVID-19, along with a review of tried therapeutic interventions and their primitive results. The COVID-19 has been a major global health crisis that is overpowering most heath care systems and multiple agencies and research teams are trying to limit and manage this spread. Currently no effective treatment is available and guidelines differ regarding the drugs that can be used, which are mostly off-label.

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

Effect of a Recombinant Human Soluble Thrombomodulin on Mortality in Patients With Sepsis-Associated Coagulopathy: The SCARLET Randomized Clinical Trial

IMPORTANCE

Previous research suggested that soluble human recombinant thrombomodulin may reduce mortality among patients with sepsis-associated coagulopathy.

OBJECTIVE

To determine the effect of human recombinant thrombomodulin vs placebo on 28-day all-cause mortality among patients with sepsis-associated coagulopathy.

DESIGN, SETTING, AND PARTICIPANTS

The SCARLET trial was a randomized, double-blind, placebo-controlled, multinational, multicenter phase 3 study conducted in intensive care units at 159 sites in 26 countries. All adult patients admitted to one of the participating intensive care units between October 2012 and March 2018 with sepsis-associated coagulopathy and concomitant cardiovascular and/or respiratory failure, defined as an international normalized ratio greater than 1.40 without other known etiology and a platelet count in the range of 30 to 150 × 109/L or a greater than 30% decrease in platelet count within 24 hours, were considered for inclusion. The final date of follow-up was February 28, 2019.

INTERVENTIONS

Patients with sepsis-associated coagulopathy were randomized and treated with an intravenous bolus or a 15-minute infusion of thrombomodulin (0.06 mg/kg/d [maximum, 6 mg/d]; n = 395) or matching placebo (n = 405) once daily for 6 days.

MAIN OUTCOME AND MEASURES

The primary end point was 28-day all-cause mortality.

RESULTS

Among 816 randomized patients, 800 (mean age, 60.7 years; 437 [54.6%] men) completed the study and were included in the full analysis set. In these patients, the 28-day all-cause mortality rate was not statistically significantly different between the thrombomodulin group and the placebo group (106 of 395 patients [26.8%] vs 119 of 405 patients [29.4%], respectively; P = .32). The absolute risk difference was 2.55% (95% CI, -3.68% to 8.77%). The incidence of serious major bleeding adverse events (defined as any intracranial hemorrhage; life-threatening bleeding; or bleeding event classified as serious by the investigator, with administration of at least 1440 mL [typically 6 units] of packed red blood cells over 2 consecutive days) was 23 of 396 patients (5.8%) in the thrombomodulin group and 16 of 404 (4.0%) in the placebo group.

CONCLUSIONS AND RELEVANCE

Among patients with sepsis-associated coagulopathy, administration of a human recombinant thrombomodulin, compared with placebo, did not significantly reduce 28-day all-cause mortality.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01598831.

Correlation of chronic obstructive pulmonary disease assessment test and clinical chronic obstructive pulmonary disease questionnaire score with BODE index in patients of stable chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) has a major impact on health status in accordance with disease severity. It is usually assessed by the various quality of life questionnaires.

OBJECTIVES

The aim of this study is to assess the disease severity and health status in stable patients of COPD using COPD assessment test (CAT) and clinical COPD questionnaire (CCQ) scores and to correlate with BODE index and its components.

METHODS

One hundred patients of stable COPD were subjected to CAT, CCQ irrespective of the stage of COPD during their visit. BODE index was also calculated.

RESULTS

COPD severity status assessed using forced expiratory volume 1% (FeV1%) predicted values correlated significantly with individual scores (CAT and FeV1%; r = -0.67; P < 0.001 and CCQ and FeV1%; r = 0.61; P < 0.001). CAT and CCQ score also correlated significantly (r = 0.84, P < 0.001) and both with the BODE index (r = 0.80; CAT and r = 0.66; CCQ, P < 0.01). Individual components of BODE index significantly correlated with CAT and CCQ scores.

CONCLUSIONS

The CAT and CCQ have similar psychometric as well physical properties to assess the health status of COPD patients and can be used as a reliable scientific research tool and can be used in clinical practise to study the disease state and plan an appropriate treatment plan. The BODE index which is more objective, correlated well.

Evaluating NISCH and CDH1 Promoter Hypermethylation in Nonsmokers, Cancer Free Smokers and Lung Cancer Patients: A Case Control Study

Lung cancer has very high mortality due to late stage diagnosis not amenable to curative resection. Cancer specific methylation patterns of tumor suppressor genes may precede precursor lesions of lung cancer. Our aim was to evaluate the promoter hypermethylation of tumor suppressor gene NISCH and CDH1 in cfDNA from plasma of lung cancer patients and its possible correlation with smoking status and various clinicopathological parameters. Forty histopathologically confirmed lung cancer cases, thirty smoker and thirty nonsmoker controls were enrolled. Plasma cfDNA was extracted and subjected to bisulfite treatment followed by MS-PCR. Serum nischarin levels were estimated by ELISA. The frequency of promoter hypermethylation of NISCH and CDH1 was significantly higher in lung cancer patients as compared to lifelong non-smoker controls (p < 0.05). It did not vary with smoking status among cancer cases. No significant association was found with staging or histological grading. NISCH methylation was found to be significantly higher among smoker controls. Pack years and packs per day were significantly higher in the methylated group. Serum nischarin levels showed no significant association with NISCH methylation or clinicopathological variables. NISCH is highly methylated in both high risk smoker controls as well as cancerousnon-smokers and may mark the convergence of varied etiologies of lung cancer. Hence NISCH and CDH1 are highly methylated in plasma cfDNA of lung cancer patients.

Corticosteroid-induced cryptococcal meningitis in patient without HIV

Cryptococcus neoformans is the most frequent cause of fungal meningitis in humans. Cryptococcus affects people of all ages and has a worldwide distribution. It is the fourth most common infection in AIDS (CD4 counts <100/mm³). Cases also occur in patients with other forms of immunosuppression and in apparently immunocompetent individuals. Chronic high-dose steroid may precipitate such an immunocompromised state and thus create susceptibility to fungal infections. In our case, we describe a 14-year-old boy who was on steroids for tubercular meningitis for a period of 8 weeks after which he developed cryptococcal meningitis. Attention is drawn to the increasing number of reported cases of this disease which have been associated with steroid therapy and this possibility should be remembered when investigating patients with tubercular meningitis especially if they are being treated with steroids.

Ruptured Sinus of Valsalva with Infective Endocarditis Complicated with Post-Infectious Acute Glomerulonephritis: A Rare Case Presentation

Ruptured Sinus of Valsalva (RSOV) is a rarely seen disease condition. RSOV can have varied presentations from being asymptomatic with just a cardiac murmur to profound hypotension. There has been simultaneous occurrence of RSOV with Infective Endocarditis (IE) in literature. Glomerulonephritis has also been reported in approximately 20% patients with IE. Large amount of proteinuria or decline in kidney functions is rarely encountered and mostly this finding has been incidental on routine evaluation. The co-existence of all the three conditions in a single patient is rare. This case was diagnosed to have RSOV with IE and was also diagnosed with post-infectious glomerulonephritis on renal biopsy. Patient was advised corrective cardiac surgery, but due to financial constraints, patient could not be operated and he died. Here, we report for the first time an unusual presence of both RSOV and sub-aortic membrane with IE complicated by glomerulonephritis.

Evaluation of BODE index and its relationship with systemic inflammation mediated by proinflammatory biomarkers in patients with COPD

Introduction

BODE index, a multidimensional grading system which is based on Body mass index, airway Obstruction, Dyspnea scale, and Exercise capacity, has been increasingly used for the evaluation of chronic obstructive pulmonary disease (COPD). Many of the systemic manifestations of COPD are shown to be mediated by elevated levels of proinflammatory biomarkers.

Objective

We aimed to investigate the relationship between the BODE index, its components, disease severity, and proinflammatory biomarkers like C-reactive protein (CRP), tumor necrosis factor (TNF)-α, and interleukin (IL)-6.

Materials and methods

A cross-sectional study which included 290 clinically stable COPD patients and 80 smoker controls was conducted. Medical history, body mass index, pulmonary function tests, 6-minute walking test, and modified scale of Medical Research Council dyspnea scale were evaluated. BODE scores were determined. Systemic inflammation was evaluated with the measurement of CRP, TNF-α, and IL-6 in the serum samples of all studied subjects. The correlation between inflammatory biomarkers and BODE index was assessed in COPD patients.

Results

We found a significant relationship between COPD stages and BODE index. Our analysis showed significant association between systemic biomarkers and components of the BODE index. Both TNF-α and CRP levels exhibited weak but significant correlation with BODE index. Serum IL-6 concentrations exhibited significant correlation with 6-minute walking test, modified scale of Medical Research Council, and BODE index (r=0.201, P=0.004; r=0.068, P=0.001; and r=0.530, P=0.001, respectively). Also, an inverse and significant correlation was observed between BODE index and FEV1 (r=0.567, P=0.001). IL-6 exhibited a highly significant and inverse correlation with FEV1 (r=−0.580, P=0.001).

Conclusion

BODE index should be considered for evaluating patients with COPD. Also, IL-6 seems to be a potential biomarker that may enable determination of the severity and prediction of the course of the disease.

The Effect of Folic Acid Supplementation on Hyperhomocysteinemia and Pulmonary Function Parameters in Chronic Obstructive Pulmonary Disease: A Pilot Study

INTRODUCTION

Preliminary studies have established the elevated plasma total Homocysteine (tHcy) levels as a risk factor for Chronic Obstructive Pulmonary Disease (COPD). However, studies describing plasma tHcy levels and their relationship to folic acid supplementation and Forced Expiratory Volume in 1 Second (FEV1) status in COPD patients are still lacking.

AIM

We investigated the role of hyperhomocysteinemia in COPD and then prospectively examined the relationship between plasma tHcy concentration and effect of folic acid supplementation on FEV1 status in COPD patients.

MATERIALS AND METHODS

This was a prospective case-control study with 50 clinically stable patients of COPD attending the chest clinic of the hospital and 30 healthy controls. The study was done at Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi, India, from August 2011 to February 2013. Plasma levels of Hcy were measured by Enzyme Linked Immuno-Sorbent Assay (ELISA) method. All the subjects were given folic acid therapy (5mg daily) for six weeks duration and were followed up. Repeat plasma Hcy and FEV1 were measured after six weeks.

RESULTS

COPD patients had higher baseline plasma tHcy concentration than controls (Mean: 27.42±23.89μmol/L, versus 15.21±15.71μmol/L, p<0.001) and COPD was associated with higher tHcy concentrations also after adjusting for smoking, and age. The mean BMI of the patients was 21.36±4.26kg/m². The mean Hcy values decreased from 27.42±23.89μmol/L to 15.2±15.71μmol/L (p-value=0.001) after six weeks of folic acid supplementation. However, no significant change was observed in FEV1 upon folic acid supplementation (FEV1=1.14±0.60 and 1.08±0.56 respectively; p-value=0.654). A significant correlation was observed between BMI and Hcy and also between plasma Hcy levels at the baseline and after six weeks of folic acid supplementation (r=0.283, p=0.04 and r=0.340, p=0.02, respectively) and (r=0.840, p=0.001).

CONCLUSION

COPD patients seem to have a poor folic acid status and as a consequence high tHcy. Also, folic acid supplementation has shown decreased plasma tHcy concentrations, but not necessarily significant change in FEV1.

Markers of Oxidative Stress and Clinical Outcome in Critically ill Septic Patients: A Preliminary Study from North India

INTRODUCTION

Sepsis is the leading cause of mortality in non-coronary Intensive Care Units (ICUs). Oxidative stress is one of the important features in pathogenesis of sepsis.

AIM

This study was undertaken to evaluate levels of oxidants and antioxidants in patients with sepsis admitted to ICU.

STUDY DESIGN

This was a non-interventional clinical case-control study undertaken at a tertiary level teaching hospital in New Delhi, India.

MATERIALS AND METHODS

Forty-six consecutive non-pediatric patients admitted to ICU with sepsis were included and subjected to detailed history, physical examination and investigations. Blood samples were drawn to evaluate oxidant Malondialdehyde (MDA) and antioxidant (alpha-tocopherol) levels. Acute Physiology and Chronic Health Evaluation II (APACHE II) and Organ Dysfunction and/or Infection (ODIN) scores were calculated and patients followed up for outcomes. Twenty age and sex matched healthy subjects served as controls.

RESULTS

Mean levels of malondialdehyde were higher in patients than controls (17.2±3.8nm/ml versus 4.6±1.6nm/ml, p<0.001) while levels of alpha-tocopherol were lower (3.2±1.3μg/ml versus 9.9±2.0μg/ml, p<0.001). The mean APACHE II and ODIN scores were 18.1±9.3 and 1.7±1.3 respectively in patients. These scores were two to three fold higher in non survivor patients (n=22) in comparison with survivors (n=18) (p<0.001). There was no significant difference between the two groups in oxidants and antioxidants levels (p>0.05). However, a significant and positive correlation was observed between oxidant -antioxidant levels and APACHE II, ODIN and International Normalized Ratio (INR) scores in septic patients overall.

CONCLUSION

The oxidants in septic patients were significantly higher while antioxidants were significantly lower than healthy controls. There was also a significant correlation with APACHE II and ODIN scores. A large patient population based study may draw more specific conclusions.

Unusual association of Turner syndrome and Mayer-Rokitansky-Küster-Hauser syndrome

Gonadal dysgenesis and Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) are the most common causes of primary amenorrhoea. Patients with gonadal dysgenesis present with primary amenorrhoea and lack of secondary sexual characteristics, which, in contrast, are present in patients with MRKHS. The coexistence of the 2 syndromes has been reported in only a few studies so far. We describe a case of a 15-year-old girl who presented with short stature and primary amenorrhoea. Investigations revealed hypergonadotropic hypogonadism, and absence of the uterus, and upper two-thirds of the vagina, with presence of the rudimentary lower third of the vagina and non-visualised bilateral ovaries on imaging. Karyotyping obtained by lymphocyte culture GTG banding revealed 45X/46XX. The patient was diagnosed as having a rare case of gonadal dysgenesis with MRKH. She was started on growth hormone therapy. The association of these syndromes is uncommon, and has further implications on fertility and pregnancy, affecting the quality of life.

Abstract A32: NISCH promoter hypermethylation, smoking and lung cancer: A case control study

Lung cancer is the most common cancer worldwide, both in terms of incidence and mortality. The high mortality of lung cancer is attributable to the presence of metastatic disease in nearly two thirds of patients at diagnosis. Detection of early stage lung cancer amenable to curative resection could potentially result in a manifold increase in survival rates.

Epigenetic alterations seemingly contribute to cancer initiation and progression. Cancer specific methylation patterns of tumor suppressor genes, which precede precursor lesions, could possibly herald earlier diagnosis of lung cancer and may even have important preventive or therapeutic implications.

Our aim was to evaluate the promoter hypermethylation of tumor suppressor gene NISCH in cfDNA from plasma of lung cancer patients and its possible correlation with smoking status and various clinicopathological parameters. NISCH codes for a nonadrenergic imidazoline-1 receptor protein nischarin that anchors to the inner layer of the plasma membrane. The orthologous mouse protein has been shown to bind alpha-5 beta-1 integrin and influence cytoskeletal organization.

Forty histopathologically confirmed lung cancer cases were enrolled along with thirty smoker and thirty nonsmoker controls. Plasma cfDNA was extracted and subjected to bisulfite treatment followed by conventional methylation specific PCR. DNA methylated using CpG methylase by the whole genome methylation protocol, was used as positive control and Nuclease free PCR grade water was used as negative control. The serum nischarin levels were estimated using commercially available ELISA kits. Statistical analysis was performed using SPSS 22.0 software.

We observed that frequency of promoter hypermethylation of tumor suppressor NISCH was significantly higher in lung cancer patients and in non-cancerous smokers as compared to lifelong nonsmoker controls. This difference in methylation status of NISCH between lung cancer cases, smoker and nonsmoker controls was found to be significant (P&lt;0.05).

There was no significant association between methylation status of tumor suppressor gene NISCH and clinicopathologic variables- staging, tumor size, lymph node status, metastasis and histopathological grading. We observed a higher frequency of NISCH methylation in adenocarcinoma as compared to Squamous Cell Carcinoma.

Methylation status of tumor suppressor gene NISCH was found to be significantly higher among smokers as compared to nonsmokers. But there was no significant difference in the frequency of NISCH methylation between smoker lung cancer patients and nonsmoker lung cancer patients. There was no significant difference in methylation status of NISCH with type or duration of smoking. The pack years and packs per day were significantly higher in those with methylated NISCH as compared to the unmethylated group.

There was no significant association of serum nischarin levels with methylation status of NISCH, demographic variables or any clinicopathological parameters.

Our findings suggest that NISCH methylation occurs in high frequencies in cfDNA from plasma of lung cancer patients. Though it was not found to correlate with stage, tumor size, lymph node status, metastases or histological grade, it was found to be significantly associated with adenocarcinomas in our study. Hence, NISCH methylation could serve as a part of blood based biomarker panel for early diagnosis of lung cancer.

In addition, since NISCH is found to be highly methylated in both high risk heavy smoker controls as well as lung cancer cases irrespective of smoking status, it can be hypothesized that NISCH methylation may be the common primogenitor at which varied etiologies for lung cancer converge. Hence, in the future, it may be investigated as a universal therapeutic target for lung cancers regardless of clinicopathological heterogeneity.

Citation Format: Kritika Krishnamurthy, TK Mishra, Alpana Saxena, MK Daga, Nita Khurana, Masroor Mirza. NISCH promoter hypermethylation, smoking and lung cancer: A case control study. [abstract]. In: Proceedings of the Fourth AACR International Conference on Frontiers in Basic Cancer Research; 2015 Oct 23-26; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2016;76(3 Suppl):Abstract nr A32.

Multi-detector computed tomography imaging of large airway pathology: A pictorial review

The tracheobronchial tree is a musculo-cartilagenous framework which acts as a conduit to aerate the lungs and consequently the entire body. A large spectrum of pathological conditions can involve the trachea and bronchial airways. These may be congenital anomalies, infections, post-intubation airway injuries, foreign body aspiration or neoplasms involving the airway. Appropriate management of airway disease requires an early and accurate diagnosis. In this pictorial essay review, we will comprehensively describe the various airway pathologies and their imaging findings by multi-detector computed tomography.

Anaplastic Thyroid Carcinoma (ATC) with Superior Vena Cava (SVC) Syndrome, Cardiac Tamponade and Pleural Effusion: An Unusual Clinical Presentation

Superior vena cava (SVC) syndrome and cardiac tamponade are potentially life-threatening conditions that are not uncommon in the oncological setting but their occurrence together in a patient is infrequent. Herein, we present a case of 50-year-old male who presented with SVC syndrome and pleural effusion; developed recurrent cardiac tamponade in the hospital. Fine needle aspiration cytology (FNAC) of left supraclavicular lymph node which appeared during hospital stay revealed high grade carcinoma and diagnosis of anaplastic thyroid carcinoma was established by FNAC of thyroid nodule. Despite rarity, clinicians must be aware of such presentation of thyroid malignancy.

Blastic Phase of CML with Microfilaria: A Rare Case Report

Filariasis is a major public health concern in tropical and subtropical countries including India. There have been very few case reports of incidental filariasis in the bone marrow aspirate smears in patients with hematological malignancies. We present a case of blastic phase of chronic myeloid leukemia (CML) with associated filariasis with monocytosis. Such an association, to the best of our knowledge, is hitherto unreported. Moreover, eosinophilia was not a feature in our case. A 37-year-old male, diagnosed case of CML, presented with low grade fever, weight loss and abdominal distension for one month. Physical examination revealed massive splenomegaly and hepatomegaly. However, there was no lymphadenopathy. His hemoglobin was 10.5 g/dl, total leukocyte count was 52.31x 109 / L with platelet count of 30x 109/L .Differential leukocyte count on peripheral smear showed 21% blasts, 30% polymorphs, 16% lymphocytes, 1% myelocyte, 1%metamyelocyte, 30%monocytoid cells and 1% eosinophils. Bone marrow aspirate smears were diluted with peripheral blood and showed blasts and monocytoid cells constituting 25% and 15% of marrow nucleated cells respectively. In addition, occasional microfilaria of Wuchereria bancrofti were also seen both in the peripheral blood and aspirate smears. Based on the above findings, a diagnosis of blastic phase of CML with monocytosis with microfilaria of W.bancrofti. Hence this was an unusual case of CML blastic phase which was associated with filariasis. Moreover, inspite of having filariasis and CML, patient lacked eosinophilia and instead showed monocytosis, which is hitherto unreported.

Anaplastic large T-cell lymphoma presenting as an isolated osseous involvement: a case report and review of the literature

This case describes a 50-year-old man with multiple lytic bone lesions involving the skull, pelvis and ribs and associated features of anaemia, hypercalcaemia, azotaemia and subsequently found to be non-Hodgkin's lymphoma of anaplastic large T cell type (ALCL) on biopsy taken from a soft tissue mass in the anterior chest wall as an aetiology. We report this case with an aim to expand our knowledge of isolated osseous involvement in case of non-Hodgkin's lymphoma. This case was unique in the sense of an isolated osseous involvement in ALCL without any organomegaly and lymphadenopathy with a normal bone marrow biopsy finding. So in rare instances, T-cell lymphoma can present with a multiple lytic lesion, anaemia, hypercalcaemia. Although B-cell non-Hodgkin's lymphoma can present with the above manifestation, it is extremely rare for T-cell non-Hodgkin's lymphoma.

Prevalence and correlates of tobacco smoking, awareness of hazards, and quitting behavior among persons aged 30 years or above in a resettlement colony of Delhi, India

AIM

To assess the prevalence and correlates of current smoking, awareness of hazards, and quitting behavior among smokers 30 years and above.

MATERIALS AND METHODS

STUDY DESIGN

Cross-sectional;

SETTING

Gokulpuri, a resettlement colony in East Delhi, India;

SAMPLE SIZE

911, persons aged 30 years and above using systematic random sampling; Study tools: Semi-structured questionnaire.

RESULTS

Prevalence of current smoking was found to be 24.6% (95% CI 21.90 - 27.49). Majority 198 (88.4%) of current smokers smoked bidi exclusively, and on an average 13.5 bidi/cigarette were smoked per day. Multivariate analysis showed the factors associated with current smoking as male sex, advancing age, illiteracy, skilled occupation, low socio-economic status, and low BMI (P < 0.001). 64.2% were aware of the hazards of smoking. 63 (21.9%) had quit smoking in the past, majority due to the health problems. Low educational status was associated with poor hazard awareness and quitting behavior.

CONCLUSION

Smoking is a significant problem among poor and illiterate males, shows an increasing trend with an advancing age and is directly associated with skilled occupation and low BMI. There are significant gaps in knowledge regarding hazards of smoking.

A study of autonomic nervous system status in children of asthmatic parents

Asthmatic patients are known to have autonomic abnormalities. This study evaluated the status of autonomic nervous system in children of asthmatic parents for any occurrences of autonomic abnormalities that are known to occur in asthma. In this study autonomic function tests were conducted in children (5 to 10 years of age) divided into two groups: Group A had children from non-asthmatic parents as Control Group and Group B had children from asthmatic parents as Test Group. Both the groups had healthy children showing no clinical signs and symptoms of asthma, allergy or any illness known to affect autonomic nervous system. In response to various parasympathetic function tests (S/L ratio, 30:15 ratio, valsalva ratio and tachycardia ratio) and sympathetic function tests (handgrip test and cold pressor test) done, the two groups did not show any statistically significant dissimilarity for any of the parameters. The results of our study showed that there were no autonomic abnormalities found in the children of asthmatic parents. Thus this study indicates that the autonomic defects seen in asthmatics could be secondary to asthma and not because of autonomic aberrations inheritance in asthmatics as shown by earlier few studies supporting the possible role of inherited automatic reactivity in the pathogenesis and progression of asthma.

A rapidly developing lung mass diagnosed as desmoplastic small round cell tumor

We present a case of a young male who presented with complaints of fever along with cough and sputum. He was diagnosed with having right pleural effusion. He was already taking anti-tubercular therapy for one month before presentation. He was started on intravenous antibiotics and continued on anti-tubercular therapy in our hospital, based on his high leukocyte count, pleural fluid analysis, and ultrasonographic report of multiple hypoechoic areas in the liver. His symptoms continued to worsen and he subsequently developed mediastinal widening and a left lung mass. Commuted tomography (CT)-guided biopsy of the lung mass revealed a desmoplastic small-round-cell tumor. Desmoplastic small-round-cell tumor is a rare and aggressive tumor, which presents rarely as a mediastinal and lung mass. This tumor has very poor prognosis.

Diagnosis of Novel Pandemic Influenza Virus 2009 H1N1 in Hospitalized Patients

A real-time RT-PCR assay was standardized and evaluated for the detection of the recent pandemic 2009 H1N1 strain that circulated around the world causing colossal loss of human life. We amplified the conserved regions of the hemagglutinin (HA) gene of 438 clinical specimens using real-time RT-PCR assay for rapid identification of pandemic influenza virus. The real-time RT-PCR was optimized and the primers and probes were tested against a panel of known negative and positive controls. RNA isolated from the HeLa cell line served as quality control. The conventional RT-PCR which is an established method of influenza virus diagnosis was compared to real-time RT-PCR. Of 438 clinical specimens tested, 212 specimens were found positive for influenza A virus (SD 46.669) in which 139 specimens were diagnosed positive for the pandemic 2009 H1N1 while 73 were the seasonal influenza viruses. We report that the real-time RT-PCR assay offers both, a high sensitivity and specificity when compared with the traditional identification method. The real-time RT-PCR assay allows rapid identification of the pandemic swine 2009-H1N1 at very low viral loads that are negative by the traditional RT-PCR. This optimized assay can be a very useful tool to assist both epidemiologists and the clinicians.

Endomyocardial fibrosis

We present a case report of a 26-year-old male from Bulandsahar, India. The patient presented with right heart failure. Evaluation revealed peripheral eosinophilia. An echocardiogram and MRI showed biventricular hypertrophy with obliteration of the ventricular apices, typical of endomyocardial fibrosis. This condition is rare in Bulandsahar, India.

Effect of omeprazole and domperidone on adult asthmatics with gastroesophageal reflux

AIM: To study the effect of combined omeprazole (Ome) and domperidone (Dom) therapy on asthma symptoms and pulmonary function in asthmatics with gastroesophageal reflux.

METHODS: We selected 198 asthmatics with gastroesophageal reflux diagnosed by 24-h esophageal pH monitoring to receive Ome 20 mg twice daily and Dom 10 mg three times daily or placebo for 16 wk (1:1 double-blind randomization). Spirometry was done at baseline and after 16 wk of treatment. The primary outcome measures were: mean daily daytime and nighttime asthma symptom scores. Mean daily reflux symptom scores, albuterol use as rescue medication (number of puffs), daytime and nighttime peak expiratory flow rate (PEFR), postbronchodilator forced expiratory volume in 1 second (FEV₁) and postbronchodilator forced vital capacity (FVC) were secondary outcome measures.

RESULTS: Comparison of mean change from baseline between antireflux therapy and placebo groups revealed significant reduction in daytime asthma symptom score (17.4% vs 8.9%), nighttime asthma symptom score (19.6% vs 5.4%), reflux symptom score (8.7% vs 1.6%) and rescue medication use (23.2% vs 3.1%) after antireflux therapy compared to mean change in placebo group (P < 0.001). There was significant improvement in morning PEFR (7.9% vs 0.2%), evening PEFR (9.8% vs 0.5%), FEV₁ (11.1% vs 3.78%) and FVC (9.3% vs 1.52%) in the antireflux therapy group compared to placebo on comparing the mean change from baseline after 16 wk (P < 0.01).

CONCLUSION: Combined therapy with Ome and Dom in adult asthmatics with gastroesophageal reflux may be beneficial by reducing asthma symptoms, rescuing medication use, and improving pulmonary function.

Emerging role of vasopressin

Ionotropic agents are frequently used in vasodilatory shock like conditions of septic or nonseptic origin. Conventional catecholamines such as norepinephrine are used at a very high dose with possibility of adverse effects in many patients. One often encounters refractoriness to these drugs. Infusion of vasopressin (VP) which is detectable at inappropriately low level in advanced phase of septic shock might allow withdrawal of catecholamines, as it maintains adequate mean arterial pressure (MAP), improves urine output and leaves perfusion of vital organs unhindered. Vasopressin has been found to be superior to epinephrine in animal models and some human trials, especially in patients with resistant ventricular fibrillation (VF) while doing cardiopulmonary resuscitation (CPR). Analogues of VP have also been used for diuresis in patients of hepatorenal syndrome.

The 2003 outbreak of Dengue fever in Delhi, India

Dengue fever (DF) and Dengue hemorrhagic fever (DHF) are widespread in Southeast Asia. An outbreak of DF/DHF in Delhi in 2003 started during September, reached its peak in October-November, and lasted until early December. This study describes the clinical and laboratory data of the 185 cases of DF/DHF admitted to Lok Nayak Hospital, New Delhi. The mean age of the patients was 26 +/- 10 years. Fever was present in all the cases with an average duration of fever being 4.5 +/- 1.2 days with headache (61.6%), backache, (57.8%), vomiting (50.8%) and abdominal pain (21%) being the other presenting complaints. Hemorrhagic manifestations in the form of a positive tourniquet test (21%), gum bleeding and epistaxis (40%), hematemesis (22%), skin rashes (20%) and melena (14%) were also observed. Hepatomegaly and splenomegaly were observed in 10% and 5% of cases, respectively. Laboratory investigations revealed thrombocytopenia (with a platelet count of < 100,000/microl) in about 61.39% of cases, Leukopenia (WBC <3,000/mm2) and hemoconcentration (Hct >20% of expected for age and sex) were found in 68% and 52% of the cases, respectively. The mortality rate was 2.7%. Despite widespread measures taken to control outbreaks of DF, it caused major outbreaks. More stringent measures in the form of vector control, improved sanitation and health education are needed to decrease morbidity, mortality and health care costs caused by a preventable disease.

Effect of esmolol on oxidant status and antioxidant activity in acute myocardial infarction

AIMS AND OBJECTIVES

The role of oxygen free radicals in reperfusion injury to the heart in myocardial infarction (MI) has been postulated. In this study, the clinical and antioxidant effects of esmolol, an ultra-short acting beta blocker in patients of acute MI was studied.

MATERIAL AND METHODS

This was a randomized, double-blind, controlled, prospective study. Total 30 patients with acute MI were included. All patients were thrombolysed with streptokinase. Fifteen of these patients were randomly selected to receive esmolol while other 15 patients served as controls. The parameters compared at 0, 2 and 24 hours between the esmolol group and the controls were--malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione peroxidase (GPX).

RESULTS

Patients with MI had 5.16 times higher MDA level at 0 hours (20.34 +/- 6.12 nmol/ml vs. 3.94 +/- 0.70 nmol/ml, p < 0.0001) than MDA level in normal healthy population. At 2 hours, patients with MI had 5.71 times higher MDA level compared to normal healthy population (22.51 +/- 5.51 nmol/ml vs. 3.94 +/- 0.70 nmol/ml, p < 0.0001). A statistically significant difference in MDA levels at 2 and 24 hours was observed in MI patients given esmolol (mean change 2.06 +/- 5.39 nmol/ml vs. -4.47 +/- 6.93 nmol/ml, p = 0.009). Esmolol infusion also caused significant difference in GPX level at 2 hours compared to controls (23.79 + 14.68 U/gm Hb vs 38.3 +/- 8.95 U/gm Hb, p = 0.003).

CONCLUSION

Free radical levels are raised in patients with MI which may contribute to reperfusion injury. The antioxidant action of esmolol was clearly observed by significant difference in MDA level and GPX sparing effect. Large scale clinical trials may establish conclusively role of beta blockers as antioxidants as adjuvant to thrombolytic therapy in MI.