Tacrolimus Concentration/Dose Ratio: A Tool for Guiding Tacrolimus Dosage Post-renal Transplantation.

Background The calcineurin inhibitor, Tacrolimus (Tac), exhibits variable absorption and undergoes first-pass metabolism when administered orally. The narrow therapeutic window and individual variability of this immunosuppressive agent make therapeutic drug monitoring essential. We hypothesized that the Tac metabolism rate - defined as the blood concentration normalized by its daily dose (the C/D ratio) - is associated with post-renal transplant (RTx) function. Methodology A retrospective observational study was conducted including 40 RTx patients. Clinical reports from four follow-up ambulatory appointments at one, three, six, and 12 months were analyzed. Tac dose and its blood levels were used to calculate the Tac concentration/dose (C/D) ratio. Patients with a Tac C/D ratio <1.05 ng/mL x 1/mg and a C/D ratio >1.05 ng/mL x 1/mg were categorized as fast and slow metabolizers. Serum creatinine levels were compared between the two groups, and their association with the Tac C/D ratio was analyzed. Student's unpaired t-test and the Mann-Whitney U test were used to analyze the difference in the C/D ratio between the groups. Spearman correlation analysis was conducted to analyze the association of the C/D ratio with serum creatinine in both groups. A P-value of <0.05 was considered statistically significant. Results Fast metabolizers showed increased serum creatinine (P < 0.05), and the C/D ratio correlated with creatinine levels. ROC analysis used to identify fast metabolizers for the C/D ratio at three months had an area of 0.925 (P < 0.01). Conclusions The Tac C/D ratio can be used as an earlier diagnostic tool to predict the development of nephrotoxicity in RTx patients.

Assessing the Burden of COVID-19 among Children Aged 6-14 Years in Karnataka, India: A Cross-sectional Survey.

Background: India experienced three coronavirus disease (COVID-19) waves, with the third attributed to the highly contagious Omicron variant. Before the national vaccination rollout for children above 6, understanding severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG) positivity in the pediatric population was essential. This study aims to assess the burden of Covid-19 infection and to estimate the seroprevalence in children aged 6 to 14 years in the state of Karnataka. Material and Methods: We surveyed 5,358 children aged 6-14 across Karnataka using 232 health facilities, from June 6 to 14, 2022. We determined the sample size using the PPS (Population Proportional to Size) technique and employed cluster sampling. We tested all participants for SARS-CoV-2 IgG with an enzyme-linked immunosorbent assay (ELISA) kit and SARS-CoV-2 RNA with reverse transcription-polymerase chain reaction (RT-PCR). We sequenced samples with a cycle threshold (CT) value below 25 using whole genomic sequencing (WGS). Result: We found an adjusted seroprevalence of IgG at 75.38% statewide, and we found 0.04% of children RT-PCR positive for COVID-19. We determined a case-to-infection ratio of 1:37 and identified the SARS-CoV-2 strains as Omicron, BA.5, and BA.2.10. Conclusion: The study showed a high seroprevalence of IgG among children with low active infection. Omicron, BA. 5, and BA. 2.10 variants were detected through WGS.

The Effectiveness of Adjuvant Attangaogam (Athanam) Yoga Asana-Pranayamam Practices With Regard to Biochemical, Inflammatory, and Hematological Markers Among COVID-19 Patients at a Tertiary Care Hospital in Southern Tamilnadu.

Background and objective Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a highly contagious infectious disease that has affected many countries globally. Attangaogam, known in Sanskrit as "Ashtanga yoga", is a practice associated with the spiritual and cultural heritage of India whose origins can be traced back to the very dawn of civilization; the practice of yoga promotes health, healing, and longevity. This study aimed to analyze the effects of Attangaogam (Athanam) yoga asana-Pranayamam practice on biochemical, inflammatory, and hematological markers in the management of COVID-19. Materials and methods A prospective observational study was conducted from August 2021 to February 2022 among hospitalized adult patients of both sexes who consented to participate and tested positive for COVID-19 reverse transcription-polymerase chain reaction (RT-PCR). Convenience sampling was employed and the study was approved by Institutional Ethics Committee (VMCIEC/74/2021). Clinical details, inflammatory markers, D-dimer, lactate dehydrogenase (LDH), ferritin, procalcitonin (PCT), interleukin 6 (IL-6), and complete blood count (CBC) were analyzed for all the volunteering patients on admission and before commencing yoga-pranayamam practices. Also, the parameters were recorded after practicing the scheduled protocol: on the day of discharge, and after the first and third months of discharge. Microsoft Excel 2013 was used for statistical analysis. Results Of the 76 patients, 32 were followed up regularly; the mean age of the cohort was 50.6 ± 4.95 years, and 62% were males. All the patients attained normal oxygen saturation and got discharged in 7-14 days. The comparison of clinical, hematological, inflammatory, and biochemical investigations between pre- and post-Attangaogam yoga-Pranayamam practice sessions showed statistically significant differences and the patients attained normal levels for all variables within three months except for serum albumin. Conclusion Based on our findings, the practice of Attangaogam yoga-Pranayamam contributed to the successful treatment of COVID-19 with the early restoration of protracted hypermetabolic and hyperinflammatory markers to normal status. The evidence related to biomarkers revealed that the patients attained metabolic normalcy of cell health with the aid of personalized physical rehabilitation counteracting inflammation and promoting tissue repair thanks to holistic natural and innate immunity provided by Attangaogam yoga-pranayamam practices.

Comparison of Serum Urea, Salivary Urea, and Creatinine Levels in Pre-Dialysis and Post-Dialysis Patients: A Case-Control Study.

Background Frequent venepuncture for monitoring of serum urea and creatinine in chronic kidney disease (CKD) patients on dialysis will result in venous damage and infection. In this research, we assessed the feasibility of utilizing salivary samples as a substitute for serum samples in determining the levels of urea and creatinine in patients with CKD undergoing dialysis. Methods The study participants included 50 patients diagnosed with CKD undergoing hemodialysis and an equal number of apparently healthy individuals. We measured the serum and salivary levels of urea and creatinine in normal subjects. CKD patients were also subjected to similar investigations both before and after hemodialysis. Results In our study, we found that the mean value of salivary urea and creatinine are significantly elevated in the case group (salivary urea: 99.56 ± 43.28 mg/dL, salivary creatinine: 1.10 ± 0.83 mg/dL) as compared to the control group (salivary urea: 33.62 ± 23.84 mg/dL, salivary creatinine: 0.15±0.12 mg/dL, p value: <0.001). There was a statistically significant reduction in the mean value of salivary urea and creatinine in the post-dialysis sample (salivary urea: 45.06 ± 30.37 mg/dL, salivary creatinine: 0.43±0.44 mg/dL) compared to the pre-dialysis sample (salivary urea: 99.56 ± 43.28 mg/dL, salivary creatinine: 1.10 ± 0.83 mg/dL; p value: <0.001) in the case group. The salivary urea is significantly positively correlated with serum urea (r value: 0.366, p value: 0.009). But there is no significant correlation seen between salivary and serum creatinine. We have created a cut-off for salivary urea (52.5 mg/dL) to diagnose CKD which has a good sensitivity (84%) and specificity (78%). Conclusion The results of our study suggest that the estimation of salivary urea and creatinine could serve as a non-invasive, alternative marker for the diagnosis of CKD, and benefit in risk-free monitoring of their progress before and after hemodialysis.

Utility of Biochemical Markers in Predicting Severe COVID-19: Experience from a Tertiary Hospital in South India.

Background: Coronavirus Disease 2019 (COVID-19) patients can present with a wide array of symptoms. For laboratory investigation of these patients several biochemical tests are routinely requested. Here we wanted to evaluate the utility of procalcitonin (PCT), ferritin, D-dimer, interleukin 6 (IL-6) and total lactate dehydrogenase (LDH) activity in predicting severe COVID-19 infection. Patients and methods: This study was undertaken at a tertiary care medical hospital in Tamil Nadu, India representing 183 COVID-19 RT-PCR positive patients, who were grouped based on their disease severity as mild (n=21), moderate (n=115) and severe (n=47) cohorts. All routine clinical chemistry analysis was performed as part of routine baseline assessment. Biomarkers of inflammation and infection were tested via the measurement of IL-6, PCT, ferritin, and D-dimer. Serum IL-6 concentration was estimated by ELISA, while total LDH activity was analyzed by kinetic colorimetric assay. Serum ferritin, PCT and D-dimer were measured by fluorescent immunoassay by sandwich immuno-detection method. Results: Biomarkers were significantly different among subgroups, and the highest concentrations were found in those with intensive care unit (ICU) admission. Serum PCT showed the best power to predict the need for ICU treatment followed by D-dimer, IL-6 and total LDH. Based on the AUC-ROC analysis, mortality was most effectively indicated by D-dimer followed by PCT, LDH, IL-6 and ferritin. Conclusion: Our study highlights the utility of some routinely available biochemical tests in the management of severe COVID-19. The higher baseline values of these biomarkers hint towards the probability of severe infection and a larger risk of death.

Assessment of Mineral Pathophysiology in Patients with Diabetic Foot Ulcer.

Chronic non-healing diabetic foot ulcers (DFU) with a recurrence rate of over 50% in 3 years account for more than 1,08000 non-traumatic lower extremity amputations. Reports of altered mineral status and their role in pathogenesis of diabetes are well documented. However, little is known regarding their status and impact on severity of complications like foot ulcer. A hospital-based case control study was conducted in 64 subjects aged 40-60 years, attending the Podiatric and the Diabetes clinic of the institutional hospitals. Study subjects included were 32 diagnosed cases of type 2 diabetes having foot ulcers along with 32 age-matched diabetics without foot ulcer as controls. Fasting and post-prandial plasma glucose were estimated by glucose oxidase peroxidase method and HbA1c by high-performance liquid chromatography method. Serum zinc, magnesium and copper levels were estimated by colorimetric methods in semi-autoanalyser. Serum levels of zinc, copper and magnesium were significantly decreased in DFU cases as compared with diabetics without ulcers (p < 0.05). Correlation analysis revealed a significant inverse correlation of these minerals with all the glycaemic indices; the association being the strongest in case of zinc in both groups. The higher degree of mineral insufficiencies in the foot ulcer group of this study could be responsible for worsening the glycaemic control in diabetics leading to delayed healing of foot ulcers. The observed decrease of serum copper, magnesium and zinc levels in diabetics with foot ulcers appears to be proportionally related to the length of the diabetic disease. Thus, continuous monitoring and dietary supplementation of minerals in case of severe deficiencies might be beneficial in halting the progression of such complications.

Effect of DOTS Treatment on Vitamin D Levels in Pulmonary Tuberculosis.

INTRODUCTION: Vitamin D (Vit D) modulates a variety of processes and regulatory systems including host defense, inflammation, immunity, and repair. Vit D Deficiency (VDD) is been implicated as a cause in diabetes, immune dysfunction and Tuberculosis (TB). Impaired metabolism of Vit D and an adverse outcome is associated with Pulmonary Tuberculosis (PTB). Directly Observed Treatment Short Course (DOTS) consist of drugs like rifampicin and isoniazid, which respectively cause accelerated loss of Vit D due to increased clearance and impairment of 25-hydroxylation causing diminished Vit D action. AIM: The aim of the present study was to estimate and compare serum Vit D status in newly diagnosed PTB patients before and after DOTS to validate the supplementation of Vit D in PTB patients. MATERIALS AND METHODS: Forty four newly diagnosed PTB patients of both the sexes in the age group of 18 to 60 years before starting DOTS were recruited to participate in this non- randomized controlled trial with their voluntary consent. Vit D status in these patients and the effect of DOTS on Vit D were evaluated. RESULTS: Mean Vit D levels of the study population aged 43±13 years was 20.74 ng/ml (normal >30 ng/ml) at the time of diagnosis. After completion of six months of therapy mean Vit D reduced to 17.49 ng/ml (p-value=0.041). On individual observations, 70% of the participants showed a decrease in Vit D levels from their baseline, whereas 30% showed an increase. Comparison between the two groups indicated the possible role of younger age in the improved status. CONCLUSION: VDD was seen in PTB patients, which worsened in majority of the study population after treatment; hence it would be advisable to recommend Vit D supplementation in PTB patients for a better outcome.

Spontaneous Tumor Lysis Syndrome in an Infant: A Case Report.

Tumor lysis syndrome has been observed in patients with malignancies with high cellular burden and high cell turnover, tumor sensitive to therapy, especially after initiating medical treatment. It very rarely occurs spontaneously. The case described here is of 6 months male infant who presented with fever since 1 month and loose stools associated with blood since 15 days. The laboratory investigations showed lactate dehydrogenase (LDH) of 6,192 IU/L and serum uric acid 18.2 mg/dl along with pancytopenia. The infant presented with electrolyte abnormalities and renal failure.

Bronze diabetes.

Thalassemia is a group of disorders characterized by deficient production of the ß-globin sub unit of hemoglobin. The mandatory blood transfusions in patients with thalassemia to maintain adequate erythrocyte levels, leads to iron overload. The prevalence of diabetes in patients with thalassemia varies from 6 to 14%. We here by present a known case of thalassemia major in an 18 year old boy. He was diagnosed with thalassemia before the age of one year and is on regular blood transfusion every two weeks since then. The repeated blood transfusion is one of the common causes for haemochromatosis. Iron overload initially leads to glucose abnormalities such as insulin resistance and hyperinsulinemia, which is followed by impaired secretion of insulin. Diagnosed as a case of bronze diabetes, this patient is on insulin therapy for the last two years. Currently the patient is on iron chelation therapy at Kasturba Medical College Hospital, Mangalore, Karnataka, India.

Beneficial effect of Omega-3 polyunsaturated fatty acids on neurosensorial impairments and oxidative status in Streptozotocin induced diabetic rats.

OBJECTIVES: The present study evaluated the beneficial effects of omega 3 PUFA present in fish oil on neurosensorial impairments, namely learning, memory and anxiety in Streptozotocin (STZ) induced diabetic rats. The brain homogenate was analysed for oxidative status following Omega 3 PUFA treatment. METHODS: Male, Wistar rats of 2-3 months old were divided into non diabetic controls, diabetic control, & fish oil treated diabetic rats (n = 6). Diabetes was induced by injection of STZ (48 mg/kg, ip). Animals were treated orally for 30 days with a dose in each group of 0.5 g/kg/day of fish oil. All experiments were conducted after ethical committee clearance was obtained. RESULTS: Memory and exploratory behavior were improved (p < 0.01) in fish oil treated rats as compared with diabetic rats. A significant (p < 0.001) decrease in MDA and a significant increase (p < 0.001) in total antioxidant level (TAO) were observed in fish oil treated rats. CONCLUSION: Omega 3 PUFA present in fish oil could be used an adjuvant therapy for treatment and prevention of neurosensorial impairment in diabetes mellitus.

Lead poisoning mimicking acute porphyria!

We are presenting a case of a 13-year-old autistic boy whose urine porphyrin test came positive on three separate occasions. The child was brought to emergency department of Kasturba Medical College Hospital, Attavar, Mangalore, India, with fever and acute abdominal pain, with no previous history of any serious illness. Investigations revealed thalassemia trait,microcytic hypochromic anaemia while the other biochemical and haematological parameters were normal. False positive urine porphyrin test may be seen in porphyria induced by liver cancer, hepatitis and heavy metal poisoning such as lead, arsenic and mercury. Blood lead (PbB) level was 59.5µg/dl. Further evaluation revealed a daily consumption of native medicine in the form of syrup.

Unique distribution by the peroneal nerves: a case report.

PURPOSE: Among the branches of common peroneal nerve, the superficial peroneal provides cutaneous innervation to major part of the dorsum of the foot and deep peroneal nerve supplies the skin over the first interdigital cleft region. METHODS: The present rare case was observed during routine dissection of leg for undergraduate students, in a 52-year-old male, formalin fixed cadaver. RESULTS: The superficial peroneal nerve provided solely motor branches to peroneus longus and brevis, whereas cutaneous branches were provided by deep peroneal nerve. In the lower one-third of the leg deep peroneal nerve divided into medial and lateral branches. The medial branch supplied tibialis anterior and the lateral branch supplied skin of medial three and half toes. Moreover, the sural nerve supplied the skin of lateral one and a half toes. CONCLUSION: Awareness of this type of variations in the course of nerves helps to alert the surgeons when there are complaints of atypical or unique pain in that particular region.

Development of matrix type transdermal patches of lercanidipine hydrochloride: physicochemical and in-vitro characterization.

BACKGROUND AND THE PURPOSE OF THE STUDY: Lercanidipine hydrochloride (LRDP) is used in the treatment of hypertension because of its selectivity and specificity on the smooth vascular cells. The pharmacokinetic parameters make LRDP a suitable candidate for transdermal delivery. The purpose of the study was to select a suitable formulation for the development of transdermal drug-delivery system (TDDS) of LRDP and to determine the effect of penetration enhancer, limonene on drug permeation METHODS: The matrix type TDDS of LRDP were prepared by solvent evaporation technique. Formulations A1, A2, A3, A4, A5 and A6 were composed of Eudragit RL100 (ERL) and hydroxypropyl methyl cellulose (HPMC) in 1.5:8.5, 3:7, 4:6, 6:4, 7:3 and 8.5:1.5 ratios respectively. All the six formulations carried 10 mg of LRDP/patch area, 8% v/w of d-limonene as a penetration enhancer, 20% v/w of propylene glycol as plasticizer in methanol and dichloromethane as solvent system. The prepared TDDS were evaluated for physicochemical characteristics, in-vitro release, ex-vivo permeation and skin irritation. The ex-vivo permeation studies were carried out across excised rat skin using Franz diffusion cell. RESULTS: All the formulations exhibited satisfactory physicochemical characteristics. Cumulative percentage of the drug released in 24 hrs from the six formulations were 82.0%, 74.9%, 63.2%, 63.5%, 59.8% and 53.5% respectively. Corresponding values for the cumulative amounts of the drug permeated across the rat skin for the above matrix films were 2644.5, 2347.2, 2249.5, 1933.4, 2021.5 and 1663.4 µg/cm(2) respectively. By fitting the data into zero order, first order and Higuchi model, it was concluded that drug release from matrix films followed Higuchi model and the mechanism of the drug release was diffusion mediated. The patches were seemingly free of potentially hazardous skin irritation. CONCLUSIONS: The patches composed of ERL, HPMC (1.5:8.5) with 8% v/w limonene as penetration enhancer may be selected for the development of TDDS of LRDP for potential therapeutic use by using a suitable adhesive layer and backing membrane.

Accessory Head of Flexor Pollicis Longus Muscle and its Significance in Anterior Interosseous Nerve Syndrome: Case Report and Review / Cabeza Accesoria del Músculo Flexor Largo del Pulgar y su Significancia en el Síndrome del Nervio Interóseo Anterior: Reporte de Caso y Revisión

During the laboratory dissection of the fore arm, an accessory head of flexor pollicis longus muscle has been observed unilaterally in the right upper limb of a male cadaver. It took its origin from the under surface of flexor digitorum superficialis muscle just distal to the origin of this muscle from medial epicondyle. On further dissection we have noticed that, the accessory belly was running downwards to the medial aspect of the tendon of flexor pollicis longus muscle for its insertion. Its possible role in anterior interosseous syndrome is discussed in detail with a brief review.

Durante una disección en el laboratorio se encontró en el antebrazo derecho de un cadáver de sexo masculino una cabeza accesoria del músculo flexor largo del pulgar. Ésta se originaba de la superficie profunda del músculo flexor superficial de los dedos, inmediatamente distal al origen de este músculo en el epicónddilo medial. El vientre accesorio se dirigía hacia abajo medial al tendón del músculo flexor largo del pulgar hasta su inserción. Se discute detalladamente su posible rol en el síndrome interóseo anterior.