Effect of Continuous Infusion vs Bolus Dose of Hydrocortisone in Septic Shock: A Prospective Randomized Study.

Aim and background: Corticosteroids are recommended for use in adult patients with septic shock requiring vasopressors for blood pressure maintenance. However, this predisposes them to hyperglycemia, which is associated with a poor outcome. This prospective randomized study compares the effect of continuous infusion with bolus hydrocortisone on blood glucose levels in septic shock. Materials and methods: Forty adult patients with sepsis and septic shock requiring vasopressor support were randomly allocated to either group C (continuous infusion of hydrocortisone 200 mg/day) or group B (intermittent bolus dose of hydrocortisone 50 mg IV 6 hourly). Blood glucose level (primary objective), number of hyperglycemic and hypoglycemic episodes, daily insulin requirement, shock reversal incidence, time to shock reversal, and nursing workload required to maintain blood glucose within the target range (82-180 mg/dL) were compared. Results: The mean blood glucose level was comparable in the two groups (136.5 ± 22.08 mg/dL in group C vs 135.85 ± 19.06 mg/dL in group B; p = 0.921). The number of hyperglycemic and hypoglycemic episodes (p = 1.000 each), insulin requirement/day (p = 1.000), and nursing workload (p = 0.751) were also comparable among groups. Shock reversal was seen in 7/20 (35%) patients in continuous group and 12/20 (60%) patients in bolus group (p = 0.113). Time to shock reversal (p = 0.917) and duration of ICU stay (p = 0.751) were also statistically comparable. Conclusion: Both the regimes of hydrocortisone, continuous infusion, and bolus dose, have comparable effects on blood glucose levels in patients with septic shock.The study was registered prospectively with ctri.nic.in (Ref. No. CTRI/2021/01/030342; registered on 8/1/2021). How to cite this article: Salhotra R, Sharahudeen A, Tyagi A, Rautela RS, Kemprai R. Effect of Continuous Infusion vs Bolus Dose of Hydrocortisone in Septic Shock: A Prospective Randomized Study. Indian J Crit Care Med 2024;28(9):837-841.

Minimum effective dose of intrathecal hyperbaric bupivacaine for cesarean section with and without prophylactic norepinephrine infusion: Randomized triple-blinded trial.

Background and Aims: Vasopressor usage can affect the rostral spread of intrathecal drug and, hence, its requirement during cesarean delivery. Although a decreased spread is evidenced with phenylephrine, there is no data for norepinephrine usage. The present study aimed to evaluate the minimum effective dose of intrathecal hyperbaric bupivacaine for cesarean section with and without prophylactic norepinephrine infusion. Material and Methods: Patients scheduled for elective cesarean section under combined spinal-epidural block were randomized to receive intravenous infusion of norepinephrine (0.05 µg/kg/min) or normal saline (placebo), initiated immediately after intrathecal injection. Postspinal hypotension in either group (systolic arterial pressure ≤0.8 baseline) was treated with norepinephrine 4 µg rescue. Dose of intrathecal hyperbaric bupivacaine (0.5%) was decided for individual patients using up-and-down sequential allocation method. Primary outcome measure was the minimum effective dose of intrathecal hyperbaric bupivacaine (0.5%) defined as ED50, while secondary observations included spinal block characteristics and neonatal outcomes. Results: Demographic parameters were statistically similar between both groups (P > 0.05). ED50 of intrathecal hyperbaric bupivacaine was 7.8 mg (95% confidence interval [CI]: 6.7-8.8) and 7.4 mg (95% CI: 6.1-8.7) for normal saline and norepinephrine group respectively (P = 0.810). Block characteristics were similar between both groups as was neonatal APGAR score, but umbilical artery base excess was greater for norepinephrine versus normal saline group (-4.4 ± 3.6 vs. -6.5 ± 2.4, P = 0.038). Conclusion: Use of prophylactic norepinephrine (0.05 µg/kg/min) during cesarean delivery does not require adjustment of intrathecal hyperbaric bupivacaine.

Vasoactive-ventilation-renal (VVR) score: A potential tool for predicting early postoperative outcomes in adult mitral valve surgery.

Background and Aims: Vasoactive-ventilation-renal (VVR) score has been validated in predicting postoperative outcomes in pediatric cardiac surgery. The aim was to evaluate its potential in predicting early postoperative outcomes in adult patients undergoing mitral valve surgery. Material and Methods: A single-center prospective observational study involved 100 patients undergoing mitral valve surgery. We evaluated preoperative variables (Ambler score), VVR, and vasoactive-inotropic score (VIS) on admission to the intensive care unit (ICU) and then at 12, 24, and 48 hrs postoperatively. Outcomes assessed were length of stay in ICU (LOS-ICU), length of hospital stay (LOHS), and mortality. The data were analyzed using multivariable logistic regression model, receiver operating characteristic (ROC) curves, and areas under curve (AUC). Conclusion: Our study showed the potential utility of the VVR score as a powerful tool for predicting early outcomes after mitral valve surgery, with VVR at 48 hrs having superior predictive capability.

RETRACTED: Padghan et al. Pyrene-Phosphonate Conjugate: Aggregation-Induced Enhanced Emission, and Selective Fe3+ Ions Sensing Properties. Molecules 2017, 22, 1417.

The Molecules Editorial Office retracts the article "Pyrene-Phosphonate Conjugate: Aggregation-Induced Enhanced Emission, and Selective Fe3+ Ions Sensing Properties" [...].

Extraovarian Fibroma with Minor Sex Cord Elements-a Rare Tumour at Rare Site.

Sex cord stromal tumour (SCST) of ovary account for 5-8% of all ovarian malignancies. These include fibroma, thecoma, fibro-thecoma, Leydig cell tumour, granulosa cell tumour, and Sertoli cell tumour. Although considered primary ovarian malignancy, SCST has been described in extraovarian location also. Extraovarian SCST is a rare occurrence, and so far, only 25 cases have been reported in literature and only one amongst them was extraovarian fibroma with minor sex cord element. Considering the rarity, diagnosis and proper treatment remain the real challenge in these tumours. To the best of our knowledge, this is the second case of extraovarian fibroma with minor sex cord element to be reported. Herein, we report a case of 41-year-old lady who presented with large abdomino-pelvic mass which was considered ovarian tumour; however, intraoperatively both ovaries and uterus were found to be normal, and the mass was actually arising from sigmoid mesocolon.

Exploring Coracohumeral Ligament Elasticity Changes With Matrix Rhythm Therapy in Idiopathic Adhesive Capsulitis: A Case Report.

Idiopathic adhesive capsulitis is a complex pathology that combines inflammation and tightness of the ligamentous and capsular structures in the shoulder joint. Using methods like mobilization, strengthening exercises, and stretching modalities, physiotherapy is still the mainstay in treating adhesive capsulitis. However, novel treatment modalities are being used in various musculoskeletal conditions. This case study investigates the effectiveness of matrix rhythm therapy (MRT) in treating a 42-year-old female patient with idiopathic adhesive capsulitis by examining the elasticity of the coracohumeral ligament (CHL). The patient received six sessions of MRT over two weeks, in addition to stretching exercises for the CHL and capsular tissues. The modality's effectiveness was recorded using a universal goniometer for measuring the range of motion, the Numeric Pain Rating Scale (NPRS) to measure pain, and elastography to measure CHL thickness. Significant improvement in pain and range of motion was noted. Additionally, ultrasonographic evaluations revealed a substantial reduction in thickness from 1.9 mm to 0.9 mm and in CHL shear ratio from 2.94 to 0.40. MRT has shown a beneficial effect on CHL elasticity, which helped in the case of idiopathic adhesive capsulitis, showing a possibility as a viable technique for addressing deeper tissue involvement in shoulder disorders.

Distinct melanocyte subpopulations defined by stochastic expression of proliferation or maturation programs enable a rapid and sustainable pigmentation response.

The ultraviolet (UV) radiation triggers a pigmentation response in human skin, wherein, melanocytes rapidly activate divergent maturation and proliferation programs. Using single-cell sequencing, we demonstrate that these 2 programs are segregated in distinct subpopulations in melanocytes of human and zebrafish skin. The coexistence of these 2 cell states in cultured melanocytes suggests possible cell autonomy. Luria-Delbrück fluctuation test reveals that the initial establishment of these states is stochastic. Tracking of pigmenting cells ascertains that the stochastically acquired state is faithfully propagated in the progeny. A systemic approach combining single-cell multi-omics (RNA+ATAC) coupled to enhancer mapping with H3K27 acetylation successfully identified state-specific transcriptional networks. This comprehensive analysis led to the construction of a gene regulatory network (GRN) that under the influence of noise, establishes a bistable system of pigmentation and proliferation at the population level. This GRN recapitulates melanocyte behaviour in response to external cues that reinforce either of the states. Our work highlights that inherent stochasticity within melanocytes establishes dedicated states, and the mature state is sustained by selective enhancers mark through histone acetylation. While the initial cue triggers a proliferation response, the continued signal activates and maintains the pigmenting subpopulation via epigenetic imprinting. Thereby our study provides the basis of coexistence of distinct populations which ensures effective pigmentation response while preserving the self-renewal capacity.

A hepatocyte-specific transcriptional program driven by Rela and Stat3 exacerbates experimental colitis in mice by modulating bile synthesis.

Hepatic factors secreted by the liver promote homeostasis and are pivotal for maintaining the liver-gut axis. Bile acid metabolism is one such example wherein, bile acid synthesis occurs in the liver and its biotransformation happens in the intestine. Dysfunctional interactions between the liver and the intestine stimulate varied pathological outcomes through its bidirectional portal communication. Indeed, aberrant bile acid metabolism has been reported in inflammatory bowel disease (IBD). However, the molecular mechanisms underlying these crosstalks that perpetuate intestinal permeability and inflammation remain obscure. Here, we identify a novel hepatic gene program regulated by Rela and Stat3 that accentuates the inflammation in an acute experimental colitis model. Hepatocyte-specific ablation of Rela and Stat3 reduces the levels of primary bile acids in both the liver and the gut and shows a restricted colitogenic phenotype. On supplementation of chenodeoxycholic acid (CDCA), knock-out mice exhibit enhanced colitis-induced alterations. This study provides persuasive evidence for the development of multi-organ strategies for treating IBD and identifies a hepatocyte-specific Rela-Stat3 network as a promising therapeutic target.

Assessment of naturally occurring radionuclides in surface soil and drinking water from western part of Yadgir district Karnataka, India.

Radionuclide activity of the selected radionuclides 238U, 232Th and 40K was measured in surface soil samples collected from 40 villages of the western part of Yadgir district of Karnataka. A 4″ × 4″ NaI (Tl) detector based on a gamma spectrometer is used for the estimation of radionuclides. The major type of soil in this region is sandy and red. The 222Rn activity concentrations in drinking water were determined by the Emanometry method. The 222Rn activity in ground water is found to vary from 1.73 to 155.6 Bql-1. The total annual effective doses because of 222Rn inhalation and ingestion range from 4.72 to 424.84 µSv y-1 with an average value of 108.8 µSv y-1, respectively. Among the sampling stations, Shahapur and Shorapur soil samples show higher activity values than the Kembhavi and Hunasagi sampling stations soil samples.

A multi-centric, single-blinded, randomized, parallel-group study to evaluate the effectiveness of nasoalveolar moulding treatment in non-syndromic patients with complete unilateral cleft lip, alveolus and palate (NAMUC study): a study protocol for a randomized controlled trial.

BACKGROUND: Cleft lip and palate (CLP) are among the most common congenital anomaly that affects up to 33,000 newborns in India every year. Nasoalveolar moulding (NAM) is a non-surgical treatment performed between 0 and 6 months of age to reduce the cleft and improve nasal aesthetics prior to lip surgery. The NAM treatment has been a controversial treatment option with 51% of the cleft teams in Europe, 37% of teams in the USA and 25 of cleft teams in India adopting this methodology. This treatment adds to the already existing high burden of care for these patients. Furthermore, the supporting evidence for this technique is limited with no high-quality long-term clinical trials available on the effectiveness of this treatment. METHOD: The NAMUC study is an investigator-initiated, multi-centre, single-blinded randomized controlled trial with a parallel group design. The study will compare the effectiveness of NAM treatment provided prior to lip surgery against the no-treatment control group in 274 patients with non-syndromic unilateral complete cleft lip and palate. The primary endpoint of the trial is the nasolabial aesthetics measured using the Asher McDade index at 5 years of age. The secondary outcomes include dentofacial development, speech, hearing, cost-effectiveness, quality of life, patient perception, feeding and intangible benefits. Randomization will be carried out via central online system and stratified based on cleft width, birth weight and clinical trial site. DISCUSSION: We expect the results from this study on the effectiveness of treatment with NAM appliance in the long term along with the cost-effectiveness evaluation can eliminate the dilemma and differences in clinical care across the globe. TRIAL REGISTRATION: ClinicalTrials.gov CTRI/2022/11/047426 (Clinical Trials Registry India). Registered on 18 November 2022. The first patient was recruited on 11 December 2022. CTR India does not pick up on Google search with just the trial number. The following steps have to be carried out to pick up. How to search: ( https://ctri.nic.in/Clinicaltrials/advsearch.php -use the search boxes by entering the following details: Interventional trial > November 2022 > NAMUC).

The Accuracy of Casts Obtained Using Different Impression Techniques and Impression Materials in Combined Parallel and Angulated Implants: An In Vitro Study.

Aim The aim of this in vitro study was to evaluate and compare the accuracy of casts made from two elastomeric impression materials (polyvinyl siloxane (PVS) and vinylsiloxanether (VSE)) using different impression techniques on parallel and angulated implants. Materials and methods The reference model was fabricated using auto-polymerizing acrylic resin on which three implant analogs were placed of which two were parallel to each other and the third at 20-degree mesial angulation. A total of 60 impressions were made of which 30 were by using PVS and 30 by VSE. For each material, 10 impressions were made by closed tray technique, 10 by open tray technique and 10 by open tray with sandblasting and adhesive coating of the impression copings technique. The inter-analog distances of the casts obtained were evaluated and compared with the reference model by a vision measuring machine. Data were analyzed using analysis of variance (ANOVA), Tukey's Honest Significant Difference (HSD) post hoc and independent samples t-test. Results When the inter-analog distances of the duplicate casts were compared with the reference model, the mean error rates for parallel implants decreased in the order of closed tray technique, open tray technique and open tray with sandblasting and adhesive coating of the impression copings technique for both PVS and VSE impression materials. Similarly, the same order was observed for angulated implants for both impression materials. Using the closed tray technique, there was no statistically significant difference in the accuracy of the cast between the two materials for parallel implants (P = 0.525) and also no significant difference between the two materials for angulated implants (P = 0.307). Similarly, there was no statistically significant difference in the accuracy of the cast between the two materials for parallel implants (P = 0.455) and also no significant difference between the two materials for angulated implants (P = 0.519) using the open tray technique. Whereas for the open tray with sandblasting and adhesive coating of the impression copings technique, VSE produced a more accurate cast than PVS for parallel implants and was statistically significant (P = 0.033); however, there was no significant difference between the two materials for angulated implants (P = 0.375). Conclusion For parallel implants, VSE by an open tray with sandblasting and adhesive coating of the impression copings technique produced a more accurate cast than PVS. For angulated implants, there was no significant difference between the two materials and it was only the technique that significantly affected the accuracy of the cast.

Heterotopic Pancreas: Unusual Cause of Usual Diarrhoea.

Heterotopic pancreas (HP) also known as ectopic pancreas, pancreatic crest or accessory pancreas is the normal pancreatic tissue, found in a remote area other than its natural location, with no anatomic or vascular connection to main pancreatic tissue. It is a rare congenital anomaly and has been reported at many locations such as stomach (antrum) and small intestine. HP is usually an incidental finding and asymptomatic, however there are reports of pancreatitis, obstruction, perforation and malignant transformation as uncommon manifestations. Diagnosis of HP is primarily based on histological examination either by biopsy or surgical excision. Surgery is the standard treatment for symptomatic HP patients. Herein, we present a case of a 58-year-old female, who presented to us with intractable diarrhoea due to HP in the jejunum and underwent minimally invasive surgery for definitive diagnosis and treatment.

Gastric Schwannoma-Two Unusual Cases with Usual Presentation and Review of Literature.

Schwannomas, also known as neurilemmomas, are characteristically benign, slow growing neoplasms originating from Schwann cell sheath. Gastrointestinal schwannomas are very rare with stomach being the most affected organ representing approximately 0.2% of all gastric tumours. Malignant transformation is rarely reported in these tumors and complete surgical resection with negative margins is the recommended treatment. Herein, we report our experience of 2 cases of gastric submucosal spindle cell tumour (SMT), which were preoperatively assumed to be as gastrointestinal stromal tumor (GIST), however postoperatively confirmed as schwannoma on immunohistochemical examination.

Comparison of efficacy of ultrasound-guided platelet rich plasma injection versus dry needling in lateral epicondylitis-a randomised controlled trial.

PURPOSE: To assess whether Ultrasound guided dry needling is adequate for both common extensor tendon tears and tendinosis or whether ultrasound guided platelet rich plasma (PRP) has a superior outcome when compared to dry needling when there are tears of the common extensor tendon. MATERIALS AND METHODS: This is a single-centre, single-blinded, randomised controlled trial conducted between November 2018 and April 2020. 40 patients diagnosed with lateral epicondylitis based on clinical and sonographic features and having comparable baseline characteristics were randomly assigned to the two study groups (dry needling and PRP). Inclusion criteria were patients aged 20 years or more who were symptomatic for at least 3 months with sonographic evidence of lateral epicondylitis. Exclusion criteria were complete tear of common extensor tendon confirmed on ultrasound and presence of other associated diseases like osteoarthritis of shoulder and elbow. RESULTS: There was significant improvement in the visual analogue scale pain score in PRP group compared to the dry needling group at 9 months. However, this difference was not evident at 3 and 6 months follow-up. Mean improvement in common extensor tendon thickness in PRP group (5.1 mm at 3 months and 4.3 mm at 6 months) was slightly better than dry needling (4.4 mm at 3 months and 4.0 mm at 6 months). There was no difference in tear (if present) healing between both groups at 3 months. However at 6 months follow up, PRP demonstrated significant (mean-2.5) healing in tear compared to dry needling (mean-3.1). CONCLUSION: Two injections of Ultrasound guided PRP are more beneficial non operative treatment compared to ultrasound guided dry needling, in lateral epicondylitis.

In vitro comparative evaluation of apical leakage using a bioceramic sealer with three different obturating techniques: A glucose leakage model.

Context: Bioceramic sealers have improved sealing ability by forming an interfacial apatite layer that chemically bonds the sealer and radicular dentin thus decrease apical leakage. Aim: This study aims to evaluate and compare the apical leakage of Cerafill RCS bioceramic sealer and gutta percha when used with three different obturating techniques. Materials and Methods: Thirty-four extracted single-rooted premolars were decoronated and prepared up to size F3. Then, the specimens were randomly divided into 3 experimental groups (n = 10) cold lateral obturation technique, warm vertical obturation technique, single-cone obturation technique, positive and negative control groups (n = 2), according to the obturation technique used along with a bioceramic sealer. To evaluate apical leakage, all specimens were mounted in a glucose leakage model and assessed at 7 and 14 days using an ultraviolet-visible spectrophotometer. Statistical Analysis: The results were subjected to ANOVA/Kruskal-Wallis ANOVA; followed by post hoc analysis using Bonferroni correction. Results: Significant differences were found in the cumulative leakage of all the three experimental groups. Significantly higher leakage was found in groups obturated using single-cone obturation technique as compared to warm vertical compaction technique at both 7 and 14 days. Conclusions: Warm vertical compaction showed a better sealing result than single-cone obturation techniques at all observation periods.

SWOT analysis of ortho-K practice in India.

PURPOSE: Orthokeratology (ortho-K) has been well established as a methodology for myopia correction and control its progression. A SWOT analysis serves as a strategic planning tool for intervention hence the purpose of this study to establish and implement ortho-K practice in India. METHOD: The study was conducted between December 2020 and June 2021. A prospective questionnaire-based study was conducted to elicit the responses in the SWOT study. Based on focus group discussion a set of five statements under strengths, weaknesses, opportunities and threats were identified. These were closed ended questions were based on a 5-point likert scale. The Content Validation Index (CVI) was computed for each item taking those answers relevant with a score of three and four on the Likert scale and omitting those with a score of one and two on the Likert scale as non-relevant. RESULTS: Strengths: 'Ortho-K is an excellent option for myopia control' was agreed by more than 50% of respondents. 67% of respondents agreed that advanced topographers has made ortho-K lens fitting easier. Weakness: More than 60% agreed that Ortho-K practice involves investment in instrumentation like topographers and trial lenses. 50% agreed that due to multiple follow up patients may be lost to follow up. OPPORTUNITY: 'Pandemic has necessitated the need for optometrists to explore myopia control options such as ortho-K' was agreed by more than 50%. Threats: 'Reluctance from adults and parents to try overnight contact lenses for myopia correction/control' was agreed by more than 50% of respondents. 62% agreed that atropine is perceived as an effective myopia control option by majority of the Indian ophthalmologists. CONCLUSION: Ortho-K as an emerging modality for Myopia management in India through SWOT analysis, allows practitioners as well as CL industry to approach Ortho-K appropriately with novel designs and practice patterns that suits the market needs.

Pankey Mann Schuyler Philosophy-Based Prosthetic Rehabilitation for an Amelogenesis Imperfecta Patient: A Case Report.

This clinical case report presents the prosthetic rehabilitation of a 23-year-old male patient with generalized discolored and worn-out teeth, which were of aesthetic and functional concern. In collaboration with the Department of Oral Medicine and Radiology and Oral Pathology, this clinical condition was diagnosed as amelogenesis imperfecta (AGI). AGI is a genetic odontological disorder that is an epithelial derivative of the developed tooth bud with enamel malformation. AGI typically affects both deciduous and permanent teeth. Patients generally have aesthetic complaints and compromised chewing efficiency with loss of vertical dimension. Prosthetically rehabilitating an AGI patient is a multidisciplinary approach to regain aesthetics, phonetics, and mastication. This article describes the full mouth rehabilitation, following the Pankey Mann Schuyler philosophy, of the patient with AGI involving all teeth. Full mouth rehabilitation was planned to restore aesthetics, phonetics, and mastication in four phases. First was prosthetic rehabilitation of the mandibular anterior teeth, followed by the maxillary anterior, mandibular posterior, and, finally, maxillary posterior teeth.

Radon activity and their radiological doses in drinking water of Chitradurga district, Karnataka, India.

In this investigation, radon activity concentration, inhalation and ingestion doses due to intake of radon in drinking water have been estimated in the Chitradurga district drinking water by using radon Emanometry technique. The average radon concentrations vary from 1.81 ± 0.11 to 300.33 ± 4.56 Bql-1 with a mean value of 56.01 ± 2.44 Bql-1. Most of the radon concentration levels are within the World Health Organization (WHO) and European Union (EU) commission recommended level of 100 Bql-1. About 70% of the drinking water had radon concentration level higher than the United States Environmental Protection Agency (USEPA) recommended Maximum Contamination Limit (MCL) of 11.1 Bql-1. The annual ingestion dose varies from 0.38 to 63.03 µSvy-1 with an average value of 11.75 µSvy-1. The estimated annual ingestion dose is well within the WHO recommended reference level of 100 µSvy-1.