Early Trends to Show the Efficacy of Cordyceps militaris in Mild to Moderate COVID Inflammation.

Background/objective Cordyceps enhances animal survival against influenza by boosting the immune system. In animal studies, it also had anti-inflammatory and preventive properties. Cordyceps stimulates the immune system by increasing the activity and production of various immune cells. Some studies have shown the role of Cordyceps in the novel SARS-CoV-2 virus responsible for the COVID-19 pandemic, in addition to other respiratory diseases caused by the Picorna viruses, SARS-CoV, MERS-CoV, and Influenza viruses. However, it remains unknown whether this food supplement is safe and has anti-inflammatory effects in patients with COVID-19. Therefore, the objectives of this study were to evaluate the use and efficacy of Cordyceps capsules as an adjunct to standard treatment in patients with mild (symptomatic) to moderate COVID-19 infection. Methods A randomised, double-blind, placebo-controlled study was conducted to evaluate the efficacy and safety of Cordyceps capsules (a food supplement) 500 mg as adjuvant therapy in patients with COVID-19. The rationale for dose selection was as per the existing evidence from toxicity studies. The inclusion criteria were patients with either a mild or moderate COVID-19 infection. Clinical features suggestive of dyspnoea or hypoxia, fever, and cough, including SpO2 <94% (range 90-94%) on room air and a respiratory rate ≥24 per minute, were also included. Results Sixty-five patients were recruited for the study, with 33 in the Cordyceps group and 32 in the placebo group. Out of 58 evaluable patients, 33 recovered on day 5, 49 on day 10, and 58 on days 16 and 30. The recovery of patients steadily increased from 56.9% on day 5 to 100% on day 30. The time to clinical recovery was shorter in the Cordyceps group than in the placebo group (mean 6.6 vs. 7.3 days; p > 0.05) overall and for mild disease. However, there was no difference in the time to recovery (time from day 1 to the resolution of all symptoms) for moderate disease. A lower frequency of normal chest X-rays on day 1 and a higher number on day 16 in the treatment group than in the placebo group suggest an improvement in the number of normal chest X-rays with Cordyceps. Significant changes were seen in biomarkers MCPIP, CxCL10, and IL-1ß for overall (both mild and moderate patients) on days 5 and 10 as compared to baseline, and in biomarkers CRP and CxCL10 in moderate category patients on days 5 and 10, respectively. There were no statistically significant changes in IL-6, ferritin, lactate dehydrogenase (LDH), C-reactive protein (CRP), or D-dimer levels between baseline and day 5/10 in patients taking Cordyceps capsules and also between the treatment and placebo groups. Conclusion Cordyceps capsules administered at a dose of 500 mg three times a day along with supportive treatment showed effectiveness in patients with mild to moderate COVID-19 infection, as evidenced by the proportionately higher number of recoveries on day 5, the relatively shorter time for improvement of clinical symptoms, and the proportionately higher number of patients showing negative RT-PCR tests on day 10. Thus, Cordyceps appears to be a safe immunological adjuvant for the treatment of patients with mild-to-moderate COVID-19. Future studies with a larger sample size would shed more light on the evidence, as there are limitations in the generalizability of the results from the present study due to the small sample size.

Macroscopic to Microscopic - A Case of Crohn's Disease Progressing to Collagenous Colitis.

The association between microscopic colitis (MC) and inflammatory bowel disease (IBD) is uncertain and infrequently reported. Rare cases in the literature consist of simultaneous MC and IBD, or progression of one condition to the other. We present a unique case of clinically and endoscopically diagnosed and successfully treated IBD that revealed MC on histology months later due to reappearance of diarrhea. Common pathophysiologic mechanisms, such as tumor necrosis factor α and T helper type 1 cells, may explain the MC and IBD relationship. During endoscopy, a prompt biopsy should be taken if suspicious for MC, thus decreasing the duration of patient's symptoms and saving healthcare costs.

Educational intervention can improve appropriateness of acid suppression therapy in hospitalized geriatric patients.

Background: Inappropriate use of acid suppression (AST) therapy may lead to unnecessary harms, especially in the geriatric population. Despite this, AST remains one of the most commonly prescribed medications in the hospital. Therefore, we aimed to assess its prevalence and create educational intervention to improve the appropriateness of inpatient acid suppression therapy. Methods: Using a time-series design, we established a historical control by performing a retrospective chart. Accepted indications for AST were based on those endorsed by the USA Food and Drug Administration and literature review. Inclusion criteria were: (1) age ≥ 65; (2) acid suppression therapy-initiated in the hospital; and (3) patients admitted to the medicine teaching services. We then created an educational intervention, which consisted of lectures and distribution of information pocket cards to residents. Data was collected for two months after the intervention. We used a two-tail fisher exact test and student's t-test to analyze our results. Results: 65% of geriatric patients were inappropriately placed on acid suppression therapy, for which 13% were discharged without further indications. After the educational intervention, the inappropriate use of acid suppression therapy decreased to 45% (P < 0.05). Conclusion: There is a significant overuse of AST in hospitalized geriatric patients. Educational interventions are one potential method that may help improve the appropriateness of acid suppression therapy for elderly inpatients.

Role of opioids as coinduction agent with propofol and their effect on apnea time, recovery time, and sedation score.

BACKGROUND: Laryngeal mask airway (LMA) is a supraglottic device which requires lesser depth of anaesthesia, evokes lesser hemodynamic response and causes lesser stimulation of airway as compared to traditional definitive airway device endotracheal tube. Its placement is possible without muscle relaxants thereby allowing maintenance of anaesthesia on spontaneous respiration thus preventing apnoea or minimizing apnoea time. Propofol, the commonly used induction agent, causes cardiorespiratory depression at higher induction doses. To attenuate this, co-induction agents combined with propofol has been a regular I/V anaesthetic technique these days. AIM: Comparing apnoea time, recovery time and sedation scores using propofol-fentanyl and propofol-butorphanol combination. METHODOLOGY: Hundred patients scheduled for various elective surgical procedures were randomly selected and divided into two groups of 50 each. As coinduction drug Group F received fentanyl and Group B received butorphanol. In both the groups induction was achieved with I/V propofol and LMA was placed. Apnoea time was noted after induction. Recovery time and sedation scores were recorded after anaesthetic agents were turned off. RESULTS: As compared to group F apnoea time was significantly less and recovery time was significantly more in group B (P < 0.05). Statistically postoperative sedation was significantly higher in group B than in group F at 1/2 hr but clinically, majority were responding to verbal commands. At 1 hour no significant difference in sedation was noted between the groups. CONCLUSION: Considering respiratory and recovery profile propofol -butorphanol combination is a safer alternative to propofol-fentanyl combination for LMA insertion.

Mallory-Weiss tear after violent hiccups: a rare association.

We present an unusual case of a 44-year-old male who developed violent hiccups soon after a ureteroscopy for nephrolithiasis; later, the forceful hiccups were followed by hematemesis. Upper esophagogastroduodenoscopy revealed Mallory-Weiss tears and esophageal erosions in the lower esophagus. Esophageal biopsy was unremarkable. The patient did not have a prior history of the gastrointestinal disorder. Although extracorporeal shock wave lithotripsy has on rare occasion been implicated in the development of gastrointestinal erosions, no such correlation exists for ureteroscopy and upper gastrointestinal bleeding in the management of nephrolithiasis. It was the development of violent hiccups for several hours before the onset of hematemesis that likely led to the upper gastrointestinal bleed.

Guide Wire Induced Cardiac Tamponade: The Soft J Tip Is Not So Benign.

Central venous catheter (CVC) insertion rarely causes cardiac tamponade due to perforation. Although it is a rare complication, it can be lethal if not identified early. We report a case of cardiac tamponade caused by internal jugular (IJ) central venous catheter (CVC) insertion using a soft J-tipped guide wire which is considered safe and rarely implicated with cardiac tamponade. A bedside transthoracic echocardiogram (TTE) revealed a pericardial effusion with tamponade. An emergent bedside pericardiocentesis was done revealing bloody fluid and resulted in clinical stabilization.

Esophageal Microperforation due to Calcified Mediastinal Lymph Node Leading to Tracheoesophageal Fistula.

A 42-year-old male presented with worsening gastroesophageal reflux disease symptoms and cough. The clinical symptoms during the early course of illness were striking for aspiration pneumonia. He was given a prescription of proton pump inhibitors and antibiotics. Rapid decline in the clinical condition with worsening respiratory status was noted. Worsening symptoms of fever, cough, and chest pain prompted further diagnostic work-up suggesting esophageal microperforation. Esophagogram was found to be suggestive of tracheoesophageal fistula. The tracheoesophageal fistula was due to subcarinal lymph node of nontuberculous origin.

What happens to the hemodynamic responses for laryngeal mask airway insertion when we supplement propofol with butorphanol or fentanyl for induction of anesthesia: A comparative assessment and critical review.

BACKGROUND: There is a delicate balance between respiratory tract anatomy, its physiology, physiological response to anesthetic agents, and airway management. The traditional gadgets to secure airway are face masks or endotracheal tubes. Recently, laryngeal mask airway (LMA) is gaining popularity. It does not require laryngoscopy thereby minimizing hemodynamic responses. For LMA placement, propofol is the induction agent of choice. Propofol, when used alone, requires large doses and leads to undesirable cardiorespiratory depression. To culminate its dose, various adjuncts are combined with it. AIM: Comparison of hemodynamic response of LMA using either butorphanol or fentanyl (according to group allocated) in combination with propofol. METHODOLOGY: Hundred patients scheduled for various surgical procedures were randomly selected and divided into two groups of 50 patients each, Group F (propofol and fentanyl) and Group B (propofol and butorphanol). One minute after giving intravenous (IV) opioids, induction was achieved with IV propofol 2.5 mg/kg. Depth of anesthesia was assessed, and LMA was inserted. Hemodynamic variables were measured before premedication, after premedication; 1, 3, and 5 min after insertion and after extubation of LMA. RESULTS: After insertion of LMA, statistically significant drop in mean heart rate, systolic blood pressure (BP), diastolic BP, and mean BP was noted in Group F as compared to Group B (P < 0.05). CONCLUSION: The use of propofol-butorphanol combination produces stable hemodynamics as compared to propofol-fentanyl combination.

The 2014 Academic College of Emergency Experts in India's INDO-US Joint Working Group (JWG) White Paper on "Developing Trauma Sciences and Injury Care in India".

It is encouraging to see the much needed shift in the understanding and recognition of the concept of "burden of disease" in the context of traumatic injury. Equally important is understanding that the impact of trauma burden rivals that of nontraumatic morbidities. Subsequently, this paradigm shift reinstates the appeal for timely interventions as the standard for management of traumatic emergencies. Emergency trauma care in India has been disorganized due to inadequate sensitivity toward patients affected by trauma as well as the haphazard, nonuniform acceptance of standardization as the norm. Some of the major hospitals across various regions in the country do have trauma care units, but even those lack protocols to ensure that all trauma cases are handled by those units, largely owing to lack of structured referral system. As a first step to reform the state of trauma care in the country, a detailed overview is needed to gain insight into the prevailing reality. The objectives of this paper are to thus weave a foundation based on the statistical and qualitative burden of trauma in the country; the available infrastructure of trauma care centers equipped to deal with trauma; the need and scope of standardized protocols for intervention; and most importantly, the application of these in shaping educational initiatives in advancing emergency trauma care in the country.

Characteristics of patients who died from traumatic brain injury in two rural hospital emergency departments in Maharashtra, India, 2007-2009.

INTRODUCTION: Trauma is one of the leading causes of morbidity and mortality in the world and in India. OBJECTIVE: To describe 1) selected epidemiological and clinical characteristics of persons with traumatic brain injury (TBI) who died within 24 h after admission to the emergency departments (EDs) of two medical facilities in rural India and 2) the methods used to transport these patients from the locale of the injury incident to the study sites. MATERIALS AND METHODS: Medical records of all injured patients regardless of age or sex who died within 24 h after admission to both EDs during January 31, 2007 through December 31, 2009 were reviewed and abstracted. Demographic variables and information on prehospital care, time and mechanism of injury, mode of transport to EDs, and primary hospital resuscitation were abstracted and analyzed. RESULTS: Of the 113 injured patients in this study, 42 had TBI and died within 24 h of ED admission. All of these TBI patients were transported to the ED by relatives or bystanders in non-ambulance vehicles. Most of the patients with TBI (78.5%) were 21-50-years-old; and overall 90.0% were males. Persons working near or along busy roads struck by vehicles accounted for 80.9% of all TBI cases. Severe TBIs were present in 97.6% of the patients; of these, 92.8% had a Glasgow Coma Scale (GCS) score of 3 on arrival. Other concurrent injuries included superficial lacerations (85.7%), facial injuries (57.1%), and upper (35.7%) and lower (30.9%) extremity fractures. Common lesions recognized on computed tomography (CT) scan were acute subdural hematoma (21.4%), subarachnoid hemorrhage with diffuse cerebral edema (16.6%), and skull base fracture with diffuse cerebral edema (14.2%); in 21.4% of cases, the CT scan were reported normal. CONCLUSION: Most of the TBI patients who died within 24 h after admission to EDs in this study were not transported to EDs in emergency medical vehicles; most were of working age (ages 20-50 years); were male; and were day laborers working on busy interstate roads where they were hit by vehicles.

An unforgettable concurrence: Successfully managed gallstone ileus accompanied by diabetic nephropathy.

BACKGROUND: Gallstone ileus is an uncommon complication of gall stones associated with potentially serious morbidity and mortality. CASE REPORT: We reported a 60-year-old male case who presented with renal failure and pain in right hypochondriac region. He also had a history of brain infarcts along with diabetes which is an additional factor for mortality. On Computed Tomography of the abdomen, he was diagnosed to have cholecystocholedochal fistula including air in the gall bladder and obstruction in the distal part of the ileum. Computed tomography plays an important role to make the proper diagnosis and in treatment. CONCLUSIONS: As in our case, diagnosis was challengeable because of renal failure,diabetes, septicaemia and intestinal obstruction (peritonitis). We did surgery on the basis of peritonitis which remains the only choice in such cases. In follow- up of 1 month patient was doing well and asymptomatic.

Epidemiology and clinical characteristics of traumatic brain injuries in a rural setting in Maharashtra, India. 2007-2009.

CONTEXT: Though some studies have described traumatic brain injuries in tertiary care, urban hospitals in India, very limited information is available from rural settings. AIMS: To evaluate and describe the epidemiological and clinical characteristics of patients with traumatic brain injury and their clinical outcomes following admission to a rural, tertiary care teaching hospital in India. SETTINGS AND DESIGN: Retrospective, cross-sectional, hospital-based study from January 2007 to December 2009. MATERIALS AND METHODS: Epidemiological and clinical data from all patients with traumatic brain injury (TBI) admitted to the neurosurgery service of a rural hospital in district Wardha, Maharashtra, India, from 2007 to 2009 were analyzed. The medical records of all eligible patients were reviewed and data collected on age, sex, place of residence, Glasgow Coma Scale (GCS) score, mechanism of injury, severity of injury, concurrent injuries, length of hospital stay, computed tomography (CT) scan results, type of management, indication and type of surgical intervention, and outcome. STATISTICAL ANALYSIS: Data analysis was performed using STATA version 11.0. RESULTS: The medical records of 1,926 eligible patients with TBI were analyzed. The median age of the study population was 31 years (range <1 year to 98 years). The majority of TBI cases occurred in persons aged 21 - 30 years (535 or 27.7%), and in males (1,363 or 70.76%). Most patients resided in nearby rural areas and the most frequent external cause of injury was motor vehicle crash (56.3%). The overall TBI-related mortality during the study period was 6.4%. From 2007 to 2009, TBI-related mortality significantly decreased (P < 0.01) during each year (2007: 8.9%, 2008: 8.5%, and 2009: 4.9%). This decrease in mortality could be due to access and availability of better health care facilities. CONCLUSIONS: Road traffic crashes are the leading cause of TBI in rural Maharashtra ffecting mainly young adult males. At least 10% of survivors had moderate or more severe TBI-related disabilities. Future research should include prospective, population based studies to better elucidate the incidence, prevalence, and economic impact of TBI in rural India.

Simultaneous hemorrhage in intracranial aneurysms and in renal cyst in a case of polycystic kidney disease.

We report an unusual case of simultaneous hemorrhage in intracranial aneurysms and in renal cyst in a case of polycystic kidney disease. A 27-year-old gentleman presented with progressive headache and intermittent vomiting of one month duration. Initial computerized tomography (CT) scan and magnetic resonance imaging/angiography revealed a large mass lesion in the right temporal fossa. Over the previous 15 days, he developed progressive weakness in his left upper and lower limbs, and the headache worsened in severity. A repeat of CT scan showed an evidence of aneurysmal bleed and a large temporal lobe hematoma. The patient underwent urgent evacuation of the intracerebral of hematoma and excision of the redundant aneurysmal sac. The patient made excellent recovery in the post-operative period; however, for him, the pain abdomen was persisting. Detailed work-up with contrast-enhanced abdominal CT scan revealed bilateral multiple cysts in the kidneys with evidence of intracystic hemorrhage on the left side. An extensive search of the literature revealed that this kind of presentation has not been reported previously.

Treating traumatic injuries of the diaphragm.

Traumatic diaphragmatic injury (DI) is a unique clinical entity that is usually occult and can easily be missed. Their delayed presentation can be due to the delayed rupture of the diaphragm or delayed detection of diaphragmatic rupture, making the accurate diagnosis of DI challenging to the trauma surgeons. An emergency laparotomy and thorough exploration followed by the repair of the defect is the gold standard for the management of these cases. We report a case of blunt DI in an elderly gentleman and present a comprehensive overview for the management of traumatic injuries of the diaphragm.

Giant solitary neurofibroma presenting as a neck mass in an infant.

Solitary neurofibroma is a rare tumor of the head and neck region. It is more common in viscera, where it is associated with features of NF1. It occurs most often between the third and fourth decade. These lesions are extremely rare in infants. We report a case of giant, solitary neurofibroma presenting as a progressive mass in parotid region in an infant. This case is unique in its age of presentation (11 months), site, size (about 8 × 15 cm) without any symptoms or neurological deficit.

Double breasting repair of urethral fistula in a patient with perineal abscess secondary to a large urethral stone.

We report here a case of urethral fistula managed successfully following incision and drainage for the urethral abscess secondary to a large urethral stone leading to a large diverticulum (another rare condition) by using the technique of double breasting, where we used the redundant urethra and overlying skin.

Blunt trauma to the parotid gland in child.

Blunt trauma to the parotid gland is extremely rare and requires considerable force. We present a unique case in which a child sustained parotid injury without any associated injury to the facial skeleton, parotid gland and ductal structures and managed successfully. A literature search revealed that this type of injury has not been reported previously.