Effects of Different Anticoagulation Doses on Moderate-to-Severe COVID-19 Pneumonia With Hypoxemia.

Background COVID-19 is a prothrombotic disease that can cause thromboembolism and microthrombi, which could lead to multiorgan failure and death. Since COVID-19 is a relatively new disease, there are guidelines for anticoagulation dosing for COVID-19 patients without consensus on the dosing. We studied the effects of different doses of anticoagulation in hospitalized patients with COVID-19 pneumonia and hypoxemia on any differences in need for high-flow oxygen, mechanical ventilation, and mortality. We also analyzed the patient population who benefited most from anticoagulation. Methodology We performed a retrospective chart review of all patients who were admitted with the diagnosis of COVID-19 infection with positive polymerase chain reaction, pneumonia (confirmed either by chest X-ray or CT chest), and hypoxemia (oxygen saturation of <94%, while on room air). These patients were studied for outcomes (the need for high-flow oxygen, the requirement for mechanical ventilation, and overall mortality) for different doses of anticoagulation (prophylactic, escalated, and therapeutic). Results The sample consists of 132 subjects, predominantly males (116, 87%), with a mean age of 59 years and a standard deviation of 15. About one-third of the participants had diabetes, and more than 50% had hypertension. Additionally, 27 (20.3%) had a history of heart disease, and 70 (53%) of the subjects were admitted to the intensive care unit (ICU) at some point during the study. Among those admitted to the ICU, about 11 (8%) subjects required mechanical ventilation and 16 (12%) passed away during the study. Those who died had higher use of high-flow oxygen, noninvasive mechanical ventilation, and invasive mechanical ventilation and had a longer stay on mechanical ventilation. There was no significant difference in mortality or need for mechanical ventilation for any strategy of anticoagulation. Conclusions Different doses of anticoagulation did not show any statistically significant relationship between the need for mechanical ventilation and mortality. More patients on high-flow oxygen had received escalated doses of anticoagulation as compared to those who were not on high-flow oxygen. Anticoagulation levels did not have any statistically significant effect on overall survival of patients.

A Study of Clinical Presentation and Correlative Histopathological Patterns in Renal Parenchymal Disease.

Suspicion and subsequent detection of renal disease is by an assessment of the urinalysis and renal function in the clinical context. Our attempt in this study is to correlate initial presenting features of urinalysis and renal function to the final histopathological diagnosis. A retrospective analysis of 1059 native kidney biopsies performed from January 2002 to June 2015 at Amrita Institute of Medical Sciences was conducted. Correlative patterns between urinalysis, renal function, and final histopathological diagnosis were studied. Five hundred and eleven (48%) patients had nephrotic syndrome. Out of these, 193 (38%) had pure: nephrotic syndrome, 181 (35.8%) had associated microhematuria, 110 (21.7%) had microhematuria and renal failure, and 27 (5.3%) had only associated renal failure. Minimal change disease (MCD) (30%), membranous nephropathy (30%), and IgA nephropathy (29%) were the major diseases in the respective groups. Five hundred and five (47.6%) patients had subnephrotic proteinuria. Out of these, 29 (5.6%) had only subnephrotic proteinuria, 134 (27%) had additional microhematuria, 300 (59%) had subnephrotic proteinuria, microhematuria, and renal failure, and 42 (8%) had subnephrotic proteinuria with renal failure. Lupus Nephritis (45% and 40%) and IgA Nephropathy (32% and 21%) were the major disorders in the subgroups respectively. Forty-two patients (3.7%) were biopsied for isolated renal failure with bland urinary sediment. Cast nephropathy and acute interstitial nephritis were the major diseases. Out of 89 patients with diabetes who were biopsied, 15 (16.8%) had diabetic nephropathy, 45 (50.5%) had no diabetic nephropathy, and 29 (32.5%) had diabetic nephropathy along with a non-diabetic renal disease. Postinfectious glomerulonephritis was the major glomerular disease. IgA nephropathy (22.2%) and membranous nephropathy (15.5%) were the major diseases in patients with diabetes with no diabetic nephropathy. In our population, MCD and membranous nephropathy formed the majority of diseases in biopsied nephrotic syndrome. Added microhematuria did not seem to decrease the incidence of either disease on the whole. We found a significant number of patients with membranous nephropathy with nephrotic syndrome, microhematuria, and additional renal failure. IgA nephropathy formed a majority of cases with nephrotic syndrome, microhematuria, and renal failure. The presence of renal failure regardless of other abnormalities in urinalysis showed a trend toward IgA nephropathy. Membranous nephropathy may have a more varied presentation than was originally thought and IgA nephropathy presenting as nephrotic syndrome may not be uncommon. MCD is the major subgroup of diseases in the pediatric population and presents both as nephrotic syndrome as well as nephrotic syndrome with microhematuria. Thus, urinalysis and renal failure may be a valuable tool in assessing renal disease.

Hemodialysis outcomes and practice patterns in end-stage renal disease: Experience from a Tertiary Care Hospital in Kerala.

This study was planned to analyze the hemodialysis practice patterns from a tertiary care referral centre as there is very limited data from India. All patients of ESRD on maintenance hemodialysis (MHD) in dialysis unit at AIMS, Kochi, Kerala for a minimum period of 3 months were included. A total of 134 patients (M: F 2:1) with age of 20 to 84 years (Mean: 59.83; SD: 11.98) were studied. The most common causes of ESRD in study population were diabetic nephropathy (DN) (59.7%) followed by unclassified group (19.4%), chronic glomerulonephritis (CGN) (11.9%). Majority (81%) were initiated on MHD through temporary vascular access on emergency basis. Majority (79%) of the patients were on twice weekly MHD. The range of eGFR (ml/min/1.73 m2) at the time of initiation of MHD was 1.26-11.78 by CG formula and 2.18-16.4 by MDRD equation. The mean duration on hemodialysis was 37.16 months and 50.7% patients had died during the follow-up period (3-108 months). The mean survival time on hemodialysis was 40.31 months (SD = 26.69). The mean survival time was lower in diabetic nephropathy (35.93 months) than in non-diabetic renal disease (47.46 months). The most common causes of deaths were cardiovascular events (51.5%), and infections (26.5%). In conclusion, males outnumbered females, among those on hemodialysis. There was no significant difference in eGFR at initiation of MHD based on etiologies. Initiation of MHD via temporary access, presence of LVH, acute coronary syndrome, use of acetate dialysate, need for parenteral iron therapy had impact on mortality. Survival rates while on hemodialysis at end 1st, 3rd, 5th and 7th years were 87.31, 45.52, 21.64 and 7.46 percentages respectively.

A case of bronchiectasis needing lung isolation for cerebello pontine angle tumor excision: Anesthetic challenges.

The main goals of neuroanesthesia are the maintenance of adequate cerebral perfusion pressure, avoidance of hypercarbia, hypoxemia, and to provide better brain relaxation. Providing anesthesia for a patient with bronchiectasis needing lung isolation for craniotomy can be challenging. A 56-year-old male patient, case of right lung bronchiectasis with a right cerebello pontine angle tumor underwent excision in the left lateral position. Since he had severe bronchiectasis of the right lung, we had isolated the right lung using right-sided double lumen tube to avoid spillage. Intraoperative split lung test was performed to assess the right lung contribution on carbon dioxide (CO2) elimination and found that there was a significant contribution from the right lung. Hence, both lungs were ventilated to control CO2. The importance of lung isolation to prevent spillage and avoidance of one lung ventilation to control the arterial CO2 are highlighted in this case report. By providing a balanced anesthetic keeping both, the neurosurgical and thoracic concerns are important for better postoperative outcome.

Sensitivity of Interfibrillar and Subsarcolemmal Mitochondria to Cobalt Chloride-induced Oxidative Stress and Hydrogen Sulfide Treatment.

Oxidative stress plays a significant role not only in cardiovascular disease but also in non-communicable diseases, where it plays a significant role the mortality rate. Hydrogen sulfide, the biological gaseous signaling molecule that preserves mitochondria in its mode of action, is an effective cardioprotective drug. However, cardiac mitochondria comprise of two distinct populations, namely interfibrillar and subsarcolemmal mitochondria, which respond distinctly in cardiovascular disease. This study was designed to determine the direct impact of cobalt chloride-induced oxidative stress in isolated mitochondrial subpopulations with an intention to examine the efficacy of hydrogen sulfide in preserving interfibrillar and subsarcolemmal mitochondria functional activities when they were incubated as pretreated, co-treated and post-treated agent. Mitochondrial subpopulations were isolated from the heart of male Wistar rats and subjected to cobalt chloride treatment (500 µM) for 20 min, followed by incubation with 10 µM sodium hydrosulfide in three different ways (Pre, Co, and Post-cobalt chloride treatment). Mitochondrial oxidative stress was measured by the concentration of thiobarbituric acid reactive species, reduced glutathione and the activities of enzymes like superoxide dismutase, catalase and glutathione peroxidase. Mitochondrial membrane potential, swelling behavior and enzyme activities were measured to assess its function. The increased level of lipid peroxidation and the decreased level of reduced glutathione in cobalt chloride-induced group confirm the induction of oxidative stress and were more predominant in the subsarcolemmal mitochondria. Hydrogen sulfide treatment to interfibrillar and subsarcolemmal mitochondria preserved their functional activities, but the effect was prominent only with co-treated group. In conclusion, the present study demonstrated that subsarcolemmal mitochondria are more prone to oxidative stress and the co-treatment of the mitochondria with hydrogen sulfide preserved the enzyme activity in the in vitro conditions.

Thyrocervical artery - jugular fistula following internal jugular venous catheterization.

Arteriovenous fistula (AVF) is an anomalous communication between an artery and a vein, caused by an iatrogenic or traumatic etiology. Surgically created upper limb AVF remains the preferred vascular access for patients on maintenance hemodialysis. Nonetheless central vein cannulation for hemodialysis is a common procedure done in patients who need hemodialysis. We incidentally detected a thyrocervical artery - jugular fistula in a patient on maintenance hemodialysis. He underwent a successful intra arterial coil embolization of the feeding vessel. Review of literature has shown that, a thyrocervical artery - internal jugular vein arteriovenous fistula following a central venous catheterization has not been reported so far.

Takayasu arteritis in an infant.

Takayasu arteritis (TA), a chronic inflammatory arteritis affecting the aorta and its main branches, is a rare condition mainly affecting young women in the second and third decades of life. Occurrence of TA in infants is extremely rare, with only less than 10 cases reported all over the world until date. We report a case of a 2-year-old girl who presented with hypertension and was diagnosed to have TA with bilateral renal artery stenosis and this is probably the youngest case reported from India.

Plasmablastic myeloma presenting as rapidly progressive renal failure in a young adult.

Multiple myeloma (MM) is a condition where there is malignant proliferation of plasma cells. There is a strong correlation with age, peaking at 60-70 years. The clinical course in adolescents and young individuals is generally indolent and the survival is longer. We report a case of a 28-year-old male, who was diagnosed to have plasmablastic myeloma, an atypical variant of MM with a poor prognosis, presenting as rapidly progressive renal failure. He was given induction chemotherapy and then underwent autologous peripheral blood stem cell transplantation.

The Churg-Strauss syndrome: An unusual presentation.

The Churg-strauss syndrome (CSS), also referred to as allergic angiitis and granulomatosis is characterized by asthma, peripheral and tissue eosinophilia, extravascular granuloma formation, and vasculitis of multiple organ systems. It is an uncommon disease with an estimated annual incidence of 1-3 per million. Here, we report a case of CSS with glomerulocentric granulomatous reaction with interstitial eosinophils and involvement of retinal vessels.

Aplastic anemia and membranous nephropathy induced by intravenous mercury.

Self-injection of mercury can be life-threatening. We report a case of attempted suicide by self-intravenous injection of elemental mercury. The patient suffered from two side effects : membranous nephropathy and aplastic anemia. She was treated and the systemic effects of mercury were reversed after 4 years. The toxicology of mercury, mechanisms of renal and systemic toxicities, and the various therapeutic measures for mercury poisoning are discussed.

Disseminated candidiasis 18 years after renal transplantation.

Although mucocutaneous candidiasis is a common infection in renal transplant recipients, disseminated candidiasis is rare. Candida pnemonia causing miliary mottling on X-ray chest with the central nervous system involvement is still rarer. We report an unusual case with disseminated candidiasis that presented 18 years after renal transplantation and improved on conventional antifungal therapy; the relevant literature is reviewed.

Impact of mass drug administration on elimination of lymphatic filariasis in Surat city, India.

Lymphatic filariasis (LF) is one of the major public health problems in some of the endemic districts in India including Surat city of Gujarat province. Historical data reveals that in 1960s, Surat city had infection rate of about 23% and infectivity rate of 1.6%. Since then, Surat city has been reporting the cases of Lymphoedema and hydrocele. Filaria Control Unit was established under National Filaria Control Programme to detect and provide treatment to the cases. Based on the reports of NFCP, Surat City has been considered as LF endemic. During 2004, the country launched campaign of Elimination of Lymphatic Filariasis through Mass Drug Administration (MDA) with annual single dose of 6 mg/kg body weight of DEC tablets in all LF endemic districts including Surat city. Four rounds of MDA (2004-2007) had shown 41% reduction in mf rate, with drastic reduction in infection rate of 88% and 100% in infectivity rate. Serious adverse effect (SAE) after 4th round of MDA was insignificant (< 0.5%) during 2007. An assessment by surveying 5058 people in different parts of Surat city revealed the drug distribution coverage of more than 95% but actual drug compliance between 70-90%. Analysis of the data revealed that though the overall Microfilaria rate has been reduced due to MDA, higher Microfilaria rate was noticed in North zone of city where the migrant populations influx is higher. The observation and analysis of the data in Surat city towards elimination of Lymphatic filariasis has been discussed in this paper.

Brachiocephalic artery thrombosis in adult nephrotic syndrome.

Thrombotic events are known to occur in nephrotic syndrome, as these patients have a hypercoagulable state. Venous thrombosis is well recognized, but arterial thrombosis is rare and is mainly noted in pediatric population. In the present study, we report a case of thrombosis of right brachiocephalic artery, embolic occlusion of right axillary artery, and right middle cerebral artery territory infarction due to thromboembolism in an adult patient with nephrotic syndrome (Minimal change disease). Patient underwent thromboembolectomy in the right axillary artery followed by anticoagulation therapy.

Cryptococcal sepsis in small vessel vasculitis.

While meningoencephalitis due to cryptococcus is well known in immunocompromised patients, disseminated cryptococcosis and cryptococcemia is rare outside the setting of advanced HIV infection. We report a case of disseminated cryptococcosis occurring in a patient with Wegener's granulomatosis on immunosuppressive medications.

N-acetylcysteine and magnesium improve biochemical abnormalities associated with myocardial ischaemic reperfusion in South Indian patients undergoing coronary artery bypass grafting: a comparative analysis.

INTRODUCTION: The clinical presentation of ischaemic reperfusion in postoperative patients correlates with oxidative stress. The limited clinical success of anti-ischaemic reperfusion agents has prompted a comparison of the efficacy of N-acetylcysteine (NAC) and magnesium (Mg) in South Indian patients undergoing coronary artery bypass grafting (CABG). METHODS: In Clinical Trial I, 52 South Indian patients who had undergone CABG surgery (with intraoperative Mg supplementation) and 40 controls (without Mg supplementation) were selected and matched. The control patients underwent the same protocol without Mg. In Clinical Trial II, the study population consisted of 50 patients, where 25 patients received NAC just before the release of the aortic cross clamp. In the NAC untreated group, dextrose solution was administered at the same time as the placebo. Six blood samples were taken at different times during the cardiac surgery and the antioxidant enzymes, ATPase and cardiac markers from the coronary sinus blood samples were analysed. RESULTS: Increased blood lipid peroxidation was observed in patients who were not treated with Mg/NAC. The administration of Mg/NAC just before the release of the aortic cross clamp reduced the lipid peroxidation significantly (p-value is less than 0.05). The above observations were supported by the antioxidant enzyme levels. Significant improvements to the erythrocyte ATPase and cardiac markers in patients treated with Mg/NAC correlated with a reduction in postoperative abnormalities. Based on the biochemical status of the patients, Mg was shown to mediate better recovery from postoperative changes. CONCLUSION: NAC and Mg decreased pump-induced oxidative stress during cardiopulmonary bypass (CPB), suggesting that it could be a novel therapy for assisting in the prevention of CPB-induced oxidative stress.

Role of Mitochondrial Enzymes and Sarcoplasmic ATPase in Cardioprotection Mediated by Aqueous Extract of Desmodium gangeticum (L) DC Root on Ischemic Reperfusion Injury.

The present study investigate the protective effect of aqueous root extract of Desmodium gangeticum in preserving mitochondrial and sarcoplasmic ATPase during ischemia reperfusion injury. The isolated rat hearts in both drug and control group were subjected to warm ischemia (37°), followed by reperfusion with the Langendorff perfusion system. The aqueous root extract of Desmodium gangeticum (L) at a dose of 50 mg/kg body weight was found to be effective in the rat heart for the management of ischemic reperfusion injury. Physiological parameters were significantly (P<0.05) improved in drug treated rat hearts. Creatine phosphokinase in coronary perfusate found to be declined. Moreover, sarcoplasmic ATPase and mitochondrial enzymes were significantly (P<0.05) improved in drug treated rat hearts. In fact, histological analysis of the myocardium also suggested an improved ultra structure in Desmodium gangeticum treated rat heart. These results suggest that Desmodium gangeticum aqueous root extract can preserve the mitochondrial and sarcoplasmic ATPase in the myocardium, resulting in the improvement of cardiac function after ischemia reperfusion injury.

Recurrent acute renal failure.

While acute renal failure secondary to intravascular hemolysis is well described in hemolytic anemias, recurrent acute renal failure as the presenting manifestation of a hemolytic anemia is rare. We report a patient with recurrent acute renal failure who was found to have paroxysmal nocturnal hemoglobinuria (PNH), on evaluation.

Zygomycosis in a renal allograft recipient.

Invasive fungal infections can cause considerable morbidity and mortality in immunocompromised patients. Zygomycosis is a type of invasive fungal infection with a rapid course and grave prognosis. Renal transplant recipients with concomitant diabetes mellitus are most susceptible to this infection. We report here a case of disseminated zygomycosis (Rhizopus sp.) in a renal allograft recipient with posttransplant diabetes mellitus (PTDM). This is the first reported case of zygomycosis caused by Rhizopus species.