Prevalence, Predictors, and Prognosis of Serious Infections in Takayasu Arteritis: A Cohort Study.

OBJECTIVE: To describe the incidence, risk factors, and outcomes associated with serious infections in patients with Takayasu arteritis (TA). METHODS: Serious infections, defined as infections resulting in hospitalization or death or unusual infections like tuberculosis, were identified from a cohort of patients with TA. Corticosteroid and disease-modifying antirheumatic drug (DMARD) use at the time of serious infection was noted. Demographic characteristics, clinical presentation, angiography, and disease activity at presentation, and the use of DMARDs during follow-up were compared between patients with TA with or without serious infections. Mortality in patients with TA who developed serious infections was compared to those who did not using hazard ratios (HR; with 95% CI). RESULTS: Of 238 patients with TA, 38 (16%) had developed serious infections (50 episodes, multiple episodes in 8; 3 episodes resulted in death). Among the 38 initial episodes, 11/38 occurred in those not on corticosteroids and 14/38 in those not on DMARDs. Pneumonia (n = 19) was the most common infection, followed by tuberculosis (n = 12). Patients with TA who developed serious infections vs those who did not had higher disease activity at presentation (active disease 97.4% vs 69.5%, mean Indian Takayasu Arteritis Activity Score 2010 12.7 (SD 7.3) vs 10.2 (SD 7.0), mean Disease Extent Index in Takayasu Arteritis 11.2 (SD 6.1) vs 8.8 (SD 6.1) and were more frequently initiated on corticosteroids or DMARDs. HRs calculated using exponential parametric regression survival-time model revealed increased mortality rate in patients with TA who developed serious infections (HR 5.52, 95% CI 1.75-17.39). CONCLUSION: Serious infections, which occurred in the absence of immunosuppressive treatment in approximately one-fifth of patients with TA, were associated with increased mortality in patients with TA.

Increased mortality rate in Takayasu arteritis is largely driven by cardiovascular disease-a cohort study.

OBJECTIVES: To analyze the risk, causes, and predictors of mortality in Takayasu arteritis (TAK). METHODS: Survival was assessed in a cohort of patients with TAK using Kaplan-Meier curves. Age- and sex-standardized mortality ratio (SMR = observed: expected deaths) for TAK were calculated by applying age- and sex-specific mortality rates for the local population to calculate expected deaths. Hazard ratios (HR with 95%CI) for predictors of mortality based on demographic characteristics, presenting features, baseline angiographic involvement, disease activity, number of immunosuppressive medications used, procedures related to TAK, and any serious infection were calculated using Cox regression or exponential parametric regression models. RESULTS: Among 224 patients with TAK (159 females, mean follow-up duration 44.36 months), survival at 1, 2, 5, and 10 years was 97.34%, 96.05%, 93.93%, and 89.23%, respectively. Twelve deaths were observed, most of which were due to cardiovascular disease (heart failure, myocardial infarction, stroke). Mortality risk was significantly higher with TAK (SMR 17.29, 95%CI 8.95-30.11) than the general population. Earlier age at disease onset (HR 0.90, 95%CI 0.83-0.98; or pediatric-onset vs adult-onset disease, HR 5.51, 95%CI 1.57-19.32), higher disease activity scores (ITAS2010: HR 1.15, 95%CI 1.05-1.25, DEI.TAK: HR 1.18, 95%CI 1.08-1.29), any serious infections (HR 5.43, 95%CI 1.72-17.12), heart failure (HR 7.83, 95%CI 2.17-28.16), or coeliac trunk involvement at baseline (HR 4.01, 95%CI 1.26-12.75) were associated with elevated mortality risk. CONCLUSION: Patients with TAK had an elevated risk of mortality as compared with the general population. Cardiovascular disease was the leading cause of death in TAK.

Paediatric-onset Takayasu's arteritis associates with worse survival than adult-onset Takayasu's arteritis. A matched retrospective cohort study.

OBJECTIVES: A subset of Takayasu's arteritis (TAK) begins in the paediatric age group (≤18 years). Differences in prognosis between paediatric-onset and adult-onset TAK are unclear. We compared the differences in the presentation and survival between paediatric-onset and adult-onset TAK in our cohort of TAK. METHODS: From a retrospective cohort of TAK, clinical presentation, angiographic features, treatments received, disease activity, and survival were compared between paediatric-onset and adult-onset TAK. Multivariable-adjusted logistic regression models were used to compute adjusted odds ratio (aOR) with 95% confidence intervals (95%CI) for paediatric-onset vs. adult-onset TAK. Hazard ratios (HR, with 95%CI) for mortality with paediatric-onset vs adult-onset TAK (crude, adjusted for prognostic covariates or differences in presentation) and propensity score-matched survival analyses were estimated. RESULTS: Among 56 paediatric-onset and 135 adult-onset TAK, chest pain (aOR 3.21, 95%CI 1.06-9.74), heart failure (aOR 3.16, 95%CI 1.05-9.53), headache (aOR 2.60, 95%CI 1.01-6.74), ascending aorta (aOR 3.02, 95%CI 1.04-8.80) and left renal artery involvement (aOR 2.45, 95%CI 1.04-5.80) were more frequent in paediatric-onset TAK. Despite similar longitudinal patterns of disease activity and glucocorticoid or disease-modifying antirheumatic drug (DMARD) use, mortality was higher for paediatric-onset TAK (HR, unadjusted 6.13, 95%CI 1.51-24.91; adjusted for prognostic covariates gender, diagnostic delay, baseline disease activity, number of conventional and biologic/targeted synthetic DMARDs used, 4.97, 95%CI 1.20-20.58; adjusted for differences between groups 5.54, 95%CI 1.22-25.09; after propensity-score matching for prognostic covariates, 54 pairs, log-rank p-value 0.026). CONCLUSIONS: Considering the greater mortality risk, greater vigilance is required while managing paediatric-onset TAK.

A retrospective audit to evaluate the appropriateness and rationalization of Fresh Frozen Plasma usage in a tertiary care hospital.

Background: General guidelines describing the potential indications and contraindications of Fresh Frozen Plasma (FFP) exist. However, their implementation is inadequate, leading to inappropriate use in various clinical settings. This study aims to define the appropriateness of the FFP usage in terms of therapeutic versus prophylactic indications. Methods: Retrospective audit was conducted over one year prior to and after an educational intervention (1122 patients for 6072 FFP units and 1061 patients for 4858 FFP units, respectively). Clinical diagnosis, indication for FFP transfusion, and coagulation profile were noted, and episodes of transfusion were divided into appropriate and inappropriate based on the guidelines of the British Committee for Standards in Hematology (2004 reviewed in 2018) and College of American Pathologists (1994). Results: Initial audit found 51.8% of FFP transfusions to be inappropriate (3069 of 5922). Coagulation profile (with INR values less than 1.5 times of the normal) was the most common cause of inappropriate transfusion (15.08%). 56.7% of FFP were prophylactically transfused. Re-audit after educational interventions showed a 22.3% reduction in the number of inappropriate transfusions. Conclusion: Inappropriate, as well as high prophylactic usage of FFP, was noticed in the initial audit, which reduced significantly after educational interventions. Regular CMEs, interactive sessions with clinicians, functioning Hospital Transfusion Committees, and prospective audits can affirm, further improve and reinforce the existing Hospital Transfusion Guidelines.

Association of CD 34 positive cell dose with engraftment kinetics in autologous peripheral blood stem cell transplant patients of multiple myeloma.

Background: Treatment with high-dose chemotherapy and stem cell transplantation has prolonged survival in patients of multiple myeloma (MM). A dose-response relationship between number of CD34+ cells infused and leukocyte and platelet recovery, exists. Patients receiving dose of <2.0 × 106 CD34+ cells/kg have delayed engraftment. The level of optimal cutoff for accelerated engraftment is yet to be validated. Hence, this study was undertaken to study the association of CD 34+ cell dose with engraftment kinetics in patients of MM who underwent autolgous peripheral blood stem cell transplant (PBSCT). Methods: We retrospectively analyzed 19 patients of MM who underwent PBSCT at our center between December 2016 to December 2018. Complete blood counts were carried out daily after transplantation to record neutrophil and platelet engraftment. Results: Based on the CD34+ cell dose given : <5 × 106/kg (category 1), 5-10 × 106/kg (category 2), >5 × 106/kg (category 3), the mean (SD) neutrophil engraftment time was 11.3 (0.5) days, 10.6 (0.9) days, and 10.2 (1.3) days respectively. Platelet engraftment time was 12.4 (2.60) days, 10.6 (1.14) days, and 11.2 (1.64) days for category 1, 2, and 3 patients, respectively. Correlation co-efficient between CD 34+cell dose and days for neutrophil and platelet engraftment was found to be -0.24 and -0.20, respectively. Time for neutrophil engraftment was found to be significantly associated with CD34+ cell dose category. Conclusion: CD 34+ cell dose appears as the strongest predictor of leukocyte and platelet engraftment. CD 34+ cell dose of >5.0 × 106 cells/kg leads to an accelerated neutrophil and platelet engraftment in patients of MM.

Protein Arginine Methyltransferase 1 Is Essential for the Meiosis of Male Germ Cells.

Protein arginine methyltransferase 1 (PRMT1) is a major enzyme responsible for the formation of methylarginine in mammalian cells; however, its function in vivo is not well understood due to its early embryonic lethality in null mice exhibiting spontaneous DNA damage, cell cycle delays, and defects in check point activation. Here, we generated germ cell-specific Prmt1 knock-out (KO) mice to evaluate the function of PRMT1 in spermatogenesis. Our findings demonstrate that PRMT1 is vital for male fertility in mice. Spermatogenesis in Prmt1 KO mice was arrested at the zygotene-like stage of the first meiotic division due to an elevated number of DNA double-strand breaks (DSBs). There was a loss of methylation in meiotic recombination 11 (MRE11), the key endonuclease in MRE11/RAD50/NBS 1 (MRN) complex, resulting in the accumulation of SPO11 protein in DSBs. The ATM-mediated negative feedback control over SPO11 was lost and, consequently, the repair pathway of DSBs was highly affected in PRMT1 deficient male germ cells. Our findings provide a novel insight into the role of PRMT1-mediated asymmetric demethylation in mouse spermatogenesis.

Clinical Characteristics and Remedy Profiles of Patients with COVID-19: A Retrospective Cohort Study.

OBJECTIVE: The aim of the study was to identify indicated homeopathic remedies based on the clinical characteristics of coronavirus disease 2019 (COVID-19) patients in India. METHODS: In this retrospective, cohort study, confirmed COVID-19 patients admitted at a COVID Health Centre in New Delhi between April 29 and June 17, 2020 were given conventional and homeopathic treatment. Patients were grouped into mild, moderate or severe categories of disease. Their symptomatologic profiles were analyzed to identify indicated homeopathic medicines. RESULTS: A total of 196 COVID-19 patients were admitted. One hundred and seventy-eight patients had mild symptoms; eighteen patients had moderate symptoms; no patients with severe symptoms were included as they were referred to tertiary care centers with ventilatory support. The mean age of patients with mild symptoms was significantly lower (38.6 years; standard deviation or SD ± 15.8) compared with patients in the moderate category (66.0 years; SD ± 9.09). The most important symptoms identified were fever (43.4%), cough (47.4%), sore throat (29.6%), headache (18.4%), myalgia (17.9%), fatigue (16.8%), chest discomfort (13.8%), chills (12.6%), shortness of breath (11.2%) and loss of taste (10.2%). Twenty-eight homeopathic medicines were prescribed, the most frequently indicated being Bryonia alba (33.3%), Arsenicum album (18.1%), Pulsatilla nigricans (13.8%), Nux vomica (8%), Rhus toxicodendron (7.2%) and Gelsemium sempervirens (5.8%), in 30C potency. CONCLUSION: Data from the current study reveal that Arsenicum album, Bryonia alba, Pulsatilla nigricans, Nux vomica, Rhus toxicodendron and Gelsemium sempervirens are the most frequently indicated homeopathic medicines. A randomized controlled clinical trial based on this finding is the next step.

Factors determining sexual behaviour amongst siddi tribe migrating to Udupi district, India: A cross-sectional study.

BACKGROUND: Afro-Indians, locally known as Siddi, are the tribal community descended from the Bantu populace from eastern Africa found in Goa, Gujarat and Karnataka along the Indian west coast. This study determines knowledge, attitude and sexual behaviour amongst the Siddi population in the Udupi district. MATERIALS AND METHODS: A cross-sectional study was conducted from October 2018 to September 2019; men and women aged above 18 years who lived in the locality at the time of the survey were included in the study. RESULTS: A total of 108 Siddi individuals participated in this study. The mean age of the respondents was 31.8 ± 9.5 years. More than half (51.8%) of the respondents received information on sexual matters through friends. Awareness regarding the usage of condoms and other preventive measures was poor (34.7%). Around 65.7% of the respondents felt that sex education in school encourages sex amongst youngsters. The mean age at the first sexual intercourse amongst men and women was 20.3 years and 16.2 years, respectively. About 18.7% of the respondents had sex with a new partner in the migrated place within the last 1 month, of which 80% were married. Only 5% of the respondents used condoms while indulging in sex with a new partner at the migrated place. Factors such as age at marriage, age at the first sexual act and attitude towards sexual activity were significantly associated with a new sex partner at the arrival site. CONCLUSION: There is a high prevalence of unsafe sexual practices amongst the migrated Siddi tribe at the place of destination. This poses the risk of sexually transmitted infections amongst the migrant tribes and local communities at the place of destination and the location of origin. The study finding shows that measures should be taken to create awareness, and change in attitude towards sexual matter should be channelised at an early age amongst the Siddi population.

Immediate impact of percutaneous transvenous mitral commisurotomy on right ventricle longitudinal strain in patients of mitral stenosis.

BACKGROUND: Right ventricular (RV) function has prognostic value in terms of survival and symptoms in patients with mitral stenosis (MS). The aim of the study was to assess RV function by strain analysis in the patients of mitral stenosis and the effect of percutaneous transvenous mitral commisurotomy (PTMC) on it. METHODS: Eighty patients of severe mitral stenosis without overt right heart failure and normal sinus rhythm undergoing PTMC were included. Conventional echocardiography and RV function by TDI-derived longitudinal strain and strain rate were assessed prior and 24 hours post PTMC and compared with 40 healthy age-matched controls. RESULTS: Eighty subjects (mean age 31 + 10 years, 70% females) were included. Patients with MS had significantly lower RV strain of basal and mid-free wall, tricuspid annular plane systolic excursion (TAPSE), and RV fractional area change (FAC) as compared to controls. There was a significant increase in pre- and post-PTMC in TAPSE (19.5 ± 2.7 mm vs 21.4 ± 3.3 mm; P < 0.001), RV basal free wall longitudinal strain (-24.4 + 6.1% vs -27.7 + 5.8%; P < 0.001), and right ventricle mid-free wall longitudinal strain (-25.6 + 5.5% vs -28.6 + 5.1%; P < 0.001), respectively. There was no significant change in RV Tei index (0.43 + 0.06 vs 0.41 + 0.03; P = 0.06). There was a significant negative correlation between RV longitudinal strain and right ventricle systolic pressure, left atrium diameter, RV Tei index, and pulmonary capillary wedge pressure, and positive correlation between RV FAC and RV TAPSE. CONCLUSION: Patients with severe MS with normal RV systolic function had decreased RV strain, which was significantly increased after a successful PTMC with reduction in afterload.

Do practice gaps exist in evidence-based medication prescription at hospital discharge in patients undergoing coronary artery bypass surgery & coronary angioplasty?

BACKGROUND & OBJECTIVES: Prescription patterns of guideline-directed medical therapy (GDMT) after coronary artery bypass surgery [coronary artery bypass graft (CABG)] and percutaneous coronary intervention (PCI) at hospital discharge are often not optimal. In view of scarce data from the developing world, a retrospective analysis of medication advice to patients following CABG and PCI was conducted. METHODS: Records of 5948 patients (post-PCI: 5152, post-CABG: 796) who underwent revascularization from 2010 to 2014 at a single tertiary care centre in north India were analyzed. RESULTS: While age and gender distributions were similar, diabetes and stable angina were more frequent in CABG group. Prescription rates for aspirin 100 per cent versus 98.2 per cent were similar, while beta-blockers (BBs, 95.2 vs 90%), statins (98.2 vs 91.6%), angiotensin-converting enzyme inhibitors (89.4 vs 41.4%), nitrates (51.2 vs 1.1%) and calcium channel blockers (6.6 vs 1.6%) were more frequently prescribed following PCI. Despite similar baseline left ventricular ejection fraction (48.1 vs 51.1%), diuretics were prescribed almost universally post-CABG (98.2 vs 10.9%, P<0.001). Nearly all (94.4%) post-CABG patients received a prescription for clopidogrel. Patients undergoing PCI were much more likely to receive higher statin dose; 40-80 mg atorvastatin (72 vs <1%, P<0.001) and a higher dose of BB. INTERPRETATION & CONCLUSIONS: Significant differences in prescription of GDMT between PCI and CABG patients existed at hospital discharge. A substantial proportion of post-CABG patients did not receive BB and/or statins. These patients were also less likely to receive high-dose statin or optimal BB dose and more likely to routinely receive clopidogrel and diuretics. Such deviations from GDMT need to be rectified to improve quality of cardiac care after coronary revascularization.

The Effects of Atorvastatin on Inflammatory Responses and Mortality in Septic Shock: A Single-center, Randomized Controlled Trial.

AIM OF THE STUDY: Pleiotropic effect of statins can modulate inflammation in septic shock. We tested the hypothesis whether statins can reduce mortality in septic shock. PATIENTS AND METHODS: We conducted a randomized double-blinded trial with treatment (40 mg dose of atorvastatin for 7 days) and control (placebo) arm in adult septic shock patients admitted to the Intensive Care Unit. Primary (28-day mortality) and secondary (vasopressor-, ventilation-, and renal replacement therapy-free days) outcomes, with lipid profile and adverse effects, were documented. Inflammatory biomarkers (interleukin [IL]-1, IL-6, tumor-necrosis-factor [TNF]-α, interferon [IFN], and C-reactive protein [CRP]), were also measured before (day 1 [D1]) and after start of trial drug (D4 and D7). RESULTS: Seventy-three septic shock patients with 36 and 37 included in the atorvastatin and placebo group, respectively. Both groups were equally matched. Twenty-eight-day mortality, event-free days, lipid profile, and adverse effects were also not significantly different between groups. Reduced levels of IL-1, IL-6, TNF-α, IFN, and CRP were observed in the atorvastatin group. Also observed were significant day-wise changes in inflammatory biomarkers. CONCLUSIONS: Atorvastatin-induced changes in inflammatory biomarkers did not confer mortality benefit in septic shock (ClinicalTrials.govNCT02681653).

Testis-Specific GTPase (TSG): An oligomeric protein.

BACKGROUND: Ras-related proteins in brain (Rab)-family proteins are key members of the membrane trafficking pathway in cells. In addition, these proteins have been identified to have diverse functions such as cross-talking with different kinases and playing a role in cellular signaling. However, only a few Rab proteins have been found to have a role in male germ cell development. The most notable functions of this process are performed by numerous testis-specific and/or germ cell-specific genes. Here, we describe a new Rab protein that is specifically expressed in male germ cells, having GTPase activity. RESULTS: Testis-specific GTPase (TSG) is a male-specific protein that is highly expressed in the testis. It has an ORF of 1593 base pairs encoding a protein of 530 amino acids. This protein appears in testicular cells approximately 24 days postpartum and is maintained thereafter. Immunohistochemistry of testicular sections indicates localized expression in germ cells, particularly elongating spermatids. TSG has a bipartite nuclear localization signal that targets the protein to the nucleus. The C-terminal region of TSG contains the characteristic domain of small Rab GTPases, which imparts GTPase activity. At the N-terminal region, it has a coiled-coil motif that confers self-interaction properties to the protein and allows it to appear as an oligomer in the testis. CONCLUSION: TSG, being expressed in the male gonad in a developmental stage-specific manner, may have a role in male germ cell development. Further investigation of TSG function in vivo may provide new clues for uncovering the secrets of spermatogenesis.

Point of care hemoglobin testing in plateletpheresis donors: Noninvasive versus invasive methods.

BACKGROUND: Predonation hemoglobin (Hb) for plateletpheresis donors is estimated by presently available invasive methods. Venous samples of only those donors whose Hb is more than 12.5 g/dl are screened for complete blood count and transfusion transmissible infections. There is a pressing need to substitute this invasive Hb test with noninvasive one to reduce donor discomfort and avoid further pricking the donor. We therefore went ahead with the aim of comparing a noninvasive Hb estimation method NBM 200 with the invasive method - Hemocue, taking SYSMEX KX-21 as a gold standard. METHODS: 500 voluntary consenting plateletpheresis donors qualifying the laid down criteria for platelet donation were included in the study. Hb readings obtained by the NBM 200 and Hemocue were compared to those obtained from the fully automated hematology analyzer SYSMEX KX-21. RESULTS: Coefficients of correlation were found to be statistically significant at <0.0001 level of confidence. Results of Friedman's test on the three methods also showed significant difference in means. Bland-Altman plots and mountain plots also confirm the same. NBM 200 was found to be more sensitive, specific, and precise than Hemocue in detecting ineligible donors. CONCLUSION: NBM 200 was found to be more sensitive, specific, and precise as compared to Hemocue for predonation screening of Hb in plateletpheresis donors and the prime benefit it offers is that it is 'noninvasive' thereby assisting in stemming the platelet donor pool. The onus lies on the blood transfusion services to make use of appropriately validated gadgets that reduce the donor discomfort.

Peeling off the Mask: Pseudo Myocardial Infarction Pattern on Electrocardiogram During AICD Implantation.

Lead induced transient right bundle branch block is not uncommon during pacemaker implantation. We describe a patient with old anterior wall myocardial infarction with severe left ventricular dysfunction presenting with recurrent ventricular tachycardia who developed transient right bundle branch block and pseudomyocardial infacrction pattern during AICD implantation.

Assessment of endothelial dysfunction in Asian Indian patients with chronic kidney disease and changes following renal transplantation.

BACKGROUND: Endothelial dysfunction may explain increased cardiovascular risk in patients with chronic kidney disease (CKD). METHODS: Brachial artery was imaged during reactive hyperemia (endothelium-dependent, flow-mediated dilatation, FMD) and during glyceryl trinitrate-mediated dilatation (nitroglycerine-mediated dilatation, NMD, endothelium-independent) in 108 patients with CKD and three months following renal transplantation (RT) in 60 of them. RESULTS: Patients with CKD had significantly lower FMD vs. controls (9.1% vs. 18.3%, p < 0.001) while NMD was comparable (19.8% vs. 21.8%, p = ns). Impaired FMD (<4.5%) was observed in 26.8% patients with CKD and was more common in those on hemodialysis (HD; 28.4% vs. 15.4%) vs. those not on dialysis. FMD for patients with glomerular filtration rate (GFR) 15-60 vs. <15 mL/min/1.73 m(2) was 12.9% and 8.8% (p = 0.05; respectively -29% and -52% lower vs. controls), indicating reduced FMD with increasing CKD severity. There was +72% increase in FMD following RT (9.1 to 15.7%, p < 0.001) while mean NMD was unchanged. Following RT, only 3.3% had impaired FMD. CONCLUSIONS: Patients with CKD have endothelial dysfunction as evidenced by reduced FMD. Decreased FMD indicating worsening endothelial function was noted with increasing severity of CKD. Within three months of RT, there was significant improvement in FMD, while NMD values did not change.

The possible advantages of cryoprecipitate prepared from fresh frozen plasma from blood stored for 24 hours.

BACKGROUND: To compare the coagulation-factor profile of cryoprecipitate produced from fresh frozen plasma from whole blood (WB) stored for 24 hours at room temperature (24CP) with that of standard cryoprecipitate (CP). METHODS: We collected 80 units of WB from healthy volunteers, of which 20 units were of each blood group. Each unit of blood was divided into 2 parts. One part was used for preparation and quality-control evaluation of CP within 8 hours of collection; the other part was stored at room temperature for 24 hours and then subjected to CP preparation. Coagulation studies were carried out on each batch of CP after production. Fibrinogen, Factor VIII (FVII), and von Willibrand factor (vWF) were measured, and the blood groups were determined. We used the Student's t-test to perform comparisons and considered results to be significant at P < .005. RESULTS: Overall, all 3 clotting factors were increased in 24CP compared with CP, with a statistically significant increase in the level of FVIII. Blood group AB had significantly increased levels of fibrinogen and vWF in 24CP compared with CP. CONCLUSION: Our study showed that 24CP has equal or greater levels of coagulation factors compared with CP. His indicates that our alternate approach for preparation of CP may enable more efficient use of blood collected in satellite blood collection centers and during blood drives.

Utility of three-dimensional proton density-weighted sequence MRI in knee for the assessment of Anterolateral complex in Anterior cruciate ligament injury.

OBJECTIVES: To assess the proportion and pattern of injury of the anterolateral ligament (ALL) and the Kaplan fibre (KF) complex in knees with anterior cruciate ligament (ACL) injuries on MRI using three-dimensional (3D) proton density (PD) sequences. METHODS: A total of 88 patients having ACL injury were included in this cross-sectional study. 3D PD sequences were used to assess injury of ALL and the KF complex and were graded on a scale of 0 to 3. MR images were evaluated by two radiologists. Interobserver agreement was determined using Cohen Kappa. RESULTS: Femoral, meniscal, and tibial portions of ALL were visualized in 90.9%, 92%, and 94.3% of the study subjects, respectively. Proximal and distal KF were visualized in 92% and 93.2% of patients, respectively. Injury to ALL and KF was seen in 63.6% and 17% of the patients, respectively. Excellent interobserver agreement was noted for the identification and grading of ALL and KF complex injuries. CONCLUSIONS: Oblique reformatted 3DPD MRI reliably detect ALC; however, ALL injury is better characterized than KF injury using this sequence. ADVANCES IN KNOWLEDGE: Given the potential role of anterolateral complex (ALC) in maintaining the rotational stability of the knee, ALC assessment using the 3D PD sequences and their oblique reformatted images should be incorporated as routine review area of the knee MRI, particularly in the setting of ACL tear.

A rare case of isoniazid mono-resistant tuberculosis presenting as cardiac tamponade along with an anterior mediastinal mass in a 15-year-old immunocompetent patient.

ABSTRACT: A 15-year-old boy presented with a sudden onset of breathlessness for 7 days, gradual loss of weight of 17.6 lbs over the last month and progressive hoarseness of voice for 7 months. The contrast-enhanced computed tomography (CECT) scan revealed a heterogeneously enhancing lesion in the anterior mediastinum with multiple discrete lymph nodes in the cervical and mediastinal locations. The GeneXpert MTB/RIF assay performed on the CT-guided biopsy of the mass was negative, but the culture for Mycobacterium tuberculosis was positive at 7 weeks of incubation. There was a suboptimal radiological response after 6 months of treatment. First-line drug susceptibility testing (DST) performed by line probe assay (LPA) on the positive culture detected high-level resistance to isoniazid. The treatment was modified as per DST results to which the patient responded well.

A bacterial vesicle-based pneumococcal vaccine against influenza-mediated secondary Streptococcus pneumoniae pulmonary infection.

Streptococcus pneumoniae (Spn) is a common pathogen causing a secondary bacterial infection following influenza, which leads to severe morbidity and mortality during seasonal and pandemic influenza. Therefore, there is an urgent need to develop bacterial vaccines that prevent severe post-influenza bacterial pneumonia. Here, an improved Yersinia pseudotuberculosis strain (designated as YptbS46) possessing an Asd+ plasmid pSMV92 could synthesize high amounts of the Spn pneumococcal surface protein A (PspA) antigen and monophosphoryl lipid A as an adjuvant. The recombinant strain produced outer membrane vesicles (OMVs) enclosing a high amount of PspA protein (designated as OMV-PspA). A prime-boost intramuscular immunization with OMV-PspA induced both memory adaptive and innate immune responses in vaccinated mice, reduced the viral and bacterial burden, and provided complete protection against influenza-mediated secondary Spn infection. Also, the OMV-PspA immunization afforded significant cross-protection against the secondary Spn A66.1 infection and long-term protection against the secondary Spn D39 challenge. Our study implies that an OMV vaccine delivering Spn antigens can be a new promising pneumococcal vaccine candidate.