Assessing the Efficacy and Outcomes Following Irrigation with Streptokinase Versus Hydrogen Peroxide in Necrotizing Pancreatitis: A Randomized Pilot Study.

BACKGROUND: Percutaneous catheter drainage (PCD's) are prone to blockage because of necrosum. To improve the efficacy of PCD, necrolytic agents have been used. The present study compared the use of Streptokinase with H2O2 in saline irrigation. MATERIALS AND METHODS: This is a single-center randomized pilot study (from July 2018 to Dec 2019). Patients with infected pancreatic necrosis not showing response to PCD and saline irrigation were included in the study. Patients received either Streptokinase (Streptokinase group 50,000 IU in 100 ml normal saline) or 3% H2O2 (3% H2O2 in 100 ml normal saline in 1:10 dilution). Primary endpoints were the need for surgery and mortality while secondary endpoints were hospital stay and complications attributable to necrolytic agents. RESULTS: There were 30 patients in the study, 15 in each arm. Organ failure was seen in 23 (76.6%), single organ failure was present in 11 (47%), and multi-organ failure in 12 (53%). Bleeding complications (20% in H2O2 vs 6.6% in Streptokinase), need for surgery (73% in H2O2 vs 33.3% in Streptokinase) and mortality (60% in H2O2 vs 33% in Streptokinase) were higher in H2O2 group but the difference was not significant statistically. Post-irrigation hospital stay was lesser in the Streptokinase group compared to H2O2 group but the difference did not reach statistical significance (14.1 ± 7.7 vs 19.2 ± 11.7, p = 0.09) CONCLUSIONS: Streptokinase irrigation led to a trend for reduced need for necrosectomy and mortality. H2O2 group had more bleeding complications. Post-irrigation hospital stay was lesser in Streptokinase group.

TB in Indian adolescents: results from a nationally representative survey, 2015-2016.

SETTING: Adolescents (age: 15-19 years) from the National Family Health Survey-4 (2015-2016), India.OBJECTIVE: To examine the sociodemographic and nutritional characteristics of adolescents with reported TB and those with a reported household TB exposure.METHODS: This was a cross-sectional study using secondary data. We assessed the factors associated with TB (reported in adolescents, or in a household member) using log binomial regression. We used height-for-age and body mass index for age Z-scores for stunting and thinness, respectively.RESULTS: Of the total 277 059 adolescents, 377 (136/100 000, 95%CI 123-151) were reported with TB and this was similar in both sexes. Another 4528 adolescents (1.6%, 95%CI 1.6-1.7) reported household TB exposure. Poverty and urban residence were associated with higher prevalence of TB and household TB exposure. The proportion of stunting was 40.7% (95%CI 33.5-48.0) in adolescents with reported TB and 38.2% (95%CI 36.2-40.2) (P = 0.248) in those with household TB exposure.CONCLUSION: Prevalence of reported adolescent TB was lower than adult TB. Poverty and urban residence were risk factors for both TB and household TB exposure. Chronic undernutrition was highly prevalent among those reported to have TB and in those at risk of TB by virtue of having household TB exposure.

Risk factors for peripherally inserted central catheter line-related deep venous thrombosis in critically ill intensive care unit patients.

INTRODUCTION: Central venous access using peripherally inserted central catheters is frequently used for patients receiving intravenous medications in the hospital or outpatients. Although there are several benefits of peripherally inserted central catheters, such as ease of insertion, low procedure-related risk and higher patient satisfaction, there are complications associated with peripherally inserted central catheter use. Despite some studies evaluating peripherally inserted central catheter line-related complications, the factors associated with peripherally inserted central catheter-related deep venous thrombosis in critically ill medical-surgical patients are poorly described. The objective of this case-control study was to identify the risk factors associated with peripherally inserted central catheter line-related deep venous thrombosis in critically ill medical-surgical intensive care unit patients in a community hospital. METHODS: We abstracted relevant clinical data from 21 cases with symptomatic peripherally inserted central catheter-related deep venous thrombosis and 42 controls with peripherally inserted central catheters but no deep venous thrombosis. RESULTS: Of the factors evaluated, female gender, the use of triple lumen peripherally inserted central catheters, larger outer diameter, and open (vs valve) peripherally inserted central catheters were associated with venous thrombosis. In this retrospective study, we did not identify any association of peripherally inserted central catheter-related deep venous thrombosis with a prior history of deep venous thrombosis, use of alteplase, antiplatelet therapy, prophylactic or therapeutic anticoagulation, international normalized ratio, platelet count and the use of peripherally inserted central catheters for total parenteral nutrition. CONCLUSION: Our study indicates that the catheter size relative to the diameter of the vein could be an important risk factor for the development of peripherally inserted central catheter-related deep venous thrombosis. The study findings should be confirmed in a larger study designed to identify risk factors of peripherally inserted central catheter-related deep venous thrombosis. In the meantime, the peripherally inserted central catheter lines should be used judiciously in critically ill patients.

Nutritional assessment and counselling of tuberculosis patients at primary care in India: do we measure up?

SETTING: Dakshina Kannada District, coastal South India, under the Revised National Tuberculosis Control Programme (RNTCP). OBJECTIVE: To identify the potential and practices at primary health centres (PHCs) for the assessment of nutritional status of patients with tuberculosis (TB), the basic tools used to measure height and weight and the type of nutritional counselling provided. DESIGN: A cross-sectional study was conducted with physical verification of availability of height and weight measuring equipment. Information was collected on the method used by medical officers for assessing nutritional status in PHCs, action taken in case the patient is undernourished and any formal training in nutritional assessment and counselling. RESULTS: Of 37 PHCs assessed, weighing machines were available in all and stadiometers in 38%. Medical officers were not calculating body mass index for nutritional assessment even when height and weight were being uniformly measured. Nutritional classification was mostly based on the appearance and physique of the patient. Counselling included advice to take milk, eggs and protein powders with efforts to arrange funds from village health, sanitation and nutrition committees. CONCLUSION: There is a need to equip the PHCs and their medical officers with necessary tools and training for nutritional assessment and counselling of patients with tuberculosis.

Flow cytometric osmotic fragility test and eosin-5'-maleimide dye-binding tests are better than conventional osmotic fragility tests for the diagnosis of hereditary spherocytosis.

INTRODUCTION: Hereditary spherocytosis (HS) is the most common inherited hemolytic anemia with heterogeneous clinico-laboratory manifestations. We evaluated the flow-cytometric tests: eosin-5'-maleimide (EMA) and flow-cytometric osmotic fragility test (FOFT) and the conventional osmotic fragility tests (OFT) for the diagnosis of hereditary spherocytosis (HS). METHODS: One hundred two suspected HS patients underwent EMA, FOFT, incubated OFT (IOFT), and room temperature OFT (RT-OFT). In addition, 10 cases of immune hemolytic anemia (IHA) were included, and performance of the above 4 tests was evaluated. For EMA and FOFT, 5 normal controls were assessed together with the patients and cutoffs were calculated using receiver-operator-characteristics curve (ROC) analysis. RESULTS: The best cutoff for %EMA decrease was 12.5%, and for FOFT, %residual red cells (%RRC) was 25.6%. The sensitivity and specificity of RT-OFT was 62.06% and 86.3%, respectively, while that of IOFT was 79.31% and 87.67%, respectively. Both flow cytometric tests performed better. Sensitivity and specificity of EMA was 86.2% and 93.9% respectively, and that of FOFT was 96.6% and 98.63%, respectively. The combination of the FOFT with IOFT or EMA dye-binding test yields a sensitivity of 100%, but with EMA, it had a higher specificity. Hb/MCHC was a predictor of the severity of the disease while %EMA decrease and %RRC did not correlate with severity of the disease. CONCLUSION: Flow-cytometric osmotic fragility test is the best possible single test followed by EMA for diagnosis of HS. A combination of FOFT and EMA can correctly diagnose 100% patients. These tests are likely to replace conventional OFTs in future.

Physical accessibility audit of primary health centers for people with disabilities: An on-site assessment from Dakshina Kannada district in Southern India.

BACKGROUND: Access to health care is important for persons with disability (PwD). The Government of India has launched the "Accessible India Campaign" (AIC) as a nationwide campaign for achieving universal accessibility for PwDs. OBJECTIVE: To conduct an on-site assessment for physical accessibility of all primary health care centers (PHCs) of Dakshina Kannada (DK) district in Karnataka using the AIC checklist. MATERIALS AND METHODS: A cross-sectional facility-based assessment of all 67 PHCs under the administrative control of the District Health and Family Welfare Office of the district was done using Physical Accessibility Audit Checklist prepared by the AIC. Ethics approval was obtained from the Institutional Ethics Committee and written permission was obtained from the District Health and Family Welfare Officer. Data were analyzed for frequencies and percentages. RESULTS: The Accessible India Physical Accessibility Audit Checklist consists of more than116 numbers of items. Out of 67 PHCs, 57 (85%) PHCs had an accessible pathway and 60 (90%) PHCs had a ramp for wheelchair. Only 25 (36%) PHCs had accessible doors. No PHCs had height-adjustable examination table, disable friendly toilets and only two PHCs had accessible weighing scales. CONCLUSION: This unique on-site assessment finds that our PHCs are not well equipped for catering to PwD. To realize AIC in terms of health care access for the PwD, there is much that remains desirable at primary health care level, a point of first contact in the public health system.

A paper based graphene-nanocauliflower hybrid composite for point of care biosensing.

We demonstrate the first report of graphene paper functionalized with fractal platinum nanocauliflower for use in electrochemical biosensing of small molecules (glucose) or detection of pathogenic bacteria (Escherichia coli O157:H7). Raman spectroscopy, scanning electron microscopy and energy dispersive spectroscopy show that graphene oxide-coated nanocellulose was partially reduced by both thermal treatment, and further reduced by chemical treatment (ascorbic acid). Fractal nanoplatinum with cauliflower-like morphology was formed on the reduced graphene oxide paper using pulsed sonoelectrodeposition, producing a conductive paper with an extremely high electroactive surface area (0.29±0.13cm(2)), confirmed by cyclic voltammetry and electrochemical impedance spectroscopy. The platinum surface was functionalized with either glucose oxidase (via chitosan encapsulation) or a RNA aptamer (via covalent linking) for demonstration as a point of care biosensor. The detection limit for both glucose (0.08±0.02µM) and E. coli O157:H7 (≈4 CFUmL(-1)) were competitive with, or superior to, previously reported devices in the biosensing literature. The response time (6s for glucose and 12min for E. coli) were also similar to silicon biochip and commercial electrode sensors. The results demonstrate that the nanocellulose-graphene-nanoplatinum material is an excellent paper-based platform for development of electrochemical biosensors targeting small molecules or whole cells for use in point of care biosensing.

A 73-Year-Old Male with Cervical Spine Osteomyelitis Presenting as Urosepsis.

Vertebral osteomyelitis is a serious debilitating infection if not detected early. Involvement of cervical vertebrae is usually seen in the presence of specific risk factors. Urinary tract infection commonly spreads to the lumbar vertebrae. This is a case presentation of an elderly male who, in the absence of specific risk factors for cervical osteomyelitis, presented with symptoms of urinary tract infection and was found to have cervical spine osteomyelitis.

Association of CYP2C19, CYP3A5 and GPIIb/IIIa gene polymorphisms with Aspirin and Clopidogrel Resistance in a cohort of Indian patients with Coronary Artery Disease.

INTRODUCTION: Dual antiplatelet therapy with clopidogrel and aspirin is the current standard of care in the management of patients with coronary artery disease (CAD) and acute coronary syndrome (ACS). The variability in response to these antiplatelet agents may be due to the underlying genetic diversity. This study was designed to determine the resistance to aspirin and clopidogrel in Indian patients and to look for correlation, if any, with selected polymorphisms. METHODS: Platelet function testing by light transmission aggregometry was performed on 72 patients with CAD/ACS who were stable on dual antiplatelet therapy (clopidogrel 75 mg OD and aspirin 150 mg OD) along with 72 controls. Aspirin resistance was considered as mean platelet aggregation ≥ 70% with 10 µm ADP and ≥ 20% with 0.75 mm arachidonic acid. Clopidogrel resistance was defined as <10% decrease from the baseline in platelet aggregation in response to ADP 10 µm and semi-response as <30% decrease from the baseline. Polymorphisms CYP2C19*2, *3, CYP3A5*3 and PLA1/A2 were genotyped. RESULTS: We found 51.4% patients with inadequate response to clopidogrel (1.4% resistant and 50% semi-responders) and 5.5% patients semi-responders to aspirin, none being completely resistant. The genotype and allele frequencies of CYP2C19*2 and PLA1/A2 gene polymorphisms were significantly different between clopidogrel semi-responders and responders. Carriers of CYP2C19*2 and CYP3A5*3 showed diminished inhibition of platelet aggregation. No significant correlation was found between coronary events, type of coronary intervention with clopidogrel nonresponsiveness. CONCLUSION: Unlike aspirin, a high proportion of partial responders to clopidogrel were identified. In an interim analysis on 72 Indian patients, a significant association was found between CYP2C19*2 and PLA1/A2 in clopidogrel semi-responders.

A comparative study of graphene-hydrogel hybrid bionanocomposites for biosensing.

Hydrogels have become increasingly popular as immobilization materials for cells, enzymes and proteins for biosensing applications. Enzymatic biosensors that utilize hydrogel as an encapsulant have shown improvements over other immobilization techniques such as cross linking and covalent bonding. However, to date there are no studies which directly compare multiple hydrogel-graphene nanocomposites using the same enzyme and test conditions. This study compares the performance of four different hydrogels used as protein encapsulants in a mediator-free biosensor based on graphene-nanometal-enzyme composites. Alcohol oxidase (AOx) was encapsulated in chitosan poly-N-isopropylacrylamide (PNIPAAM), silk fibroin or cellulose nanocrystals (CNC) hydrogels, and then spin coated onto a nanoplatinum-graphene modified electrode. The transduction mechanism for the biosensor was based on AOx-catalyzed oxidation of methanol to produce hydrogen peroxide. To isolate the effect(s) of stimulus response on biosensor behavior, all experiments were conducted at 25 °C and pH 7.10. Electroactive surface area (ESA), electrochemical impedance spectroscopy (EIS), sensitivity to methanol, response time, limit of detection, and shelf life were measured for each bionanocomposite. Chitosan and PNIPAAM had the highest sensitivity (0.46 ± 0.2 and 0.3 ± 0.1 µA mM(-1), respectively) and electroactive surface area (0.2 ± 0.06 and 0.2 ± 0.02 cm(2), respectively), as well as the fastest response time (4.3 ± 0.8 and 4.8 ± 1.1 s, respectively). Silk and CNC demonstrated lower sensitivity (0.09 ± 0.02 and 0.15 ± 0.03 µA mM(-1), respectively), lower electroactive surface area (0.12 ± 0.02 and 0.09 ± 0.03 cm(2), respectively), and longer response time (8.9 ± 2.1 and 6.3 ± 0.8 s, respectively). The high porosity of chitosan, PNIPAAM, and silk gels led to excellent transport, which was significantly better than CNC bionanocomposites. Electrochemical performance of CNC bionanocomposites were relatively poor, which may be linked to poor gel stability. The differences between the Chitosan/PNIPAAM group and the Silk/CNC group were statistically significant (p < 0.05) based on ANOVA. Each of these composites was within the range of other published devices in the literature, while some attributes were significantly improved (namely response time and shelf life). The main advantages of these hydrogel composites over other devices is that only one enzyme is required, all materials are non-toxic, the sensor does not require mediators/cofactors, and the shelf life and response time are significantly improved over other devices.

Erythroleukemia Presenting as Non-immune Haemolytic Anemia: A Rare Presentation.

Non-immune haemolysis is a rare manifestation of acute leukaemia and more so in acute myeloid leukemia. Here, we report a case of non-immune and non-fragmentation haemolysis as the initial presenting manifestation in a 55-year-old female with acute myeloid leukaemia (AML-M6). All other potential aetiologies of haemolysis were excluded, including drugs, paroxysmal nocturnal haemoglobinuria, immune and other known congenital and acquired causes of haemolytic anaemia. This case shows that malignant haematopoietic disorders should be considered in patients with newly diagnosed haemolysis.

Polypoidal choroidal vasculopathy and systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) associated with antiphospholipid syndrome can have ocular complications. We report a 44-year-old Chinese lady with recurrent relapses of SLE and antiphospholipid syndrome with high disease activity, presenting with visual distortion in her right eye for 2 months. There was subretinal hemorrhage in her right eye, confirmed on investigations to be choroidal neovascularization secondary to a variant of age-related macular degeneration known as polypoidal choroidal vasculopathy (PCV). Anti-vascular endothelial growth factor therapy resolved her eye condition. SLE could be associated with PCV via common mechanisms, including complement pathway activation and vasculitis involving the choroidal circulation.

LH750 hematology analyzers to identify malaria and dengue and distinguish them from other febrile illnesses.

INTRODUCTION: Tropical febrile illnesses such as malaria and dengue are challenging to differentiate clinically. Automated cellular indices from hematology analyzers may afford a preliminary rapid distinction. METHODS: Blood count and VCS parameters from 114 malaria patients, 105 dengue patients, and 105 febrile controls without dengue or malaria were analyzed. Statistical discriminant functions were generated, and their diagnostic performances were assessed by ROC curve analysis. RESULTS: Three statistical functions were generated: (i) malaria-vs.-controls factor incorporating platelet count and standard deviations of lymphocyte volume and conductivity that identified malaria with 90.4% sensitivity, 88.6% specificity; (ii) dengue-vs.-controls factor incorporating platelet count, lymphocyte percentage and standard deviation of lymphocyte conductivity that identified dengue with 81.0% sensitivity and 77.1% specificity; and (iii) febrile-controls-vs.-malaria/dengue factor incorporating mean corpuscular hemoglobin concentration, neutrophil percentage, mean lymphocyte and monocyte volumes, and standard deviation of monocyte volume that distinguished malaria and dengue from other febrile illnesses with 85.1% sensitivity and 91.4% specificity. CONCLUSIONS: Leukocyte abnormalities quantitated by automated analyzers successfully identified malaria and dengue and distinguished them from other fevers. These economic discriminant functions can be rapidly calculated by analyzer software programs to generate electronic flags to trigger-specific testing. They could potentially transform diagnostic approaches to tropical febrile illnesses in cost-constrained settings.

Adalimumab induced pulmonary sarcoid reaction.

Sarcoidosis is a multisystem granulomatous inflammatory disease of unknown etiology. There is evidence that Tumor Necrosis Factor alpha (TNF-α) antagonists are useful in the treatment of advanced or refractory disease. However, sarcoidosis-like reaction has been reported with TNF-α blockade in other inflammatory conditions. Here we report a case of sarcoid-like reaction in a patient with psoriatic arthritis shortly after initiation of adalimumab therapy. Stopping adalimumab and systemic anti-inflammatory therapy with corticosteroids resulted in resolution of pulmonary symptoms and chest radiographic findings. Though TNF-α plays a critical role in pathogenesis of sarcoidosis, the development of sarcoid reaction with TNF-α blockade is paradoxical and the mechanism of this response remains unknown. TNF-α induced sarcoid-reaction could involve multiple organs. Its development with one agent does not preclude therapy with other TNF-α blockers.