Dacryoadenitis as a Rare Initial Presentation in a Patient with Suspected Crest Syndrome.

Systemic sclerosis (SSc) is a rare, chronic disease with diverse clinical presentations, and only a few cases with ocular manifestations have been reported in the literature. In this case report, we describe the case of a 51-year-old South Asian woman who initially complained of painless swelling in her left upper eyelid. An ultrasound examination of the left eye revealed an enlarged lacrimal gland with increased vascularity. The presence of dacryoadenitis, which was unresponsive to initial conservative management with oral antibiotics and warm compresses, along with positive antinuclear antibodies, prompted further investigation. Dacryoadenitis or orbital inflammation is a common presentation in systemic conditions such as Sjogren's syndrome, systemic lupus erythematosus, sarcoidosis, or granulomatosis with polyangiitis. However, it can also be a rare initial symptom in a patient with CREST syndrome. To our knowledge, this is only the second case in the literature of dacryoadenitis in the context of calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia (CREST) syndrome. This case highlights the significance of serological markers and peripheral clinical presentations in individuals with chronic orbital inflammation, emphasizing the importance of considering further systemic associations. LEARNING POINTS: Broad spectrum of clinical features: Recognize that although CREST syndrome is primarily characterized by its hallmark features - calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia - it can also present with additional clinical features that may indicate the onset or presence of the syndrome.Diagnostic challenges and differentiation: Diagnostic challenges and differentiation: Bilateral dacryoadenitis can be challenging to diagnose due to its overlapping symptoms with other orbital or systemic conditions. The case report may highlight the importance of differentiating it from conditions like orbital cellulitis, sarcoidosis, or lymphoproliferative disorders. Advanced imaging techniques (like magnetic resonance imaging or computed tomography scans) and careful assessment of clinical history (including systemic symptoms like fever or autoimmune conditions) are crucial for accurate diagnosis.Awareness of atypical presentations and follow-up: The case report underscores the need for tailored management strategies for bilateral dacryoadenitis, from conservative treatments in mild cases to more aggressive therapies in severe ones, while also highlighting the importance of monitoring for complications and being vigilant about atypical presentations, such as those seen in patients with CREST syndrome.

High-yield atmospheric water capture via bioinspired material segregation.

Transforming atmospheric water vapor into liquid form can be a way to supply water to arid regions for uses such as drinking water, thermal management, and hydrogen generation. Many current methods rely on solid sorbents that cycle between capture and release at slow rates. We envision a radically different approach where water is transformed and directly captured into a liquid salt solution that is suitable for subsequent distillation or other processing using existing methods. In contrast to other methods utilizing hydrogels as sorbents, we do not store water within hydrogels-we use them as a transport medium. Inspired by nature, we capture atmospheric water through a hydrogel membrane "skin" at an extraordinarily high rate of 5.50 kgm[Formula: see text]d[Formula: see text] at a low humidity of 35%. and up to 16.9 kgm[Formula: see text]d[Formula: see text] at higher humidities. For a drinking-water application, calculated performance of a hypothetical one-square-meter device shows that water could be supplied to two to three people in arid environments. This work is a significant step toward providing new resources and possibilities to water-scarce regions.

An economic model to understand the cost-effectiveness of olanzapine orally dispersible tablets (ODT) and olanzapine film coated tablets as a group compared with other oral atypical antipsychotics for treating schizophrenia in Morocco.

BACKGROUND: Antipsychotic medications are the primary treatment for schizophrenia, with olanzapine being an effective medication for schizophrenia. The economic cost for each individual with schizophrenia is high, with antipsychotic medication being a major expense. This study aims to develop an economic decision model that compares different treatment options for schizophrenia patients, including olanzapine Orally Dispersible Tablets (ODT), olanzapine [ODT + Standard Oral Tablet (SOT)], risperidone (ODT + SOT), and aripiprazole (ODT + SOT), to determine their cost-effectiveness with an objective to optimize healthcare resource allocation in Morocco. METHODS: The study used published medical literature and a clinical expert panel to develop a decision analytic model. This model was designed to capture parameters such as adherence levels, treatment discontinuation, relapse with and without hospitalization, quality-adjusted life years (QALYs), treatment-related adverse events, healthcare resource utilization, and associated costs. The main outcomes of interest included the total annual direct cost per treatment, QALYs, and incremental cost-effectiveness ratio (ICER) per 1 QALY gained. One-way and probabilistic sensitivity analyses were employed to account for parameter uncertainty. RESULTS: According to the simulation model, the ODT and ODT + SOT as a group form of olanzapine was the most effective treatment option in terms of the lowest percentages of inpatient relapse, and patients who remained stable (11% and 79% respectively) than risperidone (19% and 62% respectively) and aripiprazole ODT (26% and 50% respectively) and ODT + SOT formulation groups. Olanzapine (ODT + SOT) therapy group was cost-effective when compared to the combined group of ODT + SOT forms of risperidone [ICER: Moroccan Dirham (MAD) 103,907], and aripiprazole (ICER: MAD 65,047). Additionally, olanzapine ODT was found to be cost-effective compared to olanzapine SOT with an ICER of MAD 3921, risperidone ODT with an ICER of MAD 1,02,298, risperidone SOT with an ICER of MAD 31,088, and aripiprazole ODT or SOT formulations. All the above ICERs fall under the willingness-to-pay threshold in Morocco of MAD 250,832.40. Sensitivity analyses confirmed the reliability of the findings. CONCLUSIONS: The model concluded that olanzapine ODT is the most cost-effective first-line treatment option for schizophrenia in Morocco when compared to other atypical antipsychotic medications in ODT and SOT formulations.

Clinical Presentation and Outcomes of Alpha-Gal Syndrome.

BACKGROUND AND AIMS: Alpha-gal syndrome (AGS) is an IgE-mediated allergic reaction to galactose-α-1,3-galactose, primarily linked with Lone Star tick bites in the United States. It presents with symptoms ranging from urticaria and gastrointestinal (GI) manifestations to delayed anaphylaxis following red meat consumption. We aimed to study AGS patients' clinical manifestations, diagnosis, and outcomes. METHODS: A retrospective chart review of patients who underwent serological testing for suspected AGS between 2014 and 2023 at Mayo Clinic was performed. Patients with positive serology were age and sex matched with those who tested negative. Clinical characteristics of seropositive cohort with and without GI symptoms were compared, and outcomes assessed. RESULTS: Of 1260 patients who underwent testing, 124 tested positive for AGS. They were matched with 380 seronegative control subjects. AGS patients reported a higher frequency of tick bites (odds ratio [OR], 26.0; 95% confidence interval [CI], 9.8-68.3), reported a higher prevalence of urticaria (56% vs 37%; P = .0008), and were less likely to have asthma (OR, 0.4; 95% CI, 0.3-0.7). They had a lower prevalence of heartburn (6% vs 12%; P = .03) and bloating (6% vs 13%; P = .03). A total of 47% had GI symptoms, and a higher proportion were female than those without GI symptoms (69% vs 35%; P = .002). During a mean follow-up of 27 months, 22 of 40 patients reported symptom resolution after avoiding red meat, and 7 were able to transition to regular diet. CONCLUSIONS: A diagnosis of AGS should be strongly considered in patients with a history of tick bites and clinical presentation of allergic or GI manifestations. Dietary intervention is effective in most but not all patients.

An Autobiographical Case Report on Papillary Thyroid Carcinoma with Positive Antithyroid Antibodies: Coincidence or Correlated?

The relationship between autoimmunity and cancer has been a gray area, with many theories but no solid proof so far. Hashimoto's thyroiditis is an autoimmune disorder and a major cause of hypothyroidism, while papillary thyroid carcinoma is the most common thyroid malignancy generally found in patients younger than 45 years of age. The literature on the correlation between these two disorders is somewhat based on potentially biased histopathological examination from pre-operative fine needle aspiration and post-thyroidectomy samples. Although recent studies are evaluating a possible holistic molecular, hormonal, and histopathological foundation for this correlation, a clear causal relationship has not been established yet. This report illustrates the author's case presentation, treatment, and eventual outcome of the disease when she was diagnosed with papillary thyroid cancer at the age of 25 years, with positive antithyroid peroxidase and antithyroglobulin antibodies.

Intestinal proteases.

PURPOSE OF REVIEW: Proteases constitute a group of enzymes that hydrolyze peptide bonds. Intestinal proteases are an integral part of gut homeostasis and digestion. This review discusses the broader classification of proteases, regulation of proteolytic activity (PA) in the intestinal tract, and how dysregulation of intestinal proteases contributes to the pathophysiology of conditions such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and celiac disease. We also discuss recent advancements in therapeutic modulation that directly or indirectly target intestinal proteases and can be utilized to treat these illnesses. RECENT FINDINGS: Host and microbiota derived proteases have been associated with symptoms in subsets of patients with IBS, IBD and celiac disease. Elevated PA mediates barrier dysfunction, visceral hypersensitivity as well as immune activation and inflammation. Recent mechanistic studies have revealed the nature of disease-associated proteases and mechanisms regulating their activity, particularly those driven by the microbiota. Advancements in activity-based probes have allowed novel ways of in vivo imaging of PA. Newer strategies targeting proteases include monoclonal antibodies, engineered microbiota as well as specific protease inhibitors. SUMMARY: Significant progresses made in the detection as well as regulation of PA is likely to provide therapeutic advancements for gastrointestinal diseases.

Safety of Enteral Nutrition Practices: Overcoming the Contamination Challenges.

Enteral nutrition (EN) has host of benefits to offer to critically ill patients and is the preferred route of feeding over parenteral nutrition. But along with the many outcome benefits of enteral feeding come the potential for adverse effects that includes gastrointestinal (GI) disturbances mainly attributed to contaminated feeds. Currently, EN is practiced using blenderized/kitchen prepared feeds or scientifically developed commercial feeds. Commercial feeds based on their formulation may be divided as ready-to-mix powder formulas or ready-to-hang sterile liquid formulas. A holistic view on potential sterility of EN from preparation to patient delivery would be looked upon. These sterility issues may potentially result in clinical complications, and hence process-related errors need to be eliminated in hospital practice, since immunocompromised intensive care unit patients are at high risk of infection. This review intends to discuss the various EN practices, risk of contamination, and ways to overcome the same for better nutrition delivery to the patients. Among the various types of enteral formulas and delivery methods, this article tries to summarize several benefits and risks associated with each delivery system using the currently available literature. HOW TO CITE THIS ARTICLE: Sinha S, Lath G, Rao S. Safety of Enteral Nutrition Practices: Overcoming the Contamination Challenges. Indian J Crit Care Med 2020;24(8):709-712.

Adsorption-Based Atmospheric Water Harvesting: Impact of Material and Component Properties on System-Level Performance.

Atmospheric water harvesting (AWH) is the capture and collection of water that is present in the air either as vapor or small water droplets. AWH has been recognized as a method for decentralized water production, especially in areas where liquid water is physically scarce, or the infrastructure required to bring water from other locations is unreliable or infeasible. The main methods of AWH are fog harvesting, dewing, and utilizing sorbent materials to collect vapor from the air. In this paper, we first distinguish between the geographic/climatic operating regimes of fog harvesting, dewing, and sorbent-based approaches based on temperature and relative humidity (RH). Because utilizing sorbents has the potential to be more widely applicable to areas which are also facing water scarcity, we focus our discussion on this approach. We discuss sorbent materials which have been developed for AWH and the material properties which affect system-level performance. Much of the recent materials development has focused on a single material metric, equilibrium vapor uptake in the material (kg of water uptake per kg of dry adsorbent), as found from the adsorption isotherm. This equilibrium property alone, however, is not a good indicator of the actual performance of the AWH system. Understanding material properties which affect heat and mass transport are equally important in the development of materials and components for AWH, because resistances associated with heat and mass transport in the bulk material dramatically change the system performance. We focus our discussion on modeling a solar thermal-driven system. Performance of a solar-driven AWH system can be characterized by different metrics, including L of water per m2 device per day or L of water per kg adsorbent per day. The former metric is especially important for systems driven by low-grade heat sources because the low power density of these sources makes this technology land area intensive. In either case, it is important to include rates in the performance metric to capture the effects of heat and mass transport in the system. We discuss our previously developed modeling framework which can predict the performance of a sorbent material packed into a porous matrix. This model connects mass transport across length scales, considering diffusion both inside a single crystal as well as macroscale geometric parameters, such as the thickness of a composite adsorbent layer. For a simple solar thermal-driven adsorption-based AWH system, we show how this model can be used to optimize the system. Finally, we discuss strategies which have been used to improve heat and mass transport in the design of adsorption systems and the potential for adsorption-based AWH systems for decentralized water supplies.

Practice Guidelines for Enteral Nutrition Management in Dysglycemic Critically Ill Patients: A Relook for Indian Scenario.

BACKGROUND AND AIM: Intensive-care practices and settings differ for India in comparison to other countries. While guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to nutritional management of EN in dysglycemic patients, specific to patients in Indian critical care settings. Advisory board meetings were arranged to develop the practice guidelines specific to the Indian context, for the use of EN in dysglycemic critically ill patients and to overcome challenges in this field. MATERIALS AND METHODS: Two advisory board meetings were organized to review various existing guidelines, meta-analyses, randomized controlled trials (RCTs), controlled trials and review articles, for their contextual relevance and strength. Three rounds of Delphi voting were done to arrive at consensus on certain recommendations. A systematic grading of practice guidelines by the advisory board was done based on strength of the consensus voting and reviewed supporting evidences. RESULTS: Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding prediction and assessment of dysglycemia (DG), acceptable glycemic targets in such settings, general nutritional aspects pertaining to DG nutrition, and nutrition in various superspecialty cases in critical care settings, where DG is commonly encountered. CONCLUSION: This paper summarizes the optimum EN practices for managing DG in critically ill patients. The practical solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance for EN management in dysglycemic critically ill patients. These guidelines also outline the model glycemic control task force and its roles in nutrition care as well as an intensive care unit DG nutrition protocol. HOW TO CITE THIS ARTICLE: Mehta Y, Mithal A, Kulkarni A, Reddy BR, Sharma J, Dixit S, et al. Practice Guidelines for Enteral Nutrition Management in Dysglycemic Critically Ill Patients: A Relook for Indian Scenario. Indian J Crit Care Med 2019;23(12):594-603.

Tunable Metal-Organic Frameworks Enable High-Efficiency Cascaded Adsorption Heat Pumps.

Rising global standards of living coupled to the recent agreement to eliminate hydrofluorocarbon refrigerants are creating intense pressure to develop more sustainable climate control systems. In this vein, the use of water as the refrigerant in adsorption heat pumps is highly attractive, but such adsorption systems are constrained to large size and poor efficiency by the characteristics of currently employed water sorbents. Here we demonstrate control of the relative humidity of water uptake by modulating the pore size in a family of isoreticular triazolate metal-organic frameworks. Using this method, we identify a pair of materials with stepped, nonoverlapping water isotherms that can function in tandem to provide continuous cooling with a record ideal coefficient of performance of 1.63. Additionally, when used in a single-stage heat pump, the microporous Ni2Cl2BBTA has the largest working capacity of any material capable of generating a 25 °C difference between ambient and chiller output.

Editors and teachers with standards: a dying breed.

I read with interest the absorbing review of Jerome P. Kassirer's memoirs by Sanjay Pai. The review brings out the essence of the man and his memoirs very well and enhances the respect and the admiration for the legendary editor. Peer reviewed print journals still remain the gold standard of dissemination of new research in spite of the availability of other methods. However, as the reviewer writes, the times are changing. If the editors who uphold the highest standards of medical publishing are removed then the whole body of knowledge being published can come under a cloud. Recent news in the lay media about non-disclosure of conflict of interest by the editors of the venerated 'Harrison's Principles of Internal Medicine' is one such example of the importance of integrity in the editorial process.

A randomized, open labeled study comparing the serum levels of cobalamin after three doses of 500 mcg vs. a single dose methylcobalamin of 1500 mcg in patients with peripheral neuropathy.

BACKGROUND: Vitamin B12 deficiency has been associated with peripheral neuropathy, loss of sensation in the peripheral nerves, and weakness in the lower extremities. Methylcobalamin is the most effective analogue of vitamin B12 used to treat or prevent the complications associated with vitamin B12 deficiency. The current study aimed to compare the serum cobalamin levels after administration of two different regimes of methylcobalamin in peripheral neuropathy patients. METHODS: The present study was a prospective, randomized, comparative study. The study consisted of two parallel groups, group A (methylcobalamin 500 µg injection intramuscularly three times a week) and group B (methylcobalamin 1500 µg injection intramuscularly once a week). A control group of healthy volunteers was also included. RESULTS: A total of 24 patients (12 in each group) were included in the study. Five healthy volunteers were also included as a control in each group. At the end of treatment, serum cobalamin levels were significantly (P = 0.028) higher in group A (1892.08 ± 234.50) as compared with group B (1438.5 ± 460.32). The serum cobalamin levels in Group A healthy volunteers were also two times higher than that of group B (P = 0.056). Both the LANSS scale and DN4 questionnaire reported similar results at end of treatment. CONCLUSIONS: The 500 µg methylcobalamin thrice weekly regime is more effective in increasing the serum cobalamin levels as compared to the 1500 µg methylcobalamin once weekly regime.

Adsorption-based atmospheric water harvesting device for arid climates.

Water scarcity is a particularly severe challenge in arid and desert climates. While a substantial amount of water is present in the form of vapour in the atmosphere, harvesting this water by state-of-the-art dewing technology can be extremely energy intensive and impractical, particularly when the relative humidity (RH) is low (i.e., below ~40% RH). In contrast, atmospheric water generators that utilise sorbents enable capture of vapour at low RH conditions and can be driven by the abundant source of solar-thermal energy with higher efficiency. Here, we demonstrate an air-cooled sorbent-based atmospheric water harvesting device using the metal-organic framework (MOF)-801 [Zr6O4(OH)4(fumarate)6] operating in an exceptionally arid climate (10-40% RH) and sub-zero dew points (Tempe, Arizona, USA) with a  thermal efficiency (solar input to water conversion) of ~14%. We predict that this device delivered over 0.25 L of water per kg of MOF for a single daily cycle.

Response to Comment on "Water harvesting from air with metal-organic frameworks powered by natural sunlight".

In their comment, Bui et al argue that the approach we described in our report is vastly inferior in efficiency to alternative off-the-shelf technologies. Their conclusion is invalid, as they compare efficiencies in completely different operating conditions. Here, using heat transfer and thermodynamics principles, we show how Bui et al's conclusions about the efficiencies of off-the-shelf technologies are fundamentally flawed and inaccurate for the operating conditions described in our study.

Response to Comment on "Water harvesting from air with metal-organic frameworks powered by natural sunlight".

The Comment by Meunier states that the process we described in our report cannot deliver the claimed amount of liquid water in an arid climate. This statement is not valid because the parameters presented in our study were inappropriately combined to draw misguided conclusions.

Low doses of amitriptyline, pregabalin, and gabapentin are preferred for management of neuropathic pain in India: is there a need for revisiting dosing recommendations?

BACKGROUND: Current therapy for the treatment of neuropathic pain is often unsatisfactory. Considerable variation in treatment pattern still exists in spite of availability of sufficient literature from various guidelines. Recent Indian market data suggested that the utilization (sale) of drugs such as amitriptyline, pregabalin, and gabapentin was more for low-dose unit packs than that of the high-dose unit packs, raising the belief that these drugs are prescribed at a lower dose than is actually recommended in the guidelines. To test this hypothesis, a survey was conducted across speciality throughout the country to observe the prescription pattern of these drugs amongst the health care providers in India. METHODS: Three hundred fifty survey forms were distributed of which 281 forms were included for analysis. RESULTS: It was observed that the commonly used initiation and maintenance dose for amitriptyline, pregabalin, and gabapentin was 5-10 mg/day, 50-75 mg/day, and 100-300 mg/day, respectively. The reason to select the lower dosages was to have a balancing effect to achieve good efficacy with minimum side effects. Care-givers reported no side effects/not many side effects as a reason in 22.2%, 16.88%, and 23.86% patients with amitriptyline, pregabalin, and gabapentin, respectively. Sedation and giddiness were commonly reported with all three drugs. CONCLUSIONS: Commonly prescribed drugs for management of neuropathic pain, such as amitriptyline, pregabalin, and gabapentin are preferred at lower doses in Indian clinical settings. Acceptable efficacy and low tolerance to the standard dosage is believed to be the reason behind the prescribed dose.

Water harvesting from air with metal-organic frameworks powered by natural sunlight.

Atmospheric water is a resource equivalent to ~10% of all fresh water in lakes on Earth. However, an efficient process for capturing and delivering water from air, especially at low humidity levels (down to 20%), has not been developed. We report the design and demonstration of a device based on a porous metal-organic framework {MOF-801, [Zr6O4(OH)4(fumarate)6]} that captures water from the atmosphere at ambient conditions by using low-grade heat from natural sunlight at a flux of less than 1 sun (1 kilowatt per square meter). This device is capable of harvesting 2.8 liters of water per kilogram of MOF daily at relative humidity levels as low as 20% and requires no additional input of energy.

A review of immunogenicity and tolerability of live attenuated Hepatitis A vaccine in children.

Changing epidemiology of Hepatitis A virus (HAV) has led to an increased susceptibility of adolescents and adults to the infection. Vaccination can remarkably reduce the incidence and associated morbidity of HAV infection. This review is focused on the safety and efficacy of H2 strain derived live attenuated Hepatitis A vaccine. We found the vaccine to be highly immunogenic with minimal or negligible safety issues. Moreover, a single dose of live attenuated vaccine persists a long term immune response and can be a preferred option for developing countries. In 2014, Indian Academy of Paediatrics (IAP) also updated their recommendations for H2 vaccine as a single dose as against the previous 2 dose schedule. A focused approach to include the vaccine in national immunization program should be explored.

Coronectomy; Good or Bad?

The removal of mandibular third molars can be complicated by injury to the inferior alveolar nerve (IAN). Coronectomy retains the tooth root; this method has been found to be preferable to extraction in the context of mandibular third molars. A failed coronectomy may cause mobilization of these roots, thereby requiring a subsequent extraction. Having undergone a previous coronectomy, extraction is then safer as the roots usually migrate away from the IAN. Computed tomography is more accurate than radiography when imaging mandibular third molars pre-operatively owing to its three-dimensional nature. Longer studies need to be conducted to evaluate the long term benefits of coronectomy. CPD/CLINICAL RELEVANCE: The removal of mandibular third molars can be complicated by the presence of the close lying inferior alveolar nerve. Coronectomy can be useful in this setting and therefore it is important to be aware of the pros and cons of this technique.

Scheduling cycles with gonadotropin-releasing hormone antagonist protocol in in vitro fertilization: Is there a scope in batch in vitro fertilization?

In India, a practice of "Batch in vitro fertilization (IVF)" has evolved in many infertility centers in an effort to align infertility management with logistics. A "Batch IVF" is an approach where the menstrual cycles of multiple women are programmed, such that they can undergo all the processes; from stimulation until embryo transfer about the same time. In "Batch IVF", the day for initiating stimulation is calculated retrospectively from the day the visiting embryologist is available at the clinic (day of ovum pick-up). Aligning the cycles of multiple women with steroids followed by down regulation with long gonadotropin-releasing hormone agonist (GnRH-A) is one of the currently employed methods for batching. There is sufficient evidence on scheduling cycles with steroids in GnRH-An protocol without compromising on the outcome. The objective of this paper is to provide evidence-based clinical concept on scheduling cycles in "Batch IVF" setup with GnRH-An protocol through literature review.