Combination therapy of nitazoxanide with oseltamivir compared with oseltamivir in hospitalized patients with seasonal influenza.

Antiviral combinations have been proposed as treatment for influenza in order to increase the antiviral activity by action at different sites of action as well as obviate the emergence of drug resistance to the commonly used antiviral agents like oseltamivir. Nitazoxanide has been found to exhibit anti-influenza viral activity with clinical benefit in a previous study. We recruited 242 cases of SARI, among whon 67 were confirmed to have influenza viral infection. In a randomized blinded fashion, 34 patients received a combination of nitazoxanide and oseltamivir whereas 33 cases received oseltamivir alone. Clinical parameters were followed in both groups and the nasal swabs were re-tested on day 6 for influenza positivity and the cycle threshold (CT) values. No significant differences were observed in terms of time for resolution of fever, other symptoms, and SOFA scores. Nine patients succumbed during the course of the illness that included three in the oseltamivir group and six in the combination group. All but one of those who expired had an underlying co-morbid illness. Our preliminary data suggest that the addition of nitazoxanide does not improve outcomes in hospitalized patients with influenza. Larger studies are recommended for statistically robust conclusions.

Correlation Between Serum Tumor Necrosis Factor-Alpha (TNF-α) and Clinical Severity of Tuberculosis: A Hospital-Based Study.

AIM: The main aim of this study was to assess the correlation between serum tumor necrosis factor-alpha (TNF-α) levels the and clinical severity of tuberculosis. METHODS: This was a hospital-based case-control prospective study and was conducted at the Sher-i-Kashmir Institute of Medical Sciences, a tertiary care hospital in the northern part of India, from May 2016 to May 2018. The subjects were recruited in the study considering inclusion and exclusion criteria. All patients with pulmonary tuberculosis as well as patients with extrapulmonary tuberculosis were included as subjects and a clinical severity score based on anemia, weight loss, presence of hypoxia, and radiological features was calculated and compared with TNF-α levels. Age- and sex-matched healthy individuals were recruited as controls. RESULTS: A total of 75 subjects comprising 50 cases and 25 controls were taken for the study. There were 34 (68.0%) patients with elevated TNF-α levels while only 16 (32.0%) patients had normal TNF-α levels. And, TNF-α levels were normal in 21 (84%) control subjects as compared to tuberculosis (TB) patients. Such difference in serum TNF-α levels between cases and controls was statistically significant (p<0.05). The mean serum TNF-α level in TB cases was 1265.63 pg/mL, while the mean serum TNF-α level in controls was 312.06 pg/mL. The difference in serum TNF-α levels between the two groups was statistically significant (p<0.01). We observed a significant increase in serum TNF-α levels with the increase in clinical severity score. CONCLUSION: Serum TNF-α levels were significantly associated with increased severity of TB.

Predictors of Prolonged Hospital Stay in Patients with Acute Pulmonary Thromboembolism- A Hospital Based Cohort Study.

AIMS AND OBJECTIVES: Patients with pulmonary thromboembolism (PTE) are commonly admitted to hospital and generally have a prolonged hospital stay in this part of the world. We aimed to determine different clinical and laboratory parameters that are associated with prolonged hospital stay in our set-up and to analyse effectiveness of Pulmonary Embolism Severity Index (PESI) score as a predictor of prolonged hospital stay in patients with PTE. MATERIALS AND METHODS: It was a hospital based observational prospective study. Confirmed cases of PTE defined as patients with evidence of thrombus on CT pulmonary angiogram (CTPA) were included in this study. Depending on the length of hospital stay, patients were divided into two cohorts: Shorter Hospital stay (less than mean i.e., < 10 Days) and Prolonged Hospital stay (longer than mean i.e., ≥ 10 Days). Logistic regression analysis was done to identify predictors of prolonged hospital stay. RESULTS: 150 patients were included in the study with 67 patients (44.67%) having shorter hospital stay (<10 days) and 83 patients (55.33%) having prolonged hospital stay (≥10 days). On multivariate regression analysis, parameters that were found to be statistically significant were hypotension at presentation, decreased level of consciousness, pco2 < 30 mmHg, presence of S1Q3T3 pattern on electrocardiogram (ECG) and high risk PESI (class III-V). CONCLUSION: PESI class can be effectively used to predict prolonged hospital stay in patients with pulmonary embolism. Patients with hypotension at presentation, decreased level of consciousness, pco2 less than 30 mmHg, and S1Q3T3 on ECG are more likely to have prolonged hospital stay in our healthcare setup.

Comparison of clinical, biochemical, and polysomnographic parameters between obese and nonobese obstructive sleep apnea.

Background: Obstructive sleep apnea (OSA) occurs in both obese and nonobese individuals. This study was designed to compare clinical, metabolic profile, and polysomnographic parameters among obese and nonobese OSA patients. Material and Methods: This cross-sectional retro-prospective study involved 148 OSA patients. OSA patients were classified as nonobese (body mass index [BMI] <27.5 kg/m2) and obese (BMI ≥27.5 kg/m2) to determine the influence of BMI on its risks, clinical, metabolic, and polysomnographic parameters. For statistical comparisons, continuous variables were analyzed by Student's t-test and categorical variables by Chi-square. Results: Of 148 patients, 106 patients were of a retrospective group and 42 in the prospective group. 116 patients were obese and 32 were nonobese with a mean BMI of 33.66 ± 5.3 versus. 25.17 ± 2.2 kg/m2 respectively. Female sex (70.7% vs. 43.4%), larger neck circumference (37.99 ± 3.93 vs. 33.67 ± 5.5 cm), loud snoring (94.8% vs. 81.3%), excessive daytime sleepiness (53.4% vs. 9.4%), fatigability (94.8% vs. 75%), high Epworth Sleepiness Scale score (16% vs. 8%), and hypertension (77.6% vs. 46.9%) were significantly (P < 0.05) more common among obese OSA patients while as smoking and sedative use was more prevalent among nonobese OSA group. However, no significant difference in median apnea-hypopnea index and severity of OSA between obese and nonobese group was observed. At the same time, the median oxygen desaturation index was significantly higher in obese patients (26.1 vs. 12.7, P = 0.005). Conclusion: Nonobese OSA patients depicted less severe disease symptoms and thus require high index of suspicion for early identification due to associated cardiovascular risk.

Spirometric abnormalities in patients with sleep-related breathing disorders.

INTRODUCTION: Patients with sleep-related breathing disorders (SRBD) have various structural and functional abnormalities of the upper airway during sleep which may get reflected on their pulmonary function tests. The aim of the study was to find the correlation between the spirometric indices and snoring, grades of apnea-hypoapnea index (AHI), and STOPBANG. There is scarcity of literature showing correlation of STOP BANG with spirometric variables. MATERIAL AND METHODS: Patient with SRBD fulfilling the inclusion and exclusion criteria were enrolled. The pretest probability sleep score STOPBANG and polysomnography (PSG) were calculated for all the patients. Spirometric indices like forced expiratory volume in one sec (FEV1), forced vital capacity (FVC), postbronchodilator ratio FEVI/FVC (PBDR), and peak expiratory flow rate (PEFR) were studied. Their association with snoring, different grades of obstructive sleep apnea (OSA), and STOPBANG were evaluated using statistical analysis. RESULTS: A total of 70 patients were enrolled. Abnormalities of spirometric indices were found to be common in patients with SRBD but their association with snoring, grades of OSA, and STOPBANG were not statistically significant. There is no statistically significant correlation between body mass index (BMI) and grades of AHI. CONCLUSION: This study found no statistically significant correlation between spirometric parameters and STOPBANG and degree of AHI. Primary care physicians should be aware that obstructive lung disease does coexist with the sleep disordered breathing but as per this study, their statistically significant association needs further validation.

Two-year mortality in survivors of acute exacerbations of chronic obstructive pulmonary disease: A North Indian study.

OBJECTIVES: Data about long-term mortality of Indian patients following acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are scant. We set out to study the 2-year mortality in north Indian patients following discharge after AECOPD. MATERIALS AND METHODS: One hundred and fifty-one (96 male) patients admitted for AECOPD and discharged were followed for 2 years at 3, 6, 12, 18, and 24 months for mortality. Statistical analysis was performed to identify risk factors associated with mortality. RESULTS: Sixty (39.7%) of the 151 recruited died during the 24 months of follow-up, 30 (19.8%) at 3-month, 43 (28.5%) at 6-month, 49 (32.4%) at 1-year, 55 (36.4%) at 18-month, and 60 (39.7%) at 2 years. There was no mortality in Global Initiative for Chronic Obstructive Lung Disease (GOLD) Stage I (0 of 6 cases), whereas it was 12.3% (n = 8 of 65 patients) in GOLD Stage II, 41.7% (n = 15 of 36 cases), in GOLD Stage III, and 84.1% (n = 37 of 4 cases), of patients with GOLD Stage IV. Mortality was associated with 6-min walk distance, oxygen saturation, low body mass index, history of congestive heart failure, and St. George Respiratory Questionnaire score. CONCLUSION: Indian patients discharged after AECOPD have a high 2-year mortality. Measures to reduce the frequency of exacerbations need to be routinely adopted in patients with COPD.

Tubercular osteomyelitis of the mandible in a young female.

A 16-year-old female presented with a 6-month history of a gradually increasing swelling of the left side of her face. A panoramic radiographic view of the mandible showed diffuse radiolucency in the ramus of the mandible with a loss of cortication on the superior and anterior portion of the condyle. The computed tomography (CT) scan revealed destruction of the mandibular bone and a large retromandibular and inferior temporal fossa mass with areas of breakdown. The biopsy was consistent with tubercular osteomyelitis. Antitubercular therapy resulted in a marked reduction of the size of the swelling over a 9-month period.

Osmotic demyelination syndrome following slow correction of hyponatremia: Possible role of hypokalemia.

A 47-year-old male presented with hyponatremia that was corrected slowly as per the recommended guidelines. The patient improved initially but went on to develop a quadriparesis with a locked-in state due to a central as well as extrapontine myelinolysis and subsequently succumbed to an intercurrent infective illness. The patient had associated hypokalemia. Hyponatremia can result in central pontine myelinolysis even when the electrolyte disorder is treated slowly, and the concomitant hypokalemia seems to play a contributory role in the pathogenesis of the neurological disorder.

High altitude pulmonary edema among "Amarnath Yatris".

BACKGROUND: Annual pilgrimage (Yatra) to the cave shrine of Shri Amarnath Ji' is a holy ritual among the Hindu devotees of Lord Shiva. Located in the Himalayan Mountain Range (altitude 13,000 ft) in south Kashmir, the shrine is visited by thousands of devotees and altitude sickness is reportedly common. MATERIALS AND METHODS: More than 600,000 pilgrims visited the cave shrine in 2011 and 2012 with 239 recorded deaths. Thirty one patients with suspected altitude sickness were referred from medical centers en-route the cave to Sher-i-Kashmir Institute of Medical Sciences, a tertiary-care center in capital Srinagar (5,000 ft). The clinical features and the response to treatment were recorded. RESULTS: Thirty-one patients (all lowlanders, 19 male; age 18-60 years, median 41) had presented with acute onset breathlessness of 1-4 days (median 1.9 d) starting within 12-24 h of a rapid ascent; accompanied by cough (68%), headache (8%), dizziness and nausea (65%). Sixteen patients had associated encephalopathy. Clinical features on admission included tachypnea (n = 31), tachycardia (n = 23), bilateral chest rales (n = 29), cyanosis (n = 22) and grade 2-4 encephalopathy. Hypoxemia was demonstrable in 24 cases and bilateral infiltrates on radiologic imaging in 29. Ten patients had evidence of high-altitude cerebral edema. All patients were managed with oxygen, steroids, nifedipine, sildenafil and other supportive measures including invasive ventilation (n = 3). Three patients died due to multiorgan dysfunction. CONCLUSIONS: Altitude sickness is common among Amaranath Yatris from the plains and appropriate educational strategies should be invoked for prevention and prompt treatment.

Comparison and agreement between venous and arterial gas analysis in cardiopulmonary patients in Kashmir valley of the Indian subcontinent.

BACKGROUND: Arterial blood gas (ABG) analysis is routinely performed for sick patients but is fraught with complications, is painful, and is technically demanding. OBJECTIVE: To ascertain agreement between the arterial and peripheral venous measurement of pH, pCO(2), pO(2), and bicarbonate levels in sick patients with cardiopulmonary disorders in the valley of Kashmir in the Indian subcontinent, so as to use venous gas analysis instead of arterial for assessment of patients. SETTING: Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, a 650-bedded tertiary care hospital in North India located at an altitude of 1584 m. METHODS: One hundred patients who required ABG analysis were admitted. Peripheral venous blood was drawn within 5 min of an ABG measurement, and the samples analyzed immediately on a point of care automated ABG analyzer. Finger pulse oximetry was used to obtain oxygen (SpO(2)) saturation. Data were analyzed using Pearson correlation and bias (Bland Altman) methods. RESULTS: The venous measurements of pH, pCO(2), pO(2) and bicarbonate, and the digital oxygen saturation were highly correlated with their corresponding arterial measurements. Bland Altman plots demonstrated a high degree of agreement between the two corresponding sets of measurements with clinically acceptable differences. The difference in pO(2) measurements was, however, higher (-22.34 ± 15.23) although the arterial saturation and finger oximetry revealed a good degree of agreement with clinically acceptable bias. CONCLUSION: Peripheral venous blood gas assessment in conjunction with finger pulse oximetry can obviate the routine use of arterial puncture in patients requiring ABG analysis.