Comparison of a Novel Score "NOD-ACLF" to Other Established Prognostic Scores for Prediction of Mortality in APASL-ACLF Patients: A Cohort Study from a Tertiary Care Center of North India.

Background: Commonly used prognostic scores for acute on-chronic liver failure (ACLF) have complex calculations. We tried to compare the simple counting of numbers and types of organ dysfunction to these scores, to predict mortality in ACLF patients. Methods: In this prospective cohort study, ACLF patients diagnosed on the basis of Asia Pacific Association for Study of the Liver (APASL) definition were included. Severity scores were calculated. Prognostic factors for outcome were analysed. A new score, the Number of Organ Dysfunctions in Acute-on-Chronic Liver Failure (NOD-ACLF) score was developed. Results: Among 80 ACLF patients, 74 (92.5%) were male, and 6 were female (7.5%). The mean age was 41.0±10.7 (18-70) years. Profile of acute insult was; alcohol 48 (60%), sepsis 30 (37.5%), variceal bleeding 22 (27.5%), viral 8 (10%), and drug-induced 3 (3.8%). Profiles of chronic insults were alcohol 61 (76.3%), viral 20 (25%), autoimmune 3 (3.8%), and non-alcoholic steatohepatitis 2 (2.5%). Thirty-eight (47.5%) were discharged, and 42 (52.5%) expired. The mean number of organ dysfunction (NOD-ACLF score) was ->4.5, simple organ failure count (SOFC) score was >2.5, APASL ACLF Research Consortium score was >11.5, Model for End-Stage Liver Disease-Lactate (MELD-LA) score was >21.5, and presence of cardiovascular and respiratory dysfunctions were significantly associated with mortality. NOD-ACLF and SOFC scores had the highest area under the receiver operating characteristic to predict mortality among all these. Conclusion: The NOD-ACLF score is easy to calculate bedside and is a good predictor of mortality in ACLF patients performing similar or better to other scores.

Virus versus humanity - Do vaccines tilt the scale?

S Srinivasan in his article "The vaccine mandates judgment: Some reflections", in this journal, analyses a judgment of the Hon'ble Supreme Court of India in summer this year [1]. Therein, he underscores significant points of interest, the logic behind them, a few points of contention, their scientific basis and areas where logic defies rationality and prudence. Nevertheless, certain relevant points about vaccination are overlooked in the article. Under the subheading, "Vaccine mandates and the right to privacy", the author states that the order "finally zeroes in on this proposition…and that is that the risk of transmission of the Severe Acute Respiratory Syndrome (SARS-CoV-2) virus from unvaccinated individuals is almost on par with that from vaccinated persons". Therefore, when the immunisation does not serve the social purpose of stopping propagation of the infection, why should the authorities mandate people to accept vaccination? This is the argument put forth by the author.

Solving crimes, balancing rights in police investigation.

Jinee Lokneeta's editorial on Police investigation and unethical "scientific interrogation" was published in the January-March 2023 issue of IJME [1]. It is a scathing critique of the way police investigators rampantly misuse/exploit loopholes in the law, extract forced confessions from the accused and use them in a court of law - sometimes leading to convictions or prolonged incarceration of innocent victims. Her Excellency, the Hon'ble President of India, expressed similar sentiments when she questioned the need for building more jails at the same time that we talk of "moving towards progress as a society" [2]. Her comment was in the context of a large number of undertrials in jails, suffering from the inefficiency of the present day criminal justice system. Therefore, the need of the hour is to fix the weaknesses in the system and advance towards a rapid, truthful, honest and impartial system of police investigation. It is against this background that the journal has published the Editorial, and we support the broader intent which impelled the author to research the current criminal investigation system and expose its deficiencies. Nevertheless, when we go deeper into the details, several features begin to appear which seem incongruous with the author's arguments in her editorial.

Health care workers' concerns during COVID-19 times.

Ground -level health care workers provide us a unique perspective of immunization programs. While our official data may be too rosy to be true, a casual / unscheduled /anonymous conversation with such foot- soldiers may bring us face -to- face with reality through another angle If we want our programs to be robust having a wide coverage, Mantra of success lies not only in making good policy while sitting in ivory -towers but also in folding our sleeves up, sweating under the tropical hot Sun, going to hinterlands and initiating a dialogue with those humble low- level workers who sometimes are invisible to us otherwise, not listened to and with whom sometimes promises are not kept. Promised amount for achieving some target may be small for us but for them that may not necessarily be true. Let's just enter their shoes for a while and try to observe the situation from their point -of- view. In our siloed system of administration when everyone has knowledge of his/ her territory, let us share our wisdom and field -experience. As an expert in one field may not be having much knowledge about another one.

Sediment-water partitioning and risk assessment of organochlorine pesticides along the urban, peri-urban and rural transects of Krishna River Basin, Peninsular India.

Organochlorine pesticides (OCPs) were widely used in the past for pest control in agricultural lands and vector control programs in India. Due to their persistence and toxic impacts, we have quantified twenty OCPs in surface water, groundwater, and surface sediment samples along the Krishna River Basin (KRB), flowing through Peninsular India. Samples were collected along the urban, peri-urban, and rural transects of the KRB to understand the relation between the occurrence of pesticidal organochlorine pollutants based on the land use and land cover (LULC) and asses potential risk. Diagnostic ratios revealed ongoing Lindane usage in rural and peri-urban transects. On the contrary, the urban transect of the Musi River (MR) showed fresh inputs of technical HCH. The ratios of (p,p'-DDE+ p,p'-DDD)/ΣDDT >0.5 and α/ß-Endosulfan < 2.33 for most of the sites across the three transects for surface water, groundwater, and sediment indicate past DDT and Endosulfan usage across KRB. Excluding p,p'-DDE, and heptachlor in most of the sites, the logKOC' was higher than logKOC for other OCPs in the urban transect. However, for all the OCPs, the logKOC' was lower than logKOC in the peri-urban and rural transects of KRB thereby indicating that riverine sediment is acting as a sink for OCPs. The Krishna River annually transport about 0.24 tons HCH, 0.11 tons of DDT and 0.1 tons of Endosulfan. Despite having low water discharge, the compound-specific fluxes of the Wyra river are higher than the other two tributaries. Ecotoxicological risk assessment based on the Hazard Quotient suggested DDT pose higher risks to scud (zooplankton) and dinoflagellate and diatom (phytoplankton) whereas Endosulfan poses a threat to Bluegill (fish).

Evaluation of Interactions Between Thyroid Dysfunction in End-Stage Renal Disease Patients: A Cross-Sectional Study.

BACKGROUND: Thyroid hormones have a very crucial role in the regulation of metabolism, synthesis of proteins, development, and influencing functions of various other hormones in the human body. While both kidneys play an essential role in the metabolism of thyroid hormone by conversion of thyroxine (T4) to triiodothyronine (T3). In patients with chronic renal failure, frequent abnormal thyroid functions are observed. AIMS: To evaluate thyroid function in patients of chronic renal failure and to find out their correlation with the severity of the disease. METHODS: A total of 192 patients were selected for the study after applying inclusion and exclusion criteria. A thyroid function test was done in all enrolled subjects. Serum estimation of T3, T4, and thyroid stimulating hormone (TSH) was done by the chemiluminescent immunoassay (CLIA) method, urea was estimated by the diacetyl monoxide method (DAM, Method), and serum creatinine by Jaffe's method. The results were evaluated for age, sex, and estimated glomerular filtration rate (eGFR) of the patients in view of thyroid dysfunction. RESULTS: Of all 192 patients enrolled in the study, 124 (64.58%) were male and 68 (35.41%) were females. The observed male-to-female ratio was 1.93:1.18. The mean age of the study group (mean +/- standard deviation, SD) in males was 42+/-18 and in females 38+/-11 years (p value = 0.258). Significant reductions of serum T3, T4, and elevation of TSH were noted in both sexes. A reduced level of T3 was observed in 38.54% (42 males and 32 females) patients, reduced T4 in 34.37% (42 males and 22 females) patients, and subclinical hypothyroidism (SCH) in 16.7% (12 males and 20 females) patients. Biochemical overt hypothyroidism was noted in 7.29% (six males and eight females) of patients. CONCLUSION: Chronic renal failure is a condition of thyroid hypofunction. A higher prevalence of SCH and clinical hypothyroidism is reported here in chronic kidney disease (CKD) patients. The severity of thyroid hypofunction increases with a progressive reduction in eGFR. Hypothyroidism in CKD patients may be due to different onset mechanisms other than anti-thyroid antibodies.

Descriptive Study to Assess Post-acute COVID-19 Complications in Patients Presenting at a Teaching Hospital in North India.

Introduction Coronavirus disease 2019 (COVID-19) caused by a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported at the end of 2019 in Wuhan, Hubei Province, People's Republic of China, at a cluster of unusual pneumonia patients. The outbreak was declared a Public Health Emergency of International Concern on 30 January 2020 by World Health Organization. We are receiving patients in our OPD (Out Patient Department) with a new set of health complications having been infected with COVID-19. We planned to collect our data and try to find by various statistical methods, quantify the complications, and assess how we can deal with the new set of complications we are witnessing in this post-acute COVID-19 group of patients. Materials and methods The study was conducted by enrolling the patients at OPD/IPD (In Patient Department) by conducting a detailed history and clinical examination, routine investigations, 2D echocardiography (2D Echo), and pulmonary function test (PFT). The study assessed the worsening of symptoms, new onset symptoms, or the symptoms that continued even in the post-COVID-19 status as post-COVID-19 sequelae. Results Maximum cases were male and most of them were asymptomatic. The most common post-COVID-19 symptom that persisted was fatigue. 2D Echo and spirometry were done and changes were noticed even in those subjects who were asymptomatic. Conclusion Since significant findings were seen on clinical evaluation accompanied by 2D Echo and spirometry, it is essential to screen all presumed and microbiologically proven cases for long-term follow-up.

To Study the ß-Globin Haplotype Pattern of Descent of a Set of Linked Alleles Occurring on the Same Chromosome in the Northern Province of India.

OBJECTIVE: To study the five mutations commonly prevalent in North India, i.e., IVS-I-5 (G→C), 619 bp deletion, IVS-I-1 (G→T), codon 41/42 (-TTCT), and codon 8/9 (+G), in the beta thalassemia (ß-thalassemia) major children. The specific ß-thalassemia mutations of different haplotype patterns of the ß-globin gene cluster will also be determined. METHODS: A total of 125 children diagnosed with ß-thalassemia major visiting the Department of Pediatrics of King George's Medical University were involved in the study. As per the QIAamp (Qiagen, Hilden, Germany) manufacturer guidelines, genomic DNA was isolated from whole blood. To identify the haplotype pattern within the ß-globin gene cluster, the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis was used. The respective restriction endonucleases used were Hind III/GƔ, Hinc II/Ψß, Hinf I/ß, Ava II/ß, and BamHI for the haplotype analysis in the ß-globin pattern of descent of a set of linked alleles occurring on the same chromosome. RESULTS: Among the five common mutations, 73 patients had IVS-I-5 (G→C), 28 patients had 619 bp deletion, 17 patients had IVS-I-1 (G→T), five patients had Cd 41/42 (-TTCT), and two patients had Cd 8/9 (+G) mutations. Fifteen haplotypes (haplotypes 1-15) were identified in 125 ß-thalassemia major children. Among the five haplotypes observed in the IVS-I-5 (G→C) mutation, the H1 haplotype was most predominant with a frequency of 27.2%, followed by the H2, H4, H3, and H10 haplotypes in the given population. In 619 bp deletion, IVS-I-1 (G→T), codon 41/42, and codon 8/9, haplotype H9, H12, H11, and H5 were seen, respectively. CONCLUSION: ß-thalassemia was found to be the most common in the northern province of Uttar Pradesh. The linkage of ß-globin gene haplotypes with ß-thalassemia mutations was explored in the northern province of Uttar Pradesh. The population of different natives is being mixed up due to migration and industrialization. These were some reasons for the occurrence of haplotypic heterogeneity. This haplotype heterogeneity was correlated with the origin of these mutations found to be unlike the origin of common ones from different provinces.

As the World Struggles With the COVID-19 Pandemic, Another Emergency Threat Arrives on the Horizon, the Monkeypox: A Systematic Review.

The whole world got threatened by COVID-19, which made a significant loss in various sectors and pushed the world into a deep valley. Now a new threat, the emerging outbreak of monkeypox is rapidly spreading across the globe and is currently being observed in more than 110 countries with 79,473 confirmed cases and 50 deaths. Data were collected from PubMed, EMBASE, MEDLINE, Cochrane, Scopus database, African Journals OnLine, internet library sub-Saharan Africa, and Google Scholar. Most data were taken from the democratic Republic of Congo, the Central African Republic, Cameroon, the Republic of Congo, Liberia, Nigeria, the US, and the UK. Case reports, outbreak investigations, epidemiological studies, and surveillance studies were reviewed to find epidemiological details about the outbreak. A total of 50 peer-reviewed articles and 20 grey literature articles, including 9050 cases, were identified for data extraction. Our systematic review revealed that the group most affected is male (95.5%), with a median age of 33.8 years. A total of 55% of the transmission was sexually transmitted. The most commonly reported symptoms such as vesicular-pustular rashes (97.54%), fever (55.25%), inguinal lymphadenopathy (53.6%), exanthema (40.21%), fatigue, headache, asthenia (26.32%), myalgia (16.33%), vesicles and ulcers (30.61%) in the anogenital regions were some of the significant findings. The case fatality rate was observed to be up to 8.65%. The most affected country was the USA, which has the most fatalities in younger ages involved in homosexuality, suffering from HIV or sexually transmitted diseases (STDs).

Tuberculous liver abscess in an immunocompetent adult male--a rare presentation.

A 20 year old young male was admitted to our hospital with complaints of pain in upper abdomen right side, anorexia and loss of weight. Ultrasonography of the upper abdomen revealed a hypoechoic area in the left lobe of liver. Entertaining the possibility of pyogenic or amoebic lesion, the patient was started on ofloxacin and metronidazole. Failing to get any response to the therapeutic intervention, ultrasound guided aspiration was undertaken. The aspirated pus did not grow any organism in pyogenic or fungal culture but showed acid fast bacilli in Z.N. stain. The treatment was shifted to four drugs ATT and there was dramatic improvement in the clinical condition. This case is being reported to emphasize that ruling out tuberculosis may avoid unnecessary delays in the initiation of specific anti-tubercular treatment. Also a greater awareness of this rare clinical condition may prevent unwarranted surgical intervention.

Azithromycin use in Covid- 19: A tale of changing guidelines.

It has been more than two years since the arrival of Covid-19 pandemic on world stage. When we look back during landmark events of last two years, several ones stand out. And one of these is utilization and then going out- of- favor of use of an antibiotic - Azithromycin. Pilva- a Croatian pharmaceutical company- headquartered in Zagreb in late 1970s discovered the drug. Then several years of research yielded a product which was highly effective and provided good therapeutic results. As this was a small company having limited resources, it made a licensing agreement with Pfizer to sell the drug at marked geographies. While initial reason of its use in SARS-CoV-2 infection was its supposedly immunomodulatory effect yet randomized controlled trials demonstrated a lack of a beneficial effect for this indication. Therefore, when recollecting our journey with the mutant Coronavirus during last two years, it's necessary to remember that when trying to discover a useful drug for the disease, we had several misses as well. As usual in Medical science, most of the hits have several collateral misses, even though this drug carries with it certain unique features. In the Editorial I chronicle a few such distinguishing features.

Locating frontline workers' position up against COVID-19.

History of mankind has been brutal and marred by wars, attacks, invasions, occupying others territory and killing other human beings with their animals in the process. But now with arrival of Industrial Revolutions in last century or so, we gradually realized that for having and maintaining economic prosperity; we need others' cooperation and since then full- scale wars almost disappeared. But when we fight now and support others in the process, we realise that brute force is only occasionally used entity and most of the times technological methods are deployed to injure others. It is this rationale which makes way for people of either gender having capability to use highly advanced weaponry to enter the arena to decide fate of their side. Therefore, now war is not exclusively masculine entity and that analogy may not be appropriate in modern era. When we use masculine notion to explain our war against COVID-19, there are many shortcomings.

Measuring impact of Covid-19 pandemic at a teaching hospital in north India.

Introduction: Government runs teaching hospitals to impart a high-quality medical education to budding medicos and paramedical students in training. The experiences these trainees at various tenure positions get then and there shape their worldview for rest of the life and have an indelible impression. The Covid-19 pandemic disrupted all the routines at the hospitals around the world-including ours-and we make an attempt to measure it in one dimension in this study. Materials and Methods: We obtained attendance data of patients at out patient department and in patient department of our hospital. During the pandemic for a certain duration offline (physical) registrations were closed and they were attended only by online ones. Hence that data (actually a part of it) got captured electronically and we analyzed it to get an idea of the traversed course of the scourge. Results: When the pandemic surged during the spring and summer of 2021, our hospital was turned into a Covid facility. Hence average routine attendance of patients got reduced to a significant extent, elective surgeries/interventions and procedures were postponed and this data is reflected in an electronic system, perhaps making a long-lasting effect on the budding trainees. This fact needs to be realized so as to take appropriate action. Conclusion: We need to realize that the effects of the viral communicable disease may be enduring, not only for the infected patients and their families but also for those who learn on those patients. Therefore, the transmissible diseases disabled not only our society, economy, and health care services when they ascended but pedagogy too. Online learning came to rescue but only up to a certain extent and with several caveats and limitations.

Freshwater discharge from the large and coastal peninsular rivers of India: A reassessment for sustainable water management.

This study offers an updated mean annual water discharge of 10 large and 11 coastal basins of the Indian Peninsula and looks into environmental parameters influencing the water flux and discharge trends. The mean annual discharge of large and coastal rivers is estimated to be 221 and 294 km3. Thus, despite draining 25% of the Indian Peninsula, coastal rivers deliver more than half of the annual flux, and west-flowing coastal rivers contribute 85% of it. This study demonstrates temporal changes in the water discharge of various river basins. The presence of dams regulates discharge regimes of large rivers. The construction of large dams resulted in a significant decline in the water discharge of the Krishna, Cauvery, and Narmada. Through this study, we demonstrate the role of rainfall, catchment size, water loss through evapotranspiration and infiltration, and societal use of water in determining the runoff of each basin. We recommend tapping the water resources of the west-flowing rivers for proper planning, development, and management to reduce the water stress in the peninsular region and promoting sustainable management.

Analysis of Government website for web-registration to assess pattern of the Covid pandemic.

Introduction: Covid-19 is an unprecedented challenge in our times leaving a trail of destruction and mayhem affecting almost all of us during the last 2 years. Various data sources are available around the globe to measure its impact using various yardsticks. Material and Methods: By carefully looking at data available at the website maintained by Government of India, we can draw some useful conclusions. Results: There is a dip in the number of online registrations at our hospital coinciding with second wave and resultant lockdown. Conclusion: Tracing digital footprints of an event as huge as the Covid pandemic may help us for future planning when we learn its lessons well.

Clinical presentation and outcomes of chronic kidney disease patients with COVID-19 admitted to the intensive care unit of a teaching hospital of Northern India during the third wave of the pandemic: A retrospective study.

Introduction: Chronic kidney disease (CKD) patients have impaired immune status; that's why these patients are prone to develop infection-related complications. The current study compares non-haemodialysis chronic kidney disease and end-stage renal disease (NO-HD-CKD and ESRD, respectively) patient outcomes, the data of which is sparse. Methods: Patients diagnosed with COVID-19 infection through reverse transcriptase polymerase chain reaction (RT-PCR) were retrospectively studied using electronic health records. Patients were divided into three categories: non-chronic kidney disease (NO-CKD), NO-HD-CKD, and ESRD, and the outcome was assessed. Results: Out of 745 patients, 92 (12.34%) had NO-HD-CKD and 31 (4.16%) had ESRD. CKD patients who were not on haemodialysis had higher rates of comorbidities and D-dimer and C-reactive protein (CRP) values compared to ESRD patients. The overall unadjusted mortality rate was found to be 17.44%, and it was 10.45% in case of NO-CKD patients, 58.69% for NO-HD-CKD patients, and 48.39% for ESRD patients. It was observed that patients having NO-HD-CKD had greater odds ratio of overall expiry in comparison to those without CKD in univariate analysis (OR: 1.58; 95% CI: 1.31-1.91). It was not significant in fully adjusted models (OR: 1.11; 95% CI: 0.88-1.40). Conclusions: During the third wave of COVID-19, we found higher mortality rates for cases with NO-HD-CKD and, to a lower extent, ESRD. However, patients with ESRD were observed to have good outcomes in comparison to those with NO-HD-CKD. Primary care physicians are the first point of contact for patients. Hence, it is critical for them to manage and to do proper referral of comorbid patients to higher centres.

Caste-based discrimination in Indian hospitals: a blight for youngsters of the 21st century.

Barua and Verma assess the role of caste in workplace bullying at Indian healthcare facilities in their recent Comment in IJME (1). They examine the possible role of caste in mental violence suffered by trainee doctors. They conclude with a call to address the issue of mental health needs of doctors. It is true that doctors work under tremendous stress, have to make rapid decisions, sometimes consider the death of a patient as a personal failure, and frequently wonder what more could have been done to save a life. I believe that should not be a pretext to shield habitual offenders of caste-based violence which, sadly, the authors appear to be doing in their Comment. Sylvia Karpagam correctly states that caste-washing the healthcare system will do little to address its discriminatory practices (2).

The suitability of surface waters from small west-flowing rivers for drinking, irrigation, and aquatic life from a global biodiversity hotspot (Western Ghats, India).

The present study provides surface water types and water quality indices (WQI) for 70 large coastal rivers of the Western Ghats (WG). Irrespective of seasons and lithology, concentration of cations (Ca2+ > Na+ > Mg2+ > K+) and anions (HCO3- > Cl- >SO42- > NO3- > PO43-) follow a typical trend all along the coast. The WG rivers can broadly be classified as calcium-bicarbonate-chloride (Ca2+-HCO3--Cl-) type. Pearson correlation analysis of major ions demonstrates natural sources influence on the riverine water composition across the WG region. Gibbs plot suggests water composition of these rivers is the result of the interaction of rock and precipitation. It means that ionic contributions from precipitation and chemical weathering of rock-forming minerals largely determine surface water quality. This biodiversity hotspot is facing high population pressure and anthropogenic activities. Despite it, quantitatively, all the physical parameters and chemical constituents are within the permissible limits of the World Health Organization (WHO) and Bureau of Indian Standards (BIS), thus making it suitable for drinking and domestic purposes. About 86% of the surface water samples are found to be suitable for irrigation (KR < 1) in non-monsoon seasons. Rivers near to Goa coast are only found unsuitable (KR > 1) for irrigation exclusively during non-monsoon seasons. From the majority of the calculated indices, it may be inferred that the river waters draining from the WG region are suitable for irrigation. Overall, the calculated WQI for studied rivers showed excellent to good water quality for drinking, agriculture, and aquatic life in monsoon seasons, which are then ranked from good to marginal in non-monsoon seasons.

Export of particulate organic carbon by the mountainous tropical rivers of Western Ghats, India: Variations and controls.

Transport of organic carbon by small mountainous rivers is essential, but the poorly constrained component of the global carbon cycle. In the current research, we sampled and analyzed particulate organic carbon (POC) contents from 70 sizeable tropical coastal rivers, draining the Western Ghats (WG) of India. This study aimed to investigate the spatiotemporal variability in POC contents, to estimate flux and to identify environmental controls on POC sources and transport characteristics across the region. The averaged value of organic carbon (OC) in the particulate samples is 3.24%, and the mean POC concentration is 2.86 mg l-1. We classified the samples based on total suspended matter (TSM) classes for source appropriation. Litter/riparian (42.5%) pools are the largest source of organic matter, followed by autochthonous (36%) and soil (21.5%) for the WG region. However, locally autochthonous sources contribute exceptionally to POC pools, indicating a favorable environmental condition for the growth of algae and phytoplankton. Land-use & land-cover, climate, topography, and sediment erosion seems to be determining the local variability in sources to POC pools and fluxes. The POC export rates suggest that within the region, the POC yields of the Deccan Trap (DT) and the Western Dharwar Craton (WDC) blocks are about two times higher than that of the Southern Granulite Terrain (SGT) region. With POC yield of 7.0 g m-2 yr-1, this region exports 0.79 Tg C (~ 0.5% of the global POC) to the Arabian Sea annually. The POC flux of the WG region (covering 0.25% of Asia's land area) is approximately 1.0% of Asia's riverine POC flux to the ocean.