Factors associated with unexplained sudden deaths among adults aged 18-45 years in India - A multicentric matched case-control study.

BACKGROUND OBJECTIVES: In view of anecdotal reports of sudden unexplained deaths in India's apparently healthy young adults, linking to coronavirus disease 2019 (COVID-19) infection or vaccination, we determined the factors associated with such deaths in individuals aged 18-45 years through a multicentric matched case-control study. METHODS: This study was conducted through participation of 47 tertiary care hospitals across India. Cases were apparently healthy individuals aged 18-45 years without any known co-morbidity, who suddenly (<24 h of hospitalization or seen apparently healthy 24 h before death) died of unexplained causes during 1 st October 2021-31 st March 2023. Four controls were included per case matched for age, gender and neighborhood. We interviewed/perused records to collect data on COVID-19 vaccination/infection and post-COVID-19 conditions, family history of sudden death, smoking, recreational drug use, alcohol frequency and binge drinking and vigorous-intensity physical activity two days before death/interviews. We developed regression models considering COVID-19 vaccination ≤42 days before outcome, any vaccine received anytime and vaccine doses to compute an adjusted matched odds ratio (aOR) with 95 per cent confidence interval (CI). RESULTS: Seven hundred twenty nine cases and 2916 controls were included in the analysis. Receipt of at least one dose of COVID-19 vaccine lowered the odds [aOR (95% CI)] for unexplained sudden death [0.58 (0.37, 0.92)], whereas past COVID-19 hospitalization [3.8 (1.36, 10.61)], family history of sudden death [2.53 (1.52, 4.21)], binge drinking 48 h before death/interview [5.29 (2.57, 10.89)], use of recreational drug/substance [2.92 (1.1, 7.71)] and performing vigorous-intensity physical activity 48 h before death/interview [3.7 (1.36, 10.05)] were positively associated. Two doses lowered the odds of unexplained sudden death [0.51 (0.28, 0.91)], whereas single dose did not. INTERPRETATION CONCLUSIONS: COVID-19 vaccination did not increase the risk of unexplained sudden death among young adults in India. Past COVID-19 hospitalization, family history of sudden death and certain lifestyle behaviors increased the likelihood of unexplained sudden death.

Persistently abnormal device-detected thoracic impedance and OptiVol fluid index related to breast reconstruction surgery.

With significant correlation shown between intrathoracic impedance and intrathoracic fluid volume, the utility of OptiVol fluid index (Medtronic, Minneapolis, MN, USA) in the management of patients with heart failure has been well-described. Although intrathoracic impedance is mainly affected by the changes in the intrathoracic fluid volume, a "false-positive" OptiVol fluid index can occur in the absence of overt congestive heart failure. We present a case of false positive Optivol fluid index elevation in a woman following breast reconstruction surgery.

Clinical outcomes of bronchiectasis in India: data from the EMBARC/Respiratory Research Network of India registry.

BACKGROUND: Identifying risk factors for poor outcomes can help with risk stratification and targeting of treatment. Risk factors for mortality and exacerbations have been identified in bronchiectasis but have been almost exclusively studied in European and North American populations. This study investigated the risk factors for poor outcome in a large population of bronchiectasis patients enrolled in India. METHODS: The European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) and Respiratory Research Network of India (EMBARC-India) registry is a prospective observational study of adults with computed tomography-confirmed bronchiectasis enrolled at 31 sites across India. Baseline characteristics of patients were used to investigate associations with key clinical outcomes: mortality, severe exacerbations requiring hospital admission, overall exacerbation frequency and decline in forced expiratory volume in 1 s. RESULTS: 1018 patients with at least 12-month follow-up data were enrolled in the follow-up study. Frequent exacerbations (≥3 per year) at baseline were associated with an increased risk of mortality (hazard ratio (HR) 3.23, 95% CI 1.39-7.50), severe exacerbations (HR 2.71, 95% CI 1.92-3.83), future exacerbations (incidence rate ratio (IRR) 3.08, 95% CI 2.36-4.01) and lung function decline. Coexisting COPD, dyspnoea and current cigarette smoking were similarly associated with a worse outcome across all end-points studied. Additional predictors of mortality and severe exacerbations were increasing age and cardiovascular comorbidity. Infection with Gram-negative pathogens (predominantly Klebsiella pneumoniae) was independently associated with increased mortality (HR 3.13, 95% CI 1.62-6.06), while Pseudomonas aeruginosa infection was associated with severe exacerbations (HR 1.41, 95% CI 1.01-1.97) and overall exacerbation rate (IRR 1.47, 95% CI 1.13-1.91). CONCLUSIONS: This study identifies risk factors for morbidity and mortality among bronchiectasis patients in India. Identification of these risk factors may support treatment approaches optimised to an Asian setting.

Bronchiectasis in India: results from the European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) and Respiratory Research Network of India Registry.

BACKGROUND: Bronchiectasis is a common but neglected chronic lung disease. Most epidemiological data are limited to cohorts from Europe and the USA, with few data from low-income and middle-income countries. We therefore aimed to describe the characteristics, severity of disease, microbiology, and treatment of patients with bronchiectasis in India. METHODS: The Indian bronchiectasis registry is a multicentre, prospective, observational cohort study. Adult patients (≥18 years) with CT-confirmed bronchiectasis were enrolled from 31 centres across India. Patients with bronchiectasis due to cystic fibrosis or traction bronchiectasis associated with another respiratory disorder were excluded. Data were collected at baseline (recruitment) with follow-up visits taking place once per year. Comprehensive clinical data were collected through the European Multicentre Bronchiectasis Audit and Research Collaboration registry platform. Underlying aetiology of bronchiectasis, as well as treatment and risk factors for bronchiectasis were analysed in the Indian bronchiectasis registry. Comparisons of demographics were made with published European and US registries, and quality of care was benchmarked against the 2017 European Respiratory Society guidelines. FINDINGS: From June 1, 2015, to Sept 1, 2017, 2195 patients were enrolled. Marked differences were observed between India, Europe, and the USA. Patients in India were younger (median age 56 years [IQR 41-66] vs the European and US registries; p<0·0001]) and more likely to be men (1249 [56·9%] of 2195). Previous tuberculosis (780 [35·5%] of 2195) was the most frequent underlying cause of bronchiectasis and Pseudomonas aeruginosa was the most common organism in sputum culture (301 [13·7%]) in India. Risk factors for exacerbations included being of the male sex (adjusted incidence rate ratio 1·17, 95% CI 1·03-1·32; p=0·015), P aeruginosa infection (1·29, 1·10-1·50; p=0·001), a history of pulmonary tuberculosis (1·20, 1·07-1·34; p=0·002), modified Medical Research Council Dyspnoea score (1·32, 1·25-1·39; p<0·0001), daily sputum production (1·16, 1·03-1·30; p=0·013), and radiological severity of disease (1·03, 1·01-1·04; p<0·0001). Low adherence to guideline-recommended care was observed; only 388 patients were tested for allergic bronchopulmonary aspergillosis and 82 patients had been tested for immunoglobulins. INTERPRETATION: Patients with bronchiectasis in India have more severe disease and have distinct characteristics from those reported in other countries. This study provides a benchmark to improve quality of care for patients with bronchiectasis in India. FUNDING: EU/European Federation of Pharmaceutical Industries and Associations Innovative Medicines Initiative inhaled Antibiotics in Bronchiectasis and Cystic Fibrosis Consortium, European Respiratory Society, and the British Lung Foundation.

Low-dose rituximab as an adjuvant therapy in pemphigus.

BACKGROUND: Pemphigus is a chronic autoimmune blistering disease where systemic steroids and immunosuppressants are the mainstay of therapy, but long-term treatment with these agents is associated with many side effects. Rituximab, a chimeric monoclonal anti-CD20 antibody, in low doses has shown efficacy as an adjuvant to reduce the dose of steroids. AIM: To study the clinical efficacy and safety of low-dose rituximab as an adjuvant therapy in pemphigus. METHODS: Fifty patients with extensive pemphigus were selected, who either had recalcitrant pemphigus, were steroid dependent, had relapsed after pulse therapy, had anti-desmoglein levels >20, had contraindications to conventional treatment or wanted to avoid conventional treatment and its side effects. Two doses of rituximab (500 mg) were given 2 weeks apart and patients were regularly followed up every 2 weeks for 3 months and then monthly upto 2 years. Complete blood counts, liver function tests, renal function tests, skin biopsy, direct immunofluorescence and desmoglein levels were checked before and after rituximab administration. Pre-rituximab chest X-ray and electrocardiograph were also obtained. RESULTS: At 3 months, 41 (82%) patients showed complete remission. Nine (18%) patients had partial remission. After 6-12 months, 20 (40% of enrolled patients) continued to be in remission and were off all systemic therapy and the remaining 19 (38%) were continuing to take low doses of steroids with or without other adjuvant immunosuppressants and 2 (4%) had to be given another 2 doses of rituximab and subsequently could be managed with low-dose steroids. Of the 9 patients in partial remission at 3 months, after 6-12 months 5 (10% of the total) were completely off treatment and went into complete remission and 4 (8%) were on additional treatment out of which 2 (4%) had to be given 2 additional doses of rituximab and were in partial remission with low-dose therapy at the end of 12 months. One patient developed urticaria as a side effect. Another developed herpes zoster. CONCLUSION: Our results show that low-dose rituximab is a well-tolerated and beneficial adjuvant therapy in recalcitrant pemphigus which helps reduce both the severity of disease as well as the dose of steroids and immunosuppressants.

Chronic obstructive pulmonary disease and cardiac comorbidities: A cross-sectional study.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a global health issue with cigarette smoking being an important risk factor. COPD affects pulmonary blood vessels, right ventricle, as well as left ventricle leading to the development of pulmonary hypertension (PH), cor-pulmonale (COR-P), right and left ventricular dysfunction. Echocardiography provides a rapid, noninvasive, portable, and accurate method to evaluate cardiac functions. Early diagnoses and intervention for cardiac comorbidities would reduce mortalities. MATERIALS AND METHODS: A cross-sectional study. Total 50 patients of moderate to severe COPD according to GOLD guidelines were taken from Department of Respiratory Medicine, Smt. B. K. Shah Medical Institute and Research Centre, Vadodara. All patients underwent investigations such as chest X-ray PA view, ECG, and spirometry followed by two-dimensional echocardiography. RESULTS: We investigated 49 males and 1 female patients ranging from 35 to 80 years of age. Twenty-nine individuals were of moderate COPD and twenty-one of severe COPD. Of these cases 29 had left ventricular diastolic dysfunction (LVDD) changes, 24 were diagnosed with PH and 16 had changes of COR-P. The study showed the linear relation between the severity of LVDD, PH, and COR-P with the severity of COPD. CONCLUSION: Our study put emphasis on early cardiac screening of all COPD patients which will be helpful in the assessment of the prognosis and will further assist in identifying the individuals likely to suffer increase morbidity and mortality.

The association between body composition and cystatin C in South Asians: results from the MASALA study.

While South Asians have high rates of obesity and kidney disease, little is known about the effect of regional body composition on kidney function. We investigated the association between body composition measures and cystatin C-based estimated glomerular filtration rate (eGFRcysC) in 150 immigrant South Asians. The inverse association between overall adiposity and eGFRcysC was attenuated by C-reactive protein (CRP), while the association of ectopic fat was completely attenuated by metabolic covariates and CRP. In immigrant South Asians, the associations between overall adiposity and ectopic fat with decreased kidney function are largely explained by metabolic alterations and inflammation.

A Study of Manifestations of Extrapulmonary Tuberculosis in the ENT Region.

Though tuberculosis (TB) primarily affects lungs, extra pulmonary tuberculosis (EPTB) is also common, especially in high disease load areas and mainly manifests in ENT region. To study the different manifestations of tuberculosis in ENT region in terms of presentation, disease process, treatment and outcome. Records of patients diagnosed and treated for TB in the ENT region at our institute's DOTS centre for a two and half year period were analysed for presenting complaints, examination findings, diagnostic features, treatment modes and outcome. Out of 3750 cases diagnosed as TB, 230 had EPTB. 211 cases had ENT manifestations. Majority of the cases were male and in the fourth decade of life. Commonest manifestation was cervical lymphadenopathy with 201 cases. Fine needle aspiration cytology was mostly diagnostic and category I anti TB treatment (AKT) achieved cure. The six cases of TB otitis media presented with ear discharge, sometimes bloody and had varied tympanic membrane findings and facial palsy in two cases with different types and degrees of hearing loss. Diagnosis was confirmed by histology of tissue removed during surgery. Patients completed category I AKT. Hearing and facial palsy did not improve. There were three cases of TB laryngitis and one of nasal TB both of which were confirmed by tissue diagnosis and responded well to AKT. Most of the results in the present study conform to findings of other studies. High degree of suspicion is necessary to reach diagnosis. Category I AKT is effective. Some cases may require surgery.

A study of flexible fiberoptic bronchoscopy aided tracheal intubation for patients undergoing elective surgery under general anesthesia.

A difficult airway complicates up to one tenths of cases of elective general anesthesia. Such situations can be anticipated and tackled by fiberoptic flexible bronchoscopy (FFB) assisted tracheal intubation. To study the indications and outcomes of FFB assisted tracheal intubation in patients with anticipated difficult airway, who are undergoing surgery under general anesthesia. Cases who were intubated using FFB assistance were included in the study. Detailed examination was done pre operatively to be able to predict the difficult airway. Intubation was done with the help of a FFB after induction of general anesthesia. There were total 52 cases. Majority were male and in the fourth decade of life. Oral submucous fibrosis was the commonest indication for the procedure. There were two cases of failure, but no significant mortality or morbidity. A difficult airway can be encountered across specialties. It can be anticipated by simple or multi factorial methods. Awake FFB aided intubation is the gold standard in cases of anticipated difficult airway. Failure rates of 4-66 % have been reported. In the present study the failure rate was less than 4 % with no morbidity or mortality. FFB assisted intubation is safe and effective in paediatric patients too. FFB assisted intubation done in an organised and skilled manner is a very important skill to have to tackle cases of difficult intubation. Hence it should be included in training programmes of anesthesia.

Adipose inflammation, insulin resistance, and cardiovascular disease.

Adiposity-associated inflammation and insulin resistance are strongly implicated in the development of type 2 diabetes and atherosclerotic cardiovascular disease. This article reviews the mechanisms of adipose inflammation, because these may represent therapeutic targets for insulin resistance and for prevention of metabolic and cardiovascular consequences of obesity. The initial insult in adipose inflammation and insulin resistance, mediated by macrophage recruitment and endogenous ligand activation of Toll-like receptors, is perpetuated through chemokine secretion, adipose retention of macrophages, and elaboration of pro-inflammatory adipocytokines. Activation of various kinases modulates adipocyte transcription factors, including peroxisome proliferator-activated receptor-gamma and NFkappaB, attenuating insulin signaling and increasing adipocytokine and free fatty acid secretion. Inflammation retards adipocyte differentiation and further exacerbates adipose dysfunction and inflammation. Paracrine and endocrine adipose inflammatory events induce a local and systemic inflammatory, insulin-resistant state promoting meta-bolic dyslipidemia, type 2 diabetes, and cardiovascular disease. Developing therapeutic strategies that target both adipose inflammation and insulin resistance may help to prevent type 2 diabetes and cardiovascular disease in the emerging epidemic of obesity.

Bitoric gas-permeable contact lens application in pellucid marginal corneal degeneration.

PURPOSE: To evaluate the authors' experience fitting patients with pellucid marginal corneal degeneration (PMCD) with bitoric gas-permeable contact lenses. METHODS: The records of 11 patients with a confirmed diagnosis of PMCD were retrospectively reviewed. The numbers of diagnostic contact lenses at the first visit, office visits, and lenses ordered to complete the fitting; uncorrected, spectacle-corrected, and contact lens-corrected Snellen visual acuities; contact lens success or failure; and complications encountered were all assessed. These data were compared to historic data for patients with other corneal irregularities (keratoconus, penetrating keratoplasty, and refractive surgery). RESULTS: The mean number of diagnostic contact lenses used at the first visit was 1.09 +/- 0.302, and the number of lenses ordered to complete the fitting was 1.82 +/- 1.33. The number of visits during 4 months was 6.18 +/- 2.14. Uncorrected visual acuity (logMAR) was 0.957 +/- 0.398 (20/181 in Snellen); the best-corrected spectacle visual acuity (logMAR) was 0.231 +/- 0.309 (20/34 in Snellen); and the best contact lens-corrected visual acuity (logMAR) was 0.0424 +/- 0.06275 (20/22 in Snellen). Corrected vision in eyes with PMCD improved approximately two lines with bitoric gas-permeable contact lenses compared to that achieved with spectacles. Ten (91) of the patients met the criteria of contact lens success during the 4-month follow-up period. CONCLUSIONS: Bitoric gas-permeable contact lenses achieved a comfortable and visually successful fit in most eyes with PMCD. Patients with PMCD used the fewest contact lenses and had the fewest lens exchanges, but required more office visits than other groups of patients with various corneal irregularities.

Gas-permeable contact lenses can protect against ocular trauma: two cases.

PURPOSE: To report two cases of rigid gas-permeable contact lens wearers who were protected from serious foreign body-related injury through the wearing of their contact lenses. METHODS: Two case reports. RESULTS: Rigid gas-permeable contact lenses appear to have protected the eyes of two patients from probable serious injury. CONCLUSIONS: Rigid gas-permeable contact lenses can have a protective effect against some types of trauma, although they are not recommended to be used for protective purposes.