Diagnostic utility of rapid on-site evaluation of endobronchial ultrasound-guided transbronchial needle aspiration samples: A study in a region of high tuberculosis burden.

INTRODUCTION: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a very useful tool for precise diagnosis of thoracic lesions. However, the procedure sometimes has a poor yield. Rapid on-site evaluation (ROSE) in EBUS-TBNA has been shown to be helpful to improve its diagnostic yield and minimise the need for repeat procedures. Most of the studies that have evaluated the utility of ROSE have focused on malignant lesions; however, it is important to understand its utility in benign lesions, particularly in a country with a high tuberculosis burden. OBJECTIVE: This study was undertaken to evaluate the utility of ROSE in EBUS-TBNA for the diagnosis of patients presenting with mediastinal lymphadenopathy and/or thoracic mass for benign and malignant pathologies. METHODS: This was a prospective study including 47 patients who underwent EBUS-TBNA for thoracic lesions (lung masses and hilar/mediastinal lymphadenopathy) over a 10-month period at a single tertiary care centre. In addition to ROSE and definitive cytology, the aspirated material was also sent for cell block and microbiological studies. Endobronchial/transthoracic biopsy was conducted for histopathological evaluation (HPE) where required, at the discretion of the clinician. ROSE diagnosis was then compared with the final diagnosis. RESULTS: Of the 47 patients examined using ROSE, granulomas were observed in 33 cases, non-specific inflammation in six cases, and malignancy in five cases; one case was inconclusive and the sample was found to be inadequate in two cases. The ROSE assessment matched the final diagnosis in 84.45% patients. CONCLUSION: ROSE is a simple procedure that is able to provide an immediate and accurate assessment of adequacy and has a significant yield, enabling a preliminary diagnosis to be made in both benign and malignant samples.

Clinical Profile, Intensive Care Unit Course, and Outcome of Patients Admitted in Intensive Care Unit with Chikungunya.

OBJECTIVE: Chikungunya is generally a mild disease, rarely requiring Intensive Care Unit (ICU) admission. However, certain populations may develop organ dysfunction necessitating ICU admission. The purpose of the study was to assess the clinical profile and course of chikungunya patients admitted to the ICU, and to ascertain factors linked with poor outcome. METHODS: All patients with chikungunya admitted to ICU were included in the study. Admission Acute Physiology and Chronic Health Evaluation (APACHE) II score and sequential organ failure assessment (SOFA) score were calculated. Primary outcome measured was 28-day mortality and secondary outcomes measured were length of hospital and ICU stay and the need for vasopressor support, renal replacement therapy (RRT), and mechanical ventilation (MV). Logistic regression analysis was performed to identify factors predicting mortality. RESULTS: The most common complaints were fever (96.67%) and altered sensorium (56.67%). Mean admission APACHE II and SOFA scores were 17.28 ± 7.9 and 7.15 ± 4.2, respectively. Fifty-one patients had underlying comorbidities. Vasopressors were required by 46.76%; RRT by 26.67%, and MV by 58.33%, respectively. The 28-day mortality was 36.67%. High APACHE II score (odds ratio: 1.535; 95% confidence interval: 1.053-2.237; P = 0.026) and need for dialysis (odds ratio: 833.221; 95% confidence interval: 1.853-374,664.825; P = 0.031) could independently predict mortality. CONCLUSIONS: Patients with chikungunya fever may require ICU admission for organ failure. They are generally elderly patients with underlying comorbidities. Despite aggressive resuscitation and organ support, these patients are at high risk of death. Admission APACHE II score and need for dialysis may predict patients at higher risk of death.

Extracorporeal treatment with high-volume continuous venovenous hemodiafiltration and charcoal-based sorbent hemoperfusion for severe metformin-associated lactic acidosis.

We present a case of a 49-year-old female with an alleged history of ingestion of approximately 100 tablets of metformin (850 mg each). Investigations revealed severe lactic acidosis with lactate levels of 13.5 mmol/L and pH of 7.17. This indicates severe toxicity and is associated with a high mortality. Charcoal-based sorbent hemoperfusion was done as a desperate effort, as patient continued to deteriorate despite supportive care and high-volume continuous venovenous hemodiafiltration. The patient survived despite metformin-associated lactic acidosis related to severe metformin toxicity.

Isolation of a novel pentasaccharide Ebaliose from immunostimulant fraction of buffalo milk oligosaccharide.

Buffalo milk processed by method of Kobata and Ginsburg for isolation of its oligosaccharide contents showed significant stimulation of anti-body, delayed type hypersensitivity response to sheep red blood cells in BALB/c mice. This oligosaccharide mixture also stimulated non-specific immune response in terms of MMI. In continuation to our previous studies of oligosaccharide contents of buffalo milk another novel pentasaccharide Ebaliose was isolated from immunostimulant oligosaccharide fraction of buffalo milk. Ebaliose was procured in its purest form, by combining the different chromatographic techniques like Gel filtration, Silica Gel column chromatography, and HPLC. The structure of novel oligosaccharide was determined by 1H,13C, HSQC, TOCSY, COSY, HMBC, ESI-MS, chemical transformation, and chemical degradation. The stereoscopic structure of this novel pentasaccharide was established as under.

What, why and how to monitor blood glucose in critically ill patients.

Critically ill patients are prone to high glycemic variations irrespective of their diabetes status. This mandates frequent blood glucose (BG) monitoring and regulation of insulin therapy. Even though the most commonly employed capillary BG monitoring is convenient and rapid, it is inaccurate and prone to high bias, overestimating BG levels in critically ill patients. The targets for BG levels have also varied in the past few years ranging from tight glucose control to a more liberal approach. Each of these has its own fallacies, while tight control increases risk of hypoglycemia, liberal BG targets make the patients prone to hyperglycemia. Moreover, the recent evidence suggests that BG indices, such as glycemic variability and time in target range, may also affect patient outcomes. In this review, we highlight the nuances associated with BG monitoring, including the various indices required to be monitored, BG targets and recent advances in BG monitoring in critically ill patients.

Marsogenin: a new pregnane ester from Marsdenia tenacissima.

A new pregnane, 12ß-O-acetyl-20(S)-O-N-methylanthranilyl-3ß, 8ß, 14ß, 17α-tetrol pregn-5-ene (12ß-O-acetyl-20(S)-O-N-methylanthranilyl-sarcostin) have been isolated from Marsdenia tenacissima (family: Asclepediaceae). The structure of new pregnane was elucidated by using spectroscopic techniques,1H,13C NMR, HMBC, HSQC, COSY and TOCSY and ESI-MS Mass spectrometry.

2-D NMR studies of geneoside, a novel pregnane pentaglycoside of 2-deoxy and 2, 6 dideoxy monosaccharides from 'Wattakaka lanceolata'.

Plants of Asclepiadaceae and Apocynaceae family are a rich source of pregnane and pregnane glycosides. They are found in nature either in free state or as their glycosides. They have shown antitumor, anticancer, and hypoglycaemic, antioxidant and antimicrobial activities. In our continued studies on the isolation of pregnane glycosides we have isolated a novel pregnane pentaglycoside comprised of 2-deoxy and 2, 6-dideoxy monosaccharides from Wattakaka lanceolata (Asclepiadaceae). The structure of the new glycoside, Geneoside was established as11α, 12ß-O-diacetyl-drevogenin-P-3-O-ß-D-cymaropyaranosyl (1→4)-ß-D-cymaropyranosyl (1→4) -ß-D-Oleandropyranosyl (1→4)-ß-D-digitalopyranosyl (1→4)-ß-D-digitalopyranoside. The stereoscopic structure was established by chemical degradation, chemical transformation and recent physicochemical techniques viz 1H,13C, 2-D NMR (COSY, TOCSY, HSQC and HMBC) and Mass spectrometry.

Post COVID-19 syndrome and new onset diseases: A prospective observational study.

Introduction: The National Institute of Health and Care Excellence (NICE) has defined the terms, 'acute coronavirus disease 2019' (COVID-19), 'ongoing symptomatic COVID-19' and 'post-COVID-19 syndrome', with the latter two described as having persistent symptoms after the onset of COVID-19 symptoms for 4-12 weeks and >12 weeks, respectively. Persistent symptoms can either be due to the after-effects of COVID-19 or new-onset diseases after acute COVID-19. All symptoms observed beyond 4 weeks after the onset of COVID-19 need not be present at the time of onset. Previous studies on persistent post-COVID-19 symptoms have not mentioned new-onset diseases after acute COVID-19, and only a select few studies have discussed such new-onset symptoms. Methods: Ninety-five patients who attended the post-COVID-19 clinic completed the requisite follow-up till 16 weeks after COVID-19 symptom onset. Data was recorded on a predesigned proforma. Necessary investigations were conducted to rule out any other cause of persistent symptoms. Results: Fatigue (62.1%), breathlessness (50.5%) and cough (27.4%) were the most common symptoms present beyond 4 weeks after the onset of COVID-19 symptoms. Forty-nine (51.57%) patients developed post-COVID-19 syndrome - their severity of symptoms (odds ratio [OR] 17.77) and longer duration of hospital stay (OR 1.095) during acute disease were significantly associated with the development of post-COVID-19 syndrome. During follow-up, 25 patients developed new-onset symptoms, such as diabetes mellitus, hypertension and idiopathic tachycardia. Conclusion: Patients can have persistent symptoms, new-onset symptoms and new-onset diseases after recovery from acute COVID-19.

Hiccups, Hypersalivation, Hallucinations in Parkinson's Disease: New Insights, Mechanisms, Pathophysiology, and Management.

Parkinson's disease (PD) is a chronic, progressive neurological disorder and the second most common neurodegenerative condition. We report three common but overlooked symptoms in PD-hiccups, hypersalivation, and hallucinations-in terms of their prevalence, pathophysiology, and up-to-date evidence-based treatment strategies. Whilst all these three symptoms do occur in many other neurological and non-neurological conditions, early recognition and treatment are paramount. Whilst hiccups affect 3% of healthy people, their rate of occurrence is higher (20%) in patients with PD. Hypersalivation (Sialorrhea) is another common neurological manifestation of many neurological and other neurodegenerative conditions such as motor neuron disease (MND), with a median prevalence rate of 56% (range: 32-74%). A 42% prevalence of sialorrhea is also reported in sub-optimally treated patients with PD. Hallucinations, especially visual hallucinations, are commonly reported, with a prevalence of 32-63% in PD, and a 55-78% prevalence is noted in patients with dementia with Lewy bodies (DLB), followed by tactile hallucinations, which are indicated by a sensation of crawling bugs or imaginary creatures across the skin surface. Whilst mainstay and primary management strategies for all these three symptoms are carried out through history taking, it is also essential to identify and treat possible potential triggers such as infection, minimise or avoid causative (such as drug-induced) factors, and especially carry out patient education before considering more definitive treatment strategies, such as botulinum toxin therapies for hypersalivation, to improve the quality of life of patients. This original review paper aims to provide a comprehensive overview of the disease mechanisms, pathophysiology, and management of hiccups, hypersalivation, and hallucinations in Parkinson's disease.

Small airway disease and its predictors in patients with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) is a connective tissue disease, characterized by symmetric peripheral polyarthritis. Extra-articular disease occurs in approximately 50% of the patients with lung being a common site. The presence of functional or morphological abnormalities in small airways has recently been noted in patients with RA but its exact prevalence and clinical significance is still a subject of debate. This study was aimed to determine the prevalence of small airway disease (SAD) in patients with RA and the factors influencing it. METHODS: Fifty consecutive patients with RA were included in this cross-sectional observational study. All patients were subjected to pulmonary function tests (PFT) including Spirometry and Forced Oscillation technique (FOT). Those with features of SAD on PFT were subjected to High-Resolution Computed Tomography (HRCT) of the chest. RESULTS: Spirometry was suggestive of SAD in 17 patients, with 34% prevalence and FOT was abnormal in 9 patients, with 18% prevalence in the study population. Of 17 patients with SAD on spirometry, 8 (47.05%) patients showed mosaic attenuation, a sign of SAD on the HRCT chest. On univariate analysis, age, Disease Activity Score (DAS-28), joint erosions on X-ray, RF and anti-CCP were found to be associated with SAD. CONCLUSION: SAD was present in one-third of the patients with RA, even in those with short duration of disease, low to moderate disease activity and no respiratory symptoms. It is thus inferred that the complete workup of RA patients should include pulmonary function assessment.

Competency-based medical education (CBME) curriculum and its effect on prevalence of anxiety, depression and stress amongst medical undergraduates.

BACKGROUND: A growing body of literature now identifies higher levels of anxiety, depression, and stress among medical students as a distinct mental health domain. The competency-based medical education (CBME) curriculum was introduced to revamp the existing curriculum with an aim to garner constructive impact on the mental health of undergraduate medical students. As such, we sought to draw comparisons between the mental health of medical students, studying the old (2018 batch) and the new (2019 batch) medical education systems in India. MATERIALS AND METHODS: We designed a survey that contained structured questions pertained to anxiety (HAM-A, GAD-7), depression (HAM-D, BDI), and stress (PSS) amongst medical undergraduate students of 2018 and 2019 batches at the Government Doon Medical College (GDMC), Dehradun, India. RESULTS: Contrasting the 2018 and 2019 batches, the introduction of CBME resulted in a significant two-fold decrease in moderate anxiety, as exhibited by both HAM-A (6.0 vs 3.0, P = 0.016) and GAD-7 (3.5 vs 1.0, P = 0.037) scales, although no significant change in mild and severe anxiety, and overall depression (BDI: P = 0.05, HAM-D: P = 0.05) or stress (PSS: P = 0.86) was found. CONCLUSION: The CBME system has made a significant impact on the mental health of undergraduate medical students for anxiety, albeit its effect on depression and stress remains equivocal. Future studies are warranted to compare the effect of CBME in other undergraduate and postgraduate courses across the country to help predict the psychological impact of the newfangled CBME education system.

Cutaneous side effects of hydroxychloroquine in health care workers in a COVID referral hospital - implications for clinical practice.

The utility of hydroxychloroquine for the prophylaxis and treatment of alarmingly rising COVID-19 infection has been widely explored in several studies. However, its cutaneous adverse effects among health care workers and COVID patients taking prophylactic doses has not been reported. We report cases of palmoplantar among health care workers who were on prophylactic doses of hydroxychloroquine and their management with cetirizine and methylprednisolone.

Paucity of cutaneous manifestations of COVID-19 among inpatients at a referral hospital in India.

Background: Varied cutaneous manifestations of COVID-19 have been described, but most studies are based on photographic or application-based observations, without a direct observed-based evaluation by dermatologists. Objective: To study the types of cutaneous manifestations of COVID-19 among confirmed inpatients admitted to COVID-19 wards and intensive care units (ICUs). Methods: This cross-sectional analysis was conducted at a referral hospital in Delhi, India. Four hundred forty consecutive reverse transcription-polymerase chain reaction (RT-PCR)-confirmed cases diagnosed with moderate or severe COVID-19 and admitted to COVID-19 wards or ICUs, respectively, were included. A cutaneous finding was considered to be associated with COVID-19 if it had been described earlier as a consequence of COVID-19 and was observed at the time of or within the first 48 hours of admission (after excluding drugs and comorbidities as causes). Results: Two hundred seventy patients with moderate COVID-19 were admitted to COVID-19 wards, whereas 170 with severe disease were admitted to ICUs. Only 7 of the 270 ward patients (2.59%) and 3 of the 170 ICU patients (1.76%) had cutaneous findings associated with COVID-19. Conclusion: Cutaneous findings attributable to COVID-19 are infrequent, and we believe that these might have been overestimated or overemphasized in earlier studies. Although coagulopathic findings may be associated with severe COVID-19, causation cannot be established in this cross-sectional study.

Foreign body aspiration.

The clinical manifestations of foreign body (FB) aspiration can range from an asymptomatic presentation to a life-threatening emergency. Patients may present with acute onset cough, chest pain, breathlessness or sub-acutely with unexplained hemoptysis, non-resolving pneumonia and at times, as an incidental finding on imaging. Patients with iatrogenic FB such as an aspirated broken tooth during difficult intubation or a broken instrument are more common scenarios in the intensive care unit (ICU). Patients with post-obstructive pneumonia with or without sepsis, or variable degree of hemoptysis often require ICU level of care and bronchoscopic interventions. Rigid bronchoscopy has traditionally been the modality of choice; however, with the innovation in instrumentation and wider availability of flexible bronchoscopes, most of the FB removal is now successfully performed using flexible bronchoscopy. Proceduralists choose instruments in accordance with their training and expertise. We describe the use of most common instruments including forceps, balloon catheters, and baskets. Role of cryoprobe and LASER in FB removal is reviewed as well. In general, larger working channel bronchoscopes are preferred; however, smaller working channel bronchoscopes may be used in situations when the patients are intubated with a smaller diameter endotracheal or tracheostomy tubes. Large size FB are removed en bloc with the grasping tool, bronchoscope, and endotracheal or tracheostomy tube, requiring preparation to safely re-establish the airway. After FB removal, bronchoscopy is re-performed to identify any residual FB, assess any injury to the airway, suction post-obstructive secretions or pus, control any active bleeding and remove granulation tissue that may be obstructing the airway. Additional interventions like balloon dilatation may be required to dislodge an impacted FB or to maintain patency of bronchial lumen. If bronchoscopic methods fail, surgery may be required for retrieval of FB in symptomatic patients or to resect suppurative or necrotizing lung process. Multidisciplinary approach involving intensivists, surgeons, and anesthesiologists is the key to optimal patient outcomes.

Evaluation and comparison of molecular and conventional diagnostic modalities for detecting pulmonary tuberculosis in bronchoalveolar lavage fluid.

CONTEXT: In cases of sputum smear-negative and sputum-scarce (SSN/SC) pulmonary tuberculosis (PTB), bronchoalveolar lavage (BAL) fluid may be helpful in establishing diagnosis. No specific recommendations for BAL samples have yet been formulated due to limited literature. AIMS: 1. To find a sensitive and specific protocol for same-day diagnosis of PTB using BAL in SSN/SC clinically suspected patients. 2. To evaluate the need to routinely perform MGIT for all BAL samples. SETTINGS AND DESIGN: Prospective observational study design in a tertiary care hospital in New Delhi. METHODS AND MATERIAL: Fibreoptic bronchoscopy was performed and BAL collected from 175 clinically suspected SSN/SC PTB patients. BAL samples were subjected to: ZN Stain, Xpert MTB/RIF CBNAAT, BACTEC MGIT 960 liquid culture and M. tuberculosis complex DNA Real time PCR. The results of the various diagnostic tests were analysed using a) MGIT as gold standard and b) a composite reference standard (CRS) for a final diagnosis of PTB. STATISTICAL ANALYSIS USED: Microsoft Excel 2016 and SPSS version 21.0 were used. Sensitivity, specificity and predictive values were calculated and compared using McNemar test. A p value of <0.05 was considered statistically significant. RESULTS: 34 Cases had a final diagnosis of TB as per the CRS. Using CRS, MGIT had a sensitivity of 50.0% (32.4%-67.6%). There was no statistically significant difference between sensitivities of CBNAAT and PCR; both were more sensitive than ZN stain. Sensitivity and specificity of CBNAAT was 79.4% (62.1%-91.3%) and 100.0% (97.4%-100.0%) respectively. The preferred protocol for the hospital is CBNAAT and ZN stain. There was no statistically significant difference in sensitivity by adding PCR or MGIT to this protocol. CONCLUSIONS: We found it a good strategy to perform CBNAAT and ZN stain on BAL fluid for accurate and same-day PTB diagnosis. CBNAAT is useful for ruling PTB in even when BAL cultures are negative. It is prudent to continue to routinely perform MGIT for all BAL samples.

Prevalence of depression and anxiety among drug resistant tuberculosis: A study in North India.

BACKGROUND: Drug Resistant Tuberculosis (DR-TB) is an emergent issue in the recent decades. Multidrug resistant (MDR-TB) and Extensive drug resistant (XDR-TB) tuberculosis are the common type of DR-TB. Psychological issues like depression and anxiety are common among the chronic illnesses like tuberculosis. This study aimed at estimating the prevalence of depression and anxiety among these patients. METHODS: Our study is conducted in a tertiary care teaching hospital in North India. This study aimed at identifying the prevalence of depression and anxiety among the drug resistant tuberculosis patients attending DOTS clinic. The depression and anxiety were screened using PHQ-9 and HAM-A inventories. Binomial and multinomial regression analysis were done to identifying the predictors of depression and anxiety. RESULTS: The prevalence rate of depression in MDR-TB and XDR-TB is 68% and 78% respectively. The prevalence of anxiety is 54% in MDR-TB and 66% in XDR-TB respectively in our study. Duration of illness and literacy were the significant predictors of depression and anxiety. CONCLUSION: Patients with DR-TB faces huge psychological burden and this study highlighted the toll of depression and anxiety among them. Adequate screening, identification and treatment for these disorders among DR-TB patients at their earlier treatment stage helps in improving the adherence to treatment and functionality.

Disseminated pulmonary mucormycosis with concomitant tuberculosis infection in a diabetic patient.

Patients with diabetes are often susceptible to various opportunistic infections such as tuberculosis and mucormycosis. However, the occurrence of both these infections simultaneously is rare. We present one such case of pulmonary tuberculosis with disseminated pulmonary mucormycosis in a patient with diabetes, which was successfully managed.

COX2 and p53 risk-alleles coexist in COPD.

BACKGROUND: Cigarette smoke stimulates airway epithelial cells to release pro-inflammatory cytokines which influence various inflammation-related genes, including COX2, whereas p53 expression is known to alter in such a condition. Since both the genes share several common physiological functions including inflammation and oxidative stress, we investigated within gene and gene-gene interactions towards susceptibility to the disease. METHOD: In a prospective gene-association study we conducted PCR-RFLP for genotyping the COX2 -765G/C and 8473T/C and p53 72Pro/Arg polymorphisms in 229 COPD patients and 147 healthy controls. RESULTS: The -765GC+CC genotypes of COX2 and Pro/Pro+Pro/Arg genotypes of p53 were prevalent in patients with significant odds ratio, 2.05 and 2.30, respectively (p=0.001; p=0.009, respectively), as a consequence, the -765C and 72Pro alleles were prevalent (p