Pituitary tumor resection in a patient with SARS-CoV-2 (COVID-19) infection. A case report and suggested airway management guidelines / Assistência perioperatória de paciente com infecção pelo SARS-CoV-2 (COVID-19) submetido a ressecção de tumor de hipófise urgente. Relato de caso e diretrizes para manejo de via aérea

Abstract The 2020 pandemic caused by the novel coronavirus, COVID-19, had its headquarters in China. It causes Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and presents a broad spectrum of clinical manifestations, ranging from entirely asymptomatic through severe acute respiratory failure and death. Presuming a significant quantity of ventilator-dependent patients, several institutions strategically delayed elective surgeries. Particularly procedures performed involving the nasal mucosa, such as a transsphenoidal approach of the pituitary gland, considering the tremendous level of viral shedding. Nevertheless, critical cases demand expeditious resolution. Those situations are severe pituitary apoplexy, declining consciousness level, or risk of acute visual loss. This case presents a successful urgent perioperative management of a 47 year-old male COVID-19 positive patient who presented to the Emergency Department with a left frontal headache that culminated with diplopia, left eye ptosis, and left visual acuity loss after 5 days. Transsphenoidal hypophysectomy was uneventfully performed, and the patient was discharged from the hospital on postoperative day four. It additionally describes in detail the University of Mississippi Medical Center airway management algorithm for patients infected with the novel coronavirus who need emergent surgical attention.

Resumo A pandemia de 2020 causada pelo novo coronavírus, COVID-19, teve seu epicentro na China. Causa Síndrome Respiratória Aguda Grave pelo Coronavírus 2 (SARS-CoV-2) e apresenta um amplo espectro de manifestações clínicas, que vão desde nenhum sintoma a insuficiência respiratória aguda grave e óbito. Com a expectativa de um número significativo de pacientes dependentes de ventilador, várias instituições estrategicamente adiaram cirurgias eletivas. Esse é o caso principalmente de procedimentos envolvendo a mucosa nasal, como a via transesfenoidal para a hipófise, devido ao nível imenso de disseminação de material viral. Não obstante, casos críticos requerem resolução acelerada. Essas situações são grave apoplexia hipofisária, diminuição do nível de consciência ou risco de perda visual aguda. O presente caso relata o manejo perioperatório bem sucedido de urgência de paciente do sexo masculino de 47 anos de idade com COVID-19 que chegou ao Pronto Socorro com cefaleia frontal à esquerda que culminou com diplopia, ptose do olho esquerdo e perda de acuidade visual à esquerda após 5 dias. A hipofisectomia transesfenoidal ocorreu sem intercorrências e o paciente recebeu alta do hospital no quarto dia do pós-operatório. Adicionalmente, descrevemos em detalhe o algoritmo de manejo de via aérea da University of Mississippi Medical Center para pacientes infectados pelo novo coronavírus e que necessitam de atenção cirúrgica de emergência.

Study of onychomycosis

Background: Onychomycosis is one of the most common fungal nail infections caused by Dermatophytes, Non-Dermatophytic Molds (NDM) and Yeast. Though it is not life-threatening, can cause pain, discomfort, and disfigurement. It decreases the nail growth rate. Objectives: This study was carried out to document the clinico-mycological pattern and antifungal susceptibility pattern of onychomycosis.Methods: The study group included 130 consecutive patients with suspected fungal nail infections, attending Dermatology outpatient department of King George Hospital, Visakhapatnam, Andhra Pradesh during November 2012 to August 2014. The nail clippings of the patients were collected and subjected to KOH mounts for direct microscopy and fungal culture and antifungal susceptibility tests.Results: Onychomycosis was common among males (66.92%) than females (33.08%) with highest incidence was in age group 31-40 years (41.37%). Finger or toenails were exclusively involved in 32.18% and 55.18% patients respectively while these were involved concurrently in the rest of the 12.65% patients. Distal and lateral subungual onychomycosis seen in 64.36% of the patients was the most common clinical type. KOH and culture positivity were recorded in 56.92% and 48.46% cases respectively. Dermatophytes (50.58%) were predominant isolate followed by NDM (27.58%) and yeast (21.84%). Clotrimazole and ketoconazole were most effective antifungals against dermatophytes. For NDM, itraconazole, nystatin and amphotericin B and for yeast fluconazole and itraconazole were effective.Conclusions: The present study gives an insight about the aetiological agents causing onychomycosis and their anti-fungal susceptibility pattern in this region. Thus, it can help in taking adequate control measures to prevent it.

Seroprevalence of syphilis in human immunodeficiency virus patients

Background: Syphilis is a sexually transmitted infection caused by, Treponema pallidum. Syphilis facilitates the transmission and acquisition of human immunodeficiency virus (HIV) and causes transient increase in the viral load. Sexually transmitted infections (STI) are 3-5 times more likely to acquire HIV infection, if exposed to the virus through sexual contact. Aim of the study was to estimate the seroprevalence of Syphilis in HIV patients.Methods: A total of 920 blood samples were collected from HIV patients attending ART (Antiretroviral therapy) centre and were tested for Syphilis by using Rapid Plasma Reagin (RPR) and Treponema pallidum Hemagglutination Assay (TPHA). A total of 100 HIV non-reactive individuals were taken as a control group.Results: Out of 920 samples, 102 (11.1%) were positive for Syphilis. Out of 102 Syphilis seropositive patients, males (76.5%) were more commonly affected in age group of 21-40 years. Both RPR and TPHA were reactive in 46% of cases and only TPHA reactive in 53.9% of cases. Out of 100 HIV non-reactive patients, 5% of patients are reactive for Syphilis.Conclusions: In the present study, prevalence of Syphilis was more in HIV patients compared to HIV non-reactive persons. Persons with HIV infection acquired through sexual route should be screened for Syphilis by one nonspecific test along with specific test to confirm the diagnosis. This will help in proper management of the patients having Syphilis and HIV co-infection.

Comparative Study between General Anesthesia and Spinal Anaesthesia in Paediatric Patients

Introduction: Anaesthesia Comprises of analgesia,unconsciousness, relaxation and suppression of reflexes. Thisstate of Anaesthesia can be achieved either by regional orGeneral Anaesthesia (GA). In G.A all the four parameters arefulfilled, where as in regional Anaesthesia the patient need notbe unconscious. Study aimed to prove the supremacy of spinalanaesthesia to general anaesthesia.Material and methods: A Comparative study was done insixty patients divided into two groups as Group ‘S’ receivedspinal anaesthesia with Butivacaine 0.5%, 0.4mg/kg bodyweight. Group ‘G’ (General Anaesthesia) consisting thirtypatients were given G.A relaxant technique with IPPV.Results: ‘S’ group is hemodynamically more stable in theimmediate post operative period when compared with the ‘G’group. Conscious levels: 100% of S group patients showed nosign of altered consciousness. Where as 9 out of 30 patientsi.e 28% G group patients were drowsy in the immediate postoperative period and needed observation for a longer period.No notable complications like nausea, vomiting, or urinaryretention were noticed in both groups.Conclusion: No complications were noted in both groupspatients were drowsy in ‘G’ group, but all are awake andco-operative in ‘S’ group.It can be concluded that the subarachnoid block is proved to be a better choice for the belowthe umbilical level surgeries in pediatric patients as it is havingno complications and will be accepted by surgical team andparents

Seroprevalence of hepatitis B virus and hepatitis C virus co-infection in human immunodeficiency virus infected patients at a tertiary care hospital in South India.

Background: About one third of human immunodeficiency virus (HIV) infected patients are co infected with either hepatitis B virus (HBV) or hepatitis C virus (HCV) as the three viruses have similar routes of transmission that is through transfusion of blood and blood products, sharing of needles to inject drugs and unprotected sexual activity. The survival of HIV infected patients has been markedly improved with highly active antiretroviral therapy (HAART). However several studies showed that the liver diseases caused by HBV or HCV have emerged as one of the leading causes of non AIDS related deaths in HIV patients. The objective of this work was to study the prevalence of HBV & HCV co-infection in HIV infected patients at a Tertiary care centre in South India. Methods: The study group includes 100 HIV seropositive individuals confirmed by three rapid tests as per NACO (National AIDS Control Organization) guidelines in ICTC (Integrated Counseling and Testing Centre), Department of Microbiology, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. Age and sex matched 100 HIV seronegative individuals were also included in the study as controls. Both the groups were screened for detection of HBV and HCV markers by one rapid test and a solid phase enzyme linked immunosorbent assay (sandwich ELISA). Results: Out of 100 HIV positive patients in the study group 12(12%) were co infected with HBV and 2(2%) were co infected with HCV. Out of 12 HIV and HBV co infected patients 7(58.3%) were females and 5(41.7%) were males. The HIV &HCV co infected patients were both females. Co infection of HBV & HCV with HIV was found to be 0(0%). Co infection was most commonly seen in the age group 31-40 years followed by 21 – 39 years. In the control group out of 100 HIV negative individuals, 1(1%) was infected with HBV infection. Conclusions: The routine screening of HBV and HCV should be mandatory for HIV infected patients, as there is more chance of co infection with these Hepatitis viruses due to enhanced immunodeficiency by HIV and similar routes of transmission. Clear National policies should be established which should include clear economic and health care strategies to improve quality of living conditions, education and easy access to health care facilities.

Isolation and speciation of genus candida in patients undergoing chemotherapy and radiotherapy for head and neck tumours.

Background: Fungal infections occur as a result of defect in the immune system. The use of wide-spectrum antibiotics, immunosuppressive therapy, HIV and an increasing incidence of diabetes are some of the causes that resulted in raising number of immunocompromised individuals, in the global scenario. Opportunistic fungal infections mainly oral candidiasis is common in patients undergoing chemotherapy (CT) or radiotherapy (RT) for Head & Neck tumors. Objectives: Isolation and speciation of Candida with antifungal susceptibility testing in patients undergoing CT and RT for Head and Neck tumors. Methods: Study group comprised of 100 saliva samples collected by oral rinse method, (50 chemotherapy and 50 radiotherapy) from inpatients of King George hospital, Visakhapatnam and 50 normal healthy individuals were taken as control group. Standard mycological tests for the Candida isolation, speciation and antifungal susceptibility were done. Results: In the study group out of the 100 patients, 38% were culture positive for Candida. The most commonly isolated species was C. albicans (60.5%) followed by non albicans species. Most of the candida species showed sensitivity to nystatin, amphotericin B, itraconazole and Ketoconazole. In control group 9 out of 50 samples (18%) were culture positive and all the isolates were Candida albicans. Conclusion: Increase in frequency of oral candidiasis in patients undergoing chemotherapy and radiotherapy was observed. The increase in positivity may be attributed to inadequate nutritional status and poor oral hygiene during chemotherapy and radiotherapy. Culture positivity is more in RT patients than in CT patients. Though C. albicans is the predominant isolate, non albicans species are also emerging. All the Candida species isolated from study group were sensitive to nystatin, amphotericin B, itraconazole and ketoconazole. In the study group all the Candida species were resistant to clotrimazole and fluconazole and in the control group all the C. albicans were sensitive to fluconazole.

Impact of CO2 Enhancement on Photosynthesis and Protein Profile - Response Studies with a CO2 Responsive Black Gram Genotype.

Black gram (Vigna mungo (L.) Hepper) var. IC-282009 - a highly CO2 responsive genotype for biomass and seed yield was grown in Open top chambers (OTCs) under three levels of CO2 i.e. ambient (390 ppm) and two elevated levels 550ppm and 700ppm to assess photosynthetic acclimation to elevated CO2. Net photosynthetic rate (PN), change in leaf soluble protein profile and leaf carbohydrate constituents such as total soluble sugars, reducing sugars and starch content in leaves was quantified at all three CO2 concentrations. Photosynthetic rate was enhanced by 78% and 30% at flowering stage with 550ppm and 700ppm CO2 as compared with ambient control. It was also observed a higher accumulation of starch, total soluble sugars and reducing sugars in leaves at elevated CO2 levels. However, the leaf protein content recorded a decrease and altered the profile of ploy peptides with enhanced CO2 levels. At elevated CO2 concentrations significant differences were observed in ploy peptide profile at vegetative and flowering stages, the intensity of 260 kDa poly peptide increased at vegetative stage, whereas 72 kDa polypeptide increased at flowering stage, while 52 kDa poly peptide decreased at both stages. Enhanced CO2 concentrations improved the PN though certain polypeptides of leaf protein are down regulated and necessitate further experimentation to confirm their involvement in responsiveness of the selected black gram genotype.

Prevalence of hepatitis C virus (HCV) coinfection in HIV infected individuals in south India and characterization of HCV genotypes.

PURPOSE: To determine anti-HCV antibodies and genomic subtype of HCV in 1487 confirmed human immunodeficiency virus (HIV) positive samples. METHODS: A total of 1487 confirmed HIV-positive samples were tested for anti-HCV antibodies by using a third generation ELISA kit (Ortho 3.0) and by RT PCR for HCV. HIV and HCV coinfected samples were selected for HCV genotyping by RFLP and subtyping with NS5-type specific primers. RESULTS: A total of 1487 HIV-infected serum samples were screened for HCV infection, of which, a 1443 (97.04%) were negative and 45 (3.02%) were coinfected. HIV-HCV coinfection was predominant in the age group 41-50 years (51.1%). HCV genotyping and subtyping was done for the 45 HCV RNA-positive specimens of which genotype 1 was observed in 31 (68.8%) and genotype 3 was observed in 14 (31.1%) subjects. Further subtyping analysis showed the genotype 1b in 23 (51.1%), 1a in eight (17.7%), 3a in 10 (22.2%) and 3b in four (8.8%) subjects. CONCLUSION: HIV and HCV seroprevalence is higher in South India, and the most prevalent genotype in coinfection was genotype 1b.

Dark after cholecystectomy.

We report a patient who complained of becoming darker after an abdominal surgery. The index patient not only had a darker complexion after cholecystectomy, but his glycaemic control was also getting better after operation to the extent that he could stop insulin, which he had been taking for five years. Also, he had lost significant weight after operation. Later, we found that he had developed primary hypocortisolism due to unrecognized bilateral adrenal haemorrhage in the immediate postoperative period.

Melatonin in pathogenesis and therapy of cancer.

Melatonin is a neuroendocrine hormone secreted by the pineal gland to transduce the body's circadian rhythms. An internal 24 hour time keeping system (biological clock) regulated by melatonin, controls the sleep-wake cycle. Melatonin production is a highly conserved evolutionary phenomenon. The indole hormone is synthesized in the pinealocytes derived from photoreceptors. Altered patterns and/or levels of melatonin secretion have been reported to coincide with sleep disorders, jetlag, depression, stress, reproductive activities, some forms of cancer and immunological disorders. Lately, the physiological and pathological role of melatonin has become a priority area of investigation, particularly in breast cancer, melanoma, colon cancer, lung cancer and leukemia. According to the 'melatonin hypothesis' of cancer, the exposure to light at night (LAN) and anthropogenic electric and magnetic fields (EMFs) is related to the increased incidence of breast cancer and childhood leukaemia via melatonin disruption. Melatonin's hypothermic, antioxidant and free radical scavenging properties, attribute it to an immunomodulator and an oncostatic agent as well. Many clinical studies have envisaged the potential therapeutic role of melatonin in various pathophysiological disorders, particularly cancer. A substantial reduction in risk of death and low adverse effects were reported from various randomized controlled trials of melatonin treatment in cancer patients. This review summarizes the physiological significance of melatonin and its potential role in cancer therapy. Furthermore, the article focuses on melatonin hypothesis to represent the cause-effect relationship of the three aspects: EMF, LAN and cancer.

Clinical relevance of alternative splicing.

The unique phenomenon of alternative splicing is gathering concern due to its promising therapeutic potential. The human genome sequencing project suggests approximately 20,000-25,000 genes. Among these, about 35-60% of genes generate multiple mRNAs by alternative splicing mechanism and contribute to the diversity of the proteomic world. This 'gene shortfall' has ignited considerable interest in alternative RNA splicing. This process leads to expression of a single gene responsible for the transcription of different mRNA isoforms that might have multiple biological functions. The disruption of splicing pattern can produce aberrant splice variants, which are implicated in more than 50% of genetic disorders including cancer. Altered splice sites in neoplastic cell contribute to the development, progression and/or maintenance of tumorous growth. The repertoire of tumor-specific variant represents a potential marker in pharmacogenomic diagnostic relevance. Alternative splice isoforms have been analyzed serendipitously by qualitative gene profiling with in silico gene prediction software. Computational approach in identifying exonic splicing enhancers in genomic DNA and focus on microarray technology will elucidate differential expression of alternative splice variants. The antisense oligonucleotides modulate alternative splicing and engender the production of therapeutic gene products. Oligonucleotides have the potential to silence the mutations caused by aberrant splicing. The efficacy of the antisense oligonucleotides lies in the chemical configuration, affinity and delivery strategies. Hence the therapeutic potential of antisense oligonucleotides as modulators of aberrant alternative splicing would be a major challenge to the upcoming proteomic era.

Opportunity for natural selection among three endogamous subpopulations of Andhra Pradesh.

The Crow's index of opportunity for natural selection has been calculated for three endogamous subpopulations namely Arya Vysya, Thrivarnika and Kalinga Vysya of North Coastal Andhra Pradesh. The total index is in the order Arya Vysya > Thrivarnika > Kalinga Vysya. However, the mortality component is more in Kalinga Vysya, reflecting the poor medical facilities available to them due to their low socio- economic profile compared to other two populations. The results of the present study are compared with those among the other caste populations of Andhra Pradesh.

Primary plasmacytoma of testis. Report of a case.

A primary testicular tumour in a 62 year old man was found to be a plasmacytoma on histopathological examination without any extra testicular disease prior to or subsequent to orchiectomy, fulfilling the criteria for the primary extramedullary plasmacytoma. Such cases are extremely rare. Evaluation of such a case was discussed and the relevant literature reviewed.

HIV infection among dental patients.

Oral manifestations may be the important indicators of ongoing human immunodeficiency virus (HIV) infection. Serum samples were collected from 100 patients repeatedly attending dental outpatients' department of SV Medical College and SVRR Hospital, Tirupati and tested for the presence of HIV antibodies. HIV 1 antibodies were detected in one person, the seropositivity rate being 1%.

Sero-prevalence of herpes simplex virus type-2 among cancer cervix patients.

Serum samples were collected from 140 cancer cervix patients aged between 25-60 years and also from 20 age matched, married, healthy women to serve as controls. These sera were tested for HSV-2 antibodies by ELISA test and HBsAg by RPHA test. HSV-2 antibodies were detected in 92 (65-71%) and HBsAg in 25 (17.8%) cancer cervix patients. Sera from control group were negative for HSV-2 antibodies and HBsAg.

An epidemic of human anthrax--a study.

Twenty-five cases of human anthrax, occurring after contact with a Jercy cow infected with B. anthracis and consumption of its improperly cooked meat after death, were reported. Cutaneous anthrax was the predominant variety in 18 persons, 7 had intestinal anthrax, out of them 2 children died, 5 adults survived and one among them developed associated cutaneous anthrax also. All the persons with cutaneous anthrax recovered with treatment.

Tinea capitis in Tirupati.

One hundred clinically diagnosed cases of Tinea capitis were studied to know the clinical types and the causative agents. The incidence of grey patch, Kerion and black dot being 60%, 31% and 9% respectively. Tinea capitis was found to be more common in males (58%) than in females (42%) and it is more prevalent in children aged between 6-15 years. Trichophyton violaceum is the predominant (63.15%) fungal species isolated.