Causal ambiguity: deciphering the etiology of secondary thrombotic microangiopathy with systemic lupus erythematosus and vivax malaria

Hemolytic uremic syndrome (HUS) falls under the spectrum of thrombotic microangiopathy (TMA) characterized by microangiopathic hemolytic anemia, thrombocytopenia, and thrombi in small vessels leading to end-organ damage. It's classified into typical HUS (caused by Shiga toxin-producing E. coli), atypical HUS (due to uncontrolled complement activation), and secondary HUS (sHUS) linked with coexisting conditions. We present a compelling case of a 21-year-old female with fever, jaundice, anemia, thrombocytopenia, and oliguric acute kidney injury (AKI), ultimately diagnosed with Plasmodium vivax malaria. Despite adequate antimalarial therapy, the patient's clinical trajectory remained intricate, characterized by sustained hematological abnormalities and renal dysfunction. A comprehensive assessment revealed Coombs-negative hemolytic anemia. Subsequently, a renal biopsy confirmed TMA. Considering the rarity of vivax malaria causing TMA, an autoimmune workup was conducted, suggesting systemic lupus erythematosus (SLE). Systemic autoimmune disease-associated HUS (SAID-HUS) is a rare entity that exhibits diverse clinical presentations, with SLE being best-described etiology in literature. SLE-associated HUS was considered and was managed with steroids and hydroxychloroquine resulting in significant renal and hematological improvement. This report underscores significance of assessing autoimmune factors in case of secondary TMA, while also shedding light on evolving understanding of vivax malaria's potential relationship with TMA.

Learning to switch gears — Steering palliative care into emergency medicine

Emergency care is largely seen as synonymous with resuscitation and saving lives. In most of the developing world where Emergency Medicine (EM) is still evolving, the concept of EM palliative care is alien. Provision of palliative care in such settings poses its own challenges in terms of knowledge gaps, socio-cultural barriers, dismal doctor-to-patient ratio with limited time for communication with patients, and lack of established pathways to provide EM palliative care. Integrating the concept of palliative medicine is crucial for expanding the dimension of holistic, value-based, quality emergency care. However, glitches in decision-making processes, especially in high patient volume settings, may lead to inequalities in care provision, based on socio-financial disparities of patients or premature termination of challenging resuscitations. Pertinent, robust, validated screening tools and guides may assist physicians in tackling this ethical dilemma.

COVID-19 Vaccination status among Health care workers diagnosed with COVID-19 in a tertiary care institute of Uttarakhand: A Cross-sectional Study

Background: Vaccines are considered as the one of the main pillars in halting and ending the presently on-going coronavirus disease (COVID-19 disease) pandemic which has spread globally since it was first detected in Wuhan, China in December 2019. In the absence of specific therapy, infection prevention practices and mass vaccination remains the mainstay in controlling the disease. Objectives: Objective of the study was to assess COVID-19 vaccination status, socio-demographic and clinical profile among healthcare workers diagnosed with COVID-19. Methodology: A cross-sectional survey from 1st March 2021 to 30th June 2021 among healthcare workers who were diagnosed with COVID-19 in a tertiary care institute of Uttarakhand, India was conducted, and universal sampling was used. Institutional Ethics Committee approved this study. Results: Total 662 healthcare workers were diagnosed with COVID-19. 429 (64.8%) of these COVID-19 diagnosed healthcare workers had received either single (129,30%) or both dose (300,70%) of COVID-19 vaccine while remaining 233 (35.2%) belonged to non-vaccinated group. History of exposure to COVID-19 positive patients was higher in vaccinated (66.4%) than in non-vaccinated group (55%) (p = 0.004). Hospitalisation was found to be higher among non-vaccinated (5.6%) than vaccinated group (2.3%) (p = 0.029). Conclusions: This study concludes that being vaccinated against COVID-19 disease provides protection against severe infection and reduces the need for hospitalization.

Does Nutritional Status Affects Oral Health Related Quality of Life Among Elderly? A Cross-Sectional Study at A Tertiary Care Health Centre, Rishikesh, India

Aim: Present study was conducted to evaluate the impact of nutritional status on oral health related quality of life using Geriatric Oral Health Assessment Index (GOHAI) among geriatric population attend-ing outpatient department (OPD) of tertiary health care centre in Rishikesh. Settings and Design: Present cross-sectional study was conducted on geriatric male & female partici-pants attending Outpatients Department(OPD) of tertiary care centre, RISHIKESH. Methods and Material:Nutritional assessment was recorded by using Mini Nutritional Assessment (MNA) tool. Oral health related quality of life was assessed using pre-validated Hindi version of Geriatric Oral Health Assessment Index (GOHAI) questionnaire. Statistical analysis: Kruskal-Wallis and Mann-Whitney U test were applied using SPSS 22.0 Software. Logistic regression analysis was done to find out risk factors. Results:A total of 281 participants completed the questionnaire with mean age of 66.89 ± 6.43 years. About three fourth (73%) of total participants were at risk of malnourishment. A statistically significant difference (P=0.005) was observed when the median GOHAI scores were compared with nutritional sta-tus (MNA scores). Conclusions: A statistically significant difference was found between nutritional status and geriatric oral health related quality of life (GOHAI). Nutritional status affects oral health related quality of life among elderly population.

Monkeypox: An Emerging Public Health Threat

In last three decades, more than 30 new infectious agents have been detected worldwide and out of which more than 60% have been found to be zoonotic in origin. Monkeypox disease is an infectious zoonotic disease caused by the monkeypox virus belonging to the Orthopoxvirus genus of the Poxviridae family. Human monkeypox was first identified in humans in 1970 in the Democratic Republic of the Congo in a 9month-old boy in a region where smallpox had been eliminated in 1968. First outbreak of human monkeypox outside Central and Western African region was detected in 2003 in United States of America which was linked to contact with the infected pet prairie dog. The latest Monkeypox outbreak in non-endemic countries started from May 2022 and have been reported from 89 member states across all six WHO regions. India reported first case of Monkeypox on 14 th July 2022.

Assessment of knowledge Vis-à-vis Food Labels

Background: Public health initiatives focused on improving food at the community level to reduce the risk of nutritionrelated disorders have gained pace in light of the enormous illness burden associated with chronic diseases connected to nutrition. Delivering straightforward, pertinent, and understandable information regarding the nutritional value of food is the goal of Front of Package Labelling (FoPLs), which are intended to assist consumers in choosing healthier foods at the point of purchase. Methodology: It was a cross-sectional study carried out online through a series of webinars using an online survey platform and a feedback-designed questionnaire to ascertain webinar participants' knowledge of front of package labeling. Results: Among the participants, only 75.4% correctly identified the characteristics of packaged foods that increase the risk of obesity. Also, it was found that 84.7% of the participants knew that food labels had to display complete nutritional information. About 93.6 percent of the individuals were aware of public health initiatives that raise awareness of FOPL. Only 38.9% of the individuals were aware that certain food products were free from labelling, in comparison. Conclusion: Front of package labelling (FOPL) regulation goals must be adopted in order to enable consumers to simply, quickly, and accurately identify items containing extra sugars, trans-fats, oils, and sodium. This will help the Government of India comply with WHO recommendations on unhealthy foods.

Developing public health capacities of Frontline Public Health Workforce in Uttarakhand

Recent COVID-19 pandemic has highlighted the importance of increase in the ability of public health workforce to detect and respond to the public health threats. For timely implementation of an adequate response and mitigation measure, the standardized and sustainable capacity building programme for frontline public health workforce is the need of hour. National Center for Disease Control (NCDC), Ministry of Health and Family Welfare, in partnership with U.S. Centers for Disease Control and Prevention (CDC), developed a three-month in-service Basic Epidemiology Training programme. This is a tailor-made programme for frontline public health workforce to strengthen epidemiological skills. This training was a practical interactive approach to field epidemiology for three months on the job training for frontline public health workforce that addressed the critical skills needed to conduct surveillance effectively at the local level while focusing on improving disease detection, reporting and feedback. The training also demonstrated the role of learning model in form of interaction between the mentor and the mentees. The importance of handhold support given by the mentors to the mentees in quality outbreak investigations and documentation.

Primary leiomyosarcoma of the thyroid gland

Sarcoma is a rare tumor of the thyroid gland, primary thyroid leiomyosarcoma (LMS) being even rarer. We present a case of LMS of the thyroid in a middle-aged female. Histopathologic examination in conjunction with immunohistochemistry helped to clinch the diagnosis. Knowledge of this entity is important to distinguish it from anaplastic thyroid carcinoma (ATC) and other sarcomas arising in the thyroid and adjacent soft tissue. The prognosis of thyroid LMS is dismal with an extremely poor survival rate.

A perspective on Master of Public Health (MPH) Graduates in India: Current role and way head

The public health sector of any country deals on the forefront and utilizes the multidisciplinary approach. In India the Masters of Public Health graduates are trained in unstandardized manner and lack a regulatory body. The gap created in serving the unserved can easily be fulfilled by utilization of this workforce in systematic manner, The emerging competition in the field, undervalued sector in terms of monitory benefits, poor demand and limited training institutions for MPH graduates along with the contribution of MPH during COVID 19 pandemic has been emphasized in the article. The perception of those working in the field has been highlighted with the way ahead of MPH program in India.

Healthcare Scenario: Health for All to Sustainable Development Goals

Poor quality care in public sector hospitals coupled with the costs of care in the private sector have trapped India's poor in a vicious cycle of poverty, ill health and debt for many decades. There is a huge cross section of the population that continues to struggle to gain access to affordable good quality healthcare. Although the rich can access healthcare by paying large sums of money, the poor are under major threat of financial duress. In Primary health care level public share is more with affordable cost but with compromised quality while in tertiary level private share is more with quality but at high cost and is focused in urban areas. Government has started spending at tertiary care level (newer AIIMS) to broaden the care spectrum but without much improvement at primary health care level. Accountable health care remains challenge for middle and low income countries. Accountability refers to “the principle that individuals, organizations and the community are responsible for their actions and may be required to explain them to others” (1). Low levels of public health financing, supply side gaps, an acute shortage of human resources and the rising cost of healthcare continue to severely affect access, affordability and quality of health services across the country. These issues make difficult for the public sector to remain accountable. The government has been attempting to address two main challenges: to ensure that all citizens can access healthcare equitably and to ensure that healthcare is made available at an affordable cost and without compromising on quality. So three important pillars for effective HCDS are cost, Access & Quality.

Modified BG Prasad Socio-economic Classification, Update - 2019

Modified BG Prasad socioeconomic scale has been in use for determining the socio-economic status of study subjects in community-based health studies in India since 1961.It is an income-based scale and, therefore, constant update is required to take inflation and depreciation of rupee into account. For industrial workers (IW), the consumer price index (CPI) is used to calculate updated income categories at any given point of time, viz Jan 2019.

Quantification of RAPD by an automated pupillometer in asymmetric glaucoma and its correlation with manual pupillary assessment

Purpose: The relative afferent pupillary defect (RAPD) is an important sign of asymmetrical retinal ganglion cell damage. The purpose of this study was to quantify RAPD by a pupillometer (RAPiDo, Neuroptics) and assess its correlation with asymmetric glaucoma and manual pupillary assessment. Methods: A total of 173 subjects were enrolled in the study and categorized into glaucoma, n = 130, and control, n = 43. Subjects were all recruited in the Glaucoma Clinic of the Aravind Eye Hospital in Madurai during their follow-up. They were 18 years and older, with best corrected visual acuity of 6/36 or better. Exclusion criteria included all retinal pathologies, optic atrophies, ocular injuries, severe uveitis, cloudy corneas, dense cataracts, or use of mydriatics or miotic drugs. RAPD was assessed in all subjects using an automated pupillometer and the results were compared with the swinging flash light test conducted on the same subjects by an experienced ophthalmologist. We looked at the correlation between RAPD and the intereye difference in cup-to-disc ratio (CDR), mean deviation (MD) of visual field testing, and retinal nerve fiber layer (RNFL) thickness. Sensitivity and specificity were assessed by area under the receiver operator characteristic (AUROC) analysis. Results: Glaucoma patients had significant RAPD (0.55 � 0.05 log units) when compared with the controls (0.25 � 0.05 log units), P < 0.001. Significant intereye differences in CDR, MD, and RNFL between glaucoma and control (P < 0.001) were seen. There was a good correlation between the magnitude and sign of RAPD and these intereye differences in CDR (r = 0.52, P < 0.001), MD (r = 0.44, P < 0.001) and RNFL thickness (r = 0.59, P < 0.001). When compared with the experienced ophthalmologist, AUROC was 0.94, with 89% sensitivity and 91.7% specificity. Conclusion: The good correlation between the magnitude of RAPD, as measured by the automated pupillometer, and intereye differences in MD, CDR, and RNFL thickness in glaucomatous, and the good sensitivity and specificity when compared with the experienced ophthalmologist, suggest that pupillometry may be useful as a screening tool to assess asymmetric glaucoma.

Specific Absorption Rate (SAR) value of mobile phones: An awareness study among mobile users

Mobile phone is an inevitable part of ones life. Once been luxury has now become necessity. It’s been used by all age group people for different application apart from calling and texting. The advance in mobile technology has brought many new applications using mobile. But while using cell phone for talking or being connected to someone the user gets exposed to harmful Electro Magnetic Radiations. The exposure rate to these radiations vary from handset to handset. When cell phones are used in close proximity to human body, the radiations emitted from cell phones penetrate deep inside the human skin. Penetrated radiations produce induced electric field inside the body, resulting in absorption of power, which can be analyzed using a parameter called specific absorption rate (SAR). But still one question arises in mind that are people really aware of Safety standard especially SAR value. What does SAR value mean? It’s the specific absorption ratio measure of amount of radio frequency intensity or energy absorbed by body while connected on cellular network. It is defined as the power absorbed per mass of tissue and has units of watts per kilogram (W/kg) and in a way defines safety range of mobile handset .This study aims to measure the knowledge and awareness of SAR value of handset and the factors that influence awareness of SAR value. This is the largest sample study about mobile usage and awareness of SAR amongst mobile users .

Why Need for National Expert Group Technical Consultation on Prevention and Treatment of Iron Deficiency Anemia

Iron deficiency anemia is the most common nutrient deficiency in India. It impacts the lives of millions of mothers and children in our country through impaired health, development, quality of life and productivity. The Government of India initiated National Iron-plus Initiative Programme (NIPI) for Control of Iron Deficiency Anaemia in 2013 with an aim to prevent and treat anaemia amongst different age groups, namely i) 6-59 months; ii) 6-10 years; iii) 11-19 years, iv) Pregnant and lactating Mothers, and v) Women in Reproductive age group.

Modified BG Prasads Socio-economic Classification-2018: The need of an update in the present scenario

Modified BG Prasad socioeconomic scale has been in use for determining the socio-economic status of study subjects in community-based health studies in India since 1961.It is an income-based scale and, therefore, constant update is required to take inflation and depreciation of rupee into account. For industrial workers (IW), the consumer price index (CPI) is used to calculate updated income categories at any given point of time, viz Jan 2018. These details of the calculations involved will help many researchers to calculate specific income categories for their ongoing and prospective research work in current calendar year. On the Department of Labour website (www.labourbureaunew.gov.in), state-specific CPI values are also available and should be used to determine more accurate income categories. The current exercise is a step towards increasing the validity of use of classification with relevance to the current price levels and enabling a real time update for a considerable time in the near future. The health behavior of an individual or a community is interdependent on their socio-economic status. The concept of socio-economic status is widely used in medical sociology. The social standing of an individual or a family in the society can be measured by it. Therefore, is an important factor affecting the health condition of an individual or a family. (1) Socio-economic status has been defined as “The position that an individual or family occupies with reference to the prevailing average standards of cultural and material possessions, income and participation in group activity of the community”. The social status may be inherited, but in modern society it is achieved on the basis of occupation, income, type of housing and neighborhood, membership of the certain associations and organizations, material, possessions, etc. (2) In India, several methods or scales have been developed for classifying different populations based on their socio-economic status, viz. Parikh scale 1964, Shirpurkar scale 1967, Jalota scale 1970, Kulsherestha scale 1972, Srivastava scale 1978, Bharadwaj scale 2001. (3-8) Modified BG Prasad’s classification that is used for both urban and rural areas. Modified Kuppuswamy classification is used in urban and peri urban areas which considers the education of the head of family, occupation of head of the family and per capita monthly income.(9,10) Another classification for rural areas is Uday Pareekh classification which takes into account following characteristics namely caste

Co-infection of Central Nervous System by M. Tuberculosis, Cryptococcus and possibly Naegleria fowleri

Co-infection due to Mycobacterium tuberculosis, Cryptococcus and Naegleria fowleri has not been reported till now in literature, to the best of our knowledge. Here we report a curious case of co-infection of the central nervous system due to these three pathogens in an apparently immune-competent, HIV negative boy. The 15 year old boy was a diagnosed case of tubercular meningitis and was on anti-tubercular and anti-epileptic treatment. However, two months later he presented again in the emergency department with sudden loss of consciousness. His CSF showed presence of capsulated budding yeast cells (suggestive of Cryptococcus) and flagellated parasites (resembling the flagellated stage of Naegleria fowleri). CSF was also positive for Cryptococcal antigens by Latex Agglutination test. The boy was HIV negative and apparently immuno-competent. He was subsequently put on amphotericin B therapy for six weeks. Repeat microscopy, done towards the end of amphotericin B course, showed clearing of CSF. However, the patient’s condition improved only slightly, owing to neurological damage caused by the pathogens as suggested by brain CT and MRI scans. Thus infection caused by the members of three different kingdoms in an apparently immunocompetent boy highlights the importance of thinking beyond the ordinary causative pathogens, and actively searching for rarer etiologies to ensure timely intervention; especially in nonresponsive cases.

articleIndicators of maternal ‘near miss’ morbidity at different levels of health care in North India: A pilot study.

Introduction: Maternal morbidity and mortality in India continues to remain high despite concerted efforts during the past decades. Objective of this study was to determine the prevalence and indicator of Potentially Life Threatening Conditions (PLTC) and ‘near miss’ obstetric cases at different tiers of health care. Material and Methods: A cross-sectional epidemiological study was carried out over a period of 12 months as per the WHO criteria for ‘near miss’. Probability sampling was done to systematically and randomly select health facilities i.e. two primary health centers (PHC), one community health centre (CHC) and a tertiary hospital all from Doiwala block of Dehradun, Uttarakhand, India. The study included all the women attending health-care facilities, who were pregnant, in labour, or who had delivered or aborted up to 42 days ago arriving at the facility. A convenient sampling was done (a hundred percent enumeration of eligible study subjects) for the audit. Result: A total of 937 pregnant women who accessed health care had 688 live births and 231 women had one or more of the Potentially Life Threatening Conditions (PLTC). Among them, 61 women had Severe Maternal Outcome (SMO) - 51 with maternal ‘near-miss’ and 10 maternal deaths. The Severe Maternal Outcome Ratio (per 1000 live births) was 88.66. The Maternal ‘near miss’ Mortality Ratio (MNM-MR) and Mortality Index (MI) were 5.1 and 16.39% respectively. Conclusion: The WHO ‘near miss’ approach has been found to be an effective measure to assess quality of care in maternal health across countries including India.

Clinicopathological characteristics of ameloblastomas in Western Uttar Pradesh population: An institutional study.

OBJECTIVE: The aim of this study was to compare the clinical, radiologic, and histopathological features of 28 intraosseous ameloblastomas. In addition, we compared the data obtained in this study with that of previous studies. MATERIALS AND METHODS: Data with regard to age, gender, clinical manifestation, radiographic aspect, anatomical distribution, and histopathological subtypes were analyzed in 28 subjects. RESULTS: The patients’ age ranged from 7 years to 65 years (mean, 30.4 years). Sixteen (57.14%) of the 28 subjects were males, and 12 (42.85%) were females. A total of 22 cases (78.5%) were located in the mandible, posterior region was more often affected with 17 cases (77.27%) than only 5 cases (22.72%) in the anterior segment. Swelling was the most common symptom and was experienced by 12 (42.85%) patients. Radiographically, 14 cases (50%) were multilocular with a well‑demarcated border. Of the remaining 14 cases, 10 were unilocular and 4 were unknown in appearance. The most common histopathological pattern was follicular followed by plexiform or acanthomatous. CONCLUSIONS: The clinical epidemiological profile to patients in the present study is similar to that in other populations, with follicular ameloblastoma being the most common histological subtypes seen.

Study of the distribution of Malassezia species in patients with pityriasis versicolor and healthy individuals in Tertiary Care Hospital, Punjab.

Purpose: Pityriasis versicolor (PV) is a chronic superficial fungal disease caused by Malassezia species. Our aim was to identify Malassezia species from PV patients and healthy individuals in Punjab. Materials and Methods: Modified Dixon agar was used as isolation culture medium. Identification was based on morphological observation and biochemical evaluation. The biochemical evaluation consisted of culture onto Sabouraud dextrose agar, catalase reaction, Tween assimilation, Cremophor EL assimilation, splitting of esculin and growth at 38 0 C. Results: Out of 58 microscopically diagnosed cases of PV, growth was obtained from 54 (93.10%) cases. The most frequently isolated species were M. globosa, M. sympodialis and M. furfur which made up 51.79%, 31.42% and 18.51% of the isolated etiological agents respectively. However, the major isolate from the back of healthy individuals was M. sympodialis (47.61%), followed by M.obtusa (19.04%), M. globosa (14.20%), M. furfur (9.52%), M. pachydermatis (4.76%) and M. slooffiae (4.76%). Conclusions: M. globosa in its mycelial phase was the main etiological agent, but as normal flora from the back of healthy subjects, it was found in significantly less number (P = 0.01), suggesting that the higher pathogenicity of M. globosa in terms of enzymatic endowment, might be the cause of its predominance in PV lesions.

Microbial forensics: An upcoming investigative discipline.

Microorganisms make good weapons and bioterorism has been known to exist since centuries. This has most recently been highlighted by the terrorist attack using anthrax in the fall of 2001 in U.S. Although such attacks of bioterrorism are few, forensic evidence to criminally prosecute the perpetrator is necessary. To strengthen defence against bio crimes, a comprehensive technological network involving various fields needs to be developed. Microbial forensics is one such new discipline combining microbiology and forensic science. It uses advanced molecular techniques like microarray analysis and DNA fingerprinting etc. to associate the source of the causative agent with a specific individual or group by measuring variations between related strains. High quality assurance and quality control standards for microbial forensics will ensure highly reliable results that will stand up in the court of law. The more precise and refined a microbial system becomes, the more proper guidelines for investigations will be defined. An integrated approach towards developing this field of microbial forensics needs to be followed, to meet the challenges of bioterrorism more effectively.