Unusual clinical presentations of scrub typhus, a neglected tropical disease: A case series from north India.

BACKGROUND & OBJECTIVES: Scrub typhus is a neglected tropical disease common in Asia and Africa. It usually presents with non-specific symptoms like fever, rashes, and lymphadenopathy. It has a varying range of clinical picture that often leads to misdiagnosis and initiation of non-specific treatment. This disease is thus associated with high morbidity and mortality. We aim to highlight the uncommon presentations of this common disease to create awareness regarding the unusual presentations of scrub typhus. METHODS: This prospective study was performed over a period of two months enrolling eleven adult patients with serological evidence of anti-scrub typhus IgM antibodies. RESULTS: All enrolled 11 cases [5 males (45.5%) and 6 females (54.5%)] were positive for anti-ST IgM antibodies and negative for other tested microbial agents. 7/11 (63.6%) patients were admitted with a clinical diagnosis of acute encephalitis syndrome (AES as per standard WHO definition), 3/11 (27.3%) patients presented with jaundice and 1/11 (9.1%) patients presented with rashes. Two out of 7 (28.6%) AES cases had developed peripheral gangrene of extremities. INTERPRETATION & CONCLUSION: Scrub typhus is a common tropical disease that can have various unusual clinical presentations like meningoencephalitis, vasculitis, acute kidney injury, jaundice, MODS. It closely mimics other infective etiologies making its diagnosis difficult. A high index of suspicion and clinical awareness is required in clinical practice to identify the different presentations of this disease so that early treatment can be initiated to reduce morbidity and mortality associated with this disease.

Correlates of prevalent syphilis infection among men who have sex with men (MSM) living with HIV attending the HIV clinic in Trinidad.

BACKGROUND: Syphilis among men who have sex with men (MSM) living with HIV is of public health concern, thus the objective of the study is to determine the correlates of prevalent syphilis infection in this population so that urgent interventions could be instituted. METHODS: A cross-sectional study was conducted during the period September 2020-June 2021 among MSM who attended a large HIV Clinic in Trinidad. A questionnaire was administered to obtain socio-demographic data and correlates of prevalent syphilis and patients were screened for syphilis using the traditional algorithm. Descriptive and bivariate analyses were conducted and multivariable logistic regression factors was used to assess factors significantly associated with a syphilis diagnosis. RESULTS: Two hundred and sixty four MSM were enrolled; age range 18-64 years, median age 33 years and 89 (34.4%) were actively bisexual. The prevalence of syphilis was 28% (74/264) and 89.2% (66/74) of these infections were asymptomatic. Multivariable logistic regression analysis showed that those patients who participated in sex with anonymous partners (OR 2.09; 95% CI, 1.03-4.26), those with a previous diagnosis of syphilis (OR 5.16; 95% CI, 1.03-25.83) and those who used marijuana in the last 12 months (OR 2.13; 95% CI, 1.14-3.96) were more likely to be diagnosed with syphilis. CONCLUSION: There is a high prevalence of asymptomatic syphilis among MSM living with HIV in Trinidad. Repeat episodes of syphilis and anonymous sex may play a role in the transmission dynamics of T pallidum infection in this population, thus urgent public health prevention interventions are warranted.

Uterine Lipoleiomyoma Presenting With Pelvic Pain in a Post-Menopausal Woman.

Uterine leiomyomas (fibroids) are the most common tumor of the reproductive system in women between menarche and menopause. Uterine lipoleiomyomas are a rare variant of leiomyoma, consisting of smooth muscle cells admixed with adipocytes. Herein is the case of a 70-year-old female who presented with acute pelvic pain and a palpable pelvic mass. A computed tomography scan of her abdomen and pelvis demonstrated a large, circumscribed, fat and soft tissue density, uterine mass suggestive of a lipoleiomyoma. Histopathology examination of the resected specimen after total abdominal hysterectomy confirmed a mature lipoleiomyoma.

A super learner ensemble of 14 statistical learning models for predicting COVID-19 severity among patients with cardiovascular conditions.

BACKGROUND: Cardiovascular and other circulatory system diseases have been implicated in the severity of COVID-19 in adults. This study provides a super learner ensemble of models for predicting COVID-19 severity among these patients. METHOD: The COVID-19 Dataset of the Cerner Real-World Data was used for this study. Data on adult patients (18 years or older) with cardiovascular diseases between 2017 and 2019 were retrieved and a total of 13 of these conditions were identified. Among these patients, 33,042 admitted with positive diagnoses for COVID-19 between March 2020 and June 2020 (from 59 hospitals) were identified and selected for this study. A total of 14 statistical and machine learning models were developed and combined into a more powerful super learning model for predicting COVID-19 severity on admission to the hospital. RESULT: LASSO regression, a full extreme gradient boosting model with tree depth of 2, and a full logistic regression model were the most predictive with cross-validated AUROCs of 0.7964, 0.7961, and 0.7958 respectively. The resulting super learner ensemble model had a cross validated AUROC of 0.8006 (range: 0.7814, 0.8163). The unbiased AUROC of the super learner model on an independent test set was 0.8057 (95% CI: 0.7954, 0.8159). CONCLUSION: Highly predictive models can be built to predict COVID-19 severity of patients with cardiovascular and other circulatory conditions. Super learning ensembles will improve individual and classical ensemble models significantly.

Importance of Routine Laboratory Investigations Before Elective Surgery.

BACKGROUND AND AIMS:  Certain routine pre-operative laboratory investigations are performed in all patients before elective surgeries. We conducted this study to assess the value of routine pre-operative tests in the ASA (American Society of Anesthesiologists) Grade I and II adults undergoing elective surgery and their influence in the conduct of anaesthesia together with the costs incurred on unwarranted tests. METHODS: A total of 1271 patients posted for elective surgery under anaesthesia were recruited. Each patient attended the Pre-Anaesthetic Checkup Clinic and underwent clinical evaluation and investigations according to institutional policy. Demographic data and other characteristics were recorded, along with the results of laboratory test, any peri-operative intervention done as a result of abnormality and the cost incurred on tests. RESULTS: Majority of the patients belonged to ASA status I (74%) and underwent moderately invasive surgery (78%). The total number of routine investigations performed was 8015. Of these, 351 (4.37%) tests had abnormal results. Amongst these 333 (4.15%) abnormalities were suspected clinically and peri-operative intervention was only performed in 0.43% of patients. Anemia was the most common abnormal finding. Abnormal blood glucose was detected in 6 patients who were not clinically suspected. Abnormal electrocardiograph (ECG) was found in 54 patients. However, the intervention was required only in 13 patients. No intervention was required because of abnormal findings of the chest X-Ray. In total cost of investigations, only 6.9% was contributed by abnormal investigations and the rest was spent on the normal tests. CONCLUSION: The incidence of tests with abnormal results was very low in our study, and less than 1% of the patients with abnormal tests required changes in their peri-anaesthetic management. No major complications were seen in any patient with normal or abnormal test results. Most of the expenses (93%) were related to the normal test, which did not contribute to the perioperative management, safety and outcome of the patient. Thus, pre-operative investigations should be judiciously advised to avoid inconvenience, surgical delays and escalation of the costs of surgical care.

Bacteriological Quality of Treated Water and Dialysate in Haemodialysis Unit of A Tertiary Care Hospital.

INTRODUCTION: Haemodialysis is one of the treatment modalities for patients suffering from end stage renal disease (ESRD). Dialysis patients are exposed to large volumes of water for production of dialysis fluids. Treated water and dialysate come in direct contact with the patient's bloodstream. Such patients suffer from abnormalities of the immune system, making them more susceptible to infections. Microbial contamination of the treated water and dialysate can lead to biofilm formation and release of endotoxins in Haemodialysis system. These can give rise to pyrogenic reactions in the short term and ß2 amyloidosis, atherosclerosis, and increased mortality in the long term. AIM: To assess the bacteriological quality of treated water and dialysate used in the Haemodialysis unit of a tertiary care hospital. MATERIALS AND METHODS: A retrospective review of records of treated water and dialysate samples sent to the Microbiology laboratory for analysis of bacteriological contamination of the water used in haemodialysis treatment from January 2013 to June 2014 was conducted. The acceptable limits for treated water and dialysate were taken as <200 CFU/ml and < 2000 CFU/ml respectively as per Government of India Guidelines for Maintenance Haemodialysis. RESULTS: Thirty six samples of treated water and 394 samples of dialysate were analysed for bacteriological contamination. 4 out of 36 (11.1%) samples of treated water and 44 out of 394 dialysate samples (11.2%) showed unacceptable bacteriological growth. CONCLUSION: Regular and continual monitoring of the disinfection protocol of the water distribution system in haemodialysis unit is necessary to get good microbiological quality of treated water and dialysate fluid.