Effectiveness of nurse-led fever, sugar-hyperglycemia, and swallowing bundle care on clinical outcome of patients with stroke at a tertiary care center: A randomized controlled trial.

Objectives: Stroke is a medical emergency, the leading cause of death, and a significant cause of disability in developing countries. The primary goals of stroke management focus on reducing disability, which needs prompt treatment in time. Fever, sugar-hyperglycemia, and swallowing (FeSS) bundle are a promising nurse-led composite for reducing disability and death. The present study aims to assess the effect of FeSS bundle care on disability, functional dependency, and death among acute stroke patients. Materials and Methods: A randomized controlled trial was conducted among 104 acute stroke patients, who were admitted within the first 48 h of stroke symptoms and had no previous neurological deficits. Randomization was stratified based on gender and type of stroke. The intervention group received FeSS bundle care, which included nurse-led fever and sugar management for the first 72 h, and a swallowing assessment done within the first 24 h or before the first oral meal. A follow-up assessment was done after 90 days to assess the disability, functional dependency, and mortality status using a modified Rankin scale and Barthel index. Results: No significant difference was noted in the 90-day disability and functional dependency between the groups. A reduction in mortality was noted in the intervention group. The risk ratio for mortality between groups was 2.143 (95% confidence interval: 0.953-4.820). Conclusion: Although no significant reduction in disability, there was a reduction in mortality in the intervention group. Hence, the study suggested the promotion of nurse-led intervention using the FeSS bundle in stroke units.

Clinical Profile and Predictors of Mortality among Patients with Melioidosis.

Introduction: Melioidosis is an under-recognized but important infection with high mortality and morbidity. It is endemic along the coastal regions of the Southern part of India. The present study focuses on the varied clinical manifestations, associated risk factors, and outcomes in patients from the Southeastern part of India. Methods: Seventy patients from January 2018 to June 2021 from a Tertiary Care Hospital were included and prospectively followed up from 6 months to 3 years. Cox regression was performed to test for the association of various clinical and demographic factors with overall survival. Results: Diabetes and occupational exposure to soil and water (78.6%) followed by alcoholism (61.4%) were the most common risk factors for melioidosis. The most frequent presentation was sepsis (47.1%), followed by skin and soft tissue infection (32.9%) and pneumonia (25.7%). Mortality was 50%. Patients with sepsis had a 3.5-fold higher risk of mortality (adjusted hazard ratio = 3.50; P = 0.01) while other risk factors were not significantly associated with mortality. Conclusion: Lifestyle-dependent risk factors (diabetes, occupational exposure, and alcoholism) were most common among patients with melioidosis. Hospitalization among patients with sepsis is associated with high mortality despite the initiation of specific therapy.

Familial Ectopia Lentis: Looking Beyond Marfan's Syndrome.

Ectopia lentis has a myriad of causes, with Marfan's syndrome and homocystinuria being well-known causes. Here, we report two siblings with ectopia lentis and tall stature presenting with a diagnostic challenge. How to cite this article: Hussain SJ, Amalnath D, Kasthuri N, et al. Familial Ectopia Lentis: Looking Beyond Marfan's Syndrome. J Assoc Physicians India 2023;71(11):94-95.

Targeted long-read sequencing identifies missing pathogenic variants in unsolved Werner syndrome cases.

BACKGROUND: Werner syndrome (WS) is an autosomal recessive progeroid syndrome caused by variants in WRN. The International Registry of Werner Syndrome has identified biallelic pathogenic variants in 179/188 cases of classical WS. In the remaining nine cases, only one heterozygous pathogenic variant has been identified. METHODS: Targeted long-read sequencing (T-LRS) on an Oxford Nanopore platform was used to search for a second pathogenic variant in WRN. Previously, T-LRS was successfully used to identify missing variants and analyse complex rearrangements. RESULTS: We identified a second pathogenic variant in eight of nine unsolved WS cases. In five cases, T-LRS identified intronic splice variants that were confirmed by either RT-PCR or exon trapping to affect splicing; in one case, T-LRS identified a 339 kbp deletion, and in two cases, pathogenic missense variants. Phasing of long reads predicted all newly identified variants were on a different haplotype than the previously known variant. Finally, in one case, RT-PCR previously identified skipping of exon 20; however, T-LRS did not detect a pathogenic DNA sequence variant. CONCLUSION: T-LRS is an effective method for identifying missing pathogenic variants. Although limitations with computational prediction algorithms can hinder the interpretation of variants, T-LRS is particularly effective in identifying intronic variants.

Detection of Entamoeba histolytica and bacterial etiological agents in patients with clinically suspected cases of liver abscesses.

Liver abscess is one of the conditions having multiple etiological agents. It can be parasitic or can be due to bacterial among other causes. Entamoeba histolytica is one of the common protozoan parasites causing amoebic liver abscess. So, accurate diagnosis is important for proper management and treatment. We have tried to detect the various bacterial etiological agents along with Entamoeba histolytica using culture of bacteria and polymerase chain reaction for E. histolytica in suspected liver abscess cases. Liver aspirates/pus collected from 63 patients were subjected to bacterial gram staining and culture along with wet mount and PCR for E. histolytica. Patients' clinical details and outcomes were also noted and co-related.It was seen that 22 (34.9%) out of 63 samples showed the presence of bacteria by gram staining whereas aerobic bacterial growth was seen in 28.6% and only 1.6% in anaerobic culture. Amoebic liver abscess showed E. histolytica  in 36 patients out of 63 study participants (57.1%) by PCR. The study showed that 44.4% of patients had a habit of alcohol consumption and 19.1% were chronic smokers. Abdominal pain (90.3%) was the most common presenting feature followed by fever (64.5%). The most common co-morbidities in the enrolled patients was diabetes mellitus (19.3%) and least with chronic liver disease (3.2%). Liver abscess, a multi-etiological condition needs a robust diagnostic method. Just a single method or a single sample type is not sufficient to diagnose, as it may miss out other causes. Treating its associated co-morbidities may help to lessen it.

Uncommon Manifestation of COVID -19 - Delayed Onset Cavitating Lung Lesions, a Retrospective Study of 22 Patients from a Tertiary Care Centre in Southern India.

Cavities of the lung are considered to be an atypical and rare finding in COVID pneumonia. In this retrospective study, we report a series of 22 patients who developed large cavities, 2 to 4 weeks from the onset of symptoms. None of them were mechanical ventilated and 18 died within a few days of detection of the cavities. The causes for cavity formation could not be found out in most patients. This suggests that delayed onset cavitation can have a poor prognosis.

Cytology of primary nocardiosis of the lymph node: A rare report.

Primary nocardiosis of the lymph node is a rare presentation even in an immunocompromised individual, with few case reports in the literature. In addition, Nocardia farcinica as observed in our case, is rarely documented, making it an interesting report. This paper clearly illustrates the subtle morphological clues that can be used to diagnose nocardial infection.

Cholemic Nephrosis: An Autopsy Study of a Forgotten Entity.

OBJECTIVE: The aim of the study is to do a clinicopathologic study of post mortem kidney biopsies with significant deposition of bilirubin pigment within tubular epithelial cells and in the lumen of distal tubules as a bile cast. MATERIAL AND METHOD: All post mortem specimens with acute tubular necrosis, with the presence of bile casts in tubules or bile pigment deposition in the tubular epithelium during the period 2015-2018 were examined for gross and histopathology along with biochemical parameters and viral markers. RESULTS: Bile casts with sloughed renal tubular epithelial cells and occasional macrophages were present in the distal convoluted tubule in 78.6% of biopsies (11/14). The plugging of distal convoluted tubule with casts was similar to that seen in myeloma and myoglobin cast nephropathies. Bilirubin pigment deposition was present in 35.7% (5/14) of cases. The frequency of bile casts in each biopsy was variable and it did not have any association with serum bilirubin levels or etiology of liver dysfunction. A striking difference from earlier studies is the high number of toxin-induced liver damage including six cases of paraquat and 2 cases of yellow phosphorus poisoning. CONCLUSION: This study proves importance of the bile cast nephropathy as a reason for kidney injury, especially with varied hepatotoxic etiologies, especially paraquat and yellow phosphorus.

Concomitant Diagnosis of Plasmablastic Lymphoma and Chronic Lymphocytic Leukemia: A Rare Phenomenon.

Plasmablastic lymphoma (PBL) is a rare, aggressive non-Hodgkin lymphoma which shows blastic morphology and an immunophenotype of plasma cell differentiation while chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma is an indolent B-cell lymphoma and has a variable clinical course. A CLL transforming into a PBL and the coexistence of CLL with PBL are both extremely rare findings. We report an unusual case of a 72-year-old HIV-negative male who presented with a gingival swelling which was diagnosed as PBL with simultaneous CLL in the blood and bone marrow. Further, in this case, the PBL spontaneously regressed postbiopsy adding to the peculiarity and rarity of this case. This could be due to immune system modulation and can open up a new window to the treatment strategies of PBL in the future.

Response to Horse ATG (Thymogam, Bharat Serums and Vaccine, India) and Cyclosporine in Aplastic Anemia: A Single Centre, Retrospective Study of 60 Patients from Southern India.

Immunosuppressive therapy (IST), consisting of anti thymocyte globulin and cyclosporine, is the standard of care for elderly patients and in younger patients without matched donor for stem cell transplant. In this retrospective study of 60 patients, most had non severe AA (51.6%) followed by very severe AA (26.7%) and severe AA (21.7%). The response rate at 6 months was 68.3% (complete response-3.3% and partial response-65%). Of the 45 who completed 12 months follow up, RR was 54.7% (CR-7.5%, PR-47.2 %). Eight patients died during the study period. Also, Indian data on IST is briefly reviewed.

Paraquat Poisoning: A Retrospective Study of 55 Patients From a Tertiary Care Center in Southern India.

BACKGROUND: In India the data on paraquat (PQ) poisoning are limited to case reports and small case series. Hence, this study was carried out to understand the clinical features and outcomes of PQ poisoning. We also briefly report the relevant Indian studies on PQ poisoning. MATERIALS AND METHODS: This was a retrospective case record-based study of PQ poisoning victims admitted over a period of 5 years. RESULTS: Of the 55 patients included in this study, the in-hospital mortality rate was 72.7%. Acute kidney injury was the most common manifestation. The use of cyclophosphamide did not affect the clinical outcome. Hemoperfusion (HP) was not done for any patient. Pulmonary edema and acute tubular necrosis were the most common histopathological findings. CONCLUSION: In India, this is one of the most comprehensive studies of PQ toxicity. Hence, we hope that this information would be of use to clinicians who deal with PQ poisoning. HOW TO CITE THIS ARTICLE: Ravichandran R, Amalnath D, Shaha KK, Srinivas BH. Paraquat Poisoning: A Retrospective Study of 55 Patients from a Tertiary Care Center in Southern India. Indian J Crit Care Med 2020;24(3):155-159.

Antibodies to Zika virus, Campylobacter jejuni and gangliosides in Guillain-Barre syndrome: A prospective single-center study from southern India.

BACKGROUND: The objective of this article was to study the presence of antibodies against Zika virus (ZIKV), Campylobacter jejuni, and gangliosides in patients with Guillain-Barre syndrome (GBS). MATERIALS AND METHODS: Ninety consecutive patients (age more than 12 years) with GBS admitted to a tertiary care center in southern India were included in this study. Data on clinical manifestations, nerve conduction studies, and response to therapy were collected. The following tests were done in stored serum samples - anti-ZIKV (IgM) antibodies, anti-C. jejuni (IgG) antibodies, and anti-ganglioside antibodies (IgG). Those samples which were positive to anti-Zika antibodies were tested for conventional polymerase chain reaction for ZIKV and IgM antibodies against dengue, and Japanese encephalitis virus. RESULTS: Of the 90 patients, 3 died and 8 had persistent weakness. Acute inflammatory demyelinating polyradiculoneuropathy was the most common type of GBS (56.7%). Anti-ganglioside antibodies were present in 62.2% patients with GT1b being the most common. Anti-C. jejuni antibodies were present in 46.6%. Anti-Zika antibodies (IgM) were present in 14 patients (15.5%). Four of these patients also had anti-dengue antibody (IgM) positivity. CONCLUSION: This is one of the largest studies on GBS from India and the first one to report on the presence of Zika virus antibodies from this geographical area. Our study had a high prevalence of anti-C. jejuni and anti-ganglioside antibodies. Evidence of recent ZIKV infection, as evidenced by anti-IgM antibodies, was present in 14 patients, with 4 of them being tested positive for anti-dengue IgM antibody. Whether this represents cross-reaction with dengue or prior/co-infection with dengue virus could not be addressed in this study.

CD56 Negative Aggressive T Cell Large Granular Lymphocytic Leukemia.

T cell large granular lymphocytic leukemia is a clonal proliferation of cytotoxic large granular T cells positive for CD3 and CD8. It is a chronic lymphoproliferative disorder with an indolent course. Therapeutic options include observation and low dose chemotherapy. Rarely, they have an aggressive course. Such cases have expression of NK cell associated antigens like CD56 in the T cells. These cases require more aggressive therapy with acute lymphoblastic leukemia regimens. We report a case of fatal CD56 negative T cell large granular lymphocytic leukemia in a 38 year old lady.

Sclerosing bone dysplasias: genetic, clinical and radiology update of hereditary and non-hereditary disorders.

There is a wide variety of hereditary and non-hereditary bone dysplasias, many with unique radiographic findings. Hereditary bony dysplasias include osteopoikilosis, osteopathia striata, osteopetrosis, progressive diaphyseal dysplasia, hereditary multiple diaphyseal sclerosis and pyknodysostosis. Non-hereditary dysplasias include melorheostosis, intramedullary osteosclerosis and overlap syndromes. Although many of these dysplasias are uncommon, radiologists should be familiar with their genetic, clinical and imaging findings to allow for differentiation from acquired causes of bony sclerosis. We present an overview of hereditary and non-hereditary bony dysplasias with focus on the pathogenesis, clinical and radiographic findings of each disorder.