Simultaneous Presentation of Takayasu Arteritis and Crohn's Disease in a Middle-Aged Patient: Are they two sides of the same coin?

Autoimmune disorders have a wide spectrum of symptoms, often with multiorgan involvement. Multiple autoimmune disorders also often occur concurrently in the same patient. These two possibilities must be distinguished in patients with multiorgan involvement to ensure early diagnosis and treatment. Here, we report a case of a previously healthy man who presented with simultaneous Takayasu arteritis and Crohn's disease. He presented with heart failure with reduced ejection fraction and severe aortic regurgitation. An echocardiogram demonstrated a greatly dilated aorta, and a diagnosis of Takayasu arteritis was made, confirmed with CT aortogram. Inpatient treatment was begun, but the patient subsequently developed bloody diarrhoea a few days after admission. Colonoscopy done to locate the source of bleeding showed colonic ulcers; a biopsy confirmed a diagnosis of Crohn's disease. The patient was successfully managed with medical management of heart failure, steroids, mesalamine and azathioprine, and has been in remission for the last 2 years.

Tuberculous pyomyositis presenting as septic arthritis and multiple site pyomyositis.

Primary tropical pyomyositis, commonly caused by Staphylococcus aureus, is characterised by suppuration in skeletal muscles, which manifests as single or multiple abscesses. Another rare causative organism is Mycobacterium tuberculosis in endemic areas. Here, we report a case of primary tuberculous pyomyositis presenting as septic arthritis of the right knee and multiple site pyomyositis of the right thigh and chest wall. A tuberculous aetiology was overlooked at first, which resulted in a diagnostic delay. The patient was initially diagnosed, using ultrasonography, MRI and an absence of systemic symptoms of tuberculosis, with bacterial pyomyositis and treated with broad-spectrum antibiotics. However, further investigations performed on knee joint aspirate yielded negative cultures and a positive cartridge-based nucleic acid amplification test, which, along with a non-resolution of his symptoms, suggested a primary tuberculous pyomyositis. He was successfully managed with incision and drainage of the lesions and completion of anti-tubercular therapy.

Comparison between stylet and bougie with the C-MAC D-blade in cervical simulated immobility. A prospective randomized controlled trial

Introduction The C-MAC D-blade was designed for difficult airway intubation scenarios. To facilítate easier and faster endotracheal intubation in the laryngoscopy paradox, an introducer is preferred. Hence, we decided to conduct a study to compare the 60° angled C-MAC stylet and the gum elastic bougie as aids to intubation while using the C-MAC D-blade laryngoscope in a simulated difficult airway setting. Objective To compare the ease of oral intubation with the use of the C-MAC stylet (60° angled stylet) versus intubation performed over a bougie inserted using the C-MAC D-blade guidance in patients with simulated restricted cervical mobility. Method Prospective, randomized controlled single-center study. Intubation using the C-MAC D-blade laryngoscope was performed in 48 surgical patients randomly assigned to 2 groups of 24 each: Stylet group, Group S (using 60° angled stylet) and Bougie group, Group B (using bougie) after providing manual in-line stabilization to restrict cervical mobility. The Mann-Whitney U test and the Chi square test were used as applicable. Results The use of stylet resulted in easier (Group S 75% vs. Group B 16.7%) and faster (Group S 26.83 ± 8.61s vs. Group B 47.18 ± 16.46s) intubation with fewer attempts compared to group B. Both groups experienced a similar hemodynamic stress response to intubation. Conclusions The 60° angled C-MAC Stylet is a more effective and time-saving intubation aid with C-MAC D-blade compared to bougie.

Introducción: El videolaringoscopio C-MAC D-blade se diseñó para los casos de intubación de la vía aérea difícil. Para facilitar una intubación más rápida y sencilla en la paradoja de la laringoscopía se prefiere un introductor. Por tanto, decidimos realizar un estudio para comparar el estilete de 60° C-MAC y el bougie elástico de goma como ayudas para la intubación utilizando el laringoscopio C-MAC D-blade en una situación simulada de vía aérea difícil. Objetivo: Comparar la facilidad de intubación oral mediante el uso del estilete del C-MAC (estilete angulado de 60°) con la intubación realizada sobre un bougie insertado con la guía del C-MAC D0-blade en pacientes con restricción simulada de la movilidad cervical. Métodos: Estudio prospectivo, aleatorizado y controlado realizado en un solo centro. Se realizó intubación utilizando el laringoscopio C-MAC D-blade D en 48 pacientes quirúrgicos asignados aleatoriamente a 2 grupos de 24 cada uno: grupo de estilete, grupo S (con el estilete angulado de 60°) y el grupo de bougie o grupo B (con bougie) después de establecer una estabilización manual del eje para restringir la movilidad cervical. Se aplicaron las pruebas U de Mann-Whitney U y de Chi cuadrado según correspondiera. Resultados: Con el estilete fue más fácil (Grupo S 75% vs. Grupo B 16.7%) y más rápida (Grupo S 26.83 ± 8.61s vs. Grupo B 47.18 ± 16.46s) la intubación, requiriéndose un menor número de intentos en comparación con el Grupo B. Los dos grupos experimentaron un estrés hemodinámico similar en respuesta a la intubación. Conclusiones: El estilete angulado de 60° C-MAC es una ayuda más efectiva y ahorra más tiempo con el C-MAC D-blade en comparación con el bougie.

Varicella pneumonia masquerading as interstitial lung disease: Non-specific interstitial pneumonitis.

Varicella-zoster virus infection also known as chickenpox is a common clinical entity especially among unvaccinated children and adults. It is said that severity increases as the age increases. Approximately 5%-15% of adult varicella can produce pulmonary manifestations. Varicella pneumonitis occurs especially in at-risk individuals like pregnant, smokers, chronic lung diseases like chronic obstructive pulmonary disease, and immunosuppression. The authors describe a case of severe varicella pneumonitis in a healthy immunocompetent middle-aged woman which posed a great diagnostic challenge. The authors also want to highlight that how a common disease can pose a diagnostic dilemma and present with life-threatening organ failure and timely intervention is needed to prevent mortality.

Effect of Supervised Exercise Program on Individuals in Peripheral Arterial Disease with Type 2 Diabetes Mellitus - A Systematic Review.

BACKGROUND: Type 2 Diabetes Mellitus (T2DM) is usually accompanied by various micro and macro vascular complications. Peripheral Arterial Disease (PAD) is one of the major complications of diabetes which is accountable for morbidity and mortality throughout the world. The first line of treatment in these individuals is life style modification and exercise. There is a dearth of literature on effect of supervised exercise program in PAD with T2DM on quality of life, walking impairment, change in Ankle Brachial Index (ABI) values. So, we conducted a systematic review to explore the available literature on supervised exercise program in PAD with T2DM. METHODS: We conducted a systematic review (PubMed, Web of Science, CINAHL and Cochrane) to summarise the evidence on a supervised exercise program in PAD with T2DM. Randomised and nonrandomised studies were included in the review. RESULTS: Three studies met the inclusion criteria. The outcomes taken into accounts by the studies were the quality of life, walking impairment questionnaire, Ankle brachial index. Neither of the studies matched in their supervised exercise program nor in their outcome. CONCLUSION: In conclusion, the data evaluating the supervised exercise program in PAD with T2DM is inadequate to determine its effect on this population. Future large-scale studies can be conducted on both subjective and objective outcomes of PAD with T2DM to have a better understanding of the condition and for a universally acceptable exercise program for these individuals which the healthcare practitioners can use in their practice. Prospero registration number: CRD42018112465.

Lab-On-A-Chip for the Development of Pro-/Anti-Angiogenic Nanomedicines to Treat Brain Diseases.

There is a huge demand for pro-/anti-angiogenic nanomedicines to treat conditions such as ischemic strokes, brain tumors, and neurodegenerative diseases such as Alzheimer's and Parkinson's. Nanomedicines are therapeutic particles in the size range of 10-1000 nm, where the drug is encapsulated into nano-capsules or adsorbed onto nano-scaffolds. They have good blood-brain barrier permeability, stability and shelf life, and able to rapidly target different sites in the brain. However, the relationship between the nanomedicines' physical and chemical properties and its ability to travel across the brain remains incompletely understood. The main challenge is the lack of a reliable drug testing model for brain angiogenesis. Recently, microfluidic platforms (known as "lab-on-a-chip" or LOCs) have been developed to mimic the brain micro-vasculature related events, such as vasculogenesis, angiogenesis, inflammation, etc. The LOCs are able to closely replicate the dynamic conditions of the human brain and could be reliable platforms for drug screening applications. There are still many technical difficulties in establishing uniform and reproducible conditions, mainly due to the extreme complexity of the human brain. In this paper, we review the prospective of LOCs in the development of nanomedicines for brain angiogenesis-related conditions.

Prevalence of peripheral arterial disease among type 2 diabetes mellitus in coastal Karnataka.

Peripheral Arterial Disease (PAD) is one of the leading complications of Type 2 Diabetes Mellitus (T2DM). According to American Heart Association, PAD is defined as, "a narrowing of peripheral arteries to the legs, stomach, arms and the head-most commonly the arteries of leg." The global prevalence for PAD with age adjusted prevalence is approximately 12%, and it affects relatively 8 to 12 million British people. The prevalence of PAD is 2-3 times higher in person with v/s without type 2 diabetes mellitus (T2DM). Various subjective and objective methods are available to diagnose PAD, which includes questionnaires for pain and quality of life as subjective and Ankle Brachial Index (ABI), toe brachial index (TBI), arterial doppler for objective. ABI is one of the most reliable and easy to carry out method in clinical setups to diagnose PAD. The normal range for ABI is 0.9-1.29, 0.91 to 0.99 are considered as borderline, 0.41 to 0.91 are considered as mild to moderate diseased and below 0.4 is severe PAD. The objective of the study is to estimate the prevalence of peripheral arterial disease with type 2 diabetes mellitus in coastal Karnataka. METHODOLOGY: A total of 317 participants were recruited for the study based on inclusion criteria. Ethical clearance was taken from the Institutional Ethics Committee. Participants were explained about the study and informed consent was obtained from the participants. Inclusion criteria was any individual with T2DM on medication. A subjective questionnaire specific to PAD was administered to the participants. Along with this the objective measure, ABI was done on the individuals. RESULT: The mean age of all the participants was 57.36 ±â€¯10.43 in years. The average Body Mass Index (BMI) was 24.62 ±â€¯11.80 in Kg/m2. The mean duration of diabetes was found to be 9.13 ±â€¯6.56 in years. The prevalence of peripheral arterial disease was found to be 8.52% in the study population. CONCLUSION: The prevalence of peripheral arterial disease was found to be 8.52% in the study population.

Serum Uric Acid Levels in Type 2 Diabetes Mellitus: Is There a Linear Relationship with Severity of Carotid Atherosclerosis?

AIMS: The aim of this study was to correlate serum uric acid (SUA) levels and carotid intima-media thickness (CIMT) in patients with type 2 diabetes mellitus (DM). SETTINGS AND DESIGN: This study was a cross-sectional observational study on 103 diabetic patients conducted from September 2015 to May 2017. SUBJECTS AND METHODS: We screened 103 patients with type 2 DM between the ages of 30-65 years. SUA levels and the CIMT were measured. The patients were divided into quartiles based on uric acid level. The CIMT of the quartiles is compared and analyzed. STATISTICAL ANALYSIS USED: Chi-squared test, Analysis of Variance, and Pearson's correlation. RESULTS: Uric acid levels were positively associated with CIMT (P = 0.001). The association remained significant after further adjustment for potential confounders. Strong correlation was found among them as depicted by correlation coefficient (r = 0.779). CONCLUSIONS: Carotid atherosclerosis as measured by IMT is associated with SUA levels in patients with type 2 DM.

A Rare Cause of Anaemia in HIV/AIDS.

Patients living with HIV are commonly diagnosed with anaemia which can have various aetiologies. However, one of the rare causes of anaemia in such patients is Auto Immune Haemolytic Anaemia (AIHA), which is difficult to diagnose due to the absence of reticulocytosis in HIV patients. Such patients can be treated with corticosteroids which can gradually be tapered off over a period of time. The following is a case of a 52-year-old male living with HIV who was diagnosed to have AIHA and was successfully treated with steroids.

Transient Thyrotoxicosis in Molar Pregnancy.

Molar pregnancy is one of the components of a broader spectrum of diseases known as Gestational Trophoblastic Disease (GTD), presenting with amenorrhoea and irregular bleeding which may be rarely associated with passage of vesicles per vagina. However, it can rarely be associated with hyperthyroidism, which may be associated with clinical features of hyperthyroidism. The following is a report of a 20-year-old woman who presented with amenorrhea followed by irregular bleeding per vagina, thyromegaly and abnormal levels of thyroid hormones. Transvaginal ultrasound revealed features consistent with molar pregnancy. A suction evacuation was done following which serum levels of ß-hCG reduced and the levels of thyroid hormones also reduced. On follow up, six weeks later, ß-hCG and thyroid hormones were within normal limits. The case and relevant literature are presented here.

Paroxysmal Atrial Fibrillation due to Venomous Snake Bite.

Snake bites are common all around the world with a great prevalence in South Asia and the Indian subcontinent. Although they are associated with common complications such as local swelling, bleeding at site of bite, coagulopathy, etc., few rare cardiac complications such as myocardial infarctions and arrhythmias have also been described in literature. The following is a case report of a patient who had a snake bite with a Russell's viper which resulted in atrial fibrillation, which resolved on treatment with anti snake venom.

Enteric Cholestatic Hepatitis with Ascites: A Rare Entity.

Typhoid fever is a very common illness in developing countries. Patients most often present with a history of fever, vomiting, anorexia, abdominal pain, etc. Rarely there is hepatic involvement due to the disease process. This is a case report of a 26-year-old male who had presented with fever, jaundice and ascites. The widal titres were found to be within normal limits (1:80) however the patient was found to have Salmonella typhi on ascitic fluid culture. The patient was treated with the appropriate antibiotics and was later discharged.

Descriptive Analysis of Mortality Predictors in H1n1 Influenza in South Indian Patients.

BACKGROUND: H1N1 (hemagglutinin-H-neuroaminidase-N) influenza infection is associated with high morbidity and mortality because of associated complications and related factors. Predictors of mortality in H1N1 patients are studied with very few without seasonal/pandemic declaration. This study was carried out to describe the clinical features, complications and different risk factors that affect the outcome in the patients with confirmed H1N1influenza infection. METHODS: A retrospective study was done in Kasturba Medical College Hospital, Manipal, India by analyzing the medical records of 141 patients admitted from January, 2011 to June, 2015. RESULTS: Of the 141 patients in the study, 51.1% of the patients were female with a mean age of 32±16.2 years. Fever with headache was observed in 92.9% patients while cough in 78.7% patients and breathlessness in 54.6% patients. On the basis of disease severity, 53.2% of the patients were put on mechanical ventilation. For all the patients, treatment for influenza management began with oseltemivir. Diuretics, antianxiety and corticosteroids were given as supportive and symptomatic care which contributed to high mortality in hospitalized patients. Mean hospitalization period was 8.5 days. During the hospitalization, patients developed different complications i.e. 31.20% patients developed respiratory tract infections, while 17.7% patients developed ARDS and 14.4% patients developed sepsis. The mortality rate of this study population was found to be 29.1 %. CONCLUSION: It was observed that low oxygen saturation during admission, high blood urea level, use of diuretics, corticosteroids, anti-anxiety drugs and complications like ARDS, sepsis influence the mortality rate of patients with H1N1 infection.

Golden Hours in Severe Paraquat Poisoning-The Role of Early Haemoperfusion Therapy.

INTRODUCTION: Paraquat is a commonly ingested poison especially in Southern India. There is no antidote for paraquat poison and consumption is often fatal. The usual cause of death is either acute lung injury or multi-organ failure. AIM: To evaluate the role of early haemoperfusion as a therapy in paraquat poisoned patients. MATERIALS AND METHODS: This study was a retrospective analysis of patients admitted to a Tertiary Medical College Hospital between January 2012 and December 2015 with history of paraquat consumption, comparing outcomes in those who received only gastric lavage and symptomatic treatment with those who received haemoperfusion as a therapy. The role of early haemoperfusion (≤ 6 hours) vs late haemoperfusion (> 6 hours) in paraquat poisoned patients was also compared. The data of these patients was extracted and analysed with respect to age, sex, mode of treatment, the outcome in patients who received early and late haemoperfusion. RESULTS: A total of 101 patients were studied out of which 62 died. Deaths were more in those patients who received only gastric lavage with symptomatic treatment as therapy compared to those who received haemoperfusion i.e., 92.1% vs 42.9% respectively. We also found that, the survival rate was better in patients who received early haemoperfusion. CONCLUSION: Early haemoperfusion was helpful in the management of severe paraquat poisoning and improved the survival rate in these patients.

Wave propagation analysis in spiral geometries.

In this paper wave propagation in strings of exponential and conical spiral geometries and in an exponential spiral horn of increasing circular cross-section area is studied. The three-dimensional wave equation in cylindrical coordinates is investigated, as the theoretical solution in the exponential spiral horn is derived and in the case of the strings, numerical simulation mainly using a centered in time and space finite difference scheme is carried out. The results suggest non-harmonic resonance modes in both of the conical and exponential spiral strings.

Acute Bilateral Tuberculous Pneumonia in a Patient with Systemic Lupus Erythematosus.

Pulmonary tuberculosis is a common infection associated with immunocompromised state. It usually presents with fibrosis or fibrocavitary lesions in the lung. We report a case of bilateral tuberculous pneumonia of acute presentation in a young lady who was being treated for systemic lupus erythematosus.

Management of patent ductus arteriosus in premature infants.

Patency of the ductus arteriosus is required for fetal survival in utero. In infants born prematurely, ductus fails to close and shunt reverses from left to right. Incidence of patent ductus arteriosus (PDA) is inversely proportional to the gestational age. A large PDA (>1.5 mm diameter) with left to right shunt in very low birth weight infants can cause pulmonary edema, congestive heart failure, pulmonary hemorrhage and increase the risk for bronchopulmonary dysplasia. Attempts to prevent or close the duct by pharmacological or surgical methods have not changed the morbidity or the long term outcome. Pharmacological treatment with indomethacin or ibuprofen is successful in 75 to 80 % of infants but its use also exposes these infants to undesirable side effects like gastrointestinal bleeding, perforation and necrotizing enterocolitis. Prophylactic therapy with indomethacin or ibuprofen to prevent PDA has not altered the morbidity or long term outcome. Currently, there is a dilemma as to how to treat, when to treat and whom to treat. Recent literature suggests a trial of conservative management during the first week followed by selective use of anti-inflammatory drugs. Surgical ligation is reserved for infants who fail medical therapy and still remain symptomatic. Spontaneous closure of the PDA has been reported in up to 40-67 % of very low birth weight (VLBW) infants by 7 d. In this review authors discuss these controversies and propose a more rational approach.

Haemolytic anaemia--PNH type II cells presenting a diagnostic dilemma.

A 28-year-old man presented with a history of intermittent haematuria over the past 10 years usually following fever episodes and requiring blood transfusions during the episodes. History of any thrombotic complications, chest pain or erectile dysfunction was not forthcoming. Examination revealed severe pallor with mild icterus and mild splenomegaly. His blood picture showed pancytopenia with elevated reticulocytes and indirect hyperbilirubinaemia. Indirect Coombs test was positive but direct was negative, serum lactate dehydrogenase was elevated and agglutinins were found to be of IgG type. Bone marrow showed a hypercellular marrow with myeloid and megakaryocytes suppressed. Donath-Landsteiner antibodies were found to be negative ruling out paroxysmal cold haemoglobinuria. Flow cytometry was performed with a suspicion of paroxysmal nocturnal haemoglobinuria (PNH) and was shown to be partially negative for CD59 but positive for CD55, a pattern consistent with type II PNH.

Pancreatitis in scrub typhus.

Scrub typhus is a rickettsial infection prevalent in most parts of India. Acute pancreatitis with pseudocyst formation is a rare complication of this condition. This paper reports acute renal failure, pancreatitis and pseudocyst formation in a 48-year-old female with scrub typhus. Ultrasonography of the abdomen revealed a bulky pancreas with fluid seen along the body of the pancreas in the lesser sac. The infection was successfully treated with doxycycline and supportive treatment. Pancreatitis was managed conservatively. This case report highlights the importance of identifying and managing uncommon complications of a common tropical disease for optimum outcome.

Optimization of flow assisted entrapment of pollen grains in a microfluidic platform for tip growth analysis.

A biocompatible polydimethylsiloxane (PDMS) biomicrofluidic platform is designed, fabricated and tested to study protuberance growth of single plant cells in a micro-vitro environment. The design consists of an inlet to introduce the cell suspension into the chip, three outlets to conduct the medium or cells out of the chip, a main distribution chamber and eight microchannels connected to the main chamber to guide the growth of tip growing plant cells. The test cells used here were pollen grains which produce cylindrical protrusions called pollen tubes. The goal was to adjust the design of the microfluidic network with the aim to enhance the uniformly distributed positioning of pollen grains at the entrances of the microchannels and to provide identical fluid flow conditions for growing pollen tubes along each microchannel. Computational fluid analysis and experimental testing were carried out to estimate the trapping efficiencies of the different designs.