The biphasic phenomenon of cytokine storm in COVID pneumonia.

COVID-19 is a viral disease that commonly presents with mild symptoms with predominant respiratory system involvement. However, it can cause serious complications such as acute respiratory disease, multi-organ dysfunction, especially in patients with comorbidities. As it is a new disease, the full picture of the disease and its complications are not yet fully understood. Moreover, the patients at risk of complications are not well identified, and the data about the biphasic pattern of cytokine storm syndrome are limited. Here, we report the case of a 64-year-old male having diabetes mellitus, hypertension, ischemic heart disease with triple-vessel coronary artery disease tested positive for severe acute respiratory syndrome coronavirus 2, then complicated with acute respiratory distress syndrome and two waves of cytokine storm in 28 days.

Résumé La COVID-19 est une maladie virale qui se présente généralement avec des symptômes bénins avec une atteinte prédominante du système respiratoire. Cependant, il peut entraîner des complications graves telles qu'une maladie respiratoire aiguë, un dysfonctionnement multiviscéral, en particulier chez les patients présentant des comorbidités. Comme il s'agit d'une nouvelle maladie, l'image complète de la maladie et de ses complications n'est pas encore entièrement comprise. De plus, les patients à risque de complications ne sont pas bien identifiés et les données sur le schéma biphasique du syndrome de tempête de cytokines sont limitées. Nous rapportons ici le cas d'un homme de 64 ans ayant un diabète sucré, une hypertension, une cardiopathie ischémique avec coronaropathie tri-vasculaire testé positif au syndrome respiratoire aigu sévère coronavirus 2, puis compliqué d'un syndrome de détresse respiratoire aiguë et deux vagues de tempête de cytokines en 28 jours. Mots-clés: Syndrome de détresse respiratoire aiguë, pneumonie COVID-19, tempête de cytokines, hyperinflammation.

A randomized and comparative study to assess safety and efficacy of supplemental treatment of a herbal formulation - Aayudh Advance comprising essential oils in patients with corona virus 2019 (COVID-19).

OBJECTIVE: The purpose of this study was to examine the effect of herbal formulation - Aayudh Advance on viral load as well as recovery duration in mild symptomatic patients diagnosed with Corona Virus Disease 2019 (COVID-19). It also aimed to study the effect of Herbal formulation - Aayudh Advance in terms of clinical improvement of various sign and symptoms in mild symptomatic COVID-19 patients. METHOD: Once the patient suffice the requirement of inclusion, exclusion criteria of the study than as per the method of 'Covariate Adaptive Randomization' technique, patient was assigned in either Aayudh Advance arm (Test arm) or Control Arm. Here standard of Care treatment was given to all patients of both the arms. Treatment was given for the period of 14 days or till patient turned COVID-19 negative, which ever was earlier. Clinical signs and symptoms viz. body temperature, SpO 2, Scoring of Cough & Scoring of Shortness of breath were recorded on all 5 Clinical visits along with biochemical testing like RT-PCR (with CT value of E gene and RDRP gene), serum ferritin, CRP and NLR observed on weekly Visit. RESULT: Total 74 patients were enrolled in the present study. Out of which 60 patients (30 patients in each group) have completed study as per the protocol, whereas 14 patients have voluntarily withdrawn from the study due to getting early discharge from the hospital. All patients in Aayudh Advance treatment group recovered (100%) after 14 days. This observed recovery was 15.38% more as compared to Standard of Care treatment alone. Further, there was statistically significant reduction (p < 0.05) in viral load as indicated by significant increase in CT value of E-gene and RDRP gene. Further, no patients reported any Adverse Reaction as well as no drug to drug interaction was observed with supplemental treatment with Aayudh Advance. CONCLUSION: The Aayudh Advance was found safe as well as more effective in terms of reduction of viral load. % recovery was more in Treatment arm as compared to Control arm in mild symptomatic COVID-19 patients.

Clinical study of spinal tuberculosis presenting with neuro-deficits in Western India.

BACKGROUND/OBJECTIVES: Spinal tuberculosis (TB) is a destructive extra-pulmonary disease manifestation of Mycobacterium tuberculosis infection. It is responsible for many cases of paraparesis and quadriparesis in developing countries where patients seek treatment late. The aim of this study was to understand and analyze the clinical and radiological profile of patients with spinal TB and correlate it with the anatomical site affected by it. METHODS: A retrospective, observational study of 100 cases of spinal TB admitted over a period of three years. Data on demography, clinical signs and symptoms and investigations were analyzed. RESULTS: Incidence of spinal TB was found to be the highest in the third and fourth decade of life (45%). Incidence among males was 64% and females was 36%. Low socioeconomic class (72%) and past history of pulmonary TB (34%) were found to be risk factors for spinal TB. Average duration between onset of symptoms and time of presentation to the hospital was 154±15.5 days. Patients with bone involvement presented later than those without bone involvement. Paraplegia (91%) and backache (62%) were the most common clinical presentation. Thoracic spine involvement (36%) and vertebral wedging and destruction (58%) were the commonest X-ray findings. 69% patients had compressive lesion with vertebral body destruction being the commonest cause of compression. CONCLUSIONS: Spinal TB with neurological deficits affected the thoracic spine. Compressive spinal cord lesions were the common form of presentation of spinal TB. Paraplegia with backache and neurological bladder-bowel involvement were the most prevalent neuro-deficits. Magnetic resonance imaging of the spine proved to be the most useful investigation to differentiate and localize the site of tubercular lesions.

Developing competency in interns for endotracheal intubation: An educational article.

BACKGROUND: Our existing undergraduate curriculum lacks developing competency for endotracheal intubation. Even though it is a lifesaving procedure, interns are exposed only during their posting in anesthesia or emergency medicine and so, when need arises, they fail to perform endotracheal intubation and it leads to catastrophes. AIMS AND OBJECTIVES: The aim of this study was to develop competency in interns for endotracheal intubation. MATERIALS AND METHODS: A study was conducted on fifty interns of medical college. Lecture and demonstration were used for cognitive domain and one-to-one training and practice on manikin for affective and psychomotor domains, respectively. Live demonstration on patients was done whenever possible. Gain in knowledge was evaluated by pre- and post-test using standardized validated questionnaire. Skills were assessed by direct observation of procedural skill on manikin, split in steps: Laryngoscopy, intubation, and ventilation. Session was evaluated using feedback questionnaire and Likert scale. RESULTS: Interns showed mean marks of 8.12 ± 1.63 in pretest compared to 13.86 ± 1.06 of posttest with a gain of 34.8% (P = 0.0001), which is highly significant. Twenty-two percent interns completed all steps correctly in the first attempt, 62% in the second attempt, while 16% required third attempt to correctly complete all steps. CONCLUSION: This training developed competency for basic knowledge and practice of endotracheal intubation in interns adequately on manikin. Training for endotracheal intubation should be carried out at the beginning of internship before they go for clinical practice and repeated during their rotation of Anesthesia and Emergency Medicine Department, so they can retain their competency for it and can do later on whenever required.

Study of clinical and radiological profile and outcome in patients of intracranial hemorrhage.

BACKGROUND: Incidence of intracerebral hemorrhage (ICH) is twice as high as in Western countries. Prognostic factors for predicting function outcome and mortality play a major role in determining the treatment outcome. METHODS: A prospective study of male and female patients ≥12 years with primary nontraumatic intracranial hemorrhage were included. Hemorrhage caused by trauma, anticoagulant or thrombolytic drugs, brain tumor, saccular arterial aneurysm or vascular malformation were excluded. Functional outcome of patients was determined by modified Rankin's scale. Glasgow Coma Scale (GCS) score and ICH score were calculated for each patient. RESULTS: Hypertension was present in 45 out of 49 patients (92%) with ICH of basal ganglia. Hypertension was significantly associated with worst clinical outcome. Mortality was high if the patient was comatose/stuporous compared to drowsy state (P < 0.0001). Mortality was found to be high when the size exceeded 30 cm3. High ICH score, low GCS score at the time of admission, presence of intraventricular hemorrhage, and midline shift were significantly associated with poor clinical outcome. CONCLUSIONS: Intracranial hemorrhage can be deleterious if present with low GCS score, high ICH score, intraventricular extension, and midline shift.

Comparative evaluation of efficacy and safety of artesunate-lumefantrine vs. artemether-lumefantrine fixed-dose combination in the treatment of uncomplicated Plasmodium falciparum malaria.

OBJECTIVE: To establish efficacy and safety of artesunate/lumefantrine fixed-dose combination (FDC) in comparison with artemether/lumefantrine FDC in treatment of uncomplicated Plasmodium falciparum malaria. METHODS: Confirmed cases of uncomplicated P. falciparum malaria were randomly assigned to receive artesunate (100 mg)/lumefantrine (480 mg) (ASLF FDC) or artemether (80 mg)/lumefantrine (480 mg) (AMLF FDC) tablets for 3 days. Patients were followed up on Day 7, 14, 21 and 28. RESULTS: Of the 158 enrolled patients, 144 completed the study. Seventy-three patients (94.8%) from the ASLF group and 71 patients (94.7%) from the AMLF group showed parasite clearance within 48 h. The mean parasite clearance time was 25.40 ± 14.82 h in the ASLF group and 24 ± 13.32 h in the AMLF group (P = 0.542). All patients showed gametocyte clearance by Day 7 and remained gametocyte free till Day 28. Sixty-five patients (84.4%) from the ASLF group and 56 patients (74.7%) from the AMLF group were afebrile within 24 h. The mean fever clearance time was 17.38 ± 12.33 h in the ASLF group and 17.2 ± 12.01 h in the AMLF group (P = 0.929). There was one early treatment failure in the AMLF group as per WHO criteria. Improvement in haemoglobin and haematocrit was comparable in both the treatment groups. In the ASLF group, of the 25 (32.47%) patients anaemic at baseline, only seven (9.09%) reported anaemia on Day 28, while in the AMLF group, of the 14 (18.67%) patients anaemic at baseline, only four (5.33%) reported anaemia on Day 28. Both study medications were well tolerated. CONCLUSION: Artesunate (100 mg)/lumefantrine (480 mg) fixed-dose combination could add one more option to currently available artemisinin combinations in treatment of uncomplicated P. falciparum malaria.