Iron Deficiency Anemia Presenting With Pancytopenia: A Study From India.

INTRODUCTION: Iron deficiency anemia (IDA) is the most common cause of anemia worldwide. IDA is commonly associated with thrombocytosis and normal or slightly decreased leukocyte count. Sometimes it can present with thrombocytopenia, but rarely present with pancytopenia. Here we are presenting six cases of severe iron deficiency presenting with pancytopenia, which responded to iron replenishment. METHODS:  This 12-month observational study was conducted in the Department of General Medicine at a tertiary care Centre in India. All cases of pancytopenia (after exclusion of other causes) with IDA were included. IDA was established with the help of a complete blood count (CBC), peripheral smear examination, serum iron studies, and serum ferritin.  Results: In our study, CBC at four weeks later of iron transfusion without other supplementation showed significant improvement in hematological parameters. CONCLUSION:  Severe iron deficiency is a reversible etiology of pancytopenia. It should be kept as a differential diagnosis of pancytopenia if common causes of pancytopenia are ruled out.

Effectiveness of early awake self proning strategy in non-intubated patients with COVID-19 hypoxemia: an open-labelled randomized clinical trial from Jodhpur, India.

Awake self-proning is being used widely as respiratory support in COVID-19 hypoxemia, in resource-limited settings. We aimed to investigate the effectiveness of early awake self-proning in preventing mortality and the need for intubation in adults with moderate COVID-19 hypoxemia. In this randomized clinical trial with inten-tion-to-treat analysis, we enrolled eligible adults with COVID-19 hypoxemia (SpO2 <94%), requiring supplemental oxygen via nasal prongs or facemask from a tertiary-care setting in Jodhpur, India between June 15 to December 24, 2020. Awake proning comprised of 4-hour cycles with prone position maintained 2 h per cycle. The control group did not maintain any specific position. All participants received standard care. The primary outcomes were 30-day mortal-ity and requirement for mechanical ventilation. Of 502 participants included, mean (SD) age was 59.7 (12.7) years with 124 women (24.6%); 257 were randomized to awake-proning, 245 to control group and all 502 were included for follow-up mortality analysis. Mortality at follow-up was 16.3% in the awake-prone and 15.1% in the control group [OR:1.10 (0.68-1.78), p=0.703). The requirement of mechanical ventilation was 10% in both groups (p=0.974). Survival time (in days) was not significantly different between the groups [Log-rank test, HR: 1.08 (95% CI, 0.70-1.68), p=0.726]. Likewise, time to intubation was comparable (Log-rank test, HR: 0.93 (95% CI, 0.56-1.70), p=0.974). Hence, awake self-proning did not improve survival or requirement of mechanical-ventilation in non-intubated patients with mild to moderate COVID-19 hypox-emia. Trial Registration: Clinical trial registry of India, ID: CTRI/2020/06/025804.   The trial is accessible from WHO's International Clinical Trials Registry Platform (ICTRP) at https://trialsearch.who.int ***************************************************************   *Appendix Authors list  Deepak Kumar1, Gopal Krishna Bohra1, Nishant Kumar Chauhan2, Nikhil Kothari3, Vijaya Lakshmi Nag4 Sanjeev Misra5  1Department of Internal Medicine; 2Department of Pulmonary Medicine; 3Department of Anaesthesiology and Critical Care; 4Department of Microbiology; 5Department of Surgical Oncology, All India Institute of Medical Sciences, Jodhpur, India.

Comparison of clinical characteristics and outcome in RT-PCR positive and false-negative RT-PCR for COVID-19: A Retrospective analysis.

Cases with SARS-CoV-2 RT-PCR negative pneumonia are an understudied group with uncertainty remaining regarding their treatment approach. We aimed to compare the clinical and radiological characteristics of RT-PCR positive and clinically diagnosed RT-PCR negative COVID-19. This was a single-centre retrospective study conducted at a tertiary care hospital in Western India. All patients (age ≥18 years) with suspicion of COVID-19 with SARI (severe acute respiratory infections) who were subjected to RT-PCR testing (nasal/oropharyngeal swab) were included. Based on RTPCR results, patients were categorized and compared for demographic, clinical, and biochemical characteristics and outcomes. Out of 500 patients, 339 (67.8%) found RT-PCR positive. Except for the radiological findings, both groups differ in clinical presentation, disease severity (inflammatory markers), and outcome. RT-PCR-positive patients had raised ferritin, NLR (Neutrophil-Lymphocyte ratio), LDH, and high mortality compared to the swab-negative group. In-hospital mortality was also significantly high in RT-PCR positive group (HR=1.9, 95% CI=1.4-2.5, p=0.001). On multivariate analysis, NLR, ferritin, and d-dimer were the independent predictors of mortality in RT-PCR-positive (p=0.038, 0.054, and 0.023). At the same time, raised TLC (total leukocyte count) and procalcitonin were the risk factors for poor outcomes in RT-PCR-negative patients (p=0.041 and 0.038). We found significantly raised ferritin, NLR, and LDH levels and increased mortality in RT-PCR positive patients compared to RT-PCR negative. Incorporating clinical features, radiological, and biochemical parameters could be prudent while managing the RT-PCR-negative patients.

Hyperglycemia and steroid use increase the risk of rhino-orbito-cerebral mucormycosis regardless of COVID-19 hospitalization: Case-control study, India.

BACKGROUND: In the ongoing COVID-19 pandemic, an increased incidence of ROCM was noted in India among those infected with COVID. We determined risk factors for rhino-orbito-cerebral mucormycosis (ROCM) post Coronavirus disease 2019 (COVID-19) among those never and ever hospitalized for COVID-19 separately through a multicentric, hospital-based, unmatched case-control study across India. METHODS: We defined cases and controls as those with and without post-COVID ROCM, respectively. We compared their socio-demographics, co-morbidities, steroid use, glycaemic status, and practices. We calculated crude and adjusted odds ratio (AOR) with 95% confidence intervals (CI) through logistic regression. The covariates with a p-value for crude OR of less than 0·20 were considered for the regression model. RESULTS: Among hospitalised, we recruited 267 cases and 256 controls and 116 cases and 231 controls among never hospitalised. Risk factors (AOR; 95% CI) for post-COVID ROCM among the hospitalised were age 45-59 years (2·1; 1·4 to 3·1), having diabetes mellitus (4·9; 3·4 to 7·1), elevated plasma glucose (6·4; 2·4 to 17·2), steroid use (3·2; 2 to 5·2) and frequent nasal washing (4·8; 1·4 to 17). Among those never hospitalised, age ≥ 60 years (6·6; 3·3 to 13·3), having diabetes mellitus (6·7; 3·8 to 11·6), elevated plasma glucose (13·7; 2·2 to 84), steroid use (9·8; 5·8 to 16·6), and cloth facemask use (2·6; 1·5 to 4·5) were associated with increased risk of post-COVID ROCM. CONCLUSIONS: Hyperglycemia, irrespective of having diabetes mellitus and steroid use, was associated with an increased risk of ROCM independent of COVID-19 hospitalisation. Rational steroid usage and glucose monitoring may reduce the risk of post-COVID.

Association of Inflammatory markers with Covid-19 Outcome among Hospitalized adult Patients.

COVID-19 is a highly infectious disease with varied presentation as well as outcome. Inflammation plays a major role in the outcome of COVID-19 infection. This study was aimed to evaluate the role of conventional feasible inflammatory markers in predicting the outcome of COVID-19 in hospitalized adult patients. MATERIAL: A total of 100 confirmed COVID-19 patients were included in the study. Clinical and demographic data were collected. Biochemical, hematological, and inflammatory markers were assessed in all the patients. Disease severity and primary outcome as survival and or mortality were recorded. OBSERVATION: Hematological indices and inflammatory markers were significantly higher among the non-survivor. N/L (Neutrophil/Lymphocyte) ratio and CRP (C-reactive protein) can differentiate non-survivor from survivors with the sensitivity of 85.7%, 85.7%, and specificity of 96.8 %, 77.4% with a cut-off value of 6.44, 23.02 respectively in the receiver operator curve (ROC). N/L ratio and CRP were significantly increased among the patients with severe COVID-19 infection. Cox regression Survival analysis showed that an elevated N/L ratio and CRP were significantly associated with mortality with the Hazard ratio of 1.331 (P <0.001) and 1.014 (P <0.015) respectively. CONCLUSION: The present study implicates that increased N/L ratio and CRP were significantly correlated with severity and mortality in COVID-19 patients. These conventional feasible markers can be useful in predicting the outcome of COVID-19 infection.

Acute Myocardial Infarction in Hemophilia A with HIV and Hyperhomocysteinemia- a rare case report.

BACKGROUND: Patients with hemophilia have a hypocoagulable state and less chances of thrombus formation. Therefore, expected to have a lower cardiovascular mortality than the general population. The lower cardiovascular mortality can be explained by less chances of thrombus formation due to hypocoagulability. CASE PRESENTATION: Here we present a case of a 42-year-old male patient presented with severe chest pain radiating to back for 4 days. ECG was suggestive of recent acute anteroseptal myocardial infarction. There was a history of receiving intravenous recombinant factor VIII, 1 hour prior to the onset of chest pain for knee joint swelling. The occurrence of acute coronary syndromes in patients with hemophilia A is uncommon and rarely reported. CONCLUSION: Here we report a patient of severe hemophilia A who developed acute myocardial infarction after administration of recombinant factor VIII.

Rapid Response Preparedness for Management of Post-Covid Invasive Rhino-Orbito-Cerebral Fungal Infections: Experience from a Tertiary Care Government Institute in India.

Sudden surge of Post Covid-19 Rhino-orbito-mucormycosis cases has left entire ENT fraternity in the center of a war room. We present a quick administrative preparedness for this situation in a tertiary care Government Institute in India. This model may serve as a reference for other centers.

Right Atrial Thrombus in a Patient of Rheumatic Heart Disease with Severe Mitral Regurgitation: A Rare Association.

BACKGROUND: Right atrial thrombus is a rare phenomenon, and its incidence is not well- defined. It usually occurs in the presence of predisposing factors like tricuspid stenosis or following central venous catheterization. Isolated right atrial thrombus without any predisposing factors occurs rarely. CASE PRESENTATION: We herein report a 30-year-old male patient, a known case of rheumatic heart disease with mitral regurgitation, presented with severe breathlessness and orthopnea. He was diagnosed with acute pulmonary oedema with biventricular dysfunction and congestive symptoms. On transthoracic 2D echocardiography, he was found to have severe mitral and severe tricuspid regurgitation. All cardiac chambers were dilated, and an incidental finding of right atrial thrombus was noted. Patient The patient was managed conservatively, but he succumbed to his worsening heart failure. CONCLUSION: Treating physicians should be aware of the possibility of right atrial thrombus in rheumatic mitral valve disease because of its clinical implications, like life life-threatening pulmonary embolization and need of surgical management.

Endocrine Dysfunction among Patients with COVID-19: A Single-center Experience from a Tertiary Hospital in India.

OBJECTIVE: COVID-19 has emerged as a multi-system disease with the potential for endocrine dysfunction. We aimed to study the hormonal profile of hospitalized patients with COVID-19 at a tertiary care referral hospital at Jodhpur, India. DESIGN: A hospital-based clinical study of endocrine profile of COVID-19 patients conducted from 15th May to 30th June 2020 after ethical approval. MEASUREMENTS: Fasting blood samples for free thyroxine (T4), free tri-iodothyronine (T3), thyroid stimulating Hormone (TSH), serum prolactin; basal and 1 h post-intramuscular adrenocorticotropic hormone (ACTH) stimulated cortisol, interleukin-6 (IL-6), and high sensitivity C-reactive protein (hsCRP) were collected within 24 h of admission after written informed consent. All hormones and IL-6 were analyzed by chemiluminescent immunoassay. hsCRP was measured by immune-turbidimetric assay. RESULTS: Of 235 patients studied, 14% had severe disease and 5.5% died. Adrenal insufficiency was present in 14%, most of whom had mild disease. A robust adrenal response was observed in those with severe disease. Basal and post-ACTH serum cortisol were significantly increased in severe disease or those who died compared to those who were mild or asymptomatic. Basal and post-ACTH serum cortisol showed a significant positive correlation with hsCRP but not with IL-6. Low T3 and low T4 syndrome were documented in 25% and 5%, respectively. Serum TSH and FT3 levels declined significantly from asymptomatic to severe category. Hyperprolactinemia was found in 21 patients. hsCRP showed a rising trend with disease severity while IL-6 did not. CONCLUSIONS: Endocrine dysfunction in the form of adrenal insufficiency, low T3, and low TSH syndrome and hyperprolactinemia were common COVID-19 hospitalized patients.

Pseudothrombocytosis in Case of Betathalassaemia Intermedia Masquerading as Myeloproliferative Neoplasm.

Finding spurious thrombocytopenia is a common occurrence in clinical practice, whereas pseudothrombocytosis is a very uncommon event. Despite several technical advancements in automated haematology analysers, a careful peripheral smear examination remains standard examination in cases of discrepancy of platelet counts. We are presenting a case of betathalassaemia intermedia who had pseudothrombocytosis, which was falsely labelled as myeloproliferative neoplasm before the patient visited our haematology clinic.

New-onset hyperglycaemia and prolonged systemic corticosteroids therapy in mild COVID-19 patients as major risk factors for invasive mucormycosis: a preliminary study.

Background and Purpose: Rapid surge of invasive mucormycosis has surprised the Indian healthcare system amidst the coronavirus disease-19 (COVID-19) pandemic. Hence, there is an urgent need to find the risk factors for the sudden rise in cases of invasive mucormycosis among COVID-19 patients. This study aimed to find crucial risk factors for the sudden surge of invasive mucormycosis in India. Materials and Methods: This case-control study included 77 cases of COVID-19 associated mucormycosis (CAM) who matched the controls (45 controls) in terms of age , gender, and COVID-19 disease severity. The control group included subjects that matched controls without mucormycosis confirmed by reverse transcription-polymerase chain reaction at our tertiary care center during April-May 2021. Probable predisposing factors, such as duration of diabetes mellitus (DM), history of recent hospitalization, duration of hospital stay, mode of the received oxygen supplementation, and use of steroids, zinc, vitamin c, and any other specific drugs were collected and compared between the two groups. Moreover, the laboratory parameters, like glycated hemoglobin (HbA1c), highly sensitive C-reactive protein (hs-CRP), and erythrocyte sedimentation rate (ESR) were analyzed to find out the significant association with CAM. Results: DM (Odds ratio=7.7, 95% CI 3.30-18.12; P=<0.0001) and high glycated hemoglobin level (HbA1c>7.5 gm %) (odds ratio=6.2, 95% CI 1.4-26.7; P=0.014) were significant risk factors for the development of invasive mucormycosis among the COVID-19 cases. A higher number of mild COVID-19 cases developed CAM, compared to the moderate to severe cases (59.7% vs 40.3%). Use of systemic corticosteroids (odd ratio=5 with 95% CI 1.5-16.9; P=0.007) was found to be a risk factor for invasive mucormycosis only in mild COVID-19 cases. Use of oxygen, zinc, and vitamin C supplementation, and proprietary medicine did not lead to a significant risk of invasive mucormycosis in cases, compared to controls. Cases with invasive mucormycosis had a higher level of inflammatory markers (hs-CRP and ESR, P=<0.001 and 0.002, respectively), compared to the controls. Conclusion: Uncontrolled and new-onset DM and the use of systemic corticosteroids in mild cases were significantly associated with a higher risk of invasive mucormycosis in COVID-19 cases. There should be a strong recommendation against the use of systemic corticosteroids in mild COVID-19 cases.

Association of Inflammatory Markers with COVID-19 Outcome among Hospitalized Patients: Experience from a Tertiary Healthcare Center in Western India.

Introduction: COVID-19 is a highly infectious disease and varies in the severity of presentation as well as survival outcome due to varied inflammatory responses. Hence, the present study is aimed to evaluate the role of inflammatory markers in predicting the outcome of COVID-19 in hospitalized patients. Methods: A total of 272 confirmed COVID-19 patients were included in the study. Clinical and demographic data were collected. Biochemical, hematological, and inflammatory markers were assessed in all patients. Disease severity and primary outcome as survival and or mortality were recorded. Results:Hematological indices and inflammatory markers were significantly higher among the non-survivors. Interleukin-6 (IL-6) can differentiate non-survivors from survivors with 100% sensitivity and 70.2% specificity, with a cut-off value of 79.6 in the receiver operator curve (ROC). As disease severity was increasing, IL-6 and C-reactive protein (CRP) were significantly increased among patients. Survival analysis showed that an elevated level of IL-6 was significantly associated with mortality and Cox regression analysis showed the hazard ratio (HR) of IL-6 was 0.996 (P<0.007). Conclusion:The results of the present study implicate that increased levels of IL-6 and CRP were significantly correlated with severity and mortality in COVID-19 patients. In addition, the dynamic measurement of neutrophil-to-lymphocyte (N/L) ratio, IL-6, and CRP in COVID-19 might be used as predictors of prognosis and outcome.

Clinico-radiologic Profile of Pediatric Traumatic Brain Injury in Western Rajasthan.

OBJECTIVE: The aim of this study was to evaluate clinico-radiological profile and outcome of pediatric traumatic brain injury (TBI). DESIGN: Prospective observational study. SETTING: Intensive Care Unit, ward and OPD of Pediatrics, Dr. S. N. Medical College, Jodhpur (tertiary care hospital). PARTICIPANTS: A total of 188 children (1 month-18 years) were enrolled and 108 admitted. INTERVENTION: TBI classified as mild, moderate, or severe TBI. Neuroimaging was done and managed as per protocol. Demographic profile, mode of transport, and injury were recorded. OUTCOME: Measured as hospital stay duration, focal deficits, mortality, and effect of early physiotherapy. RESULTS: Males slightly outnumbered females mean age was 5.41 ± 4.20 years. Fall from height was the main cause of TBI (61.11%) followed by road traffic accident (RTA) (27.78%). Majority (56.56%) reached hospital within 6 h of injury, out of which 27% of patients were unconscious. Mild, moderate, and severe grade of TBI was seen in 50%, 27.78%, and 22.22% of cases, respectively. About 12.96% of cases required ventilator support. The average duration of hospital stay was 11.81 ± 12.9 days and was lesser when physiotherapy and rehabilitation were started early. In all children with temporal bone fracture, magnetic resonance imaging (MRI) brain revealed a temporal lobe hematoma and contusion in spite of initial computed tomography (CT) head normal. Children who have cerebrospinal fluid (CSF) rhinorrhea/otorrhea had a high chance of fracture of base of skull and contusion of the basal part of the brain. CONCLUSION: In India, fall from height is common setting for pediatric TBI besides RTA. Early initiation of physiotherapy results in good outcome. MRI detects basal brain contusions in children presenting with CSF rhinorrhea/otorrhea even if initial CT brain is normal.

Behavioral Problems and Intelligence Quotient Changes in Pediatric Epilepsy: A Case-Control Study.

BACKGROUND: Epilepsy is the most common chronic neurological disease and has neurological impairment as an important comorbidity. OBJECTIVE: To find behavioral problems and intelligence quotient (IQ) changes associated with epilepsy and to know the association of variables such as frequency, type of seizures, and duration of disease with cognitive impairment. MATERIALS AND METHODS: A descriptive cross sectional study, consisting of 50 cases (patients of epilepsy) and 50 controls (other patients of same socioeconomic status) was conducted at S.P. Medical College, Bikaner. The patients were subjected to detailed clinical history, thorough examination, Pediatric Symptom Checklist, and Bhatia's Battery of Performance intelligence Test. Data analysis was carried out with the help of SPSS 22 software. RESULTS: The prevalence of behavioral problems in generalized and partial seizure group was high (42% and 53.8%) as compared to control group (9%). Low IQ was present more in the patients (44%) of generalized and partial seizure group as compared with the control group, and results were statistically significant. Furthermore, behavioral problems were more in patients who were having more number of seizures (≥3 per year) with significant P values (χ2 = 5.067, P = 0.024). CONCLUSION: We conclusively found that behavioral problems and cognitive factors, apart from control of seizures, must be kept in mind to determine how well a child with epilepsy progresses toward independence.

Serum uric acid level as a determinant of the metabolic syndrome: A case control study.

AIMS: To determine whether elevations of uric acid levels are associated with the cluster of disorders described in metabolic syndrome and to evaluate whether hyperuricemia may be considered a component of this syndrome. METHODS: One year case-control study was conducted in Bikaner, Rajasthan, India from January to December 2013. The study population consisted of 200 subjects, 100 with metabolic syndrome (case) and 100 without metabolic syndrome (control) aged between 18 and 80 years, attending OPD at PBM Hospital were studied. Controls were age and sex matched to the cases. Blood tests and all physical variables were examined using standard methods. Subjects were divided into 6 groups according to their possession of 0, 1, 2, 3, 4 or 5 components of the metabolic syndrome. Statistical analysis was done using ANOVA, linear regression analysis and multivariate linear regression model. RESULTS: Mean serum UA level was significantly associated with all components of metabolic syndrome (p<0.001) and had strong positive correlation (r=+0.66 to +0.77, p<0.0001) with all of them except serum HDL with which it showed strong negative correlation(r=-0.71, p<0.0001). It increased as the number of metabolic factors increased showing a highly significant trend (p<0.0001). On multivariate regression analysis UA contributed to 66.84% variance of metabolic syndrome. CONCLUSION: The current multivariate regression analysis clearly infers that uric acid can be considered as a marker and potential modifier of metabolic syndrome.

Urban Rural Comparison of Anthropometry and Menarcheal Status of Adolescent School Going Girls of Jodhpur, Rajasthan, India.

INTRODUCTION: Adolescence is the formative period of life. Poor adolescent health translates into poor maternal health leading to increased maternal morbidity with inter-generational consequences. AIM: To compare anthropometric, socio-demographic, menstrual and nutritional status of rural and urban adolescent school going girls of Western Rajasthan, India. MATERIALS AND METHODS: A cross-sectional comparative study was conducted in two rural schools and one urban school of Jodhpur region. Anthropometric, socio-economic (family history, menstrual history, maternal education) and dietary habit data of 327 (137 urban and 190 rural) school going adolescent girls aged 11-16 years were collected using structured questionnaires by a school based survey after consent from parents and school officials. Height and weight were taken using the standard procedure. Stunting (height for age) and thinness [Body Mass index (BMI) for age] were calculated as per the National Center for Health and Statistics (NCHS) standards. Statistical analysis was done using student t-test, fisher-exact test and Chi-square test. RESULTS: Mean height was significantly higher in urban girls while mean BMI of adolescents was significantly higher in rural areas as compared to their urban counterparts. Growth spurt was between 12-13 years showing maximum increase in mean height, coinciding with or immediately post-menarche. Menarche was one year earlier in urban girls as compared to rural girls (p<0.001). Thinness was more prevalent among females in urban areas and stunting was more common amongst girls residing in rural areas. CONCLUSION: Life style habits (poor dietary habits, sedentary life style) of the urban girls may contribute to an early menarche but rural girls despite having a later onset of menarche; have a lower final height which may be attributed to their poor nutritional status. Improving nutrition of rural girls and modifying the life style of urban girls and educating their mothers will reduce the disparity and lead to better health and development of adolescent girls in this region and this could be expected to improve maternal health in future.