A Case of Palmoplantar Keratoderma in the Constellation of Connective Tissue Diseases.

Overlap syndrome is a clinical challenge and brings together a wide range of treatment options for the treating physician. Addressing each and every complaint of the patient is crucial. A 50-year-old female patient presented with skin thickening, blackening, and hyperkeratosis; dysphagia; joint pain; features of myopathy; Raynaud's phenomenon; and dry mouth. Inflammatory markers were raised along with a positive antinuclear antibody (ANA) with Golgi apparatus pattern, anti-Sjögren's-syndrome-related antigen A (anti-SSA)/Ro60 3+, anti-SSA/Ro52 3+, and anti-PM/Scl 2+ antibodies that suggested overlap syndrome. Although the patient had no respiratory complaints, a unique interstitial lung disease (ILD) pattern was noted during the evaluation. Skin manifestations were puzzling, but the histopathology analyses of skin biopsies taken from two different sites revealed distinguishing features of cutaneous lupus and dermatomyositis. Treatment with hydroxychloroquine, pilocarpine, nifedipine, methotrexate, and topical tacrolimus produced a dramatic improvement in the clinical features. This case highlights subtle and florid features of different autoimmune diseases. The hyperkeratotic skin changes were the most striking feature, but the whole evaluation process unveiled many rare presentations of known autoimmune conditions that can open doors to new areas of our understanding toward connective tissue diseases (CTDs). Our case report demonstrates significant heterogeneity in the ANA patterns, ILD patterns, clinical manifestations, and treatment approaches.

Chronic Adult-Onset Still's Disease With Positive Antinuclear Antibodies: Navigating Diagnostic Dilemmas and Clinical Implications.

Adult-onset Still's disease (AOSD) is a rare systemic autoinflammatory disorder characterized by fever, rash, and joint pain. Despite primarily affecting young adults, it can occur at any age, presenting diagnostic challenges due to its heterogeneous nature and lack of specific laboratory findings. The subset of AOSD with positive antinuclear antibody (ANA) adds complexity, potentially overlapping with other autoimmune conditions. We describe a case of a 30-year-old female with a two-year history of fever, weight loss, and joint pain, initially misdiagnosed as seronegative arthritis with hypothyroidism. Further evaluation revealed severe anemia, leucocytosis, and hepatosplenomegaly. Despite a strongly positive ANA, the absence of systemic lupus erythematosus (SLE) features led to a diagnosis of chronic AOSD. Treatment with steroids and disease-modifying antirheumatic drugs (DMARDs) resulted in clinical improvement, highlighting the importance of accurate disease classification for tailored management in ANA-positive AOSD. This case underscores the diagnostic challenges of AOSD and emphasizes the need for precise classification for optimal treatment strategies.

Analysis of Drugs Prescribed to Elderly Patients in a Tertiary Health Care Center in Raipur, Central India: An Observational Study.

Background Most elderly patients suffer from multiple diseases and are on multiple drugs for treatment. Polypharmacy in the elderly, physiological changes with old age, changes in the pharmacokinetics and pharmacodynamic effects of many drugs, and newer drug prescription trends for diseases like diabetes and cardiovascular disease make drug prescribing in the elderly more difficult. There are many chances of drug-drug interactions with easily available over-the-counter (OTC) medications. To prevent the irrational use of drugs in the elderly, there is a need for prescription analysis studies. Prescription analysis studies will help in finding errors in prescriptions and also change trends in the use of medication among the elderly. Methodology This cross-sectional observation study was conducted on 234 elderly patients to investigate medicine use patterns among the geriatric patients attending the Medicine Outpatient Department in a tertiary care teaching hospital. Drug data were collected from the study participants after obtaining written informed consent and analysed, including demographic details, personal history, disease history, and details of the drug, including the generic name of the drug, dose and duration of therapy, and prescription pattern. The proportions of drugs prescribed for different diseases were analysed. Also, the drugs were analysed as per their pharmacological profiles. Results and interpretation A total of 1298 drug prescriptions were analysed in this study. Of the total participants, 60.26% were male, 35% were unemployed, 53% were retired, and 27% were taking OTC herbal medications. Most of the patients included in this study were suffering from diabetes, hypertension, and other comorbidities. Telmisartan and telmisartan in combination with other drugs were the most commonly encountered prescription drugs, i.e., 24% among the cardiovascular drugs. Aspirin and statins alone or in combination were the most commonly encountered prescriptions, i.e., 27.88% of the drugs used for prophylaxis of cardiovascular diseases. Conclusion This study showed a prescription pattern for the elderly and highlighted precautions to be taken with some of the prescribed drugs. As polypharmacy is observed with elderly prescriptions, possible drug interactions must be taken into account. Regular prescription analysis of drugs prescribed to the elderly will help in the appropriate and rational use of drugs.

A retrospective observational insight into COVID-19 exposures resulting from personal protective equipment (PPE) breaches.

BACKGROUND: Healthcare workers (HCWs) stand the risk of acquiring infection directly, while attending to patients or indirectly while handling and testing patient specimens. Considering this, the present study was planned to assess Personal Protective Equipment (PPE) breaches and exposures among HCWs working in COVID-19 wards/ screening areas and to evaluate their COVID-19 positivity rates post-exposure concerning the level of exposure, type of PPE breach, and the cadre of HCWs exposed in COVID-19 wards. METHODS: This retrospective cross-sectional study involved the analysis of all instances of PPE breaches which occurred during a period of nine months from June 2020 to February 2021 at a tertiary care level hospital in Central India. The analysis included all exposures involving any cadre of HCWs that occurred while handling the patients or while doffing the contaminated PPE in COVID -19 wards. RESULTS: A total of 347 PPE breaches were analyzed from the available records of the Hospital Infection Control team repository. Amongst the 347 breaches, 268 (77.2%) were classified as low-risk exposures and 79 (22.8%) as high-risk exposures. Cadre wise distribution of high and low-risk exposures revealed that, PPE breaches occurred most commonly in the category of nursing officers (n = 174, 50.1%). Among all of the breaches, 15.2% of high-risk exposures and 2.6% of low-risk exposures resulted in COVID-19 positivity with a cumulative positivity of 5.4%. Collectively, non-mask related breaches accounted for the majority (63.2%) of the positive COVID-19 cases. CONCLUSION: Appropriate use of PPE by HCWs is vital for their protection. However, breaches in the use of PPE may occur while managing COVID-19 patients due to physical and mental exhaustion among HCWs resulting from work overload. Early identification and appropriate management of HCWs with high-risk exposures can help prevent transmission to other hospital staff and patients, thus preserving resources and workforce.

Usefulness of STOPP/START criteria and Beers criteria for prescribing in geriatric patients in a tertiary health care center, Raipur, Central India.

Background: Polypharmacy and inappropriate prescribing are risk factors for adverse clinical outcomes in older people. Screening tools can identify potential medicine-related patient safety incidents for the elderly on multiple medicines and with chronic diseases. Methods: In this prospective observational study, details of demography, diagnosis, history of constipation/peptic ulcer disease, over-the-counter medications, and clinical and laboratory findings were noted. Information obtained was reviewed and analyzed with the help of STOPP/START and Beers 2019 criteria. At 1 month follow-up, improvement was assessed with the help of a structured questionnaire. Results: As per the criteria, modification in drugs was recommended for 213 drugs; it was actually performed for 27.73% and 48.71% drugs as per Beers and STOPP/START criteria, respectively. Glimepiride was replaced with short-acting sulfonylureas because of hypoglycemia, and angiotensin receptor blockers were stopped because of hyperkalemia as per Beers criteria. Statins were started in 19 patients by START criteria. Overall general health improvement was observed at 1 month, but an increase in anxiety, tension, worry, depressed feel, and insomnia was observed in initial days of the coronavirus disease 2019 pandemic. Conclusions: In view of polypharmacy in the prescriptions, the combination of prescribing criteria need to be considered while prescribing medications to the elderly to get optimum therapeutic benefits and improvement in the quality of life. The quality of primary care of the elderly can also be improved by use of screening tools such as STOPP/START and Beers criteria by a primary/family physician. Prescription evaluation by a trained pharmacologist/physician for possible drug/food/disease interactions and for therapy modification can be incorporated for routine geriatric care at a tertiary care center. Clinical trial registry of India registration number: CTRI/2020/01/022852.