Navigating the Challenges of Takayasu Arteritis in a 26-Year-Old Female With Recurrent Chest Pain and a Complex Medical History.

Takayasu arteritis, a rare and complex vasculitis, presents unique diagnostic and management challenges, particularly when encountered in young adults. We present the case of a 26-year-old female with obesity, prediabetes, hepatic steatosis, an adnexal cyst, Helicobacter pylori gastritis, and asthma, who was transferred to our facility due to concerns about aortitis. Her presentation to the referring institution included dysphagia, heartburn that responded to over-the-counter antacids, and recurrent episodes of stabbing chest pain, which had been occurring intermittently since the age of 17. Previous visits to the emergency room for these symptoms had been approached as gastritis, the last being two weeks before this episode. On evaluation, laboratory findings revealed elevated inflammatory markers, and subsequent imaging studies identified extensive circumferential wall thickening of the ascending thoracic aorta, suggestive of aortitis, and the patient was transferred to our institution. The patient's complex medical history and psychosocial stressors, including estrangement from her family, added to the intricacies of her case. Rheumatology consultation was instrumental in guiding further evaluation and management. A diagnosis of Takayasu arteritis with large vessel vasculitis was considered, supported by positron emission tomography-computed tomography findings showing significant metabolic activity in major arteries. The patient was initiated on prednisone therapy, Pneumocystis jirovecii pneumonia prophylaxis, and methotrexate. Ongoing monitoring for disease activity and medication side effects was emphasized. This case highlights the importance of considering rare conditions such as Takayasu arteritis in young adults with atypical presentations and underscores the need for comprehensive, multidisciplinary care that addresses not only the medical aspects but also the psychosocial well-being of the patient.

Exploring the Role of Insulin Resistance in Fueling Stroke Vulnerability and Worsening Post-stroke Prognosis: A Narrative Review of Current Literature.

Stroke remains one of the world's greatest causes of disability and death. Insulin resistance (IR) impairs insulin's beneficial effects on the brain and can change the course of illness in post-stroke patients. This review aims to find sufficient evidence to support the causal association of IR in ischemic stroke and with post-stroke prognosis (PSP). The review will also list probable mechanisms to better understand how IR affects stroke pathology. Various articles from PubMed Central, MEDLINE, and PubMed databases were reviewed, and then after careful consideration, 17 articles were selected. The studies, using various genetic and metabolic markers, have linked IR to increased incidence of ischemic stroke. Among the various types of strokes investigated from this standpoint, silent lacunar infarct stands out as a widely researched subtype. Even though the exact pathogenesis is still unclear, current evidence shows an interplay of atherosclerosis, embolism, and platelet dysfunction. The development of early neurological decline (END) in post-stroke patients has been used to link IR to poor PSP. It is also acknowledged to have contributed in some way to poor three-month outcomes. Modifying inflammatory pathways and developing glucotoxicity are some of the pathways by which IR affects PSP. After reviewing the studies, significant evidence was found to support the role of IR in causing ischemic stroke as well as in poor PSP. Additional investigation is required to assess its influence on three-month prognosis and its significance in various stroke subcategories.

Paediatric Cogan Syndrome masquerading as IgA vasculitis.

Paediatric Cogan Syndrome is a rare and underrecognised autoimmune vasculitis characterised by ocular inflammation and sensorineural hearing loss. Its etiopathogenesis, diagnosis, and management are not well defined. We report a 12-year-old girl who initially presented with symptoms of IgA vasculitis formerly called Henoch Schoenlein Purpura (HSP) and eventually developed anterior uveitis and bilateral sensorineural hearing loss leading to the diagnosis of atypical Cogan Syndrome. The workup for infectious etiologies and other systemic rheumatologic disorders was negative. The management was multidisciplinary involving Rheumatology, Ophthalmology, Otorhinolaryngology, and Audiology. The anterior uveitis responded well to systemic glucocorticoids and Methotrexate, but the hearing loss was grossly progressive warranting a cochlear implant. We are not aware of Paediatric Cogan Syndrome being reported as a mimicker of IgA vasculitis previously in the literature. It is an important finding as IgA vasculitis is prevalent in the paediatric age group and new-onset ocular or vestibular symptoms after IgA vasculitis should alert the clinician to the possibility of Cogan Syndrome. In the absence of well-defined diagnostic criteria, it is crucial to recognise the clinical symptoms of Paediatric Cogan Syndrome for early diagnosis and treatment since the delay in diagnosis can lead to permanent disability.

Exploring the Effects of Elevated Serum Uric Acid Levels on Hypertension: A Scoping Review of Hyperuricemia.

Hypertension (HTN) is a global health concern due to its increasing prevalence and association with life-threatening complications. An intriguing area of investigation in HTN research is the relationship between HTN and hyperuricemia. In light of this, we conducted a review to summarize the relevant studies exploring the link between elevated serum uric acid (sUA) concentration and new-onset HTN. Through a comprehensive search of PubMed Central, MEDLINE, and PubMed databases, we identified 20 studies that met our inclusion criteria. The research encompassed various study designs, including cohort studies, cross-sectional studies, reviews, and clinical trials. Pathologically, the elevated sUA levels activate the renin-angiotensin system and also cause the formation of urate crystals, triggering inflammation in the kidneys. Additionally, direct effects on the endothelium contribute to inflammation, oxidative stress, nitric oxide depletion, and smooth muscle cell proliferation, ultimately leading to atherosclerosis. These diverse mechanisms collectively play a role in the pathogenesis of HTN. Interestingly, lowering sUA has been shown to reverse early-stage HTN dependent on uric acid. However, this effect is not observed in the uric acid-independent second stage of HTN. Various studies have demonstrated an independent and dose-dependent association between sUA levels and the prevalence of HTN across different populations and genders. The review highlights the potential role of uric acid-lowering drugs, like allopurinol, in the prevention and early-stage management of HTN. However, there is scarce research on the efficacy of other uric acid-lowering agents and combination therapies. We believe our review provides compelling evidence of the association between elevated sUA concentration and new-onset HTN. Identifying and managing hyperuricemia can provide a preventive approach to reducing the burden of HTN and its associated complications.

Gut-brain axis: altered microbiome and depression - review.

The concept of a 'gut-brain axis' was recently developed when the complex communications between the brain and the gut became evident. The interaction may affect emotions, motivation, mood, and higher cognitive functions as well as gut homeostasis. Human microbe symbiosis's merits are now acknowledged to transcend human mental health. Research has recently indicated that the gut-brain axis plays a vital role in brain health maintenance. The term 'gut-brain axis' can only partially capture the intricacy of these interactions. Dysbiosis of the gut commensals has been seen in patients with psychiatric diseases, such as depression. Major depressive disorder is caused by complicated interactions between the individual gene and the environment. In a forced swimming test, P. Zheng et al. discovered that germ-free mice with no gut microbiota had a shorter immobility duration than healthy mice. More radical effects were expressed on the use of probiotics rather than prebiotics and postbiotics in reducing the symptoms of depression in patients with major depressive disorder. One of prime importance can be given to exploring more microbiota to investigate the better therapeutic effects of probiotics, prebiotics, and postbiotics.

Hyperferritinemia and the Extent of Mucormycosis in COVID-19 Patients.

Introduction Coronavirus disease 2019 (COVID-19) disease attributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has shown associations with various fungal opportunistic infections such as mucormycosis, invasive candidiasis, and aspergillosis, which have contributed to the mortality of the disease. In India, the incidence of mucormycosis had risen rapidly during the second wave. There is ample literature demonstrating the role of iron in the pathogenesis of mucormycosis. The hyperferritinemia associated with COVID-19 may have played a significant role in promoting the invasion and extent of the fungus. Aims and objectives The study aimed to analyze the association between serum ferritin levels and the extent of involvement of mucormycosis in patients affected with COVID-19. Methodology A single-center cross-sectional study was conducted using retrospective hospital record data. G*Power statistical analysis software was used to compute the sample size of 62 (31+31). The radiological data were used to determine the extent of involvement. Results A statistically significant difference was seen in levels of serum ferritin (p = 0.008) between the radiologically judged two groups of the mild extent of invasion of mucormycosis (rhinosinusitis) and severe extent of invasion (rhino-orbital/cerebral mucormycosis), with a severe extent seen with the group having higher levels of serum ferritin. Severe extent of invasion was seen in 53.6% of patients with diabetes mellitus and 62.5% of patients with both diabetes and hypertension. Conclusion The hyperferritinemia not only presents as a marker of the systemic inflammatory process in COVID-19 but also indicates increased free iron, which thereby aids the growth and extent of involvement by the fungus (R hizopus oryzae). In individuals with diabetes and hypertension, the severity was greater. Controlling catastrophic outcomes in individuals with high serum ferritin levels necessitates extra caution.

Comparative Effectiveness of a Web-Based Patient Decision Aid for Therapeutic Options for Sickle Cell Disease: Randomized Controlled Trial.

BACKGROUND: Hydroxyurea, chronic blood transfusions, and bone marrow transplantation are efficacious, disease-modifying therapies for sickle cell disease but involve complex risk-benefit trade-offs and decisional dilemma compounded by the lack of comparative studies. A patient decision aid can inform patients about their treatment options, the associated risks and benefits, help them clarify their values, and allow them to participate in medical decision making. OBJECTIVE: The objective of this study was to develop a literacy-sensitive Web-based patient decision aid based on the Ottawa decision support framework, and through a randomized clinical trial estimate the effectiveness of the patient decision aid in improving patient knowledge and their involvement in decision making. METHODS: We conducted population decisional needs assessments in a nationwide sample of patients, caregivers, community advocates, policy makers, and health care providers using qualitative interviews to identify decisional conflict, knowledge and expectations, values, support and resources, decision types, timing, stages and learning, and personal clinical characteristics. Interview transcripts were coded using QSR NVivo 10. Alpha testing of the patient decision aid prototype was done to establish usability and the accuracy of the information it conveyed, and then was followed by iterative cycles of beta testing. We conducted a randomized clinical trial of adults and of caregivers of pediatric patients to evaluate the efficacy of the patient decision aid. RESULTS: In a decisional needs assessment, 223 stakeholders described their preferences, helping to guide the development of the patient decision aid, which then underwent alpha testing by 30 patients and 38 health care providers and iterative cycles of beta testing by 87 stakeholders. In a randomized clinical trial, 120 participants were assigned to either the patient decision aid or standard care (SC) arm. Qualitative interviews revealed high levels of usability, acceptability, and utility of the patient decision aid in education, values clarification, and preparation for decision making. On the acceptability survey, 72% (86/120) of participants rated the patient decision aid as good or excellent. Participants on the patient decision aid arm compared to the SC arm demonstrated a statistically significant improvement in decisional self-efficacy (P=.05) and a reduction in the informed sub-score of decisional conflict (P=.003) at 3 months, with an improvement in preparation for decision making (P<.001) at 6 months. However, there was no improvement in terms of the change in knowledge, the total or other domain scores of decisional conflicts, or decisional self-efficacies at 6 months. The large amount of missing data from survey completion limited our ability to draw conclusions about the effectiveness of the patient decision aid. The patient decision aid met 61 of 62 benchmarks of the international patient decision aid collaboration standards for content, development process, and efficacy. CONCLUSIONS: We have developed a patient decision aid for sickle cell disease with extensive input from stakeholders and in a randomized clinical trial demonstrated its acceptability and utility in education and decision making. We were unable to demonstrate its effectiveness in improving patient knowledge and involvement in decision making. TRIAL REGISTRATION: ClinicalTrials.gov NCT03224429; https://clinicaltrials.gov/ct2/show/NCT03224429 and ClinicalTrials.gov NCT02326597; https://clinicaltrials.gov/ct2/show/NCT02326597.

Diagnostic Practices for Suspected Community-Acquired Central Nervous System Infection in the Post-Conjugate Vaccine Era.

OBJECTIVE: The aim of this study was to evaluate diagnostic practices for suspected community-acquired central nervous system (CNS) infection in an urban pediatric population. METHODS: This is an observational, retrospective single-center review of cerebrospinal fluid (CSF) studies in children, 1 month to 21 years old, evaluated for suspected CNS infection from 2004 to 2014. Cases of suspected nosocomial meningitis were excluded. The frequency of N-methyl-D-aspartate receptor antibody (NMDAR ab) encephalitis was analyzed from 2010 to 2014. RESULTS: A total of 940 unique patient visits with CSF studies were included in the final analysis. There were 940 bacterial cultures sent; 4 (0.42%) grew suspected CSF bacterial pathogens, and 18 (1.9%) grew organisms that were suspected contaminants. Bacterial pathogens included late-onset group B Streptococcus in 3 infants younger than 3 months and Streptococcus pneumoniae in an unvaccinated 9-year-old child. Viral CNS infection was 7.5 times more frequent than bacterial infection. Enterovirus was the only virus isolated. Five cases positive for NMDAR ab were identified since 2010. CONCLUSIONS: Bacterial studies were performed more frequently than viral and other studies. Cerebrospinal fluid bacterial culture was nearly 5 times more likely to yield a contaminant than a pathogen. The frequency of viral infection was likely underestimated as only 20% were tested, mainly by culture, which is suboptimal. These data suggest diagnostic practices for the evaluation of suspected community-acquired CNS infections in children need to be modified to reflect current epidemiology and highlight the need for greater accessibility to polymerase chain reaction for viral diagnostics. Furthermore, NMDAR ab-mediated encephalitis should be considered early in children presenting with suggestive symptoms.

Ambient Processed, Water-Stable, Aqueous-Gated sub 1 V n-type Carbon Nanotube Field Effect Transistor.

In this paper we report for the first time an n-type carbon nanotube field effect transistor which is air- and water-stable, a necessary requirement for electrolyte gated CMOS circuit operation. The device is obtained through a simple process, where the native p-type transistor is converted to an n-type. This conversion is achieved by applying a tailor composed lipophilic membrane containing ion exchanger on the active channel area of the transistor. To demonstrate the use of this transistor in sensing applications, a pH sensor is fabricated. An electrolyte gated CMOS inverter using the herein proposed novel n-type transistor and a classical p-type transistor is demonstrated.

Regenerative, Highly-Sensitive, Non-Enzymatic Dopamine Sensor and Impact of Different Buffer Systems in Dopamine Sensing.

Carbon nanotube field-effect transistors are used extensively in ultra-sensitive biomolecule sensing applications. Along with high sensitivity, the possibility of regeneration is highly desired in bio-sensors. An important constituent of such bio-sensing systems is the buffer used to maintain pH and provide an ionic conducting medium, among its other properties. In this work, we demonstrate highly-sensitive regenerative dopamine sensors and the impact of varying buffer composition and type on the electrolyte gated field effect sensors. The role of the buffer system is an often ignored condition in the electrical characterization of sensors. Non-enzymatic dopamine sensors are fabricated and regenerated in hydrochloric acid (HCl) solution. The sensors are finally measured against four different buffer solutions. The impact of the nature and chemical structure of buffer molecules on the dopamine sensors is shown, and the appropriate buffer systems are demonstrated.

Flexible, Low-Cost Sensor Based on Electrolyte Gated Carbon Nanotube Field Effect Transistor for Organo-Phosphate Detection.

A flexible enzymatic acetylcholinesterase biosensor based on an electrolyte-gated carbon nanotube field effect transistor is demonstrated. The enzyme immobilization is done on a planar gold gate electrode using 3-mercapto propionic acid as the linker molecule. The sensor showed good sensing capability as a sensor for the neurotransmitter acetylcholine, with a sensitivity of 5.7 µA/decade, and demonstrated excellent specificity when tested against interfering analytes present in the body. As the flexible sensor is supposed to suffer mechanical deformations, the endurance of the sensor was measured by putting it under extensive mechanical stress. The enzymatic activity was inhibited by more than 70% when the phosphate-buffered saline (PBS) buffer was spiked with 5 mg/mL malathion (an organophosphate) solution. The biosensor was successfully challenged with tap water and strawberry juice, demonstrating its usefulness as an analytical tool for organophosphate detection.

Paradoxical bronchospasm from benzalkonium chloride (BAC) preservative in albuterol nebulizer solution in a patient with acute severe asthma. A case report and literature review of airway effects of BAC.

Nebulized bronchodilator solutions are available in the United States as both nonsterile and sterile-filled products. Sulfites, benzalkonium chloride (BAC), or chlorobutanol are added to nonsterile products to prevent bacterial growth. Bronchoconstriction from inhaled BAC is cumulative, prolonged, and correlates directly with basal airway responsiveness. The multi-dose dropper bottle of albuterol sulfate solution contains 50 µg BAC per/2.5 mg of albuterol, which may be below or at the lower limit of the threshold dose for bronchoconstriction. However, with repeated albuterol nebulization, the effect can be additive and cumulative, often exceeding the bronchoconstriction threshold. We report a case of a 17 years old patient, who received 32 mg of BAC via nebulization over a period of 3.5 days that probably caused persistent bronchospasm evidenced by failure to improve clinically and to increase peak expiratory flow rate (PEFR) from 125 L/min (27% of predicted value) to 300 L/min (68% of predicted value) within 2 hours of withdrawing BAC. The patient's respiratory status and PEFR improved dramatically once the nebulization solution was switched to BAC free lev-albuterol solution. The pediatric providers, particularly the emergency department physicians, intensivists and pulmonologists need to be aware of this rare albeit possible toxicity to the respiratory system caused by BAC used as a preservative in albuterol nebulizer solution.

Development, Content Validity, and User Review of a Web-based Multidimensional Pain Diary for Adolescent and Young Adults With Sickle Cell Disease.

BACKGROUND: Vaso-occlusive pain, the hallmark of sickle cell disease (SCD), is a major contributor to morbidity, poor health-related quality of life, and health care utilization associated with this disease. There is wide variation in the burden, frequency, and severity of pain experienced by patients with SCD. As compared with health care utilization for pain, a daily pain diary captures the breadth of the pain experience and is a superior measure of pain burden and its impact on patients. Electronic pain diaries based on real-time data capture methods overcome methodological barriers and limitations of paper pain diaries, but their psychometric properties have not been formally established in patients with SCD. OBJECTIVES: To develop and establish the content validity of a web-based multidimensional pain diary for adolescents and young adults with SCD and conduct an end-user review to refine the prototype. MATERIALS AND METHODS: Following identification of items, a conceptual model was developed. Interviews with adolescents and young adults with SCD were conducted. Subsequently, end-user review with use of the electronic pain diary prototype was conducted. RESULTS: Two iterative cycles of in-depth cognitive interviews in adolescents and young adults with SCD informed the design and guided the addition, removal, and modification of items in the multidimensional pain diary. Potential end-users provided positive feedback on the design and prototype of the electronic diary. CONCLUSION: A multidimensional web-based electronic pain diary for adolescents and young adults with SCD has been developed and content validity and initial end-user reviews have been completed.

Emotional intelligence scale for medical students.

BACKGROUND: Emotional Intelligence has been associated with positive outcome process in varied professions. There is paucity of Indian literature on the subject; especially involving medical undergraduates; and presently there is no scale available to measure the same in the Indian scenario. OBJECTIVE: To develop a scale to measure Emotional Intelligence among medical undergraduates. MATERIALS AND METHODS: Four domains of Emotional intelligence were selected, viz. Self-Awareness, Self-Management, Social-Awareness & Social-Skills and these were included for the purpose of domains of the scale. On the basis of focused group discussions and in-depth deliberations with experts, undergraduate and postgraduate medical students a pool of 50 items was generated. The items were reduced to 27 based on expert consensus and on the basis of frequency of endorsement by expert reviews. It was followed by a pilot study of 50 undergraduates. This completed the preparation of the preliminary draft based on content analysis. The questionnaire was then administered in 480 students and the data was analyzed by appropriate statistical methods. For the purpose of concurrent validity, emotional intelligence scale developed by Dr. Ekta was used. RESULTS: The Cronbach's Alpha for Internal Consistency Reliability was 0.68. The EIS had a significant correlation with social awareness domain of Emotional Intelligence Test (EIT) establishing Concurrent Validity. CONCLUSION: Emotional Intelligence Scale for medical undergraduates was constructed. Reliability and concurrent validity were also established for the same.