Multidisciplinary Management of COVID-Associated Mucormycosis Syndemic in India.

The study aimed to determine clinical presentation, contributing factors, medical and surgical management, and outcome of patients with coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM). A cross-sectional, single-center study was conducted on patients receiving multidisciplinary treatment for mucormycosis following the second wave of COVID-19 pandemic from April to June 2021 in India. Clinicoepidemiological factors were analyzed, 30-day overall survival and disease-specific survival were determined, and t-test was used to determine the statistical significance. A total of 215 patients were included in the study, the cases were stratified into sino-nasal 95 (44.2%), sino-naso-orbital 32 (14.9%), sino-naso-palatal 55 (25.6%), sino-naso-cerebral 12 (5.6%), sino-naso-orbito-cerebral 16 (7.4%), and sino-naso-orbito-palato-cerebral 5 (2.3%) based on their presentation. A multidisciplinary team treated patients by surgical wound debridement and medical therapy with broad-spectrum antibiotics and amphotericin B. Across all disease stages, cumulative 30-day disease-specific survival is 94% (p < 0.001, intergroup comparison, Breslow (generalized Wilcoxon) CI 95%) and overall 30-day survival is 87.9% (p < 0.001, intergroup comparison, Breslow (generalized Wilcoxon) CI 95%) (censored). Early identification, triaging, and proper multidisciplinary team management with systemic antifungals, surgical debridement, and control of comorbidities lead to desirable outcomes in COVID-associated mucormycosis. The patients with intracranial involvement have a higher chance of mortality compared to the other group. Supplementary Information: The online version contains supplementary material available at 10.1007/s12262-021-03134-0.

Idiopathic Hypoparathyroidism: Still a Diagnostic Conundrum - A Tertiary Centre Experience.

Idiopathic hypoparathyroidism leads to hypocalcemia and hyperphosphatasemia and usually has a genetic aetiology. The variable but often subtle signs and symptoms usually lead to a misdiagnosis of hypoparathyroidism. Case records of 32 patients of idiopathic hypoparathyroidism admitted over a period of five years were analysed. There was a lag period of 5.94 years from the onset of symptoms to the diagnosis. Carpopedal spasm was the most common indication for admission to the hospital. Trivial symptoms such as fatigue (84%) and paresthesia (62.5%) were the most common reported symptoms. A sum of 46.5% of the patients were on antiepileptic drugs before the correct diagnosis of hypoparathyroidism was made. This observation emphasized that Calcium profile should be obtained in patients with history of paresthesia and seizure to avoid the long delay in diagnosis of hypoparathyroidism.

Oral hygiene, prevalence of gingivitis, and associated risk factors among pregnant women in Sarlahi District, Nepal.

BACKGROUND: The oral health status of pregnant women in low-resource communities such as Nepal has not been well characterized. This sub-population is also of specific interest given associations between poor oral health and adverse pregnancy outcomes previously documented in other settings. We explored relationships between gingivitis and risk factors among pregnant women in rural Nepal. METHODS: The design was a community-based, cross-sectional study in a sub-area of Sarlahi District, Nepal. Pregnant women < 26 weeks gestation underwent clinical periodontal exams conducted by community-based oral health workers. Exams included a full mouth assessment measuring bleeding on probing (BOP), probing depth (PD) (six sites per tooth), and gingival recession, the distance from the cemento-enamel junction to the free gingival margin (two direct sites per tooth). Data on participant risk factors were collected through household surveys, including demographic characteristics, oral health behaviors, care seeking, and health attitudes. Multivariable logistic regression modeling was used to assess relationships between gingivitis and risk factors. RESULTS: We enrolled 1452 participants, of which 40% (n = 582) had signs of clinical gingivitis and 60% (n = 870) clinical health. Average participant age was 23. Most participants (88%) had never received oral health care. Participants averaged 10% of sites with BOP with most (79%) having ≥1 site with BOP. Nine percent of participants had ≥1 site with PD ≥4 mm, although very few participants (0.7%) had sites with PD ≥5 mm. Few participants (13%) had any recession (≥1 mm). In the final adjusted model, odds of gingivitis increased by 3% for each year of age (aOR 1.03, 95% CI 1.00, 1.06) and were higher for women of short maternal stature (< 150 cm) (aOR 1.43, 95% CI: 1.14, 1.79) and among women reporting cost to be a barrier to seeking dental care (aOR 2.13, 95% CI: 1.09, 4.15). CONCLUSIONS: Gingivitis was common and associated with age, maternal stature, self-reported high cost of dental care, and other risk factors among pregnant women in rural Nepal. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study) and NCT02788786 (Pilot Trial).

Norepinephrine augmented in vitro growth of uropathogenic E. coli in Type 2 diabetes mellitus and its suppression by silodosin (alpha blocker).

Norepinephrine is secreted under conditions of stress in humans. The ability of bacteria to sense mammalian hormone may have a role in propagation of infection. The present study investigated the effect of norepinephrine on in vitro growth of uropathogenic E. coli (UPEC) and the effect of silodosin on norepinephrine-induced changes. The spot urine samples were collected from 56 individuals (14 diabetic patients with UTI, 14 diabetic without UTI, 14 non-diabetic UTI and 14 healthy volunteer controls) for the measurement of urinary norepinephrine concentrations. The concentration of norepinephrine, as found in urine of human subjects, was reproduced in artificial urine medium to study the growth of UPEC. The norepinephrine concentration showing maximum growth response was selected to study the effect of silodosin on the growth inhibition of UPEC. Result showed significantly elevated urinary norepinephrine in diabetic patients with and without UTI and also in nondiabetic UTI groups. The norepinephrine concentration equivalent to that in diabetic UTI patients enhanced the growth of UPEC. Furthermore, silodosin (0.32 µM) inhibited the growth of the UPEC.

Oral health knowledge, behavior, and care seeking among pregnant and recently-delivered women in rural Nepal: a qualitative study.

BACKGROUND: Oral health behavior and attitudes of pregnant women in low-income countries are rarely examined, yet should be considered when designing preventative or therapeutic studies to reduce burden of oral diseases. We aimed to understand dental care-seeking behavior, as well as oral health knowledge and attitudes of oral health among pregnant women in rural Nepal. METHODS: Semi-structured in-depth interviews (n = 16) and focus group discussions (3 groups, n = 23) were conducted among pregnant and recently-delivered women in Sarlahi, Nepal. Transcripts were translated from the local language to English then analyzed using a hybrid approach to thematic coding with Atlas.ti version 7. RESULTS: Women felt confident describing the signs and symptoms of tooth decay and gum disease, but were not knowledgeable about where to receive care for tooth and/or gum pain and relied heavily on the knowledge of their community. Some women used a toothbrush and toothpaste at least once a day to clean their teeth, but many reported the traditional use of a branch of a local shrub or tree as their teeth cleaning instrument. Women suggested a willingness to consider using an oral rinse throughout pregnancy, perceiving that it might have a positive impact on infant health. CONCLUSIONS: Future studies should focus on providing adequate and sustainable resources for pregnant women in Nepal and other low income settings to engage in good oral health behaviors (possibly supported through community-based workers), to maintain dental hygiene, and to access qualified dentists as a means of improving their oral health. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study) and NCT02788786 (Pilot Trial).

Testing an association between TLR4 and CXCR1 gene polymorphisms with susceptibility to urinary tract infection in type 2 diabetes in north Indian population.

BACKGROUND: Genetic variations of Toll like receptor 4 (TLR4) and CXC-chemokine receptor type1 (CXCR1), the key elements of innate immune system and their association with urinary tract infection (UTI) were studied in general population. In present study we investigate genetic variation of these genes in diabetic patients (3 to 4 times higher prevalence of UTI in comparison to general population). METHODS: A total 1100 subjects (318 diabetic patients with UTI, 324 diabetic patients without UTI, 200 non-diabetic UTI patients and 260 age matched healthy control) were enrolled in the study. SNPs of TLR4 rs4986790, rs4986791 and CXCR1 rs2234671 was assessed by PCR-RFLP and PCR-SSP respectively. RESULTS: Statistical analysis revealed that A/G genotype and G allele of TLR4 rs4986790 are significantly associated with UTI in both diabetics and nondiabetic patients in comparison to healthy control. Similarly CT genotype and T allele of TLR4 rs4986791 are also significantly associated with UTI in both groups. We also found that prevalence of A/G genotype of TLR4 rs4986790 and CT genotype of TLR4 rs4986791 are significantly higher in patients of diabetes with UTI in comparison to diabetic patients without UTI. We did not find any association of CXCR1 rs2234671 polymorphism with UTI by comparing with any group. CONCLUSION: We found that TLR4 rs4986790 and rs4986791 gene polymorphism is a risk for UTI development in both diabetic and nondiabetic patients in north Indian population.

Coronary artery calcium scoring is a better predictor of cardiac risk in subclinical hypothyroidism patients with low-risk Framingham score.

CONTEXT: Overt hypothyroidism accelerates the cardiovascular disease. Subclinical hypothyroidism (SCH), being considered as a preclinical state, impacts on cardiovascular status is not clear. AIMS: This study was aimed at assessing cardiac risk stratification by Framingham risk scoring (FRS) and coronary coronary artery calcium score (CACS) by noncontrast cardiac computed tomography in SCH. STUDY DESIGN: Observational study. SUBJECTS AND METHODS: We enrolled thirty treatment-naive SCH patients (aged 30-60 years with no serious concurrent medical conditions), thirty euthyroid (age, sex, and body mass index-matched) controls, and ten healthy controls. All cases were evaluated for coronary artery calcium scoring and Framingham risk score. STATISTICAL ANALYSIS: Qualitative data were analyzed using the Chi-square test. In addition, demographics and CACS are summarized graphically or in a table. RESULTS: SCH cases had higher thyroglobulin, while there was a trend toward an increase in total cholesterol, low-density lipoprotein (LDL), very LDL, and decrease in HDL levels. All participants had low-risk FRS (10-year FRS < 10%). The mean CACS in SCH was significantly higher than simple obese and healthy controls (47.17 vs. 2.67 vs. 0.00). CONCLUSION: This study suggests that SCH is an independent risk factor for coronary artery disease in apparently healthy controls. The risk of occult coronary artery disease is increased in SCH cases.

Association of the gonadotrophin-regulated testicular RNA helicase gene polymorphism with human male infertility.

Gonadotrophin-regulated testicular RNA helicase (GRTH) plays an important role in RNA functions including nuclear transcription, pre-mRNA splicing and it regulates the translation of specific genes required for the progression of spermatogenesis. In this study, we analysed the association of GRTH gene IVS6+55G/T and c.852C/T polymorphisms with human male infertility. The study showed c.852 T allele was associated with an increased risk of male infertility (OR: 3.16, P = 0.008), whereas IVS6+55G/T allele conferred no risk. In Indian population, this is the first report on association of GRTH gene SNP polymorphism and male infertility and it underscores the significance of GRTH genotypes in modulating the risk of male infertility.

Management of hirsutism.

Although hirsutism is a frequent and distressing disorder often signaling an underlying endocrine disorder, a systematic approach to evaluation and the use of combination therapy will provide satisfactory treatment for most patients.

Surgical removal of traumatic herniation of buccal fat pad in young children.

Intraoral herniation of the buccal fat pad is traumatic lesion of oral cavity occurring in young children. It frequently presents as an expanding pedunculated mass of soft tissue emanating from the buccal mucosa following a minor trauma to the buccal soft tissues. This article aims to report an interesting and rare lesion, wherein a tiny traumatic perforation of the buccal mucosa and buccinator muscle forced a large portion of the buccal fat pad to extrude into the oral cavity in a young boy. Such a situation can alarm any clinician and reinforces the importance of careful history taking and thorough examination, before treating patients.

Steroid cell tumor: a rare cause of hirsutism in a female.

UNLABELLED: Ovarian steroid cell tumors are very rare functioning sex-cord stromal tumors. They comprise <0.1% of all ovarian tumors. Previously designated as lipoid cell tumors, one-third of these tumors are considered malignant with the mean age of presentation at around 40 years. We present a case of a 28-year-old female with 2-year history of hirsutism, virilization, and amenorrhea. She was diagnosed with left ovarian tumor, for which she underwent left salpingo-oophorectomy. Histopathology revealed not otherwise specified subtype of steroid cell tumors. The patient resumed menses 2 months after the features of masculinization regressed. Within 1 year of surgery, the patient successfully conceived a full-term baby without any complications. In a young female, the neoplastic etiology of a rapid virilization or menses changing should always be kept in mind. Though commonly observed in adult females, steroid cell tumors have very good surgical outcomes if age at presentation is less and tumor is unilateral, and there are no evidences of bilateral malignancy. Bilateral salpingo-oophorectomy is not required. LEARNING POINTS: In a case of severe rapid hirsutism and virilization with serum testosterone level more than 200 ng/dl or more than threefold of the normal range, neoplastic conditions should always be suspected.Steroid cell tumor in young women without evidence of malignancy on histopathology has excellent surgical outcomes.Unilateral salpingo-oophorectomy is the surgery of choice.As the frequency of bilateralism is only 6%, prophylactic unaffected side oophorectomy need not be done.

Cerebrotendinous xanthomatosis: a rare disorder with a rare presentation.

A young man was brought for mental retardation, frequent non-bloody diarrhoea and swellings at ankles and elbow. He became bed-ridden due to cataract, mental retardation and pain in the back and lower limb. There were repeated pathological fractures and vitamin D deficiency without renal dysfunction. There were low low-density lipoprotein and triglyceride levels. MRI of the brain revealed hypointense lesions in cerebellar white matter, heterogenous hyperintensity in dentate nucleus and adjacent white matter, right basal ganglia and in the periventricular region with diffuse cerebral atrophy. T1-weighted MRI (ankle region) revealed bilaterally thickened and irregular achilles tendons with hyperintense masses surrounded by patchy hypointensities. A similar xanthomatous lesion (cholestanol deposits) was also present in the sacral region. Vitamin D and calcium supplementation and chenodeoxycholic acid therapy improved pain at lower limbs and body weight. Cerebrotendinous xanthomatosis is a rare autosomal-recessive familial mutation of the sterol 27 hydroxylase causing lipid metabolic disease.

Primary empty sella with isolated ACTH deficiency and microprolactinoma.

The empty sella turcica is defined as the herniation of the subarachnoid space within the sella with displacement of the pituitary towards the posteroinferior wall. By autopsy studies, the incidence in the general population is around 20%. The association of prolactinoma and empty sella has been coincidental & infrequently reported. As such for microadenoma, visual field testing and screening for hypopituitarism is not needed, but if it is associated with empty sella, both visual field testing and screening for hypopituitarism is necessary.

V-Y gastrocnemius muscle slide with turnover fascial flap for compound Achilles defects: a simple solution.

BACKGROUND: Compound defects of the Achilles region pose a reconstructive challenge. Poor vascularity of the Achilles region predisposes to complications. Repair of the tendon with simultaneous soft-tissue cover gives the patient the best chance to recover. MATERIALS AND METHODS: Gastrocnemius musculotendinous V-Y slide for Achilles tendon defect with non-axial turnover fascial flaps based on the proximal end of the defect with a split-skin graft on the fascial flap was used in two patients. The vascular bases of such flaps and the technical details has been discussed. RESULTS: The functional and aesthetic results were highly satisfactory with minimal donor-site morbidity. The flap was thin enough to fit the contour of the Achilles region. The fascial flap with skin graft was durable and withstood footwear well. The flap also allowed tendon gliding beneath it, with near-complete movements at the ankle joint. CONCLUSION: Large flaps can sufficiently be raised with a wide base to cover small- to medium-sized defects. It is a good, rapid and cost-effective solution for a difficult clinical problem.

Cystathionine B-Synthase 844ins68 Gene Variant and Idiopathic Male Infertility.

Male infertility is a multifactorial disorder that affects approximately 10% of couples at childbearing age, with substantial clinical and social impact. The main regulating enzymes in folate and homocysteine metabolism are methylenetetrahydrofolate reductase (MTHFR) and cystathionine beta-synthase (CBS). In our previous study, we showed that a mutation C677T in the gene, MTHFR is a risk factor for idiopathic male infertility in the Indian population. To assess that a common polymorphism in the cystathionine beta-synthase (CBS) gene (844ins68) is acting as susceptibility factor for male infertility or not, we investigated this variant in 120 idiopathic male infertile patients and 200 fertile male controls. No significant association was observed (OR = 0.8348, 95% CI: 0.1578 to 4.4164, chi(2) = 0.040, P > .05); therefore we conclude that this common 844ins68 variant is a neutral insertion variant for idiopathic male infertility in the Indian population.

Thyroid hormone resistance.

Thyroid hormone resistance (THR) is a rare syndrome of reduced end organ sensitivity. Patients with THR have elevated serum free thyroxine (FT4), free triiodothyronine (FT3), but normal or slightly elevated serum thyrotropin values. The characteristic clinical feature is goitre without symptoms and metabolic consequences of thyroid hormone excess. THR can be classified on the basis of tissue resistance into pituitary, peripheral or generalised (both pituitary and peripheral) types. Mutations in the TRbeta gene, cell membrane transporter and genes controlling intracellular metabolism of thyroid hormone have been implicated. THR is differentiated from thyroid stimulating hormone (TSH) secreting pituitary adenoma by history of THR in the family. No specific treatment is often required for THR; patients with features of hypo- or hyperthyroidism are appropriately treated with levo-triiodothyronine (L-T3), levo-thyroxine (L-T4), dextro-thyroxine(D-T4) or 3,3,5 triiodo-thyroacetic acid (TRIAC). The diagnosis helps in appropriate genetic counselling of the family.