Symmetrical peripheral gangrene and Roth spots in a patient with infective endocarditis.

We present a case of a young man with symmetrical peripheral gangrene (SPG) resulting from Streptococcus viridans-related infective endocarditis, an association which has not previously been reported. SPG is associated with up to 40% mortality and may necessitate amputation; early identification and treatment of the precipitating factors is very important.

The 'myth of Hydroxychloroquine (HCQ) as post-exposure prophylaxis (PEP) for the prevention of COVID-19' is far from reality.

The efficacy of Hydroxychloroquine (HCQ) as post-exposure prophylaxis (PEP) for the prevention of COVID-19 was contentious. In this randomized control double-blind clinical trial, asymptomatic individuals with direct contact with laboratory-confirmed COVID-19 cases were randomized into PEP/HCQ (N = 574) and control/placebo (N = 594) group. The PEP/HCQ group received tablet HCQ 400 mg q 12 hourly on day one followed by 400 mg once weekly for 3 weeks, and the control/Placebo group received matching Placebo. The incidence of COVID-19 was similar (p = 0.761) in PEP [N = 24 out of 574, (4.2%)] and control [N = 27 out of 594, (4.5%)] groups. Total absolute risk reduction for the incidence of new-onset COVID-19 was -0.3% points with an overall relative risk of 0.91 (95% confidence interval, 0.52 to 1.60) and the number needed to treat (NNT) was 333 to prevent the incident of one case of COVID-19. The study found that, PEP with HCQ was not advantageous for the prevention of COVID-19 in asymptomatic individuals with high risk for SARS-CoV-2 infection. Though HCQ is a safer drug, the practice of irrational and indiscriminate use of HCQ for COVID-19 should be restrained with better pharmacovigilance.

Formulation and Characterization of Self-Microemulsifying Drug Delivery System (SMEDDS) of Sertraline Hydrochloride.

BACKGROUND: Sertraline hydrochloride is the most widely used selective serotonin reuptake inhibitor (SSRI) for the treatment of several depressive disorders. Its applicability is limited due to extensive metabolism and poor oral bioavailability of 44 %. OBJECTIVE: The current research focused on improving the solubility and oral bioavailability of Sertraline by using microemulsions developed by a self-micro emulsifying drug delivery system (SMEDDS) for significant antidepressant action. METHOD: SMEDDS were developed by selecting appropriate proportions of oil, surfactant, and co-solvents and out of them isopropyl myristate, tween 80 and propylene glycol were identified as best. The emulsification zone was demonstrated by a ternary phase diagram, and compatibility was confirmed with Fourier-transformed infrared spectroscopy (FT-IR). The formulated SMEDDS were characterized for robustness to dilution, globule size (GS), polydispersity index (PDI), viscosity, in-vitro dissolution and diffusion study, and drug release kinetics study. RESULTS: All the batches (A1-A9) passes the test and A3 was selected as an optimized batch that doesn't show phase separation, precipitation with globule size (101 nm), PDI (0.319), drug content (99.14±0.35 %), viscosity (10.71±0.02 mPa), self-emulsification time (46 sec), in-vitro drug release (98.25±0.22 %) within 8 h, release kinetics (Higuchi) and effective antidepressant in in-vitro diffusion studies. CONCLUSION: An optimized batch A3 observed circular in shape estimated by Transmission electron microscopy (TEM) and passes all the thermodynamic stability testing with loss of 0.271 mg of the drug after 90 days and showed marked antidepressant action with higher stability.

Efficacy and safety of CARTIGROW® in patients with articular cartilage defects of the knee joint: a four year prospective studys.

INTRODUCTION: Research shows autologous chondrocyte implantation (ACI) is a promising treatment for articular cartilage lesions. In this study, we assessed mid-term efficacy and safety of gel-based ACI or autologous adult live cultured chondrocytes (CARTIGROW®) implantation in patients with cartilage defects of the knee joint. METHODS: In this prospective, open-label study, patients (19-38 years) with focal, international cartilage repair society grade III or IV articular cartilage defects of the knee joint were enroled at four centres across India from April 2015 to September 2015. Punch biopsy was conducted to harvest cartilage, from which chondrocytes were isolated and cultured, and the characterised chondrocytes were implanted into the cartilage defect. Key efficacy outcomes were assessed by quantitative changes in international knee documentation committee (IKDC), visual analogue scale (VAS) scores, and qualitative changes in magnetic resonance imaging at six months and four years from baseline. RESULTS: Of the14 patients enroled in the study, all patients completed the six month follow-up and 11 completed the four year follow-up. The IKDC score improved significantly from 32.84 ± 9.25 at baseline to 67.49 ± 13.03 at six months (mean difference [MD] 34.66 ± 13.00, p < 0.0001) and to 60.18 ± 10.33 at four years (MD 28.21 ± 15.14, p = 0.0001). The VAS score reduced from 72.00 ± 14.40 at baseline to 16.64 ± 17.03 at six months (MD 55.36 ± 24.50, p < 0.0001) and further to 12.72 ± 9.05 at four years (MD 62.09 ± 10.66, p < 0.0001). All patients showed improvement on MRI of the knee joint. No adverse events were reported. CONCLUSION: Autologous adult live cultured chondrocytes (CARTIGROW®) implantation showed good mid-term efficacy in patients with cartilage defects of the knee joint with no side-effects.

Autonomic dysfunction with areflexic quadriplegia: An unusual presentation of snake envenomation.

Rapidly progressing descending areflexic quadriplegia with autonomic dysfunction in the form of hypertension, tachycardia, hypersalivation, sweating and lacrimation in the absence of proper history from attendants poses a challenge in emergency area. Neuroparalytic snake envenomation by elapid species has been known to produce autonomic symptoms and even locked-in states. Here we present a case of young male with rapidly progressing areflexic quadriplegia with autonomic dysfunction; with no documented history of snake bite who improved after antisnake venom and ventilatory support.

A Retrospective Observational Study of Neurological Manifestations in COVID-19 (SON-CoV).

OBJECTIVES: Coronavirus disease 2019 (COVID-19) has neurologic manifestations associated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study aimed to retrospectively analyze SARS COVID-19 patients with neurological manifestations and identify patterns of presentation including the site of neuroaxis involvement, neuroimaging, and associated systemic involvement. METHODS AND SUBJECTS: This retrospective observational study was conducted at two tertiary care hospitals in western Rajasthan. Data on age, sex, presenting symptoms, and comorbidities (hypertension, diabetes, cardiac, cerebrovascular disease, and cancer) were collected from 28th February 2020 to 31st December 2020 through medical records, discharge summaries, and radiological studies. Verbal/written patient consent was obtained due to the prevailing COVID-19 norms at the time of the first wave. Major inclusion criteria were as follows: age >18 years, consent from patient/surrogate, positive RT-PCR report in case of active COVID cases, or positive COVID antibody test in case of post-COVID neurological sequelae. All neurological manifestations were reviewed by at least two neurologists and were divided into central nervous system (CNS) and peripheral nervous system (PNS) manifestations. Systemic features and their temporal relationship with neurological features were recorded. Various other specialized assessments and therapeutic interventions were conducted. Statistical analysis was performed using the SPSS software. A Chi-square test was performed to determine the association between variables. Student's t-test and one-way analysis of variance were used to determine differences in mean values. Statistical significance was set at p < 0.05. RESULTS: The mean age was 57.32 years for the CNS group and 40 years for the PNS group (p = 0.025). Age was significantly lower in the PNS group than in the CNS group (p = 0.025). Anemia, leucocytosis, and elevated serum creatinine were more commonly seen in the CNS group, although the difference was not statistically significant. The most common CNS manifestations were stroke (41.8%), of which ischemic stroke constituted 83% of cases, followed by seizure (22%), encephalopathy (20.9%), headache (15.1%), and vertigo (3.8%). The most common PNS manifestation was neuropathy (57%), which included Guillain-Barré syndrome (GBS), critical illness neuropathy, and autonomic neuropathy Conclusion: CNS symptoms of COVID-19 are more common than PNS symptoms. Stroke is the most frequent (46%) COVID-CNS symptom, which occurs in people of age above 35 years and is associated with high mortality.

Amelioration of diethylnitrosamine (DEN) induced renal oxidative stress and inflammation by Carissa carandas embedded silver nanoparticles in rodents.

INTRODUCTION: Inflammation and oxidative stress are the main factors ascribed with interruption in the process of renal tissue impairment. The toxicity of different types of nitrosamine is well recognized in animals and humans. Administration of the smallest quantities of diethylnitrosamine or dimethylnitrosamine either orally or parenterally results into renal damage. Therapeutic effects of phytofabricated silver nanoparticles of Carissa carandas aqueous extract has been scrutinised in current study for the assessment of renal cancer activity in animal model. METHODOLOGY: Phytofabricated silver nanoparticles were characterized by using different instrumentation. Nephroprotective activity of silver nanoparticles at different doses was evaluated against N-diethylnitrosamine (200 mg/kg b.w., intraperitoneal) in animal model. Serum and renal homogenate were taken to evaluate the renal toxicity markers, oxidative stress, and antioxidant parameter, proinflammatory cytokines and histopathological study. RESULT: Significant outcomes of silver nanoparticles in dose dependent manner down regulated the elevated serum marker, tumour marker enzymes and histopathology observation of repaired tissue assured the renal cancer activity in animals. In addition, profile of enzymatic and non-enzymatic antioxidant, proinflammatory cytokines and tumour promotion marker also favours the anticancer property of silver nanoparticles. CONCLUSION: The data of current study reveals silver nanoparticles ameliorates renal oxidative stress and carcinogenesis which was induced by N-diethylnitrosamine and accredited to antioxidant and anticancer activities of phytofabricated nanoparticles by biological approach.

Management Guidelines for Infection After ACL Reconstruction: Expert Opinion Statement Based on the Modified Delphi Survey of Indian Arthroscopy Surgeons.

AIM: Infection after anterior cruciate ligament (ACL) reconstruction, though rare, is a potentially devastating complication and the evidence-based recommendation on the various topics in its management is limited. The purpose of this study was to develop recommendations for the prevention and management of infections in ACL reconstruction surgery by performing a structured expert consensus survey using Delphi methodology. MATERIALS AND METHODS: 22 topics of relevance in the prevention and management of infection following ACL reconstruction were chosen from an extensive literature review. 30 panelists were requested to respond to a three-round survey, with feedback, to develop a consensus statement on the topics. RESULTS: Consensus statements could be prepared in eleven out of twenty-two topics including: the graft is retained at the first arthroscopic debridement, the graft is removed when repeated debridement are needed, and revision ACL reconstruction is needed only if the patient develops instability. Concurrence could be obtained in the topics including: longer duration of antibiotics is needed in immunocompromised patients, soaking graft in antibiotic solution reduces infection risk, and knee swelling without warmth does not suggest infection. CONCLUSIONS: A proper skin preparation, a longer course of antibiotics in immunocompromised patients, and soaking the graft in antibiotics reduces the risk of infection. In case of infection, a healthy-looking graft must be retained at the first debridement and if the graft must be removed, revision ACL reconstruction is advised only if the patient develops instability. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00363-z.

Preparation and Surface Modification of Polymeric Nanoparticles for Drug Delivery: State of the Art.

Nanotechnology is one of the emerging fields in drug delivery for targeting the drug to the site of action. The polymeric nanoparticles as drug delivery systems have gained importance for the last few decades. They offer advantages over liposomes, dendrimers, emulsions etc. Surface engineering of polymeric nanoparticles is widely utilized to effectively target the cells in various diseases such as cancer, HIV infection. Surface modified nanoparticles offer various advantages such as targeted drug delivery, reduction in side effects, dose reduction and improved therapeutic efficacy. Moreover, they can aid in improving physical and biochemical properties, pharmacokinetic and pharmacodynamic profiles of the drug. Surface modified polymeric nanoparticles can provide targeted delivery of drugs into specific cells, especially when targets are intracellularly localized. This approach of surface modification would be more advantageous for the delivery of various anticancer, anti-inflammatory, anti-HIV drugs for more effective therapy. This review focuses on the techniques used for the fabrication of polymeric nanoparticles, the material used for surface modification and their applications.

Incidence, management and outcome assessment of post operative infection following single bundle and double bundle acl reconstruction.

INTRODUCTION: Post-operative infection is a dreadful complication of ACL reconstruction with gray zone over management guidelines. We aimed to establish commonest etiology, assess incidence of infection and effect on outcome, individually for single and double bundle ACL reconstruction techniques, so as to formulate appropriate management guidelines. METHODS: Our prospective study involved 1152 patients operated for ACL reconstruction (437- DBACL, 715- SBACL) from 2010-2013. Post-operative infection was diagnosed clinically supported by positive gram stain/ culture and increased cell count in knee aspirate. All patients were started on empirical antibiotics and arthroscopic lavage and debridement was done. Graft was retained if it was stable and intact. Data recorded at follow up was analysed statistically. RESULTS: In SBACL infection rate was 0.84% while in DBACL it was 2.52%. All patients with infection presented with pain, effusion, fever and increased WBC, ESR & CRP. Average time of presentation after the surgery was 2.27 weeks for DBACL and 2.16 weeks for SBACL. In both groups, S.aureus followed by S. epidermidis were commonest isolates. Patients were given IV antibiotics for 2 weeks and oral for further 4 weeks. DISCUSSION: Incidence of infection is higher with the double bundle technique, however, the functional outcome is not affected (p value 0.231). Joint aspirate is the gold standard diagnostic test for infection. CRP and ESR are the next dependable tests with high sensitivity but their specificity is low. A thorough debridement is necessary apart from recommended antibiotic cover of 2 weeks IV followed by 4 weeks oral antibiotics.

Reversal agents: do we need to administer with neuromuscular monitoring - an observational study.

BACKGROUND AND AIMS: In clinical practice, in the majority of patients, recovery from the effect of muscle relaxants is assessed using subjective methods such as head lift, eye-opening, or by sustained hand grip after giving anticholinesterases (neostigmine) at the end of surgery. We planned a prospective observational cohort study to test the hypothesis that objective neuromuscular monitoring can help us in avoiding the use of anticholinesterases for reversal. METHODS: The patients posted for surgery of <2 h duration were included in the study. The cohort of patients was formed on the basis of those who were exposed to objective neuromuscular monitoring of recovery (train-of-four [TOF] ratio of 0.9 or more; exposed group) and the patients who were not exposed to objective neuromuscular monitoring (non-exposed group) acting as a control. Using objective neuromuscular monitoring, the time required for recovery from muscle relaxation when neostigmine was not given for reversal was noted and it was then compared with that of the control group. RESULTS: A total of 190 patients were enrolled over a period of 3 years. With the use of TOF ratio of 0.9 for extubation, patients safely recovered from neuromuscular blockade, without using neostigmine, with no difference in the mean recovery time (14.48 ± 1.138 min) as compared to the control group (12.14 ± 1.067 min, P = 0.139). There was no incidence of reintubation in post-operative period. CONCLUSION: With objective neuromuscular monitoring, we can ensure complete recovery from the neuromuscular blockade while avoiding the use of anticholinesterases.

Anthropometric and Radiologic Measurements of Coracoid Dimensions and Clinical Implications in an Indian Population.

BACKGROUND: Recurrent shoulder dislocation and anterior instability are most commonly attributed to pathology of the capsulolabral complex with the presence of bony loss at the humeral and glenoid surfaces. Unassessed bone loss has been a cause of failure of primary soft tissue procedures or recurrence of symptoms, despite adequate address of soft tissue pathology. PURPOSE: To study the anthropometric and radiologic dimensions of the coracoid in relation to glenoid bone loss, its adequacy in filling glenoid defects in an Indian population, and whether the choice of surgical technique (congruent arc vs classical) and graft positioning alters the surgical results. This study also intended to establish whether computed tomography measurements correlate with actual anthropometric measurements. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 64 participants with 108 healthy shoulders were included in this study. Additionally, 100 skeletally mature bone specimens of the scapula were measured to assess glenoid diameter as well as coracoid width and length in 2 perpendicular planes with a humeral subtraction 3-dimensional en face glenoid view. RESULTS: Specimen and participant measurements proved that the congruent arc technique was able to fill up to 50% more glenoid bone loss than the classical technique in an Indian population (mean ± SD, 13.45 ± 6.97 vs 7.96 ± 4.89 mm, respectively), with computed tomography being the best and most accurate modality to study it. The mean difference in the bone block length restoration of the glenoid bony arc was 5.41 ± 2.08 mm. Radii of curvature were congruent in populations of the Indian subcontinent. CONCLUSION: The congruent arc technique can be performed in an Indian population but with caution and careful presurgical assessment of bone loss. However, adequate coracoid dimension to accommodate the implant for fixation without failure must be ensured, as anthropometry suggests the existence of a subset of the population in whom the graft may have compromised width for accommodating standard implants for fixation.

Capsulotomy as a measure to control pain and reducing hemarthrosis in arthroscopic DB ACL reconstruction surgery: a prospective randomized control study.

PURPOSE: The aim of the study was to evaluate the effect of capsulotomy as a measure of pain relief and hemarthrosis prevention in the arthroscopic double-bundle anterior cruciate ligament reconstruction. METHODS: This was a case control study conducted between April 2013 and Dec 2013, in which 64 patients were enrolled. Capsulotomy was done at the end of the procedure in 31 patients, who were compared with a control group. Pain score (VAS) and grade of hemarthrosis on post-op day 1 and post-op day 2 were compared between the two groups and patients followed up to a minimum of 24 months. RESULTS: There was a statistically significant difference (p value < 0.05) in the pain scores and hemarthrosis grade of the capsulotomy group compared to the control group. The mean pain score on post-op day 1 in the capsulotomy group was 2.71 ± 0.97, whereas it was 4 ± 1.22 in the non-capsulotomy group. The difference between the two groups was statistically significant both at day 1 of post-op and day 2 of post-op (p value < 0.05). The difference between the two groups in terms of hemarthrosis grading was statistically significant both at day 1 of post-op and day 2 of post-op (p value < 0.05). The difference between the two groups in terms of thigh circumference measurements was statistically significant both on day 1 and day 2 of post-op (p value < 0.05). CONCLUSION: We conclude that capsulotomy is a safe and effective measure of pain relief and hemarthrosis management in arthroscopic ACL reconstruction surgeries.

Practice Guidelines for the Management of Multiligamentous Injuries of the Knee.

BACKGROUND: Multiligamentous injuries of knee remain a gray area as far as guidelines for management are concerned due to absence of large-scale, prospective controlled trials. This article reviews the recent evidence-based literature and trends in treatment of multiligamentous injuries and establishes the needful protocol, keeping in view the current concepts. MATERIALS AND METHODS: Two reviewers individually assessed the available data indexed on PubMed and Medline and compiled data on incidence, surgical versus nonsurgical treatment, timing of surgery, and repair versus reconstruction of multiligamentous injury. RESULTS: Evolving trends do not clearly describe treatment, but most studies have shown increasing inclination toward an early, staged/single surgical procedure for multiligamentous injuries involving cruciate and collateral ligaments. Medial complex injuries have shown better results with conservative treatment with surgical reconstruction of concomitant injuries. CONCLUSION: Multiligamentous injury still remains a gray area due to unavailability of a formal guideline to treatment in the absence of large-scale, blinded prospective controlled trials. Any in multiligamentous injuries any intervention needs to be individualized by the presence of any life- or limb-threatening complication. The risks and guarded prognosis with both surgical and non-surgical modalities of treatment should be explained to patient and relations.

Outcome of repair of chronic tear of the pectoralis major using corkscrew suture anchors by box suture sliding technique.

AIM: To assess the functional and clinical results of repair of chronic tears of pectoralis major using corkscrew and sliding suture technique. METHODS: In this retrospective study, we reviewed the results of pectoralis major repair in 11 chronic cases (> 6 wk) done between September 2011 and December 2014 at our institute. In all cases repair was done by same surgeon using corkscrew suture anchors and box suture sliding technique. At 6 mo, after surgery magnetic resonance imaging was done to see the integrity of the repair. Functional evaluation was done using Penn and ASES scores. Pre and postoperative Isokinetic strength was measured. RESULTS: Average follow-up was 48.27 ± 21.0 mo. The Wilcoxon signed rank test was used to evaluate the outcome scores. The average ASES score increased from an average of 54.63 ± 13.0 preoperatively to 95.09 ± 2.60 after surgery at their last follow-up. The average Penn score also increased from 5.72 ± 0.78, 2.81 ± 1.32 and 45.81 ± 1.72 to 9.36 ± 0.80, 8.27 ± 0.90 and 59 ± 1.34 for pain, satisfaction and function respectively. Follow up magnetic resonance imaging (MRI) (at 6 mo) showed continuity and the bulk of pectoralis major muscle in all cases. Average isokinetic strength deficiency in horizontal adduction at 60° was 13.63% ± 6.93% and at 120° was 10.18% ± 4.93% and in flexion at 60° was 10.72% ± 5.08% and at 120° was 6.63% + 3.74%. Results showed that both ASES and Penn score improved significantly (2 tailed P value = 0.0036). CONCLUSION: We could conclude from this series that pectoralis major repair even in chronic cases using 5.5 mm corkscrew anchors give excellent functional and cosmetic results. In chronic cases the repairable length of the tendon is not available and sliding suture technique allows for fixation of worn out tendomuscular junction to bone without letting cutting through the muscle.

A six months old neglected anterior shoulder dislocation managed by closed reduction and Latarjet procedure.

A neglected shoulder dislocation is a rarer entity and only few cases are reported in the literature. An anterior dislocation of the shoulder is rarely missed as patients present with limb in abduction and external rotation, an attitude very familiar to orthopaedic surgeon. Occasionally such cases are missed when they present with fracture of proximal humerus or when they receive treatment from unqualified practitioners who commonly practise in rural areas. Owing to very few reports there is paucity of literature and no standard treatment protocol exists for neglected anterior dislocation of the shoulder, though most such chronic cases are managed by open reduction. This case report describes a six months old neglected anterior dislocation with a significant Hill Sachs lesion, which was managed by closed reduction and Latarjet procedure.