Reverse cardio-oncology: A budding concept.

Having established the significance of cardiovascular side-effects of anti-neoplastic drugs, present day cardio-oncology has forayed into newer territories buoyed by research into the multiple connections that exist between cardiovascular disease and cancer. An emerging concept of reverse cardio-oncology focuses on the heightened risk of cancer in patients with cardiovascular disease. Common mechanistics of cancer and heart failure (HF) like chronic inflammation and clonal haematopoesis as well as common predisposing factors like obesity and diabetes underline the relation between both cardiovascular disease and various cancers.This review discusses the potential magnitude of the problem, the underlying pathophysiological mechanisms and classification of this novel subject.

Rheumatoid Arthritis Co-relation with Anti-CCP Antibodies with special reference to its Prevalence in Asymptomatic First-Degree Relatives.

Objectives: Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune disease. First-degree relatives (FDR) of patients with RA sharing genetic and environmental risk factors for RA may represent a pre-RA state. This study showed the clinical co-relation of RA with Anti-Cyclic citrullinated peptide (anti-CCP) antibody and prevalence of sero-positive anti-CCP antibody in asymptomatic first-degree relatives (AFDR) of rheumatoid arthritis patients. Methods: Total 85 RA patients, 105 AFDR, and 105 healthy controls who belonged to the same geographical area having no family history of autoimmune diseases were enrolled in this cross-sectional study. RA patients were clinically examined, and DAS-28 was calculated. Anti-CCP was sent for RA patients, AFDR, and control group. Appropriate statistical tools were applied to find if any significant co-relation exists. Results: DAS 28 co-related significantly with anti-CCP positivity (p≤0.01) but not with Rheumatoid Factor (RF). No significant co-relation was observed between anti-CCP and extra-articular manifestation (EAM) (p≥0.05). Seropositivity for anti-CCP antibody was detected in 22/105 (20.9%) AFDR and in 13/105 (12.3%) control group respectively. Anti-CCP antibody seropositivity was more prevalent in AFDR than in control group but the difference was not statistically significant (p = 0.1378). Conclusions: Anti-CCP should be preferred over RF as it correlated well with disease activity, but it does not guide well for the EAM. The higher sero-prevalence of Anti-CCP in AFDR may lead to higher risk of development of RA in near future. Thus, all AFDR should be screened so that we may follow up the positive cases for early detection and treatment of RA.

Clinico-Laboratory Profile, Complications and Therapeutic Outcome of Scrub Typhus in Children.

BACKGROUND: Scrub typhus, an important cause of undifferentiated fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to describe the clinico-laboratory profile, drug used in treatment, predictor of PICU admission and therapeutic outcome of serologically confirmed scrub typhus among Nepalese children. METHODS: A prospective observational study was carried out in children aged up to 14 years with serologically (IgM ELISA) diagnosed Scrub typhus, admitted in a tertiary care hospital of central Nepal between Jan 2019 to Dec 2019. RESULTS: All 100 children with scrub typhus presented with fever. Other symptoms and sign were cough (29%), abdominal distension (22%) hepatomegaly (45%), splenomegaly (28%), crepitation (10%) and eschar (6%). Similarly, thrombocytopenia (72%), and increased liver enzymes SGPT (51%) and SGOT (62%) were found. Co-infection with dengue (5%) brucella (5%) and UTI (5%) were seen. Thirty six percent has some form of complication. Fifty eight percent of children were treated with azithromycin and 25% treated with doxycycline. The mean length of hospital stay was 6.68 ±2.97 days with a mean duration of defervescence being 30.07 ± 26.65 hours. The increased risk of PICU admission was found in those children with crepitation in chest (OR: 15.17, 95% CI: 3.4-66.8) during presentation and those children not getting azithromycin as treatment (OR: 3.8, 95% CI: 1.2-11.7) Conclusions: Scrub typhus should be considered as a differential diagnosis in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Sepsis, meningitis and pneumonia are important complications. Child having crepitation on presentation has an increased chance admission in critical care unit. The child receiving azithromycin has less chance to land in PICU.

Role and Outcome of Laparoscopic/Minimally Invasive Surgery for Variety of Colorectal Emergencies.

BACKGROUND: Recently, the laparoscopic or minimally invasive approach has become common practice for planned colorectal malignancies. Its use in the emergency setting is limited by various factors, including resource availability and surgical expertise. However, more recent evidence suggests a laparoscopic approach to colorectal emergencies, which is comparable with laparoscopic routine work, and often promising. In this study, authors have investigated the outcome of the laparoscopic approach in both benign and malignant colorectal emergencies. METHOD: Retrospective analysis of prospectively collected data (theater records, histology database, and discharge records) over the course of 9 years. The standard surgical approach included conventional laparoscopic and single-port technique (single-incision laparoscopic surgery). The outcome variables included in the final analysis were: success of the minimally invasive approach, conversion rate, postoperative complications, return to theater, and mortality. RESULTS: A total of 202 (males, 110 and females, 92) emergency patients with a median age of 59 years underwent surgery between December 2009 and 2019. The mean operating time was 169 minutes and median American Society of Anesthesiology grade III. Single-incision laparoscopic surgery was used in 19 patients (9.4%). The conversion to open surgery was 12.3% (n=25). The majority of them had primary anastomosis (n= 132, 65.3%).The complications from most to least frequent were: CONCLUSION:: The favorable results obtained in this study underline the theme that with the availability of resources and expertise, it is possible to offer minimal invasive approach to emergency colonic pathology.

Sensitivity and Specificity of the Neutrophil-lymphocyte Ratio in the Diagnosis of Acute Appendicitis.

OBJECTIVE: Acute appendicitis is a common surgical emergency; however, its misdiagnosis resulting in negative appendicectomy is not uncommon. Novel diagnostic methods will help reduce the rate of negative appendicectomy. We hypothesise that the neutrophil-lymphocyte ratio (NLR) will increase upon peritoneal involvement by inflammation, as it does in severe disease. METHODS: We conducted a retrospective analysis on prospectively collected data for all emergency appendicectomy patients during the study period. We studied blood results at the time of presentation, and histology of the removed appendices. Receiver Operating Characteristics were calculated to classify histologically normal versus inflamed appendices and moderate versus severe disease. Moderate disease was that confined to the sub-serosal layers, while severe disease involved the serosa and beyond. RESULTS: A total of 372 patients underwent emergency appendicectomy, 254 (78.4%) of which subsequently had acute appendicitis on histology. Sixty-five (25.6%) and 189 (74.4%) patients had moderate and severe disease, respectively. The median age was 27 years (range 16-84). In diagnosing acute appendicitis, the cut-off value of the NLR was 4.2, while the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 79.5%, 67.0%, 89.8%, and 47.5%, respectively. In identifying the moderate versus severe disease, the cut-off value was 9.7, while the sensitivity, specificity, PPV and NPV were 71.4%, 53.8%, 85.4% and 43.7%, respectively. CONCLUSIONS: Inflammatory markers are useful adjuncts to history, examination, and radiological investigations in making the diagnosis of appendicitis. However, due to low sensitivity and specificity, they cannot be used alone. Calculation of the NLR has no additional benefit over the neutrophil count in diagnosis, or in distinguishing moderate and severe disease.

Quality of life among HIV-tuberculosis co-infected patients.

BACKGROUND: India is the world's third leading country in terms of people living with human deficiency virus (HIV) (2.1 million) with 0.4 million deaths due to HIV-associated tuberculosis (TB). Physical and mental stress degrades the quality of life (QOL) in these patients. Studies have been done in HIV patients but very few on HIV-TB co-infected patients. Our study aims at assessing and comparing the QOL in HIV patients with and without TB. MATERIALS AND METHODS: It was a cross-sectional study done at Antiretroviral Treatment Center of KMC, Mangalore and District Wenlock Hospital, Mangalore, over 6 months. A sample size was 104. Semi-structured questionnaire to collect clinico-demographic data, World Health Organization QOL (WHOQOL)-HIV BREF to assess the QoL, and Beck's Depression Inventory Scale (Physical health, psychological well-being, social relationship, environmental health, level of independence, and spiritual health) to identify depression were used. The Cronbach's alpha was used to measure the internal consistency for each domain of the WHOQOL-HIV instrument. RESULTS: HIV-TB co-infected patients had a lower mean score in all domains as compare to only HIV patients, suggesting that HIV-TB co-infected patients had a poor QOL (P < 0.05). Internal consistency of each domain was good (α >0.7). CONCLUSION: To improve the QOL in HIV patients, it is important to identify the determinants of QOL and work toward its improvement.

An atypical initial presentation of AIDS as cryptococcal lymphadenitis.

A patient complained of fever on and off, difficulty in swallowing and cough (with scanty expectoration) since one and a half months and weight loss over 2 months. On examination, pallor was found to be present. Then ultrasonography of abdomen was done and it showed mesenteric and retroperitoneal lymphadenopathy. Sputum for acid-fast Bacilli was examined and found to be negative but despite this, based on the epidemiological data, antitubercular therapy (ATT) was started but after 2 weeks no clinical improvement was found. Then, fine-needle aspiration cytology of lymph node was done and it resulted in the presence of cryptococcal lymphadenitis as the final report. Antifungal therapy was initiated with amphotericin B followed by fluconazole and there was clinical improvement. Ultrasonographical findings also supported it. Though it is a rare case (but not impossible) that cryptococcus is the cause of lymphadenopathy. Thus, in initial presentation of acquired immuno deficiency syndrome it should always be kept in mind that such cases may happen. In India, presuming Mycobacterium tuberculosis as the leading cause exposes the patient to unwanted hepatic and renal toxicity of ATT.

Etiological Yield of Global Developmental Delay in Kanti Children's Hospital.

INTRODUCTION: Global developmental delay is the common pediatric problem having spectrum of underlying causes. Etiological diagnosis is very vital for providing information regarding pathogenesis, prognosis, recurrence, risk and treatment options. The aim of this study was to determine etiological yield of global developmental delay. METHODS: This descriptive cross-sectional study included children of 6 months to 5 year of age with global developmental delay referred to pediatric outpatient Neurology clinic of Kanti Children's Hospital. Diagnostic study included detailed history, examination followed by required investigations neuroimaging, electroencephalogram, hearing and visual assessment. Thyroid function test, karyotyping and enzyme essay were done in selected patients depending on the condition. RESULTS: In this study, 110 patients were evaluated out of which 70 were male and 40 were female. An etiological diagnosis was determined in 86 (78%) of the patients classified under following categories perinatal asphyxia 49 (44.5%), post infectious sequelae 11 (10%), cerebral dysgenesis 6 (5.45%), genetic syndrome 6 (5.45%), metabolic causes 5 (4.54%), neurocutaneous syndrome 4 (3.63%) and non-specific leucodystrophy changes . Etiology was unknown in 24 (21 %) of the patients. CONCLUSIONS: A specific etiology can be determined in majority of cases of global developmental delay after comprehensive evaluation. The most common etiologies were perinatal asphyxia and post infectious sequelae.

Is There a Preventive Role for Vernix Caseosa?: An Invitro Study.

BACKGROUND: Vernix caseosa is a naturally occurring substance covering the skin of the newborn babies. Chemical composition of Vernix caseosa has been studied. But the antibacterial properties have not been explored phenotypically. There has been only a few studies related to the properties of Vernix caseosa (VC) and most of them focused on deciphering the chemical nature of VC. These studies found that VC has enzymes such as lysozyme, cathelicidin, lactoferrin, defencins, etc, but no study has proved their presence phenotypically. AIM: To know the anti-bacterial and mechanical barrier properties of VC. MATERIALS AND METHODS: A cross-sectional study done at Government Lady Goshen Hospital, Mangalore, India. Subjects- 63 healthy infants born by LSCS (Lower Segment Caesaren Section) (Confidence interval- 95%, Power- 90%). In lab, sterility of Vernix caseosa was determined. Lawn culture of S.aureus and E.coli on nutrient agar was done and wells were made in it. Vernix broth was prepared using Tween 80 and was put into the well. It was incubated overnight at 37°C and observed for area of Decreased Bacterial Growth (DBG) around the well. Filter papers impregnated with VC were used for testing for mechanical barrier properties. STATISTICAL ANALYSIS: Data was entered in SPSS 12.0 version and analysed. The zone of inhibition (in mm) in case of bacterial growth was expressed as mean with standard deviation. Student's independent t-test was used to compare the means across the groups (males and females). RESULTS: There was no significant difference in the anti-bacterial property based on gender. DBG {mean (SD)} for E.coli and S.aureus was 18.06 mm (1.56) and 13.34 mm (1.94) respectively (p-value <0.000). Result for mechanical barrier was inconclusive due to limitations explained in the article. CONCLUSION: Vernix caseosa has antibacterial properties. But further studies are needed to explore the mechanical barrier properties against bacteria.

Evaluation of adverse drug reactions in HIV positive patients in a tertiary care hospital.

CONTEXT: The advancement and development of new drugs and treatment strategies increase the risk of unusual Adverse Events (AEs) in HIV patients. AIMS: The objective of our study was to assess the incidence, types and nature of AEs in HIV positive subjects. SETTINGS AND DESIGN: Patients with WHO stage IV disease irrespective of the CD4 cell count, or WHO stage III disease with a CD4 cell count <350 cell/cu. Mm, or, WHO stage I or II disease with a CD4 cell count of <200 cells/cu. mm, and on prior anti-retroviral therapy for not more than six months preceding the observation date, were included in the study. After initiation of therapy, the patients were examined for the occurrence any adverse events including the type and severity, or any other abnormal laboratory findings. Causality assessment of the adverse events was done using the Naranjo's scale. RESULTS: Out of 327 patients studied prospectively, 43 patients developed AEs. Out of these, 23 (53.5%) were males and 20 (46.5%) were females. A total of 53 (16.21%) AEs were reported. Antitubercular drugs caused the maximum AEs (28.3%) followed by zidovudine (20.7%), nevirapine (15.0%) and efavirenz (5.6%). Stavudine, ethambutol, sulfamethoxazole and trimethoprim, and atazanavir were also responsible for 3.7% of AEs individually. Causality assessment done according to the Naranjo's scale revealed that 66.04% AEs were 'probable' and 33.96% were 'possible'. CONCLUSIONS: Anemia, hepatitis and dermatological adverse effects are the most common AEs. Antitubercular drugs contributed significantly for the incidence of AEs in these patients. Frequency of AEs was slightly more in males compared to females.