Posterior nasal nerve neurectomy for the treatment of rhinitis: a systematic review and meta-analysis.

Summary: Background. Posterior nasal nerve neurectomy (PNNN) is a surgical option for the treatment of refractory chronic rhinitis. It can be performed by surgical dissection, cryotherapy, or laser ablation. This systematic review aimed to assess the effect of PNNN on Total Nasal Symptom Score (TNSS) in adults with chronic rhinitis. Methods. A systematic review of EMBASE, MEDLINE, PubMed and ClinicalKey databases was conducted in November 2021. Studies reporting PNNN performed as a single procedure in adult patients with allergic, non-allergic or mixed chronic rhinitis, and TNSS as the outcome measure, were included. Results. Database search identified 39 articles, of which 8 (463 patients) were included in the review. Two were randomised sham-controlled trials and six were prospective single-arm, unblinded and uncontrolled studies. Pooled analysis of data from the two randomized controlled trials found active treatment was associated with a significantly greater responder (≥ 30% reduction in TNSS from baseline) rate (OR 3.85, 95%CI 2.23-6.64, p < 0.00001). Conclusions. This systematic review identified there is some limited evidence to suggest cryotherapy or radiofrequency ablation of the posterior nasal nerve can improve TNSS in adult patients. However, this is from a limited number of trials with short follow-up. Future research should focus on prospective randomised controlled trials with larger numbers of participants and medium to long term follow up in order to help draw more valid conclusions regarding the true effectiveness of PNNN in this patient cohort.

Bedside open tracheostomy in COVID-19 patients - a safe and swift approach.

BACKGROUND: Tracheostomy can be performed as an open surgical procedure, percutaneous, or hybrid and forms an important step in the management of patients infected with coronavirus disease 2019 (COVID-19) requiring weaning from mechanical ventilation. The purpose of this article is to share our experience to performing bedside surgical tracheostomy in COVID-19 patients in a safe and effective manner, whilst minimising the risk of viral transmission, to optimise patient outcomes and reduce risk to healthcare professionals. MATERIAL AND METHODS: As recommended by ENT UK, we prospectively established a COVID Airway Team within the ENT department at Birmingham Heartlands Hospital, consisting of four head and neck consultant surgeons to perform either open-bedside, open-theatre or percutaneous tracheostomy in COVID-19 patients. A specific stepwise method for bedside open surgical tracheostomy was based on ENT UK and British Laryngological Society recommendations. RESULTS: Thirty patients underwent tracheostomy during the study period (14 bedside-open, 5 open-theatre, 11 percutaneous). Mean duration of mechanical intubation prior to bedside-open tracheostomy was 14.5 days. The average time for open-bedside tracheostomy was 9 minutes compared to 31 minutes for open-theatre. There were no significant tracheostomy related complications with bedside-open tracheostomy. No healthcare professional involved reported acute COVID-19 infection. CONCLUSIONS: We describe our effective, safe and swift approach to bedside open tracheostomy during the COVID-19 pandemic. Our experience demonstrated a short mean procedural time, with no tracheostomy-related complications and no reported viral transmission amongst the healthcare members involved.

A comparative study of novel fibrosis index and transient elastography for predicting fibrosis in patients of chronic liver disease.

Progressive deterioration of liver functions for more than 6 months is considered Chronic liver disease (CLD). Hepatic fibrosis occurs in response to chronic liver injury. The gold standard for assessment of hepatic fibrosis is Liver biopsy, which is an invasive and painful procedure. and rarely can pass on potential life-threatening complications. Thus non-invasive tests that can correctly indicate the severity of liver fibrosis is essential. A number of non-invasive markers have been developed which are useful supplements to assess stages of fibrosis. These are biomarkers (aspartate transaminase (AST) to alanine transaminase (ALT) ratio (AAR), AST to Platelet Ratio Index (APRI), fibrosis index (FI), fibrosis-4 (FIB-4), Age Platelet Index (API), Pohl score, Fibrosis Cirrhosis Index (FCI)) and transient elastography. In our study, we will compare Novel Fibrosis Index (NFI) with other available noninvasive serum indices and transient elastography in predicting Liver Fibrosis Stages. NFI=[(bilirubin×(ALP)2)/ (platelet count (albumin)2)]-n, where n=2000 is a constant. MATERIAL: In this study, a total of 142 cases of confirmed Chronic liver disease were included. All the patients underwent transient elastography and routine hematological and biochemical investigations. Fibrosis staging was done according to Metavir staging (F0-F4) using the fibroscan score. Then the serum indices for predicting liver fibrosis were calculated and compared for various fibrosis stages with Novel Fibrosis index. OBSERVATION: Out of 142 patients, the majority of the patients belonged to age above 40 years and were males(65%). The majority of the patients belonged to F4 fibrosis stage(77.4%) and the most common etiology of Chronic liver disease was Viral hepatitis(47%), the most common being Hepatitis B.The optimum cutoff of NFI for F4 stage was ≥6670 with a sensitivity of 75.8% and specificity of 81.8%. The optimum cutoff of NFI for F3 stage was ≥2112 with a sensitivity of 63.6% and specificity of 72.7%.%. The optimum cutoff of NFI for F2 stage was ≥1334 with a sensitivity of 100% and specificity of 5.3%.The NFI had maximum area under the curve compared to other indices in predicting F2,F3 and F4 stage. CONCLUSION: NFI was the best index in predicting various fibrosis stages in chronic liver disease patients compared to other available serum indices and had maximum accuracy in predicting F4 stage.

Evaluation of Serum Cystatin C as an Early Biomarker of Acute Kidney Injury in Patients with Acute Pancreatitis.

INTRODUCTION: Acute pancreatitis (AP) is an inflammatory process of pancreas with varying degree of involvement of regional tissues. The aim of this study was to investigate the potential use of serum cystatin C (Cys-C) for the early and accurate diagnosis of acute kidney injury (AKI) in patients of AP. MATERIALS AND METHODS: This was a prospective study conducted in 1 year. Total of 215 cases of AP fulfilling the inclusion criteria were enrolled in this study. Patients suffering from chronic pancreatitis, neoplasm, chronic liver disease, and chronic kidney disease were excluded from the study. Diagnosis of AP was based on the Atlanta classification 2012. All patients were classified into a non-AKI group (n = 152) and an AKI group (n = 38) according to the dynamic changes in serum creatinine levels. Serum Cys-C was measured by particle-enhanced immune nephelometric assay. RESULTS: By univariate logistic regression analysis, body mass index (BMI) (OR = 1.44, 95% CI: 1.23-1.68; p < 0.001), blood urea (OR = 1.15, 95% CI: 1.06-1.23; p < 0.001), Cys-C (OR = 1.04, 95% CI: 1.01-1.07; p < 0.05), serum calcium (OR = 0.59, 95% CI: 0.41-0.86; p < 0.05), and serum lactate dehydrogenase (LDH) (OR = 1.001, 95% CI: 1.0-1.001; p < 0.05) were the significant indicators for AKI in patients with AP. Using multivariate logistic regression analysis, urinary albumin and Cys-C were independent and significant indicators of AKI in patients with AP (OR = 1.026, 95% CI: 1.01-1.07; p < 0.01). Receiver operating characteristic (ROC) curve of serum Cys-C, for AKI in patient with AP could be identified with a sensitivity of 92.06% at specificity of 96.0% [area under the curve (AUC) = 0.96, 95% CI: 0.92-0.98] by baseline serum Cys-C (cutoff value = >32.32 mg/L). CONCLUSION: Increase of baseline serum Cys-C was associated with AKI in patients with AP. HOW TO CITE THIS ARTICLE: Patel ML, Shyam R, Bharti H, Sachan R, Gupta KK, Parihar A. Evaluation of Serum Cystatin C as an Early Biomarker of Acute Kidney Injury in Patients with Acute Pancreatitis. Indian J Crit Care Med 2020;24(9):777-782.

Evaluation of enzyme-linked immunoelectrotransfer blot for diagnosis of cysticercosis in swine from North India.

Taenia solium cysticercosis is a major public health problem in developing countries. Swine cysticercosis results in economic losses for pig farmers in disease endemic areas. Consumption of cysticercotic pork leads to taeniasis in humans. Eggs excreted in the faeces of T. solium carriers disseminate to humans and pigs through the faecal-oral route, thus maintaining the life cycle in endemic areas. An enzyme-linked immunoelectrotransfer blot (EITB) assay was developed using whole crude T. solium cysticercus antigens (WCA) for the diagnosis of swine cysticercosis. Sera from 30 swine with cysticercosis confirmed by magnetic resonance imaging were subjected to EITB assay. Sera from 50 swine that were raised in a government farm and not allowed to roam freely were included as negative controls. Two or more bands of 8, 11, 14, 24, 26 and 29 kDa were immunoreactive on blot with sera from all infected swine except two, and none from swine raised on the government farm. The overall sensitivity and specificity of EITB assay for diagnosis of swine cysticercosis were 93.3% and 100%, respectively. Hence, EITB assay based on WCA may be a suitable diagnostic tool for swine cysticercosis in endemic areas.

Effect of gingival displacement cord and cordless systems on the closure, displacement, and inflammation of the gingival crevice.

STATEMENT OF PROBLEM: The gingival sulcus should remain open long enough for the impression material to flow into it and completely fill the space provided by the gingival displacement. Impressions with less sulcal width have a higher incidence of voids, tearing of impression materials, and reduction in marginal accuracy. PURPOSE: The purpose of this clinical study was to investigate the closure, gingival displacement, and gingival inflammation of the gingival crevice after the use of medicated gingival displacement cord and cordless systems. MATERIAL AND METHODS: Gingival sulcus closure was studied in 40 participants. They were divided into 4 groups: 2 cord (Ultrapack, SilTrax AS) and 2 cordless (Expasyl, Traxodent Hemodent paste) methods. The labial surfaces of the maxillary right and left central incisors were evaluated. Gingival sulcus was photographed every 20 seconds from 0 to 180 seconds after the removal of the cord or cordless system. The bleeding index (BI) and gingival index (GI) were measured at day 0, day 1, and day 7. The width of the sulcal orifice was measured at the mid-buccal (MB) and transitional line angle (TLA) on a digital image, using computer software (Photoshop version 7.0; Adobe). Data were analyzed with ANOVA, Tukey honest significant difference (HSD), Kruskal-Wallis, and Mann-Whitney U tests (α=.05). RESULTS: All groups showed a sulcal width greater than 0.22 mm up to 60 seconds after the removal of the displacement materials at the MB and up to 40 seconds at the TLA. Among all groups, Expasyl showed the fastest closure. Gingival displacement in the MB area for the cord group was greater than for the cordless groups. GI and BI indices were larger for the cord group than for the cordless group at days 0 and 1. CONCLUSIONS: At up to 60 seconds, the cord and cordless techniques were equally effective. The cord group showed a greater amount of displacement than the cordless group. However, the cordless materials showed reduced frequency of changes to the gingival index.

Aerothermoelastic-Acoustics Simulation of Flight Vehicles.

This paper describes a novel computational-fluid-dynamics-based numerical solution procedure for effective simulation of aerothermoacoustics problems with application to aerospace vehicles. A finite element idealization is employed for both fluid and structure domains, which fully accounts for thermal effects. The accuracies of both the fluid and structure capabilities are verified with flight- and ground-test data. A time integration of the structural equations of motion, with the governing flow equations, is conducted for the computation of the unsteady aerodynamic forces, which uses a transpiration boundary condition at the surface nodal points in lieu of the updating of the fluid mesh. Two example problems are presented herein to that effect. The first one relates to a cantilever wing with a NACA 0012 airfoil. The solution results demonstrate the effect of temperature loading that causes a significant increase in acoustic response. A second example, the hypersonic X-43 vehicle, is also analyzed; and relevant results are presented. The common finite element-based aerothermoelastic-acoustics simulation process, its applicability to the efficient and routine solution of complex practical problems, the employment of the effective transpiration boundary condition in the computational fluid dynamics solution, and the development and public domain distribution of an associated code are unique features of this paper.

COX-2 gene polymorphisms and risk of chronic periodontitis: a case-control study and meta-analysis.

OBJECTIVE: Cyclooxygenase-2 (COX-2) enzyme is a major mediator of inflammation in periodontitis, leading to loss of gingival tissues and alveolar bone supporting the teeth. Previous studies have explored the role of COX-2 polymorphisms with the risk of periodontitis in different ethnic groups; however, findings are inconsistent. So, we aimed to investigate the association of COX-2 polymorphisms (rs20417, rs689466, and rs5275) in susceptibility to chronic periodontitis (CP) in northern Indian population. Meta-analysis was also carried out to precisely estimate the effect of COX-2 polymorphisms in CP. MATERIALS AND METHODS: Genotyping of COX-2 polymorphisms was carried out through PCR-RFLP in 200 CP cases and 200 controls. For risk estimation, binary logistic regression was applied using SPSS, version 15.0, while meta-analysis was carried using MIX 2.0 software. RESULTS: None of the COX-2 polymorphisms independently were associated with the risk of CP. Meta-analysis suggested a significant reduced risk of CP with rs5275+8473 C allele and rs20417 in Chinese population. CONCLUSIONS: No association was observed in any of the studied COX-2 polymorphisms with CP in North India. But, the study should be replicated in larger sample size to arrive at a definitive conclusion. Meta-analysis suggested a role of rs5275 COX-2 polymorphisms in susceptibility to overall CP, and on ethnic basis, rs20417 showed reduced risk of CP in Chinese population.

On exploiting nonparametric kernel-based probabilistic machine learning over the large compositional space of high entropy alloys for optimal nanoscale ballistics.

The large compositional space of high entropy alloys (HEA) often presents significant challenges in comprehensively deducing the critical influence of atomic composition on their mechanical responses. We propose an efficient nonparametric kernel-based probabilistic computational mapping to obtain the optimal composition of HEAs under ballistic conditions by exploiting the emerging capabilities of machine learning (ML) coupled with molecular-level simulations. Compared to conventional ML models, the present Gaussian approach is a Bayesian paradigm that can have several advantages, including small training datasets concerning computationally intensive simulations and the ability to provide uncertainty measurements of molecular dynamics simulations therein. The data-driven analysis reveals that a lower concentration of Ni with a higher concentration of Al leads to higher dissipation of kinetic energy and lower residual velocity, but with higher penetration depth of the projectile. To deal with such conflicting computationally intensive functional objectives, the ML-based simulation framework is further extended in conjunction with multi-objective genetic algorithm for identifying the critical elemental compositions to enhance kinetic energy dissipation with minimal penetration depth and residual velocity of the projectile simultaneously. The computational framework proposed here is generic in nature, and it can be extended to other HEAs with a range of non-aligned multi-physical property demands.

Management of Gastric Variceal Bleed by Endoscopic Cyanoacrylate Injection: A Case Series.

Background and aims Cyanoacrylate glue (CAG) is the standard of care for gastric varices (GVs) but has serious complications too. The literature is scarce on determining the safe and effective amount of glue before the procedure objectively. Our study aimed to fill this gap.  Methods It was an interventional case series, from January to December 2022. Patients with GVs, in whom CAG was injected, were included. Demographic, clinical, and endoscopic data with emphasis on cumulative variceal diameter (CVD, sum of maximum diameter of each varix), the total amount of glue injected (GTotal), outcomes (technical and clinical success), and complications intra- and post-procedural) were noted. Results Among 467, 18 (4%) patients had gastric varices. Glue was injected in six (1%) patients. Five had type 2 gastro-esophageal varices (GOV2) and one had type 1 isolated gastric varix (IGV1). Four had a history of upper GI bleed. Numbers of GVs ranged between 1 and 4, sizes 0.5-2.5 cm, and CVDs between 3.5 and 5.0 cm. GTotal ranged between 2 and 4 ml, the number of aliquots was one to two, and the maximum amount of glue in each aliquot was between 2 and 3 ml. The calculated relationship between CVD and GTotal ranged was CVD minus 0.5 to 1. Clinical and technical success was achieved in all. Two patients had intra-procedural, self-subsiding bleeding, and one patient had severe abdominal pain, which subsided with analgesics. None of them had fatal complications, transfusion requirements, or prolonged hospital stays. Conclusions CVD is a potential determinant factor for the total amount of glue injected during the endotherapy of GVs to achieve favorable clinical and technical outcomes.

A Comparative Study of Novel Fibrosis Index and Other Non-invasive Serum Indices for Predicting Fibrosis in Patients of Chronic Liver Disease.

Introduction Chronic liver disease progression leads to liver fibrosis/cirrhosis. Transient Elastography is used for staging liver fibrosis but ascites, obesity, and operator experience limit its applicability. In this study, we compared various non-invasive serum indices in predicting fibrosis in chronic liver disease patients. Materials and methods A total of 142 cases of confirmed Chronic Liver Disease were included. Quantitative determination of liver stiffness by Transient Elastography and relevant blood investigations was done. We compared the liver stiffness measurement by Transient Elastography and fibrosis indices, i.e., Aspartate Transaminase (AST) to Alanine Transaminase (ALT) Ratio (AAR), AST to Platelet Ratio Index (APRI), Fibrosis Index (FI), Fibrosis-4 (FIB-4) Index, Age-Platelet Index (API), Pohl score, and Fibrosis Cirrhosis Index (FCI) with Novel Fibrosis Index (NFI), to predict liver fibrosis stages. Results The optimum cutoff of NFI for the F4 stage was ≥ 6670 with a sensitivity of 75.8% and specificity of 81.8%, for the F3 stage was ≥ 2112 with a sensitivity of 63.6% and specificity of 72.7%, and for the F2 stage was ≥ 1334 with a sensitivity of 100% and specificity of 56.3%. The NFI had the maximum area under the curve compared to other indices in predicting fibrosis stages. Conclusion The Novel Fibrosis Index was the best in predicting fibrosis stages in Chronic Liver Disease patients, with good performance in predicting the F4 stage.

Comparison of clinical indices with halitosis grading in chronic periodontitis: A randomized control trial.

Background: Oral malodor is a major periodontal complaint, but the best method for assessing the halitosis grade is still undefined. The primary objective of the study was to detect the halitosis grade in the exhaled breath using the three distinct techniques and to compare the readings with different clinical indices to find out the best method of halitosis grading. Materials and Methods: A total of 90 patients with chronic periodontitis having oral malodor were included in the study. The subjective assessment of the exhaled breath (halitosis grading) was done by three different methods; using a handheld portable Tanita FitScan sulfide monitor, by Halitox toxin assay, and by organoleptic (Sniff test) method. The findings were then compared with the clinical parameters of poor oral hygiene like plaque index (PI), gingival index (GI), gingival bleeding index (BI), and pocket depth (PD) to detect the best method of halitosis grading. Results: The mean age of the patients included was 38.23 ± 8.83 (mean ± standard deviation) years. The median value of halitosis grading as obtained by Tanita FitScan was 3.0 (95% confidence interval as 2 and 4) which was then compared with clinical indices (PI, GI, BI, and PD) and the results were statistically significant (P < 0.05), whereas the other two techniques of halitosis grading gave insignificant results. Conclusion: The results confirmed that the halitosis grading done using Tanita FitScan sulfide monitor is more appropriate with respect to clinical indices when compared with the other two techniques.

Human Brucellosis: An Observational Study From a Tertiary Care Centre in North India.

AIM: The main aim/objective of this study was to detect and characterize the Brucella species from patients having complaints of joint pain and also to know the potential causes of human brucellosis. In our study, we focused on joint pain symptoms that may be due to arthralgia or arthritis.  Introduction: Brucellosis is a neglected zoonotic disease that affects both humans and animals. In humans, brucellosis begins with chronic illness leading to great financial losses from not being able to work well and continued treatment costs, but few such studies have come from northern India. Joint pain is the common presentation of brucellosis and there are several risk factors associated with brucellosis. METHODS: A total of 200 blood samples were collected from the participants having joints pain from September 2019 to September 2021 at Gandhi Memorial & Associated Hospitals of King George's Medical University, Lucknow, India, and tested by serology for anti-Brucella IgM and IgG enzyme-linked immunosorbent assay (ELISA), molecular tests byreverse transcriptase-polymerase chain reaction (RT-PCR), conventional polymerase chain reaction (PCR), and automated blood culture system. The anti-Brucella IgM and IgG ELISA were performed using the kit from NovaTec Immundiagnostica GmbH (Dietzenbach, Germany). Isolation of DNA was carried out using the QIAamp DNA Mini kit (QIAGEN, Hilden, Germany), and the primers and probes specific for targeted regions (BCSP31 and IS711 gene) in the Brucella genome were procured from Eurofins Scientific SE (Luxembourg, France), and for internal control from CDC. RESULT: The study showed 19 (9.5%) and 23 (11.5%) positive results by anti-Brucella IgM ELISA and anti-Brucella IgG, respectively, and of these, one (0.5%) was positive for both anti-Brucella IgM and anti-Brucella IgG ELISA. Out of 19 anti-Brucella IgM ELISA positive, eight (4%) samples were positive for PCR/RT-PCR and that was negative for anti-Brucella IgG ELISA. All blood culture reports of all patients were negative.  Conclusion: Anti-Brucella IgM ELISA was more accurate than anti-Brucella IgG ELISA in detecting human brucellosis. Consumption of animal products (i.e. milk, a dairy product of cow, buffalo, goat, and meat of goat) and contact with animals were the main risk factors that were identified for Brucella disease.

Seroprevalence of Brucellosis in Patients Having Complained of Joint Pain: A Case Control.

BACKGROUND: Brucellosis is a neglected zoonotic disease affecting humans and animals. OBJECTIVES: This study aimed to estimate the seroprevalence of brucellosis in patients with joint pain. METHODS: A total of 200 participants aged from 7 to 86 years were involved in this study. Blood samples were collected from all the participants for two years, from September 2019 to September 2021, and screened for Brucella using anti-brucella IgM ELISA and anti-brucella IgG ELISA antibodies. A questionnaire was used to collect data on socio-demographic characteristics and human brucellosis-related risk factors. RESULTS: Human Brucella seroprevalence was 19 (9.5%) for Brucella IgM ELISA and 23 (11.5%) for Brucella IgG ELISA. The sensitivity for Brucella IgM ELISA and Brucella IgG ELISA was 65.2% and 31.6%, respectively, while the specificity was 44.1% for Brucella IgM ELISA and 77.9% for Brucella IgG ELISA. All blood culture reports of all patients were negative. The principal presentation was the observable symptoms of human brucellosis: fever, headache, chills, myalgia, and Joint pain. CONCLUSION: Risk factors like consumption of raw milk or their products were found to be the most important for Brucella infection, so the awareness or information of risk factors and the modes of transmission is much more important in control and prevention programs. General awareness about clinical symptoms should be increased, which will improve proper diagnosis and will be helpful in early treatment. An ELISA test should be considered for diagnosing brucellosis in both acute and chronic phases.

Serum Ammonia Levels as a Non-invasive Predictor of the Presence and Severity of Esophageal Varices in Chronic Liver Disease Patients.

Background Portal hypertension leads to the formation of portosystemic collateral veins, of which esophageal varices (EV) are the most severe complications and have the greatest clinical impact. The possibility of identifying cirrhotic patients with varices by non-invasive tests is appealing, as they can lead to reduced healthcare costs and can be done in resource-limited settings. In this study, we investigated ammonia as a potential non-invasive predictor of EV. Methods This was a single-center cross-sectional observational study that was done at a tertiary health care hospital in north India. It included 97 chronic liver disease patients irrespective of etiology after excluding patients with portal vein thrombosis and hepatocellular carcinoma to participate in endoscopic screening for the presence of EV and correlate it with various non-invasive markers like serum ammonia levels, thrombocytopenia and aspartate aminotransferase to platelet ratio index (APRI ). On the basis of endoscopy, enrolled patients were divided into two groups, i.e., group A consisting of large varices (grade III and grade IV) and group B consisting of patients with low-grade varices and no varices (grade II, grade I, and no varices). Results This study included 97 patients, out of which 81 patients have varices on endoscopy, and mean serum ammonia levels were found to be significantly higher in cases with varices (135 ±69.70 ) vs. those without varices (94±43) (p value=0.026). Further, on comparing serum ammonia values between patients with large varices (Grade III/IV) (Group A) with a mean value of 176 ± 83 vs. Grade I/II/No varices (Group B) with a mean value of 107±47, which were significantly higher in Group A patients (<0.001). In our study, we also found a correlation between blood urea level as a non-invasive predictor of varices, but no statistically significant relation was found between thrombocytopenia and APRI. Conclusion This study found that serum ammonia can be used as a useful marker for the prediction of EV and can also be used to determine the severity of varices. Apart from ammonia, serum urea levels can also prove to be a good non-invasive marker for the prediction of varices although further multicentric studies are warranted to reach this conclusion.

Scrub typhus manifesting with intracerebral hemorrhage: Case report and review of literature.

Scrub typhus (ST), hitherto absent from many parts of India, is now recently being recognized as a significant cause of morbidity and mortality throughout the country. Its diverse clinical presentations, low of the index of suspicion by the treating physician, and lack of diagnostic testing in many parts of the country result in delayed treatment, leading to a host of complications. We here report such a complication, where ST manifested with a large intracerebral hemorrhage, of which, to the best of our knowledge, only nine cases have been reported in the English language worldwide. Family physicians, who are the often first point of contact for treatment of febrile illness, as ST typically manifests, need to be aware of this entity to prevent such catastrophic consequences.

Bilateral limb gangrene in an HIV patient due to vasculopathy: Managing the dual challenge of psychosocial issues and an uncommon medical condition.

Patients with human immunodeficiency virus (HIV) have been reported to experience a spectrum of homeostatic dysregulation and resulting manifestations in their vascular system. This may be due to either disruption in the coagulation-anticoagulation pathways or due to damage to vessels from either HIV or other opportunistic infections. However, gangrene in an HIV-infected patient is an uncommon phenomenon. We herein report a case of a 30-year-old female, who had been taking antiretrovirals irregularly for 10 years, developing bilateral limb gangrene during her hospitalization for cryptococcal meningitis. Unfortunately, her condition continued to deteriorate and her attendants took her from the hospital against medical advice, with her death soon after. We illustrate how several biopsychosocial factors came together here to result in poor outcomes. To note, peripheral arterial disease (PAD) in HIV can rapidly lead to critical limb ischemia, resulting in limb gangrene. Aggravating risk factors for the same include smoking, poor glycemic control, and/or low CD4 T-cell count (<200 cells/mm3). General practitioners should be aware that HIV patients are far more prone to PAD than the normal population. Early recognition of at-risk patients, both medically and psychosocially, by family physicians is thus critical.

Study of microalbuminuria in chronic obstructive pulmonary disease patients at tertiary care teaching hospital.

BACKGROUND: Hypoxemia-induced endothelial dysfunction leads to microalbuminuria. Microalbuminuria (MAB) has also been used as a parameter to assess the risk of cardiovascular events in an individual. The aim of this study was to observe the relationship of MAB in patients with chronic obstructive pulmonary disease (COPD) and to correlate MAB with different stages of COPD. MATERIALS AND METHODS: This cross sectional study included 140 patients with COPD selected according to GOLD guidelines based on COPD test assessment score and the number of exacerbations who had smoking pack years of more than 10 years. Urine albumin creatinine ratio (UACR) more than 30 mg/gm represents MAB. RESULTS: The UACR increases as the severity of groups of COPD increases with significant differences in UACR values among different COPD groups. Significant differences were seen among various groups of COPD when compared for different clinical parameters such as SPO2, PaO2, PaCO2, pH, and C-reactive protein (CRP). Pearson correlation analysis revealed that UACR was significantly inversely related with PaO2 (r = -0.514, P < 0.001), SPO2 (r = -0.397, P < 0.001) and FEV1 (r = -0.441, P < 0.001) and it was significantly positively correlated with PaCO2 (r = 0.675, P < 0.001). CONCLUSION: This study indicates that there is strong relationship of MAB in patients with COPD and the levels of MAB increase as the severity of COPD increases due to hypoxia and endothelial dysfunction. As MAB is a marker for cardiovascular risk, patients with COPD can be routinely evaluated for the urine test of MAB specially who are at increased risk for cardiovascular events.