Of "Cotton Balls" and "Owl's eyes".

Report of a 3-month old girl child who died due to multi-systemic infection of cytomegalovirus (CMV) involving the lungs, liver and kidneys along with pneumocystis jiroveci pneumonia (PJP). The mother of the child tested positive for CMV IgG and HIV with a very low CD4 count (160/ µl). Co-infection of cytomegalovirus and pneumocystis jiroveci always occurs in the setting of immunocompromise. Congenital CMV infection is transmitted through the placenta, especially during the first trimester and causes severe multi-systemic disease whereas perinatal infection is acquired during childbirth/ breastfeeding where the babies have maternal protective antibodies leading to much milder or asymptomatic infection. PJP is more common in infancy and presents as hypoxic pneumonia. CMV causes cyto-nucleomegaly and classic "owl's eye" inclusions on histology while PJP presents with characteristic fluffy "cotton ball" alveolar exudates.

Pesticides in the environment: Degradation routes, pesticide transformation products and ecotoxicological considerations.

Among rising environmental concerns, emerging contaminants constitute a variety of different chemicals and biological agents. The composition, residence time in environmental media, chemical interactions, and toxicity of emerging contaminants are not fully known, and hence, their regulation becomes problematic. Some of the important groups of emerging contaminants are pesticides and pesticide transformation products (PTPs), which present a considerable obstacle to maintaining and preserving ecosystem health. This review article aims to thoroughly comprehend the occurrence, fate, and ecotoxicological importance of pesticide transformation products (PTPs). The paper provides an overview of pesticides and PTPs as contaminants of emerging concern and discusses the modes of degradation of pesticides, their properties and associated risks. The degradation of pesticides, however, does not lead to complete destruction but can instead lead to the generation of PTPs. The review discusses the properties and toxicity of PTPs and presents the methods available for their detection. Moreover, the present study examines the existing regulatory framework and suggests the need for the development of new technologies for easy, routine detection of PTPs to regulate them effectively in the environment.

Magnetic resonance imaging in paediatric ocular and orbital lesions: A pictorial review.

Paediatric orbital lesions encompass a wide spectrum of benign and malignant entities that can arise from different components of the orbit. Clinical symptoms and signs are often nonspecific, and imaging plays a crucial role in the diagnosis and management. Ultrasonography has a limited role and radiation is a major concern with CT especially in the paediatric population. MRI is the modality of choice that avoids the radiation hazard and provides superior soft tissue contrast. The lesions can be localized using the 'compartment' approach which helps to narrow the list of differentials. MRI also provides critical information for management such as presence of perineural spread and intracranial extension. This article depicts the spectrum of Magnetic Resonance imaging findings encountered in paediatric ocular and orbital lesions.

Comparative assessment of platelet GpIIb/IIIa receptor occupancy ratio with Eptifibatide/Tirofiban in patients presenting with ACS and undergoing PCI.

BACKGROUND: The level of platelet inhibition by a Glycoprotein IIb/IIIa (GpIIb/IIIa) antagonist therapy necessary to minimize thrombotic complications in patients undergoing percutaneous coronary intervention (PCI) is a subject of debate. The degree of platelet inhibition obtained 10 min after start of GpIIb/IIIa antagonist therapy predicts adverse events after PCI. The aim of this study was to look at platelet inhibition and to compare platelet GpIIb/IIIa receptors occupancy ratio (GpRO) with Eptifibatide and Tirofiban using various dose regimens and correlate with 30-day clinical outcomes in patients presenting with high-risk acute coronary syndromes (ACS) and undergoing PCI. METHODS: The patients were divided into four sub groups: (1) Eptifibatide two intracoronary bolus (180 µg/kg) alone (E(B)); or (2) two intravenous bolus (180 µg/kg) followed by infusion at 2 µg/kg/min for 24 h (E(B + Inf)); and (3) Tirofiban standard bolus dose (0.4 µg/kg) over 30 min followed by infusion at 0.1 µg/kg/min (T(Std)); or (4) at ADVANCE dose bolus (25 µg/kg) over 3 min, followed by infusion at 0.1 µg/kg/min (T(Adv)). Number of GpIIb/IIIa receptors was assessed by flow cytometry at baseline and 10 min after the bolus and percentage of free receptors was determined to calculate the GpRO. Patients were followed for 30 days for any major adverse cardiac events (MACE). RESULTS: 200 consecutive patients (including 74% with ST-elevation ACS) were enrolled. GpRO in groups E(B) (n = 48) and E(B + Inf) (n = 44) were 62.7% ± 27.2% and 61.4% ± 6.1% respectively while in the groups T(Std) (n = 96) and T(Adv) (n = 12) groups were 35.1% ± 17.74% and 68.8% ± 27.3% respectively. The GpRO was similar in E(B), E(B + Inf) and T(Adv) groups and was significantly higher than T(Std) group (p < 0.0001). The 30-day MACE rates in E(B) (4.2%), E(B + Inf) (4.5%) and T(Adv) (4.2%) were significantly lower than T(Std) group (12.5%) (p < 0.01). CONCLUSIONS: Standard dose Tirofiban results in significantly lower rates of GpIIb/IIIa receptor occupancy ratio and this correlated with higher incidence of 30-day MACE in high-risk ACS patients undergoing PCI.

Depression and the heart.

Cardio Vascular disease (CVD) as well as depression are both highly prevalent disorders and both of them cause a significant decrease in quality of life and increase the economic burden for the patient. Depressed individuals are more likely to develop angina, fatal or non-fatal myocardial infarction, than those who are not depressed. Over the past decade, evidence has accumulated to suggest that depression may be a risk factor for cardiac mortality in patients with established coronary artery disease (CAD). The 'vicious cycle' linking CVD to major depression and depression to CVD, deserves greater attention from both cardio-vascular and psychiatric investigators.(1).

Giant coronary artery aneurysm following implantation of Endeavour stent presenting with fever.

Coronary artery aneurysms are a known but uncommon complication of percutaneous coronary intervention (PCI) probably related to effects of vessel wall trauma and possibly a combination of hypersensitivity and incomplete endothelisation associated with drug-eluting stents (DES). We present here a case of giant coronary artery aneurysm 3 months following implantation of a zotarolimus eluting endeavour stent presenting with fever.

Giant right atrial aneurysm presenting as right heart failure.

Idiopathic aneurysmal dilatations of the right atrium are rare anomalies. We report one such case of a young man presenting with fatigue, abdominal distension, pedal oedema, unremarkable cardiac examination except for raised jugular venous pressure, an electrocardiogram showing normal sinus rhythm with right bundle-branch block, and an radiograph of the chest showing cardiomegaly. The echocardiographic examination revealed a giant right atrium with low pressure tricuspid regurgitation. The computed tomography confirmed the findings of two-dimensional echocardiography. He was put on medical treatment and remained symptomatically controlled on follow-up.

Patterns and determinants of dyslipidaemia in 'Young' versus 'Not so Young' patients of coronary artery disease: a multicentric, randomised observational study in northern India.

AIMS: The aims of the study were to ascertain difference in lipid levels of 'Young' onset of coronary artery disease (CAD) (≤ 45 years) vs. 'Not so Young' onset of CAD (≥ 55 years) among north Indians and also to investigate determinants of 'dyslipidaemia' in CAD patients. METHODS: This was a prospective, multicentric, randomised, observational study carried in eight centres of UP, India. All blood investigations were performed employing a central laboratory. RESULTS: Out of a total 435 patients studied, 218 were in the 'young group' (YG) and 235 were in the 'Not so Young Group' (NSYG). Dyslipidaemia was more common in YG as evident by significantly higher levels of total cholesterol, triglycerides, low- and very low-density lipoprotein cholesterol as compared to NSYG. Diabetes, hypertension, urban lifestyle, and family history of CAD were found to be important determinants of dyslipidaemia in YG. CONCLUSION: We conclude that lipid levels among north Indians are significantly higher in younger patients with CAD when compared with elderly.

A cross sectional study on psychological impact of covid19 on post graduate doctors and Compulsory Rotatory Residential interns in COVID isolation ward of a tertiary care centre, Madurai.

BACKGROUND: COVID-19 pandemic causes major impact on economic, physical, mental well-being of people all over the world. Doctors are working in stressful, unprepared, limited resource setting, and they are under the continuous threat of getting infection. Managing mental health of these warriors is great importance. Hence the present study to estimate the psychological impact of COVID-19* and factors associated with it among doctors in tertiary care hospital, Madurai. METHODS: A Cross-sectional study was conducted during October-November 2020 using a pre-designed semi structured questionnaire and DASS-21 scale which were sent through Google form to doctors who were in their quarantine period after the COVID duty. Totally 292 responses were received. Descriptive statistics done to find frequencies and percentages. Correlation for continuous variables; Univariate and multivariate regression for categorical variables were used to predict the factors influencing the psychological impact. RESULTS: In our study, 42.1% doctors were depressed, 43.8% were stressed and 50.7% had anxiety. Depression*, anxiety*, stress* scores were positively correlated with number of COVID duties(r2 0.163,0.138,0.133), number of elderly persons(r2 0.188,0.169,0.188) in their family and negatively correlated with sleep duration(r 2-0.219,-0.281,-0.239), attitude of study participants(r2-0.319,-0.274,-0.291). Multiple logistic regression showed that disturbed sleep(odd'sratio = 3.931,2.734,3.420) and poor quality of sleep which affect the next day function(odd'sratio = 3.470,2.968,3.122) were significant predictors for all three psychological impacts. CONCLUSION: High prevalence of psychological impact estimated, ensures the requirement of early screening with timely psychological intervention and establishment of guideline policies to support mental health of healthcare workers* for maintaining the functionality of healthcare system.

Lipid Profile and Small Dense Low-Density Lipoprotein in Acute Coronary Syndrome Patients: Relationships to Demographic, Clinical, Angiographic, and Therapeutic Variables.

Background: Several lines of evidence have supported small dense low-density lipoproteins (sd-LDL) as a marker of cardiovascular disease. The present study assessed the relationship between lipid profile and sd-LDL levels with demographic, clinical, angiographic, and therapeutic variables in acute coronary syndrome (ACS) patients. Methods: This was a single-centre, prospective, cross-sectional study conducted from September 2014 to September 2015. Patients with a diagnosis of ACS were included in this study. High-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) were determined by direct homogenous assay and sd-LDL levels were calculated using an earlier described equation by Srisawadi et al. Results: A total of 200 patients with a diagnosis of ACS were studied. Males constituted 78% of the population cohort and almost 45% of participants were aged <45 years. Patients aged ≤45 years displayed higher mean sd-LDL levels of 30.40 ± 14.18 mg/dL versus patients aged >45 years with mean sd-LDL levels of 28.01 ± 11.58 mg/dL, but the difference was not statistically significant (p = 0.19). Females also displayed higher mean sd-LDL levels, but the difference also failed to achieve statistical significance (30.95 ± 13.44 mg/dL and 28.54 ± 12.64, respectively; p = 0.185). Diabetics had higher mean sd-LDL levels (33.64 ± 13.01 mg/dL and 28.07 ± 12.60 mg/dL; p = 0.273) whilst smokers had lower mean levels (27.21 ± 12.12 mg/dL and 30.51 ± 13.21 mg/dL, respectively; p = 0.071). However, the ratio of sd-LDL/lb-LDL (large buoyant LDL) was significantly higher in diabetics (0.48 vs. 0.39; p = 0.023). In the angiography cohort (n = 88), single-vessel disease was the most predominant overall while among patients aged >45 years, triple-vessel disease was significantly higher (p = 0.005). Similarly, the sd-LDL levels were 33.12 ± 11.13 mg/dL, 27.68 ± 9.80 mg/dL, and 31.65 ± 15.26 mg/dL among patients with single, double, and triple-vessel disease and did not differ significantly (p = 0.262). Prior statin users had significantly lower mean sd-LDL levels of 24.79 ± 12.23 mg/dL compared to statin-naïve patients with a mean sd-LDL of 30.01 ± 12.79 mg/dL (p = 0.027). Non-HDL levels were also significantly lower in prior statin users (112.83 mg/dL vs. 128.9 mg/dL; p = 0.017). Conclusion: In this cohort of ACS patients, age, sex, diabetes, smoking, and the angiographic severity of coronary artery disease had no significant impact on sd-LDL levels, while prior statin usage led to significantly lower sd-LDL levels. Diabetic patients, however, did have significantly higher sd-LDL/lb-LDL ratios.

Is aorto-arteritis a manifestation of primary antiphospholipid antibody syndrome?

A 23 year old female presented with dyspnea on exertion and absent pulses in the left upper limb. She had prior history of two first trimester abortions and pre-eclampsia with premature delivery. A Doppler examination had revealed left subclavian and axillary artery thrombosis for which she had been given warfarin six months previously. She was admitted and investigated. Patient had low positive aCL IgG antibody, positive antibeta2gp1 antibody, negative lupus anticoagulant and negative ANA. Patient had cardiomegaly and her echocardiography showed severe aortic regurgitation, moderate mitral regurgitation and moderate pulmonary artery hypertension with poor ejection fraction with normal aortic root. A diagnosis of primary antiphospholipid antibody syndrome with valvular involvement with dilated cardiomyopathy was entertained. A CT angiogram of the aorta revealed narrowing and irregularity of the aorta and its multiple branches suggestive of type III Takayasu's arteritis. Temporal relationship suggests development of aorto-arteritis secondary to APS but simultaneous presence of both these disorders in this patient cannot be ruled out.

Depression in patients of myocardial infarction--a cross-sectional study in northern India.

OBJECTIVES: To assess the prevalence of major depressive disorder and subsyndromal depression in patients with first episode of myocardial infarction (MI) and to compare the socio-demographic, clinical and coronary risk factors in patients with and without depression. METHODS: Patients of acute MI (n = 101) attending OPD at 4 to 6 weeks after the index event were the subjects. Diagnoses of Major Depressive Disorder were established according to Diagnostic and Statistical Manual for Mental Disorders fourth edition Test Revision (DSN-IV-TR) criteria. Schedule for Affective Disorder and Schizophrenia changed version modified for Bipolar disorder (SADS-CB) was applied to detect cases with depressive symptoms not amounting to major depressive disorder (sub-syndromal). It was a single point cross sectional study. RESULTS: No depressive symptoms (Group-A) were found in 56 patients (55.4%). Major Depressive Disorder (Group-B) was found in 24 patients (23.8%) and subsyndromal symptoms (Group-C) in 21 patients (20.8%). Sociodemographic and clinical variables were similar amongst three groups except, more patients in Group-C were from nuclear family (p = 0.01) and were educated (p = 0.03). More patients in Group-B had hypertension (p = 0.001), diabetes (p = 0.03) or were overweight (p = 0.02) as compared to Group-A. Similarly higher number of Group-C patients had hypertension (p = 0.04), diabetes (p = 0.01) and were current smokers (p = 0.01) as compared to Group-A. CONCLUSION: Unrecognized and untreated major depressive disorder and sub-syndromal symptoms were frequent in patients of MI. Established coronary factors were more commonly present in these groups as compared to no depressive symptom group. This emphasizes the need for routine screening for depression in post MI phase in our population.

Significance of self-reported sleep quality (SQ) in chronic kidney disease (CKD): the Renal Research Institute (RRI)-CKD study.

BACKGROUND: There has been limited research on sleep quality (SQ) in CKD. METHODS: This prospective cohort study of adults with CKD Stages 3 - 5 at four US centers collected self-reported SQ information from the Kidney Disease Quality of Life (KDQOL) instrument, including an estimated SQ score (0 - 100), and 3 SQ-related questions. "Poor" SQ was defined as SQ score < or = 60. Logistic and multiple linear regression assessed associations between SQ and its potential predictors. Times to death and end stage renal disease (ESRD) were examined using Cox regression. A comparison with SQ in ESRD patients from the Dialysis Outcomes and Practice Patterns Study (DOPPS), was additionally performed. RESULTS: Mean SQ score was 59.4 +/- 23.6 (n = 689), and "poor" SQ was reported by 57%. Mean estimated glomerular filtration rate (eGFR) was 24.9 +/- 10.6 ml/min/1.73 m2. Higher SQ significantly correlated with KDQOL mental and physical component summary scales. Significant predictors of lower SQ score included--younger age, presence of dyspnea, self-reported depression, pain, and itchness. There were no significant pairwise differences in SQ from CKD Stage 3 through ESRD. Self-reported daytime sleepiness was significantly associated with higher risk of mortality prior to ESRD (HR = 1.85, p = 0.02). CONCLUSION: Self-reported "poor" SQ was common in a CKD cohort (Stages 3 - 5) and was not only associated with lower quality of life scores and several modifiable symptoms, but also with higher risk of pre-ESRD mortality. Greater attention to this clinical problem is highly recommended in this high-risk population.

Giant intramuscular calcifying aponeurotic fibroma of gluteus maximus: case report.

Calcifying aponeurotic fibroma (CAF) is a rare soft tissue tumour which occurs mainly in children and adolescents. It usually involves the distal portion of the extremities, i.e. the hands and feet. A 2-year-old child with a large CAF is presented. The case was unusual in view of its large size (10 × 7 × 5 cm), dense calcification in such a young child, and because it was situated in the substance of gluteus maximus muscle. There has been no recurrence at 3-year follow-up.

3-Methoxy-4-hydroxyphenylglycol in cerebrospinal fluid and vanillylmandelic acid in urine of humans with hypertension.

3-Methoxy-4-hydroxyphenylglycol (MHPG) was measured in lumbar spinal fluid of 20 subjects with hypertension of varied etiology and severity. There was a significant correlation between the concentration of MHPG and the severity of hypertension. However, changes in the concentration of vanillylmandelic acid in the urine of these subjects were insignificant. In six subjects, administration of clonidine or alpha-methyldopa, two centrally acting antihypertensive drugs, was associated with a significant lowering of MHPG concentrations. These data support the hypothesis that central catecholamines are involved in clinical hypertension.

"Tenecteplase--the best among the equals.".

Tenecteplase is a genetically engineered product of the Alteplase molecule. Mutations of Alteplase at three locations result in a more fibrin specific thrombolytic agent with a longer half life. Such properties would allow bolus administration, leading to faster reperfusion of occluded arteries. Tenecteplase is equivalent to front loaded Alteplase in terms of mortality and is the only bolus thrombolytic drug for which equivalence has been demonstrated. Tenecteplase seems more potent than Alteplase when symptoms duration is more than 4 hours. Moreover, Tenecteplase significantly reduces the rate of major bleeds and the need for blood transfusion. The efficacy of Tenecteplase may be further improved by reducing re-infarction rate by enoxaparin instead of unfractionated heparin. Several large scale Clinical trials of Tenecteplase in acute myocardial infarction (MI) has been done making this drug truly evidence based. Available randomized studies and international clinical registries reveal that pre hospital thrombolysis by Tenecteplase is as effective as primary angioplasty. In fact Tenecteplase is now included in many prehospital thrombolytic reperfusion protocols, such as the Vienna STEMI registry, The Mayoclinic STEMI protocol and the French FAST-MI registry. Tenecteplase with so many evidence based advantages is a fair option in acute MI patients in whom primary PCI can not be offered due to logistic reasons.

Utility of cytomorphology in distinguishing solid pseudopapillary neoplasm of pancreas from pancreatic neuroendocrine tumor with emphasis on nuclear folds and nuclear grooves.

BACKGROUND: Pancreatic solid pseudopapillary tumor (SPN) and pancreatic neuroendocrine tumors (Pan-NET) have close resemblance on imaging and cytomorphology, though they differ in their prognosis and treatment strategy. SPNs are low-grade indolent tumors while Pan-NETs harbor malignant potential with propensity to metastasize. We aim to differentiate SPN from Pan-NET based on cyto-morphology; to classify nuclear membrane (NM) irregularities or nuclear folds into four grades and see whether they bear any difference with respect to the two entities. METHODS: Eighteen and ten confirmed cases of SPN and Pan-NET were included in the study. Smears were assessed for architecture, background changes, cellular, and nuclear features, which were compared between the two study groups. Nuclear folds were classified into four grades. Nuclear folds and nuclear grooves were also compared between the two groups. RESULTS: All SPN patients were females; mean age of 28 years. Pan-NET patients had equal male to female ratio; mean age of 46 years. Both SPN (78%) and Pan-NET (71%) showed predilection for pancreatic head. Mean size of lesion was 4.8 cm and 3.1 cm in SPN and Pan-NET groups. Papillary pattern, branching capillaries, degenerative background were significantly more prominent in SPN; sudden anisonucleosis and cytoplasmic granularity in Pan-NET. Metachromatic matrix, hyaline globules, and nuclear grooves were noted exclusively in SPNs. Nuclear fold grades 2 and 3 were more characteristic of SPN than Pan-NET (P = 0.041 and 0.002, respectively). CONCLUSIONS: Cytomorphology is vital in differentiating SPN from Pan-NET with nuclear folds being an important nuclear feature.