Role of Matrix Degradation, Oxidative Stress, Inflammation & Trace Elements in COVID-19 Patients: A Multivariate Study from India.

The interrelationship between matrix degradation, oxidative stress, inflammation and trace elements can be speculated in COVID-19. The objective of the study was to evaluate the oxidative stress, inflammation and matrix degradation markers and trace elements in COVID-19 positive patients. A group of confirmed severe COVID-19 positive patients (n = 30) along with COVID-19 negative patients (n = 30) with similar symptoms were included. Both group of patients were assessed for oxidative stress markers, inflammatory cytokines, matrix metalloproteinase (MMP)s and their inhibitors along with trace elements in blood. All the data were subjected to univariate as well as multivariate analysis including PCA, PLS-DA, OPLS-DA. Diagnostic accuracy was tested by ROC curve analysis. Further relationship with Neutrophil/ lymphocyte (N/L) ratio was established if any. Increased oxidative stress, inflammation and matrix degradation is evidenced by significant rise in oxidative markers, inflammatory cytokines and MMP9/TIMP-1 ratio. Decreased Cu/Zn ratio is also observed in COVID-19 positive patients. Multivariate analysis identified SOD, Cu/Zn ratio, IL-6 and TOS, as effective discriminant among the two groups of patients. Further, accuracy was confirmed by ROC curves. Neutrophil/ lymphocyte (N/L) ratio, shows significant negative association with SOD (r= -0.75, p < 0.005) and Cu/Zn ratio (r = -0.88, p < 0.005). These data suggest the attributes of these biomarkers in disease severity. The potential use of these blood-based laboratory markers in disease prognosis seems promising and warrants further attention. Given by the symptoms and severity of the disease, it will be promising to monitor Cu/Zn ratio along with other prognostic indicators.

An atypical presentation of toxic epidermal necrolysis without mucosal involvement.

Toxic epidermal necrolysis (TEN) is a severe adverse cutaneous drug reaction with ubiquitous involvement of mucosa. Drugs are identified as the main etiology in most cases. Cutaneous involvement in TEN occurs in the form of widespread painful erythematous macules, targetoid lesions, full-thickness or focal epidermal necrosis, whereas mucosal involvement involves oral, genital, and ocular mucous membranes along with preceding prodromal flu-like symptoms. Atypical presentations include involvement of only mucosa without involvement of skin. We report a rare case of TEN without any mucosal involvement.

Study of angiogenesis in invasive breast carcinoma by morphometry and immunohistochemistry.

Background: Breast cancer is the leading cause of cancer-related deaths in Asia and is emerging as the commonest female malignancy. Angiogenesis or neovascularization is important for the growth and spread of malignant tumors, and quantitative assessment of angiogenesis may prove valuable in prognostication. This study was undertaken to quantify and explore angiogenesis with immunohistochemistry with CD 34, CD 105, and vascular endothelial growth factor (VEGF), as well as morphometric analysis and correlate with the grades of the invasive breast carcinoma. Methods: Angiogenesis was assessed by morphometry and immunohistochemistry. Seventy cases of invasive ductal carcinoma (IDC) and twenty-five benign cases as controls were included in the study. Morphometry was performed on the CD34 and CD105 (Endoglin) stained representative histologic sections with the use of a computerized digital photomicrograph system using image analyzing software. Morphometric analysis and evaluation of vascular parameters, i.e. microvessel density (MVD), microvessel caliber (VC), and total microvessel boundary density (TVBD), were calculated. Semiquantitative assessment of angiogenesis of VEGF-stained sections was done by scoring. Immunohistochemical staining was correlated with the histological grade of the tumors. MVD, mean VC, TVBD with their mean values, SD, and range were calculated using Statistical Package for The Social Sciences (Version 20). One-way analysis of variance (ANOVA) with Tukey HSD was performed to assess the difference of the parameters for the groups. Spearman rank correlation coefficients ρ were calculated. Results: The vascular parameters were significantly more in malignant lesions as compared to benign lesions and showed differences with increasing grade. Grades of breast carcinoma showed a mild positive correlation with VEGF (ρ = 0.467), MVD-CD34 (ρ = 0.422) and VC-CD34 (ρ = 0.482); and moderate positive correlation with TVBD-CD34 (ρ = 0.615), VC-CD105 (ρ = 0.527), and TVBD-CD105 (ρ = 0.354). When these parameters were compared with each other for all four groups, VEGF showed a mild positive correlation with MVD-CD34 (ρ = 0.295), TVBD-CD34 (ρ = 0.339), and TVBD-CD105 ((ρ = 0.277). MVD-CD105 showed a mild positive correlation with MVD-CD34 TVBD-CD105 also showed a strong positive correlation with MVD-CD34. VC-CD105 showed a moderate positive correlation with VC-CD34. CD 105 stained fewer but larger caliber vessels. Conclusions: In this study, vascular parameters showed significant differences in three grades of IDC with CD34. Differences were seen in vascular parameters stained with CD105 in three grades of IDC. Expression of VEGF also showed significant differences with positive correlations in the three grades of IDC. CD34 highlighted both old and newly formed microvessels. CD 105 stained fewer but larger caliber microvessels. VC-CD105 can be an extremely useful adjunct along with VEGF and CD34 to study angiogenesis of vessels in IDC.

Pattern of Fatal Injuries in Counter Terrorist Operations: An Innovative Analysis through Embalming Services.

BACKGROUND: Mortal remains of the soldiers killed in counter-terrorist operations in Kashmir valley are sent to their home after undergoing mandatory embalming. METHODS: Injuries on the mortal remains of the soldiers killed in counter terrorist operations between Jan 1999 to Dec 2006 were analysed with respect to the agent, mode of injury, age, rank structure, body parts involved, seasonal variations and changing trends. Fatalities consequent to enemy action across line of control and fatalities of Kargil war were also analysed for comparison. Statistical analysis was done using chi square test for difference in proportions. RESULT: Over the study period, terrorist induced injuries accounted for 8.16 deaths per thousand troops deployed whereas enemy action from across the line of control accounted for 0.63 deaths per thousand. Terrorist induced fatalities peaked in 2001 and thereafter revealed a declining trend ('p' < 0.001). Fatalities due to enemy action across line of control declined to zero since 25 Nov 2003 consequent to effective ceasefire. Of the total fatalities, 89.5% were killed in action (KIA) while 10.5% died of their wounds after reaching the hospital. Fatality to total injured ratio peaked to 29% in 2001 and than stabilized to about 23%. Mean KIA to total casualty ratio was 21%. The rank structure of the fatalities was officers 8.6%, JCOs 7.3%, and Other Ranks 84.1%. Most of the soldiers died young, 51% being below 25 years of age. Out of the terrorist induced fatalities, 78.2% died of gunshot wounds and 21.5% by splinters and improvised explosive devices (IED). The ratio was reversed in enemy induced fatalities and in Kargil war. Fatalities peaked during June to November and declined in winters. Body region wise, 23.4% of all deaths were due to head injury, 8.4% due to neck and maxillofacial injury, 18.4% due to injury to lungs and 11% due to heart injury. Most frequent target of the fatal bullet was brain (25.4%), closely followed by lungs (22.5%) and heart (12.3%). When soldier died of splinters / IED, multiple body parts were injured in 57.5%, brain in 17.3%, face & neck in 3.5%, heart in 6.6%, lungs in 5.3%, abdomen in 3.5% and limbs in 5.8%. Fatality due to head and heart injury peaked in 2001, while multiple injuries peaked in 2000, declined in 2001 and peaked again in 2004 and 2005 ('p' < 0.001). In fatalities of Kargil war, chest injuries were less but multiple injuries were more. CONCLUSION: Most of the fatalities were due to gunshot wounds selectively aimed at head, face, neck and thorax. Therefore, a lightweight flexible and effective bulletproof protection for this area will conserve manpower.

Analysis of Non Enemy Action Deaths in Counter Insurgency Operations through Mortuary Services.

BACKGROUND: Regional Trauma Centre in the northern India receives the mortal remains of all fallen soldiers for embalming. Non enemy action deaths during counter insurgency operations (CI Ops) were analysed for planning preventive measures. METHODS: Mortal remains received for embalming from Jan 1999 to Dec 2006 were analysed with respect to mode of injury, causation, body parts involved, fatality, seasonal variation and changing trends. RESULT: Accidents accounted for 3.02 deaths per thousand troops and environmental factors were responsible for 1.14 deaths per thousand troops deployed. Accidental deaths peaked in 2000, declined in 2001 and then remained more or less static. Of the accidental deaths, 88% were brought in dead and 12% died after reaching hospital. Road traffic accidents were the major killers accounting for 48.2%, followed by accidental discharge of weapon 35.5%. The latter is showing a rising trend from 8% of total accidents in 2001 to 65% in 2005 and 51% in 2006 (p<.01). Most (49.7%) of the deaths were below 25 years of age. Proportion of persons below 25 years was more in fatalities due to accidental gunshot wound. Amongst the road traffic accidents, 40% died of head injury and 51.2% due to multiple injuries. When deaths occurred due to accidental discharge of own weapon, 36.4% had brain injury and 22% heart injury. Of the environmental fatalities all but one were brought in dead. Majority were due to avalanches and landslides (51.2%), followed by earthquake (22.4%), lightning (12.8%), high altitude pulmonary oedema (10.4%) and hypothermia (3.2%). Most of the deaths due to avalanches occurred in February while all deaths due to earthquake were in October 2005. Of the deaths due to lightning, 75% occurred in April and May. CONCLUSION: Prevention of death caused by road traffic accidents, accidental discharge of weapon, avalanches and lightning will conserve manpower and add to operational preparedness.

Splenic Syndrome due to Sickle Cell Trait amongst Indian Soldiers Serving in Kashmir.

BACKGROUND: Heterozygous transmission of gene for Haemoglobin S leads to sickle cell trait. Mostly the trait remains silent with no additional morbidity or mortality. When these persons migrate to higher altitudes, in times of high oxygen demand, some of them develop splenic infarction. This is a rare phenomenon and only 47 such cases had been reported till 2005. METHODS: This study was conducted at an Indian military hospital serving the troops deployed in Kashmir valley at altitudes ranging from 5500 ft to 13000 ft. When two consecutive splenectomies for splenic abscesses, turned out to be sickling induced infarction histopathologically, we reviewed splenectomy specimens received in last six years for evidence of sickling. RESULT: Out of 33 splenectomies performed during the period of study, 22 were due to trauma (gun shot injury 11; splinter injury one and blunt injury 10). Of the rest eleven, who presented without any history of trauma, seven had evidence of vascular occlusion with aggregates of sickled red blood cells. In none, Gram stain or Periodic Acid Schiff stain revealed any bacterial or fungal colonies. One patient of splenic syndrome was found to have unrecognised sickle cell trait and he was managed conservatively. CONCLUSION: Sickle cell trait should be excluded before considering splenectomy in ethnically vulnerable patients presenting with splenic syndrome. An uncomplicated splenic infarction can be managed conservatively.

Aggressive Use of Diagnostic Services is Counterproductive.

BACKGROUND: Medical fraternity requisitions diagnostic tests for multiple reasons. More often than not, the tests lead to more tests either to exclude or to confirm doubts raised by the test results. These tests have an inherent morbidity, discomfort and cost. Growing expenditure on diagnostic tests without matching improvement in the health status warrants an internal audit of the laboratory utilization. METHODS: A retrospective utility audit was done for certain routinely advised laboratory tests at a hospital. Blood urea estimation in annual / periodic medical examination (AME/ PME), bleeding and clotting time in pre-anaesthetic check-up and aspartate aminotransferase (AST) and antibodies to hepatitis C virus (anti-HCV) in diagnostic work-up of acute onset jaundice were included in the audit. RESULTS: During the study period, 793 individuals underwent AME / PME and urea estimation did not provide any additional information in these cases which was not inferred by serum creatinine. Similarly, in diagnostic workup of acute onset jaundice, 6049 aspartate aminotransferase (AST) estimations in 1024 patients did not contribute anything more than what was inferred by alanine aminotransferase (ALT). Prevalence of anti HCV antibodies in acute onset jaundice in serving soldiers (11 out of 1225; 0.89%) though more than that in the blood donors from the same population (17 out of 4105; 0.41%) was less than anticipated false positives (18 out of 1225; 1.5%) as per the claimed specificity (98.5%) of the test kit. None of the 2766 bleeding and clotting time tests detected a bleeding or coagulation disorder. CONCLUSION: The study reveals significant overuse of the laboratory that may not be good for the patient and the organization in terms of direct and indirect costs due to false positive results. This laboratory overload adversely affects the quality and availability of laboratory results. Therefore, a test should only be advised, if positive or negative result would dictate a change in patient management.

Reemergence of Chloramphenicol Sensitivity in Enteric Fever.

BACKGROUND: Enteric fever is a global health problem and rapidly developing resistance to various drugs makes the situation more alarming. Drug sensitivity in Salmonella enterica serovar typhi and Salmonella enterica serovar paratyphi A isolated from 45 blood culture positive cases of enteric fever was tested to determine in-vitro susceptibility pattern of prevalent strains in northern India. METHODS: Strains isolated from 45 blood culture positive cases of typhoid and paratyphoid fever over a period of three years were studied and their sensitivity patterns to chloramphenicol, ampicillin, ciprofloxacin, ceftriaxone, nalidixic acid, amikacin and ofloxacin were analysed. RESULTS: Our results show a high sensitivity of both Salmonella enterica serovar typhi (96%) and Salmonella enterica serovar paratyphi A (100%) to chloramphenicol. Sensitivity to ciprofloxacin and amikacin was 88% and 84% respectively. All the isolates were sensitive to ofloxacin, nalidixic acid and ceftriaxone. Sensitivity of Salmonella enterica serovar paratyphi A was 100% to chloramphenicol, ciprofloxacin, ofloxacin, nalidixic acid and ceftriaxone, 95% to amikacin and 30% to ampicillin. Overall 44 out of 45 isolates of Salmonellae were sensitive to chloramphenicol. CONCLUSION: These findings suggest changing pattern of antibiotic resistance in enteric fever with reemergence of chloramphenicol sensitivity in northern India.

The dynamics of the vestibulo-ocular reflex after peripheral vestibular damage. I. Frequency-dependent asymmetry.

Accurate performance by the vestibulo-ocular reflex (VOR) is necessary to stabilize visual fixation during head movements. VOR performance is severely affected by peripheral vestibular damage; after one horizontal semicircular canal is plugged, the horizontal VOR is asymmetric and its amplitude is reduced. The VOR recovers partially. We investigated the limits of recovery by measuring the VOR's response to ipsilesional and contralesional rotation after unilateral peripheral damage in cats. We found that the VOR's response to rotation at high frequencies remained asymmetric after recovery was complete. When the stimulus was a pulse of head velocity comprising a dynamic overshoot followed by a plateau, gain was partially restored and symmetry completely restored within 30 days after the plug, but only for the plateau response. The overshoot in eye velocity remained asymmetric. The asymmetry was independent of stimulus velocity throughout the known linear velocity range of primary vestibular afferents. Sinusoidal rotation at 0.05-8 Hz revealed that, within this range, the persistent asymmetry was significant only at frequencies above 2 Hz. Asymmetry was independent of the peak head acceleration over the range of 50-500 degrees/s2. When both horizontal canals were plugged, a small residual VOR was observed, suggesting residual signal transduction by plugged semicircular canals. However, transduction by plugged canals could not explain the enhancement of the VOR gain, at high frequencies, for rotation away from the plugged side compared with rotation toward the plug. Also, the high-frequency asymmetry was present after recovery from a unilateral labyrinthectomy. These results suggest that high-frequency asymmetry after unilateral damage is not due to residual function in the plugged canal. The findings are discussed in the context of a bilateral model of the VOR that includes central filtering.

The dynamics of the vestibulo-ocular reflex after peripheral vestibular damage. II. Comparison with dynamics after optically induced learning.

The vestibulo-ocular reflex (VOR) stabilizes gaze adequately under a variety of conditions because it is capable of a simple form of motor learning. Learning is induced by changed visual conditions or to compensate for vestibular sensory loss. We asked whether the mechanisms that are triggered by visual signals can fully account for recovery from vestibular damage. We addressed this question by comparing the effects of optically induced motor learning (i.e., changes in gain induced by telescopic lenses) and recovery from a unilateral horizontal canal plug on the dynamics of the cat VOR. Optically induced learning modified the gain of the VOR more effectively for rotation at low frequencies (below 5 Hz) than for higher-frequency stimuli. During recovery from a plug, the gain of the VOR increased at all frequencies tested, with a similar time course for all frequencies. After recovery the gain for rotation at 5 Hz or above was relatively enhanced. After recovery reached its upper limit, optically induced learning could bring about further changes in gain. The results are interpreted with respect to partially (but not completely) shared mechanisms for optically induced learning and recovery after a unilateral canal plug.