Scrub Typhus: A Spatial and Temporal Analysis from South India.

Scrub typhus is a zoonotic rickettsial disease caused by the bacterium Orientia tsutsugamushi. The non-specificity of presentation, low index of suspicion and the poor availability of diagnostic tests often lead to delayed diagnosis and significant morbidity and mortality. Temperature, humidity, rainfall and Normalized Difference Vegetation Index (NDVI) on the spatio-temporal clustering of scrub typhus cases in children in three contiguous administrative districts in South India over 5 years were studied. A total of 419 children were diagnosed with scrub typhus during the study period. A surge of children with scrub typhus was noted when the NVDI ranged between 0.6 and 0.8 µm. Temperature, humidity and rainfall had a major role in the incidence of scrub typhus.

Practice Patterns and Outcome of Extracorporeal Membrane Oxygenation Therapy for Severe Acute Respiratory Distress Syndrome in Indian ICUs.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is increasingly used in managing patients with severe acute respiratory distress syndrome (ARDS). The aim of the study is to describe the practice of ECMO and evaluate the outcomes in patients with severe ARDS in Indian intensive care units (ICUs). METHODS: Data of 39 patients with severe ARDS managed with ECMO in two tertiary centers between 2012 and 2018 were retrospectively studied. RESULTS: The mean age of the patient was 44.6 ± 13.5 years and 51% were female. Primary ARDS due to viral pneumonia was the common indication for ECMO. Mean APACHE II and Murray scores were 32.3 ± 7.8 and 3.64 ± 0.21, respectively. Prone ventilation and/or inhaled nitric oxide were used in 69.3% of the patients prior to ECMO therapy. Among 39 patients, 38 patients were managed with venovenous ECMO and 1 patient was managed with venoarterial ECMO. Average ECMO duration was 9.4 ± 6.9 days. Among the 17 (43.5%) patients successfully weaned off ECMO, 15 (38.5%) survived to discharge home. The average ICU and hospital length of stay were 18.9 ± 15.5 and 20.6 ± 16.6 days, respectively. While, sepsis was the common complication noted in 19 (49%) patients, bleeding and thrombotic complications were also noted in six and two patients, respectively. CONCLUSION: In conclusion, ECMO support was used as rescue therapy in severe ARDS with a survival rate of 39%. Sepsis was the common complication of ECMO followed by bleeding and thrombosis. HOW TO CITE THIS ARTICLE: Mariappan R, Kumar M, Ramakrishnan N, Mani AK, Kumar S, Chandrasekaran V. Practice Patterns and Outcome of Extracorporeal Membrane Oxygenation Therapy for Severe Acute Respiratory Distress Syndrome in Indian ICUs. Indian J Crit Care Med 2021;25(11):1263-1268.

Extracorporeal Membrane Oxygenation in Drug Overdose: A Clinical Case Series.

Overdose of cardiovascular medications such as beta blockers and calcium channel blockers cause impaired cardiac contractility, vasoplegia, and/or rhythm disturbances. In addition to conventional management of limiting absorption, increasing elimination and hemodynamic support intravenous (IV) calcium infusion, hyperinsulinemia-euglycemia therapy, glucagon infusion, and IV lipid emulsion have been tried. Extracorporeal circulatory assist device support has been reported as a rescue therapy in overdose refractory to maximal medical therapy. We report three patients with cardiovascular medication overdose presenting with profound cardiovascular instability refractory to medical therapy. Venoarterial extracorporeal membrane oxygenation support (VA ECMO) was initiated to provide hemodynamic support. Despite the occurrence of device-associated complications, the outcome was good and all patients survived. VA ECMO may be considered in patients with severe refractory shock due to cardiotoxic medication overdose.

Workplace violence against resident doctors in a tertiary care hospital in Delhi.

BACKGROUND: Healthcare workers particularly doctors are at high risk of being victims of verbal and physical violence perpetrated by patients or their relatives. There is a paucity of studies on work-related violence against doctors in India. We aimed to assess the exposure of workplace violence among doctors, its consequences among those who experienced it and its perceived risk factors. METHODS: This study was done among doctors working in a tertiary care hospital in Delhi. Data were collected by using a self-administered questionnaire containing items for assessment of workplace violence against doctors, its consequences among those who were assaulted, reporting mechanisms and perceived risk factors. RESULTS: Of the 169 respondents, 104 (61.4%) were men. The mean (SD) age of the study group was 28.6 (4.2) years. Sixty-nine doctors (40.8%) reported being exposed to violence at their workplace in the past 12 months. However, there was no gender-wise difference in the exposure to violence (p=0.86). The point of delivery of emergency services was reported as the most common place for experiencing violence. Verbal abuse was the most common form of violence reported (n=52; 75.4%). Anger, frustration and irritability were the most common symptoms experienced by the doctors who were subjected to violence at the workplace. Only 44.2% of doctors reported the event to the authorities. 'Poor communication skills' was considered to be the most common physician factor responsible for workplace violence against doctors. CONCLUSIONS: A large proportion of doctors are victims of violence by their patients or relatives. Violence is being under-reported. There is a need to encourage reporting of violence and prepare healthcare facilities to tackle this emerging issue for the safety of physicians.

Recognizing clinical features of primary ciliary dyskinesia in the perinatal period.

Primary ciliary dyskinesia (PCD) is a rare, motile ciliopathy inherited through mostly autosomal recessive variants that results in chronic ear, sinus, and respiratory disease. Despite neonatal respiratory distress being a common presenting symptom in term infants with PCD, the diagnosis is often delayed due to non-familiarity of neonatal caregivers with phenotypic and diagnostic features of this disease. Organ laterality defects, prenatal cerebral ventriculomegaly, and a family history of suppurative respiratory disease may occur in PCD and should prompt neonatal testing for this condition. In this review of neonatal PCD diagnoses in a large PCD clinic, prevalence and details of neonatal PCD issues are presented, highlighting the typically delayed onset of neonatal respiratory distress and lobar atelectasis on chest radiography, specific presentations in premature neonates, and responses to perinatal therapies.

Calciphylaxis: An Unusual and Silent Usher for an Underlying Carcinoma.

Calciphylaxis is an uncommon but serious and potentially life-threatening painful condition that is characterized by cutaneous vascular calcification and ischemia. It is typically seen in patients with end-stage renal disease but has been known to occur less commonly in patients with normal renal function. A rare but established etiology of non-uremic calciphylaxis is malignancy. We have thus far been successful in documenting an association between calciphylaxis and certain solid tumor types. The objective of this clinical case study is to better define a possible association between calciphylaxis and underlying malignancy.

Pancreatic, hepatobiliary, and gastrointestinal manifestations of children with cystic fibrosis: A 10-year experience from a tertiary care center in southern India.

OBJECTIVES: To describe the demography and spectrum of pancreatic, hepatobiliary, and gastrointestinal (GI) manifestations in children with cystic fibrosis (CF) from the Indian subcontinent. METHODS: In this retrospective study, relevant information from the database of all children with CF below 18 years of age was collected and analyzed. RESULTS: Among the total 109 children, 58 (53%) were from the southern states of India. The most common manifestation was pancreatic insufficiency (PI) in 85 (83%) children. Those with PI presented at an earlier age (1.8 vs. 6.9 years). Cirrhosis with portal hypertension was documented in only one patient and meconium ileus in three (2.8%). There was significant malnutrition in the PI cohort with a mean weight-for-age Z-score of - 3.17 ± 1.79 at diagnosis. Twenty-one (19%) patients had died during the follow-up and 18 (90%) of them had PI. There was no difference in the prevalence of selected pulmonary manifestations in the PI and pancreatic sufficient (PS) groups. Among children with PI, 78 were screened for ΔF508 mutation, 16 (21%) were homozygous, and 17 (22%) were heterozygous. In the PS group, only 2 (14%) were heterozygous for ΔF508 mutation. The median duration of follow-up of the patients was 1.8 (1.5) years. CONCLUSION: PI is the most common GI manifestation of children with CF and is associated with severe malnutrition and poor outcome. Timely identification and management of the comorbidities involving the digestive system are essential for better growth and quality of life in these children.

Management of Children and Adolescents with Wilson Disease and Neurological Worsening Following D-Penicillamine Therapy: A Single Centre Experience.

Background: Most centers in developing countries prefer chelation therapy with D-penicillamine for the management of Wilson's disease (WD) because of its easy availability and affordability. Neurological worsening following treatment with D-penicillamine is not uncommon. However, there is a paucity of Indian data on the incidence of neurological worsening in children and adolescents with WD following chelation therapy. Our study objectives were to identify the prevalence of neurological worsening in children and adolescents with WD following chelation with D-penicillamine therapy and to describe the management options and outcomes in these patients. Materials and Methods: In this retrospective chart review, children and adolescents with an established diagnosis of WD from 2010 to 2020 were identified from the hospital electronic database. Among these patients, data of children and adolescents with neurological worsening following D-penicillamine therapy were extracted and analyzed. Results: Neurological worsening was observed in 27/122 (22.1%) children and adolescents with WD on chelation therapy with D-penicillamine. Fifteen patients with neurological worsening following D-penicillamine therapy were managed with zinc monotherapy. Four patients were managed with a combination therapy of zinc and trientine. Five patients were treated with trientine monotherapy. Re-challenging with D-penicillamine at a lower dose followed by a slow dose escalation was attempted in three patients. Gradual clinical and functional status improvement was observed in 24 cases while one patient succumbed to pneumonia. Conclusion: Children and adolescents with WD who had neurological worsening on D-penicillamine therapy may be managed with trientine. Zinc monotherapy with copper restricted diet was also found to be effective in non-affordable patients.

Frequency of iron deficiency anemia in type 2 diabetes - Insights from tertiary diabetes care centres across India.

AIM: To study the frequency of iron deficiency anemia (IDA) in individuals with type 2 diabetes mellitus (T2DM) seen at tertiary diabetes care centres across India. METHODS: This is a retrospective study (January 1, 2017-December 31, 2019), which included 1137 individuals with T2DM, aged ≥18 years, for whom data on glycemic, lipid and haematological parameters were available. Anthropometric measurements were done using standardized techniques. Biochemical investigations included fasting plasma glucose[FPG], post prandial plasma glucose, HbA1c, lipids and serum ferritin and iron wherever feasible. RESULTS: Of the 1137 individuals included for the study, 117 (10.3%) were categorized as no 'iron deficiency' (ID) group [normal hemoglobin: male ≥13 g/dl, female ≥12 g/dl and normal serum ferritin ≥70 µg/L], 123 (10.8%) as ID group [normal hemoglobin and low serum ferritin <70 µg/L)], 447 (39.3%) as IDA group [low haemoglobin: male <13 g/dl, female <12 g/dl and low serum ferritin] and 450 (39.6%) as 'anemia of chronic disease' (ACD) group [low hemoglobin and normal serum ferritin]. The percentage of women having ID (57.7%) and IDA (65.3%) was significantly higher than their male counterparts. ID was most prevalent (61.7%) in the individuals with duration of diabetes <5 years whereas ACD was most prevalent (50.5%) in individuals with long standing diabetes (>10 years). Independent risk factors for IDA were female gender (OR 3.3,95% CI:1.75-6.23, p < 0.001), duration of diabetes (OR 1.05, 95% CI 1.01-1.11, p = 0.028) and FPG (OR 1.01, 95% CI 0.99-1.00, p = 0.018). CONCLUSIONS: There is a need of identifying and monitoring iron status and anemia in patients with T2DM.

Infant Dengue a 10-Year Experience from a Tertiary Center in South India.

Dengue remains a major problem in the tropics. Several Asian countries have reported an increasing trend in the proportion of infants with dengue fever. However, most studies are limited to case reports or small case series from isolated outbreaks. We planned this study to look at clinico-laboratory profile, outcome, and predictors of severity in a large cohort of infants over a decade. Electronic medical records of infants admitted at a tertiary center of South India, with laboratory confirmed dengue infection between 2009 and 2019 were reviewed. Diagnosis was based on detection of NS-1 antigen and/or immunoglobulin M antibody against DENV(dengue virus) or positive DENV RNA polymerase chain reaction in infants presenting with acute febrile illness and clinical features consistent with dengue. Of 395 children with dengue admitted during study period, 99 (25%) were infants. A cyclical incidence pattern was noted, with higher cases in alternate years. Fever (99%) was most common, followed by gastrointestinal symptoms (vomiting, diarrhea-28%) and upper respiratory symptoms (cough, coryza-22%). Fifty-three infants had severe dengue, and 39 had shock. Fourteen children had multiorgan dysfunction syndrome, and 13 died. Infants with severe dengue were older than those with nonsevere disease, had lower serum albumin and greater frequency of severe thrombocytopenia, and had coagulopathy. On multivariable analysis, low serum albumin predicted development of severe dengue [P = 0.003, odds ratio 12.4 (95% confidence interval: 2.42-63.7)]. Dengue in infants may be challenging to recognize because of its undifferentiated presentation, with gastrointestinal and upper respiratory symptoms that are similar to other viral illness. Severe dengue is common in this sample, and lower serum albumin at presentation was predictive of severe disease.

Effect of malnutrition in infants with cystic fibrosis in India: An underestimated danger.

AIMS: To assess the clinical profile and nutritional status of infants with cystic fibrosis (CF) and track their nutritional outcomes with treatment. MATERIALS AND METHODS: This retrospective study was conducted in a tertiary-care institute in South India. Demographic and clinical information were collected. The nutritional status and treatment outcome was assessed by Z-scores for weight-for-age (WAZ), length-for-age (LAZ), and weight-for-length (WLZ) at diagnosis and follow-up. RESULTS: Nineteen infants with CF had mean follow-up duration of 9.7 ± 8.7 months. There was a mean delay of 2.9 ± 2.1 months from symptom onset to diagnosis, by which time infants were severely malnourished (mean WAZ -4.68 ± 1.8). Pneumonia, summer dehydration with electrolyte abnormalities (42.1%), and a combination of anemia, hypoalbuminemia, and malnutrition (42.1%) were the predominant features. Significant weight loss had been recorded in undiagnosed infants by second month of life before symptom onset. At follow-up, there was a remarkable improvement in WAZ (P 0.001), but not LAZ and WLZ. There was a high mortality rate of 37% in these infants. CONCLUSIONS: Malnutrition is a significant morbidity in infants with CF in India. There was significant improvement of WAZ with treatment, but it lagged behind the recommended targets. There is an opportunity for identification of CF infants at the time of vaccination at six and ten weeks of age, by the primary care physician and pediatrician. Screening of young infants having failure to thrive in the immunization clinic may be a strategy for early diagnosis of infants with severe CF phenotype.

Cellular immune response to Mycobacterium tuberculosis-specific antigen culture filtrate protein-10 in south India.

The Mycobacterium tuberculosis (M. tuberculosis)-specific culture filtrate protein-10 (CFP-10) is highly recognized by M. tuberculosis infected subjects. In the present study, the proliferative response and IFN-gamma secretion was found for C-terminal peptides of the protein (Cfp6(51-70), Cfp7(61-80), Cfp8(71-90), and Cfp9(81-100)). The alleles HLA DRB1 *04 and HLA DRB1 *10 recognized the C-terminal peptides Cfp7, Cfp8, and Cfp9 in HHC. Cfp6 was predominantly recognized by the alleles HLA DRB1 *03 and HLA DRB1 *15 by PTB. The minimal nonameric epitopes from the C-terminal region were CFP-10(56-64) and CFP-10(76-84). These two peptides deserve attention for inclusion in a vaccine against tuberculosis in this region.

Management of Shallow Vestibule with Reduced Attached Gingiva in Fixed Prosthetic Intervention.

Shallow vestibule has long been considered a deterring factor in the use of removable dental prosthetics. The need for management in fixed prosthetic replacement is not widely discussed. Adequate attached gingiva is essential for continued proper oral hygiene. Muscular and fibrous traction leads to gingival recession, which can cause marginal leakage in a fixed prosthetic restoration. In the long-term, this causes the suprastructure to fail and, ultimately, the restoration also fails. Therefore, shallow vestibule with reduced attached gingiva should be identified in the diagnostic stage and should be effectively managed prior to restoration of lost tooth structure. This case report discusses the management of a shallow vestibule in a LeFort I fracture with emphasis on a fixed prosthetic replacement.

Four-headed biceps and triceps brachii muscles, with neurovascular variation.

Anatomical variations of the biceps brachii and triceps brachii have been described by various authors, but the occurrence of four-headed biceps brachii and triceps brachii in an ipsilateral arm is rare and has not been reported before in the literature. During routine cadaveric dissection in the department of anatomy, Kasturba Medical College, Mangalore, India, various unusual variants were noted in the left arm of a cadaver of a 67-year-old man. The variants include a four-headed biceps, a four-headed triceps, communication between the musculocutaneous and median nerves, and a high origin of deep brachial artery from the axillary artery. The occurrence of these anomalies and the clinical and morphological significance are discussed.

Bispyranopyrazoles as Green Corrosion Inhibitors for Mild Steel in Hydrochloric Acid: Experimental and Theoretical Approach.

In the present study, we have synthesized two novel corrosion inhibitors BP-1 and BP-2 and evaluated their corrosion inhibition property on mild steel (MS) in acid solution through weight loss and electrochemical corrosion techniques. The corrosion test results reveal that both compounds inhibit corrosion by an adsorption mechanism and display inhibition efficiency more than 95% at a low concentration of 1.72 × 10-4 M. From the surface analysis of the protective film on MS, it was corroborated that adsorption of inhibitor molecules occurred on the MS surface through chemisorption, which further suppresses the corrosion rate. Density functional theory simulated data helps correlate the experimental trend with the theoretical study.

Population distance between Dakshina Kannada (South India) and Gujarati (North India) population using infracranial nonmetric traits.

Infracranial nonmetric variations have been considered for determining population distance between different regions and continents, in recent times. We studied different infracranial nonmetric traits from the Dakshina Kannada (South India) region to compare with the data available from the Gujarati (North India) region. The mean measure of divergence between the two different geographic regions showed significant variation. In our study, the incidence like i) Allen's fossa of the femur, ii) plaque formation in the upper end of the femur, iii) exostosis in trochanteric fosse of femur, iv) third trochanter of femur, v) os trigonum of talus, vi) medial talar facet, vii) peroneal tubercle of calcaneus, viii) bipartite transverse foramen in the cervical vertebra, too showed significant side difference.

Electrochemical Corrosion and In Vitro Bioactivity of Nano-Grained Biomedical Ti-20Nb-13Zr Alloy in a Simulated Body Fluid.

The bioactivity and the corrosion protection for a novel nano-grained Ti-20Nb-13Zr at % alloy were examined in a simulated body fluid (SBF). The effect of the SPS's temperature on the corrosion performance was investigated. The phases and microstructural details of the developed alloy were analyzed by XRD (X-ray Diffraction), SEM (Scanning Electron Microscopy), and TEM (Transmission Electron Microscope). The electrochemical study was investigated using linear potentiodynamic polarization and electrochemical impedance spectroscopy in a SBF, and the bioactivity was examined by immersing the developed alloy in a SBF for 3, 7, and 14 days. The morphology of the depositions after immersion was examined using SEM. Alloy surface analysis after immersion in the SBF was characterized by XPS (X-ray Photoelectron Spectroscopy). The results of the bioactivity test in SBF revealed the growth of a hydroxyapatite layer on the surface of the alloy. The analysis of XPS showed the formation of protective oxides of TiO2, Ti2O3, ZrO2, Nb2O5, and a Ca3(PO4)2 compound (precursor of hydroxyapatite) deposited on the alloy surface, indicating that the presented alloy can stimulate bone formation. The corrosion resistance increased by increasing the sintering temperature and the highest corrosion resistance was obtained at 1200 °C. The improved corrosion protection was found to be related to the alloy densification. The bioactivity and the corrosion resistance of the developed nanostructured alloy in a SBF renders the nanostructured Ti-20Nb-13Zr alloy a promising candidate as an implant material.