Every lid swelling is not stye: A rare presentation of scrub typhus eschar.

A 17-year-old female patient presented to us with complaints of diffuse swelling in her left upper eyelid with preauricular lymphadenopathy for three days. She was diagnosed with a case of hordeolum externum and was treated on the same line. However, during follow-up, she developed a mild- to moderate-grade fever, which did not subside with treatment. On further investigation, her IgM rapid ELISA for Scrub typhus was positive, which was further confirmed by the Weil-Fellix test (OXK=1:360). She was treated with systemic doxycycline. Within a week, her fever returned to normal baseline, with resolution of local eye lid swelling, and her black scab was also gone. We have reported a case of scrub typhus as a rare manifestation with lid swelling and subsequently eschar formation on the upper eye lid. The patient was promptly treated with oral antibiotics without any morbidity.

Home Blood Pressure monitoring: An economical, reliable, and convenient Tool over ambulatory Blood Pressure monitoring in Patients on Dialysis.

BACKGROUND: Hypertension and cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients on dialysis. Blood pressure (BP) control is of paramount importance in reducing morbidity and mortality in this high-risk population, although there is no consensus on target BP. Ambulatory BP recording is considered gold standard in estimating the BP among patients on dialysis. But, ambulatory BP recording is cumbersome, not economical, and not easily available to Indian patients. Therefore, an easier and more convenient method has to be implemented to monitor the BP. Some studies demonstrated that home BP recordings may be promising in making a more accurate diagnosis of hypertension in hemodialysis patients. However, there is paucity of research that compares home-based BP monitoring with ambulatory BP recordings in patients on hemodialysis. The present study was thus planned to examine the hypothesis that out-of-dialysis unit BP measurement in the form of home-based measurement of BP is as efficacious as ambulatory BP monitoring (ABPM) in evaluating hypertension among patients on hemodialysis. AIM: To assess the accuracy of home-based BP monitoring in comparison to ABPM among chronic kidney disease (CKD) patients on hemodialysis. OBJECTIVE: To assess the ability of home-based BP monitoring to detect hypertension among CKD patients on hemodialysis. MATERIALS AND METHODS: This was a prospective observational study carried out in the Department of Medicine in a tertiary care hospital. The total duration of the study was 24 months. Fifty-two CKD patients on hemodialysis fulfilling the eligibility criteria were taken up for the study after informed consent. Blood pressure was measured using a standardized BP measuring equipment at home, thrice a day for 3 days in the interdialysis period. Also, all these patients were subjected to 24 hours of ABPM in the interdialysis period. Home-based BP monitoring records are then compared with the one-time ABPM records. All statistical calculations were done using computer programs Microsoft Excel 2007 (Microsoft Corporation, NY, USA) and SPSS (Statistical Product and Service Solutions; SPSS Inc., Chicago, Illinois, USA) version 21. RESULT: In our study, the mean awake, asleep, and average ABPM readings of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 141.69/81.33, 139.39/80.04, and 141.23/80.67 mm Hg, respectively, while the mean SBP and DBP recorded on home-based measurements were 143.6 and 82.69 mm Hg, respectively. All the subjects showing mean SBP ≥140 mm Hg as per ABPM had home-based readings of above 140 mm Hg while 23 out of 27 patients (85.2%) with mean SBP <140 mm Hg as per ABPM had similar observation by home-based monitoring (kappa 0.847; p<0.01). All the subjects showing mean DBP ≥90 mm Hg as per ABPM had home-based readings of above 90 mm Hg while 42 out of 44 patients (95.5%) with mean DBP <90 mm Hg as per ABPM had similar observation by home-based monitoring (kappa 0.866; p<0.01). CONCLUSION: Our study shows that there is no difference between BP readings as observed by ABPM and home-based BP monitoring. Also, home-based BP monitoring can detect hypertension as effectively as ABPM among patients on hemodialysis, thereby making home-based BP monitoring a safe and reliable method of BP measurement in clinical practice.

Four Cases of Multisystem Inflammatory Syndrome in Adults Associated with SARS-COV-2 Infection - An Overview of Clinical Features, Diagnosis and Treatment.

The varied spectrum of presentation of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is intriguing. Multisystem inflammatory syndrome in children (MIS-C) is a well described and documented condition that is associated with the active or recent COVID-19 infection. A similar presentation in adults is termed as Multisystem inflammatory syndrome in Adults (MIS-A). With only very limited cases reported from the west, MIS-A is considered a rare and serious complication of COVID-19. However, it is not as uncommon as we think. Many cases go undiagnosed for lack of COVID -19 like symptoms and unawareness among treating clinicians about this newer clinical entity. Further, antibody testing and inflammatory markers are not easily available in many of the Indian hospitals especially in rural India where the second wave had been intense, thereby making it difficult for the diagnosis of MIS-A. Also, there is no clear treatment guideline for MIS-A unlike MIS-C where the treatment protocol is well laid out. Awareness about MIS-A among treating clinicians can thus help in further evaluation and increased identification of the syndrome at the early stages thereby helping in the early institution of treatment. Our tertiary COVID care hospital in South India which has handled about 5200 cases of COVID-19 is been able to identify 04 cases of MIS-A proving that this clinical entity is not as rare as it is thought but lacks reporting and prompt identification. Here we describe 04 cases of MIS-A and strive to bring in the various aspects of it, including the clinical presentation, laboratory markers, diagnostic criteria and treatment considerations in this post second wave of the COVID-19 pandemic in India.

Effectiveness of Medical Nutritional Therapy in the Management of Type 2 Diabetes Mellitus.

AIM: To assess the effect of medical nutritional therapy (MNT) provided by dieticians on medical and clinical outcomes for adults with Type 2 Diabetes Mellitus. OBJECTIVE: To compare effectiveness of MNT administered monthly to MNT administered once in 03 months. METHOD: The study was conducted at the Department of Endocrinology in a tertiary care hospital. 98 men and women of the age group above 18 years were recruited in the study. 49 consenting individuals were randomly assigned to each of the 02 groups namely Group A and Group B. Group A consisted of 02 visits with dietician (including the initial visit) in the first month and thereafter every monthly. Group B consisted of initial visit with the dietician and there after every 03 monthly. An additional 49 adults with type 2 Diabetes mellitus at one site who had no facility for a contact with dietician were included as a comparison group.Medical outcome measures including fasting plasma glucose (FPG), glycated haemoglobin (HbA1c) and serum lipid levels were compared and analysed. Clinical outcomes included Body weight, Height and Body mass index (BMI).Data was collected at the entry to the study and at 03 and 06 months interval. RESULT: In our study, the baseline fasting plasma glucose (FPG), HbA1C, total cholesterol and BMI was more or less similar in all 3 groups. There was a sustained decrease in all the four parameters in Group A which received the maximum nutritional therapy over a period of 06 months (A mean decrease of FPG 15.2 mg/dL, HbA1C 0.59%, total cholesterol 19.6 mg/dL, BMI 0.5 kg/m2 from baseline at 03 months and a mean decrease of FPG 33.4 mg/dL, HbA1C 1.24%, total cholesterol 40.8 mg/dL, BMI 1.1 kg/m2 from baseline at 06 months was seen). However, in Group B which received intermitted nutritional therapy, the decrease in these parameters were observed initially but over a period of 06 months, they increased to more or less near the baseline value months (A mean decrease of FPG 12.9 mg/dL, HbA1C 0.73%, total cholesterol 16.1 mg/dL, BMI 0.5 kg/m2 from baseline at 03 months but a mean increase of FPG 3.2 mg/dL and a mean decrease of HbA1C 0.24%, total cholesterol of 4.3 mg/dL and BMI 0.15 kg/m2 from baseline at 06 months was seen). In Group C which had no means of access to nutritional therapy, there was a subtle decrease in FPG and gradual increase in HbA1C, total cholesterol and BMI at 03 months but all four parameters increased significantly higher than the baseline value at the end of 06 months months (A mean decrease of FPG 6.2 mg/dL and mean increase of HbA1C 0.31%, total cholesterol 16.0 mg/dL, BMI 0.3 kg/m2 from baseline at 03 months and a mean increase of FPG 5.9 mg/dL, HbA1C 0.73%, total cholesterol 31.1 mg/dL, BMI 0.81 kg/m2 from baseline at 06 months was seen). CONCLUSION: Our study has clearly indicated that medical nutritional therapy is of great importance in the holistic management of Type 2 Diabetes mellitus in adults. MNT has got the advantage of not only maintaining a strict glycemic control (in terms of FPG and HbA1C reduction) but also in the lowering of cholesterol and BMI which are the main contributors to cardiovascular (CVD) events among people with type 2 Diabetes mellitus. Also, people who were given frequent MNT had a clear advantage over those who received intermittent MNT in terms of all the measured parameters.

Open-label randomized control trial of hydroxychloroquine in patients with moderate to severe coronavirus disease 2019 infection.

BACKGROUND: At onset of coronavirus disease 2019 (COVID-19) pandemic, hydroxychloroquine (HCQ) was repurposed for treatment of patients based on reports that it had in vitro activity. The aim of this study was to find out if HCQ reduces number of days of hospitalization when given to patients with moderate to severe COVID-19 infections who require hospitalized care. METHODS: This was an open-label randomized control trial of HCQ administered 400 mg twice on day 1, then 400 mg once daily from day 2 to day 5 in patients with moderate to severe COVID-19 infection. Assessment was not blinded. Standard of care was given to both arms.Primary outcome was number of days of hospitalization till discharge or death. RESULT: One hundred ten patients (55 in each arm) were included. Mean age was 58 years. Baseline characteristics were well matched. There was no difference in the primary outcome (13.67 vs 13.89; p = 0.98). Number of deaths were more in HCQ arm (RR: 1.81; 95% CI: 1.13-2.93; p = 0.03). There was no difference in number of days on oxygen or normalization of oxygen saturation, number who needed ventilator, days to ventilator requirement and days on ventilator. Twenty-nine patients in control arm received remdesivir. When adjusted analysis was done after removal of these patients, there was no difference in primary or secondary outcomes. Number of deaths in adjusted analysis were not significant (RR: 1.28; 95% CI: 0.87-1.88; p = 0.37). CONCLUSION: HCQ does not change the number of days of hospitalization when compared with control.

Two Cases of Early Morning Neuroparalytic Syndrome (EMNS) in the Tropics - Masquerading as Brain Death.

Neurotoxicity from elapid bite may masquerade as early morning neuroparalytic syndrome (EMNS). We are reporting a series of two cases who presented as EMNS with absent brain stem reflexes, mimicking brain death. The first case was being considered for potential organ retrieval when the diagnosis was revised, and he recovered completely with Anti-snake venom (ASV). The second patient developed severe anaphylaxis to ASV, which made continuation of the empirical therapy in a comatose patient very tricky. She gradually tolerated a low dose ASV infusion under steroid and adrenaline cover, with reversal of paralysis and coma. Both the patients showed excellent recovery post ASV treatment. A simple bedside Neostigmine challenge test and timely ASV therapy can save many helpless patients of EMNS from certain death.

Diagnostic Accuracy of Stress Myocardial Perfusion Imaging in Diagnosing Stable Ischemic Heart Disease.

OBJECTIVE: To determine the diagnostic accuracy of Stress Myocardial Perfusion Imaging (MPI) in diagnosing Stable Ischemic Heart Disease (SIHD). METHODS: To analyze the sensitivity and specificity of Stress Myocardial Perfusion Imaging (MPI) in diagnosing Stable Ischemic Heart Disease (SIHD) by comparing with "gold standard" Coronary Angiogram. RESULTS: A total of 80 patients were studied (51 male, 29 female). 52 patients had significant stenosis in coronary angiography and 49 patients had reversible perfusion defect in myocardial perfusion imaging (MPI). MPI had a sensitivity of 88.46% and a specificity of 89.29% in diagnosing stable ischemic heart disease. CONCLUSION: Coronary Angiography remains the near gold standard in diagnosing ischemic heart disease but is associated with serious complications like stroke, arrhythmias, acute renal failure, infection, etc. Though Myocardial perfusion imaging cannot replace coronary angiogram, it can be used as a reliable and sensitive non-invasive alternate investigation to diagnose stable ischemic heart disease in high risk individuals who are unwilling for angiogram.

Development of Lipidic Nanoplatform for Intra-Oral Delivery of Chlorhexidine: Characterization, Biocompatibility, and Assessment of Depth of Penetration in Extracted Human Teeth.

Microorganisms are the major cause for the failure of root canal treatment, due to the penetration ability within the root anatomy. However, irrigation regimens have at times failed due to the biofilm mode of bacterial growth. Liposomes are vesicular structures of the phospholipids which might help in better penetration efficiency into dentinal tubules and in increasing the antibacterial efficacy. Methods: In the present work, chlorhexidine liposomes were formulated. Liposomal chlorhexidine was characterized by size, zeta potential, and cryo-electron microscope (Cryo-EM). Twenty-one single-rooted premolars were extracted and irrigated with liposomal chlorhexidine and 2% chlorhexidine solution to evaluate the depth of penetration. In vitro cytotoxicity study was performed for liposomal chlorhexidine on the L929 mouse fibroblast cell line. Results: The average particle size of liposomes ranged from 48 ± 4.52 nm to 223 ± 3.63 nm with a polydispersity index value of <0.4. Cryo-EM microscopic images showed spherical vesicular structures. Depth of penetration of liposomal chlorhexidine was higher in the coronal, middle, and apical thirds of roots compared with plain chlorhexidine in human extracted teeth when observed under the confocal laser scanning microscope. The pure drug exhibited a cytotoxic concentration at which 50% of the cells are dead after a drug exposure (IC50) value of 12.32 ± 3.65 µg/mL and 29.04 ± 2.14 µg/mL (on L929 and 3T3 cells, respectively) and liposomal chlorhexidine exhibited an IC50 value of 37.9 ± 1.05 µg/mL and 85.24 ± 3.22 µg/mL (on L929 and 3T3 cells, respectively). Discussion: Antimicrobial analysis showed a decrease in colony counts of bacteria when treated with liposomal chlorhexidine compared with 2% chlorhexidine solution. Nano-liposomal novel chlorhexidine was less cytotoxic when treated on mouse fibroblast L929 cells and more effective as an antimicrobial agent along with higher penetration ability.

Psychological Health Among Armed Forces Doctors During COVID-19 Pandemic in India.

BACKGROUND: A pandemic poses a significant challenge to the healthcare staff and infrastructure. We studied the prevalence of anxiety and depressive symptoms among armed forces doctors in India during the COVID-19 pandemic and the factors that contribute to these symptoms. METHODS: The study was conducted from March 30, 2020, to April 2, 2020, using a self-administered questionnaire questionnaire using the hospital anxiety and depression scale (HADS), which was sent through Google Forms. Responses were received from 769 respondents. Data were analyzed for demographic details and HADS scores using the chi-square test and backward logistic regression. RESULTS: Anxiety and depressive symptoms were seen in 35.2% and 28.2% of the doctors, respectively. In doctors with anxiety symptoms, significant associations were observed with age (20-35 years, 39.4%, P = 0.01), gender (females, 44.6%, P < 0.001), duration of service (0-10 years, 38%, P = 0.03), and clinical versus non-clinical specialties (non-clinical, 41.3%, P < 0.001) as opposed to marital status, education level, and current department of work.In doctors with depressive symptoms, significant associations were observed with age (P = 0.04), clinical versus non-clinical specialties (P < 0.001), duration of service (0-10 years, 30.1%, P = 0.03), and doctoral degree (P = 0.04) as opposed to gender, marital status, education level, and current working department. CONCLUSION: The study revealed a high prevalence of anxiety and depressive symptoms among armed forces doctors. The main contributing factors are female gender, young age group, non-clinical specialties, and having a doctoral degree.

Design, synthesis, and evaluation of novel diphenyl ether derivatives against drug-susceptible and drug-resistant strains of Mycobacterium tuberculosis.

In our efforts to develop druggable diphenyl ethers as potential antitubercular agents, a series of novel diphenyl ether derivatives (5a-f, 6a-f) were designed and synthesized. The representative compounds showed promising in vitro activity against drug-susceptible, isoniazid-resistant, and multidrug-resistant strains of Mycobacterium tuberculosis with MIC values of 1.56 µg/ml (6b), 6.25 µg/ml (6a-d), and 3.125 µg/ml (6b-c), respectively. All the synthesized compounds exhibited satisfactory safety profile (CC50  > 300 µg/ml) against Vero and HepG2 cells. Reverse phase HPLC method was used to probe the physicochemical properties of the synthesized compounds. This series of compounds demonstrated comparatively low logP values. pKa values of representative compounds indicated that they were weak acids. Additionally, in vitro human liver microsomal stability assay confirmed that the synthesized compounds possessed acceptable stability under study conditions. The present study thus establishes compound 6b as the most promising antitubercular agent with acceptable drug-likeness.

Insights on the antioxidant potential of 1, 2, 4-triazoles: synthesis, screening & QSAR studies.

The aligned manuscript reports synthesis, screening and QSAR analysis of twenty six 1, 2, 4-triazole analogues from their respective aromatic carboxylic acids. The structures of synthesized analogues were characterized using physical and spectral analysis. 1, 2, 4-Triazole analogs antioxidant capacity was determined using DPPH radical scavenging assay. Results revealed that out of L, T & VRT series, VRT series of 1, 2, 4-triazoles have significant antioxidant activities when compared with standard ascorbic acid. To obtain structural insights for development of new antioxidants a 2D-QSAR analysis of this dataset of 26 molecules was performed. The 2D-QSAR models correlate with the in vitro results and explain the salient structural features predominant in the molecules responsible for antioxidant activity.

Monastrol mimic Biginelli dihydropyrimidinone derivatives: synthesis, cytotoxicity screening against HepG2 and HeLa cell lines and molecular modeling study.

Biginelli dihydropyrimidinone derivatives as structural analogs of monastrol, a known human kinesin Eg5 inhibitor, were synthesized. IC50 values of the synthesized compounds against the proliferation of human hepatocellular carcinoma and human epithelial carcinoma cell lines were determined through MTT assay. Molecular docking study gave a clear insight into the structural activity relationship of the compounds in comparison with monastrol.

Vasorelaxant and antihypertensive effect of Cocos nucifera Linn. endocarp on isolated rat thoracic aorta and DOCA salt-induced hypertensive rats.

ETHNOPHARMACOLOGICAL RELEVANCE: The fruits of Cocos nucifera Linn. (Arecaceae) have long been used in traditional medicine for the treatment of cardio-metabolic disorders. AIM OF THE STUDY: To evaluate the ethanolic extract of Cocos nucifera Linn. endocarp (CNE) for its vasorelaxant activity on isolated rat aortic rings and antihypertensive effects in deoxycorticosterone acetate (DOCA) salt-induced hypertensive rats. MATERIALS AND METHODS: Cocos nucifera Linn. endocarp was extracted with ethanol and characterized by HPLC. CNE was examined for its in vitro vascular relaxant effects in isolated norepinephrine, phenylephrine or potassium chloride pre-contracted aortic rings (both intact endothelium and denuded). In vivo anti-hypertensive studies were conducted in DOCA salt-induced uninephrectomized male Wistar rats. RESULTS: Removal of endothelium or pretreatment of aortic rings (intact endothelium) with l-NNA (10µM) or ODQ (10 µM) followed by addition of contractile agonists prior to CNE significantly blocked the CNE-induced relaxation. Indomethacin (10µM) and atropine (1 µM) partially blocked the relaxation, whereas glibenclamide (10 µM) did not alter it. CNE significantly reduced the mean systolic blood pressure in DOCA salt-induced hypertensive rats (from 185.3 ± 4.7 mmHg to 145.6±6.1 mmHg). The activities observed were supported by the polyphenols, viz. chlorogenic acid, vanillic acid and ferulic acid identified in the extract. CONCLUSIONS: These findings reveal that the vasorelaxant and antihypertensive effects of CNE, through nitric oxide production in a concentration and endothelium-dependent manner, is due to direct activation of nitric oxide/guanylate cyclase pathway, stimulation of muscarinic receptors and/or via cyclooxygenase pathway.