A comparison of swab types on sample adequacy, suspects comfort and provider preference in COVID-19.

AIM: This study was aimed to compare the virological, suspect reported outcomes and provider preferences during COVID-19 swab taking procedure used for sampling. METHODS: The COVID-19 suspects are subjected to nasopharyngeal (NP) and oropharyngeal (OP) swabs for testing. Two types of swabs (Nylon and Dacron) are used for sample collection. Prospectively each suspect's response is collected and assessed for self-reported comfort level. The provider's experience with each suspect and virological outcomes recorded separately. The sample adequacy was compared based on swab types and demographic characteristics. RESULTS: A total of 1008 COVID-19 suspects were considered for comparison of various outcomes. Dacron and flocked Nylon swab sticks are used for taking 530 and 478 samples, respectively. Suspects who underwent the procedure using Nylon swabs were six times more likely to have pain/discomfort compared to when Dacron swab was used (Adj RR (95% CI: 6.76 (3.53 to 13, p=0.0001))). The providers perceived six times more resistance with the Nylon swabs compared to Dacron Swabs (Adj RR (95% CI: 5.96 (3.88 to 9.14, p=0.0001))). The pediatric population had a higher rate of blood staining in Dacron swab [Dacron 66 (80.5%); Nylon 51 (54.8%) p=0.0001]. The sample adequacy rate and laboratory positivity rate were not significantly different from each other. CONCLUSIONS: Given the comparable virological outcomes, the difference in suspect and providers comfort should drive swab selection based on characteristics of the suspects. The bulbous Nylon swab caused more pain/discomfort in adults compared to Dacron.

Methemoglobinemia: Living with Dormant Devil.

Methemoglobin is an oxidized form of hemoglobin. NADH methemoglobin reductase deficiency or inactivity is the cause of methemoglobin. Excessive production, resulting in accumulation, causes methemoglobinemia. It can be congenital or acquired. We present a case of dormant congenital methemoglobinemia detected accidentally on preoperative assessment, due to low oxygen saturation even at F1O2-1.0 associated with central cyanosis. The patient had 27.7 % methemoglobin, living his life without any complications. The patient was operated upon successfully for tympanoplasty and mastoidectomy under local anesthesia by taking proper precautions.

Misplaced Intracystic Lacrimal Implant- An Unusual Cause of Failed External Dacryocystorhinostomy.

Background: Various techniques of dacryocystorhinostomy (DCR) by an external or endonasal endoscopic approaches are in practice of ophthalmologists and otorhinolaryngologists. The purpose of this paper is to report a case of misplaced intracystic implant in the orbit following external DCR leading to persistence of watering, diplopia and visual diminution. Case Report: A thirty nine year old female patient presented with recurrent left eye pain, swelling over medial side of the left eye, watering, progressive blurring of vision and diplopia after revision external DCR. The ophthalmology examination revealed bilateral decreased vision, left side restricted extraocular eye movements, sub capsular cataract. The computed tomography dacryocystograph (CT-DCG) revealed tubular foreign body in the extra-conal space abutting the medial rectus with proximal block in the nasolacrimal duct. Conclusion: This is the first reported case of misplaced implant following external DCR in the literature. It may be suggested that patients undergoing intracystic larimal implant shall be on close follow up for such an occurrence later for timely intervention.

C-reactive Protein Kinetics During In-Patient Treatment of COVID-19-Associated Rhino-Orbito-Cerebral Mucormycosis: A Retrospective Cohort Study in a Tertiary Hospital in Central India.

COVID-associated rhino-orbito-cerebral Mucormycosis (CA-ROCM), henceforth referred to as Covid-Associated Mucormycosis (CAM), is a serious and fatal condition unless treated promptly and completely. The main treatment of the CAM is complete surgical debridement and administration of systemic antifungals. The first line antifungal recommended for CAM is Amphotericin-B. Since Amphotericin-B has systemic side effects mainly on the renal system, a timely decision to start and end Amphotericin-B therapy is very essential. Besides the Computed Tomography (CT) scan, serum levels of C-reactive protein (CRP) levels are a good indicator of CAM-associated inflammation levels in the patient's body. By monitoring the CRP levels, we can titrate amphotericin treatment to cause minimal harm to the kidneys. Our study was done to analyze the kinetics of C-reactive protein in patients of CAM admitted in a tertiary-care hospital and compare it with the CRP levels in COVID-associated non-Mucormycosis Sinusitis patients. Aim and objective To study the kinetics of serum C-reactive protein (CRP) levels among patients undergoing in-patient care for COVID-associated rhino-orbito-cerebral mucormycosis and compare with serum CRP levels in COVID-19 patients suffering from sinusitis without rhino-orbito-cerebral mucormycosis.  Materials and methods This was a retrospective cohort study. The source of data was post-COVID sinusitis patients who were admitted during 2nd wave of COVID-19 in India in our hospital whose medical records were accessed by the Medical Records Department. The subjects were recruited into the two study groups namely the Mucormycosis group and the non-Mucormycosis group based on the histopathological report of the nasal biopsy specimen. The medical records of each member of the two groups were studied for the levels of serum C-reactive protein measured at the time of admission and every 5(+1) days thereafter till the time of discharge. The kinetics of serum C-reactive protein levels, which is a marker of inflammation is studied in each of the two groups and compared using statistical methods. Results There was a significant difference between Mucormycosis and Non-Mucormycosis groups in CRP-level kinetics. However, there was no significant trend of decrease or increase over time in Mucormycosis as well as non-Mucormycosis cases. Conclusion CRP is an important biomarker in assessing the septic response to COVID-associated rhino-orbito-cerebral mucormycosis. Detection of raised CRP levels helps in prompt early initiation of anti-fungal treatment. Also, monitoring the levels of serum CRP will guide in deciding the time to stop the antifungals at an appropriate time. CRP monitoring is commonly available and affordable. Hence, we recommend CRP monitoring of in-patients of CAM.

Sinonasal and Orbital Imaging Findings in COVID-Associated Rhino-Orbito-Cerebral Mucormycosis During the Second Wave of COVID-19: A Retrospective Cohort Study in a Tertiary Hospital in Central India.

Background Mucormycosis is a consequence of the angioinvasive disease caused by filamentous fungi that belong to the order Mucorales, particularly Mucor, Rhizopus, and Rhizomucor. Rhizopus oryzae is the most prevalent form. The invading hyphae lead to damage of blood vessels leading to thrombosis and consequent tissue necrosis. The incidence of this disease entity witnessed a significant rise during the second wave of the coronavirus disease 2019 (COVID-19) pandemic. Timely diagnosis and prompt treatment are crucial to diminish both the mortality and morbidity associated with this disease. Imaging plays a pivotal role in diagnosing the ailment, evaluating its extent, identifying complications such as thrombosis, and facilitating surgical planning. It demonstrates exceptional sensitivity in detecting the disease at its early stages, often before symptoms manifest. Due to the angioinvasive nature of Mucor, early detection assumes utmost importance as it necessitates intensive antifungal therapy and the removal of devitalized tissue through debridement. Methodology We conducted a retrospective cohort study to analyze computed tomography (CT) imaging findings in patients with COVID-associated rhino-orbito-cerebral mucormycosis (ROCM) confirmed by histopathological examination. We compared these findings with CT findings of the nose and paranasal sinuses in patients without mucor following COVID-19 sinusitis (non-ROCM). Results All 16 cases in the non-ROCM group were in stage 1 disease. In contrast, in the ROCM group, three patients had stage 1 disease, five patients had stage 2 disease, and 10 patients had stage 3 disease (p = 0.0001). The pterygopalatine fossa was significantly affected in 10 of 18 ROCM patients and in none of the non-ROCM patients. Conclusions Imaging plays a crucial role in the early detection of mucormycosis. It assists treating physicians in initiating prompt and aggressive treatment, thereby improving the prognosis of this frequently fatal disease.

Conventional Naso-Oropharyngeal Sampling Versus Self-Collected Saliva Samples in COVID-19 Testing.

Comparing the diagnostic utility of salivary specimen samples with conventional nasopharynx-oropharynx (NP-OP) specimen samples to identify COVID-19 cases by reverse transcription-polymerase chain reaction (RT-PCR). Eighty COVID-19 suspects enrolled for the paired sampling. In addition to conventional sampling, suspects were asked to follow stepwise pictorial instructions for self salivary sampling. Separate nylon swab stick was used for taking the samples from NP-OP and the floor of the oral cavity. The data were analyzed for sensitivity, specificity, concordance of COVID-19 status, and limits of agreement for cycle threshold (ct) values by either method. Forty-nine suspects (61.3%) were males, the mean age was 36.4 years. To determine the diagnostic test performance of the saliva, RT-PCR results of the NP-OP samples were used as the reference standard. Out of 80 suspects, 41 showed positivity by NP-OP swabs and 12 by salivary samples. The salivary samples showed significantly lesser positivity rate. The sensitivity and specificity of salivary samples against conventional reference standards are 24.4%, 94.9% respectively. Concordance of these two types of samples in terms of agreement kappa statistics is estimated as K = 0.252 (0.09-0.42). Median ct values of both the E and ORF1ab gene for the salivary samples were higher compared to the corresponding NP-OP sample. This study showed lesser sensitivity with salivary swab samples as compared to conventional NP-OP sampling for RT-PCR, COVID-19 detection. Hence, we are of opinion that more studies are required to establish the utility of salivary sampling in COVID-19 diagnostics.

Incidence of COVID-19 infection and its variation with demographic and clinical profile: lessons learned at a COVID-19 RT-PCR laboratory in Nagpur, India.

Introduction. The coronavirus disease 2019 (COVID-19) pandemic emerged as a global health crisis in 2020. The first case in India was reported on 30 January 2020 and the disease spread throughout the country within months. Old persons, immunocompromised patients and persons with co-morbidities, especially of the respiratory system, have a more severe and often fatal outcome to the disease. In this study we have analysed the socio-demographic trend of the COVID-19 outbreak in Nagpur and adjoining districts. Methods. The study was conducted from April to December 2020. Nasopharyngeal and oropharyngeal swabs collected from suspected cases of COVID-19 were tested using reverse-transcription polymerase chain reaction (RT-PCR) at a diagnostic molecular laboratory at a tertiary care hospital in central India. Patient-related data on demographic profile and indication for testing were obtained from laboratory requisition forms. The results of the inconclusive repeat samples were also noted. The data were analysed using SPSS v24.0. Results. A total of 46 898 samples were received from April to December 2020, of which 41 410 were included in the study; 90.6 % of samples belonged to adults and 9.4 % belonged to children. The overall positivity rate in the samples was 19.3 %, although it varied over the period. The yield was significantly high in the elderly age group (25.5 %) and symptomatic patients (22.6 %). On repeat testing of patients whose first test was inconclusive, 17.1% were positive. There was a steady increase of both the number of tests and the rate of positivity in the initial period of the study, followed by a sharp decline. Conclusion. We can conclude that rigorous contact tracing and COVID-appropriate behaviour (wearing a mask, social distancing and hand hygiene) are required to break the chain of transmission. Elderly people are more susceptible to infection and should follow stringent precautions. It is also important to perform repeat testing of those individuals whose tests are inconclusive with fresh samples so that no positive cases are missed. Understanding of demographics is crucial for better management of this crisis and proper allocation of resources.

A Study of Symptomatology of COVID-19 Laboratory-Confirmed Cases at Tertiary Care Center: A Cross-Sectional Study.

Background and objectives People with coronavirus disease 2019 (COVID-19) have had a wide range of symptoms reported such as fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, a new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and diarrhea. The severity of disease, mortality, symptoms of COVID-19 showed significant variation in different parts of the world. The purpose of this study was to describe epidemiological characteristics and symptoms of confirmed COVID-19 patients and to identify factors associated with the severity of the disease. Methods This is a cross-sectional descriptive study conducted on hospitalized COVID-19 patients from May 2020 to July 2020. We obtained data on the demographic characteristics, symptoms, and infection severity for 150 patients by pre-tested semi-structured interview. Information was recorded in a Microsoft Excel sheet and exported to SPSS Statistics (Armonk, NY: IBM Corp.) for analysis. Results The median age of the patients was 31.5 years, where 42% of the patients were female; 52.7% of patients were symptomatic while 47.3% of patients were asymptomatic. Common symptoms at the time of admission were fever (40.5%), sore throat (36.7%), cough (32.9%), rhinitis (19.0%), and body ache (13.9%). At least one comorbidity was reported in 20.0% of the patients, with the most common comorbidity being hypertension (14.7%). History of contact with known confirmed cases of COVID-19 within the last 14 days was present in 94% of patients. The presence of any coexisting illness was significantly higher among patients with severe disease than among those with non-severe disease (80% vs. 17.9%, p=0.012). Conclusions High proportions of COVID-19 patients were asymptomatic in our study. Fever and cough were the most common symptoms. The presence of any coexisting illness was significantly higher among patients with severe disease than among those with a non-severe disease.

Symptomatology and Relationship Between Symptoms and Duration Among COVID-19 Patients in a COVID-19 Care Hospital in Central India.

The COVID-19 pandemic has affected the world population across the globe. India has the second largest number of cases and the third largest number of deaths due to COVID-19 in the world. There have been close to 4.4 lakh deaths due to COVID-19 in India alone. The second wave in India has led to devastating consequences, particularly among the young population. The initial clinical symptoms of COVID-19 are similar to all types of viral pneumonia, with varying degrees of severity. The cases' clinical manifestations include fever, nonproductive cough, dyspnea, myalgia, and fatigue. This study was undertaken with the purpose of identifying the relationship between the symptoms and duration in COVID-19-affected patients. The common presenting symptoms were fever (44.5%), sore throat (38.7%), and cough (36.12%). Most of the cases presented with a combination of fever with cough (35%) and fever with sore throat (33%). The duration of symptoms varied from one to 17 days with a mean of 5.75 days. Despite vaccination being started, the risk of the imminent third wave in the country is existential. Mutations in the coronavirus pose a threat to the vulnerable population. It is important to identify the combination of symptoms most predictive of COVID-19 to help guide recommendations for self-isolation, testing, and preventing further spread of the disease. Further studies using these models can yield better results in surveillance and containing this infectious disease.

Tracing, Tracking and Treating COVID-19 Associated Rhino-Orbito Cerebral Mucormycosis (ROCM).

Surge in the number of mucormycosis cases following second wave of coronavirus disease-19 (COVID-19) infection posed several diagnostic and prognostic challenges. This study was aimed to describe clinical, diagnostic features and survival outcomes among patients of mucormycosis in post COVID-19 context. Retrospective chart review. This study included 44 COVID-19 positive screened cases who presented with clinical features suggestive of mucormycosis. Demography, clinical profile, diagnostic findings, and the treatment outcome are studied. Medical and surgical outcomes are summarised as frequencies and percentages. The reliability of microbiological, and radiological findings against the pathological findings was analyzed using Kappa statistics (k). Based on constellation of microbiological, pathological and radiological findings 28 cases (63%) confirmed with mucormycosis infection. The mean (SD) age was 54.9 (12.9) years and two-third were males. The majority (90%) of cases presented with the feature of facial swelling, headache nasal blockade. Inpatient care for treatment of COVID-19 was recorded in 33 (75%). Diabetes mellitus was the commonest comorbidity in 27 (61.4%), 38 (86.4%) cases were treated by steroids and 30 (68.2%) were given oxygen therapy. There is a strong agreement (k = 0.83) between pathological and microbiological investigations. In thirty-eight cases (86.3%) remission was achieved when assessed after 8 weeks. Of the 44 cases, four patients died. The results of the current study suggest that the disease residues and/or recurrences in critical areas are frequent in mucormycosis. However, using the strategy of screening at risk patients, diagnosing, treating them with combination of antifungals, surgical debridement, and timely follow up may help in improving outcomes as compared to pre COVID-19 era.

Testing Olfactory and Gustatory Dysfunctions among Quarantine COVID-19 Suspects.

The World Health Organization (WHO) has cautioned on specific respiratory symptoms for suspecting an individual of Corona Virus Disease 2019 (COVID-19). Meanwhile, many suspects are reporting dysfunctions of smell and taste. This study aimed to investigate the percentage of positive COVID-19 who had associated loss of sensation as detected by psychophysical testing. Eight hundred and thirty two suspects were enrolled. At the time of sampling for testing COVID-19 status, olfactory dysfunction (OD) and gustatory dysfunction (GD) tested using odorants like coffee and camphor and solutions of sweet and salty solvants, respectively. The strength of the association between test results of these sensory losses and COVID-19 positivity was assessed by calculating sensitivity, specificity, and predictive values. The responses in positive and negative individuals presented as age-adjusted odds ratio with 95% CI. Seventy six (9.1%) [95% CI: 7.4%-11.3%] of 832 suspects were tested positive for COVID-19. Paediatric cases of age between 2 and 10 years could not reply appropriately, hence OD in 134 and GD in 118 could not be tested. Anosmia or hyposmia was present in 62 (81.6%) and ageusia in 64 (84.2%) of the total 76 confirmed cases. The OD and GD dysfunctions were significantly higher among confirmed COVID-19 cases compared to negative subjects [Adj OR (95% CI): Smell 3.22 (1.77-5.88); taste 3.05 (1.61-5.76), p < 0.001]. In this study, testing of smell and taste dysfunctions had higher sensitivity in identifying recent-onset loss of sensations in COVID-19 cases. Hence, it may be used as a simple and cost-effective screening test.

Role of Computed Tomography Findings in the Quest of Understanding Origin of Antrochoanal Polyp.

Aetio pathogenesis of antrochoanal polyp (ACP) remains unclear. Correlation of clinical, computed tomography (CT) and histopathological findings is attempted in this study for understanding of their origin. A retrospective chart and image review of 22 patients having ACP was done for clinical, histopathological and CT findings on affected and non affected side for extent of opacificattion, thickness of alveolar bone (AB) in the region of medial wall and the floor of maxillary sinus. Also, widening of accessory ostium was measured and compared. The mean of average thickness of AB medially on affected side was [30.91/11.27] [mean (mm)/SD)] compared to non affected side [55.60/20.74] p = 0.0001 (p < 0.05). The vertical AB thickness at floor on affected side [34.05/14.69] versus [68.14/35.29] p = 0.0001. Ipsilateral side accessory ostium widening on affected was measuring [91.45/57.00] against [55.32/38.96] p = 0.018. The additional CT findings in present study showed reduction in thickness of AB in the medial part and floor of maxillary sinus region. These findings to our knowledge have not been reported in the literature till date. The reduction in bone thickness of AB substantiates theory of antral cyst in origin of ACP. However, their association with embryonic dental lamellae needs further evaluation.

Acquired Angioedema: A Rare Manifestation of Angioimmunoblastic T Cell Lymphoma.

The clinical presentation except age of onset is similar in different types of angioedema. A lymphoproliferative disorder like angioimmunoblastic T cell lymphoma (AITL) rarely presents with symptoms of angioedema. We present extremely rare case of elderly male with recurrent tongue swelling, pruritus with normal levels of complements and C1 esterase inhibitor protein featuring as acquired angioedema, a rare manifestation of AITL. Initial response to corticosteroids may be misleading and occurs as a result of immunosuppression of AITL. High index of suspicion may prompt need for histopathological diagnosis of lymph node biopsy. Definitive chemotherapeutic treatment may achieve long term remission.

Perioperative only versus extended antimicrobial usage in tympanomastoid surgery: a randomized trial.

OBJECTIVES/HYPOTHESIS: Antimicrobial prophylaxis is still a matter of debate in ear surgeries. Previous studies have focused on prophylaxis in middle ear surgery alone without inclusion of mastoidectomy. We therefore investigated efficacy of two regimes of antimicrobial prophylaxis in tympanoplasty with cortical mastoidectomy done for mild middle ear disease in chronic otitis media. STUDY DESIGN: Prospective, randomized, controlled, double-blind study. METHODS: Patients undergoing tympanoplasty with cortical mastoidectomy were included and randomized into two study groups. The group I patients received parenteral perioperative antimicrobials; only group II patients received additional extended oral antimicrobials for 8 days more postoperatively. Primary outcomes evaluated were postaural wound infection and graft success, assessed weekly until 1 month. Adverse events and length of hospital stay were evaluated as secondary outcome. RESULTS: Seventy-eight patients were randomized into group I (n = 39) and group II (n = 39). The two groups showed no difference in wound infection rate. The graft success rate in both the group was comparable (94.87% in group I and 97.44% in group II, respectively; P = 1.00). The length of hospital stay was significantly longer (P = 0.00001) in group II (3.05 [0.72], mean [SD]) as compared to group I (2.36 [0.49]). During the first postoperative week, a significantly higher incidence of gastrointestinal disturbances were observed in group II (19 [48.72%] as compared to 1 [2.56%] in group I, P = 0.00001). CONCLUSION: The present study shows that there is no need of extended antimicrobial prophylaxis for tympanoplasty with cortical mastoidectomy done for mild middle ear disease. An indiscriminate use of antimicrobials may lead to increase incidence of adverse events and prolonged hospital stay. LEVEL OF EVIDENCE: 1b.