Clinico-epidemiological profile and disease severity of chronic obstructive pulmonary disease among patients in a primary care centre at central Kerala

Background: Chronic obstructive pulmonary disease (COPD) is a chronic disease usually caused by significant exposure to noxious particles and are not fully reversible. COPD represents an important public health challenge that is both preventable and treatable. The aim of this study was to describe the clinico-epidemiological profile of COPD patients and to assess the disease severity using spirometry among respiratory symptomatic in a primary care centre. Methods: A cross sectional study was conducted among the COPD patients attending monthly pulmonology clinic in Urban Health centre, Ettumanoor, Kottayam from June to August 2019. The study comprised of 120 patients with symptoms suggestive of COPD attending the monthly respiratory clinic. Severity of airflow limitation assessed using spirometry results based on GOLD criteria. Clinical and epidemiological data were collected using a semi structured interview schedule. Results: The mean age of the participants were 64� and 51.7% were males. The median duration of COPD symptoms for the study participants was 10 (IQR 11) years and 62.5% were having productive cough with dyspnoea as the major symptom. All males except two were smokers and the mean packyears were 42�years. As per GOLD guidelines 44 (36.7%) had severe disease, 11 (9.2%) had mild, 39 (32.5%) had moderate and 26 (21.7%) had very severe disease. The average forced expiratory volume in one second (FEV1) in study subjects was 54.8�5. Conclusions: In view of the emerging public health risk, COPD need to be diagnosed and managed at the earliest to slow down the progression.

COVID-19 vaccination status and its effect on outcome and disease severity

Background: The cardinal method for preventing future SARS-CoV-2 infections, hospitalizations, long-term sequelae, and death is COVID-19 vaccination, despite the possibility that the epidemiology of COVID-19 may change as new variants appear. There is little research on the vaccination status of adult COVID-19 patients and the role of vaccines in mitigating the severity and clinical presentation of COVID-19 patients among local population in Kerala. Objectives were to assess vaccination status and clinical profile of adult COVID-19 patients in Arpookara, Panchayath in Kerala and its association with disease severity and outcome among same. Methods: A cross sectional study was conducted in Arpookara Panchayath in central Kerala, among adult COVID-19 patients during the months of September and October 2021. The required 380 samples were selected by simple random sampling and data was collected by interviewing the subjects using semi structured questionnaire. Results: It was found that 46.1% of the study population were unvaccinated, whereas 30.8% of the population were partially vaccinated and 23.1% were fully vaccinated at the time of COVID-19 infection. A significantly higher proportion of unvaccinated population required hospital admissions, oxygen support and ICU stay when compared to those who took at least one dose of vaccine. Conclusions: Increasing the vaccination coverage of at least single dose of vaccine can reduce rate of hospital admission, ICU stay, oxygen requirement and can improve the outcome of disease. Steps to increase vaccine coverage should be implemented for better outcome of COVID-19 disease as well as to reduce the admission load on the hospitals.

Temperature integrity and exposure to freezing temperature during vaccine transfer under the universal immunization program in Three States of India

Temperature excursion and exposure to sub-zero temperatures may reduce the potency of the freeze-sensitive vaccines. This study assessed temperature during vaccine transfers at various levels under the Universal Immunization Program. This cross-sectional study undertaken in 21 districts of three states of India – Bihar (n = 8), Kerala (n = 8), and Gujarat (n = 5). We documented temperature inside the cold boxes and vaccine carriers using LogTag-Trix8 data loggers. In total, 110 vaccine transportation episodes were observed; 55 inter-facility transfers and 55 outreach sessions. Sizable proportions of inter-facility (9% to 35%) and outreach vaccine transfers (18%) were exposed to sub-zero temperature. The proportions of exposure to temperature to >8°C were in the range of 0.8%–11.3% for inter-facility transfers and 2.3% for outreach sessions. The vaccines were exposed to freezing temperatures for significant durations during transportation across the cold chain. Rigorous monitoring of temperature integrity is essential to ensure the delivery of potent vaccines and to avoid vaccine failure.

Advancements in temporomandibular joint total joint replacements (TMJR)

The goal of this paper is to review the advantages and disadvantages of the various treatment options of temporomandibular joint (TMJ) total joint replacement (TJR). TMJ articles published within the last 20 years were reviewed to collect the information on non-invasive and invasive TMD treatment methods. Recent technological advancements helped the evolution of treatment methods and offered significant value to TMD patients and surgeons. Considering the TMD levels, the therapeutic procedures can involve general health examiniations, physical therapy, medication, oral rehabilation or as an end stage clinical invention, temporomandibular joint replacement. In fact when intra-articular TMD is present, the effective treatment method appears to be TJR. However, concern for infection, material hypersensitivity, device longevity and screws loosening issues still exists. Further combined research utilizing the knowledge and expertise of, surgeons, material scientists, and bioengineers is needed for the development of improved TMD therapeutic treatment.

Using loop connectors as an interim mode of treatment: An interdisciplinary approach.

To tackle a large midline diastema and generalized spacing existing before extraction often poses a challenge to the treating prosthodontist. The situation becomes even more complicated if the patient is a teenager, with multiple missing teeth, associated deep bite and where the jaw bone growth has not yet been completed. Possible treatment options would include a removable prosthesis, a fixed partial denture or an implant supported prosthesis. Treating such cases with a simple removable prosthesis cannot be justified if a deep bite existed which would result in posterior disocclusion. Also a conventional fixed partial denture or closure of the diastema with light cure composite (LCC), would result in a seemingly large tooth, which would be unaesthetic in appearance. Implant supported prosthesis is a possibility, if the patient’s jaw bone growth has been completed. Another simple non-invasive solution to this problem would be to fabricate a non-rigid connector using loops. This presentation describes the procedure for fabrication of an interim loop connector for a 16 year old female patient who had lost one of her maxillary central incisors as a result of trauma. Patient also had multiple spacing in the maxillary anterior teeth and an associated deep bite. Her cephalogram revealed that she had a Class III skeletal pattern. A permanent treatment at this stage was not possible due to ontoward mandibular growth pattern as revealed on the cephalogram. Hence to dodge all these problems, a simple and non-invasive treatment using loop connectors was chosen till the growth period was completed.

Post-exposure prophylaxis against rabies at two newly designated intradermal rabies vaccination clinics in Kerala, India.

Background. The two-site intradermal rabies vaccination (IDRV) regimen was recently introduced in Kerala. We aimed to determine factors associated with exposure of category III severity among patients seeking prophylaxis against rabies at IDRV clinics. Methods. This hospital-based, cross-sectional study was done at two clinics in Thiruvananthapuram district, Kerala. Data were collected using a semi-structured questionnaire by direct interview and 320 patients were included. Bivariate analysis of quantitative variables was done using t-test and that of qualitative variables using chi-square test. Results. The mean (standard deviation) age of patients was 32.4 (19.6) years. Among the 320 cases, 202 (63.1%) had category III exposure. Lower extremities were the most frequent site of exposure (146, 45.6%). The most frequent mode of exposure was being bitten by an animal (214, 66.9%), often a dog. Residence in rural areas, exposure to dogs and wounds on the extremities had a significant association with severity of exposure. Conclusion. Animal exposures were more among people from rural areas. About two-thirds of exposures which necessitated post-exposure prophylaxis were category III.

Cryptococcal meningitis: Clinical, diagnostic and therapeutic overviews.

Cryptococcal meningitis has emerged as a leading cause of infectious morbidity and mortality in patients with AIDS. Among the human immunodeficiency virus (HIV)-seropositive subjects, cryptococcal meningitis is the second most common cause of opportunistic neuro-infection. Current trends are changing due to the marked improvement of quality and length of life produced by highly active antiretroviral therapy (HAART). The introduction of generic HAART in India has resulted in an increase in the number of individuals getting treatment for HIV infection, as the cost of highly active antiretroviral therapy (HAART) has decreased 20- fold. Cryptococcal meningitis occurs in non-HIV patients who are immunodeficient due to diabetes, cancer, solid organ transplants, chemotherapeutic drugs, hematological malignancies etc and rarely in healthy individuals with no obvious predisposing factors. Diagnosis of cryptococcal meningitis is fairly straightforward once the diagnosis is considered in the differential diagnosis of chronic meningitis. Treatment of a patient with cryptococcal infection is a challenge for both the physician and the patient, but rewarding, as many would recover with timely and adequate antifungal therapy.

Spontaneous tumour lysis syndrome associated with non-Hodgkin's lymphoma--a case report.

Spontaneous tumour lysis syndrome is characterized by hyperuricemia, hyperkalemia, hyperphosphatemia, metabolic acidosis and hypocalcemia, that occur even prior to the treatment of a neoplasm. This rare occurrence was encountered in a patient with non-Hodgkin's lymphoma (NHL), of follicular cell type. Conservative but intensive treatment led to complete resolution. Subsequent chemotherapy was well tolerated.

Neurological manifestations of Ehlers-Danlos Syndrome.

Ehlers-Danlos Syndrome (EDS) is more identified for its cutaneous features but its neurological manifestations have not received the focused attention. Four patients of Ehlers-Danlos Syndrome (EDS) with neurological manifestations were evaluated for phenotypic data. These four men were from three families and two had consanguineous parentage. The mean age at onset and presentation of neurological symptoms were 10.5 years and 19 years respectively. Patient 1 presented with bilateral optic atrophy, sensorineural deafness, cerebellar ataxia and neuropathy. Patient 2 had marfanoid habitus, chorea and cerebellar ataxia. Patient 3 had action and percussion myotonia, wasting and weakness of sternocleidomastoid and distal limb muscles. Patient 4 had action myotonia, mirror movements of both hands and neuropathy. MRI of brain showed right parietal polymicrogyria. Neuroaxis involvement at multiple levels in EDS may have prognostic significance.

Role of topoisomerases in cytotoxicity induced by DNA ligand Hoechst-33342 and UV-C in a glioma cell line.

DNA ligand Hoechst-33342 significantly enhances UV induced cytotoxicity in human glioma cell lines (BMG-1 & U-87) with supra additive increase in cell death, cytogenetic damage, cell cycle delay, apoptosis and inhibition of PLDR. Cytotoxicity of Hoechst-33342 arises due to its interference in the breakage-rejoining reaction of DNA topoisomerases by stabilization of cleavable complexes. Since topoisomerases have also been implicated in the generation of potentially lethal DNA breaks by interaction with various types of DNA damage including UV induced DNA lesions, we investigated in present studies the role of functional topoisomerases in the synergistic cytotoxicity of Hoechst-33342 and UV in a human glioma cell line (BMG-1). Topoisomerase I activity analyzed by the plasmid relaxation assay, was significantly enhanced upon UV irradiation, implying a possible role of this enzyme in the processing of UV induced lesions. However, this increase in the activity was reduced by >50% in cells incubated with Hoechst-33342 for 1 hr prior to irradiation. Imunoflowcytometric analysis of the chromatin bound topoisomerases I and II levels (cleavable complex) using topoisomerases I and II anti-antibodies showed a good correlation between the induction of apoptosis by Hoechst-33342 and UV and enhancement in the level of topoisomerase II mediated cleavable complexes. Induction of apoptosis was associated with a decline in the level of Bcl2. Taken together, these studies show that supra additive cytotoxic effects of UV-C and Hoechst-33342 in BMG-1 cells are consequences of enhanced stabilization of topo II mediated cleavable complexes and alterations in specific signal transduction pathways of apoptosis, besides the inhibition of topoisomerase mediated repair processes.

Candida tropicalis causing prosthetic valve endocarditis.

The incidence of endocarditis produced by the so-called "opportunists" as a complication of prosthetic valve surgery is progressively increasing in frequency and gradually transforming the clinical picture habitually associated with this disease. Candida endocarditis is an unusual but severe complication caused by Candida albicans or other fungal species. This case and a review of the literature indicate that Candida endocarditis treated with amphotericin B and prosthetic valve replacement may recur months after treatment, and that late recurrent Candida endocarditis, which is difficult to diagnose and treat, may be best prevented by lifelong antifungal suppressive therapy.

Suicidal oxidative stress induced by certain antioxidants.

Well known antioxidants-coumarins (7,8-dihydroxy-4-methyl coumarin-DHMC and 7,8-diacetoxy-4-methyl coumarin-DAMC) and flavonoids (quercetin-Q and quercetin penta-acetate-QPA) were investigated for their pro-oxidant effects in two human tumor cell lines. The breast carcinoma cell line (MDA-MB-468) was found to be more sensitive to treatment by the drugs-DAMC, Q and QPA at 10 microM than the glioma cell line (U-87MG), while DHMC was non toxic in both cell lines at this concentration. In MDA-MB-468 distinct growth inhibition was observed by 48 hr post treatment. Paradoxically, an increase in the formazan production was revealed by MTT assay at this time indicating an increase in the production of free radicals. An increase in the levels of reactive oxygen species (ROS) was also confirmed by DCFH-DA assay. In cells treated with DAMC, Q and QPA an increase in the percentage of cells with the hypodiploid DNA content was suggestive of apoptotic cell death. Taken together, these results suggest that an increase in oxidative stress caused by the pro-oxidant action of these drugs is responsible for cell death.

Unexpected presentations--four cases of lead poisoning.

OBJECTIVE: To describe the clinical presentation and response to treatment of four patients who presented with abdominal pain and were diagnosed to have lead poisoning. METHODS: After ruling out the more obvious causes of abdominal pain by barium studies, gastrointestinal endoscopies, and biochemical studies, blood lead levels were estimated by atomic absorption spectrophotometry. The patients were treated with oral d-penicillamine. RESULTS: The four patients had blood lead levels from 79 microg/dL to 365 microg/dL. All four of them showed marked improvement in their clinical condition and lowering of blood lead levels on follow up. CONCLUSIONS: Clinicians need to develop a high index of suspicion of lead poisoning as a possible cause of unexplained abdominal pain or altered sensorium, especially against a background of environmental lead contamination in India.

A comparative study of the intestinal parasites prevalent among children living in rural and urban settings in and around Chennai.

A comparative analysis of the various intestinal parasites detected among children attending schools was carried out in a rural and urban location in and around Chennai. A total of 324 stool samples were examined by routine microscopy using normal saline and Lugol's iodine preparation as well as by saturated sodium chloride flotation technique. All suspicious samples were subjected to zinc sulphate concentration technique as well as modified Ziehl Neelson stain and Trichrome stains to identify the other uncommon intestinal parasites. Out of 125 specimens tested from the rural location, the overall prevalence of intestinal parasites was 91%. Ascaris lumbricoides was the most common helminthic parasite detected (52.8%) followed by Trichuris trichura (45.6%), Ancylostoma duodenale (37.6%), Strongyloides stercoralis (3.2%) and Hymenolepis nana (1.6%). Giardia lamblia was the most common protozoan parasite detected (16%), followed by Entamoeba histolytica (4%). In contrast under urban settings, out of the 199 stool specimens tested the positivity rate was 33%. Giardia was the most common parasite detected (22.6%) followed by Entamoeba histolytica (10.6%). All other intestinal parasites such as T. trichura (2.01%), H. nana (1.01%) and A. lumbricoides (0.50%) were found to have much lower prevalence in comparison to the rural area tested. Enterobius vermicularis (0.50%) was also detected. Ancylostoma duodenale and Strongyloides stercoralis were not encountered at all in the urban setting studied.

Streptococcus agalactiae endocarditis.

Streptococcus agalactiae (S. agalactiae) is a rare cause of infective endocarditis, which is associated with a high mortality rate. Endocarditis in adults is generally related to immunocompromised states. We hereby report the case of a 35 year old man who presented with fever and delirium in whom aortic valve endocarditis due to S. agalactiae was detected. Though most patients with S. agalactiae endocarditis need surgical intervention along with antibiotics, our patient improved with medical therapy alone.

Rapid identification of fluconazole resistance using Chrom agar Candida.

All though extremely rare 10 years ago, antifungal drug resistance is becoming a major problem in certain populations, especially in those infected with HIV. This study was undertaken to study the resistance of Candida species isolated in our hospital to Fluconazole using Chrom agar Candida. The Candida strains which were routinely isolated from clinical specimens like blood, urine, sputum, pus, fluid and homograft isolates were included in the study. 142 Candida isolates were tested by using Chrom agar Candida incorporated with Fluconazole. 16 strains were found to be resistant to Fluconazole and 126 strains sensitive to Fluconazole. Nine were C. tropicalis, 3 C. krusei, 2 C. guillermondii, 1 Geotrichum candidum and one was an unidentified strain of Candida. The MIC of the 16 strains were done using RPMI 1640 medium by macro broth dilution method. MIC of 9 strains was 64 & > 64 ug/ml of 6 strains 32 ug/ml and 1 strain 16 ug/ml.

Rapid identification of fluconazole resistance using Chromagar Candida.

Although extremely rare 10 years ago, antifungal drug resistance is becoming a major problem in certain populations, especially in those infected with HIV. This study was undertaken to study the resistance of Candida species isolated in our hospital to Fluconazole using Chrom agar Candida. The Candida strains which were routinely isolated from clinical specimens like blood, urine, sputum, pus, fluid and homograft isolates were included in the study. 142 Candida isolates were tested by using Chrom agar Candida incorporated with fluconazole. 16 strains were found to be resistant to Fluconazole and 126 strains sensitive to Fluconazole. Nine were C tropicalis, 3 C krusei, 2 C guillermondii, 1 Geotrichum candidum and one was an unidentified strain of Candida. The MIC of the 16 strains were done using RPMI 1640 medium by macro broth dilution method. MIC of 9 strains was 64 & > 64 micrograms/ml of 6 strains 32 micrograms/ml and 1 strain 16 micrograms/ml.