Challenges of managing HIV cytomegalovirus co-infection in the presence of pancytopenia

A 60-year-old male patient who presented with generalized weakness and low-grade fever was diagnosed to be human immunodeficiency virus (HIV) positive with a CD4 count of 17. Routine laboratory investigations revealed pancytopenia. Serum cytomegalovirus (CMV) DNA polymerase chain reaction (PCR) was positive and fundoscopy showed CMV retinitis in the right eye. The patient was started on tablet valganciclovir. After 2 weeks, the patient was brought back in an altered sensorium. He was found to have hyponatremia which was corrected. He was started on antiretroviral therapy and tablet valganciclovir was continued. The patient came back again after one and a half months with a urinary tract infection and fissure-in-ano. He was found to have severe neutropenia. Valganciclovir was stopped. He was started on injection granulocyte colony-stimulating factor. The patient clinically improved and his hematological parameters became normal. Patients having HIV and CMV co-infection with pre-existing pancytopenia have to be closely monitored as the medicines used for treatment can exacerbate the existing conditions.

Open injury, robotic repair—moving ahead! Total robotic Roux-en-Y hepaticojejunostomy for post-open cholecystectomy Bismuth type 2 biliary stricture using indocyanine green dye

Hepaticojejunostomy is currently the best treatment for post-cholecystectomy biliary strictures. Laparoscopic repair has not gained popularity due to difficult reconstruction. We present case of 43-year-old-female with Bismuth type 2 stricture following laparoscopic converted open cholecystectomy with bile duct injury done elsewhere. Position was modified Llyod-Davis position and four 8-mm robotic ports (including camera) and 12-mm assistant port were placed. The procedure included noticeable steps such as adhesiolysis, identification of gallbladder fossa, identification of common hepatic duct, lowering of hilar plate etc. Operating and console time were 420 and 350 minutes and blood loss was 100 mL. Patient was discharged on postoperative day 4. Robotic repair (hepaticojejunostomy) of biliary tract stricture after cholecystectomy is safe and feasible with good outcomes.

JOB SATISFACTION AMONG SECONDARY SCHOOL TEACHERS

Teaching is a highly noble profession and teachers are always a boon to the society. The ultimate process of education could be simpli?ed as a meaningful interaction between the teacher and the taught. The teacher thus plays a direct and crucial role in moulding a pupil towards education. Since a teacher is a role model for the students, job satisfaction and professional commitment of teachers become very vital in the ?elds of education. Thus, the researcher felt the need to investigate the job satisfaction in relation to professional commitment of secondary school teachers. An attempt was made in the present investigation is Job Satisfaction Among Secondary School Teachers. To Aim: Objective: study the differences between gender (male & female) and management (government & private) on Job Satisfaction among secondary school teachers. Sample of the present study consists of 400 teachers in Hyderabad and Ranga Reddy Sample: districts of Telangana State. Job Satisfaction scale developed by Meera Dixit (1993) was used. Results Tool: Conclusion: revealed signi?cant differences between gender (male & female) and management (government & private) with regard to Job Satisfaction.

Association of hyperglycaemia at-admission & diabetes mellitus with 28 day mortality in patients admitted with moderate-severe SARS-CoV-2 infection: A retrospective study

Background & objectives: The association between hyperglycaemia at admission, diabetes mellitus (DM) status and mortality in hospitalized SARS-CoV-2 infected patients is not clear. The purpose of this study was to determine the relationship between DM, at-admission hyperglycaemia and 28 day mortality in patients admitted with moderate-severe SARS-CoV-2 infection requiring intensive care. Methods: All consecutive moderate-to-severe patients with SARS-CoV-2 infection admitted to the intensive care units (ICUs) over six months were enrolled in this single-centre, retrospective study. The predicators for 28 day mortality were analysed from the independent variables including DM status and hyperglycaemia at-admission. Results: Four hundred and fifty two patients with SARS-CoV-2 were admitted to the ICU, with a mean age of 58.5±13.4 yr, 78.5 per cent being male, HbA1c of 7.2 per cent (6.3-8.8) and 63.7 per cent having DM. Overall, 28 day mortality was 48.9 per cent. In univariate analysis, mortality in diabetes patients was comparable with non-diabetes (47.9 vs. 50.6%, P=0.58), while it was significantly higher in hyperglycaemic group (60.4 vs. 35.8%, P<0.001). In multivariate Cox regression analysis, after adjusting for age, sex and comorbidities, hyperglycaemia at-admission was an independent risk factor of mortality [hazard ratio (HR) 1.45, 95% confidence interval (CI) (1.06-1.99), P<0.05]. Interpretation & conclusions: This study showed that the presence of hyperglycaemia at-admission in critically ill SARS-CoV-2 patients was an independent predictor of 28 day mortality. However, the findings may be susceptible to unmeasured confounding, and more research from prospective studies is required.

Robotic-assisted resection of proximal jejunal ischemic stricture and intracorporeal robot-sewn anastomosis

With the advent of robotic surgery as an effective means of minimally invasive surgery in the last decade, more and more surgeries are being performed robotically in today’s world. Robotic surgery has several advantages over conventional laparoscopic surgery, such as three-dimensional vision with depth perception, magnified view, tremor filtration, and, more importantly, degrees of freedom of the articulating instruments. While the literature is abundant on robotic cholecystectomy and highly complex hepatobiliary surgeries, there is hardly any literature on robotic small bowel resection with intracorporeal anastomosis. We present a case of a 50-year-old male patient with a symptomatic proximal jejunal ischemic stricture who underwent robotic-assisted resection and robot-sewn intracorporeal anastomosis in two layers. He did well in the postoperative period and was discharged on postoperative day 4 with uneventful recovery. We hereby discuss the advantages and disadvantages of robotic surgery in such a scenario with a review of the literature.

Conservation of gene architecture and domains amidst sequence divergence in the hsrω lncRNA gene across the Drosophila genus: an in silico analysis

The developmentally active and cell-stress responsive hsrx locus in Drosophila melanogaster carries two exons, one omega intron, one short translatable open reading frame (ORFx), long stretch of unique tandem repeats and an overlapping mir-4951 near its 30 end. It produces multiple long noncoding RNAs (lncRNAs) using two transcription start and four termination sites. Earlier cytogenetic studies revealed functional conservation of hsrx in several Drosophila species. However, sequence analysis in three species showed poor conservation for ORFx, tandem repeat and other regions while the 16 nt at 50 and 60 nt at 30 splice junctions of the omega intron, respectively, were found to be ultra-conserved. The present bioinformatic study using the splice-junction landmarks in D. melanogaster hsrx identified orthologues in publicly available 34 Drosophila species genomes. Each orthologue carries a short ORFx, ultra-conserved splice junctions of omega intron, repeat region, conserved 30 -end located at mir-4951, and syntenic neighbours. Multiple copies of conserved nonamer motifs are seen in the tandem repeat region, despite a high variability in the repeat sequences. Intriguingly, only the omega intron sequences in different species show evolutionary relationships matching the general phylogenetic history in the genus. Search in other known insect genomes did not reveal sequence homology although a locus with similar functional properties is suggested in Chironomus and Ceratitis genera. Amidst the high sequence divergence, the conserved organization of exons, ORFx and omega intron in this gene’s proximal part and tandem repeats in distal part across the Drosophila genus is remarkable and possibly reflects functional importance of higher order structure of hsrx lncRNAs and the small omega peptide.

Role of peritoneal drainage in moribund patients of perforation peritonitis

Background: Objective of the present study was to evaluate applicability of primary peritoneal drainage under local anesthesia in moribund patients as pre-laparotomy support when laparotomy under general anesthesia could not be done. Also to assess outcome in terms of survival, patients needing definitive surgery and complications associated with the procedure on immediate and follow up basis.Methods: We conducted this study in Teerthanker Mahaveer Medical College, Moradabad, UP, India from October 18 to October 2019. 71 patients were admitted as cases of perforation peritonitis in moribund condition, demographic data of all patients was noted, peritoneal drainage under local anesthesia in flanks was done and variable amount of fluid was drained in different patients, simple parameters were taken in to consideration in pre and post drainage phase. We also noted the complications after the definitive surgery.Results: Out of 71 patients, admitted in late and in very critical state, 61 patients improved after drainage and resuscitative procedures, although in ASA grade 3 and 4 they underwent surgical treatment and we were able to save their lives. 13 patients expired after definitive surgery inspite of best efforts.Conclusions: Peritoneal drainage under local anesthesia in late reporting and critical patients, not only improves general condition but makes patients better to undergo further surgery, and can prove to be life saver. It being a simple procedure can easily be done at even PHC level, before patient is referred or shifted to higher centre for further management.

A simplified prognostic scoring and grading system for Fournier’s gangrene

Background: Fournier’s gangrene is life threatening, necrotizing fasciitis, affecting external genetalia of male greater than female with mortality 7 to 53%. Fournier gangrene severity, LRINR and LNR scoring used to evaluate morbidity and mortality. Aim and objective of our study was to simplify a system, especially for Indian peripheral health centers which can predict mortality, morbidity.Methods: This study was conducted in department of surgery of Teerthankar Mahaveer University. Body mass index, blood urea nitrogen and patient demography used to develop the scoring system with minimum and maximum points and correlated our results.Results: Our simplified scoring system also has a direct bearing on mortality, morbidity, recovery and hospital stay. In our study 3 male and 2 females died.Conclusions: Simplified scoring and grading system will be helpful in predicting the morbidity and mortality, early surgical intervention, hospital stay, time for reconstruction.

Experience with Peroral Endoscopic Myotomy for Achalasia and Spastic Esophageal Motility Disorders at a Tertiary U.S. Center

Background/Aims@#Peroral endoscopic myotomy (POEM) is a novel procedure for the treatment of achalasia and spastic esophageal disorders. Experience with POEM is limited, but its reported outcomes are excellent. It is deemed safe even for patients with prior interventions. @*Methods@#This retrospective review included patients who underwent POEM at a tertiary US center. POEM was performed in a multidisciplinary approach by advanced endoscopists and foregut surgeons. Clinical success was defined as a post-POEM Eckardt score ≤3. @*Results@#A total of 125 patients were included. Median follow-up period was 18 months (interquartile range, 10–22 months). Clinical success was achieved in 92% of patients and persisted at 12 months in 88% of patients. Mucosal barrier failure (MBF) occurred in 7 patients, 2 of whom required surgical intervention. MBF was more common in patients with prior laparoscopic Heller myotomy (19% vs. 3%, p=0.015). MBF requiring surgical intervention occurred early in the learning curve. @*Conclusions@#POEM is safe and effective in the treatment of achalasia and spastic esophageal disorders even after failed prior interventions.

Reproductive health status of women in the matrilineal tribes of Meghalaya: a field-based quantitative study

Background: Reproductive health of the tribal women in India is less studied and the present study attempts to fill the gap by understanding the reproductive health of women in the matrilineal tribes in Meghalaya. The objective of the study was to study the reproductive health status of tribal women.Methods: A field-based quantitative study was conducted among randomly chosen 900 tribal women in their reproductive age from the 142 villages selected randomly across 15 PHCs functional in five districts. We used a semi-structured validated questionnaire consisting of the socio-demographic profile, reproductive health status, blood pressure and haemoglobin level.Results: Median age of the 900 respondents was 28.9 years, 83% had primary education and 82% got married between 13-18 years. Over 96% lived with their spouse, and 80% had a monthly income ?Rs. 5000. Their mean age at menarche was 14.3 years, 10% reported menstrual issues: stomach ache, back pain and vomiting. Though 58% planned their pregnancy, 77% had their first pregnancy before 18 years, and 10.3% of respondents had three deliveries within a four-year period. 76% had poor self-rated health, 83% had abnormal blood pressure and 95% reported anaemia. Out of 81 deaths, 69% were infants and 33.3% did not avail medical service from PHC.Conclusions: Reproductive health risks, anaemia and abnormal blood pressure were found among women in Garo tribes. Mitigating the ill effects of reproductive health issues through indigenous interventions as part of the NRHM program is needed.

To Correlate The Modified Triple Test (MTT) For Palpable Breast Mass With Histopathology.

Discrete breast mass in young women are common cause of anxiety though majority of these lesion are benign.It is frightful experience for the patient to undergo invasive procedure i.e. biopsy of breast mass. So there is obvious need of such diagnostic tool which is noninvasive or minimally invasive, quick , reliable , equivalent or nearly equivalent to current existing diagnostic procedure to avoid unnecessary biopsy, reduce patients anxiety and cost effective.Aims and objective–To study the role of modified triple test in the diagnosis of palpable breast mass.Material and method- The study was a prospective study done in tertiary care center Dehradun from June 2017 to June 2018. It was carried out in the department of surgery in SGRRIM and HS and included 148 patients who presented with palpable breast mass. Patients who were already diagnosed case of carcinoma breast were excluded from the study. Thorough clinical examination of breast was done. All the patients were investigated firstly by sonomammography then FNAC.Either core biopsy or excisional biopsy of breast mass was done in all the cases. Findings were recorded and data analysis was done. Sonomammography report was recorded according BIRADS protocol besides giving probable diagnosis. Breast mass histopathology (HPE) report was considered to be gold standard and all the results were compared with HPE of the same breast mass.Result: results of MTT is comparable with histopathology of the same breast mass. Conclusion: modified triple test is sufficient and reliable investigation for diagnosing palpable breast mass and biopsy of breast mass should be reserved only for doubtful cases.

Assisted Physical Exercise and Stress in Preterm Neonates

Objective: To evaluate the markers of stress before and after a session of assisted physicalexercise in infants born before 35 weeks’ gestation. Methods: 25 infants born at 280/7 to 346/7weeks were subjected to assisted physical exercise daily for about 10-15 min at one week ofpostnatal age or 33 weeks of post menstrual age, whichever was later. Primary outcome wassalivary cortisol and secondary outcome was Premature infant pain profile (PIPP) score.Outcomes were measured, on day 5 (±1) of exercise. Results: There was no difference insalivary cortisol between baseline and immediately after (P=0.16), at 90 min (P=0.6) or 120min (P=0.7) after exercise. Salivary cortisol was lower at 30 min after exercise as compared tobaseline (mean difference -0.08 ?g/dL; 95% CI -0.16 to -0.002; P=0.04). The median (IQR)PIPP score was significantly higher at 5 min into exercise (4 (3-6) vs 4 (3-5); P=0.04) and atcompletion of exercise 6 (4-8) vs 4 (3-5); P<0.01), as compared to baseline. Conclusion:Assisted physical exercise does not seem to result in stress in premature infants

Assisted Physical Exercise for Improving Bone Strength in Preterm Infants Less than 35 Weeks Gestation: A Randomized Controlled Trial

Objective: To compare the efficacy of daily assisted physicalexercise (starting from one week of postnatal age) on bonestrength at 40 weeks of post menstrual age to no intervention ininfants born between 27 and 34 weeks of gestation.Design: Open-label randomized controlled trial.Setting: Tertiary-care teaching hospital in northern India from 16May, 2013 to 21 November, 2013.Participants: 50 preterm neonates randomized to Exercisegroup (n=26) or Control group (n=24).Intervention: Neonates in Exercise group underwent onesession of physical exercise daily from one week of age, whichincluded range-of-motion exercises with gentle compression,flexion and extension of all the extremities with movements ateach joint done five times, for a total of 10-15 min. Infants inControl group underwent routine care and were not subjected toany massage or exercise Outcome measures:Primary: Bone speed of sound of lefttibia measured by quantitative ultrasound at 40 weeks postmenstrual age. Secondary:Anthropometry (weight length andhead circumference) and biochemical parameters (calcium,phosphorus, alkaline phosphatase) at 40 weeks post menstrualage.Results:The tibial bone speed of sound was comparablebetween the two groups [2858 (142) m/s vs. 2791 (122) m/s;mean difference 67.6 m/s; 95% CI - 11 to 146 m/s; P=0.38]. Therewas no difference in anthropometry or biochemical parameters.Conclusion:Daily assisted physical exercise does not affectthe bone strength, anthropometry or biochemical parameters inpreterm (27 to 34 weeks) infants.

Including the Sheath Rinse to Improve Cellular Yield in Biliary Brushing Cytology

No abstract available.

Comparison of nested-multiplex, Taqman & SYBR Green real-time PCR in diagnosis of amoebic liver abscess in a tertiary health care institute in India.

Background & objectives: Amoebiasis is a common parasitic infection caused by Entamoeba histolytica and amoebic liver abscess (ALA) is the most common extraintestinal manifestation of amoebiasis. The aim of this study was to standardise real-time PCR assays (Taqman and SYBR Green) to detect E. histolytica from liver abscess pus and stool samples and compare its results with nested-multiplex PCR. Methods: Liver abscess pus specimens were subjected to DNA extraction. The extracted DNA samples were subjected to amplification by nested-multiplex PCR, Taqman (18S rRNA) and SYBR Green real-time PCR (16S-like rRNA assays to detect E. histolytica/E. dispar/E. moshkovskii). The amplification products were further confirmed by DNA sequence analysis. Receiver operator characteristic (ROC) curve analysis was done for nested-multiplex and SYBR Green real-time PCR and the area under the curve was calculated for evaluating the accuracy of the tests to dignose ALA. Results: In all, 17, 19 and 25 liver abscess samples were positive for E. histolytica by nested-multiplex PCR, SYBR Green and Taqman real-time PCR assays, respectively. Significant differences in detection of E. histolytica were noted in the real-time PCR assays evaluated (P<0.0001). The nested-multiplex PCR, SYBR Green real-time PCR and Taqman real-time PCR evaluated showed a positivity rate of 34, 38 and 50 per cent, respectively. Based on ROC curve analysis (considering Taqman real-time PCR as the gold standard), it was observed that SYBR Green real-time PCR was better than conventional nested-multiplex PCR for the diagnosis of ALA. Interpretation & conclusions: Taqman real-time PCR targeting the 18S rRNA had the highest positivity rate evaluated in this study. Both nested multiplex and SYBR Green real-time PCR assays utilized were evaluated to give accurate results. Real-time PCR assays can be used as the gold standard in rapid and reliable diagnosis, and appropriate management of amoebiasis, replacing the conventional molecular methods.

Spontaneous Thrombosis of above knee perforator veins of the lower limb: A Case Report.

Varicose veins have troubled mankind for thousands of years, and their various treatments and complications have been documented from the times of Hippocrates. Although thrombophlebitis is a relatively common condition in the superficial veins of the upper or lower limbs, it usually follows some intravenous intervention or trauma. Thrombosis followed by thrombophlebitis in varicose veins has seldom been reported in literature but the occurrence of spontaneous thrombosis in only the above knee perforator veins of the lower limb has been seldom mentioned. We report the case of a patient with long standing varicose veins of the left lower limb presenting with spontaneous thrombosis of only the above knee perforators and our subsequent management.

Improving the Availability of Adequately Iodized Salt by Mobilizing the Network of Salt Traders in Uttar Pradesh, India.

Objectives: Uttar Pradesh (UP) is a non-salt producing state in India. Most of the salt is imported and traded in 18 of the 75 districts in the state. In 2009, the household coverage of adequately iodized salt in UP was 43%. This presentation features the important initiative taken by the state government with support by UNICEF to increase the availability of adequately iodized salt by mobilizing the network of salt wholesalers and retailers in UP. Methods: A total of 204 wholesalers and retailers were mapped across the 18 salt unloading districts. Four titration laboratories in the state medical colleges were revitalized. Salt samples were collected from shops and storage points on a monthly basis and sent to the laboratories to test the samples' iodine content. Reports on the iodization adequacy of salt were issued, shared with the wholesalers and retailers and used to monitor the iodization quality of salt. Monthly dialogue with salt wholesalers and retailers was carried out to sensitize and motivate them to procure and sell only adequately iodized salt. The salt testing results were also used by the Salt Department and the Department of Food and Drug Administration to take punitive actions against manufacturers producing inadequately iodized salt. Results: The availability of non-iodized salt decreased by 2.5% and availability of adequately iodized salt increased by 10% over a one-year period. Conclusions: Mapping, sensitization and using a combination of punitive and non punitive approach with the wholesalers and retailers proves to be an effective strategy to ensure adequate availability of appropriately iodized salt.

Design and development of buccal mucoadhesive drug deliverysystem for perindopril

The main objective of present study was to develop a buccal mucoadhesive drug delivery system for perindopril.Perindopril buccal mucoadhesive patches were developed by solvent casting technique using hydroxy propylmethylcellulose [HPMC], polycarbophil, sodium carboxymethylcellulose [SCMC] and sodium alginate as polymersfor extended release of perindopril. Glycerine and DMSO were used as plasticizer and penetration enhancerrespectively. Ethanol, methanol and dichloromethane were used as solvents. FTIR and DSC studies revealed nointeraction between drug and polymers. The drug content in the perindopril patches was found to be uniform. The filmsexhibited good physical and mechanical properties. The surface pH of all the patches was within salivary pH range.Residual solvent content in patches are below the tolerated limits. The patches were found to have an extended releaseof the drug upto a period of 12 hours during ex vivo permeation studies with non-Fickian diffusion mechanism. Thepresent study demonstrated the possibility of designing a buccal drug delivery system for perindopril

Clinical and Microbiological Profiles of Shigellosis in Children.

Shigellosis presents with varied clinical features are dictated by the species involved, virulence factors of the strain, and the host immune status. We studied the species, virulence genes, and antibiotic susceptibility pattern of the Shigella strains isolated from 33 children aged less than 12 years, with clinical features of shigellosis. Identification and antibiotic sensitivity of Shigella species were done using disc diffusion and E-test. Multiplex PCR was done for the detection of virulence genes (ipaH, ial, set1A, set1B, sen, and stx) and ESBL genes. Parents of the children were interviewed using structured questionnaire to assess the severity of the disease; 26 (79%) of the isolates were Shigella flexneri. Ciprofloxacin and ceftriaxone resistance was seen in 23 (69%) and 3 (9%) Shigella isolates respectively. Two ceftriaxone-resistant strains were found to harbour blaCTX gene and the third blaTEM gene. Virulence gene ipaH was detected in 100% of strains while ial, sen, set1A, and set1B were detected in 85%, 61%, 48%, and 48% respectively.

Post-treatment alterations of serum cancer antigen 125, cancer antigen 19.9 and carcinoembryonic antigen levels in patients with gynecological malignancies in a tertiary care hospital in eastern India.

Gynecological carcinomas form a significant proportion of all malignancies in women across the globe. These are associated with an increase in the serum concentrations of certain tumor markers such as cancer antigen (CA)125, CA19.9 and carcinoembryonic antigen (CEA) that correlate with the tumor burden. Methods: Pre- and post-treatment serum levels of CA125, CA19.9 and CEA were determined in 36 patients of ovarian carcinoma, 31 patients of cervical carcinoma and 20 patients of endometrial carcinoma using enzyme-linked immunosorbent assay. The pre- and the post-treatment levels of these markers have been compared and correlated. Results: With primary treatment, CA125 level was significantly reduced in ovarian, endometrial (ps < 0.001) and cervical (p = 0.001) carcinomas and that of CA19.9 was significantly decreased in cervical and endometrial carcinomas (ps < 0.001). Surprisingly, post-treatment CEA level was significantly increased in cervical carcinoma (p = 0.001) with significant increase after radiotherapy (p = 0.003), but not after surgery (p = 0.091). Treatment had no effects on CA19.9 level in ovarian carcinoma and on CEA levels in ovarian and endometrial carcinomas. Pre- and post-treatment levels of CA125, CA19.9 and CEA showed strong positive correlation in cervical carcinoma, while those of CA19.9 showed very strong positive correlation in endometrial carcinoma. Conclusions: Post-treatment serum CA125 level best reflects the treatment effect in all three types of gynecological carcinomas. CA19.9 is reliable to evaluate treatment effect in patients of cervical and endometrial carcinomas. Studies involving larger population size should be conducted to identify the changes in CEA while assessing treatment effect in cervical carcinoma patients.