Unconventional” Causes of Acute Kidney Injury: A Critical Nuance of Interpretation and Intervention

Background: Acute kidney injury (AKI) is one of the most common clinical problems encountered by physicians in day-to-day practice which is associated with increased morbidity and mortality. The incidence of AKI is increasing so the right approach for interpretation of clinical clues and investigation may be lifesaving. Aim: The study aimed to document the variety of unusual cases of AKI and suggest a case-based approach for clinical evaluation and investigations to help physicians treat such cases. Materials and methods: This was a retrospective analysis of medical/electronic records of 10 patients who were admitted in medical wards between January 2020 and June 2021 and diagnosed to have AKI. Results: We present the history, clinical findings, and investigations of 10 patients diagnosed with unusual causes of AKI. Conclusion: It is important for physicians to recognize unusual causes of AKI. A high index of suspicion and timely diagnosis and treatment interventions may bring complete recovery of renal functions in patients of AKI.

A comparative study of transcervical foley’s catheter with intracervical PGE2 gel for pre-induction cervical ripening

Background: To compare the efficacy of transcervical foley’s catheter with intracervical PGE2 gel for pre -induction cervical ripening.Methods: It was a prospective interventional study conducted between April 2012 to April 2013 in the department of obstetrics and gynecology at L. L. R. M. medical college and S. V. B. P. hospital Meerut. A total of 80 pregnant women of ≥28 weeks of gestation with bishop score less than or equal to 4 and with various indications for induction of labour were randomly allocated to receive intracervical PGE2 gel (Group A) or transcervical foley’s catheter (Group B). Bishop score was repeated after 6 hours by the same person and the results were compared.Results: The groups were comparable with respect to maternal age, gestational age, indications of induction of labour and initial bishop’s score. The intragroup results were calculated by Wilcoxon signed rank test and intergroup results were calculated by Mann Whitney U-test. The change in bishop score in PGE2 group was 3 and in foley’s group was 3.25 after 6 hours of induction (interquartile range of median) which is significant. The mean change in bishops score was 2.65 in PGE2 group and 3.1 in foley’s group after 6 hours of induction and was significant, however the bishop’s score was comparable in both the groups and statistically insignificant.Conclusions: Both foley’s catheter and PGE2 gel are equally effective in pre-induction cervical ripening of cervix.

Comparative study of intravenous hydralazine and labetalol in severe hypertensive disorders of pregnancy

Background: Hypertensive disorders of pregnancy are among the most common medical complications of pregnancy and major cause of maternal, fetal and neonatal morbidity and mortality. The purpose of this study was to compare the efficacy and safety of intravenous hydralazine and labetalol for management of severe hypertensive disorders of pregnancy.Methods: This prospective study was conducted among 100 women admitted with SBP ≥ 160 or DBP ≥ 110 mmHg or both. Patients were divided into 2 groups randomly: labetalol and hydralazine group.Results: Majority of patients (38%) were in the age group of 21-25 years and primigravida (52%). There was more significant decrease in the systolic, diastolic and mean arterial blood pressure at the end of 15 and 30 minutes in labetalol group. Labetalol required fewer doses as compared to hydralazine to achieve the target blood pressure (average 1.95 versus 3.1). Total numbers of term deliveries were 19 (38%) in hydralazine group and 16 (32%) in labetalol group. Pre-term deliveries in hydralazine and labetalol group were 14 (28%) and 15 (30%) respectively. Headache was significantly more common in hydralazine treated patients than labetalol group.Conclusions: Both hydralazine and labetalol were effective and well-tolerated in the treatment of severe hypertensive disorders of pregnancy. Labetalol may be preferred because it was more effective in lowering the systolic blood pressure, diastolic blood pressure and mean arterial pressure to achieve target levels with less number of doses.

Sirenomelia with Potter syndrome: a case report and review of literature

Sirenomelia or mermaid syndrome is a rare congenital anomaly characterized by variable degree of fusion of lower extremities. Awareness to this rare condition is important for prenatal diagnosis and prognosticating the fetus. The exact etiopathogenesis is still an area of research. Two pathogenic hypotheses are the vascular steal hypothesis and the defective blastogenesis hypothesis with exceptions reported in literature.

Pattern of susceptibility to azoles by E test method in candidemia patients.

Background: Blood stream infections due to Candida sp have considerably increased in recent years, along with the increase of drug-resistant isolates in immunocompromised patients. This increase in resistance makes it important to determine the antifungal susceptibility profile of each Candida species isolated from blood prior to treatment. Hence, this study was done to detect the resistant strains of Candida causing candidemia. Methods: About Seventy Candida species isolated from blood cultures were used for this study. These included 27 Candida albicans, 23 Candida tropicalis, 8 Candida parapsilosis, 3 Candida krusei, 2 Candida glabrata and 7 other candida species. Minimum inhibitory concentrations (MIC) of the most commonly used azoles like fluconazole, ketoconazole, itraconazole and voriconazole were determined by E test method. Results: The resistance percentage of Candida albicans for fluconazole and itraconazole was 11.1% and 7.4%; fluconazole resistance in Candida tropicals was 8.7%. Candida parapsilosis had good activity against all azoles with only 12.5% resistance for itraconazole. Conclusions: Fluconazole had good activity against most of the Candida sp except for Candida glabrata and Candida krusei with MIC 90 > 256 μg/ml. Itraconazole was less effective for Candida albicans, Candida glabrata and Candida parapsilosis (MIC 90 >32 μg/ml). Voriconazole was found to be the most effective drug against all species of Candida with low MIC values (MIC 90 < 0.25 μg/ml). Hence it can be used to treat blood stream infections caused by Candida species.

Childhood Lupus with Microangiopathic Antiphospholipid Syndrome and Pulmonary Hemorrhage.

Background: Concurrent thrombotic and hemorrhagic manifestations are uncommon in patients with Antiphospholipid Syndrome. Case characteristics: A 10-year-old girl with fever, edema, rash and joint pains, who later developed deep venous thrombosis (DVT), stroke, thrombotic microangiopathic hemolytic anemia and pulmonary hemorrhage. Investigations confirmed Antiphospholipid syndrome associated with systemic lupus erythematosus. Outcome: She went into complete remission with intravenous immunoglobulins, plasmapheresis, immunosuppression and anticoagulation. Message: Thrombotic microangiopathic hemolytic anemia and anti-phospholipid syndrome can be the presenting manifestations of systemic lupus erythematosus..

In vitro Screening of Some Indian Medicinal Plants for Their Activity against Extended Spectrum Beta Lactamases.

Context: Extended Spectrum Beta Lactamases (ESBLs) play an important role in pathogenesis of various infections by enabling the bacterial species to be resistant to β-lactam antibiotics including extended-spectrum cephalosporins. Plants were selected on the basis of their traditional applications. Objective: Our investigation screens and evaluates15 Indian medicinal plants for antimicrobial efficacy and synergistic potential against ESBLs producing bacteria. Materials and Methods: 6 bacterial strains were screened for their ability to release ESBLs. Plant extracts in methanol and aqueous solvents were screened for their effect on ESBLs producing bacteria. Antimicrobial-linked ESBLs inhibition activity and minimum inhibitory concentration (MIC) of extracts were evaluated by agar well diffusion and microdilution method. Synergistic interactions between plant extracts exhibiting good antimicrobial activity and extended spectrum cephalosporins were explored by Checkerboard method. Results: Three strains were detected as ESBL positive. The results of susceptibility assay clearly showed strong ESBLs inhibitory effect of Crinum latifolium, Oroxylem indicum, Punica granatum, Sapindus emarginatus and Terminalia chebula and their MIC values ranged from 1.87-30 mg/ml. In vitro interactions between plant extracts and antibiotics cefotaxime and ceftaizidime evaluated in terms of fractional inhibitory concentration (FIC) indices indicated synergism. Discussion and Conclusion: Higher resistance of ESBLs positive strains to β-lactam antibiotics encourages us to search the novel ESBLs inhibitors. Maximum 10-fold decline in the MIC of antibiotics cefotaxime and ceftaizidime was achieved in combination with plant extracts. Owing to enormous clinical significance of ESBL-producing organisms coupled with limited therapeutic options, the results revealed by present study are of paramount importance.

Evaluation of antifungal susceptibility testing in Candida isolates by Candifast and disk-diffusion method.

With the increase in invasive fungal infections due to Candida species and resistance to antifungal therapy, in vitro antifungal susceptibility testing is becoming an important part of clinical microbiology laboratories. Along with broth microdilution and disk diffusion method, various commercial methods are being increasingly used for antifungal susceptibility testing, especially in the developed world. In our study, we compared the antifungal susceptibility patterns of 39 isolates of Candida to three antifungal drugs (fl uconazole, amphotericin B, ketoconazole) by Candifast and disk diffusion method. The following resistance pattern was found by Candifast: Fluconazole (30.8%), ketoconazole (12.8%), amphotericin B (0%). The results obtained by disk diffusion method were in complete agreement with Candifast results.

In vitro and in silico Approach to Evaluate the Urease and Collagenase Inhibitory Activity of Embilica officinalis Gaertn Fruit.

Aim: The key virulent factors of bacteria are enzymes. Urease and collagenase enzyme play a vital role in pathogenesis of wide array of bacterial strains and cause numerous diseases. So the aim of present study was to find out the potent drug candidate from Emblica officinalis Gaertn. fruit for these pathogenically important enzymes. Study Design: A study was done to screen out the bacteria producing urease and collagenase from a stack of 19 bacterial strains and the positive strains were checked for their susceptibility to methanol and ethyl acetate extracts of Emblica officinalis Gaertn. fruit. Further extracts were investigated for their potential to antagonize these enzymes. Place and duration of study: Department of Biotechnology KUK, Jwahar Lal University, Delhi between February 2012 and December 2013. Methodology: Screening of bacteria and their susceptibility to methanol and ethyl acetate extracts of E. officinalis was done by using agar diffusion assay. Further investigation of extracts to antagonize urease and collagenase enzymes was checked by using phenol hypochlorite and gelatin diffusion assay respectively. GC-MS analysis, docking and ADME studies were conducted to screen for plant-based urease and collagenase inhibitors. Results: Methanol extract inhibited Jack bean urease enzyme (IC50:0.74 mg/ml) more potently than collagenase Type 1 (IC50:1.13 mg/ml), while ethyl acetate extract inhibited collagenase completely (IC50:4.19 mg/ml) and was observed to be more effective than methanol extract (IC50:5.51 mg/ml). GC-MS analysis revealed an array of 28 and 30 compounds in methanol and ethyl acetate extract respectively. In silico study identified xylenol and erucylamide as active compounds of E. officinalis having good binding score with better ADME properties compared to standard compounds. Conclusion: So our observations find application for the consideration of E. officinalis compounds for further validation towards development of effective drugs against these significant bacterial enzymes.

Antibacterial, Synergistic and β-lactamase Inhibitory Activity of Oroxylem indicum: An In vitro and Molecular Interaction Study.

Aims: The study was aimed to evaluate the antibacterial, synergistic and β-lactamase inhibitory potential of O. indicum against ampicillin resistant and Extended Spectrum β- lactamase (ESBL) producing bacterial strains. Methods: Bacterial strains were screened for ampicillin resistance and ESBL production by disk diffusion method and modified double disc synergy test respectively. Antibacterial and synergistic activities of O. indicum methanol extract and ethyl acetate sub fraction of methanol extract were explored by agar well diffusion method and Checkerboard method respectively. Extracts were subjected to Gas chromatography and Mass spectroscopy (GC-MS) analysis to identify the bioactive compounds. Molecular docking studies were carried out to verify the β-lactamase inhibitory potential of the bioactive compounds. Results: All bacterial strains were found to be resistant to ampicillin and only one strain was detected as ESBL positive. Ethyl acetate sub fraction exhibited strong antibacterial and synergistic activity than the methanol extract. Zone of inhibition and Minimum inhibitory concentration for ethyl acetate sub fraction was 16 mm and 15mg/ml respectively. In vitro interactions between plant extracts and ampicillin evaluated in terms of fractional inhibitory concentration (FIC) indices revealed synergistic effects of plant extracts. The molecular docking studies of major bioactive compounds depicted by GCMS analysis revealed that Wogonin, a flavonoid (GLIDE Score-5.77) possessed the best inhibitory profile against β–lactamase. Conclusion: Synergistic activity of O. indicum may be attributed to the β–lactamase inhibitory potential of the bioactive compounds present in the extract. The findings provide substantial basis for the future use of O. indicum crude extracts as potential antibacterial and antibiotic modulating agent.

Anomalous drainage of left renal vein.

A rare anatomical variation found during routine anatomical dissection for teaching purposes in which the retro aortic left renal vein opened in to the left common iliac vein instead of inferior vena cava. Retro aortic left renal vein is an uncommon anomaly in the development of Inferior Vena cava (IVC) and its collaterals. It may courses behind the abdominal aorta to enter the IVC. According to the reviewed literature, incidence of a case like this is around 0.16% and is only scarcely described in the literature. The embryological and clinical significance of the above variations have been highlighted in this communication.

Comparative analysis of protein profiles of wild virulent (E156) and aroA-htrA double deletion mutant vaccine strain (S30) of Salmonella enterica subsp. enterica serovar Abortusequi under in vivo and in vitro growth conditions.

In the present study, cell lysate and cell supernatant of the both strains i.e., virulent wild type (E156) and mutant (S30) vaccine strains of Salmonella enterica subspecies enterica serovar Abortusequi (S. Abortusequi), grown under varied in vivo and in vitro conditions were subjected to SDS PAGE and western blotting (using rabbit hyperimmune serum). Variation in growth conditions did not have any significant effect on expression of different proteins. SDS PAGE of E156 and S30 cell lysate (CL) revealed 26 and 28 bands, respectively with 3 prominent proteins of 71, 46 and 42 kDa in cell lysate of E 156 and 4 prominent proteins 71, 65, 46 and 40 kDa in S30 strain. The cell supernatant (CS) from both the strains, subjected to SDS PAGE, exhibited similarity in protein profile among these strains, however three bands of 65, 53 and 40 kDa were more prominent in CS preparation of S30, whereas a 56 kDa protein was prominent in CS of E156. Western blotting of E156 and S30 revealed 3 unique proteins of 65, 53 and 40 kDa present in CS preparation of S30 strains which could be used for differentiation of mutant and wild strains and also in development of test for differentiating vaccinated animals from naturally infected.

Partial purification and cytotoxic effects of Salmonella proteinous moieties on chick embryo fibroblasts.

Salmonella enterica serovars, viz., S. Weltevreden, S. Typhimurium, S. Gallinarum and S. Bareilly were treated with cephotaxime to release of intracellular proteins. The cephotaxime extract (CE) was salt precipitated with ammonium sulphate (45-70%) and dialyzed, and denoted as precipitated dialyzed proteins (PDP). Further, both CE and PDP of Salmonella Weltevreden and PDP of rest of the serovars were subjected to gel filtration using Sephacryl S-200HR. Different fractions along with CE and PDP were studied for their cytotoxicity using chicken embryo fibroblast (CEF). All the CE and PDP exerted cytotoxic effects, characterized by rounding, detachment, shrinkage and clumping of cells with syncytia formation. Also, the fractions eluted in the 2nd and 3rd peaks through Sephacryl S-200HR column invariably had cytotoxic activity. It was concluded that in place of Vero cell line, CEF cells could also be used to test cytotoxicity.

Phosphaturic mesenchymal tumor: a case report.

Osteomalacia induced by tumor is a rare phenomenon in which the resection of tumor is followed by dramatic amelioration of clinical signs and symptoms. We hereby report a case of a 66 years old male who presented with features of osteomalacia in which the characteristic clinical presentation was associated with the phosphaturic mesenchymal tumor, mixed connective tissue variant. The case is reported for its rarity.

Sclerosing stromal tumour of ovary--a clinicopathological and immunohistochemical study of five cases.

We describe the clinicopathological and immunohistochemical findings in five cases of sclerosing stromal tumours of ovary and compare our findings with other reported cases of this uncommon tumour and with fibromas and thecomas which they may mimic.

p53 protein alterations in adult astrocytic tumors and oligodendrogliomas.

BACKGROUND: p53 is a tumor suppressor gene implicated in the genesis of a variety of malignancies including brain tumors. Overexpression of the p53 protein is often used as a surrogate indicator of alterations in the p53 gene. AIMS: In this study, data is presented on p53 protein expression in adult cases (>15 years of age) of astrocytic (n=152) and oligodendroglial (n=28) tumors of all grades. Of the astrocytic tumors, 86% were supratentorial in location while remaining 14% were located infratentorially - 8 in the the cerebellum and 13 in the brainstem. All the oligodendrogliomas were supratentorial. MATERIALS AND METHODS: p53 protein expression was evaluated on formalin-fixed paraffin-embedded sections using streptavidin biotin immunoperoxidase technique after high temperature antigen retrieval. RESULTS: Overall 52% of supratentorial astrocytic tumors showed p53 immunopositivity with no correlation to the histological grade. Thus, 58.8% of diffuse astrocytomas (WHO Grade II), 53.8% of anaplastic astrocytomas (WHO Grade III) and 50% of glioblastomas (WHO Grade IV) were p53 protein positive. In contrast, all the infratentorial tumors were p53 negative except for one brainstem glioblastoma. Similarly, pilocytic astrocytomas were uniformly p53 negative irrespective of the location. Among oligodendroglial tumors, the overall frequency of p53 immunopositivity was lower (only 28%), though a trend of positive correlation with the tumor grade was noted - 25% in Grade II and 31.5% in grade III (anaplastic oligodendroglioma). Interestingly, p53 labeling index (p53 LI) did not correlate with the histopathological grade in both astrocytic and oligodendroglial tumors. CONCLUSIONS: Thus, this study gives an insight into the genetic and hence biological heterogeneity of gliomas, not only between astrocytic tumors vs. oligodendrogliomas but also within astrocytic tumors with regard to their grade and location. With p53 gene therapy trials in progress, this will possibly have future therapeutic implications.

Increase in minimum inhibitory concentration to quinolones and ceftriaxone in salmonellae causing enteric fever.

Multidrug resistance among Salmonella typhi is well known. Reports of treatment failure in enteric fever with Ciprofloxacin made us undertake this study to determine the antibiotic susceptibility pattern of S. typhi and S. paratyphi A isolated from typhoid bacteremia cases, by disc diffusion and MIC by broth dilution method. A total of 50 strains were tested, 48 of Salmonella typhi and 2 of S. paratyphi A. The disc diffusion method was done using ampicillin, chloramphenicol, cotrimoxazole, tetracycline, ciprofloxacin, ofloxacin, cefuroxime and ceftriaxone as antibiotics. The MIC was performed using ciproloxacin, ofloxacin and ceftriaxone based on standard procedure. ACCOT resistance as determined by disc diffusion method was seen in 68% of isolates. All the strains remained susceptible to flouroquinolones cephalosporins and aminoglycosides. The MIC of ciprofloxacin, ofloxacin and ceftriaxone were in the recommended range of susceptibility as given by NCCLS, 14 (28%) strains had MIC of ciprofloxacin greater than 0.5 ug/ml with 4 strains having an MIC of 1.56 ug/ml; 25 (50%) strains had MIC of ofloxacin greater than 0.5 ug/ml and 20 (40%) strains had MIC of ceftriaxone greater than 0.5 ug/ml. The high levels of MIC of ciprofloxacin may account for treatment failure cases. The rising levels of MIC of ofloxacin and ceftriaxone in S. typhi and S. paratyphi is also of concern. We document here the emergence of high levels of MIC not only to ciprofloxacin, but also ofloxacin and ceftriaxone in S. typhi and S. paratyphi A. We recommend that MIC levels of ofloxacin and ceftriaxone should be monitored along with ciprofloxacin in treatment failure cases of enteric fever.

Concentration of organochlorines in Ganges River dolphins from Patna, Bihar.

Concentrations of DDT, HCH, aldrin and endosulfan were determined in river dolphins from the River Ganges, Patna. Among the organochlorines studied in the dolphins, DDT concentration was highest followed by HCH. This shows exposure of dolphins to these organochlorine pesticides. Presences of organochlorines to higher degree in tissues suggest that the river dolphins be at greater risk due to pesticidal contamination of the river system.