Study of Efficacy of Injection Remdesivir in Patients of COVID-19

Introduction: The coronavirus disease of 2019 (COVID-19) is a highly contagious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). World Health Organization (WHO) declared it a pandemic on 11th March 2020. Injectable remdesivir (RDV), a repurposed antiviral, was first accorded approval by the United States of America (USA) Food and Drug Administration (FDA) on 1st May 2020, for emergency use to treat suspected or laboratory-confirmed COVID-19 patients. Interim analysis of the Solidarity trial revealed no benefits in patients treated with RDV in any group of patients with COVID-19. Here, we have attempted to place our data on the efficacy of RDV in patients of COVID-19 with moderate to severe categories. Materials and methods: A retrospective review and data analysis of 100 COVID-19 patients with reverse transcriptase polymerase chain reaction (RT-PCR)/rapid antigen test positive was performed. Among them, 50 received RDV in addition to the standard treatment protocol (STP), while the remaining 50 received only the STP. STP is an injectable steroid and heparin, along with other supportive management. Prevalent government guidelines were followed as per usual for the classification of the patients and treatment protocol. Every day of hospitalization, the status of respiratory support was checked, and every 3rd-day inflammatory markers [C-reactive protein (CRP) and D-dimer] were measured until the patient was discharged or died. Statistical analysis of the data was done using online software. Results: Age and comorbidity distribution in both groups ensures adequate matching between the two groups. A statistically significant difference in hospitalization days was obtained in RDV-treated patients (15 vs 19 days, p-value ?0.003). Statistically significant differences were not found in mortality (6 vs 10 deaths, p-value ?0.27) and reduction in oxygen (O2)/ventilatory support requirements (p-value ?0.75) in the RDV group as compared to other groups. The difference in the value of CRP (p-value 0.001) and D-dimer (p-value 0.049) on day 5 is statistically significant in the RDV group as compared to the other groups. Discussion: The finding of a reduction in days of hospitalization was similar to the Adaptive COVID-19 Treatment Trial (ACTT) 1 study conducted by Beigel et al. The mortality data were also comparable to those from WHO’s Solidarity trial. No similarity was found in data on the reduction in ordinal scale from higher to lower scale for O2/ventilatory support on day 10 from 0. Similarity regarding the reduction in values of inflammatory markers on day 5 was found in studies conducted by Kannan et al. and Stoeckle et al. Conclusion: We found mortality benefit and reduction in O2 requirements/ventilatory support in RDV plus STP-administered cases as compared to STP only, but statistically, this difference is not significant, which suggests that mortality benefit in the RDV group in our study is merely by chance. Here, we can definitely conclude that days of hospital stay and inflammatory markers are reduced in the RDV plus STP-administered group, and the difference between the two groups is statistically significant, which suggests that early use of RDV could shorten the time to clinical improvement.

Pathological findings in COVID-19: A conventional autopsy-based study from India

Background & objectives: Autopsy study has been considered the gold standard method for studying the effects of any disease on the body. Since COVID-19 is a novel disease, autopsy is crucial to understand its pathophysiology. This study was conducted to analyze the microscopic and macroscopic findings of various organs in COVID-19 and to associate those findings with clinical observations and laboratory findings. Methods: Conventional invasive autopsies were performed on 33 patients with COVID-19 from September 7, 2020 to December 23, 2020. All the organs were removed by routine dissection techniques and preserved in 10 per cent formalin. The tissues were processed and stained according to standard practices using haematoxylin-eosin (H & E) and periodic acid-schiff (PAS) stain. Results: The study included 28 males and 5 females with a median age of 61 yr (range 30-90 yr). Massive pulmonary oedema and thrombi in the lungs were the characteristic features macroscopically. On microscopic examination, diffuse alveolar damage in the exudative/proliferative phase was found in 29 (87.88%) cases. Among the other notable microscopic findings were bronchopneumonia and lung abscesses due to secondary bacterial infection (n=17, 51.52%), acute tubular injury (n=21, 63.64%) and thrombi in the lungs, heart, and kidneys. Interpretation & conclusions: COVID-19 primarily affected the respiratory and the renal systems in the vast majority of severely affected patients in our study. We also found signs of hypercoagulability, as evidenced by widespread thrombi in multiple organs, along with a raised d-dimer level and a hyperinflammatory state manifested by elevated inflammatory markers. Our autopsy findings and altered laboratory investigations support

Thyroid abnormalities among Down syndrome children from Kerala, India

Down syndrome (DS), caused by trisomy of human chromosome 21, is one of the most common chromosomal abnormalities in live born infants with a prevalence rate of 1 in 700 live births. Individuals with DS usually have comorbid conditions such as thyroid dysfunction, growth retardation, diabetes mellitus and obesity. The most frequent among these are the thyroid abnormalities which range from subclinical to overt hypothyroidism, and rarely hyperthyroidism.1-3 Individuals with DS are more susceptible to thyroid disorders compared to the general population. Primary hypothyroidism, referred to as elevated TSH, is the most common thyroid abnormality in DS; secondary hypothyroidism indicated by normal/reduced TSH is extremely rare. The prevalence of hypothyroidism varies between 3-54% in adults with DS.4 The aim of this study was to examine the incidence of thyroid abnormalities among children with DS registered in a tertiary referral center for neurodevelopmental disorders and non-communicable neurological disorders in Kerala, a south Indian state. 100 children with DS in the age range of 4 months-15 years, registered at Institute for Communicative and Cognitive Neurosciences (ICCONS), Shoranur, Kerala during the period of 2012-2016, were recruited for the study. The mean age of the participants (57 males, 43 females) was 5.4'3.8 years. The diagnosis of DS was confirmed by karyotyping. All the participants were drug-naive at the time of blood collection. 500 'l of serum samples was used for thyroid function test (TFT) which measured the levels of TSH, triiodothyronine (T3) and thyroxine (T4) by chemiluminescence immunoassay (CLIA). The reference range for TSH, T3 and T4 were as follows, TSH: 0.4-4mIU/ml, T3: 70-170ng/dl, T4: 4.5-12.5mg/dl.

Cross-sectional study reveals a high prevalence of vitamin D deficiency among healthy school children in central Kerala, India

Background: Authors examined serum vitamin D status among the healthy school children belonging to the south Indian state of Kerala.Methods: A cross-sectional study, participants were recruited through medical camps organized in Thrissur and Palakkad districts of central Kerala during the months of March and April 2017. A 174 healthy school children (98 males and 76 females) aged 5-13 years were recruited for the study. The children were found to be healthy on the basis of physical examination by a Paediatrician. None of the children had any symptoms of skeletal deformities. All the children were drug-naive. Data on height, weight, skin color, food habits, physical activities and socio-economic status were recorded. A 2ml of peripheral blood samples were collected from the participants. Total vitamin D in the serum was estimated by chemiluminescence immunoassay (CLIA).Results: VDD was observed in 60.92% and insufficiency in 30.46% of the participants. Only 8.62% of the participants had normal vitamin D levels. The mean vitamin D level was 19.93 ng/ml. Males had significantly higher vitamin D levels compared to females. Factors such as age, height, weight, diet, skin color and socio-economic status did not influence vitamin D levels.Conclusions: This is the first study of vitamin D status among the school-age children of Kerala. This paper adds further evidence to the reports indicating high prevalence of subclinical VDD among children across India and calls for action.

Pre-anesthesia evaluation leading to a diagnosis of long QT syndrome - a case study

Long QT Syndrome is a rare disorder characterized by prolongation of QT interval on an ECG. Patients with this disorder have an increased risk of developing life-threatening arrhythmias such as torsades de pointes, and occasionally sudden cardiac arrest. We present this case of undiagnosed Long QT Syndrome in a 7 years old boy, who presented to our service for incision and drainage of an abscess in the left axilla under general anesthesia. This case highlights the importance of proper and meticulous preanesthesia evaluation, even in low risk patients, so that potentially harmful medical conditions are diagnosed well in time and managed accordingly

Attenuation of Cardiovascular Responses to Laryngoscopy and Intubation-A Comparative Study between IV Esmolol hydrochloride and Lignocaine Hydrochloride.

Background: Laryngoscopy and tracheal intubation is invariably associated with a reflex Sympathetic pressor response resulting in elevated heart rate and blood pressures. This may prove detrimental in high-risk patients. Objective of this study is to compare the effects of lignocaine and esmolol in attenuation of this response. Methods: 150 ASA I - II status normotensive patients scheduled for elective surgical procedures were selected randomly and divided into three groups of 50 each. All patients received premedication with pentazocine 0.5mg/kg i.m and midazolam 0.05 mg/kg i.m. Induction of anesthesia was standardized for all patients who received, thiopentone 5-mg/kg i.v. and Glycopyrrolate 0.01. mg/kg and were relaxed with succinylcholine 2mg/kg i.v. First group did not receive any attenuation. The second group received 2mg/kg lignocaine i.v. bolus and the third group received 1mg/kg Esmolol iv. bolus, 3 minutes before laryngoscopy and intubation. HR, systolic, diastolic blood pressure was recorded noninvasively before induction, post induction-1,3,5, 7 and 10 minutes from the onset of laryngoscopy. ‘z’ test was used for statistical analysis. Results: After intubation incidence of tachycardia (HR>100/min) was significantly greater in control and lignocaine group than in esmolol group (z>1.96, p<0.05- 0.001). Rise in SBP and DBP were also statistically significant in control and lignocaine group than in esmolol group (z>1.96, p<0.05). Conclusion: Attenuation of pressor response is seen both with lignocaine and with esmolol. Of the two drugs Esmolol 1mg/kg i.v. bolus provides a consistent, reliable and effective attenuation as compared to lignocaine 2mg/kg iv. bolus.

Drug-induced Oral Candidiasis: A Case Report.

Oral candidiasis is a broad term which describes the fungal infections mainly caused by the yeasts belonging to the genus Candida. In developing countries, it is the third most common presenting compliant of the HIV-infected patients. Varied incidences have been observed depending on age and predisposing factors. Oropharyngeal candidiasis and dysphonia are among the local side effects of the use of several different topical steroids for the treatment of asthma. Long-term use of inhaled steroids renders oropharyngeal mucosa to opportunistic fungal infections by their local immunosuppressive actions. Here, we report a case of a 55-year-old male chronic asthmatic patient, who was on a steroid inhaler and presented with oral candidiasis.

Healicoll: An Alternate to Flap Cover for Bare Bones and Tendons.

Background: Wounds with bare bone, joint and tendons in the extremities have been a formidable challenge to plastic surgeons. Although several skin substitutes are used in West, as both dermal and epidermal analogue, they are expensive and most of them are unavailable in India. It is in this scenario that Healicoll – a type 1 pure collagen as a possible dermal substitute is being investigated. The material ‘Healicoll’ is a type-1 native collagen derived from the bovine source and is bioengineered, biocompatible and biodegradable skin substitute. The advantages of Healicoll have led us to an increase in its use for complex wounds. Medical literature on Healicoll, thus far has only reported its use for superficial burns and ulcers. Materials & Methods: The purpose of this study was to evaluate the advantages of using an inexpensive, easily available, bioengineered skin substitute ‘Healicoll’ for the closure of bare bone, joints and tendon. Results: Healicoll was used in three patients with two patients having undergone surgery involving use of Healicoll for bare bones, joints and tendons after release of contracture following burns and trauma, and one patient was treated with Healicoll as an outpatient procedure for bare bones following electrical burns. The mean hospital stay was 15 days. In all the three cases, a clear neodermis had covered the bones and joints in 5 days time and was ready to support the take of skin graft. Conclusions: Based on our initial experience, Healicoll skin substitute offers an excellent alternative for rapid reconstruction obviating the need for flap cover for wounds that have been difficult to reconstruct.

Management Of Choledocholithiasis By Choledochoduodenostomy (CDD) And T-Tube Drainage.

Background and Aim: Choledocholithiasis is a one of common diagnosed condition in India. Biliary passage should be clear to prevent obstructive jaundice and its complications. This study intends to study management of choledocholithiasis by Choledochoduodenostomy (CDD) and T-tube drainage in our institute. Methodology:12 patients of choledocholithiasis were included in study from January 2014 –December 2014. Ethics approval from institutional commitee was obtained. Patients were treated by Choledochoduodenostomy (CDD) and T-tube drainage. Routine follow up for 6 months was done for any complications.Conclusion:Combined Choledochoduodenostomy (CDD) and T-tube drainage prevents the chances of recurrent or residual stones that occur after Choledocholithotomy and Only T-tube drainage as well prevent chances of leakage and narrowing of stroma that occur after only CDD.

A Study of Cardiac Autonomic Neuropathy and Its Correlation with QTc Dispersion in Type-2 Diabetes Mellitus.

Aims: To evaluate the presence of cardiac autonomic neuropathy in Type-2 Diabetes and to correlate autonomic dysfunction with QTc dispersion. Study Design: This was a hospital based cross-sectional study carried out in the department of Medicine JSS Hospital Mysore, India between March 2012 and March 2013. Methodology: We included 50 Diabetes patients (Cases) and 50 Non Diabetes healthy adults (Controls) of both genders. Five standard cardiovascular response tests were carried out (Valsalva ratio, expiration-inspiration ratio, immediate heart rate response to standing, fall of systolic blood pressure on standing and sustained hand grip test) to determine the severity of cardiac autonomic neuropathy. QTc dispersion was determined by subtracting heart rate-corrected minimum QTc interval (QTc min) from maximum QT interval (QTc max) from standard electrocardiogram. Results: 17 patients (34%) had evidence of cardiac autonomic neuropathy. Of this 8 (16%) had borderline and 9(18%) had abnormal CAN. In the control group only 1(2%) had CAN. (P value of 0.000) Mean QTc in cases was 41.60+/-18.11) and in controls was 20.80(+/-4.88) QTc dispersion was 32.7(+/-13.0) in those without CAN and 48.75(+/-9.71) in borderline CAN and 67.77(+/-9.71_in abnormal CAN group. (P =0.000). Conclusion: Prolonged QTc a feature of autonomic dysfunction due to diabetes. QTc dispersion correlates significantly with presence of cardiac autonomic neuropathy and may be a simple and useful measure for detection of cardiac autonomic neuropathy.

Fournier’s Gangrene: A Case Report.

Fournier’s gangrene is a rare, idiopathic, life-threatening, necrotizing fasciitis of the genitals and perineum caused by both aerobic and anaerobic bacterial flora. The synergistic effect of the bacteriae results in fulminating gangrene, multiple organ failure, and can even lead to death. Most commonly it has a predilection for diabetic and alcohol abused individuals, those who have impaired immunity. Genital trauma is frequently recognized vector for infection initiation. Timely recognition of the disease process and initiation of treatment with aggressive debridement and antibiotic administration is called for. The advanced age of the patient, extensive disease, delayed presentation with shock or sepsis and organ failures, all contribute to mortality in Fournier’s gangrene. In this case report, we recall an account of our tryst with Fournier’s gangrene management.

Undiagnosed Chronic Abdominal Pain and Colonic Perforation: A Rare Cause: Gossypiboma.

The term gossypiboma is used to describe as a mass due to retained surgical sponge after surgery. It is rare, but serious complication that is seldom reported because of the legal implications. The present study was carried out at the tertiary health center from January 2013 to April 2015. Five cases were studied prospectively. Gossypiboma usually has a varied and a vague presentation that makes it difficult to detect on radiological investigations. Sometimes, it can remain quiescent and could even present years after the operation. Though rare, gossypiboma should be kept in mind as a differential diagnosis in post-operative cases presenting as vague pain or recurrent chronic abdominal pain or long term foul smelling sinus discharge even years after the operation. Four out of five cases had colonic perforation, which was managed by primary closure. Fecal diversion was not required in any of the patient. Gossypiboma is avoidable, but serious rare post-operative complication. It is usually asymptomatic and has non-specific radiological findings. Hence, the diagnosis is often delayed. Gossypiboma can cause wide variety of complications like perforation and adhesion to the adjacent structures.

Management of Hydatid Disease: A Prospective Observational Study.

Background: Hydatid disease also known as Arterius (9-79 AD) and Galen (130-200 AD). It was known at that time as “water tumor of the chest” and “liver full of water.” Reddi (1664), Hartmann (1683) and Tyson (1691) first suspected cystic disease of the liver in animals. Materials and Methods: Hydatid disease is still a major health problem in the infested areas of the world. Surgery is the mainstay of treatment. A disease with a recurrence rate of 10-12% makes it mandatory to have a high diagnostic accuracy of investigations, a full proof treatment regimen and better preventive methods aiming at control and eradication of this age-old disease. Results: Hydatid disease commonly affects liver followed by lung other less common organs are the spleen, kidney, pancreas, and muscle. Surgery is the treatment of choice. Ultrasonography and computed tomography scan having tremendous value in the diagnosis of hydatid disease. Conclusion: Liver is the most common organ involved followed by lung, spleen and kidney. Females are more affected than male. Enucleation is the treatment of choice.

Mucoepidermoid Carcinoma of Palate: A Case Report.

The most common types of salivary gland tumors are the pleomorphic adenoma and the mucoepidermoid carcinoma (MEC). MEC mainly occurs in the parotid gland; intraorally MEC appears as asymptomatic swellings in minor salivary glands, most commonly occurs on palate. It shows a variety of biological behaviors and variable natural history. Clinical, radiological and histopathological findings of palatal MEC in a young woman presented here. Surgical resection was done. Follow-up of one and half year did not show any recurrence.

A study of first episode of acute myocardial infarction in type 2 diabetes mellitus patients.

Background & objectives: Diabetes mellitus, both insulin and non insulin dependent, is an independent risk factor for coronary artery disease which have a larger infarct size, atypical ischemic symptoms and more post infarct complication than non diabetic patients.So the present study was undertaken with following objectives: (1) To study occurrences of various ischemic symptoms, complications and mortality between diabetics and non diabetics. (2) To find out the relation between duration of diabetes, glycemic control and mortality due to first episode of acute myocardial infarction. Methods: Total 100 cases of acute myocardial infarction included comprising 50 type 2 diabetic patients and 50 non diabetic patients. Patients having first episode of acute myocardial infarction and who is already known case of diabetes mellitus were included. Results: Highest incidence of first episode of acute myocardial infarction in diabetics was occurring at earlier age than non diabetics and more incidences in obese persons and diabetic females. There was less frequent occurrence of chest pain and perspiration in diabetics. Higher incidence of recurrent angina, bundle branch block, atrio-ventricular block and heart failure was noted in diabetics than non diabetics. 30 days mortality was higher in patients having Random blood sugar >198 gm% on admission and diabetes since more than 5 years. Interpretation & conclusion: In the present study, the overall conclusion has been made that in diabetic patients acute myocardial infarction occurs at earlier age, there are atypical ischemic symptoms and also higher incidence of complications and higher mortality rate. So in every patient of acute myocardial infarction glycaemia status should be assessed on admission and hyperglycaemia should be aggressively treated.

A comparative evaluation of film and digital panoramic radiographs in the assessment of position and morphology of impacted mandibular third molars.

Background and Objective: Digital photo stimulable phosphor (PSP)-based radiography has many known theoretical advantages over conventional film radiography but its diagnostic efficacy has to be assessed clinically. This study compared the efficiency of conventional film-based panoramic radiographs with that of digital PSP-based panoramic radiographs in the assessment of position and morphology of impacted mandibular third molars. Materials and Methods: We selected a total of 80 impacted mandibular third molars that fulfilled the inclusion and exclusion criteria of this study. Both conventional film-based panoramic radiographs and digital PSP-based panoramic radiographs were taken of all the study samples and the teeth were later surgically removed. Conventional film-based and digital PSP-based panoramic radiographs were compared for their relative efficiencies in the assessment of impaction status, position of tooth, number of roots, root morphology, and proximity to mandibular canal of impacted mandibular third molars. An oral surgeon graded these same factors during/after surgical exploration and this assessment was considered the gold standard. The data obtained were statistically analyzed using descriptive statistics, chi-square test, and McNemar's test. Results: There was no statistically significant difference between conventional film-based radiographic assessment and digital PSP-based panoramic radiographic assessment of impaction status, position of tooth, number of roots, and proximity to mandibular canal of impacted mandibular third molars (P>0.05). However, there was significant difference between the two methods with regard to assessment of root morphology of impacted mandibular third molars (P=0.00). Interpretation and Conclusion : Conventional film-based panoramic radiographs and digital PSP-based panoramic radiographs were comparable in their accuracy in the preoperative study of impacted mandibular third molar with regard to impaction status, tooth position, number of roots, and proximity to the mandibular canal. Digital PSP-based panoramic radiographs were more accurate than conventional film-based panoramic radiographs in the assessment of root morphology of impacted mandibular third molars. Hence, we conclude that digital PSP-based panoramic radiographs can be used as an effective alternative to conventional film-based panoramic radiographs for assessment of position and morphology of impacted mandibular third molars.

Isolation and characterization of extracellular thermostable alkaline phosphatase enzyme from bacillus spp.

Alkaline phosphatase (E C 3.1.3.1) belongs to the class of hydrolases and catalyzes the alkaline hydrolysis of a number of phosphoric acid esters, nucleotides etc. Alkaline phosphatase was produced from Bacillus spp, isolated from soil samples. The Bacillus spp. was identified by staining and standard biochemical tests after which screening was done using modified Pikovoskaya’s agar method. Production of alkaline phosphatase using different substrates like calcium phosphate along with casein, starch, glucose and glutamic acid was carried out. High activity was found in calcium phosphate along with the casein. The specific activity of the crude extract was found to be 0.825U and it was subjected to purification by DEAE-Cellulose ion exchange chromatography. Finally,36% recovery was obtained. The molar mass was estimated by using 10% SDS-PAGE and was found to be approximately 84 KD. The optimum activity was at pH 8.8 and temperature of 650C. Alkaline phosphatase activity was enhanced by Mg2++ upto 66% and 80% activity was inhibited by EDTA. Alkaline Phosphatase activity was also confirmed by zymography using malachite green staining method.