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Naproxen is a widely used nonsteroidal anti-inflammatory drug (NSAID) in pediatric population, used for mild-to-moderate pains, arthritis, and other immune-mediated disorders. It rarely causes clinically apparent liver injury in the adult population taking high doses of the drug over a prolonged period and is reported even rarer in pediatric population. We present a case of drug-induced liver injury (DILI) in a 13-year-old girl taking naproxen in therapeutic doses for juvenile rheumatoid arthritis. There was a complete recovery of liver function following discontinuation of naproxen therapy.
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Introduction: Lysosomal storage disorders (LSDs) are rare disorders and pose a diagnostic challenge for clinicians owing to their generalized symptomatology. In this study, we aim to classify LSDs into two broad categories, namely, Gaucher disease (GD) and Niemann–Pick/Niemann–Pick-like diseases (NP/NP-like diseases) based on the morphology of the storage cells in the bone marrow (BM) aspiration smears and trephine biopsy sections. Materials and Method: This retrospective study includes 32 BM specimens morphologically diagnosed as LSDs at our institute, in the last 10 years. Subsequently, they were subclassified into GD and NP/NP-like diseases. Further, we have compared and analyzed the clinical, hematological, and biochemical parameters for the two groups of LSDs. Results: Based on BM morphology, 59.4% (n = 19) cases were diagnosed as NP/NP-like diseases and 40.6% (n = 13) cases as GD. Abdominal distension and failure to thrive were the most common clinical manifestations in both groups of LSDs. Anemia and thrombocytopenia were frequently seen in either of the LSDs. On the assessment of metabolic profile, elevated total/direct bilirubin and liver enzymes were more commonly seen in NP/NP-like diseases when compared with GD. Conclusion: We have classified LSDs into GD and NP/NP-like diseases based on the morphology of the storage cells in the BM specimen. The hallmark findings on BM biopsy annexed with the comparative features of the two proposed categories can aid the clinician in clinching the diagnosis. Formulation of such a methodology will prove instrumental for patient care in an underresourced setting.
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Background: Ineffective erythropoiesis is a predominant feature in ?-thalassemia major (?-TM), causing marked erythroid expansion leading to highly raised levels of growth differentiation factor-15 (GDF-15), which, in turn, suppresses hepcidin production in liver resulting in increased iron absorption from gut. We aim to study the serum GDF-15 in polytransfused ?-TM patients and its correlation with serum ferritin and serum hepcidin. Method: Thirty-nine polytransfused ?-TM children aged between 5 and 17 years and 33 age- and gender-matched healthy controls were enrolled in the study. Complete blood count, serum GDF-15, serum ferritin, and serum hepcidin were performed. Results: The mean serum GDF-15, serum hepcidin, and serum ferritin levels were 638.65 ± 306.96 pg/ml, 108.21 ± 191.30 ng/ml, and 2274.60 ± 1216.08 ng/ml, respectively, which were significantly higher than control group (P < 0.001, P = 0.003, P < 0.001, respectively). There was significant positive correlation of GDF-15 with blood transfusions (r = 0.415, P = 0.009), positive correlation with serum ferritin (r = 0.653, P = 0), and significant negative correlation with serum hepcidin (r = ?0.508, P = 0.001). Conclusion: The findings of the present study suggest that GDF-15 is an important regulator of hepcidin in ?-TM patients. GDF-15 and serum hepcidin together can be used to monitor iron overload and its related complications in such patients.
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Background: Anti-retroviral therapy (ART) for HIV has changed a highly fatal disease to a chronic manageable condition. National technical guidelines by NACO say that adherence of >95%(optimal) is required for optimal viral load suppression which is a challenge both for the patient and the health system. Objectives: This study was conducted to determine the reasons for missed and lost to follow-up (LFU) cases and to assess the impact of the COVID pandemic on ART adherence. Settings and Design: Cross-sectional study conducted at ART center, Jhansi. Methods and Material: 357 patients were administered a self-designed questionnaire after taking informed consent to enquire about the reasons for missing doses and LFU and whether they missed treatment during the lockdown. Statistical analysis used: the results were expressed in frequencies and percentages and appropriate statistical tests were applied. Results: 72% HIV patients had optimal adherence and 6.7% were on second-line treatment. Out of 357 patients, 56 had missed treatment and 10 were LFU. The main reasons for the missing were run out of pills, busy with other things and being away from home. The number of episodes of missed and LFU increased during the pandemic. The main problems faced were lack of transport (24), fear of catching the disease (7), no money to hire a vehicle (5). Conclusions: Constant monitoring and handholding of those with suboptimal adherence is required. Travel allowance to such patients and regular counseling will help to ensure adherence. Long-term solutions include vocational rehabilitation and awareness programs to reduce stigma and discrimination.
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Background: The Coronavirus Disease (COVID-19) pandemic continues its deadly reign all over the world. Devising effective strategies for detecting and controlling the infection has become ever more critical. Effective prevention and control of the pandemic is entirely dependent on human behavior in terms of practicing preventive and curative measures. During the second wave of COVID-19, people’s perceptions of preventive and curative measures changed. Objective: To study healthcare-seeking behavior of hospitalized COVID-19 patients. Methods: Hospitalized patients due to COVID-19 in the month of March, April and May of 2021 were included in the study. Their attendants/close relatives were contacted telephonically to know about the admitted patients’ healthcare-seeking behavior. Verbal consent was taken from attendants before the commencement of the interview, followed by informing them about the purpose of the interview. Results: Amongst the subjects, there were more males than females (67.5 vs 32.4%), age ranged between 18 to 88 with a mean value of 56.61 ± 14.7 years. Self-medication was significantly associated with study subjects’ mortality (p=0.03). Conclusion: Elderly people were having higher mortality rate than their younger counterparts. People were hesitant to visit primary care physicians after having symptoms of COVID-19.
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Monoclonal antibodies (mAbs), which are commonly used to treat rheumatoid arthritis (RA), have been linked to a variety of adverse events (AEs). The objective of the study was to compare the safety profiles of six FDA approved mAbs (sarilumab, tocilizumab, adalimumab, golimumab, infliximab, and rituximab) marketed for the treatment of RA. A systematic review of the literature was conducted using the databases PubMed, Cochrane Library, and Science Direct. The manuscript comprised a total of 23 clinical studies. The percentage of patients who had AEs was calculated and presented using box-whisker and forest plots. Infections and infestations were found to be the most common AEs in RA patients treated with mAbs. Raised alanine aminotransferase (ALT), aspartate aminotransferase (AST), upper respiratory tract infection (URTI), and nasopharyngitis were frequently reported. The most common AEs were reported with adalimumab. The highest percentage of patients reporting AEs was associated with golimumab (52%), while rituximab had the fewest AEs (4.9%). In conclusion, rituximab appears to be a safer treatment option for RA as it is found to be associated with a lower risk of AEs, particularly respiratory infections.
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Thrombus in transit (TIT) is a rare but potentially fatal condition. Transthoracic echocardiography is the diagnostic modality of choice. The major complications of TIT are pulmonary embolism, right ventricular dysfunction, obstructive shock, and paradoxical embolism through patent foramen ovale. We hereby present a case series of four patients with TIT and the challenges faced while managing them
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Context: After introducing ‘Treat all policy’ in the country and free ART (Anti-retroviral therapy) for all patients the biggest challenge is to optimize adherence to therapy and ensure viral suppression. The present study is aimed to determine the adherence pattern of HIV positive patients at ART center, Jhansi in Uttar Pradesh and to determine the factors influencing adherence. Methods and Material: This cross-sectional study was conducted in an ART Centre of a teaching hospi-tal. In this study 357 patients were interviewed using a modified version of ACTG questionnaire and ad-herence was calculated by pill count and recall method. Chi square test and logistic regression was done using SPSS. Results: Nearly 72% patients had optimum adherence. On univariate analysis the factors found signifi-cant were sex of the patient, the education, the socioeconomic status, financial constraints, family sup-port, WHO stage at diagnosis, alcohol addiction and tobacco addiction. On logistic regression four factors, having less than college education, WHO stage IV at diagnosis, alcohol intake and lack of family support were found to be predictors of non-adherence. Conclusions: Family support, treatment of alcohol addiction improving education and job opportunities for these patients will improve adherence in HIV positive patients.
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Objective: Anomalous origin of coronary arteries (ACA) is rare. The objective of this communication is to describe the difficulties in angiographic recognition and challenges in percutaneous management. Methods: The material for this retrospective study was provided by contributing interventional cardiologists practicing in tertiary care centers. Results: From 2010 to 2019, 27 patients underwent percutaneous coronary intervention (PCI) for ACA. Four groups were encountered including anomalous origin from opposite sinus [left anomalous coronary artery from opposite sinus (L-ACAOS, n = 5), right anomalous coronary artery from opposite sinus (R-ACAOS n = 4)], origin of left circumflex from right sinus (n = 12), and origin of right coronary artery from posterior sinus (n = 6). The selection of a guiding catheter is the crucial step and a wide range of accessories was required to achieve an excellent outcome. Radial access may have an advantage in R-ACAOS, although the majority had a successful procedure from the femoral approach. Conclusion: Percutaneous management of patients with anomalous coronary arteries is challenging but can be accomplished with an excellent immediate outcome.
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Medical and nursing students may have to face healthcare-related violence, especially now as they may be doing clinical duty during the Covid-19 pandemic. This study was conducted to analyse the perceptions and attitudes of medical and nursing students towards violence against healthcare workers (HCWs), when presented with audio-visual depiction of simulated scenarios. This cross-sectional study was conducted over a period of six months (April to September 2019) among the undergraduate medical and nursing students of first, second, pre-final and final years making it a total of 800 students. Video clips were shown to the students pertaining to HCWs’ interactions with patients and relatives, and their responses were noted. Among 615 participants who completed the proforma, 248 (40%) students reported having observed or experienced violence in their clinical postings. Overall, 70.7% of medical and 68.5% of nursing students said that they would report incidents of violence to the authority. The questionnaire based on video-based simulated scenarios brought forth the perception that in triggering an act of violence, both the healthcare worker and the attendant could be at fault and full disclosure of complications was a necessary step in preventing such an act of violence. Sensitisation about the same should be incorporated into the teaching curriculum by using simulated scenarios to prepare them to manage such incidents.
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Objective: The objective of this study was to evaluate the presence of interstitial lung disease (ILD) in rheumatoid arthritis (RA) and to determine the role of clinical, spirometry, and high-resolution computed tomography (HRCT) findings to facilitate early detection of ILD in RA. Materials and methods: This is a prospective study at a tertiary care hospital from February 2016 to June 2019. All patients satisfying the American College of Rheumatology (ACR) criteria for RA and having respiratory symptoms or signs were included. All patients had detailed history, clinical examination, laboratory evaluation, spirometry, and HRCT chest. Results: A total of 280 patients of RA with respiratory symptoms were evaluated, out of which 82 (29.29%) had pulmonary involvement. There were 70 women and 12 men. Rheumatoid factor was positive in 90.2% of patients while anti-CCP antibody was positive in 43.9%. Chest X-ray (CXR) showed bilateral haziness in 36.9%. HRCT findings revealed a usual interstitial pneumonia (UIP) pattern in 73.2% patients and 24% had an nonspecific interstitial pneumonia (NSIP) pattern. Spirometric evidence of lung involvement was present in 84.2% of these cases. 2D Echo showed pulmonary hypertension (PH) in 46.3% of patients. Conclusion: Screening for respiratory symptoms and signs is essential in the clinical evaluation of RA. CXR, HCRT chest, and spirometry can be used effectively to diagnose RA-ILD early.
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Background: Psychological morbidity in medical undergraduate students has always been reported from various countries across the globe. Studies which document this burden among medical students in India are very few. Aims and Objectives: The presence of depression and anxiety among medical undergraduate students was assessed using a previously validated and standardized instrument, hospital anxiety and depression scale (HADS) and the associations with their sociodemographic and comorbidities were identified. Materials and Methods: In a cross-sectional survey, a self-administered, pre-designed, pre-tested HADS was used to collect information on basic sociodemographic (age, gender, semester, and socioeconomic status) and comorbidities through a Google Forms. Informed written consent was obtained from all participants. Scores for each of the respondents over each of the subscales (depression and anxiety) were calculated as per the severity rating index. Results: The study showed that majority (77.4%) of the students did not feel that they were depressed which was found to be similar in both male and female students. However, about 50% of both male and female students were found to be suffering from either mild or moderate anxiety. The present study showed that there was no significant association between HADS score and socioeconomic and sociodemographic characteristics among medical undergraduate students. Conclusion: A substantial proportion of medical undergraduate students was found to be anxious and quite a lot of them were found to be suffering from mild to moderate depression, revealing a neglected area of the students’ psychology requiring urgent attention. Student counseling services need to be made available and accessible to curb this morbidity.
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Peripheral neuropathy is one of the most common neurological conditions of the nervous system. Hereditary neuropathies (HNs) form an important group with varying degrees of severity, causing a significant disease burden. Accurate diagnosis is essential for management, counseling, and preventing unnecessary extended workups for acquired etiologies and inappropriate treatment. Several hereditary neuropathies have characteristic or diagnostic histologic findings; however, in the era of molecular diagnostics, the role of nerve biopsy in the diagnosis of hereditary neuropathy has reduced significantly. Nevertheless, in sporadic cases, cases without a clear family history, clinical mimics, cases with rare mutations, and genetic variants of unknown significance, a nerve biopsy can confirm the diagnosis, provide an unexpected diagnosis, or direct a targeted molecular testing. HN may be non-syndromic, affecting predominantly the peripheral nervous system or syndromic where it is a part of more widespread neurological or multisystem involvement. This review summarizes the microscopic pathological features in a nerve biopsy in some of the more commonly encountered inherited peripheral neuropathies highlighting their utility in selected cases.
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Looking towards the evidence of physical activityand dietary effect on mental health, a massive search of literatures was done and it was concluded that, lifestyle behavioral practices like yoga, exercises and healthy food intake enhances self-esteem capacity and promotes a healthy life by balancing emotions and cognition with daily hurdles.The narration reports the means of preventing mental illness like depression, anxiety and stress among married women through the light of physical activity and diet. However,lack ofexercise and negligence towards mainstreaming of mental health services in primary health care raises the burden of common mental disorders in the community.
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Erythrophagocytosis (EP) is extremely rare in de novo acute lymphoblastic leukemia (ALL). We document a rare case, which in addition, showed extensive blast vacuolization. A detailed literature review has also been incorporated with the aim of unraveling the prognostic import of our morphological observations if any. A five-year-old male presented with fever and progressive pallor for 1 month. He had hepatosplenomegaly and bicytopenia. Peripheral smear examination showed 43% blasts. Nuclear and cytoplasmic vacuolations were seen in 75% blasts and EP in 4% blasts. The blasts showed block positivity on periodic acid-Schiff (PAS) stain. Marrow aspirate smears showed 58% blasts displaying a similar morphology. Flow cytometry showed features of a common acute lymphoblastic leukemia antigen (CALLA) positive B-cell ALL with aberrant, dim CD 33 expression in 53.4% of the gated blasts. Fluorescence in situ hybridization showed translocation (12; 21) (p13;q22). The patient responded well to standard induction therapy. To conclude, EP is rarely seen in de novo ALL and is associated with a favorable translocation, t(12;21).
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Accessory breast tissue occurs due to failure of resolution of embryonic mammary ridges present from axilla to groin bilaterally. It may be functional or non-functional. This condition is more commonly seen in the females and very few cases have been reported in males. Development of ectopic breast tissue is dependent on hormonal stimulation similar to normal breast.It remains asymptomatic usually and increases in size after a hormonal stimulation at the time or after puberty. Majority of the occurrences are completely benign, but this condition also has the potential to convert into a malignant lesion. Apocrine hidrocystoma is regarded as cystic retention and adenomatous proliferation of apocrine sweat glands. It commonly occurs on the head & neck, but can infrequently be present in other locations like axilla, vulva, penis. This is the report of case of apocrine hidrocystoma with accessory breast tissue in a 30 year old male presented with left axillary swelling. Cytomorphological assessment revealed benign epithelial lesion and a diagnosis was established only after a histopathological examination. It emphasises the role of histopathology in diagnosis of axillary breast lesions
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Tramadol, a synthetic codeine analogue having a weak ? receptor agonist action has been widely used for relief of mild to moderate pain. Most commonly, tramadol addiction or abuse is reported among doctors or people with previous history of drug abuse. However, rare cases of tramadol dependence have been described in patients without prior substance abuse history. We are describing one such case of a 35-year-old male who presented with history of using injection tramadol regularly for three years where there was no prior history of drug abuse but who was prescribed tramadol for medical reason. The frequency of one ampule of tramadol increased from once in two to three days to almost daily up to 12-14 ampules/day. The management was a serious challenge. We admitted the patient for inpatient detoxification. He required tramadol injections to manage his withdrawal symptoms, along with lorazepam and clonidine which were gradually tapered over a period of 14 days. This case highlights that tramadol dependence though very rare but still can happen in a patient without substance abuse history. Also, the physician should be aware of the abuse potential of tramadol and should keep in mind short and judicious prescription, and educating the person regarding the risk of abuse can help to minimise this debilitating and sometimes fatal addiction.
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Objective:To compare the levels of serum 25 Hydroxyvitamin D levels after a single large oral dose (60,000 IU) of different vitamin D3 formulations. Materials and Methods: Ninety?one volunteers with mild vitamin D deficiency (18–29 ng/ml) were selected and randomly assigned to three parallel groups. Groups-I received liquid, Group-II received sachet, and Group-III received tablet formulation of cholecalciferol as a single dose of 60,000 IU orally after 8–10 h of overnight fasting. Serum 25(OH) D concentrations were measured at baseline, 24 h, 7 days, and 14 days after drug administration. Various hematology and biochemical parameters were also assessed for baseline safety evaluation. Results: Baseline serum 25(OH) D concentrations in Groups I (liquid), II (sachet), and III (tablet) was 24.75 ± 4.77 ng/mL, 23.25 ± 4.15 ng/mL, and 23.18 ± 5.52 ng/mL, respectively. After supplemented with three formulations, only tablet group after 24 h showed increase in serum 25-OH-D concentration of 8.07 units from its baseline. Whereas after 7th day, no significant difference in absorption was observed but after 14 th day, all three groups showed increase in serum 25-OH-D concentration, in which tablet group (50.10 ± 94.99 ng/ml) showed highest increase in absorption (26.92 units) from their baseline values. During intergroup comparison between three formulations at the time of investigation, only liquid group after 24 h showed increased serum concentration by P values (0.03, 0.02) as compared to sachet and tablet group. However, After 7th and 14th day, there was no statistically difference was observed between three groups. Conclusion: Single oral dose of 60,000 IU dose of vitamin D liquid formulation has higher absorption value as after 24 h and tablet formulation showed higher absorption after 7th days. In emergency paucity of vitamin D, these observations findings can have critical conclusions to state the suitable dietary formulation of vitamin D.
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Aim: The present study aimed to assess the phytoextraction potential of plant geranium (CIM BIO-171) to remove metals from sewage sludge and to investigate the growth, yield and quality of essential oil of this aromatic plant grown in contaminated sludge.Methodology: The experiment was conducted at research farm of CSIR-CIMAP, Lucknow during 2017-18 in vertical cemented column pots dug into soil. Six treatment groups of sewage sludge and soil were taken with four replication, i.e., T1-100% sewage sludge, T2-80% sewage sludge + 20% soil, T3-60% sewage sludge + 40% soil, T4-40% sewage sludge + 60% soil, T5-20% sewage sludge + 80% soil and T6-soil (only soil). Experimental soil was analysed at pre-harvest and post-harvest stage for soil characters. All plant attributes were recorded at the time of harvesting. Results: Result of the present study showed reduction in the heavy metals in the soil at harvest in comparison to the contents observed in soil at initial stage. All the parameters of growth, yield, biomass and essential oil were found to increase with the application rate of sewage sludge in geranium (CIM BIO-171). Interpretation: The results of the present study clearly indicate the phytoextraction capability of geranium plant (CIM BIO-171). Furthermore, the plants grown in contaminated sludge has all the beneficial impact on growth, yield and quality of essential oil.