Early infection risk in patients with systemic lupus erythematosus treated with rituximab or belimumab from the British Isles Lupus Assessment Group Biologics Register (BILAG-BR): a prospective longitudinal study

Background: Patients with systemic lupus erythematosus (SLE) are at an increased risk of infection relative to the general population. We aimed to describe the frequency and risk factors for serious infections in patients with moderate-to-severe SLE treated with rituximab, belimumab, and standard of care therapies in a large national observational cohort. Method(s): The British Isles Lupus Assessment Group Biologics Register (BILAG-BR) is a UK-based prospective register of patients with SLE. Patients were recruited by their treating physician as part of their scheduled care from 64 centres across the UK by use of a standardised case report form. Inclusion criteria for the BILAG-BR included age older than 5 years, ability to provide informed consent, a diagnosis of SLE, and starting a new biological therapy within the last 12 months or a new standard of care drug within the last month. The primary outcome for this study was the rate of serious infections within the first 12 months of therapy. Serious infections were defined as those requiring intravenous antibiotic treatment, hospital admission, or resulting in morbidity or death. Infection and mortality data were collected from study centres and further mortality data were collected from the UK Office for National Statistics. The relationship between serious infection and drug type was analysed using a multiple-failure Cox proportional hazards model. Finding(s): Between July 1, 2010, and Feb 23, 2021, 1383 individuals were recruited to the BILAG-BR. 335 patients were excluded from this analysis. The remaining 1048 participants contributed 1002.7 person-years of follow-up and included 746 (71%) participants on rituximab, 119 (11%) participants on belimumab, and 183 (17%) participants on standard of care. The median age of the cohort was 39 years (IQR 30-50), 942 (90%) of 1048 patients were women and 106 (10%) were men. Of the patients with available ethnicity data, 514 (56%) of 911 were White, 169 (19%) were Asian, 161 (18%) were Black, and 67 (7%) were of multiple-mixed or other ethnic backgrounds. 118 serious infections occurred in 76 individuals during the 12-month study period, which included 92 serious infections in 58 individuals on rituximab, eight serious infections in five individuals receiving belimumab, and 18 serious infections in 13 individuals on standard of care. The overall crude incidence rate of serious infection was 117.7 (95% CI 98.3-141.0) per 1000 person-years. Compared with standard of care, the serious infection risk was similar in the rituximab (adjusted hazard ratio [HR] 1.68 [0.60-4.68]) and belimumab groups (1.01 [0.21-4.80]). Across the whole cohort in multivariate analysis, serious infection risk was associated with prednisolone dose (>10 mg;2.38 [95%CI 1.47-3.84]), hypogammaglobulinaemia (<6 g/L;2.16 [1.38-3.37]), and multimorbidity (1.45 [1.17-1.80]). Additional concomitant immunosuppressive use appeared to be associated with a reduced risk (0.60 [0.41-0.90]). We found no significant safety signals regarding atypical infections. Six infection-related deaths occurred at a median of 121 days (IQR 60-151) days from cohort entry. Interpretation(s): In patients with moderate-to-severe SLE, rituximab, belimumab, and standard immunosuppressive therapy have similar serious infection risks. Key risk factors for serious infections included multimorbidity, hypogammaglobulinaemia, and increased glucocorticoid doses. When considering the risk of serious infection, we propose that immunosupppressives, rituximab, and belimumab should be prioritised as mainstay therapies to optimise SLE management and support proactive minimisation of glucocorticoid use. Funding(s): None.Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

Outcome of patients admitted in Covid ICU during first wave and second wave in Mumbai Tertiary Hospital

Introduction: India has recorded over 4.23 Crores of COVID -19 cases and 5.04 lakh deaths till now. Available literature shows mortality in Covid ICU of 30-35%. Aim(s): To study mortality and comorbidities in Covid Pandemic First & Second wave. Methodology: In this retrospective study conducted at Covid ICU in Mumbai, all patients needing ICU admission were enrolled. We studied 214 Covid patients in first wave and 97 patients in second wave. Covid patients (pts) with breathlessness, fever, sore throat were included. Patients with underlying chronic respiratory lung diseases were also treated as per standard Covid protocol. Result(s): Of the 214 patients in first Covid wave, 210 patients needed high flow oxygen (92.51%);180 pts needed NIV (82.94%);30 pts needed Mechanical Ventilation (MV);28 pts expired (13.33%). Most patients belonged to sixth decade. The major co morbidities in dead pts were diabetes (33.33%) followed by hypertension (24.20%). Comorbidities of chronic respiratory diseases were COPD (12.1%), post TB sequelae (3%) and tuberculosis (3%) In 2nd covid wave(n=97), 95 needed oxygen. 67 needed NIV (69.07%) and 28 needed MV (28.86%). Of these, 25 pts expired (28.86%). The major comorbidities in dead pts were hypertension (38.3%), followed by diabetes(25.5%). In chronic respiratory diseases, COPD (4.3%) was the most common comorbidity. Conclusion(s): The COVID-ICU mortality was high at 13.33% (first wave) and 28.86%(second wave). Pt's mean age was 56.0 yrs and 63.5 yrs in first and second wave respectively. Respiratory failure with high oxygen requirement and ARDS were leading causes of deaths. Comorbidities like diabetes and COPD had high mortality.

The impact of risk perceptions on tourists' revisit intention: the case of COVID-19 and Fiji

The tourism industry is fragile as it is prone to numerous risks such as the outbreak of deadly viruses, and natural and human-made disasters. These risks have a significant impact on tourists' decisions when choosing a destination and while in a destination. This paper investigates the risks perceived by Australian tourists and how these risks affect their intention to revisit the Pacific Island Country of Fiji. Through a quantitative survey with 301 tourists, augmented by qualitative interviews conducted among management of hotels, as well as the DMO, the results show that tourists continue to perceive Fiji as a relatively safe destination however there are increased in the perceptions of risk concerning disease risk and financial risk.

An efficacy and safety report based on randomized controlled single-blinded multi-centre clinical trial of ZingiVir-H, a novel herbo-mineral formulation designed as an add-on therapy in adult patients with mild to moderate COVID-19.

OBJECTIVE: Coronaviruses, hence named because of the crown-like spikes on the viral envelope, are members of Coronaviridae family and Order Nidovirales. SARS-CoV-2 is the seventh human pathogenic coronavirus identified after HCoV-229E, HCoV-OC43, SARS-CoV (SARS-CoV-1), HCoV-NL63, CoV-HKU1, and MERS-CoV. SARS-Cov-2 is highly similar to SARS-CoV. COVID-19 is the corresponding acute disease caused by SARS-CoV-2 that was initially reported in Wuhan, China towards the end of 2019 and spread to millions of humans globally. Unfortunately, limited studies were available on the efficacy of antiviral drugs to treat COVID-19 at the time of this study. ZingiVir-H is an Ayurvedic formulation for use in early therapy of viral disease. This clinical trial was planned to investigate (1) the efficacy and safety of ZingiVir-H and (2) the efficacy of ZingiVir-H as an add-on therapy to the standard of care in hospitalized adults diagnosed with COVID-19. METHODS: A total of 123 eligible subjects as per inclusion criteria were randomized within the study. Three subjects later declined to participate in the study and four subjects didn't meet inclusion criteria, which brought the final evaluable subject count to 116 for the efficacy and safety endpoint analysis. Thus, a total of 116 patients were equally randomised into two groups, namely, ZingiVir-H and Placebo for this clinical trial. The study patients were assigned to receive either ZingiVir-H or Placebo along with the standard of care as per the National Indian COVID-19 treatment protocol. The time interval until a negative RT-PCR obtained, was evaluated during treatment with ZingiVir-H or Placebo for ten days. Liver and kidney function tests were regularly assessed to ensure the safety profile of ZingiVir-H. RESULTS: The study found that patients who were administered ZingiVir-H had a median recovery time of 5 days (95% confidence interval (CI) 5-5) when compared to 6 days (95% CI 5-6) in those who received Placebo. Besides, in Ordinal Scale analysis of all the patients treated with ZingiVir-H demonstrated significant redistribution to a better clinical status from ordinal scale 5 to 6 and 7 within five to seven days when compared to that of placebo treatment. The time required for clinical improvement and the number of days needed for hospitalization was significantly less in the ZingiVir-H treated group when compared to placebo. The absence of liver and kidney function changes affirmed the safety profile of ZingiVir-H. No serious adverse events were reported in ZingiVir-H treated patients. CONCLUSION: We found that ZingiVir-H is effective and safe in managing COVID-19 infections and delaying the disease progression from mild to moderate and moderate to severe. To the best of our knowledge, this is the first clinical trial report on the efficacy/safety of a herbo-mineral Ayurvedic drug against COVID-19 as of yet. TRIAL REGISTRATION: Clinical Trial Registry of India CTRI/2020/04/024883. Registered on 28/04/2020.

A Unified Analysis of Masked Face Recognition & Social Distancing Detection

Facial recognition is an important application in today's world but given the importance of wearing face masks due to the COVID-19 pandemic, it is essential that masked face recognition performs well. It is also equally important to ensure that protective measures such as wearing face masks and social distancing are being followed. Hence, this paper introduces an approach unifying masked face recognition, mask detection, and social distancing detection into a single system. The proposed method uses RetinaFace for face detection, VGG-19 for image classification, as well as VGGFace and SVC for facial recognition. As part of experimental analysis, CNN models such as ResNet50 and Inceptionv3 were used to evaluate mask detection while FaceNet and ArcFace were used to evaluate masked face recognition. The entire system was evaluated using accuracy, precision, recall, and F1-score. The obtained results indicate that the proposed system performs efficiently. © 2022 IEEE.

Subjective norms as a moderator in the consumption behaviour of branded functional beverages post-COVID-19 pandemic: a pragmatic view

Purpose: This study aims to experimentally investigate branded functional beverage (BFB) consumption behaviour post-COVID-19 through the lens of a conceptual framework built on three renowned behaviour modification models and to critically evaluate how well subjective norms serve as a moderator in the consumption behaviour relating to such beverage products. Design/methodology/approach: A conceptual model was developed based on the tenets of the theory of planned behaviour (TPB), health belief model (HBM) and value-attitude-behaviour (VAB) model. The study was performed on a convenience sample of 537 respondents aged 18 and up from diverse regions in India using the PLS-SEM method. A total of 444 useable questionnaires were utilized for the final data analysis. Findings: Given the post-pandemic setting, the perceived benefits of BFBs significantly influenced its purchase intention and consumption behaviour. It could grossly impact the media's role (information about COVID-19) and the consumers' interest in healthy food. The study revealed that the information about COVID-19 (role of media) strongly increased interest in healthy food, whereas interest in healthy food positively influenced purchase intention of functional beverages. With interest in healthy food as a “mediator”, the role of media (information about COVID-19) positively influenced purchase intention. It is worth noting the moderating role of subjective norms in the relationship between the role of media (information about COVID-19) and interest in healthy food and that between interest in healthy food and BFB purchase intention. Practical implications: Food marketers shall skillfully use “opinion” leaders and subject experts in marketing communication campaigns to popularize the link between good food and immunity through COVID-19 and healthy diet-related messages sent via a suitable media platform. This would grab food consumers' interest in BFBs and persuade them to incorporate such items in their daily food milieu. Consumers need to be assured that consuming “functional” products would deliver health benefits and upkeep their body immunity in the post-COVID-19 times. Originality/value: There has been minimal research on the link between perceived benefits, the role of media, interest in healthy food and consumption behaviour on functional beverages in the post-COVID-19 setting. Moreover, subjective norms have never been probed as a moderator in the consumer behaviour studies on BFBs. This pioneering study applied the tenets of the TPB, HBM and VAB model in the context of post-pandemic functional beverage consumption. The altered study settings caused by the COVID-19 pandemic and the context of a developing economy like India have amplified the research value of this study. © 2022, Emerald Publishing Limited.

Exploring SVM for Federated Machine Learning Applications

The traditional machine learning algorithms focus on centralised data repository where the aggregate data used for training is stored in a common location and processed. This approach is not suitable when data is stored in different locations and owned by different entities. Many crucial machine learning applications need computationally efficient and privacy-preserving solution. Also the central data repository has the risk of single point of failure. Federated learning is an emerging field in machine learning where the centralised concept is changed to distributed. Federated learning approach helps to train a model in machine learning without really sharing the data to a common server. In this approach, training is done locally at client side. A technique called federated averaging is applied at server side, where the model parameters from clients are aggregated and the updated parameters are computed. We propose a federated SVM architecture for solving a binary supervised classification problem. Here the experiments are done for MNIST dataset and COVID-19 dataset. Also the results are compared with centralised training approach. © 2022, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

RESPIRATORY DISTRESS IN A NEONATE - WHEN BOARDS MEET REAL LIFE

Case Report A male infant is born at 37w to a 34-year-old G3P2 mother by vaginal delivery after an uncomplicated pregnancy. Prenatal screens are negative. The patient had a birth weight of 2,620 g, with Apgar scores of 9 and 9. On day 2 after birth, had increased work of breathing which prompted transfer to a level II NICU for further management. On arrival to the unit, the infant is tachypneic with mild chest wall retractions and thick nasal secretions. A CBC and blood culture were collected and empiric antibiotic therapy was started. Respiratory viral panel and COVID test are negative. A chest radiograph shows a middle lobe opacity concerning for pneumonia (figure 1). His clinical status failed to improve and on day 4 after birth, supplemental oxygen was provided. The primary team consulted ENT and Pulmonology services. Flexible laryngoscopy showed a normal anatomy. Pulmonology recommended transferring to our NICU for a chest CT with bronchoscopy. Our differential diagnosis for this neonate with respiratory distress that fails to improve over time or with antibiotics was broad, but further testing revealed this infant's condition. A CBC, CRP and a blood gas were collected on admission and were normal. ID service was consulted. A Chest CT showed bilateral atelectasis. Bronchoscopy showed a normal anatomy. Bronchoalveolar lavage was sent. Umbilicus swab was positive for MRSA, nasal wash/sputum culture/bronchoalveolar fluid also grew moderate S. aureus. Nasal ciliary biopsy sent for electron microscopy. Positive umbilicus and nasal swab, and subsequently BAL for MRSA led to a diagnosis of MRSA neonatal rhinitis. Therapy with IV vancomycin was initiated and later changed to oral clindamycin to complete a total of 14 days of therapy. The neonate was weaned off oxygen support on day 11. His clinical symptoms improved. He was discharged on oral clindamycin with follow up appointments with pulmonology and ID clinics. His ciliary biopsy showed absence of outer and inner dynein arms, compatible with the diagnosis of primary ciliary dyskinesia (PCD) (figure 2). Genetic testing for PCD showed mutations in the DNAAF1 and CCDC40 genes. This neonate was diagnosed with primary ciliary dyskinesia (PCD) but his presentation at birth was nonspecific and the differential diagnosis was broad. There is no gold standard diagnostic test for PCD and high clinical suspicion is important. Since it is most likely an AR inheritance, screening of family members is essential. Initial management of neonates may include measures that manage the respiratory distress, airway clearance to prevent respiratory infections and treat bacterial infections. Chest physiotherapy may help if recurrent atelectasis. Flexible bronchoscopy and bronchoalveolar lavage may help both to diagnose and treat the underlying infection. Antibiotic therapy based on organism growth for exacerbations may prevent development of bronchiectasis. (Figure Presented).

Outcome of COVID-19 and tuberculosis coinfection

Background: Covid 19 and Tuberculosis are the infectious diseases primarily affecting the lung. Both of them present with cough, fever and difficulty in breathing but Tuberculosis has a longer incubation period and onset of disease is slower. The patients of Tuberculosis are more likely to have comorbidities (malnutrition, diabetes mellitus, Human Immunodeficiency Virus) that increases their vulnerability to covid-19. Aim: To study the clinical profile, course, management and outcome in patient presented with covid-19 and tuberculosis in covid pandemic in Mumbai. Methods: We studied the 323-patient admitted in covid Intensive Care Unit and ward who were proven covid 19 positives by Reverse Transcriptase Polymerase Chain Reaction, Cartridge Based Nucleic Acid Amplification Test or rapid antigen test. All patients were given standard medical care, ventilatory support if required as per covid19 protocol. The chest x-ray, blood investigation and sputum investigation were studied till the time of discharge or death. Results: Out of 323 patients studied 14 had Tuberculosis. Out of those 14 patients 10 patient had pulmonary tuberculosis, 3 had Tuberculous pleural effusion and one had abdominal tuberculosis. All of them had pneumonia on chest x-ray which can be attributed to covid-19 or Tuberculosis. Conclusion: In our study all 14 patients were survived and discharged. As there is high burden of tuberculosis the covid-19 only helped in exposing the tip of the iceberg of the grave problem of undiagnosed tuberculosis in community. It seems that there is just coincidental occurrence of tuberculosis and covid19 coinfection than a causal association.

An unexplained death in the COVID-19 isolation ward: A case report

A 35-year-old male was referred for autopsy from a District Headquarter hospital, where he was admitted to the COVID isolation ward with suspicion of being infected. His clinical history was a day of fever with chills and abdominal pain. He was alone overnight in the isolation ward post collection of his nasal swabs for screening and blood for routine laboratory tests. However, he was found lying dead on the floor within 18 hours of hospitalization © 2021. Journal of Indian Academy of Forensic Medicine. All rights reserved.

Spontaneous Pneumothorax in Patients of COVID 19 Pneumonia

COVID 19 pandemic has put a massive strain on healthcare all over the world. Every day new data is getting released and various complications are being reported in patients of COVID 19 Pneumonia. One such complication is pneumothorax and pneumomediastinum. Both these conditions can lead to an increase in mortality and morbidity in patients with COVID 19 pneumonia. We studied 476 patients of COVID 19 pneumonia at our hospital, out of which 18 (3.78%) had developed pneumothorax and/or pneumomediastinum. While most of these patients were on some form of positive pressure ventilation (invasive/non-invasive), some of them had a HRCT Chest suggestive of either air trapping and/or cyst formation. Three patients had developed bilateral pneumothorax while on non-invasive ventilator. Nine of the 18 patients expired and nine were discharged. Through this article, we would like to emphasize that an acute deterioration in hypoxemia in a COVID-19 patient could indicate a pneumothorax. Pneumothorax as well as pulmonary thromboembolism are reported complications in COVID-19 and clinician vigilance is required during assessment of patients, as both share the common symptom of breathlessness and therefore can mimic each other. © 2022 Journal of Association of Physicians of India. All rights reserved.

Deep Learning Approaches for Detection of Covid-19 Using Chest X-Ray Images

According to studies, covid-19 affects the respiratory tract along with the lungs. Thus it is critical to efficiently detect and diagnose COVID-19 and the non-COVID i.e., pneumonia/normal cases at the earliest. This helps in reducing the fast spread and stops the condition from becoming virulent. Deep learning models are found to have an extraordinary capacity in providing accurate results, forming an efficient system for detecting COVID-19 as well as pneumonia. Here, 6432 images of chest X-ray, consisting of 5144 images for training and 1288 images for testing, each containing 3 classes - Covid-19 affected, Pneumonia affected and normal were used. The data was preprocessed and a comparison of VGG-16, ResNet-50, and CNN models were done. Models classify data as Covid-19 or Pneumonia or Normal. In the final analysis, the ResNet-50 model gave the highest accuracy of 96.61 percentage followed by VGG-16 with an accuracy of 94.58 percentage, and CNN model with an accuracy of 88.98 percentage. © 2021 IEEE.

Bilateral fungus ball: An uncommon complication post severe COVID 19 infection

COVID 19 is one of the world’s worst hit pandemics. WHO first learned of this new virus on 31 December 2019, following a report of cluster of cases of ‘viral pneumonia’ in Wuhan, China. Covid 19 causes systemic infection but it worst hits the lungs and can cause ARDS (<5%). Bilateral lung fibrosis is a commonly observed sequela after severe Covid 19 infection. Covid 19 pneumonia also acts as a nidus for superadded bacterial and fungal infections. However we haven’t come across fibrocavitation and fungus ball as post Covid 19 sequelae. We here present a case report of a patient who was diagnosed as ARDS due to SARS CoV2, was treated as per standard Covid 19 protocols, required NIV and discharged on home oxygen. The HRCT on discharge showed bilateral fibrosis. The follow up HRCT after 45 days of discharge showed evidence of Bilateral cavities with Fungus ball. © 2021 Journal of Association of Physicians of India. All rights reserved.

Suspected COVID-19 Induced Acute Viral Myocarditis

Introduction: COVID-19 virus has been known to be a major cause of mortality secondary to cytokine storm and respiratory failure. Other manifestations include GI symptoms, loss of taste and smell and thromboembolism. Here we introduce a case of suspected COVID-19 induced viral myocarditis in an 86 year old woman. Case presentation: An 86-year-old female with no reported past medical history, not on daily medications, was brought in by ambulance after fall and unable to get up for many hours. On presentation, she was in mild distress due to left sided musculoskeletal pain, afebrile, tachycardic, tachypneic, and saturating at 93% on room air. Patient denied chest pain throughout her hospitalization. Tenderness in the left chest wall, left upper and lower extremities was elicited on physical examination. Labs obtained were significant for a creatine kinase of 37,000 IU/L and troponin I of 9.93ng/mL. EKG showed nonspecific T wave abnormalities, and prolonged QTC of 548ms. Chest x-ray showed multifocal pneumonia with no features suggestive of trauma. She was admitted to telemetry for further management of COVID-91 pneumonia and cardiac work up. Her troponin I peaked to 12.52ng/mL and she was treated with empiric intravenous heparin and aspirin. Echocardiogram shows global hypokinesis with left ventricular ejection fraction of 35-40%. Heart failure regimen with beta blocker and aldosterone receptor blocker were started. Rhabdomyolysis normalized with intravenous fluids. For COVID-19 pneumonia, she received dexamethasone and remdesivir and was weaned to 4L oxygen on discharge. Discussion:Viral myocarditis often results from a combination of direct viral injury and subsequent cellular immune activation. There is limited knowledge for COVID-19 associated viral myocarditis;most documented cases are from existing case reports, where most patients are male, and under the age of 70 years. Diagnosis is often challenging, as endomyocardial biopsy is often forgone in the setting of the ongoing pandemic and increased infection risk. Treatment for viral myocarditis involves heart failure management followed by directed therapy based on suspected etiology. Lymphocytic myocarditis, as seen in the setting of COVID-19, would typically involve immunosuppression in the form of glucocorticoids and intravenous immunoglobulin;although these regimens have yet to be extensively studied in COVID-19 associated myocarditis. As literature on this infection is rapidly evolving, it is vital to recognize and document suspected cases. This case helps to establish presentation of COVID-19 induced viral myocarditis and facilitate future understanding and raises awareness of this extrapulmonary presentation.

A critical review of Jwarahara Yogas of ayurvedic classics: A paradigm to reverse pharmacology

Jwara is the first and foremost among all somatic diseases. Although an independent disease, it is also seen manifested in the form of premonitory symptom, symptom and causative factor of various disorders. 2019-20 has witnessed a new pandemic identified as Corona virus (COVID-19) with adverse health issues. In proportion to the wide variety of diseases, viral vaccines are very few, that too with adverse effects. Hence there is an urgent need of most promising Indigenous drugs with antipyretic and anti-viral activity in the current scenario. A critical analysis is made to explore the Jwarahara Yogas of classics to unfold the Antiviral, Antipyretic, Antioxidant and Immunomodulatory potential of phytochemicals in formulations. An attempt has been made to explore the antiviral and antipyretic potential of Amrutotharam Kashayam, one of the most popular and widely used Jwarahara yoga in classics. The review will definitely give new insights on the synergistic actions of phytochemicals in formulations to revalidate the clinical evidences and will throw lime light on repurposing of the documented novel drugs and combinations in classics to offer unique preventive strategies and therapeutic solutions to the present pandemic and emerging viral infections.