Oral Fluid, Electrolytes, and Energy Management in Various Adult and Geriatric Illnesses beyond Diarrhea: An Indian Expert Panel Delphi Consensus Recommendation.

BACKGROUND: Dehydration is a highly prevalent clinical challenge in adults which can go undetected. Although dehydration is commonly associated with an increased risk of hospitalization and mortality, only a few international guidelines provide recommendations regarding oral fluids, electrolytes, and energy (FEE) management in adults/geriatrics with dehydration due to nondiarrheal causes. Currently, there is a lack of comprehensive recommendations on the role of oral FEE in nondiarrheal dehydration in adult and geriatric Indian patients. MATERIALS AND METHODS: A modified Delphi approach was designed using an online questionnaire-based survey followed by a virtual meeting, and another round of online surveys was used to develop this consensus recommendation. In round one, 130 statements, including 21 open-ended questions, were circulated among ten national experts who were asked to either strongly agree, agree, disagree, or strongly disagree with statements and provide responses to open-ended questions. The consensus was predefined at 75% agreement (pooling "strongly agree" and "agree" responses). Presentation of relevant literature was done during a virtual discussion, and some statements (the ones that did not achieve predefined agreement) were actively discussed and deliberately debated to arrive at conclusive statements. Those statements that did not reach consensus were revised and recirculated during round two. RESULTS: Consensus was achieved for 130/130 statements covering various domains such as assessment of dehydration, dehydration in geriatrics, energy requirement, impact of oral FEE on patient outcome, and fluid recommendations in acute and chronic nondiarrheal illness. However, one statement was not added as a recommendation in the final consensus (129/130) as further literature review did not find any supporting data. Oral FEE should be recommended as part of core treatment from day 1 of acute nondiarrheal illness and started at the earliest feasibility in chronic illnesses for improved patient outcomes. Appropriately formulated fluids with known electrolyte and energy content, quality standards, and improved palatability may further impact patient compliance and could be a good option. CONCLUSION: These consensus recommendations provide guidance for oral FEE recommendations in Indian adult/geriatric patients with various nondiarrheal illnesses.

Effectiveness of ORSL® Variants as an Adjuvant along with Standard-of-care Treatment in the Restoration of Oral Fluid, Electrolytes, and Energy in Patients with Fever and/or General Weakness in Indian Patients in an Outpatient Setting.

BACKGROUND: Dehydration due to reduced intake or increased losses including insensible losses in patients with acute nondiarrheal diseases may lead to fluid, electrolytes, and energy (FEE) deficits. The impact of oral FEE supplementation adjuvant to standard of care (SOC) treatment on recovery in patients with acute nondiarrheal diseases is yet to be evaluated. AIM: To determine the effectiveness of ORSL® variants (ORSL® Apple Drink and ORSL® PLUS Orange Drink), fruit juice-based electrolyte drinks as an adjuvant along with SOC in the restoration of oral FEE in patients with acute nondiarrheal disease with fever and/or general weakness who attended an outpatient department (OPD). MATERIALS AND METHODS: This was a prospective, interventional, open-label, multicenter, real-world, study conducted at eight sites across India. Patients with fever and/or general weakness due to an acute nondiarrheal illness were given either ORSL® Apple Drink or ORSL® PLUS Orange Drink as an adjuvant along with SOC treatment per physician's discretion. The primary endpoint of the study was to assess improvement from baseline in energy or hydration levels after ORSL® variants consumption at 6, 24, and 48 hours measured by a new aided recovery scale (ARS). Secondary endpoints were to assess the improvement in energy and hydration levels at 20, 40, and 60 minutes, as well as energy levels and hydration levels at 20, 40, and 60 minutes, 6, 24, and 48 hours after the consumption of ORSL® Apple Drink or ORSL® PLUS Orange Drink. The patient's consumption of ORSL® variants and treatment experience, physician's experience of recommending ORSL® variants, and product safety were evaluated. RESULTS: In total, 612 patients were enrolled with mean age 38.3 years, of whom 62.9% were male. The mean baseline level of energy and hydration was 1.59 (range 1.0-2.0) on ARS. Statistically significant (p < 0.0001) improvements were observed in energy or hydration 6 hours after first consumption of ORSL formulations. Furthermore, improvement was observed from 40 minutes, and in levels of energy, hydration, and both energy and hydration from 60 minutes. Patients and physicians reported a positive experience with ORSL® variants. CONCLUSION: ORSL® Apple Drink and ORSL® PLUS Orange Drink are clinically proven to provide hydration and/or energy to patients with fever and/or general weakness.

Unraveling the genetic landscape of pulmonary arterial hypertension in Indian patients: A transcriptome study.

BACKGROUND: Pulmonary hypertension (PH) is the abnormal elevation of pressure in the pulmonary vascular system, with various underlying causes. A specific type of PH is pulmonary arterial hypertension (PAH), a severe condition characterized by high pulmonary arterial pressure resulting from structural changes in distal pulmonary vessels, altered arterial tone, and inflammation. This leads to right ventricular hypertrophy and heart failure. The molecular mechanisms behind PAH are not well understood. This manuscript aims to elucidate these mechanisms using the genetic tool, aiding in diagnosis and treatment selection. METHOD: In our present study, we have obtained blood samples from both patients with pulmonary arterial hypertension (PAH) and healthy individuals. We conducted a comparative transcriptome analysis to identify genes that are either upregulated or downregulated in PAH patients when compared to the control group. Subsequently, we carried out a validation study focusing on the log2-fold downregulated genes in PAH, employing Quantitative Real-Time PCR for confirmation. Additionally, we quantified the proteins encoded by the validated genes using the ELISA technique. RESULTS: The results of the transcriptome analysis revealed that 97 genes were significantly upregulated, and 6 genes were significantly downregulated. Among these, we chose to focus on and validate only four of the downregulated genes, as they were directly or indirectly associated with the hypertension pathway. We also conducted validation studies for the proteins encoded by these genes, and the results were consistent with those obtained in the transcriptome analysis. CONCLUSION: In conclusion, the findings of this study indicate that the four validated genes identified in the context of PAH can be further explored as potential targets for both diagnostic and therapeutic applications.

Association of underlying comorbidities and progression of COVID-19 infection amongst 2586 patients hospitalised in the National Capital Region of India: a retrospective cohort study.

This study is conducted to observe the association of diabetes (DM), hypertension (HTN) and chronic kidney disease (CKD) on the prognosis and mortality of COVID-19 infection in hospital admitted patients with above mentioned comorbidities. This is a single centre, observational, retrospective study carried out at Sir Ganga Ram Hospital, Delhi, India. The burden of comorbidities on the prognosis and clinical outcome of COVID-19 patients admitted patients from April 8, 2020, to October 4, 2020. Chi-square and relative risk test were used to observe the association of comorbidities and disease prognosis. A total of 2586 patients were included in the study consisting of 69.6% of male patients. All the comorbidities were significantly associated with ICU admission and mortality. The relative risk showed that CKD is most prone to severity as well as mortality of the COVID-19 infection followed by HTN and DM. Further with the increase in number of underlying comorbidities, the risk of ICU admission and mortality also increases. Relative risk of the severity of COVID-19 infection in younger patients with underlying comorbidities are relatively at higher risk of severity of disease as well as to mortality compared to the elderly patients with similar underlying condition. Similarly, it is found that females are relatively at higher risk of mortality as compared to the males having same comorbid conditions except for the hypertensive patients. Diabetes, hypertension and CKD, all are associated with progression of COVID-19 disease to severity and higher mortality risk. The number of underlying comorbid condition is directly proportional to the progression of disease severity and mortality.

Scrub typhus meningoencephalitis presenting as opsoclonus myoclonus syndrome: A video-based case.

Opsoclonus myoclonus syndrome secondary to scrub typhus infection is a rare clinical entity. Hence, it is important to know its clinical manifestations and complications, so that it can be properly managed. We report a 28-year-old female whose initial manifestation was only fever, which subsided in four days. Two days later, she developed opsoclonus myoclonus syndrome. This was managed with doxycycline and clonazepam, but as it persisted, intravenous immunoglobulin was added. She showed excellent response to treatment.

The Hindi Version of International Consensus Criteria: A Cross-cultural Adaptation and Validation Study for Myalgic Encephalomyelitis in Post-COVID Patients.

CONTEXT: Fatigue is the most prominent feature of long COVID. With the increasing burden of long COVID cases post-acute phase of illness after recurrent waves of the pandemic, understanding its pathophysiology is of paramount importance. Such fatigue and post-viral illness could be associated with features of neuroimmune exhaustion and thus be a part of a larger syndrome such as myalgic encephalomyelitis (ME). Identifying the proportion of patients having ME from those experiencing fatigue would bring us one step closer to understanding the pathophysiology. International consensus criteria (ICC) originally published in English (ICC-E) is a valid and reliable tool for identifying cases of ME. However, a validated Hindi version of ICC-E is not available. : To develop and validate an equivalent version of ICC-E in the native Hindi language (ICC-H) to suit Indian patients and health care workers even at peripheries and to make conducting large scales surveys more feasible. SUBJECTS AND METHODS: Once permission from the ethics board was granted, guidelines given by MAPI Research Trust were followed and ICC-H was developed from ICC-E, in the following steps: (a) translation to Hindi, (b) back translation, (c) comparison between the translated and back-translated version performed by experts, and (d) pre-pilot test in the intended population. The ICC-H was applied to 53 bilingual individuals knowing both Hindi and English. STATISTICAL ANALYSIS USED: The distribution of Hindi and English questionnaires was analyzed using the Chi-square test and Spearman's correlation coefficient was used for correlation between answers of each question. RESULTS: The score of individual items and its global score was highly correlated with each other (p<0.001). The scores of individual components and global scores of ICC-H at baseline and original ICC-E after 4 weeks did not differ significantly. CONCLUSION: This study shows that the ICC-H is a valid and reliable instrument for the assessment of ME. ICC-H can be used for Hindi speaking population for identifying cases of ME. Key Messages There is a significant overlap in symptoms of long COVID and ME, with fatigue being a major component in both. Understanding the prevalence of ME in the post-acute phase of COVID illness can bring us a step closer to understanding its pathophysiology. In a multilingual country like ours, regionally translated criteria are a must for conducting large-scale surveys.

Pancytopenia in a patient with HIV: A diagnosis often missed.

A 31 years old male presented with fever, dry cough, weight loss. Patient was found to be HIV positive and was started on empirical Anti-tubercular drugs (ATT). However, his symptoms persisted and he developed pancytopenia along with jaundice, and was shifted to our health care facility for further investigations. The patient has a history of travel to Bali and Thailand a few months ago. Patient was examined and relevant investigations were performed.

Safety and immunogenicity of SURE RAB™, an inactivated cell culture derived rabies vaccine: A comparative, phase III clinical trial.

INTRODUCTION: Rabies is a viral zoonotic disease widespread across the world. In India, various cell culture vaccines are available for pre and post exposure prophylaxis (PEP) but are not sufficient to meet the rising demand. The present study evaluated the safety and immunogenicity of Rabies vaccine Human I.P. (Brand name: SURE RAB™) in PEP and demonstrated its non-inferiority to already approved rabies vaccine (Brand name: VERORAB). MATERIAL AND METHODS: It was a phase-III randomized, open label, comparative, single centre clinical trial in post exposure subjects. Safety and immunogenicity were evaluated at Day 0, 14 and 45 ±â€¯7 post vaccination. Day 14 serum samples were analyzed by Enzyme Linked Immunesorbent assay (IgG ELISA, Bio-Rad) and Day 0, 14 and 45 ±â€¯7 serum were tested by Rapid Fluorescent Focus Inhibition Test (RFFIT). Paired t-test was applied to compare the results of Rabies virus neutralizing antibody (RVNA). The severity of adverse reactions was measured on a scale of excellent, good, fair and bad; p-value (p < 0.05) was considered as statistically significant. RESULTS: All the subjects achieved a protective titer value between 0.5 and 9.0 IU/ml by Day 14 tested by ELISA and significant rise in the antibody titer in all the groups when tested after 45 days. Statistically significant p-value (p < 0.001) observed with RFFIT test indicated biological potency of rabies vaccine. Adverse events and safety was comparable statistically between three groups (p â€‹= â€‹0.886) and Group I â€‹+ â€‹II combined versus Group III (p = 0.495). CONCLUSION: The study results conclusively demonstrate that SURE RAB™ is comparable to VERORAB in terms of safety and immunogenicity and can be used for PEP in rabies.

COVID-19 in pregnancy: A review.

COVID-19 has led on to a global healthcare crisis, similar to none in the recent past. Special emphasis must be laid on the status of pregnant women amid this outbreak, considering the vulnerability seen in pregnant women toward previous coronavirus diseases. In this review, we will try to elicit the correlation between the complications of previous coronavirus diseases (Severe Acute Respiratory Syndrome and Middle East Respiratory Syndrome) and COVID-19, the possibility of materno-fetal vertical transmission and the obstetric management protocol.

Acute pancreatic injury induced by COVID-19.

We report a patient with COVID-19 infection presenting with acute pancreatitis. The diagnosis of pancreatitis was based on laboratory as well as radiological evidence, and all the usual etiologies were ruled out. The temporal association with COVID-19 is strongly suggestive of novel coronavirus induced pancreatic injury.

Pulmonary Cryptococcosis in a Human Immunodeficiency Virus Negative Patient: A Case Report.

Cryptococcosis is a major life-threatening fungal infection in patients with severe HIV infection and other immunocompromised states. Lung and central nervous system (CNS) are the most commonly involved organs in disseminated cryptococcosis. Others include skin, prostate, medullary cavity of bones, eyes, heart, liver, etc. Pulmonary cryptococcosis may be misdiagnosed because of comparatively nonspecific clinical and radiological features. We report the case of a 61-year-old male patient who is a known case of gastroesophageal reflux disease (GERD), myasthenia gravis, and steroid-induced diabetes mellitus. He was diagnosed with gangrenous cholecystitis at another institution but refused surgery. At our hospital, he experienced loss of consciousness in the out-patient department (OPD) and was therefore admitted for further evaluation where he was found to have pulmonary cryptococcosis and pancytopenia. Pulmonary cryptococcosis is usually found in HIV-positive immunosuppressed patients. However, sometimes it is also seen in HIV-negative patients, and they tend to have a good prognosis with adequate treatment.

Evaluation of soluble urokinase-type plasminogen activator receptor (suPAR) quick test for triage in the emergency department.

BACKGROUND: *Soluble urokinase-type plasminogen activator receptor (suPAR) is a new biomarker, which is increased in conditions associated with inflammatory immune cell activation. In low resource, densely populated countries, there is a need for a quick test for triage and prognosticating in the emergency department. MATERIALS AND METHODS: *A pilot, observational study was conducted wherein all consenting adult patients (>18 years) presented to casualty with acute medical illnesses were included. Detailed clinical history, examination, and suPAR quick tests were done and patients were categorized into five groups based on the emergency severity index (ESI) triage algorithm. Patients with suPAR level more than 5.5 ng/mL were advised hospitalization and those below were advised follow-up. All patients were followed-up after 3 days. RESULTS: Total 190 patients (20-80 years), 80 males and 110 females participated. ESI triage 1, 2, and 3 had suPAR levels > 5.5 ng/mL and ESI triage 4 and 5 had suPAR level of <5.5 ng/mL. In ESI-1, 29 patients were admitted in ICU and 16 left against medical advice (LAMA) and on follow-up mortality was 96% (P = <0.05). In ESI-2, all patients were admitted in high dependency units and on follow-up they still needed hospitalization. In ESI-3, 22 patients admitted in ward and 24 went LAMA, on follow-up all improved except LAMA patients who required hospitalization (P - <0.05). Patients in ESI-4 and 5 did not require admission (P = <0.001). CONCLUSION: *suPAR can reliably be used in the emergency department to prognosticate and triage.

A rare combination: chylous polyserositis and autoimmune myelofibrosis as a presentation of systemic lupus erythematosus.

Chylous polyserositis and autoimmune myelofibrosis occurring concomitantly inn a case of SLE are a rare phenomenon. We here report a case of a 38-year-old woman who was admitted with a history of cough and shortness of breath for 1½ months along with fever and abdominal distension for 1 month. She also had arthralgias, weight loss and pancytopenia. She was diagnosed as a case of SLE with Chylous polyserositis and autoimmune myelofibrosis. She was started on steroids and immunosuppressive therapy, to which she responded. To summarize, this is the first case report where chylous polyserositis and pancytopenia due to autoimmune myelofibrosis occurred which was responsive to steroids and immunosuppressive therapy.

Waist-thigh Ratio: A Surrogate Marker for Type 2 Diabetes Mellitus in Asian North Indian Patients.

INTRODUCTION: Diabetes is a major world-wide healthcare problem. Cost effective markers for screening and diagnosis of T2DM are the need of the day especially in developing and under-developed countries. Simple anthropometric measurements may help us in identifying individuals likely to have diabetes. MATERIAL AND METHODS: Data from 1055 North-Indian subjects was analysed. RESULTS: Out of several anthropometric measurements studied, Waist-Thigh ratio (WTR) correlated significantly and positively with all three measures of diabetes i.e. FPG, RPG and PPG. (P < .0001) suggesting that it is the best predictor of diabetes. Subjects with diabetes had greater WTR (mean 2.088) than those without (mean1.842). (P < .0001). A thresh-hold effect was evident at a cut-off WTR of 2.3. Out of those subjects who were diagnosed to have diabetes by AACE/AHA guidelines, 82% had WTR greater than this value (P < 0.001). CONCLUSION: WTR may prove to be a simple and inexpensive marker for detecting Type 2 diabetes. Larger studies are required to develop population norms.

Persistent Marked Peripheral Eosinophilia due to Tuberculosis: A Case Report.

We report a case of a 68-year-old female who was a known case of diabetes mellitus and chronic liver disease and presented with complaints of dry cough and other constitutional symptoms since one month. During initial investigations, the patient was found to have peripheral blood eosinophilia. Upon investigating further,the patient was found to have mediastinal lymphadenopathy and fine-needle aspiration of mediastinal lymph nodes showed features of tuberculosis. The patient was started on anti-tubercular treatment and her eosinophil counts returned to normal levels. Correlation between eosinophilia and tuberculosis has not been established in classical literature. This case highlights the same association and raises awareness on this crucial finding. Coexistence of eosinophilia and tuberculosis in our patient is suggested since peripheral blood eosinophilia improved with anti-tubercular treatment. The exact pathogenesis of coexistence of tuberculosis and peripheral blood eosinophilia yet remains to be deciphered, but tissue pathology is mainly associated with the discharge of toxic eosinophil products.

Low backache in adults as an initial presentation of acute lymphoblastic leukemia.

Low backache as an initial manifestation of acute lymphoblastic leukemia (ALL) in adults has been rarely reported. In this hematological disorder, although bone marrow is replaced by malignant cells, not many cases of low backache as an initial presentation of ALL are reported. We present a series of clinical cases with low backache, which on evaluation found to have ALL.

Unusual complication of prolonged indwelling urinary catheter - iatrogenic hypospadias.

Long-time urethral catheterization may be responsible for various complications such as urethral stricture, urethral fracture, urinary tract infections, and hypospadias. Hypospadias is the most common congenital anomaly of male external genitalia. However, urethral catheter-induced iatrogenic hypospadias is a rare entity. In this article, we describe a case of an elderly male who was found to have iatrogenic hypospadias 2 months after urinary catheterization.