To Study the Clinical Profile of Thromboembolic Events in Covid 19 Patients.

The sars -cov 2 causing covid 19 disease. B/l pneumonia, systemic inflammation, coagulation activation, ards , multiorgan failure are key features of covid 19. Patients need icu admission. Proinflammatory cytokines, tnf, il 6, 8, 1 beta, causes cytokine storm in covid 19 disease. MATERIAL: In this single-center, retrospective, cross sectional study, the clinical and laboratory characteristics of 154 patients with severe covid-19 were collected. 38 Patients with severe covid -19 had incidence of thromboembolism with its symptoms, and 116 patients (ie, the controls) did not have incidence of thromboembolism. A severe case was defined as including at least one of the following criteria: (1) respiratory rate >30/ min. (2) Oxygen saturation ≤90%. (3) Pao2 /fio2 ≤300mm hg. (4) Patients, either with shock or respiratory failure, requiring mechanical ventilation, or combined with other organ failure, requiring admission to intensive care unit (icu). Also pe cases were those patients with high clinical suspicion [tachycardia >100 bpm, systolic arterial tension <100 mmhg or signs of right ventricular pressure overload]. Pe severity was assessed using the simplified pulmonary embolism severity index (s -pesi). OBSERVATION: Of 154 patients with severe covid-19, 38 (24.67%) Had incidence of thromboembolism. Compared with patients with severe covid-19 without incidence of thromboembolism, patients with incidence of thromboembolism were older, susceptible to receiving mechanical ventilation and admission to icu, and had higher mortality. In addition, patients with severe covid-19 with thromboembolism had higher levels of leukocyte count, neutrophil count, high-sensitivity c reaction protein, procalcitonin, ferritin, interleukin (il) 2 receptor, il-6, il-8, tumor necrosis factor α, D-dimer, fibrinogen, lactic dehydrogenase and n-terminal probrain natriuretic peptide. Among patients with severe covid-19 with incidence of thromboembolism, more non-survivors were men (30 (75%) vs women (25%)). Non-survivors had severe inflammatory response, and cardiac, hepatic, renal and coagulation impairment. Finally, the kaplan-meier survival curve showed a trend towards poorer survival in patients with severe covid-19 with incidence of thromboembolism than patients without incidence of thromboembolism. The hr was 2.24 [95% Ci 1.17-4.29], P = 0.015). After adjustment for age, sex, hypertension, cardiovascular disease and cerebrovascular disease by cox regression. The median survival durations from hospital admission in patients with severe covid-19 with and without incidence of thromboembolism were 8 days and 15 days, respectively. CONCLUSION: The mortality rate in patients with severe covid-19 with incidence of thromboembolism is high. Incidence of thromboembolism may lead to an increase in the risk of death.

A Statement of Solidarity on COVID-19 Pandemic 2020 by the South Asian Family Physicians.

The World Organization of Family Doctors (WONCA) is a not-for-profit organization and was founded in 1972 by member organizations in 18 countries. WONCA now has 118 Member Organizations in 131 countries and territories with a membership of about 500,000 family doctors and more than 90 percent of the world's population. WONCA has seven regions, each of which has its own regional Council and run their own regional activities including conferences. WONCA South Asia Region is constituted by the national academies and colleges and academic member organizations of this region namely India, Pakistan, Bangladesh, Nepal, Sri Lanka, Bhutan, and the Maldives. In the background of the ongoing COVID 19 pandemic, the office bearers, academic leaders, practitioners, and researchers of primary care from the South Asia Region have issued a solidarity statement articulating the role of primary care physicians.

Bladder Endometriosis: Management by Cystoscopic and Laparoscopic Approaches.

STUDY OBJECTIVE: Endometriosis of the urinary system accounts for less than 1% of all endometriosis, wherein bladder endometriosis is the most common. Bladder endometriosis is defined as endometriosis infiltrating the detrusor muscle and represents 85% of urinary tract endometriosis [1,2]. Segmental bladder resection/partial cystectomy is the bladder-preserving surgery and offers the complete removal of bladder endometriotic nodules [3,4]. Laparoscopic/robotic excision increases the chances of complete removal of nodules but may lead to inadvertent removal of excess bladder wall and increase the risk of complications, especially in cases of large lesions in close proximity to ureteric orifices. Thus, simultaneous laparoscopy and cystoscopy offers the most effective way of complete resection of bladder endometriotic nodules, relieving symptoms and minimizing intraoperative and postoperative complications and recurrence rates in patients [5-11]. This article with accompanying video describes the systematic approach and step-by-step surgical excision of a bladder endometriotic nodule in a patient with frozen pelvis. DESIGN: Step-by-step surgical excision of a bladder endometriotic nodule by simultaneous cystoscopy and laparoscopy. (Canadain Task Force classification: level III) SETTING: Jyoti Hospital and Minimum Invasive Surgery Center, Ahmedabad, India. PATIENT: A 41-year-old women, P2L2, presented with cyclical dysmenorrhea, dysuria, and chronic pelvic pain. Informed consent was obtained from the patient, and the local institutional board provided the approval. INTERVENTION: Simultaneous cystoscopy and laparoscopy. MEASUREMENTS AND MAIN RESULTS: A preoperative assessment was done with transvaginal ultrasonography with a partially full bladder that showed an intravesical 3-cm endometriotic nodule along with chocolate cysts of the ovary and adenomyosis of the uterus. A simultaneous cystoscopy by a urologist and laparoscopy by a gynecologist was performed. On cystoscopy the nodule was seen away from both the ureteric orifices. The nodule was marked cystoscopically with a monopolar needle and laparoscopically with bipolar scissors. Laparoscopy began with a full inspection of the abdomen, pelvis, and adhesions. Dissection started from the left round ligament, and both paravesical spaces were dissected gently, keeping the bladder partially full. Good uterine manipulation helped to delineate vaginal fornices during dissection. Dissection continued over the isthmus, and bladder was gently separated from the isthmus. The bladder was partially filled with methylene blue and intentionally cut opened to excise the demarcated bladder nodule with a monopolar hook, taking a disease-free margin of 5 mm [12]. Two stay sutures were taken at both the lateral angles of the bladder, and suture ends were brought outside the abdomen to facilitate closure of the bladder transversely. After mobilization of the bladder, both uterine vascular bundles were desiccated with bipolar and laparoscopic hysterectomy. Vaginal closure was done away from bladder stitches. The patient was discharged on day 3 with catheter and DJ stents. On day 21, 3-dimensional computed tomography cystogram showed adequate bladder volume. Catheter and DJ stents were removed, low-pressure cystoscopy showed a smooth stitch line with mucosa over it and no residual endometriosis. The patient was found to have no symptoms at the 2-year follow up. CONCLUSION: The video demonstrates the feasibility of simultaneous laparoscopic and cystoscopic approach for excision of a bladder endometriotic nodule. Marking the nodule by simultaneous cystoscopy and laparoscopy before excision helps in removing the disease completely and avoiding unnecessary normal bladder wall excision, thus reducing the risk of recurrence and resultant small bladder symptoms.

Reducing the economic burden in management of Guillain-Barre syndrome using modified plasmapheresis.

BACKGROUND: Guillain-Barre syndrome (GBS) is an autoimmune acute inflammatory demyelinating polyneuropathy affecting the peripheral nervous system treated with high-dose immunoglobulin, physical therapy, or plasmapheresis. Immunoglobulins are expensive and even plasmapheresis might not be affordable to patients visiting government set-ups. AIMS: This study was undertaken to emphasize the efficacy of plasmapheresis in treatment of adult GBS patients and to narrate methods of reducing the economic burden in the treatment of these patients using modified plasmapheresis. METHODS: A study was conducted on 12 adult GBS patients at Sir Takhtasinhji General Hospital, Bhavnagar from July 2012 to July 2014. Patients were assessed on a 6-point disability scale. They were treated with plasmapheresis over 10 days with REF627 kit from Haemonetics Corporation Limited on MCS+ machine. Improvement was noted by the change in the disability scale score and expenses of various modes of treatment were also considered. RESULTS: Seventy-five percent showed improvement at the end of the treatment. The cost of modified plasmapheresis was Rs. 8000/cycle, i.e., Rs. 40,000/patient. CONCLUSION: Plasmapheresis along with proper supportive measures is a more cost-effective efficacious mode of therapy in adult patients of GBS. Further, modified plasmapheresis using REF627 kit and 6% hexastarch as replacement fluid on MCS+ apheresis machine reduces the cost of therapy for poor patients visiting government set-ups.

An unusual occurrence of hepatic granulomas and secondary sitosterolemia in turner syndrome.

Although abnormal liver function tests occur in 50-80% of cases with Turner syndrome, there are no previous reports of overt hepatic disease or hepatic granulomas associated with Turner's syndrome. We report three cases of Turner syndrome associated with hepatic granulomas with a wide range of liver dysfunction. Of the three patients, first patient underwent liver transplantation; second patient remained stable on immunosuppressants; and third patient died from complications of decompensated liver cirrhosis as she declined liver transplantation due to multiple comorbidities. One patient had sitosterolemia, a rare inherited autosomal recessive disorder of cholesterol metabolism, after she ingested ß-sitosterol supplement and had worsening liver function tests and lipid panel. She had remarkably abnormal lipid panel that responded to ezetimibe and by stopping the ß-sitosterol supplement.