Seasonal variation and Vitamin-D status in ostensibly healthy Indian population: An experience from a tertiary care institute.

Background: 25-hydroxy vitamin-D (25(OH)D) deficiency is prevalent worldwide including India. Earlier some cross-sectional studies have discussed 25(OH)D deficiency and its prevalence. The correlation of 25(OH)D with seasonal variation has been reported rarely in India. To determine the 25(OH)D levels and seasonal changes of 25(OH)D status at a tertiary care hospital in North-western India. Materials and methods: 25(OH)D assessments performed in laboratories between 2018 and 2020 was acquired using hospital records. A total of 11,428 assays of serum 25(OH)D were analyzed in the study. Subjects were divided into three groups based on the International Endocrine Society's recommendation for serum 25(OH)D level. The 25(OH)D deficiency <20 ng/ml, insufficiency 20-29 ng/mL and sufficiency ≥30 ng/mL was defined. The months have been separated into the following seasons to analyze seasonal trends: Summer/monsoon (April-September), and winter/spring (October-March). Results: The median 25(OH)D was 17.2 ng/mL. We observed the prevalence of 60 %, 24.1 % & 15.9 % of 25(OH)D deficiency, 25(OH)D insufficiency, and sufficiency respectively in the total number of individuals tested. 56 % male and 63 % females were 25(OH)D deficient. Notably, the lowest median 25(OH)D value was found in the 21-30 age group (14.8 ng/mL). A significant difference in 25(OH)D levels between the summer (18.7 ng/mL) and winter (15.8 ng/mL) seasons has been noticed. Discussion: Current study revealing that 25(OH)D deficiency is common in all age groups and genders, according to our findings. Surprisingly, the lowest levels were reported in young adults. Seasonal variation has an impact on 25(OH)D status, however in all seasons 25(OH)D levels are lower than reference intervals. These findings suggest that the criteria for determining the state of 25(OH)D insufficiency and deficiency in the Indian population should be reconsidered.

Clinical characteristics and outcomes in pseudomonas endocarditis: a systematic review of individual cases : Systematic review of pseudomonas endocarditis.

BACKGROUND: The landscape of Pseudomonas infective endocarditis (IE) is evolving with the widespread use of cardiac implantable devices and hospital-acquired infections. This systematic review aimed to evaluate the emerging risk factors and outcomes in Pseudomonas IE. METHODS: A literature search was performed in major electronic databases (PubMed, Scopus, and Google Scholar) with appropriate keywords and combinations till November 2023. We recorded data for risk factors, diagnostic and treatment modalities. This study is registered with PROSPERO, CRD42023442807. RESULTS: A total of 218 cases (131 articles) were included. Intravenous drug use (IDUs) and prosthetic valve endocarditis (PVE) were major risk factors for IE (37.6% and 22%). However, the prosthetic valve was the predominant risk factor in the last two decades (23.5%). Paravalvular complications (paravalvular leak, abscess, or pseudoaneurysm) were described in 40 cases (18%), and the vast majority belonged to the aortic valve (70%). The mean time from symptom onset to presentation was 14 days. The incidence of difficult-to-treat resistant (DTR) pseudomonas was 7.4%. Valve replacement was performed in 57.3% of cases. Combination antibiotics were used in most cases (77%), with the aminoglycosides-based combination being the most frequently used (66%). The overall mortality rate was 26.1%. The recurrence rate was 11.2%. Almost half of these patients were IDUs (47%), and most had aortic valve endocarditis (76%). CONCLUSIONS: This review highlights the changing epidemiology of Pseudomonas endocarditis with the emergence of prosthetic valve infections. Acute presentation and associated high mortality are characteristic of Pseudomonas IE and require aggressive diagnostic and therapeutic approach.

Assessing the accuracy of pleural puncture sites in patients with pleural effusion as determined by clinical examination versus ultrasound-A single-centre prospective study.

INTRODUCTION: This study aimed to ascertain the accuracy of clinical examination for the determination of pleural puncture sites as compared to the use of ultrasonography in patients with pleural effusion. MATERIAL AND METHODS: A single-centre, prospective, observational study was carried out amongst 115 patients with pleural effusion in a tertiary care hospital in western India. Patients were subjected to clinical assessment for determination of pleural puncture sites and the same were confirmed with ultrasonography. All physicians were blinded to the marking of the previous physician to prevent any influence on their assessment. RESULTS: The study had 345 physician observations. The overall accuracy of the clinical examination was 94.8%. Multivariate logistic regression of the factors responsible for the accuracy of clinical examination demonstrated a significant role of higher body mass index (BMI) (OR-1.19) and lower zone pleural effusions (OR-4.99) when adjusted for age, gender, side of effusion, and experience of examining doctors. When the effusions were classified according to their location, lower zone pleural effusions and loculated pleural effusions had an error rate of 15.9% and 8.33%, respectively. CONCLUSION: An ultrasound is the standard of care to assess all pleural effusions and guide the best point for aspiration.

Metformin-Induced Chronic Diarrhea Misdiagnosed as Irritable Bowel Syndrome for Years.

Metformin is the most prescribed and recommended drug for type 2 diabetes mellitus because of its better tolerability, pleiotropic benefits, and cost-effectiveness. Metformin inhibits hepatic glucose production and increases muscle glucose uptake. Metformin is also associated with gastrointestinal side effects like abdominal bloating, flatulence, diarrhea, nausea, and vomiting. Metformin-related gastrointestinal side effects are mainly due to alteration in gut microbiota, raised intestinal glucose, and increased ileal bile salt reabsorption. We report a case of a 62-year-old diabetic patient who presented with chronic diarrhea with a weight loss of 6 kg from the last six years after initiation of metformin. He underwent multiple investigations and was finally misdiagnosed with irritable bowel syndrome for years. After discontinuation of metformin, there was a significant improvement in gastrointestinal symptoms. Our case highlights the importance of metformin-induced chronic diarrhea if no other causes for the diarrhea are obvious in patients with type 2 diabetes taking metformin. Consideration of this potential side effect of metformin must be valuable to avoid unwarranted investigations, additional drug therapy, and annoyance of the patients.

First report of clinically significant bites due to Platyceps ventromaculatus (GRAY, 1834) from Thar Desert region, Rajasthan, India.

BACKGROUND: Platyceps ventromaculatus is a non-front-fanged colubrid snake of unknown medical significance. In this study, we highlight the clinical manifestations and outcomes of P. ventromaculatus bites. We also emphasise the need to create awareness among clinicians and the public for its potential to be confused with serious venomous bites such as Echis carinatus sochureki. METHODS: This series is part of an ongoing observational clinical study from our tertiary care hospital in Jodhpur, India on the profile and outcomes of snakebite envenoming. Data was collected after approval from Institute Ethics Committee. The date and time of the bite, geographical location, type of human-snake conflict, time-to-reach a healthcare facility, antivenom used (dose), and outcomes were recorded. We retrospectively examined our clinical data for images suggestive of P. ventromaculatus and present the clinical details of these patients. The photographs were identified utilising taxonomic keys for species identification. RESULTS: A total of four images and three patients with bites due to P. ventromaculatus were identified. The clinical effects included mild local erythema, pain, transient local bleeding, and edema. All bites occurred during daylight hours, 2 during agricultural activities, and one at home. Twenty-minute Whole Blood Clotting Test was persistently prolonged for 12 h after the bite in one patient. All patients were treated symptomatically, observed at the emergency department, and discharged within 24 h. None of the patients received antivenom. CONCLUSIONS: To our knowledge, P. ventromaculatus has so far not been reported to result in envenoming or medically significant bites. This study highlights that Platyceps bite can present with clinically significant local and possibly systemic findings that may lead to confusion with saw-scaled viper (Echis) envenoming. Clinicians must receive appropriate training so as to be aware and recognize regional snake species that do not require antivenom so as to avoid unnecessary antivenom administration.

Abnormal Body Composition Increases the Cardiometabolic Risk in Adolescents and Young Adults With Turner Syndrome.

OBJECTIVE: To determine the cardiometabolic risk of adolescents and adults with Turner syndrome (TS) and whether and how anthropometry and body composition predict this risk. METHODS: We compared the anthropometric, biochemical, and dual-energy x-ray absorptiometry-derived body composition parameters of 103 girls and women with TS aged 12 to 30 years and 103 controls of the same age and body mass index: (1) between TS with and without metabolic syndrome (MetS), (2) between the different karyotypes of TS, and (3) between growth hormone recipients and nonrecipients. RESULTS: Individuals with TS had higher prevalence rates of truncal obesity (57.2%), MetS (37.9%), prediabetes (20.4%), dyslipidemia (73.8%), hypertension (9.7%), and hepatic steatosis (15.5%) and a greater total body fat percentage (38.43% vs 34.26%) and fat mass index (9.15 vs 6.71 kg/m2) but a lower lean mass index (11.05 vs 12.49 kg/m2) than controls (P <.001). Individuals with TS and MetS (n = 39) had a higher total body fat percentage (41.74% vs 36.42%, P <.0001), truncal fat percentage (44.66% vs 36.09%, P <.0001), and visceral adipose tissue mass (495.57 vs 276 g, P <.0001) than those with TS but without MetS. Those with classic TS (45,X) had a higher prevalence of prediabetes (32.6% vs 10.5%, P =.01). Growth hormone recipients had a lower prevalence of MetS and lesser truncal obesity. Altered body composition was significantly correlated with metabolic risk. The truncal fat percentage independently predicted MetS (odds ratio, 1.12; 95% confidence interval, 1.003-1.24; P =.04). Waist circumference and waist-hip ratio predicted metabolic risk with good sensitivity and specificity. CONCLUSION: Adverse cardiometabolic risk and altered body composition start early in life in TS. Postpubertal women with TS should be routinely assessed for truncal obesity, dysglycemia, dyslipidemia, and liver steatosis, irrespective of body mass index and karyotype.

Monocrotophos-Induced Intermediate Syndrome Complicated by Hyperammonemic Encephalopathy: A Case Report.

Organophosphorus (OP) poisoning is the most common type of poisoning in India. Amongst the OP, monocrotophos poisoning has the highest lethality and need for mechanical ventilation. Monocrotophos is also implicated in causing OP-induced intermediate syndrome, the prevalence of which is 10-40% of all OP poisoning. The other neurological manifestations are delayed neuropathy and neuropsychiatric syndrome. We herein discuss a case of a 58-year-old male who presented with monocrotophos poisoning and intermediate syndrome. During the hospitalisation course, the patient developed hyperammonemic encephalopathy, resulting in difficulty in weaning from mechanical ventilation. After ruling out all possible causes of hyperammonemia, it was attributed to monocrotophos poisoning. The patient improved significantly after initiating lactulose and was successfully weaned off from the ventilator. This report highlights the high index of suspicion of hyperammonemic encephalopathy in monocrotophos toxicity, which can be easily missed due to other commoner neurological manifestations of organophosphorus poisoning.

The emergence of multidrug-resistant Gram-positive bloodstream infections in India - a single center prospective cohort study.

Introduction: Gram-positive bloodstream infections (BSIs) are an emerging health concern, especially in resource-limited settings. There is a paucity of data regarding the antimicrobial resistance (AMR) pattern of Gram-positive BSIs. The rise in multidrug-resistant infections further convoluted antibiotic selection. We aimed to assess the incidence, clinical and microbiological profile, antimicrobial resistance (AMR) and outcome in Gram-positive BSIs. Methods: This was a single-center prospective study conducted at a tertiary care hospital in Western India. All patients (age ≥18 years) with culture-proven Gram-positive BSIs were included. Data were collected on all patients' demography, risk factors, AMR and clinical outcome. Results: A total of 210 clinically significant isolates were grown from July 2020 to December 2021. The incidence of Gram-positive BSIs was 29% (n=61); 55.9% of cases were healthcare-associated, while 44.1% were community-acquired. Coagulase-negative staphylococci (CoNS) were the major isolates (36.1%), followed by Enterococcus spp. (27.9%), methicillin-susceptible Staphylococcus aureus (MSSA) (18%) and methicillin-resistant Staphylococcus aureus (MRSA) (14.7%). The proportion of vancomycin and teicoplanin-resistant CoNS isolates was 13.6% and 19%. Among Enterococcus isolates, the proportion of vancomycin-resistant enterococci (VRE) and linezolid-resistant enterococci (LRE) were 11.8% and 5.9%. The overall mortality in Gram-positive BSIs was 42.6%. Older age, MRSA infection, septic shock, and high NLR were significantly associated with mortality. On the Cox regression model, age ≥65 years (HR: 2.5; 95%CI: 1.1-5.8; p=0.024) and MRSA infection (HR: 3.6; 95%CI: 1.5-8.5; p=0.021) were found as independent predictors of 30-day mortality. Conclusions: This study found substantial mortality with Gram-positive BSIs, especially MRSA infections. Moreover, the emergence of VRE and LRE is also alarming. Active surveillance of AMR and evaluation of mortality predictors may help overcome the therapeutic challenges in managing BSIs.

Iron Deficiency Anemia Presenting With Pancytopenia: A Study From India.

INTRODUCTION: Iron deficiency anemia (IDA) is the most common cause of anemia worldwide. IDA is commonly associated with thrombocytosis and normal or slightly decreased leukocyte count. Sometimes it can present with thrombocytopenia, but rarely present with pancytopenia. Here we are presenting six cases of severe iron deficiency presenting with pancytopenia, which responded to iron replenishment. METHODS:  This 12-month observational study was conducted in the Department of General Medicine at a tertiary care Centre in India. All cases of pancytopenia (after exclusion of other causes) with IDA were included. IDA was established with the help of a complete blood count (CBC), peripheral smear examination, serum iron studies, and serum ferritin.  Results: In our study, CBC at four weeks later of iron transfusion without other supplementation showed significant improvement in hematological parameters. CONCLUSION:  Severe iron deficiency is a reversible etiology of pancytopenia. It should be kept as a differential diagnosis of pancytopenia if common causes of pancytopenia are ruled out.

Scorpion Sting Envenomation, a Neglected Tropical Disease: A Nationwide Survey Exploring Perspectives and Attitudes of Resident Doctors from India.

Scorpion sting envenomation (SSE) is a commonly encountered and a significant problem in the tropics, affecting rural and marginalized communities. However, it is not formally listed as a neglected tropical disease (NTD) by the WHO. We designed this cross-sectional study to explore medical graduates' and resident doctors' perspectives on SSE as an NTD and to assess their experiences, knowledge, and confidence in managing these patients. An online questionnaire was developed, validated, and administered to interns and resident doctors across India. Adjusted odds ratios were calculated for factors predicting high self-reported confidence scores for managing scorpion stings using multivariable logistic regression. The final questionnaire contained 26 items including participant background, perspectives about SSE being an NTD, experiences, knowledge, and skills needed to manage, and prevent stings effectively. Of 454 participants, 69% opined that SSE was an NTD, and > 60% felt that SSE was inadequately addressed within undergraduate training. Predictors of high self-reported confidence scores in management competencies were residency in a clinical branch that commonly encountered SSE (internal/emergency medicine or pediatrics, P < 0.0001), having ever managed an SSE patient alone or as a part of a team (P < 0.0001), and attending a class or teaching session on SSE during undergraduate training (P = 0.048). Our results suggest that residents across India believe that there is an urgent need to declare SSE an NTD to increase its visibility, further paving the way for innovative multilevel cross-cutting solutions for mitigation. Designing authentic learning experiences can help produce competent and empathetic physicians in managing and preventing SSE.

Epidemiology, clinical presentation, and predictors of outcome in nontuberculous mycobacterial central nervous system infection: a systematic review.

BACKGROUND: CNS manifestations represent an emerging facet of NTM infection with significant mortality. Due to protean presentation and low index of suspicion, many cases are often treated erroneously as tubercular meningitis or fungal infections. OBJECTIVES: Literature on NTM CNS disease is scarce, with most available data on pulmonary disease. This systematic review aimed to evaluate the epidemiology, clinical presentation, diagnostic modalities, and predictors of outcome in CNS NTM infection. METHODS: The literature search was performed in major electronic databases (PubMed, Google Scholar, and Scopus) using keywords "CNS," "Central nervous system," "brain abscess," "meningitis," "spinal," "Nontuberculous mycobacteria," "NTM". All cases of CNS NTM infection reported between January 1980 and December 2022 were included. RESULTS: A total of 77 studies (112 cases) were included in the final analysis. The mean age of all patients was 38 years, with most patients male (62.5%). Mycobacterium avium complex (MAC) was the most common aetiology, followed by M. fortuitum and M. abscessus (34.8%, 21.4% and 15.2%, respectively). The disseminated disease was found in 33% of cases. HIV (33.9%) and neurosurgical hardware (22.3%) were the common risk factors. Intracranial abscess (36.6%) and leptomeningeal enhancement (28%) were the most prevalent findings in neuroimaging. The overall case fatality rate was 37.5%. On multivariate analysis, male gender (adjusted OR 2.4, 95% CI 1.2-7.9) and HIV (adjusted OR 3.7, 95% CI 1.8-6.1) were the independent predictors of mortality). M. fortuitum infection was significantly associated with increased survival (adjusted OR 0.18, 95% CI (0.08-0.45), p value 0.012). CONCLUSIONS: Current evidence shows the emerging role of rapid-grower NTM in CNS disease. Male gender and HIV positivity were associated with significant mortality, while M fortuitum carries favourable outcomes.

Association of Serum Complement C3 Levels with Severity and Mortality in COVID 19.

The severe acute respiratory distress syndrome-associated coronavirus-2 infection can activate innate and adaptive immune responses which may lead to harmful tissue damage, both locally and systemically. C3, a member of complement system of serum proteins, is a major component of innate immune and inflammatory responses. This study is aimed to assess serum C3 as a marker of COVID-19 severity and a predictor of disease progression. A total of 150 COVID-19 patients, confirmed by RT-PCR, and 50 healthy controls were recruited. Serum C3 levels were determined by using direct colorimetric method. Median levels of serum C3 in total cases and controls were 157.8 and 165.7 mg/dL respectively. Serum C3 although not significantly decreased, they were lower in cases when compared to controls. Similarly, significant differences were found between the groups, with severe group (140.6 mg/dL) having low levels of serum C3 protein when compared to mild (161.0 mg/dL) and moderate group (167.1 mg/dL). Interestingly, during hospitalization, significant difference between baseline (admission) and follow-up (discharge) was observed only in patients with moderate disease. Based on our results, lower levels of C3, with an increase in IL-6 and d-dimer levels, are associated with higher odds of mortality. Therefore, we would like to emphasize that measuring serum C3 levels along with other inflammatory markers might give an added advantage in early identification of patients who are prone to having a severe disease course and can help in a more effective follow-up of disease progression. Supplementary Information: The online version contains supplementary material available at 10.1007/s12291-023-01148-x.

Clinical Utility of Bronchoalveolar Lavage Neutrophilia and Biomarkers for Evaluating Severity of Chronic Fibrosing Interstitial Lung Diseases.

Introduction It is hypothesized that bronchoalveolar lavage (BAL) neutrophilia, Krebs von den Lungen-6 (KL-6), and C-reactive protein (CRP) predict the severity of chronic fibrosing interstitial lung diseases (CF-ILDs). Methods This cross-sectional study enrolled 30 CF-ILD patients. Using Pearson's correlation analysis, BAL neutrophils, KL-6, and CRP were correlated with forced vital capacity (FVC), diffusing lung capacity for carbon monoxide (DLCO), six-minute walk distance (6MWD), partial pressure of oxygen (PaO2), computed tomography fibrosis score (CTFS), and pulmonary artery systolic pressure (PASP). Using the receiver operator characteristic (ROC) curve, BAL KL-6 and CRP were evaluated against FVC% and DLCO% in isolation and combination with BAL neutrophilia for predicting the severity of CF-ILDs. Results BAL neutrophilia significantly correlated only with FVC% (r = -0.38, P = 0.04) and DLCO% (r = -0.43, P = 0.03). BAL KL-6 showed a good correlation with FVC% (r = -0.44, P < 0.05) and DLCO% (r = -0.50, P = 0.02), while BAL CRP poorly correlated with all parameters (r = 0.0-0.2). Subset analysis of BAL CRP in patients with CTFS ≤ 15 showed a better association with FVC% (r = -0.28, P = 0.05) and DLCO% (r = -0.36, P = 0.04). BAL KL-6 cut-off ≥ 72.32 U/ml and BAL CRP ≥ 14.55 mg/L predicted severe disease with area under the curve (AUC) values of 0.77 and 0.71, respectively. The combination of BAL neutrophilia, KL-6, and CRP predicted severity with an AUC value of 0.89. Conclusion The combination of BAL neutrophilia, KL-6, and CRP facilitates the severity stratification of CF-ILDs complementing existing severity parameters.

Trends and Pattern of Diseases Under Integrated Disease Surveillance Project in Jodhpur, Rajasthan: A Retrospective Observational Study.

Background: Progress of the Integrated Disease Surveillance (IDSP) is of utmost importance to ensure optimal performance in Jodhpur, Rajasthan, India. The purpose of the study was to document the physical performance of the surveillance system on its core and support functions. Material and Methods: Mixed method study was conducted between September 2020 to October 2020. Quantitative data was collected from the district IDSP unit of the Chief Medical and Health Office (CMHO) for various blocks of Rajasthan using syndromic, presumptive, and laboratory-confirmed reporting formats. Ethical clearance was obtained from the Institutional Ethical Committee of AIIMS, Jodhpur. Results: Rajasthan reported outbreaks between 0.55 to 1.2% of the national average between 2015-2019. Acute respiratory infections, fever of unknown origin, and acute diarrhea were the leading diseases under the presumptive reporting format. Major syndromic cases reported were cough with/without fever (more than three weeks) and fever less than seven days with the rash. Laboratory-confirmed Dengue, Malaria, and hepatitis were reported more in urban Jodhpur. Conclusion: Despite some pitfalls, IDSP has made satisfactory improvements in its core and support functions in the Jodhpur district of Rajasthan. The number of preventable morbidity and mortality cases associated with notifiable infectious diseases in our country can be effectively countered by strengthening the IDSP reporting system.

The epidemiology, clinical presentation and treatment outcomes in CNS actinomycosis: a systematic review of reported cases.

BACKGROUND: CNS actinomycosis is a rare chronic suppurative infection with non-specific clinical features. Diagnosis is difficult due to its similarity to malignancy, nocardiosis and other granulomatous diseases. This systematic review aimed to evaluate the epidemiology, clinical characteristics, diagnostic modalities and treatment outcomes in CNS actinomycosis. METHODS: The major electronic databases (PubMed, Google Scholar, and Scopus) were searched for the literature review by using distinct keywords: "CNS" or "intracranial" or "brain abscess" or "meningitis" OR "spinal" OR "epidural abscess" and "actinomycosis." All cases with CNS actinomycosis reported between January 1988 to March 2022 were included. RESULTS: A total of 118 cases of CNS disease were included in the final analysis. The mean age of patients was 44 years, and a significant proportion was male (57%). Actinomycosis israelii was the most prevalent species (41.5%), followed by Actinomyces meyeri (22.6%). Disseminated disease was found in 19.5% of cases. Most commonly involved extra-CNS organs are lung (10.2%) and abdomen (5.1%). Brain abscess (55%) followed by leptomeningeal enhancement (22%) were the most common neuroimaging findings. Culture positivity was found in nearly half of the cases (53.4%). The overall case-fatality rate was 11%. Neurological sequelae were present in 22% of the patients. On multivariate analysis, patients who underwent surgery with antimicrobials had better survival (adjusted OR 0.14, 95% CI 0.04-0.28, p value 0.039) compared to those treated with antimicrobials alone. CONCLUSION: CNS actinomycosis carries significant morbidity and mortality despite its indolent nature. Early aggressive surgery, along with prolonged antimicrobial treatment is vital to improve outcomes.

Difficult-to-treat resistant gram-negative blood stream infections - the beginning of a superbug era - a prospective observational study.

INTRODUCTION: Carbapenem resistant gram-negative bacterial infections are a growing concern worldwide. However, India is already in the era of a shortage of effective antibiotics for the management of these infections. Moreover, Difficult-to-Treat Resistance (DTR) gram-negative infections, which are not much studied, further complicate the scenario. This study emphasized the incidence and outcomes of DTR infections. METHODOLOGY: This is a single-center prospective observational study. The study included hospitalised patients aged ≥18 years with gram-negative bacterial bloodstream infections (GNBSI). Blood cultures with the growth of contaminants and/or single positive culture taken from the femoral site were excluded. Incidences of DTR infections and outcomes in the form of 30-day mortality were analysed. RESULTS: Two hundred forty patients with GNBSI episodes were recorded. The Incidence of DTR GNBSI was 37.9% (91/240). Multivariate analysis found that Hospital-acquired infections, ICU admission and mechanical ventilation were independent risk factors for DTR GNBSI. The most common DTR GNB isolates were Klebsiella pneumoniae (31/49, 63.3%) and Acinetobacter baumannii (26/52, 50%). The adjusted relative risk of mortality was remarkably high in DTR GNBSI (aRR 3.9; 95% CI 1.9-7.9) as compared to CR+/DTR- GNBSI (aRR 0.3; 95% CI 0.1-1.0) and ESCR/CS GNBSI (aRR 1.1; 95% CI 0.5-2.4). CONCLUSION: DTR GNB infections are growing concern in India and this need to be evaluated in multicentric studies. Moreover, DTR GNBSI was associated with significantly higher mortality and there is need of further empowerment of antibiotic stewardship practices.

Delayed Compression Paralysis Following an Iliopsoas Hematoma 30 Days After Saw-Scaled Viper (Echis carinatus sochureki) Envenoming: A Case Report.

Snakebite envenoming is a neglected tropical disease disproportionately affecting the rural and marginalized population in low-middle-income countries. The saw-scaled viper (Echis carinatus) is a clinically important snake that causes serious morbidity and mortality in the Indian subcontinent. Even though it is within the so-called big-four snakes against which polyvalent antivenom is available throughout India, reports of antivenom ineffectiveness are emerging in saw-scaled viper envenoming, especially around Jodhpur, Rajasthan, India. This case report highlights a patient with saw-scaled viper envenoming with an ineffective antivenom response complicated by acute kidney injury as well as local and systemic bleeding complications, which subsequently resulted in a pelvic hematoma that compressed the lumbosacral nerves, causing lower-limb weakness and sensory deficits. He was successfully managed with hematoma aspiration and supportive care. This case brings into focus the challenges of managing saw-scaled viper envenoming in this region with antivenom ineffectiveness, resulting in delayed and significant coagulopathy and its complications leading to prolonged hospital stay and morbidity. Our report spotlights less emphasized aspects of long-term morbidity in snakebite survivors, such as loss of working days and productivity. We also highlight the need for an organized system of long-term follow-up of snakebite survivors to screen for possible complications and manage them early.

Musculoskeletal disorders among doctors and nursing officers : an occupational hazard of overstrained healthcare delivery system in western Rajasthan, India.

BACKGROUND: The present study was conducted to estimate the prevalence and distribution of MSDs in different anatomical regions among Doctors and NO and to determine their ergonomic risk factors and predictors. METHODS: This cross-sectional study was conducted in an apex institution in Western India. The socio-demographic information, medical and occupational history, and other personal and work-related attributes were captured using a semi-structured questionnaire, which was developed and finalized by piloting on 32 participants (who were not part of the study). Nordic Musculoskeletal and International Physical Activity Questionnaires were used to assess MSDs and Physical activity. Data were analyzed using SPSS v.23. Prevalence of Musculoskeletal Symptoms (M.S.), Multisite Musculoskeletal Symptoms (MMS), and Widespread Musculoskeletal Symptoms (WMS) were calculated. A comparison was made to estimate the burden and distribution of MSD among Doctors and Nursing officers. Logistic regression was applied to identify the predictors of MSDs and pinpoint the risk factors associated with MSDs. RESULTS: A total of 310 participants, of which 38.7% were doctors, and 61.3% were Nursing Officers (NOs) were included in the study. The mean age of the respondents was 31.63 ± 4.9 years. Almost 73% (95%CI: 67.9-78.1) of participants had MSD in the last 12 months, with approximately 41.6% (95%CI: 36.1-47.3) suffering from MSDs in the previous seven days of the survey. The lower back (49.7%) and the neck (36.5%) were the most affected sites. Working in the same position for a long time (43.5%) and not taking adequate breaks (31.3%) were the highest self-reported risk factors. Females had significantly higher odds of having pain in the upper back [aOR:2.49(1.27-4.85)], neck [aOR:2.15(1.22-3.77)], shoulder [aOR:2.8 (1.54-5.11)], hips [aOR:9.46 (3.95-22.68)] and knee [aOR:3.8(1.99-7.26)]. CONCLUSIONS: Females, who are NOs, work for > 48 h per week, and fall in the obese category were significantly at more risk of developing MSDs. Working in an awkward position, treating an excessive number of patients in a day, working in the same position for a long period, performing repeated tasks, and not having enough rest breaks were significant risk factors for MSDs.

Invasive cerebral aspergillosis in non-neutropenic patients: A case series from Western India.

PURPOSE: Invasive cerebral aspergillosis (ICA) is a rare but fatal infection affecting neutropenic immunocompromised patients. Recently cases have been reported in non-neutropenic settings also. We hereby present a series of ICA cases in non-neutropenic patients diagnosed at our tertiary care centre in Western India between March to October 2021. METHODS: All patients with clinico-radiological suspicion of CNS infections were analysed. Data regarding Clinico-radiological features, diagnosis, treatment and outcome were collected. After ruling out bacterial, viral and mycobacterial causes, appropriate samples were sent for KOH (potassium hydroxide) wet mount, fungal culture, histopathology and serum/CSF galactomannan. RESULTS: A total of four patients were diagnosed with ICA with a mean age of 43.5 years. Three patients had significant comorbidities; Diabetes mellitus, chronic liver disease and COVID-19 pneumonia treated with dexamethasone, respectively. One patient had no known predisposing factor. Radiologically, one patient presented with a frontal brain abscess and two patients had multiple subcortical hyperintensities. Three patients were diagnosed based on CSF galactomannan (Platelia™ Aspergillus antigen, Bio-Rad, France) with OD >1 and one patient had high serum galactomannan (OD >2). CSF culture grew Aspergillus species in two patients. All patients were treated with Voriconazole. One patient recovered, and the remaining three succumbed due to delayed presentation and extensive cerebral involvement. CONCLUSION: Even in non-neutropenic patients, a high index of suspicion is warranted for cerebral aspergillosis. CSF galactomannan can be considered a reliable marker for diagnosing ICA in non-neutropenic settings. Early diagnosis allows timely antifungal therapy, which could be a key to improving the outcomes.

Economic Evaluation of Nucleic Acid Testing for Screening of Blood Donations for Thalassemia Patients (ECONAT) in Western India.

Background: Transfusion Transmitted infections(TTI) are of significant concern for blood safety. The thalassemia patients who receive multiple transfusions are at an increased risk of TTIs and the Nucleic Acid Test (NAT ) has been advocated for safe blood. Though NAT can reduce the window period compared to serology, cost is a constraint. Methods: The thalassemia patient and NAT yield data from the centralized NAT lab in AIIMS Jodhpur was evaluated for cost-effectiveness using the Markov model. The incremental cost-effectiveness ratio (ICER) was calculated by dividing the difference between the cost for NAT and the cost of medical management of TTI-related complications by the product of the difference in utility value of a TTI health state with time and Gross National Income(GNI) per capita. Results: Out of the 48,762 samples tested by NAT, 43 samples were discriminated NAT yield all of which were reactive for Hepatitis B (NAT yield of 1:1134). There was no HCV and HIV NAT yield despite HCV being the most prevalent TTI in this population. The cost of this intervention was INR 5,85,14,400. The number of lifetime QALY saved was 1.38 years. The cost of medical management is INR 82,19,114. Therefore the ICER for intervention is INR 3,64,45,860 per QALY saved which is 274 times the GNI per capita of India. Conclusions: The provision of IDNAT-tested blood for thalassemia patients in Rajasthan state was not found to be cost-effective. Measures to bring down the cost or alternative options to increase blood safety should be explored.