Reconditioned monocytes are immunomodulatory and regulate inflammatory environment in sepsis

Sepsis is caused by dysregulated immune response to severe infection and hyper inflammation plays a central role in worsening the disease. The immunomodulatory properties of mesenchymal stem cells (MSCs) have been evaluated as a therapeutic candidate for sepsis. Reconditioned monocytes (RM), generated from healthy human peripheral blood mononuclear cells (PBMCs) exhibit both macrophage and MSCs-like properties. RM were administered at different stages of sepsis in a mouse model. It reduced serum levels of IL6, MCP-1, IL-10, improved hypothermia, increased survival, and recovery from 0 to 66% when combined with antibiotics in the mouse model. The reduced human leucocyte antigen DR molecules expression on RM enables their co-culture with PBMCs of sepsis patients which resulted in reduced ROS production, and up-regulated TGF-β while down-regulating IL6, IL8, and IL-10 in-vitro. RM are potentially immunomodulatory, enhance survival in sepsis mouse model and modulate inflammatory behaviour of sepsis patient's PBMCs.

Post COVID-19 syndrome and new onset diseases: A prospective observational study

Introduction

The National Institute of Health and Care Excellence (NICE) has defined the terms, 'acute coronavirus disease 2019' (COVID-19), 'ongoing symptomatic COVID-19' and 'post-COVID-19 syndrome', with the latter two described as having persistent symptoms after the onset of COVID-19 symptoms for 4-12 weeks and >12 weeks, respectively. Persistent symptoms can either be due to the after-effects of COVID-19 or new-onset diseases after acute COVID-19. All symptoms observed beyond 4 weeks after the onset of COVID-19 need not be present at the time of onset. Previous studies on persistent post-COVID-19 symptoms have not mentioned new-onset diseases after acute COVID-19, and only a select few studies have discussed such new-onset symptoms.

Methods

Ninety-five patients who attended the post-COVID-19 clinic completed the requisite follow-up till 16 weeks after COVID-19 symptom onset. Data was recorded on a predesigned proforma. Necessary investigations were conducted to rule out any other cause of persistent symptoms.

Results

Fatigue (62.1%), breathlessness (50.5%) and cough (27.4%) were the most common symptoms present beyond 4 weeks after the onset of COVID-19 symptoms. Forty-nine (51.57%) patients developed post-COVID-19 syndrome - their severity of symptoms (odds ratio [OR] 17.77) and longer duration of hospital stay (OR 1.095) during acute disease were significantly associated with the development of post-COVID-19 syndrome. During follow-up, 25 patients developed new-onset symptoms, such as diabetes mellitus, hypertension and idiopathic tachycardia.

Conclusion

Patients can have persistent symptoms, new-onset symptoms and new-onset diseases after recovery from acute COVID-19.

Assessment of Lung Functions by Spirometry in Diabetics with no Respiratory Complaints

BACKGROUND AND OBJECTIVES

Diabetes produces a number of biochemical, morphological, and functional abnormalities that can affect the kidney, cardiovascular and neurological systems, as well as the skin and liver by altering collagen and elastic fibers. Diabetics' lungs show histological alterations such as thicker alveolar epithelium and pulmonary capillary basal lamina, resulting in decreased pulmonary elastic rebound and lung volume. Spirometry is a test to assess lung function in various respiratory diseases. The aim of our study was to assess the lung function by spirometry in patients with diabetes mellitus with no respiratory complaints and compare with lung function among healthy controls. Our additional intention was to find out the association between duration of disease and lung function impairment, if any, and further to compare impairment in lung function, if any, between diabetic patients with controlled and uncontrolled glycemic status. We also compared lung function between diabetic patient with diabetic complications and diabetic patient without diabetic complications.

MATERIAL AND METHODOLOGY

This cross-sectional observational study was conducted in Department of Medicine. Patients attending the Medicine OPD for Diabetes Mellitus with no respiratory complaints were interviewed. After application of appropriate inclusion and exclusion criteria, qualifying subjects underwent detailed history, clinical examination, routine investigations and spirometric evaluation. A total of thirty cases were included in the study. A total of thirty age and sex matched apparently healthy subjects were also taken as controls.

OBSERVATION AND RESULTS

In our study, FEV1 (Measured Value) was normally distributed and, therefore, student t-test (2 tailed) was used to analyze the difference between the groups. No statistically significant difference was found between the cases and controls (p value = 0.437). FVC was also normally distributed and, therefore, student t-test (2 tailed) was used to analyze the groups. No statistically significant difference was found between the cases and controls (p value = 0.331). FEV1/FVC Ratio (Measured) was not normally distributed and therefore a non parametric test was used to analyze the groups. No statistically significant difference was found between the cases and controls (p value 0.336). The Mean ± SD of FEV1 (Measured Value) was 2.55 ± 0.66 for the diabetic subjects with duration 0- 5 Years, 2.21 ± 0.69 for those with duration 6-10 Years and 2.53 ± 0.67 for those with duration >10 years. No statistically significant difference was found between the three groups (p value 0.433) as assessed by One way ANNOVA. The Mean ± SD of FVC (Measured Value) was 3.19 ± 0.82 for diabetics with duration 0- 5 Years, 2.79 ± 0.81 for those with duration 6-10 Years and 3.29 ± 0.93 for those with duration >10 years. Again, no statistically significant difference was found between the 3 groups (p value 0.523) as assessed by One way ANNOVA. The Mean ± SD of the FEV1/FVC (Measured Value) was 0.8 ± 0.05 for the subjects with diabetes duration 0- 5 Years, 0.79 ± 0.07 for those with duration 6-10 Years and 0.78 ± 0.04 for those with duration >10 years. No statistically significant difference was found between the 3 groups (p value 0.563). On basis of spirometry interpretation out of 30 cases, 2 patients (6.67%) were found to have a restrictive pattern of airway disease. On other hand, all controls were found to have a normal pattern of spirometry. No statistically significant difference between spirometric parameters of FEV1, FVC, FEV1/FVC, FEF25-75% was found between diabetic subjects with and without complications abd among diabetics with controlled and uncontrolled diabetes.

CONCLUSION

This study shows that spirometric variables FEV1, FVC, FEV1/FVC and FEF 25-75% were not different between diabetic subjects who were not having respiratory complaints and healthy controls. Also, duration of diabetes, diabetic control and presence of other diabetes related complications do not affect the lung function among diabetics. So, unlike eye and kidney, there is no need for screening for lung function abnormality among diabetics with no respiratory complaints.

Tracing Historical Forms of Servitude: Introductory Remarks and Elementary Reflections

History of domestic service in South Asia is beginning to attract scholars but a rich historiography around it is still distant and difficult. The forms of servitude are different across different times, places and contexts. The sources available to scholars for specific sites and moments in history are marked by extreme diversity of language, genre, concerns, and vantage points. Studies based on exploration of particular kinds of texts across dissimilar contexts make for a good beginning. Using insights from apparently disjointed explorations of servitude in uneven locales, we sketch a tentative template to study changing patterns of service relations and their articulations in the long duration beginning with the early modern period and reaching up to our own times. The study of domestic service yields empathetic vignettes of lives of domestic servants. They also yield insights on various forms of servitude and their centrality to social and economic relationships in a manner that can potentially upset the set historiographic paradigms of work, leisure, household, labour and 'labour laws' in the early modern and modern periods.

Role of Modified RALES and Brixia Scores Section in Predicting the COVID-19 Positivity among the Suspected Patients: A Cross-sectional Observational Study

Introduction: Computed Tomography (CT) chest plays an important role in triaging and managing patients of suspected COVID-19, especially in those where Coronavirus Disease 2019 (COVID-19) report is pending but CT chest has constraints of availability and cost. Chest X-ray (CXR) is a readily available investigation and is cheaper than a CT chest. Hence, any scoring on CXR which proves to be helpful in triaging and managing suspected COVID19 patients will alleviate the dependency on CT chest. Modified Radiographic Assessment of Lung Edema Score (mRALES) and Brixia scores have been used to assess severity of disease and prognosis in COVID-19 confirmed cases. However, these two scores have never been used as a method to predict the confirmed COVID-19 pateints among the the suspected COVID-19 cases. Aim: To evaluate the role of mRALES and Brixia score along with clinical and laboratory parameters in predicting confirmed positive cases among suspected COVID-19 patients. Materials and Methods: This retrospective cross-sectional, observational study was conducted in Department of Medicine at Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India, from 1st to 15th December 2020. Case records of patients admitted with severe acute respiratory illness (suspected COVID-19) were accessed and used to fill up a proforma where clinical and laboratory parameters were recorded. Chest radiographs (posteroanterior and anteroposterior) of the patients were evaluated to calculate mRALES and Brixia scores. Sensitivity, specificity, positive preditive value and negative predictive value were calculated. The p-value <0.05 was considered as statistically significant. Results: Out of the 113 patients, 62 were males and 51 females. The COVID-19 positivity rate was 15.04% (n=17). Mean age of patients was 52.64±15.63 years. Overall, the mean mRALES and Brixia scores were not statistically different between suspected (mRALES=3.94±2.51, Brixia=7.29±4.642), and confirmed COVID19 (mRALES=4.25±2.56, Brixia=7.73±4.84) patients. However, in the subgroup of patients with history of obstructive airway disease, Brixia score was significantly higher among COVID-19 positive patients (7.09±4.70) as compared to COVID-19 suspected patients (0.53±4.31). Presence of low TLC {<9550/mm3 with sensitivity of 70.62%, specificity of 67.3%, Positive Predictive Value (PPV) of 26.7% and Negative Predictive Value (NPV) of 92.4%} and low ANC {< 7580/mm3 with sensitivity of 64.7%, specificity of 63.2%, PPV of 22.9% and NPV of 90.5%} significantly predicted the COVID-19 positivity among the suspected COVID-19 patients. Conclusion: mRALES and Brixia scores on CXR are not significantly different between suspected and confirmed COVID-19 patients and hence, cannot be used to judge who among suspected COVID-19 patients will turn out to be COVID-19 positive later. However, a TLC of less than 9550/ mm3 and an ANC of less than 7580/mm3 can predict COVID-19 positivity among suspected patients.

Human immunodeficiency virus encephalitis

Here, we present a case of pyrexia with altered sensorium in a young healthy male individual. On evaluation, he was detected to have human immunodeficiency virus infection with low CD4. He had no opportunistic infection or any other acquired immunodeficiency syndrome-defining illnesses although his magnetic resonance imaging brain showed features of encephalitis. He recovered tremendously within 3 months of antiretroviral therapy.

Consensus and development of document for management of stabilized acute decompensated heart failure with reduced ejection fraction in India

Aim

Ensuring adherence to guideline-directed medical therapy (GDMT) is an effective strategy to reduce mortality and readmission rates for heart failure (HF). Use of a checklist is one of the best tools to ensure GDMT. The aim was to develop a consensus document with a robust checklist for stabilized acute decompensated HF patients with reduced ejection fraction. While there are multiple checklists available, an India-specific checklist that is easy to fill and validated by regional and national subject matter experts (SMEs) is required.

Methodology

A total of 25 Cardiology SMEs who consented to participate from India discussed data from literature, current evidence, international guidelines and practical experiences in two national and four regional meetings.

Results

Recommendations included HF management, treatment optimization, and patient education. The checklist should be filled at four time points- (a) transition from intensive care unit to ward, (b) at discharge, (c) 1st follow-up and (d) subsequent follow-up. The checklist is the responsibility of the consultant or the treating physician which can be delegated to a junior resident or a trained HF nurse.

Conclusion

This checklist will ensure GDMT, simplify transition of care and can be used by all doctors across India. Institutions, associations, and societies should recommend this checklist for adaptability in public and private hospital. Hospital administrations should roll out policy for adoption of checklist by ensuring patient files have the checklist at the time of discharge and encourage practice of filling it diligently during follow-up visits.

Computational fluid dynamics analysis of the hydraulic (filtration) efficiency of a residential swimming pool

Hydraulic or filtration efficiency of residential swimming pools, quantified in terms of residence time characteristics, is critical to disinfection and thus important to public health. In this study, a three-dimensional computational fluid dynamics model together with Eulerian and Lagrangian-based techniques are used for investigating the residence time characteristics of a passive tracer and particles in the water, representative of chemicals and pathogens, respectively. The flow pattern in the pool is found to be characterized by dead zone regions where water constituents may be retained for extended periods of times, thereby potentially decreasing the pool hydraulic efficiency. Two return-jet configurations are studied in order to understand the effect of return-jet location and intensity on the hydraulic efficiency of the pool. A two-jet configuration is found to perform on par with a three-jet configuration in removing dissolved constituents but the former is more efficient than the latter in removing or flushing particles. The latter result suggests that return-jet location and associated flow circulation pattern have an important impact on hydraulic efficiency. Thus return-jet configuration should be incorporated as a key parameter in the design of swimming pools complementing current design standards.

Secondary Hypertriglyceridemia Causing Recurrent Acute Pancreatitis with Normal Pancreatic Enzymes

Hypertriglyceridemia (HTG) is the third leading cause of acute pancreatitis (APs) worldwide which is invariably associated with elevated pancreatic enzyme levels. We present a case of HTG-induced recurrent AP with normal serum amylase and lipase levels in a patient of Syndrome Z.

Isotopic study of intraseasonal variations of plant transpiration: an alternative means to characterise the dry phases of monsoon

The isotopic characteristics of plant transpired water are strongly controlled by soil evaporation process, primarily by relative humidity. The monsoon system is characterised by large variability of several atmospheric parameters; the primary one being the rainfall, which in turn, modulates the relative humidity. Due to the strong dependency of transpiration on relative humidity, it is expected that this process would vary in accordance with the active and break periods of the monsoon season, which are known to produce cycles of humid and relatively dry phases during a monsoon season. To study the transpiration process, an experiment was conducted wherein rainwater and transpired water were collected from a few plants and analyzed for their isotopic ratios during the summer monsoon seasons of 2016 and 2017. The difference between the isotopic characteristics of the transpired water and rain water is expected to be nominally positive, however, a large variability was observed. This difference is found to be high (low) during the reduced (enhanced) humidity conditions and varies in tandem with the break and active phases of the monsoon season. This characteristic feature may thus be used to delineate the dry and wet phases of monsoon on local to regional scale.

Diagnostic and Prognostic Role of Neutrophil-to-Lymphocyte Ratio in Early and Late Phase of Sepsis

Objective

Early diagnosis of sepsis is necessary to decrease morbidity and mortality. This study aims to evaluate neutrophil-to-lymphocyte ratio (NLR) as diagnostic and prognostic of early and late phase of sepsis.

Methods

It was a prospective, observational study, conducted in Intensive Care and High Dependency Unit (Daycare) of the Department of Pulmonary and Critical Care Medicine (tertiary care center), Rohtak, from January 2017 to December 2017. A total of 56 cases of newly diagnosed cases of sepsis were included in the study and 20 healthy adults were taken as controls. Daily NLR was calculated in cases till the primary outcome.

Results

The results suggested that NLR seems to have promising role as diagnostic and prognostic marker (with P = 0.001 and P = 0.045, respectively) in sepsis.

Conclusion

The study suggests that NLR can be a useful diagnostic and prognostic marker in sepsis.

Transport of Liposome Encapsulated Drugs in Voxelized Computational Model of Human Brain Tumors

There are many obstacles in the transport of chemotherapeutic drugs to tumor cells that lead to irregular and non-uniform uptake of drugs inside tumors. The study of these transport problems will help with accurate prediction of drug transport and optimizing treatment strategy. To this end, liposome mediated drug delivery has emerged as an excellent anticancer therapy due to its ability to deliver drugs at site of action and reducing the chances of side effects to the healthy tissues. In this paper, a computational fluid dynamics (CFD) model based on realistic vasculature of human brain tumor is presented. This model utilizes dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) data to account for heterogeneity in tumor vasculature. Porosity of the interstitial space inside the tumor and normal tissue is determined voxel-wise by processing the DCE-MRI images by general tracer kinetic model (GTKM). The CFD model is applied to predict transport of two different types of liposomes (stealth and conventional) in tumors. The amount of accumulated liposomes is compared with accumulated free drug (doxorubicin) in the interstitial space. Simulation results indicate that stealth liposomes accumulate more and remain for longer periods of time in tumors as compared with conventional liposomes and free drug. The present model provides us a qualitative and quantitative examination on the transport and deposition of liposomes as well as free drugs in actual human brain tumors.

Perfusion kinetics in human brain tumor with DCE-MRI derived model and CFD analysis

Cancer is one of the leading causes of death all over the world. Among the strategies that are used for cancer treatment, the effectiveness of chemotherapy is often hindered by factors such as irregular and non-uniform uptake of drugs inside tumor. Thus, accurate prediction of drug transport and deposition inside tumor is crucial for increasing the effectiveness of chemotherapeutic treatment. In this study, a computational model of human brain tumor is developed that incorporates dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) data into a voxelized porous media model. The model takes into account realistic transport and perfusion kinetics parameters together with realistic heterogeneous tumor vasculature and accurate arterial input function (AIF), which makes it patient specific. The computational results for interstitial fluid pressure (IFP), interstitial fluid velocity (IFV) and tracer concentration show good agreement with the experimental results. The computational model can be extended further for predicting the deposition of chemotherapeutic drugs in tumor environment as well as selection of the best chemotherapeutic drug for a specific patient.

Clinical and laboratory factors associated with mortality in dengue

Dengue is endemic in more than 100 countries, giving rise to an increased number of deaths in the last five years in the South-East Asian region. We report our findings from a retrospective study of adults admitted with confirmed dengue at our institution. We studied the clinical and laboratory parameters associated with mortality in these patients. Of the 172 hospitalised patients studied, 156 (90.69 %) recovered while 16 (9.3%) died. Univariate analysis showed altered sensorium on presentation, lower haemoglobin and haematocrit levels, higher serum creatinine, higher serum transaminase and lower serum albumin levels to be significantly associated with mortality in dengue. Further, using stepwise multivariate logistic regression, altered sensorium ( P = 0.006) and hypoalbuminemia ( P = 0.013) were identified as independent predictors of mortality in dengue. Identification of these parameters early in the course of disease should prompt intensification of treatment in dengue cases.

Targeted radiotherapy enhancement during electronic brachytherapy of accelerated partial breast irradiation (APBI) using controlled release of gold nanoparticles

Several studies have demonstrated low rates of local recurrence with brachytherapy-based accelerated partial breast irradiation (APBI). However, long-term outcomes on toxicity (e.g. telangiectasia) and cosmesis remain a major concern. The purpose of this study is to investigate the dosimetric feasibility of using targeted non-toxic radiosensitizing gold nanoparticles (GNPs) for localized dose enhancement to the planning target volume (PTV) during electronic brachytherapy APBI while reducing normal tissue toxicity. We propose to incorporate GNPs into a micrometer-thick polymer film on the surface of routinely used lumpectomy balloon applicators and provide subsequent treatment using a 50 kVp Xoft device. An experimentally determined diffusion coefficient was used to determine space-time customizable distribution of GNPs for feasible in-vivo concentrations of 7 mg/g and 43 mg/g. An analytical approach from previously published work was employed to estimate the dose enhancement due to GNPs as a function of distance up to 1 cm from the lumpectomy cavity surface. Clinically significant dose enhancement values of at least 1.2, due to 2 nm GNPs, were found at 1 cm away from the lumpectomy cavity wall when using electronic brachytherapy APBI. Higher customizable dose enhancement was also achieved at other distances as a function of nanoparticle size. Our preliminary results suggest that significant dose enhancement can be achieved to residual tumor cells targeted with GNPs during APBI with electronic brachytherapy.

Analysis of carbapenem-resistant Acinetobacter from a tertiary care setting in North India

Multidrug-resistant (MDR) Acinetobacter baumannii is a worldwide concern as cause of serious nosocomial infections. We analysed 140 non-duplicate Acinetobacter sp. isolates from hospitalised patients in a tertiary care centre; 87% were MDR and 20% (28/140) meropenem resistant. Metallo-β-lactamase was produced by 16 of these, detected by ethylene-diamine-tetra-acetic acid disc synergy test. AmpC β-lactamase and efflux pump were present in 17 and 4 of the meropenem-resistant Acinetobacter, respectively. 9/16 MBL-positive isolates carried genes for carbapenem resistance as shown by polymerase chain reaction.

Caregiver characteristics and economic cost of home-based care: a case study of Maun and Gumare villages in North West District, Botswana

The home-based care programme in Botswana was initiated partly to augment hospital or clinical care by reducing the healthcare costs associated with chronic illnesses such as HIV/AIDS. A number of studies have pointed to the psyco-social impacts of home based care, however there has been few attempts to quantify the direct and indirect costs associated with home based care. This study was carried out in the North West District of Botswana, which is noted for a relatively larger proportion of households with critically ill persons. The objectives of the study were to identify the characteristics of the caregivers and their patients; to estimate the direct and indirect costs of home-based care; and to estimate caregivers' willingness to pay for care services. Data was collected using a structured questionnaire addressed to 120 primary caregivers and analyzed using SPSS. The economic cost of caregiving was estimated using the replacement cost method. The annual value per caregiver was estimated at P31 320 (US$4818.46). The study also revealed that more often than not, women are involved in caregiving activities.