The role of inflammatory markers in COVID-19 associated rhino-orbital-cerebral mucormycosis patients

Background: India has experienced an unprecedented heave of mucormycosis (MCR) cases during second wave of COVID-19. Possible mechanisms may involve immune and inflammatory processes. The aim of the study is to estimate the role of inflammatory markers for triaging patients of COVID-19 associated rhino-orbital-cerebral mucormycosis (CAROCM) at tertiary care hospital in north India. Methods: A retrospective observational study was conducted between September 2021 to December 2021, at Government medical college and hospital, Patiala (Pb), 83 CAROCM patients admitted in ENT department were evaluated for serum ferritin, D-dimer and PCT. Results: The median age of the patients was 50 years. The number of male patients were 45 and female patients were 38. Based upon the medical history and associated comorbidities involved, 83 CAROCM patients were divided into three groups. 43 diabetic patients in group I, 33 patients with multiple risk factors in group II and 7 patients with no comorbidity in group III. The mean D-dimer levels were 702 ng/ml in group 1, 831ng/ml in group II and 399 ng/ml in group III, and ferritin levels were 522 ng/ml, 711 ng/ml and 426 ng/ml in group I, II and III respectively. Mean PCT levels in group I were 0.27 ng/ml, 1.32 ng/ml in group II and 0.42 ng/ml in group III. Conclusions: Our study concluded that a significant association was observed between levels of inflammatory markers and susceptibility factors. Serum ferritin, D-dimer and procalcitonin, can be used for assessing the severity of infection and decreases the mortality and morbidity in CAROCM patients.

Impact of coagulopathy in geriatric traumatic brain injury

Background: Traumatic brain injury (TBI) is the leading cause of death in trauma patients in various parts of the world including India. Coagulation cascade is affected in TBI.  The severity of coagulopathy correlates with degree of primary injuries thus affecting the prognosis of geriatric patients. Since the prognosis of isolated TBI can be a challenge to predict at times. AIM: we wanted to study the potential of international normalized ratio (INR) test, prothrombin test (PT), platelet count as a prognostic tool in isolated TBI. Methods: INR, PT, platelet count reflects the coagulation status. In most trauma cases, it is a routine test as well. We collected the INR, PT, platelet count value at admission of 200 isolated geriatric TBI cases over a period of three months. Then, patients were followed-up and their outcome at three months from admission is scored using Glasgow outcome scale (GOS). The relationship of INR, PT, platelet count with GOS was studied.Results: From our limited study, we found that INR of 1.52, PT 17 sec or more and platelet count less than 1.10 lac predicts poor prognosis in cases of isolated geriatric TBI.Conclusions: It is important to early diagnose and early manage the coagulation abnormalities in isolated geriatric head injury patients

Tea Cup in the brain, a rare case of penetrating brain injury in pediatric patient

Head injuries are very common in children. All over the world, the most common mechanism is fall. These injuries are more prevalent in developing countries due to lack of education, poverty, lack of standard and scientific ways to child upbringing. Penetrating injuries in pediatric patients is extremely uncommon and usually occur due to sharp objects like knife, screw driver, drills, nails. We are reporting a rare case of a child with penetrating head injury due to tea cup, very commonly used crockery in every house hold. To the best of our knowledge, no similar case has ever been reported in world literature. Our case also emphasized the need for educating people about child care

Interval-type and affine arithmetic-type techniques for handling uncertainty in expert systems

AbstractExpert knowledge consists of statements Sj (facts and rules). The facts and rules are often only true with some probability. For example, if we are interested in oil, we should look at seismic data. If in 90% of the cases, the seismic data were indeed helpful in locating oil, then we can say that if we are interested in oil, then with probability 90% it is helpful to look at the seismic data. In more formal terms, we can say that the implication “if oil then seismic” holds with probability 90%. Another example: a bank A trusts a client B, so if we trust the bank A, we should trust B too; if statistically this trust was justified in 99% of the cases, we can conclude that the corresponding implication holds with probability 99%.If a query Q is deducible from facts and rules, what is the resulting probability p(Q) in Q? We can describe the truth of Q as a propositional formula F in terms of Sj, i.e., as a combination of statements Sj linked by operators like &, ∨, and ¬; computing p(Q) exactly is NP-hard, so heuristics are needed.Traditionally, expert systems use technique similar to straightforward interval computations: we parse F and replace each computation step with corresponding probability operation. Problem: at each step, we ignore the dependence between the intermediate results Fj; hence intervals are too wide. Example: the estimate for P(A∨¬A) is not 1. Solution: similar to affine arithmetic, besides P(Fj), we also compute P(Fj&Fi) (or P(Fj1&⋯&Fjd)), and on each step, use all combinations of l such probabilities to get new estimates. Results: e.g., P(A∨¬A) is estimated as 1

Post traumatic vertebro basilar dissection: Case report and review of literature

Posterior circulation territory stroke following mild head injury is a known entity although rarely seen. Numerous case reports appear in literature from time to time highlighting this complication. Blunt trauma to the head and neck possibly causes injury to the vertebrobasilar system in the form of angiorrhexis, subintimal, intramural and perivascular hemorrhage which causes secondary narrowing of the injured vessel. These processes can be complicated by progressive thrombosis & vascular occlusion. Here we are reporting a case of post traumatic vertebra-basilar dissection causing bilateral cerebellar and brainstem infarct

Retrieval of a retained broken scalpel blade from lumbar intervertebral disc space: A case report

Lumbar diskectomy is a common procedure in neurosurgery, besides the common complications broken scalpel blade during disc removal is a rare event. Usually retrieval of such sharp retained fragments in same sitting is difficult and to prevent further complications another session is warranted [1]. We report a case of broken scalpel blade during L1-L2 lumbar intervertebral disc removal and successful surgical retrieval of that tip of knife with the help of operative microscope under fluoroscopic guidance during same sitting before any hazardous complications develop

A Randomized Controlled Exploratory Evaluation of Standardized Ayurvedic Formulations in Symptomatic Osteoarthritis Knees: A Government of India NMITLI Project

The multidisciplinary “New Millennium Indian Technology Leadership Initiative” Arthritis Project was undertaken to validate Ayurvedic medicines. Herbal formulations in popular use were selected by expert consensus and standardized using modern tools. Our clinical strategy evolved from simple exploratory evaluations to better powered statistically designed drug trials. The results of the first drug trial are presented here. Five oral formulations (coded A, B, C, D and E), with a common base of Zingiber officinale and Tinospora cordifolia with a maximum of four plant extracts, were evaluated; with placebo and glucosamine as controls. 245 patients suffering from symptomatic OA knees were randomized into seven arms (35 patients per arm) of a double blind, parallel efficacy, multicentric trial of sixteen weeks duration. The groups matched well at baseline. There were no differences for patient withdrawals (17.5%) or adverse events (AE) of mild nature. Intention-to-treat efficacy analysis, demonstrated no significant differences (P < .05) for pain (weight bearing) and WOMAC questionnaire (knee function); placebo response was high. Based on better pain relief, significant (P < .05) least analgesic consumption and improved knee status, “C” formulation was selected for further development. Controlled exploratory drug trials with multiple treatment arms may be used to economically evaluate several candidate standardized formulations

RAPID DETECTION OF MULTI DRUG RESISTANCE AMONG MULTI DRUG RESISTANT TUBERCULOSIS SUSPECTS USING LINE PROBE ASSAY

Objective: GenoType MTBDRplus line probe assay (LPA) is developed for performing drug susceptibility testing (DST) for Rifampicin (RIF) and isoniazid in sputum specimens from smear-positive pulmonary tuberculosis (TB) patients and revised national TB control Programme (RNTCP) has endorsed LPA for the diagnosis of multi drug resistant TB (MDR-TB). This study was conducted to assess the potential utility of LPA for MDR-TB patient management.Methods: MDR-TB suspects under RNTCP PMDT criteria C referred from different districts in Delhi state were included in the study January 2013 toDecember 2014. Sputum specimens found acid-fast bacilli positive by fluorescent microscopy were processed for LPA.Results: Out of 3062 specimens, 2055 (67.1%) MDR-TB suspects were read as positive and specimens from 1007 (32.9%) suspects were read as negative in sputum smear microscopy. Out of 2019 specimens valid LPA results, 1427 were found to be pan-sensitive, 280 were MDR-TB, 40 were RIF monoresistant, 183 were Isoniazid (INH) monoresistant, and 89 specimens were found negative for Mycobacterium tuberculosis.Conclusion: Routine use of LPA can substantially reduce the time to diagnosis of RIF and/or INH-resistant TB and can hence potentially enable earlier commencement of appropriate drug therapy and thereby facilitate prevention of further transmission of drug resistant strains.Keywords: Multi drug resistant tuberculosis, Line probe assay, Rifampicin, Isoniazid

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950–2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

Background: Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020–21 COVID-19 pandemic period. Methods: 22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution. Findings: Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5–65·1] decline), and increased during the COVID-19 pandemic period (2020–21; 5·1% [0·9–9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98–5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50–6·01) in 2019. An estimated 131 million (126–137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7–17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8–24·8), from 49·0 years (46·7–51·3) to 71·7 years (70·9–72·5). Global life expectancy at birth declined by 1·6 years (1·0–2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67–8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4–52·7]) and south Asia (26·3% [9·0–44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations. Interpretation: Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions