ST Elevation in a Patient With COVID-19 Infection-Associated Fever: A Case of Brugada Pattern.

Coronavirus disease 2019 (COVID-19) is a global pandemic presenting with various cardiovascular manifestations. Although Brugada pattern ST-segment elevation (STE) is well described in patients admitted with febrile illness, the implication of recognizing this abnormality in patients with COVID-19 is critical in providing appropriate care for the patient and also reducing the exposure of healthcare professionals to the risk of infection. We report a patient with COVID-19 infection presenting with STE due to fever-related unmasking of Brugada pattern, who was managed conservatively

FLUORIDE INDUCED NEPHROTOXICITY: APOPTOSIS, ULTRASTRUCTURAL CHANGES AND RENAL TUBULAR INJURY IN EXPERIMENTAL ANIMALS

Fluorosis is endemic in many countries across the globe. Most of the Indian states are endemic for fluorosis. Fluoride is known to cause many types of health complications and affects skeletal & soft tissues. The kidneys are one of the highly exposed organs for all the ingested toxins including fluoride. Therefore fluoride exposed subjects are highly vulnerable to fluoride induced nephrotoxicity. In recent years it has been demonstrated that the prevalence of renal impairment is remarkably high in different fluorosis endemic areas. Higher prevalence of CKD observed in central dry zone of Sri Lanka, a fluorosis endemic region. The prevalence of renal tubular dysfunctions is significantly high in residents of El Quel, which is also an endemic fluorosis area in Southern Algeria. On the basis of previous research reports it may be concluded that fluoride induces renal impairments and renal tubular injuries, cellular and sub-cellular ultrastructural changes. But all the research reports available are confined to animal models only. The data available on fluoride associated renal impairment in human is scant and limited to case reports and epidemiological studies. Due to the variation in types of animal models used in the studies, variations in quantity of fluoride administered and variations in route of fluoride administration, the generated insight cannot be translated to clinic. Therefore there is need to adopt a direct holistic approach to evaluate the adverse effects of fluoride on kidney structure and function in human subjects.

Urinary exosome isolation in fluorosis patients with early symptoms of nephrotoxicity

596-600Polyureic nephropathy, a kidney disease characterized by excess thirst & frequent urination, are established manifestations of non-skeletal fluorosis. This study aimed to isolate the urinary exosomes from fluorosis patients with early renal impairment. Fluorosis patients having urinary fluoride above 1ppm were recruited as test group (Group-1). The recruited fluorosis patients were sub-divided in two groups i.e., fluorosis patients with normal renal functions (G-1A) and fluorosis paints with renal impairments (G-1B). Healthy individuals having urinary fluoride up to 1ppm were included as control (Group-2). Urinary Exosomes were isolated and correlated with fluoride toxicity associated nephrotoxicity. A significantly (P = 0.002) higher urinary fluoride (G-1A: 2.62 ± 0.94 ppm and G-1B: 3.87±1.6 ppm) in fluorosis patients were observed compared to the normal control (G-2: 0.40±0.19 ppm), (P = 0.004).The serum creatinine levels was significantly increased in G-1B (3.33±0.76 mg/dL) compared to G-1A (1.11±0.89 mg/dL), (P = 0.003) and G-2, (0.64±0.17), (P = 0.005). A significant (P = 0.001) increase in BUN were observed in G-1B, compared to G-1A and control. The urinary protein was also significantly higher in G-1A (P = 0.005) and G-1B (0.001) compared to G-2. The number of exosomes per/ml of urine in G1-B was significantly higher (P = 0.05) than the G-1A and G-2. The number of urinary exosomes in G-1A and G-1B were also significantly higher than G-2 (P = 0.05). Chronic fluoride toxicity may induce renal impairments and increased urinary excretion of exosomes

The role of multimedia in surgical skills training and assessment.

INTRODUCTION Multimedia is an educational resource that can be used to supplement surgical skills training. The aim of this review was to determine the role of multimedia in surgical training and assessment by performing a systematic review of the literature. METHODS A systematic review for published articles was conducted on the following databases: PubMed/MEDLINE (1992 to November 2014), SCOPUS (1992 to November 2014) and EMBASE (1992 to November 2014). For each study the educational content, study design, surgical skill assessed and outcomes were recorded. A standard data extraction form was created to ensure systematic retrieval of relevant information. RESULTS 21 studies were included; 14 randomized controlled trials (RCTs) and 7 non-randomized controlled trials (Non-RCTs). Technical skills were assessed in 7 RCTs and 3 non-RCTs; cognitive skills were assessed in 9 RCTs and 4 non-RCTs. In controlled studies, multimedia was associated with significant improvement in technical skills (4 studies; 4 RCTs) and cognitive skills (7 studies; 6 RCTs). In two studies multimedia was inferior in comparison to conventional teaching. Evaluation of multimedia (9 studies) demonstrated strongly favourable results. CONCLUSIONS This review suggests that multimedia effectively facilitates both technical and cognitive skills acquisition and is well accepted as an educational resource

Rate and predictors of electrical failure in non-recalled defibrillator leads

Background: Implantable cardioverter defibrillator (ICD) leads are considered as the ‘weakest link’ in defibrillator systems due to FDA recalls and advisories involving popular lead models from major manufacturers. The rate of electrical failure of ICD leads not implicated in a recall is however not well determined. Methods: Medical records of patients implanted with ICDs at hospitals of the University of Pittsburgh Medical Center between 2002 and 2014 were analyzed. Leads were classified as having electrically failed if removed or replaced for reasons other than infection or heart transplantation. Patients were followed to endpoint of death or electrical lead failure. Results: 2410 consecutive ICD recipients (mean age 66 ± 13 years, women 22%, single/dual/biventricular-ICD 20%/44%/36%) were included. During a mean follow-up of 3.9 ± 3.3 years, 1272 patients (53%) died, 55 patients (2.3%) had ICD lead electrical failure, and 1052 (44%) patients were alive with functional leads at the time of last follow-up. Patients with failed leads had higher BMI (p = 0.07), better functional status (p = 0.04), higher serum creatinine (p = 0.004), wider QRS complex (p = 0.01), higher number of implanted leads (p = 0.06) and were more likely to have ischemic cardiomyopathy (p = 0.03). After adjusting for these variables in a binary logistic regression model, only a lower BMI, presence of non-ischemic cardiomyopathy, and a better functional status remained independently predictive of electrical failure. Conclusions: Only 2.3% of non-recalled ICD leads experience electrical failure (annual failure rate of 0.6%). A higher patient functional status, lower BMI, and non-ischemic etiology of cardiomyopathy are independently associated with higher rates of ICD lead failure. Keywords: Defibrillator, Leads, Electrical failure, Recall, Predictor

Multiple Myeloma-Like Spinal MRI Findings in Skeletal Fluorosis: An Unusual Presentation of Fluoride Toxicity in Human

Endemic fluorosis is a worldwide environmental problem due to excessive fluoride, commonly due to increased drinking water fluoride levels but sometimes due to other sources such food with high fluoride content. In India, 21 of the 35 states are known to have health problems associated with fluoride toxicity. The present report is a case of a 50-year-old female who was seen with progressive spinal complications and a MRI of the spine suggestive of multiple myeloma. The MRI of the lumbo-sacral spine showed a diffuse and heterogeneous marrow signal of the lower dorsal and lumbo-sacral vertebrae. The MRI was also suggestive of coarse trabeculation and appeared predominantly hypointanse on the T1W image and had mixed signal intensity on the T2W image. These findings were suggestive of neoplastic bone marrow infiltration and the presence of a proliferative disorder, with multiple myeloma being the most likely. During the patient workup, it was found that other family members were also having similar complications and, after investigation of these family members, it was found that they are suffering from systemic fluorosis. The patient was then evaluated for skeletal fluorosis and this condition was found to be present. Multiple myeloma was ruled out by the finding of a negative serum protein electrophoresis. The spinal complications appeared to be mainly due to the compression of the spinal cord and nerve roots by protruding osteophytes, thickening of the posterior longitudinal ligament, and thickening of the ligamentum flavum resulting in a compressive myeloradiculopathy and compressive myelopathy. The finding of multiple myeloma- like findings on the spinal MRI in association with skeletal fluorosis was considered to be a very rare event. This case report underlines the need to consider the presence of spinal skeletal fluorosis when evaluating spinal complications with unusual pseudo-multiple myeloma-like changes on the spinal MRI

Apoptotic and Degenerative Changes in the Enteric Nervous System Following Exposure to Fluoride During Pre- and Post-natal Periods

Children born in fluorosis endemic areas usually suffer from gastrointestinal complications and are unable to attain normal growth as per their age group. The enteric nervous system (ENS) controls gut movement and functions. It is highly vulnerable to any ingested toxins. Based on observations, it was hypothesized that fluoride exposure during pregnancy and lactation might induce ENS developmental defects. The aim of this study is to investigate the effects of fluoride exposure during pregnancy and lactation on ENS of the first-generation rat pups. After confirmation of pregnancy, female rats were divided into 3 groups and kept on normal water (group 1), 50 ppm of fluoride (group 2), and 100 ppm of fluoride (group 3). The fluoride exposure started at the start of pregnancy and continued until lactation. On the 21st post-natal day, the pups were euthanized and the gut tissue and blood were harvested and subjected to fluoride measurement, oxidative stress estimation, histopathological and ultrastructural analysis, TUNEL, and immunofluorescence. The quantitative expressional analysis of embryonic lethal abnormal vision-like 4 (ELAVL4) (a pan-neuronal marker) and glial fibrillary acidic protein (GFAP) (a glial cell marker) genes was performed by RT-qPCR. An increase in oxidative stress, subcellular and cellular injuries, and apoptosis in enteric neuronal, glial, and epithelial cells was observed in the distal colon of the first-generation pups. Ganglionic degeneration, reduced expression of HuC/D and GFAP, altered colon muscle layer thickness, and tissue edema were observed in the fluoride-treated groups compared with the control. Fluoride exposure during prenatal and lactation period leads to subcellular and cellular injuries due to increased oxidative stress and apoptosis in the ENS. The reduction in the number of neurons and glia due to increased apoptosis may cause alterations in ENS development

Upregulation of Psoriasinin Cholesteatoma associated with inflammation, bone destruction and severity of disease: Histo-cyto-chemical and ultrastructural studies

624-631Cholesteatoma remains a mystery and the factors triggering and propagating it unknown. This study was aimed to evaluate the role of Psoriasin and pro-inflammatory cytokines in progression of middle ear cholesteatoma. In this study 18 patients (12 cases of cholesteatoma and six cases of posterosuperior retraction pocket (PSRP) without cholesteatoma) were included in the study. Clinical aggressiveness was evaluated on-table under operative microscope by evaluating erosion of ossicles, invasion of surrounding structures. The classification of disease was also based on the radiological (CT-scan) findings. Based on clinical aggressiveness, the cholesteatoma cases were divided into mild, moderate, and severe. The tissues were processed for histopathological, ultrastructural and immunohistochemical analysis. The Psoriasin expression in cholesteatoma tissues was significantly higher (P< 0.05) compared to the PSRP tissue and increased with the increasing severity of the disease. The pro-inflammatory cytokines (IL-6 and IL-1β) were also upregulated along with vascular endothelial growth factor and Matrix metalloproteinase-13 in cholesteatoma cases compared to control. Transmission Electron Microscopic images of ultra-thin sections of the tissues showed numerous secretory vesicles, most likely containing cytokines and a unique ultrastructural feature of bacterial localization within the membrane pocket was seen, which gave direct evidence of bacterial infection in the middle ear cholesteatoma