Abstract Background In this phase 2 randomised placebo-controlled clinical trial in patients with COVID-19, we hypothesised that blocking mineralocorticoid receptors using a combination of dexamethasone to suppress cortisol secretion and spironolactone is safe and may reduce illness severity. Methods Hospitalised patients with confirmed COVID-19 were randomly allocated to low dose oral spironolactone (50 mg day 1, then 25 mg once daily for 21 days) or standard of care in a 2:1 ratio. Both groups received dexamethasone 6 mg daily for 10 days. Group allocation was blinded to the patient and research team. Primary outcomes were time to recovery, defined as the number of days until patients achieved WHO Ordinal Scale (OS) category ≤ 3, and the effect of spironolactone on aldosterone, D-dimer, angiotensin II and Von Willebrand Factor (VWF). Results One hundred twenty patients with PCR confirmed COVID were recruited in Delhi from 01 February to 30 April 2021. 74 were randomly assigned to spironolactone and dexamethasone (SpiroDex), and 46 to dexamethasone alone (Dex). There was no significant difference in the time to recovery between SpiroDex and Dex groups (SpiroDex median 4.5 days, Dex median 5.5 days, p = 0.055). SpiroDex patients had significantly lower D-dimer levels on days 4 and 7 (day 7 mean D-dimer: SpiroDex 1.15 µg/mL, Dex 3.15 µg/mL, p = 0.0004) and aldosterone at day 7 (SpiroDex 6.8 ng/dL, Dex 14.52 ng/dL, p = 0.0075). There was no difference in VWF or angiotensin II levels between groups. For secondary outcomes, SpiroDex patients had a significantly greater number of oxygen free days and reached oxygen freedom sooner than the Dex group. Cough scores were no different during the acute illness, however the SpiroDex group had lower scores at day 28. There was no difference in corticosteroid levels between groups. There was no increase in adverse events in patients receiving SpiroDex. Conclusion Low dose oral spironolactone in addition to dexamethasone was safe and reduced D-dimer and aldosterone. Time to recovery was not significantly reduced. Phase 3 randomised controlled trials with spironolactone and dexamethasone should be considered. Trial registration The trial was registered on the Clinical Trials Registry of India TRI: CTRI/2021/03/031721, reference: REF/2021/03/041472. Registered on 04/03/2021.
Neurofibromas (NF) are benign peripheral nerve sheath tumors that arise from schwann cells and intraneural fibroblasts. Solitary NF are extremely rare with only a few reported cases in the literature that involve the nasal cavity and paranasal sinuses. Due to its slow growth and the non-specific nature of the symptoms, its clinical presentation and diagnosis is often delayed. Here we present a case of a 65 year old female with left sinonasal neurofibroma which was surgically managed in our department successfully. It was 9.5 cm in greatest dimension and weighed 380 gm which is the largest amongst the available published reports that we could find.
Nasopharyngeal carcinoma is a prevalent head and neck cancer, especially in Southeast Asia. Although its potential for distant metastasis is well established, metastasis to the breast has seldom been reported. To the best of our knowledge, this is the fourth report of a case of nasopharyngeal carcinoma metastasizing to bilateral breasts. A 35-year-old patient presented with left nasal obstruction, epistaxis, and a palpable mass in her left breast, without any cervical or axillary lymph nodal enlargement. Radiological examination with contrast-enhanced computed tomography scan and magnetic resonance and imaging of breast revealed the presence of enhancing mass lesions in bilateral breasts. Histopathology of the nasal mass was suggestive of undifferentiated nasopharyngeal carcinoma. Breast fine needle aspiration revealed an abundance of metastatic squamous cells. Immunohistochemistry examination was positive for chromogranin A, synaptophysin, and cluster of differentiation-56, confirming the diagnosis of a primary nasopharyngeal malignancy metastasizing to bilateral breasts. Differentiation between metastatic disease and a coexisting second primary is imperative for planning appropriate treatment and defining the further outcomes.
Abstract Avoidable surgical complications account for a large proportion of preventable medical injuries and deaths globally. Surgical Safety Checklist is evidence-based, internationally accepted valid instrument, which has been found to reduce postoperative morbidity and mortality; the benefits of which are most striking in low- and middle-income countries (LMICs) Despite implementation in many hospitals throughout the country, there is still lack of awareness and concern in many LMICS health care facilities towards SSCL and its use, even after a decade of WHO checklist. We conducted a survey to assess the knowledge, attitudes and beliefs about the WHO-surgical checklist in which 65.4% (138) surgeons, 25.1% (53) anaesthetists and 9.5% (20) nurses participated. Majority believed that use of SSCL improves the safety of procedures, improves communication amongst theatre staff and will result in a reduction in errors in theatre yet there was no commitment for use of SSCL. Although all theatre personnel support implementation and use of SSCL however hierarchical issues, lack of administrative support, lack of training, logistics and timing, high patient volume and overburdened residents, lack of co-ordinator or leadership role and shortage of man power can be impediment to effective use. Nurses and junior doctors play a crucial role. Commitment rather than compliance and teamwork will be the key, ably supported by education and training which should be mandatory for all OT stake holders. Therefore, any measure that can potentially improve patient safety should be embraced and benefits of SSCL be told to motivate them and enhance participation for patient safety. Committed leadership, knowledge sharing and periodic trainings, interdisciplinary communication, feedback and regular audits can define and determine effective implementation process.
Twelve cases of Primary Thyroid Non-Hodgkin's Lymphoma (PT-NHL) were retrieved from the records suspected or diagnosed as NHL on fine needle aspiration cytology (FNAC) over a period of nine years from 2010-2018. During this period 5236 patients underwent thyroid FNAC;of these 685 cases were diagnosed under Bethesda Caregory V and VI. Thyroid NHL constituted 0.23 % of all thyroid FNA (12/5236 cases)and 1.7% (12/685) of all thyroid malignancies. Patients ranged in age from 40-61 years with Female:Male 7:5. All patients presented with thyroid enlargement (5-14 cms), and were of two months to five years duration. Patients had history of tobacco intake (smoking/chewing)in nine cases (75%). Thyroid function tests showed hypothyroidism in four (33%), positive antithyroid antibodies in three (25%) and; two cases(16.7%) were known cases of Hashimotos thyroiditis with follow up.Eight cases (66.7%) had monomorphic large cell morphology,other four had mostly intermediate cell types (33.3%). A panel of immunocyto/ histochemistry (ICC/ IHC) showed CD 19 and CD 20 positivity in all cases;sixof these could be correlated on Flow cytometry (FC) with expression of FMC7, CD20, CD19 with kappa light chain restriction (5) and Lambda (1). FC findings corroborated completely with IHC on biopsy sections. The final diagnosis were Diffuse large B cell Lymphoma (DLBCL,8) and MALT- Lymphoma(4). The follow up was available in DLBCL (4) and MALT- Lymphoma (1). CHOP therapy were given in all patients followed by radiotherapy in DLBCL; one patient of DLBCL died following pulmonary complications, rest are well and alive on follow-up.PT-NHL is rare in India. DLBCL is the commonest histological type reported. In the present study, tobacco exposure has shown strong association. Combined FNAC-FC provide definitive diagnosis and thus can replace histopathology reducing turn around time.FNAC -FC provides a definitive diagnosis and thus can reduce turnaround time.
Abstract This study evaluates the effectiveness of air purifiers in reducing the viral load of SARS-CoV-2 in the atmospheric air of rooms housing COVID-19 patients. Air samples were collected using an air sampler before and after the implementation of air purifiers equipped with high-efficiency particulate air (HEPA) filters. Additionally, swab samples were collected from various filters within the air purifiers to assess viral RNA presence. The results demonstrate the detection of SARS-CoV-2 RNA in particulate matter samples collected before air purification, indicating viral presence in the atmospheric air. Moreover, viral load was inversely correlated with the flow rate of the air sampler, with higher flow rates associated with increased viral load. Swab samples from air purifier filters revealed positive RT-PCR results for both the E-gene and RdRp gene of SARS-CoV-2, highlighting viral retention within the filtration system. Notably, the photo-catalyst oxidation filter demonstrated a reduction in viral RNA presence over time. Following air purification, SARS-CoV-2 RNA was undetectable in samples collected from the PVDF membrane filter at lower flow rates, while positive results were obtained at higher flow rates. These findings underscore the potential of air purifiers in reducing viral load and mitigating airborne transmission within healthcare settings. Further research is warranted to optimize air purification strategies and assess long-term efficacy in controlling viral dissemination.
Chemotherapy can be best used by understanding the principles of pharmacology, tumor biology, cellular kinetics and drug resistance. Here we try to focus on the major classes of chemotherapeutic drugs, their mechanisms of action, toxicities; and the therapeutic window.
There is no large contemporary data from India to see the prevalence of burnout in HCWs in covid era. Burnout and mental stress is associated with electrocardiographic changes detectable by artificial intelligence (AI). The present study aims to estimate the prevalence of burnout in HCWs in COVID-19 era using Mini Z-scale and to develop predictive AI model to detect burnout in HCWs in COVID-19 era. This is an observational and cross-sectional study to evaluate the presence of burnout in HCWs in academic tertiary care centres of North India in the COVID-19 era. At least 900 participants will be enrolled in this study from four leading premier government-funded/public-private centres of North India. Each study centre will be asked to recruit HCWs by approaching them through various listed ways for participation in the study. Interested participants after initial screening and meeting the eligibility criteria, will be asked to fill the questionnaire (having demographic and work related with Mini Z questionnaire) to assess burnout. The healthcare workers will include physicians at all levels of training, nursing staff and paramedical staff who are involved directly or indirectly in COVID-19 care. The analysis of the raw electrocardiogram (ECG) data and development of algorithm using convolutional neural networks (CNN) will be done by experts. In Summary, we propose that ECG data generated from the people with burnout can be utilized to develop AI-enabled model to predict the presence of stress and burnout in HCWs in COVID-19 era.
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