Inadvertent Use Research Articles

A Case Series on COVID-19 Associated Mucormycosis (CAM): Experience from a Tertiary Care Centre in India

Aim: During the second wave of the COVID 19 pandemic, a life threatening fungal infection, mucormycosis have been detected in patients post COVID 19 disease. Commonly known as the ‘black fungus’ can causes tissue necrosis, inflammation and necrosis of the head and neck regions, paranasal sinuses, facial bones, orbits and it can also cause intracranial spread. In the current study we describe a series of cases of COVID 19 associated mucormycosis (CAM), the clinical presentations, risk factors, diagnosis, management and follow up experience from a tertiary care centre in India.
 Methods: This is a retrospective observational study conducted over a period of one year (April 2021 to April 2022) at our tertiary care centre. The diagnosis of COVID 19 was done by RT PCR (reverse transcription-polymerase chain reaction). The diagnosis of Mucormycosis was done by Histopathology and fungal cultures. The demographic details of the patients were retrieved from the medical records.
 Results: In the present study we report four cases of Rhino-orbital-cerebral Mucormycosis, three cases of Rhino-orbital Mucormycosis, two cases of Pulmonary Mucormycosis and one case of Disseminated Mucormycosis. All the patients had undergone extensive surgical debridement and received Liposomal Amphotericin B as initial antifungal medication and Posaconazole or Isavuconazole as step down therapy. Six patients responded to treatment while four patients did not have a favorable outcome and succumbed to the illness. 
 Conclusion: Mucormycosis is a deadly disease with high mortality and morbidity if not diagnosed and treated at an early stage. Factors like poor control of blood sugars, inadvertent use of corticosteroids, immune dysfunction due to COVID 19 can result in poor outcome of the disease despite aggressive treatment interventions.

The use of elevated ferritin levels in neonates and young infants as a screening lab for HLH

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory state due to primary genetic defect in T/NK cell cytotoxicity or secondary to infection, rheumatologic process, or malignancy. Activated macrophages/cytotoxic lymphocytes lead to elevated cytokines and T-cell activation. Ferritin is a screening tool, with levels >10,000 mug/L reported to be 90% sensitive and 96% specific for HLH. Its use in neonatal/early infancy hasn’t been specifically evaluated.In our retrospective case review we included patients 3 months or younger, treated in the past 5 years at our institution with an elevated ferritin >5000 mug/L. 20 patients were evaluated, demographic/diagnostic information seen in table 1. Average ferritin was 44 515 IQR (9922–54 853) Four patients, (20%) were diagnosed with primary HLH (pHLH), with non-HLH conditions including: 4 (20%) sepsis/infection, 4 (20%) with acute liver failure/galactosemia, 3 (15%) hematologic complications, and 5 (25%) without definitive diagnosis.All patients with HLH had splenomegaly and thrombocytopenia (< 100); 2 patients with pHLH had anemia (< 9), and 3 with ANC< 1000. Of those without HLH, 1 had splenomegaly, 9 with anemia, 6 with thrombocytopenia, and 1 with neutropenia. Soluble IL-2 receptor (sIL2R), a specific marker for T-cell activation was measured in 12 patients. pHLH patients had sIL2R levels >10 000 U/ml: pHLH average 31 432 (11 000–47 474), without pHLH average 2039 (1123–3161). sIL2R is more specific than ferritin but there are limitations (turn-around-time and locations performing). Figure 1 depicts ferritin/sIL2R levels in these groups.We utilized direct flow-based detection of T-cell activation markers for identification of HLH. As a proof of concept, patient 19 had fulminant HSV and a ferritin >200 000 mug/L. HLH diagnostic criteria were fulfilled, the T-cell activation profile was unremarkable (Figure 2). HLH treatment was not initiated; an unremarkable sIL2R result followed which validated our approach.A broad spectrum of etiologies drives high ferritin in neonatal/early infancy and can cause ferritin of >5000 mug/L. Thus, HLH 2004 criteria can be fulfilled in patients without pHLH resulting in inadvertent use of immune suppression. sIL2R and/or T-cell activation flow should be obtained when evaluating and initiating treatment for HLH. Further, genetic evaluation for other conditions is warranted in this patient population. [Display omitted] [Display omitted] Table 1(abstract: 128) Patient characteristics and information: laboratory values, genetics, and underlying diagnosis included.PatientPeak Ferritin (ng/ml)Large SpleenHgb (g/dL)Platelets (thou/ul)NCFibrinogen (mg/dl)SIL2R (units/ml)CXCL9 (pg/ml)PerforinCD107aGenetic FindingFinal DiagnosisCurrent Status127436+13.45042602761123N/ADecreasedLowNo definitive diagnosisUnknownAlive217491–10.43609700224N/N/AN/AN/ANon-contributoryABO incompatibilityAlive3106635–10809110132N/N/AN/AN/ANon-contributoryUnknownAlive482270–6.511540179N/N/AN/AN/AGALT, compound heterozygoteGalactosemiaDeceased59423N/A9.64010420621665N/AN/AN/AWES without definitive diagnosisUnknownAlive6150000+11.7632143024411,0006603N/ALowSTXBP2(homozygous)pHLHDeceased724304–11.91610480185N/AN/AN/AN/ANot collectedUnknownDeceased87494–8.841960603161N/AN/AN/APendingGalactosemiaAlive911412–9.1408770912144N/AN/AN/AWES without definitive diagnosisAcute liver failureAlive1014175–7.93721575173N/AN/AN/AN/ANo definitive diagnosisFulminant liver failureDeceased1117032–10.9332106023,000N/AAbsentPresentPRF1 (homozygous)pHLHDeceased12140000–5.52211880601644N/AN/AN/ANon-contributoryVitamin-K def hemorrhageDeceased139673–9.96992190216N/AN/AN/AN/ANon-contributoryCOVID-19 infectionAlive1410171–8.52952480N/2297N/AN/AN/ANot collectedViral hepatitisAlive155906–8.6103N/1081791N/AN/AN/ANot collectedCampylobacter bacteremiaAlive1614855+7.2101806844256325N/ALowRAB27A compound heterozygotepHLH, Griscelli SyndromeAlive179615–8.2263N/N/N/AN/AN/ALowIFIH1 heterozygous, pending further evaluationUnknownAlive1818730–7.61851940165N/AN/AN/AN/ANot collectedIntrauterine hydrops, secondary to Rh alloimmunization, liver failureAlive19>200000–6.3411400872493N/AN/AN/ATNFRSF13B HeterozygousHSV2 viremiaAlive2013675+6.8404506047474N/AN/ALowUNC13D, compound heterozygotepHLHDeceased

ATAGI Targeted Review 2022: Vaccination for prevention of herpes zoster in Australia

In November 2016, herpes zoster (HZ) vaccination for older adults, using the live-attenuated zoster vaccine (Zostavax; ZVL) was added to the Australian National Immunisation Program (NIP) with the aim of reducing morbidity from HZ and its complications, particularly for people at increased risk. Prior to the program, there were on average 5.6 cases of HZ per 1,000 persons annually in Australia, with highest risk of disease in older and in immunocompromised people. The burden of complications of HZ, such as post-herpetic neuralgia (PHN), was also highest in older and immunocompromised groups. No formal comprehensive program evaluation has been undertaken since program commencement. This review examined published literature and available vaccine administration data to summarise the evidence and considerations underpinning current use of HZ vaccines and potential future program directions in Australia. There have been modest reductions in the incidence of HZ and its complications since program introduction. However, five years into the program, challenges remain, including suboptimal vaccine coverage and significant safety concerns arising from inadvertent use of ZVL in immunocompromised people, who are contraindicated to receive this vaccine. This reduces opportunities to offset the burden of HZ-related disease. The recombinant subunit zoster vaccine (Shingrix; RZV), first registered in Australia in 2018, became available on the Australian market in June 2021. This vaccine has higher efficacy than ZVL and, as a non-live vaccine, can be used in both immunocompetent and immunocompromised people. RZV has potential to address the unmet needs of at-risk population groups. However, it has not yet demonstrated cost-effectiveness for inclusion as a funded vaccine under the NIP. The Australian HZ vaccination program has had limited effectiveness in meeting its aim in highest risk groups. Future options and challenges anticipated in using vaccination to reduce the burden of HZ and its complications are discussed in this review.

Teaching Neuro Images : The lentiform fork sign

A 63-year-old woman with type 2 diabetes mellitus on hemodialysis presented with subacute onset of slurred speech and difficulty walking after 1 week of inadvertent metformin use.

Natural language based malicious domain detection using machine learning and deep learning

Cyberattacks are still challenging since they are increasing day by day. Cybercriminals employ a variety of strategies to manipulate and exploit their targets vulnerabilities. Malicious URLs are one such strategy which is used to target large groups on various social media platforms. To draw internet users, these web addresses are disguised as being safe. Deliberate or inadvertent use of such URLs exposes the user or the organization in the cyberspace and opens the way for further attacks. Systems that use rules-based or machine learning algorithms to find malicious URLs usually rely on feature engineering. This requires domain expertise and experience. Sometimes, even after extracting features from a dataset, it may not completely leverage the potential of the dataset. The proposed method employs Natural Language Processing (NLP) approaches to vectorize the words in the URLs and applies machine learning and deep learning models for classification. Vectorization technique in NLP reduces the effort of feature engineering and maximizing the use of the dataset. For the experiment, two separate datasets are used. To vectorize the URL text, three different vectorization methods are used. To evaluate the performance of the proposed method, two different datasets (D1 and D2) that are regularly utilized in the research domain were used. The results demonstrate that the superior accuracy of 92.4 % with the D1 dataset is achieved by the Decision Tree (DT) with count vectorizer and the Random Forest (RF) with Term Frequency-Inverse Document Frequency (TF-IDF) vectorizer. With the D2 dataset, DT with TF-IDF vectorizer obtains a greater accuracy of 99.5 %. The Artificial Neural Network (ANN) model achieves 89.6 % accuracy with the D1 dataset and 99.2 % accuracy with the D2 dataset.

Dietary supplements could prevent cardiometabolic syndrome: Are they safe and reliable enough for disease prevention and health promotion?

Dietary supplements (DS) and their purchase is often based on a consumer's personal choice and advertisements. The associated DS regulations, particularly in manufacturing and marketing, are far more flexible and permissive than that of the well-regulated prescription pharmaceuticals. However, the adverse health effects associated with the inadvertent use of mega-doses of DS are not well understood. The demand for DS, nutraceuticals, and herbal remedies has experienced an upswing during the past two to three decades, and global product sales have thrived. More so, the prevention of cardiometabolic syndrome (CMS) and related disorders like diabetes mellitus, obesity, hypertension, and serum lipid abnormalities, as well as of other noncommunicable diseases (NCDs), is of highest health care priority globally, since these disorders impose very high economic burdens on health care systems and society. In this review, we argue why DS could prevent cardiometabolic syndrome, by providing the potential benefits and risks associated with them, especially self-medication considering their intake by the public at large. Good manufacturing practices and quality control are absolutely necessary for the manufacture of DS products, and proper labeling is needed regarding the optimal dose schedules of various DS and bioactive ingredients. Specific examples are used to underscore the indications and dosage recommendations made for the marketing and promotion of fish oil, coenzyme Q10, and Mg-containing products for the prevention of cardiometabolic syndrome.

Outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury stratified by Society for Vascular Surgery grade

ObjectivesAlthough the Society for Vascular Surgery (SVS) aortic injury grading system is used to depict the severity of injury in patients with blunt thoracic aortic injury, prior literature on its association with outcomes after thoracic endovascular aortic repair (TEVAR) is limited. MethodsWe identified patients undergoing TEVAR for BTAI within the VQI between 2013 and 2022. We stratified patients based on their SVS aortic injury grade (grade 1, intimal tear; grade 2, intramural hematoma; grade 3, pseudoaneurysm; and grade 4, transection or extravasation). We assessed perioperative outcomes and 5-year mortality using multivariable logistic and Cox regression analyses. Secondarily, we assessed the proportional trends in patients undergoing TEVAR based on SVS aortic injury grade over time. ResultsOverall, 1311 patients were included (grade1, 8%; grade 2, 19%; grade 3, 57%; grade 4, 17%). Baseline characteristics were similar, except for a higher prevalence of renal dysfunction, severe chest injury (Abbreviated Injury Score >3), and lower Glasgow Coma Scale with increasing aortic injury grade (Ptrend < .05). Rates of perioperative mortality by aortic injury grade were as follows: grade 1, 6.6%; grade 2, 4.9%; grade 3, 7.2%; and grade 4, 14% (Ptrend = .003) and 5-year mortality rates were 11% for grade 1, 10% for grade 2, 11% for grade 3, and 19% for grade 4 (P = .004). Patients with grade 1 injury had a high rate of spinal cord ischemia (2.8% vs grade 2, 0.40% vs grade 3, 0.40% vs grade 4, 2.7%; P = .008). After risk adjustment, there was no association between aortic injury grade and perioperative mortality (grade 4 vs grade 1, odds ratio, 1.3; 95% confidence interval, 0.50-3.5; P = .65), or 5-year mortality (grade 4 vs grade 1, hazard ratio, 1.1; 95% confidence interval, 0.52-2.30; P = .82). Although there was a trend for decrease in the proportion of patients undergoing TEVAR with a grade 2 BTAI (22% to 14%; Ptrend = .084), the proportion for grade 1 injury remained unchanged over time (6.0% to 5.1%; Ptrend = .69). ConclusionsAfter TEVAR for BTAI, there was higher perioperative and 5-year mortality in patients with grade 4 BTAI. However, after risk adjustment, there was no association between SVS aortic injury grade and perioperative and 5-year mortality in patients undergoing TEVAR for BTAI. More than 5% of patients with BTAI who underwent TEVAR had a grade 1 injury, with a concerning rate of spinal cord ischemia potentially attributable to TEVAR, and this proportion did not decrease over time. Further efforts should focus on enabling careful selection of patients with BTAI who will experience more benefit than harm from operative repair and preventing the inadvertent use of TEVAR in low-grade injuries.

Nuclear Weapons, Cyber Warfare, and Cyber Security: Ethical and Anticipated Ethical Issues

In this paper, we discuss the interrelationship of nuclear weapons, cyber warfare, and cyber security. Some of the most significant cyber threats to nuclear stability are now due to the intersection of technologies related to nuclear weapons and cyber technology. Cyber warfare can now be used to engage in and influence international events through cyber attacks upon nuclear systems and weapons. In the current war between Russia and Ukraine there has been the threat of the use of nuclear weapons. Since cyber warfare has already been employed in the Russia/Ukraine conflict it is possible that cyber attacks could be employed to trigger a nuclear event. To prevent cyber warfare from leading to nuclear warfare there needs to be a focus on cyber security in order to protect nuclear systems and nuclear arsenals but also to mitigate cyber attacks that could lead to the use of nuclear weapons.&#x0D; &#x0D; One of the main risks to nuclear weapons systems is sabotage. It is easy to imagine cyber attackers placing incorrect information into systems and even taking control of nuclear weapons. Various parts of nuclear weapons systems are capable of being targeted. Command and control systems, alert systems, launch systems, and target-positioning systems could all become targets. Scenarios in which alert systems are hacked and show a nuclear attack by adversaries, may lead to an accidental nuclear conflict. It is also conceivable that hackers could manipulate the coordinates of (pre-programmed) targets of nuclear missiles, or to spoof GPS-like systems that some missiles use to calculate their positions their targets. At the present time there is no evidence that any state or non-state actor is able to successfully perform such manipulations but considering the exponential rate of developments in the cyber arena, in the near future, such attacks might be possible. In the worst-case scenarios, these possibilities could lead to the inadvertent use of nuclear weapons, and/or use against unintended targets. In less dramatic scenarios, the perceived vulnerabilities of the nuclear weapons systems may affect nuclear stability. This could lead to a decrease in the deterrent value of nuclear weapons. This could come about because potential adversaries may think they have options to manipulate these weapons when being used. It is difficult to forecast the effects of decreasing nuclear deterrence.&#x0D; This analysis will define a stakeholder framework for identifying the ethical and anticipated ethical issues with cyber warfare and nuclear warfare and relate these issues to the importance of cyber security. Ethics should be at the center of the discussion of the use of nuclear weapons, nuclear warfare and cyber warfare. Moral concerns should be at the center of the discussion of nuclear warfare. The need for this moral concern is due to the threat to vulnerable populations by nuclear systems and nuclear weapons, as well as the threat posed to democratic institutions by the use of nuclear weapons.

Developmental programming of the neuroendocrine axis by steroid hormones: Insights from the sheep model of PCOS.

The reproductive neuroendocrine system is a key target for the developmental programming effects of steroid hormones during early life. While gonadal steroids play an important role in controlling the physiological development of the neuroendocrine axis, human fetuses are susceptible to adverse programming due to exposure to endocrine disrupting chemicals with steroidal activity, inadvertent use of contraceptive pills during pregnancy, as well as from disease states that result in abnormal steroid production. Animal models provide an unparalleled resource to understand the effects of steroid hormones on the development of the neuroendocrine axis and their role on the developmental origins of health and disease. In female sheep, exposure to testosterone (T) excess during fetal development results in an array of reproductive disorders that recapitulate those seen in women with polycystic ovary syndrome (PCOS), including disrupted neuroendocrine feedback mechanisms, increased pituitary responsiveness to gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH) hypersecretion, functional hyperandrogenism, multifollicular ovarian morphology, and premature reproductive failure. Similar to a large proportion of women with PCOS, these prenatally T-treated sheep also manifest insulin resistance and cardiovascular alterations, including hypertension. This review article focuses on the effects of prenatal androgens on the developmental programming of hypothalamic and pituitary alterations in the sheep model of PCOS phenotype, centering specifically on key neurons, neuropeptides, and regulatory pathways controlling GnRH and LH secretion. Insights obtained from the sheep model as well as other animal models of perinatal androgen excess can have important translational relevance to treat and prevent neuroendocrine dysfunction in women with PCOS and other fertility disorders.

Orthopedic Problems due to Overuse of Smartphones

Abstract Recent advances in technology have changed our lives dramatically, in many ways for the better. Increasingly, people are using their electronic mobile devices to stay connected to the digital world. However, overuse of handheld devices can lead to unintended problems involving the hand, wrist, and arm. The article summarizes and reviews the literature with the musculoskeletal problems and adverse effects that can occur by excessive and inadvertent use of a smart phone.

Recent trends in uropathogenic infections in patients of a tertiary care center, New Delhi, India, – a topic of urgent attention

ABSTRACT Urinary tract infections (UTIs) are the leading cause of outpatient visits and nosocomial infections worldwide resulting in increased healthcare costs. Information about the disease-associated pathogens and their susceptibility profile is of paramount importance for choosing antimicrobials and containing the alarming rise in microorganisms’ drug resistance. This study aimed to investigate the prevalence of gram-negative and gram-positive uropathogens in hospitalized adult patients, considering their sensitivity profile. The study retrospectively analyzed 2099 urine samples received from December 2019 to May 2020. The isolates were identified by standard microbiological methods, and sensitivity testing was done following the Clinical and Laboratory Standards Institute (CLSI) guidelines (2019). Out of the 2099 samples tested, 212 were positive. The vast majority of samples (97.6%) was received from women. Escherichia coli (34.9%) was the most common gram-negative pathogen, while Enterococcus spp. (15.1%) prevailed among gram-positive organisms. Among gram-negative organisms, a high susceptibility was observed for aminoglycosides (amikacin, netilmicin), nitrofurantoin, and carbapenems, while a high resistance was found towards co-trimoxazole, fluoroquinolones, and cephalosporins. We confirmed that nitrofurantoin, a traditional oral drug, still demonstrates good activity against uropathogens. Thus, there is an urgent need to study uropathogens and their susceptibility patterns to control the inadvertent use of antimicrobials and the spread of multidrug-resistant strains.

Paediatric Head Injury: Concordance between CT Findings and GCS Scores- A Retrospective Study in a Tertiary Care Hospital

Introduction: Computed Tomography (CT) remains the mainstay in the detection of traumatic brain injuries in children just as in the adult population. However, unnecessary and inadvertent use of CT in minor and less significant head injuries exposes children to harmful ionising radiation and subsequently increases the lifetime cancer risk. So, there is a need to use CT judiciously in cases of minor head injuries. The Glasgow Coma Score (GCS) can provide a comprehensive framework for proper stratification of neural impairment and head injury severity. Aim: To assess the concordance between CT scan findings and GCS scores in paediatric patients with acute Traumatic Brain Injury (TBI). Materials and Methods: This was a retrospective study of paediatric head injury cases who were referred to the Department of Radiodiagnosis, Mysore Medical College, Karnataka, India. from January 2021 to December 2021. The head CT of 110 patients was reviewed. Demographic details, mode of accident, CT findings, and GCS scores were collected from hospital records. Descriptive statistics were used and results were expressed in terms of frequency and percentages. Results: Out of 110 patients (mean age: 9.17±3.02 years) reviewed, males were 78 (71%) and females were 32 (29%). Road traffic accident was found to be the most common cause, i.e., in 71 patients (64.5%). The most common CT scan finding was fracture as seen in 12 cases. Out of 110 patients, 94 had mild injury according to GCS scores, 12 had a moderate head injury and four had a severe head injury. As the GCS scores decreased, the percentage of positive findings on CT increased. Conclusion: Percentage of positive CT findings was higher in the moderate and severe head injury category, where the role of CT scans in acute settings becomes valuable.

A study on demographic profile and predisposing factors of corneal ulcer in South India

To study the epidemiological characteristics and predisposing factors of infective corneal ulcer.: 222 cases fulfilling the inclusion criteria were recruited for the study. A standardised proforma was used to record demographic data like, age, sex, occupation, rural/urban background and relevant history like associated ocular and systemic disorders, history of corneal injury, previous treatment and duration of symptoms. Statistical analysis was done using SPSS 22 software for chi square test.: 222 cases of infectious corneal ulcer was enrolled to the study out of which 138 (62.16%) were males and 84 (37.83%) were females. Out of the total, 132 (59.45%) were hailing from rural and 90 (40.54%) were hailing from urban background. Mean age of presentation was 52.009 years with standard deviation 12.26. 45.44% were farmers. 21.62% patients were diabetic. Ocular trauma was the most common predisposing factor, which was present in 24.32% (n=54). There was statistically significant association between trauma with vegetative matter and fungal corneal ulcer (p=0.004). These findings are in consensus with the epidemiological characterstics and predisposing factors in our geographic zone. Large number of fungal keratitis is associated with agriculture based economy, inadvertent use of steroid drops which implies lack of awareness.

Extensive Striae Secondary to Inadvertent use of Topical Corticosteroids: Through the Dermoscope

Topical steroids form the mainstay of treatment of dermatological disorders. Unfortunately, these are also one of the most common drugs being abused by patients in our country. The present case showcases one of the more common side effects of overuse of topical corticosteroids, skin atrophy in the form of striae, with their dermoscopic characterization.

Detection of Deltamethrin Resistance in Cattle Tick, Rhipicephalus microplus Collected in Western Haryana State of India.

Out of 931 species of ticks, Rhipicephalus microplus is the most widely studied tick species due to its pivotal role in transmission of babesiosis and anaplasmosis, resulting in huge economic loss in cattle and buffalo's industry. Chemical control using deltamethrin forms the mainstay of tick control strategy because of high potency and low toxicity. However, inadvertent use of deltamethrin has led to the development of deltamethrin resistance in field ticks. The engorged female ticks were collected in a plastic container covered with a cotton plug from 10 places (Jarwa, Barwa, Khajakhera, Banisi, Nakipur, Dhangar, Badopal, Shivalya Dharamshala, Siwani and Meham) of five districts of western Haryana. The Larval Packet Test (LPT) was conducted for the characterization of resistance in field tick. In the present study, ticks were collected from 10 places from 5 districts of western Haryana and evaluated against deltamethrin using larval packed test. The LC50 values (confidence interval) of ticks larvae against deltamethrin collected from Nakipur, Dhangar, Barwa, Badopal, Shivalya Dharamshala, Siwani, Jarwa, Khajakhera, Meham and Banisi are 73.6 (67.2-81.9), 61.2 (61.6-98.5), 52.7 (14.4-101.0), 140.0 (86.7-448.6), 65.8 (37.1-95.2), 232.1 (201.0-304.7), 3.72 (0.20-9.87), 21.3 (12.0-31.6), 107.6 (96.8-127.6), 54.2 (43.4-58.4) ppm, respectively. The resistance factor ranges from 0.31 to 11.86, indicating variable resistance among field isolates. Data generated on deltamethrin resistance status in R. microplus from Haryana, India can be used as an indicator for the management of the species in the state.

Post-ROCM restrictive strabismus: A challenge for strabismus surgeon

Abstract Restrictive strabismus is characterized by extraocular motility restriction, which is confirmed by performing forced duction test. It can be congenital because of various syndromes or acquired after thyroid eye disease, after long-standing strabismus, after sinus surgery, or after trauma. Recently, we have faced a devastating epidemic of rhino-orbito-cerebral mucormycosis (ROCM) during the second wave of COVID-19 pandemic, which was treated by both surgical (sinus surgery) and medical (antifungal agents) modalities. Diabetes mellitus and the inadvertent use of systemic steroid were the leading risk factors for ROCM outbreak. India being the diabetic capital of the world favored this condition. We are reporting a challenging case of ROCM with diabetes mellitus, who presented to us with troublesome diplopia with extraocular motility restriction. He had a history of right-sided ROCM treated by sinus surgery and systemic antifungal agents 1 year back, followed by a good residual vision and restrictive strabismus leading to the symptoms. A previous history of sinus surgery and post-ROCM scarring and narrow surgical field posed a great challenge for strabismus surgery. In spite of all odds, a good postoperative alignment was achieved by a single-stage strabismus surgery, and the patient was asymptomatic after 3 months of follow-up.

Expressive Speech Acts in Political Discourse: An Integrative Approach Perspective

The article aims at analyzing of the contemporary political discourse modality that has acquired specific characteristic features of highly emotional utterances based on deliberate or unintended violation of political etiquette principles recently. The article’s generalized theorizing is illustrated by a sample of case study of invectives in political discourse. This analysis aims at distinguishing “agonal” signs (a deliberate use of invectives in speech) and pragmatic borrowings (inadvertent use of invectives) in their functioning, their pragma-semantic characteristics and discursive markers, which helps us in identification of both types of political discourse linguistic items. This research represents an integrative approach combining the Critical Discourse Analysis, the Political Discourse Semiotics Theory, the Role Theory, the Communication Theory, and others, in order to discover the actual reasons and consequences of these changes in the society in general, and in political discourse in particular.

Antimicrobial susceptibility pattern of an emerging multidrug resistant &lt;em&gt;Acinetobacter baumannii &lt;/em&gt;from intensive care units of a tertiary care hospital

Introduction: Acinetobacter baumannii is one of the most challenging gram negative, lactose non-lactose fermenting bacilli with ability to cause nosocomial infections and develop resistance to many classes of antibiotics. Multidrug-resistant (MDR) A. baumannii is a well known agent causing life-threatening infections with limited therapeutic options. In recent years, the numbers of reported carbapenem-resistant Acinetobacter spp. are increasing, which has further narrowed the treatment options and emerging as extensively drug resistant (XDR) strain. There are only a few effective drugs such as colistin, polymyxin B, and tigecycline. But given the side effects and cost effectiveness, treatment of resistant nosocomial infections by A. baumanii is the biggest challenge for clinicians and policy makers all over the world.Aim:1. To know the antibiotic susceptibility pattern of Acinetobacter baumnii2. To know the prevalence of multidrug resistant Acinetobacter baumanii in critical areas of our tertiary care centre.Methodology: Clinical samples from both critical and non critical areas were processed routinely. Only non lactose fermenting colonies were included for the study and Acinetobacter baumanii isolates were identified using standard culture method and antibiotic susceptibility testing done by disk diffusion method.Results: Of 308 NLFs, 160 were Acinetobacter baumanii. 106 (66.25%) samples were from ICU and 54 (33.75%) from non critical areas. Commonest sample was endotracheal secretion 72(45%) followed by blood 38(23.75) and others. 70% of our isolates were resistant to Aminoglycosides. Among Fluoroquinolones, maximum resistance was shown for Ciprofloxacin. 59% of the isolates were resistant to Piperacillin-tazobactum and their resistance to Cephalosporins ranged from 60-80%. 42 (39.62% of our isolates were Multidrug resistant (MDR) and 19 (17.92%) were extensively drug resistant (XDR).Conclusion: Multidrug resistant and extensively drug resistant strains of Acinetobacter baumanii are on the rise and slowly getting established in our healthcare set up especially the critical areas. Treatment options are very few and limited. Thus leaving us with call to take stringent measures to stop the inadvertent use of antibiotics and to review our infection control policies.

PARADIGM SHIFTS IN VITAMIN D TESTING AND DIAGNOSIS: A DECADE-LONG OBSERVATIONAL STUDY

Objective: Awareness about vitamin D deficiency has linearly increased over the years. Lack of clear guidelines regarding optimum dosage and inadvertent use of higher doses can lead to toxicity. This study was done to evaluate the changes in trends of vitamin D testing and status of serum levels of 25-hydroxy vitamin D (25-OHD) submitted for analysis to a large-volume reference laboratory. Material and Methods: An observational study was conducted at the section of Chemical Pathology, Department of Pathology and Laboratory Medicine, Aga Khan University. Data analysis of serum 25-OHD tests from January 2010 to December 2019 was performed. The patients were categorized as deficient, insufficient, optimal, hypervitaminosis or toxic based on 25-OHD values. Data was analyzed using Microsoft Excel version 16. Results: Total 903,282 tests were analyzed during the 10 years’ period Mean age (SD) was 40.7 (16.5) years, with 35.8% males. The 25-OHD testing since 2010 to 2019 increased by 62.3% in adults and 66.6% in children. The mean 25-OHD levels improved from 18.8 ng/ml in 2010 to 24.5 ng/ml in 2019 in adults, while no change in mean 25-OHD levels was noted in children. Conclusion: Testing and status of vitamin D improved with increased mean vitamin D levels and a decline in deficiency over 10 years. Our study calls for developing local guidelines for vitamin D-deficiency management, and taking caution when prescribing supplements, as vitamin D intoxication is concurrently increasing in the population. Key Words: 25OHD, Deficiency, Toxicity, Pakistan.

Radar-based monitoring system for medication tampering using data augmentation and multivariate time series classification

Inadvertent use of medication that has been tampered with can cause serious harm. Monitoring how and when medication was last used or touched is important for mitigating risks. In this paper, we present a new radar-based monitoring system that can detect eight different types of tampering methods with three types of medication containers. Our system works by using a FMCW and CW Doppler radar to capture motion speed, direction, and range, which we use for classifying activities. For monitoring activities at home, our system can be set up underneath a kitchen cabinet to monitor medication left out on the countertop. As our system uses radar, we can preserve privacy of individuals as the signatures from the radar are specific to the locations of the antennas and not necessarily associated with an individual. For classifying activities we created a processing pipeline that extracts a set of features from the raw multivariate time series signals from the radar. We then used three types of data augmentation techniques including jittering, scaling, and magnitude warping, to increase our data sets and increase our classification model accuracy. In addition, we evaluated our system using 5-fold cross validation and with different types of augmentation data sets. Our system can achieve 99% accuracy using a logistic regression classifier with multiple people.