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Wilson's disease is a genetic disorder characterized by abnormal accumulation of copper in the brain, liver, eye, and kidney. Various neuropsychiatric manifestations such as dystonia, parkinsonism, choreoathetosis, tremor, ataxia, personality disorders, mood changes, psychosis, cognitive abnormalities, sleep disorders, dystonia, tremor, ataxia, and seizures are known to occur in Wilson's disease. Status epilepticus is a very rare presentation of this disease. Here, we present a case of Wilson's disease occurring in an adolescent, who presented with refractory convulsive status epilepticus. His magnetic resonance imaging of the brain showed bilateral external capsular hyper intensities, with only subtle changes in other brain areas and the only clue to the presence of Wilson's disease was the presence of mildly deranged hepatic enzymes. The 24-h-urinary copper levels were subsequently found to be elevated in this patient.

We describe successful usage of low dose Tissue plasminogen activator (tPA) (30–50 mg) in three COVID19 critically ill patients, who were in worsening respiratory failure in-spite of being on therapeutic anticoagulation. All patients had respiratory rate > 40; FiO2 > 0.7(on NIV); PiO2/FiO2 ratio < 100 and D-dimer>1000 ng/ml. C.T. Pulmonary Angiography could not be done in these patients due to poor general condition, but 2D echo was normal and none of the patients was in shock. So there was no conventional indication of thrombolysis in these patients, yet after thrombolysis, we saw dramatic changes in oxygenation. All patients became off oxygen within 3–7 days and were discharged within 2 weeks. The whole idea was to prevent intubation, since mortality rates are very high in intubated COVID19 patients. tPA is associated with <1% risk of fatal bleed. In this unprecedented pandemic with high mortality rates, thrombolysis could be an effective and safe option in carefully selected critically ill patients of COVID19.

Bone repair and regeneration following an injury still present challenges worldwide. Three-dimensional (3D) scaffolds made from various materials are used for bone tissue engineering (BTE) applications. Polymers, minerals and nanotechnology are now being used in combination to achieve specific goals for BTE, including the delivery of antimicrobials through the scaffolds to prevent post-surgical infection. While several materials are utilised for BTE, natural polymers present a unique set of materials that can be manipulated to formulate scaffolds for BTE applications. They have been found to demonstrate higher biocompatibility, biodegradability and lower toxicity. Some even naturally mimic the bone microarchitecture, providing inherent structural support for BTE. Natural polymers may be simply classified as those from plant and animal sources. From both sources, there are different types of proteins, polysaccharides and other specialised materials that are already in use for research in BTE. Interestingly, these have the potential to revolutionise the field of BTE with a sustainable approach. In this review, we first discuss the different natural polymers used in BTE from plant sources, followed by animal sources. We then explore novel materials that are aimed at sustainable approaches, focusing on innovation from the last decade. In these sections, we outline studies of these materials with different types of bone cells, including bone marrow mesenchymal stromal cells (MSCs), which are the progenitors of bone. We finally outline the limitations, conclusions and future directions from our perspective in this dynamic field of polymers in BTE. With this review, we hope to bring together the updated existing knowledge and the potential future of innovation and sustainability in natural polymers for biomimetic BTE applications for fellow scientists, researchers and surgeons in the field.

Emphysematous pyelonephritis (EPN) is a potentially fatal infection of the kidney, predominantly affecting diabetic patients. Despite advances in management, predictors of mortality remain incompletely understood. Analysing the factors associated with a high risk of death can help in identifying high-risk EPN patients and initiating early, aggressive therapy. This study was conducted with the aim of understanding and describing the clinical, biochemical, and microbiological profile of patients diagnosed with EPN and analysing the factors influencing mortality.  A retrospective observational study was conducted at Kasturba Hospital, Manipal (2017-2022). Data from 117 EPN patients were collected and analysed for demographic, clinical, laboratory, microbiological, and radiological characteristics. Primary endpoints used were successful treatment and all-cause mortality to assess markers of mortality. Risk factors for mortality were assessed using independent samples t-tests. Statistical significance was set at p<0.05. A total of 117 patients were included in our study. The mean age was 55.5 years, with a female predominance (56.4%). The most common symptom reported was flank pain (77.8%). Diabetes mellitus (DM) was the most common risk factor identified in 96.6% of patients, and Escherichia coli (E. coli) was the most common isolated organism (54.7%). Most patients had Class 1 (33.3%) and Class 2 (28.2%) disease. The average duration of inpatient treatment was reported to be 17.25 days in our patients. Treatment included antibiotics (94%) and drainage procedures, including DJ stenting (55%). Of the 117 patients, mortality occurred in seven patients (6%). Elevated serum creatinine at admission was significantly associated with mortality (p=0.004), while other laboratory markers (hemoglobin A1c (HbA1c), total leukocyte count (TLC), platelet count, sodium) did not show a significant correlation. Serum creatinine at admission emerged as a key predictor of mortality in EPN, emphasizing the need for early renal function assessment and close monitoring in high-risk patients. The low mortality rate observed in our cohort suggests that early intervention combining empirical antibiotic therapy guided by resistance patterns and minimally invasive drainage techniques may improve survival. Future prospective studies are needed to validate these findings and refine EPN management strategies.

IntroductionPositional therapy has been described as add-on therapy to a mandibular advancement device, but the efficacy of combination of positional therapy and positive airway pressure (PPAP) has not been documented. We have found PPAP therapy as an effective method of titration in patients with difficult to treat OSA (obstructive sleep apnea).MethodologyThis retrospective analysis was done in patients who had difficult to treat OSA, i.e., in whom titration in the supine position was unacceptable with any PAP device (CPAP or bilevel PAP) and could only be successfully titrated with a PAP device in the lateral position. This study describes our experience of PPAP therapy. Baseline characteristics and polysomnography data of patients who were successfully titrated in supine v/s lateral positions were compared.ResultsOf 272 consecutive patients with OSA selected for analysis, 218 patients (191 and 27 with CPAP and bilevel PAP, respectively) could be successfully titrated in supine position. Further 54 (20%) patients in whom titration in supine position was unacceptable were titrated in lateral position. Patients titrated with PAP in the lateral position therapy group had higher BMI, higher neck and waist circumference, and lower awake sPO2 and nadir sPO2 during sleep, and spent more time in sleep with sPO2 < 90%.ConclusionCombination of positional therapy and PAP device is an effective way of titration for difficult to treat OSA patients. It can be tried in patients who fail titration in supine position.

The clinical and experimental data on seasonal variation in blood pressure is mainly from office and home blood pressure (BP) monitoring studies. There are few studies from temperate climates on seasonal changes with ambulatory blood pressure (ABP) monitoring and none from India. This is a prospective, observational study among healthy adults. ABP was measured in four different seasons in 28 subjects. Mean arterial pressure (MAP), ambulatory systolic blood pressure (SBP), and ambulatory diastolic blood pressure (DBP) were significantly higher in winter compared to summer season. 24-hour MAP was lowest in summer while highest MAP was recorded in winter (97.04 ± 8.30 and 103.89 ± 8.54, respectively). The mean difference was −6.86 mm Hg (95% CI: −10.74 to −2.97, p = 0.001). This difference was mainly due to increase in day time MAP. There was no difference in 24 h systolic and diastolic blood pressure between summer and winter. There was significant difference between summer and winter in the SBP (day time) [125.61 ± 11.44 and 131.93 ± 9.46, mean difference −6.32 (95% CI: −10.69 to −1.95, p = 0.005)] and DBP (day time) [79.57 ± 9.95 and 87.07 ± 9.9, mean difference −7.50 (95% CI: −12.49 to −2.51, p = 0.003)]. The night time systolic and diastolic BP was similar during winter and summer. Thus, BP increases significantly during winter compared to summer season. This change is primarily in the day time systolic, diastolic and mean blood pressures. Larger studies are required to further validate our findings.

Background Obstructive sleep apnea syndrome (OSAS) is a condition characterized by repeated episodes of partial or complete blockage of the upper airway during sleep, leading to disrupted breathing and poor sleep quality. In individuals with OSAS, blood oxygen levels can drop significantly due to repeated interruptions in breathing during sleep. The retina is highly sensitive to oxygen levels, and prolonged hypoxemia can contribute to retinal damage and worsen macular edema. Objective The study aims to correlate the effect of OSAS on the severity of macular edema as evaluated through optical coherence tomography (OCT) in patients with diabetic retinopathy and retinal vein occlusion. Additionally, the study seeks to assess treatment outcomes following anti-vascular endothelial growth factor (VEGF) therapy. It will also evaluate the relationship between subfoveal choroidal thickness (SFCT) and OSAS using enhanced depth imaging OCT. Methods Patients with macular edema secondary to diabetic retinopathy or retinal vein occlusion were identified through a complete ophthalmological examination and referred to pulmonology for level 1 polysomnography to diagnose concomitant OSAS. All patients received anti-VEGF ranibizumab for macular edema, with monthly follow-ups until the macular edema resolved (central macular thickness (CMT) less than 250 µm) or until three intravitreal ranibizumab injections were administered. All data were collected and analyzed. Results The study included 12 participants, with a mean age of 51.33 ± 14.16 years, a mean height of 163.41 ± 7.21 cm, and a mean weight of 65.08 ± 13.31 kg. Among the participants, 25% had mild OSAS, 50% had moderate OSAS, and 25% had severe OSAS. All participants showed improvement in visual acuity when comparing the first and third visits, with a p-value < 0.05 for the mild and moderate OSAS groups. The decline in CMT post-intravitreal ranibizumab was significant across all levels of OSAS, with a p-value < 0.05. The mean SFCT was reduced in all participants relative to normal age-matched controls; however, these results were not statistically significant. A weak positive correlation was observed between the apnea-hypopnea index and CMT, as well as between the oxygen desaturation index and CMT. Conclusions The study findings indicate that while there was no significant association between the severity of OSAS and CMT, there was a statistically significant improvement in visual acuity following anti-VEGF injections in patients with mild to moderate OSAS. In cases of severe OSAS, the improvement in vision was minimal and statistically insignificant. Additionally, the mean SFCT was significantly reduced in the study population compared to normal age-matched controls, but no significant differences were found when comparing the different severities of OSAS individually.

Background: Bronchoalveolar lavage (BAL) is a widely accepted investigative tool for the diagnosis of pulmonary lesions. This study was done to find out the usefulness of BAL in diagnosis of pulmonary lesions from central Indian patient population. Methods: A cross-sectional prospective study was performed over a period of three years. All the BAL specimens of patients presenting to Department of Pulmonary Medicine and Tuberculosis during a period of January 2017 to December 2019 were included in the study. Cyto-histopathologic correlation was done, wherever available. Results: Of total 277 cases, there were 178 (64.5%) males and 99 (35.5%) females. The age of patients ranged from 4 years to 82 years. In 92 (33%) cases, specific infective etiology could be identified on BAL cytology, the most common being tuberculosis (26%) followed by fungal infections (2%). Rarely, infections like nocardia, actinomycosis, and hydatidosis were also identified. Eight cases (3%) of malignancy were identified which included two cases of adenocarcinoma, one case of small cell carcinoma, three cases of poorly differentiated carcinoma, and two cases suspicious for malignancy. Some rare diagnoses like diffuse alveolar damage, pulmonary alveolar microlithiasis, and pulmonary alveolar proteinosis could be identified on BAL. Conclusion: BAL is useful in primary diagnosis of infections and malignancies of lower respiratory tract. BAL may aid in diagnostic workup of diffuse lung diseases. A combination of clinical information, high-resolution computed tomography, and BAL analysis may furnish an assured diagnosis to the clinician and obviate need for invasive procedures.