Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare occurrence in systemic sclerosis (SSc) patients. AAV is an inflammatory disease that can lead to kidney failure due to the infiltration of mononuclear cells and the destruction of blood vessels. Also, crescentic glomerulonephritis (GN) has rarely been reported with coronavirus disease 2019 (COVID-19) and acute tubular injury is the most common renal pathology lesion in these patients. We present a rare case of a 46-year-old woman with SSc with new onset of renal failure after a recent diagnosis of COVID-19. Her serology was positive for p-ANCA and myeloperoxidase antibodies. Kidney biopsy was done and showed crescentic GN. We suggest during this pandemic, patients with an immunological disorder that are infected with COVID-19 be closely monitored for any organ involvement.

BackgroundThe R2CHADS2 is a new prediction rule for stroke risk in atrial fibrillation (AF) patients wherein R stands for renal risk. However, it was created from a cohort that excluded patients with advanced renal failure (defined as glomerular filtration rate of <30 mL/min). Our study extends the use of R2CHADS2 to patients with advanced renal failure and aims to compare its predictive power against the currently used CHADS and CHA2DS2VaSc.MethodsThis retrospective cohort study analyzed the 1-year risk for stroke of the 524 patients with AF at Metropolitan Hospital Center. AUC and C statistics were calculated using three groups: (i) the entire cohort including patients with advanced renal failure, (ii) a cohort excluding patients with advanced renal failure and (iii) all patients with GFR < 30 mL/min only.ResultsR2CHADS2, as a predictor for stroke risk, consistently performs better than CHADS2 and CHA2DS2VsC in groups 1 and 2. The C-statistic was highest in R2CHADS compared with CHADS or CHADSVASC in group 1 (0.718 versus 0.605 versus 0.602) and in group 2 (0.724 versus 0.584 versus 0.579). However, there was no statistically significant difference in group 3 (0.631 versus 0.629 versus 0.623).ConclusionOur study supports the utility of R2CHADS2 as a clinical prediction rule for stroke risk in patients with advanced renal failure.

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Osmotic demyelination syndrome (ODS) is a demyelinating disorder of the central nervous system. It usually occurs with rapid correction of severe chronic hyponatremia. ODS is rarely seen as a complication of hyperglycemia. Herein, we report a rare presentation of ODS secondary to hyperosmolar hyperglycemic state. A 28-year-old female with type 1 diabetes, hypertension, seizure disorder, and end-stage renal disease on hemodialysis was brought from a shelter with two days of unresponsiveness and developed ODS after hyperosmolar hyperglycemic state in long-standing uncontrolled diabetes with normal serum electrolyte levels.

Background & Aims: Brachial plexus block is a useful alternative to general anaesthesia. Postoperative analgesia is an added advantage. Buprenorphine, an agonist antagonist opioid has been used by various routes to prolong analgesia. The present study was undertaken to assess the analgesic efficacy of Buprenorphine with Bupivacaine in brachial plexus block. Methods: A prospective, randomized, double blind study was done on 60 adult patients of American Society of Anesthesiologists 1 and 2, aged between 18-50 years and scheduled for various upper limb surgeries. Patients were divided into two groups of 30 each. Group C (control group) received 38ml of inj. bupivacaine 0.25% +2ml normal saline and group B (Buprenorphine group) received 38ml of inj. bupivacaine 0.25% +2ml inj. Buprenorphine (preservative free) (0.3 mg). Patients were observed for onset and duration of motor block, onset and duration of sensory block, duration of pain relief and occurrence of any complications. Results: Post operative analgesia was significantly longer (901.33±60.04 min) in group B, as compared to group C (343.00±33.02 min) with p value <0.001. Duration of sensory block in group C was 322.16±31.80 min and in group B 647.83±55.70 min. with p value <0.001. Pain score was significantly low in group B (mean 1.44), compared to group C (mean 5.60) at 12 hours postoperatively. Conclusion: Addition of Buprenorphine 0.3 mg to 38ml of bupivacaine 0.25% for supraclavicular brachial plexus block prolonged sensory blockade and post-operative analgesia without increasing the risk of adverse effects.

Hyponatremia is one of the most common electrolyte imbalances in HIV patients. The differential diagnosis may include hypovolemic hyponatremia, syndrome of inappropriate antidiuretic hormone secretion (SIADH), and adrenal insufficiency. Here, we describe a case of hyponatremia secondary to cerebral salt wasting syndrome (CSWS) in an HIV patient with cryptococcal meningitis. A 52-year-old man with a history of diabetes and HIV was admitted for headache and found to have cryptococcal meningitis. He was also found to have asymptomatic hyponatremia. He had signs of hypovolemia, such as orthostatic hypotension, dry mucosa, decreased skin turgor, hemoconcentration, contraction alkalosis, and high BUN/Cr ratio. The laboratory findings revealed sodium of 125 mmol/L, potassium of 5.5 mmol/L, urine osmolality of 522 mOsm/kg, urine sodium of 162 mmol/L, and urine chloride of 162 mmol/L. We started normal saline for hypovolemia, each 1 L prior and after amphotericin therapy. However, hypovolemia did not improve significantly despite IV fluid. Cosyntropin stimulation test was negative, and renin level was 0.25 ng·mL·h, with the aldosterone level of <1 ng/dL, the serum brain natriuretic peptide of 15 pg/mL, and serum uric acid of 2.8 mg/dL. The diagnosis of CSWS was suspected, fludrocortisone was tried, and hypovolemia and hyponatremia improved. Cryptococcal meningitis in HIV patients can present with CSWS, and the distinction between CSWS and SIADH is important because the treatment for CSWS is different than that of SIADH. Both share a similar clinical picture except that CSWS presents with constant hypovolemia despite volume replacement. Salt tablets, normal saline, or fludrocortisone can be used for treatment.

Background: Laryngeal Mask Airways are increasingly being used now a day as an option to endotracheal intubation, as it is less invasive and causes less discomfort in the postoperative period. The aim of this study was to evaluate the clinical use of the laryngeal mask airway SupremeTM in patients undergoing elective gynaecological surgeries under general anaesthesia and compare it with endotracheal intubation.Methods: 60 ASA I and II females, having BMI <30kg.m-2 in the range of 20-50 years of age, scheduled for elective gynaecological surgeries were randomly allocated to one of the two groups according to the device used (LMAS or ETT). Time required for insertion, number of attempts, hemodynamic response to insertion/removal and incidence of immediate and late postoperative complications such as coughing, laryngospasm, sore throat, dysphagia etc. were assessed.Results: Number of attempts for successful insertion was similar but time required for LMA Supreme™ insertion was significantly less (25.40±12.90 versus 33.27±14.82 sec) similarly, time required for nasogastric tube insertion was significantly more in ETT group (30.28±16.22 versus 21.93±12.64 sec). No episode of failed ventilation or hypoxia was recorded. The changes in hemodynamic parameters were significantly higher after endotracheal intubation and during extubation. Incidence of postoperative complications was significantly higher after endotracheal intubation (p<0.05).Conclusions: The LMA Supreme™ is a suitable alternative to endotracheal intubation during general anaesthesia for elective gynaecological surgeries with the added advantage of less hemodynamic response during airway management and lower incidence of postoperative complications.

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