Publications by authors named "Surjit Singh"

476 Publications

Few concerns about evidence - feasibility and safety of performing cesarean myomectomy: a systematic review and meta-analysis.

Authors:
Surjit Singh

J Matern Fetal Neonatal Med 2021 Sep 1. Epub 2021 Sep 1.

Department of Pharmacology, AIIMS Jodhpur, Jodhpur, Rajasthan, India.

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http://dx.doi.org/10.1080/14767058.2021.1951210DOI Listing
September 2021

Recent advances in pediatric rheumatology: April to June 2021.

Int J Rheum Dis 2021 Aug 31. Epub 2021 Aug 31.

Pediatric Allergy Immunology Unit, Advanced Pediatrics Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.1111/1756-185X.14212DOI Listing
August 2021

BCG vaccination impact on mortality and recovery rates in COVID-19: A meta-analysis.

Monaldi Arch Chest Dis 2021 Aug 9. Epub 2021 Aug 9.

Department of Dentistry, All India Institute of Medical Sciences, Jodhpur.

COVID-19 is a pandemic caused by SARS-CoV-2 virus which is a very worrisome public health emergency. In this study, we compared the mortality rate and recovery rate in countries with and without BCG vaccination policy. The data of mortality of COVID-19 was extracted from worldometer (https://www.worldometers.info/coronavirus/) on 26th July 2020. The data of countries where BCG vaccination is being done for all individuals is taken from BCG world atlas (http://www.bcgatlas.org/index.php), updated in 2017. BCG vaccination policy recommended countries are intervention group versus countries without BCG vaccination policies which are regarded as control group. Pooled analysis of countries with and without BCG vaccination policy revealed mortality rate of 1.31% (95%CI - 1.31% to 1.32%; I2 = 100%, p<0.01) and 3.25% (95%CI - 3.23% to 3.26%; I2 = 100%, p<0.01), respectively. The recovery rate in two country groups were found to be 72.60% (95%CI - 72.57% to 72.63%) and 55.94% (95%CI - 55.90% to 55.98%), respectively. 52 individuals need to be BCG vaccinated to prevent one death (NNT = 52). In BCG vaccination program countries, there is statistically and clinically significant less mortality (p-value <0.001) as compared to countries without BCG policy. Our findings corroborate the hypothesis that BCG vaccination may provide protection from COVID-19. High quality evidence from randomised controlled trials are required to establish causality between BCG vaccination and protection from severe COVID-19.
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http://dx.doi.org/10.4081/monaldi.2021.1875DOI Listing
August 2021

Autoimmunity in Wiskott-Aldrich Syndrome: Updated Perspectives.

Appl Clin Genet 2021 20;14:363-388. Epub 2021 Aug 20.

Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Wiskott-Aldrich syndrome (WAS) is an uncommon X-linked combined-immunodeficiency disorder characterized by a triad of thrombocytopenia, eczema, and immunodeficiency. Patients with WAS are also predisposed to autoimmunity and malignancy. Autoimmune manifestations have been reported in 26%-72% of patients with WAS. Autoimmunity is an independent predictor of poor prognosis and predisposes to malignancy. Development of autoimmunity is also an early pointer of the need for hematopoietic stem-cell transplantation. In this manuscript, we have collated the published data and present a narrative review on autoimmune manifestations in WAS. A summary of currently proposed immunopathogenic mechanisms and genetic variants associated with development of autoimmunity in WAS is also included.
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http://dx.doi.org/10.2147/TACG.S213920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8384432PMC
August 2021

Abbreviated MRI in patients with suspected acute appendicitis in emergency: a prospective study.

Abdom Radiol (NY) 2021 Aug 11. Epub 2021 Aug 11.

Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, India.

Purpose: To determine the diagnostic performance of an abbreviated non-contrast MRI protocol in diagnosing acute appendicitis.

Methods: Prospectively, a total of 67 consenting consecutive patients with clinical suspicion of acute appendicitis (Alvarado score ≥ 5) were evaluated with an abbreviated three-sequence non-contrast MRI protocol (axial T2WI, coronal T2WI, axial DWI) at a single tertiary care center. MRI was interpreted by two radiologists blinded to the clinical details, other investigations, and outcome of the patients. Diagnostic performance of MRI was determined using either histopathological examination (HPE) results as the reference standard in surgical cases (n = 39), or final clinical diagnosis at discharge and 3-months follow-up in non-operatively managed cases (n = 28).

Results: Sixty-seven patients comprising 42 males, 25 females including 1 pregnant patient were enrolled (median age 24 years; age range 6-70 years). The median acquisition duration of the MRI protocol was 12.5 min. In the analysis of the complete cohort including both surgical and non-operatively managed cases (n = 67), MRI showed sensitivity of 93.3% (95% CI 81.7-98.6%), specificity of 86.4% (95% CI 65.1-97.1%), and diagnostic accuracy of 91.0% (95% CI 81.5-96.6%) (p < 0.001). In the subset of surgical cases with HPE as the reference standard (n = 39), MRI showed sensitivity of 97.1% (95% CI 84.7-99.9%), specificity of 100% (95% CI 47.8-100%), and diagnostic accuracy of 98% (95% CI 87.5-100%) (p < 0.001).

Conclusion: MRI may be performed to diagnose acute appendicitis or alternative causes of right iliac fossa pain. An abbreviated MRI protocol consisting of only three sequences without IV contrast, patient preparation, or antiperistaltic agents could shorten the examination duration while retaining diagnostic accuracy.
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http://dx.doi.org/10.1007/s00261-021-03222-5DOI Listing
August 2021

Madarosis in acute Kawasaki disease-an uncustomary accompaniment.

Clin Rheumatol 2021 Aug 11. Epub 2021 Aug 11.

Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.

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http://dx.doi.org/10.1007/s10067-021-05882-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8354682PMC
August 2021

Systematic review and meta-analysis of efficacy and safety of hydroxychloroquine and chloroquine in the treatment of COVID-19.

J Family Med Prim Care 2021 Jun 2;10(6):2126-2139. Epub 2021 Jul 2.

Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.

Repurposed drugs like hydroxycloroquine (HCQ) and chloroquine (CQ) are being tested for potential therapeutic role in COVID-19. We aimed to evaluate efficacy and safety of HCQ and CQ in COVID-19. Using PubMed, EMBASE, medRxiv, Google Scholar, clinicaltrials.gov, electronic search was carried out to identify relevant articles till June 2020 with re-evaluation in last week of November 2020. Observational and interventional clinical studies comparing efficacy of CQ or HCQ to standard management or other drug/s for SARS-CoV-2 infection patients were included. Cochrane review manager version 5.3 was used for synthesis of meta-analysis results. For randomized controlled trials, risk of bias was assessed using Cochrane Collaboration risk of bias assessment tool, version 2.0 (ROB-2). ROBINS-I was used for quality assessment of observational studies. Overall evidence quality generated by review was graded as per GRADE Recommendation. A total of 903 studies were screened. Nineteen studies were included in synthesis of meta-analysis with total of 4,693, 1,626, and 6,491 patients in HCQ/CQ, HCQ/CQ + AZ and control groups, respectively. HCQ/CQ treatment was associated with significantly increased rates of virological cure (OR = 2.08, 95%CI = 1.36-3.17; = 0.0007) and radiological cure (OR = 3.89, 95%CI = 1.35 - 11.23; = 0.01) compared to control. HCQ/CQ had no difference in unadjusted mortality rate (unadjusted OR = 0.98 95% CI = 0.70-1.37, = 0.89, random effect model) and adjusted hazard ratio for mortality (adjusted HR = 1.05, 95%CI = 0.86--1.29; = 0.64). However, a significant increase in odds of disease progression (OR = 1.77, 95%CI = 1.46-2.13; < 0.00001) and QT prolongation (OR = 11.15, 95%CI = 3.95-31.44; < 0.00001) was noted. The results with HCQ/CQ and azithromycin combination were similar to HCQ/CQ mono-therapy. In the light of contemporary evidence on effectiveness of HCQ/CQ, judicious and monitored use of HCQ/CQ for treatment of COVID-19 patients is recommended in low to middle income countries with emphasis on no mortality benefit. PROSPERO database: cRD42020187710.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_2338_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284216PMC
June 2021

Transient neutropenia in Kawasaki disease: Is it the disease, drugs or both?

Pediatr Blood Cancer 2021 Jul 21:e29242. Epub 2021 Jul 21.

Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

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http://dx.doi.org/10.1002/pbc.29242DOI Listing
July 2021

Deficiency of Adenosine Deaminase 2-a Monogenic Cause of Wunderlich Syndrome.

J Clin Immunol 2021 Jul 14. Epub 2021 Jul 14.

Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.

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http://dx.doi.org/10.1007/s10875-021-01097-1DOI Listing
July 2021

Clinical profile, long-term follow-up and outcome of juvenile systemic scleroderma: 25 years of clinical experience from North-West India.

Clin Exp Rheumatol 2021 Jul-Aug;39 Suppl 131(4):149-156. Epub 2021 Jul 6.

Allergy Immunology Unit, Department of Paediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Objectives: To describe the clinical profile, long-term follow-up and outcome of juvenile systemic scleroderma (JSSc) from a tertiary care referral hospital in North-West India.

Methods: A review of case records was performed and children with JSSc (disease onset <14 years of age) were analysed. Diagnosis was based on the Paediatric Rheumatology European Society/American College of Rheumatology/European League against Rheumatism provisional classification criteria for JSSc.

Results: Forty patients (28 girls and 12 boys; F:M ratio= 2.3:1) were diagnosed with JSSc (including 22 children with overlap) in the last 25 years. Mean age at symptom onset was 7.75±3.19 years with a mean delay in diagnosis of 2.275±2.09 years. Raynaud's phenomenon was seen in 26/40 (65%) patients at presentation. Lung involvement was noted in 40% patients. Methotrexate was the most commonly used therapy, followed by oral prednisolone. Patients without overlap had higher incidence of cutaneous ulcers as compared to patients with overlap (55% vs. 18%; p-value: 0.01). Patients with overlap required significantly higher oral prednisolone (81% vs. 22%), methotrexate (72% vs. 38%) and hydroxychloroquine (54% vs. 5%) while cyclophosphamide (13% vs. 44%) and azathioprine (9% vs. 44%) were used relatively less in this group. Mortality was 15% at a mean follow-up of 51.75 months. Infections were noted to be the most common cause of death. There was no significant difference in the mortality between patients with and without lung disease or patients with or without overlap.

Conclusions: We describe the largest single-centre cohort with longest follow-up of juvenile systemic scleroderma from India.
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August 2021

What Lies Ahead for Young Hearts in the 21 Century - Is It Double Trouble of Acute Rheumatic Fever and Kawasaki Disease in Developing Countries?

Front Cardiovasc Med 2021 24;8:694393. Epub 2021 Jun 24.

Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Rheumatic heart disease (RHD), the principal long-term sequel of acute rheumatic fever (ARF), has been a major contributor to cardiac-related mortality in general population, especially in developing countries. With improvement in health and sanitation facilities across the globe, there has been almost a 50% reduction in mortality rate due to RHD over the last 25 years. However, recent estimates suggest that RHD still results in more than 300,000 deaths annually. In India alone, more than 100,000 deaths occur due to RHD every year (Watkins DA et al., N Engl J Med, 2017). Children and adolescents (aged below 15 years) constitute at least one-fourth of the total population in India. Besides, ARF is, for the most part, a pediatric disorder. The pediatric population, therefore, requires special consideration in developing countries to reduce the burden of RHD. In the developed world, Kawasaki disease (KD) has emerged as the most important cause of acquired heart disease in children. Mirroring global trends over the past two decades, India also has witnessed a surge in the number of cases of KD. Similarly, many regions across the globe classified as "high-risk" for ARF have witnessed an increasing trend in the incidence of KD. This translates to a double challenge faced by pediatric health care providers in improving cardiac outcomes of children affected with ARF or KD. We highlight this predicament by reviewing the incidence trends of ARF and KD over the last 50 years in ARF "high-risk" regions.
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http://dx.doi.org/10.3389/fcvm.2021.694393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263915PMC
June 2021

Epigenetics in Kawasaki Disease.

Front Pediatr 2021 25;9:673294. Epub 2021 Jun 25.

Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Kawasaki disease (KD) is a common febrile multisystemic inflammatory illness in children that preferentially affects coronary arteries. Children with KD who develop coronary artery aneurysms have a life-long risk of premature coronary artery disease. Hypothesis of inherent predisposition to KD is supported by epidemiological evidence that suggests increased risk of development of disease in certain ethnicities and in children with a previous history of KD in siblings or parents. However, occurrence of cases in clusters, seasonal variation, and very low risk of recurrence suggests an acquired trigger (such as infections) for the development of illness. Epigenetic mechanisms that modulate gene expression can plausibly explain the link between genetic and acquired predisposing factors in KD. Analysis of epigenetic factors can also be used to derive biomarkers for diagnosis and prognostication in KD. Moreover, epigenetic mechanisms can also help in pharmacogenomics with the development of targeted therapies. In this review, we analysed the available literature on epigenetic factors such as methylation, micro-RNAs, and long non-coding RNAs in KD and discuss how these mechanisms can help us better understand the disease pathogenesis and advance the development of new biomarkers in KD.
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http://dx.doi.org/10.3389/fped.2021.673294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8266996PMC
June 2021

Reno-protective potential of sodium glucose cotransporter-2 (SGLT2) inhibitors: Summary evidence from clinical and real-world data.

Eur J Pharmacol 2021 Sep 8;907:174320. Epub 2021 Jul 8.

Dept. of Pharmacology, All India Institute of Medical Sciences, Jodhpur, 342005, India.

Type 2 diabetes mellitus is an independent risk factor for renal impairment, developing in due course to end-stage kidney disease (ESKD). Such progressive renal damage is related to an increased predisposition to cardiovascular events and mortality. Even with intensive glycemic control and use of nephro-protective renin angiotensin system (RAS) blockers, rise in the worldwide prevalence of diabetic kidney disease remains tenacious. Identifying drugs with potential to halt progressive renal damage is the pressing priority at present. Sodium glucose cotransporter 2 (SGLT2) inhibitors, by virtue of their glucose-lowering and additional pleotropic effects, such as weight reduction, blood pressure lowering, anti-inflammatory, anti-fibrotic effects etc. are postulated to affect systemic and intrarenal hemodynamic mechanisms in a favorable manner which ultimately contribute to beneficial processes in the kidney. The promising reno-protective efficacy of these drugs is further highlighted by a reduction in development/progression of albuminuria and stabilization of renal function associated with their use. In particular, recent cardiovascular and kidney disease focused outcome trials have effectively demonstrated reduced rates of ESKD and other hard renal end-points, including doubling of serum creatinine, renal transplantation, death due to renal causes etc. with SGLT2 inhibitors. In this review, we dig further deep into the proposed reno-protective benefit furnished by this class of drugs by summarizing the evidence generated from clinical trials and large real-world studies. Current guideline recommendations and probability of reno-protection being influenced by factors, such as diabetic status, baseline renal function, RAS blockade is also explored to discuss their intended use in clinical settings.
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http://dx.doi.org/10.1016/j.ejphar.2021.174320DOI Listing
September 2021

Computed tomographic age estimation from the pubic symphysis using the Suchey-Brooks method: A Systematic Review and Meta-analysis.

Forensic Sci Int 2021 Aug 29;325:110811. Epub 2021 Apr 29.

Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur 342005, India. Electronic address:

Forensic age estimation is routinely applied in investigations involving identification of individuals. Over the past century a myriad of methods have been devised for age estimation. One such method, proposed by Suchey and Brooks in 1990, groups the observed changes occurring in the pubic symphysis into six phases, each defined by a corresponding age range. The present study was piloted with the focussed question being to empirically determine the accuracy of the Suchey-Brooks method in computed tomographic age estimation by analysing morphological changes occurring in the pubic symphysis. Original articles pertaining to the use of the Suchey-Brooks method for CT based age estimation were extracted from four different databases- PubMed, CENTRAL, Google Scholar and ScienceDirect. Research papers which were answering the focussed question were selected for data analysis. After assessing the risk of bias of the selected articles, the data was subjected to Meta-analysis. Pooled analysis of correctly/accurately aged individuals/remains using the random and fixed effect models yielded a prediction percentage of 78% and 86%, respectively. Higher percentages were obtained for phase-wise and subgroup analysis, indicating that the Suchey-Brooks method is a reliable method for age estimation.
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http://dx.doi.org/10.1016/j.forsciint.2021.110811DOI Listing
August 2021

Tapering Doses of Methylprednisolone Pulse in the Treatment of Macrophage Activation Syndrome Associated with Systemic Juvenile Idiopathic Arthritis.

Indian J Pediatr 2021 Oct 1;88(10):1056. Epub 2021 Jul 1.

Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

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http://dx.doi.org/10.1007/s12098-021-03831-4DOI Listing
October 2021

Recent advances in pediatric rheumatology: January to March 2021.

Int J Rheum Dis 2021 Jul 27;24(7):966-969. Epub 2021 Jun 27.

Pediatric Allergy Immunology Unit, Advanced Pediatrics Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.1111/1756-185X.14159DOI Listing
July 2021

Efficacy and safety of remdesivir in COVID-19 caused by SARS-CoV-2: a systematic review and meta-analysis.

BMJ Open 2021 06 24;11(6):e048416. Epub 2021 Jun 24.

Department of Dentistry, All India Institute of Medical Sciences, New Delhi, India.

Objectives: Evaluation of remdesivir, an RNA polymerase inhibitor, for effectiveness in adults with COVID-19.

Data Sources: Electronic search for eligible articles of PubMed, Cochrane Central and clinicaltrials.gov was performed on 20 September 2020.

Participants And Study Eligibility Criteria: Only randomised controlled trials (RCTs) evaluating efficacy of remdesivir in COVID-19 were included for meta-analysis.

Interventions: Remdesivir was compared with standard of care.

Primary And Secondary Outcomes: Primary outcome was mortality and secondary outcomes were time to clinical improvement and safety outcomes like serious adverse events, respiratory failure.

Study Appraisal And Synthesis Methods: Data synthesis was done with Cochrane review manager 5 (RevMan) V.5.3. Cochrane risk of bias V.2.0 tool was used for methodological quality assessment. The GRADE pro GDT was applied for overall quality of evidence.

Results: 52 RCTs were screened and 4 studies were included in analysis, with total of 7324 patients. No mortality benefit was observed with remdesivir versus control group (OR=0.92 (95% CI 0.79 to 1.07), p=0.30, moderate quality evidence). Significantly higher rates of clinical improvement (OR=1.52 (95% CI 1.24 to 1.87), p<0.0001, low quality) and faster time to clinical improvement (HR=1.28 (95% CI 1.12 to 1.46), p=0.0002, very low quality) was observed with remdesivir versus control group. Significant decrease was found in the risk of serious adverse events (RR=0.75 (95% CI 0.62 to 0.90), p=0.0003, low quality); however, no difference was found in the risk of respiratory failure (RR=0.85 (95% CI 0.41 to 1.77), p=0.67, very low quality evidence) with remdesivir.

Conclusions: As per the evidence from current review, remdesivir has shown no mortality benefit (moderate quality evidence) in the treatment of COVID-19. From a cost-benefit perspective, it is our personal opinion that it should not be recommended for use, especially in low and lower middle income countries.

Trial Registration Number: PROSPERO registration number: CRD42020189517.
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http://dx.doi.org/10.1136/bmjopen-2020-048416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8228818PMC
June 2021

Antimicrobial resistance in Shigella species: Our five years (2015-2019) experience in a tertiary care center in north India.

Indian J Med Microbiol 2021 Jun 18. Epub 2021 Jun 18.

Division of Pediatric Allergy & Immunology, Head of Department, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, 160012, India. Electronic address:

Purpose: Shigella is the second leading cause of diarrhoeal mortality especially in children <5 years of age in African and Asian countries. Rapid changes are occurring in the epidemiology of shigellosis and Shigella are increasingly becoming highly drug resistant. To determine the serogroup distribution and antimicrobial resistance of Shigella isolated at our tertiary care centre in North India.

Methods: A retrospective study was conducted where demographic details along with antimicrobial susceptibility data of Shigella isolated from stool specimens from 1 January 2015 till 31 December 2019 were retrieved from records and analyzed by WHONET 2019 software.

Results: Shigella species was isolated in 1.31% (n = 137) of a total of 10,456 stool samples. Males predominated (n = 82; 59.8%) and majority of cases were admitted (n = 94; 68.6%). Children ≤5 years of age (n = 47; 34.3%) were the most commonly affected. Adults in the 21-40 age group contributed 27% of cases (n = 37). Overall, Shigella flexneri (n = 87; 63.5%) was the most common serogroup followed by non-agglutinable Shigella (n = 28; 20.4%) while Shigella sonnei (n = 12, 8.8%) and Shigella boydii (n = 9, 6.6%) fluctuated over the years. Shigella dysenteriae reappeared in 2019 after a hiatus of ten years. Overall, 45.3% (n = 62) of isolates were multidrug resistant to CLSI recommended drugs and high resistance was noted for ampicillin/amoxicillin (68.1%), cotrimoxazole (75.8%) ciprofloxacin (61.5%) and ceftriaxone/cefotaxime (45.2%).

Conclusions: Shigella have become highly drug resistant to fluoroquinolones and cephalosporins. Community based studies are required to truly assess the burden of AMR in India.
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http://dx.doi.org/10.1016/j.ijmmb.2021.06.002DOI Listing
June 2021

Muehrcke's lines in an adolescent boy with Kawasaki disease.

Clin Rheumatol 2021 Jun 16. Epub 2021 Jun 16.

Allergy Immunology Unit, Department of Pediatrics and Chief, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India, 160012.

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http://dx.doi.org/10.1007/s10067-021-05809-1DOI Listing
June 2021

Modified Taylor Retractor in Unilateral Subperiosteal Lumbar Microdiscectomy: A Frugal Alternative to the Tubular Retractor.

World Neurosurg 2021 08 19;152:44-55. Epub 2021 Jun 19.

Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India. Electronic address:

Objective: To do a comparative surgical outcome and cost-benefit analysis of our simple modified Taylor retractor with both open and tubular techniques in lumbar discectomy.

Methods: We retrospectively divided 52 lumbar disc patients operated by 2 different techniques between January 2019 and June 2020 into 2 groups- group 1 (n = 20): standard open macrodiscectomy (4-5 cm incision); group 2 (n = 32): unilateral translaminar microdiscectomy using our modified Taylor retractor with a small incision (18-20 mm, comparable to the tubular retractor). We compared both groups in terms of surgical outcomes and cost-benefit analysis. In addition, a cost-benefit comparison between our modified Taylor technique and that of the already published tubular microdiscectomy cohort was done.

Results: Complete symptom resolution occurred in 85% group 1 and 84.4% group 2 patients, with no difference in complication rates. Mean hospital stay was significantly less in group 2 (1.2 ± 0.37 days) as compared with group 1 (2.4 ± 1.15, P < 0.001). The mean total cost per patient was $2253.17 ± 69.16 in the modified Taylor microdiscectomy group compared with $2495.76 ± 214.85 (P < 0.001) in standard macrodiscectomy. Compared with the previously published tubular microdiscectomy cohort ($3069.91 ± 69.16), the modified Taylor retractor was $816.74 cheaper per patient with similar length of incision, surgical outcome, and hospital stay.

Conclusions: Similar clinical outcomes at decreased costs are obtained using the modified Taylor retractor compared with the tubular retractor. The modified Taylor retractor has a simple design, is user-friendly, and frugal alternative to the tubular retractor system for microscopic discectomy, especially in the resource-constrained countries.
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http://dx.doi.org/10.1016/j.wneu.2021.05.119DOI Listing
August 2021

Comparison of Conventional Technique versus Modified Tube First Technique of Awake Nasotracheal Fiber-optic Intubation: A Randomized Control Open-Label Trial.

Anesth Essays Res 2020 Jul-Sep;14(3):395-400. Epub 2021 Mar 22.

Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.

Background: Although the conventional awake fiber-optic nasal intubation is most commonly used in anticipated difficult tracheal intubation, it has several potential difficulties.

Aims: The aim of this study is to compare another technique modified tube first (MTF) technique with the conventional one in terms of time taken, ease of glottis visualization, number of attempts needed, and complications.

Settings And Design: This was a prospective, randomized, open-label trial conducted on 60 patients with an anticipated difficult airway undergoing oromaxillofacial surgery at a tertiary care center.

Materials And Methods: The patients were randomized into the MTF and conventional technique groups. Times from insertion of the fiber-optic scope into nares till vocal cord visualization (T1) and from T1 to complete intubation (T2) were measured and compared.

Statistical Analysis Used: Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software version 21.

Results: Time taken to visualize glottis was significantly less in the MTF technique as compared to the conventional method (mean ± standard deviation = 108.6 ± 43.1 vs. 142 ± 49.2 s, respectively, = 0.007). Similarly, the total time taken for nasotracheal intubation with modified technique is significantly less as compared to the conventional technique ( = 0.004). Furthermore, there is significantly better ease of glottis visualization ( = 0.001), higher success in minimal attempts ( = 0.02) with significantly lesser incidence of desaturation in MTF technique ( = 0.026).

Conclusion: The alternative technique (MTF) is a quicker, easier approach with higher success rate and lesser complications for the placement of an endotracheal tube in a difficult airway scenario.
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http://dx.doi.org/10.4103/aer.AER_104_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8159060PMC
March 2021

Diagnostic accuracy of semirigid thoracoscopy in exudative pleural effusions and relationship of thoracoscopic findings with probability of malignant diagnosis.

Monaldi Arch Chest Dis 2021 May 26. Epub 2021 May 26.

Department of Clinical Pharmacology, All India Institute of Medical Sciences (AIIMS), Jodhpur.

Semirigid thoracoscopy is increasingly becoming the procedure of choice for evaluation of undiagnosed exudative pleural effusions. Few studies have reported relationship of thoracoscopic appearances of pleural abnormalities and etiological diagnoses. We aimed our study to assess the diagnostic utility and safety of semirigid thoracoscopy for evaluation of patients with undiagnosed exudative pleural effusion. Further, we also pursued to find any relation of various thoracoscopic findings with the final diagnosis. We prospectively enrolled hospitalized patients with undiagnosed exudative pleural effusion who underwent semirigid thoracoscopy. Demographic, clinical and laboratory data along with data on thoracoscopic appearance of various pleural abnormalities and histopathological diagnosis of pleural biopsy specimens were collected and analysed. Semirigid thoracoscopy was diagnostic in 46 (N=55) patients (83.64%). Malignancy was diagnosed in 31 patients (56.36%), of which adenocarcinoma was the most common histopathological diagnosis (45.16%).  Sensitivity, specificity, PPV, NPV LR+ and LR- of thoracoscopy were 93.87%, 100%, 100%, 66.67%, 40.30 and 0.06, respectively. Pleural nodules, masses and hemorrhagic pleural fluid significantly increased the diagnosis yield of malignancy [OR= 37.16 (95%CI = 3.61-382.65),  =0.002]. The procedure related complications were mild and transient. Post- procedural pain (20%) was most commonly reported followed by dry cough (18.18%), sub-cutaneous emphysema (7.27%) and anaesthesia related complication (1.82%). Semirigid thoracoscopy is simple, safe and effective procedure in diagnosing exudative pleural effusion of unknown etiology with high diagnostic accuracy and minor procedure related complications. The likelihood of diagnosing malignancy is high if combination of pleural nodules, masses and hemorrhagic pleural fluid is present.
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http://dx.doi.org/10.4081/monaldi.2021.1554DOI Listing
May 2021

Toxicoepidemiology of poisoning exhibited in Indian population from 2010 to 2020: a systematic review and meta-analysis.

BMJ Open 2021 05 24;11(5):e045182. Epub 2021 May 24.

Pharmacology, AIIMS Jodhpur, Jodhpur, India

Objective: To determine the prevalence of pesticide, corrosive, drugs, venom and miscellaneous poisoning in India.

Setting: Systematic literature search was done in PubMed Central, Cochrane and Google Scholar databases for studies that satisfied the inclusion criteria. Systematic review and meta-analyses of all observational studies published in the English language from January 2010 to May 2020 were included in this review.

Participants: Patients exposed to poisoning reported to hospitals were included.

Primary And Secondary Outcome Measures: The prevalence of pesticide poisoning was analysed. The prevalence of poisoning due to corrosives, venom, drugs and miscellaneous agents, along with subgroup analysis based on age and region, was also determined. The percentage of persons with poisoning along with 95% CI was analysed.

Results: Pooled analysis of studies revealed that pesticides were the main cause of poisoning in adults, with an incidence of 63% (95% CI 63% to 64%), while miscellaneous agents were the main cause of poisoning in children, with an incidence of 45.0% (95% CI 43.1% to 46.9%), among those presenting to hospitals. Pesticide poisoning was the most prevalent in North India (79.1%, 95% CI 78.4% to 79.9%), followed by South (65.9%, 95% CI 65.3% to 66.6%), Central (59.2%, 95% CI 57.9% to 60.4%), West (53.1%, 95% CI 51.9% to 54.2%), North East (46.9%, 95% CI 41.5% to 52.4%) and East (38.5%, 95% CI 37.3% to 39.7%). The second most common cause of poisoning was miscellaneous agents (18%, 95% CI 18% to 19%), followed by drugs (10%, 95% CI 10% to 10%), venoms (6%, 95% CI 6% to 6%) and corrosives (2%, 95% CI 1% to 2%).

Conclusions: Pesticide poisoning is the most common type of poisoning in adults, while miscellaneous agents remain the main cause of poisoning in children.

Prospero Registration Number: CRD42020199427.
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http://dx.doi.org/10.1136/bmjopen-2020-045182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8149432PMC
May 2021

Reference Ranges of Different Lymphocyte Subsets in Indian Children: A Multi-Centric Study.

Indian Pediatr 2021 May;58(5):424-429

Indian Council of Medical Research, New Delhi, India.

Objective: To determine the reference ranges of various lymphocyte subsets in healthy Indian children.

Design: Descriptive cross-sectional study.

Setting: Four centers in India representing four geographical regions.

Participants: 1104 children from neonatal age to 18 years of age.

Measurement: One time measurement of absolute count and percentages of different lymphocyte subsets i.e. T lymphocytes (CD3+T, CD4+T, CD8+T cells), B lymphocytes (CD19+B cells) and Natural Killer lymphocytes (CD15/16+NK cells) in whole blood using multicolor flow cytometry.

Results: The absolute cell counts of various lymphocytes were found to increase from newborn to 10 months of age, followed by gradual decline until 18 years; however, the proportion of immune cells remained largely similar. Gender did not have a significant impact on the reference ranges, whereas counts were found to vary as per the geographical locations.

Conclusions: These reference ranges will be useful to monitor and predict the immune status in pediatric population. The variation in region wise ranges could be confirmed by testing more number of samples in the specific age groups.
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May 2021

Transformational Effect of COVID Pandemic on Postgraduate Programme in Oral and Maxillofacial Surgery in India-A Trainee Perspective.

J Maxillofac Oral Surg 2021 May 4:1-6. Epub 2021 May 4.

Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan India.

Background And Purpose: The purpose of the survey was to evaluate transformation in mode of teaching during the COVID pandemic on a postgraduate program in oral and maxillofacial surgery in India.

Methods: A standardised e-questionnaire was created on Google Forms™ and was shared using emails and WhatsApp™. A total of 103 postgraduate students of oral and maxillofacial surgery from different universities participated in this cross-sectional survey. The collected data were analysed using bivariate and multivariate analysis.

Results: A total of 95.1% of postgraduates in the survey believed that their overall regular speciality work was deprived during first 5 months of COVID. 90.3% participants accepted that webinar/online teaching program become more beneficial for their academics. But 78.1 % participants think that because of overburdening of these academic sessions, they have reduced the enthusiasm in attending them.

Conclusion: This survey highlighted the intense negative impacts of this pandemic on the postgraduate program from the eyes of the trainees themselves. This triggers us to hasten this process of medical education transformation in a way to cope with any such calamity with minimal consequences.
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http://dx.doi.org/10.1007/s12663-021-01582-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8095466PMC
May 2021

Wiskott Aldrich Syndrome: A Multi-Institutional Experience From India.

Front Immunol 2021 16;12:627651. Epub 2021 Apr 16.

Department of Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Background: Wiskott Aldrich syndrome (WAS) is characterized by bleeding manifestations, recurrent infections, eczema, autoimmunity, and malignancy. Over the last decade, improved awareness and better in-house diagnostic facilities at several centers in India has resulted in increased recognition of WAS. This study reports collated data across major primary immunodeficiency diseases (PID) centers in India that are involved in care of children with WAS and highlights the varied clinical presentations, genetic profile, and outcomes of patients in India.

Methods: Request to share data was sent to multiple centers in India that are involved in care and management of patients with PID. Six centers provided requisite data that were compiled and analyzed.

Results: In this multi-institutional cohort, clinical details of 108 patients who had a provisional diagnosis of WAS were received. Of these, 95 patients with 'definite WAS' were included Fourteen patients were classified as XLT and 81 patients as WAS. Median age at onset of symptoms of patients was 3 months (IQR 1.6, 6.0 months) and median age at diagnosis was 12 months (IQR 6,48 months). Clinical profile included bleeding episodes (92.6%), infections (84.2%), eczema (78.9%), various autoimmune manifestations (40%), and malignancy (2.1%). DNA analysis revealed 47 variants in 67 cases. Nonsense and missense variants were the most common (28.4% each), followed by small deletions (19.4%), and splice site defects (16.4%). We also report 24 novel variants, most of these being frameshift and nonsense mutations resulting in premature termination of protein synthesis. Prophylactic intravenous immunoglobulin (IVIg) was initiated in 52 patients (54.7%). Hematopoietic stem cell transplantation (HSCT) was carried out in 25 patients (26.3%). Of those transplanted, disease-free survival was seen in 15 patients (60%). Transplant related mortality was 36%. Outcome details were available for 89 patients. Of these, 37% had died till the time of this analysis. Median duration of follow-up was 36 months (range 2 weeks- 12 years; IQR 16.2 months- 70 months).

Conclusions: We report the first nationwide cohort of patients with WAS from India. Bleeding episodes and infections are common manifestations. Mortality continues to be high as curative therapy is not accessible to most of our patients.
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http://dx.doi.org/10.3389/fimmu.2021.627651DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086834PMC
September 2021

Skewed TCR Alpha, but not Beta, Gene Rearrangements and Lymphoma Associated with a Pathogenic TRAC Variant.

J Clin Immunol 2021 Aug 28;41(6):1395-1399. Epub 2021 Apr 28.

Paediatric Allergy Immunology Unit, Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education & Research, Sector 12, Chandigarh, 160012, India.

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http://dx.doi.org/10.1007/s10875-021-01047-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8316983PMC
August 2021

Chest-X-ray-Based Scoring, Total Leukocyte Count, and Neutrophil-to-Lymphocyte Ratio for Prediction of COVID-19 in Patients with Severe Acute Respiratory Illness.

Turk Thorac J 2021 Mar 1;22(2):130-136. Epub 2021 Mar 1.

Department of Surgical Oncology, All India Institute of Medical Sciences, Jodhpur, India.

Objective: This study aimed to use chest-X-ray (CXR)-based scores along with total leukocyte count (TLC) and neutrophil-to-lymphocyte ratio (NLR) in the prediction of coronavirus disease 2019 (COVID-19) in patients presenting with clinical features of severe acute respiratory illness (SARI).

Material And Methods: This is a retrospective study involving all patients who presented with clinical features of SARI and who had undergone bedside chest X-ray (CXR), hemograms with TLC, NLR, and reverse transcriptase-polymerase chain reaction (RT-PCR) at our institute from May 1 to June 30, 2020.

Results: Of 204 patients, 115 tested RT-PCR-positive and 89 tested negative. The patients who presented with SARI, using CXR-based score of 4 or more, TLC of less than 8,700 cells/μL, and NLR of <7 had a statistically significant area under the curve (p<0.001) for diagnosing COVID-19. The sensitivity and specificity of the CXR score was 80.8% and 73.0%, of TLC was 70.1% and 74.7%, and of NLR was 70.1% and 59.0%, respectively, in diagnosing COVID-19 alone. The specificity further increased to 90.4% when we used the CXR score with NLR and to 92.8% when we used the CXR score with TLC. The post-test odds ("rule in" disease) of a positive test for having the disease were 3, 2.77, and 1.71 times with the use of either CXR score, TLC, or NLR criteria, respectively; whereas, combined use of CXR score and NLR increased the post-test odds by 5.53 times, and combination of CXR score with TLC increased the post-test odds by 7.5 times.

Conclusion: CXR score with TLC and NLR can predict COVID-19 infection among those who presented with features of SARI. This may help in the early isolation of the patient until the RT-PCR report becomes available.
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http://dx.doi.org/10.5152/TurkThoracJ.2021.20239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051298PMC
March 2021

Spectrum of Systemic Auto-Inflammatory Diseases in India: A Multi-Centric Experience.

Front Immunol 2021 19;12:630691. Epub 2021 Mar 19.

Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Systemic autoinflammatory diseases (SAID) are rare inherited disorders involving genes regulating innate immune signaling and are characterized by periodic or chronic multi-systemic inflammation. To describe spectrum of clinical, immunological, molecular features, and outcomes of patients with SAID in India. Request to share data was sent to multiple centers in India that are involved in care and management of patients with Inborn Errors of Immunity. Six centers provided requisite data that were compiled and analyzed. Data on 107 patients with SAID were collated-of these, 29 patients were excluded due to unavailability of complete information. Twelve patients (15%) had type 1 interferonopathies, 21 (26%) had diseases affecting inflammasomes, 30 patients (41%) had non-inflammasome related conditions and 1five patients (19%) had Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA). Type1 interferonopathies identified in the cohort included patients with Deficiency of Adenosine Deaminase 2 ( (six patients; five families); STING-associated vasculopathy infantile-onset (SAVI) (three patients, one family); Spondyloenchondro-dysplasia with Immune Dysregulation (SPENCD) (two patients). Diseases affecting inflammasomes include Mevalonate Kinase Deficiency (eight patients); Cryopyrin-Associated Periodic Syndromes (CAPS) (seven patients); NLR Family, Pyrin domain-containing 12 NLRP12) (two patients); Familial Mediterranean fever (FMF) (two patients); Autoinflammation and PLCG-associated antibody deficiency and immune dysregulation (APLAID) (two patients). TNF receptor-associated periodic syndrome (TRAPS) (three patients); A20 haploinsufficiency (four patients); Deficiency of Interleukin 1 Receptor Antagonist (DIRA) (two patients) were categorized as non-inflammasome related conditions. There were significant delays in diagnosis Corticosteroids and other immunosuppressive agents were used for treatment as anti-IL-1 drugs and other biological agents were and still are not available in India. Eight (16.3%) patients had so far succumbed to their illness. This is the first nationwide cohort of patients with SAID from India. Clinical manifestations were diverse. Overlapping of clinical features with other relatively common rheumatological disorders often resulted in delays in diagnosis. More nationwide efforts are needed to enhance awareness of SAID among health care professionals and there is an urgent need to make targeted immunotherapies universally available.
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http://dx.doi.org/10.3389/fimmu.2021.630691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8017183PMC
March 2021

Nebulized Magnesium Sulphate in Bronchiolitis: A Randomized Controlled Trial.

Indian J Pediatr 2021 Mar 27. Epub 2021 Mar 27.

Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajathan, India.

Objective: To evaluate the efficacy and safety of nebulized magnesium sulphate as a bronchodilator in young children aged 1-24 mo with moderate to severe bronchiolitis in comparison to standard therapy.

Methods: This was an open labeled randomized controlled trial comprising 60 children with moderate to severe bronchiolitis which was randomly assigned to 2 groups. Intervention group received nebulization with 3 mL of 3.2% magnesium sulphate (MgSO) (iso-osmolar) every 4 hourly for 24 h in addition to standard care and the control group received standard care alone. The primary outcome measure was to compare the improvement of bronchiolitis severity score (BSS) and length of hospitalization. The secondary outcome was to measure the need for noninvasive ventilation, need for admission to intensive care unit (ICU) in the initial visit, to evaluate the safety of magnesium sulphate and need for clinic revisit, hospital readmission and ICU readmission within 2 wk after discharge in both the groups.

Results: The mean age of children allocated in the control group was 7.4 ± 5.1 mo and 7.7 ± 4.5 mo in the intervention group. There was no significant difference with respect to improvement of BSS or reduced length of hospitalization in both the groups (p > 0.05). BSS monitored sequentially after enrollment at 1, 2, 4, 8, 12, 16, and 24 h did not show statistically significant differences between the groups. Mean length of hospital stay was 2.89 ± 2.25 d in treatment group and 2.96 ± 1.86 d in control group (p = 0.902). No adverse events were observed in both the groups.

Conclusion: Nebulized magnesium sulphate is not superior to standard therapy in children with moderate to severe bronchiolitis.

Clinical Trial Registration Number: CTRI/2018/06/014400.
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http://dx.doi.org/10.1007/s12098-021-03695-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997787PMC
March 2021
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