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COVID-19 has created additional challenges in mental health services, including the impact of social distancing measures on care and treatment. For situations where a detention under mental health legislation is required to keep an individual safe, psychiatrists may consider whether to conduct an assessment in person or using video technology. The Mental Health (Care and Treatment) (Scotland) Act 2003 does not stipulate that an assessment has to be conducted in person. Yet, the Code of Practice envisions that detention assessments would be conducted face to face in all circumstances. During the pandemic, the Mental Welfare Commission for Scotland, a statutory body with a duty to promote best practice of the Act, has been asked whether it may be acceptable and indeed preferable for some assessments to be conducted via video technology. Where an assessment is needed to determine if a patient needs to be detained, and where there is a need for social distancing or the need for ‘shielding’, remote assessments may in some circumstances be preferable. In this article, we outline the modification of the Mental Welfare Commission’s previous outright rejection of virtual assessments as the pandemic progressed and discuss the ethical and legal issues the possibility of remote assessments has exposed. We also discuss the limits and when a virtual assessment is not considered ethical. As the pandemic moves from a state of emergency into a ‘new normal’ in psychiatric services during second, or subsequent, waves, the use and place (if any) of remote assessments for detention needs to be considered.

Metabolic syndrome is a clinical entity characterized by abdominal obesity, atherogenic dyslipidemia, impaired glucose tolerance, and hypertension (HT). Despite various attempts at definition, the syndrome has remained mired in controversy over its components and utility. Insulin resistance and its association with risk of cardiovascular disease are discussed at length in this article.This review also discusses the controversies in the definition of this syndrome, the unique role of insulin resistance in its development, and the causes and implications of this clustering of risk factors characteristic to it, along with suggestions for a more comprehensive approach to this common problem.

Dyslipidemias are the most important coronary artery disease (CAD) risk factor. Proper management of dyslipidemia is crucial to control the epidemic of premature CAD in India. Cardiological Society of Indiastrived to develop consensus-based guidelines for better lipid management for CAD prevention and treatment. The executive summary provides a bird's eye-view of the ‘CSI: Clinical Practice Guidelines for Dyslipidemia Management’ published in this issue of the Indian Heart Journal.The summary is focused on the busy clinician and encourages evidence-based management of patients and high-risk individuals. The summary has serialized various aspects of lipid management including epidemiology and categorization of CAD risk. The focus is on management of specific dyslipidemias relevant to India-raised low density lipoprotein (LDL) cholesterol, non-high density lipoprotein cholesterol (non-HDL-C), apolipoproteins, triglycerides and lipoprotein(a). Drug therapies for lipid lowering (statins, non-statin drugs and other pharmaceutical agents) and lifestyle management (dietary interventions, physical activity and yoga) are summarized. Management of dyslipidemias in oft-neglected patient phenotypes-the elderly, young and children, and patients with comorbidities-stroke, peripheral arterial disease, kidney failure, posttransplant, HIV (Human immunodeficiency virus), Covid-19 and familial hypercholesterolemia is also presented. This consensus statement is based on major international guidelines (mainly European) and expert opinion of lipid management leaders from India with focus on the dictum: earlierthe better, lower the better, longer the better and together the better. These consensus guidelines cannot replace the individual clinician judgement who remains the sole arbiter in management of the patient.

The rising burden of cardiovascular disease (CVD) has made the achievement of optimal lipoprotein levels a major public health priority. As nearly a fifth of global mortality is associated with dietary factors, and recommendations have been mired in controversy, a fresh look on the available data is attempted. Well established concepts regarding nutrition and cardiometabolic health, role of macronutrients, calories, and controversial foods are discussed followed by recommendations in the Indian context. A healthy dietary pattern rather than individual foods or nutrients is emphasized, and this is generally plant based with optional consumption of dairy, eggs, and meats within the suggested limits. Suggestions/recommendations are given for consumption of individual foods, remembering that choosing appropriate replacement foods is as important as restricting unhealthy foods.

In ST-elevation myocardial infarction (STEMI), prehospital delay is a significant factor, decreasing likelihood of revascularization and increasing mortality. Prehospital delays are substantive in Indian patients with STEMI. Our study aimed to investigate factors associated with prehospital delay in patients with STEMI.

Aims and methodTo determine features associated with better perceived quality of training for psychiatrists on advance decision-making in the Mental Capacity Act 2005 (MCA), and whether the quality or amount of training were associated with positive attitudes or use of advance decisions to refuse treatment (ADRTs) by psychiatrists in people with bipolar disorder. An anonymised national survey of 650 trainee and consultant psychiatrists in England and Wales was performed.ResultsGood or better quality of training was associated with use of case summaries, role-play, ADRTs, assessment of mental capacity and its fluctuation. Good or better quality and two or more sessions of MCA training were associated with more positive attitudes and reported use of ADRTs, although many psychiatrists would never discuss them clinically with people with bipolar disorder.Clinical implicationsConsistent delivery of better-quality training is required for all psychiatrists to increase use of ADRTs in people with bipolar disorder.

The PANARrhythMia and Heart Failure Registry (PANARM HF) characterized demographic, clinical and interventional therapy indication profiles of cardiac arrhythmia (CA) and heart failure (HF) patients in India.

Aims and methodTo determine features associated with better perceived quality of training for psychiatrists on advance decision-making in the Mental Capacity Act 2005 (MCA), and whether the quality or amount of training were associated with positive attitudes or use of advance decisions to refuse treatment (ADRTs) by psychiatrists in people with bipolar disorder. An anonymised national survey of 650 trainee and consultant psychiatrists in England and Wales was performed.ResultsGood or better quality of training was associated with use of case summaries, role-play, ADRTs, assessment of mental capacity and its fluctuation. Good or better quality and two or more sessions of MCA training were associated with more positive attitudes and reported use of ADRTs, although many psychiatrists would never discuss them clinically with people with bipolar disorder.Clinical implicationsConsistent delivery of better-quality training is required for all psychiatrists to increase use of ADRTs in people with bipolar disorder.

Despite a paucity of supporting literature, acetazolamide is commonly used in critically ill children with metabolic alkalosis (elevated plasma bicarbonate pHco–3 and pH). The objective of this study was to assess the change in 18 hours after initiation of acetazolamide therapy.

Clopidogrel has been the only available antiplatelet drug used along with aspirin in patients of ACS. In recent years 2 new antiplatelet drugs (Prasugrel and Ticagrelor) have become available. Prasugrel in the dose of 10 mg OD has been found to be more efficacious but with increased risk of major bleeding. For this reason it has not gained widespread usage in ACS patients undergoing PCI. There are no systematic data on the use of Prasugrel in Indian population.

To report our experience with the use of IV enoxaparin in neonatal and pediatric patients in the ICU.

PA63, a proteolytically activated 63-kDa form of anthrax protective antigen (PA), forms heptameric oligomers and has the ability to bind and translocate the catalytic moieties, lethal factor (LF), and edema factor (EF) into the cytosol of mammalian cells. Acidic pH triggers oligomerization and membrane insertion by PA63. A disordered amphipathic loop in domain II of PA (2β2–2β3 loop) is involved in membrane insertion by PA63. Because conditions required for membrane insertion coincide with those for oligomerization of PA63 in mammalian cells, residues constituting the 2β2–2β3 loop were replaced with the residues of the amphipathic membrane-inserting loop of its homologue iota-b toxin secreted by Clostridium perfringens. It was hypothesized that such a molecule might assemble into hetero-heptameric structures with wild-type PA ultimately leading to the inhibition of cellular intoxication. The mutation blocked the ability of PA to mediate membrane insertion and translocation of LF into the cytosol but had no effect on proteolytic activation, oligomerization, or binding LF. Moreover, an equimolar mixture of purified mutant PA (PA-I) and wild-type PA showed complete inhibition of toxin activity both in vitroon J774A.1 cells and in vivoin Fischer 344 rats thereby exhibiting a dominant negative effect. In addition, PA-I inhibited the channel-forming ability of wild-type PA on the plasma membrane of CHO-K1 cells thereby indicating protein-protein interactions between the two proteins resulting in the formation of mixed oligomers with defective functional activity. Our findings provide a basis for understanding the mechanism of translocation and exploring the possibility of the use of this PA molecule as a therapeutic agent against anthrax toxin action in vivo.

Anthrax toxin consists of three proteins, protective antigen, lethal factor and oedema factor. A proteolytically activated 63‐kDa fragment of protective antigen binds lethal factor/oedema factor and translocates them into the cytosol. Domain II of protective antigen has been implicated in membrane insertion and channel formation. In the present study, alanine substitutions in 14 consecutive residues of the 2β1 strand that are highly homologous to the putative membrane interacting segment of Clostridium perfringensiota‐b toxin were generated and the effect on the biological activity of protective antigen studied. One of the mutants, Pro260Ala, showed considerably reduced toxicity in combination with lethal factor. The mutant also showed decreased membrane insertion and translocation of lethal factor into the cytosol. The data suggest that Pro260 is important for membrane insertion and translocation by protective antigen.

Anthrax toxin consists of three separate proteins, protective antigen (PA), lethal factor (LF), and edema factor (EF). PA binds to the receptor on mammalian cells and facilitates translocation of EF or LF into the cytosol. PA is the primary component of several anthrax vaccines. In this study we expressed and purified PA fromEscherichia coli.The purification of PA fromE. coliwas possible after transporting the protein into the periplasmic space using the outer membrane protein A signal sequence. The purification involved sequential chromatography through hydroxyapatite, DEAE Sepharose CL-4B, followed by Sephadex G-100. The typical yield of purified PA from this procedure was 500 μg/liter. PA expressed and purified fromE. coliwas similar to the PA purified fromBacillus anthracisin its ability to lyse a macrophage cell line (J774A.1). The present results suggest that a signal sequence is required for the efficient translocation of PA intoE. coliperiplasmic space.

ABSTRACTThe structural gene for the 90-kDa lethal factor (LF) isolated fromBacillus anthraciswas expressed as a fusion protein with six histidine residues in Escherichia coli. Expression of LF in E. coliunder the transcriptional regulation of the T5 promoter yielded a soluble cytosolic protein with an apparent molecular mass of 90 kDa, as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Recombinant LF reacted with anti-LF antibodies. The protein was purified to homogeneity by nickel nitrilotriacetic acid affinity chromatography and gel filtration on a Sephacryl S-200 column followed by anion exchange on a fast-performance liquid chromatograph with a Resource-Q column. The yield of purified LF from this procedure was 1.5 mg/liter. In solution, trypsin cleaved protective antigen bound to native and recombinant LF with comparable affinities. In macrophage lysis assays, native and recombinant LF exhibited identical potencies. The results suggest that large amounts of biologically active LF can be purified by this procedure.

We evaluated whether procalcitonin (PCT) might aid diagnosing serious bacterial infections in a general pediatric intensive care unit population. Two-hundred and one patients accounted for 332 PCT samples. A PCT ≥1.45 ngmL had a positive predictive value of 30, a negative predictive value of 93 and a sensitivity of 72 and a specificity of 75. These data suggest PCT can assist in identifying patients without serious bacterial infections and limit antimicrobial use.

To demonstrate the utility of rescue with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and to demonstrate the feasibility of administration of chemotherapy during VA-ECMO in a child with an anterior mediastinal mass.