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Scrub typhus is a zoonotic disease caused by the bite of a mite Orientia tsutsugamushi, a bacterium from the Rickettsiaceae family, which is transmitted to humans by bite of trombiculid mite. Scrub typhus is widely spread all across India, and despite its vast occurrence, it remains underdiagnosed. The probable reasons could be the lack of specific symptoms, poor access to the diagnostic facilities, and low index of suspicion by the clinicians. It is a common trend to rule out the common causes of infection such as malaria, typhoid, and leptospirosis, and then, a good number of cases are ultimately diagnosed as scrub typhus. The common presentation is high-grade fever (98%), tender regional/generalized lymphadenopathy (40%–97%), hepatosplenomegaly, cough, and a characteristic eschar that is found in nearly 50% of cases, which represents the site of bite by the mite. Here, we present with a series of cases from Indore of scrub typhus with pulmonary complications which too were underdiagnosed. Immunoglobulin M typhus (enzyme-linked immunosorbent assay) confirmed the diagnosis, and all three were efficiently managed with doxycycline.

Obesity is a rapidly increasing pandemic, with almost one-third of the world population being affected. It has its impact on various systems, of which musculoskeletal system is also majorly affected. Its impact on rheumatoid arthritis and psoriatic arthritis are already known, but its association with ankylosing spondylitis is debatable and very few studies are being conducted to support its impact. The below article is a review of the association and impact of obesity on the disease activity, factors involved in its pathogenesis, impact on others underlying diseases, and therapeutic affections. This article also urges the need for the physicians to treat obesity as a separate disease condition which requires treatment like any other disease to improve the quality of life of individuals and to limit the progress of other diseases.

Significance Alu elements, comprising more than 10% of the human genome, propagate via retrotransposition. This genomic expansion requires enzymatic activity of L1 that reverse transcribes Alu RNA into Alu cDNA in the nucleus. We report Alu also undergoes L1-mediated reverse transcription via self-priming in the cytoplasm independent of retrotransposition, providing evidence of human DNA synthesis in this cellular compartment. This newly discovered shunt molecule in the Alu replication cycle also induces death of the retinal pigmented epithelium, a hallmark of atrophic age-related macular degeneration. A Big Data Archeology analysis of multiple health insurance databases reveals that use of FDA-approved nucleoside reverse transcriptase inhibitors is associated with protection against macular degeneration, identifying a repurposing candidate for this blinding disease.

A close association between periodontal disease (PD) and ankylosing spondylitis (AS) has long been speculated. Both diseases are characterized by dysregulation of the host inflammatory response, leading to further destruction of the soft and hard connective tissue. There is evidence of increased levels of tumor necrosis factor-alpha and various interleukins in both patients of AS and periodontitis. This study aimed to conduct a systematic review exploring the relationship between AS and PD. We searched MEDLINE & Embase databases (from their inception till October 2019) using appropriate combinations of the following search items with limits '(English, Human)': Ankylosing spondylitis, spondyloarthritis, spondyloarthropathies, spondyloarthritides, spinal disease, musculoskeletal disease, rheumatic disease and periodontitis, PD, periodontoses, parodontoses, chronic periodontitis, gum disease, gingivitis, oral health, dental health, plaque index (PI), bleeding on probing (BOP), probing pocket depth (PPD), and clinical attachment loss (CAL). This search was supplemented by the manual search of bibliographies of the selected articles and conference proceedings of the European League against Rheumatism. Only the reviews and observational studies of cross-sectional, cohort, or case-control type on adult patients with AS were selected. Data were extracted from a predesigned PROforma. A total of 984 articles were identified, and 12 were selected for a detailed appraisal. All the identified studies were of the case-control type. The prevalence of periodontitis ranged from 38% to 88% in patients with AS and 26% to 71% in the control group. Of the 12 studies, 2 showed significant changes in PI, 2 showed altered PPD, 3 showed significantly increased CAL, and 2 showed increased BOP. In 7 studies, periodontitis was seen in a significant number of patients with AS (p

Autoimmune connective tissue diseases possess difficulty in diagnosis and treatment due to uncertainty in etiology, a wide array of clinical presentation, and unpredictable disease course. Many such diseases like Sjogren syndrome, Rheumatoid arthritis, Systemic Lupus Erythematosus, Systemic Sclerosis, have characteristic oral findings, the identification of which may allow for early diagnosis and treatment. For the purpose of this narrative review we searched the databases such as MEDLINE the Embase and Cochrane library using search terms including “rheumatic” “autoimmune,” “connective tissue diseases,” “dental,” “oral,” and “manifestations” and the names of individual known diseases and also a manual search of bibliographies of these articles and of previously published reviews and animal studies. In this review, we describe the oral manifestation and dental considerations associated with these diseases which will allow the practitioner in holistic management of these patients.

BACKGROUND: Total knee replacement surgery is among the most common major orthopedic surgery performed in cases of osteoarthritis on the knee joint. Total knee arthroplasty is considered to cause moderate-to-severe postoperative pain. No clear consensus in the available literature suggests a clear advantage between epidural tramadol and intravenous tramadol postoperatively due to the complications associated with an epidural catheter. AIM: This study aimed to determine the effectiveness of epidural tramadol and intravenous tramadol in pain relief and functional recovery in postoperative total knee replacement patients. MATERIALS AND METHODS: All cases operated for total knee replacement and postoperatively managed by epidural tramadol and intravenous tramadol were studied. This group included 20 patients of total knee replacement managed by epidural tramadol compared to 20 patients of total knee replacement managed by intravenous tramadol. RESULTS: Patients in the group managed postoperatively with intravenous tramadol for postoperative pain management showed a better functional outcome and pain relief as compared to patients managed with epidural tramadol. It was noted that in patients managed with intravenous tramadol, the knee range of motion and static and dynamic quadriceps exercises were started earlier and the patients were more compliant, which intern helped to achieve a better functional outcome posttotal knee replacement surgery. CONCLUSION: We would like to suggest in our limited 40 patient study group, the pain managed in patients by intravenous tramadol showed a better functional outcome as compared to the pain managed in the patients by epidural tramadol. Within our study group of 40 patients, it was noted that patient compliance and comfort was better in cases where tramadol was administered through an intravenous line as compared to an epidural catheter with no statistically significant difference in postoperative pain as well as functional outcome and recovery.

Introduction: Among the vasopressor Dopamine and Norepinephrine are most widely used. Till date there is a continuing controversy about whether one agent is superior to the other. Method: This was a prospective randomized trial conducted in a 12 bedded ICU at a tertiary care center from 1st August 2014 to 31stAugust 2015 a total of 1046 patients requiring a vasopressor were randomized, received either Dopamine or Norepinephrine as the first drug of choice to maintain target Mean arterial Pressure.The outcome of the trial at the end was the rate of death at 28 days. Further at the end we would also see the adverse events due to drug and mortality during ICU stay and number of days stay in the ICU and hospital. Result: In the study 521 were assigned to receive Dopamine and 525 were assigned to receive Norepinephrine. The 28 days mortality in Dopamine arm was 51.6% (269/521) and in Norepinephrine arm was 47.2 % (248/525). Arrhythmias was seen more in Dopamine arm (26.12%) compared to Norepinephrine arm (14.40%). Mortality during ICU stay was more in patients who receive Dopamine (51.6%) then to patients who receive Norepinephrin (46.1%) although this difference was not statically significant (P-value >0.05). Further the length of stay in ICU and in hospital was more in patients who received Dopamine (59.20%) than Norepinephrin (57.30%) but it was statically not significant (P-value >0.05). Conclusion: Dopamine when compared with norepinephrine in this study was associated with more arrhythmias and with an increased rate of death in the subgroup of patients with cardiogenic shock. Although the rate of death did not differ significantly between the group of patients treated with dopamine and the group treated with norepinephrine.

Innate immune signaling through the NLRP3 inflammasome is activated by multiple diabetes-related stressors, but whether targeting the inflammasome is beneficial for diabetes is still unclear. Nucleoside reverse-transcriptase inhibitors (NRTI), drugs approved to treat HIV-1 and hepatitis B infections, also block inflammasome activation. Here, we show, by analyzing five health insurance databases, that the adjusted risk of incident diabetes is 33% lower in patients with NRTI exposure among 128,861 patients with HIV-1 or hepatitis B (adjusted hazard ratio for NRTI exposure, 0.673; 95% confidence interval, 0.638 to 0.710; P, Inflammasome activation may contribute to type 2 diabetes, but whether targeting inflammasome is beneficial is unclear. Here the authors show that repurposing nucleoside reverse transcriptase inhibitors for inhibiting inflammasome activation is associated with reduced diabetes development in people and improves insulin sensitivity in experimental settings.

We have read the recent report by Mathian et al with great interest where they described the clinical course of COVID-19 in 17 patients with systemic lupus erythematosus (SLE).1 The COVID-19 pandemic has caught the attention of the rheumatology fraternity due to a variety of reasons, such as the in vitro inhibition of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by hydroxychloroquine (HCQ),2 use of tocilizumab in the treatment of cytokine storm3 and concerns regarding cardiac toxicity due to HCQ.4 Patients with SLE are routinely prescribed HCQ and other immunosuppressants. The clinical picture of COVID-19 (such as pneumonia, cardiac injury, renal injury, venous thrombosis and septic shock) in patients with SLE on long-term HCQ described by Mathian et al intrigued the global rheumatology community.1 We assessed the impact of the pandemic on Indian patients with SLE in a larger multicentric survey. We expected that differences in disease expression, ethnicity and treatment may possibly alter the impact of the pandemic in contrast to the aforementioned study. We included patients who had visited their …

Background:A close association between periodontal disease and Ankylosing spondylitis (AS) has long been specualted. Both diseases are characterized by dysregulation of the host inflammatory response, leading to further destruction of soft and hard connective tissue with there being evidence of increased levels of TNF-α and various interleukins in both patients of AS and periodontitis.Objectives:The aim of this systematic review was to appraise the available literature exploring the relationship between AS and periodontal disease.Methods:We searched Medline & Embase databases (from their inception till October 2019) using appropriate combinations of following search items with limits ‘(English, Human)’; Ankylosing spondylitis, spondyloarthritis, spondyloarthropathies, spondyloarthritides, spinal disease, musculoskeletal disease, Rheumatic disease AND periodontitis, periodontal disease, periodontoses, parodontoses, chronic periodontitis, gum disease, gingivitis, oral health, dental health, plaque index, bleeding on probing, probing pocket depth, clinical attachment loss. This search was supplemented by the manual search of bibliographies of articles selected and conferences proceedings of EULAR. Only be reviews, observational study of cross-sectional, cohort or case control type on adult patients with AS were selected. Data was extracted from a predesigned proforma. A close association between periodontal disease and Ankylosing spondylitis (AS) has long been specualted. Both diseases are characterized by dysregulation of the host inflammatory response, leading to further destruction of soft and hard connective tissue with there being evidence of increased levels of TNF-α and various interleukins in both patients of AS and periodontitis.Results:A total number of 984 articles were identified and 12 were selcted for detailed appraisal (Figure 1, PRISMA flow chart). They were all case control studies. The prevalence of periodontitis ranged from 38% to 88% in patients with AS whereas in the control group from 26% to 71 % in controls. Out of 12 studies, two showed significant changes in Plaque Index (PI), two studies showed altered Pocket Probing Depth (PPD), three showed significant increased in Clinical Attachment Loss (CAL) and increased Bleeding On Probing (BOP) was seen in 2 studies. In 7 studies, periodontitis was seen in a significant number of patients with AS (PConclusion:Our systematic review found an association between AS and periodontal disease. Patients with AS show higher prevalence of periodontitis and a poor oral hygiene as compared to healthy controls. At practice level, this systematic review underscores the need for a collaboration between dentists and rheumatologist.Disclosure of Interests:None declared

Background Chikungunya virus is an alphavirus, family Togaviridae. Chikungunya fever is a mosquito born disease transmitted to humans by the bite of infected Aedes aegypti mosquitoes. An outbreak of chikungunya virus is currently ongoing in many Asian countries since January 2005. The recent outbreak and epidemic of Chikungunya fever in our state reflect the survival capability and tenacity of mosquitoes that continues to be man’s biggest foes.An Observational study was conducted to evaluate epidemiological, virological and clinical features of chikungunya fever in patients presenting with acute febrile illness in our state of madhya pradesh. Objectives To observe the clinical features and laboratory parameters of patients coming with Chikungunya coming to our referral setup during the three months of epidemic presenting from 1 st July to 30th September 2017. Methods We included all patients(n=325) presenting to us from age 16 years with acute history( Results We included 325 patients in which Males(M) were 140 and Females(F) were 185, F:M ratio of 1:0.75). The distribution of patients according to age was quite similar across all age groups. Small joints involvement in total of 287 patients (M:40.4%,F:59.6%), axial involvement in 219 patients (M:36.1% and F:67.6%), knee joint involvement in 285 patients (M:41.1% and F:58.9%), ankle pain in 285 patients(M:42.8% and F:57.2%), early morning stiffness was seen in 308 patients (M:44.8% and F:55.19%), eyes involvement in 53 patients (M:35.8% and F:64.2%), Neurological manifestations in 134 patients (M:43.3% and F:56.7%), stomatitis and oral ulcers in 85 patients (M:45.9% and F:54.1%), retrobulbar pain occurred in 73 patients (M:45.2% and F:54.8%), rashes were seen in 47 patients (M:59.6% and F:40.4%). Forty two patients(12.9%) had history of Diabetes(F:73% and M:26%) and 31 patients(9.5%) were hypothyroid with female predominant(100%). Urea and creatinine was also raised(n=18). Rheumatoid factor was positive in 19 patients (M:42.1% and F:57.9%). IgM Chikungunya was positive in 202 patients (M:46.04% and F:53.96%), and out of those 65 patients in which it was negative, we did RT-PCR in 18 patients due to unaffordability being a major factor and we found that RT-PCR came out positive in 15 patients. The mean ESR in males was 41.76±19.98, in females it was 53.66±24.66, mean CRP in males was 29.84±19.61 and in females it was 40.74±25.94. Conclusions We conclude that Chikungunya is a multisystem disease affecting both genders. In our setup, we observed it affected females more and seropositivity for chikungunya was seen in around half of the patients presenting with signs and symptoms. PCR test is more reliable for confirmation. Skin rashes with neurological symptoms, severe pain causing disability and dependence on others for personal care were main complaints. No mortality was reported in our study. Disclosure of Interest None declared

Aim: Understanding the impact of smoking on the development and severity of ankylosing spondylitis (AS) is pivotal, as it affects the management of the disease. This study investigated the effect of smoking in patients with AS and its outcome on the disease. Methods: This was a cross-sectional study from September 1, 2018, to November 30, 2018, in a rheumatology outpatient department enrolled patients aged >18 years diagnosed with AS and divided into two groups according to their smoking status. Demographic details and hematological and biochemical parameters were noted. Modified Schober's test, chest expansion, and duration of disease measurements were performed. Disease activity and functional state were evaluated using the Bath AS Disease Activity Index (BASDAI) and Bath AS Functional Index (BASFI). Results: A total of 48 patients were enrolled (smoker, n = 20; nonsmoker, n = 28). The mean age in smoker and nonsmoker groups was 39.40 years and 26.18 years, respectively, and male preponderance was observed; the mean duration of disease was 42.90 months and 43.14 months, respectively. BASDAI and BASFI scores were significantly higher in the smoker group (5.08 and 4.51, respectively) as compared to nonsmoker group (3.40 and 2.34, respectively) (P < 0.001). The modified Schober's test showed a significant decrease in the range of spinal mobility in the smoker group (2.67 cm) than in the nonsmoker group (4.40 cm) (P < 0.001). A significant decrease in the mean chest expansion was seen in the smoker group than the nonsmoker group (3.08 vs. 5.68 cm; P < 0.001). Conclusion: Results demonstrate the negative effect of smoking on disease and functional activity in patients with AS.