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The reaction of 3,7-bis­(di­methyl­amino)­pheno­thia­zin-5-ium chloride pentahydrate (methyl­ene blue) with silver nitrate in a 1:2 molar ratio in water yielded the title compound, C16H18N3S+·NO3−·2H2O, as one of the products. The cationic dye mol­ecules are planar and stacked in an antiparallel fashion, exhibiting π–π associations at a distance of 3.7040 (18) Å. The nitrate anion and the two water mol­ecules are involved in a hydrogen-bonding network that also includes the pheno­thia­zinium N atom. [ABSTRACT FROM AUTHOR]

The article presents a case study of a young postpartum female with left-sided abdominal pain and fever for 10 days. It discusses results of her clinical examination and contrast-enhanced computed tomography of the abdomen. The patient had thalassemia intermedia and was diagnosed of septicemic melioidosis with ruptured splenic abscess.

Background and Objectives: Upper urinary tract infections (UTIs) that require in-patient care can be expensive. Comorbid conditions such as diabetes as well as UTI due to extended-spectrum beta-lactamase (ESBL) producing bacteria may affect costs. The quality of life of patients with this condition has not been described. Methods: This was a cost of illness study that prospectively evaluated patients admitted with upper UTI to a medical ward in a tertiary care hospital. Direct medical and nonmedical costs, indirect costs were collected to make the total cost per admission. Quality of life was assessed using the World Health Organization Quality of Life-BREF score. We also compared costs between those with and without diabetes or ESBL infection. Results: Between March 2016 and July 2017, 92 eligible patients were included in the study. The average age was 55.8 years; two thirds were diabetics. The mean overall cost of a single admission for upper UTI was INR.88, 330.2 (1370.4 USD). This was INR.96, 193.0 (1492.6 USD) and INR.1, 03,154.9 (1600.4 USD) among those with diabetes mellitus and ESBL infection, respectively. The cost was higher among those with diabetes and ESBL than those without; this difference reached statistically significance for the ESBL group. The quality of life was affected in all domains; the psychological being most affected among diabetics and ESBL infected. Conclusions: The mean total cost of admission for an upper UTI in a tertiary care hospital in South India was INR 88,330 (1370.4 USD). This is higher if the patient has diabetes or ESBL organism causing the UTI. Quality of life is clearly reduced especially in the psychological domain.

Background and Objectives: Upper urinary tract infections (UTIs) that require in-patient care can be expensive. Comorbid conditions such as diabetes as well as UTI due to extended-spectrum beta-lactamase (ESBL) producing bacteria may affect costs. The quality of life of patients with this condition has not been described. Methods: This was a cost of illness study that prospectively evaluated patients admitted with upper UTI to a medical ward in a tertiary care hospital. Direct medical and nonmedical costs, indirect costs were collected to make the total cost per admission. Quality of life was assessed using the World Health Organization Quality of Life-BREF score. We also compared costs between those with and without diabetes or ESBL infection. Results: Between March 2016 and July 2017, 92 eligible patients were included in the study. The average age was 55.8 years; two thirds were diabetics. The mean overall cost of a single admission for upper UTI was INR.88, 330.2 (1370.4 USD). This was INR.96, 193.0 (1492.6 USD) and INR.1, 03,154.9 (1600.4 USD) among those with diabetes mellitus and ESBL infection, respectively. The cost was higher among those with diabetes and ESBL than those without; this difference reached statistically significance for the ESBL group. The quality of life was affected in all domains; the psychological being most affected among diabetics and ESBL infected. Conclusions: The mean total cost of admission for an upper UTI in a tertiary care hospital in South India was INR 88,330 (1370.4 USD). This is higher if the patient has diabetes or ESBL organism causing the UTI. Quality of life is clearly reduced especially in the psychological domain. [ABSTRACT FROM AUTHOR]

Dual anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) characterized by the presence of both anti-proteinase-3 (PR3-ANCA) and anti-myeloperoxidase (MPO-ANCA) antibodies is a rare clinical entity. Only few cases have been reported previously, most of which were associated with infections, drugs, autoimmune diseases and malignancies. Herein, we describe a young woman who presented with rapidly progressive glomerulonephritis with hypocomplementemia and markedly elevated anti-PR3 and anti-MPO titres. Meticulous work-up ruled out all possible secondary causes. Renal biopsy showed the presence of focal fibrocellular crescents with focal mesangial hypercellularity. Immunofluorescence and electron microscopy showed pauci-immune deposits. The patient was treated with an induction regimen comprising oral prednisolone and cyclophosphamide. She attained both clinical and serological remission at 3 months and is currently on an azathioprine-based maintenance regimen. We have extensively reviewed all previous cases of dual AAV and have formulated an approach to diagnose and treat this rare entity.

Background: Tuberculosis (TB) is a major global health problem, mainly in developing countries. Despite the availability of highly effective first-line antitubercular (ATT) drugs, ATT drug-induced liver injury (ATT DILI) leads to treatment interruption and consequently loss of therapeutic efficacy. Methods: In this prospective cohort study from India, all consecutive patients who met inclusion criteria and started on ATT were included. The incidence, risk factors, and outcome of ATT DILI were determined. A clinical prediction score for ATT DILI was derived. Results: A total of 393 patients were included. The incidence of ATT DILI was 9.7% (95% confidence interval 7%–13.2%). HIV infection, daily regimen, disseminated disease, and chronic liver disease were identified as significant risk factors (P < 0.05) for developing DILI. A prediction score derived from the risk factors showed that a score of >5 could predict DILI with a sensitivity of 74% and a specificity of 67%. All-cause mortality in DILI was 4.7%. Conclusion: The incidence of ATT DILI was 9.7% in our cohort with higher incidence among the patients on daily regimen. The study suggests that the combination of risk factors of extensive TB disease, HIV infection, chronic liver disease, and under nutrition increases the vulnerability to DILI, particularly with daily treatment regimen, emphasizing the role of acquired risk factors in the development of DILI.

• Coordinated Data falsification attack vector for distributed generation domain. • Use of parallel branches for deep learning to detect additive and deductive attacks. • Use of environmental parameters to detect attacks on distributed generators. • Case studies on a US based real distribution system. This paper proposes a deep learning-based multi-label classification approach to detect coordinated and simultaneously launched data falsification attacks on a large number of distributed generators (DGs). The proposed approach can detect coordinated additive, deductive, and combination of additive and deductive (attackers use the combination of additive and deductive attacks to camouflage their attacks) types of power output manipulation and falsification attacks on DGs. In training the proposed classifier, readings from DG meters and data from supervisory control and data acquisition (SCADA) systems along with meteorological data are used as input and class labels (additive, deductive, and combination) are used as output. The output class labels are developed based on the comparison between normal and compromised outputs of DGs. Two parallel data falsification classifiers with separate class labels are developed to increase the detection accuracy. The proposed approach is demonstrated on several systems including a 240-node real distribution system (based in the USA) and the IEEE 123-node distribution test system. The results show that the proposed approach can detect low margin coordinated attacks (as low as 5% of actual DG readings) with up to 99.9% accuracy. The performance of the proposed work is compared with multi-layer perceptron (MLP), convolutional neural network (CNN), and residual neural network. All of the developed source codes (including unbalanced quasi-static power flow in OpenDSS-MATLAB environment and deep learning in Python) of the proposed solution are publicly available at GitHub. [ABSTRACT FROM AUTHOR]

Dual anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) characterized by the presence of both anti-proteinase-3 (PR3-ANCA) and anti-myeloperoxidase (MPO-ANCA) antibodies is a rare clinical entity. Only few cases have been reported previously, most of which were associated with infections, drugs, autoimmune diseases and malignancies. Herein, we describe a young woman who presented with rapidly progressive glomerulonephritis with hypocomplementemia and markedly elevated anti-PR3 and anti-MPO titres. Meticulous work-up ruled out all possible secondary causes. Renal biopsy showed the presence of focal fibrocellular crescents with focal mesangial hypercellularity. Immunofluorescence and electron microscopy showed pauci-immune deposits. The patient was treated with an induction regimen comprising oral prednisolone and cyclophosphamide. She attained both clinical and serological remission at 3 months and is currently on an azathioprine-based maintenance regimen. We have extensively reviewed all previous cases of dual AAV and have formulated an approach to diagnose and treat this rare entity., Learning Points: Dual anti-neutrophil cytoplasmic antibody-associated vasculitis characterized by both PR3-ANCA and MPO-ANCA antibodies is a rare clinical entity.Prior to treating with immunosuppression, we need to rule out secondary aetiologies such as drugs, certain infections, autoimmune diseases and haematological malignancies.Atypical presentations such as hypocomplementemia, other serological abnormalities like positive ANA, cryoglobulins, anti-histone antibody and histology showing mesangial hypercellularity, interstitial inflammation and lack of pauci-immunity, may create a diagnostic dilemma., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interest, (© EFIM 2022.)

Background: Postnatal gestational age (GA) estimation is crucial in neonates with absent early trimester ultrasonography (USG) reports to evaluate the risk of morbidity and mortality. Widely used Expanded New Ballard (ENBS) is complex and needs an expert medical professional to assess. Eregie (ES) and Parkin (PS) scores are easy to perform with good inter-observer reliability. We aimed to compare these scores for their ability in predicting GA with early trimester USG-GA as the gold standard., Methods: This cross-sectional study was conducted among 1114 intramural neonates who qualified according to the selection criteria. All neonates were evaluated using the three scores by residents (blinded to USG-GA) with a pre-defined inter-observer difference of <10%. Method applicability was compared in terms of accuracy, precision and validity., Results: GA was systematically overestimated by 0.65, 0.68 and 0.32 weeks by ENBS, PS and ES, respectively. For GA subgroups, ES had better overall accuracy with mean difference of 0.32 ± 0.88 weeks. Validity was highest for ES (79.6%)., Interpretation: We conclude that all three scores were found to be of acceptable accuracy and validity. ES had better overall accuracy and validity among the subjects and for subgroups. In limited resource settings, ES or PS can substitute for ENBS., (© The Author(s) [2021]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Tuberculosis (TB) is a major global health problem, mainly in developing countries. Despite the availability of highly effective first-line antitubercular (ATT) drugs, ATT drug-induced liver injury (ATT DILI) leads to treatment interruption and consequently loss of therapeutic efficacy., Methods: In this prospective cohort study from India, all consecutive patients who met inclusion criteria and started on ATT were included. The incidence, risk factors, and outcome of ATT DILI were determined. A clinical prediction score for ATT DILI was derived., Results: A total of 393 patients were included. The incidence of ATT DILI was 9.7% (95% confidence interval 7%-13.2%). HIV infection, daily regimen, disseminated disease, and chronic liver disease were identified as significant risk factors (P < 0.05) for developing DILI. A prediction score derived from the risk factors showed that a score of >5 could predict DILI with a sensitivity of 74% and a specificity of 67%. All-cause mortality in DILI was 4.7%., Conclusion: The incidence of ATT DILI was 9.7% in our cohort with higher incidence among the patients on daily regimen. The study suggests that the combination of risk factors of extensive TB disease, HIV infection, chronic liver disease, and under nutrition increases the vulnerability to DILI, particularly with daily treatment regimen, emphasizing the role of acquired risk factors in the development of DILI., Competing Interests: None

Competing Interests: Conflict of Interests: None Declared.

Purpose: The aim of this study was to ascertain whether diffusion tensor imaging (DTI) metrics fractional anisotropy (FA), mean diffusivity (MD), linear case (CL), planar case (CP), spherical case (CS)-can characterize a threshold dose and temporal evolution of changes in normal-appearing white matter (NAWM) of adults with low-grade gliomas (LGGs) treated with radiation therapy (RT)., Methods and Materials: Conventional and DTI imaging were performed before RT in 5 patients and subsequently, on average, at 3 months (n = 5), 8 months (n = 3), and 14 months (n = 5) following RT for a total of 18 examinations. Isodose distribution at 5-Gy intervals were visualized in all the slices of fluid attenuated inversion recovery (FLAIR) and the corresponding DTI images without diffusion sensitization (b0DTI). The latter were exported for relative quantitative analysis., Results: Compared to pre-RT values, FA and CL decreased, whereas CS increased at 3 and 8 months and recovered partially at 14 months for the dose bins >55 Gy and 50-55 Gy. For the 45 50 Gy bin, the FA and CL decreased with an increase in CS at 3 months; no further change was seen at 8 or 14 months. For the >55 Gy and 50-55 Gy bins, CP decreased and MD increased at 3 months and returned to baseline at 8 months following RT., Conclusion: Radiation-induced changes in NAWM can be detected at 3 months after RT, with changes in FA, CL, and CS (but not CP or MD) values seen at a threshold dose of 45-50 Gy. A partial recovery was evident by 14 months to regions that received doses of 50-55 Gy and >55 Gy, thus providing an objective measure of radiation effect on NAWM.