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The Indian Council of Medical Research (ICMR) has issued revised guidelines for Covid-19 in the wake of the surge of cases in the past week across the country.

“@ICMRDELHI COVID19 National Task Force, @aiims_newdelhi & Dte.GHS revised clinical guidance for management of adult #COVID19 patients. Guideline does not advice use of Lopinavir-ritonavir, HCQ, Ivermectin, Convalescent plasma, Molnupiravir, Favipiravir, Azithromycin, Doxycycline,” Dr Lokesh Sharma, Heath informatics researcher, ICMR tweeted.

“Antibiotics should not be used unless there is clinical suspicion of bacterial infection. The possibility of coinfection of COVID-19 with other endemic infections must be considered. Systemic corticosteroids are not indicated in mild disease,” revised guidelines said.

As per the revised Ccovid-19 guidelines, maintain “Physical distancing, indoor mask use, hand hygiene, Symptomatic management (hydration, anti-pyretics, antitussive) Monitor temperature and oxygen saturation (by applying a SpO probe to fingers) Stay in contact with treating physician.

“Seek immediate medical attention if difficulty breathing, High-grade fever/ severe cough, particularly if lasting for more than 5 days. A low threshold is to be kept for those with any of the high-risk features,” guidelines discussed and prepared in January said.

Additionally, in moderate or severe diseases at high risk of progression, the guidelines recommend, “Consider Remdesivir for up to 5 days (200 mg IV on day 1 followed by 100 mg IV OD for the next 4 days)”.

Union Health and Family Welfare Ministry on Thursday wrote to the State governments of Maharashtra, Gujarat, Telangana, Tamil Nadu, Kerala and Karnataka to follow a five-fold strategy of test, track, treat and vaccinations as these states witness a rise in Covid-19 cases.

India has observed a significant decline in the number of Covid-19 cases during the past few months. However, in the past few weeks a rise in cases has been noted specifically in certain parts of the country with a total of 2,082 cases reported in the week ending March 8, 2023, which rose to 3,264 cases in the week ending March 15, said the Union Home Ministry’s letter.

There are few States which are reporting a higher number of cases indicating the possible localized spread of infection and there is a need to follow a risk assessment-based approach to prevent and contain the infection, without losing the gains made so far in the fight against the pandemic, said the Union Health Ministry.

Gujarat has reported an increase in weekly cases from 105 in the week ending March 8, 2023, to 279 in the week ending March 15. Further, the State reported a positivity rate of 1.11 per cent in the week ending March 15 which is higher than India’s positivity rate of 0.61 per cent during the same period, the letter said.

The Ministry of Health and Family Welfare has issued revised guidelines for Covid-19 in the wake of the surge of cases in the past week across the country.

“Antibiotics should not be used unless there is clinical suspicion of bacterial infection. The possibility of coinfection of COVID-19 with other endemic infections must be considered. Systemic corticosteroids are not indicated in mild disease,” revised guidelines said. As per the revised Ccovid-19 guidelines, maintain “Physical distancing, indoor mask use, hand hygiene, Symptomatic management (hydration, anti-pyretics, antitussive) Monitor temperature and oxygen saturation (by applying a SpO probe to fingers) Stay in contact with treating physician.

“Seek immediate medical attention if difficulty breathing, High-grade fever/ severe cough, particularly if lasting for more than 5 days. A low threshold is to be kept for those with any of the high-risk features,” guidelines discussed and prepared in January said.

Additionally, in moderate or severe diseases at high risk of progression, the guidelines recommend, “Consider Remdesivir for up to 5 days (200 mg IV on day 1 followed by 100 mg IV OD for the next 4 days)”.

Union Health and Family Welfare Ministry on Thursday wrote to the State governments of Maharashtra, Gujarat, Telangana, Tamil Nadu, Kerala and Karnataka to follow a five-fold strategy of test, track, treat and vaccinations as these states witness a rise in Covid-19 cases.

India has observed a significant decline in the number of Covid-19 cases during the past few months. However, in the past few weeks a rise in cases has been noted specifically in certain parts of the country with a total of 2,082 cases reported in the week ending March 8, 2023, which rose to 3,264 cases in the week ending March 15, said the Union Home Ministry’s letter.

There are few States which are reporting a higher number of cases indicating the possible localized spread of infection and there is a need to follow a risk assessment-based approach to prevent and contain the infection, without losing the gains made so far in the fight against the pandemic, said the Union Health Ministry.

Gujarat has reported an increase in weekly cases from 105 in the week ending March 8, 2023, to 279 in the week ending March 15. Further, the State reported a positivity rate of 1.11 per cent in the week ending March 15 which is higher than India’s positivity rate of 0.61 per cent during the same period, the letter said.

An ectopic pregnancy is when a fertilized egg implants at any other site in the body except Uterus. Most commonly this phenomenon occurs in fallopian tubes in majority of the cases and rarely it may also happen in ovary or elsewhere in abdomen as well. Major risk in these cases is that of rupture of these thin fallopian tube as this pregnancy grows. A rupture can lead to major internal bleeding which is a life threatening emergency and requires surgery immediately.

One wonders, why an ectopic pregnancy would occur in the first place in some women. There are some risk factors which increase this risk. Majority of these risk factors are because of damage to the inner lining of fallopian tubes thus leading to poor movement of fertilized egg through fallopian tubes thus causing implantation of pregnancy in the tube itself. These risk factors are pelvic inflammatory disease, prior ectopic pregnancy, prior fallopian tube surgery, previous pelvic surgery, endometriosis etc. Some other risk factors are cigarette smoking, history of inability to conceive, use of assisted reproductive technology , such as IVF and sometimes older age.

An ectopic pregnancy may be completely silent till it ruptures and leads to massive internal bleeding which may present as sudden severe pain the abdomen, fainting, dizziness etc or may present as abnormal vaginal bleeding, low back pain or mild pain in abdomen or pelvis. A woman may experience either a missed period making her think she is pregnant or a period which is lighter in flow than her usual period. Urine pregnancy kit test may show faint positive. Diagnosis is made on an ultrasound along with a blood test called as beta hcg levels.

An ectopic pregnancy cannot move or be moved to the uterus, so it always requires treatment. There are two methods used to treat an ectopic pregnancy which depends on the stage at which it gets detected, medication till it has not ruptured and surgery for a ruptured or large unruptured ectopic pregnancy. Several weeks of follow-up are required with each treatment.

An obstetrician gynaecologist is the best person to take decision regarding the mode of treatment. A surgery when performed can either be performed laparoscopically or via an open surgery which would depend on factors like condition of the patient, skill of the surgeon etc. Surgery may require removal of damaged fallopian tube or removal of ectopic pregnancy contents after giving a small incision on the fallopian tube.

It should be kept in mind that once an ectopic pregnancy occurs, there is higher risk of ectopic pregnancy again. Thus whenever a pregnancy occurs in future, a woman with previous history of ectopic pregnancy must seek immediate consultation with her Obstetrician Gynaecologist and may be asked to get an early ultrasound with certain blood tests.

Dr. Payal Chaudhary
Senior Consultant
Obstetrics and Gynaecology
Rosewalk Healthcare by Rainbow Hospitals, New Delhi.

Many people who want to cut back on meat are turning to legumes, which are high in protein, vitamins, and fiber. Allergies to legumes, such as soy and peanuts, are common and fatal. Are meat-free proteins made of legumes dangerous to patients who are allergic to specific legumes, even if the legumes are different? Dr. Mark Smits and his colleagues at Utrecht University Medical Center set out to investigate.

“Both protein consumption and the world’s population are increasing which leads to an urgent demand for sustainable protein sources,” said Dr. Thuy-My Le, senior author of the study published in Frontiers in Allergy. “An increase in the consumption of legumes may increase the number of allergies to these foods. Furthermore, these new legumes may elicit allergic complaints in already legume-allergic patients. Therefore, we investigated how often sensitization and allergy to different legumes occur in these patients.”

Any other name for an allergy, Food allergies occur when the immune system misidentifies food proteins as a threat and produces Immunoglobulin E (IgE) antibodies. Individuals who have been sensitised to food may develop allergy symptoms if exposed to it again. Patients who are allergic to one food may also be allergic to another: this is known as co-allergy. Co-allergies are often accompanied by co-sensitization, which occurs when patients produce IgE antibodies against multiple foods. Cross-reactivity, in which IgE antibodies bind to proteins from different foods because their structures are similar, may cause co-sensitization.

Co-sensitization can lead to a diagnosed co-allergy, but it does not always: it is possible to be co-sensitized to a food and not have a reaction when eating it. So, do patients who are allergic to specific legumes react to other legumes?

Smits and colleagues recruited legume-allergic patients from the University Medical Center Utrecht’s Allergology Clinic and divided them into six groups based on allergies: peanuts, soybeans, green peas, lupines, lentils, and beans. Allergies were validated in all patients through an oral food challenge or a positive IgE test combined with a history of reactions. IgE antibodies against the other legumes were tested in each group separately.

“We showed that a large number of patients produced antibodies against more than one legume,” said Dr. Kitty Verhoeckx, second author of the study. “However, clinical data showed that only a small part of these patients had actual symptoms.”

Co-sensitization is common among legumes, but not always co-allergy.
Co-sensitization to additional legumes was observed in all six patient groups, with nearly a quarter of patients sensitised to all legumes. Almost all of the patients in the bean allergy group developed sensitivities to other legumes. Patients who were allergic to green peas, lupines, or lentils were more likely to be sensitised to other legumes, whereas patients who had peanut or soybean allergies were not.

The researchers also investigated which of these patients had documented co-allergies to various legumes. Only a small number of patients had clinical symptoms as a result of the high co-sensitization rate. Co-allergies to green peas, lupine, lentil, and bean were uncommon in peanut and soybean-allergic patients, but patients who were allergic to this second group of legumes were more likely to be allergic to peanuts or soybeans.

Patients who were allergic to peanuts were frequently also allergic to soybeans, and vice versa. Peanut sensitization was linked to clinically significant co-allergy in almost all other legume groups. However, the researchers cautioned that the study should be expanded to a larger group and co-allergies confirmed with oral food challenges before determining how clinically relevant this co-sensitization is in practise.

“Legumes are an attractive sustainable protein source, but allergic reactions in the already legume-allergic population cannot be excluded as antibodies in the blood of legume-allergic patients frequently react to different legumes,” said Le.

“However, this reaction does not always lead to a clinically relevant food allergy. Introduction of novel foods into the market should be accompanied by an appropriate assessment of the risk of developing (new) food allergies.”

Is there a risk from meat-free proteins derived from legumes, even if the legumes are different? Dr. Mark Smits and his colleagues at Utrecht University Medical Center set out to investigate.

According to research published in the European Heart Journal – Open, an ESC journal, sleeping less than five hours per night is associated with a 74% increased risk of developing the peripheral arterial disease (PAD) compared to sleeping seven to eight hours.

“Our study suggests that sleeping for seven to eight hours a night is a good habit for lowering the risk of PAD,” said study author Dr. Shuai Yuan of the Karolinska Institute, Stockholm, Sweden. More than 200 million people globally have peripheral artery disease (PAD),2 where arteries in the legs are clogged, restricting blood flow and increasing the risk of stroke and heart attack. Dr. Yuan said: “Insufficient night-time sleep and daytime napping have previously been associated with a raised risk of coronary artery disease which, like PAD, is caused by clogged arteries. In addition, sleeping problems are among the top-ranked complaints in PAD patients. There are limited data on the impact of sleep habits on PAD and vice versa, and our study aimed to fill that gap.”

The study had over 650,000 participants and was divided into two parts. 3 First, the researchers looked at the links between sleep duration and daytime napping, and the risk of PAD. In the second part, the researchers used genetic data to conduct naturally randomised controlled trials, also known as Mendelian randomisation, to investigate the causality of the associations.

Dr. Yuan said: “Observational analyses are limited by reverse causality – meaning that if an association between sleep habits and PAD is found, we cannot be certain if sleep habits caused PAD or having PAD caused the sleep habits. Mendelian randomisation is a robust method for evaluating causality and provides more certainty about the results.”

Taken together, the strongest evidence was for insufficient sleep, where the relationship with PAD was bidirectional. In a study of 53,416 adults, sleeping less than five hours per night was linked to a nearly doubled risk of PAD compared to sleeping seven to eight hours (hazard ratio [HR] 1.74; 95 percent confidence interval [CI] 1.31-2.31). This finding was supported by additional analyses of 156,582 and 452,028 people, respectively. Short sleep was linked to an increased risk of PAD in the causal studies, and PAD was linked to an increased likelihood of short sleep.

Dr. Yuan said: “The results indicate that brief night-time sleep can raise the chance of developing PAD and that having PAD increases the risk of getting insufficient sleep.”

In an observational study of 53,416 adults, sleeping eight hours or more per night was associated with a 24% increased risk of PAD compared to seven to eight hours (HR 1.24; 95 percent CI 1.08-1.43). Analyses in two larger populations of 156,582 and 452,028 people supported this finding. However, no causal relationships between long sleep and PAD were discovered. Similar findings were reported for napping, with daytime nappers having a 32% higher risk of PAD than those who did not nap (HR 1.32; 95% CI 1.18-1.49) but no causal links were found.

“More studies are needed on the relationships between lengthy night-time sleep, daytime napping, and PAD,” said Dr. Yuan. “Although we found associations in the observational studies, we could not confirm causality.”
He concluded: “More research is needed on how to interrupt the bidirectional link between short sleep and PAD. Lifestyle changes that help people get more sleep, such as being physically active, may lower the risk of developing PAD. For patients with PAD, optimising pain management could enable them to have a good night’s sleep.”

A diet high in vitamin A or its analogues may help adolescents and young adults with acute lymphoblastic leukaemia (ALL) reduce their risk of painful pancreatic inflammation during chemotherapy, according to a study.
Details about this potential dietary solution to prevent a potentially fatal adverse event were published in Science Translational Medicine on March 15, 2023.

Sohail Husain, MD, chief of Pediatric Gastroenterology, Hepatology, and Nutrition at Stanford University, and Anil Goud Jegga, DVM, MRes, a computational biologist at Cincinnati Children’s Hospital Medical Center, led the research team. Treatment with the enzyme asparaginase helps starve cancer cells by lowering the amount of asparagine circulating in the blood, which cancer cells require but cannot produce.

The medication, which is frequently used in conjunction with other chemotherapies, is administered by injection into a vein, muscle, or under the skin. However, an estimated 2% to 10% of asparaginase users develop pancreatic inflammation as a result of asparaginase treatment. The symptoms can be severe for one-third of these people.

Jegga and colleagues used over 100 million data points from gene expression data, small-molecule data, and electronic health records to better understand the mechanisms underlying asparaginase-associated pancreatitis (AAP) and to identify potential interventions to prevent or mitigate AAP.

First, they analysed massive amounts of gene expression data to discover that retinoids could reverse gene activity associated with asparaginase or pancreatitis (vitamin A and its analogs). More evidence was discovered by “mining” millions of electronic health records from the TriNetX database and the US Food and Drug Administration Adverse Event Reporting System.

The AERSMine software developed at Cincinnati Children’s by Mayur Sarangdhar, PhD, MRes, and colleagues was used in this number crunching and predictive analytics work. The researchers also analysed data from mouse experiments and compared plasma samples from ALL patients who developed pancreatitis to those who did not.

Finally, the team came up with two sets of human “real-world” experiences. They discovered that when asparaginase was combined with vitamin A, only 1.4% of patients developed pancreatitis, compared to 3.4% of patients who did not. Concurrent vitamin A use was associated with a 60% reduction in the risk of AAP. Lower dietary vitamin A levels were linked to an increased risk and severity of AAP.

“This study demonstrates the potential of mining ‘real-world’ data to identify therapy modifiers for improving patient outcomes. In cases where a primary drug induces toxicity but is critical to therapy, such as asparaginase, therapy modifiers, such as vitamin A and its analogs, may be of immediate relevance to patients on asparaginase and ‘at-risk’ for AAP,” says Sarangdhar, a co-first author of the study.

Says Jegga: “Our study highlights the power of heterogeneous data integration and analysis in translational research. By leveraging existing ‘omics and patient-centric data and a systems approach, we were able to identify new insights into the development of AAP and potential interventions to prevent or mitigate this side effect.”

Next steps

In some ways, the findings of this study could be immediately applied to patient care. More clinical research is needed, however, to determine how much vitamin A is required to protect ALL patients from pancreatitis, and whether a protective level can be achieved through diet or supplements. In fact, target vitamin levels may need to vary based on individual metabolic differences.

By Shailesh Kumar Singh, Sr. Physiotherapist AIIMS New Delhi

Physiotherapy is thought to be a supportive mode of treatment whereas according to the definition given by WHO, DCPT, and Healthcare Profession Act, “It is an INDEPENDENT PROFESSION in which a physiotherapist practices by undertaking comprehensive examination and appropriate investigation, provides treatment and advice to any person with movement or functional dysfunction, malfunction, disability, and pain from trauma and disease, using modalities, exercises, mobilization, manipulations, for prevention, screening, diagnosis, and treatment.

Despite the definition given by these reputed institutions, there is still a lack of awareness about the different treatment approaches that a therapist uses to treat a patient not only among the common public but also among the health stakeholders therefore physiotherapists receive a referral with already written treatment including only machines and basic exercise which is been in practice for more than 70 years now and making the gap between conventional physiotherapy and advance physiotherapy deeper.

Physiotherapy had been started with more reliance on machines and thereby offering only diplomas earlier but with the passing of time the bachelor’s degree has been started and later on looking into the role of physiotherapy in specialized areas masters in different fields viz; MPT in Neuro, ortho, obs and gynae, sports, pediatrics, oncology, etc have been started like we have different MDs after MBBS. Ph.D. is also now being offered in physiotherapy as the research in the field has shown accelerated growth.

We need to understand that the equipment which is been used in physiotherapy is only to give temporary relief but not to provide a permanent solution for the primary complaint which is possible only with a bottom-up approach that means assessing the patient thoroughly and then planning the treatment accordingly.

A physiotherapist uses his extra ear that means his hands for the assessment of the patient includes not only the history of the primary complaint but also looking deep into the local structures giving that symptom while keeping in mind the far-off structures that could be the contributing factors for the problem thereby reaching to the root cause of primary complaint rather than a superficial treatment of just the symptoms.

After the assessment comes the role of evidence-based treatment for the condition which includes the re-alignment of the joints, and bones, manual releases for the tight fascia and muscles, realign scar tissues that can get in the way of your body’s full range of motion, manual lymph drainage, etc using manual therapy, osteopathy, dry needling, Kinesio tape, cupping therapy. etc with the individualized exercise program which ultimately leads to chucking out the root cause of the primary problem which is giving those superficial symptoms and thereby providing the patients a permanent solution to their problem and reduce their need to visit the physiotherapy clinic again and again for the same problem that frequently happens with the use of only physiotherapy machines rather than wholesome approach.

For Example: A patient comes in with pain in the back radiating to the right lower limb. so the conventional approach for the case would be using diathermy, ultrasound locally, and IFT for pain relief along with traction giving the patient symptomatic relief rather on the other hand, in the advanced physiotherapy approach, the physiotherapist will assess the patient for the root cause of the symptoms .he will take a detailed history and later on a detailed assessment by looking into the posture of the patient is in because of the pain, the gait pattern, muscles in spasms, muscles which are short with trigger points, the mobility of the spine not only the lumbar spine but the spine as a whole with the areas of hypomobility and hypermobility, alignment of the nearby joints like sacroiliac joints, hip joints, pelvic bones, fascial restrictions, breathing pattern, abdominal viscera movement, etc to reach into a clinical diagnosis and thence start with the individualized treatment protocol.

So physiotherapy is already been shifted from mere dependence on the equipment with a blinded approach to a more scientific approach using novel techniques making it a full-fledged system in itself. This treatment approach is time taking so the patient should understand the need for the same, should be compliant and vigilant to what is happening to their system and what should be done to help them come out of their suffering permanently. So in the end a small request to the patient” Don’t let your body be fooled by masking your symptoms rather love it to the fullest by giving it the gift of the right treatment”

The sample of a 27-year-old man who died with Covid symptoms in Tamil Nadu’s Trichy has been sent for testing to check for the presence of H3N2 virus, officials said on Tuesday.

According to the reports, the victim was a resident of Trichy and worked in Bengaluru. Recently, he had gone on a vacation to Goa with his friends, where he fell sick and returned to Trichy on a flight on March 9. He died at GBR private hospital in Trichy on March 10.

According to hospital sources, he was admitted there with severe stomach pain and a vomiting sensation.
On medical examination, it was found that his wealth was critical and was tested positive for Covid-19 infection. Following this, the hospital authorities sent his samples to check for the presence of H3N2 virus.

Reportedly, H3N2 cases are on the rise in Tamil Nadu. The authorities have asked the public not to panic about the situation and assured them of taking necessary precautions to contain the spread.

According to a new study, COVID-19-related stress had a larger impact on the mental health of pregnant women during the pandemic than on those who were not.

Dr Susanne Schweizer from UNSW Science, together with colleagues in Europe and the United States, collected data on mental health at several time periods during and after pregnancy in a longitudinal research of 742 pregnant individuals. Their analysis found COVID-19 related stress had the greatest impact on pregnant people who had a tendency to worry, felt lonely, or had a low tolerance for uncertainty.

A follow-up study, published today in JAMA Network Open, looked at COVID-19 related stress in the postpartum period, 1.5 years after the first investigation. The team found that feeling stressed about the pandemic during pregnancy not only had a lasting effect on participants’ own mental health, but was also associated with an increase in negative mood in their infants.

“The Centre for Disease Control identifies pregnant women as a vulnerable group in terms of physical health during pandemics and disease outbreaks,” says Dr Schweizer. “Based on these findings, and those of others, we should also identify pregnant women as a vulnerable group in terms of mental health.”
Mental health vulnerability factors

Importantly, the research team compared the pregnant women who took part in the study to gender, age and country matched controls. “So, you have someone who’s as similar as possible, but who isn’t pregnant at that point in time. And we looked at the impacts of pandemic related stress on their mental health,” says Dr Schweizer.

Pandemic stress was measured using the Pandemic Anxiety Scale, which measures individuals’ concerns about the pandemic, including worries about contracting the virus, having enough food and job-related impacts.

Unsurprisingly, COVID-19 related stress was associated with more mental health problems in both women who were pregnant and those who weren’t. “But not all women were affected in the same way. There were vulnerability factors, such as lack of social support, increased loneliness, worry and intolerance of uncertainty, which had a greater impact on mental health in the context of pandemic related stress in pregnant women, compared to their non pregnant counterparts,” says Dr Schweizer.

Effect on infant behaviour

At the final timepoint, on average 18 months after the initial assessment, the team administered the same set of measures to the cohort.

“But this time, we also administered a measure on postpartum distress, which captures mental health symptoms that are related to the postpartum period, such as thoughts of harm befalling the child or inflicting harm on a child, and we also measured infant mood and behaviour.”

The follow-up study found that COVID-19 related stress during pregnancy, captured in the first paper, was significantly associated with poor postpartum maternal mental health outcomes.

“What’s always going to predict your mental health best is your mental health at a previous timepoint,” says Dr Schweizer. “So I was surprised that pandemic related stress during pregnancy adversely impacted maternal depression, anxiety and distress that far into the future, even when we controlled for their previous levels of mental wellbeing.”

But it wasn’t just the mothers who were negatively impacted. For those who were stressed by the pandemic, there was a higher chance of what researchers call ‘negative affectivity’ in their infants.

Negative affectivity includes the infant being more likely to cry and less easily settled, as well as less likely to venture into an unknown situation.

“Negative affectivity is a measure of infant mood. But it’s been associated with a range of behavioural problems, and importantly, also cognition. It has also been associated with developmental outcomes across the lifespan.”
While there is already a robust literature showing that maternal postpartum mental health is significantly associated with infant behaviour, this is one of the first studies to examine the association of stress during pregnancy with mother and infant mental health outcomes during the pandemic.

Bringing mental health to the forefront

Dr Schweizer herself has lived experience of being pregnant during the pandemic.
“I was very lucky in that I knew I was in a position that I could continue working, so I didn’t have those economic pressures, but I was a high-risk pregnancy. And then my child was born premature,” said Dr Schweizer.

“That’s a distressing experience anyway, even under normal circumstances, but it was very much compounded by the fact that I was separated from my other children, I was never able to see my daughter with my husband together until much later.

“And so for me, it was a very direct and personal experience of how this the pandemic impacted the peripartum period.”
She argues more support is urgently needed for pregnant people’s mental health as part of standard pregnancy care. “Pregnancy is a period of vulnerability for mental health problems. Intense and rapidly fluctuating moods and emotions are a normal part of pregnancy and after birth many people will experience intrusive, unwanted thoughts. But we are not told enough about this.

“Pregnant individuals need to be given information about what to expect, what is common and when they should seek help.”