Introduction: The importance of early recognition and treatment of sepsis and its effects on short-term survival outcome have long been recognized. Having reliable indicators and markers that would help prognosticate the survival of these patients is invaluable and would subsequently assist in the course of effective dynamic triaging and goal directed management. Study Objectives: To determine the prognosticative value of Shock Index (SI), taken upon arrival to the emergency department and after 2 hours of resuscitation on the shortterm outcome of severe sepsis and septic shock patients. Methodology: This is a retrospective observational study involving 50 patients admitted to the University of Malaya Medical Centre between June 2009 and June 2010 who have been diagnosed with either severe sepsis or septic shock. Patients were identified retrospectively from the details recorded in the registration book of the resuscitation room. 50 patients were selected for this pilot study. The population comprised 19 males (38%) and 31 females (62%). The median (min, max) age was 54.5 (17.0, 84.0) years. The number of severe sepsis and septic shock cases were 31 (62%), and 19 (38%) respectively. There were 17 (34%) cases of pneumonias, 13 (26%) cases of urological sepsis, 8 (16%) cases of gastro intestinal tract related infections and 12 (24%) cases of other infections. There were a total of 23 (46%) survivors and 27 (54%) deaths. The value of the shock index is defined as systolic blood pressure divided by heart rate was calculated. Shock Index on presentation to ED (SI 1) and after 2 hours of resuscitation in the ED (SI 2). The median, minimum and maximum variables were tested using Mann-Whitney U and Chi square analysis. The significant parameters were re-evaluated for sensitivity, specificity and cut-off points. ROC curves and AUC values were generated among these variables to assess prognostic utility for outcome. Results: Amongst all 7 variables tested, 2 were tested to be significant (p: < 0.05). From the sensitivity, specificity and ROC analysis, the best predictor for death was (SI 2) with a sensitivity of 80.8%, specificity of 79.2%, AUC value of 0.8894 [CI95 0.8052, 0.9736] at a cut-off point of ≥1.0. Conclusion: (SI 2) may potentially be utilized as a reliable predictor for death in patients presenting with septic shock and severe sepsis in an emergency department. This parameters should be further analyzed in a larger scale prospective study to determine its validity.

In recent times, the emergence of Clostridium perfringens has posed a significant challenge to public health due to its antibiotic resistance and the formation of biofilms. It is the neuraminidase enzyme that supplies toxin secretion from C. perfringens. Since the sialic acid bond is a target recognition point for bacteria, new molecules are needed to treat infections caused by dangerous pathogens such as C. perfringens.The present work focused on an alternative strategy using compounds from Polygonum cuspidatum Sieb. et Zucc. Nine bioactive compounds derived from this plant emodin, physcion, emodin-1-O-β-D-glucopyranoside, emodin-8-O-β-D-glucopyranoside, physcion-8-O-β-D-glucopyranoside, 2-methoxy-6-acetyl-7-methyl juglone, torachrysone-8-O-β-D-glucoside, polydatin and resveratrol were used as ligands and coupled. The neuraminidase enzyme from C. perfringens was chosen as the target protein. The optimal ligand insertion score and ADMET parameters were determined by employing the Lipinski rules as selection criteria. Emodin-8-O-β-D-glucopyranoside and physcion-8-O-β-D-glucopyranoside exhibited drug-like characteristics in their ability to inhibit neuraminidase, as evidenced by a chelation score of −11.9. A comparison was conducted between emodin-8-O-β-D-glucopyranoside and physcion-8-O-β-D-glucopyranoside, and the positive control quercetin.A comprehensive analysis of the drug-like properties of emodin-8-O-β-D-glucopyranoside and physcion-8-O-β-D-glucopyranoside revealed that exhibited superiority over quercetin across multiple aspects. Quercetin showed a binding affinity of −9.9, while emodin-8-O-β-D-glucopyranoside and physcion-8-O-β-D-glucopyranoside showed a binding affinity of −11.9. The results showed acceptable differential kinetic properties of emodin-8-O-β-D-glucopyranoside and physcion-8-O-β-D-glucopyranoside compared to quercetin. It has been shown to inhibit the neuraminidase enzyme from C. perfringens.

Objective: To document the clinical, biochemical and imaging phenotypes of immunocompetent patients with adrenal histoplasmosis. Methods: The clinical, biochemical and radiologic data of 18 immunocompetent patients [age: 45.00 (39.25, 56.25) years, median (IQR), m/f (16/2)] with adrenal histoplasmosis presenting in the Department of Endocrinology, BSMMU between 2014 and 2020 were retrospectively analyzed. Results: All patients were seronegative for HIV infection, and 27.8% (5/18) had well controlled diabetes mellitus. The median duration of the symptoms was 6.00 (IQR: 4.00, 11.25) months. All had significant weight loss, anorexia and weakness. Fever was present in 61.1% (11/18) patients and night sweat was present in 27.8% (5/18) cases. Hypotension and hyperpigmentation were present in 55.6% (10/18) and 66.7% (12/18) cases, respectively. Three of 18 patients presented with adrenal crisis. Hyponatremia occurred in 55.6% (10/18) cases, but none had hyperkalemia. Thirteen of 18 patients had adrenal insufficiency whereas 83.3% (15/18) had high adrenocorticotropic hormone. CT scan revealed bilateral adrenal enlargement in all cases with oval shape and regular margin. All were hypodense having radiodensity 21-90 hounsfield unit, and 11.1% (2/18) were heterogeneous in contrast enhancement. None had noticeable calcification whereas 1.1% (2/18) cases had central necrosis with peripheral rim enhancement. Hepatomegaly was present in 6 cases, splenomegaly in 3 cases and 5 patients had abdominal lymphadenopathy. Histoplasmosis were confirmed by positive fine needle aspiration cytology of adrenal tissue. Conclusions: Adrenal histoplasmosis should be considered in the list of differentials of bilateral adrenomegaly in immunocompetent individuals even living in non-endemic areas.

Introduction: Trauma is a Global threat and the 5th highest cause of all-cause mortality in Malaysia caused predominantly due to road traffic accidents. Majority of trauma victims are young adults aged between 21-40 years old. In Malaysia, 24 out of 100,000 population die annually due to trauma, rating us amongst the highest in South East Asia. These alarming figures justify aggressive preventive and mitigation strategies. The aim of this paper is to promote the implementation of evidence-based interventions that will reduce the rate of preventable death because of trauma. Tranexamic acid is one of the few interventions in the early management of severe trauma with level-one evidence. Tranexamic acid has been proven to reduce all causes of mortality and mortality due to bleeding. Evidence proves that it is most effective when administered early, particularly within the 1st hour of trauma. This proposed guideline is formulated based upon quality evidence from multicentre studies, clinical practices in other countries and consideration of the local demographic factors with the intent of enabling an easy and simple pathway to administer tranexamic acid early in the care of the severely injured. Conclusion: The guideline highlights select pre-hospital criteria’s and the methods for drug administration. The authors recognise that some variants may be present amongst certain institutions necessitating minor adaptations, nevertheless the core principles of advocating tranexamic acid early in the course of pre-hospital trauma should be adhered to.