S S Jha

Teriparatide (TPTD) (recombinant Parathyroid Hormone 1-34) is one of the pioneer osteo-anabolic agents approved for management of osteoporosis. Being an anabolic agent, it increases bone mineral density by inducing formation of new bone by the action on osteoblasts. As new bone formation is an important aspect of fracture healing as well, Teriparatide has long been a product of interest with respect to its effect on the process of fracture healing. Though fracture healing is not an approved indication for Teriparatide, there is quite a substantial amount of published data related to its effectiveness in fracture healing. With an intent to better understand the role of teriparatide in fracture, we share few case reports of successful fracture healing after giving Teriparatide and also review the published evidences of union taking place in difficult delayed union and non-union cases secondary to mechanical instability, inadequate fixation support or other reasons. This article thus, intended to summarize the accumulating preclinical and clinical evidence for role of TPTD in accelerating fracture healing in various conditions like conservative management of fractures, vertebral fractures, non-unions, delayed unions and atypical femoral fractures.   Keywords: Teriparatide, Fracture healing, rPTH, Nonunion, Delayed union

Rheumatic disease inspite of improvement during pregnancy, is a challenging problem. The disease has a tendency to flare up in immediate postpartum stage and sometimes also during pregnancy. Hence, planning of pregnancy should be deferred to the stage when the rheumatic diseases are quiescent for six to twelve months. Drugs with teratogenic effects like methotrexate and leflunomide must be stopped three to six months prior to conception. Lower dosage of corticosteroid is advocated with a limit upto 10 mg /day. In third trimester NSAIDs must be avoided. The safer drugs during pregnancy are sulfasalazine, hydroxychloroquine and azathioprine. Cholestyramine wash or use of charcoal for leflunomide is must if this drug has been taken within two years of planned conception. With lack of evidence regarding teratogenic potentials of biologics, they are to be withheld prior to conception, with the exception of TNF inhibitors, may be allowed to continue. During lactation, NSAIDs preferably short acting Ibuprofen should be given just after feeding. In lactation, the drugs considered safe are the same as used during pregnancy - low dose corticosteroids, sulfasalazine, hydroxychloroquine, and azathioprine. Similarly, anti TNF agents are also considered safe during lactation. Evidence-based recommendations regarding use of DMARDs and biologics is a powerful tool / guide for rheumatologists in pregnant and lactating women with rheumatic diseases. Counselling of male patients with rheumatic diseases regarding conception is also mandatory. Keywords: DMARDs, TNF inhibitors, Lactation, Pregnancy, Rheumatic diseases.

Fracture neck femur following high velocity injury is likely to increase after resumption of vehicular traffic and other day to day activities including fall from height, sporting injuries etc. In this covid era, in a positive covid scenario in a patient, surgery should preferably be deferred till four weeks, by which time the “second cytokine storm” response settles down. In a covid negative scenario also, the patient subsequently developing covid positive is a definite possibility. In displaced unstable fracture neck femur, osteosynthesis can be contemplated because of factors present in the fracture and surgeon’s preference requiring emergency intervention since earliest surgical intervention will prognosticaly give better results in terms of union. This study emphasises on inferior calcar buttress reduction with positive cortical apposition and reverse triangular design of conventional cancellous screw fixation as contributory factors to sustainable reduction and union. Keywords: Fracture neck femur, Valgus reduction, Osteosynthesis, Cancellous screw, Union, Stress, Reduction, Conventional fixation, Covid, Cytokine reaction and storm

Severity of COVID-19 disease and heightened levels of prominent cytokines like IL-6, TNF-? and IFN-? do not bear uniform correlation. Evaluation of a specific cytokine panel at least confined to these three will be the key to precisely identify the differential cytokine pattern in each patient whether in ICU or out of ICU. Administration of selective immunosuppressive therapy becomes far more simpler after deciphering the particular cytokine level and targeting this cytokine. Tocilizumab, anti IL-6 biologic usually is the targeted immunosuppressive therapy against the specific raised IL-6 titre for ICU severe COVID-19 patients. A combination of targeted therapeutic approach against the specific raised cytokines with possibly, an effective antiviral therapy should guide the management protocol. Keywords: Cyotikines, IL-6, Tocilizumab, COVID-19, Cytokine storm, Cytokine panel, Immunosuppressive, Therapy.

No speci?c therapeutic drug has been found. In the absence of any specific therapy and non-availability of vaccine, anaesthetic ether (diethyl ether) is recommended to be used as a prophylactic and therapeutic intervention in the management of COVID-19 disease. Strong evidence based property of ether as lipid solvent has provided the impetus for this approach. The lipid content of the outer envelope of the virus is the weak-link to get dissolved ether and thus leading to disintegration of the single-stranded RNA. The viruses present inside the blood stream are bound to be killed by the presence of ether in the blood circulation. Keywords: Lipid bilayer, Lipid solvent, Oxygenation, Recreational, Halothane, Ether.

Viruses, though non-living particle, are real physical entities. Amongst various classifications, the Baltimore’s one (by Nobel Laureate Mr. Baltimore) places the virus in one of the seven groups. Basically, the nucleic acid composition classifies them into DNA or RNA virus. Strandedness-single or double, absence of envelope are two key components further details out the virus. Apart from ACE-2, TMPRSS also is important on the surface of the target host cell for entry of the virus. Human to human transmission is confirmed. All coronaviruses possess a fat envelope. “Wash your hands” is the buzz word. Keyword: SARS-CoV-2, ACE-2, TMPRSS-2, Viral envelope, Viral protein, Nucleic acid.

Ivermectin, one of the “wonder drugs” manufactured totally in Japan is another wonder drug and easily available all over the world for its anti-parasitic property. Single dose removing the viral RNA within 48 hours is an epoch making in vitro finding in Australia. Intracellular transport of the virus in the target host cell is blocked and multiplication of the virus is stopped, thus aborting infection. Patna dose recommendation has been advocated for both prevention and treatment of SARS-COVID-19 with definite claim that it will have no side effects. Keywords: Cargo transporter, Viricidal, wonder drug, Viral RNA, Filariasis, Round worm, River blindness.

Hydroxychloroquine, a safe derivative of chloroquine has been in practice since 1950. This drug has been used successfully as anti-viral agent previously. Its role in COVID-2 has been authenticated in the management protocol. The sudden death assigned to hydroxychloroquine is misplaced though it can be a very uncommon complication in cardiac patients with arrhythmia. Its prophylactic and therapeutic dose schedule needs to be streamlined at a lower dose schedule and is recommended to be used in early part of the disease and not during the stage of later complication. Keywords: Hydroxychloroquine, Arrhythmia, Pathogen, Host target cell, ACE-2, Intracellular.

The innate and adaptive immune systems are two interdependent bandwidths of immunity advanced during evolution process. Protection from foreign pathogens is the central theme of defense mechanism. Components of the immune system are well laid orchestra for keeping the immune system on alert. Robust host defense and cytokine storms are the key areas requiring attention with finality with introduction of IL-6 inhibitors or small molecules. Keywords: Immune system, T cells and B cells, Innate, Adaptive, Cytokine, Lymphatic system.

Spondyloarthropathy, a group of overlapping disorders of chronic inflammatory diseases of autoimmune nature has undergone critical changes in its management, specially with introduction of newer biologics and targeted synthetic DMARDs. Secukinumab and Tofacitinib are newer additions to proper management targeting various cytokines. Cost being an important factor in developing world, conventional synthetic DMARDs are being advocated to be used in situations where patient can not afford the treatment with biologics / small molecules i.e. JAK Inhibitors. It is heartening to know that methotrexate can achieve 20% remission in psoriatic arthritis almost equivalent to some biologics. Drug antibody is also a challenging problem in management with biologics. Keywords: Biologic, DMARDs, Secukinumab, Tofacitinib, JAK Inhibitors, Cost.

Synovial inflammation in rheumatic diseases leads to cartilage damage, bone erosions and subsequent joint destruction causing significant morbidity. Seronegative spondyloarthropathy or seropositive rheumatoid arthritis and their variants once diagnosed should be treated early to prevent the bony erosion. Delay of up to nine months in initiating Disease-Modifying Anti-rheumatic Drug (DMARD) definitely impacts clinical outcome several years later. During the last decade, introduction of biologics like TNF inhibitors have revolutionized the management of rheumatic diseases leading to early and prompt control over disease activity. One of the TNF inhibitors, Etanercept over the time has proven itself to be a reliable option for treatment of rheumatoid arthritis, spondyloarthropathy, psoriatic arthritis and other rheumatic diseases. Major drawback with biologics like Etanercept is their cost. Indian population differs substantially from western population in terms of height, weight, phenotype as well as genotype. Due to this difference in demographic profile and cost-affordability, many drugs have been used in low dose in Indian population. Etanercept can be a safe and effective option in rheumatic diseases even at half its recommended dose in countries like India where the average weight of people is less as compared to western population. Low dose also improves affordability, reduces risk of infections and may be, minimizes need for vaccination. In the modern era of biologicals, biosimilars have a huge potential to treat rheumatic diseases in India where affordability is a real challenge. This study was over 256 patients. Keywords: Spondyloarthropathy, DMARD, TNF inhibitor, Biologicals, Biosimilars.

In rheumatoid arthritis, there has been a paradigm shift from controlling symptoms to controlling the disease progress with abrogation of inflammation. Achieving this remission or very low disease activity has become increasingly possible with USA FDA approved first JAK inhibitor, Tofacitinib in November 2012 (not in Europe). This new small molecule JAK inhibitors are oral drug working intra-cellularly in comparison to TNF? inhibitors targeting a singly cytokine within extra-cellular space confining themselves to cell surface receptors. The second JAK inhibitor Baracitinib approved in Europe in February 2017 and in USA in May 2018 has greater promises. Once daily 2 mg oral dose used either as monotherapy or in combination with methotrexate in moderate to severe active rheumatoid arthritis in adults have provided remission, even in patients who have responded inadequately or are intolerant to one or more DMARDs / bDMARDs. It is a safe second line therapy after methotrexate. In DMARD naïve patients, it is likely to become first-line agents Keywords: JAK inhibitor, TNF? inhibitor, NSAID, bDMARD, Methotrexate, Tofacitinib.