Bronchopleural Fistula after High-flow Nasal Cannula Use in Patient with COVID-19

How to cite this article: Venkateswaran V, Chaturvedi A, Soni KD, Aggarwal R, Trikha A. Bronchopleural Fistula after High-flow Nasal Cannula Use in Patient with COVID-19. Indian J Crit Care Med 2021;25(7):830–831.

Epidemiology and Prognostic Utility of Cellular Components of Hematological System in Sepsis

Background

Data are lacking on the role of cellular components of hematological system as biomarkers for prognosis of sepsis. We planned to identify if these parameters measured at admission to ICU and at 72 hours can be useful as prognostic marker in septic critically ill patients.

Materials and methods

In this prospective observational study, 130 adult patients with sepsis were recruited. Various hematological study parameters (total, differential, and absolute leukocyte count, platelet count, platelet distribution width, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio) were noted at day 1 and day 3 of admission. Primary outcome was 28-day mortality, and secondary outcomes were duration of mechanical ventilation, vasopressor requirement, ICU length of stay, and requirement of renal replacement therapy. The variables were compared between two groups and using binary regression model and were evaluated as prognostic markers for 28-day mortality.

Results

Data from n = 129 were analyzed. At day-28, n = 58 (44.96%) patients survived. Baseline and demographic parameters were comparable between survivors and nonsurvivors. Admission Sequential Organ Failure Assessment score was more in nonsurvivors than survivors [8 (6–8) vs 6 (4–8); p = 0.002]. In nonsurvivors, monocyte, lymphocyte, basophil, eosinophil, and platelet count were significantly less at day 1 and lymphocyte, eosinophil, basophil and platelet count were significantly less at day 3. NLR and PLR at day 3 were significantly more in nonsurvivors. On logistic regression analysis, age, thrombocytopenia on day 1, and low eosinophil count on day 3 predicted 28-day mortality (p = 0.006, p = 0.02, and p = 0.04, respectively).

Conclusion

Thrombocytopenia on day 1 and eosinopenia on day 3 may predict 28-day mortality in sepsis.

How to cite this article

Sinha H, Maitra S, Anand RK, Aggarwal R, Rewari V, Subramaniam R, et al. Epidemiology and Prognostic Utility of Cellular Components of Hematological System in Sepsis. Indian J Crit Care Med 2021;25(6):660–667.

Outcome of Conservative Therapy in Coronavirus disease-2019 Patients Presenting With Gastrointestinal Bleeding

BACKGROUND/OBJECTIVE

There is a paucity of data on the management of gastrointestinal (GI) bleeding in patients with Coronavirus disease -2019 (COVID-19) amid concerns about the risk of transmission during endoscopic procedures. We aimed to study the outcomes of conservative treatment for GI bleeding in patients with COVID-19.

METHODS

In this retrospective analysis, 24 of 1342 (1.8%) patients with COVID-19, presenting with GI bleeding from 22nd April to 22nd July 2020, were included.

RESULTS

The mean age of patients was 45.8 ± 12.7 years; 17 (70.8%) were males; upper GI (UGI) bleeding: lower GI (LGI) 23:1. Twenty-two (91.6%) patients had evidence of cirrhosis- 21 presented with UGI bleeding while one had bleeding from hemorrhoids. Two patients without cirrhosis were presumed to have non-variceal bleeding. The medical therapy for UGI bleeding included vasoconstrictors-somatostatin in 17 (73.9%) and terlipressin in 4 (17.4%) patients. All patients with UGI bleeding received proton pump inhibitors and antibiotics. Packed red blood cells (PRBCs), fresh frozen plasma (FFPs) and platelets were transfused in 14 (60.9%), 3 (13.0%) and 3 (13.0%), respectively. The median PRBCs transfused was 1 (0-3) unit(s). The initial control of UGI bleeding was achieved in all 23 patients and none required an emergency endoscopy. At 5-day follow-up, none rebled or died. Two patients later rebled, one had intermittent bleed due to gastric antral vascular ectasia, while another had rebleed 19 days after discharge. Three (12.5%) cirrhosis patients succumbed to acute hypoxemic respiratory failure during hospital stay.

CONCLUSION

Conservative management strategies including pharmacotherapy, restrictive transfusion strategy, and close hemodynamic monitoring can successfully manage GI bleeding in COVID-19 patients and reduce need for urgent endoscopy. The decision for proceeding with endoscopy should be taken by a multidisciplinary team after consideration of the patient's condition, response to treatment, resources and the risks involved, on a case to case basis.

Check Central Venous Catheter Set thoroughly or Bite the Bullet!

How to cite this article: Singh AK, Kumar S, Aggarwal R, Trikha A. Check Central Venous Catheter Set thoroughly or Bite the Bullet! Indian J Crit Care Med 2021;25(7):832–833.

Endocervicoscopy with office hysteroscope for complete visualization of transformation zone in cases of invisible squamocolumnar junction on colposcopy

Aim:

To evaluate the role of endocervicoscopy for the visualization of the T3 transformation zone (TZ) on colposcopy.

Materials and Methods:

Forty patients with either abnormal Pap smear or positive VIA-VILI and T3 TZ on colposcopy were recruited from the colposcopy clinic and subjected to endocervicoscopy with a 4-mm office hysteroscope. The view of the endocervical canal was recorded before and after the application of 5% acetic acid and the squamocolumnar junction was identified in its entirety. An endocervical curettage was taken in all the cases and compared with the final histopathology report.

Results:

Squamocolumnar junction was visible in all the 40 cases; however, in two patients (5%), cervical dilatation had to be done. The positive predictive value (PPV) of endocervicoscopy in our study was 33.3% and negative predictive value (NPV) was 100%. Dense acetowhitening/irregular polypoidal endocervical mucosa with dilated blood vessels was significant in predicting the premalignant and malignant lesions with PPV of 67% and NPV of 100%.

Conclusion:

Endocervicoscopy allows a panoramic view of the endocervical canal. It is a safe, effective, and feasible technique for visualization of squamocolumnar junction with 5% acetic acid in cases of T3 TZ on colposcopy.

Clinicoepidemiological Features and Mortality Analysis of Deceased Patients with COVID-19 in a Tertiary Care Center

Background and objective

A large number of studies describing the clinicoepidemiological features of coronavirus disease-2019 (COVID-19) patients are available but very few studies have documented similar features of the deceased. This study was aimed to describe the clinicoepidemiological features and the causes of mortality of COVID-19 deceased patients admitted in a dedicated COVID center in India.

Methodology

This was a retrospective study done in adult deceased patients admitted in COVID ICU from April 4 to July 24, 2020. The clinical features, comorbidities, complications, and causes of mortality in these patients were analyzed. Pediatric deceased were analyzed separately.

Results

A total of 654 adult patients were admitted in the ICU during the study period and ICU mortality was 37.7% (247/654). Among the adult deceased, 65.9% were males with a median age of 56 years [interquartile range (IQR), 41.5-65] and 94.74% had one or more comorbidities, most common being hypertension (43.3%), diabetes mellitus (34.8%), and chronic kidney disease (20.6%). The most common presenting features in these deceased were fever (75.7%), cough (68.8%), and shortness of breath (67.6%). The mean initial sequential organ failure assessment score was 9.3 ± 4.7 and 24.2% were already intubated at the time of admission. The median duration of hospital stay was 6 days (IQR, 3-11). The most common cause of death was sepsis with multi-organ failure (55.1%) followed by severe acute respiratory distress syndrome (ARDS) (25.5%). All pediatric deceased had comorbid conditions and the most common cause of death in this group was severe ARDS.

Conclusion

In this cohort of adult deceased, most were young males with age less than 65 years with one or more comorbidities, hypertension being the most common. Only 5% of the deceased had no comorbidities. Sepsis with multi-organ dysfunction syndrome was the most common cause of death.

How to cite this article

Aggarwal R, Bhatia R, Kulshrestha K, Soni KD, Viswanath R, Singh AK, et al. Clinicoepidemiological Features and Mortality Analysis of Deceased Patients with COVID-19 in a Tertiary Care Center. Indian J Crit Care Med 2021; 25(6):622-628.

Practical consensus recommendations regarding the management of sentinel lymph node issues in early breast cancer

Axillary lymph node involvement is a very important poor prognostic factor in the clinical staging and management of breast cancer patients. Traditionally, axillary lymph node dissection (ALND) has been used for determining the status of the axillary lymph nodes. More recently the sentinel lymph node biopsy (SLNB) procedure has gained wider acceptance as the standard of care, having the advantage of being less invasivewhile providing good accuracy. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of the two different procedures and other issues in patients with early breast cancer for the benefit of community oncologists.

Gargle lavage as a viable alternative to swab for detection of SARS-CoV-2

Background & objectives

Nasopharyngeal and oropharyngeal swab (NPS and OPS) collection is widely accepted as the preferred method for obtaining respiratory samples. However, it has certain disadvantages which may be overcome by gargling. The primary objective of this study was to assess agreement between gargle lavage and swab as an appropriate respiratory sample for the detection of SARS-CoV-2. The secondary objective was to assess the patient acceptability of the two sampling methods.

Methods

It was a cross-sectional study done at a tertiary care hospital in New Delhi, India, on 50 confirmed COVID-19 patients. Paired swab (NPS and OPS) and gargle samples were taken within 72 h of their diagnosis. Samples were processed by reverse transcription-polymerase chain reaction (RT-PCR) for detection of SARS-CoV-2. Post-sample collection, a 10-point scale was administered to assess the level of discomfort with either of the collection methods.

Results

All gargle samples were positive and comparable to their corresponding swab samples irrespective of the symptoms and duration of illness. The cycle threshold (C_t) values for gargle samples were slightly higher but comparable to those of swabs. Bland-Altman plot showed good agreement between the two methods. Majority (72%) of the patients reported moderate-to-severe discomfort with swab collection in comparison to 24 per cent reporting only mild discomfort with gargle collection.

Interpretation & conclusions

Our preliminary results show that the gargle lavage may be a viable alternative to swabs for sample collection for the detection of SARS-CoV-2. Adoption of gargle lavage for sample collection will have a significant impact as it will enable easy self-collection, relieve healthcare workers and also lead to substantial cost savings by reducing the need for swabs and personal protective equipment.

A cross-sectional study of immune seroconversion to SARS-CoV-2 in frontline maternity health professionals

COVID-19, the respiratory disease caused by SARS-CoV-2, is thought to cause a milder illness in pregnancy with a greater proportion of asymptomatic carriers. This has important implications for the risk of patient-to-staff, staff-to-staff and staff-to-patient transmission among health professionals in maternity units. The aim of this study was to investigate the prevalence of previously undiagnosed SARS-CoV-2 infection in health professionals from two tertiary-level maternity units in London, UK, and to determine associations between healthcare workers' characteristics, reported symptoms and serological evidence of prior SARS-CoV-2 infection. In total, 200 anaesthetists, midwives and obstetricians, with no previously confirmed diagnosis of COVID-19, were tested for immune seroconversion using laboratory IgG assays. Comprehensive symptom and medical histories were also collected. Five out of 40 (12.5%; 95%CI 4.2-26.8%) anaesthetists, 7/52 (13.5%; 95%CI 5.6-25.8%) obstetricians and 17/108 (15.7%; 95%CI 9.5-24.0%) midwives were seropositive, with an overall total of 29/200 (14.5%; 95%CI 9.9-20.1%) of maternity healthcare workers testing positive for IgG antibodies against SARS-CoV-2. Of those who had seroconverted, 10/29 (35.5%) were completely asymptomatic. Fever or cough were only present in 6/29 (21%) and 10/29 (35%) respectively. Anosmia was the most common symptom occurring in 15/29 (52%) seropositive participants and was the only symptom that was predictive of positive seroconversion (OR 18; 95%CI 6-55). Of those who were seropositive, 59% had not self-isolated at any point and continued to provide patient care in the hospital setting. This is the largest study of baseline immune seroconversion in maternity healthcare workers conducted to date and reveals that one out of six were seropositive, of whom one out of three were asymptomatic. This has significant implications for the risk of occupational transmission of SARS-CoV-2 for both staff and patients in maternity units. Regular testing of staff, including asymptomatic staff should be considered to reduce transmission risk.

Outcome of Conservative Therapy in COVID-19 Patients Presenting with Gastrointestinal Bleeding.. [DOI: 10.1101/2020.08.06.20169813]

Background/Objective

There is a paucity of data on the management of gastrointestinal (GI) bleeding in patients with COVID-19 amid concerns about the risk of transmission during endoscopic procedures. We aimed to study the outcomes of conservative treatment for GI bleeding in patients with COVID-19.

Methods

In this retrospective analysis, 24 of 1342 (1.8%) patients with COVID-19, presenting with GI bleeding from 22 April to 22 July 2020, were included.

Results

The mean age of patients was 45.8±12.7 years; 17 (70.8%) were males; upper GI (UGI) bleeding: lower GI (LGI) 23:1. Twenty-two (91.6%) patients had evidence of cirrhosis-21 presented with UGI bleeding while one had bleeding from hemorrhoids. Two patients without cirrhosis were presumed to have non-variceal bleeding. The medical therapy for UGI bleeding included vasoconstrictors-somatostatin in 17 (73.9%) and terlipressin in 4 (17.4%) patients. All patients with UGI bleeding received proton pump inhibitors and antibiotics. Packed red blood cells (PRBCs), fresh frozen plasma and platelets were transfused in 14 (60.9%), 3 (13.0%) and 3 (13.0%), respectively. The median PRBCs transfused was 1 (0-3) unit(s). The initial control of UGI bleeding was achieved in all 23 patients and none required an emergency endoscopy. At 5-day follow-up, none rebled or died. Two patients later rebled, one had intermittent bleed due to gastric antral vascular ectasia, while another had rebleed 19 days after discharge. Three (12.5%) cirrhosis patients succumbed to acute hypoxemic respiratory failure during hospital stay.

Conclusion

Conservative management strategies including pharmacotherapy, restrictive transfusion strategy, and close hemodynamic monitoring can successfully manage GI bleeding in COVID-19 patients and reduce need for urgent endoscopy. The decision for proceeding with endoscopy should be taken by a multidisciplinary team after consideration of the patient’s condition, response to treatment, resources and the risks involved, on a case to case basis.

Fast tracking intensive care units and operation rooms during the COVID-19 pandemic in resource limited settings

The ongoing pandemic of COVID-19 has affected more than 43 million people all over the world with about 280000 deaths worldwide at the time of writing this article The outcome of this pandemic is impossible to predict at the present time as the numbers of both, infected patients and those dying of the disease are increasing on a daily basis. China, Italy, France, Spain, Germany, United Kingdom, and USA are the worst affected countries. All these countries have robust health care systems but despite this there has been a huge shortage of health care facilities especially intensive care beds in these countries. A country like India has different challenges as far as medical care during this pandemic is concerned. The need of the hour is to improve the health care system as a whole. In the present pandemic this involves setting up of patients screening facilities for the disease, enhancing the number of hospital beds, setting up of dedicated high dependency units, intensive care units and operation theatres for COVID positive patients. The present article describes in brief the way this can be done in a short time.

Poor Outcomes in Patients with Cirrhosis and COVID-19.. [DOI: 10.21203/rs.3.rs-40220/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background and AimThere is a paucity of data on the clinical presentations and outcomes of Coronavirus disease 2019(COVID-19) in patients with underlying liver disease. We aimed to summarize the presentations and outcomes of COVID-19 positive patients and compare with historical controls.MethodsPatients with known chronic liver disease who presented with superimposed COVID- 19(n=28) between 22nd April and 22nd June 2020 were studied. Seventy-eight cirrhotic patients from historical controls were taken as comparison group.ResultsA total of 28 COVID patients- two without cirrhosis, one with compensated cirrhosis, sixteen with acute decompensation (AD), and nine with acute-on-chronic liver failure(ACLF) were included. The etiology of cirrhosis was alcohol(n=9), non-alcoholic fatty liver disease(n=2), viral(n=5), autoimmune hepatitis(n=4), and cryptogenic cirrhosis(n=6). The clinical presentations included complications of cirrhosis in 12(46.2%), respiratory symptoms in 3(11.5%) and combined complications of cirrhosis and respiratory symptoms in 11(42.3%) patients. The median hospital stay was 8(7-12) days. The mortality rate in COVID-19 patients was 42.3%(11/26), as compared to 23.1%(18/78) in the historical controls(p=0.077). All COVID-19 patients with ACLF(9/9) died compared to 53.3%(16/30) in ACLF of historical controls(p=0.015). Mortality rate was higher in COVID patients with compensated cirrhosis and AD as compared to historical controls 2/17(11.8%) vs 2/48(4.2%), though not statistically significant (p=0.278). Requirement of mechanical ventilation independently predicted mortality (hazard ratio, 13.68). Both non-cirrhotic patients presented with respiratory symptoms and recovered uneventfully.ConclusionCOVID-19 is associated with poor outcomes in patients with cirrhosis, with worst survival rates in ACLF. Mechanical ventilation is associated with a poor outcome.

Prognostic Value of Serially Estimated Serum Procalcitonin Levels in Traumatic Brain Injury Patients With or Without Extra Cranial Injury on Early In-hospital Mortality: A Longitudinal Observational Study

Background

Traumatic brain injury (TBI) is associated with majority of trauma deaths, and objective tools are required to understand the severity of injury. The application of a biomarker like procalcitonin (PCT) in TBI may allow for assessment of severity and thus aid in prognostication and correlation with mortality and outcome.

Aims

The primary objective is to determine the correlation between PCT concentrations with TBI outcomes (mainly in terms of mortality) at intensive care unit (ICU)/hospital discharge. Secondary objectives are to evaluate correlation with associated extra cranial injuries and complications during hospital stay.

Methods

In total, 186 TBI patients aged > 18 years with minimum survival for at least 12 h admitted to the ICU at the level 1 trauma center were prospectively included in the study and divided into two groups: TBI with and without extra cranial injuries. All admitted patients were treated according to the standard institutional protocol. The PCT levels were obtained on admission, on day 2, and 5. Clinical, laboratory, diagnostic, and therapeutic data were also collected. Primary mortality is defined as death related to central nervous system (CNS) injury, while secondary mortality defined as death related to sepsis or extracranial cause.

Results

Median PCT levels at admission, day 2, and day 5 in TBI patients with extracranial injuries were 3.0, 0.83, and 0.69 ng/ml. In total, primary mortality was observed in 18 (9.7%) patients, while secondary causes were attributable in 20 (12.3%) patients. Regression analysis for primarily CNS cause of mortality showed PCT cutoff level at admission more than 5.5 ng/ml carried sensitivity and specificity of 75%, but for secondary cause (sepsis) of mortality, PCT cutoff values on day 2 > 1.15 ng/ml were derived significant with sensitivity of 70% and specificity of 66%. No significant association of parameters like length of ICU stay, Glasgow outcome scale (GOS), and primary/secondary mortality with the presence of extracranial injuries in TBI patients as compared with TBI alone was noted.

Conclusion

This observational study demonstrates the poor correlation between PCT concentrations with outcome at days 1, 2, and 5 post-injury. The predicted relationship between PCT levels and outcome was not confirmed, and that these results do not support the prognostic utility of PCT biomarker in this population for outcome (mortality) assessment in TBI patients with or without extracranial injuries.

AB0581 HIGH PREVALENCE OF TUBERCULOSIS IN ADULTS AND CHILDREN WITH IIM AS COMPARED WITH SLE: RETROSPECTIVE DATA REVIEW FROM A LARGE COHORT AT A TERTIARY CARE CENTER IN INDIA

Background:

Infections are the most common cause of morbidity and mortality in idiopathic inflammatory myositis (IIM). India is endemic for Tuberculosis (TB) with a prevalence of 2.3 cases per thousand population.

Objectives:

Thus, we studied the prevalence of TB in our cohort of IIM patients and compared with that in systemic lupus erythematosus (SLE).

Methods:

Medical records from paper charts and electronic medical records were reviewed for adults and juvenile patients with SLE (ACR criteria 1997) and IIM (Bohan and Peter criteria 1975) first presented at a tertiary care hospital in India from 1989 to 2016. Clinical variables including disease characteristics variables, the frequency, site, duration and complication of active TB as well as dose of corticosteroids and other immunosuppressive drugs were extracted retrospectively from the medical records. Descriptive statistics were used to describe the cohort and TB characteristics. Chi-square and t-test were used to evaluate association of TB with clinical diagnosis as well as medication data.

Results:

There were 167 (132 adults and 35 juvenile) IIM and 280 (131 adults and 149 juvenile) SLE in our cohort. Active TB occurred in 24 (14.4%) of all IIM cases (18, 13.6% adults; 6, 17.1% juvenile) as compared to 18 (6.4%) of all SLE cases (8, 6.1% adults; 10, 6.7% juvenile, p value < 0.01). Of all the TB in myositis, most often it was seen in Dermatomyositis (n=11, 45.8%) followed by Polymyositis (5, 20.8%), and occasionally in Overlap myositis (3, 12.5) and juvenile dermatomyositis (1,4.1%).

Considering an annual TB rate of 211 per 100,000 of the general population, the risk of developing active TB was 62-fold higher in patients with IIM and 27-fold higher in those with lupus. Patients with IIM had higher odds of developing TB as compared with Lupus [odds ratio 2.86 (CI 1.5-5.47), p=0.007).

Amongst 24 IIM patients with TB, 10 had pulmonary TB and 14 had extra-pulmonary TB. The median glucocorticoid dose at the diagnosis of TB was 0.25 (0-1.5) mg/kg/day. Half the cases of active TB occurred during inactive myositis. Seventeen patients with active TB were followed up over 27 months (8-184), with remission of TB in all cases but required prolonged courses of Anti-Tuberculous Therapy (ATT) in 25% cases with 10 ATT related adverse events in 8 patients and 5 patients with relapse of myositis due to lowering of immunosuppression.

Conclusion:

Patients with IIM have higher prevalence of active TB as compared with SLE patients. The risk is highest in patients with Dermatomyositis possibly related to high doses of steroids. Extra-pulmonary forms of TB are more common, and patients commonly require prolonged course of ATT and may suffer relapses of myositis during ATT. Screening for latent TB may be useful in IIM patients before prescribing steroids and other immunosuppressive drugs.

References:

[1]TB Statistics India | National, treatment outcome & state statistics [Internet]. TB Facts | TB, tests, drugs, statistics. [cited 2019 Jun 13]. Available from:https://www.tbfacts.org/tb-statistics-india/

[2]Muhammed H, Gupta L, Zanwar A, Misra DP, Lawrence A, Agarwal V, Aggarwal A, Misra R;OPC0243: Infections are leading cause of in-hospital mortality in patients with inflammatory myositis; Indian J Rheumatol 2018;13, Suppl S2:93-241

[3]Gaitonde S, Pathan E, Sule A, Mittal G, Joshi VR. Efficacy of isoniazid prophylaxis in patients with systemic lupus erythematosus receiving long term steroid treatment. Ann Rheum Dis. 2002 Mar;61(3):251–3.

[18]He D, Bai F, Zhang S, Jiang T, Shen J, Zhu Q, et al. High incidence of tuberculosis infection in rheumatic diseases and impact for chemoprophylactic prevention of tuberculosis activation during biologics therapy. Clin Vaccine Immunol CVI. 2013 Jun;20(6):842–7.

Figure 1.

(A) Prevalence and (B) sites of tuberculosis

Table 1.

Table 2.

Clinical profile of patients with Tuberculosis

Disclosure of Interests:

Latika Gupta: None declared, Abhishek Zanwar: None declared, Rohit Aggarwal Grant/research support from: Pfizer, Genentech, BMS, Mallinckrodt, Consultant of: Pfizer, Genentech, BMS, Mallinckrodt, Bristol Myers-Squibb, octapharma, CSL Behring, AstraZeneca, Corbus, Kezar, Abbvie, Able Lawrence: None declared, Durga Misra: None declared, Vikas Agarwal: None declared, Ramnath Misra: None declared, Amita Aggarwal: None declared

AB0599 TREATMENT OF REFRACTORY DERMATOMYOSITIS WITH TOFACITINIB

Background:

Dermatomyositis (DM) is a systemic, autoimmune disease affecting the skin and proximal skeletal muscles. A subset of DM patients present with subclinical or resolved muscle involvement but continue to have skin disease. In these cases, first and second line treatments including glucocorticoids are sometimes insufficient for controlling the disease, necessitating escalation of treatment. Several recent studies have investigated the response of Tofacitinib, an oral Janus Kinase inhibitor approved for the treatment of rheumatoid arthritis, in DM patients and patients with inflammatory skin diseases.

Objectives:

Due to the reported ability of JAK inhibitors to suppress type 1 interferon (IFN) signaling, which is suspected to be upregulated in DM, we evaluated the efficacy of treatment with Tofacitinib in four refractory DM patients.

Methods:

Four patients with dermatomyositis without evidence of current muscle involvement began treatment with Tofacitinib 11 mg daily after they had failed or had adverse effects to first and second line immunosuppressive agents. Their medical records were reviewed at 0, 3, and 6 months, with improvement measured using the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) activity score. Throughout their treatment they were additionally monitored for improvement in markers of inflammation and the necessity for concomitant treatments. Patients were monitored for adverse effects to Tofacitinib treatment.

Results:

All four patients within the case series showed significant improvement of their cutaneous disease activity (CDASI scores improved by 8-15 points) over the first 6 months, with three of the four having achieved minimal clinically improved difference of >= 5 point by three months. Based on the CDASI, three of the cases’ disease classification changed from moderate-to-severe disease to mild disease. The last patient initially presented with mild disease. Other outcomes noted included improved pruritus in 3 patients and improvement of calcinosis in 1 patient. One patient was additionally able to stop concomitant treatment with prednisone and IVIG at 3 and 6 months, respectively. This patient had been on daily prednisone for 4 years. Only other patient on prednisone was on low dose of 3mg daily. The patients all had normal muscle exams prior to treatment with Tofacitinib. No worsening muscle involvement or adverse effects were noted with Tofacitinib use.

Conclusion:

Tofacitinib is believed to play a role in the inhibition of IFN signaling pathways that are overactive in dermatomyositis. All four patients within this retrospective study showed significant improvement of cutaneous disease with Tofacitinib use.

References:

[1]Moghadam-Kia S.Rheumatology. 2019;58(6):1011-1015.

[2]Kurtzman D.JAMA Dermatol. 2016;152(8):944.

[3]Paik J.Semin Arthritis Rheum. 2017;46(4):e19.

[4]Kurasawa K.Rheumatology. 2018;57(12):2114-2119.

[5]Anyanwu CO.Br J Dermatol. 2015; 173(4):969-974.

Gender/ Age/ EthnicityDM Subtype /disease durationPrevious TreatmentConcomitant Treatment with TOFCDASI ActivityCDASI Activity 3 monthCDASI Activity 6 monthOther OutcomeM/ 55/ CaucasianAmyopathic DM; 5 yearsAZA, HCQ, IVIG, MTX, MMF, Prednisone, RCI, RTX, TACHCQ1254NoneF/ 37/ CaucasianAmyopathic DM; 7 yearsAZA, HCQ, IVIG, MTX, MMF, Prednisone, RCI, TACPrednisone, IVIG, MTX1585Pruritus and CRP improvedF/ 60/ CaucasianAmyopathic DM; 4 yearsAZA, MTX, PrednisonePrednisone, MTX17155Pruritus improvedF/ 47 African AmericanClassic DM; 5 yearsAZA, colchicine, HCQ, IVIG, MTX, MMF, pamidronate Prednisone, RCI, RTX, TACIVIG, Colchicine2287Pruritus and calcinosis improved

Abbreviations: CDASI, Cutaneous Dermatomyositis Disease Area and Severity Index; AZA, azathioprine; CRP, C-reactive protein; DM, Dermatomyositis, HCQ, hydroxychloroquine; IVIG, intravenous immunoglobulin; MTX, methotrexate; MMF, mycophenolate mofetil; RCI, repository-corticotropin injection; RTX, rituximab; TAC, tacrolimus; TOF, tofacitinib;

Disclosure of Interests:

Kirsten Riggle: None declared, Aarat Patel Speakers bureau: Abbvie, Mallinckrodt, Celgene, Lilly, Rohit Aggarwal Grant/research support from: Pfizer, Genentech, BMS, Mallinckrodt, Consultant of: Pfizer, Genentech, BMS, Mallinckrodt, Bristol Myers-Squibb, octapharma, CSL Behring, AstraZeneca, Corbus, Kezar, Abbvie

SAT0323 MYOSITIS-SPECIFIC AND MYOSITIS-ASSOCIATED AUTOANTIBODIES IN A LARGE INDIAN COHORT OF INFLAMMATORY MYOSITIS REVEAL NOVEL CLINICO-PHENOTYPIC PATTERNS

Background:

Idiopathic Inflammatory Myositis (IIM) are heterogenous, with distinct autoantibodies reflecting upon possible clinical evolution and outcomes. Ethnicity has major influence on both antibody prevalence patterns as well as phenotypic behaviours linked to them.

Objectives:

Thus we sought prevalence and co-existence of myositis specific autoantibodies (MSAs) and myositis associated autoantibodies (MAAs) and associated clinical characteristics in a large cohort of patients with IIM.

Methods:

Adult patients with a physician diagnosis of IIM as per ACR/EULAR classification criteria were investigated for the presence of MSAs/MAAs by Line immunoassay (G4, Euro-Immune, Lubeck, Germany). Anti-Nuclear Antibody (ANA) was tested by Immunofluorescence assay (IFA), and patterns in various antibody subsets explored. Prevalence and associations of different antibodies were assessed in disease subsets and clinical phenotypes.

Results:

MSA and MAAs were tested in 250 IIM patients (F:M 3.8:1) of median age 37 (25-47) and disease duration 6 (3-17) years. Dermatomyositis (DM) was seen in most patients 83 (33.2%) followed by overlap myositis (OM), juvenile DM, Anti-synthetase syndrome (ASS), polymyositis (PM), and cancer associated myositis (CAM). MSAs/MAAs were found in 148 (59.2%) of patients, of which 95 (64.2%) had an MSA and 53 (35.8%) had MAAs (Fig, 1A). 93 (62.8%) of autoantibody positive patients were positive for a single antibody, and only 2 (0.8%) of total had more than one MSA (Table 1).

Table 1.

Multiple antibodies positive upon testing for MSA and MAA by the LIA

Note: ** PL-7 co-exists with Ku + Pm/Scl, **PL-12 co-exists with Pm/Scl + Ro52, **SRP co-exists with Pm/Scl + Ro52

The most frequently detected MSA was anti-Jo-1 (8%), with a further 9 specificities each found in 0.5–7.0% of patients. Amongst the autoantibody positive patients, 21% (n=53) had isolated MAA positivity, anti-Ro52 (33, 62.3%) being the most common, followed by anti-Pm/Scl (11, 20.8%) and anti-Ku (9, 17.0%) (Fig. 1B).

Figure 1.

A. MSA and MAA in Indian cohort of myositis B. ANA patterns in myositis C. MSA in ANA negative IIM

On ANA, 76.0% (172 of 226) were positive, with speckled being the most common pattern (37%,Fig. 1C). Of those ANA negative (n=54), 61% had either MSA or MAA (Fig 1D). 18 (54.6%) had autoantibodies associated with cytoplasmic patterns suggesting that cytoplasmic ANA may be underreported.

Clinical presentation akin to DM was seen with all MSA except anti-SRP. PM group was heterogenous, and included ASS, OM and necrotizing phenotype (Fig. 2A). On occasion, anti-SRP, anti-Mi-2 and anti-MDA5 presented with clinical phenotype of ASS. (Fig 2A,C). Patients with ARS or anti-SAE were often clinically amyopathic (Figure 2B,C)

Figure 2.

A. Phenotypic associated with various antibody subsets B,C,and D. MSA/MAA in muscle weakness, rash and ILD phenotype. E. Unique feature of eye-lid edema in some patients with MDA-5 positive myositis

ARS were associated with mechanic’s hand (p<0.0001,OR 7.6), ILD (p<0.0001,OR 4.4), and arthritis (p=.002,OR 2.6) though there was no difference between Jo-1 and non-Jo-1 ASS. Anti-MDA-5 associated with fever (p=0.003,OR 12) and weight loss (p=0.008,OR 10.2) and unique phenotype of eye-lid edema in some adults (Figure 2E) and arthritis in children (p=0.01, OR 11.5). Anti-TIF-1ɣ associated with alopecia (p=0.007,OR 5.9) and malignancy (p= <0.0001,OR 34) in adults but not children.

Conclusion:

Myositis autoantibodies are seen in two-thirds IIM and identify distinct clinical subsets as well as unique phenotypes. MSA/MAA are positive in two-thirds of those negative on ANA, adding diagnostic value. MSAs are nearly always mutually exclusive and thus useful as biomarkers for diagnosis.

Acknowledgments:

MSA testing supported by grants from APLAR and Association of Physicians of India.

Disclosure of Interests:

Latika Gupta: None declared, Priyanka Gaur: None declared, Vikas Agarwal: None declared, Rohit Aggarwal Grant/research support from: Pfizer, Genentech, BMS, Mallinckrodt, Consultant of: Pfizer, Genentech, BMS, Mallinckrodt, Bristol Myers-Squibb, octapharma, CSL Behring, AstraZeneca, Corbus, Kezar, Abbvie, Ramnath Misra: None declared

Treatment and management strategies of onychomycosis

Onychomycosis is one of the most prevalent and severe nail fungal infections, which is affecting a wide population across the globe. It leads to variations like nail thickening, disintegration and hardening. Oral and topical drug delivery systems are the most desirable in treating onychomycosis, but the efficacy of the results is low, resulting in a relapse rate of 25-30%. Due to systemic toxicity and various other disadvantages associated with oral therapy like gastrointestinal, hepatotoxicity, topical therapy is commonly used. Topical therapy improves patient compliance and reduces the cost of treatment. However, due to poor penetration of topical therapy across the nail plate, research is focused on different chemical, mechanical and physical methods to improve drug delivery. Penetration enhancers like Thioglycolic acid, Hydroxypropyl-β-cyclodextrin (HP-β-CD), Sodium lauryl sulfate (SLS), carbocysteine, N-acetylcysteine etc. have shown results enhancing the drug penetration across the nail plate. Results with physical techniques such as iontophoresis, laser and Photodynamic therapy are quite promising, but the long-term suitability of these devices is in need to be determined. In this article, a brief analysis of the treatment procedures, factors affecting drug permeation across nail plate, chemical, mechanical and physical devices used to increase the drug delivery through nails for the onychomycosis management has been achieved.

Prone positioning in a patient with fat embolism syndrome presenting as diffuse alveolar haemorrhage: new perspective

Diffuse alveolar haemorrhage (DAH) is a rare complication of fat embolism syndrome leading to severe hypoxaemia due to the effusion of blood into the alveoli from the damaged pulmonary microvasculature. The management is usually supportive with patients being nursed in supine position. The use of prone position ventilation in a DAH has rarely been reported before. We report an interesting case of a 26-year-old male patient diagnosed with DAH caused by fat embolism in whom prone position ventilation improved the lung dynamics and oxygenation.

Comparison of Bispectral Index-Guided Administration of Desflurane and Propofol for Endoscopic Transnasal Transsphenoidal Resection of Pituitary Tumors

Background Use of short-acting anesthetic agents such as propofol and desflurane allows rapid awakening and prompt neurological assessment of patients undergoing endoscopic transnasal transsphenoidal resection of pituitary tumors. However, there are no studies comparing the effect of these two agents in these patients. We performed this study to compare the intraoperative hemodynamics and postoperative recovery characteristics of patients undergoing endoscopic transnasal transsphenoidal (TNTS) pituitary tumor surgery using bispectral index (BIS)-guided administration of desflurane and propofol.

Materials and Methods In this prospective, randomized trial, 60 patients undergoing endoscopic TNTS pituitary surgery were randomized to receive BIS-guided administration of either propofol (Group P) or desflurane (Group D) for the maintenance of anesthesia. Heart rate (HR), mean arterial pressure (MAP), intraoperative complications, time to emergence, extubation, cognition, and modified Aldrete score were evaluated. Statistical analysis was performed using STATA 12.0. Categorical and continuous variables were compared between the groups using Fisher’s exact test and t-test, respectively. Emergence from anesthesia and hemodynamics at various stages of surgery was compared between the groups using Wilcoxon rank sum test. The p-value < 0.05 was considered statistically significant.

Results The HR was significantly higher at all stages of surgery in group P (p = 0.01). MAP was comparable between the groups at various time points (p > 0.05). Both emergence time (8.5 vs. 15 minutes; p < 0.00) and extubation time (10 vs. 17.5 minutes; p < 0.00) were significantly shorter in Group D compared with Group P. Modified Aldrete score at 5 and 10 minutes after extubation was higher with desflurane than propofol, but early cognition was comparable between the two groups.

Conclusion The hemodynamics and early cognition score were comparable in patients receiving propofol or desflurane. Desflurane provides rapid emergence and recovery when compared with propofol.

Crosstalk between T Helper Cell Subsets and Their Roles in Immunopathogenesis and Outcome of Polytrauma Patients

Purpose

One of the leading causes of morbidity and early-age mortality across the globe is trauma. It disrupts immune system homeostasis and intensely affects the innate and adaptive immune responses, predisposing patients to posttrauma complications and poor outcomes. Most of the studies on posttrauma cellular immune response have been centered on the T helper-1-T helper-2 imbalances after trauma. This study was conducted to understand the role of circulating novel T helper cells in the acute posttraumatic period and clinical outcome of trauma patients.

Materials and methods

Signature cytokines and transcription factors of circulating Th (T helper)-9, Th-17, Th-22, and regulatory T helper cells were studied using flowcytometry along with serum biomarkers in 49 patients with polytraumatic injuries admitted to a tertiary care hospital. The patients were followed up until their outcome. The results were correlated with their clinical outcomes.

Results

In patients who died, higher nTreg, iTreg, Tr1 (early-phase), and higher IRF4+Th-9, IL17+ Th-17, and RORγT+ Th-17 (mid-phase) were seen. However, by the late phase, only RORγT+ Th-17 remained higher. Serum IL-6 and PCT were found to be consistently higher. In survivors, higher Th-3 (early phase), Th-22 (mid-phase), and IRF4+Th-9, IL17+ Th-17, nTreg, Th-3 (late phase) were observed to have played a protective role. Serum IL-2, IL-4, IL-17A and IL-22 were significantly higher in survivors.

Conclusion

Different T helper subsets were observed to be playing pathogenic and protective roles in different phases of trauma and could be used for early prognostication and make way for noninvasive management of critically injured trauma patients by immunomodulation.

How to cite this article

Khurana S, Bhardwaj N, Kumar S, Sagar S, Pal R, Soni KD, et al. Crosstalk between T Helper Cell Subsets and Their Roles in Immunopathogenesis and Outcome of Polytrauma Patients. Indian J Crit Care Med 2020;24(11):1037–1044.

Acquiring Ventilators: Fighter Planes without High-octane Fuel and Pilots: Indian Perspective in COVID Era

During this coronavirus disease-19 (COVID-19) pandemic, all the countries are emphasizing on procurement of more and more sophisticated machineries for the intensive care unit (ICU) like ventilators. But do all countries have to follow the same? The requirements are different for low- and middle-income countries like India, which are resource limited. The ventilators require oxygen supply and manpower to function which are deficient in these countries. These countries might do well only by procurement of oxygen delivery machinery, as most of the patients of COVID require oxygen only. Only approx. Five percent of COVID-19 patients require ventilators. Moreover, the patients on ventilators have high mortality. Thus, low-resource countries need to redefine their priority as to how to utilize their resources. This manuscript emphasizes the need for the same.