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Kansal A, Latour JM, See KC, Rai S, Cecconi M, Britto C, Conway Morris A, Dominic Savio R, Nadkarni VM, Rao BK, Mishra R. Correction to: Interventions to promote cost-effectiveness in adult intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study. Crit Care 2024; 28:121. [PMID: 38610027 PMCID: PMC11015536 DOI: 10.1186/s13054-024-04888-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Affiliation(s)
- Amit Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, Jurong Health Campus, National University Health System, Singapore, Singapore.
| | - Jos M Latour
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Sumeet Rai
- Intensive Care Unit, Canberra Hospital, Canberra, Australia
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Carl Britto
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, USA
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- John V Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Vinay M Nadkarni
- Department of Anesthesiology, Critical Care, and Pediatrics at the Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - B K Rao
- Department of Critical Care Medicine, Sir Ganga Ram Hospital, New Delhi, India
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Kansal A, Latour JM, See KC, Rai S, Cecconi M, Britto C, Conway Morris A, Dominic Savio R, Nadkarni VM, Rao BK, Mishra R. Interventions to promote cost-effectiveness in adult intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study. Crit Care 2023; 27:487. [PMID: 38082302 PMCID: PMC10712165 DOI: 10.1186/s13054-023-04766-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources. METHODS A three-round modified online Delphi process, using a web-based platform, sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilized a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. Thereafter, the steering committee endorsed interventions that were identified as 'critical' by more than 50% of steering committee members. These interventions and experts' comments were summarized as final considerations for best practice. RESULTS At the conclusion of round 3, consensus was obtained on 50 best practice considerations for cost-effectiveness in adult ICU. Finally, the steering committee endorsed 9 'critical' best practice considerations. This included adoption of a multidisciplinary ICU model of care, focus on staff training and competency assessment, ongoing quality audits, thus ensuring high quality of critical care services whether within or outside the four walls of ICUs, implementation of a dynamic staff roster, multidisciplinary approach to implementing end-of-life care, early mobilization and promoting international consensus efforts on the Green ICU concept. CONCLUSIONS This Delphi study with international experts resulted in 9 consensus statements and best practice considerations promoting cost-effectiveness in adult ICUs. Stakeholders (government bodies, professional societies) must lead the efforts to identify locally applicable specifics while working within these best practice considerations with the available resources.
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Affiliation(s)
- Amit Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, Jurong Health Campus, National University Health System, Singapore, Singapore.
| | - Jos M Latour
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Sumeet Rai
- Intensive Care Unit, Canberra Hospital, Canberra, Australia
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Carl Britto
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, USA
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- John V Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Vinay M Nadkarni
- Department of Anesthesiology, Critical Care, and Pediatrics at the Children's Hospital of Philadelphia (CHOP), University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - B K Rao
- Department of Critical Care Medicine, Sir Ganga Ram Hospital, New Delhi, India
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Ng HJH, Kansal A, Abdul Naseer JF, Hing WC, Goh CJM, Poh H, D’souza JLA, Lim EL, Tan G. Optimizing Best Practice Advisory alerts in electronic medical records with a multi-pronged strategy at a tertiary care hospital in Singapore. JAMIA Open 2023; 6:ooad056. [PMID: 37538232 PMCID: PMC10393867 DOI: 10.1093/jamiaopen/ooad056] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 05/23/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
Objective Clinical decision support (CDS) alerts can aid in improving patient care. One CDS functionality is the Best Practice Advisory (BPA) alert notification system, wherein BPA alerts are automated alerts embedded in the hospital's electronic medical records (EMR). However, excessive alerts can change clinician behavior; redundant and repetitive alerts can contribute to alert fatigue. Alerts can be optimized through a multipronged strategy. Our study aims to describe these strategies adopted and evaluate the resultant BPA alert optimization outcomes. Materials and Methods This retrospective single-center study was done at Jurong Health Campus. Aggregated, anonymized data on patient demographics and alert statistics were collected from January 1, 2018 to December 31, 2021. "Preintervention" period was January 1-December 31, 2018, and "postintervention" period was January 1-December 31, 2021. The intervention period was the intervening period. Categorical variables were reported as frequencies and proportions and compared using the chi-square test. Continuous data were reported as median (interquartile range, IQR) and compared using the Wilcoxon rank-sum test. Statistical significance was defined at P < .05. Results There was a significant reduction of 59.6% in the total number of interruptive BPA alerts, despite an increase in the number of unique BPAs from 54 to 360 from pre- to postintervention. There was a 74% reduction in the number of alerts from the 7 BPAs that were optimized from the pre- to postintervention period. There was a significant increase in percentage of overall interruptive BPA alerts with action taken (8 [IQR 7.7-8.4] to 54.7 [IQR 52.5-58.9], P-value < .05) and optimized BPAs with action taken (32.6 [IQR 32.3-32.9] to 72.6 [IQR 64.3-73.4], P-value < .05). We estimate that the reduction in alerts saved 3600 h of providers' time per year. Conclusions A significant reduction in interruptive alert volume, and a significant increase in action taken rates despite manifold increase in the number of unique BPAs could be achieved through concentrated efforts focusing on governance, data review, and visualization using a system-embedded tool, combined with the CDS Five Rights framework, to optimize alerts. Improved alert compliance was likely multifactorial-due to decreased repeated alert firing for the same patient; better awareness due to stakeholders' involvement; and less fatigue since unnecessary alerts were removed. Future studies should prospectively focus on patients' clinical chart reviews to assess downstream effects of various actions taken, identify any possibility of harm, and collect end-user feedback regarding the utility of alerts.
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Affiliation(s)
- Hannah Jia Hui Ng
- Corresponding Author: Hannah Jia Hui Ng, MBBS, MRCS, Department of Medical Informatics, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore 609606, Singapore;
| | - Amit Kansal
- Department of Medical Informatics, Ng Teng Fong General Hospital, Singapore, Singapore
| | | | - Wee Chuan Hing
- Department of Medical Informatics, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Carmen Jia Man Goh
- Department of Medical Informatics, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Hermione Poh
- Department of Medical Informatics, Ng Teng Fong General Hospital, Singapore, Singapore
| | | | - Er Luen Lim
- Department of Medical Informatics, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Gamaliel Tan
- Department of Medical Informatics, Ng Teng Fong General Hospital, Singapore, Singapore
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Li A, Cove ME, Phua J, Puah SH, Ng V, Kansal A, Tan QL, Sahagun JT, Taculod J, Tan AYH, Mukhopadhyay A, Tay CK, Ramanathan K, Chia YW, Sewa DW, Chew M, Lew SJW, Goh S, Dhanvijay S, Jit-Ern Tan J, See KC. Correction: Expanding the utility of the ROX index among patients with acute hypoxemic respiratory failure. PLoS One 2023; 18:e0282136. [PMID: 36795711 PMCID: PMC9934329 DOI: 10.1371/journal.pone.0282136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0261234.].
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Kansal A, Ong WJD, Dhanvijay S, Siosana ATP, Padillo LM, Tan CK, Gulati Kansal M, Khan FA. Comparison of ROX index (SpO2/FIO2 ratio/respiratory rate) with a modified dynamic index incorporating PaO2/FIO2 ratio and heart rate to predict high flow nasal cannula outcomes among patients with acute respiratory failure: a single centre retrospective study. BMC Pulm Med 2022; 22:350. [PMID: 36114516 PMCID: PMC9482300 DOI: 10.1186/s12890-022-02121-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background High flow nasal cannula (HFNC) is increasingly being used to support patients with acute respiratory failure (ARF) and to avoid need for intubation. However, almost one third of the patients do not respond and require escalation of respiratory support. Previously, ROX index (SpO2/FIO2 [SF] ratio/respiratory rate) has been validated among pneumonia patients to facilitate early recognition of patients likely to fail HFNC and therefore, benefit from timely interventions. However, it has been postulated that incorporation of PaO2/FIO2 (PF) ratio from arterial blood gas (ABG) analysis may better predict the outcome of HFNC compared to indices that utilizes SF ratio. Similarly, heart rate increase after HFNC therapy initiation has been found to be associated with HFNC failure. Therefore, we aimed to compare ROX index with a new modified index to predict HFNC outcomes among ARF patients. Materials and methods This single centre 2-year retrospective study included ARF patients of varying etiologies treated with HFNC. The modified index incorporated heart rate and substituted PF ratio for SF ratio in addition to respiratory rate. We named the index POX-HR and calculated Delta POX-HR index as the difference pre- and post-HFNC initiation POX-HR. We also recorded ROX index at the time when post-HFNC initiation ABG was done (‘post-HFNC initiation ROX’) and calculated Delta ROX. HFNC success was defined as no need of escalation of respiratory support or discharged to ward within 48 h of HFNC initiation, or successful wean off HFNC for at least 12 h. Evaluation was performed using area under the receiver operating characteristic curve (AUROC) and cut-offs assessed for prediction of HFNC outcomes. Results One hundred eleven patients were initiated on HFNC for ARF, of whom 72 patients (64.9%) had HFNC success. Patients with HFNC failure had significantly lower values for all the indices. At median of 3.33 h (IQR 1.48–7.24 h), Delta POX-HR demonstrated the best prediction accuracy (AUROC 0.813, 95% CI 0.726–0.900). A Delta POX-HR > 0.1 was significantly associated with a lower risk of HFNC failure. Conclusions Our proposed modified dynamic index (Delta POX-HR) may facilitate early and accurate prediction of HFNC outcomes compared to ROX index among ARF patients of varied etiologies.
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Li A, Cove ME, Phua J, Puah SH, Ng V, Kansal A, Tan QL, Sahagun JT, Taculod J, Tan AYH, Mukhopadhyay A, Tay CK, Ramanathan K, Chia YW, Sewa DW, Chew M, Lew SJW, Goh S, Dhanvijay S, Tan JJE, FCCP KCS. Expanding the utility of the ROX index among patients with acute hypoxemic respiratory failure. PLoS One 2022; 17:e0261234. [PMID: 35472205 PMCID: PMC9041854 DOI: 10.1371/journal.pone.0261234] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 11/24/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Delaying intubation in patients who fail high-flow nasal cannula (HFNC) may result in increased mortality. The ROX index has been validated to predict HFNC failure among pneumonia patients with acute hypoxemic respiratory failure (AHRF), but little information is available for non-pneumonia causes. In this study, we validate the ROX index among AHRF patients due to both pneumonia or non-pneumonia causes, focusing on early prediction. METHODS This was a retrospective observational study in eight Singapore intensive care units from 1 January 2015 to 30 September 2017. All patients >18 years who were treated with HFNC for AHRF were eligible and recruited. Clinical parameters and arterial blood gas values at HFNC initiation and one hour were recorded. HFNC failure was defined as requiring intubation post-HFNC initiation. RESULTS HFNC was used in 483 patients with 185 (38.3%) failing HFNC. Among pneumonia patients, the ROX index was most discriminatory in pneumonia patients one hour after HFNC initiation [AUC 0.71 (95% CI 0.64-0.79)], with a threshold value of <6.06 at one hour predicting HFNC failure (sensitivity 51%, specificity 80%, positive predictive value 61%, negative predictive value 73%). The discriminatory power remained moderate among pneumonia patients upon HFNC initiation [AUC 0.65 (95% CI 0.57-0.72)], non-pneumonia patients at HFNC initiation [AUC 0.62 (95% CI 0.55-0.69)] and one hour later [AUC 0.63 (95% CI 0.56-0.70)]. CONCLUSION The ROX index demonstrated moderate discriminatory power among patients with either pneumonia or non-pneumonia-related AHRF at HFNC initiation and one hour later.
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Affiliation(s)
- Andrew Li
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
- Department of Intensive Care Medicine, Woodlands Health, Singapore, Singapore
- * E-mail:
| | - Matthew Edward Cove
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
| | - Jason Phua
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
- Fast and Chronic Programmes, Alexandra Hospital, National University Health System, Singapore, Singapore
| | - Ser Hon Puah
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vicky Ng
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Amit Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
| | - Qiao Li Tan
- Department of Respiratory Medicine and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Juliet Tolentino Sahagun
- Division of Critical Care, National University Hospital, National University Health System, Singapore, Singapore
| | - Juvel Taculod
- Division of Critical Care, National University Hospital, National University Health System, Singapore, Singapore
| | - Addy Yong-Hui Tan
- Department of Anaesthesia, National University Hospital, National University Health System, Singapore, Singapore
| | - Amartya Mukhopadhyay
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
| | - Chee Kiang Tay
- Department of Respiratory Medicine and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Kollengode Ramanathan
- Department of Cardiac Thoracic and Vascular Surgery, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Yew Woon Chia
- Department of Cardiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Duu Wen Sewa
- Department of Respiratory Medicine and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Meiying Chew
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
| | - Sennen J. W. Lew
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Shirley Goh
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Shekhar Dhanvijay
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
| | - Jonathan Jit-Ern Tan
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Kay Choong See FCCP
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
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Singla P, Kaur S, Kaur S, Kansal A, Bansal A, Singh A. Proton pump inhibitor induced subacute cutaneous lupus erythematosus: A case series of 7 patients and brief review of literature. Indian Dermatol Online J 2022; 13:64-72. [PMID: 35198470 PMCID: PMC8809160 DOI: 10.4103/idoj.idoj_237_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 10/02/2021] [Indexed: 11/09/2022] Open
Abstract
Background: Subacute cutaneous lupus erythematosus (SCLE) manifests with erythematous, nonscarring, annular, or papulosquamous plaques. Proton pump inhibitors (PPIs) are increasingly being incriminated in its causation, but reports of similar nature from India are lacking. Aims: To describe the characteristics of seven patients with SCLE induced by PPIs and to review the published cases in order to provide a better perspective of the association. Materials and Methods: We describe seven patients of PPI-induced SCLE, seen over a period of 6 years. We also review the literature for additional data on PPI-induced SCLE. The selected publications were reviewed, and relevant clinical and laboratory data were extracted. Results: Of the total seven cases, there were four males and three females with a mean age of 60.2 ± 5.5 years (range 53-70 years). Nine episodes of PPI-induced SCLE were recorded in the seven patients. Of the initial episodes, esomeprazole was implicated in four, pantoprazole in two, and rabeprazole in one patient. Latency period ranged from 2 weeks to 1 year (mean 11.4 ± 16.2 weeks). Morphology was described as annular scaly plaques in six and papulosquamous in one. Antinuclear antibodies and anti-Ro antibodies were positive in all patients. Naranjo probability scale was used in all patients; two were categorized as definite and five as probable. Treatments included drug withdrawal in six patients, topical steroids in one, systemic corticosteroids in all seven, and hydroxychloroquine in one patient, used alone or in combinations. Complete remission was achieved in six cases, while one had partial remission. Limitation: Retrospective nature of this study and limited number of patients. Conclusion: PPIs can trigger SCLE.
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Puah SH, Cove ME, Phua J, Kansal A, Venkatachalam J, Ho VK, Sewa DW, Gokhale RS, Liew MF, Ho BCH, Ng JJ, Abisheganaden JA, Leo YS, Young BE, Lye DC, Yeo TW. Association between lung compliance phenotypes and mortality in
COVID-19 patients with acute respiratory distress syndrome. Ann Acad Med Singap 2021. [DOI: 10.47102/annals-acadmedsg.2021129] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
ABSTRACT
Introduction: Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with a high
mortality rate, though outcomes of the different lung compliance phenotypes are unclear. We aimed to
measure lung compliance and examine other factors associated with mortality in COVID-19 patients
with ARDS.
Methods: Adult patients with COVID-19 ARDS who required invasive mechanical ventilation at 8
hospitals in Singapore were prospectively enrolled. Factors associated with both mortality and differences
between high (<40mL/cm H2O) and low (<40mL/cm H2O) compliance were analysed.
Results: A total of 102 patients with COVID-19 who required invasive mechanical ventilation were
analysed; 15 (14.7%) did not survive. Non-survivors were older (median 70 years, interquartile
range [IQR] 67–75 versus median 61 years, IQR 52–66; P<0.01), and required a longer duration of
ventilation (26 days, IQR 12–27 vs 8 days, IQR 5–15; P<0.01) and intensive care unit support
(26 days, IQR 11–30 vs 11.5 days, IQR 7–17.3; P=0.01), with a higher incidence of acute kidney injury
(15 patients [100%] vs 40 patients [46%]; P<0.01). There were 67 patients who had lung compliance
data; 24 (35.8%) were classified as having high compliance and 43 (64.2%) as having low compliance.
Mortality was higher in patients with high compliance (33.3% vs 11.6%; P=0.03), and was associated
with a drop in compliance at day 7 (-9.3mL/cm H2O (IQR -4.5 to -15.4) vs 0.2mL/cm H2O (4.7 to -5.2)
P=0.04).
Conclusion: COVID-19 ARDS patients with higher compliance on the day of intubation and a
longitudinal decrease over time had a higher risk of death.
Keywords: ARDS, COVID-19-associated respiratory failure, high-flow nasal cannula therapy, HFNC,
post-intubation, ventilation strategies
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tsin Wen Yeo
- Singapore 2019 Novel Coronavirus Outbreak Research Team
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Puah SH, Li A, Cove ME, Phua J, Ng V, Kansal A, Tan QL, Sahagun JT, Taculod J, Tan AYH, Mukhopadhyay A, Tay CK, Ramanathan K, Chia YW, Sewa DW, Chew M, Lew SJW, Goh S, Dhanvijay S, Tan JJE, See KC. High-flow nasal cannula therapy: A multicentred survey of the practices among physicians and respiratory therapists in Singapore. Aust Crit Care 2021; 35:520-526. [PMID: 34518063 DOI: 10.1016/j.aucc.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 07/28/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Use of high-flow nasal cannula (HFNC) has become a regular intervention in the intensive care units especially in patients coming in with hypoxaemic respiratory failure. Clinical practices may differ from published literature. OBJECTIVES The objective of this study was to determine the clinical practices of physicians and respiratory therapists (RTs) on the use of HFNC. METHODS A retrospective observational study looking at medical records on HFNC usage from January 2015 to September 2017 was performed and was followed by a series of questions related to HFNC practices. The survey involved physicians and RTs in intensive care units from multiple centres in Singapore from January to April 2018. Indications and thresholds for HFNC usage with titration and weaning practices were compared with the retrospective observational study data. RESULTS One hundred twenty-three recipients (69.9%) responded to the survey and reported postextubation (87.8%), pneumonia in nonimmunocompromised (65.9%), and pneumonia in immunocompromised (61.8%) patients as the top three indications for HFNC. Of all, 39.8% of respondents wanted to use HFNC for palliative intent. Similar practices were observed in the retrospective study with the large cohort of 63% patients (483 of the total 768 patients) where HFNC was used for acute hypoxaemic respiratory failure and 274 (35.7%) patients to facilitate extubation. The survey suggested that respondents would initiate HFNC at a lower fraction of inspired oxygen (FiO2), higher partial pressure of oxygen to FiO2 ratio, and higher oxygen saturation to FiO2 ratio for nonpneumonia patients than patients with pneumonia. RTs were less likely to start HFNC for patients suffering from pneumonia and interstitial lung disease than physicians. RTs also preferred adjustment of FiO2 to improve oxygen saturations and noninvasive ventilation for rescue. CONCLUSIONS Among the different intensive care units surveyed, the indications and thresholds for the initiation of HFNC differed in the clinical practices of physicians and RTs.
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Affiliation(s)
- Ser Hon Puah
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore.
| | - Andrew Li
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Matthew Edward Cove
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Jason Phua
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore; Fast and Chronic Programmes, Alexandra Hospital, National University Health System, Singapore
| | - Vicky Ng
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Amit Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Qiao Li Tan
- Department of Respiratory Medicine and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Juliet Tolentino Sahagun
- Division of Critical Care, National University Hospital, National University Health System, Singapore
| | - Juvel Taculod
- Division of Critical Care, National University Hospital, National University Health System, Singapore
| | - Addy Yong-Hu Tan
- Department of Anaesthesia, National University Hospital, National University Health System, Singapore
| | - Amartya Mukhopadhyay
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Chee Kiang Tay
- Department of Respiratory Medicine and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Kollengode Ramanathan
- Department of Cardiac Thoracic and Vascular Surgery, National University Heart Centre, National University Hospital, Singapore
| | - Yew Woon Chia
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Duu Wen Sewa
- Department of Respiratory Medicine and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Meiying Chew
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Sennen J W Lew
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Shirley Goh
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Shekhar Dhanvijay
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Jonathan Jit-Ern Tan
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore
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Kansal A, Dhanvijay S, Li A, Phua J, Cove ME, Ong WJD, Puah SH, Ng V, Tan QL, Manalansan JS, Zamora MSN, Vidanes MC, Sahagun JT, Taculod J, Tan AYH, Tay CK, Chia YW, Sewa DW, Chew M, Lew SJW, Goh S, Tan JJE, Ramanathan K, Mukhopadhyay A, See KC. Predictors and outcomes of high-flow nasal cannula failure following extubation: A multicentre observational study. Ann Acad Med Singap 2021; 50:467-473. [PMID: 34195753 DOI: 10.47102/annals-acadmedsg.2020564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Despite adhering to criteria for extubation, up to 20% of intensive care patients require re-intubation, even with use of post-extubation high-flow nasal cannula (HFNC). This study aims to identify independent predictors and outcomes of extubation failure in patients who failed post-extubation HFNC. METHODS We conducted a multicentre observational study involving 9 adult intensive care units (ICUs) across 5 public hospitals in Singapore. We included patients extubated to HFNC following spontaneous breathing trials. We compared patients who were successfully weaned off HFNC with those who failed HFNC (defined as re-intubation ≤7 days following extubation). Generalised additive logistic regression analysis was used to identify independent risk factors for failed HFNC. RESULTS Among 244 patients (mean age: 63.92±15.51 years, 65.2% male, median APACHE II score 23.55±7.35), 41 (16.8%) failed HFNC; hypoxia, hypercapnia and excessive secretions were primary reasons. Stroke was an independent predictor of HFNC failure (odds ratio 2.48, 95% confidence interval 1.83-3.37). Failed HFNC, as compared to successful HFNC, was associated with increased median ICU length of stay (14 versus 7 days, P<0.001), ICU mortality (14.6% versus 2.0%, P<0.001) and hospital mortality (29.3% versus 12.3%, P=0.006). CONCLUSION Post-extubation HFNC failure, especially in patients with stroke as a comorbidity, remains a clinical challenge and predicts poorer clinical outcomes. Our observational study highlights the need for future prospective trials to better identify patients at high risk of post-extubation HFNC failure.
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Affiliation(s)
- Amit Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, Singapore
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11
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Lyu T, Khan FA, Sajeed SM, Kansal A, Kansal MG, Dhanvijay S, Tan RA, D'Souza J, Cendana I, Leong P, Tan CK. In-hospital cardiac arrest incidence and outcomes in the era of COVID-19: an observational study in a Singapore hospital. Int J Emerg Med 2021; 14:33. [PMID: 34058983 PMCID: PMC8165958 DOI: 10.1186/s12245-021-00356-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 05/17/2021] [Indexed: 12/16/2022] Open
Abstract
Background COVID-19 pandemic has resulted in significant strain on healthcare resources and this requires diligent resource re-allocation. We aim to describe the incidence and outcomes of in-hospital cardiac arrest (IHCA) during this period as compared to non-pandemic period. Methods We conducted a retrospective study in a tertiary care hospital in Singapore. The study compared the incidence and outcomes of code blue activations over a 3-month period from March to May 2020 (COVID-19 period) with the same months in 2019 (pre-COVID-19 period). The primary outcome of the study was the rate of survival to hospital discharge for IHCA. The secondary outcomes included incidence of all code blue activation per 1000 hospital admissions, incidence of IHCA per 1000 hospital admissions. Outcomes The rate of survival to hospital discharge for IHCA was 5.88% in the COVID-19 period as compared to 10.0% in the pre-COVID-19 period [odds ratio (OR), 0.72; 95% confidence interval (CI), 0.26-1.95]. Compared to pre-COVID-19 period, there were more IHCA incidences per 1000 hospital admissions in the COVID-19 period (1.86 vs 1.03; OR, 1.81; 95% CI, 0.78-4.41). Conclusions The study observed a trend towards higher incidence of IHCA and lower rate of survival to hospital discharge during COVID-19 pandemic compared to pre-COVID-19 period.
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Affiliation(s)
- Ting Lyu
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606, Singapore.,Department of Intensive Care Medicine, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Faheem Ahmed Khan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606, Singapore.
| | - Shanaz Matthew Sajeed
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Amit Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Monika Gulati Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Shekhar Dhanvijay
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Rou An Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Jared D'Souza
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Ian Cendana
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Patricia Leong
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606, Singapore
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Chew SY, Lim HY, Ong HA, Vijayan Sannasi V, Wee B, Tan CK, Kansal A. Inferior vena cava filter migration due to guidewire ensnarement during peripherally inserted central catheterisation. Anaesth Intensive Care 2021; 49:240-241. [PMID: 33951943 DOI: 10.1177/0310057x20979320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Si Y Chew
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Huey Y Lim
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, NUHS, Singapore
| | - Heng A Ong
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, NUHS, Singapore
| | | | - Bernard Wee
- Department of Radiology, Ng Teng Fong General Hospital, NUHS, Singapore
| | - Chee K Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, NUHS, Singapore
| | - Amit Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, NUHS, Singapore
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Khan FA, Lyu T, Lee EK, Dhanvijay S, Kansal A, Kansal MG, Tan RA, D'Souza J, Lee YS, Lim N, Liew MP, Cerdana I, Leong P, Tan CK. Impact of implementing novel automated code blue activation system on in-hospital cardiac arrest: A single center study. Resuscitation 2020; 157:149-155. [PMID: 33129913 DOI: 10.1016/j.resuscitation.2020.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 09/13/2020] [Accepted: 10/13/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prompt identification and management of patients having clinical deterioration on wards is one of the key steps to reduce in-hospital cardiac arrests (IHCA). Our organization implemented a novel Automated Code Blue Alert and Activation (ACBAA) system since 1st March 2018. METHODS We conducted a retrospective before-and-after ACBAA system implementation study in JurongHealth Campus (JHC) of National University Health system (NUHS), Singapore. In JHC, code blue can be activated by both manual activation and ACBAA system activation from 1st March 2018. The ACBAA system will be activated when any of the pre-defined peri-arrest criteria is met. The primary outcome of the study was the incidence of IHCA. The secondary outcome included return of spontaneous circulation (ROSC) of IHCA and in-hospital survival to home discharge of code blue activation. OUTCOMES The incidence of IHCA per 1000 hospital admissions after-ACBAA system implementation was 14.6% lower than before-ACBAA system though not statistically significant [relative risk (RR): 0.86, 95% confidence interval (CI) 0.55-1.34, P > 0.05]. Compared to the before-ACBAA system period, the after-ACBAA system period had a trend for higher rate of survival to home discharge after IHCA (RR: 2.13, 95% CI 0.65-6.93, P > 0.05) with good neurological outcome. CONCLUSIONS Implementation of a novel ACBAA system has shown a trend in reducing IHCA incidence. In the era of digitalised healthcare system, the ACBAA system is practical and advisable to implement in order to reduce IHCA. Further studies are required to validate the criteria for peri-arrest code blue activation.
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Affiliation(s)
- Faheem Ahmed Khan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System (NUHS), 609606, Singapore.
| | - Ting Lyu
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System (NUHS), 609606, Singapore.
| | - Eng Kiang Lee
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System (NUHS), 609606, Singapore
| | - Shekhar Dhanvijay
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System (NUHS), 609606, Singapore
| | - Amit Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System (NUHS), 609606, Singapore
| | - Monika Gulati Kansal
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System (NUHS), 609606, Singapore
| | - Rou An Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System (NUHS), 609606, Singapore
| | - Jared D'Souza
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System (NUHS), 609606, Singapore
| | - Yee Shay Lee
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System (NUHS), 609606, Singapore
| | - Nicholas Lim
- Group Facility Management, JurongHealth Campus (JHC), National University Health System (NUHS), 609606, Singapore
| | - Mei Pheng Liew
- Medical Informatics, JurongHealth Campus (JHC), National University Health System (NUHS), 609606, Singapore
| | - Ian Cerdana
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System (NUHS), 609606, Singapore
| | - Patricia Leong
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System (NUHS), 609606, Singapore
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System (NUHS), 609606, Singapore
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Bruce-Hickman D, Jiang X, Thia JJP, Kansal A. Stevens-Johnson Syndrome complicated by obstructive uropathy, pneumothorax, and pneumomediastinum: a case report and literature review. Burns & Trauma 2019; 7:14. [PMID: 31205959 PMCID: PMC6558859 DOI: 10.1186/s41038-019-0153-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 04/01/2019] [Indexed: 11/25/2022]
Abstract
Background Stevens-Johnson Syndrome (SJS) is an acute mucocutaneous eruption with blisters of the skin and haemorrhagic erosions of mucous membranes. This report describes air-leak syndrome and obstructive uropathy occurring simultaneously in a teenage patient affected by SJS. Case presentation A 17-year-old Malay female with SJS suffered from bilateral pneumothoraces, pneumomediastinum, and obstructive uropathy as early complications of her disease. She required intubation, chest tube insertion, and bilateral ureteric stenting as part of her intensive care management. These extra-cutaneous complications of renal and pulmonary systems were likely secondary to widespread epithelial detachment. Conclusion Despite paucity of cases in adult literature, post-renal causes for acute kidney injury must be considered in SJS, especially in the setting of gross haematuria. Bedside point-of-care ultrasonography may be a useful tool for excluding obstructive uropathy. Pneumothorax is a rare but documented complication of SJS in paediatric cases and, to a lesser extent, adult patients. Extra care should be exercised when caring for mechanically ventilated patients suffering from SJS.
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Affiliation(s)
- Damian Bruce-Hickman
- Department of Intensive Care Medicine Ng Teng Fong Hospital Singapore, Singapore
| | - Xiao Jiang
- Department of Intensive Care Medicine Ng Teng Fong Hospital Singapore, Singapore
| | - Joshua Jin-Ping Thia
- Department of Intensive Care Medicine Ng Teng Fong Hospital Singapore, Singapore
| | - Amit Kansal
- Department of Intensive Care Medicine Ng Teng Fong Hospital Singapore, Singapore
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15
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Kansal A, Reifsnider OS, Proskorovsky I, Zheng Y, Pfarr E, George JT, Kandaswamy P, Ruffolo A. Cost-effectiveness analysis of empagliflozin treatment in people with Type 2 diabetes and established cardiovascular disease in the EMPA-REG OUTCOME trial. Diabet Med 2019; 36:1494-1502. [PMID: 31295358 PMCID: PMC6851686 DOI: 10.1111/dme.14076] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2019] [Indexed: 01/24/2023]
Abstract
AIM In the EMPA-REG OUTCOME trial, empagliflozin therapy reduced cardiovascular death by 38% compared with placebo when added to standard of care. Using the trial results, we created a discrete-event simulation model to assess lifetime health economic outcomes in people with Type 2 diabetes and established cardiovascular disease. METHODS Time-dependent survival regression analysis was performed on data from EMPA-REG OUTCOME for 10 cardiovascular and renal events (e.g. stroke, heart failure hospitalization, macroalbuminuria, cardiovascular mortality) to capture event rates over time, and interaction between events. Model performance was assessed by comparing predicted and observed outcomes at 3 years. Costs in the United Kingdom (UK) and health utilities were obtained from published literature. Outcomes included cumulative event rates, life-years, costs and quality-adjusted life-years (QALYs). RESULTS The model predicted an 18% relative increase (by 2.1 life-years) in survival for empagliflozin (14.0 life-years) vs. standard of care (11.9 life-years), attributable to direct treatment effect on cardiovascular mortality, and to indirect effect via reductions in other events. Participants treated with empagliflozin may experience improved quality of life (1.0 QALY) and higher costs (£3737/participant), yielding an incremental cost-effectiveness ratio (ICER) of £4083/QALY. Sensitivity analyses confirmed the robustness of these results to changes in input parameters. CONCLUSIONS Based on extrapolation of EMPA-REG OUTCOME trial data using a participant-level simulation model, empagliflozin in addition to standard of care is projected to be highly cost-effective using UK healthcare costs. The impact in other countries will vary due to differences in drug pricing and accrual of other costs. (Clinical Trial Registry No: NCT01131676).
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Affiliation(s)
| | | | | | | | - E. Pfarr
- Boehringer Ingelheim InternationalIngelheim am RheinGermany
| | | | - P. Kandaswamy
- Boehringer Ingelheim InternationalIngelheim am RheinGermany
| | - A. Ruffolo
- Boehringer Ingelheim InternationalIngelheim am RheinGermany
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Reifsnider O, Kansal A, Wanner C, Lee J, Pfarr E, Koitka-Weber A, Brand S, Kuti E, Ustyugova A. SAT-296 COST-EFFECTIVENESS ANALYSIS OF EMPAGLIFLOZIN TREATMENT IN PATIENTS WITH TYPE 2 DIABETES AND CHRONIC KIDNEY DISEASE BASED ON SUBGROUP OF EMPA-REG OUTCOME. Kidney Int Rep 2019. [DOI: 10.1016/j.ekir.2019.05.336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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17
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Shah SB, Bhardwaj M, Bhargava AK, Kansal A. Meeting the challenges in HIV patients undergoing robotic oncosurgery. J Anaesthesiol Clin Pharmacol 2018; 34:402-404. [PMID: 30386029 PMCID: PMC6194818 DOI: 10.4103/joacp.joacp_111_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- S B Shah
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - M Bhardwaj
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - A K Bhargava
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - A Kansal
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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18
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Monreal-Bosch M, Soulard S, Crespo C, Brand S, Kansal A. [Comparison of the cost-utility of direct oral anticoagulants for the prevention of stroke in patients with atrial fibrillation in Spain]. Rev Neurol 2017; 64:247-256. [PMID: 28272725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Apixaban, dabigatran and rivaroxaban are three new direct oral anticoagulants (DOACs) used in the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF) in Spain. AIM To assess the relative cost-utility of the three DOACs compared with vitamin K antagonists. PATIENTS AND METHODS A Markov model with 3-month cycles was used to simulate NVAF patients starting with treatment and followed up for their lifetime from the perspective of the National Health System. The model included 36 health states including treatment combinations, disability and events history and considered a hypothetical cohort of 10,000 NVAF patients. Relative efficacy was calculated from a formal indirect treatment comparison using data from the pivotal trials of each DOAC. RESULTS Dabigatran was associated with the highest number of quality-adjusted life years (QALY) (8.40 QALY), followed by apixaban (8.33 QALY), rivaroxaban (8.15 QALY) and acenocoumarol (8.03 QALY). Patients taking acenocoumarol had the lowest total costs (€22,230), followed by dabigatran (€24,564), apixaban (€24,655) and rivaroxaban (€25,900). Incremental cost-utility ratios compared to vitamin K antagonists, were €6,397, €8,039 and €29,957/QALY for dabigatran, apixaban and rivaroxaban, respectively. If compared together, dabigatran dominated apixaban and rivaroxaban. Sensitivity analyses confirmed the robustness of the baseline case. CONCLUSIONS All three direct anticoagulants are cost-effective against acenocoumarol. Dabigatran is economically dominant over rivaroxaban and apixaban in the Spanish setting, as it is more effective and cheaper.
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Affiliation(s)
- M Monreal-Bosch
- Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Espana
| | - S Soulard
- Boehringer Ingelheim Espana, Sant Cugat del Valles, Espana
| | - C Crespo
- Boehringer Ingelheim Espana, Sant Cugat del Valles, Espana
| | - S Brand
- Evidera, Londres, Reino Unido
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Kansal A, Tripathi D, Rai MK, Agarwal V. Persistent expression and function of P-glycoprotein on peripheral blood lymphocytes identifies corticosteroid resistance in patients with systemic lupus erythematosus. Clin Rheumatol 2015; 35:341-9. [PMID: 26415739 DOI: 10.1007/s10067-015-3079-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/15/2015] [Accepted: 09/17/2015] [Indexed: 12/18/2022]
Abstract
Corticosteroids (CS) are the mainstay of treatment in systemic lupus erythematosus (SLE) patients. However, some patients have poor response to CS treatment. Among the multiple mechanisms of CS resistance, overexpression of P-glycoprotein (P-gp) on peripheral blood lymphocytes (PBL) may be one of them as this result in efflux of CS from lymphocytes. Thus, we evaluated the role of P-gp protein on PBLs in patients with SLE in its response to CS therapy. SLE patients (n = 42) (fulfilling ACR revised criteria) who were naïve to CS and immunosuppressive drugs were enrolled. Disease activity was assessed using SLE disease activity index (SLEDAI) and expression, and function of P-gp was evaluated by flow cytometry at baseline and after 3 months of therapy with CS. At 3 months, patients with SLEDAI >4 and SLEDAI ≤4 were grouped as nonresponders and responders, respectively. P-gp expression was significantly increased on PBLs of SLE patients as compared to healthy controls (p < 0.001). P-gp expression and function correlated with SLEDAI (r = 0.49, p = 0.005; and r = 0.49, p = 0.001, respectively). P-gp expression and function were not different in responders and nonresponders at baseline. However, at 3 months of CS therapy, P-gp expression and function decreased in responders (p < 0.001 and p < 0.005, respectively), whereas in nonresponders, it remained unchanged. Persistent overexpression and activity of P-gp are associated with poor response to CS in CS naïve patients of SLE.
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Affiliation(s)
- Amit Kansal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of medical Sciences, Raebareli Road, Lucknow, 226014, India
| | - Deepak Tripathi
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of medical Sciences, Raebareli Road, Lucknow, 226014, India
| | - Mohit K Rai
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of medical Sciences, Raebareli Road, Lucknow, 226014, India
| | - Vikas Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of medical Sciences, Raebareli Road, Lucknow, 226014, India.
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BenJoseph R, Yang E, Huse S, Bhagnani TD, Holly P, Kansal A. Rates of Diagnosed Opioid Abuse Or Dependence and Incremental Direct Health Care Costs Among Patients With Long-Term Use of Immediate Release Hydrocodone. Value Health 2014; 17:A527-A528. [PMID: 27201666 DOI: 10.1016/j.jval.2014.08.1667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
| | - E Yang
- Evidera, Lexington, MA, USA
| | - S Huse
- Evidera, Lexington, MA, USA
| | | | - P Holly
- Purdue Pharma L. P., Stamford, CT, USA
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21
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Kansal A, Tafazzoli A, Leipold R, Sarda S. Comparison of a Markov Cohort Model and a Discrete-Event Simulation for Economic Analyses of Treatments for Multiple Sclerosis. Value Health 2014; 17:A398. [PMID: 27200939 DOI: 10.1016/j.jval.2014.08.901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
| | | | | | - S Sarda
- Biogen Idec, Weston, MA, USA
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22
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Kansal A, Jain A, Thenozhi S, Agarwal V. Intestinal pseudo-obstruction associated with biliary tract dilatation in a patient with systemic lupus erythematosus. Lupus 2012; 22:87-91. [PMID: 23104391 DOI: 10.1177/0961203312464091] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intestinal pseudo-obstruction (IpsO) is an uncommon and severe complication of systemic lupus erythematosus (SLE). We report a patient with SLE who presented with IpsO and biliary dilatation (megacholedochus). The co-manifestation of these two conditions in SLE is unusual and has been reported only twice previously. The patient responded well to immunosuppressive treatment. IpsO is a rare but recognized manifestation of SLE that may be the presenting manifestation of the systemic disease or occur more commonly during disease course. Early recognition of IpsO is necessary to institute appropriate medical treatment and to avoid inappropriate surgical intervention.
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Affiliation(s)
- A Kansal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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Kansal A, Havill K. The effects of introduction of new observation charts and calling criteria on call characteristics and outcome of hospitalised patients. CRIT CARE RESUSC 2012; 14:38-43. [PMID: 22404060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To determine the impact on call characteristics and patient outcomes since the implementation of a two-tiered rapid-response system along with new observation charts and calling criteria. DESIGN AND SETTING A retrospective before-and-after study in an Australian tertiary referral hospital. PARTICIPANTS Consecutive adult patients (_18 years), who had a rapid-response call between June and October 2009 ("before") and between June and October 2010 ("after"). MAIN OUTCOME MEASURES Incidence of "serious adverse events" (cardiac arrests, unexpected deaths, and unplanned intensive care unit/high-dependency unit [HDU] admissions); subsequent illness severity and ICU/HDU and hospital mortality and length of stay; episodes of repeat calls for the same patient, time since admission and treatment limitation/ not-for-resuscitation order profiles. RESULTS Statistically significant increase in number of rapid response calls from 14.3 to 21.2 per 1000 hospital admissions before and after, respectively (P < 0.001); this was associated with a 16% decrease in composite serious adverse events (not significant). There were no significant differences in the number of unplanned ICU/HDU admissions, admission severity scores and subsequent ICU/HDU and hospital mortality and length of stay. There was a significant increase in number of calls for patients who were admitted to hospital within 24 hours (2.5 v 4.7 per 1000 hospital admissions before and after, respectively; P < 0.05) and for patients who were transferred from acute care areas within 24 hours (3.7 v 6.2 per 1000 hospital admissions before and after, respectively; P < 0.05). There was a significant increase in number of repeat calls for the same patient (1.6 v 4.2 per 1000 hospital admissions before and after, respectively; P < 0.001); this was associated with higher mortality compared with single review in the after period (35.8% v 18.5%, respectively; P = 0.005). CONCLUSIONS Implementation of a two-tiered rapid-response system and new observation charts and calling criteria increased the number of rapid-response calls with a nonsignificant trend towards a decreased incidence of serious adverse events. Further improvements in care of hospitalised patients may be possible by preventing repeat calls or calls within 24 hours of hospital admission and discharge from acute care areas.
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Affiliation(s)
- Amit Kansal
- John Hunter Hospital, Newcastle, NSW, Australia.
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Saigal R, Singh Y, Mittal M, Kansal A, Maharia HR. Pyoderma gangrenosum. J Assoc Physicians India 2010; 58:378-383. [PMID: 21125780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Pyoderma gangrenosum (PG) is an idiopathic, ulcerative, noninfective chronic inflammatory skin disorder of unknown etiology. It is associated with systemic medical illness in 50% of cases like inflammatory bowel disease, systemic arthritis, haematological diseases and malignancies. Characteristic lesions begin as pustule or vesiculopustule and progresses to an ulcer or deep erosion with violaceous overhanging or undermined borders. Diagnosis of pyoderma gangrenosum is clinical and depends on exclusion of other causes of cutaneous ulceration. The management of PG is treatment of underlying systemic medical illness and judicious use of immunosuppressants. Association of PG with these medical illnesses and treatment with immunosuppressants make the clinical utility for internists, gastroenterologists, haematologists and rheumatologists.
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Affiliation(s)
- Renu Saigal
- Incharge Rheumatology Clinic, Department of Medicine, Sawai Man Singh Medical College and Hospital, Jaipur, India
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Saigal R, Kansal A, Mittal M, Singh Y, Ram H. Raynaud's phenomenon. J Assoc Physicians India 2010; 58:309-313. [PMID: 21117349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Raynauds phenomena (RP) is a commonly encountered clinical manifestation which may be primary or secondary to underlying disease. There is imbalance between vasoconstricting and vasodilating factors. Physical examination, nailfold capillaroscopy and immunological tests can differentiate primary from secondary RP. Treatment involves prevention of RP so that permanent ischemic damage i.e. gangrene can be avoided. Avoidance of exposure to cold, emotional stress and certain drugs is mandatory and if attacks are occurring then vasodilators, prostaglandin analogues, anticoagulants and antiplatelet drugs may be added. An attempt has been made to guide the clinician to diagnose and treat a patient of RP through this article.
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Affiliation(s)
- Renu Saigal
- Department of Medicine, Sawai Man Singh Medical College and Hospital, Jaipur, India
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Saigal R, Kansal A, Mittal M, Singh Y, Ram H. Pachydermoperiostosis with myelofibrosis and empty sella. J Assoc Physicians India 2010; 58:253-255. [PMID: 21046885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
A case of pachydermoperiostosis presented to us in rheumatology clinic with complaints of pain and swelling in knee joints unresponsive to treatment, characteristic facial features, grade four clubbing of nails and broadening of distal parts of extremities. He also complained of fatiguability which was due to anemia. The natural history of the disease was reviewed and investigated.
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Affiliation(s)
- Renu Saigal
- Department of Medicine, Sawai Man Singh Medical College and Hospital, Jaipur, India
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Saigal R, Kansal A, Mittal M, Singh Y, Ram H. Antiphospholipid antibody syndrome. J Assoc Physicians India 2010; 58:176-184. [PMID: 20848817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The 2006 International Consensus Statement on an Update of the Classification Criteria for Definite Antiphospholipid Syndrome has increased the time between the two laboratory studies required for diagnosis from 6 to 12 weeks. Antibody to beta2 glycoprotein 1 has been included as a criterion. Various non-criteria diagnostic clues such as livedo reticularis, heart valve disease, thrombocytopenia, renal thrombotic microangiopathy, neurological manifestations, non-criteria antibodies (IgA aCL, IgA anti-beta2 glycoprotein I) and some research laboratory-identified antibodies (antiphosphatidylserine antibodies, antiphosphatidylethanolamine antibodies, antibodies against prothrombin alone and antibodies to the phosphatidylserine-prothrombin complex) have been recognised. New concepts of pathogenesis now implicate complement activation and participation of the innate immune system upstream to thrombosis. Warfarin remains the treatment of choice for patients who have suffered thrombosis, but antiplatelet agents and heparin are other options. Target INR is 2.0-3.0. The other drugs which are used in resistant cases are: rituximab, hydroxychloroquine, thrombin inhibitors and statins.
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Affiliation(s)
- Renu Saigal
- Department of Medicine, Sawai Man Singh Medical College and Hospital, Jaipur, India
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Saigal R, Mittal M, Kansal A, Singh Y, Kolar PR, Jain S. Fat embolism syndrome. J Assoc Physicians India 2008; 56:245-249. [PMID: 18702388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Fat embolism syndrome is a rare complication occurring in 0.5 to 2% of patients following a long bone fracture. It is believed to be caused by the toxic effects of free fatty acids. Diagnosis is clinical, based on respiratory, cerebral and dermal manifestations. Treatment is only supportive, directed mainly at maintaining respiratory functions.
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Affiliation(s)
- Renu Saigal
- Department of Medicine, Sawai Man Singh Medical College and Hospital Jaipur, India
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Saigal R, Mittal M, Kansal A, Singh Y, Ram H. Inflammatory Myopathy During Etanercept Therapy in a Patient with Rheumatoid Arthritis. Indian Journal of Rheumatology 2008. [DOI: 10.1016/s0973-3698(10)60085-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Saigal R, Mittal M, Kansal A. What is your diagnosis? Indian Journal of Rheumatology 2008. [DOI: 10.1016/s0973-3698(10)60078-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Kansal A, Brueton L, Lahiri A, Lester R. Hypoplastic thumb in Gorlin's syndrome. J Plast Reconstr Aesthet Surg 2006; 60:440-2. [PMID: 17349603 DOI: 10.1016/j.bjps.2006.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2006] [Revised: 06/13/2006] [Accepted: 06/16/2006] [Indexed: 11/22/2022]
Abstract
Gorlin's syndrome or naevoid basal cell carcinoma syndrome (NBCCS) is an autosomal dominant disorder that predisposes to basal cell carcinomas of the skin, ovarian fibromas, and medulloblastomas. This condition is due to mutations in the Patched (PTCH) gene which maps to chromosome 9q22 and acts as a tumour suppressor gene. Gorlin's syndrome is characterized by the development of multiple jaw keratocysts and/or basal carcinomas. There is a distinctive coarse facial appearance with macrocephaly, frontal bossing and prognathism. Most individuals have skeletal anomalies such as bifid ribs or wedge-shaped vertebrae. We present a case in which the patient presented with bilateral thumb hypoplasia. Various hand deformities have been reported in patients with Gorlin's syndrome including short metacarpals, cutaneous syndactyly of the second and third fingers, and pre- or post-axial polydactyly, but hypoplasia of the thumb has not been reported previously. These features of Gorlin's syndrome may be helpful diagnostically. The thumbs should be examined carefully in Gorlin's syndrome patients as minor degrees of hypoplasia are easy to miss. However, they still needs a specialist input to give the patient an optimum function of the thumb and the hand.
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Affiliation(s)
- A Kansal
- Diana, Princess of Wales Children's Hospital, Steelhouse Lane, Birmingham, UK.
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Kansal A, Lahiri A, Nishikawa H. Sympathetic paraganglioma presenting with Horner's syndrome in a child. J Plast Reconstr Aesthet Surg 2006; 59:772-4. [PMID: 16782577 DOI: 10.1016/j.bjps.2005.12.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Accepted: 12/28/2005] [Indexed: 11/19/2022]
Abstract
Paragangliomas of the head and neck arise from collections of cells from the neural crest associated with cranial or sympathetic nerves. Such lesions are rare in children. The majority of paragangliomas in the paediatric age groups have been familial, occurring in association with an adrenal pheochromocytoma. Children typically present with a neck mass and systemic evidence of catecholamine hypersecretion. We present the case of a 12-year-old boy with a history of increasing headache, drowsiness and Horner's syndrome for 8 months. The patient underwent exploration of the neck mass under general anaesthesia. The lesion was found to be in continuity with the left sympathetic chain. It was highly vascular but was removed en mass and sent for histological analysis. The histology showed that the mass was a well-circumscribed encapsulated tumour and that complete excision was achieved. The post-operative period was uneventful and the patient recovered well after the operation. On review at 6 months following surgery, his scars were maturing satisfactorily but the Horner's syndrome was persistent. Sympathetic chain paragangliomas are very rare tumours in the head and neck but should be considered in the differential diagnosis when clinical and radiographic evidence suggest a paraganglioma. The presentation is typically of a slow-growing neck mass with the presence of an ipsilateral Horner's syndrome. To our knowledge, this is the first reported case of a sympathetic chain paraganglioma in a child.
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Affiliation(s)
- Amit Kansal
- Diana, Princess of Wales Children's Hospital, Steelhouse Lane, Birmingham, UK
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Kansal A, Mohta M, Sethi AK, Tyagi A, Kumar P. Randomised trial of intravenous infusion of ephedrine or mephentermine for management of hypotension during spinal anaesthesia for Caesarean section. Anaesthesia 2005; 60:28-34. [PMID: 15601269 DOI: 10.1111/j.1365-2044.2004.03994.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study compared the effects of intravenous infusions of ephedrine and mephentermine for maintenance of maternal arterial pressure and neonatal outcome in pregnant women receiving subarachnoid block for lower segment Caesarean section. Sixty patients who developed hypotension following subarachnoid block for Caesarean section were randomly divided into two groups of 30 each to receive an intravenous infusion of ephedrine or mephentermine. Hypotension was defined as a decrease in systolic blood pressure of > or = 20% from the baseline value or an absolute value of <100 mmHg, whichever was higher. The vasopressor infusion was titrated to maintain systolic blood pressure between 'hypotension' and baseline values. Baseline haemodynamic parameters, haemodynamic changes subsequent to the start of vasopressor infusion, duration of hypotension and amount of vasopressor required were statistically similar for both groups. Neonatal APGAR scores and acid-base profiles were also comparable. To conclude, mephentermine can be used as safely and effectively as ephedrine for the management of hypotension during spinal anaesthesia in patients undergoing elective Caesarean section.
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Affiliation(s)
- A Kansal
- Department of Anaesthesiology and Critical care, University College of Medical Sciences, Guru Teg Bahadur Hospital, Delhi 110096, India
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Tantin D, Kansal A, Carey M. Recruitment of the putative transcription-repair coupling factor CSB/ERCC6 to RNA polymerase II elongation complexes. Mol Cell Biol 1997; 17:6803-14. [PMID: 9372911 PMCID: PMC232536 DOI: 10.1128/mcb.17.12.6803] [Citation(s) in RCA: 161] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Cockayne's syndrome (CS) is a disease characterized by developmental and growth defects, sunlight sensitivity, and a defect in transcription-coupled nucleotide excision repair. The two principle proteins involved in CS, CSA and CSB/ERCC6, have been hypothesized to bind RNA polymerase II (Pol II) and link transcription to DNA repair. We have tested CSA and CSB in assays designed to determine their role in transcription-coupled repair. Using a unique oligo(dC)-tailed DNA template, we provide biochemical evidence that CSB/ERCC6 interacts with Pol II molecules engaged in ternary complexes containing DNA and nascent RNA. CSB is a DNA-activated ATPase, and hydrolysis of the ATP beta-gamma phosphoanhydride bond is required for the formation of a stable Pol II-CSB-DNA-RNA complex. Unlike CSB, CSA does not directly bind Pol II.
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Affiliation(s)
- D Tantin
- Molecular Biology Institute, UCLA School of Medicine, Los Angeles, California 90095-1737, USA
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