An observational study of root-cause analysis of medication errors in elderly with methotrexate toxicity

INTRODUCTION

Medication errors are inherent in a healthcare system. This results in both time and cost burdens for both the patient and the health system. The aim of this study was to conduct a root-cause analysis of medication errors in elderly patients with methotrexate toxicity, analyze associated factors, and propose solutions.

METHODS

This single-center prospective study was designed to identify medication errors in cases of methotrexate toxicity between November 2022 to May 2023. Categorical data and free-text data are used to describe incidents. Harm assessment, factors related to medication errors, and preventability were evaluated for each case. Possible strategies to prevent similar occurrences are discussed.

RESULTS

Out of a total of 15 patients who presented during the study period, nine suffered from methotrexate toxicity due to medication errors. Most medication errors occurred during prescribing or dispensing (seven cases). Inadequate knowledge about medication and dosage, inadequate communication was identified as a contributing factor for all medication errors. Patients on long-term methotrexate treatment are at high risk of methotrexate toxicity.

CONCLUSION

This study highlights the challenges of health literacy and lacking communication between healthcare providers and patients that can be met through community pharmacy programs for the elderly in lower-middle-income countries.

Defining anthropometric thresholds (mid-arm circumference and calf circumference) in older adults residing in the community: a cross-sectional analysis using data from the population representative Longitudinal Aging Study in India (LASI DAD)

OBJECTIVES

To identify factors associated with malnutrition (undernutrition and overnutrition) and determine appropriate cut-off values for mid-arm circumference (MAC) and calf circumference (CC) among community-dwelling Indian older adults.

DESIGN

Data from the first wave of harmonised diagnostic assessment of dementia for Longitudinal Ageing Study in India (LASI-DAD) were used. Various sociodemographic factors, comorbidities, geriatric syndromes, childhood financial and health status were included. Anthropometric measurements included body mass index (BMI), MAC and CC.

SETTING

Nationally representative cohort study including 36 Indian states and union territories.

PARTICIPANTS

4096 older adults aged >60 years from LASI DAD.

OUTCOME MEASURES

The outcome variable was BMI, categorised as low (<18.5 kg/m2), normal (18.5-22.9 kg/m2) and high (>23 kg/m2). The cut-off values of MAC and CC were derived using ROC curve with BMI as the gold standard.

RESULTS

902 (weighted percentage 20.55%) had low BMI, 1742 (44.25%) had high BMI. Undernutrition was associated with age, wealth-quintile and impaired cognition, while overnutrition was associated with higher education, urban living and comorbidities such as hypertension, diabetes and chronic heart disease. For CC, the optimal lower and upper cut-offs for males were 28.1 cm and >31.5 cm, respectively, while for females, the corresponding values were 26 cm and >29 cm. Similarly, the optimal lower and upper cut-offs for MAC in males were 23.9 cm and >26.9 cm, and for females, they were 22.5 cm and >25 cm.

CONCLUSION

Our study identifies a high BMI prevalence, especially among females, individuals with higher education, urban residents and those with comorbidities. We establish gender-specific MAC and CC cut-off values with significant implications for healthcare, policy and research. Tailored interventions can address undernutrition and overnutrition in older adults, enhancing standardised nutritional assessment and well-being.

Yoga therapy on elderly patients with fear of fall: an open-label randomised controlled trial (YOFEAR trial)

INTRODUCTION

Fear of fall is experienced by the elderly irrespective of the presence or absence of history of fall. Falls contribute to injuries that culminate in hospitalisation that incur unwarranted medical expenses. Yoga is unique to Indian cultural practices, with a potential to enhance proprioception. It increases self-body awareness, ultimately improving the balancing capacity of older adults. Thus, the objective of this study is to compare the effect of yoga therapy in the study and control groups at 12 weeks from the baseline.

METHODS AND ANALYSIS

This study is designed as an open-label, randomised controlled trial (1:1) with a sample size of 62 elderly patients more than or equal to 60 years of age. Participation of either sex, male or female with a fear of fall will be considered. Two randomised groups of 31 participants each will receive standard therapy for their primary diseases as per the local, national or international guidelines. However, participants in the intervention arm will receive additional structured yoga therapy sessions. The primary objective of this study is to assess and compare the change in fear of fall score of participants in each group using Falls Efficacy Scale (FES) and Berg Balance Scale (BBS) at 12 weeks versus baseline. The secondary endpoint will assess the change in the quality of life of participants at 3 months compared with the baseline.Data will be gathered, entered into Microsoft Excel and further analysed by R software (V.4.3.0). Changes in FES-Intervention and BBS of two groups will be compared either by Student's t-test for parametric data or Mann-Whitney U test for non-parametric data. Statistical significance will be considered if p<0.05 at 95% confidence level.

ETHICS AND DISSEMINATION

Ethical approval for this study protocol (version 1.0, 22 April 2022) was obtained from the institute ethics committee (AIIMS/IEC/22/195).

TRIAL REGISTRATION NUMBER

CTRI/2022/06/043287.

Post-COVID pulmonary fungal infections: An unanticipated predicament or a ticking time bomb? Clinico-microbiological profile of cases encountered during the second wave of COVID-19 pandemic at a teaching hospital in the Himalayas with a brief literature review

Introduction

This study attempts to generate preliminary data regarding post-COVID pulmonary fungal infections, namely, COVID-19-associated pulmonary aspergillosis (CAPA), COVID-19-associated pulmonary mucormycosis (CAPM), and mixed infections from the Himalayas and compares the micro-radio-clinical profile and outcomes of the affected patients.

Materials and Methods

A retrospective data analysis was conducted, where clinical profiles, microbiological and radiological reports, and outcomes of n = 16 patients of post-COVID pulmonary infections were compared.

Results

Of n = 16 patients, n = 7 had CAPA (n = 5 Aspergillus fumigatus, n = 1 Aspergillus flavus, and n = 1 Aspergillus niger), n = 5 CAPM (Rhizopus arrhizus), and n = 4 with mixed infections (n = 3 infected with Aspergillus fumigatus and Rhizopus spp. and n = 1 with Aspergillus flavus and Rhizopus arrhizus). Thick-walled cavitary lesions, air-fluid levels, and multiple centrilobular nodules were some of the common radiological findings reported among these patients.

Conclusion

The immuno-compromised state following COVID-19 infection and treatment might be responsible for the progression of regular exposure to the dense Himalayan vegetation into an invasive pulmonary fungal infection. Suspecting post-COVID pulmonary fungal infection is necessary for primary care physicians to ensure timely referral to higher centers. Mixed pulmonary fungal infections (coinfection with Aspergillus spp. and Rhizopus spp.) are also emerging as important sequelae of COVID-19.

Hypercalcemic Crisis: A Rare Presentation of Ewing's Sarcoma

Ewing's sarcoma (ES) is a rare malignancy of adolescence that usually presents with clinically apparent disease involving long bones, brought to attention by trauma and/or fractures. Hypercalcemia of malignancy is a well-known phenomenon; however, hypercalcemia is exceptionally rare in ES. This case report discusses a 20-year-old lady who experienced chronic bone pains in her hip and lower limbs, ultimately leading to a hypercalcemic crisis. We emphasize the importance of considering ES as a potential cause of hypercalcemia, highlighting the mechanism, diagnostic and therapeutic challenges, the associated poor prognosis, and the necessity for a multidisciplinary approach to managing the condition.

Effectiveness of ayurvedic formulation, NAOQ19 along with standard care in the treatment of mild-moderate COVID-19 patients: A double blind, randomized, placebo-controlled, multicentric trial

BACKGROUND

Medicines in indigenous systems such as Ayurveda have strong antimicrobial activity but double-blind randomized control trials are infrequent in this system of medicine. The efficacy of a new ayurvedic formulation was evaluated during the pandemic.

METHODS

150 mild-moderate COVID-19 patients were enrolled and randomized in 1:1 to NAOQ19 and placebo group. RT-PCR was done on Day 3, 5 and 7. CBC, CRP, LFT, and KFT were assessed at baseline and exit. Duration of hospital stay was noted and clinical assessment was also performed.

RESULT

The results demonstrated more people turning RT-PCR negative in the NAOQ19 group compared to the placebo group on day 3 (p-value = 0.033). The mean time duration to turn RT-PCR negative was significantly lower in the NAOQ19 group (4.6 days) compared to placebo group (5.2 days) (p-value = 0.018). There was significant reduction in hospital stay among patients in the NAOQ19 arm who were discharged earlier (5.6 days) compared to placebo group (6.4 days) (p-value = 0.046). Patients in NAOQ19 arm did not show any adverse life-threatening events.

CONCLUSION

The ayurvedic preparation given along with standard of care therapy reduced the duration of hospital stay and there was earlier conversion to RT-PCR negative.The integrated approach can help to reduce patient workload in the hospitals as well as limit the transmission of the virus in the community.

STUDY REGISTRATION

CTRI/2021/05/033790.

Serum sodium improvement: change in Comprehensive Geriatric Assessment parameters in geriatric patients with hyponatremia

BACKGROUND

Hyponatremia presents with symptoms considered age-associated in the elderly. We assess the change in Comprehensive Geriatric Assessment (CGA) parameters after hyponatremia improvement in hospitalized geriatric patients.

METHODS

We took 100 hyponatremic and same number of eunatremic geriatric patients (> 60 years) who were comorbidity, presenting-complaints, and age-matched. Four CGA parameters were utilized, the new Hindi Mental State Examination (HMSE), Barthel's index of activities of daily living (ADL), Timed up and go Test (TUG), and handgrip strength by hand dynamometer (HG). We analyzed these at admission and discharge, and their relationship with change in sodium levels.

RESULTS

Average age was 68.1 ± 5.8 years, with males constituting 75%. The CGA parameters demonstrated worse values amongst the hyponatremia than the normonatremia group. Severe hyponatremia group showed worse CGA scores in comparison with moderate and mild. With improvement in sodium level, the improvements in ADL, TUG, and HMSE scores were greater in the hyponatremia group (8.8 ± 10.1, 2.2 ± 2.5, and 1.7 ± 2.3 respectively) in comparison to the normonatremia reference group (4.7 ± 9.0, 1 ± 2.0, and 0.7 ± 1.3 respectively, P < 0.05).

CONCLUSION

Our study is the first utilizing HMSE to assess change in cognitive ability with improvement in serum sodium levels in the Indian elderly. Hyponatremic patients show worse baseline CGA parameters, and hyponatremia severity correlates with worse motor and cognitive function. Improvement in the serum sodium level improves the CGA parameters. Correction of hyponatremia in the geriatric age group significantly impacts life quality.

Artificial intelligence in clinical medicine: catalyzing a sustainable global healthcare paradigm

As the demand for quality healthcare increases, healthcare systems worldwide are grappling with time constraints and excessive workloads, which can compromise the quality of patient care. Artificial intelligence (AI) has emerged as a powerful tool in clinical medicine, revolutionizing various aspects of patient care and medical research. The integration of AI in clinical medicine has not only improved diagnostic accuracy and treatment outcomes, but also contributed to more efficient healthcare delivery, reduced costs, and facilitated better patient experiences. This review article provides an extensive overview of AI applications in history taking, clinical examination, imaging, therapeutics, prognosis and research. Furthermore, it highlights the critical role AI has played in transforming healthcare in developing nations.

Geriatric Goalposts: Of Independence And Interdependence

Our elder population has a unique set of needs and necessities, challenges and concerns. This reflects in the approach of geriatric medicine, which aims to ensure functional freedom and independence, as well as healthy ageing, of older citizens. We propose another, higher, aim of geriatric medicine: that is interdependence. This creates a spirit of optimism, in persons of geriatric age group as well as in their health care providers, who are able to interpret goals of medical care in a broader perspective.

Prevalence of dementia in India: National and state estimates from a nationwide study

INTRODUCTION

Prior estimates of dementia prevalence in India were based on samples from selected communities, inadequately representing the national and state populations.

METHODS

From the Longitudinal Aging Study in India (LASI) we recruited a sample of adults ages 60+ and administered a rich battery of neuropsychological tests and an informant interview in 2018 through 2020. We obtained a clinical consensus rating of dementia status for a subsample (N = 2528), fitted a logistic model for dementia status on this subsample, and then imputed dementia status for all other LASI respondents aged 60+ (N = 28,949).

RESULTS

The estimated dementia prevalence for adults ages 60+ in India is 7.4%, with significant age and education gradients, sex and urban/rural differences, and cross-state variation.

DISCUSSION

An estimated 8.8 million Indians older than 60 years have dementia. The burden of dementia cases is unevenly distributed across states and subpopulations and may therefore require different levels of local planning and support.

HIGHLIGHTS

The estimated dementia prevalence for adults ages 60+ in India is 7.4%. About 8.8 million Indians older than 60 years live with dementia. Dementia is more prevalent among females than males and in rural than urban areas. Significant cross-state variation exists in dementia prevalence.

Dermatomyositis Masquerading As Generalized Body Swelling: A Case Report

Dermatomyositis (DM) is a systemic autoimmune disease that primarily affects the skin and muscles. The hallmark skin manifestation is a violaceous rash on the face, neck, shoulders, upper chest, and extensor surfaces of the arms and legs, which is often accompanied by edema and can be exacerbated by exposure to sunlight. Generalized limb edema and dysphagia are rare presentations of dermatomyositis. Here we present a case of a 69-year-old woman presenting with generalized limb swelling, periorbital swelling, and dysphagia which was diagnosed as dermatomyositis based on a combination of clinical, laboratory, and imaging findings. The patient had an absence of complaints of limb weakness and a predominance of complaints of edema and dysphagia which posed a diagnostic challenge. The patient was treated with high-dose steroids and immunosuppressive therapy, leading to a significant improvement in her symptoms. Edematous dermatomyositis has been associated with underlying malignancy in 25% of the cases and this warrants close follow-up and malignancy screening for such patients. In some cases, subcutaneous edema might be the only manifestation of the disease. This case underscores the importance of recognizing DM as a potential differential diagnosis in patients presenting with generalized edema and dysphagia, particularly in the initial absence of classic skin findings. This rare presentation of dermatomyositis may be a hallmark of a severe form of the disease and requires prompt recognition and aggressive treatment.

A comparative study of mortality differences and associated characteristics among elderly and young adult patients hospitalised with COVID-19 in India

INTRODUCTION

Studies have shown that elderly have been disproportionately impacted by COVID pandemic. They have more comorbidities, lower pulmonary reserve, greater risk of complications, more significant resource utilization, and bias towards receiving lower-quality treatment.

OBJECTIVES

This research aims to determine the characteristics of those who died inhospital due to COVID illness, and to compare these factors between elderly and young adults.

METHODS

We conducted a large retrospective study at a government run center in Rishikesh, India, from 1^st May 2020 till 31^st May 2021, and divided study population into adults (aged 18 to 60 years) and elderly (aged 60 years). We evaluated and compared our data for presenting symptoms, vitals, risk factors, comorbidities, length of stay, level of care required, and inhospital complications. Long-term mortality was determined using telephonic follow-up six months after discharge.

RESULTS

Analysis showed that elderly had 2.51 more odds of dying inhospital compared to younger adults with COVID. Presenting symptoms were different for elderly COVID patients. The utilization of ventilatory support was higher for elderly patients. Inhospital complications revealed similar profile of complications, however, kidney injury was much higher in elderly who died, while younger adults had more Acute Respiratory Distress. Regression analysis showed that model containing cough and low oxygen saturation on admission, hypertension, Hospital Acquired Pneumonia, Acute Respiratory Distress Syndrome, and shock, predicted inhospital mortality.

CONCLUSION

Our Study determined characteristics of inhospital and long-term mortality in elderly COVID patients and compared them from adults, to help better triaging and policy making in future.

Association of Vitamin D Status With Metabolic Syndrome and Its Individual Risk Factors: A Cross-Sectional Study

Background Vitamin D deficiency has been associated with metabolic syndrome and its related outcomes, including type 2 diabetes mellitus, cardiovascular disease, myocardial infarction, and stroke. However, studies in Indian populations have provided conflicting results. Methods This single-center cross-sectional study was conducted in a tertiary care hospital in north India to determine the prevalence of vitamin D deficiency in patients with metabolic syndrome and to study the correlations of individual components of metabolic syndrome with 25 hydroxy vitamin D levels. The study included 235 patients aged between 30 to 70 years who met the criteria for metabolic syndrome. Patients with diabetes, hypothyroidism, Cushing's, and other disorders affecting vitamin D status, on supplements of vitamin D or anti-dyslipidaemic drugs were excluded. Information regarding socio-demographic characteristics, medical history, and anthropometric measurements were collected. Blood samples were collected to assess vitamin D levels. Results The prevalence of vitamin D deficiency (<20 ng/ml) was 76% among the study population. There was a significant negative correlation between vitamin D levels and diastolic blood pressure (Spearman's rho: -0.134, 95% CI: -0.82,-0.260, p=0.040), fasting blood glucose (Spearman's rho: -0.142, 95% CI: -0.101,-0.269, p=0.029), A weak correlation was also found between vitamin D3 levels and total cholesterol (Spearman's rho: -0.246, 95% CI: -0.119,-0.367, p<0.001), triglyceride levels (Spearman's rho: -0.246, 95% CI: -0.118,-0.370, p<0.001) and low-density lipoprotein (LDL) levels (Spearman's rho: -0.229, 95% CI: -0.102,-0.351, p<0.001). Conclusion The study findings suggest that vitamin D deficiency is prevalent among patients with metabolic syndrome in north India. There is a significant negative correlation between vitamin D levels and some components of metabolic syndrome. This highlights the need for further research to understand the underlying mechanisms and potential benefits of vitamin D supplementation in this population. Identification of high-risk individuals for hypovitaminosis D can aid in streamlining treatment guidelines and preventing unnecessary prescription of investigations in developing countries.

Effectiveness of Preparedness Training Delivered to Pre-final and Final Year Nursing Undergraduates to Combat COVID-19: A Need-based Initiative

A major concern during the COVID-19 pandemic has been the shortage of manpower for patient care. The recommendation of various authorised bodies encouraged the training of students from medical, nursing, and allied fields to manage COVID-19 cases by tele-consultation and monitoring of mild cases under the supervision of faculty. Anticipating a further shortage of human resources, leading to dire consequences, preparedness training for the final year and pre-final nursing undergraduates was initiated. The current study was conducted to evaluate the effectiveness of and feedback on COVID-19 preparedness training delivered to final-and pre-final-year undergraduate nursing students. A 3-day training was given to pre-final and final year nursing undergraduates on ECG, COVID-19 management protocols, personal protective equipment "donning and doffing", "hand hygiene", "biomedical waste management", "contact tracing" and cleaning and disinfection and simulation-based skills. Scores before and after training were conducted and mean scores were compared using a paired t-test. In total, 154 nursing students participated in the training program. Mean pre-test and post-test scores included: general instructions (21.69±2.5 and 25.09±3.29); skill procedures (5.4±1.21 and 6.3±1.2) and COVID management (22.84±3.26 and 26.48±2.06). There was a statistically significant improvement in knowledge and skills in all training sessions (p=0.0001). The mean post-test scores obtained at the OSCE stations for cardiac monitoring, prone positioning, compression-only CPR, airway, ECG and ABG ranged from 97.0% to 100.0% and all participants scored >70.0%. About 92.8% of the students felt that hands-on training enhanced their learning experiences. A need-based initiative of training final-and pre-final-year nursing students in COVID-19 support care effectively and efficiently created a skilled workforce.

Giant Cell Arteritis in an Elderly Female With Pulmonary Tuberculosis

Giant cell arteritis (GCA) is a type of systemic vasculitis that primarily affects people over the age of 50 and affects the medium to large arteries. GCA's clinical manifestations can be varied and non-specific, similar to those observed in atherosclerosis. Here, the authors present a case of an elderly woman with pulmonary tuberculosis with GCA masquerading as atherosclerosis.

Deep phenotyping and genomic data from a nationally representative study on dementia in India

The Harmonized Diagnostic Assessment of Dementia for the Longitudinal Aging Study in India (LASI-DAD) is a nationally representative in-depth study of cognitive aging and dementia. We present a publicly available dataset of harmonized cognitive measures of 4,096 adults 60 years of age and older in India, collected across 18 states and union territories. Blood samples were obtained to carry out whole blood and serum-based assays. Results are included in a venous blood specimen datafile that can be linked to the Harmonized LASI-DAD dataset. A global screening array of 960 LASI-DAD respondents is also publicly available for download, in addition to neuroimaging data on 137 LASI-DAD participants. Altogether, these datasets provide comprehensive information on older adults in India that allow researchers to further understand risk factors associated with cognitive impairment and dementia.

[Profiling patients with early onset psychosis in Flanders]

BACKGROUND

Little is known about patients with early onset psychosis (EOP) because of the low prevalence and separation of mental health care for adolescents and adults.

AIM

To describe characteristics of patients with EOP, their global functioning and their journey concerning healthcare, education, employment status, living situation and wellbeing in the years following onset of psychosis.

METHOD

Data about demography, symptoms, treatment and functioning were collected from electronic patient records for 31 patients with EOP. Fourteen of these patients completed a questionnaire after discharge from inpatient treatment in ZNA University Child and Youth Psychiatry in Antwerp (UKJA) regarding after care, education, work and living conditions and wellbeing.

RESULTS

Most patients developed severe psychotic symptoms before the age of 16 that required prolonged intensive psychiatric treatment. They showed multiple risk factors associated with psychosis. Following inpatient treatment most patients received special needs education and a majority transitioned into adult psychiatric care. Parents were the main source of social support for patients.

CONCLUSION

During recovery access to support in different domains of life is needed. If we want to offer adequate care for each patient the organization of mental healthcare and assistance needs to be improved.

Clinico-etiological profile of the elderly population with altered mental status in a teaching hospital

Background

This study aimed at evaluating the clinico-etiological profile of altered mental status (AMS) among elderly patients and making recommendations regarding management based on etiologies, thereby improving both morbidity and mortality outcomes.

Materials and Methods

This retrospective observational study was conducted in a teaching cum tertiary care hospital. Two years data (from July 2017 to June 2019) were extracted from the medical records section, and 172 eligible participants were analyzed using descriptive statistics for clinical outcomes, demographic profiles, and various etiological factors.

Results

A total of 1784 elderly inpatients (age >60 years) were screened from the records, and 172 eligible elderly AMS patients were found eligible for the study. The male elderly population consisted of 110 (63.95%), and the female elderly was 62 (36.04%). The mean age of the study population was 67.82 years. The etiological factors of AMS in the study population were neurological - 47.09% (n = 81), infection - 30.23% (n = 52), metabolic/endocrine - 16.27% (n = 28), pulmonary - 2.32% (n = 4), fall - 1.74% (n = 3), toxic cause - 1.16% (n = 2), and psychiatric illness - 1.16% (n = 2). The total mortality rate was 9.30% (n = 16).

Conclusion

The main etiological factors of AMS in the elderly population were predominantly of neurological, septic, and metabolic causes. These factors were preventable and treatable by training physicians, staff (as most of the physicians in the developing countries are not trained in managing this fragile group of population with multiple comorbidities), and by decentralizing geriatrics health-care setups.

Association Between Cognitive Performance and Nutritional Status: Analysis From LASI-DAD

Malnutrition in low- and middle-income countries causes cognitive decline and other health problems. Harmonized Diagnostic Assessment of Dementia for Longitudinal Aging Study in India (LASI DAD) is an extensive study on late-life cognition and dementia. This study examines the link between nutrition and cognitive abilities in older adults using data from the LASI DAD. We conducted descriptive statistics on nutritional parameters (body-mass index, waist-hip ratio, and Mini-Nutritional Assessment), cognitive functions, and socio-demographic variables in 2,892 adults aged ≥60 years. Cognitive domains assessed included delayed recall, orientation, language, executive function, abstract reasoning, and attention. Cognitive impairment was defined as impaired performance in two or more domains. Mean age was 69.3 ± 7.1 years, 52.9% were female, and 57.5% were illiterate. Low body-mass index (adjusted OR: 1.88, p < .001), at risk of malnutrition (adjusted OR: 1.89, p < .001) and malnourished (adjusted OR: 2.86, p < .001) on Mini-Nutritional Assessment were associated with the presence of cognitive impairment. Better cognitive performance was associated with increased body mass index (adjusted OR: 0.74, p-.03), hemoglobin (adjusted OR: 0.91, p-.006), and serum albumin (adjusted OR: 0.38, p < .001). This study shows that nutritional status assessed by anthropometric measures and blood markers is strongly linked to cognitive performance in older adults.

Symptoms are known by their companies: towards association guided disease diagnosis assistant

Over the last few years, dozens of healthcare surveys have shown a shortage of doctors and an alarming doctor-population ratio. With the motivation of assisting doctors and utilizing their time efficiently, automatic disease diagnosis using artificial intelligence is experiencing an ever-growing demand and popularity. Humans are known by the company they keep; similarly, symptoms also exhibit the association property, i.e., one symptom may strongly suggest another symptom's existence/non-existence, and their association provides crucial information about the suffering condition. The work investigates the role of symptom association in symptom investigation and disease diagnosis process. We propose and build a virtual assistant called Association guided Symptom Investigation and Diagnosis Assistant (A-SIDA) using hierarchical reinforcement learning. The proposed A-SIDDA converses with patients and extracts signs and symptoms as per patients' chief complaints and ongoing dialogue context. We infused association-based recommendations and critic into the assistant, which reinforces the assistant for conducting context-aware, symptom-association guided symptom investigation. Following the symptom investigation, the assistant diagnoses a disease based on the extracted signs and symptoms. The assistant then diagnoses a disease based on the extracted signs and symptoms. In addition to diagnosis accuracy, the relevance of inspected symptoms is critical to the usefulness of a diagnosis framework. We also propose a novel evaluation metric called Investigation Relevance Score (IReS), which measures the relevance of symptoms inspected during symptom investigation. The obtained improvements (Diagnosis success rate-5.36%, Dialogue length-1.16, Match rate-2.19%, Disease classifier-6.36%, IReS-0.3501, and Human score-0.66) over state-of-the-art methods firmly establish the crucial role of symptom association that gets uncovered by the virtual agent. Furthermore, we found that the association guided symptom investigation greatly increases human satisfaction, owing to its seamless topic (symptom) transition.

Stroke Characteristics as Predictors of New-onset Seizure in Patients with Acute Ischemic Stroke

INTRODUCTION

The current guidelines on diagnosis and management of new-onset seizures in stroke are not well defined, especially in the Indian setting. Our study aims at providing insight into the hospital prevalence risk of new-onset seizures following ischemic stroke and to correlate seizure risk with the characteristics of stroke and other clinical parameters.

METHODS

A total of 127 patients were analyzed for the study where we assessed the clinical severity and the imaging severity of stroke using the National Institute of Health Stroke Scale (NIHSS) score and Alberta Stroke Program Early CT (ASPECT) score, respectively. Seizure-related variables including semiology, timing, and details of antiepileptic drugs (AEDs) were assessed under the domain of early and late poststroke seizures (PSSs). All patients were followed for 6 months for the seizure recurrence and change in Barthel index. In statistical analysis, quantitative variables were compared using the independent t-test/Mann-Whitney U test, and qualitative variables were correlated using Chi-square test/Fisher's exact test. Univariate and multivariate logistic regression was used to find out the significant risk factors of acute symptomatic seizure.

RESULTS

The mean age of the study population was 59.72 years (±14.77), with a male predominance (60.63%). About 78.74% of the cases had an NIHSS score more than or equal to 6.24% had posterior circulation strokes and the rest had anterior circulation strokes. A cortical location of infarct was observed in 62.2% of cases and a subcortical location in 61.4% of cases. The prevalence of early PSSs observed in our study was 10.6%. Of those, 80% had generalized seizures, 13.3% had focal seizures, and 6.67% had focal seizures with secondary generalizations. No patient in the study group had late-onset seizures. Total leukocyte count, serum protein levels, serum uric acid levels, and erythrocyte sedimentation rate (ESR) values were associated with early seizures (p&lt;0.05). Patients with early seizures were found to have a longer hospital stay (8 vs 6 days with p&lt;0.05). In the Trial of Org 10,172 in Acute Stroke Treatment (TOAST) etiological classification, an acute stroke of undetermined etiology was found to have a significant association with the occurrence of early seizure in both univariate and multivariate analysis [p = 0.030; odds ratio (OR) 4.735 (1.160-22.576)]. There was no difference in change in the Barthel index among the two groups.

CONCLUSION

There was no recurrence of seizures in those who defaulted for AED and one patient had a seizure even on AED. Prophylactic AEDs in stroke patients based on stroke characteristics could not be ascertained, but the sample size was small. Knowing the fact that antiepileptics cause sedation and increase the chance of aspiration, continuing AEDs in patients who develop acute symptomatic seizures should be judged judiciously.

P262 Clinico- microbiological profile of post-COVID pulmonary fungal infections encountered during the second wave of COVID-19 pandemic at a tertiary care teaching hospital in the Himalayas

 

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

Objective

The study aims to generate preliminary data about post-COVID pulmonary fungal infections in the Himalayas and analyze patients’ micro-radio-clinical profiles and outcomes.

Methodology

We conducted a retrospective study at a tertiary care teaching hospital in the Himalayas to generate preliminary post-COVID pulmonary fungal infection data. Sputum, Endotracheal Tube (ET), and Bronchoalveolar lavage (BAL) samples of patients sent to the Mycology laboratory were subjected to KOH mount and aerobic inoculation on Sabouraud dextrose agar plates at 37°C. The patients’ symptoms, diagnosis, clinical-radiological profile, and outcome were collected from the hospital database.

Results

Among n = 16 cases of post-COVID pulmonary fungal infections aged 53 +/- 13.38 years, n = 7 (43.75%) had Pulmonary Aspergillosis (n = 5 A. fumigatus, n = 1 A. flavus, n = 1 A. niger), n = 5 (31.25%) had Pulmonary Mucormycosis (Rhizopus arrhizus), and n = 4 (25%) had mixed infection. In 2 of 4 mixed infection patients, R. arrhizus was identified on KOH microscopy and A. fumigatus on SDA Agar. Both A. fumigatus and R. arrhizus were identified on KOH Microscopy of the third patient, while only A. fumigatus was cultivated on his SDA Agar. Aspergillus flavus and R. arrhizus were isolated simultaneously from the sample of the last patient, but only R. arrhizus was identified on KOH Microscopy.

Clinical symptoms were similar among Pulmonary Aspergillosis and Mucormycosis patients, but hemoptysis was reported only among Pulmonary Aspergillosis patients. Pre-existing co-morbid end-organ damage, AKI, CKD, CLD, COPD, and CAD was more common among Pulmonary Mucormycosis patients and rare among Pulmonary Aspergillosis patients. Treatment requirements and clinical outcomes of patients infected with either mold were similar. The clinical profile of mixed infection patients was notably different from the others. All the patients were males, none complained of chest pain or expectoration, and none had a history of PTB, AKI, CKD, CLD, COPD, or CAD. Only 2 (50%) mixed infection patients needed supplemental high flow oxygen, unlike all (100%) patients diagnosed with single mold infection. None of the mixed infection patients required steroids. Moreover, none of the mixed infection patients died, unlike 60% mortality in cases of single-species infections.

On radiological investigation, n = 6 had typical thick-walled cavitary lesions with air-fluid levels and multiple centrilobular nodules giving a tree in bud appearance, of which n = 4 had bilateral lung involvement, and n = 2 had only one lung involved. n = 1 patient had a well-circumscribed lung abscess.

Conclusion

COVID patients from the Himalayas had a higher prevalence of invasive pulmonary fungal infections, probably due to the dense surrounding vegetation. The immuno-compromised state following COVID-19 infection/treatment might be responsible for the progression of regular exposure to invasive pulmonary infection.

Rhupus Syndrome: A Diagnostic Dilemma

Rhupus syndrome, a rare coexistence of systemic lupus erythematosus (SLE) and rheumatoid arthritis, is characterized by symmetrical erosive polyarthritis and permanent deformities in addition to the clinical and serological characteristics of SLE. Its prognosis is further complicated by neurological and hematological involvement, which dramatically lowers patients' perceptions of their quality of life in terms of their health. Rhupus individuals have significantly less kidney involvement than SLE patients do. We present a case of a young female who had symmetric, bilateral, erosive polyarthritis for one and a half years preceding the signs and symptoms of SLE, which occurred about six months later.

Yoga as an Adjuvant therapy in management of migraine- An open label randomised trial

Introduction

Drug treatment is not very satisfactory in migraine and is associated with adverse effects. The effect of yoga as an add-on therapy in migraine was evaluated in the present study.

Methods

Patients between the age of 18 and 60 years suffering from migraine were recruited from Internal Medicine and Neurology OPD. Migraine was diagnosed according to the International Headache Society, International Classification of Headache Disorders-3^rd edition (IHS, ICHD-3). At baseline, clinical and autonomic parameters of patients were assessed, and consenting patients were randomized into two equal groups by using a computer-based random number generator program (version 1): conventional (C group) and conventional plus yoga (C+Y group). Both groups were given conventional therapy for migraine, and the C+Y group was given yoga as an add-on therapy. Yoga therapy was given for 5 days/week for 12 weeks, and a post-intervention assessment was done at the 14^th week. Subjective variables such as frequency and average duration were assessed through headache diaries or telephonic conversation, while severity was assessed using the visual analog scale (VAS) and headache impact test (HIT-6).

Statistical Analysis

Independent t test and Mann-Whitney U Test (Wilcoxon rank-sum test) were used for comparing normally and non-normally distributed endpoint outcomes after treatment (AT).

Results

Out of 170 patients screened, 75 were diagnosed with migraine and only 34 patients completed the study (17 in each group). All clinical and autonomic parameters showed significant improvement in pre- and post-intervention values in both groups (P < 0.0001). On comparing the conventional (C) group and conventional + yoga (C+Y) group, the change in the VAS score was more in the C+Y group (P = 0.041) and heart rate variability showed more reduction in the C+Y group (P = 0.032).

Conclusion

We did not find any significant difference in the clinical outcome by adding yoga therapy to conventional therapy, except reduction in VAS score and reduction in heart rate variability.

Nutritional assessment in hospitalized elderly patients, its sociodemographic determinants and co-relation with activities of daily life

Introduction

Present study was planned to identify various sociodemographic factors influencing nutritional status in elderly and impact of nutritional status on activities of daily living in them.

Methods

Total of 177 patients were enrolled in a prospective observational study. Nutritional status was assessed at the time of discharge by using Mini Nutritional Assessment form (MNA). Kartz Activity of Daily Living was assessed at 3 months before admission, at the time of admission, at discharge and 3 months after discharge. After written informed consent and ethics clearance patients were enrolled in the study. Analysis was done using the SPSS version 23 and Chi Square test was used to find the association between different qualitative variables. Statistical significance was set at P < 0.05.

Results

Mean age of the study participants was 68.64 ± 7.73 years. 40 patients (22.6%) were found to be malnourished. Higher age, living alone, high CCI score and low ADL at discharge were associated with malnutrition. Mean ADL score was 5.82 at - 3 months time point in well-nourished patients which decreased during admission and then increased to 4.94 at the 3 months after discharge. Mean ADL score was of 5.33 at -3 months time point which kept on decreasing during admission and at 3 months after discharge in malnourished group. All these changes were statistically significant (P < 0.001).

Conclusion

Nutritional status is a modifiable risk factor in elderly so identifying and optimizing nutritional status of elderly will optimise their functional status and improve quality of life.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Asian Best Practices for Care of Diabetes in Elderly (ABCDE)

The elderly population with diabetes is diverse with the majority experiencing a decline in physical and mental capabilities, impacting the entire diabetes management process. Therefore, a need for geriatric-specific guidelines, especially for the Asian population, was identified and subsequently developed by an expert panel across government and private institutions from several Asian countries. The panel considered clinical evidence (landmark trials, position papers, expert opinions), recommendations from several important societies along with their decades of clinical experience and expertise, while meticulously devising thorough geriatric-specific tailored management strategies. The creation of the ABCDE best practices document underscores and explores the gaps and challenges and determines optimal methods for diabetes management of the elderly population in the Asian region.

A Comparative Study of Baseline Heart Rate Variability, Sleep Quality, and Oxidative Stress Levels in Hypertensive Versus Normotensive Subjects: A Cross-Sectional Study

Objectives: To understand sleep quality, oxidative stress levels, and heart rate variability (HRV) in subjects with hypertension. This study aims to create baseline data in hypertensive subjects to research the possibility of further estimating the risk of developing cardiovascular mortality and morbidity in a patient with hypertension.

Design and methods: This analytical cross-sectional study, encompassing 128 study subjects of both genders, with 64 hypertensive subjects, analyse the co-relation of sleep quality, malondialdehyde, and heart rate variability in hypertensive and normotensive subjects. The study was done in a tertiary teaching institute in northern India for 14 months. Descriptive statistics were used, and the independent t-test, Mann-Whitney U test, and Chi-square were used to find the association among the variables. Linear regression was used to estimate the effect of blood pressure on malondialdehyde levels.

Results: Subjects with hypertension were found to have poor sleep quality (Global PSQI score ≥5, p=0.0001) and an increased malondialdehyde level (0.30303±0.17193 µM/L, p=0.0001). The hypertensive subjects were found to have lower parasympathetic activity as indicated by low high frequency (2.79463±473.220280; p=0.0001) and increased sympathetic activity; low frequency/high frequency (2.29823±2.792441; p=0.0001). Multivariate linear regression predicts that with one unit increase in systolic blood pressure, the malondialdehyde level increases by 0.006 units (p=0.002; 95% CI).

Conclusion: Among the hypertensive group, there is significantly increased oxidative stress level, poor quality of sleep, and increased sympathetic activity, thereby predisposing the subjects to increased risk of cardiac morbidity and mortality.

Adjuvant testosterone therapy in chronic heart failure (ATTIC): a randomised open-label trial

INTRODUCTION

Heart failure is a major contributor to morbidity and mortality in the geriatric population, with no promising therapy currently available with considerable benefit. Testosterone therapy is an emerging viable treatment option given its beneficial effects, including improving cardiac functional capacity, alleviating symptoms and low cost, among others.

METHODS

We have planned an open-label, parallel design, 1:1 randomised controlled trial, which aims to recruit 986 adult males above the age of 60 diagnosed with chronic stable heart failure fulfilling the eligibility criteria. The participants will be randomised into 2 groups of 493 each. Both groups will receive standard recommended treatment regimen of chronic stable heart failure and intervention arm participants will receive additional testosterone gel. All participants will be assessed at baseline, 4 weeks, 6 weeks and 12 weeks. The primary endpoints will assess the differences in functional capacity, frailty and quality of life at 3 months compared with baseline. The secondary endpoints will include the mean change from baseline at 3 months in cardiac remodelling using echocardiography, serum brain natriuretic peptide levels, the incidence of adverse drug reaction.

STATISTICAL ANALYSIS

The data will be analysed with the help of SPSS 23 software. Primary objectives of change in 6-minute walk test, frailty index and quality of life will be analysed using the student's t-test. The statistical significance will be defined as p value<0.05 and taking confidence level as 95%.

ETHICAL CLEARANCE

Institutional Ethics Committee clearance taken via letter no AIIMS/IEC/20/847, dated 21 November 2020. This study involves human participants and was approved by institutional ethical committee, DHR Reg: EC/NEW/Inst/2020/1046CDSCO, Reg No: ECR/736/Inst/UK/2015/RR-18. Participants gave informed consent to participate in the study before taking part.

TRIAL REGISTRATION NUMBER

(CTRI)-REF/2020/12/030292.

Clinical Characteristics and Outcomes in Elderly Patients With COVID-19: A Single-Centre Retrospective Study

Background: Even with the wide base of knowledge that has been accumulated regarding coronavirus disease 2019 (COVID-19), only limited studies have tried to establish differences in outcomes of elderly patients hospitalized with COVID-19. We, thus, conducted a retrospective study on a large cohort of hospitalized patients with COVID-19 to improve the understanding of such differences and add to the evidence available regarding this age group. 

Methods: This is a single-centre retrospective study conducted at a tertiary level hospital in the state of Uttarakhand in North India to determine clinical characteristics and outcomes in elderly patients (≥ 60 years) hospitalized with COVID-19 between May 1, 2020, and May 31, 2021. Our study included a retrospective follow-up at six months to also determine rehospitalizations and post-discharge mortality.

Results: There was a statistically significant difference (p<0.05) in in-hospital mortality, various in-hospital complications, duration of stay, number of rehospitalizations at six months, and post-discharge mortality up to six months in the elderly age group hospitalized with COVID-19.

Conclusions: This retrospective study demonstrates that the clinical characteristics and outcomes in hospitalized elderly with COVID-19 differ significantly from the younger adult population and demonstrates a need for greater hospital resource utilization in this age group. These results will help policymakers be better prepared for future pandemics. 

Serum Sodium Improvement: Effect on Comprehensive Geriatric Assessment Parameters in Hyponatremic Geriatric Patients in a Tertiary Care Center

Hyponatremia prevalence is 22.2% in the geriatric age group as compared to 6% for other patients. Symptomatology of hyponatremia is subtle and is often interpreted as age-related in the geriatric patients. We use various Comprehensive Geriatric Assessment (CGA) parameters to analyze the impact of improvement in serum sodium levels.

MATERIAL

We utilized four simple CGA parameters, the new Hindi Mental State Examination (HMSE) for assessing the cognition, Barthel index of activities of daily living (ADL) for the level of independence, Timed up and go test (TUG test) for risk of fall evaluation, and handgrip strength (HG) by hand dynamometer for frailty. All parameters were analyzed at admission and at discharge, and their relation with the severity of hyponatremia in 100 geriatric patients (&gt;60 years) was seen. Equal number of hyponatremic geriatric patients were taken, matched for comorbidity, reason for presentation, and age.

OBSERVATION

Mean age of the study population was 68.1 ± 5.8 years, with a male: female ratio of 3:1. Baseline sodium level in hyponatremia and normonatremia groups were 129.7 ± 5.1 and 139 ± 3.4 meq/L (P=2.4) respectively. All CGA parameters tested showed lower values among hyponatremic patients compared to normonatremic patients, although only ADL (71.6 ± 12.3 v/s 76.7 ± 11.5, P=0.001) and HMSE (23.4 ± 3.1 v/s 24.4 ± 2.4, P=0.01) were statistically significant. All parameters were worse in the severe hyponatremia group (Na&lt;125 meq/L) compared to moderate (Na=125-130 meq/L) and mild (Na=130-135 meq/L), but significant only for TUG (17.9 ± 3.4 v/s 16.4 ± 4.2 v/s 14.6 ± 3.5, P=0.003, higher value being worse) and HMSE (21.1 ± 4.0 v/s 22.6 ± 2.8 v/s 24.1 ± 2.5, P=0.0007). Improvement in ADL, TUG, and HMSE scores with serum sodium improvement was significantly higher in the hyponatremia group (8.8 ± 10.1, 2.2 ± 2.5, and 1.7 ± 2.3 respectively) when compared to the normonatremic reference group (4.7 ± 9.0, 1 ± 2.0, and 0.7 ± 1.3 respectively, P&lt;0.05). Although HG improvement was also greater, the difference was not statistically significant.

CONCLUSION

Ours is the first study utilizing HMSE for assessing the cognition in the Indian patients. Hyponatremic patients have poor baseline CGA parameter values, and severity of hyponatremia correlates with poor motor and cognitive functions. Improvement in serum sodium levels improve CGA parameters. Hyponatremia correction should be prioritized in the elderly as it significantly impacts the quality of life in the elderly.

The Prevalence and Associated Risk Factors of Fear of Fall in the Elderly: A Hospital-Based, Cross-Sectional Study

Background

Falls are one of the most common but serious health issues faced by the elderly population. Falls-related injuries not only add to the morbidity and economic burden they also have a significant negative impact on psychological health and the quality of life of the elderly. In this study, we assess the prevalence of fear of falling among the geriatric population and the risk factors associated with fear of falling.

Methodology

This prospective, cross-sectional study was conducted among geriatric patients aged more than 60 years attending the medical outpatient department of a tertiary care hospital in Uttarakhand, India. This study aimed to determine the prevalence of fear of falling among the geriatric population and compare various demographic and clinical parameters in elderly patients with and without fear of falling. Fear of fall was assessed using a questionnaire by asking the elderly if they had fear of falling, how often they had fear of falling, and under which circumstances did they have fear of falling. Information regarding demographics, history of daily activities, and chronic diseases was collected and assessed from all geriatric patients with and without fear of falls.

Results

Almost half (334; 42%) of the geriatric population had a history of fear of falling. Demographic parameters such as age over 80 years, female gender, living alone, and rural background were significantly associated with fear of falling. Similarly, a history of chronic diseases such as stroke, hypertension, and history of visual and motility impairment was significantly related to fear of falls among geriatric patients. Around 70% (571) of geriatric patients aged over 60 years had associated health problems.

Conclusions

This study reinstates that fear of falls is a significant health issue in the elderly age group. It also highlights multiple risk factors related to fear of falling which if controlled can significantly improve the quality of life of the geriatric population.

Nutritional and Functional Status as a Predictor of Short-Term Mortality in Hospitalized Elderly Patients in a Tertiary Care Hospital

Context

Elderly people are at a high risk of malnutrition leading to poor outcomes and quality of life.

Aims

We aimed to find an association between the nutritional and functional status of hospitalized elderly patients and the three-month all-cause mortality among them.

Settings and design

A cross-sectional study was carried out at a tertiary care hospital in North India from July 2018 to December 2019.

Methods and material

A total of 177 patients were recruited for the study, and their demographic and clinical data were collected on a preformed questionnaire. Comorbidity, nutritional status, functional status, and depression were calculated using the Charlson Comorbidity Index (CCI), Mini Nutritional Assessment (MNA) form, Katz Index of Independence in Activities of Daily Living (Katz ADL), and Geriatric Depression Scale (GDS), respectively.

Statistical analysis

A Chi-square test was used to find the association between different qualitative variables. A regression model was used to find out the odds for mortality. Statistical significance was set at p<0.05.

Results

According to the MNA score, 49.7% (88) were at risk of malnutrition, and 22.6%(40) were malnourished. Malnutrition, Charlson Comorbidity Index, and the functional status of the patients were found to be associated with three-month mortality, with a p value of 0.005, 0.017, and 0.021, respectively. On regression analysis, malnutrition (odds ratio (OR): 3.796; 95% confidence interval (CI): 1.178-12.234; p=0.025) and the functional status (OR: 3.160; 95% CI: 1.256-7.952; p=0.015) of the study participants were found to have higher odds for three-month all-cause mortality.

Conclusions

Nutritional status and ADL assessed at the time of discharge are good prognostic markers of health outcomes in the elderly population.

Key message

ADL and nutritional assessment at admission and discharge should be routinely incorporated in the geriatric assessment of hospitalized patients to triage and prognosticate.

Parotid Tuberculosis as the Presenting Manifestation of Disseminated Disease in an Otherwise Asymptomatic HIV Patient

Parotid tuberculosis is not widely described in the literature. Even though a rare presentation of a commonly occurring disease, it is still missed as a differential diagnosis and often mistaken for neoplasms, eventually leading to unnecessary surgical resections. Here, we present a case of a young lady with a slowly growing unilateral parotid mass along with matted, non-tender cervical, axillary, and inguinal lymphadenopathy, who was incidentally found to have HIV with a cluster of differentiation 4 (CD4) lymphocyte count of 38 per microliter. Fine needle aspiration revealed acid-fast bacilli and CT thorax showed features of pulmonary tuberculosis, thus suggesting a disseminated tuberculosis infection. She was started on anti-tubercular and anti-retroviral therapy, after which there was a symptomatic improvement.

Effectiveness of Large-Scale Preparedness Training on Electrocardiogram for Medical, Surgical, and Pre-clinical Doctors: A Need-Based Initiative for COVID-19 Patient Care

Introduction: One of the competencies expected of all doctors posted in coronavirus disease 2019 (COVID-19) wards, is ECG rhythm identification, interpretation, and intervention for immediate management of patients. This study was undertaken to evaluate the effectiveness of the ECG training module as a component of preparedness training to combat COVID-19.

Methodology: This was a cross-sectional study conducted during training on ECG rhythm identification, interpretation, its management in COVID-19 patients. Study participants included faculty, senior residents, junior residents, and interns of medical, surgical, and paraclinical disciplines. The training session included one hour of didactic lecture and one and half hours of interactive session during which case scenarios were discussed. An objective assessment was conducted through pre-test and post-test. Mean of pre and post-test scores were compared using paired t-test for evaluating statistical significance. Feedback was also taken from participants.

Results: Out of the 800 participants who gave consent, only 682 who completed both pre and post-test were included in the final analysis. Mean pre-test and post-test scores were 9.29/15 (61.9%) and 11.63/15 (77.5%), respectively, with a mean improvement of +2.34/15 (+15.6%). Of the participants, 38.6% obtained low scores in pre-test and 82% of respondents agreed that knowledge and skills gained from training would be useful in providing patient care.

Conclusion: Low baseline knowledge on ECG highlights the need for re-training doctors posted in COVID-19 care on cardiac rhythm identification and interpretation. Interactive training is effective in improving ECG interpretative skills among doctors across disciplines and is the appropriate method to retrain/reskill, especially for large-scale capacity building.

Early Initiation of Low-Dose Hydrocortisone Therapy for Septic Shock in Geriatric Patients: A Randomized Control Trial

BACKGROUND

The management of septic shock has undergone significant modifications in the past decade. Various studies have concluded that while corticosteroids reduce the duration of shock, they do not have any proven mortality benefit. Moreover, the time of initiation of corticosteroids has been debatable. Since, little literature is available on geriatric patients, we have designed a randomized trial to assess the importance of early initiation of low dose hydrocortisone comparing with the standard therapy.

OBJECTIVES

To determine the efficacy of early initiation of low dose hydrocortisone in reducing mortality in septic shock in geriatric patients.

METHODS

We conducted a single blinded, randomized controlled trial at a tertiary care hospital in India. Geriatric patients (age&gt;60 years) fulfilling the criteria for septic shock were included in the study. All the participants were randomly assigned to two arms- intervention and standard therapy group. The outcomes were studied in terms of 28-day mortality, duration of ICU stay, duration of vasopressor requirement and need for mechanical ventilation.

RESULTS

Total 120 patients were randomized to either Intervention arm (N=61) or the Standard therapy arm (N=59). The number of patients with reversal of shock was higher in the intervention arm (53.4%) but no statistically significant association (p= 0.575) was found. There was no significant difference between the two groups in terms of 28- day mortality, length of ICU stay, need for mechanical ventilation and duration of vasopressor support.

CONCLUSION

This single centre trial demonstrated that there was no survival benefit associated with the early initiation of low dose hydrocortisone treatment in patients with vasopressor-dependent septic shock. It raised the concern that whether steroids are safe in elderly patients with septic shock.

The Assessment of Baseline Comprehensive Geriatric Assessment Parameters in Geriatric Patients With Varying Severity of Hyponatremia at a Tertiary Care Center

Background and objective

The prevalence of hyponatremia is estimated to be significantly higher in the geriatric age group compared to non-geriatric patients. The clinical symptoms of hyponatremia are often subtle and interpreted as age-related in geriatric patients. In this study, we aimed to perform the baseline comprehensive geriatric assessment (CGA) among a group of geriatric population with hyponatremia.

Methods

We utilized four simple CGA parameters: the Hindi Mental State Examination (HMSE) to assess the cognition, the Barthel Index for Activities of Daily Living (ADL) for assessing the level of independence, the Timed Up and Go (TUG) test for risk of fall evaluation, and handgrip (HG) strength by hand dynamometer for frailty. All CGA parameters were analyzed at admission among 100 geriatric patients (>60 years old), and an assessment of their relationship with the severity of hyponatremia was done. An equal number of age-, comorbidity-, and reason for acute presentation-matched hyponatremic patients were enrolled as controls. The student’s t-test and analysis of variance (ANOVA) were used for evaluation. Ethical clearance was obtained from the Institutional Ethics Committee, All India Institute of Medical Sciences, Rishikesh, and informed consent from patients or next of kin was taken before enrollment.

Results

The mean age of the study population was 68.1 ± 5.8 years, with a male-to-female ratio of 3:1. All CGA parameters tested showed lower values among hyponatremic patients compared to normonatremic patients, although only ADL (71.6 ± 12.3 vs. 76.7 ± 11.5, p=0.001) and HMSE (23.4 ± 3.1 vs. 24.4 ± 2.4, p=0.01) were statistically significant. All parameters were found to be worse in the severe group compared to moderate and mild groups, but significance was found only for TUG (17.9 ± 3.4 vs. 16.4 ± 4.2 vs. 14.6 ± 3.5, p=0.003, with higher values indicating worse status) and HMSE (21.1 ± 4.0 vs. 22.6 ± 2.8 vs. 24.1 ± 2.5, p=0.0007).

Conclusion

Based on our findings, hyponatremic patients have poor baseline CGA parameter values, and the severity of hyponatremia correlates with poor motor and cognitive functions. Hence, the prompt recognition and correction of hyponatremia should be prioritized in the elderly as both these parameters significantly impact the quality of life in this population. As the severity of hyponatremia increases, the elderly tend to have a higher incidence of the two main geriatric giants: impaired cognition and falls.

Impact of cognitive impairment on activities of daily living among older adults of North India

Background

Older persons are at risk of developing cognitive impairment, often considered a precursor to more severe conditions, such as dementia or Alzheimer's disease. Cognitive impairment among older adults is one of the most rapidly growing burdens, especially in developing countries.

Aim

To assess the impact of cognitive impairment on activities of daily living (ADL) among older adults.

Materials and Methods

A cross-sectional descriptive study was conducted among 135 older adults visiting a selected tertiary care centre in Uttarakhand (India) during December 2020, recruited using total enumerative sampling. Data were collected using standardized and validated tools that consisted of socio-demographic information, Hindi Mental Status Examination, and Everyday Abilities Scale for India. Data were analyzed using SPSS version 23, including descriptive (frequency, percentage, mean, and median) and inferential statistics (Chi-square test, binary logistic regression).

Results

The results with pooled analysis have shown that 30% of the older adults had mild cognitive impairment, 9% had moderate cognitive impairment, and 61% had normal cognition. About 16% of the older adults' ADL were affected. The statistically significant predictors for cognitive impairment were age group 80 years [odds ratio (OR) = 36.21; 95% confidence interval (CI) = 6.23-210.59], Muslim religion (OR = 6.26; 95% CI = 1.12-34.93), and middle-class families (OR = 11.95; 95% CI = 1.84-77.78).

Conclusion

A considerably large proportion of the older adults had cognitive impairment, which further impacted activities of daily living. There is an urgent need to develop geriatric mental health services across all hospitals in the region.

Study protocol: IMPETUS: Implementing a uniform stroke care pathway in medical colleges of India: IMPETUS Stroke

Introduction:

In India, a national program for stroke (national programme for the control of cardiovascular diseases, diabetes, cancer, and stroke) and stroke management guidelines exist. Its successful implementation would need an organized system of stroke care in practice. However, many challenges exist including lack of awareness, prehospital notification systems, stroke ready hospitals, infrastructural weaknesses, and rehabilitation. We present here a protocol to investigate the feasibility and fidelity of implementing a uniform stroke care pathway in medical colleges of India.

Methods and Analysis:

This is a multicentric, prospective, multiphase, mixed-method, quasi-experimental implementation study intended to examine the changes in a select set of stroke care-related indicators over time within the sites exposed to the same implementation strategy. We shall conduct process evaluation of the implementation process as well as evaluate the effect of the implementation strategy using the interrupted time series design. During implementation phase, education and training about standard stroke care pathway will be provided to all stakeholders of implementing sites. Patient-level outcomes in the form of modified Rankin Scale score will be collected for all consecutive patients throughout the study. Process evaluation outcomes will be collected and reported in the form of various stroke care indicators. We will report level and trend changes in various indicators during the three study phases.

Discussion:

Acute stroke requires timely detection, management, and secondary prevention. Implementation of the uniform stroke care pathway is a unique opportunity to promote the requirements of homogenous stroke care in medical colleges of India.

Life-threatening disseminated tuberculosis masquerading as cervical spondylosis--- Case report “Cervical TB v/s Cervical Spondylosis”

Tuberculosis (TB) is quite prevalent in developing countries, with an ever-rising incidence of extrapulmonary cases. TB of bones and joints is quite challenging to diagnose. Most spinal TB lesions localize at the thoracic and lumbar levels; cervical lesions are a rarity. Hence, most neck pains are labelled cervical spondylosis as the symptomatology of cervical spine tuberculosis (CTB) remains unclear. A 38-year-old male had long-standing neck pain for six months, not associated with any focal neurological deficit, nausea, vomiting, or blurred vision. After the initial evaluation by local practitioners, the pain was, as usual, attributed to cervical spondylosis and conservatively managed. However, his pain worsened, and he ultimately came to us with altered mental status. In reality, he had CTB, which later complicated to life-threatening disseminated TB with intracranial and pulmonary involvement, and he could only survive after prolonged ICU care. Even mild cervical pain should not be neglected and must undergo proper evaluation. We should consider CTB in the differential diagnosis of chronic neck pain, especially in countries where TB is endemic.

Quantitative Definition of Fever Needs a Change: A Longitudinal Study from the Hospital Workers and their Family Members

Introduction: The age-old definition of fever was derived using cross-sectional population surveying utilising old techniques without considering symptomatology. However, the diagnosis of fever must be made only in the presence of associated symptoms that can distinguish it from the mere asymptomatic physiologic rise of temperature. Aim: Analysis of symptoms to re-define the cut-off of fever based on symptomatology. Materials and Methods: A longitudinal study on the healthy population of Uttarakhand, India was conducted and the population was followed up from July 2019 to September 2020. Healthy staff and students of All India Institute of Medical Sciences (AIIMS), and their family members between 4-100 years of age were chosen. Participants were advised to self-monitor oral temperature with a standard digital thermometer in either left or right sublingual pocket and record it in the thermometry diary. The study was considered complete if the participant had all the three phases of the study (i.e., prefebrile, febrile, and postfebrile phases) or completed the duration of the study. The febrile phase was defined when the participants subjectively ‘felt feverish’. Associated symptoms like fatigue, warmth, headache, and feeling malaise were also recorded. Results: Mean age of the participants was 24.24±5.92 years, and 52.1% (75) were males. Per protocol analysis was done for febrile participants (n=144, temperature recordings=6544). The mean febrile phase temperature was 100.25±1.440 F. A temperature of 99.10 F had maximum diagnostic accuracy for feeling feverish (98.2%), along with one (98.3%) or two (99%) associated symptoms. Summer and spring months showed higher temperatures (100.38±1.44 v/s 99.80±1.49, p-value<0.001), whereas no significant temperature difference could be noted amongst the genders. Conclusion: Based on the findings of this study, the revised temperature cut-off to define fever should be 99.10 F along with one or two associated symptoms.

Raised Amylase/Lipase levels in Enteric Fever: Prognostic marker or a sign of Pancreatitis? - Case Report

Enteric fever is a commonly diagnosed entity in developing nations. Mostly uneventful, it can sometimes manifest with a plethora of complications, including gastrointestinal hemorrhage, intestinal perforation, peritonitis, encephalopathy, and pancreatitis. We are discussing a case of enteric fever with the presentation in the form of bleeding per rectum. The patient's raised amylase and lipase levels confused the scenario as it could not be decided whether this rise was due to enteric fever or its possible but rare complication, pancreatitis. There was no radiological or clinical evidence of pancreatitis; hence the rise in the amylase and lipase levels was due to enteric fever only and not pancreatitis. Serial titers showed declining enzyme values with the improvement of patient condition. A correlation of amylase and lipase levels with enteric fever and the use of serial amylase and lipase levels as a prognostic marker for enteric fever are proposed hereby, hence, proposed.

Factors responsible for Uncontrolled Hypertension in the Adults over 50 years of age: A pilot study from Northern India

Hypertension is the most common chronic disease of older adults and an important modifiable cause of mortality and morbidity. In this cross-sectional study, we gathered information about the demographic profile and biochemical parameters associated with hypertension in 897 study subjects above 50 years by structured questionnaires and various laboratory investigations. Higher body mass index, sedentary lifestyle, male sex, living alone, diabetes mellitus, alcohol consumption, medication non-compliance, and a higher serum cholesterol level were associated significantly with uncontrolled hypertension in our study. Hence, weight reduction, adopting an active lifestyle, improving social support, and strict compliance with anti-hypertensives are the cornerstones of blood pressure control.

Antiviral Combination Clinically Better Than Standard Therapy in Severe but Not in Non-Severe COVID-19

Purpose

Definitive antiviral treatment is not available for COVID-19 infection, with the exception of remdesivir, which still evokes many doubts. Various monotherapy or combination therapies with antivirals or other agents have been tried. The present study aims to evaluate the therapeutic potential of hydroxychloroquine and lopinavir–ritonavir in combination with ribavirin in mild–severe COVID-19.

Patients and Methods

A single-center, open-label, parallel-arm, stratified randomized controlled trial evaluated the therapeutic potential of combination antiviral therapies. Enrolled patients in the severe category were randomized into three groups: (A) standard treatment, (B) hydroxychloroquine+ribavirin+standard treatment, or (C) lopinavir+ritonavir+ribavirin+standard treatment; while the non-severe category comprised two groups: (A) standard treatment or (B) hydroxychloroquine+ribavirin. Combination antivirals were given for 10 days and followed for 28 days. The primary endpoints were safety, symptomatic and laboratory recovery of organ dysfunctions, and time to SARS-CoV-2 RT-PCR negative report.

Results

In total, 111 patients were randomized: 24, 23, and 24 in severe categories A, B, and C, respectively, and 20 in each of the non-severe groups. Two patients receiving ribavirin experienced drug induced liver injury, and another developed QT prolongation after hydroxychloroquine. In the severe category, 47.6%, 55%, and 30.09% in A, B, and C groups, respectively, showed symptomatic recovery, compared to 93.3% and 86.7% in A and B groups, respectively, in the non-severe category at 72 hours (P>0.05).

Conclusion

Though the results failed to show statistical superiority of the antiviral combination therapies to that of the standard therapy in both the severe and non-severe categories in symptomatic adult patients of COVID-19 due to very small sized trial, clinically hydroxychloroquine+ribavirin therapy is showing better recovery by 7.4% than standard therapy in the former category. However, results do indicate the benefit of standard therapy in the non-severe category by 6.6%. Furthermore, the dose of ribavirin needs to be reconsidered in the Indian population.

Expanded dengue syndrome with small-medium-vessel vasculitis: A case report

Expanded dengue syndrome (EDS) is a well-described entity in the literature (after 2009), with various new atypical presentations being identified each year. We report a case of 38-year-old man who presented to the emergency department with high-grade, intermittent fever for 7 days along with myalgia and headache. He had multiple painless palpable purpura over both lower limbs and breathlessness from the 4^th day of fever. On admission, purpura progressed in the severity and dry impending gangrene of the toes of both feet developed. Blood cultures turned out to be sterile, and other infectious markers (malaria, scrub typhus, and chikungunya) were negative except for dengue serology (enzyme-linked immunosorbent assay-immunoglobulin M [ELISA-IgM]). Skin biopsy confirmed to be cutaneous small-vessel vasculitis. The respiratory distress was due to myocarditis (supported by raised NT-pro-BNP levels) and pulmonary edema. He also had possibly hemolytic anemia due to microangiopathy. Although there are many EDS cases of dengue myocarditis reported till date, dengue resulting in widespread endothelial activation and extensive vasculitis (small vessel due to purpura and medium vessel due to gangrene) is a rare phenomenon.