Unraveling antiviral efficacy of multifunctional immunomodulatory triterpenoids against SARS-COV-2 targeting main protease and papain-like protease

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be over, but its variants continue to emerge, and patients with mild symptoms having long COVID is still under investigation. SARS-CoV-2 infection leading to elevated cytokine levels and suppressed immune responses set off cytokine storm, fatal systemic inflammation, tissue damage, and multi-organ failure. Thus, drug molecules targeting the SARS-CoV-2 virus-specific proteins or capable of suppressing the host inflammatory responses to viral infection would provide an effective antiviral therapy against emerging variants of concern. Evolutionarily conserved papain-like protease (PLpro) and main protease (Mpro) play an indispensable role in the virus life cycle and immune evasion. Direct-acting antivirals targeting both these viral proteases represent an attractive antiviral strategy that is also expected to reduce viral inflammation. The present study has evaluated the antiviral and anti-inflammatory potential of natural triterpenoids: azadirachtin, withanolide_A, and isoginkgetin. These molecules inhibit the Mpro and PLpro proteolytic activities with half-maximal inhibitory concentrations (IC50) values ranging from 1.42 to 32.7 μM. Isothermal titration calorimetry (ITC) analysis validated the binding of these compounds to Mpro and PLpro. As expected, the two compounds, withanolide_A and azadirachtin, exhibit potent anti-SARS-CoV-2 activity in cell-based assays, with half-maximum effective concentration (EC50) values of 21.73 and 31.19 μM, respectively. The anti-inflammatory roles of azadirachtin and withanolide_A when assessed using HEK293T cells, were found to significantly reduce the levels of CXCL10, TNFα, IL6, and IL8 cytokines, which are elevated in severe cases of COVID-19. Interestingly, azadirachtin and withanolide_A were also found to rescue the decreased type-I interferon response (IFN-α1). The results of this study clearly highlight the role of triterpenoids as effective antiviral molecules that target SARS-CoV-2-specific enzymes and also host immune pathways involved in virus-mediated inflammation.

Community-acquired multidrug-resistant pneumonia, bacteraemia, and infective endocarditis: A case report

BACKGROUND

The prevalence of multidrug-resistant (MDR) bacteria has increased globally, with extensive drug-resistant (XDR) bacteria posing a threat to patients.

CASE SUMMARY

This case report describes a young man admitted for suspected tropical fever infections who experienced rapid deterioration in health. Despite negative results for tropical fever infections, he had neutrophilic leucocytosis, acute kidney injury, and chest imaging findings suggestive of bilateral consolidations. On day two, he was diagnosed with infective endocarditis with possible rheumatic heart disease and MDR methicillin-resistant Staphylococcus aureus bacteraemia, and community-acquired pneumonia. Despite treatment with broad-spectrum antibiotics, he did not respond and succumbed to death on day five.

CONCLUSION

This case highlights that clinicians/public should be aware of MDR community-acquired pneumonia, bacteraemia, and endocarditis which ultimately culminate in high rates of morbidity and mortality. Early identification of pathogenic strain and prompt antibiotic treatment are a mainstay for the management and prevention of early fatalities. Simultaneously, route cause analysis of community-acquired MDR/XDR pathogens is a global need.

Baseline findings of a multicentric ambispective cohort study (2021-2022) among hospitalised mucormycosis patients in India

In India, the incidence of mucormycosis reached high levels during 2021-2022, coinciding with the COVID-19 pandemic. In response to this, we established a multicentric ambispective cohort of patients hospitalised with mucormycosis across India. In this paper, we report their baseline profile, clinical characteristics and outcomes at discharge. Patients hospitalized for mucormycosis during March-July 2021 were included. Mucormycosis was diagnosed based on mycological confirmation on direct microscopy (KOH/Calcofluor white stain), culture, histopathology, or supportive evidence from endoscopy or imaging. After consent, trained data collectors used medical records and telephonic interviews to capture data in a pre-tested structured questionnaire. At baseline, we recruited 686 patients from 26 study hospitals, of whom 72.3% were males, 78% had a prior history of diabetes, 53.2% had a history of corticosteroid treatment, and 80% were associated with COVID-19. Pain, numbness or swelling of the face were the commonest symptoms (73.3%). Liposomal Amphotericin B was the commonest drug formulation used (67.1%), and endoscopic sinus surgery was the most common surgical procedure (73.6%). At discharge, the disease was stable in 43.3%, in regression for 29.9% but 9.6% died during hospitalization. Among survivors, commonly reported disabilities included facial disfigurement (18.4%) and difficulties in chewing/swallowing (17.8%). Though the risk of mortality was only 1 in 10, the disability due to the disease was very high. This cohort study could enhance our understanding of the disease's clinical progression and help frame standard treatment guidelines.

Burkholderia-associated polymyositis

A diagnosis of polymyositis can readily be made when there is a typical history of proximal muscle weakness together with clinical findings, and there is corroboratory evidence in the form of elevated creatine kinase lactate dehydrogenase, aldolase, and serum glutamic-oxaloacetic transaminase (aspartate aminotransferase). A muscle biopsy usually helps in making the confirmatory diagnosis. A female in her 50s presented with non-healing multiple deep necrotic ulcers with muscle weakness. The initial possibility of vasculitis ulcers remained. Later, this proved to be a case of polymyositis with mildly elevated creatine kinase (which is usually not the case), atypical skin manifestations (usually there is no skin involvement), and negative extended myositis specific antibody panel with the growth of Burkholderia cepacia (perhaps the triggering factor). Hence, polymyositis can present with a myriad of atypical findings. Thus, thorough clinical examination and an integrated approach are necessary for early identification and treatment of the disease.

Amoxicillin Induced Fever, Rash, and Catatonia - A Case Study

INTRODUCTION

Adverse drug reactions (ADR) are defined as any harmful or unpleasant events or injuries resulting from the use of any particular drug. Among those antibiotics that cause adverse reactions, amoxicillin is one of them. Catatonia and vasculitic rash are its rare adverse effects.

CASE PRESENTATION

A 23-year-old postpartum female, with a history of taking empirical Amoxiclav (amoxicillin-clavulanic acid 625 mg) injection and oral tablets for episiotomy wound, presented with altered sensorium and fever followed by maculopapular rash. On examination, she had generalized rigidity with waxy flexibility that improved by lorazepam challenge and was diagnosed as catatonia. On evaluation, amoxicillin was found to be precipitating catatonia in this patient.

CONCLUSION

Since the diagnosis of catatonia is often missed, any cases with clinical presentation of fever, rash, altered sensorium, and generalized rigidity should also be suspected for druginduced ADR and the precipitating factor should be searched for.

Study on good clinical practices among researchers in a tertiary healthcare institute in India

BACKGROUND

Good clinical practice (GCP) is put in place to protect human participants in clinical trials as well as to ensure the quality of research. Non-adherence to these guidelines can produce research that may not meet the standards set by the scientific community. Therefore, it must be ensured that researchers are well-versed in the GCP. But not much is known about the knowledge and practices of the GCP in the medical colleges of North India.

AIM

To assess the knowledge and practices of researchers about GCP and analyze these with respect to the demographics of participants.

METHODS

This is a cross-sectional study. A self-structured questionnaire about GCP, after expert validations, was circulated among researchers, at a tertiary healthcare institute, All India Institute of Medical Sciences (AIIMS), Rishikesh. A total of 59 individuals, who were selected by universal sampling, participated in the study. All healthcare workers who have been investigators of Institutional Ethics Committee-approved research projects, except residents and faculty, and are still a part of the institute have been included in the study. The study was approved by the Institutional Ethics Committee of AIIMS, Rishikesh. We used descriptive analysis and the Chi-squared test to analyze data. P value < 0.05 was considered significant.

RESULTS

Out of 59 participants, only 11 (18.6%) were certified for GCP. Most of the participants (64.4%) had "Average" knowledge, 33.9% had "Good" knowledge and 1.7% had "Poor" knowledge. Only 49% of participants had satisfactory practices related to GCP. There was a significant difference in the knowledge based on the current academic position for the items assessing knowledge of institutional review board (P = 0.010), confidentiality & privacy (P = 0.011), and participant safety & adverse events (P < 0.001). There was also a significant difference in knowledge of research misconduct (P = 0.024) and participant safety & adverse events (P = 0.011) based on certification of GCP. There was a notable difference in the practices related to recruitment & retention on the basis of current academic position (P < 0.001) and certification of GCP (P = 0.023). We also observed a considerable difference between the knowledge and practices of GCP among the participants (P = 0.013).

CONCLUSION

Participants have basic knowledge of GCP but show a lack thereof in certain domains of GCP. This can be addressed by holding training sessions focusing on these particular domains.

Ground level utility of Access, Watch, Reserve classification: Insights from a tertiary care center in North India

BACKGROUND

The overuse and misuse of antimicrobials contribute significantly to antimicrobial resistance (AMR), which is a global public health concern. India has particularly high rates of AMR, posing a threat to effective treatment. The World Health Organization (WHO) Access, Watch, Reserve (AWaRe) classification system was introduced to address this issue and guide appropriate antibiotic prescribing. However, there is a lack of studies examining the prescribing patterns of antimicrobials using the AWaRe classification, especially in North India. Therefore, this study aimed to assess the prescribing patterns of antimicrobials using the WHO AWaRe classification in a tertiary care centre in North India.

AIM

To study the prescribing patterns of antimicrobials using WHO AWaRe classification through a cross-sectional study in All India Institute of Medical Sciences Rishikesh.

METHODS

A descriptive, cross-sectional study was conducted from July 2022 to August 2022 at a tertiary care hospital. Prescriptions containing at least one antimicrobial were included in the study. Data on prescriptions, including patient demographics, departments, types of antimicrobials prescribed, and duration of treatment, were collected. A questionnaire-based survey was also conducted to assess the knowledge and practices of prescribing doctors regarding the utility of AWaRe classification.

RESULTS

The study involved a total of 123 patients, each of whom received at least one antimicrobial prescription. Most prescriptions were for inpatients, evenly distributed between Medicine (Internal medicine, Pediatrics, Dermatology) and Surgical departments (General surgery and specialties, Otorhinolaryngology, Ophthalmology, Obstetrics and Gynecology). Metronidazole and ceftriaxone were the most prescribed antibiotics. According to the AWaRe classification, 57.61% of antibiotics fell under the Access category, 38.27% in Watch, and 4.11% in Reserve. Most Access antibiotics were prescribed within the Medicine department, and the same department also exhibited a higher frequency of Watch antibiotics prescriptions. The questionnaire survey showed that only a third of participants were aware of the AWaRe classification, and there was a lack of knowledge regarding AMR and the potential impact of AWaRe usage.

CONCLUSION

This study highlights the need for better antimicrobial prescribing practices and increased awareness of the WHO AWaRe classification and AMR among healthcare professionals. The findings indicate a high proportion of prescriptions falling under the Access category, suggesting appropriate antibiotic selection. However, there is a significant difference between the WHO Defined Daily Dose and the prescribed daily dose in the analysed prescriptions suggesting overuse and underuse of antibiotics. There is room for improvement and educational interventions and antimicrobial stewardship programs should be implemented to enhance knowledge and adherence to guidelines, ultimately contributing to the containment of AMR.

Emerging leishmaniasis in southern Himalayas: A mini-review

Leishmaniasis is a vector-borne parasitic disease affecting millions of people worldwide. However, in the last decade, the number of cases has been reduced from well-documented endemic parts, but sporadic cases have been reported widely from various non-endemic areas, especially from the southern Himalayan zone. This raises concerns about the emergence of new ecological niches. This warrants a critical evaluation of key factors causing this rapid spread and possibly indigenous transmission. This mini-review article is aimed to briefly address the parasite, the vector, and the environmental aspects in the transmission of leishmaniasis in these new foci against a background of worldwide endemic leishmaniasis with a special focus on the southern Himalayan zone. As the lack of knowledge about the causative parasites, vectors, reservoir hosts, atypical presentations, and their management make the problem serious and may lead to the emergence of public health issues. The present works also reviewed the existing information regarding clinical variations, diagnostic methods, treatment, its outcome, and ignite for further research in these aspects of the disease.

Characteristics and outcomes of an international cohort of 600 000 hospitalized patients with COVID-19

BACKGROUND

We describe demographic features, treatments and clinical outcomes in the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) COVID-19 cohort, one of the world's largest international, standardized data sets concerning hospitalized patients.

METHODS

The data set analysed includes COVID-19 patients hospitalized between January 2020 and January 2022 in 52 countries. We investigated how symptoms on admission, co-morbidities, risk factors and treatments varied by age, sex and other characteristics. We used Cox regression models to investigate associations between demographics, symptoms, co-morbidities and other factors with risk of death, admission to an intensive care unit (ICU) and invasive mechanical ventilation (IMV).

RESULTS

Data were available for 689 572 patients with laboratory-confirmed (91.1%) or clinically diagnosed (8.9%) SARS-CoV-2 infection from 52 countries. Age [adjusted hazard ratio per 10 years 1.49 (95% CI 1.48, 1.49)] and male sex [1.23 (1.21, 1.24)] were associated with a higher risk of death. Rates of admission to an ICU and use of IMV increased with age up to age 60 years then dropped. Symptoms, co-morbidities and treatments varied by age and had varied associations with clinical outcomes. The case-fatality ratio varied by country partly due to differences in the clinical characteristics of recruited patients and was on average 21.5%.

CONCLUSIONS

Age was the strongest determinant of risk of death, with a ∼30-fold difference between the oldest and youngest groups; each of the co-morbidities included was associated with up to an almost 2-fold increase in risk. Smoking and obesity were also associated with a higher risk of death. The size of our international database and the standardized data collection method make this study a comprehensive international description of COVID-19 clinical features. Our findings may inform strategies that involve prioritization of patients hospitalized with COVID-19 who have a higher risk of death.

Correlation of serum SARS-CoV-2 IgM and IgG serology and clinical outcomes in COVID-19 patients: Experience from a tertiary care centre

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has become a pandemic for the last 2 years. Inflammatory response to the virus leads to organ dysfunction and death. Predicting the severity of inflammatory response helps in managing critical patients using serology tests IgG and IgM.

AIM

To investigate the correlation of the serology (IgM and IgG) with reverse transcriptase polymerase chain reaction (RT-PCR) status, disease severity [mild to critical], intensive care unit (ICU) admission, septic shock, acute kidney injury, and in-hospital mortality.

METHODS

We conducted a longitudinal study to correlate serum SARS-CoV-2 immunoglobulin M (IgM) and immunoglobulin G (IgG) serology with clinical outcomes in coronavirus disease 2019 (COVID-19) patients. We analyzed patient data from March to December 2020 for those who were admitted at All India Institute of Medical Sciences Rishikesh. Clinical and laboratory data of these patients were collected from the e-hospital portal and analyzed. A correlation was seen with clinical outcomes and was assessed using MS Excel 2010 and SPSS software.

RESULTS

Out of 494 patients, the mean age of patients was 48.95 ± 16.40 years and there were more male patients in the study (66.0%). The patients were classified as mild-moderate 328 (67.1%), severe 131 (26.8%), and critical 30 (6.1%). The mean duration from symptom onset to serology testing was 19.87 ± 30.53 d. In-hospital mortality was observed in 25.1% of patients. The seropositivity rate (i.e., either IgG or IgM > 10 AU) was 50%. IgM levels (AU/mL) (W = 33428.000, P ≤ 0.001) and IgG levels (AU/mL) (W = 39256.500, P ≤ 0.001), with the median IgM/ IgG levels (AU/mL), were highest in the RT-PCR-Positive group compared to RT-PCR-Negative clinical COVID-19. There was no significant difference between the two groups in terms of all other clinical outcomes (disease severity, septic shock, ICU admission, mechanical ventilation, and mortality).

CONCLUSION

The study showed that serology levels are high in RT-PCR positive group compared to clinical COVID-19. However, serology cannot be useful for the prediction of disease outcomes. The study also highlights the importance of doing serology at a particular time as antibody titers vary with the duration of the disease. In week intervals there was a significant correlation between clinical outcomes and serology on week 3.

Predictors of Mortality among Patients Hospitalized with COVID-19 during the First Wave in India: A Multisite Case-Control Study

Severe acute respiratory syndrome coronavirus 2 disease (COVID-19) has caused more than 6 million deaths globally. Understanding predictors of mortality will help in prioritizing patient care and preventive approaches. This was a multicentric, unmatched, hospital-based case-control study conducted in nine teaching hospitals in India. Cases were microbiologically confirmed COVID-19 patients who died in the hospital during the period of study and controls were microbiologically confirmed COVID-19 patients who were discharged from the same hospital after recovery. Cases were recruited sequentially from March 2020 until December-March 2021. All information regarding cases and controls was extracted retrospectively from the medical records of patients by trained physicians. Univariable and multivariable logistic regression was done to assess the association between various predictor variables and deaths due to COVID-19. A total of 2,431 patients (1,137 cases and 1,294 controls) were included in the study. The mean age of patients was 52.8 years (SD: 16.5 years), and 32.1% were females. Breathlessness was the most common symptom at the time of admission (53.2%). Increasing age (adjusted odds ratio [aOR]: 46-59 years, 3.4 [95% CI: 1.5-7.7]; 60-74 years, 4.1 [95% CI: 1.7-9.5]; and ≥ 75 years, 11.0 [95% CI: 4.0-30.6]); preexisting diabetes mellitus (aOR: 1.9 [95% CI: 1.2-2.9]); malignancy (aOR: 3.1 [95% CI: 1.3-7.8]); pulmonary tuberculosis (aOR: 3.3 [95% CI: 1.2-8.8]); breathlessness at the time of admission (aOR: 2.2 [95% CI: 1.4-3.5]); high quick Sequential Organ Failure Assessment score at the time of admission (aOR: 5.6 [95% CI: 2.7-11.4]); and oxygen saturation < 94% at the time of admission (aOR: 2.5 [95% CI: 1.6-3.9]) were associated with mortality due to COVID-19. These results can be used to prioritize patients who are at increased risk of death and to rationalize therapy to reduce mortality due to COVID-19.

Effects of Active Compounds of Nigella sativa in COVID-19: A Narrative Review

BACKGROUND

SARS-CoV-2 infection that led to the COVID-19 pandemic has changed human health and the economy globally. SARS CoV-2 is a type of Coronaviruses that has caused pneumonia and its complications with many deaths over the past two years. The use of hydroxychloroquine and chloroquine, accepted as generally safe for patients with autoimmune diseases or malaria, was attempted in many trials for COVID-19 treatment. Nigella sativa (NS) (black caraway, also known as black cumin, nigella or Kalonji) is an annual flowering plant of the Ranunculaceae family, chemically composed of the main constituent natural Thymoquinone (TQ) (30%- 48%) in forms of thymohydroquinone, dithymoquinone (Nigellone) is a native to wider regions, including parts of eastern Europe, west Asia, North of Africa and east of Myanmar. In this review, we explored the Randomized Controlled Trial, Controlled Trial, and Systematic review studies that support Nigella sativa Thymoquinone-targeted SARS-CoV-2 targeting. Therefore, A literature search was performed for publications published on the electronic databases (PubMed, Embase, Scopus, CNKI, and Google Scholar) for Nigella sativa, black seeds, Kalonji, coronavirus, SARS-CoV -2 and COVID-19. This review aimed to find relevant evidence of Nigella sativa preferences as a natural feasible remedy with no side effects in COVID-19. Studies reported the benefits of NS as beneficial, another appropriate remedy for patients with COVID-19. However, all studies have shown limitations, such as limiting clinical symptom outcomes due to regulations imposed by isolation policies and lack of adequate funding. Therefore, the evidence suggests that the chemical contents of NS are a safe and possible treatment for COVID-19 patients that helps to improve COVID-19 infection in patients with no side effects.

CONCLUSION

Nigella sativa seeds were one of the well-documented herbal products. Three reviewed randomized controlled trials reported that NS reduced covid-19 risk and could improve immune function. It was also helpful in upper respiratory infections such as asthma and bronchitis, with one RCT showing that honey and NS significantly improved symptoms, viral clearance, and mortality of COVID-19 patients. This review concludes that NS has a positive barrier effect on people at risk of acquiring a COVID-19 infection.

Hyper-Eosinophilic Syndrome with Myocarditis after Inactivated SARSCoV- 2 Vaccination - A Case Study

INTRODUCTION

COVID-19 vaccine-induced serious adverse reactions are rare. Hypereosinophilia syndrome with myocarditis has not been reported earlier following BBV152 vaccine administration.

CASE PRESENTATION

A young man without any co-morbidities presented with persistent periorbital swelling along with itchy swelling over fingers, resting tachycardia, and exertional breathlessness following the first dose of an inactivated SARS-CoV-2 vaccine (BBV152, COVAXIN). On investigation, the patient had elevated blood eosinophils (maximum 21.5% with an absolute eosinophil count of 2767/mm³) and myocarditis (Lake Louise Criteria). He was successfully treated with steroids and supportive treatment.

CONCLUSION

This is the first reported case of hyper-eosinophilia syndrome after COVAXIN administration. Prior history of the allergic disease may be a predisposing factor in this case. Hypereosinophilia can present with variable symptoms. In the current case, myocarditis was present with persistent resting tachycardia and dyspnea. Steroid and antiallergic drugs may be successful for the treatment of vaccine-induced hyper-eosinophilia with myocarditis. Increased vigilance is needed for such adverse events.

Convalescent Plasma the Experience and Journey from Blockbuster to Incognito: A Single Centre Experience

BACKGROUND

Convalescent plasma has been used to provide passive immunotherapy to patients with COVID-19 with a high level of safety. Very few efficacy studies were available, and due to COVID being a relatively new disease, its exact therapeutic role was unclear. This observational study on the impact of COVID convalescent plasma (CCP) on clinical outcomes attempts to evaluate the effectiveness of convalescent COVID-19 plasma therapy in the treatment of COVID-19 patients at the tertiary care center in the Uttarakhand state of India.

METHODS

CCP was collected by plasmapheresis/whole blood from willing COVIDrecovered donors who underwent pre-donation testing including ABO and RhD grouping, mandatory blood screening tests for HIV, HBV, HCV, syphilis and Malaria, Haemoglobin estimation and COVID IgG assay. Hospitalized patients with severe COVID-19 pneumonia who received these CCP units were followed up and the outcome (Recovery/death) was observed.

RESULTS

A total of 63 patients who received CCP were included in the study. Out of the total, 13 (20.7%) were females and 50 (79.3%) were males and their ages ranged from 24 to 80 years with a median age of 53 years. The period between the start of symptoms and hospitalization ranged from 1 to 14 days with an average duration of 4.7 days. Symptoms on presentation included Fever 53/63 (84.1%), Tachypnoea 60/63 (95.2%) and Cough 42/63 (66.7%). Among these patients, 22/63 (34.9%) were on non-invasive ventilation (NIV), 6/63 (9.5%) on non-rebreather mask (NRBM) and 32/63 (50.8%) were on Ventilator support. The infused convalescent plasma had a Mean IgG value of 57.3 AU with a range of (10-142 AU). A total of 37 (58.7%) patients were lost to COVID-19 infection and 26 (41.3%) were discharged from the hospital in a healthy state.

CONCLUSION

The use of convalescent plasma in addition to standard treatment in our study on patients with severe pneumonia due to COVID-19 did not demonstrate reduced mortality of COVID-19 patients amidst numerous variables. The results showed that the use of convalescent plasma as a treatment option in the present conditions needs a serious re-evaluation. Studies on a strictly defined recipient group and transfusion of CCP units, with adequate antibody titer and/or neutralization activity, must be analyzed for future works.

Symptom-based case definitions for COVID-19: Time and geographical variations for detection at hospital admission among 260,000 patients

Introduction

Case definitions are used to guide clinical practice, surveillance and research protocols. However, how they identify COVID-19-hospitalised patients is not fully understood. We analysed the proportion of hospitalised patients with laboratory-confirmed COVID-19, in the ISARIC prospective cohort study database, meeting widely used case definitions.

Methods

Patients were assessed using the Centers for Disease Control (CDC), European Centre for Disease Prevention and Control (ECDC), World Health Organization (WHO) and UK Health Security Agency (UKHSA) case definitions by age, region and time. Case fatality ratios (CFRs) and symptoms of those who did and who did not meet the case definitions were evaluated. Patients with incomplete data and non-laboratory-confirmed test result were excluded.

Results

A total of 263,218 of the patients (42%) in the ISARIC database were included. Most patients (90.4%) were from Europe and Central Asia. The proportions of patients meeting the case definitions were 56.8% (WHO), 74.4% (UKHSA), 81.6% (ECDC) and 82.3% (CDC). For each case definition, patients at the extremes of age distribution met the criteria less frequently than those aged 30 to 70 years; geographical and time variations were also observed. Estimated CFRs were similar for the patients who met the case definitions. However, when more patients did not meet the case definition, the CFR increased.

Conclusions

The performance of case definitions might be different in different regions and may change over time. Similarly concerning is the fact that older patients often did not meet case definitions, risking delayed medical care. While epidemiologists must balance their analytics with field applicability, ongoing revision of case definitions is necessary to improve patient care through early diagnosis and limit potential nosocomial spread.

COVID-19 Infection After Vaccination Among Healthcare Workers at a Tertiary Level Health Care Center in Northern India: A Cross-Sectional Study

Background and aims:

COVID19 vaccines are now accessible to all Indian citizens. Infection with COVID19, on the other hand, continues to spread continuously. Our study aimed to determine the number of persons who had COVID-19 infections despite receiving the recommended number of doses of the COVID 19 vaccination at AIIMS Rishikesh, a tertiary care facility in Uttarakhand, India.

Methods:

We analysed meticulously preserved data regarding COVID-19 vaccination, COVID-19 infection, Clinical symptoms, and RT-PCR testing among all HCWs in our healthcare institution during period from 16 January 2021 to 30th June 2021..

Results:

During this period, 5273 (90.3%) HCWs received two doses of COVID-19 vaccine, while 566 (9.7%) received only one dose. 628 HCWs (10.8%) were BBV152 recipients and 5211(89.2%) AZD1222 (ChAdOx1-S) recipients. 423 HCWs (7.2%,confidence interval of 95% - 13.8, 22.0) reported COVID-19 infections.274(5.19% of total vaccinated HCWs ) breakthrough infections and 149 non-breakthrough COVID-19 infections reported in HCWs who had previously received a single dose of the COVID-19 vaccination. .

Conclusion:

Viral infections sepecially breakthrough infections following adequate vaccination are a cause for concern, but there is a lack of data on these infections in the actual world. Therefore, the primary focus of research should be on the emergence of illness in India following the completion of a full vaccine course.

Fabrication and characterization of super-hydrophilic poly (ε-caprolactone)/hydroxypropyl methylcellulose (HPMC) based composite electrospun membranes for tissue engineering applications

Tissue engineering (TE) employs scaffolds as a structural support for initially seeding of cells followed by development of new tissues. Electrospun scaffolds generally function as a template of native extracellular matrix (ECM). The chemical composition of the scaffold and its surface morphology strongly influence the interaction between various cell types and materials. In this work, PCL and PCL/HPMC-based composite membranes with varying concentrations of HPMC (20-30% by weight) were fabricated using electrospinning technique. The membranes were evaluated for their surface, physio-chemical and biological properties. It was observed probably for the first time that blending of HPMC with PCL produced super-hydrophilic scaffolds. DSC studies confirmed the semi- crystalline nature of HPMC. PCL/HPMC composite scaffolds are found biocompatible from cytotoxicity assay. From the cell culture studies (apoptosis), PCL/HPMC composite scaffolds did not inhibit the adhesion of L929 cells due to their super-hydrophilic nature. The cell adhesion and spreading varied with HPMC concentration. PCL/HPMC (70/30) membranes showed highest cell adhesion among others due to its porous structure.

Utility of IL-6 in the Diagnosis, Treatment and Prognosis of COVID-19 Patients: A Longitudinal Study

COVID-19 has caused devastating effects worldwide ever since its origin in December 2019. IL-6 is one of the chief markers used in the management of COVID-19. We conducted a longitudinal study to investigate the role of IL-6 in diagnosis, treatment, and prognosis of COVID-19-related cytokine storm. Patients with COVID-19 who were admitted at AIIMS Rishikesh from March to December 2020 were included in the study. Patients with no baseline IL-6 value at admission and for whom clinical data were not available were excluded. Clinical and laboratory data of these patients were collected from the e-hospital portal and entered in an excel sheet. Correlation was seen with other inflammatory markers and outcomes were assessed using MS Excel 2010 and SPSS software. A total of 131 patients were included in the study. Of these, 74.8% were males, with mean age 55.03 ± 13.57 years, and mean duration from symptom onset being 6.69 ± 6.3 days. A total of 82.4% had WHO severe category COVID-19, with 46.56% having severe hypoxia at presentation and 61.8% of them having some comorbidity. Spearman rank correlation coefficient of IL-6 with D-dimer was 0.203, with LDH was -0.005, with ferritin was 0.3, and with uric acid was 0.123. A total of 11 patients received Tocilizumab at a mean duration from symptom onset of 18.09 days, and 100% mortality was observed. Deaths were reported more in the group with IL-6 ≥ 40 pg/mL (57.1% vs. 40.2%, p = 0.06). ICU admissions and ventilator requirement were higher in the IL-6 ≥ 40 pg/mL group (95.9% vs. 91.4%, p = 0.32 and 55.1% vs. 37.8%, p = 0.05). The study showed that IL-6 can be used as a possible "thrombotic cytokine marker". Higher values of IL-6 (≥40 pg/mL) are associated with more deaths, ICU admissions, and ventilator requirement.

Respiratory support in patients with severe COVID-19 in the International Severe Acute Respiratory and Emerging Infection (ISARIC) COVID-19 study: a prospective, multinational, observational study

BACKGROUND

Up to 30% of hospitalised patients with COVID-19 require advanced respiratory support, including high-flow nasal cannulas (HFNC), non-invasive mechanical ventilation (NIV), or invasive mechanical ventilation (IMV). We aimed to describe the clinical characteristics, outcomes and risk factors for failing non-invasive respiratory support in patients treated with severe COVID-19 during the first two years of the pandemic in high-income countries (HICs) and low middle-income countries (LMICs).

METHODS

This is a multinational, multicentre, prospective cohort study embedded in the ISARIC-WHO COVID-19 Clinical Characterisation Protocol. Patients with laboratory-confirmed SARS-CoV-2 infection who required hospital admission were recruited prospectively. Patients treated with HFNC, NIV, or IMV within the first 24 h of hospital admission were included in this study. Descriptive statistics, random forest, and logistic regression analyses were used to describe clinical characteristics and compare clinical outcomes among patients treated with the different types of advanced respiratory support.

RESULTS

A total of 66,565 patients were included in this study. Overall, 82.6% of patients were treated in HIC, and 40.6% were admitted to the hospital during the first pandemic wave. During the first 24 h after hospital admission, patients in HICs were more frequently treated with HFNC (48.0%), followed by NIV (38.6%) and IMV (13.4%). In contrast, patients admitted in lower- and middle-income countries (LMICs) were less frequently treated with HFNC (16.1%) and the majority received IMV (59.1%). The failure rate of non-invasive respiratory support (i.e. HFNC or NIV) was 15.5%, of which 71.2% were from HIC and 28.8% from LMIC. The variables most strongly associated with non-invasive ventilation failure, defined as progression to IMV, were high leukocyte counts at hospital admission (OR [95%CI]; 5.86 [4.83-7.10]), treatment in an LMIC (OR [95%CI]; 2.04 [1.97-2.11]), and tachypnoea at hospital admission (OR [95%CI]; 1.16 [1.14-1.18]). Patients who failed HFNC/NIV had a higher 28-day fatality ratio (OR [95%CI]; 1.27 [1.25-1.30]).

CONCLUSIONS

In the present international cohort, the most frequently used advanced respiratory support was the HFNC. However, IMV was used more often in LMIC. Higher leucocyte count, tachypnoea, and treatment in LMIC were risk factors for HFNC/NIV failure. HFNC/NIV failure was related to worse clinical outcomes, such as 28-day mortality. Trial registration This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Presence of SARS-CoV-2 in the lower genital tract of women with active COVID-19 infection: A prospective study

SARS‐CoV‐2 may present in the lower genital tract of women with active COVID‐19 infection and the probability is significantly higher with high viral load.

Impact of Pregnancy on Susceptibility and Severity of COVID-19: A Hospital-Based Prospective Observational Study

OBJECTIVE

 Pregnancy is a transient state of immunosuppression. The objective of this study was to ascertain whether pregnant women are more susceptible to coronavirus disease 2019 (COVID-19) than non-pregnant women and the impact of pregnancy on the severity of COVID-19 and associated morbidity and mortality.

METHODS

 A prospective observational study was performed at All India Institute of Medical Sciences (AIIMS) Rishikesh for a period of two months. A total of 42 and 33 COVID-19 positive women were included in the obstetric and non-obstetric cohorts respectively.

RESULTS

 Baseline characteristics were similar in both groups. Approximately 48% of the obstetric cohort had no COVID-19-related symptoms. Whereas, 100% of the non-obstetric cohort was symptomatic and had a significantly higher number of patients presenting with fever, cough, and breathlessness. The obstetric cohort had a significantly higher incidence of mild disease (p=0.009). In the obstetric cohort, the mean gestational age was 32.59 ± 2.57 weeks, with patients spread across all trimesters. Most of the patients with severe disease were in their second trimester. There was no difference in intensive care unit (ICU) admission, duration of ICU stay, duration of hospital stay, and mortality among both groups. A significantly smaller number of patients in the obstetric cohort required ventilatory support (p=0.0002). The maternal mortality rate was 16.67%. All of them had severe diseases requiring ICU admission. The cause of death was attributed to severe COVID pneumonia with septic shock in all cases. The mortality rate was comparatively higher (27.27%) in the non-obstetric group.

CONCLUSION

 Pregnancy, unlike other immunocompromised conditions, does not seem to affect the prognosis of COVID-19 in terms of disease severity or mortality.

Hypereosinophilic syndrome presenting as eosinophilic gastroenteritis disorder and splinter hemorrhages: A case report

BACKGROUND

Eosinophilia and related organ damage are extensively studied hot topics among rare disorders. Any addition to the cohort of available case reports of the same will be adding knowledge for better management of this less known entity.

CASE SUMMARY

In this article, we describe a 27-year-old Indo-Aryan man who presented with abdominal pain, abdominal distension, and loose stools for variable days. He had splinter hemorrhages in the majority of fingernails. He was diagnosed with predominant eosinophilic gastrointestinal involvement with bowel obstruction and ascites, and was managed with intravenous immunoglobulin. He was subsequently treated with oral low dose steroid therapy and responded completely.

CONCLUSION

Our experience is evidence that prompt management of this hypereosinophilic lethal gastrointestinal (all three layers) infiltrative disease provides a cure and avoids complications. Splinter nail hemorrhages may be seen in the same disease.

Disseminated Intravascular Coagulation Score and Sepsis-induced Coagulopathy Score in Prediction of COVID-19 Severity: A Retrospective Analysis

Background

The novel disseminated intravascular coagulation (DIC) score (platelet count, prolonged prothrombin time, D-dimer, and fibrinogen) and sepsis-induced coagulopathy (SIC) score (platelet count, international normalized ratio, and sequential organ failure assessment score) are markers of coagulopathy, which, for the first time, are explored in line with the coronavirus disease-2019 (COVID-19) disease outcomes. The correlation of D-dimer with these findings is also studied.

Materials and methods

A retrospective analysis of hospital-based records of 168 COVID-19 patients was done. Data including D-dimer, routine investigations, DIC, and SIC scorings (all within 3 days of admission) were collected and correlated with the outcomes. The study was conducted in a tertiary care center catering to North India's population.

Results

Higher DIC score (1.59 ± 1.18 vs 0.96 ± 1.18), SIC score (1.60 ± 0.89 vs 0.63 ± 0.99), and D-dimer titers (1321.33 ± 1627.89 vs 583·66 ± 777.71 ng/mL) were significantly associated with severe COVID-19 disease (p <0.05). DIC score and SIC score ≥1, and D-dimer ≥1315 ng/mL for severe disease; DIC score ≥1, SIC score ≥2, and D-dimer ≥600 ng/mL for pulmonary embolism (PE); and DIC score and SIC score ≥1, and D-dimer level ≥990 ng/mL for mortality were the respective cutoff values we found from our study.

Conclusion

Higher DIC scores, SIC scores, and D-dimer values are associated with severe COVID-19 disease, inhospital mortality, and PE risk. They can serve as easily accessible early markers of severe disease and prioritize hospital admissions in the presently overburdened scenario and may be used to develop prognostic prediction models.

How to cite this article

Kapoor M, Panda PK, Saini LK, Bahurupi Y. Disseminated Intravascular Coagulation Score and Sepsis-induced Coagulopathy Score in Prediction of COVID-19 Severity: A Retrospective Analysis. Indian J Crit Care Med 2021;25(12):1357–1363.

Chronic Indolent Community-acquired Pneumonia due to Pseudomonas Infection in an Immunocompetent Patient- A Case Report

Pseudomonas is an uncommon cause of community-acquired pneumonia in immunocompetent patients. It is an opportunistic pathogen resulting in serious infection in patients who are hospitalised, mechanically ventilated, or immunocompromised. A 47-year-old male, forest worker without any co-morbidities presented with a history of chronic cough, fever, and shortness of breath complicated with pseudohemoptysis for 45 days. This patient was admitted and treated as a lower respiratory tract infection. Work-up for tuberculosis, invasive fungal balls, was negative but sputum culture revealed Pseudomonas aeruginosa growth. This case report demonstrates a rare Pseudomonas infection which can also cause chronic indolent respiratory illness in immunocompetent.

Comparing India's Second COVID Wave with the First Wave-A Single-Center Experience

BACKGROUND

The COVID-19 pandemic has resurfaced in India as a hardhitting second wave. This study aims to compare the clinical profile of the first wave (April-June 2020) and the second wave (March-May 2021) of the severe acute respiratory syndrome coronavirus-2 pandemic (SARS-CoV-2) in a single tertiary care center in India.

METHODS

In this retrospective observational study, we examined the demographic profile, symptoms at presentation, severity of illness, baseline investigations, treatments received, underlying comorbidities, and outcomes of the COVID-19 patients belonging to the first (W1) and the second wave (W2) of the pandemic in India.

RESULTS

The age group affected most in the W2 is 50.5 (17.7) versus 37·1 (16·9) years for W1. The baseline oxygen saturation is lower in W2, being 84·0 (13·4) % compared with 91·9 (7·4) % in W1 [SpO2 < 90% OR 14.3 (6.1-33), P < 0.0001]. 70.2 % of the cases belonged to the severe category in W2 compared to 37.5% in W1. W2 has worse outcomes. Incidence of acute respiratory distress syndrome (ARDS) [48.7% v/s 6.45%; OR 15.4 (6.5-35.7), P<0.0001], Acute Kidney Injury (AKI) [18% v/s 2.4%; OR 6 (1.7- 22.2), P = 0.005], Acute Liver Injury (transaminitis) [12.8% v/s 6.4%, OR 7.3 (3.7- 14.3), P < 0.0001], and deaths (29% v/s 9.6%, standardized mortality ratio 3.5) is higher in W2. Similarly, the CT severity score for W2 [29.5 (6.7)] was higher than W1 [23·2 (11·5), P < 0.05]. The proportion of patients requiring oxygen [81.8% v/s 11.2%; OR 125 (40-333.3), P < 0.0001], high flow nasal cannula (HFNC) (11.4% v/s 5.6%), Non- Invasive Ventilation (NIV) (41.2% v/s 1.5%), invasive ventilation [24.5% v/s 0.9%; OR 22.72 (2.94-166.6), P = 0.003], as well as ICU/HDU admissions [56.4% v/s 12.0%; OR 10.5 (5.3-21.2), P < 0.0001] was higher for W2 as compared with W1. Cough, invasive ventilation, inotrope requirement, and ARDS are significantly related to higher mortality in the W2 than W1.

CONCLUSION

Higher age, oxygen requirement, ventilator requirement, ICU admission, and organ failure are more prevalent in the admitted COVID-19 cases during the second wave that hit India than in the first wave and are associated with more fatalities. Strategy for another wave should be planned accordingly.

Predictive Value of Chest CT Score in Assessing Disease Severity and Short-term Mortality in COVID-19 Pneumonia at a Tertiary Care Centre in Northern India: A Prospective Observational Study

Introduction: Severe Acute Respiratory Syndrome-Coronavirus (SARS-CoV-2) infection, also known as Coronavirus Disease2019 (COVID-19) is the global pandemic, first described in Wuhan city of China in December of 2019. Its diagnosis depends upon real-time Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR). On chest Computerised Tomography (CT), it is almost similar to other viral pneumonia with extensive parenchymal involvement. Semiquantitative scores depicting this extensiveness of involvement could correlate with disease severity, laboratory parameters, mortality, like Intensive Care Unit (ICU) admission, requirements of ventilatory support and longer hospital stay. Aim: To define role of chest CT score in determining disease severity, predicting poor prognosis and mortality of COVID-19 pneumonia in short-term follow-up. Materials and Methods: This prospective study enrolled all admitted real-time RT-PCR positive patients for COVID19 at All India Institute of Medical Sciences, Rishikesh, India between 15th April and 31st May 2021. All patients were assigned semiquantitative CT scores based on the extent of lung parenchymal involvement of 20 lung regions in chest CT. Clinical severity was matched with chest CT scoring and laboratory findings. Survival curves along with univariate and multivariate analysis were applied to define the role of CT scoring in predicting short term prognosis. Results: Total 547 subjects were included in the study, of which the chest CT score showed a significant association with clinical severities (p-value <0.001). CT score were correlating significantly with increased serum C-Reactive Protein (CRP) (p-value=0.001) and D-dimer (p-value=0.01), and decreased lymphocyte count (p-value=0.003). A CT score ≥31 was found to be associated with an increased risk of mortality in both univariate and multivariate analysis {Odd Ratio (OR)=276.8; 95% Confidence Interval (CI)= 45.21-1695.43; p-value <0.001}. Conclusion: Chest CT score can be imaging measure of disease severity and predict a higher probability of mortality in score ≥31. It can also predict other defined variables of short-term prognosis. So, it has an advantage in speedy diagnostic workflow of symptomatic cases, timely referral of patients to higher centre, and better management of critical care resources.

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.

Mixed invasive fungal infections among COVID-19 patients

Background and Purpose

The healthcare system in India collapsed during the second wave of the COVID-19 pandemic. A fungal epidemic was announced amid the pandemic with several cases of COVID-associated mucormycosis and pulmonary aspergillosis being reported. However, there is limited data regarding mixed fungal infections in COVID-19 patients. Therefore, we present a series of ten consecutive COVID-19 patients with mixed invasive fungal infections (MIFIs).

Materials and Methods

Among COVID-19 patients hospitalized in May 2021 at a tertiary care center in North India, 10 cases of microbiologically confirmed COVID-19-associated mucormycosis-aspergillosis (CAMA) were evaluated.

Results

All patients had diabetes and the majority of them were infected with severe COVID-19 pneumonia (6/10, 60%) either on admission or in the past month while two were each of moderate (20%) and mild (20%) categories of COVID-19; and were treated with steroid and cocktail therapy. The patients were managed with amphotericin-B along with surgical intervention. In total, 70% of all CAMA patients (Rhizopus arrhizus with Aspergillus flavus in seven and Aspergillus fumigatus complex in three patients) survived.

Conclusion

The study findings reflected the critical importance of a high index of clinical suspicion and accurate microbiological diagnosis in managing invasive dual molds and better understanding of the risk and progression of MIFIs among COVID-19 patients. Careful scrutiny and identification of MIFIs play a key role in the implementation of effective management strategies.

Serum ferritin as a predictive biomarker in COVID-19. A systematic review, meta-analysis and meta-regression analysis

Ferritin is a known inflammatory biomarker in COVID-19. However, many factors and co-morbidities can confound the level of serum ferritin. This current metaanalysis evaluates serum ferritin level in different severity levels in COVID-19. Studies evaluating serum ferritin level in different clinical contexts (COVID-19 vs. control, mild to moderate vs. severe to critical, non-survivor vs. survivor, organ involvement, ICU and mechanical ventilation requirement) were included (total 9 literature databases searched). Metaanalysis and metaregression was carried out using metaphor “R” package. Compared to control (COVID-19 negative), higher ferritin levels were found among the COVID-19 patients [SMD −0.889 (95% C.I. −1.201, −0.577), I² = 85%]. Severe to critical COVID-19 patients showed higher ferritin levels compared to mild to moderate COVID-19 patients [SMD 0.882 (0.738, 1.026), I² = 85%]. In meta-regression, high heterogeneity was observed could be attributed to difference in “mean age”, and “percentage of population with concomitant co-morbidities”. Non-survivors had higher serum ferritin level compared to survivors [SMD 0.992 (0.672, 1.172), I² = 92.33%]. In meta-regression, high heterogeneity observed could be attributed to difference in “mean age” and “percentage of male sex”. Patients requiring ICU [SMD 0.674 (0.515 to 0.833), I² = 80%] and mechanical ventilation [SMD 0.430 (0.258, 0.602), I² = 32%] had higher serum ferritin levels compared to those who didn't. To conclude, serum ferritin level may serve as an important biomarker which can aid in COVID-19 management. However, presence of other co-morbid conditions/confounders warrants cautious interpretation.

Xerophthalmia with secondary malabsorption syndrome in a young lady

Delayed recognition and treatment of vitamin A deficiency (VAD) in adults leads to devastating complications. A 24-year-old woman presented with diarrhea, malaise, and shortness of breath. Her medical history included blunt abdominal trauma for which, she had bowel resection surgery and revision surgery within a year of the last surgery at the age of 8 years. She had difficulty in night vision and dry eyes. The best-corrected visual acuity was 6/18 in the BE. On slit-lamp examination in the both eyes (BE), the conjunctiva was thick, dry-looking with wrinkling, and the cornea had diffused superficial punctate keratitis and in the left eye, there was corneal xerosis of 1.5 × 1.5 mm. Tear film breakup time was 0-s in the BE. Schirmer's were 30 mm BE. The rest of the ocular examination was within normal limits. A clinical diagnosis of xerophthalmia secondary to malabsorption was made and treated with systemic vitamin A and intense lubrication. With time, ophthalmic conditions improved, but she died due to poor general wellbeing and repeated hospital-acquired infections. The infrequent presentation of VAD in adults and the unusual etiology in this patient make this case interesting, whereas its potentially devastating consequences highlight the importance of its early recognition, treatment, and regular follow up needed by both patient and physician in the community (general practitioner and ophthalmologists) for the prevention of VAD complications and poor prognosis.

Fear, Anxiety, Stress, and Depression of Novel Coronavirus (COVID-19) Pandemic Among Patients and Their Healthcare Workers - A Descriptive Study

PURPOSE

Disease pandemics are known to cause psychological distress. The ensuing mental health issues are not only restricted to the patients and their relatives/friends but affect the healthcare workers (HCWs) as well. Our study aims to assess these psychological trends during the COVID-19 pandemic between the two most affected population groups, that is, patients and frontline healthcare workers.

PATIENTS AND METHODS

A survey questionnaire, including scales to assess fear, anxiety, stress, depression - PSS 10, and DASS 21, was distributed and sent to all COVID-19 suspected/confirmed individuals and healthcare workers at a tertiary care center along with a second visit after 14 days of answering the first questionnaire and this continued as follow-up. Data were analyzed with the SPSS version 23 using various tests of significance.

RESULTS

In the community, COVID-19 patients in the age group 41-50 with respiratory tract symptoms and those who were home isolated/quarantined experienced a greater tendency of mental health problems. Healthcare workers posted in COVID-19 designated areas of the hospital displayed higher levels of stress, anxiety, and depression.

CONCLUSION

The high degree of uncertainty associated with novel pathogens has a profound effect on the psychological state of suspected/confirmed cases as well as healthcare workers. Within the community, individuals suspected of having COVID-19 display a significant mental health burden, while HCWs also experience an unprecedented amount of stress, anxiety, depression and fear during such enduring situations.

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.

Compliance with the 4Ds of antimicrobial stewardship practice in a tertiary care centre

Background

Antimicrobial stewardship describes the practice of promoting the selection of the right drug, dosage, delivery and duration of antimicrobial therapy (the 4Ds) in order to curtail the emergence of resistant organisms. It is important to quantify the inappropriate use of antimicrobials in terms of percentage adherence to each of the 4Ds mentioned.

Methods

We undertook a prospective review of medical records of patients admitted to the medical wards of a tertiary care centre in North India. All patients on antimicrobials were included and their records reviewed for indication, drug, dose, delivery and duration (or by asking the treating physician if not documented). Adherence to the 4Ds was determined by referring to updated literature-based standard treatment guidelines (STGs) for each specific disease.

Results

Of 304 patients, drugs were appropriate and matched STGs in 218 (72%) patients, with adherence to the right dose in 210 (69%), route of delivery in 216 (71%) and duration in 197 (65%). Full adherence to the 4Ds was observed in 196 (64.5%). Maximum adherence was observed in treating skin and soft tissue infections (100%), while minimum adherence was observed in administering medical prophylaxis (40%). WHO Access, Watch and Reserve categories comprised 29%, 63% and 8.5% of all prescribed antibiotics, respectively.

Conclusions

The right drug, dose, delivery and duration of therapy are prescribed in 72%, 69%, 71%, and 65% of patients, respectively. In order to increase the adherence to 100%, bedside stewardship practices in the form of prospective audits and feedback must be improved. There is a need to integrate WHO AWaRe classification of antibiotics into treatment guidelines.

Altered electrochemical properties of iron oxide nanoparticles by carbon enhance molecular biocompatibility through discrepant atomic interaction

Recent advancement in nanotechnology seeks exploration of new techniques for improvement in the molecular, chemical, and biological properties of nanoparticles. In this study, carbon modification of octahedral-shaped magnetic nanoparticles (MNPs) was done using two-step chemical processes with sucrose as a carbon source for improvement in their electrochemical application and higher molecular biocompatibility. X-ray diffraction analysis and electron microscopy confirmed the alteration in single-phase octahedral morphology and carbon attachment in Fe3O4 structure. The magnetization saturation and BET surface area for Fe3O4, Fe3O4/C, and α-Fe2O3/C were measured as 90, 86, and 27 emu/g and 16, 56, and 89 m2/g with an average pore size less than 7 nm. Cyclic voltammogram and galvanostatic charge/discharge studies showed the highest specific capacitance of carbon-modified Fe3O4 and α-Fe2O3 as 213 F/g and 192 F/g. The in vivo biological effect of altered physicochemical properties of Fe3O4 and α-Fe2O3 was assessed at the cellular and molecular level with embryonic zebrafish. Mechanistic in vivo toxicity analysis showed a reduction in oxidative stress in carbon-modified α-Fe2O3 exposed zebrafish embryos compared to Fe3O4 due to despaired influential atomic interaction with sod1 protein along with significant less morphological abnormalities and apoptosis. The study provided insight into improving the characteristic of MNPs for electrochemical application and higher biological biocompatibility.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Poly (ε-caprolactone)-based electrospun nano-featured substrate for tissue engineering applications: a review

The restoration of normal functioning of damaged body tissues is one of the major objectives of tissue engineering. Scaffolds are generally used as artificial supports and as substrates for regenerating new tissues and should closely mimic natural extracellular matrix (ECM). The materials used for fabricating scaffolds must be biocompatible, non-cytotoxic and bioabsorbable/biodegradable. For this application, specifically biopolymers such as PLA, PGA, PTMC, PCL etc. satisfying the above criteria are promising materials. Poly(ε-caprolactone) (PCL) is one such potential candidate which can be blended with other materials forming blends, copolymers and composites with the essential physiochemical and mechanical properties as per the requirement. Nanofibrous scaffolds are fabricated by various techniques such as template synthesis, fiber drawing, phase separation, self-assembly, electrospinning etc. Among which electrospinning is the most popular and versatile technique. It is a clean, simple, tunable and viable technique for fabrication of polymer-based nanofibrous scaffolds. The design and fabrication of electrospun nanofibrous scaffolds are of intense research interest over the recent years. These scaffolds offer a unique architecture at nano-scale with desired porosity for selective movement of small molecules and form a suitable three-dimensional matrix similar to ECM. This review focuses on PCL synthesis, modifications, properties and scaffold fabrication techniques aiming at the targeted tissue engineering applications.

Recreational cannabis use causing non-ischaemic cardiomyopathy and cardioembolism in a young adult

Cannabis is one of the most common illicit drugs and has been implicated with various complications which include stroke, acute myocardial infarction, arrhythmia and limb arteritis. We are reporting a case of a young man, who is a recreational cannabis smoker along with tobacco, who developed exertional progressive breathlessness for the last 4 months, mild cough for 2 months and acute left-sided hemiparesis along with ipsilateral facial palsy for 1 day that was attributed to an acute right middle cerebral artery territory infarct. There was also gangrene in his left forearm as a result of left radial artery thrombosis. Non-ischaemic-dilated cardiomyopathy was found in contrast-enhanced cardiac MRI and he was managed in the line of decompensated heart failure; the right-hand gangrene was later amputated in the subsequent follow-ups. Hence, cannabis can lead to cardiomyopathy and resulting cardioembolism. The mainstay of management remains supportive and avoidance of the offending agent. Social education is the need of the hour.

Paraquat poisoning in Andaman and Nicobar Islands - Government must intervene

Paraquat poisoning is a grave public health problem in the Andaman and Nicobar islands of India. To evaluate various aspects of paraquat poisoning that influence the outcome, a retrospective study was planned. In this case series study, the information about all cases of acute paraquat poisoning who were admitted to GB Pant Hospital, Port-Blair, in a 12-year period (January 2007–December 2018) were evaluated. A total of 29 referred patients were evaluated with the majority from the early productive age of 16–30 years (68.97%). The case fatality rate was 100%. Most of the incidents took place in South Andaman district (68.97%) and during the rainy season (55.17%). Initially, they presented with local symptoms like mouth and throat pain with ulceration (48.27%), vomiting (44.82%), breathlessness (34.48%), epigastric and abdominal pain (31.03%), hematemesis (27.58%), and oliguria (20.68%). Later on, major organ dysfunctions like a respiratory failure (65.51%), acute kidney injury (62.08%), acute liver failure (55.17%), cardiac dysfunction (31.03%), and multiorgan failure (58.62%) ensued. Patients who were referred early had a significantly longer hospital stay. Few received advanced care, like, methyl prednisolone (24.12%), cyclophosphamide (10.34%), Mesna/NAC (06.89%), charcoal tablets (10.34%), mechanical ventilation (06.89%), and hemodialysis (10.34%). Apart from hemodialysis in acute kidney injury patients and steroid pulse, no other modalities showed improved hospital survival duration. Primary prevention especially government laws, public awareness, and education of health professionals regarding the seriousness of this problem are the keys to get rid of this incurable poisoning in these islands. The government should prioritize preventive works in the south Andaman district and during the rainy season to avoid catastrophe each year and if possible should ban it. Methyl prednisolone therapy and hemodialysis might be advocated to have a better outcome.

Febrile neutropenia due to COVID-19 in an immunocompetent patient

While lymphopenia has been a common finding in COVID-19 infection, particularly in severe cases, febrile neutropenia has been very rarely reported in immunocompetent patients with COVID-19. Herein, we report the case of a 76-year-old hypertensive and diabetic man who was hospitalised with severe COVID-19 infection and developed delayed-onset severe neutropenia with neutropenic fever, which responded to treatment with antibiotics and granulocyte colony-stimulating factor. This case highlights the importance of identifying a rare complication (febrile neutropenia on the fifth week) of COVID-19 infection in hospitalised patients by intensive monitoring and aggressive management for favourable outcomes.

Febrile neutropenia due to COVID-19 in an immunocompetent patient

While lymphopenia has been a common finding in COVID-19 infection, particularly in severe cases, febrile neutropenia has been very rarely reported in immunocompetent patients with COVID-19. Herein, we report the case of a 76-year-old hypertensive and diabetic man who was hospitalised with severe COVID-19 infection and developed delayed-onset severe neutropenia with neutropenic fever, which responded to treatment with antibiotics and granulocyte colony-stimulating factor. This case highlights the importance of identifying a rare complication (febrile neutropenia on the fifth week) of COVID-19 infection in hospitalised patients by intensive monitoring and aggressive management for favourable outcomes.

COVID-19 Sample Collection Kiosk in AIIMS Rishikesh: A safe and efficient model

Introduction:  Following the pandemic, screening suspected individuals on a large scale is imperative to curtail the disease's spread to enormous proportions. The walk-in kiosk is an ideal example of an innovation that is time and labour efficient and safe to use. Methodology and review of literature: Embase, Google Scholar, and Pubmed were used to extract scholarly articles about the subject published worldwide. The Walk-in kiosk concept was an idea taken from the biosafety chamber used in the advanced microbiology laboratories. Results: This ergonomic design enables the HCW to perform better without bending forwards or reaching out for the oropharyngeal or nasopharyngeal swab. It avoids a great deal of inconvenience for both the HCW and the patient.

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.

Steroid harms if given early in COVID-19 viraemia

COVID-19 is a biphasic illness with an initial viraemia phase and later effective adaptive immune phase, except in a minority of people who develop severe disease. Immune regulation is the key target to treat COVID illness. In anticipation, an elderly man self-medicated himself with dexamethasone on the day of symptom onset of a flu-like illness, took other symptomatic measures and was tested positive for SARS-CoV-2. His condition deteriorated with each passing day resulting in hospitalisation. He demanded oxygen and declared as severe COVID. With supportive treatment, he recovered after the 20th day of illness. Immunosuppression and anti-inflammation are likely to benefit when the immune response is dysregulated and turning into a cytokine storm. A medication that has saved many could be the one predisposing to severity if taken as a preventive measure, too early in the disease course, especially the viraemia phase.

Cycle threshold values versus reverse transcription-polymerase chain reaction positivity in COVID-19 de-isolation

In the modern COVID-19 pandemic, reverse transcription-polymerase chain reaction (RT-PCR) positivity has a major role in the diagnosis of the disease. However, in deciding the patient's discharge or de-isolation, its role is still debatable. We are, hereby, describing three cases (an intern, a nursing officer and a caretaker of another patient) where only RT-PCR could not help much since it was persistently positive for >20 days of the illness course. Instead, the cycle threshold (Ct) values could have better correlated with the infectivity of COVID. We propose a rising trend (24 h apart) and absolute Ct value > 25, instead of RT-PCR negativity (which was taken as Ct value > 36 in our laboratory), to be used in deciding the infective potential of the patients, their discharge from the hospital and de-isolation of the patients. This will help in the timely discharge of patients from health-care institutions and home isolation, which, as a result, will lead to optimal utilisation of the limited hospital resources we have available in the line of the ongoing pandemic. Future studies are required to define the exact cut-off of Ct value for de-isolation purposes.