Critical care practice in India: Results of the intensive care unit need assessment survey (ININ2018)

BACKGROUND

A diverse country like India may have variable intensive care units (ICUs) practices at state and city levels.

AIM

To gain insight into clinical services and processes of care in ICUs in India, this would help plan for potential educational and quality improvement interventions.

METHODS

The Indian ICU needs assessment research group of diverse-skilled individuals was formed. A pan- India survey "Indian National ICU Needs" assessment (ININ 2018-I) was designed on google forms and deployed from July 23^rd-August 25^th, 2018. The survey was sent to select distribution lists of ICU providers from all 29 states and 7 union territories (UTs). In addition to emails and phone calls, social medial applications-WhatsApp™, Facebook™ and LinkedIn™ were used to remind and motivate providers. By completing and submitting the survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status.

RESULTS

There were total 134 adult/adult-pediatrics ICU responses from 24 (83% out of 29) states, and two (28% out of 7) UTs in 61 cities. They had median (IQR) 16 (10-25) beds and most, were mixed medical-surgical, 111(83%), with 108(81%) being adult-only ICUs. Representative responders were young, median (IQR), 38 (32-44) years age and majority, n = 108 (81%) were males. The consultants were, n = 101 (75%). A total of 77 (57%) reported to have 24 h in-house intensivist. A total of 68 (51%) ICUs reported to have either 2:1 or 2≥:1 patient:nurse ratio. More than 80% of the ICUs were open, and mixed type. Protocols followed regularly by the ICUs included sepsis care, ventilator- associated pneumonia (83% each); nutrition (82%), deep vein thrombosis prophylaxis (87%), stress ulcer prophylaxis (88%) and glycemic control (92%). Digital infrastructure was found to be poor, with only 46 % of the ICUs reporting high-speed internet availability.

CONCLUSION

In this large, national, semi-structured, need-assessment survey, the need for improved manpower including; in-house intensivists, and decreasing patient-to-nurse ratios was evident. Sepsis was the most common diagnosis and quality and research initiatives to decrease sepsis mortality and ICU length of stay could be prioritized. Additionally, subsequent surveys can focus on digital infrastructure for standardized care and efficient resource utilization and enhancing compliance with existing protocols.

Prospective Randomised Open-label Comparison of Danaparoid with Dextran 70 in the Treatment of Heparin-induced Thrombocytopaenia with Thrombosis

Aim: To compare clinical outcomes in a randomised comparison of treatment with danaparoid sodium (a heparinoid), or dextran 70, for heparin-induced thrombocytopaenia (HIT) plus thrombosis. Methods: Forty-two patients with recent thrombosis and a clinical diagnosis of probable HIT who presented at ten Australian hospitals during a study period of six and one half years were randomly assigned to open-label treatment with intravenous danaparoid or dextran 70, each combined with oral warfarin. Thirty-four patients (83%) had a positive platelet aggregation or 14C-serotonin release test for HIT antibody. Twenty-five received danaparoid as a bolus injection of 2400 anti-Xa units followed by 400 units per hour for 2 h, 300 units per hour for 2 h, and then 200 units per hour for five days. Seventeen received 1000 mL dextran 70 on day one and then 500 mL on days 2-5. Patients were reviewed daily for clinical evidence of thrombus progression or resolution, fresh thrombosis or embolism, bleeding or other complications. The primary trial endpoint was the proportion of thromboembolic events with complete clinical resolution by the time of discharge from hospital. Results: With danaparoid, there was complete clinical recovery from 56% of thromboembolic events compared to 14% after dextran 70 (Odds Ratio 10.53, 95% Confidence Interval 1.6–71.4; p = 0.02). Clinical recovery with danaparoid was complete or partial in 86% of thromboembolic events compared with 53% after dextran 70 (Odds Ratio 4.55, 95% Confidence Interval 1.2–16.7; p = 0.03). Overall clinical effectiveness of danaparoid was rated as high or moderate in 88% of patients compared with 47% for dextran 70 (p = 0.01). One patient given danaparoid died of thrombosis compared with three patients given dextran 70. The platelet count returned to normal after a mean of 6.7 days with danaparoid and 7.3 days with dextran 70. There was no major bleeding with either treatment. Conclusion: danaparoid plus warfarin treatment for HIT with thrombosis is effective, safe, and superior to dextran 70 plus warfarin.

UV crosslinked poly(acrylic acid): a simple method to bio-functionalize electrolyte-gated OFET biosensors

A sensitive EGOFET biosensor fabricated by anchoring bioprobes through a UV crosslinked poly(acrylic acid) coating deposited on an organic semiconductor.

The effects of a low-carbohydrate versus low-fat diet on adipocytokines in severely obese adults: three-year follow-up of a randomized trial

BACKGROUND

Adipocytokines are associated with insulin resistance and cardiovascular disease and can be modified with weight loss. While we previously demonstrated weight loss and a reduction in leptin in obese adults who followed a low-carbohydrate diet for 6 months, the long-term effects of this diet on adipocytokines are unknown.

METHODS

132 obese adults with a body mass index of > or = 35 kg/m2 were randomized to receive one year of dietary counseling to follow either a low-carbohydrate diet < 30 g/day (LC) or a caloric-restricted diet (reduced by 500 calories/day with < 30% of calories from fat) (LF). Weight, leptin, adiponectin, TNF-alpha, CRP, and insulin were measured at 0, 6, and 36 months (24 months post-counseling). Follow-up data at was collected for 53 participants who returned at 36 months.

RESULTS

Mean weight change from baseline was not different between the groups at 36 months. Between 6 and 36 months weight was unchanged for LF, while LC appeared to regain weight [+ 4.84 +/- 35.6 kg (+ 3.0%)]. This difference, however, was not significant (p = 0.08). Leptin was unchanged in LF at both 6 and 36 months. In LC leptin decreased by 8.49 +/- 6.4 ng/mL or 22.7% at 6 months (p < 0.001) and increased by 10.68 +/- 25.2 ng/mL or 41.9% between 6 and 36 months (p = 0.02). There were no differences in insulin, adiponectin, TNF-alpha, or CRP between the groups.

CONCLUSIONS

Favorable changes in leptin that accompany weight loss are not sustained in individuals who followed a low-carbohydrate diet for one year. A low-carbohydrate diet had no significant effect on insulin, adiponectin, TNF-alpha, or CRP compared to a low-fat diet at 36 months.

Serum resistin is not associated with obesity or insulin resistance in humans

BACKGROUND

Resistin has proposed link with obesity related insulin resistance and type 2 diabetes. The physiologic role of resistin in humans remains unknown. It is suggested that circulating resistin levels are not associated with obesity or insulin resistance in humans. However, the effects of weight loss on serum resistin concentration has not been studied. In order to better understand the physiologic role of resistin in human obesity, we measured the serum resistin concentration in subjects with severe obesity (before and after 6-months of dietary intervention) to test the hypothesis that serum resistin concentrations are elevated amongst individuals with severe obesity and weight loss would reduce these levels.

METHODS

Seventy-one obese subjects (defined as BMI > 35 kg/m2) who were randomized to low fat (LF) vs low carbohydrates (LC) diets and who completed the 6-month follow-up were studied. Their baseline demographic information was collected and serum resistin, insulin, glucose were measured at baseline and at 6-months.

RESULTS

Subjects in LC diet lost more weight than LF (-19.54 +/- 7.87 lbs vs -7.83 +/- 11.23 lbs., p = 0.001). Insulin sensitivity (HOMA) improved in LC group compared with LF group [-3.72 +/- 9.84 (LC) vs +1.31 +/- 7.31 (LF), p = 0.006]. Serum resistin levels did not decrease in either diet.

CONCLUSIONS

Our study found that despite a significant weight loss and improvement in insulin sensitivity there was no reduction in serum resistin concentration in morbidly obese men with metabolic syndrome suggesting that resistin does not play a central role in obesity related insulin resistance.

Local recurrence and survival after laparoscopic mesorectal resection forrectal adenocarcinoma

BACKGROUND

Laparoscopic resection for rectal cancer is controversial. Actuarial survival and local recurrence rates have not been determined.

METHODS

A prospective database containing 80 consecutive unselected laparoscopic resections of rectal cancers performed between November 1991 and 1999 was reviewed. Local recurrence was defined as any detectable local disease at follow-up assessment occurring either alone or in conjunction with generalized recurrence. The tumor node metastases (TNM) classification for colorectal cancers and the Kaplan-Meier method were used to determine staging and survival curves. The mesorectal excision technique was used during surgery.

RESULTS

The median follow-up period was 31 months for patients with stages I, II, and III cancer, and 15.5 months for patients with stage IV cancer. The overall 5-year survival rate was 65.1% for all cancer stages and 72.1% for stages I, II, and III cancer. No trocar-site recurrence was observed. The overall local recurrence rate was 3.75% (3/80) for all cancer stages, and 4.3% (3/70) for stages I, II, and III cancer.

CONCLUSIONS

The survival and local recurrence rates for patients with rectal cancer treated by laparoscopic mesorectal excision do not differ negatively from those in the literature for open mesorectal excision. Further validation is needed.

Prospective randomised open-label comparison of danaparoid with dextran 70 in the treatment of heparin-induced thrombocytopaenia with thrombosis: a clinical outcome study

AIM

To compare clinical outcomes in a randomised comparison of treatment with danaparoid sodium (a heparinoid), or dextran 70, for heparin-induced thrombocytopaenia (HIT) plus thrombosis.

METHODS

Forty-two patients with recent thrombosis and a clinical diagnosis of probable HIT who presented at ten Australian hospitals during a study period of six and one half years were randomly assigned to open-label treatment with intravenous danaparoid or dextran 70, each combined with oral warfarin. Thirty-four patients (83%) had a positive platelet aggregation or 14C-serotonin release test for HIT antibody. Twenty-five received danaparoid as a bolus injection of 2400 anti-Xa units followed by 400 units per hour for 2 h, 300 units per hour for 2 h, and then 200 units per hour for five days. Seventeen received 1000 mL dextran 70 on day one and then 500 mL on days 2-5. Patients were reviewed daily for clinical evidence of thrombus progression or resolution, fresh thrombosis or embolism, bleeding or other complications. The primary trial endpoint was the proportion of thromboembolic events with complete clinical resolution by the time of discharge from hospital.

RESULTS

With danaparoid, there was complete clinical recovery from 56% of thromboembolic events compared to 14% after dextran 70 (Odds Ratio 10.53, 95% Confidence Interval 1.6-71.4; p = 0.02). Clinical recovery with danaparoid was complete or partial in 86% of thromboembolic events compared with 53% after dextran 70 (Odds Ratio 4.55, 95% Confidence Interval 1.2-16.7; p = 0.03). Overall clinical effectiveness of danaparoid was rated as high or moderate in 88% of patients compared with 47% for dextran 70 (p = 0.01). One patient given danaparoid died of thrombosis compared with three patients given dextran 70. The platelet count returned to normal after a mean of 6.7 days with danaparoid and 7.3 days with dextran 70. There was no major bleeding with either treatment.

CONCLUSION

danaparoid plus warfarin treatment for HIT with thrombosis is effective, safe, and superior to dextran 70 plus warfarin.

Hairy cell leukemia: treatment prospects

The recent advances in the management of hairy cell leukemia, a chronic and indolent B-cell lymphoproliferative disorder are reviewed. The introduction of alpha-interferon, purine analogs and recombinant monoclonal antibodies/immunotoxins has dramatically improved the outcome in a disease that once had a dismal prognosis. The underlying genetic defect remains unknown.

Acute necrotising vasculitis in hairy cell leukemia--rapid response to cladribine: case report and a brief review of the literature

A 61-year-old woman with extensive cutaneous vasculitis and hairy cell leukemia treated with cladribine is described. She achieved a dramatic hematological and dermatological response which has lasted more than 6 years.

Effects of serotonin reuptake inhibitors on hemostasis

OBJECTIVE

To examine the hematologic safety profile of the selective serotonin reuptake inhibitors (SSRIs), with particular emphasis on the effects of these drugs on platelet aggregation.

METHODS

Platelet aggregation studies were undertaken at baseline, and repeated 2 and 4 weeks after the initiation of treatment with an SSRI. Other investigations undertaken included analysis of serum electrolyte and liver enzyme concentrations, complete blood count, and coagulation studies. Patients were also assessed for clinical signs of bleeding. Eight patients (7 treated with fluoxetine, 1 with paroxetine) completed the study protocol.

RESULTS

Repeated ANOVA revealed no abnormalities in platelet aggregation, hematopoiesis, or coagulation profile. No patient developed clinical signs of abnormal hemostasis during the study period. A statistically significant elevation in the mean serum bilirubin concentration was detected, but this was not of clinical significance.

CONCLUSIONS

Although the SSRIs may cause abnormal hemostasis, this effect is probably rare. Another possibility is that abnormal hemostasis is more likely to occur when high doses of SSRIs are administered.

Rheumatic manifestations of the myelodysplastic syndromes: a comparative study

BACKGROUND

The myelodysplastic syndromes (MDS) are a group of common haematological disorders that increase in incidence with age. Case reports have suggested an arthritis associated with myelodysplasia. This comparative study reviews patients with myelodysplasia and patients with a myeloproliferative disorder (MPD) as the control group.

AIM

To document the rheumatological manifestations in patients with MDS and to determine if there is an association between MDS and an inflammatory arthritis/vasculitis.

METHODS

Between July 1990 and July 1995 all patients with a known diagnosis of MDS and MPD attending the Haematology clinics of two teaching hospitals were reviewed. There were 87 MDS patients and 86 MPD patients identified. Twenty-six of the MDS patients and 28 of the MPD patients attended a clinical review by a single examiner. A history of joint symptoms, skin rashes, family and drug history was obtained. Physical examination and serology were routinely performed. The case notes of the remaining patients were reviewed by a single observer. Approval was obtained from the Ethics Committee at both hospitals.

RESULTS

The two patient groups were matched for sex and age. There were equal numbers of patients with osteoarthritis, rheumatoid arthritis and crystal arthritis in the two groups. The significant finding was the presence of a seronegative inflammatory arthritis in five patients in the MDS group. One patient had both a seronegative arthritis and a cutaneous leukocytoclastic vasculitis, and another a cutaneous leukocytoclastic vasculitis only. These rheumatic manifestations were not seen in the MPD group. Five of six patients were treated with prednisolone and responded impressively. The rheumatological symptoms preceded the diagnosis of MDS in two of the six cases.

CONCLUSIONS

A seronegative arthritis is an associated finding in MDS. The arthritis can precede the development of the bone marrow disorder, and can be a guide to the diagnosis of this haematological disorder in elderly patients presenting with an inflammatory arthritis and cytopenias.

The role of autologous blood transfusion in joint replacement surgery

The efficacy of predeposited autologous blood transfusion (PABT) with and without intra/postoperative blood salvage to reduce or eliminate the need for homologous blood transfusion (HBT) in primary total hip or knee replacement surgery was investigated by retrospective and prospective studies. Depending on the type of surgery, one to three units of PABT eliminated the need for HBT in 50 to 78% of patients, but, intra/postoperative blood salvage alone reduced the need only in 11 to 29%. In contrast, blood salvage, when combined with three units of PABT, eliminated the need for HBT in all patients undergoing primary joint replacement surgery. A cost comparison analysis showed that blood salvage was more expensive than PABT, and therefore it should be limited to patients who had predeposited fewer than three units of autologous blood.

Cimetidine in the treatment of interstitial cystitis

OBJECTIVES

To assess the effect of the H2-antagonist cimetidine in the treatment of patients with interstitial cystitis (IC) refractory to other conservative therapies.

METHODS

A group of 9 patients previously treated conservatively for IC without success were entered in the study. They were thoroughly investigated and treated with cimetidine at the dose of 300 mg orally twice a day for 1 month.

RESULTS

Six of the 9 patients (66%) experienced various degrees of symptomatic relief while on the drug. Of these, 4 (44%) have noted a complete and sustained response to the medication.

CONCLUSIONS

The encouraging results observed in this pilot study together with the simplicity and tolerance of the treatment makes it an alternative when other options have been exhausted. Its use as a first-line monotherapy remains speculative.

Phenotypic and genotypic analysis of mononuclear cells from patients with Felty's syndrome

Phenotypic and genotypic characteristics of the peripheral blood mononuclear cells in nine patients with Felty's syndrome have been examined. One patient had an increased number and percentage of peripheral blood mononuclear cells with the phenotype CD3+ Leu-7+ CD16+ and showed a clonal rearrangement of the T cell receptor B chain gene. The remaining eight patients all showed a germline configuration of the T cell receptor B chain gene. In two patients an increased proportion of CD3+ Leu-7+ CD16- peripheral blood mononuclear cells (45 (SD 11)% of peripheral blood mononuclear cells) were found, while the remaining six patients had proportions of CD3+ Leu-7+ cells similar to those of patients with uncomplicated rheumatoid arthritis. These data confirm that patients with Felty's syndrome are heterogeneous, with at least three different peripheral blood mononuclear cell phenotypic subsets. One subset is characterised by a clonal expansion of an unusual lymphocyte subpopulation, another by polyclonal expansion, and the third subset has the same proportions of peripheral blood mononuclear cells as patients with uncomplicated rheumatoid arthritis.