Therapeutic high-dose vitamin D for vitamin D-deficient severe COVID-19 disease: randomized, double-blind, placebo-controlled study (SHADE-S)

BACKGROUND

efficacy of therapeutic cholecalciferol supplementation for severe COVID-19 is sparingly studied.

OBJECTIVE

effect of single high-dose cholecalciferol supplementation on sequential organ failure assessment (SOFA) score in moderate-to-severe COVID-19.

METHODS

participants with moderate to severe COVID-19 with PaO2/FiO2 ratio < 200 were randomized to 0.6 million IU cholecalciferol oral (intervention) or placebo.

OUTCOMES

primary outcome was change in Day 7 SOFA score and pre-specified secondary outcomes were SOFA and 28-day all-cause mortality.

RESULTS

in all, 90 patients (45 each group) were included for intention-to-treat analysis. 25(OH)D3 levels were 12 (10-16) and 13 (12-18) ng/ml (P = 0.06) at baseline; and 60 (55-65) ng/ml and 4 (1-7) ng/ml by Day 7 in vitamin D and placebo groups, respectively. The SOFA score on Day 7 was better in the vitamin D group [3 (95% CI, 2-5) versus 5 (95% CI, 3-7), P = 0.01, intergroup difference - 2 (95% CI, -4 to -0.01); r = 0.4]. A lower all-cause 28-day mortality [24% compared to 44% (P = 0.046)] was observed with vitamin D.

CONCLUSIONS

single high-dose oral cholecalciferol supplementation on ICU admission can improve SOFA score at Day 7 and reduce in-hospital mortality in vitamin D-deficient COVID-19. ClinicalTrials.gov id: NCT04952857 registered dated 7 July 2021. What is already known on this topic-vitamin D has immunomodulatory role. Observational and isolated intervention studies show some benefit in COVID-19. Targeted therapeutic vitamin D supplementation improve outcomes in severe COVID-19 is not studied in RCTs. What this study adds-high-dose vitamin D supplementation (0.6 Million IU) to increase 25(OH)D > 50 ng/ml is safe and reduces sequential organ failure assessment score, in-hospital mortality in moderate to severe COVID-19. How this study might affect research, practice or policy-vitamin D supplementation in vitamin D-deficient patients with severe COVID-19 is useful may be practiced.

Analysis of Predictors and Outcomes of COVID-19 Patients Requiring ICU Admission from COVID-19 Registry, India

Background

Patients admitted to intensive care units (ICUs) with severe coronavirus disease (COVID-19) are associated with high mortality. The present retrospective, multicenter study describes the predictors and outcomes of COVID-19 patients requiring ICU admission from COVID-19 Registry of Indian Council of Medical Research (ICMR), India.

Materials and methods

Prospectively collected data from participating institutions were entered into the electronic National Clinical Registry of COVID-19. We enrolled patients aged >18 years with COVID-19 pneumonia requiring ICU admission between March 2020 and August 2021. Exclusion criteria were negative in RT-PCR report, death within 24 hours of ICU admission, or incomplete data. Their demographic and laboratory variables, ICU severity indices, treatment strategies, and outcomes were analyzed.

Results

A total of 5,865 patients were enrolled. Overall mortality was 43.2%. Non-survivors were older (58.2 ± 15.4 vs 53.6 ± 14.7 years; p = 0.001), had multiple comorbidities (33.2% vs 29.5%, p = 0.001), had higher median D-dimer (1.56 vs 1.37, p = 0.015), higher CT severity index (16.8 ± 5.2 vs 13.5 ± 5.47, p = 0.001) and longer median hospital stay (10 vs 8 days, p = 0.001) and ICU stay (5 vs 4 days, p = 0.001), compared with survivors.On multivariate analysis, high CRP (HR 1.008, 95% CI: 1.006-1.010, p = 0.001) and high D-dimer (HR 1.089, 95% CI: 1.065-1.113, p < 0.001) were associated with invasive mechanical ventilation while older age (HR 1.19, CI: 1.001-1.038, p = 0.039) and high D-dimer (HR-1.121, CI: 1.072-1.172, p = 0.001) were independently associated with mortality and while the use of prophylactic low molecular weight heparin (LMWH) (HR 0.647, CI: 0.527-0.794, p = 0.001) lowered mortality.

Conclusion

Among 5,865 COVID-19 patients admitted to ICU, mortality was 43.5%. High CRP and D-dimers were independently associated with the need for invasive mechanical ventilation while older age and high D-dimer were associated with higher mortality. The use of prophylactic LMWH independently reduced mortality.

How to cite this article

Kajal K, Singla K, Puri GD, Bhalla A, Mukherjee A, Kumar G, et al. Analysis of Predictors and Outcomes of COVID-19 Patients Requiring ICU Admission from COVID-19 Registry, India. Indian J Crit Care Med 2023;27(8):552-562.

Postpartum Collapse Subsequent to Catatonia in a Female with COVID-19 Infection: a Rare Entity Visited

Postpartum collapse is a life-threatening condition caused by obstetrical and non-obstetrical events. In this case report, we discuss a case of postpartum collapse in COVID-19-positive woman who required intensive care and mechanical ventilation for two days. After confusing collision of many provisional diagnoses soldiering for three days, she was ultimately diagnosed with malignant catatonia. Targeted therapy with lorazepam challenge resulted in drastic improvement, and she was discharged with her baby in healthy condition.

Correction to: Postpartum Collapse Subsequent to Catatonia in a Female with COVID-19 Infection: A Rare Entity Visited

[This corrects the article DOI: 10.1007/s13224-022-01737-5.].

Evaluation of efficiency and ranking of Indian hotels and restaurants: a bootstrap DEA approach

Purpose

The main purpose of this paper is to determine the bias-corrected efficiencies and rankings of the selected hotels and restaurants (H&Rs) in India.

Design/methodology/approach

The data for the Indian H&R sector are collected from the Prowess database. The bootstrap data envelopment analysis (DEA) based on a constant return to scale (CRS), variable return to scale-input oriented (VRS-IP) and variable return to scale-output oriented (VRS-OP) are applied on H&Rs to obtain the bias-corrected efficiencies.

Findings

It is found that relative efficiencies using basic DEA methods of all the 45 H&Rs of India are overestimated. These efficiencies are corrected using bias correction through bootstrap DEA methods. The bounds for the efficiencies of each H&R are computed using all the adopted methods. All H&Rs are ranked using bias-corrected efficiencies, and the linear trend between ranks suggests that the H&Rs are ranked almost similarly by all the adopted methods.

Practical implications

To improve efficiency, Indian H&R companies must rethink their personnel needs by enhancing their workforce management capabilities. The government needs to extend more support to this sector by introducing a liberal legislation framework and supporting infrastructure policies.

Originality/value

There is a paucity of studies on H&Rs in India. The current study focused on measuring bias-corrected efficiencies of the selected H&Rs of India. This study is one of the few initiatives to explore bias-corrected efficiencies extensively using the bootstrap DEA method.

Does Arterial Blood Gas (ABG) Provide a Safety Net for Extubation in Surgical Patients?

Background Extubation has always been a critical aspect of anaesthesia. Guidelines and recommendations are in place for achieving successful extubation, but the risk of failure always persists. Through this study, we assess whether arterial blood gas (ABG) values taken intraoperatively help predict extubation success in the operation theatre. Materials and methods This was a prospective observational study for one year of extubated patients whose blood gas values were not within the normal range. The patients of age 18 years and above undergoing high-risk elective and emergency surgeries where at least one intraoperative arterial blood sample was taken for blood gas analysis were included. Apart from parameters of ABG demographic data, urgency and duration of surgery, blood loss, urine output, use of intraoperative fluid(s), and blood product(s) were also observed.  Results Of 578 patients enrolled, 116 patients were extubated based on the predefined extubation criteria. Of these, 24 patients were reintubated within 24 hours. ABG parameters such as partial pressure of arterial oxygen (PaO₂) and serum HCO_3- levels were significantly lower in the reintubated patients compared to non-reintubated patients (p-values of 0.045 and 0.003, respectively). Conclusion This study showed that the PaO₂ <100 mm Hg or ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F ratio) of less than 200 and an HCO_3- value of less than 18 are plausible ABG parameters to decide extubation in post-surgery patients in OT. PaCO₂, base deficit, and lactate were less reliable parameters for planning extubation.

Unmasking the ties of snake bite poisoning and COVID-19

Background

Snake bite envenoming is a neglected tropical disease with variable clinical presentation, neurotoxic manifestations (respiratory paralysis), rhabdomyolysis, cardiotoxicity, autonomic hyperactivity, and/or coagulation abnormalities. There is limited data on the clinical course of the envenomation in an incidentally diagnosed COVID-19 patient.

Case presentation

A 17-year-old male with history of snake bite and neuroparalysis developed shortness of breath. He was treated with lyophilized polyvalent anti-snake venom (ASV) on admission in the emergency department and mechanical ventilation. Subsequently, he tested positive for COVID-19 infection. No immunomodulatory therapy was administered, and patient was extubated on the 5th day of ICU admission without any neurological deficit.

Conclusions

Coinfections of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus with snake bite poisoning lead to diagnostic dilemmas and controversies in management practices. Abnormalities of coagulation need to be cautiously addressed, and cause of development of pneumonia needs to be identified. The rapid recovery of the patient in our case theoretically can be explained on the organ-protective potential of snake-derived peptides; a large case series is however needed to prove the same.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42077-022-00256-9.

Biochemical Predictors of Acute Kidney Injury in Critically Ill COVID-19 Patients

It is estimated that 50% of patients with coronavirus disease 2019 (COVID-19) have varying degrees of renal involvement. In this clinical biomarker development research, we examined in a retrospective study design the temporal changes in biochemical laboratory parameters in relation to the development of acute kidney injury (AKI). In a sample of 399 patients admitted from May 2020 to May 2021 to a tertiary health care intensive care unit (ICU), the incidence of AKI was 27.3%, and the median time to AKI was on 7th day of ICU admission. Most common etiology of AKI was kidney hypoperfusion. Within 72 h of developmental of low blood pressure, 63.76% developed AKI. The likelihood of AKI was higher in those with elevated serum ferritin, aspartate transaminase, and thrombocytopenia (low platelet count). A cutoff value of 750.3 ng/mL [area under the ROC curve (AUC) = 0.777] for serum ferritin, and 40.05 U/L for alanine aminotransferase (AUC = 0.677) 1 day before development of AKI displayed, respectively, a sensitivity of 76.2% and 64.3%, whereas the specificity was 69.5% and 64.1%, respectively, for these two biochemical predictors. A cutoff value of platelets (152.50 × 10⁹/L [AUC = 0.75]) measured 4 days before development of AKI, displayed 83.3% sensitivity and 16.4% specificity. Taken together, our study thoroughly examined the temporal association of various clinical and laboratory parameters with AKI and prediction models were developed as per results of the time series data. These observations in a tertiary health care setting contribute to ongoing efforts for biomarker discovery and development using routine biochemical tests so as to forecast AKI in patients with COVID-19.

Characteristics and outcomes of parturients with COVID-19, admitted to a critical care unit: A single-center retrospective observational study

Background

Data on outcomes of coronavirus disease 2019 (COVID-19) in pregnancy are scarce, although they represent a unique physiological state affecting both the mother and child. We present collated data from a tertiary care center in North India, encompassing the outcome, clinical characteristics, and management of these patients.

Materials and Methods

Parturients ≥ 18 years old, with COVID-19 reverse transcriptase polymerase chain reaction positive for severe acute respiratory syndrome coronavirus 2, requiring intensive care unit (ICU) admission at a tertiary care hospital were included. Data were retrospectively collected from April 2020 to November 2021.

Results

In all, 26 parturients were admitted to ICU with COVID-19. Five patients were admitted during the first wave, and all were asymptomatic. Twenty-one patients presented during the second wave (March 2021 onward), among which four were asymptomatic and 17 symptomatic (all with severe pneumonia). Three patients presented in the second trimester, all with critical disease, out of which one did not survive. Two patients had twin gestation, and others were singleton pregnancies. Seven patients (27%) were primigravida, and five patients (19.2%) had more than third pregnancy. Twenty critically ill women (77%) delivered during the hospital stay. Six patients died during the second wave, and four deaths (66.7%) were because of COVID-19 acute respiratory distress syndrome (ARDS).

Conclusions

The number of admissions and mortality related to COVID-19 ARDS was higher in the second wave than in the first. We report the safe use of remdesivir and tocilizumab in our patients.

Factors Associated With Non-invasive Oxygen Therapy Failure in COVID-19 Pneumonia: A Single Center, Retrospective Study in a Tertiary Hospital in North India

Background: Non-invasive oxygen therapy (NIT) consists of high-flow nasal oxygen (HFNO) and continuous positive airway pressure (CPAP). NIT is routinely being used for the management of acute respiratory failure secondary to coronavirus disease-2019 (COVID-19) with variable outcomes. However, previously published studies show that NIT failure might delay endotracheal intubation and invasive mechanical ventilation and results in worse outcomes in patients with hypoxemic respiratory failure. Early prediction of failure of NIT, will help in early decision-making in initiating invasive mechanical ventilation. We retrospectively studied the predictors for NIT failure in patients with moderate to severe COVID-19.

Methods: Adult patients (>18 years) admitted to the intensive care unit (ICU) with moderate to severe COVID-19 ARDS and received NIT [HFNO and CPAP non-invasive ventilation (NIV)] were included in this study. Baseline clinical and laboratory data were collected retrospectively from the electronic hospital information system. NIT failure was defined as the need for invasive mechanical ventilation after the initiation of NIT in the ICU. Univariate and multivariate logistic regression analyses were used to find out the possible predictors of NIT failure.

Results: Out of 254 patients admitted to ICU, 127 patients were initiated NIT at admission to ICU. During the course of the ICU stay, 33 (26%) patients subsequently required invasive mechanical ventilation (NIT failure). Respiratory rate-oxygenation index (ROX index) of <2.97 at two hours and <3.63 at six hours of ICU admission predicted NIT failure in our cohort of patients with a high positive predictive value.

Conclusion: Patient selection is crucial for successful NIT in COVID-19. Application of ROX index measured in the first six hours of ICU admission helps in the identification of patients at risk of NIT failure with moderate to severe COVID-19 ARDS.

Predictors of the Outcomes Following the Tocilizumab Treatment for Severe COVID-19

Background: Tocilizumab is used in severe COVID-19 yet has significant rates of treatment failure.

Objectives: This retrospective study aimed to identify early predictors of the response to tocilizumab therapy.

Methods: Biochemical and clinical characteristics of adult patients who received tocilizumab for severe COVID-19 pneumonia were retrospectively examined. A multivariable logistic regression model was constructed to identify factors that could predict the failure of tocilizumab therapy. A predictive nomogram was also created using the selected model.

Results: Out of 101 eligible patients, 30 had treatment failure, and 71 survived on a 28-day follow-up. The partial pressure of oxygen to fraction of inspired oxygen ratio (PFR) on the day of tocilizumab administration (100 vs 80.5), lactate dehydrogenase (LDH; 668 vs 507 U/L), neutrophil-to-lymphocyte ratio (NL ratio; 24.7 vs 10), and creatine kinase myocardial band (CKMB; 30.9 vs 22.7 U/L) were significantly different among the non-survivors and survivors, respectively. A logistic regression model was created, identifying LDH, NL ratio, pro-brain natriuretic peptide (ProBNP), and PFR on the day of tocilizumab administration as best predictors of mortality with an optimism-corrected area under the receiver operator characteristics (ROC) curve of 0.82. The model-implied odds ratios for mortality were 1.89 (95% CI 1.13-3.15) for every 100 U/L rise in serum LDH, 2.29 (95% CI 2.2-4.39) for every 10 unit rise in NL ratio, 1.23 (95% CI 0.95-1.58) for every 100 pg/ml increase in ProBNP, and 0.36 (95% CI 0.13-0.95) for every mmHg rise in PFR at intervention.

Conclusion: This study identified NL ratio, LDH, CKMB, and PFR at intervention as important markers of risk of treatment failure following the tocilizumab therapy. A multivariable logistic regression model including LDH, NL ratio, ProBNP, and PFR at intervention best predicted the risk of mortality in patients with severe COVID-19 pneumonia treated with tocilizumab.

Validation of a noninvasive aMMP‐8 point‐of‐care diagnostic methodology in COVID‐19 patients with periodontal disease

Objectives

The aim of this study was to validate an active matrix metalloproteinase (MMP‐8) point‐of‐care diagnostic tool in COVID‐19 patients with periodontal disease.

Subjects, Materials, and Methods

Seventy‐two COVID‐19‐positive and 30 COVID‐19‐negative subjects were enrolled in the study. Demographic data were recorded, periodontal examination carried out, and chairside tests run for evaluating the expression of active MMP‐8 (aMMP‐8) in the site with maximum periodontal breakdown via gingival crevicular fluid sampling as well as via a mouth rinse‐based kit for general disease activity. In COVID‐19‐positive patients, the kits were run again once the patients turned COVID‐19 negative.

Results

The overall (n = 102) sensitivity/specificity of the mouthrinse‐based kits to detect periodontal disease was 79.41%/36.76% and that of site‐specific kits was 64.71%/55.88% while adjusting for age, gender, and smoking status increased the sensitivity and specificity (82.35%/76.47% and 73.53%/88.24, respectively). Receiver operating characteristic (ROC) analysis for the adjusted model revealed very good area under the ROC curve 0.746–0.869 (p < .001) and 0.740–0.872 (p < .001) (the aMMP‐8 mouth rinse and site‐specific kits, respectively). No statistically significant difference was observed in the distribution of results of aMMP‐8 mouth rinse test (p = .302) and aMMP‐8 site‐specific test (p = .189) once the subjects recovered from COVID‐19.

Conclusions

The findings of the present study support the aMMP‐8 point‐of‐care testing (PoCT) kits as screening tools for periodontitis in COVID‐19 patients. The overall screening accuracy can be further increased by utilizing adjunctively risk factors of periodontitis. The reported noninvasive, user‐friendly, and objective PoCT diagnostic methodology may provide a way of stratifying risk groups, deciding upon referrals, and in the institution of diligent oral hygiene regimens.

Quantification of diurnal variation in “glove hygiene” compliance in COVID ICUs: an exploratory study

Background

Hand hygiene compliance (HHC) monitoring is almost always done in daytime. Documentation of HHC in health care workers (HCWs) is limited during odd hours and nighttime. The objective of the study was to determine diurnal variation in HHC in different categories of health care workers in tertiary care hospital in North India.

Methods

A prospective, observational study was conducted in 3 COVID-19 intensive care units (ICUs) with closed-circuit television (CCTV) cameras. Dedicated infection control nurses monitored HHC among various HCWs (doctors, nursing staff, technicians, hospital and sanitary attendants) during day and nighttime, in 20-minute durations. The difference in HHC by-professional category and for each WHO moment was assessed using χ² test and P value.

Results

A total of 705 opportunities were observed over a period of 7 days, with overall compliance of 53%. Day and nighttime compliance was recorded to be 60.7% and 42.1%, respectively (P < .001). HCC was highest amongst resident doctors with little diurnal variation. However, nurses and housekeeping staff exhibited significant diurnal variation. The compliance at “after” moments was much higher than “before” moments in all professional categories.

Conclusion

There was a significant decrease in compliance during nighttime, amongst all HCWs, with maximum variation exhibited by nursing staff. The present study underlines the importance of monitoring HHC at odd hours, to elicit a more accurate picture round the clock. Health care facilities monitoring compliance only during the daytime may substantially overestimate HHC.

COVID-19-related dynamic coagulation disturbances and anticoagulation strategies using conventional D-dimer and point-of-care Sonoclot tests: a prospective cohort study

OBJECTIVES

Coagulation changes associated with COVID-19 suggest the presence of a hypercoagulable state with pulmonary microthrombosis and thromboembolic complications. We assessed the dynamic association of COVID-19-related coagulation abnormalities with respiratory failure and mortality.

DESIGN

Single-centre, prospective cohort study with descriptive analysis and logistic regression.

SETTING

Tertiary care hospital, North India.

PARTICIPANTS

Patients with COVID-19 pneumonia requiring intensive care unit (ICU) admission between August 2020 and November 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

We compared the coagulation abnormalities using standard coagulation tests like prothrombin time, D-dimer, platelet count, etc and point-of-care global coagulation test, Sonoclot (glass beaded(gb) and heparinase-treated(h)). Incidence of thromboembolic or bleeding events and presence of endogenous heparinoids were assessed. Cox proportional Hazards test was used to assess the predictors of 28-day mortality.

MEASUREMENT

All patients underwent Sonoclot (glass beaded) test at admission apart from the routine investigations. In patients at risk of thromboembolic or bleeding phenomena, paired tests were performed at day 1 and 3 with Sonoclot. Activated clotting time (ACT) <110 s and peak amplitude >75 units were used as the cut-off for hypercoagulable state. Presence of heparin-like effect (HLE) was defined by a correction of ACT ≥40 s in h-Sonoclot.

RESULTS

Of 215 patients admitted to ICU, we included 74 treatment naive subjects. A procoagulant profile was seen in 45.5% (n=5), 32.4% (n=11) and 20.7% (n=6) in low-flow, high-flow and invasive ventilation groups. Paired Sonoclot assays in a subgroup of 33 patients demonstrated the presence of HLE in 17 (51.5%) and 20 (62.5%) at day 1 and 3, respectively. HLE (day 1) was noted in 59% of those who bled during the disease course. Mortality was observed only in the invasive ventilation group (16, 55.2%) with overall mortality of 21.6%. HLE predicted the need for mechanical ventilation (HR 1.2 CI 1.04 to 1.4 p=0.00). On multivariate analysis, the presence of HLE (HR 1.01; CI 1.006 to 1.030; p=0.025), increased C reactive protein (HR 1.040; CI 1.020 to 1.090; p=0.014), decreased platelet function (HR 0.901; CI 0.702 to 1.100 p=0.045) predicted mortality at 28days.

CONCLUSION

HLE contributed to hypocoagulable effect and associated with the need for invasive ventilation and mortality in patients with severe COVID-19 pneumonia.

TRIAL REGISTRATION

NCT04668404; ClinicalTrials.gov.in. Available from https://clinicaltrials.gov/ct2/show/NCT04668404.

Effect of head-end of bed elevation on respiratory mechanics in mechanically ventilated patients with moderate-to-severe COVID-19 ARDS - A cohort study

Background

Head-end elevation (HEE) is known to improve oxygenation and respiratory mechanics. In ARDS, poor lung compliance limits positive pressure ventilation causing delivery of inadequate minute ventilation (MVe). We observed that, in moderate-to-severe COVID-19 ARDS, the respiratory system compliance (Crs) reduces upon elevating the head-end of the bed, and vice-versa, which can be utilized to improve ventilation and avoid respiratory acidosis.We hypothesized that increasing the degree of HEE reduces Crs.

Methods

We included 20 consecutive mechanically ventilated, moderate-to-severe COVID-19 ARDS patients in this pilot study (CTRI/2021/06/034,182). The Crs, Mve and Rinsp were recorded at 0°, 10°, 20° and 30° HEE. Repeated measures ANOVA was used to determine significant differences in measurements with increasing degrees and repeated measures correlation (rmcorr) for correlation.

Results

Repeated measures ANOVA showed a significant difference (p < 0.0001) between values of Crs, MVe and Rinsp. Rmcorr showed a strong negative correlation between increasing degrees and Crs and Mve (r-0.87 [95% CI -0.79 to -0.92, p < 0.0001 and r-0.77 [95% CI -0.64 to -0.85, p < 0.0001]) and a moderate negative correlation for Rinsp (r-0.67; 95% CI -0.79 to -0.50; p < 0.0001).

Conclusions

Increasing degree of HEE reduces compliance in moderate-to-severe COVID-19 ARDS. Reducing HEE may optimize ventilation and mitigate ventilator induced lung injury.

Incidence & outcomes of clinically significant bleeding events in critically ill COVID-19 patients receiving Therapeutic dose AntiCoagulanTs: A retrospective cohort study (INTerACT study)

Background & objectives

The high mortality associated with the thrombotic events in hospitalized COVID-19 patients resulted in the usage of anticoagulants in varying doses. Whether high-dose anticoagulants have led to better outcomes or higher incidence of clinically significant bleeding events is debatable. Thus, this study was conducted to find the incidence of clinically significant bleeding events in moderate-to-severe COVID-19 ARDS (acute respiratory distress syndrome) patients on therapeutic anticoagulation and their outcomes.

Methods

In this retrospective, single-centre study of 155 critically ill COVID-19 patients, the incidence of clinically significant bleeding was observed. Multivariate regression models were used to evaluate the association between anticoagulant regimen, coagulation and inflammatory markers with the incidence of bleeding and thrombotic events.

Results

The incidence of clinically relevant non-major bleeding was 33.54 per cent (26.17-41.46%) and major bleeding was 9.03 per cent (5.02-14.69%). The anticoagulation intensity at baseline had a high odds of major bleeding when enoxaparin and dual antiplatelet therapy were used together [adjusted odds ratio OR of 434.09 (3.81-49502.95), P<0.05]. At admission, bleeders had a poorer PaO₂/FiO₂ ratio with more patients on invasive ventilation. At the time of bleeding, the bleeders had a higher D-dimer, ferritin, C-reactive protein and procalcitonin compared to non-bleeders. The subhazard ratio for death in bleeders was 3.35 (95% confidence interval, 1.97-5.65; P<0.001).

Interpretation & conclusions

The incidence of bleeding in critically ill COVID-19 patients on therapeutic anticoagulation may increase with the severity of the disease as well as with concurrent use of dual antiplatelets. Major bleeding may also contribute to higher mortality.

High-Dose Dexamethasone Versus Tocilizumab in Moderate to Severe COVID-19 Pneumonia: A Randomized Controlled Trial

Background and objectives

Recent randomized controlled trials (RCTs) have indicated potential therapeutic benefits with high-dose dexamethasone (HDD) or tocilizumab (TCZ) plus standard care in moderate to severe coronavirus disease 2019 (COVID-19) with acute respiratory distress syndrome (ARDS). No study has compared these two against each other. We aimed to compare the efficacy and safety of HDD against TCZ in moderate to severe COVID-ARDS.

Methods

Patients admitted with moderate to severe COVID-19 ARDS with clinical worsening within 48 hours of standard care were randomly assigned to receive either HDD or TCZ plus standard care. The primary outcome was ventilator-free days (VFDs) at 28 days. The main secondary outcomes were 28-day all-cause mortality and the incidence of adverse events. Our initial plan was to perform an interim analysis of the first 42 patients.

Results

VFDs were significantly lower in the HDD arm (median difference: 28 days; 95% confidence interval (CI): 19.35-36.65; Cohen’s d = 1.14;p < 0.001). We stopped the trial at the first interim analysis due to high 28-day mortality in the HDD arm (relative risk (RR) of death: 6.5; p = 0.007; NNT (harm) = 1.91). The incidence of secondary infections was also significantly high in the HDD arm (RR: 5.5; p = 0.015; NNT (harm) = 2.33).

Conclusions

In our study population, HDD was associated with a very high rate of mortality and adverse events. We would not recommend HDD to mitigate the cytokine storm in moderate to severe COVID-19 ARDS. TCZ appears to be a much better and safer alternative.

Mortality Prediction of COVID-19 Patients at Intensive Care Unit Admission

Background

Coronavirus-2019 (COVID-19) patients admitted to the intensive care unit (ICU) have mortality rates between 30%-50%. Identifying patient factors associated with mortality can help identify critical patients early and treat them accordingly.

Patients and methods

In this retrospective study, the records of patients admitted to the COVID-19 ICU in a single tertiary care hospital from April 2020 to September 2020 were analysed. The clinical and laboratory parameters between patients who were discharged from the hospital (survival cohort) and those who died in the hospital (mortality cohort) were compared. A multivariate logistic regression model was constructed to identify parameters associated with mortality. 

Results

A total of 147 patients were included in the study. The age of the patients was 55 (45, 64), median (IQR), years. At admission, 23 (16%) patients were on mechanical ventilation and 73 (50%) were on non-invasive ventilation. Sixty patients (40%, 95% CI: 32.8 to 49.2%) had died. Patients who died had a higher Charlson comorbidity index (CCI): 3 (2, 4) vs. 2 (1, 3), p = 0.0019, and a higher admission sequential organ failure assessment (SOFA) score: 5 (4, 7) vs. 4 (3, 4), p < 0.001. Serum urea, serum creatinine, neutrophils on differential leukocyte count, neutrophil to lymphocyte ratio (N/L ratio), D-dimer, serum lactate dehydrogenase (LDH), and C-reactive protein were higher in the mortality cohort. The ratio of partial pressure of arterial oxygen to fraction of inspired oxygen, platelet count, lymphocytes on differential leukocyte count, and absolute lymphocyte count was lower in the mortality cohort. The parameters and cut-off values used for the multivariate logistic regression model included CCI > 2, SOFA score > 4, D-dimer > 1346 ng/mL, LDH > 514 U/L and N/L ratio > 27. The final model had an area under the curve of 0.876 (95% CI: 0.812 to 0.925), p < 0.001 with an accuracy of 78%. All five parameters were found to be independently associated with mortality. 

Conclusions

CCI, SOFA score, D-dimer, LDH, and N/L ratio are independently associated with mortality. A model incorporating the combination of these clinical and laboratory parameters at admission can predict COVID-19 ICU mortality with good accuracy.

Bacterial coinfections and secondary infections in COVID-19 patients from a tertiary care hospital of northern India: Time to adhere to culture-based practices

OBJECTIVE

Bacterial co-pathogens are common in various viral respiratory tract infections, leading to increased disease severity and mortality. Still, they are understudied during large outbreaks and pandemics. This study was conducted to highlight the overall burden of these infections in COVID-19 patients admitted to our tertiary care hospital, along with their antibiotic susceptibility patterns.

MATERIAL AND METHODS

During the six-month study period, clinical samples (blood samples, respiratory samples, and sterile body fluids, including cerebrospinal fluid [CSF]) of COVID-19 patients with suspected bacterial coinfections (at presentation) or secondary infections (after 48 hours of hospitalization) were received and processed for the same.

RESULTS

Clinical samples of 814 COVID-19 patients were received for bacterial culture and susceptibility. Out of the total patient sample, 75% had already received empirical antibiotics before the samples were sent for analysis. Overall, 17.9% of cultures were positive for bacterial infections. Out of the total patients with bacterial infection, 74% (108/146) of patients had secondary bacterial infections (after 48 hours of hospitalization) and 26% (38/146) had bacterial coinfections (at the time of admission). Out of the 143 total isolates obtained, the majority (86%) were gram-negative organisms, of which Acinetobacter species was the commonest organism (35.6%), followed by Klebsiella pneumoniae (18.1%). The majority (50.7%) of the pathogenic organisms reported were multidrug resistant.

CONCLUSION

The overall rate of secondary bacterial infections (SBIs) in our study was lower (7.9%) than reported by other studies. A rational approach would be to adhere to the practice of initiating culture-based guidance for antibiotics and to restrict unnecessary empirical antimicrobial therapy.

Pulmonary Function, Mental and Physical Health in Recovered COVID-19 Patients Requiring Invasive Versus Non-invasive Oxygen Therapy: A Prospective Follow-Up Study Post-ICU Discharge

Background Survivors of COVID-19 pneumonia may have residual lung injury and poor physical and mental health even after discharge. We hypothesized that COVID-19 severe acute respiratory distress syndrome (ARDS) patients needing mechanical ventilation may be at a greater risk of deterioration in pulmonary function, mental health, and quality of life (QOL). This study analyses the differences in pulmonary function, mental health, and QOL after recovery, in patients having received non-invasive oxygen therapy versus invasive mechanical ventilation during ICU stay. Methods Patients aged >18 years, who had completed 3 months post ICU discharge, with moderate to severe COVID-19 ARDS, were consecutively enrolled from May 1 to July 31, 2021. Patients were allocated into Group A - having required high flow nasal cannula (HFNC)/non-invasive ventilation (NIV) and Group B - having received invasive mechanical ventilation. Pulmonary function tests, 6-minute walk test (6-MWT), and health-related quality of life were compared. Results Of the 145 eligible patients, 31 were lost to follow-up and 21 died. Seventy-four patients were allocated into Groups A (57 patients) and B (17 patients). In Group A, abnormal forced expiratory volume in first second (FEV₁), forced vital capacity (FVC), forced expiratory flow in mid-half of FVC (FEF_25-75), and peak expiratory flow rate (PEFR) values were obtained in 27 (47.37%), 43 (75.44%), 11 (19.3%), and 25 (43.86%) patients, and in Group B, in 13 (76.47%), 17 (100%), 1 (5.88%), and 8 (47%) patients, respectively. No patient had abnormal FEV₁/FVC. All Group B patients had a restrictive pattern in spirometry as compared to 77% in Group A. Group B had a lower arterial partial pressure of oxygen (PaO₂) (p=0.0019), % predicted FVC (p<0.0001), % predicted FEV₁ (p=0.001), and 6-MWT distance (p<0.001). The physical component score in the short-form survey 12 questionnaire was higher in group A, p<0.001, whereas the mental component score was comparable. Conclusions Patients requiring invasive mechanical ventilation (MV) have a greater risk of impaired pulmonary function and reduced QOL post-ICU discharge. This warrants a greater need for following these patients for better rehabilitation.

The clinical association between Periodontitis and COVID-19

OBJECTIVES

The study aimed to clinically assess the association between periodontitis and COVID-19-related outcomes.

MATERIAL AND METHODS

Data pertaining to patient demographics, medical history, blood parameters, periodontal clinical examination and aMMP-8 point-of-care diagnostics (both site-level and patient-level) was recorded for eighty-two COVID-19-positive patients. COVID-19-related outcomes such as COVID-19 pneumonia, death/survival, types of hospital admission and need of assisted ventilation were also assessed.

RESULTS

Males were predominantly afflicted with COVID-19, with advanced age exhibiting a greater association with the presence of periodontitis. Higher severity of periodontitis led to 7.45 odds of requiring assisted ventilation, 36.52 odds of hospital admission, 14.58 odds of being deceased and 4.42 odds of COVID-19-related pneumonia. The aMMP-8 mouthrinse kit was slightly more sensitive but less specific than aMMP-8 site-specific tests.

CONCLUSIONS

Based on the findings of the present study, periodontitis seems to be related to poorer COVID-19-related outcomes. However, within the constraints of this work, a direct causality may not be established. Periodontitis, by means of skewing the systemic condition for a number of comorbidities, may eventually influence COVID-19 outcomes in an indirect manner.

CLINICAL RELEVANCE

The study is the first to clinically, and by means of a validated point-of-care diagnostic methodology, assess the association between periodontal health and COVID-19-related outcomes. Assessment of the periodontal status of individuals can aid in the identification of risk groups during the pandemic along with reinforcing the need to maintain oral hygiene and seeking periodontal care.

Screening of Onion (Allium cepa L.) Genotypes for Drought Tolerance Using Physiological and Yield Based Indices Through Multivariate Analysis

Drought is a leading abiotic constraints for onion production globally. Breeding by using unique genetic resources for drought tolerance is a vital mitigation strategy. With a total of 100 onion genotypes were screened for drought tolerance using multivariate analysis. The experiment was conducted in a controlled rainout shelter for 2 years 2017-2018 and 2018-2019 in a randomized block design with three replications and two treatments (control and drought stress). The plant was exposed to drought stress during the bulb development stage (i.e., 50-75 days after transplanting). The genotypes were screened on the basis of the drought tolerance efficiency (DTE), percent bulb yield reduction, and results of multivariate analysis viz. hierarchical cluster analysis by Ward's method, discriminate analysis and principal component analysis. The analysis of variance indicated significant differences among the tested genotypes and treatments for all the parameters studied, viz. phenotypic, physiological, biochemical, and yield attributes. Bulb yield was strongly positively correlated with membrane stability index (MSI), relative water content (RWC), total chlorophyll content, antioxidant enzyme activity, and leaf area under drought stress. The genotypes were categorized into five groups namely, highly tolerant, tolerant, intermediate, sensitive, and highly sensitive based on genetic distance. Under drought conditions, clusters II and IV contained highly tolerant and highly sensitive genotypes, respectively. Tolerant genotypes, viz. Acc. 1656, Acc. 1658, W-009, and W-085, had higher DTE (>90%), fewer yield losses (<20%), and performed superiorly for different traits under drought stress. Acc. 1627 and Acc. 1639 were found to be highly drought-sensitive genotypes, with more than 70% yield loss. In biplot, the tolerant genotypes (Acc. 1656, Acc. 1658, W-085, W-009, W-397, W-396, W-414, and W-448) were positively associated with bulb yield, DTE, RWC, MSI, leaf area, and antioxidant enzyme activity under drought stress. The study thus identified tolerant genotypes with favorable adaptive traits that may be useful in onion breeding program for drought tolerance.

Spectrum of Endocrine Dysfunction and Association With Disease Severity in Patients With COVID-19: Insights From a Cross-Sectional, Observational Study

INTRODUCTION

Evidence on new-onset endocrine dysfunction and identifying whether the degree of this dysfunction is associated with the severity of disease in patients with COVID-19 is scarce.

PATIENTS AND METHODS

Consecutive patients enrolled at PGIMER Chandigarh were stratified on the basis of disease severity as group I (moderate-to-severe disease including oxygen saturation <94% on room air or those with comorbidities) (n= 35) and group II (mild disease, with oxygen saturation >94% and without comorbidities) (n=49). Hypothalamo-pituitary-adrenal, thyroid, gonadal axes, and lactotroph function were evaluated. Inflammatory and cell-injury markers were also analysed.

RESULTS

Patients in group I had higher prevalence of hypocortisolism (38.5 vs 6.8%, p=0.012), lower ACTH (16.3 vs 32.1pg/ml, p=0.234) and DHEAS (86.29 vs 117.8µg/dl, p= 0.086) as compared to group II. Low T3 syndrome was a universal finding, irrespective of disease severity. Sick euthyroid syndrome (apart from low T3 syndrome) (80.9 vs 73.1%, p= 0.046) and atypical thyroiditis (low T3, high T4, low or normal TSH) (14.3 vs 2.4%, p= 0.046) were more frequent in group I than group II. Male hypogonadism was also more prevalent in group I (75.6% vs 20.6%, p=0.006) than group II, with higher prevalence of both secondary (56.8 vs 15.3%, p=0.006) and primary (18.8 vs 5.3%, p=0.006) hypogonadism. Hyperprolactinemia was observed in 42.4% of patients without significant difference between both groups.

CONCLUSION

COVID-19 can involve multiple endocrine organs and axes, with a greater prevalence and degree of endocrine dysfunction in those with more severe disease.

Administering Cardiopulmonary Resuscitation to Personal Protective Equipment-Protected Health Care Worker During COVID-19

Supplemental Digital Content is available in the text.

Patho-epidemiological and risk factor studies for detection of Neospora-associated abortion in cattle and buffaloes in Punjab, India

The diagnosis of abortion in livestock is difficult. In this paper, Neospora caninumassociated abortion in cattle and buffaloes in India is reported for the first time. A total of 184 animals (cattle, n = 133; water buffaloes, n = 51) were randomly selected for seroprevalence studies from 28 farms with a history of abortion. Antibodies to N. caninum were detected using a commercial competitive enzymelinked immunosorbent assay (c-ELISA); the percentage seropositivity was 10.5% for cattle and 21.6% for buffaloes. Risk factors such as species, i.e. buffaloes in comparison to cattle (odds ratio [OR] = 2.33, calculated probability [p] = 0.05), disposal of foetus and foetal membranes by throwing them into the field, in comparison with burning/burial (OR = 2.63, p = 0.03), and origin of the animal, i.e. purchased from outside in comparison to born on the farm (OR = 4.69, p = 0.002), were significantly associated with N. caninum seropositivity in univariate logistic regression. In multivariate analysis, only two risk factors, animal purchased from outside (OR = 6.15, p = 0.001) and buffaloes (OR = 3.20, p = 0.01), were significantly associated with Neospora seropositivity at a p-value < 0.05. Histopathological examination of aborted foetal tissues (cattle, n = 13; buffaloes, n = 8) revealed N. caninum tachyzoites in the heart and liver of three foetuses, and the diagnosis was confirmed by positive immunoreactivity to anti-N. caninum polyclonal antibody in the placenta of one foetus. To the authors' knowledge, this is the first report of confirmed neosporosis abortion in cattle and buffaloes in India.

A core outcome set for future endometriosis research: an international consensus development study

OBJECTIVE

To develop a core outcome set for endometriosis.

DESIGN

Consensus development study.

SETTING

International.

POPULATION

One hundred and sixteen healthcare professionals, 31 researchers and 206 patient representatives.

METHODS

Modified Delphi method and modified nominal group technique.

RESULTS

The final core outcome set includes three core outcomes for trials evaluating potential treatments for pain and other symptoms associated with endometriosis: overall pain; improvement in the most troublesome symptom; and quality of life. In addition, eight core outcomes for trials evaluating potential treatments for infertility associated with endometriosis were identified: viable intrauterine pregnancy confirmed by ultrasound; pregnancy loss, including ectopic pregnancy, miscarriage, stillbirth and termination of pregnancy; live birth; time to pregnancy leading to live birth; gestational age at delivery; birthweight; neonatal mortality; and major congenital abnormalities. Two core outcomes applicable to all trials were also identified: adverse events and patient satisfaction with treatment.

CONCLUSIONS

Using robust consensus science methods, healthcare professionals, researchers and women with endometriosis have developed a core outcome set to standardise outcome selection, collection and reporting across future randomised controlled trials and systematic reviews evaluating potential treatments for endometriosis. TWEETABLE ABSTRACT: @coreoutcomes for future #endometriosis research have been developed @jamesmnduffy.

Effects of personal protective equipment on the physiological parameters of health care workers

We would like to add to the study, Understanding the physiological effects of wearing enhanced personal protective equipment while providing patient care by Bulson and Shawl from the November/December 2019 issue of Journal of Emergency Management.

Structural changes and trade competitiveness in the Indian pharmaceutical industry in product patent regime

Purpose

This paper aims to present structural changes and trade competitiveness in Indian pharmaceutical industry in pre and post product patent regime. The study shows the impact of product patent on market structure, ownership, trade, revealed comparative advantage, R&D and mergers and acquisitions.

Design/methodology/approach

The study is based on secondary data and extensive relevant conceptual and empirical literature review.

Findings

The study finds that this oligopoly Indian dominant pharmaceutical industry has many challenges ahead such as in R&D expenditure, patent expiration of many major drugs manufactured in Ireland, growing competition in generic global market, bulk drugs dependence on China, rise in the number of M&As, rising costs of new drug discovery and tightening safety and efficacy testing requirements. The smaller firms are likely to act as the contract manufacturers for medium and bigger companies at a lower value chain. The Normalised Revealed Comparative Advantage (NRCA) index was calculated for top exporters of pharmaceutical. It was found that NRCA index of IPI has shown deterioration from 1996 to 2005 and thereafter, improvement except in the year 2009. Switzerland, Belgium and Ireland are the top three countries in NRCA index, which are followed by Germany, the UK and France.

Originality/value

It attempts to capture recent trends in market structure, comparative advantage indices, R&D, trade, M&A and ownership, especially in new IPR regime. There is a dearth of studies providing detailed analyses of India’s comparative advantage vis-a-vis other leading exporters of pharmaceutical products in the world. The paper would be of value to practitioners and scholars interested in structural changes of IPI, especially in product patent regime. The findings have significant implications for managers and government for future policymaking.

Long-term outcome of diffuse large B-cell lymphoma: Impact of biosimilar rituximab and radiation

INTRODUCTION

Rituximab (R)-CHOP improves survival over CHOP in diffuse large B-cell lymphoma (DLBCL). The availability of biosimilar rituximab in India has increased access of this drug. We report on the impact of treatment on outcomes with special emphasis on the impact of biosimilar rituximab and radiation.

METHODS

Outcomes of adults (age 15-60 years) treated with CHOP+/- Rituximab radiation were analyzed retrospectively to look at baseline features, treatment, and event-free and overall survival (EFS and OS).

RESULTS

In the period 2000-2013, 444 patients (median age 47 years: 15-60; males: 288 [65%]; Stage III/IV: 224 [50%]; age-adjusted international prognostic index [aaIPI] Score 2 or 3 in 50%) received either CHOP (n = 325 [73%]) or RCHOP (n = 119 [27%]) therapy. Biosimilar rituximab and the original were used in 95 (80%) and 24 (20%) patients, respectively. Radiation was given in 134 (30%) patients (Stages I and II, 100/220 [45%] and Stages III and IV, 34/224 [15%]). After a median follow-up of 46 (0.2-126) months, the 5-year EFS and OS were 59% and 68%, respectively. The factors predicting inferior EFS and OS were age> 40 years, performance status 2-4, Stage III/IV, hemoglobin <12 g/dL, the aaIPI Score 2 or 3, and nonuse of rituximab and radiation. Radiation used in early stage disease benefitted all subgroups regardless of bulky disease, use of rituximab, or the number of cycles of chemotherapy. Addition of rituximab improved survival across all categories of aaIPI.

CONCLUSION

Availability of biosimilar rituximab has increased access and survival of patients with DLBCL in India. Radiotherapy improved outcomes in early stages.

Comparison of diagnostic tests for the detection of bovine brucellosis in the natural cases of abortion

Rapid and precise diagnosis in natural field cases of bovine abortion caused by Brucella abortus warrants the use of the most sensitive and reliable diagnostic methods. In the present study, bacterial isolation, serology, gross, histopathology, immunohistochemistry and polymerase chain reaction technique(s) were applied. Sero-prevalence studies showed the rate of 28.86% positive cases using the competitive ELISA. Histopathological changes were mainly seen in the placenta, fetal lungs, kidney, liver and spleen. Immunohistochemical (IHC) staining of Brucella spp. was evident as brown, finely granular intracytoplasmic staining in trophoblasts of placental sections and in section(s) of liver, lung, kidney and spleen. Twenty-eight out of the 103 samples (17 from stomach contents, 3 from placental cotyledons, 2 from vaginal discharges and 6 from pooled fetal tissues) produced 193 bp amplicon specific for Brucella genus. Moreover, the species-specific primers amplified a 498 bp amplicon which corresponded to B. abortus. Comparison of diagnostic tests revealed PCR and IHC provide a reliable test for the diagnosis of bovine brucellosis in aborted fetal tissue and placental cotyledons whereas serology is most important for detection of Brucella positive animals in a herd.

Epidemiological and immunopathological studies on Porcine parvovirus infection in Punjab

Aim:

The aim of this study was to get the first-hand knowledge about the seroprevalence of Porcine parvovirus (PPV) in Punjab and a diagnosis of PPV from abortion cases of swine using gross, histopathological, and immunohistopathological techniques to observe the tissue tropism of the virus strain.

Materials and Methods:

Tissue samples from the reproductive tract of pig (n=32), placental tissue (n=10), and aborted fetuses (n=18) were collected from Postmortem Hall of the Department of Veterinary Pathology, GADVASU, field outbreaks and from butcher houses in and around Ludhiana. These samples were processed for histopathological and immunohistochemical (IHC) studies. For seroprevalence study, 90 serum samples of different sex and age were collected from 15 swine farms of Punjab and were subjected to indirect enzyme linked immunosorbent assay using commercial kit.

Results:

Overall, seroprevalence of PPV was found to be 41.1%. Sex and age related difference in the prevalence was noted. In abortion cases grossly congested and emphysematous lungs, congested internal organs with fluid in abdominal cavity and congestion in brain, changes were noted in fetuses, while diffuse hemorrhages and edema was observed in placental tissue. Histopathologically, the most frequent fetal lesions in aborted fetuses were noted in lungs, liver, and brain. IHC staining revealed PPV antigens in sections of heart, liver, lung, spleen, brain, lymph node of fetuses, placenta, and uterus of sow. Gross, histopathological, and IHC examination of the samples confirmed 5 fetus, 2 placenta and 3 female reproductive samples positive for parvovirus infection.

Conclusions:

Seroprevalence results may serve as a support either in prevention or control of the disease. IHC is the sensitive technique for diagnosis of PPV associated with the reproductive tract of swine and was found to supplement the gross and histopathological alterations, respectively, associated with the disease.

Adverse drug reactions profile of antimicrobials: A 3-year experience, from a tertiary care teaching hospital of India

AIM OF STUDY

To evaluate adverse drug reaction (ADR) profile of antimicrobials over 3-year period.

MATERIAL AND METHODS

A retrospective cross-sectional study was undertaken using suspected adverse drug data collection form available under Pharmacovigilance Programme of India (PvPI).

RESULTS

A total of 2,586 ADR events were recorded in 3 years, out of which 392 (15.15%) were because of antimicrobials. Male: female was 1.02:1. Medicine department contributed maximally (98.97%). The intravenous (IV) route of drug administration accounted maximum ADRs (53.32%), followed by oral route (45.41%). Monotherapy was responsible for 80.87%, whereas combination therapy for 19.13%. Combinations therapy was irrational in 79.67%. The most common antibiotic resulting in ADRs was injection ceftriaxone (35.71%), followed by tab. azithromycin (7.39%), tab. ofloxacin+ornidazol (5.35%), ofloxacin (3.57%), ciprofloxacin (2.29%), amoxicillin (2.55%), tab. cefixime (2.29%), inj. linezolid (2.04%). Rash remained the most common ADR, followed by diarrhoea and gastritis. Most common organ system involved was dermatological (47.44%), followed by gastrointestinal (GI) (39.28%), central nervous system (CNS) (5.35%), cardiovascular system (CVS) (3.57%) and renal and genitourinary (1.78%). While 47.96% ADR's were latent, 26.785% were acute and 25.26% were sub-acute. Moreover, 89.79% of ADRs were moderate in nature, whereas 26.88% were severe and 3.33% mild in nature. Furthermore, 92.86% were non-serious and 7.14% serious in nature. Also, 65.06% of antimicrobial caused ADRs were type A and 34.64% were type B reactions. As per World Health Organization-The Uppsala Monitoring Centre (WHO-UMC) scale, 73.98% of ADRs were probable/likely and 26.02% as possible. However, 99.47% of ADRs required intervention.

CONCLUSION

The current study suggest that ADRs due to antimicrobials is a significant health problem.

Phase II study of interim PET-CT-guided response-adapted therapy in advanced Hodgkin's lymphoma

BACKGROUND

Combination chemotherapy ABVD (doxorubicin, bleomycin, vinblastine and dacarabazine) cures ∼70% of patients with advanced Hodgkin's lymphoma (aHL, stages IIB, III and IV) while more toxic escalated BEACOPP (EB, combination of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine and prednisolone) increases cure rates to 85%. Patients with a positive interim positron emission tomography-computerized tomography (PET-CT) scan after two cycles (PET-2) of ABVD have very poor outcomes with continued ABVD. Intensifying therapy with EB in PET-2-positive patients ('response-adapted therapy') may improve cure rates, whereas the negative patients can continue ABVD alone.

PATIENTS AND METHODS

Eligible patients with newly diagnosed aHL received two cycles of ABVD and underwent PET-2 (scored with semi-quantitative 5-point visual criteria, 'Deauville score'). PET-2-negative patients continued four additional cycles of ABVD, whereas PET-2-positive patients received four cycles of EB. A phase II sample size of 50 was estimated keeping the lower and higher proportion of rejection of the event-free survival (EFS) as 70% and 85%, respectively.

RESULTS

Fifty patients [median age 28 (12-60) years; male : female: 39 : 11; stages: IIB-3 (6%), III-29 (58%) and IV-18 (36%); International Prognostic Score (IPS): 0-3: 34 (68%); 4-7: 16 (32%)] were enrolled; 49 underwent PET-2. Eight (16%) were PET-2-positive, whereas 41 (84%) were negative. Forty-seven were evaluable for EFS and all 50 for overall survival (OS). The 2-year EFS was 76% (95% CI: 68-83) and OS was 88% (95% CI: 82-94). PET-2 was strongly prognostic-2-year EFS, negative versus positive: 82% versus 50%; P = 0.013.

CONCLUSION

PET-2 response-adapted strategy could not achieve EFS of 85% in aHL. However, escalated therapy improved outcomes in PET-2-positive patients compared with historical data.

TRIAL REGISTRATION

CTRI/2012/06/002741 (http://www.ctri.nic.in) and NCT01304849 (http://www.clinicaltrials.gov).

Evaluation of lateral flow assay as a field test for investigation of brucellosis outbreak in an organized buffalo farm: A pilot study

Aim:

The aim was to evaluate lateral flow assay (LFA) as a field test for investigation of brucellosis outbreak in organized buffalo farm.

Materials and Methods:

A total of 153 serum samples were tested to detect the presence of brucella antibodies by LFA and three other serological tests i.e. rose bengal plate test (RBPT), protein G based indirect enzyme-linked immunoassay (iELISA), and competitive ELISA (cELISA). The performances of LFA and other serological tests were evaluated using OIE complaint cELISA as the gold standard.

Results:

Serological tests revealed 50% of the animals were seropositive for Brucella antibodies and correlated with clinical history of abortions, infertility, and productive failures. The newly developed assay showed 87.1% and 92.6% sensitivity and specificity, which was even higher than the specificity of RBPT.

Conclusions:

The investigation proved the potential usefulness of LFA for field diagnosis of brucellosis in the regions where laboratory facilities are limited.

Trade performance and revealed comparative advantage of Indian pharmaceutical industry in new IPR regime

Purpose

– The purpose of this paper is to examine the trade performance, revealed comparative advantage and trade specialisation indices of Indian pharmaceutical in the post-modified Indian Patent Act.

Design/methodology/approach

– The main data sources for this paper are United Nations Conference on Trade and Development, PROWESS of Centre for Monitoring Indian Economy, Government of India reports and Reserve Bank of India databases. Revealed comparative advantage index (RCAI) and trade specialisation coefficient (TSC) have been calculated in the study.

Findings

– India is ranked third in regard of TCS, far behind Ireland and Israel. While Ireland has moved up the value chain faster after 1995, Israel has moved up swiftly after 2000 through global production network and supply chain. The Indian pharmaceutical industry, on the other hand, has largely capitalised on its low-cost production of generic drugs and a large domestic market. The RCAI also supports the results of TSC. India is positioned at 11th place, far behind Ireland, which stands tall at the top with distantly followed by Israel, Switzerland, Belgium, the UK, etc.

Practical implications

– The study shows the policy implications for future sustainable development of the industry as the new IPR regime has given opportunities as well as threats to both domestic pharmaceutical companies as well as the multinational corporations. The Indian pharmaceutical industry can be a good learning experience for other developing countries hopeful to enter the global market for generic drugs.

Originality/value

– There are no major studies providing detailed analyses of India’s comparative advantage vis-à-vis other leading exporters of pharmaceutical products in the world. This study endeavours to fill this gap. It also attempts to capture recent trends in exports and imports during the global recession period.