Publications by authors named "Anjan Trikha"

137 Publications

Risk Factors, Clinical Characteristics, and Outcome of Air Leak Syndrome in COVID-19: A Systematic Review.

Indian J Crit Care Med 2021 Dec;25(12):1434-1445

Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Air leak consisting of pneumothorax, pneumomediastinum, and subcutaneous emphysema has been described as one of the complications of coronavirus disease-2019 (COVID-19) infection affecting disease course and outcome. We aimed to conduct a systematic review of published literature to highlight the risk factors, types, and outcomes in COVID-19.

Method: A systematic search of PubMed, Embase, Scopus, and Google Scholar was performed from November 1, 2019, to February 28, 2021. Seventy-one studies fulfilled the inclusion criteria and 136 adult patients were included in the final analysis.

Results: Majority of patients were male (75.2%) with the mean age of 58 years. Hypertension was the most common comorbidity followed by diabetes mellitus. Moreover, 12.5% of patients had a history of smoking while 11.7% had preexisting lung disease. Isolated pneumothorax (48.5%) was the most common and 17.65% had developed spontaneous pneumothorax. Mean onset time was 11.6 days and 67% of patients required an intercostal drainage tube for management. Mortality was 40%, and elderly, female gender, obese and hypertensive were at higher risk.

Conclusion: COVID-19-related air leaks are associated with higher mortality and longer hospital stay and can occur even without positive pressure ventilation. History of smoking and preexisting lung disease has not been shown to increase the incidence of air leak. A well-designed study is required for a better understanding of COVID-19-related air leak.

How To Cite This Article: Singh A, Singh Y, Pangasa N, Khanna P, Trikha A. Risk Factors, Clinical Characteristics, and Outcome of Air Leak Syndrome in COVID-19: A Systematic Review. Indian J Crit Care Med 2021;25(12):1434-1445.
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http://dx.doi.org/10.5005/jp-journals-10071-24053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8693124PMC
December 2021

Outcomes of Trauma Victims with Cardiac Arrest Who Survived to Intensive Care Unit Admission in a Level 1 Apex Indian Trauma Centre: A Retrospective Cohort Study.

Indian J Crit Care Med 2021 Dec;25(12):1408-1412

Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India.

Background And Aims: The prognosis of patients with cardiac arrest following trauma is poor. Our objectives were: (1) to determine outcomes of patients following in-hospital cardiac arrest posttrauma and admitted to the intensive care unit (ICU) and (2) to identify characteristics associated with in-hospital mortality.

Materials And Methods: This was a single-center retrospective analysis of patients admitted to ICU after resuscitation following in-hospital cardiac arrest between January 2017 and July 2018. Patients with isolated head injuries and multiple cardiac arrests were excluded. Bivariate analysis was done to determine a significant association between baseline characteristics and in-hospital mortality.

Results: A total of 37 patients were included. About 35.1% of trauma subjects survived hospital discharge. Bivariate analysis showed positive association between admission Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores with in-hospital mortality. Other characteristics, such as age, duration of cardiopulmonary resuscitation (CPR), and serum lactate levels on admission, were not associated with in-hospital mortality.

Conclusion: Despite being at lower survival following a cardiac arrest after trauma, approximately one-third of the patients survived hospital discharge. This implies that aggressive support of this population is not necessarily futile. Optimization of postresuscitation physiological factors and their impacts on outcomes for these patients need further studies.

How To Cite This Article: Soni KD, Rai N, Aggarwal R, Trikha A. Outcomes of Trauma Victims with Cardiac Arrest Who Survived to Intensive Care Unit Admission in a Level 1 Apex Indian Trauma Centre: A Retrospective Cohort Study. Indian J Crit Care Med 2021;25(12):1408-1412.
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http://dx.doi.org/10.5005/jp-journals-10071-24057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8693116PMC
December 2021

Clinical Course and Outcome of Critically Ill Obese Patients with COVID-19 Admitted in Intensive Care Unit of a Single Center: Our Experience and Review.

Indian J Crit Care Med 2021 Dec;25(12):1382-1386

Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India.

Introduction: Obesity has been considered as one of the independent risk factors for a severe form of coronavirus disease-2019 (COVID-19) and relationship between obesity, critical illness, and infection is still poorly understood. We herein discuss clinical course and outcome of critically ill obese patients with COVID-19 admitted to critical care unit.

Materials And Methods: We retrospectively analyzed data of critically ill obese patients hospitalized with COVID-19 over a span of 6 months. Management was guided according to the institutional protocol. Collected data included demographic parameters (age, sex, comorbidities, and body mass index (BMI)), complications, inflammatory markers (interleukin (IL)-6, Ferritin), length of mechanical ventilation, length of intensive care unit (ICU) stay, and inhospital death.

Results: There was no appreciable difference in terms of demographics, inflammatory markers, predictors of mortality scores, and comorbidity indices between the survivors and nonsurvivors. Among outcome analysis, there was a statistically significant difference between ventilator days between survivors and nonsurvivors ( = 0.003).

Conclusion: Obesity itself is a significant risk factor for severe COVID-19 infection; however, if efficiently managed and in a protocol-determined manner, it can have a favorable outcome.

How To Cite This Article: Kaur M, Aggarwal R, Ganesh V, Kumar R, Patel N, Ayub A, . Clinical Course and Outcome of Critically Ill Obese Patients with COVID-19 Admitted in Intensive Care Unit of a Single Center: Our Experience and Review. Indian J Crit Care Med 2021;25(12):1382-1386.
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http://dx.doi.org/10.5005/jp-journals-10071-24047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8693112PMC
December 2021

Temporal Evolution of the PcvCO-PaCO/CaO-CcvO Ratio vs Serum Lactate during Resuscitation in Septic Shock.

Indian J Crit Care Med 2021 Dec;25(12):1370-1376

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Background: Lactate as a target for resuscitation in patients with septic shock has important limitations. The PcvCO-PaCO/CaO-CcvO ratio may be used as an alternative for the same. The primary outcome of the study is to evaluate the correlation between serum lactate and PcvCO-PaCO/CaO-CcvO ratio measured at various time points to a maximum of 24 hours in patients with septic shock [mean arterial pressure (MAP) <65 mm Hg]. The secondary outcomes were to study the (1) relationship between the PcvCO-PaCO/CaO-CcvO ratio and lactate clearance at 6, 12, and 24 hours as compared to the initial serum lactate, (2) to ascertain whether the PcvCO-PaCO/CaO-CcvO ratio and the arterial lactate levels in the first 24 hours are able to predict mortality at day 28 of enrollment, and (3) to determine whether the PcvCO-PaCO/ CaO-CcvO ratio and arterial lactate are useful in discriminating survivors from nonsurvivors.

Materials And Methods: Thirty patients with sepsis-induced hypotension who were being actively resuscitated were enrolled. Paired arterial and central venous blood samples were obtained 0.5 hourly till stabilization of MAP and 6 hourly thereafter for the first 24 hours. Patients were followed up to day 28 of enrollment for mortality and organ system failure.

Results: A positive correlation was observed between arterial lactate and PcvCO-PaCO/CaO-CcvO ratio at 0, 6, 12, and 18 hours ( = 0.413, = 0.02; = 0.567, = 0.001; = 0.408, = 0.025; = 0.521, = 0.003, respectively). No correlation was seen between PcvCO-PaCO/CaO-CcvO ratio and lactate clearance. The subgroup analysis showed that PcvCO-PaCO/CaO-CcvO ratio >1.696 at 24 hours of resuscitation predicted 28-day mortality (sensitivity: 80%, specificity 69.2%, area under the receiver operating characteristic curve 0.82).

Conclusion: The PcvCO-PaCO/CaO-CcvO ratio and lactate are positively correlated during the first 24 hours of active resuscitation from sepsis-induced hypotension, and a threshold of 1.696 mm Hg/mL/dL at 24 hours significantly differentiates survivors from nonsurvivors (CTRI/2017/11/010342).

How To Cite This Article: Madabhushi S, Trikha A, Anand RK, Ramachandran R, Singh PM, Rewari V. Temporal Evolution of the PcvCO-PaCO/CaO-CcvO Ratio vs Serum Lactate during Resuscitation in Septic Shock. Indian J Crit Care Med 2021; 25(12):1370-1376.
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http://dx.doi.org/10.5005/jp-journals-10071-24044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8693105PMC
December 2021

Clinical Features and Outcome of Stroke with COVID-19. COVID-19 Stroke Study Group (CSSG), India.

Ann Indian Acad Neurol 2021 Sep-Oct;24(5):668-685. Epub 2021 Aug 30.

Department of Neurology, Ramesh Hospitals Guntur, Andhra Pradesh, India.

Background And Purpose: Occurrence of stroke has been reported among patients with COVID-19. The present study compares clinical features and outcomes of stroke patients with and without COVID-19.

Methods: The COVID-19 Stroke Study Group (CSSG) is a multicentric study in 18 sites across India to observe and compare the clinical characteristics of patients with stroke admitted during the current pandemic period and a similar epoch in 2019. The present study reports patients of stroke with and without COVID-19 (CoVS and non-CoVS, respectively) seen between February 2020 and July 2020. Demographic, clinical, treatment, and outcome details of patients were collected.

Results: The mean age and gender were comparable between the two groups. CoVS patients had higher stroke severity and extent of cerebral involvement on imaging. In-hospital complications and death were higher among CoVS patients (53.06% vs. 17.51%; < 0.001) and (42.31% vs. 7.6%; < 0.001), respectively. At 3 months, higher mortality was observed among CoVS patients (67.65% vs. 13.43%; < 0.001) and good outcome (modified Rankin score [mRS]: 0-2) was seen more often in non-CoVS patients (68.86% vs. 33.33%; < 0.001). The presence of COVID-19 and baseline stroke severity were independent predictors of mortality.

Conclusions: CoVS is associated with higher severity, poor outcome, and increased mortality. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and baseline stroke severity are independent predictors of mortality.
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http://dx.doi.org/10.4103/aian.AIAN_122_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8680894PMC
August 2021

Risk factors for Coronavirus disease-associated mucormycosis.

J Infect 2021 Dec 30. Epub 2021 Dec 30.

Department of Medicine, AIIMS, Delhi, India.

Background: The epidemiology of the Coronavirus-disease associated mucormycosis (CAM) syndemic is poorly elucidated. We aimed to identify risk factors that may explain the burden of cases and help develop preventive strategies.

Methods: We performed a case-control study comparing cases diagnosed with CAM and taking controls as recovered COVID 19 patients who did not develop mucormycosis. Information on comorbidities, glycemic control, and practices related to COVID-19 prevention and treatment was recorded. Multivariate regression analysis was used to identify independent predictors.

Results: A total of 352 patients (152 cases and 200 controls) diagnosed with COVID-19 during April-May 2021 were included. In the CAM group, symptoms of mucormycosis began a mean of 18.9 (SD 9.1) days after onset of COVID-19, and predominantly rhino-sinus and orbital involvement was present. All, but one, CAM cases had conventional risk factors of diabetes and steroid use. On multivariable regression, increased odds of CAM were associated with the presence of diabetes (adjusted OR 3.5, 95% CI 1.1-11), use of systemic steroids (aOR 7.7, 95% CI 2.4-24.7), prolonged use of cloth and surgical masks (vs. no mask, aOR 6.9, 95%CI 1.5-33.1), and repeated nasopharyngeal swab testing during the COVID-19 illness (aOR 1.6, 95% CI 1.2-2.2). Zinc therapy was found to be protective (aOR 0.05, 95%CI 0.01-0.19). Notably, the requirement of oxygen supplementation or hospitalization did not affect the risk of CAM.

Conclusion: Judicious use of steroids and stringent glycemic control are vital to preventing mucormycosis. Use of clean masks, preference for N95 masks if available, and minimizing swab testing after the diagnosis of COVID-19 may further reduce the incidence of CAM.
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http://dx.doi.org/10.1016/j.jinf.2021.12.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8717704PMC
December 2021

Effect of Change in Body Weight on Clinical Outcomes in Critically Ill Patients.

Indian J Crit Care Med 2021 Sep;25(9):1042-1048

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India.

Background: Intravenous fluid optimization is an essential component of managing patients in a critical care setting. A cumulative positive fluid balance is consistent with poor outcomes in patients admitted to the intensive care unit (ICU). The overall utility of net cumulative fluid balance as a surrogate for assessing fluid overload has been interrogated.

Materials And Methods: This study was a prospective single-center observational study, which was done to correlate body weight changes with fluid balance in ICU patients and evaluate its impact on clinical outcomes. Inclusion criteria consisted of adult patients who were admitted to the critical care unit on specialized beds with integrated weighing scales between September 2017 and December 2018. The evaluation of the effect of changes in body weight on ICU survival was the primary objective of the study.

Results: We enrolled 105 patients in this study. The ICU mortality was 23.80% with non-survivors showing more weight gain than the survivors. Statistically significant weight gain was documented in the non-survivors on days 3 and 4 (1.9 vs 1.05; = 0.0084 and 2.6 vs 1.6; = 0.0030) of ICU admission. Non-survivors had greater cumulative positive fluid balance on fourth, fifth, and sixth days post-ICU admission when compared to survivors (3586 vs 1659 mL, = 0.0322; 5418 vs 1255 mL, = 0.0017; and 5430 vs 2305 mL = 0.0264, respectively). In multivariate regression analysis, cumulative fluid balance did not correlate with days on mechanical ventilation or length of stay in ICU. Changes in body weight and cumulative fluid balance showed a good correlation.

Conclusion: In patients admitted to the ICU, weight gain on third and fourth days of admission is concordant with increased ICU mortality. Body weight changes were seen to correlate well with the cumulative fluid balance.

How To Cite This Article: Mishra RK, Pande A, Ramachandran R, Trikha A, Singh PM, Rewari V. Effect of Change in Body Weight on Clinical Outcomes in Critically Ill Patients. Indian J Crit Care Med 2021;25(9):1042-1048.
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http://dx.doi.org/10.5005/jp-journals-10071-23978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8664026PMC
September 2021

Extracorporeal Membrane Oxygenation in COVID-19 Patients: More Hype than Substance?

Indian J Crit Care Med 2021 Nov;25(11):1322-1323

Department of Critical and Intensive Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.

Trikha A, Venkateswaran V, Soni KD. Extracorporeal Membrane Oxygenation in COVID-19 Patients: More Hype than Substance? Indian J Crit Care Med 2021;25(11):1322-1323.
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http://dx.doi.org/10.5005/jp-journals-10071-24005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8608628PMC
November 2021

Epidemiology and clinical characteristics of COVID- 19 patients requiring critical care in a Tertiary care teaching hospital.

J Anaesthesiol Clin Pharmacol 2021 Jul-Sep;37(3):366-370. Epub 2021 Oct 12.

Department of Anaesthesiology, Pain Medicine and Critical Care, JPNATC, AIIMS, New Delhi, India.

Background And Aims: We describe the epidemiological and clinical characteristics, and 28 day outcome of critically ill COVID-19 patients admitted to a tertiary care centre in India.

Material And Methods: We included 60 adult critically ill COVID-19 patients in this prospective observational study, admitted to the intensive care unit (ICU) after obtaining ethics committee approval and informed consent. Demographics, clinical data, and treatment outcome at 28 days were assessed.

Results: Demographic characteristics of the COVID-19 patients reveal that compared to the survivors, the non-survivors were significantly older [57.5 vs. 47.5 years], had more comorbid disease [Charlson's comorbidity index 4 vs. 2], higher Apache II scores [19 vs. 8.5], and had significantly higher percentage of smokers. Diabetes mellitus and hypertension were the most common comorbidities. Dyspnea, fever, and cough were the most common presenting symptoms. Total leucocyte count as well as blood lactate level were significantly higher in non-survivors. Around 47% patients had severe ARDS, and 60% patients required invasive mechanical ventilation. 28 day ICU mortality was 50%, with a mortality of 75% in patients receiving invasive mechanical ventilation. Mortality was higher in males than females (57% vs. 33%). Acute kidney injury and septic shock were the most common non-pulmonary complications during ICU stay. Incidence of liver dysfunction, septic shock, and vasopressor use was significantly higher in the non-survivors.

Conclusion: This study demonstrates a high 28 day mortality in severe COVID-19 patients. Further well designed prospective studies with larger sample size are needed to identify the risk factors associated with poor outcome in such patients.
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http://dx.doi.org/10.4103/joacp.JOACP_585_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8562446PMC
October 2021

Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Markers for Predicting the Severity in COVID-19 Patients: A Prospective Observational Study.

Indian J Crit Care Med 2021 Aug;25(8):847-852

Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India.

Coronavirus disease-2019 (COVID-19) pandemic has shown unpredictable course in individual patients. Few patients develop severe disease with progression after admission to a healthcare facility. Multiple parameters have been investigated to identify a marker to predict disease progression. Neutrophil-to-lymphocyte ratio (NLR) or platelet-to-lymphocyte (PLR) ratio has shown some promise. The current investigation explores the role of NLR and PLR to predict the disease progression. After obtaining ethics committee approval, 608 patients were screened for inclusion in the prospective observational study, and 201 patients were included in the final analysis. The NLR and PLR were derived from routinely obtained complete blood count analysis. The patients were followed to determine the development of severity of the disease during the course. The NLR and PLR were analyzed in both univariate and multivariable models to assess the association and prediction. In nonsevere (NS) group, the mean age of patients was 50.9 ± 16.3 years, and 66 (61.2%) were male, while in severe group (S), the mean age of patients was 53.7 ± 16.4 years, and 65 (69.89%) were male. NLR at day 1 and day 3 was significantly lower in survivors as compared to nonsurvivors, while the relation of PLR in both the groups was not statistically significant. The NLR is better in predicting the severity of disease as well as mortality than PLR. The NLR calculated at the time of admission has high predictive value for disease deterioration and adverse clinical outcome. Singh Y, Singh A, Rudravaram S, Soni KD, Aggarwal R, Patel N, Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Markers for Predicting the Severity in COVID-19 Patients: A Prospective Observational Study. Indian J Crit Care Med 2021;25(8):847-852.
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http://dx.doi.org/10.5005/jp-journals-10071-23906DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8559739PMC
August 2021

Predictors of in-hospital outcomes in patients with Cirrhosis and Coronavirus disease-2019.

J Clin Exp Hepatol 2021 Oct 29. Epub 2021 Oct 29.

Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.

Background: Coronavirus disease-2019 (COVID-19) cases continue to increase globally. Poor outcomes in patients with COVID-19 and cirrhosis have been reported; predictors of outcome are unclear. The existing data is from the early part of the pandemic when variants of concern (VOC) were not reported.

Aims: We aimed to assess the outcomes and predictors in patients with cirrhosis and COVID-19. We also compared the differences in outcomes between the first wave of pandemic and the second wave.

Methods: In this retrospective analysis of a prospectively maintained database, data on consecutive cirrhosis patients (n=221) admitted to the COVID-19 care facility of a tertiary care center in India were evaluated for presentation, the severity of liver disease, the severity of COVID-19, and outcomes.

Results: The clinical presentation included: 18 (8.1%) patients had compensated cirrhosis, 139 (62.9%) acute decompensation (AD), and 64 (29.0%) had an acute-on-chronic liver failure (ACLF). Patients with ACLF had more severe COVID-19 infection than those with compensated cirrhosis and AD (54.7% vs. 16.5% and 33.3%, P<0.001). The overall mortality was 90 (40.7%), highest among ACLF (72.0%). On multivariate analysis, independent predictors of mortality were high leukocyte count, alkaline phosphatase, creatinine, child class, model for end-stage liver disease (MELD) score, and COVID-19 severity. The second wave had more cases of severe COVID-19 as compared to the first wave, with a similar MELD score and Child score. The overall mortality was similar between the two waves.

Conclusion: Patients with COVID-19 and cirrhosis have high mortality (40%), particularly those with ACLF (72%). A higher leukocyte count, creatinine, alkaline phosphatase, Child class, and MELD score are predictors of mortality.
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http://dx.doi.org/10.1016/j.jceh.2021.10.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8553413PMC
October 2021

Proteinaceous Lung With COVID-19: The Mimicker.

Cureus 2021 Sep 20;13(9):e18144. Epub 2021 Sep 20.

Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, New Delhi, IND.

Pulmonary alveolar proteinosis (PAP) is a syndrome, in which surfactants get deposited slowly in alveoli, blocking the airway exchange. PAP severity also varies from mild to severe, presenting with dyspnea, cough, hemoptysis with or without fever. The radiological findings are ground-glass opacities along with septal thickening (Crazy Paving), consolidations, and less commonly air bronchograms. COVID-19 is a viral infection caused by SARS COV2 primarily affecting the lungs and causing atypical viral pneumonia. The clinical picture of the disease varies from a milder form of fever, dry cough with or without expectoration, to severe disease-causing respiratory distress, pneumonia, acute respiratory distress syndrome (ARDS), and even death. Radiologically, the findings of COVID-19 are similar to PAP. So, PAP mimics the COVID-19, posing a differential challenge, though our patient was a known case of PAP. Therefore, for proper management of the disease, it is important to differentiate it from other pathologies. In this case report, we describe a patient who was a known case of autoimmune pulmonary alveolar proteinosis. She presented with acute exacerbation in the emergency department and tested positive for COVID-19. We followed a systematic approach consisting of clinical, laboratory, radiologic parameters to differentiate the cause of this exacerbation.
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http://dx.doi.org/10.7759/cureus.18144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8529101PMC
September 2021

Outcomes of multisystem inflammatory syndrome in children temporally related to COVID-19: a longitudinal study.

Rheumatol Int 2021 Oct 19. Epub 2021 Oct 19.

All India Institute of Medical Sciences, New Delhi, India.

To study the clinical, laboratory characteristics and outcomes of multisystem inflammatory syndrome in children (MIS-C) temporally related to coronavirus disease 2019 (COVID-19) in a resource-limited setting. All children meeting the World Health Organization case definition of MIS-C were prospectively enrolled. Baseline clinical and laboratory parameters were compared between survivors and non-survivors. Enrolled subjects were followed up for 4-6 weeks for evaluation of cardiac outcomes using echocardiography. The statistical data were analyzed using the stata-12 software. Thirty-one children with MIS-C were enrolled in an 11-month period. Twelve children had preexisting chronic systemic comorbidity. Fever was a universal finding; gastrointestinal and respiratory manifestations were noted in 70.9% and 64.3%, respectively, while 57.1% had a skin rash. Fifty-eight percent of children presented with shock, and 22.5% required mechanical ventilation. HSP like rash, gangrene and arthritis were uncommon clinical observations.The median duration of hospital stay was 9 (6.5-18.5) days: four children with preexisting comorbidities succumbed to the illness. The serum ferritin levels (ng/ml) [median (IQR)] were significantly higher in non-survivors as compared to survivors [1061 (581, 2750) vs 309.5 (140, 720.08), p value = 0.045]. Six patients had coronary artery involvement; five recovered during follow-up, while one was still admitted. Twenty-six children received immunomodulatory drugs, and five improved without immunomodulation. The choice of immunomodulation (steroids or intravenous immunoglobulin) did not affect the outcome. Most children with MIS-C present with acute hemodynamic and respiratory symptoms.The outcome is favorable in children without preexisting comorbidities.Raised ferritin level may be a poor prognostic marker. The coronary outcomes at follow-up were reassuring.
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http://dx.doi.org/10.1007/s00296-021-05030-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8524205PMC
October 2021

Antimicrobial consumption in intensive care unit patients at level 1 trauma centre in India.

Indian J Med Microbiol 2021 Sep 30. Epub 2021 Sep 30.

Department of Microbiology, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Purpose: Increase in the antimicrobial resistance causes a concern globally. To mitigate the rapidly rising antimicrobial resistance in the health system globally antimicrobial stewardship programs (AMSP) have been advocated. Therefore, we aim to measure aggregate antibiotic consumption by both Defined Daily Dosage (DDD) and Days of Therapy (DOT) methods.

Methods: As a part of Indian Council of Medical Research initiative to develop local AMSP, this prospective study of six months was conducted at a level -1 Trauma Centre of AIIMS, New Delhi. In this, we have included all the patients of polytrauma and neurosurgical Intensive care units between April to October 2019. Consumption of antibiotics data were collected manually daily by infection control practitioners. Data were presented as Days of Therapy (DOT) and Defined Daily Dose (DDD).

Results: During the six months of study, antimicrobial consumption of ICU was compared with empirical therapy v/s culture-based therapy. Overall average antimicrobial consumption for the six months for both empirical therapy and culture-based therapy DDD/1000 patient days was 531.8 and 460.7 whereas DOT/1000 patient days 489.9 and 426.04 respectively.

Conclusions: Antimicrobial Stewardship activities aim to ensure judicious consumption of antimicrobials. Such data will be of value in establishing, evaluating and monitoring the function of the AMSP in the healthcare settings.
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http://dx.doi.org/10.1016/j.ijmmb.2021.09.006DOI Listing
September 2021

COVID-19-associated subacute invasive pulmonary aspergillosis.

Mycoses 2022 Jan 29;65(1):57-64. Epub 2021 Sep 29.

Department of Anaesthesia and Critical Care, All India institute of Medical Sciences, New Delhi, India.

Background: Though invasive pulmonary aspergillosis is a well known complication of COVID-19 pneumonia, indolent forms of aspergillosis have been rarely described.

Methods: We prospectively collected the clinico-radio-microbiological data of 10 patients of subacute invasive pulmonary aspergillosis (SAIA), who presented to our hospital with recent history of COVID-19 pneumonia along with cavitary lung disease, positive IgG (against Aspergillus) with or without positive respiratory samples for Aspergillus spp.

Result: The mean age of presentation of SAIA was 50.7 ± 11.8 years. All the patients had recently recovered from severe COVID-19 illness with a mean duration of 29.2 ± 12 days from COVID-19 positivity. Cough was the predominant symptom seen in 8/10 (80%) patients followed by haemoptysis. 7/10 (70%) patients were known diabetic. While serum galactomannan was positive in 5/9 patients (55.5%), fungal culture was positive in 2/7 patients (28.5%) and polymerase chain reaction (PCR) for Aspergillus was positive in three patients. Eight (80%) patients presented with a single cavitary lesion; pseudoaneurysm of pulmonary artery was seen in two patients and post-COVID-19 changes were seen in all patients. All patients were treated with voriconazole, out of which four (40%) patients died during the follow-up period.

Conclusion: SAIA should be considered in the differential diagnosis of cavitating lung lesions in patients with recent history of COVID-19 in the background of steroid use with or without pre-existing diabetes.
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http://dx.doi.org/10.1111/myc.13369DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8662253PMC
January 2022

Paranephric air in COVID-ARDS patient: an extension of pneumothorax.

Intensive Care Med 2022 Jan 30;48(1):118. Epub 2021 Aug 30.

Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

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http://dx.doi.org/10.1007/s00134-021-06511-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8404757PMC
January 2022

Clinical Profile and Outcome of Critically Ill COVID-19 Patients With Malignancy Admitted in Intensive Care Unit of a Tertiary COVID Center, India.

Cureus 2021 Jul 22;13(7):e16553. Epub 2021 Jul 22.

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, IND.

Introduction There is a dearth of literature describing the clinical profile of coronavirus disease 2019 (COVID-19) in patients with malignancy. Patients with associated malignancy can have a more severe course of the disease. The aim was to study clinical course and outcome of critically ill patients admitted in ICU with associated malignancy. Methods The study was a single-center, retrospective, study conducted at a tertiary care hospital. Patients with active or recent malignancy on follow-up and with confirmed COVID-19 infection who were admitted to the Intensive care unit of COVID-19 dedicated hospital between November 1, 2020 to January 15, 2021 were included. Demographic data, clinical features, clinical course and outcome were retrieved from the hospital electronic medical records. Results A total of 24 patients with malignancy and COVID-19 were admitted to the ICU of COVID-19 center. There were 20 patients with solid organ malignancy and four patients with hematological malignancy. The most common malignancy was breast carcinoma in six (25 %) patients. Fifty percent of the patients were diagnosed with malignancy within the previous six months. Among the presenting symptoms, 13 (54.1%) patients presented with symptoms of severe acute respiratory infection (SARI), eight (33.3%) patients presented with altered sensorium, and three (12.5%) with pain abdomen. Regarding the severity of COVID-19, six (25%) patients had moderate COVID-19 and 18 (75%) had severe COVID-19. Out of 24 patients, six survived and 18 died, the mortality being 75%. The most common cause of death was sepsis with multiorgan dysfunction syndrome (MODS) in 10 (42.6 %) patients followed by severe acute respiratory distress syndrome (ARDS) and neurological cause in four (16.6 %) patients each. When survivors were compared with non-survivors, advanced age and presence of altered sensorium were more in non-survivors. Conclusion Severe COVID-19 and advanced malignancy is a sinister combination that has high mortality. These patients require close monitoring and aggressive care. Presence of altered sensorium and advanced age predicts poorer outcome.
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http://dx.doi.org/10.7759/cureus.16553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8378308PMC
July 2021

Effectiveness of enteral ivabradine for heart rate control in septic shock: A randomised controlled trial.

Anaesth Intensive Care 2021 Sep 18;49(5):366-378. Epub 2021 Aug 18.

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Persistent tachycardia in patients with septic shock predicts poor outcome. This study sought to investigate the effect of the cardiac pacemaker current inhibitor ivabradine on heart rate and cardio-circulatory function in patients with septic shock. After informed consent, 60 patients with septic shock and persistent tachycardia (heart rate >95 /minute) were prospectively randomly assigned to receive either standard therapy for septic shock (group S) or standard therapy along with enteral ivabradine (group I) for the initial 96 hours after enrolment. Primary outcome was the difference in heart rate between the two groups during the first 96 hours. Secondary outcomes included the effect of ivabradine on haemodynamic, oxygenation, myocardial function and organ function parameters, incidence of adverse events and 30-day overall survival. Heart rate was lower in group I compared to group S (median difference in area under the curve -25.6 (95% confidence intervals -31.4 to -15.9) /minute; <0.001). Vasopressor requirements, blood lactate levels, Sequential Organ Failure Assessment scores and E/e' ratio were lower in group I compared to group S. Stroke volume index and ejection fraction were higher in group I while cardiac index and oxygen delivery parameters were maintained similar to group S. There was no difference in 30-day mortality or in the incidence of serious adverse events. Enteral ivabradine is effective in reducing heart rate, and improving haemodynamic parameters and cardiac function in patients with septic shock and persistent tachycardia, without increasing the incidence of adverse events.
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http://dx.doi.org/10.1177/0310057X211009913DOI Listing
September 2021

To Assess Technical Feasibility of Ultrasound Lumbar Sympathetic Block with Electrical Stimulation Needle in Out of Plane Needle Orientation: A Prospective Interventional Study.

Pain Med 2021 Aug 17. Epub 2021 Aug 17.

Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi, India.

Objective: We describe technical feasibility of a new technique of ultrasound lumbar sympathectomy (ULS) validated by fluoroscopy.

Design: Prospective interventional study.

Setting: Pain block area.

Subjects: Thirty patients of peripheral arterial disease (PAD) with rest pain numerical rating score (NRS) ≥ 3 were recruited.

Methods: In lateral position, curved probe (FUJIFILM SonoSite Edge, 2-5 MHz) was placed transversely at iliac crest. An electrical stimulation needle was inserted out-plane, below lower pole of kidneys directed anterior to the vertebral body below. When needle tip was not visualized, current of 2.0 A was applied. Patients quadriceps contractions, ultrasound psoas contractions and bone contact guided needle placement and confirmed on fluoroscopy. Other parameters noted were: number of needle insertions, vertebral level, Pain NRS at baseline and at 4 hrs, 24 hrs, one week and two weeks post block, temperature rise and any other complications.

Results: In all patients, needle tip was correctly placed in one to three attempts. In 73% patients, needle tip was at L3. Baseline Pain NRS was 8 (IQR 7-8) which decreased to 2 (IQR 2-3) at one week post-procedure and maintained at this range till 2 weeks later. Temperature rise of > 20C was noted in all patients.

Conclusion: ULS can safely be performed in patients of PAD by out-plane approach in lateral patient position with electrical stimulation needle. Before injection of drug, aspiration of blood should be ruled out in view of possibility of aortocaval injection.
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http://dx.doi.org/10.1093/pm/pnab258DOI Listing
August 2021

Coronavirus Disease-Associated Mucormycosis from a Tertiary Care Hospital in India: A Case Series.

Cureus 2021 Jul 3;13(7):e16152. Epub 2021 Jul 3.

Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences, New Delhi, New Delhi, IND.

Background:  Coronavirus disease (COVID-19) remains a health concern with new challenges emerging as the pandemic progresses. The recent rise of opportunistic infections especially mucormycosis in COVID-19 patients is further complicating their outcomes. Mucormycosis is well known to infect patients with diabetes mellitus, malignancy, chemotherapy, and other immunocompromised conditions. The treatment of COVID-19 largely remains systemic steroids and other immunomodulators that add to the risk of invasive fungal infection.

Methodology: Here, we present a retrospective case series of 13 patients with individual clinical characteristics along with the demography and treatment details. The data were collected retrospectively in a single center that caters to a large population of COVID-19 patients with varying severity.

Results: Thirteen patients were presented with COVID-19 associated mucormycosis (CAM). The median age was higher in non-survivors (49.5 years), with a higher odds of death (23.8) in those with severe COVID, having overall mortality of 64.3%. Moreover, diabetes mellitus was present in 61.5% of patients with a mortality of 75%. About 11 (84.6%) patients had received prior steroids for COVID-19. The incidence of hyperglycemia at admission was equal among both survivors and non-survivors.

Conclusion: The prevalence of mucormycosis seems to be increasing among COVID-19 patients which may be associated with increased use of steroids, the possible immunocompromised state imposed by SARS-CoV-2, or co-existing conditions such as diabetes mellitus. The mortality of CAM is remarkably high and apart from preventive practices and rational use of immunomodulators, a high index of suspicion with early diagnosis would be key to survival.
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http://dx.doi.org/10.7759/cureus.16152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8329523PMC
July 2021

Check Central Venous Catheter Set thoroughly or Bite the Bullet!

Indian J Crit Care Med 2021 Jul;25(7):832-833

Department of Anaesthesia, Pain Medicine and Critical Care, All India Institute of Medical Science, New Delhi, India.

Singh AK, Kumar S, Aggarwal R, Trikha A. Check Central Venous Catheter Set thoroughly or Bite the Bullet! Indian J Crit Care Med 2021;25(7):832-833.
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http://dx.doi.org/10.5005/jp-journals-10071-23891DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286390PMC
July 2021

Bronchopleural Fistula after High-flow Nasal Cannula Use in Patient with COVID-19.

Indian J Crit Care Med 2021 Jul;25(7):830-831

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Venkateswaran V, Chaturvedi A, Soni KD, Aggarwal R, Trikha A. Bronchopleural Fistula after High-flow Nasal Cannula Use in Patient with COVID-19. Indian J Crit Care Med 2021;25(7):830-831.
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http://dx.doi.org/10.5005/jp-journals-10071-23890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286376PMC
July 2021

Epidemiology and Prognostic Utility of Cellular Components of Hematological System in Sepsis.

Indian J Crit Care Med 2021 Jun;25(6):660-667

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Background: Data are lacking on the role of cellular components of hematological system as biomarkers for prognosis of sepsis. We planned to identify if these parameters measured at admission to ICU and at 72 hours can be useful as prognostic marker in septic critically ill patients.

Materials And Methods: In this prospective observational study, 130 adult patients with sepsis were recruited. Various hematological study parameters (total, differential, and absolute leukocyte count, platelet count, platelet distribution width, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio) were noted at day 1 and day 3 of admission. Primary outcome was 28-day mortality, and secondary outcomes were duration of mechanical ventilation, vasopressor requirement, ICU length of stay, and requirement of renal replacement therapy. The variables were compared between two groups and using binary regression model and were evaluated as prognostic markers for 28-day mortality.

Results: Data from = 129 were analyzed. At day-28, = 58 (44.96%) patients survived. Baseline and demographic parameters were comparable between survivors and nonsurvivors. Admission Sequential Organ Failure Assessment score was more in nonsurvivors than survivors [8 (6-8) vs 6 (4-8); = 0.002]. In nonsurvivors, monocyte, lymphocyte, basophil, eosinophil, and platelet count were significantly less at day 1 and lymphocyte, eosinophil, basophil and platelet count were significantly less at day 3. NLR and PLR at day 3 were significantly more in nonsurvivors. On logistic regression analysis, age, thrombocytopenia on day 1, and low eosinophil count on day 3 predicted 28-day mortality ( = 0.006, = 0.02, and = 0.04, respectively).

Conclusion: Thrombocytopenia on day 1 and eosinopenia on day 3 may predict 28-day mortality in sepsis.

How To Cite This Article: Sinha H, Maitra S, Anand RK, Aggarwal R, Rewari V, Subramaniam R, . Epidemiology and Prognostic Utility of Cellular Components of Hematological System in Sepsis. Indian J Crit Care Med 2021;25(6):660-667.
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http://dx.doi.org/10.5005/jp-journals-10071-23874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286394PMC
June 2021

Clinicoepidemiological Features and Mortality Analysis of Deceased Patients with COVID-19 in a Tertiary Care Center.

Indian J Crit Care Med 2021 Jun;25(6):622-628

Department of Anaesthesiology, Pain Medicine and Critical Care, AIIMS, New Delhi, India.

Background And Objective: A large number of studies describing the clinicoepidemiological features of coronavirus disease-2019 (COVID-19) patients are available but very few studies have documented similar features of the deceased. This study was aimed to describe the clinicoepidemiological features and the causes of mortality of COVID-19 deceased patients admitted in a dedicated COVID center in India.

Methodology: This was a retrospective study done in adult deceased patients admitted in COVID ICU from April 4 to July 24, 2020. The clinical features, comorbidities, complications, and causes of mortality in these patients were analyzed. Pediatric deceased were analyzed separately.

Results: A total of 654 adult patients were admitted in the ICU during the study period and ICU mortality was 37.7% (247/654). Among the adult deceased, 65.9% were males with a median age of 56 years [interquartile range (IQR), 41.5-65] and 94.74% had one or more comorbidities, most common being hypertension (43.3%), diabetes mellitus (34.8%), and chronic kidney disease (20.6%). The most common presenting features in these deceased were fever (75.7%), cough (68.8%), and shortness of breath (67.6%). The mean initial sequential organ failure assessment score was 9.3 ± 4.7 and 24.2% were already intubated at the time of admission. The median duration of hospital stay was 6 days (IQR, 3-11). The most common cause of death was sepsis with multi-organ failure (55.1%) followed by severe acute respiratory distress syndrome (ARDS) (25.5%). All pediatric deceased had comorbid conditions and the most common cause of death in this group was severe ARDS.

Conclusion: In this cohort of adult deceased, most were young males with age less than 65 years with one or more comorbidities, hypertension being the most common. Only 5% of the deceased had no comorbidities. Sepsis with multi-organ dysfunction syndrome was the most common cause of death.

How To Cite This Article: Aggarwal R, Bhatia R, Kulshrestha K, Soni KD, Viswanath R, Singh AK, Clinicoepidemiological Features and Mortality Analysis of Deceased Patients with COVID-19 in a Tertiary Care Center. Indian J Crit Care Med 2021; 25(6):622-628.
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http://dx.doi.org/10.5005/jp-journals-10071-23848DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286396PMC
June 2021

Letter re 'Breakthrough COVID-19 infections among health care workers after two doses of ChAdOx1 nCoV-19 vaccine'.

QJM 2021 Jul 23. Epub 2021 Jul 23.

Department of Anaesthesia & Critical Care Medicine, All India Institute of Medical Sciences.

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http://dx.doi.org/10.1093/qjmed/hcab205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344412PMC
July 2021

Coinfections with Other Respiratory Pathogens among Patients with COVID-19.

Microbiol Spectr 2021 09 21;9(1):e0016321. Epub 2021 Jul 21.

Department of Microbiology, All India Institute of Medical Sciencesgrid.413618.9, New Delhi, India.

Emerging evidence indicates that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected individuals are at an increased risk for coinfections; therefore, physicians need to be cognizant about excluding other treatable respiratory pathogens. Here, we report coinfection with SARS-CoV-2 and other respiratory pathogens in patients admitted to the coronavirus disease (COVID) care facilities of an Indian tertiary care hospital. From June 2020 through January 2021, we tested 191 patients with SARS-CoV-2 for 33 other respiratory pathogens using an fast track diagnostics respiratory pathogen 33 (FTD-33) assay. Additionally, information regarding other relevant respiratory pathogens was collected by reviewing their laboratory data. Overall, 13 pathogens were identified among patients infected with SARS-CoV-2, and 46.6% (89/191) of patients had coinfection with one or more additional pathogens. Bacterial coinfections (41.4% [79/191]) were frequent, with Staphylococcus aureus being the most common, followed by Klebsiella pneumoniae. Coinfections with SARS-CoV-2 and Pneumocystis jirovecii or Legionella pneumophila were also identified. The viral coinfection rate was 7.3%, with human adenovirus and human rhinovirus being the most common. Five patients in our cohort had positive cultures for Acinetobacter baumannii and K. pneumoniae, and two patients had active Mycobacterium tuberculosis infection. In total, 47.1% (90/191) of patients with coinfections were identified. The higher proportion of patients with coinfections in our cohort supports the systemic use of antibiotics in patients with severe SARS-CoV-2 pneumonia with rapid de-escalation based on respiratory PCR/culture results. The timely and simultaneous identification of coinfections can contribute to improved health of COVID-19 patients and enhanced antibiotic stewardship during the pandemic. Coinfections in COVID-19 patients may worsen disease outcomes and need further investigation. We found that a higher proportion of patients with COVID-19 were coinfected with one or more additional pathogens. A better understanding of the prevalence of coinfection with other respiratory pathogens in COVID-19 patients and the profile of pathogens can contribute to effective patient management and antibiotic stewardship during the current pandemic.
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http://dx.doi.org/10.1128/Spectrum.00163-21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8552727PMC
September 2021

Clinico-pathological features in fatal COVID-19 infection: a preliminary experience of a tertiary care center in North India using postmortem minimally invasive tissue sampling.

Expert Rev Respir Med 2021 10 24;15(10):1367-1375. Epub 2021 Jul 24.

Department of Medicine, AIIMS, New Delhi, India.

Objectives: To study the histopathology of patients dying of COVID-19 using post-mortem minimally invasive sampling techniques.

Methods: This was a single-center observational study conducted at JPNATC, AIIMS. Thirty-seven patients who died of COVID-19 were enrolled. Post-mortem percutaneous biopsies were taken from lung, heart, liver, kidney and stained with hematoxylin and eosin. Immunohistochemistry was performed using CD61 and CD163. SARS-CoV-2 virus was detected using IHC with primary antibodies.

Results: The mean age was 48.7 years and 59.5% were males. Lung histopathology showed diffuse alveolar damage in 78% patients. Associated bronchopneumonia was seen in 37.5% and scattered microthrombi in 21% patients. Immunopositivity for SARS-CoV-2 was observed in Type II pneumocytes. Acute tubular injury with epithelial vacuolization was seen in 46% of renal biopsies. Seventy-one percent of liver biopsies showed Kupffer cell hyperplasia and 27.5% showed submassive hepatic necrosis.

Conclusions: Predominant finding was diffuse alveolar damage with demonstration of SARS-CoV-2 protein in the acute phase. Microvascular thrombi were rarely identified in any organ. Substantial hepatocyte necrosis, Kupffer cell hypertrophy, microvesicular, and macrovesicular steatosis unrelated to microvascular thrombi suggested that liver might be a primary target of COVID-19.
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http://dx.doi.org/10.1080/17476348.2021.1951708DOI Listing
October 2021

Evaluation of COVID-19 Antigen Fluorescence Immunoassay Test for Rapid Detection of SARS-CoV-2.

J Glob Infect Dis 2021 Apr-Jun;13(2):91-93. Epub 2021 May 31.

Department of Laboratory Medicine (Microbiology Division), JPNATC, AIIMS, New Delhi,, India.

Introduction: Tests detecting SARS-CoV-2-specific antigen have recently been developed, and many of them are now commercially available. However, the real-world performance of these assays is uncertain; therefore, their validation is important. In this study, we have evaluated the performance of STANDARD F COVID-19 antigen fluorescence immunoassay (FIA) kit.

Methods: Nasopharyngeal samples collected from patients were subjected to the test as per manufacturer's instructions. The performance of the kit was compared with the gold standard real-time polymerase chain reaction.

Results: A total of 354 patients were tested with STANDARD F COVID-19 antigen FIA test kit. The overall sensitivity, specificity, positive predictive value, and negative predictive value of this test were found to be 38%, 99%, 96.2%, and 72%, respectively, with a diagnostic accuracy of 75.7%.

Conclusion: STANDARD F COVID-19 antigen FIA showed high specificity and positive predictive value but low sensitivity and negative predictive value.
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http://dx.doi.org/10.4103/jgid.jgid_316_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8213088PMC
May 2021

Is it Time to Go Back to Basics?

Indian J Crit Care Med 2021 May;25(5):598

Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India.

Chaturvedi A, Trikha A. Is it Time to Go Back to Basics? Indian J Crit Care Med 2021;25(5):598.
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http://dx.doi.org/10.5005/jp-journals-10071-23808DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8196384PMC
May 2021
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