Publications by authors named "Richa Aggarwal"

70 Publications

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

Tofacitinib Associated with Reduced Intubation Rates in the Management of Severe COVID-19 Pneumonia: A Preliminary Experience.

Indian J Crit Care Med 2021 Oct;25(10):1108-1112

Department of Anesthesiology and Critical Care, PGIMS, Rohtak, Haryana, India.

Background: The second wave of COVID-19 pandemic was not only associated with a rapid and severe surge in the number of cases but also limited availability of recommended medicines. Baricitinib has been known to reduce recovery time in COVID-19 pneumonia in association with remdesivir. Tofacitinib, with limited evidence, was used in severe COVID-19 pneumonia based on its similarity of action with baricitinib.

Methods: Data of all patients admitted to the COVID-19 intensive care unit in the month of April were accessed and analyzed. Data of patients who were on other immunomodulators, invasive ventilation, or suffering from end-stage organ diseases were excluded from the analysis.

Results: Out of 73 patients, data of 50 were analyzed. Twenty-five received tofacitinib and the other 25 were managed with standard of care. Age, comorbidities, and gender distribution between the two groups were similar. On day 7 of admission, the change in SpO/FiO ratio was 1.26 ± 1 and 0.72 ± 1 in the tofacitinib group and control group, respectively. Similarly, a higher number of subjects in the control group showed worsening in the World Health Organization (WHO) ordinal scale (36 vs 12%, = 0.01). The clinical objective improvement was similar in the two groups. The intubation rates in the tofacitinib group were significantly lower than that in the control group (32% vs 8%, = 0.034).

Conclusion: Tofacitinib, in this retrospective single-center experience, was found to be associated with reduced intubation rates and reduced worsening in the WHO ordinal scale. There was no difference in mortality in the two groups.

How To Cite This Article: Singh PK, Lalwani LK, Govindagoudar MB, Aggarwal R, Chaudhry D, Kumar P, et al. Tofacitinib Associated with Reduced Intubation Rates in the Management of Severe COVID-19 Pneumonia: A Preliminary Experience. Indian J Crit Care Med 2021;25(10):1108-1112.
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http://dx.doi.org/10.5005/jp-journals-10071-23964DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8645820PMC
October 2021

Acute critical care course for interns to develop competence.

Natl Med J India 2021 May-Jun;34(3):167-170

Department of Surgery, Wirral Teaching Hospitals, Birkenhead, Liverpool, UK.

Background All medical graduates must know how to stabilize and manage critically ill patients. A 2-day intensive course, called the acute critical care course (ACCC), was conducted to train interns in technical and non-technical skills for managing a patient whose condition is deteriorating. This analysis aims to assess the feasibility and effectiveness of ACCC for interns. Methods We developed and conducted the ACCC to train interns. It included lectures and skill stations. Twenty-four interns participated in the course. Immediate, post-course, quantitative and qualitative feedback was taken online. Qualitative information was also collected verbally and later by email. These data were analysed both quantitatively and qualitatively. Thematic analysis was used to identify, analyse and report the patterns of responses and behaviour. Results The average score for the utility of the course was 4.7 and for the skill stations it was 4.6 on a scale of 5. The qualitative analysis of the feedback emphasized the need for the course before the clinical posting and more skill-based modules rather than lectures. The interactive style of teaching and training in communication using role-play was appreciated. Few suggestions to improve the course were provided. Conclusions Implementing the ACCC needed simulation, interactive discussions, role-play, modified Pendleton's feedback, and reflective exercise that form the basis of a range of educational principles. The blended learning set of objectives of ACCC were the pillars for this successful internship training programme.
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http://dx.doi.org/10.25259/NMJI_103_19DOI Listing
December 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

Chronic Exposure to Palmitic Acid Down-Regulates AKT in Beta-Cells through Activation of mTOR.

Am J Pathol 2022 Jan 5;192(1):130-145. Epub 2021 Oct 5.

Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Southern California, Los Angeles, California; Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California. Electronic address:

High circulating lipids occurring in obese individuals and insulin-resistant patients are considered a contributing factor to type 2 diabetes. Exposure to high lipid concentration is proposed to both protect and damage beta-cells under different circumstances. Here, by feeding mice a high-fat diet (HFD) for 2 weeks to up to 14 months, the study showed that HFD initially causes the beta-cells to expand in population, whereas long-term exposure to HFD is associated with failure of beta-cells and the inability of animals to respond to glucose challenge. To prevent the failure of beta-cells and the development of type 2 diabetes, the molecular mechanisms that underlie this biphasic response of beta-cells to lipid exposure were explored. Using palmitic acid (PA) in cultured beta-cells and islets, the study demonstrated that chronic exposure to lipids leads to reduced viability and inhibition of cell cycle progression concurrent with down-regulation of a pro-growth/survival kinase AKT, independent of glucose. This AKT down-regulation by PA is correlated with the induction of mTOR/S6K activity. Inhibiting mTOR activity with rapamycin induced Raptor and restored AKT activity, allowing beta-cells to gain proliferation capacity that was lost after HFD exposure. In summary, a novel mechanism in which lipid exposure may cause the dipole effects on beta-cell growth was elucidated, where mTOR acts as a lipid sensor. These mechanisms can be novel targets for future therapeutic developments.
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http://dx.doi.org/10.1016/j.ajpath.2021.09.008DOI Listing
January 2022

Communication skills training through 'role play' in an acute critical care course.

Natl Med J India 2021 Mar-Apr;34(2):92-94

Wirral Teaching Hospitals, Core Surgical Training Merseyside, North West of England, University of Liverpool, Liverpool, UK.

Background: . Effective patient-doctor communication is a key component of patient-centred care, which is one of the six pillars of quality healthcare delivery. Structured and effective communication skills training for healthcare providers is the need of hour in medical education. We assessed the efficacy of role play and simulation in developing communication skills.

Methods: . As a key component of an acute critical care course (ACCC), communication skills are taught using role play models and simulation. Live feedback is critical in learning during this course as per the principles of adult learning (andragogy). Quantitative and qualitative data were collected to assess the efficacy of ACCC.

Results: . The 19th ACCC was introduced to interns at the All India Institute of Medical Sciences, New Delhi in December 2018. The teaching methodology and objective-oriented structured training in ACCC were much appreciated for training in human factors with emphasis on communication. A positive response was obtained from the candidates 3 weeks after they completed the course to assess whether interns are able to make use of this training in their day-to-day clinical practice amounting to a reliable evidence level of Kirkpatrick's 'return of investment'.

Conclusion: . The use of 'role play' to teach communication skills is effective and superior to lecture-based teaching. Further structured and interactive programmes in communication skills training will improve patient care, relatives' satisfaction and the image of medical profession.
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http://dx.doi.org/10.4103/0970-258X.326757DOI Listing
October 2021

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

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

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

COVID-19 Illness in a Patient With Anti-Glomerular Basement Membrane Disease: A Clinical Dilemma.

Cureus 2021 May 8;13(5):e14912. Epub 2021 May 8.

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

Anti-glomerular basement membrane (anti-GBM) disease is a rare autoimmune disease affecting the kidneys and lungs. COVID-19 infection in a patient with pre-existing anti-GBM disease presents a unique set of clinical challenges. The formulation of a judicious treatment plan balancing both disease processes is tricky, especially with regard to anticoagulation. We present the case of a young patient with anti-GBM disease who acquired COVID-19 infection and eventually succumbed to his illness.
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http://dx.doi.org/10.7759/cureus.14912DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191424PMC
May 2021

Changes in extracellular cytokines in predicting disease severity and final clinical outcome of patients with blunt chest trauma.

Immunobiology 2021 05 27;226(3):152087. Epub 2021 Mar 27.

Division of Trauma Surgery & Critical Care, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Background: Chest trauma causes substantial morbidity and mortality and its severity is assessed using clinical diagnosis or scoring systems like Injury severity score (ISS) and thoracic trauma severity score (TTSS). Association of inflammatory cytokines with severity of disease and final clinical outcome is not clearly defined in patients with chest trauma. In this study, we thought to evaluate the inflammatory response in serum and bronchoalveolar lavage fluid (BALF) in chest trauma patients and correlate the level of extracellular cytokines with diseases severity and final outcome.

Methods: A total of 65 patients with blunt chest trauma and 30 healthy controls were enrolled in this prospective observational study. Assessment of inflammatory cytokines such as Interleukin (s) - IL-5, IL-13, IL-2, IL-6, IL-9, IL-1β, IFN-γ, TNF-α, IL-17A, IL-17F,IL-4, IL-21 and IL-22 was performed in both serum and bronchoalveolar lavage fluid using 13-plex multiplex kit using fluorescence-encoded bead based immunoassays.

Results: A significantly higher level of IL-13, IL-2, IL-6, IL-9, IL-1β, IFN-γ, TNF-α, IL-17A, IL-17F, IL-21 and IL-22 cytokines were observed in patients with blunt chest trauma compared to healthy controls. Level of IL-2, IL-6, IL-1β and IL-17A was significantly raised in the patients with blunt chest trauma who had a fatal outcome during the hospital stay. An elevated cytokine response of IL-13, IL-4, and IL-21 was noted in the group of patients with high (>5) thoracic trauma severity score.

Conclusion: Routine monitoring of the inflammatory cytokine level in patients with chest trauma may be used routinely. Longer prospective studies should be encouraged to determine the role of cytokines in patients with chest trauma in predicting the patient final clinical outcome.
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http://dx.doi.org/10.1016/j.imbio.2021.152087DOI Listing
May 2021

Rapid chromatographic immunoassay-based evaluation of COVID-19: A cross-sectional, diagnostic test accuracy study & its implications for COVID-19 management in India.

Indian J Med Res 2021 Jan & Feb;153(1 & 2):126-131

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

Background & Objectives: Coronavirus disease 2019 (COVID-19) has so far affected over 41 million people globally. The limited supply of real-time reverse transcription-polymerase chain reaction (rRT-PCR) kits and reagents has made meeting the rising demand for increased testing incompetent, worldwide. A highly sensitive and specific antigen-based rapid diagnostic test (RDT) is the need of the hour. The objective of this study was to evaluate the performance of a rapid chromatographic immunoassay-based test (index test) compared with a clinical reference standard (rRT-PCR).

Methods: A cross-sectional, single-blinded study was conducted at a tertiary care teaching hospital in north India. Paired samples were taken for RDT and rRT-PCR (reference standard) from consecutive participants screened for COVID-19 to calculate the sensitivity and specificity of the RDT. Further subgroup analysis was done based on the duration of illness and cycle threshold values. Cohen's kappa coefficient was used to measure the level of agreement between the two tests.

Results: Of the 330 participants, 77 were rRT-PCR positive for SARS-CoV-2. Sixty four of these patients also tested positive for SARS-CoV-2 by RDT. The overall sensitivity and specificity were 81.8 and 99.6 per cent, respectively. The sensitivity of RDT was higher (85.9%) in participants with a duration of illness ≤5 days.

Interpretation & Conclusions: With an excellent specificity and moderate sensitivity, this RDT may be used to rule in COVID-19 in patients with a duration of illness ≤5 days. Large-scale testing based on this RDT across the country would result in quick detection, isolation and treatment of COVID-19 patients.
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http://dx.doi.org/10.4103/ijmr.IJMR_3305_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8184078PMC
April 2021

Increase in optic nerve sheath diameter predicts early cerebral involvement in fat embolism syndrome.

Chin J Traumatol 2021 May 9;24(3):180-182. Epub 2021 Feb 9.

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

Early diagnosis of cerebral fat embolism in a patient with contradiction to MRI is challenging. Here we report an interesting case, where the raised optic nerve sheath diameter helped us to predict the early cerebral involvement with fat emboli in a left femoral shaft fracture patient. MRI scan could not be performed due to the presence of a metallic implant in the patient from a previous surgery. He was later diagnosed as an atypical presentation of fat embolism syndrome. Optic nerve sheath monitoring also helped us to guide further management of the patient.
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http://dx.doi.org/10.1016/j.cjtee.2021.02.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173580PMC
May 2021

Outcome of Conservative Therapy in Coronavirus disease-2019 Patients Presenting With Gastrointestinal Bleeding.

J Clin Exp Hepatol 2021 May-Jun;11(3):327-333. Epub 2020 Oct 3.

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

Background/objective: There is a paucity of data on the management of gastrointestinal (GI) bleeding in patients with Coronavirus disease -2019 (COVID-19) amid concerns about the risk of transmission during endoscopic procedures. We aimed to study the outcomes of conservative treatment for GI bleeding in patients with COVID-19.

Methods: In this retrospective analysis, 24 of 1342 (1.8%) patients with COVID-19, presenting with GI bleeding from 22nd April to 22nd July 2020, were included.

Results: The mean age of patients was 45.8 ± 12.7 years; 17 (70.8%) were males; upper GI (UGI) bleeding: lower GI (LGI) 23:1. Twenty-two (91.6%) patients had evidence of cirrhosis- 21 presented with UGI bleeding while one had bleeding from hemorrhoids. Two patients without cirrhosis were presumed to have non-variceal bleeding. The medical therapy for UGI bleeding included vasoconstrictors-somatostatin in 17 (73.9%) and terlipressin in 4 (17.4%) patients. All patients with UGI bleeding received proton pump inhibitors and antibiotics. Packed red blood cells (PRBCs), fresh frozen plasma (FFPs) and platelets were transfused in 14 (60.9%), 3 (13.0%) and 3 (13.0%), respectively. The median PRBCs transfused was 1 (0-3) unit(s). The initial control of UGI bleeding was achieved in all 23 patients and none required an emergency endoscopy. At 5-day follow-up, none rebled or died. Two patients later rebled, one had intermittent bleed due to gastric antral vascular ectasia, while another had rebleed 19 days after discharge. Three (12.5%) cirrhosis patients succumbed to acute hypoxemic respiratory failure during hospital stay.

Conclusion: Conservative management strategies including pharmacotherapy, restrictive transfusion strategy, and close hemodynamic monitoring can successfully manage GI bleeding in COVID-19 patients and reduce need for urgent endoscopy. The decision for proceeding with endoscopy should be taken by a multidisciplinary team after consideration of the patient's condition, response to treatment, resources and the risks involved, on a case to case basis.
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http://dx.doi.org/10.1016/j.jceh.2020.09.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7833290PMC
October 2020

Artificial Intelligence-assisted chest X-ray assessment scheme for COVID-19.

Eur Radiol 2021 Aug 20;31(8):6039-6048. Epub 2021 Jan 20.

Indian Institute of Technology, Delhi, New Delhi, India.

Objectives: To study whether a trained convolutional neural network (CNN) can be of assistance to radiologists in differentiating Coronavirus disease (COVID)-positive from COVID-negative patients using chest X-ray (CXR) through an ambispective clinical study. To identify subgroups of patients where artificial intelligence (AI) can be of particular value and analyse what imaging features may have contributed to the performance of AI by means of visualisation techniques.

Methods: CXR of 487 patients were classified into [4] categories-normal, classical COVID, indeterminate, and non-COVID by consensus opinion of 2 radiologists. CXR which were classified as "normal" and "indeterminate" were then subjected to analysis by AI, and final categorisation provided as guided by prediction of the network. Precision and recall of the radiologist alone and radiologist assisted by AI were calculated in comparison to reverse transcriptase-polymerase chain reaction (RT-PCR) as the gold standard. Attention maps of the CNN were analysed to understand regions in the CXR important to the AI algorithm in making a prediction.

Results: The precision of radiologists improved from 65.9 to 81.9% and recall improved from 17.5 to 71.75 when assistance with AI was provided. AI showed 92% accuracy in classifying "normal" CXR into COVID or non-COVID. Analysis of attention maps revealed attention on the cardiac shadow in these "normal" radiographs.

Conclusion: This study shows how deployment of an AI algorithm can complement a human expert in the determination of COVID status. Analysis of the detected features suggests possible subtle cardiac changes, laying ground for further investigative studies into possible cardiac changes.

Key Points: • Through an ambispective clinical study, we show how assistance with an AI algorithm can improve recall (sensitivity) and precision (positive predictive value) of radiologists in assessing CXR for possible COVID in comparison to RT-PCR. • We show that AI achieves the best results in images classified as "normal" by radiologists. We conjecture that possible subtle cardiac in the CXR, imperceptible to the human eye, may have contributed to this prediction. • The reported results may pave the way for a human computer collaboration whereby the expert with some help from the AI algorithm achieves higher accuracy in predicting COVID status on CXR than previously thought possible when considering either alone.
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http://dx.doi.org/10.1007/s00330-020-07628-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816060PMC
August 2021

Crosstalk between T Helper Cell Subsets and Their Roles in Immunopathogenesis and Outcome of Polytrauma Patients.

Indian J Crit Care Med 2020 Nov;24(11):1037-1044

Department of Laboratory Medicine, JPNA Trauma Center, All India Institute of Medical Sciences, New Delhi, India.

Purpose: One of the leading causes of morbidity and early-age mortality across the globe is trauma. It disrupts immune system homeostasis and intensely affects the innate and adaptive immune responses, predisposing patients to posttrauma complications and poor outcomes. Most of the studies on posttrauma cellular immune response have been centered on the T helper-1-T helper-2 imbalances after trauma. This study was conducted to understand the role of circulating novel T helper cells in the acute posttraumatic period and clinical outcome of trauma patients.

Materials And Methods: Signature cytokines and transcription factors of circulating Th (T helper)-9, Th-17, Th-22, and regulatory T helper cells were studied using flowcytometry along with serum biomarkers in 49 patients with polytraumatic injuries admitted to a tertiary care hospital. The patients were followed up until their outcome. The results were correlated with their clinical outcomes.

Results: In patients who died, higher nTreg, iTreg, Tr1 (early-phase), and higher IRF4+Th-9, IL17+ Th-17, and RORγT+ Th-17 (mid-phase) were seen. However, by the late phase, only RORγT+ Th-17 remained higher. Serum IL-6 and PCT were found to be consistently higher. In survivors, higher Th-3 (early phase), Th-22 (mid-phase), and IRF4+Th-9, IL17+ Th-17, nTreg, Th-3 (late phase) were observed to have played a protective role. Serum IL-2, IL-4, IL-17A and IL-22 were significantly higher in survivors.

Conclusion: Different T helper subsets were observed to be playing pathogenic and protective roles in different phases of trauma and could be used for early prognostication and make way for noninvasive management of critically injured trauma patients by immunomodulation.

How To Cite This Article: Khurana S, Bhardwaj N, Kumar S, Sagar S, Pal R, Soni KD, Crosstalk between T Helper Cell Subsets and Their Roles in Immunopathogenesis and Outcome of Polytrauma Patients. Indian J Crit Care Med 2020;24(11):1037-1044.
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http://dx.doi.org/10.5005/jp-journals-10071-23577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751033PMC
November 2020

Rapid chromatographic immunoassay-based evaluation of COVID-19: A cross-sectional, diagnostic test accuracy study & its implications for COVID-19 management in India.

Indian J Med Res 2020 Oct 31. Epub 2020 Oct 31.

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

Background & Objectives: : Coronavirus disease 2019 (COVID-19) has so far affected over 41 million people globally. The limited supply of real-time reverse transcription-polymerase chain reaction (rRT-PCR) kits and reagents has made meeting the rising demand for increased testing incompetent, worldwide. A highly sensitive and specific antigen-based rapid diagnostic test (RDT) is the need of the hour. The objective of this study was to evaluate the performance of a rapid chromatographic immunoassay-based test (index test) compared with a clinical reference standard (rRT-PCR).

Methods: : A cross-sectional, single-blinded study was conducted at a tertiary care teaching hospital in north India. Paired samples were taken for RDT and rRT-PCR (reference standard) from consecutive participants screened for COVID-19 to calculate the sensitivity and specificity of the RDT. Further subgroup analysis was done based on the duration of illness and cycle threshold values. Cohen's kappa coefficient was used to measure the level of agreement between the two tests.

Results: : Of the 330 participants, 77 were rRT-PCR positive for SARS-CoV-2. Sixty four of these patients also tested positive for SARS-CoV-2 by RDT. The overall sensitivity and specificity were 81.8 and 99.6 per cent, respectively. The sensitivity of RDT was higher (85.9%) in participants with a duration of illness ≤5 days.

Interpretation & Conclusions: : With an excellent specificity and moderate sensitivity, this RDT may be used to rule in COVID-19 in patients with a duration of illness ≤5 days. Large-scale testing based on this RDT across the country would result in quick detection, isolation and treatment of COVID-19 patients.
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http://dx.doi.org/10.4103/ijmr.IJMR_3305_20DOI Listing
October 2020

Fast tracking intensive care units and operation rooms during the COVID-19 pandemic in resource limited settings.

J Anaesthesiol Clin Pharmacol 2020 Aug 31;36(Suppl 1):S7-S14. Epub 2020 Jul 31.

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

The ongoing pandemic of COVID-19 has affected more than 43 million people all over the world with about 280000 deaths worldwide at the time of writing this article The outcome of this pandemic is impossible to predict at the present time as the numbers of both, infected patients and those dying of the disease are increasing on a daily basis. China, Italy, France, Spain, Germany, United Kingdom, and USA are the worst affected countries. All these countries have robust health care systems but despite this there has been a huge shortage of health care facilities especially intensive care beds in these countries. A country like India has different challenges as far as medical care during this pandemic is concerned. The need of the hour is to improve the health care system as a whole. In the present pandemic this involves setting up of patients screening facilities for the disease, enhancing the number of hospital beds, setting up of dedicated high dependency units, intensive care units and operation theatres for COVID positive patients. The present article describes in brief the way this can be done in a short time.
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http://dx.doi.org/10.4103/joacp.JOACP_262_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574016PMC
August 2020

Early hospital discharge following non-operative management of blunt liver and splenic trauma: A pilot randomized controlled trial.

Injury 2021 Feb 3;52(2):260-265. Epub 2020 Oct 3.

Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India.

Background: Despite the acceptance of non-operative management (NOM), there is no consensus on the optimal length of hospital stay in patients with blunt liver and splenic injury (BLSI). Recent studies on pediatric patients have demonstrated the safety of early discharge following NOM for BLSI. We aimed at evaluating the feasibility and safety of early discharge in adult patients with BLSI following NOM in a randomized controlled trial.

Materials And Methods: After initial assessment and management, patients aged 18-60 years with BLSI planned for NOM were randomized into 2 groups: Group A (test group; discharge day 3), and Group B (control group; discharge day 5). Standard NOM protocol was followed. These patients were discharged on the proposed day if they met the pre-defined discharge criteria. All patients were followed at days 7, 15, and 30 of discharge.

Results: Sixty patients were recruited, 30 randomized to each arm. Most patients were males and aged less than 30 years. Road traffic injury was the most common mode of injury. Both groups were comparable in demography and injury-related parameters. 27 patients (90%) from group A and 28 patients (93%) from group B were discharged on the proposed day. Three patients had unplanned hospital visits for reasons unrelated to BLSI. All patients were asymptomatic and had a normal examination during their scheduled follow-up visits.

Conclusion: Adult patients undergoing NOM for BLSI can be safely discharged after 48 h of in-hospital observation, provided other injuries precluding discharge do not exist.
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http://dx.doi.org/10.1016/j.injury.2020.10.013DOI Listing
February 2021

Acquiring Ventilators: Fighter Planes without High-octane Fuel and Pilots: Indian Perspective in COVID Era.

Indian J Crit Care Med 2020 Aug;24(8):735-736

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

During this coronavirus disease-19 (COVID-19) pandemic, all the countries are emphasizing on procurement of more and more sophisticated machineries for the intensive care unit (ICU) like ventilators. But do all countries have to follow the same? The requirements are different for low- and middle-income countries like India, which are resource limited. The ventilators require oxygen supply and manpower to function which are deficient in these countries. These countries might do well only by procurement of oxygen delivery machinery, as most of the patients of COVID require oxygen only. Only approx. Five percent of COVID-19 patients require ventilators. Moreover, the patients on ventilators have high mortality. Thus, low-resource countries need to redefine their priority as to how to utilize their resources. This manuscript emphasizes the need for the same.

How To Cite This Article: Aggarwal R, Trikha A. Acquiring Ventilators: Fighter Planes without High-octane Fuel and Pilots: Indian Perspective in COVID Era. Indian J Crit Care Med 2020;24(8):735-736.
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http://dx.doi.org/10.5005/jp-journals-10071-23525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7519605PMC
August 2020

Gargle lavage as a viable alternative to swab for detection of SARS-CoV-2.

Indian J Med Res 2020 Jul & Aug;152(1 & 2):77-81

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

Background & Objectives: Nasopharyngeal and oropharyngeal swab (NPS and OPS) collection is widely accepted as the preferred method for obtaining respiratory samples. However, it has certain disadvantages which may be overcome by gargling. The primary objective of this study was to assess agreement between gargle lavage and swab as an appropriate respiratory sample for the detection of SARS-CoV-2. The secondary objective was to assess the patient acceptability of the two sampling methods.

Methods: It was a cross-sectional study done at a tertiary care hospital in New Delhi, India, on 50 confirmed COVID-19 patients. Paired swab (NPS and OPS) and gargle samples were taken within 72 h of their diagnosis. Samples were processed by reverse transcription-polymerase chain reaction (RT-PCR) for detection of SARS-CoV-2. Post-sample collection, a 10-point scale was administered to assess the level of discomfort with either of the collection methods.

Results: All gargle samples were positive and comparable to their corresponding swab samples irrespective of the symptoms and duration of illness. The cycle threshold (C) values for gargle samples were slightly higher but comparable to those of swabs. Bland-Altman plot showed good agreement between the two methods. Majority (72%) of the patients reported moderate-to-severe discomfort with swab collection in comparison to 24 per cent reporting only mild discomfort with gargle collection.

Interpretation & Conclusions: Our preliminary results show that the gargle lavage may be a viable alternative to swabs for sample collection for the detection of SARS-CoV-2. Adoption of gargle lavage for sample collection will have a significant impact as it will enable easy self-collection, relieve healthcare workers and also lead to substantial cost savings by reducing the need for swabs and personal protective equipment.
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http://dx.doi.org/10.4103/ijmr.IJMR_2987_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853282PMC
September 2020

Poor outcomes in patients with cirrhosis and Corona Virus Disease-19.

Indian J Gastroenterol 2020 06 15;39(3):285-291. Epub 2020 Aug 15.

Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India.

Background And Aim: There is a paucity of data on the clinical presentations and outcomes of Corona Virus Disease-19 (COVID-19) in patients with underlying liver disease. We aimed to summarize the presentations and outcomes of COVID-19-positive patients and compare with historical controls.

Methods: Patients with known chronic liver disease who presented with superimposed COVID-19 (n = 28) between 22 April 2020 and 22 June 2020 were studied. Seventy-eight cirrhotic patients without COVID-19 were included as historical controls for comparison.

Results: A total of 28 COVID-19 patients (two without cirrhosis, one with compensated cirrhosis, sixteen with acute decompensation [AD], and nine with acute-on-chronic liver failure [ACLF]) were included. The etiology of cirrhosis was alcohol (n = 9), non-alcoholic fatty liver disease (n = 2), viral (n = 5), autoimmune hepatitis (n = 4), and cryptogenic cirrhosis (n = 6). The clinical presentations included complications of cirrhosis in 12 (46.2%), respiratory symptoms in 3 (11.5%), and combined complications of cirrhosis and respiratory symptoms in 11 (42.3%) patients. The median hospital stay was 8 (7-12) days. The mortality rate in COVID-19 patients was 42.3% (11/26), as compared with 23.1% (18/78) in the historical controls (p = 0.077). All COVID-19 patients with ACLF (9/9) died compared with 53.3% (16/30) in ACLF of historical controls (p = 0.015). Mortality rate was higher in COVID-19 patients with compensated cirrhosis and AD as compared with historical controls 2/17 (11.8%) vs. 2/48 (4.2%), though not statistically significant (p = 0.278). Requirement of mechanical ventilation independently predicted mortality (hazard ratio 13.68). Both non-cirrhotic patients presented with respiratory symptoms and recovered uneventfully.

Conclusion: COVID-19 is associated with poor outcomes in patients with cirrhosis, with worst survival rates in ACLF. Mechanical ventilation is associated with a poor outcome.
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http://dx.doi.org/10.1007/s12664-020-01074-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428422PMC
June 2020

COVID-19: Possible Cause of Induction of Relapse of Plasmodium vivax Infection.

Indian J Pediatr 2020 09 3;87(9):751-752. Epub 2020 Jul 3.

Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.

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http://dx.doi.org/10.1007/s12098-020-03441-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332844PMC
September 2020

Prognostic Value of Serially Estimated Serum Procalcitonin Levels in Traumatic Brain Injury Patients With or Without Extra Cranial Injury on Early In-hospital Mortality: A Longitudinal Observational Study.

Neurocrit Care 2021 02;34(1):182-192

Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, 7th Floor, 710, New Delhi, 110029, India.

Background: Traumatic brain injury (TBI) is associated with majority of trauma deaths, and objective tools are required to understand the severity of injury. The application of a biomarker like procalcitonin (PCT) in TBI may allow for assessment of severity and thus aid in prognostication and correlation with mortality and outcome.

Aims: The primary objective is to determine the correlation between PCT concentrations with TBI outcomes (mainly in terms of mortality) at intensive care unit (ICU)/hospital discharge. Secondary objectives are to evaluate correlation with associated extra cranial injuries and complications during hospital stay.

Methods: In total, 186 TBI patients aged > 18 years with minimum survival for at least 12 h admitted to the ICU at the level 1 trauma center were prospectively included in the study and divided into two groups: TBI with and without extra cranial injuries. All admitted patients were treated according to the standard institutional protocol. The PCT levels were obtained on admission, on day 2, and 5. Clinical, laboratory, diagnostic, and therapeutic data were also collected. Primary mortality is defined as death related to central nervous system (CNS) injury, while secondary mortality defined as death related to sepsis or extracranial cause.

Results: Median PCT levels at admission, day 2, and day 5 in TBI patients with extracranial injuries were 3.0, 0.83, and 0.69 ng/ml. In total, primary mortality was observed in 18 (9.7%) patients, while secondary causes were attributable in 20 (12.3%) patients. Regression analysis for primarily CNS cause of mortality showed PCT cutoff level at admission more than 5.5 ng/ml carried sensitivity and specificity of 75%, but for secondary cause (sepsis) of mortality, PCT cutoff values on day 2 > 1.15 ng/ml were derived significant with sensitivity of 70% and specificity of 66%. No significant association of parameters like length of ICU stay, Glasgow outcome scale (GOS), and primary/secondary mortality with the presence of extracranial injuries in TBI patients as compared with TBI alone was noted.

Conclusion: This observational study demonstrates the poor correlation between PCT concentrations with outcome at days 1, 2, and 5 post-injury. The predicted relationship between PCT levels and outcome was not confirmed, and that these results do not support the prognostic utility of PCT biomarker in this population for outcome (mortality) assessment in TBI patients with or without extracranial injuries.
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http://dx.doi.org/10.1007/s12028-020-01009-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292243PMC
February 2021
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