Study of Clinical Spectrum of Severe COVID-19 Infection in Elderly Patients and its Outcome-A Major Mumbai Tertiary Care Hospital Observations

Background: At 140 million, India has the second largest population of old people in the world, as per the 2011 census. 1 The covid 19 pandemic has wreaked havoc in millions of lives. Elderly are especially vulnerable to COVID-19 and experience high morbidity and mortality as a result of immunosenescence. Age is independently linked with mortality, but age alone does not adequately capture the robustness of older adults who are a heterogeneous group. The current research was done in a tertiary healthcare hospital in Maharashtra to understand the clinical profile and factors that affected the outcome of elderly during the second wave of the COVID pandemic. Method: This was a single centre retrospective observational study done in a tertiary hospital which was admitting both covid and non-covid patients during the time of this study. All elderly patients admitted with COVID 19 disease in Covid ward and covid ICU (Intensive care unit) were included in the study. Their Demographic details, duration of illness, vital parameters, oxygen saturation, partial pressure of arterial oxygen compared to fraction of inspired oxygen (PaO2-FiO2 ratio) were recorded and also relevant investigations such as complete blood count, kidney function tests, liver function tests, arterial blood gases, chest X-rayand ECG (Electrocardiogram),CT scan of the brain, CSF(cerebrospinal fluid) studies and other tests where relevant were recorded. Inflammatory markers such as C-Reactive Protein (CRP), Ferritin, D-Dimer and Chest CT scan were noted. Clinical profiles and outcomes were noted till discharge or death. Results: Among 231 patients that were included in this study, 81(35%) were female and 150 (65%) were male. Ninety-two patients died (39.8%) while 139 patients (60.2%) survived in our study. Majority of our patients (211;91.3%) presented in category E(pneumonia with respiratory failure) or category F(pneumonia with respiratory failure and multiorgan dysfunction syndrome). Factors which had a major impact on mortality were- a low PaO2-FiO2 ratio on admission, high C-Reactive Protein (CRP) levels, high d-dimer levels, a finding of bilateral ground glass opacities on x-ray, and need for invasive ventilation on admission. Conclusions: Elderly remain vulnerable to severe consequences of COVID-19 infection owing to the increasing comorbidities and immunosenescence in them. Prolonged oxygen therapy and intensive respiratory rehabilitation are the mainstays of effective management. Given the constant threat of mutating virus, masking, maintaining hand sanitization, vaccination and also caring for our elders while still maintaining social distance are our best bet against a fatal third wave.

Pneumonia Severity Index In Predicting Outcome In Elderly Patients With Community Acquired Pneumonia At A Tertiary Level Hospital In Mumbai

Background:Prognostication of patients with community-acquired pneumonia (CAP) is important from clinical, research, and quality-improvement perspectives. The pneumonia severity index (PSI) is a rigorously studied prediction rule for prognosis that objectively stratifies patients into quintiles of risk. The present study aimed to assess whether PSI can predict mortality, need for intensive care and ventilator support. Methods: An observational study of fifty patients aged 60 years or higher who were admitted in the general medicine ward of Department of Medicine, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai from April 2014 till September 2015 was conducted. A questionnaire with demographic information, clinical signs and symptoms, laboratory and radiographic findings was completed for each patient. Patients were classified according to PSI risk classification and their clinical outcome was noted. Results: Mean age of the patients was 66.5± 6.3 years; 68% were males, and 32% were females. The sensitivity, specificity, positive and negative predictive value of PSI risk class IV in predicting ICU admissions was 100%, 55.9%, 40.9% and 100%, respectively. Similarly, the sensitivity and specificity of PSI in predicting death and ventilator support to patient were maximum for PSI class IV. Defervescence time significantly correlated with PSI score (Spearman’s rho = 0.563, p value = 0.001). Conclusion: PSI was a good predictor of mortality, need of ICU admission and mechanical ventilation. Future studies are needed to support our findings and should further assess the long term outcome in these patients.

Factors Associated with GOLD Staging and BODE Index in Patients with Chronic Obstructive Lung Disease in Elderly

Background:We aimed to assess the clinical profile of Chronic obstructive pulmonary disease (COPD) occurring in elderly patient according to GOLD criteria/BODE index and to study the association of COPD with various risk factors in an elderly patient. Methods: We designed a hospital based observational study, in which we included patients with COPD who are elderly and admitted at the Lokmanya Tilak Municipal Medical College and Hospital, Mumbai from January 2015 till July 2016. After obtaining approval of the institutional ethics committee, all the eligible patients were interviewed for socio-demographic variables, clinical history and examination and risk factors for COPD. Post- bronchodilator spirometry and imaging studies were performed on the study patients, based on which patients were classified as per the GOLD criteria and BODE index. Associations between various risk factors and severity of pulmonary function impairment and prognosis was analysed. Results: During the study period 50 patients were included in the study. Body mass index and two dimensional echocardiography findings of pulmonary artery hypertension were found to be significantly associated with the staging of pulmonary function according to GOLD staging criteria. Additionally, statistically significant association between BODE index and smoking index, body index and two dimensional echocardiography findings of pulmonary artery hypertension (p value less than 0.01, 0.01 and 0.05 respectively) was found. We found higher creatinine levels, leucocyte count and acute on chronic type 2 respiratory failure to be significantly associated with death. Conclusion: Patient variables have a strong association with severity and prognosis of COPD.

Utility of Cerebrospinal Fluid Adenosine Deaminase and C-Reactive Protein in patients with Meningitis

Introduction: We aimed to assess the utility of cerebrospinal fluid (CSF) Adenosine deaminase (ADA) and C-reactive protein (CRP) in differentiating various types of meningitis in adult population. Materials and methods: The present observational study, conducted in the Department of Medicine, Lokmanya Tilak Municipal Medical College and Hospital from February 2016 till August 2017, included all meningitis and meningococcemia cases diagnosed according to the clinical and/or laboratory criteria during the study period were included in the study. Comparisons were made with respect to various biochemical investigations between patient groups diagnosed with various types of meningitis. Results: 38% were diagnosed as bacterial meningitis, 54% as tubercular meningitis and rest as viral meningitis. CSF ADA was significantly higher in tubercular meningitis as compared to bacterial or viral meningitis. Similarly, CSF CRP was found to be significantly higher among patients with bacterial meningitis. In tubercular meningitis, CSF ADA and CRP were not found to be significantly associated with CSF cell count, CSF protein or ratio of CSF/Blood glucose. In bacterial meningitis, CSF CRP was found to be significantly higher among patients with CSF protein between 101 to 200 mg/dl. Using a cut off value of 5 IU/L, CSF ADA was found to have a sensitivity of 100% and specificity of 91.3% in diagnosing tubercular meningitis and with cut off value of 9 mg/L, CSF CRP had a sensitivity of 97% and specificity of 100% in diagnosing bacterial meningitis. Conclusion: CSF ADA and CRP should be included in the workup of meningitis patients.

Clinico-epidemiological profile of meningitis patients diagnosed at a tertiary care hospital in Mumbai

Introduction: Meningitis is an inflammatory disease of the leptomeninges, the tissues surrounding the brain and spinal cord. Recently improved awareness, extensively available antibiotics and vaccines can change the epidemiological pattern of the disease. Materials and methods: The present observational study was conducted in the Department of Medicine, Lokmanya Tilak Municipal Medical College and Hospital from February 2016 till August 2017. The study population consisted of 100 patients admitted with features of acute meningitis. All meningitis and meningococcemia cases diagnosed according to the clinical and/or laboratory criteria during the study period were included in the study. Demographic and clinical data of the patients were recorded. Results: Of all the patients included in the study, 38% were diagnosed as bacterial meningitis, 54% as tubercular meningitis and rest as viral meningitis. All patients presented with symptoms of fever and neck stiffness. Headache, vomiting and altered sensorium were other common complaints. Most common CT head findings were that of a basal meningeal enhancement (89%). CSF was clear in 62% of the patients and raised erythrocyte count was observed in 74% of the patients. Mean adenosine deaminase (ADA) of the CSF in the study population was 7.93 ± 6.24 IU/L, ranging from 1 to 43 IU/L. Mean CSF C-reactive protein (CRP) in the study was 5.83 ± 7.11 mg/L, ranging from 0 to 25 mg/L. Conclusion: Understanding the current and future trends in meningitis are needed to improve the quality of patient care and outcomes.

Acute renal failure in pregnancy at a tertiary level hospital in Mumbai: An epidemiological profile.

Background: To study the clinical profile of pregnancy related acute renal failure, management and outcome in terms of cure, maternal morbidity and maternal – fetal mortality. Methods: This is a prospective observational study carried out on hospitalized patients in our hospital over a period of fourteen months (August 2007 – September 2008) after approval from the ethical clearance committee. Results: A total of 41 patients, with age ranging between 15 – 45 years. The majority of the patients 25 (60.98%) were multigravida and 16 (39.02%) were primigravida. The bimodal frequency pattern were also observed in our study, first between 19 to 24 weeks of gestation and second around 31 to 36 weeks of gestation. The incidence of PR-ARF was about 1 in 270 pregnancies. Sepsis was the commonest cause of PR-ARF (46.34 %) followed by Toxaemia of Pregnancy (31.69%) and Haemorrhage (14.62%). The incidence of septic abortion as a cause of PR-ARF has declined to 7.31%. Oliguria was the commonest symptom (58.53%). Fluid overload was the most common complication encountered (33.33%). Conclusion: Incidence of PR-ARF is still high in our country as compared to western countries. Multigravidas were more commonly affected than primigravidas. Sepsis was the commonest cause of PR-ARF followed by toxaemia of pregnancy and haemorrhage. Maternal and fetal mortality were high , 17.07 % and 2.43 % respectively.