Psychosocial impact of SARS- CoV-2 outbreak on patients with pediatric-onset systemic lupus erythematosus and their caregivers.

Aim: To assess distress, insomnia, and psychosocial impact of SARS-CoV-2 outbreak on children with SLE and their caregivers. Methods: Patients with pSLE undergoing treatment in the Department of Pediatrics, PGIMER, Chandigarh, and their caregivers were enrolled. Questionnaires were sent to eligible patients and their parents through email or WhatsApp and telephonic interviews were conducted. Self-designed SLE-COVID-19 stress questionnaire; Peritraumatic Distress Inventory; Insomnia Severity Index, Positive and Negative Affect Schedule were used. Ethical approval was sought from Institutes Ethics Committee (IEC/2020/000583). Results: Telephonic connection was possible with 80 families (160 participants). Telephonic contact was possible with 80 families (160 participants); off these 61 children with pSLE (78.2%) and 55 caregivers (70.5%) responded to the questionnaire. Among participants, 23% patients, and 21.8% caregivers were severely stressed about SARS-CoV-2 infection; 78.7% patients and 80% caregivers had heard about hydroxychloroquine (HCQ) being used for the treatment of COVID-19; 52.7% caregivers exhibited moderate concern about shortage of HCQ; and 52.5% patients, and 43.6% caregivers were worried about side effects of HCQ. We found that 20 (32.8%) patients and 18 (32.7%) caregivers experienced significant distress. Majority of participants reported sleep disturbances. High positive affect scores were seen in 40 (65.5%) patients and 43 (78.2%) caregivers, low positive affect scores were noted in 21 (34.5%) patients and 12 (21.8%) caregivers. Conclusion: Patients with pSLE and their caregivers are at risk of psychosocial problems during the COVID-19 pandemic. Psychological interventions can be very helpful.

COVID-19 associated Mucormycosis (CAM): Implications for perioperative physicians - A narrative review.

Mucormycosis once considered a rare disease with an incidence of 0.005 to 1.7 per million, has become one of the greatest menaces during the coronavirus disease (COVID-19) pandemic. India alone has contributed to nearly 70% of the global caseload of COVID-associated mucormycosis (CAM) and it had even been declared as a notifiable disease. Second wave of COVID-19 pandemic saw a steep rise in the incidence of mucormycosis and these patients have been presenting to anesthesiologists for various surgical procedures due to its primary or secondary sequelae. Rhino-orbito-cerebral mucormycosis (ROCM) is the commonest manifestation and is caused by Rhizopus arrhizus. Injudicious use of corticosteroids in vulnerable patients could have been a major contributing factor to the sudden rise in ROCM during the pandemic. Concerns related to anesthetic management include COVID-19 infection and post COVID sequalae, common presence of uncontrolled diabetes mellitus, possibility of difficult mask-ventilation and/or intubation, various drug therapy-associated adverse effects, and interaction of these drugs with anesthetic agents. Thorough preoperative optimization, multidisciplinary involvement, perioperative care, and vigilance go a long way in improving overall outcomes in these patients.

Thermotropic effects of PEGylated lipids on the stability of HPPH-encapsulated lipid nanoparticles (LNP).

In this work, we demonstrate the enhanced thermal and steric stability of lipid-based formulations in the presence of encapsulated HPPH that have demonstrated potential cancer applications in previously presented in vivo studies. Differential scanning calorimeter (DSC) was used to study the phase transitions, and domain formations, and to qualify the thermodynamic properties associated with change in lipid bilayer behavior due to the presence of PEGylated at varying concentrations and sizes, and the encapsulated HPPH molecules. Thermal instability was quantified by dramatic changes in calculated enthalpy, and the shape of the melting peak or calculated half width of melting peak. This systematic study focused on understanding the effects of varying molecular mass and concentrations of PEG polymers in the photopolymerizable lipid DC8, 9PC lipid bilayer matrix for four weeks at room temperature of 25 °C. The major findings include increased thermal stability of the lipid bilayer due to the presence of PEG-2 K and the HPPH that resulted from the van der Waals forces between various molecular species, and the change in bilayer curvature confirmed via mathematical correlations. It is demonstrated that the encapsulation of therapeutics in lipid formulations can alter their overall thermal behavior, and therefore, it is imperative to consider calorimetric effects while designing lipid-based vaccines. The presented research methodologies and findings presented can predict the stability of lipid-based vaccines that are under development such as COVID-19 during their storage, transport, and distribution.

Do children with severe acute respiratory infection need cohorting & isolation before screening for COVID-19?

This retrospective analysis was done to ascertain the SARS-CoV-2-positivity rate in children (0-12 yr) with severe acute respiratory infection (SARI) and compare it to those without SARI to determine the need for running a dedicated SARI isolation facility for paediatric COVID-19 care. The case records of 8780 children (0-12 yr) admitted and/or tested for SARS-CoV-2 between June 2020 and May 2021 at a tertiary care centre in north India were analyzed. The overall SARS-CoV-2 reverse transcription (RT)-PCR positivity rate was 3.0 per cent (262/8780). There were 1155 (13.15%) children with SARI. Fifty of these 1155 (4.3%) children with SARI, as against 212 of the 7625 (2.8%) children without SARI, tested positive for COVID-19. The absolute difference in the positivity rate among SARI and non-SARI groups was only 1.54 per cent which translates to cohorting and isolating 65 children with SARI to pick up one extra SARS-CoV-2-positive child (compared to those without SARI). The positive predictive value of SARI as a screening test was 4.3 per cent. Our findings suggest that isolation of children with SARI as a transmission-prevention strategy for COVID-19 may not be required. This is particularly relevant in resource-limited settings.

A Cross-Sectional Study to Ascertain the Effect of COVID-19 Pandemic on Regional Anaesthesia Practices Amongst Anaesthesiologists of India

Background and aims Regional anaesthesia has been advocated as a preferred modality during the coronavirus disease 2019 (COVID‑19) pandemic, but pursuing regional anaesthesia during COVID-19 is challenging. Our cross-sectional survey aimed to analyze the challenges in conducting regional anaesthesia and the alterations in practices imposed by the COVID‑19 pandemic across the nation. Material and methods The questionnaire was validated by seven experts. Following ethical approval and trial registration, this Google Forms-based survey was circulated to anaesthesiologists across the country via emails over 3 months (April 2021 to June 2021). Weekly reminders were sent to the non-responders till the desired sample size was attained, after which the survey was closed and responses were analyzed. Results Five hundred and thirty-two of 1100 anaesthesiologists completed the survey (48.3% response rate). Among the 532 respondents, 65.8% reported an increase in the use of regional anaesthesia due to the pandemic, with 77.4% reporting a change in practice. Almost 90% of the respondents used a dedicated operation theatre for all infected patients. Most respondents (75%) used disposable plastic drapes (75%) and full personal protective equipment (PPE) for COVID-19-positive patients during the procedure. However, using PPE resulted in poor vision due to fogging and multiple attempts and increased performance duration. Most respondents (74.4%) used gloves to maintain ultrasound probe sterility, while many other respondents (65.7%) used a sterile camera cover for the same. Many respondents ordered inflammatory markers during preoperative evaluation. Conclusion The present survey revealed that there was increased utilization of regional anaesthesia with increased utilization of PPE, sterility routines, and ordering of investigations. The use of PPE led to many challenges while performing regional anaesthesia. However, many deviations were identified from the accepted recommendations, and one needs to be aware of proper practices to achieve optimal patient outcomes and provider safety.

Nationwide impact of COVID-19 pandemic on postgraduate medical teaching, research, and mental stress: A cross-sectional online questionnaire-based survey.

Background and Aims: Coronavirus disease-2019 (COVID-19) pandemic has affected postgraduate medical education, training, and ongoing research work across specialties. Our survey aimed to analyze the effect of COVID-19 on challenges in pursuing research and academics and ascertain the stressors on residents across medical specialties. Material and Methods: The questionnaire was validated by 10 experts and following ethical approval, this google form-based survey was circulated to postgraduates across specialties across the country through social media platforms over 1 month (22 August 2020 to 21 September 2020). On clicking the link, the participants received brief information regarding the survey followed by the questionnaire. Weekly reminders were sent to the nonresponders till the desired sample size was attained, after which the survey was closed, and responses were analyzed. Results: Four hundred and nineteen of 900 residents completed the survey (46.6% response rate). Majority (88.8%) admitted that the inability to conduct the thesis and break in academics caused a significant amount of mental stress upon them. Though classes had resumed through online platforms for most residents (75.4%), the residents reported that lack of bedside learning (65.4%), inadequate progress tests (26.4%), and delay in thesis topic allotment (84.6% among those not allotted thesis) correlated with increased stress. Fear of extension of the course (53%; P = 0.019) and getting infected with COVID-19 (46.6%; P = 0.019) were most cited reasons for significant stress in most of the residents. Many residents (26%) were unable to sleep properly and 22.1% were unable to concentrate on academics. Majority believed that extension of the submission deadline, reduction in sample size, and change in topic would help to complete thesis. Conclusion: The present survey revealed that there is a major impediment to research and academics of medical postgraduates during COVID-19 pandemic which has markedly increased their stress levels.

Prevalence, severity, and risk factor of breakthrough infection after vaccination with either the Covaxin or the Covishield among healthcare workers: A nationwide cross-sectional study.

Background and Aims: The coronavirus disease-2019 (COVID-19) pandemic has grappled the entire globe since the beginning of 2020. In India, two vaccines were released in January 2021, the Covaxin® and the Covishield™. However, despite vaccination, many breakthrough infections were reported during the second wave in India. The present cross-sectional study aimed to find out prevalence, severity, and associated risk factors of breakthrough infection among healthcare workers (HCWs) vaccinated against COVID-19. Material and Methods: After ethical approval and CTRI registration, a validated questionnaire was circulated as Google form-based survey to HCWs across the nation through e-mail over 3 weeks. Biweekly reminders were sent to nonresponders till the desired sample size was attained, after which the survey was closed, and responses were charted. Data obtained from the responses were collated and analyzed. Results: A total of 1096 HCWs responded to the survey (54.8% response rate) and 23.36% had breakthrough infection. The severity of infection was more in the 30-50 years age group (P = 0.0170) and doctors belonging to clinical branches (P = 0.0005). The point estimate for effectiveness in preventing infection was significantly better with Covishield™ (78.5% vs. 72.4%) (P = 0.0260). Nearly all those who were infected after vaccination thought that vaccination decreased disease severity. Conclusion: Breakthrough COVID-19 infection still occurred after vaccination though the prevalence of severe infection was low. Covishield™ performed significantly better than Covaxin® in terms of preventing the disease. Clinical branches of medicine were found at a higher risk and younger HCWs or those with comorbidities had a higher severity of the disease.

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

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, et al. 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.

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

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.

Evaluation of Tele-rheumatology during the COVID-19 Pandemic in Asian Population: A Pilot Study.

OBJECTIVE: Rheumatoid arthritis (RA) is a chronic autoimmune condition associated with a potential for deformities. It is one of the common conditions to seek health care. Hence, the present study was conducted to assess the telemedicine services for patients suffering from rheumatoid arthritis during the COVID-19 pandemic in an Asian Indian population. METHODS: A prospective study was conducted (March 2020-June 2020) in the telemedicine department of a premier northern Indian tertiary care institution. Out of the total patients enrolled (N = 7577) in telemedicine services, 122 rheumatoid arthritis patients (1.6%) were followed for 1 month to assess change in functional status by modified Health Assessment Questionnaire (mHAQ). Telephonic interviews of the enrolled patients were conducted to determine the level of understanding of advice given by consultants, barriers during the consultation, and satisfaction with teleconsultations for rheumatology clinics. RESULTS: For the native people, language of the clinicians was the main barrier (20%) in telerheumatology. Saving of time and money was observed as beneficial factors for patients. More than three-quarters of all rheumatoid arthritis patients were ready to use teleconsultation in the near future. A similar proportion of patients were in support for the recommendation of these services to other persons. CONCLUSION: We report the successful use of telemedicine services in the evaluation and management of rheumatic diseases in the current COVID-19 pandemic situation.

Rare case of gastrointestinal mucormycosis with colonic perforation in an immunocompetent patient with COVID-19.

Primary gastrointestinal mucormycosis is a rare disease associated with an increased mortality and is rarely reported in an immunocompetent host. We report the first case of mucormycosis-associated colonic perforation in a COVID-19 patient with a favourable outcome. A 48-year-old healthy male doctor in home isolation due to COVID-19 was admitted to COVID-19 intensive care unit when his symptoms deteriorated. The patient was put on non-invasive ventilation (NIV) using Bilevel Positive Airway Pressure (BiPAP) and treatment given as per existing hospital protocol. The patient improved clinically, and was discharged on day 10 of admission. Two days later, he presented with acute gastrointestinal symptoms to the emergency department. A diagnosis of perforation peritonitis was made, the patient was stabilised and sigmoid colectomy with descending colon colostomy was done. A diagnosis of gastrointestinal mucormycosis was made and injectable antifungal was started. The patient was discharged after his general conditions improved.

Comparison of KingVision Videolaryngoscope channelled blade with Tuoren Videolaryngoscope non-channelled blade in a simulated COVID-19 intubation scenario by non-anaesthesiologists and experienced anaesthesiologists: a prospective randomised crossover mannequin study

Purpose A videolaryngoscope has been recommended for intubation in the COVID-19 scenario but the videolaryngoscope providing optimal intubation conditions is not ascertained. We compared KingVision channelled blade with a non-Channelled videolaryngoscope for intubation times in a simulated COVID-19 intubation scenario by both anaesthesiologists and non-anaesthesiologists. Methods This prospective randomised cross over mannequin study was conducted in a skill training lab. 25 anaesthesiologists and 25 non-anaesthesiologists donned in standard personal protective equipment performed 100 intubations with KingVision and Tuoren videolaryngoscopes in a mannequin covered with a transparent plastic sheet. The total intubation time, percentage of glottic opening scores, first attempt success rates were assessed. Results The mean difference in intubation times in anaesthesiologists and non-anaesthesiologist less with KingVision videolaryngoscope (21.1s;95% CI 9.6 to 32.6s vs. 35.9s;95% CI 24.4 to 47.4 s;P=0.001). Percentage of glottic opening score was significantly better with KingVision by non-anaesthesiologists (60;IQR 42.5 to 75 vs. 70;IQR 50 to 100;P=0.019). KingVision provided superior first attempt success rate in non-anaesthesiologists (84% vs. 61.9%;P=0.02) and anaesthesiologists (96% vs. 76%;P=0.12). Conclusion KingVision channelled videolaryngoscope provided faster intubation times, glottic views and first attempt success rates in a simulated COVID-19 scenario in manikins and might be preferred over videolaryngoscopes with non-channelled blade. The findings need to be further verified in humans.