Discharge Planning for People with Inpatient Hyperglycaemia: A Review on Pharmacological Management.

Inadequate glycaemic control post-discharge is the root cause of readmission in people with diabetes mellitus (DM) and is often linked to improper discharge planning (DP). A structured DP plays a crucial role in ensuring continuing home care and avoiding readmissions. DP should help patients in self-care and provide appropriate guidance to maintain optimal glycaemic control. There is a scarcity of reports and recommendations on the proper DP for people with DM on insulin therapy. The present review provides important consideration based on experts' opinions from the National Insulin and Incretin summit (NIIS), focusing on the effective treatment strategies at the time of discharge, especially for insulin therapy. A review of literature from PubMed and Embase was conducted. The consensus was derived, and recommendations were made on effective DP for patients with DM. Recommendations arrived at the NIIS for post-discharge treatment for medical and surgical cases, stress-induced hyperglycaemia, elderly, pregnant women, and coronavirus disease 2019 (COVID-19) cases. The committee also recommended a comprehensive checklist to assist the physicians during discharge.

Management of Obese Type 1 Diabetes Mellitus (Double Diabetes) Through Telemedicine During COVID-19 Pandemic Lockdown: A Case Report.

Metabolic syndrome in Type 1 diabetes mellitus (T1DM) has been shown to be an independent risk factor for macro-vascular and micro-vascular complications. Obesity also affects many people with T1DM across their lifetime with an increasing prevalence in recent decades. Individuals with T1DM who are overweight, have a family history of type 2 diabetes, and/or have clinical features of insulin resistance, are known as "double diabetes". It is challenging for a person with double diabetes to achieve reasonable glycemic control, avoid insulin-related weight gain, and prevent hypoglycaemia. This was especially true during the coronavirus disease 2019 (COVID-19) pandemic lockdown. The aim of this report is to show that lifestyle modification through telemedicine can immensely help in managing uncontrolled T1DM with associated morbid obesity in lockdown situations, with the help of the diabetes educator. In this case, the complicated history of double diabetes was taken through telephonic and online consultations with the help of a nutritionist and diabetes educator, and the treating clinician supervised the insulin doses and frequency. Patient Health Questionnaire (PHQ)-9 questionnaire was used to assess depression. Medical nutrition therapy (MNT) was given through online consultations, where the patient was reoriented to carbohydrate counting, insulin dose adjustment, along with modifications in the diet. Regular exercise was advised along with frequent self-monitoring of blood glucose (SMBG). Moreover, the diet order was changed to eat protein and fibre first, followed by carbohydrates, later. The three-tier system of the medical expert, clinical dietitian, and diabetes educator was applied. The subject was trained for carbohydrate counting and insulin dose adjustment by teaching her about the insulin-to-carb ratio and insulin sensitivity factor (ISF). She was asked to examine her insulin injection sites by visual and palpatory methods for lipohypertrophy. Once a week, the diabetes educator and nutritionist did telephonic follow-up and counselling, while online consultation was done by the treating clinician once a month. As a result, her weight, BMI, and waist circumference were reduced drastically, and there was an improvement in haemoglobin A1C (HbA1C), lipid parameters, and blood pressure after the intervention. Thus, implementing diabetes education via telemedicine in circumstances such as the COVID-19 pandemic can help achieve the best possible compliance for strict diet adherence, regular exercise and monitoring, reducing obesity, glycosylated HbA1c, insulin doses, and risk of depression in a person with double diabetes.

Deep learning models for COVID-19 chest x-ray classification: Preventing shortcut learning using feature disentanglement.

In response to the COVID-19 global pandemic, recent research has proposed creating deep learning based models that use chest radiographs (CXRs) in a variety of clinical tasks to help manage the crisis. However, the size of existing datasets of CXRs from COVID-19+ patients are relatively small, and researchers often pool CXR data from multiple sources, for example, using different x-ray machines in various patient populations under different clinical scenarios. Deep learning models trained on such datasets have been shown to overfit to erroneous features instead of learning pulmonary characteristics in a phenomenon known as shortcut learning. We propose adding feature disentanglement to the training process. This technique forces the models to identify pulmonary features from the images and penalizes them for learning features that can discriminate between the original datasets that the images come from. We find that models trained in this way indeed have better generalization performance on unseen data; in the best case we found that it improved AUC by 0.13 on held out data. We further find that this outperforms masking out non-lung parts of the CXRs and performing histogram equalization, both of which are recently proposed methods for removing biases in CXR datasets.

Effective deep learning approaches for predicting COVID-19 outcomes from chest computed tomography volumes.

The rapid evolution of the novel coronavirus disease (COVID-19) pandemic has resulted in an urgent need for effective clinical tools to reduce transmission and manage severe illness. Numerous teams are quickly developing artificial intelligence approaches to these problems, including using deep learning to predict COVID-19 diagnosis and prognosis from chest computed tomography (CT) imaging data. In this work, we assess the value of aggregated chest CT data for COVID-19 prognosis compared to clinical metadata alone. We develop a novel patient-level algorithm to aggregate the chest CT volume into a 2D representation that can be easily integrated with clinical metadata to distinguish COVID-19 pneumonia from chest CT volumes from healthy participants and participants with other viral pneumonia. Furthermore, we present a multitask model for joint segmentation of different classes of pulmonary lesions present in COVID-19 infected lungs that can outperform individual segmentation models for each task. We directly compare this multitask segmentation approach to combining feature-agnostic volumetric CT classification feature maps with clinical metadata for predicting mortality. We show that the combination of features derived from the chest CT volumes improve the AUC performance to 0.80 from the 0.52 obtained by using patients' clinical data alone. These approaches enable the automated extraction of clinically relevant features from chest CT volumes for risk stratification of COVID-19 patients.

Design and model of facemask to inactivate the novel coronavirus

Due to the novel coronavirus spread (COVID-19) globally, governments across the world recommended the mandatory use of facemasks. The facemask helps people prevent and control the spread of virus infection. In this paper, we propose a design and model of facemask to inactivate the virus particles present in our surroundings. The proposed facemask is able to purify the air when a person inhales and exhales. The proposed mask is cost-effective, reusable, washable, and possesses the ability to disinfect the surface of facemask. The mask has the capability to trap all dust particles and virus present in the air, drastically decreasing the chance of infection. The mask is well-designed on the concept of activated carbon and copper filter.

Updates on Management of Leprosy in the Context of COVID-19 Pandemic: Recommendations by IADVL SIG Leprosy.

The Special Interest Group (SIG) on leprosy thought it to be prudent to revisit its previous practice recommendations through this update. During this period, the pandemic course shifted to a 'second wave' riding on the 'delta variant'. While the number of cases increased manifold, so did the research on all aspects of the disease. Introduction of vaccination and data from various drug trials have an impact on current best practices on management of diseases including leprosy. The beneficial results of using steroids in management of COVID-19, gives elbow room regarding its usage in conditions like lepra reactions. On the other hand, the increase in cases of Mucormycosis again underlines applying due caution while recommending immunosuppressants to a patient already suffering from COVID-19. This recommendation update from SIG leprosy reflects current understanding about managing leprosy while the dynamic pandemic continues with its ebbs and flows.

A Large London District General Hospital Highlights CLL and Bame As Risk Factors for Severe Disease Amongst Haematology-Oncology Patients

IntroductionThe earliest documented transmission of the coronavirus SARS-CoV-2, causing the disease Covid-19 occurred in the United Kingdom in February 2020. With data from Wuhan and Italy indicating a significant mortality rate in the region of 1-3% and identification of the risks of co-morbidities, hemato-oncology patients were quickly identified as being at a heightened risk from the virus due to baseline and chemotherapy induced immunosuppression. Data has shown that patients with cancer have a significantly higher incidence of severe events following infection with SARS-CoV-19 than those without cancer. Unlike many reported case series, our institution sees an unselected take of all hemato-oncology diagnoses within a large, ethnically-diverse locality and therefore provides an unfiltered snapshot of the impact of SARS-CoV-2 at an all-inclusive, population level.MethodsProspective data collection was carried out on all hemato-oncology patients admitted with a confirmed diagnosis of Covid-19 during March and April 2020 by reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay on a nasopharyngeal aspirate across two sites in one of London's largest District General Hospital Trusts. Our institution has a catchment area of 810 000 heads of population of which 38-46.5% are of black, Asian and minority ethnic (BAME) ethnicity depending on locality.ResultsWe identified a total of 30 hemato-oncology patients admitted with PCR proven SARS-CoV-19. Their baseline characteristics are shown in figure 1. When compared with our cancer registry data (Fig 2A) this highlights a disproportionate representation of BAME patients (57% of cases vs 26% of base population). Lymphoid malignancies and plasma cell dyscrasias (PCD) accounted for 90% of the admissions. CLL and PCD accounted for 30% and 23% respectively (Fig 2C).Co-morbidities were less prevalent than those seen in patient cohorts without hematological malignancy. 70% of patients had </=1 co-morbidity and only 29% had >/= 2 comorbidities (Fig 2B) highlighting that, unlike other non-oncology series, hematological malignancy alone acts as a major risk factor for serious illness. Hypertension and Diabetes were the most common risk factors, seen in 50% and 43% of patients respectively.The most common presenting features were cough (84%), fever (72%) and shortness of breath (80%). 16% had Gastrointestinal symptoms, but only seen in the context of concurrent respiratory symptoms. The vast majority (84%) had radiological changes consistent with a diagnosis of COVID-19.Our cohort had a mortality rate of 47%. Of those that died, 57% were from BAME groups and 43% were White. 71% of those that died had either CLL (6/14 cases) or multiple myeloma (MM) (4/14 cases). CLL appears to be an independent risk factor from age, as two of the patients with CLL that died were amongst the youngest in our cohort (47 years and 59 years). Two patients that died had Myelodysplastic syndrome, one had Diffuse large B cell lymphoma and one had Hodgkin's lymphoma. We found that age and number of co-morbidities were positively associated with death. Of the patients that died, 79% were 70 years of age or over and the majority of survivors were 60 years old or younger (56%). Lymphopenia was a consistent finding at diagnosis (median lymphocyte count 0.8 x 109/l), neutropenia was rare (median neutrophil count 5.9 x 109/l) and C-reactive protein was elevated in all cases (median value 169, range 42-473 mg/l).Of our 4 patients with plasma cell dyscrasias who died, 2 had end stage myeloma (4th line+ of therapy), 1 had primary refractory MM and 1 had plasma cell leukaemia, thus identifying these patients as extremely high risk from the outset.ConclusionIt is of great importance to identify patient and disease specific risk factors conferring poor risk amongst our hemato-oncology patients. With shielding, invariably comes the increased risk of morbidity from social isolation and delayed presentation of non-COVID illness. Our data shows that CLL and BAME patients appear to be at particular risk of sever illness and poor outcomes. In a local ethnically diverse population, our patients are at heightened risk of morbidity and mortality and must be offered all strategies for interventions that may reduce likelihood of becoming infected with COVID 19 and should be considered early for vaccination, convalescent plasma and monoclonal antibodies.

Post Covid-19 Infection Presenting as Rhino-Orbital Mycosis.

Rhino-orbital mycosis has been recently recognised as one of the sequelae in COVID-19 recovered patients. In India, detection of mucormycosis is declared as notifiable disease. In this article, the authors aim to describe the characteristics of patients presenting with post covid fungal infection which could be detected on 10% potassium hydroxide (KOH) wet mount and Giemsa stain put on crush biopsy smear. We describe 10 COVID-19 recovered patients admitted to ENT department of the hospital during second wave of COVID-19 infection. They presented with post covid fungal sinusitis and ophthalmic complications and planned for surgery. KOH mount and Giemsa stain were used for possible opinion and confirmed by culture. The observations were described in mean and percentages. All ten (100%) COVID-19 recovered patients were previously diagnosed with type 2 diabetes mellitus (DM) for 2-11 years. All 10 patients (100%) were given oral or intravenous corticosteroids for mean of 21 days (3 weeks-till presentation to ENT department). Simple procedures with 10% KOH mount and Giemsa stain could detect fungal hypae in all the cases and could provide possible opinion in 9 of 10 (90%) cases for timely management of the patients. The authors hypothesize that uncontrolled DM and prolonged use of corticosteroids may act as culprits of rhino-orbital mycosis in COVID-19 recovered patients. Simple and routine 10% KOH mount and Giemsa stain may provide early opinion of fungal hypae to ensure quick management and survival of the patients.

Feasibility of Conducting a Virtual Exit Exam in Neurosurgery During the SARS-COV19 Pandemic.

BACKGROUND: Skills assessment forms an integral part of the exit examination in neurosurgical training programs. The established method of evaluating trainees for their clinical knowledge and surgical proficiency in the operating room is not feasible in the current time of SARS-COV19 pandemic. OBJECTIVE: The feasibility of conducting such an assessment using case modules on an online meeting platform is discussed. METHODS: Six candidates were evaluated on two consecutive days with two internal examiners located at the examination site and two external examiners situated at their own institutions elsewhere in the country. Clinical details, including images and videos of patients managed at our institute were recorded and provided to the candidates as case modules. Four sessions were conducted in the form of long and short cases, operative neurosurgery, neuroradiology, and neuropathology and a general viva-voce using "Zoom" (Zoom-Video-Communications, Inc. USA) platform. Feedback from the examinee and the examiners were obtained for any modification in the current format. RESULT: The online platform worked well without any interruption except for slight lag in the audio-visual system and occasional difficulty in using microphone and screen simultaneously. Trainees were able to interpret the clinical details and rated this format close to actual clinical evaluation. The examiners uniformly agreed that the online format for assessment was satisfactory and made some suggestions for improvement. CONCLUSION: Clinical and surgical skill evaluation is feasible using case modules and online meeting platforms. Use of original patient's data, images, videos demonstrating clinical signs, and operative procedures makes this assessment more objective.

The collateral fallout of COVID19 lockdown on patients with head injury from north-west India.

BACKGROUND: The COVID19 lockdown has altered the dynamics of living. Its collateral fallout on head injury care has not been studied in detail, especially from low- and middle-income countries, possibly overwhelmed more than developed nations. Here, we analyze the effects of COVID19 restrictions on head injury patients in a high-volume Indian referral trauma center. METHODS: From the prospective trauma registry, clinico-epidemiological and radiological parameters of patients managed during 190 days before and 190 days during COVID19 phases were studied. As an indicator of care, the inpatient mortality of patients with severe HI was also compared with appropriate statistical analyses. RESULTS: Of the total 3372 patients, there were 83 head injury admissions per week before COVID19 restrictions, which decreased to 33 every week (60% drop) during the lock phases and stabilized at 46 per week during the unlock phases. COVID19 restrictions caused a significant increase in the proportion of patients arriving directly without resuscitation at peripheral centers and later than 6 h of injury. Though the most common mechanism was vehicular, a relative increase in the proportion of assaults was noted during COVID19. There was no change in the distribution of mild, moderate, and severe injuries. Despite a decrease in the percentage of patients with systemic illnesses, severe head injury mortality was significantly more during the lock phases than before COVID19 (59% vs. 47%, p = 0.02). CONCLUSIONS: COVID19 restrictions have amplified the already delayed admission among patients of head injury from north-west India. The severe head injury mortality was significantly greater during lock phases than before COVID19, highlighting the collateral fallout of lockdown. Pandemic control measures in the future should not ignore the concerns of trauma emergency care.

The Risk of Spread of Infection During Craniotomy/Craniostomy on Patients with Active Coronavirus Disease 2019 (COVID-19) Infection: Myth or Fact?

OBJECTIVES: Craniotomies/craniostomies have been categorized as aerosol-generating procedures and are presumed to spread coronavirus disease 2019 (COVID-19). However, the presence of severe acute respiratory distress syndrome coronavirus 2 virus in the generated bone dust has never been proved. Our objective is to evaluate the presence of virus in the bone dust (aerosol) generated during emergency neurosurgical procedures performed on patients with active COVID-19. This would determine the true risk of disease transmission during the surgery. METHODS: Ten patients with active COVID-19 infection admitted to our institute in 1 month required emergency craniotomy/craniostomy. The bone dust and mucosal scrapings form paranasal sinuses (if opened) collected during these procedures were tested for the virus using reverse transcription polymerase chain reaction. The entire surgical team was observed for any symptoms related to COVID-19 for 14 days following surgery. RESULTS: Nine patients had moderate viral load in their nasopharyngeal cavity, as detected on reverse transcription polymerase chain reaction. None of the samples of bone dust from these 10 patients tested positive. Mucosal scrapping obtained in 1 patient in which mastoid air cells were inadvertently opened tested negative as well. No health workers from the operating room developed COVID-19-related symptoms. CONCLUSIONS: The bone dust generated during craniotomy/stomy of active patients does not contain the virus. The procedure on an active patient is unlikely to spread the disease. However, a study with larger cohort would be confirmatory.

COVID-19: changing patterns among neurosurgical patients from North India, efficacy of repeat testing, and inpatient prevalence.

OBJECTIVE: COVID-19 has affected surgical practice globally. Treating neurosurgical patients with the restrictions imposed by the pandemic is challenging in institutions with shared patient areas. The present study was performed to assess the changing patterns of neurosurgical cases, the efficacy of repeated testing before surgery, and the prevalence of COVID-19 in asymptomatic neurosurgical inpatients. METHODS: Cases of non-trauma-related neurosurgical patients treated at the Postgraduate Institute of Medical Education and Research (PGIMER) before and during the COVID-19 pandemic were reviewed. During the pandemic, all patients underwent a nasopharyngeal swab reverse transcription-polymerase chain reaction test to detect COVID-19 at admission. Patients who needed immediate intervention were surgically treated following a single COVID-19 test, while stable patients who initially tested negative for COVID-19 were subjected to repeated testing at least 5 days after the first test and within 48 hours prior to the planned surgery. The COVID-19 positivity rate was compared with the local period prevalence. The number of patients who tested positive at the second test, following a negative first test, was used to determine the probable number of people who could have become infected during the surgical procedure without second testing. RESULTS: Of the total 1769 non-trauma-related neurosurgical patients included in this study, a mean of 337.2 patients underwent surgery per month before COVID-19, while a mean of 184.2 patients (54.6% of pre-COVID-19 capacity) underwent surgery per month during the pandemic period, when COVID-19 cases were on the rise in India. There was a significant increase in the proportion of patients undergoing surgery for a ruptured aneurysm, stroke, hydrocephalus, and cerebellar tumors, while the number of patients seeking surgery for chronic benign diseases declined. At the first COVID-19 test, 4 patients (0.48%) tested were found to have the disease, a proportion 3.7 times greater than that found in the local community. An additional 5 patients tested positive at the time of the second COVID-19 test, resulting in an overall inpatient period prevalence of 1%, in contrast to a 0.2% national cumulative caseload. It is possible that COVID-19 was prevented in approximately 67.4 people every month by using double testing. CONCLUSIONS: COVID-19 has changed the pattern of neurosurgical procedures, with acute cases dominating the practice. Despite the fact that the pandemic has not yet reached its peak in India, COVID-19 has been detected 3.7 times more often in asymptomatic neurosurgical inpatients than in the local community, even with single testing. Double testing displays an incremental value by disclosing COVID-19 overall in 1 in 100 inpatients and thus averting its spread through neurosurgical services.

Adaptations in Radiosurgery Practice during COVID Crisis.

BACKGROUND: The world is in the midst of the COVID crisis, which has forced the neurosurgical community to change its practices. OBJECTIVE: To advocate the necessary adaptations in radio surgical practices to effectively manage the radio surgical patients, resource utilization, and protecting the healthcare provider during the COVID pandemic. MATERIAL AND METHODS: In addition to the literature review, pertinent recommendations are made in respect to the gamma knife radiosurgery (GKRS). RESULTS: Every patient presenting to GKRS treatment should be considered as a potential asymptomatic COVID carrier. Patients should be categorized based on the priority (urgent, semi-urgent, or elective) on the basis of pathological and clinical status. The only urgent indication is a non-responding or enlarging cerebral metastasis. There is a high risk of aerosol dispersion during gamma radiation delivery in the gamma gantry. CONCLUSION: These recommendations should be used to minimize the chances of pathogenic exposure to the patient and caregivers both.

Geolocated Twitter-based population mobility in Victoria, Australia, during the staged COVID-19 restrictions.

Using geotagged Twitter data in Victoria, we created a mobility index and studied the changes during the staged restrictions during the coronavirus disease 2019 (COVID-19) pandemic. We describe preliminary evidence that geotagged Twitter data may be used to provide real-time population mobility data and information on the impact of restrictions on such mobility.

Diagnosis and principles of management of gestational diabetes mellitus in the prevailing COVID-19 pandemic.

BACKGROUND: Limited medical facilities are available due to Covid-19 pandemic. Nevertheless, all efforts should be made in planning judicial and possible methods of delivering health care, particularly to pregnant woman with GDM. GDM may play a crucial role in the increasing prevalence of diabetes and obesity and also may be the origin of cardiometabolic diseases. METHODS: It is mandatary to diagnose and care pregnant woman with GDM. The test suggested to diagnose GDM has to be evidence based and in this regard "a single test procedure" evaluated meets this requirement. This doable test has been accepted by the Diabetes in Pregnancy Study Group India (DIPSI) and approved by MHFW-GOI, WHO, International Diabetes Federation, and International Federation of Obstetricians and Gynecologists. MHFW-GOI also recommends testing at first antenatal visit and then at 24-28 weeks of gestation. This opportunity can also be utilized for performing ultrasonography for assessing fetal development. RESULT: The first-line management is MNT and life style modifications. Non-responders may require insulin or OHA. The target glycemic control is FPG ~ 5.0 mmol/dl (90 mg/dl) and 2 h PPPG ~ 6.7 mmol/dl (120 mg/dl). The goal is to obtain newborns birth weight appropriate for gestational age between 2.5 and 3.5 kg, a step to prevent offspring developing diabetes. CONCLUSION: The essential precaution required during COVID pandemic is to wear face mask, avoid crowded places, and maintain social distancing. Finally, the economical and evidence based "single test procedure" of DIPSI is most appropriate for screening during the COVID pandemic.

The Aftermath of COVID-19 Lockdown- Why and How Should We Be Ready?

INTRODUCTION: Severe acute respiratory syndrome, coronavirus 2 (SARS-COV 2) has inexplicably and irreversibly changed the way of neurosurgery practice. There has been a substantial reduction in neurosurgical operations during the period of lockdown. The lockdown might be the most effective measure to curtail viral transmission. Once we return to the normalization of the lifestyle, there will be a backlog of unoperated pending cases along with the possibility of further spread of the coronavirus. METHODS: We reviewed the available literature and protocols for neurosurgical practice in different geographic locations. We drafted a consensus statement based on the literature and protocols suggested by the World Health Organization (WHO) and various professional societies to prevent the spread of SARS-COV2 while streamlining the neurosurgical practice. RESULTS: The consensus statement suggests the patient triage, workflow, resource distribution, and operational efficacy for care providers at different stages of management. The priority is set at personal protection while ensuring patients' safety, timely management, and capacity building. We performed a detailed subsection analysis for the management of trauma and set up for COVID-free hospitals for simultaneous management of routine neurosurgical indications. In this time of medicolegal upheaval, special consent from the patients should be taken in view of the chances of delay in management and the added risk of corona infection. The consensus statements are applicable to neurosurgical setups of all capacities. CONCLUSION: Along with the glaring problem of infection, there is another threat of neurosurgery emergency building up. This wave may overwhelm the already stretched systems to the hilt. We need to flatten this curve while avoiding contagion. These measures may guide neurosurgery practitioners to effectively manage patients ensuring the safety of caregivers and care seekers both.

Proposal for the return to routine endoscopy during the COVID-19 pandemic.

In response to the coronavirus disease 2019 (COVID-19) pandemic, many jurisdictions and gastroenterological societies around the world have suspended nonurgent endoscopy. Subject to country-specific variability, it is projected that with current mitigation measures in place, the peak incidence of active COVID-19 infections may be delayed by over 6 months. Although this aims to prevent the overburdening of healthcare systems, prolonged deferral of elective endoscopy will become unsustainable. Herein, we propose that by incorporating readily available point-of-care tests and conducting accurate clinical risk assessments, a safe and timely return to elective endoscopy is feasible. Our algorithm not only focuses on the safety of patients and healthcare workers, but also assists in rationalizing the use of invaluable resources such as personal protective equipment.