Knowledge, Attitude and Practice in Medical Management of Glaucoma: A Cross-sectional Study from a Tertiary Care Hospital at Uttarakhand, India

introduction: Glaucoma is most common cause of irreversible blindness in the world. Hence, awareness about the disease, importance of drugs effect and its side-effects and accurate method of eye drop instillation is very crucial. Aim(s): To assess Knowledge, Attitude and Practice (KAP) at the medication, doctor and patient level in clinical practice. Material(s) and Method(s): It was a cross-sectional, descriptive, questionnaire based study conducted at Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India, for duration of two years from July 2020 to June 2022. It included 290 patients diagnosed with glaucoma. They were asked to demonstrate method of instillation of eye drop to assess correct method and to cover a few aspects of questionnaire regarding medication instillation. The statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software version 21.0. The p-value was determined for questions in the questionnaire using Chi-square test. The p-value <0.05 was considered significant. Result(s): About 88 (30.34%) patients were educated about the nature and progression of glaucoma. Punctal occlusion was explained to 40 (13.79%) patients and assisted instillation to 25 (8.62%) patients. Approximately 62 (70.45%) patients were educated about their disease. About 244 (84.14%) patients noticed that their ophthalmologist clinic had a television in Outpatient Department (OPD). Family screening was advised in only 67 (23.1%) of the patients. Only 53 (18.28%) patients were emphasised on strict control of associated systemic illness. conclusion: Proper patient education about glaucoma and treatment by healthcare provider plays a crucial role. Most of the patients were not educated about method of instillation of drops. Correct instillation of drops was crucial to achieve target Intra Ocular Pressure (IOP), minimising side-effects and reducing the cost of treatment. Family screening and control of associated systemic conditions were often missed by majority of ophthalmologists however, it is important to keep in mind. Copyright © 2022 Journal of Clinical and Diagnostic Research. All rights reserved.

Intravenous Branched Chain Amino Acid Infusion Is Associated with Early but Ill-Sustained Recovery of Overt Hepatic Encephalopathy in Acute-on- Chronic Liver Failure: A Pilot Protocol

Background: Hepatic encephalopathy (HE) in acute-on- chronic liver failure (ACLF) is associated with significant morbidity and mortality. There is paucity of data regarding HE management in patients with ACLF and most of the evidence is extrapolated from patients with cirrhosis. We conducted a prospective, randomized controlled clinical trial to study the efficacy of intravenous branched chain amino acids (IV-BCAA) with lactulose versus lactulose alone for improvement in HE scores at 24h, day 3 & day 7. Duration of ICU stay and survival at days 7 and 28 was compared. Method(s): CANONIC ACLF patients with HE grades >= 2 were assessed for eligibility and randomized into two groups -experimental arm (IV-BCAA -500mL/ day for 3 days + Lactulose;n=39) and comparator arm (Lactulose alone;n=37). Six patients developed COVID-19 after randomization & were excluded (4-experimental arm & 2-comparator arm). Grade of HE was assessed by West Haven Classification and Hepatic Encephalopathy Scoring Algorithm (HESA). ACLF severity was determined by CLIF-C ACLF and MELD scores. All patients received standard of care for HE and ACLF management. Result(s): Both groups were similar in baseline characteristics including grade of HE (2.85 +/- 0.75 vs 2.82 +/- 0.66;P = 0.864) and CLIF-C ACLF score (54.19 +/- 5.55 vs 54.79 +/- 5.74;P = 0.655). Overall survival was 40% at 28 days (48.5% vs 31.4%;P=0.143). Significant improvement in HESA score by >=1 grade at 24h was seen in 14 patients (40%) in BCAA arm and 6 patients (17.14%) in control group (P=0.034) which translated to a shorter ICU stay in the BCAA arm (Table 1). Median change in HESA score at 24h was significantly more in BCAA arm than control arm (P=0.006), however, this was not sustained at day 3 or 7. Ammonia levels did not correlate with the grade of HE (Spearman's correlation coefficient(rho) = -0.0843;P=0.295). Conclusion(s): Intravenous BCAA leads to early but ill-sustained improvement in grade of HE and reduced ICU stay in ACLF.

Predictors of venous thromboembolism in hospitalised COVID-19 positive patients

Background: Inpatients with COVID-19 have a high rate of venous thromboembolism (VTE), yet those that are most unwell have been shown to exhibit excess bleeding following thromboprophylaxis. Risk profiling of those at highest thrombotic risk may therefore improve outcomes. Aim(s): To derive and validate a risk assessment model for VTE in COVID-19 inpatients. Method(s): Electronic health records were used to assess all patients admitted for >=1 night with laboratory-confirmed COVID-19 between March 2020 and July 2021 to Barts Health NHS Trust in East London. The primary event of interest was VTE within 28 days from diagnosis. The study population was split into derivation (n = 4655) and validation sets (n = 1844). Potential predictors of VTE included demographic and lifestyle variables, clinical characteristics, and biomarkers. A logistic regression model was developed with predictors identified using least absolute shrinkage and selection operator (LASSO) methodology. Result(s): The study population comprised 6499 patients (45% women, median age 60). 394 patients (6.1%) were diagnosed with >=1 VTE event (30 DVT, 364 PE +/-DVT) within 28 days of diagnosis. D-dimer on admission was the strongest predictor for VTE. The risk of VTE was associated with increasing D-dimer up to 10 mg/L. Further rises in D-dimer above this level did not confer additional risk. Chronic cardiac disease, chronic obstructive pulmonary disease, and oxygen flow rate were also independently associated with increased risk. High peripherally measured oxygen saturations, ischaemic heart disease and supraventricular arrhythmias were associated with a reduced risk of VTE (Figure 1). The risk assessment model offered a strong discriminatory value (c-index 0.77) and achieved good calibration in both the derivation and validation set (Table 1). Conclusion(s): The proposed model was robust in predicting VTE risk in successive waves of COVID-19 infection (original, alpha and delta variants) and supports the use of the D-dimer level for guiding thromboprophylaxis. (Table Presented).

Intravenous branched chain amino acid infusion is associated with early but ill-sustained recovery of overt hepatic encephalopathy in acute-on-chronic liver failure: a pilot protocol

Background and Aim: Hepatic encephalopathy (HE) in acute-on-chronic liver failure (ACLF) is associated with significant morbidity and mortality. There is limited evidence regarding HE management in patients with ACLF. We conducted a prospective, randomized controlled clinical trial to study the efficacy of intravenous branched chain amino acids (IV-BCAA) with lactulose versus lactulose alone for improvement in HE at 24h, day 3 & day 7. Duration of ICU stay and survival at days 7 and 28 was compared. Methods: CANONIC ACLF patients with HE grades>=2 were randomized into two groups - experimental arm (IV-BCAA - 500mL/day for 3 days + Lactulose;n=39) and comparator arm (Lactulose alone;n=37). Six patients developed COVID-19 after randomization & were excluded (4-experimental arm & 2-comparator arm). HE Grade was assessed by West Haven Classification and Hepatic Encephalopathy Scoring Algorithm (HESA). ACLF severity was determined by CLIF-C ACLF and MELD scores. All patients received standard of care. Results: Both groups were similar in baseline characteristics including grade of HE (2.85 ± 0.75 vs 2.82 ± 0.66;P = 0.864) and CLIF-C ACLF score (54.19 ± 5.55 vs 54.79 ± 5.74;P = 0.655). Overall survival was 40% at 28 days (48.5% vs 31.4%;P=0.143). Significant improvement in HESA score by 1 grade at 24h was seen in 14 patients (40%) in BCAA arm and 6 patients (17.14%) in control group (P=0.034) which translated to shorter ICU stay in the BCAA arm. Median change in HESA score at 24h was significantly more in BCAA arm than control arm (P=0.006), however, this was not sustained at day 3 or 7. Ammonia levels did not correlate with HE grade (Spearman correlation coefficient (-0.0843;P=0.295). Conclusion: Intravenous BCAA leads to early but ill-sustained improvement in grade of HE and reduced ICU stay in ACLF.

2022 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer, including patients with COVID-19

The International Initiative on Thrombosis and Cancer is an independent academic working group of experts aimed at establishing global consensus for the treatment and prophylaxis of cancer-associated thrombosis. The 2013, 2016, and 2019 International Initiative on Thrombosis and Cancer clinical practice guidelines have been made available through a free, web-based mobile phone application. The 2022 clinical practice guidelines, which are based on a literature review up to Jan 1, 2022, include guidance for patients with cancer and with COVID-19. Key recommendations (grade 1A or 1B) include: (1) low-molecular-weight heparins (LMWHs) for the initial (first 10 days) treatment and maintenance treatment of cancer-associated thrombosis;(2) direct oral anticoagulants for the initial treatment and maintenance treatment of cancer-associated thrombosis in patients who are not at high risk of gastrointestinal or genitourinary bleeding, in the absence of strong drug-drug interactions or of gastrointestinal absorption impairment;(3) LMWHs or direct oral anticoagulants for a minimum of 6 months to treat cancer-associated thrombosis;(4) extended prophylaxis (4 weeks) with LMWHs to prevent postoperative venous thromboembolism after major abdominopelvic surgery in patients not at high risk of bleeding;and (5) primary prophylaxis of venous thromboembolism with LMWHs or direct oral anticoagulants (rivaroxaban or apixaban) in ambulatory patients with locally advanced or metastatic pancreatic cancer who are treated with anticancer therapy and have a low risk of bleeding.

Rv thrombus-a hidden iceberg behind sudden deterioration in a COVID-19 patient

Patients with COVID-19 pneumonia are at higher risk of developing thromboembolic events including pulmonary embolism, deep vein thrombosis, ischemic stroke, and myocardial infarction. We report a case of a patient who developed a right sided ventricular thrombus despite being on therapeutic anticoagulation. A 49-year-old man with no past medical history was admitted to the hospital due to COVID-19 pneumonia. He was started on therapeutic Enoxaparin due to D-dimer of 17710ng/ml. Lower extremity duplex was negative for deep vein thrombosis. Patient was enrolled in Sarilumab trial and received the intervention on day 3 and 4 of admission. Initially patient's oxygen requirements decreased, and D-dimer levels trended down. But on day 11, patient was hypotensive, hypoxic to 84% on 5L NC. Differentials included-Pulmonary embolism, Progression of COIVD-19 pneumonia, ARDS, superimposed bacterial pneumonia. Further workup included repeat chest x-ray which showed resolving bilateral infiltrates. D-dimer was 4388ng/ml. A bedside echocardiogram showed right ventricular dilation and a large mobile echo-dense mass measuring 12mm∗11mm compatible with a Right Ventricular thrombus. CT chest revealed right lower lobe pulmonary embolus and evidence of right heart strain. Patient was transferred to the ICU. Enoxaparin was stopped, a bolus of tissue plasminogen activator (tPA) 50mg was administered over 2 hours followed by a 1mg/hr infusion. Heparin drip with a PTT goal of 30-50 seconds was administered simultaneously for 24 hours. Fibrinogen levels were checked every 6 hours to ensure levels remained above 150 mg/dl. After 24 hours, echocardiogram showed persistent RV mobile thrombus and McConnell's sign. The above infusion protocol was repeated for 24 hours. After tPA infusion patient O2 requirements down trended from nonrebreather 15L to NC 5L. Repeat echo showed resolution of RV thrombus. Repeat CTPE had no new filling defects. There were no bleeding events. Patient was transitioned to apixaban and transferred stable to the floors. Patients with COVID-19 are at higher risk of developing hypercoagulability and it is associated with a worse prognosis. Bedside echocardiogram is a rapid accessible test that can be used in acute decompensating patients. Consecutive doses of tPA appear to be a safe and effective option for the treatment of right heart thrombus. Infusion endpoint for such patients include significant bleeding, drop in hemoglobin by 2 g/dl, fibrinogen <150mg/dl, and/or thrombus resolution on echocardiogram. Our patient showed improvement after tPA infusion perhaps by the thrombus lysis or lysis of the microthromboemboli and fibrin deposits of the pulmonary microvasculature.

Heuristic “bottom-up”: Covid-19

Background: COVID 19, a global pandemic has led to the disruption all over the world. Not only the COVID outbreak but the measures taken to straighten the curve led to the psychological distress amongst people. The disruption in daily routine which changed People’s lifestyle, the changed business working environment while COVID and post COVID. The concept to adapt to the new normal still seems abrupt. Method: This present study was done amongst Indian youth and working professionals (age 18-28) in order to understand their psychological well-being in these COVID times. With collection of data through an online questionnaire more than 350 people participated. The instrument used was DASS-21 and a self-conceptualized VIRUS scale. All statistical analysis was computed through SPSS 21. Conclusion: This paper aims to contribute through exploration into the stressors and how the COVID situation has brought about vexation, immediate concern, routine disruption and uncertainty about future. Through these four factors we obtain results that elaborates on what will affect their life’s the most, highlighting the need for post-COVID interventional strategies in business environments and in one’s lifestyle. © 2020, Institute of Medico-Legal Publications. All rights reserved.