Pre-pandemic autonomic function as a predictor of the COVID clinical course in young adults.

Long coronavirus disease (COVID) is emerging as a common clinical entity in the current era. Autonomic dysfunction is one of the frequently reported post-COVID complications. We hypothesize a bi-directional relationship between the autonomic function and the COVID course. This postulation has been inadequately addressed in the literature. A retrospective cohort (pre and post-comparison) study was conducted on 30 young adults whose pre-COVID autonomic function test results were available. They were divided into case and control groups based on whether they tested reverse transcription polymerase chain reaction positive for COVID-19. Autonomic function tests were performed in both the case and control groups. COVID infection in healthy young adults shifts the sympatho-vagal balance from the pre-disease state. Postural orthostatic tachycardia syndrome was present in 35% of the COVID-affected group. COVID course parameters were found to be associated with parasympathetic reactivity and the baroreflex function. Baseline autonomic function (parasympathetic reactivity represented by Δ heart rate changes during deep breathing and 30:15 ratio during lying-to-standing test) was also associated with the COVID course, the post-COVID symptoms and the post-COVID autonomic function profile. Additionally, multiple regression analysis found that the baseline parasympathetic reactivity was a very important determinant of the clinical course of COVID, the post-COVID symptoms and the post-COVID autonomic profile. Sympatho-vagal balance shifts to parasympathetic withdrawal with sympathetic predominance due to COVID infection in healthy young adults. There is a bi-directional relationship between the autonomic function and the COVID course.

Cadaver dissection for oculoplastic procedures: A beginner's guide.

The purpose of this article is to form a basic guide for beginning the cadaver dissection training programs focused on oculoplastic surgical procedures. Ours was a collaborative study between the departments of Ophthalmology and Anatomy in a tertiary care teaching institute. We formed a step-wise approach to begin the cadaver dissection focused on the oculoplastic surgical procedures. The basics of cadaver procurement, processing, and preparation for dissections were described. The operative requirements of trainees, surgical handling of cadavers, and basic oculoplastic surgical steps were discussed. The types of embalming (cadaver preservation process) and steps have been described in detail. We have emphasized the preoperative discussion about the proposed dissections using standard teachings and skull models for easier understanding. Additional helping tools like soft embalming and injectable substances for better intra-dissection understanding (intra-arterial, intravenous and orbital injections) have been described. Post-dissection cadaver handing and soft-tissue disposal protocols have also been described. Overall, the cadaver dissections provide holistic surgical learning for the residents, specialty trainees, and practitioners. This article may act as a basic step-wise guide for starting the cadaver-based oculoplastics lab dissection in various institutes and workshops.

SARS-CoV-2 Mutations Responsible for Immune Evasion Leading to Breakthrough Infection.

BACKGROUND AND OBJECTIVES: India had faced a devastating second outbreak of COVID-19 infection, in which a majority of the viral sequences were found to be of the B.1.617.2 lineage (Delta-variant). While India and the world focused on vaccination, reports of vaccine-immunity evasion by the virus, termed "breakthrough cases", emerged worldwide. Our study was focused on the primary objective to identify the mutations associated with breakthrough infections SARS-CoV-2. METHODS: In our study, we extracted the SARS-CoV-2 RNA (ribonucleic acid) from reverse transcription-polymerase chain reaction (RT-PCR) positive COVID-19 patients, and 150 random samples were sent for sequencing to the Centre for Cellular & Molecular Biology, Hyderabad. Whole genome sequences of 150 SARS-CoV-2 viral samples were analyzed thoroughly. We mostly found B.1.617 and its sub-lineages in the genomic sequencing results. RESULTS AND INTERPRETATION: On further analysis of patient data, it was seen that nine patients had been vaccinated against the SARS-CoV-2 previously. These nine patients had B.1.617/B.1 or A strains, and all of them had similar genomic variations in spike proteins as well as non-structural proteins (NSPs). The mutations seen in these sequences in the Spike (S), NSPs, and open reading frame (ORF) regions would have produced amino acid changes known to improve viral replication, confer drug resistance, influence host-cell interaction, and lead to antigenic drift. CONCLUSIONS: Increased virulence culminating in vaccine immunity evasion may be inferred from these specific mutations. Our study adds to the growing body of evidence linking rapidly emerging mutations in the S (Spike) and ORF genes of the SARS-CoV-2 genome to immune evasion.

Does Vitamin D Improve All-cause Mortality in Critically Ill Adults? An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials.

Introduction: Vitamin D deficiency is an amendable risk factor linked to increase in mortality in critically ill patients. The aim of this systematic review was to evaluate if vitamin D supplementation reduced the mortality, and length of stay (LOS) in intensive care units (ICU) and hospitals in critically ill adults including coronavirus disease-2019 (COVID-2019) patients. Materials and methods: We searched the literature using the PubMed, Web of Science, Cochrane and Embase databases until January 13, 2022, for RCTs comparing vitamin D administration to placebo or no treatment in ICUs. The fixed-effect model was used for the primary outcome (all-cause mortality) and the random effect model for secondary objectives (LOS in ICU, hospital, mechanical ventilation). Subgroup analysis included ICU types and high vs low risk of bias. Sensitivity analysis compared severe COVID-19 vs no COVID disease. Results: Eleven RCTs (2,328 patients) were included in the analysis. Pooled analysis of these RCTs, showed no significant difference in all-cause mortality between the vitamin D and placebo groups [odds ratio (OR) 0.93, p = 0.47]. Inclusion of COVID-positive patients did not change the results (OR 0.91, p = 0.37). No significant difference was observed between the vitamin D and placebo groups in LOS in ICU (p = 0.34); hospital (p = 0.40) and mechanical ventilation duration (p = 0.7). In the subgroup analysis, there was no improvement in mortality in medical ICU (p = 0.36) or surgical ICU (p = 0.03). Neither low risk of bias (p = 0.41) nor high risk of bias (p = 0.39) reduced mortality. Conclusion: Vitamin D supplementation in the critically ill did not have statistically significant benefits on clinical outcomes in terms of overall mortality, duration of mechanical ventilation, and LOS in ICU and hospital. How to cite this article: Kaur M, Soni KD, Trikha A. Does Vitamin D Improve All-cause Mortality in Critically Ill Adults? An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2022;26(7):853-862.

Successful application of wastewater-based epidemiology in prediction and monitoring of the second wave of COVID-19 with fragmented sewerage systems-a case study of Jaipur (India).

The present study tracked the city-wide dynamics of severe acute respiratory syndrome-corona virus 2 ribonucleic acids (SARS-CoV-2 RNA) in the wastewater from nine different wastewater treatment plants (WWTPs) in Jaipur during the second wave of COVID-19 out-break in India. A total of 164 samples were collected weekly between February 19th and June 8th, 2021. SARS-CoV-2 was detected in 47.2% (52/110) influent samples and 37% (20/54) effluent samples. The increasing percentage of positive influent samples correlated with the city's increasing active clinical cases during the second wave of COVID-19 in Jaipur. Furthermore, wastewater-based epidemiology (WBE) evidence clearly showed early detection of about 20 days (9/9 samples reported positive on April 20th, 2021) before the maximum cases and maximum deaths reported in the city on May 8th, 2021. The present study further observed the presence of SARS-CoV-2 RNA in treated effluents at the time window of maximum active cases in the city even after tertiary disinfection treatments of ultraviolet (UV) and chlorine (Cl2) disinfection. The average genome concentration in the effluents and removal efficacy of six commonly used treatments, activated sludge process + chlorine disinfection (ASP + Cl2), moving bed biofilm reactor (MBBR) with ultraviolet radiations disinfection (MBBR + UV), MBBR + chlorine (Cl2), sequencing batch reactor (SBR), and SBR + Cl2, were compared with removal efficacy of SBR + Cl2 (81.2%) > MBBR + UV (68.8%) > SBR (57.1%) > ASP (50%) > MBBR + Cl2 (36.4%). The study observed the trends and prevalence of four genes (E, RdRp, N, and ORF1ab gene) based on two different kits and found that prevalence of N > ORF1ab > RdRp > E gene suggested that the effective genome concentration should be calculated based on the presence/absence of multiple genes. Hence, it is imperative to say that using a combination of different detection genes (E, N, RdRp, & ORF1ab genes) increases the sensitivity in WBE.

Simple but Significant Modifications of High-Flow Nasal Cannula.

High-flow nasal cannula (HFNC) is one of the most commonly used devices for oxygen therapy during the coronavirus disease 2019 (COVID-19) pandemic in different hospital settings. Multiple alternative options include non-invasive and invasive ventilation. But non-invasive ventilation is very uncomfortable for patients, and weaning from invasive ventilation in a patient with lung pathology is challenging. Hence, HFNC has come up as a safe alternative that averts invasive ventilation. However, its widespread application is difficult in patients with nasal deformities. We discuss two patients, one with caudal dislocation of the nasal septum with a crooked nose and the other patient with septal hypertrophy. In both cases, invasive ventilation was deferred, and target oxygen saturation was achieved after a simple dispositive modification.

Relational demography in organizations: an assessment of the explored and overlooked

Purpose>The study aims to present an in-depth review of previous research on relational demography (individual–team dissimilarity) over the past 30 years. In doing so, the authors highlighted the main theoretical underpinnings, teased out the common methodological approaches and identified the major mediating processes and contingency factors that influence relational demography's effect on individual outcomes in teams.Design/methodology/approach>The authors searched and examined eight databases (ABI/INFORM Complete, ProQuest, EBSCO, Web of Science, JSTOR, PsycARTICLES, PsycINFO and Science Direct) and distilled 106 studies from 34 journals. The authors synthesized and analyzed this body of work to identify extant patterns and themes in relational demography.Findings>The findings reveal that the majority of theories used are categorized into three segments. The antecedents used are mainly surface- and deep-level variables, while the outcomes are classified into personal- and work-related constructs. For research testing, Euclidean distance and Blau's index are primarily utilized as heterogeneity measures, while various forms of regression are used as the analytical tool for hypotheses testing.Originality/value>Extant literature reviews on relational demography are scant. This study provides an extensive synthesis and analysis of the studies in the area over the past 30 years and offers an agenda that can motivate future research.

Dual Fungal Infections (Aspergillosis and Mucormycosis) in a Diabetic Mellitus Patient Leading to Maxillary Sinusitis as a Post-COVID Manifestation: First Case Report.

Coronavirus infectious disease-19 caused by Severe acute respiratory distress syndrome-coronavirus-2 has emerged to be an emergency global health crisis for more than a year. And, as the disease has spread, a number of new clinical features have been observed in these patients. Immunosuppression caused by this disease results in an exacerbation of pre-existing infections. While corticosteroids are considered a life-saving therapeutic intervention for this pandemic, they have proved to be a double-edged sword and their indiscriminate use has produced some deleterious results. Recently, in the backdrop of this expression, a notable rise in invasive fungal infections has been identified even in the post-remission phase. Mucormycosis, Aspergillosis, and Candidiasis are the three most common opportunistic fungal infections among those observed. COVID-19 patients with diabetes mellitus are already at a higher risk of developing such secondary infections due to impaired immunity. Here we present a rare case report of a 50-year old male diabetic mellitus patient diagnosed with dual fungal infections (Aspergillosis along with Mucormycosis) leading to maxillary sinusitis as a post-COVID manifestation. To our knowledge, this is the first such case reported till date.

Flap amputation for long-standing post-LASIK flap dislocation with epithelial ingrowth.

A man aged 26 years presented with complaints of diminution of vision in his right eye for 1 year following a fist injury. He had a history of laser-assisted in situ keratomileusis in both eyes 5 years earlier. On examination, his uncorrected distance visual acuity (UDVA) in the right eye was 1.0 logMAR. Slit-lamp examination of the right eye revealed a superotemporal dislocation of the flap with coexisting epithelial ingrowth encroaching the pupillary area. Due to the presence of long-standing fixed flap folds, a flap amputation was performed along with removal of the epithelial ingrowth using 0.02% mitomycin C as adjunct. Postoperatively, the UDVA was 0.3 logMAR on day 1, which improved to 0.2 logMAR at 1 week. At 1 year, the UDVA was 0.2 logMAR improving to 0.1 logMAR with refraction, with minimal paracentral corneal haze and no signs of corneal ectasia.

COVID-19 and Ludhiana's woolen knitwear industry: way forward

[...]the pattern of unlocking the economy after 68 days of total lockdown was aimed at saving both lives and livelihoods. [...]specific aim of the paper is to highlight the difficulties that the woolen knitwear industry faces, specifically during the time of total lockdown and partial unlocking of the economy to decipher the impact of COVID-19. Smith and Keogh-Brown (2013) assessed the macroeconomic impact of Swine Flu (H1N1/09) pandemic in 2009 on South Africa, Uganda and Thailand and found that Uganda's economy suffered greater than Thailand and South Africa. Since the outbreak of COVID-19, the focus of researchers and policymakers has been upon assessing and documenting the impact of pandemic on different firms, industries, sectors and countries for finding appropriate policies for revival. According to Ministry of Health and Family Welfare (MoHFW) (2020) first confirmed case of COVID-19 was recorded in India on January 30,2020. Henceforth, the confirmed cases started increasing in these regions (Figure 1), especially after unlocking of the nation. [...]June 26,2020, India recorded 4,90,401 confirmed COVID-19 positive cases and death toll reached to 15,301.

Impact of Taping The Upper Mask Edge On Ocular Surface Stability and Dry Eye Symptoms.

PURPOSE: To evaluate the impact of taping the upper mask edge on ocular surface stability, dry eye symptomology, and tear osmolarity in N95 mask users. DESIGN: Prospective interventional before-and-after study. METHODS: Fifty eyes of 50 health care workers regularly using N95 masks were included. Preintervention, ocular surface parameters, subjective dry eye score, and visual acuity were assessed at the end of an 8-hour shift when the subjects used an N95 face mask without taping the upper edge. Next day, the upper edge of the N95 mask was taped to the nasal bridge in all subjects at the beginning of the 8-hour shift, and postintervention assessment was performed after the shift. The primary outcome measure was change in noninvasive tear break-up time (NIBUT). Secondary outcome measures were change in the symptom score, tear lipid layer thickness (LLT), tear break-up time (TBUT), Schirmer I test, tear meniscus height (TMH), osmolarity, and visual acuity. RESULTS: Mean age of the cohort was 26.7 ± 3.67 years. Post-taping, significantly better ocular surface stability was observed in terms of NIBUT (P < .001), TBUT (P < .001), LLT (P < .001), TMH (P = .01), corneal staining score (P = .001), and tear osmolarity (P = .04). There was no significant change in visual acuity, Schirmer I, and Ocular Surface Disease Index score (P > .05). Symptom improvement was reported by 68% patients (SANDE version 2), which correlated well with change in NIBUT (r = 0.38; P = .005), TMH (r = 0.37; P = .007), LLT (r = 0.35; P = .01), and TBUT (r = 0.28; P = .04). CONCLUSION: Taping of the upper mask edge resulted in significantly better ocular surface stability, which correlated well with decrease in dry eye symptoms.

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.

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 (p = 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, et al. 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.

Serum ferritin as a predictive biomarker in COVID-19. A systematic review, meta-analysis and meta-regression analysis.

Ferritin is a known inflammatory biomarker in COVID-19. However, many factors and co-morbidities can confound the level of serum ferritin. This current metaanalysis evaluates serum ferritin level in different severity levels in COVID-19. Studies evaluating serum ferritin level in different clinical contexts (COVID-19 vs. control, mild to moderate vs. severe to critical, non-survivor vs. survivor, organ involvement, ICU and mechanical ventilation requirement) were included (total 9 literature databases searched). Metaanalysis and metaregression was carried out using metaphor "R" package. Compared to control (COVID-19 negative), higher ferritin levels were found among the COVID-19 patients [SMD -0.889 (95% C.I. -1.201, -0.577), I2 = 85%]. Severe to critical COVID-19 patients showed higher ferritin levels compared to mild to moderate COVID-19 patients [SMD 0.882 (0.738, 1.026), I2 = 85%]. In meta-regression, high heterogeneity was observed could be attributed to difference in "mean age", and "percentage of population with concomitant co-morbidities". Non-survivors had higher serum ferritin level compared to survivors [SMD 0.992 (0.672, 1.172), I2 = 92.33%]. In meta-regression, high heterogeneity observed could be attributed to difference in "mean age" and "percentage of male sex". Patients requiring ICU [SMD 0.674 (0.515 to 0.833), I2 = 80%] and mechanical ventilation [SMD 0.430 (0.258, 0.602), I2 = 32%] had higher serum ferritin levels compared to those who didn't. To conclude, serum ferritin level may serve as an important biomarker which can aid in COVID-19 management. However, presence of other co-morbid conditions/confounders warrants cautious interpretation.