Drug Utilization Study in Patients with COVID-19 Associated Mucormycosis in a Tertiary Care Hospital, South India

COVID-19 associated Mucormycosis (CAM) is a serious condition in India considering its unprecedented surge due to COVID-19 and associated high morbidity and mortality. Diabetes and widespread usage of steroids in a background of COVID-19 appear to increase the risk of CAM exponentially. Management includes control of the underlying disease or risk factor, strict glycemic control, surgical debridement of necrotic infected tissue, and specific antifungal therapy. First-line antifungal treatment consists of intravenous liposomal Amphotericin-B (LAB) or deoxycholate Amphotericin-B (AMB) and second-line antifungals are intravenous (IV) or oral Posaconazole (POS) which can also be used as salvage therapy. This study is conducted to observe the drug utilization pattern in CAM patients in tertiary care hospital in South India. A prospective, observational study of 55 patients admitted with CAM are studied in terms of drug usage. POS (98.2%) is the most used drug followed by intravenous AMB (49.1%). POS-Oral are used in 83.6 %, POS-IV in 49.1% and AMB-retrobulbar is used in 12.7% of the patents and average doses are within recommended limits. Anti-bacterial and other antifungal are used in 12.7% and 1.8% of the patients respectively, and 34.5% underwent debridement surgery. Though LAB is the recommended 1st line treatment, AMB and POS are used as a reasonably accepted alternative. Guidelines and recommendations should consider cost, compliance (availability ot oral formulations), safety profile, and accessibility aspects which suit the needs of Low-and middle-income countries (LMIC) especially during an unprecedented event like COVID-19 and CAM. Copyright © 2022, Dr. Yashwant Research Labs Pvt. Ltd.. All rights reserved.

Using wisely: Lessons from HIV- haemophilia crisis for curricular learning and continued professional development

Background: 'Choosing wisely' is a multinational initiative. Recommendations for Blood Transfusion asks clinicians to consider indication, consent, dose, thresholds, and use of O- blood. Compliance with this initiative is variable and hard to mandate. Furthermore, recent incidents of delayed transfusion have provoked an alert from SHOT. These guidances enable treating clinicians to optimize use of blood products. However, the notion of 'optimal' varies with time and across nations. The COVID-19 pandemic has posed challenges to clinical decision-making in the context of prolonged uncertainties in clinical, scientific and social areas. An example is the use of plasma outside of a clinical trial. Haemophilia care during the early 1980s posed unique problems in clinical decision-making regarding blood transfusion. A renewed understanding of these, 40 years on, can be of value in learning. Aims: Compile, structure and analyse audio interviews from physicians involved in haemophilia care in the 80s to generate learning material for curricular learning. Methods: Between June and November 2019 oral history interviews were conducted using a semi-structured questionnaire with 16 senior haemophilia doctors (13 male, 3 female) from Australia, Canada, France, Italy, The Netherlands. 28 person-hours of interview material was analysed using pre-established criteria1. Audio recordings and transcripts from UK Infected Blood Inquiry2 held between Oct 2020 and Jan 2021 were analysed for content. 18 oral evidences comprising c286 person-hours were examined to extract themes addressing difficulties and dilemmas in clinical decision-making. Following ethical approval, an audio-podcast series3 was produced to address specific domains and themes. Results: Audio material from six oral histories and 18 evidences was compiled into segments which were interspersed with commentary by (Table Presented) the author. Domains of content included testing, treating, communication, cross-national themes and personal dilemmas. These domains could be mapped to relevant curricular domains defined by the UK General Medical Council. The compilation was published as a podcast series comprising eight podcasts over 4 h. Access was via free public platforms. Between November 21 and February 22, 472 downloads were logged on one of four platforms. Six medical students and six faculty provided triangulation including feedback. Their feedback confirmed the pedagogic relevance of these podcasts for undergraduate students as part of curricular learning in transfusion. Feedback from postgraduate trainees in Haematology, other specialities and consultants confirmed the relevance of this material in their continued professional development. Summary/Conclusions: An understanding of professional and personal concerns faced by haemophilia doctors of the 1980s can inform learning and CPD by clinicians. Lessons from haemophilia-AIDS crisis are relevant for transfusion practice world-wide. - Oral history interviews and oral evidence submitted at an inquiry differ in nature but provide complimentary insights. - Podcasts can provide an effective platform for curricular and selfdirected learning, worldwide. - A structured platform to draw lessons from recent history can provide the narrative equivalent to recommendations fromorganizations such as SHOT. Future research could address the scope and applicability of this pragmatic approach to history ofmedicine in learning opportunities in Transfusion.

"TITLE" - HEPARIN AS AN INHALTION AGENT AMONG MODERATE AND SEVERE COVID-19 PATIENTS

Introduction COVID-19 is a pandemic prevailing for the past 16 months, which led to many innovations in the treatment in order to achieve good recovery rate. Lung involvement appears to be the single most determining factor in the outcome of patients. Various treatment protocols ranging from Pharmacotherapeutics to Physiotherapy have been tried. Multiple mutations, different presentations in different countries, different ethnics have posed additional problems. Along with the accepted protocols, Heparin nebulization was used in some countries particularly China with promising results. This method is innocuous and needs to be tested in our country. Aim of this study is to use Heparin nebulization to improve lung function and reduce the mortality in COVID-19 patient'sunfractionated heparin which is cheap and easily available and its ease of use can give promising good results in Covid management in developing and thickly populated country like INDIA. Materials and Methods Study design: Hospital based randomized comparative study Study type: Interventional Intervention mode: Parallel Assessment Primary purpose: Therapeutic Place of study: ICUs of CSR block, a dedicated COVID center, King George Hospital, Visakhapatnam. Andhra Pradesh., INDIA. Study population: 200 cases of COVID-19 positive patients with lung involvement admitted in Intensive care unit (ICU). Permission from IEC, AMC/KGH, Visakhapatnam. Selection of patients as per inclusion criterion. Written informed consent from patient and attendant along with high risk consent as they are treated in ICUs are taken prior to the study.The patients are divided into two groups one would be the study group and other group will act as controls. Outcome from both groups will be compared and analyzed for outcomes. Data is spread over excel sheet and data is analyzed using SPSS version 22.Results -Heparin nebulization is 6 times more effective in treating lung inflammation in covid than the standard routine treatment and regarding the outcome the deaths are two times more among the standard treatment (control) than the heparin nebulization (study) group. P<0.05 there is a significant association between hospital stay in days and Outcome of study. Conclusion - Heparin nebulization used in treating covid -19 lung pathology has given promising results. The mortality rate is reduced when compared to standard ICU protocols. UFHeparin used is cheap, easily available, low systemic side effects when compared to LMWH. India being developing country, with large population and limited resources,manpower, heparin nebulization can give good results in managing the covid-19 Pandemic for those who required treatment in ICUs.

Pegylated Interferon is an effective and well-tolerated cytroreductive agent in patients with myeloproliferative neoplasms aged over 60 years

Pegylated Interferon (PegIFN) is the recommended first-line cytoreductive therapy in patients aged <40 years with essential thrombocythaemia (ET) or polycythaemia vera (PV). However, its use in patients >60 years is often limited due to concerns about tolerability. In this study, we evaluate the efficacy and tolerability of PegIFN in patients >60 years at University College London Hospitals (UCLH). Using electronic medical records, we identified patients with ET, PV or myelofibrosis at UCLH who commenced treatment with PegIFN between 2010 and 2020 and were aged >60 years on starting therapy. Data were collected until April 2021 to allow a minimum of 1-year follow-up. Complete Haematological responses were defined as per standard European Leukaemia Net criteria. Adverse events (AE) were graded 1-5 according to Common Terminology Criteria for Adverse Events (CTCAE). Thrombosis risk was graded according to IPSET criteria for ET patients. Patients with PV were classed as high risk if they were aged >65 or had a previous history of thrombosis. Eighteen patients were included in the study. The median age was 75.1 years (range 63-91), 61% were female. Ten out of 18 (56%) had a diagnosis of ET, seven out of 18 (39%) of PV and 1/18 (6%) of post-ET myelofibrosis. Fifteen out of 18 (83%) were positive for JAK2 V617F, and two out of 18 (17%) were positive for CALR mutation. Ten out of 18 (56%) had significant cardiovascular co-morbidities at diagnosis. Five out of 18 (28%) had arterial or venous thromboembolic disease at diagnosis. Sixteen out of 18 (89%) were high-risk for thromboembolic events at diagnosis. Seventeen (94%) patients had PegIFN as a second-or thirdline agent. Of these, 15 out of 17 had received hydroxycarbamide (HU) as first-line therapy;two out of 17 had interferon alpha. PegIFN was started at a median age of 70 years (range 50-86) and continued for 5.7 years (range 2-13). Twelve out of 18 (67%) patients achieved complete remission (CR) on PegIFN monotherapy;1 out of 18 (6%) achieved CR on PegIFN and HU combination therapy, and the remaining 5 out of 18 (28%) achieved a partial remission (PR). The median time to CR was 5 months (range 1-40 months). Ten out of 18 (56%) had grade 1-2 AEs including skin rashes, cytopenia and fatigue. Three out of 18 (17%) developed a major thromboembolic event while on treatment (brachial artery embolism, transient ischaemic attack and a non-ST elevation myocardial infarction). Of these, two out of three failed to achieve a CR on PegIFN and required ongoing venesection. The third had suboptimal response due to dose escalation limited by grade 3 neutropenia. Thirteen patients (72%) remained on pegIFN at the end of the study period. Of those who discontinued, three out of five stopped due to cytopenias, one out of five died during the study period of Covid-19 infection and one out of five transformed to myelodysplastic syndrome. In this study, we present a group of patients who were at high risk for thrombosis due to their age and cardiovascular risk factors. The majority of AEs documented were grade 1-2, with only three out of 18 (17%) patients discontinuing due to AEs. The rate of CR 72% similar to that quoted in imminent studies including MPN-RC (Knudsen et al, 2018) and DALIAH trials (Mascarenhas et al, 2018), which recruited larger numbers of youngers ET and PV patients on PegIFN. Over 20% of MPN patients develop resistance or intolerance to HU (Sever et al, 2014);therefore, there is a need for alternative cytoreductive agents. Our study demonstrates PegIFN to be effective and well-tolerated for use in patients >60 years and is an excellent cytoreductive option in this cohort.

Short-Term and Long-Term Replenishment of Water Storage Influenced by Lockdown and Policy Measures in Drought-Prone Regions of Central India

Central India faces a freshwater shortage due to its diverse terrain, sudden change in precipitation patterns and crystalline rock covered subsurface. Here, we investigate the patterns in terrestrial water storage anomaly (TWSA) over the last two decades, and also study the influence of the COVID-19 lockdown on TWSA in the drought-prone regions of central India, mostly covering the Vidarbha region of the Indian state of Maharashtra. The Vidarbha region is arguably the most drought-affected region in terms of farmer suicides due to crop failure. Our forecast data using multiple statistical approaches show a net TWSA rise in the order of 3.65 to 19.32 km3 in the study area in May 2020. A short-term rise in TWSA in April–May of 2020 is associated with lockdown influenced human activity reduction. A long-term rise in TWSA has been observed in the study region in recent years;the rising TWSA trend is not directly associated with precipitation patterns, rather it may be attributed to the implementation of water management policies.