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Case Presentation: A 19 year old male presented with sudden onset chest pain radiating to back. He was a smoker and denied using cocaine since his last hospitalization for cocaine-induced myocardial infarction 2 years ago. UDS was negative. EKG showed normal sinus rhythm with no ST-T wave changes. Initial troponin was 0.850. Potassium levels were low at 2.9 mmol/L but other labs were normal. Chest CT angiography ruled out aortic dissection. He was started on heparin drip. Stat Echocardiogram showed LVEF of 55-60% with no wall motion abnormalities. Repeat potassium levels normalized after replacement, however, his troponins were trending up from 3.9 and 11.5. He continued to complain of severe chest pain, so underwent cardiac catheterization which showed normal coronary arteries and LVEF 55-60%. Heparin drip was discontinued and NSAIDs and colchicine were started. Cardiac MRI (see Figure) was done that showed patchy mid-wall and epicardial delayed gadolinium enhancement involving the basal inferolateral wall, with mild hyperintense signal on the triple IR sequence, suggestive of myocarditis. On further probing, he reported receiving a second dose of Moderna COVID vaccine 3 days prior to presentation. Discussion(s): In December 2019, a novel RNA virus causing COVID-19 infection was reported, which quickly reached a pandemic level. COVID-19 vaccines were granted emergency use authorization by FDA. With millions of people receiving COVID-19 vaccinations worldwide, rare adverse effects are now being reported. The benefits of vaccination undoubtedly outweigh any minor side effects. However major adverse effects like this are potentially fatal. This case report warrants further investigation into the association of myocarditis with COVID-19 vaccinations and further recommendations regarding vaccination in younger adults.
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Background: Various studies have pinned longevity of protective Immunoglobulin-G (IgG) titres at 2-5 months. The robustness and longevity of the IgG antibody response to COVID-19 infection has been gauged in a cohort of 214 single institutional health care workers by serial quantitative immunometric tests. Currently no separate guidelines exist for vaccination of COVID-survivors and this study provides data to fill this lacuna in knowledge. Methodology: Prospective longitudinal panel survey administered to the same cohort of Health Care Workers (HCW) till such time they got vaccinated under Indian Government's free vaccination drive for HCW. Depending upon the date of contraction of infection the HCW could be longitudinally monitored for variable periods (2-9 months). The survey questionnaire comprising multiple-choice, dichotomous, matrix and Likert-scale questions was deployed to the respondents online via email/WhatsApp. Data was expressed as box-whisker plots, trendlines and trend areas. A p-value<0.05 was considered statistically significant. The composite index of 'Effective Immunity' was calculated. Result(s): The mean IgG antibody titre was 11.13+/-8.6AU at 1-2m, 9.68+/-8.9AU at 3-4m, 8.35+/-5.9 AU at 6-7m and 7.87+/-4.4 AU at 8-9m after first symptom, respectively. The lowest titre at all time points was 0 while the highest titres were 46.8 AU, 56.5 AU, 23.4 AU and 17.4 AU at 1-2m, 3-4m, 6-7m and 8-9m, respectively. Conclusion(s): Adaptive active immunity acquired through natural infection may last for at least 9 months post-initial exposure and lies in the moderate protection range in 77% HCW, which can be extrapolated to vaccination and immunity passports. Separate vaccination guidelines are required for COVID-survivors. The first shot of vaccine serves as a booster second exposure/booster dose in all COVID-survivors.HCW with low IgG-titre may suffer from a false sense of security. Periodic quantitative IgG-titre based serological tests can help guide timing of second shot of vaccination and predict likelihood of re-infection.Copyright © 2022 Indian Medical Association. All rights reserved.
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Objective: Flash Continuous Glucose Monitoring (flash CGM) has been rapidly accepted in real life clinical setting. Methods: We conducted a cross sectional study across two centres, delivering the similar standard of care, over three years (n=362), in patients who utilised FreeStyle Libre Pro CGM to understand glycemic metrics and variability. The key glycemic metrics;TIR, Time Below Range (TBR), Time Above Range (TAR), estimated HbA1c, average glucose was analysed. Descriptive statistics, Pearson r and ANOVA were utilised for analysis. Results: Overall, in total 24.8% (90/362) were in TIR >70%, with 14.7% (18/122) patients in 2018, 17.6% (30/170) in 2019 and 60% (42/70) in 2020. In total 37% (134/362) were in TAR < 25%, 29.5% (36/122) in 2018, 28.2% (48/170) in 2019 and 71.4% (50/70) in 2020. In total 45.3% (164/362) were in TBR < 4%, 44.2% (54/122) in 2018, 46.4% (79/170) in 2019 and 44.2% (31/70) in 2020. Overall, 9.3% (34/362) achieved all three metrices (TIR >70%, TAR < 25%, TBR < 4%), with 4.9% (6/122) in 2018, 7.6% (13/170) in 2019, 24.2 (17/70) in 2020. There was a significant negative correlation between the eHbA1c and TIR (Pearson r – 0.74, 95% CI -0.79 to -0.69, p < 0.0001). There was significant improvement in TIR and TAR over three years. The eHbA1c (6.5%) and average glucose (139.7mg/dl) were lowest in the year 2020, which were comparable with values in previous years. Lesser hypoglycaemic events were noticed in CGM. (figure). [Formula presented] Discussion/Conclusion: There was a significant change in the glycemic metrics. We attribute the remarkable improvement, over three years, to the better awareness in the patients to manage diabetes, greater adoption of guideline directed, contemporary therapeutics including SGLT2 inhibitors, advanced insulins. This coincided with the COVID-19 induced fear of mortality and lockdown led better metabolic health, that resulted in better self-care of diabetes.
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Objective: Continuity of care has demonstrated positive outcomes from the advanced countries with insurance care model. There is limited evidence for the benefits from developing countries, in limited resource setting where the patients directly pay from the pocket for the diabetes care. Methods: We retrospectively analysed the relationship between the continuity of care and the glycemic control in patients who atleast had a biannual visit to our comprehensive care centre from 2016 to 2020 (n=1160). Results: The mean number of visits in the year 2016, 2017, 2018, 2019 and 2020 were 3.6 (±1.6, max 11, 95% CI 3.38 to 3.98), 5 (±2.5, max 16, 95% CI 4.5 to 5.5), 4.8 (±2.1, max 12, 95% CI 4.4 to 5.2), 4.7 (±2.2, max 14, 95% CI 4.3 to 5.1), 3.4 (±1.6, max 12, 95% CI 3 to 3.7) (p< 0.0001), respectively. The mean number of visits cumulatively for the continuous five years for each patient was 22 (±7.9, min 11, max 56, 95% CI 20 to 23). The mean number of HbA1c readings done cumulatively for the continuous five years for each patient was 22 (±3.8, min 1, max 17, 95% CI 3.3 to 4.4). The mean interval (days) between the two consecutive visits was 85 (±26, min 33, max 155, 95% CI 81 to 90). The mean number of HbA1c tests were 3.8 (±2.8, min 1, max 17, 95% CI 3.3 to 4.4). The mean number of visits were 4.3 (±1.6, min 2.2, max 11, 95% CI 4 to 4.6). There was a non-significant positive correlation between the mean number of visits and the mean HbA1c readings (Pearson r 0.113, p= 0.22). The baseline value of HbA1c (%) was 8.0 (±1.5, min 5.3, max 13.3, 95% CI 7.7 to 8.3), which reduced by 0.7 when compared for the minimum value of HbA1c achieved at any point of time as mean 7.2 (±7.2, min 4.8, max 10.9, 95% CI 7 to 7.5), (p< 0.0001). There were 360 patients who had atleast one visit in 3 months and achieved HbA1c < 7, as compared to 250 patients with more than 3 months interval for consecutive visits and with HbA1c ≥ 7 (p=0.0404, OR 1.2 95% CI 1.01 to 1.62). COVID-19 induced lockdown led to the decrease in the patient visits in the year 2020. There were 55 all cause hospitalizations. Discussion/Conclusion: The results of our study demonstrate that comprehensive diabetes care have a potential positive implication, even in out-of-pocket ecosystem, which can drive the demand for a continuous follow up visits. We attribute long continuity of care for the smaller number of hospitalizations.
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Objective: Uncontrolled hyperglycaemia is associated with poor clinical outcomes in patients with COVID-19. Basal-bolus (BB) insulin regimen is recommended for intensification and is safe and effective. However, this is complex in COVID era, especially for initiation with challenges in deployment of healthcare personnel with gaps in required expertise. Hence, implementation of an effective insulin therapy is challenging. Methods: We evaluated the impact of initiating premix analog insulin regimen (PA) in T2D patients diagnosed with COVID-19 during the second wave of the pandemic (n=434), who consulted virtually. Insulin initiation was based on random blood sugar (RBS) as reported through SMBG by the patients who were already under regular care, across two dedicated diabetes management centres. Patients were advised to contact over Whatsapp in case self-reported RBS was above 300 mg/dL Results: The mean age of the patients was 59 years (SD±13, 95% CI 58 to 60). 256 were male. 48 patients (11%) were started with basal insulin (43 glargine, 5 degludec) and were optimally managed by dose uptitration. There were 92 patients (21.1%) who were initiated on PA twice daily to achieve glycemic control. Of these, 56 patients (12.9%) were diagnosed as moderate COVID-19 and required corticosteroids. Among these, 42 patients (75%), on PA regimen reported post lunch and dinner glycemic spikes which necessitated additional pre-lunch dose of premix analogue. 36 patients with mild COVID-19, were continued on PA twice daily and doses were uptitrated based on the SMBG reports. The rest 378 (87%) mild COVID-19 cases, were managed by standard care approach for diabetes care, including oral drugs. The mean RBS at the first consultation at insulin initiation was 211 mg/dL (SD±98, 95% CI 192 to 230). On first follow up teleconsultation;mean RBS in mild COVID-19 was 178 mg/dL (SD±50, 95% CI 138 to 195), while those who progressed to moderate COVID-19, RBS was 267 mg/dL (SD±101, 95% CI 210 to 298). On second follow up;mean RBS in mild COVID-19 was 168 mg/dL (SD±54, 95% CI 148 to 183) and in moderate COVID-19 was 203 mg/dL (SD±88, 95% CI 174 to 258). 138 patients (31.7%) needed uptitration of insulin regimen Discussion/Conclusion: Simplified insulin regimen based on premix analog insulin has the potential for timely initiation of insulin, titration and intensification to third dose of PA to optimise the management of T2D in COVID-19. Our study did not account for the compliance to beyond the second teleconsultation and the pandemic prevented the estimation of A1C and did not account for patients who transformed as severe COVID-19 patients who needed hospitalisation
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Background:Healthcare workers (HCWs) have high risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to the increased likelihood of clinical exposure during patient management. The study objective was to determine the seroprevalence of antibodies to SARS-CoV-2 and its predictors among hospital employees. Methods:The cross-sectional study was conducted in a teaching hospital from August 2020 to September 2020, among 1401 employees, including 1217 healthcare workers in New Delhi, India. The serum samples were examined for IgG an- tibodies to SARS-CoV-2 using the COVID KavachTM-Anti-SARS-CoV-2 IgG Antibody Detection ELISA kit. Data were col- lected electronically using the EpiCollect mobile platform. P < 0.05 was considered statistically significant. Results:A total of 169 (12.1%) participants had detectable IgG antibodies to SARS-CoV-2. The highest seropositivity rate was observed in the administrative staff (20.1%), while it was lowest among medical doctors (5.5%) (p<0.001). Conclusions:The probability of HCW-to-HCW, or patient-to-HCW transmission of SARS-CoV-2 was found to be lower than the risk of acquisition of infection from general population
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Aims: To assess medical students' perception of online teaching to suggest transforming the future curriculum in low-economic countries. Study Design: Cross-sectional online interview study. Place and Duration of Study: A team of collaborators interviewed final year medical and dental students of Pakistan from 07/08/2020 till 17/09/2020. Methodology: A questionnaire was developed based on open and close-ended questions in Google forms;focusing on institutional preparedness, views on online education, the institute's closure and COVID-19, and long-term effects of closure of the institute. Independent fellow researchers systematically analyzed the unaltered transcripts of the responses, and themes were then identified and coded to conclude the results. SPSS version 23 used for analysis. As this study was based on final year students. Results: In response to an invitation email, 2442/2661 (91.77%) students voluntarily participate in this qualitative study. Most participants were females (1614, 66.10%). Closing down institutes was directly linked to a lack of motivation and feel of helplessness. As most showed dissatisfaction with online teaching compounded by psychological effects, students feared losing clinical skills and life during the pandemic. Conclusion: The psychological impact of the crisis led to resistance to accepting the change for a better outcome. Incorporating telemedicine, different interactive learning style to online teaching, and resilience training would result in fruitful outcomes. Developed countries may also guide build infrastructure in developing countries to develop a more robust online teaching methodology in the long-run.
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Background: Antibiotic overuse leading to increasing antibiotic resistance has been a growing concern. Patients presenting with acute respiratory tract infections (RTI) are often started empirically on antibiotics and continued for days, unless confirmatory results are reported by microbiological testing. Procalcitonin is a serum inflammatory marker that increases in bacterial infections and is utilized as an adjunct to help differentiate viral versus bacterial pneumonia. Procalcitonin-guided management is associated with significantly lower antibiotic exposure and mortality. No studies exist in literature that assess the appropriate utilization of negative procalcitonin test for antibiotic discontinuation. This study assesses utilization of a negative PCT (<0.25 ng/ml) to guide antibiotic discontinuation in patients with pneumonia in a community hospital. Methods:Retrospective observational study including adult patients admitted to our community hospital in 1 year (July 2019-June 2020) with diagnosis of community acquired pneumonia and started on empiric antibiotic therapy and had procalcitonin levels checked. Our hypothesis was that PCT is not being appropriately used for discontinuation of antibiotics and that rate of discontinuation of antibiotics will be less despite a negative PCT. Statistical analysis was performed using XLSTAT. Categorical variables were represented by frequencies and proportions and compared using Chi-square and z test for two proportions. Results: 516 charts were reviewed. After excluding missing data, 176 patients were included. 100 patients had negative PCT. Antibiotics were discontinued in 16% of patients with negative PCT, compared to 58% (p<0.0001), in whom antibiotics were continued without any other indication (including UTI, severe COPD exacerbation, COVID pneumonia) despite a negative PCT. The difference between the percentage of antibiotic discontinuation in our PCT guided treatment sample (9%, n=16/176) was also found to be statistically significant (p< 0.001) compared to percentage of antibiotic discontinuation in population using data from a meta-analysis of 7 RCTs (42%, n=698/1658).1 Conclusion:Previous studies have shown that procalcitonin guided treatment aids in decreasing antibiotic exposure. In lower respiratory tract infections, clinicians order PCT test to aid in differentiating viral versus bacterial etiology and ultimately help guide antibiotic therapy. Our data analysis reveals that despite negative PCT, thus indicating a likely viral etiology, clinicians are not consistently making changes to empiric antibiotic use. This study addresses need for further recommendations from antibiotic stewardship programs regarding procalcitonin-guided antibiotic use and prevent unnecessary ordering of PCT test.