Possible Ambiguity in Interpretation Between Immunoglobulin G4-Related Disease (IgG4-RD) and Sarcoidosis in a Post-COVID-19 Pandemic.

A 36-year-old lady presented with fever, cough, maculopapular rash, painless sialadenitis, episcleritis, and arthralgia of more than 10 months, occurring in episodes since she tested positive for COVID-19 in 2020. Her symptoms were well controlled with corticosteroid and immunosuppressant therapy. Her clinical presentation and findings on bronchoscopy resembled that of sarcoidosis. However, the bronchial biopsy histopathology ruled out sarcoidosis. An increased serum immunoglobulin G4 level and its possible association with COVID-19 raises the question of whether the possibility of immunoglobulin G4-related disease (IgG4-RD) could be entertained.

Incidence and Impact of Healthcare-associated Infections on Patients Primarily Admitted with Sepsis and Non-sepsis Diagnoses.

Objectives: To compare the incidence of healthcare-associated infections (HAI) and their outcomes between patients admitted to the ICU with sepsis and those admitted with non-sepsis diagnoses. Materials and methods: We performed a single-center, prospective, observational study of ICU patients at a tertiary level medical-surgical unit from April 2018 to October 2018. All patients admitted to the ICU with a length of stay (LOS) > 48 hours were included. Baseline data including demographics, comorbidities, and severity of illness scores were collected. Index occurrence of HAI in all these patients was noted and data regarding organ support and patient outcomes were recorded. The incidence, complications, ICU LOS, and 30-day mortality of HAI were compared between the patients admitted to ICU originally with sepsis and non-sepsis diagnoses. Results: A total of 271 patients were evaluated in our study (N = 106 for the sepsis group and N = 165 for the non-sepsis group). No significant difference between the groups was found in the incidence of HAI (29.2% in sepsis group vs 24.4% in non-sepsis group; p = 0.07). Complications (acute kidney injury (AKI): 71 vs 45%; p = 0.01, shock: 81 vs 55%; p = 0.05, need for mechanical ventilation (MV): 30 vs 15%; p = 0.04) were more common in sepsis group compared to the non-sepsis group. The ICU LOS (12.2 ± 5.2 days vs 8.8 ± 2.05 days; p = 0.01) was significantly longer in the sepsis group. There was no significant difference in 30-day mortality between the groups (45 vs 25%; p = 0.07). Conclusion: The incidence of HAI seems to be similar between patients admitted with sepsis and non-sepsis diagnoses. However, patients admitted with sepsis develop higher rates of organ failure secondary to HAI and have a longer ICU LOS compared to patients admitted with non-sepsis diagnoses. The mortality rate of HAI did not differ between these two groups. How to cite this article: Chintamani A, Prakash B, Abraham BK, Kumar S, Ramakrishnan N, Venkataraman R. Incidence and Impact of Healthcare-associated Infections on Patients Primarily Admitted with Sepsis and Non-sepsis Diagnoses. Indian J Crit Care Med 2021;25(3): 292-295.

Should We Fiddle with Gut Microbiome in Critically Ill?

The gut that we took for granted in the critically ill, as just a conduit for food passage has over the decade or so shown us that it is an active endocrine and exocrine organ with over 40 trillion microorganisms living commensally within it. This cosmos of microorganisms that is called the gut microbiome comprises roughly 1,000 different species and put together is more DNA than the entire human genome. Under normal circumstances, in a healthy individual multiple elements of the gut viz intestinal epithelium, gut barrier function, the microbiomes, all put together offer protection against infection and this is crucial in maintenance of health. Any change to the norm, be it in the form of surgical interventions, the introduction of medications, or the pathophysiological effects of systemic disease leads to a 360° alteration in this finely construed ecosystem leading to devastating effects that go beyond the boundaries of the gut itself. Intestinal epithelium helps to absorb nutrients as well as acts as the coordinator of mucosal immunity (first line of immune defense). During ill health, gut epithelial apoptosis occurs, alterations happen in the tight epithelial junctions leading to loss of gut barrier function and loss of the mucosal immunity leading to mucosal damage and hyperpermeability. Lastly, the microbiome is transformed into a pathobiome, with resultant increase in pathogenic bacteria and induction of virulence in commensal gut bacteria. Multiple organ damage starts to set in, caused by toxins leaving the intestine via both portal blood flow and mesenteric lymph. This review article traces the gut microbiomic ecology in health and sickness, modern tools that are used to manipulate gut microbiome in the search for the prevention and treatment of critical illness and will explore if appropriate manipulation of gut microbiome can influence or modulate the course of critical illness. How to cite this article: Venkatachalam B, Abraham BK. Should We Fiddle with Gut Microbiome in Critically Ill? Indian J Crit Care Med 2020;24(Suppl 4):S211-S214.

Value of Routine Sonographic Screening of Internal Jugular Vein to Detect Catheter Related Thrombosis in Intensive Care Unit.

BACKGROUND AND AIMS: Internal jugular vein (IJV) cannulation is a common procedure in the ICU with thrombosis being an uncommon, albeit serious complication. Thrombosis is one of the important complications of IJV cannulation. This study aims to evaluate the use of ultrasound screening by intensivists to assess the incidence of catheter-related IJV thrombosis in ICU. MATERIALS AND METHODS: Fifty consecutive IJV cannulations meeting the inclusion criteria were analyzed in the ICU. Duplex scanning and color doppler sonography were performed by the intensivist on day 3, 6, 9, 12 and 15 after cannulation. The thrombus, when detected, was confirmed independently by a radiologist. The patient demographics, the type of catheter, laterality and the mean duration of catheterization were recorded. Risk factors like presence of circulatory shock, thrombocytosis, DIC, liver disease, and absence of chemoprophylaxis for DVT were documented. RESULTS: A total of 39 patients and 50 cannulations were studied. The mean age of patients was 56.5±16.2 years and mean duration of catheterization was 6.6±2.1 days. We found a 38% (19/50) incidence of thrombosis in our study. There was 100% correlation in detection of thrombosis by the intensivist and the radiologist. The thrombus was detected at 6.9±2.1 days after cannulation. All the patients who developed thrombosis had one or more risk factors. The most common risk factor was circulatory shock (40%). Central line associated blood stream infection (CLABSI) was seen only in the patients in whom IJV thrombus was detected (5/19). CONCLUSION: Catheter-related IJV thrombosis is a frequent complication in ICU patients and is associated with the increased risk of CLABSI. Ultrasound screening is simple, feasible and accurate in diagnosing IJV thrombosis. HOW TO CITE THIS ARTICLE: Bhat MNM, Venkatraman R, Ramakrishnan N, Abraham BK, Rajagopalan S. Value of Routine Sonographic Screening of Internal Jugular Vein to Detect Catheter Related Thrombosis in Intensive Care Unit. Indian J Crit Care Med 2019;23(7):326-328.

What Happens to Patients Discharged Against Medical Advice?

INTRODUCTION: Discharge against medical advice (DAMA) when requested by family members of patients in Indian Critical Care Units (CCUs) leads to loss of follow-up and unknown patient outcomes. Exclusion of these patients from research analysis and quality audits confounds these results. We hence explored the proportion of patients leaving DAMA, reasons, and their outcomes at 30 and 90 days. METHODS: This was a prospective study of CCU patients admitted from July 2013 to February 2014. All patients, who were DAMA during this period, were included in this study. Demographics, APACHE data, and outcomes were collected and compared to patients discharged regularly during the same period. Outcomes of DAMA patients at 30 and 90 days were gathered by telephone follow-up. RESULTS: Among the 663 patients admitted to the CCU, 15.1% (100 patients) were DAMA. The baseline APACHE score of the DAMA group was higher than the regular discharge group (29.5 ± 8.6 vs. 26.1 ± 10.3; P = 0.002). During the 30-day follow-up, 23% were alive, 56% dead, and 21% could not be contacted. At 90 days, mortality was 62% and survivors decreased to 14%. Common reasons for DAMA were - wanting to take the patient to another hospital (21%), reluctance for further treatments (12%), financial constraints (9%), and overall poor prognosis (7%). CONCLUSION: A significant proportion of patients in the CCU get DAMA despite high severity of illness. Understanding the outcomes of these patients will help refine CCU quality audit reports and research study results.

Mortality Prediction Using Acute Physiology and Chronic Health Evaluation II and Acute Physiology and Chronic Health Evaluation IV Scoring Systems: Is There a Difference?

BACKGROUND: Mortality prediction in the Intensive Care Unit (ICU) setting is complex, and there are several scoring systems utilized for this process. The Acute Physiology and Chronic Health Evaluation (APACHE) II has been the most widely used scoring system; although, the more recent APACHE IV is considered an updated and advanced prediction model. However, these two systems may not give similar mortality predictions. OBJECTIVES: The aim of this study is to compare the mortality prediction ability of APACHE II and APACHE IV scoring systems among patients admitted to a tertiary care ICU. METHODS: In this prospective longitudinal observational study, APACHE II and APACHE IV scores of ICU patients were computed using an online calculator. The outcome of the ICU admissions for all the patients was collected as discharged or deceased. The data were analyzed to compare the discrimination and calibration of the mortality prediction ability of the two scores. RESULTS: Out of the 1670 patients' data analyzed, the area under the receiver operating characteristic of APACHE II score was 0.906 (95% confidence interval [CI] - 0.890-0.992), and APACHE IV score was 0.881 (95% CI - 0.862-0.890). The mean predicted mortality rate of the study population as given by the APACHE II scoring system was 44.8 ± 26.7 and as given by APACHE IV scoring system was 29.1 ± 28.5. The observed mortality rate was 22.4%. CONCLUSIONS: The APACHE II and IV scoring systems have comparable discrimination ability, but the calibration of APACHE IV seems to be better than that of APACHE II. There is a need to recalibrate the scales with weights derived from the Indian population.

Extracorporeal Membrane Oxygenation in Drug Overdose: A Clinical Case Series.

Overdose of cardiovascular medications such as beta blockers and calcium channel blockers cause impaired cardiac contractility, vasoplegia, and/or rhythm disturbances. In addition to conventional management of limiting absorption, increasing elimination and hemodynamic support intravenous (IV) calcium infusion, hyperinsulinemia-euglycemia therapy, glucagon infusion, and IV lipid emulsion have been tried. Extracorporeal circulatory assist device support has been reported as a rescue therapy in overdose refractory to maximal medical therapy. We report three patients with cardiovascular medication overdose presenting with profound cardiovascular instability refractory to medical therapy. Venoarterial extracorporeal membrane oxygenation support (VA ECMO) was initiated to provide hemodynamic support. Despite the occurrence of device-associated complications, the outcome was good and all patients survived. VA ECMO may be considered in patients with severe refractory shock due to cardiotoxic medication overdose.

Multicenter Observational Study to Evaluate Epidemiology and Resistance Patterns of Common Intensive Care Unit-infections.

BACKGROUND: There is limited data regarding the microbiology of Intensive Care Unit (ICU)-acquired infections, such as ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI), and catheter-related bloodstream infections (CRBSI) from India. OBJECTIVES: To explore the microbiology and resistance patterns of ICU-acquired infections and evaluate their outcomes. MATERIALS AND METHODS: This was a multicenter observational study, conducted by Indian Society of Critical Care Medicine (MOSER study) between August 2011 and October 2012. Patients in the ICU ≥48 h with any ICU-acquired infection within 14 days of index ICU stay were included. Patient demographics, relevant clinical, and microbiological details were collected. Follow-up until hospital discharge or death was done, and 6-month survival data were collected. RESULTS: Of the 381 patients included in the study, 346 patients had 1 ICU infection and 35 had more than one ICU infection. Among patients with single infections, 223 had VAP with Acinetobacter being the most common isolate. CAUTI was seen in 42 patients with Klebsiella as the most common organism. CRBSI was seen in 81 patients and Klebsiella was the most common causative organism. Multidrug resistance was noted in 87.5% of Acinetobacter, 75.5% of Klebsiella, 61.9% of Escherichia coli, and 58.9% of Pseudomonas isolates, respectively. Staphylococcus constituted only 2.4% of isolates. Mortality rates were 26%, 11.9%, and 34.6% in VAP, CAUTI, and CRBSI, respectively. CONCLUSION: VAP is the most common infection followed by CRBSI and CAUTI. Multidrug-resistant Gram-negative bacteria are the most common organisms. Staphylococcus aureus is uncommon in the Indian setting.

Critical care: Are we customer friendly?

OBJECTIVE: Assessing and enhancing family satisfaction are imperative for the provision of comprehensive intensive care. There is a paucity of Indian data exploring family's perception of Intensive Care Unit (ICU) patients. We wanted to explore family satisfaction and whether it differed in families of patients admitted under intensivists and nonintensivists in our semi-open ICU. METHODOLOGY: We surveyed family members of 200 consecutive patients, between March and September 2009 who were in ICU for >3 days. An internationally validated family satisfaction survey was adapted and was administered to a family member, on day 4 of the patient's stay. The survey consisted of 15 questions in five categories - patient care, medical counseling, staff interaction, visiting hours, and facilities and was set to a Likert scale of 1-4. Mean, median, and proportions were computed to describe answers for each question and category. RESULTS: A total of 515 patients were admitted during the study period, of which 200 patients stayed in the ICU >3 days. One family member each of the 200 patients completed the survey with 100% response rate. Families reported the greatest satisfaction with patient care (94.5%) and least satisfaction with visiting hours (60.5%). Chi-square tests performed for each of the five categories revealed no significant difference between satisfaction scores of intensivists and nonintensivists' patients. CONCLUSION: Family members of ICU patients were satisfied with current care and communication, irrespective of whether they were admitted under intensivists or nonintensivists. Family members preferred open visiting hours policy than a time limited one.

Noninvasive ventilation: Are we overdoing it?

BACKGROUND: Use of noninvasive ventilation (NIV) outside guideline recommendations is common. We audited use of NIV in our tertiary care critical care unit (CCU) to evaluate appropriateness of use and patient outcomes when used outside level I recommendations. MATERIALS AND METHODS: Prospective observational study of all patients requiring NIV. Clinical parameters and arterial blood gases were recorded at initiation of NIV and 2 h later (or earlier if clinically warranted). NIV titration and decision to intubate were left to the discretion of treating intensivist. Patients were categorized into two groups: Group 1: Those with level I indications for use of NIV and group 2: All other levels of indications. Patients were followed until hospital discharge. RESULTS: From January 2010 to June 2010, 1120 patients were admitted to the CCU. Of these 106 patients required NIV support with 40.6% (n = 43/106) being in group 1 and 59.4% (n = 63/106) in group 2. Of these 35.8% patients (38/106) failed NIV and required endotracheal intubation. NIV failure rates (41.27% vs. 27.91%; P = 0.02) and mortality (30.6% vs. 18.6%; P = 0.03) were significantly higher in group 2 patients. In a logistic regression analysis Acute Physiology and Chronic Health Evaluation (APACHE) II score (P = 0.02), time on NIV before intubation (P = 0.001) and baseline PaCO2 levels (P = 0.01) were strongly associated with mortality. CONCLUSION: Noninvasive ventilation failure and mortality rates were significantly higher when used outside level I recommendations. APACHE II score, baseline PaCO2 and duration on NIV prior to intubation were predictors of increased mortality.

Funding sources for continuing medical education: An observational study.

AIMS: Medical accreditation bodies and licensing authorities are increasingly mandating continuing medical education (CME) credits for maintenance of licensure of healthcare providers. However, the costs involved in participating in these CME activities are often substantial and may be a major deterrent in obtaining these mandatory credits. It is assumed that healthcare providers often obtain sponsorship from their institutions or third party payers (i.e. pharmaceutical-industry) to attend these educational activities. Data currently does not exist exploring the funding sources for CME activities in India. In this study, we examine the relative proportion of CME activities sponsored by self, institution and the pharmaceutical-industry. We also wanted to explore the characteristics of courses that have a high proportion of self-sponsorship. MATERIALS AND METHODS: This is a retrospective audit of the data during the year 2009 conducted at an autonomous clinical training academy. The details of the sponsor of each CME activity were collected from an existing database. Participants were subsequently categorized as sponsored by self, sponsored by institution or sponsored by pharmaceutical-industry. RESULTS: In the year 2009, a total of 2235 participants attended 40 different CME activities at the training academy. Of the total participants, 881 (39.4%) were sponsored by self, 898 (40.2%) were sponsored by institution and 456 (20.3%) by pharmaceutical-industry. About 47.8% participants attended courses that carried an international accreditation. For the courses that offer international accreditation, 63.3% were sponsored by self, 34.9% were sponsored by institution and 1.6% were sponsored by pharmaceutical-industry. There were 126 participants (5.6%) who returned to the academy for another CME activity during the study period. Self-sponsored (SS) candidates were more likely to sponsor themselves again for subsequent CME activity compared with the other two groups (P < 0.001). CONCLUSIONS: In our study, majority of healthcare professionals attending CME activities were either self or institution sponsored. There was a greater inclination for self-sponsoring for activities with international accreditation. SS candidates were more likely to sponsor themselves again for subsequent CME activities.

Intra- specific variation in response of Jatropha (Jatropha curcas L.) to elevated CO2 conditions.

Twenty genotypes of Jatropha collected from diverse eco-geographic regions from the states of Chhattisgarh (3), Andhra Pradesh (12), Rajasthan (4) and Uttarakhand (1) of India were subjected to elevated CO2 conditions. All the genotypes showed significant difference (p < 0.05 and 0.01) in the phenotypic traits in both the environments (elevated and ambient) and genotype x environment interaction. Among the physiological traits recorded, maximum photosynthetic rate was observed in IC565048 (48.8 µmol m(-2) s(-1)) under ambient controlled conditions while under elevated conditions maximum photosynthetic rate was observed in IC544678 (41.3 µmol m(-2) s(-1)), and there was no significant difference in the genotype x environment interaction. Stomatal conductance (Gs) emerged as the key factor as it recorded significant difference among the genotypes, between the environments and also genotype x environment interaction. The Gs and transpiration (E) recorded a significant decline in the genotypes under the elevated CO2 condition over the ambient control. Under elevated CO2 conditions, the minimum values recorded for Gs and E were 0.03 mmol m(-2) s(-1) and 0.59 mmol m(-2) s(-1) respectively in accession IC565039, while the maximum values for Gs and E were 1.8 mmol m(-2) s(-1) and 11.5 mmol m(-2) s(-1) as recorded in accession IC544678. The study resulted in the identification of potential climate ready genotypes viz. IC471314, IC544654, IC541634, IC544313, and IC471333 for future use.

Natural course of left atrial thrombi after bioprosthetic mitral valve replacement in a patient with heparin-induced thrombocytopenia.

Left atrial (LA) clots involving prosthetic mitral valves are unusual complications of heparin-induced thrombocytopenia (HIT), and little is known about their natural history. A 73-year-old woman underwent bioprosthetic mitral valve replacement, which was complicated by atrial fibrillation and LA thrombus due to HIT. She was treated medically and followed up for 18 months. The present case provides unique insights into the natural history of HIT-related LA thrombus involving a bioprosthetic valve. It highlights the importance of having a high index of suspicion for this condition and avoiding the use of warfarin early in the course of the condition.

Prone ventilation following witnessed pulmonary aspiration: the effect on oxygenation.

OBJECTIVE: Pulmonary aspiration is a significant cause of admission to the ITU and is associated with significant morbidity and mortality. Aspiration in the supine position produces posterior collapse/consolidation, similar to that seen in ALI/ARDS patients. Prone positioning has been shown to improve oxygenation in ALI/ARDS, but no studies have been performed on pulmonary aspiration. DESIGN: A prospective crossover study. SETTING: Twelve-bed ITU. PATIENTS AND PARTICIPANTS: Eleven patients admitted to ITU with respiratory failure secondary to witnessed pulmonary aspiration requiring ventilation and an FIO(2) >0.50 after 12 h. INTERVENTIONS: Patients were placed in a prone position for 8 h and then turned supine for 8 h. Prone positioning was repeated if the FIO(2) remained >0.50. Ventilator settings were not altered in the study period. MEASUREMENTS AND RESULTS: Arterial blood gas analysis was performed every 2 h. The PaO(2)/FIO(2) gradient was calculated. Oxygenation improved on turning prone, with a significant increase in the PaO(2)/FIO(2) ratio ( P<0.01). There was a fall in this gradient on return to the supine position. There was a significant improvement in oxygenation on turning prone for the second period ( P<0.01). Overall, there was a significant improvement in the PaO(2)/FIO(2) ratio in the final supine position when compared to the first ( P<0.05). CONCLUSION: This study demonstrates a significant improvement in oxygenation in the prone position in pulmonary aspiration. Early prone positioning in patients with pulmonary aspiration requiring ventilation may improve oxygenation by altering V/Q relationships similarly to ARDS, but also may aid drainage of secretions, opening up alveoli and preventing progression to established pneumonitis.