Prevalence of SARS-CoV-2 virus in saliva, stool, and urine samples of COVID-19 patients in Bihar, India.

Introduction. The coronavirus illness caused by SARS-CoV-2 can cause multiple organ involvement, with varying degrees of severity. Besides inhalation as a route for transmission, feco-oral has also been proposed. Its transmission to sewage systems is a growing public health issue. Objective. To detect SARS-CoV-2 RNA in non-respiratory samples (saliva, urine, and stool) collected from COVID-19 cases, in Bihar. Methods. This cross-sectional observational study was conducted from January 2021 to March 2022 on human non-respiratory samples. A total of 345 samples including saliva (116), stool (97), and urine (132) were collected from 143 COVID-19 cases. Samples were analysed for SARS-CoV-2 by multiplex RT-PCR targeted against E, ORF 1ab, and RdRp genes. Results. In this study, out of 143 cases, a total of 107 (74.8 %) were positive for SARS-CoV-2 RNA in at least one of the non-respiratory samples. Conclusion. There is a high prevalence of SARS-CoV-2 virus in non-respiratory samples.

The Kaleidoscope of Polyautoimmunity: An Odyssey of Diagnostic Dilemmas.

Diagnostic accuracy is of the utmost importance, both in the clinical setting and for research purposes. Mixed connective tissue disease (MCTD), rheumatoid arthritis (RA), Sjogren's syndrome (SS), and overlap syndrome (OS) frequently exhibit symptoms that mimic those of other conditions. Unfortunately, there is no singular definitive test for diagnosing these connective tissue diseases (CTDs), necessitating the reliance on expert opinions. Further complicating the matter, these diseases have overlapping clinical and serological features, and some individuals with one autoimmune disease may develop additional autoimmune disorders, either concurrently or at a later stage of their ailment. Autoimmune diseases (ADs) may manifest as a single AD or, concurrently with other ADs, a condition named polyautoimmunity (polyA). Polyautoimmunity refers to the presence of numerous autoimmune disorders in a single patient. Multiple autoimmune syndrome (MAS) is a condition that occurs when three or more autoimmune illnesses coexist. Moreover, the coexistence of two or more ADs with classification criteria is named "overt polyA," whereas the presence of autoantibodies not related to the index AD, without criteria fulfillment, is termed "latent polyA." Furthermore, both conditions can exist simultaneously within an individual patient. This case report's findings underscore that patients exhibiting both latent and overt polyautoimmunity tend to group, exhibiting distinct clinical and immunological characteristics. Additionally, CTDs not only have overlapping features amongst their various subclasses but also tend to mimic other conditions due to an underlying chronic inflammatory state. This case study also attempts to highlight the diagnostic dilemmas faced in such situations.

The Prevalence of Thyroid Abnormalities in Patients With Chronic Kidney Disease: A Cross-Sectional Study at a Tertiary Care Hospital.

Background and objective Chronic kidney disease (CKD) is a clinical syndrome characterized by the irreversible loss of kidney function. It is a widespread condition affecting populations worldwide. The kidneys play a crucial role in the metabolism, breakdown, and elimination of thyroid hormone and thyroid-stimulating hormone (TSH). Consequently, thyroid dysfunction can occur as an endocrine manifestation in CKD patients. Previous studies investigating thyroid abnormalities and the severity of CKD have yielded diverse outcomes. In light of this, this study aimed to determine the prevalence of thyroid dysfunction in CKD patients and explore the association between different thyroid dysfunctions and markers of kidney function. Methods A total of 140 CKD patients who met the inclusion criteria were recruited, and their demographic details and routine investigations were recorded. Blood samples were collected for kidney function tests and thyroid function tests. The primary outcome measures included markers of kidney function [urea, creatinine, and estimated glomerular filtration rate (e-GFR)] and thyroid profile [TSH, free thyroxine (FT4), and free triiodothyronine (FT3)]. Mean and standard deviation (SD) were calculated for continuous variables, while frequencies were calculated for categorical data. Fisher's exact test was employed to evaluate the association between two categorical variables, and p-values below 0.05 were considered statistically significant. Results The mean (± SD) urea, creatinine, and e-GFR were found to be 139 (± 81.1) mg/dL, 5.33 (± 4.1) mg/dL, and 20.1 (± 15) ml/min/1.73 m2, respectively. Of note, 133 (95%) patients had elevated urea levels, with the majority (n = 109, 77.8%) having urea levels between 40 and 199 mg/dL; 70 (50%) patients had creatinine levels less than 4 mg/dL, and 107 (76.4%) had e-GFR of less than 30 ml/min/1.73 m2. The mean (± SD) TSH, FT4, and FT3 levels were found to be 6.64 (± 11.2) mIU/ml, 13.6 (± 4.54) pmol/L, and 2.65 (± 1.89) pmol/L, respectively. It was observed that 18 (12.9%, 95% CI: 8.29-19.4%) of the CKD patients had hypothyroidism and 21 (15%, 95% CI: 10.02-21.8%) had subclinical hypothyroidism (SCH), while only two (1.4%, 95% CI: 0.39-5.05%) and five (3.6%, 95% CI: 1.5-8.08%) had hyperthyroidism and subclinical hyperthyroidism, respectively. Thirty-nine (27.9%, 95% CI: 21.1-35.8%) patients had low FT4 levels, whereas a considerable majority (n = 123, 87.9%, 95% CI: 81.41-92.28%) of the patients suffering from CKD were found to have low FT3 levels. The associations of urea levels with SCH, low FT4, and FT3 status were found to be statistically significant with p-values of 0.002, 0.033, and <0.001, respectively. The association between e-GFR and low FT3 status was also statistically significant, with a p-value of 0.014. Conclusion Nine out of 10 patients with CKD were discovered to have low FT3 levels, whereas one in four patients had low FT4 levels. The study participants also exhibited a significant presence of SCH and hypothyroidism, with prevalence rates of 15% and 12.9%, respectively. Urea levels and e-GFR, indicating the severity of CKD, showed a significant association with the presence of various thyroid abnormalities. Hypothyroidism in CKD patients can complicate disease progression, impact mortality rates, and affect overall quality of life. Therefore, routine screening for thyroid abnormalities should be conducted in all CKD patients.

Interference of anti-nuclear antibodies on determination of anti-neutrophil cytoplasmic antibodies in patients suspected of vasculitis: a case series.

Anti-neutrophil cytoplasmic antibodies (ANCA) are mainly associated with medium and small vessel vasculitis. Two main methodologies currently available for detection of these antibodies are indirect immunofluorescence (IIF) and monospecific proteinase 3 (PR3) and myeloperoxidase (MPO) based immunoassays. However, well-defined guidelines regarding mode of testing for ANCA in laboratories still don't exist, leading to problems in diagnosis and further patient management. Anti-neutrophil cytoplasmic antibodies testing by IIF and enzyme linked immunosorbent assay (ELISA) often pose a significant challenge in diseases other than vasculitis and in overlapping autoimmune conditions. Anti-neutrophil cytoplasmic antibodies reporting by IIF can be challenging in certain circumstances. This case series aims to discuss four cases with probable interference of anti-nuclear antibodies (ANA) during ANCA testing by IIF resulting in ANCA false positivity. All four cases on subsequent reflex testing by line immunoassay (LIA) for PR3, MPO and glomerular basement membrane (GBM) antigens proved otherwise. While analysing for the presence of ANCA by IIF, the possible interference of ANA leading to a false positive ANCA result should be kept in mind and alternative methods of testing like ELISA, extended granulocyte based IIF assays with MPO and PR3 coated beads, etc., should also be advised. Probability of atypical ANCA in diseases other than vasculitis should also be considered in case of ambiguous results.

Efficacy of intravenous vitamin C in management of moderate and severe COVID-19: A double blind randomized placebo controlled trial.

Aim: To study the efficacy of intravenous vitamin C in management of moderate and severe COVID-19. Objective: To determine the efficacy of intravenous vitamin C in reducing in-hospital mortality in moderate and severe cases of COVID-19. Design: Parallel, double-blinded randomized controlled trial with placebo. Ethical clearance was obtained from the institutional ethics committee, AIIMS Patna. The trial was registered with the Clinical Trials Registry - India (registration number- CTRI/2020/11/029230.). Setting: A tertiary care centre in Bihar, India. Participants: All patients above the age of 18 years both males and females, admitted in ICU with a diagnosis of moderate and severe COVID-19 (on the basis of a positive reverse transcriptase polymerase chain reaction (RT-PCR) report) at our facility during the study period (01/10/2020-31/12/2020) not having any of the exclusion criteria. Intervention: The patients in the intervention arm were given 1 gram (2 ampoules of 2 ml each containing 500 mg of vitamin C mixed in 100 ml normal saline) intravenous vitamin C 8 hourly for four days. The patients in the placebo arm received similar looking ampoules (2 ampoules of 2 ml sterile water for injection mixed in 100 ml normal saline) intravenously 8 hourly for four days. The rest of the treatment was given as per the standard operating procedure (SOP) of the institute with adjustments as per treating team's judgement. Outcome Measures: Primary outcome was reduction in in-hospital mortality. Secondary outcomes were improvement in qSOFA score, pO2/fiO2 ratio, fall in inflammatory markers, need for mechanical ventilation and vasopressors. Results: Regarding primary outcome, 10 (33.3%) patients died in intervention group compared to 13 (43.3%) in placebo. Worth noting from baseline characteristics is that 86.7% in intervention arm were of severe category compared to 66.7% severe category patients in placebo group. Though number of severe cases were more in intervention arm there has been comparatively less mortality in this group. Regarding secondary outcomes, amongst 30 patients in vitamin C group, 11 (36.7%) required invasive mechanical ventilation compared to 14 (46.7%) out of 30 in placebo group but the difference was not statistically significant. Although there were a greater number of moderate cases in placebo group, invasive ventilation requirement (and NIV requirement) was more in this group, thus it could be considered that vitamin C might have a role in reducing the severity of disease. The need for vasopressor therapy was higher in intervention arm 33.3% compared to 26.7% in placebo but not significant statistically. The secondary outcomes of the study such as improvement in organ failure score (qSOFA Score), fall in level of inflammatory markers, improvement in respiratory index (pO2/fiO2 ratio), need for mechanical ventilation and need for vasopressors also shown encouraging results but not up to the statistically significant level due to moderate dosage of the drug and small sample size. Conclusion: In the current study, by the observations and results of the double-blind placebo controlled randomised trial, we concluded that as the primary outcome of the study, there was reduction in In-hospital mortality and need for mechanical ventilation in the vitamin C intervention group compared to placebo, although these results did not reach statistical significance due to small sample size and use of moderate dose of IV vitamin C. The secondary outcomes of the study such as improvement in organ failure score (qSOFA Score), fall in level of inflammatory markers, improvement in respiratory index (pO2/fiO2 ratio), need for mechanical ventilation and need for vasopressors also shown encouraging results but not up to the statistically significant level due to moderate dosage of the drug and small sample size. In summary, high dose of intravenous vitamin C may reduce inflammatory reaction, improve oxygen support status, and reduce mortality in COVID-19 patients, without adverse events. High dose intravenous vitamin C may be a promising therapy for patients of moderate to severe COVID-19.

Role of cystatin C and calprotectin as potential early prognostic biomarkers in COVID-19 patients admitted to a dedicated COVID care facility.

Background: The COVID-19 pandemic has claimed millions of lives. A tool for early prediction of severity and mortality risk is desirable for better utilization of health care facilities. Several biomarkers like D-dimer, lactate dehydrogenase (LDH), C-reactive protein (CRP) and some recently explored biomarkers like serum cystatin C and serum calprotectin have been proposed as prognostic markers of COVID-19, but their role as prognostic markers is so far undefined. The present work attempted to investigate the possible role of serum cystatin C and serum calprotectin as prognostic tools to predict severity and outcome ahead of time. Material and Methods: This observational cohort study was carried out on 95 COVID-19 patients admitted to a dedicated COVID care facility from mid-October 2020 to January 2021. Serial estimations of serum cystatin C and serum calprotectin levels were done and assessed for significant difference between severe (NEWS 2 score ≥5) and non-severe (NEWS 2 score <5) groups, survivors and deceased and on the basis of comorbidities at each time points. Survival analysis was done based on the optimal thresholds for severity and mortality, calculated from the receiver operating characteristic (ROC). Result: The results showed that median cystatin C levels were significantly higher on the first day in the severe group (P < 0.001) and in patients with cardiovascular disease (P < 0.05), chronic lung disease (P = 0.009) and among patients who died (P < 0.05). It remained raised on day 3 in severe (P < 0.05) and deceased (P < 0.05) group. Serum calprotectin levels were significantly higher in patients with chronic lung disease (P = 0.008) and in those who died (P < 0.05). Conclusion: Serum cystatin C could be used as a tool for early prognosis and therapeutic decision-making for COVID-19 patients. Serum calprotectin seems to be a better marker of critical illness.

Clinical utility of MRI in acute stroke beyond reperfusion therapy.

Background: Stroke is primarily a clinical diagnosis. It can be hemorrhagic or ischemic in etiology. Computed tomography (CT) brain is usually the initial investigation in most patients with suspected stroke. Although it has excellent accuracy in diagnosing hemorrhage, ischemic changes may not be apparent in the first few hours. Some centers use focused magnetic resonance imaging (MRI) studies to help in selecting appropriate patients for reperfusion therapy. However, clinicians often use this investigation even when reperfusion therapy is not being considered. This study aims to find out whether doing an MRI in addition to a CT scan has any clinical utility in this situation. Primary Objective: To determine the proportion of patients who undergo a change in their management based on MRI findings. Secondary Objectives: 1. To determine the time duration from the onset of symptoms to presentation at the hospital. 2. To determine the time duration from presentation to the hospital to get CT performed. 3. To determine the proportion of patients who had MRI in addition to CT. 4. To determine the time duration from CT performed to MRI performed. Materials and Methods Study Design: Retrospective, descriptive observational study. Inclusion Criteria: Patients above age 18 admitted at a tertiary hospital with a clinical diagnosis of stroke between 1/8/2018 and 30/7/2019. Exclusion Criteria: Patients who had already undergone MRI before presentation to the hospital and patients undergoing thrombolysis. Patients meeting the inclusion and exclusion criteria were identified from the hospital information system and the ward admission register and by manual examination of the patients' case notes. Relevant data were obtained from the case notes and collected on a google form and downloaded in Microsoft Excel 2019. SPSS version 22 was used for data analysis. Results: Out of the 106 patients, 54% (n = 57) were diagnosed as having ischemic stroke, whereas 46% (n = 49) were diagnosed with hemorrhagic stroke after initial assessment and CT scan. Only 2.8% (n = 3) of the patients presented within 4.5 hours of the onset of symptoms. 43.4% (n = 46) presented between 4.5 and 24 hours from the onset, whereas 53.8% (n = 57) presented more than 24 hours after the onset. Twenty-seven patients had their CT scan performed prior to their presentation at the center. For the remaining 79, the median time from presentation to CT scanning was 2 ± 1.5 hours. 24.5% (n = 26) of all patients had an MRI performed in addition to the CT scan. There was wide variation in the time from CT scanning to the MRI. Among the patients who had an MRI, additional information was obtained by the investigation in 58% (n = 15). However, this led to a change in management in only three (11.5%) of the patients. On review, it was found that the change was justified in only two patients. Furthermore, one patient who was diagnosed with tuberculoma had a long history of fever which was missed on initial evaluation. Considering these, MRI can be credited for a meaningful change in management in only 4% (n = 1) of the cases. Conclusion: The findings of this study do not support the routine use of MRI in patients who are not candidates for reperfusion therapy. Their use should be restricted to cases where some specific information is sought or where there is diagnostic uncertainty. Allocation of resources in developing integrated acute stroke pathways is likely to give a better value for money.

Clinico-pathological profile of pancytopenia patients in a single health care centre of northern India.

Background: Pancytopenia is a clinical outcome of various pathological conditions ranging from bone marrow suppression, bone marrow infiltration, infections, hypersplenism, haemolysis, and haematological malignancies. As such is the most common cause in drug induced (chemotherapy) bone marrow suppression. As most of these patients first contact their primary care physicians, a quick workup will resolve many diagnosis and can give a hint towards a life threatening condition too. Material and Methods: We included all patients admitted with pancytopenia at our tertiary care centre except those who were drug induced. They were evaluated and given appropriate treatment. Results: We observed 73 patients in a year, after excluding drug-induced pancytopenia, and showed aplastic anaemia was the foremost cause (31.5%) followed by vitamin B12 deficiency (19.2%), infections (13.7%), hypersplenism and haematological malignancies. Conclusion: Majority of adult patients admitted with pancytopenia are diagnosed to have curable cause like vitamin deficiency and infections but significant number was also of aplastic anaemia, a condition that requires specialist care.

Determinants of Survival in obstetric Sepsis: Retrospective Observational Study.

Introduction: Sepsis is the dysregulated response of the body to the infection. Obstetric sepsis carries significantly greater morbidity and mortality as the condition is also augmented by the physiological adaptation of body during pregnancy. We conducted this study to determine the various epidemiological and clinical determinants of severity of sepsis which can help in prediction of survival in case of obstetric sepsis. Materials and Methods: This retrospective study was conducted in a tertiary care center and all cases admitted with the diagnosis of obstetric sepsis as per the defined criteria between January 1, 2016 and December 31, 2020 were included in the study. Patients were evaluated for their clinical presentation, SOFA score, biochemical and microbiological parameters and the treatment given during their course of stay. Variables were compared among survivor and non-survivor group using appropriate statistical tests. Parameters which have significant association were further taken for binary logistic regression analysis. Result: A total 46 patients of obstetric sepsis were admitted under defined criteria. Twelve out of 46 patients did not survive (26.09%). On statistical analysis, mean SOFA score (p = 0.005) as well as patients with SOFA score > 6 (p = 0.029), presence of multi organ failure (0.04) and septic shock (p = 0.012) were found to be significantly associated with mortality. Conclusion: The study suggests that these determinants of survival should always be evaluated while catering to a patient of obstetric sepsis in order to guide the treatment, prognostication and improving outcome of the patients.

Platypnea-orthodeoxia Syndrome: An Important Cause of Morbidity in Post Coronavirus Disease Patients.

Platypnea-orthdeoxia syndrome (POS) is a clinical scenario where patient get breathless while sitting or standing. Its important causes are cardiac shunts, hepatopulmonary syndrome and pulmonary ventilation perfusion mismatch. During this pandemic as cases of pulmonary fibrosis increased, we find POS as one of the important cause of morbidity during recovery. Early recognition of this will decrease the morbidity and unrealistic expectation of fast recovery. How to cite this article: Bhushan D, Kumar V, Sahoo BH, Hegde A. Platypnea-orthodeoxia Syndrome: An Important Cause of Morbidity in Post Coronavirus Disease Patients. Indian J Crit Care Med 2022;26(3):401-402.

An observational study on clinico aetiological profile and response to treatment and outcome of patients diagnosed with severe hyponatremia in medicine intensive care unit of a tertiary care centre.

Hyponatremia is defined as serum sodium concentration less than 135meq/l. More severe symptoms are seen when serum sodium falls below 120 meq/l. Hyponatremia in ICU is a very common scenario. Treatment strategy is decided after thorough history taking and clinical examination. Judicious treatment is necessary as rapid correction and delayed correction both can lead to various neurological sequelae. This study was done on critically ill patients who had hyponatremia on the day of admission and clinical and aetiological profile was studied. MATERIAL: An observational study was conducted between March 2020 to July 2021. With in this period of time 210 patients got admitted in medical ICU with serum sodium value less than 120meq/L on the day of admission. Clinico aetiological profile in terms of age, gender, symptoms, co morbidities, response to standard treatment approach, time taken for correction and complications were studied. OBSERVATION: Mean age was 65.5 years. 52.3 % of patients were male. SYMPTOMS: 92.3% had generalised weakness. 89.5% had confusion. 83.8% had nausea and vomiting. 23.8% had body swelling. 26.1% had restlessness. 9% had loss of consciousness and 7.6% had diarrhoea. Comorbidities: Hypertension was present in 41.4% of the patients. Diabetes was present in 24.7%. Hypothyroidism was present in 14.2%. Heart failure, cirrhosis or chronic kidney disease was present in 22.8%. Known pulmonary disease was present in 11.9%. 11.9% patients had history of taking diuretic drugs along with other factors. 1.1% patients were taking other SIADH causing drugs. 94.2% patients had history of low solute intake. In 93.3% Patients hyponatremia was multifactorial. 70.4% patients had hyponatremia due to increased renal excretion of sodium. 82.8% patients were having SIADH. 12.3 % patients had hypokalemia too. DIAGNOSIS: 35.7% patients had intracerebral pathology like CVA, meningitis or SOL. 32.3% had sepsis or underlying infection. 21.9% had dilutional hyponatremia due to underlying CKD/HF/CLD. 7.1% had adrenal insufficiency. 3% patients had other causes of hyponatremia like SIADH causing drugs and malignancy. Mean time to correction of hyponatremia with standard treatment methods was observed to be 3.5 days after admission. COMPLICATIONS: 20.9% patients died in ICU stay. One Patient presenting with Acute liver failure, sepsis developed locked in syndrome. Two Patients developed rest tremor. CONCLUSION: Hyponatremia in ICU in seen in elderly patients more commonly. Hyponatremia remains associated with diseases involving every organ system. Treatment strategies differ with clinical presentation of the patient. Prompt diagnosis and correction at proper pace prevents dreaded complications.

Interim Analysis of Impact of Adding Low Dose Pulmonary Radiotherapy to Moderate COVID-19 Pneumonia Patients: IMpaCt-RT Study.

Background: Treatment for coronavirus disease 2019 (COVID-19) pneumonia remains largely supportive till date and multiple clinical trials took place within the short span of time to evaluate the role of investigational therapies. The anti-inflammatory effect of low dose whole lung radiation in treating pneumonia has been documented earlier. This clinical trial analyzed the effect of low dose radiation therapy (LDRT) in a moderately affected COVID-19 pneumonia patient cohort and has evaluated its effect in stopping the conversion of moderate disease into severe disease. Methods: Patients with moderate COVID-19 pneumonia as characterized by the Ministry of Health and Family Welfare (MOHFW), Government of India, were randomized (1:1) to low dose whole lung radiation versus no radiation. All treatment of patients was concurrently being given as per institutional protocol. Patients were followed up with clinical and laboratory parameters monitored on Days 1, 3, 7, and 14. Computed tomography scan (CT scan) of thorax was performed on Days 1 and 7. Patients were evaluated for conversion of moderate into severe disease as per National Early Warning Score-2 (NEWS-2 score) as the primary end point. The secondary endpoints included changes in ratio between peripheral capillary oxygen saturation and fraction of inspired oxygen (SpO2/FiO2), biochemical markers, 25-point CT severity score, and radiation induced acute pulmonary toxicities. Findings: At the interim analysis, there were seven patients in the radiation arm and six in the control. A whole lung LDRT improved the outcome of SpO2/FiO2 at Day 3; however it did not convert into a statistically significant improvement for the NEWS-2 score. The serum levels of LDH, CRP, Ferritin and D-dimer were significantly reduced on 14 days in the LDRT arm in comparison to the baseline value but were not significant between the two groups. Interpretation: LDRT seems to have the potential to prevent moderate COVID-19 pneumonia from a deteriorating to severe category. However, further randomized clinical trial with an adequate number of such patients is warranted to establish the definitive role of LDRT in the management of COVID-19 pneumonia. Funding: An intramural research project bearing code: I-27/621, was sanctioned from the All India Institute of Medical Sciences, Patna, India. Clinical Trial Registration: Clinical Trials Registry-India (CTRI/2021/06/033912, 25th May 2021) ctri.nic.in/Clinicaltrials/login.php.

Role of Dantabija, Haridra, and Zingiber (DHZ) combination to restore health and immunity in mild to moderate COVID-19 patients.

Background: COVID-19 (SARS-CoV-2) has caused various clinical manifestations ranging from asymptomatic, minor flu-like symptoms to acute respiratory distress syndrome (ARDS), pneumonia, and even death. Early restriction of viruses is of utmost importance in controlling the spread of COVID-19. The present study aimed to evaluate the role of a common herbal extract combination of pomegranate (dantabija), turmeric (haridra), and zinger (DHZ) in mild to moderate covid cases. Methods: A hundred covid-positive subjects of mild to moderate severity have been randomized to control and study groups. The study population has been given the fixed-dose combination of DHZ as an adjuvant to standard treatment. Data have been analyzed using standard statistical tools. Finding: DHZ as an adjuvant helped in turning 83.33% of patients negative in the home quarantine group whereas 40% of patients in the hospitalized group turned negative with the addition of DHZ in the standard management. The percent negativity was lower in patients who received only standard management. Out of all patients, who did not receive DHZ, only 38% of patients in home quarantine and 32% in hospitalized patients became negative for COVID-19. Patients who received DHZ also showed improvement in blood pressure levels, oxygen levels as well as improvement in all symptoms associated with COVID-19 infections. Interpretation: DHZ has shown a promising effect in mild to moderate cases of COVID-19 as an adjuvant to the standard therapy. The study results indicated that the combination probably produces its effect by its immunomodulatory action.

The COSEVAST Study Outcome: Evidence of COVID-19 Severity Proportionate to Surge in Arterial Stiffness.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection affects the cardiovascular system at many levels. It initially infects endothelial cells, inducing marked endothelial damage and inflammation. However, there was no empirical evidence of functional compromise of arterial walls. AIMS AND OBJECTIVE: Our primary objective was to study functional arterial damage in coronavirus disease 2019 (COVID-19) and establish the noninvasive measurement of arterial stiffness as an independent marker of disease severity. MATERIALS AND METHODS: We recorded the arterial stiffness of 23 mild, 21 moderate, and 20 severe COVID-19 patients grouped on the latest National Institute of Health (NIH) severity criteria. We observed arterial stiffness of COVID-19 patients with standard parameters like noninvasive estimated carotid-femoral pulse wave velocity (cfPWV), age-normalized increase in cfPWV (ANI_cfPWV), age-normalized increase in aortic augmentation pressure (ANI_AugP), and heart rate-normalized augmentation index (HRN_ AIx). All the parameters were also corrected for statistically significant confounding factors. RESULTS: Moderate and severe COVID-19 patients have extremely significantly elevated arterial stiffness than mild patients. In mild patients, cfPWV (829.1 ± 139.2 cm/second) was significantly lower than both moderate (1067 ± 152.5 cm/second, p <0.0001) and severe (1416 ± 253.9 cm/second, p <0.0001) patients. ANI_cfPWV in moderate and severe patients was significantly higher than mild patients (mild: 101.2 ± 126.1 cm/second; moderate: 279 ± 114.4 cm/second; severe: 580.1 ± 216.4 cm/second; intergroup p <0.0001). The results even after correction for significant confounding factors did not show any considerable change in the increasing trend of arterial stiffness. CONCLUSION: This study establishes the functional deterioration of arteries in proportion to the severity of COVID-19. HOW TO CITE THIS ARTICLE: Kumar N, Kumar S, Kumar A, Bhushan D, Kumar A, Kumar A, et al. The COSEVAST Study Outcome: Evidence of COVID-19 Severity Proportionate to Surge in Arterial Stiffness. Indian J Crit Care Med 2021;25(10):1113-1119.

Extrahepatic portal vein thrombosis in a pregnant patient with COVID-19: a rare thrombotic event survivor.

A COVID-19 infection predisposes the infected person to thrombotic events. Myocardial infarction, acute limb ischaemia, mesenteric artery thrombosis and pulmonary embolism are all well-documented complications of this infection. Here we describe a pregnant patient who presented with obstructed labour with asymptomatic COVID-19 infection and developed ascites during the postoperative period. Further work-up of the patient revealed portal hypertension due to portal vein thrombosis (PVT). As the patient was healthy before this index pregnancy, a causative link between COVID-19 and PVT cannot be ruled out. Her COVID-19 infection progressed to a moderate disease. She was managed with steroids and appropriate antibiotics for secondary bacterial peritonitis. She was finally discharged after 2.5 months of multidisciplinary treatment. This is a case of a survivor of complications due to pregnancy, COVID-19 and extrahepatic portal vein obstruction.

Antibiotic audit in medicine intensive care unit of tertiary care centre: A must do exercise.

PURPOSE: Antimicrobial resistance (AMR) is a serious threat to the humanity now a days. To prevent it, the first step is to know about our antibiotic practices. Audit is the first step in continuous quality improvement which intend to go ahead. Antibiotic stewardship involves appropriate antibiotic (empirical or definitive) at correct time in correct doses and frequency for appropriate duration. METHOD: We conducted a retrospective study in intensive care unit at our tertiary care center of Bihar, India. Our aim was to know about empirical antibiotic we are prescribing in suspected sepsis patients and their rationality too. National treatment guidelines for infectious disease released by National Centre for Disease Control (NCDC) was taken as standard of care. We recorded demographic profile, SOFA (Sequential Organ Failure Assessment), APACHE II (Acute Physiology and Chronic Health Evaluation), antibiotic prescribed, final etiology of infection, and outcome of the patient and total ICU stay. RESULT: We found that combination of two antibiotics were given in majority of patients (53%) and the third generation cephalosporin was the most commonly prescribed antibiotic. In our audit, rational combinations according to the antibiotic policies were given in 73.7% of patients. Appropriate doses of antibiotics were given in 89.5% of patients. CONCLUSION: Audit is a mandatory exercise to provide quality care in the health care system.

Hypopituitarism: A Rare but Often Neglected Condition.

Pituitary insufficiency is an uncommon disorder. The most common cause is compression due to a pituitary mass. Other causes include inflammatory damage and vascular injury like postpartum pituitary apoplexy. Postpartum pituitary apoplexy, also known as Sheehan's syndrome, leads to hormonal deficiencies and causes postpartum amenorrhea, lactational failure, chronic hyponatremia, hypoglycemia, and loss of secondary sexual characters. Here we are discussing the clinical course of 15 female patients of panhypopituitarism. Most of them had a history of postpartum hemorrhage. Knowledge about this entity is essential as it is a treatable condition and ignorance could prove to be fatal. HOW TO CITE THIS ARTICLE: Bhushan D, Agarwal M, Shukla RK. Hypopituitarism: A Rare but Often Neglected Condition. Indian J Crit Care Med 2020;24(5):350-352.

Deep Sedation or Paracervical Block for Daycare Gynecological Procedures: A Prospective, Comparative Study.

CONTEXT: Many minor gynecological procedures are done for diagnostic and therapeutic reasons. A balance has to be struck between ability to discharge a patient at the earliest with minimum procedure-related discomfort to ensure patient safety as well as satisfaction. AIM: This prospective randomized study was designed to compare deep sedation versus paracervical block for minor gynecological surgeries comparing the time to discharge readiness, pain after the procedure, and overall patient satisfaction. SETTING AND DESIGN: This prospective randomized comparative study was conducted at a tertiary level hospital after institutional ethics committee approval and registry of trial at CTRI (India). METHODS: Seventy young women underwent minor gynecological procedures under these two modes of anesthesia. Time to discharge readiness from hospital to home was assessed using modified postanesthesia discharge score system (PADSS). Pain after procedure as well as patient satisfaction was evaluated. Patients were also asked whether they would recommend the same anesthetic technique for the procedure in the future. Answers were noted on a Likert scale. RESULTS: Patients were ready to be discharged faster in deep sedation group compared to paracervical block group based upon modified PADSS score (1 h 9.6 min vs. 1 h 18 min) (P = 0.005). Pain in the perioperative period was analyzed using repeated-measures ANOVA and found to be significantly lesser in deep sedation group when considered till 80 min after surgery. The mean satisfaction score in patients who underwent deep sedation was 91.24 (standard deviation [SD] 2.8) compared to patients given paracervical block which was low at 64.67 (SD 15.8). All patients given deep sedation were ready to recommend the anesthesia technique as compared to only 53.3% of patients who were given paracervical block. CONCLUSIONS: Deep sedation may be preferred over paracervical block for daycare minor gynecological procedures.

Guaiacum Toxicity: An Unusal Poisoning.

Guaiacum is a homeopathic medicine used for arthritis, syphilis and tonsillitis. Its use as a substance abuse is not properly described in literature. Its excess intake may be life threatening and can damage the vision permanently.