Oxygenation Index and Oxygen Saturation Index for Predicting Postoperative Outcome in Patients Undergoing Emergency Surgery: A Prospective Cohort Study.

Background: The OI was originally evaluated as a prognostic tool for acute hypoxemic respiratory failure in children and was an independent predictor for mortality in adult patients with acute respiratory distress syndrome (ARDS). Methods: Oxygenation index and OSI of 201 adult patients undergoing emergency surgery were evaluated at different time points. The primary objective of this study was to find the correlation between OI and OSI. The secondary objectives were to find the prognostic utility of OI and OSI for postoperative mechanical ventilation and mortality. Results: Significant statistical correlation was found between OI and OSI both at the beginning (r 2 = 0.61; p < 0.001) and immediately after surgery (r 2 = 0.47; p < 0.001). Oxygen saturation index at the beginning [area under the receiver operating characteristics curve (AUROC) (95% CI) 0.76 (0.62-0.89); best cutoff 3.9, sensitivity 64% and specificity 45%] and immediately after surgery [AUROC (95% CI) 0.82 (0.72-0.92); best cutoff 3.57, sensitivity 79%, and specificity 62%] were reasonable predictors of the requirement of invasive ventilatory support. Exploratory analysis reported that older age (p = 0.02), higher total leukocyte count (p = 0.002), higher arterial lactate (p = 0.02), and higher driving pressure (p < 0.001) were independently associated with hospital mortality. Conclusion: In adult patients undergoing emergency laparotomy under general anesthesia, OI and OSI were found to be correlated. Both metrics demonstrated reasonable accuracy in predicting the need for invasive ventilatory support beyond 24 hours and hospital mortality. How to cite this article: Thakuria R, Ernest EE, Chowdhury AR, Pangasa N, Kayina CA, Bhattacharjee S, et al. Oxygenation Index and Oxygen Saturation Index for Predicting Postoperative Outcome in Patients Undergoing Emergency Surgery: A Prospective Cohort Study. Indian J Crit Care Med 2024;28(7):645-649.

Association between baseline insulin resistance and hospital mortality in moderate-to-severe coronavirus disease 2019 patients without diabetes mellitus: An observational study.

Background: Insulin resistance is often implicated as a risk factor of cell-mediated immune dysfunction in sepsis patients and results in poor clinical outcome. However, it is unclear whether early insulin resistance is contributory to T-cell dysfunction and poor clinical outcome in coronavirus disease 2019 (COVID-19) patients. Methods: Adult patients with moderate-to-severe or critically ill COVID-19 infection were included in this study. Serum samples were collected at the time of diagnosis for fasting plasma glucose, serum insulin, serum cortisol, and serum glucagon measurements, and the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) score was calculated. Results: One hundred and twenty-six subjects with a mean (standard deviation) age of 49.6 (16.3) years were recruited in this study, and 62.4% (78 of 125 patients) were male. HOMA-IR was a predictor of inhospital mortality with the area under the receiver operating characteristics curve (AUROC) (95% confidence interval [CI] of 0.61 [0.49-0.73]). With a cutoff value of 1.91, sensitivity was 75.5% and specificity was 45.2%. Higher serum insulin was associated with higher survival with AUROC (95% CI) of 0.65 (0.53-0.76), and the best cutoff was 7.15, with a sensitivity and specificity of 62.1% and 64.5%. Serum cortisol was also a predictor of inhospital mortality with an AUROC (95% CI) of 0.67 (0.56-0.77). Conclusion: An independent association between baseline serum cortisol and poor outcome in moderate-to-severe COVID-19 patients was observed. Hyperglycemia and HOMA-IR can also predict poor outcome in these patients with some accuracy.

Lung Ultrasound Findings in a Patient with Lymphangitic Carcinomatosis.

How to cite this article: Bhattacharjee S, Prasanna M, Maitra S, Ray BR. Lung Ultrasound Findings in a Patient with Lymphangitic Carcinomatosis. Indian J Crit Care Med 2024;28(1):82-83.

Effect of incremental PEEP titration on postoperative pulmonary complications in patients undergoing emergency laparotomy: a randomized controlled trial.

Postoperative pulmonary complications (PPC) has a significant negative impact and are associated with increased length of hospital stay and cost of care. Emergency surgery is a well-established risk factor for PPC. Previous studies reported that personalized positive end-expiratory pressure (PEEP) might reduce postoperative atelectasis and postoperative pulmonary complications. N = 168 adult patients undergoing major emergency laparotomy under general anesthesia were recruited in this study. A minimum driving pressure based incremental PEEP titration was compared to a fixed PEEP of 5 cmH2O. The primary outcome was PPC up to postoperative day 7. The mean (standard deviation) of the recruited patients was 41.7(16.1)y, and 48.8% (82 of 168 patients) were female. The risk of PPC at postoperative day 7 was similar in both the study groups [Relative risk (RR) (95% Confidence interval, CI) 0.81 (0.58, 1.13); p = 0.25]. In addition, the incidence of intraoperative hypotension [p = 0.75], oxygen-free days at day 28 [p = 0.27], duration of postoperative hospital stay [p = 0.50], length of postoperative intensive care unit stay [p = 0.28], and in-hospital mortality [p = 0.38] were similar in two groups. Incidence of PPC was not reduced with the use of an individualized PEEP strategy based on lowest driving pressure. However, the incidence of hypotension and bradycardia was also not increased with titrated PEEP.Trial Registration: www.ctri.nic.in ; CTRI/2020/12/029765.

Postoperative pulmonary complications with high versus standard FiO2 in adult patients undergoing major abdominal surgery: A noninferiority trial.

BACKGROUND: Despite the possible clinical benefit of high intraoperative oxygen therapy on surgical site infection, the effect on postoperative respiratory function is debatable. However, it remains yet to be elucidated whether hyperoxia due to a high fraction of inspired oxygen used in conjunction with lung protective ventilation can lead to increased incidence of postoperative pulmonary complications. METHODS: In this noninferiority randomized trial, an intraoperative high fraction of inspired oxygen of 0.8 (group H) was compared to a standard fraction of inspired oxygen of 0.3 to 0.4 (group S) in adult patients undergoing major elective or emergency surgery. A lung protective ventilation strategy was employed in all patients, including volume control ventilation with a tidal volume of 6 to 8 mL/kg of predicted body weight, respiratory rate of 12 beats per minute, and positive end-expiratory pressure of 5 to 8 cm H2O. Postoperative pulmonary complications were assessed on postoperative days 3 and 5 by the Melbourne group scale. RESULTS: In this trial, n = 226 patients were randomized; among them, 130 patients underwent routine surgery, and 96 patients underwent emergency surgery. The median (interquartile range) of the patients was 48 (35-58) years, and 47.3% were female. Melbourne group scale scores at postoperative day 3 (median [interquartile range] 2 [1-4] in group S vs 2 [1-3] in group H; the difference in median [95% confidence interval] 0 [0, -1]; P = .13) and day 5 (median [interquartile range] 1 (0-3) in group S vs 1 [0-3] in group H; the difference in median [95% confidence interval] 0 [0, 0.5]; P = .34) were statistically similar in both the groups and the upper margin was within the predefined margin of 1. Incidence of surgical site infection (P = .46), postoperative hospital stay (P = .29), and days alive without antibiotic therapy at postoperative day 28 (P = .95) were similar in both groups. CONCLUSION: High intraoperative fiO2 was noninferior to standard fiO2 in postoperative pulmonary complications in adult patients undergoing major surgery.

Malarial Antibodies and Endemicity: Does It Affect SARS-CoV-2 Severity and Outcomes?

Background India has a disproportionately lower rate of coronavirus disease 2019 (COVID-19) severe disease and lower death rates with respect to other parts of the world. It has been proposed that malaria-endemic countries such as India are relatively protected against severe COVID-19 disease and deaths. Methods This was a cross-sectional, analytical, observational study conducted from August 2020 to July 2021 at a tertiary care COVID-19-designated center in New Delhi, India. It aimed to study the association between antimalarial antibody levels and COVID-19 disease severity and outcomes. Results One hundred forty-six patients were included in the final analysis. The mean (standard deviation {SD}) age of the study population was 44.6 (17.2) years, and there were 85 (58.2%) males. Sixty-five patients had mild disease, 14 patients had moderate disease, and 67 patients had severe disease at the time of enrolment in the study. Forty-six patients expired during the hospital stay. For the antimalarial antibody, there was a statistically significant difference between mild and moderate (p=0.018), mild and severe (p=0.016), and mild and combined moderate and severe diseases (p=0.013). However, there was no difference between the patients who survived and those who did not. Conclusion Antimalarial antibody levels may not be associated with the outcomes of COVID-19 during hospital stay. However, this study has provided some insights into the relationship between the severity and outcomes of COVID-19 and the levels of antimalarial antibodies.

Subphenotypes of SARS-CoV-2-Associated ARDS Overlap Each Other: A Retrospective Analysis.

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus-associated pneumonia and acute respiratory distress syndrome (ARDS) were often associated with hyperinflammation and elevation of several serum inflammatory markers but usually less than what is observed in non-coronavirus disease (COVID) ARDS. Elevated inflammatory markers such as C-reactive protein, interleukin (IL)-6, etc., are associated with severe infection. This study identified subphenotypes of COVID-19 ARDS patients by latent profile analysis in a cohort of Indian patients. Methods Data of n = 233 adult Indian patients with laboratory-confirmed SARS-CoV-2 infection admitted to a tertiary care teaching hospital were analyzed in this retrospective study. Only patients with acute respiratory failure (defined by partial pressure of oxygen/fraction of inspired oxygen ratio < 200 mm Hg) and chest X-ray showing bilateral infiltrates were included. Results The patients' mean (standard deviation) age was 53.3 (14.9) years, and 62% were male. A two subphenotypic model was formulated based on the lowest Bayesian information criterion. Neutrophil-to-lymphocyte ratio and serum IL-6 were latent variables in that model (entropy 0.91). The second phenotype (hyperinflammatory) had lower platelet count ( p = 0.02), higher serum creatinine ( p = 0.004), higher C-reactive protein ( p = 0.001), higher ferritin ( p < 0.001), and serum lactate dehydrogenase ( p = 0.009). Age-adjusted hospital mortality ( p = 0.007), duration of hospital stay ( p < 0.001), and duration of intensive care unit stay ( p < 0.001) were significantly higher in the second subphenotype. Conclusion Two distinct but overlapping subphenotypes were identified in SARS-CoV-2-associated respiratory failure. Hyperinflammatory subphenotype was associated with significantly poor short-term outcomes.

Prediction of Delirium in the Critically Ill Obstetric Patients: An Old Friend to the Rescue?

How to cite this article: Sinha S, Bhattacharjee S. Prediction of Delirium in the Critically Ill Obstetric Patients: An Old Friend to the Rescue? Indian J Crit Care Med 2023;27(5):301-302.

Comparison of ultrasound guided dorsal radial artery cannulation and conventional radial artery cannulation at the volar aspect of wrist: A pilot randomized controlled trial.

BACKGROUND: Distal radial artery cannulation at the "anatomical snuffbox" carries several theoretical advantages over conventional radial arterial cannulation at the wrist. However, these two techniques have not been evaluated in perioperative settings. METHODS: In this randomized controlled trial, n = 200 patients requiring arterial cannulation for perioperative monitoring were recruited. Patients were randomized to either ultrasound guided distal radial artery cannulation group (group D) or ultrasound guided conventional radial artery cannulation group (group W). Primary outcome of this study was first attempt cannulation success rate. RESULTS: First attempt cannulation success rate was significantly lower in distal radial artery cannulation (57% in group D and 77% in group W; p = 0.003). Use of alternative cannulation site was significantly higher in group D when compared to group W (p = 0.015) and number of attempts for successful cannulation was significantly higher in group D when compared to group W (p = 0.015). None of the patients in any group developed thrombosis and related complications and intraoperative catheter dislodgement. Time to puncture the artery (p < 0.0001), total cannulation time (p < 0.0001), and actual catheter insertion time (p < 0.0001) were significantly higher in group D in comparison to group W. CONCLUSION: Distal radial artery cannulation was associated with lower first attempt cannulation success rate and requires longer time to perform. As distal radial artery is a new technique, further studies are required in different clinical settings.

Chemical, physical, and biological stimuli-responsive nanogels for biomedical applications (mechanisms, concepts, and advancements): A review.

The development of nanotechnology has influenced the advancements in biomedical and pharmaceutical fields. The design and formulation of stimuli-responsive nano-drug delivery systems, also called smart drug delivery systems, have attracted significant research worldwide and have been seen as a breakthrough in nanomedicines. The ability of these nanocarriers to respond to external and internal stimuli, such as pH, temperature, redox, electric and magnetic fields, enzymes, etc., has allowed them to deliver the cargo at targeted sites in a controlled fashion. The targeted drug delivery systems limit the harmful side effects on healthy tissue by toxic drugs and furnish spatial and temporal control drug delivery, improved patient compliance, and treatment efficiency. The polymeric nanogels (hydrogel nanoparticles) with stimuli-responsive characteristics have shown great potential in various biomedical, tissue engineering, and pharmaceutical fields. It is primarily because of their small size, biocompatibility, biodegradability, stimuli-triggered drug deliverability, high payload capacity, and tailored functionality. This comprehensive review deals distinctively with polymeric nanogels, their chemical, physical, and biological stimuli, the concepts of nanogels response to different stimuli, and recent advancements. This document will further improve the current understanding of stimuli-responsive materials and drug delivery systems and assist in exploring advanced potential applications of these intelligent materials.

A Double-Blind, Randomized Controlled Pilot Trial to Assess the Analgesic Efficacy of Ultrasound-Guided Preemptive Caudal Morphine as an Adjunct to Bupivacaine for Lumbosacral Spine Surgeries in Adults.

Background The analgesic efficacy of preemptive administration of caudal morphine for spine surgeries in adults is not well studied. In a double-blinded, randomized controlled trial, safety and analgesic efficacy of preemptive, single-shot caudal morphine and bupivacaine was compared with caudal bupivacaine alone in lumbosacral spine surgeries. Methods After Institutional Ethics Committee approval, 40 patients aged 18-60 yrs planned for lumbosacral spine surgery were randomized to groups of 20 patients each. After induction and prone positioning, an ultrasound-guided caudal block was performed with morphine 50 µg/kg with 20 ml 0.25% bupivacaine in the study group (LM) and only bupivacaine in the control group (LA). Postoperatively, both groups received intravenous morphine via patient-controlled analgesia (PCA) pump (No basal, 1 mg/bolus, 10 minutes lockout interval). Intraoperative fentanyl use, postoperative 24-h morphine consumption, visual analogue pain scores (VAS) and adverse effects of morphine were noted. Results Demographics and baseline data were comparable. Postoperative 24-hour morphine requirement was more in LA group (34.3 ± 10.7 mg vs 19.65 ± 11.8 mg, p=0.0001). Total intraoperative supplemental fentanyl requirement was similar (79.25 ± 67.60 µg in LA vs 54 ± 50.20 µg in LM group, p=0.28). VAS scores at 2/4/6/12-hour in group-LM were significantly less than group-LA (p=0.005, 0.002, 0.001 and 0.047) but were comparable at 18 and 24 hours (p=0.25, 0.42). Postoperative incidence of adverse effects of morphine was comparable. Conclusions Ultrasound-guided, single-shot preemptive administration of caudal morphine with bupivacaine is a safe and effective modality of analgesia for patients undergoing lumbosacral spine surgeries.

Epidemiology and clinical characteristics of COVID- 19 patients requiring critical care in a Tertiary care teaching hospital.

BACKGROUND AND AIMS: We describe the epidemiological and clinical characteristics, and 28 day outcome of critically ill COVID-19 patients admitted to a tertiary care centre in India. MATERIAL AND METHODS: We included 60 adult critically ill COVID-19 patients in this prospective observational study, admitted to the intensive care unit (ICU) after obtaining ethics committee approval and informed consent. Demographics, clinical data, and treatment outcome at 28 days were assessed. RESULTS: Demographic characteristics of the COVID-19 patients reveal that compared to the survivors, the non-survivors were significantly older [57.5 vs. 47.5 years], had more comorbid disease [Charlson's comorbidity index 4 vs. 2], higher Apache II scores [19 vs. 8.5], and had significantly higher percentage of smokers. Diabetes mellitus and hypertension were the most common comorbidities. Dyspnea, fever, and cough were the most common presenting symptoms. Total leucocyte count as well as blood lactate level were significantly higher in non-survivors. Around 47% patients had severe ARDS, and 60% patients required invasive mechanical ventilation. 28 day ICU mortality was 50%, with a mortality of 75% in patients receiving invasive mechanical ventilation. Mortality was higher in males than females (57% vs. 33%). Acute kidney injury and septic shock were the most common non-pulmonary complications during ICU stay. Incidence of liver dysfunction, septic shock, and vasopressor use was significantly higher in the non-survivors. CONCLUSION: This study demonstrates a high 28 day mortality in severe COVID-19 patients. Further well designed prospective studies with larger sample size are needed to identify the risk factors associated with poor outcome in such patients.

Clinicoepidemiological Features and Mortality Analysis of Deceased Patients with COVID-19 in a Tertiary Care Center.

BACKGROUND AND OBJECTIVE: A large number of studies describing the clinicoepidemiological features of coronavirus disease-2019 (COVID-19) patients are available but very few studies have documented similar features of the deceased. This study was aimed to describe the clinicoepidemiological features and the causes of mortality of COVID-19 deceased patients admitted in a dedicated COVID center in India. METHODOLOGY: This was a retrospective study done in adult deceased patients admitted in COVID ICU from April 4 to July 24, 2020. The clinical features, comorbidities, complications, and causes of mortality in these patients were analyzed. Pediatric deceased were analyzed separately. RESULTS: A total of 654 adult patients were admitted in the ICU during the study period and ICU mortality was 37.7% (247/654). Among the adult deceased, 65.9% were males with a median age of 56 years [interquartile range (IQR), 41.5-65] and 94.74% had one or more comorbidities, most common being hypertension (43.3%), diabetes mellitus (34.8%), and chronic kidney disease (20.6%). The most common presenting features in these deceased were fever (75.7%), cough (68.8%), and shortness of breath (67.6%). The mean initial sequential organ failure assessment score was 9.3 ± 4.7 and 24.2% were already intubated at the time of admission. The median duration of hospital stay was 6 days (IQR, 3-11). The most common cause of death was sepsis with multi-organ failure (55.1%) followed by severe acute respiratory distress syndrome (ARDS) (25.5%). All pediatric deceased had comorbid conditions and the most common cause of death in this group was severe ARDS. CONCLUSION: In this cohort of adult deceased, most were young males with age less than 65 years with one or more comorbidities, hypertension being the most common. Only 5% of the deceased had no comorbidities. Sepsis with multi-organ dysfunction syndrome was the most common cause of death. HOW TO CITE THIS ARTICLE: Aggarwal R, Bhatia R, Kulshrestha K, Soni KD, Viswanath R, Singh AK, et al. Clinicoepidemiological Features and Mortality Analysis of Deceased Patients with COVID-19 in a Tertiary Care Center. Indian J Crit Care Med 2021; 25(6):622-628.

Outcome of Conservative Therapy in Coronavirus disease-2019 Patients Presenting With Gastrointestinal Bleeding.

BACKGROUND/OBJECTIVE: There is a paucity of data on the management of gastrointestinal (GI) bleeding in patients with Coronavirus disease -2019 (COVID-19) amid concerns about the risk of transmission during endoscopic procedures. We aimed to study the outcomes of conservative treatment for GI bleeding in patients with COVID-19. METHODS: In this retrospective analysis, 24 of 1342 (1.8%) patients with COVID-19, presenting with GI bleeding from 22nd April to 22nd July 2020, were included. RESULTS: The mean age of patients was 45.8 ± 12.7 years; 17 (70.8%) were males; upper GI (UGI) bleeding: lower GI (LGI) 23:1. Twenty-two (91.6%) patients had evidence of cirrhosis- 21 presented with UGI bleeding while one had bleeding from hemorrhoids. Two patients without cirrhosis were presumed to have non-variceal bleeding. The medical therapy for UGI bleeding included vasoconstrictors-somatostatin in 17 (73.9%) and terlipressin in 4 (17.4%) patients. All patients with UGI bleeding received proton pump inhibitors and antibiotics. Packed red blood cells (PRBCs), fresh frozen plasma (FFPs) and platelets were transfused in 14 (60.9%), 3 (13.0%) and 3 (13.0%), respectively. The median PRBCs transfused was 1 (0-3) unit(s). The initial control of UGI bleeding was achieved in all 23 patients and none required an emergency endoscopy. At 5-day follow-up, none rebled or died. Two patients later rebled, one had intermittent bleed due to gastric antral vascular ectasia, while another had rebleed 19 days after discharge. Three (12.5%) cirrhosis patients succumbed to acute hypoxemic respiratory failure during hospital stay. CONCLUSION: Conservative management strategies including pharmacotherapy, restrictive transfusion strategy, and close hemodynamic monitoring can successfully manage GI bleeding in COVID-19 patients and reduce need for urgent endoscopy. The decision for proceeding with endoscopy should be taken by a multidisciplinary team after consideration of the patient's condition, response to treatment, resources and the risks involved, on a case to case basis.

Intraoperative lung protective ventilation in peritonitis patients undergoing emergency laparotomy: A randomised controlled trial.

BACKGROUND AND AIMS: Lung protective ventilation (LPV) is recommended in acute respiratory distress syndrome. However, role of intraoperative LPV in elective laparotomy is controversial and it has not been evaluated in emergency laparotomy (EL). The aim of the study was to identify whether use of intraoperative LPV in EL in peritonitis patients reduces postoperative pulmonary complications (POPC). METHODS: After institutional ethics committee approval and informed written consent, 98 adult patients undergoing EL for peritonitis were randomised into two groups. Patients in group 1 received LPV (tidal volume 6-8 ml/kg, positive end expiratory pressure (PEEP) 6-8 cm H2O and recruitment manoeuvre every 30 min) and patients in group 2 received conventional ventilation (tidal volume 10-12 ml/kg, without PEEP/recruitment). Primary outcome was incidence of POPC on day 7. RESULTS: Data of 94 patients (n = 45 in group 1 & n = 49 in group 2) were available. Baseline demographic & laboratory parameters were comparable. Incidence of POPC was similar in both the groups [42.9% in group 1 vs. 53.3% in group 2; risk difference -10.4% (-30.6%, 9.6%); P = 0.31]. Mortality during hospital stay was 26.7% patients in group 1 and 26.5% patients in group 2 [risk difference (95% CI) 0.14%, (-17.7, 18.0); P = 0.98]. Length of hospital stay [median interquartile range (IQR) 13 (9-18) days in group 1 vs. 13 (8-21) days in group 2; P = 0.82] and length of intensive care unit stay [median (IQR) 7 (4-10) days vs. 6 (3-12) days; P = 0.88] were also similar in both groups. CONCLUSION: LPV during EL in peritonitis patients does not reduce the incidence of POPC compared to conventional ventilation.

Comparison of KingVision videolaryngoscope channelled blade with Tuoren videolaryngoscope non-channelled blade in a simulated COVID-19 intubation scenario by non-anaesthesiologists and experienced anaesthesiologists: A prospective randomised crossover mannequin study.

Purpose: A videolaryngoscope has been recommended for intubation in the COVID-19 scenario but the videolaryngoscope providing optimal intubation conditions is not ascertained. We compared KingVision channelled blade with a non-Channelled videolaryngoscope for intubation times in a simulated COVID-19 intubation scenario by both anaesthesiologists and non-anaesthesiologists. Methods: This prospective randomised cross over mannequin study was conducted in a skill training lab. 25 anaesthesiologists and 25 non-anaesthesiologists donned in standard personal protective equipment performed 100 intubations with KingVision and Tuoren videolaryngoscopes in a mannequin covered with a transparent plastic sheet. The total intubation time, percentage of glottic opening scores, first attempt success rates were assessed. Results: The mean difference in intubation times in anaesthesiologists and non-anaesthesiologist less with KingVision videolaryngoscope (21.1s; 95% CI 9.6-32.6s vs. 35.9s; 95% CI 24.4-47.4 s; P = 0.001). Percentage of glottic opening score was significantly better with KingVision by non-anaesthesiologists (60; IQR 42.5 to 75 vs. 70; IQR 50 to 100; P = 0.019). KingVision provided superior first attempt success rate in non-anaesthesiologists (84% vs. 61.9%; P = 0.02) and anaesthesiologists (96% vs. 76%; P = 0.12). Conclusion: KingVision channelled videolaryngoscope provided faster intubation times, glottic views and first attempt success rates in a simulated COVID-19 scenario in manikins and might be preferred over videolaryngoscopes with non-channelled blade. The findings need to be further verified in humans. Trial registration: ctri.nic.in identifier: REF/2020/05/033338.