Drug-induced Kidney Disease: Revisited.

Drug-induced kidney disease (DIKD) is a frequent cause of acute and chronic kidney disease (CKD) that leads to high morbidity, hospitalization, and increased healthcare costs. There is a need to constantly update our knowledge in this field, given the ever-burgeoning list of newer treatments that are emerging, especially in the field of cancer immunotherapy. Generalizing the complex pathways causing DIKD from different agents, the common mechanisms include direct toxicity, immune-mediated injury, and drug-induced alterations in renal blood flow. Proper management of this condition involves risk minimization, early detection of renal damage, and timely discontinuation of potential agents to avoid irreversible renal damage.

Analgaesic efficacy of single-injection serratus anterior plane block for breast surgery: A systematic review, meta-analysis and trial sequential analysis of randomised controlled trials.

There is conflicting evidence regarding the analgaesic efficacy of single-shot serratus anterior plane block (SAP) for breast surgery. This meta-analysis aimed to evaluate the analgaesic efficacy of SAP compared with non-block care (NBC) and other regional blocks, i.e. paravertebral block (PVB) and modified pectoral nerve block (PECS block) for breast surgery. PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov were searched. We included randomized controlled trials reporting the use of the SAP block in adult breast surgery. The primary outcome was postoperative oral morphine equivalent (OME) consumption for up to 24 hours. Random-effects models were used to pool results and mean difference (MD), and odds ratio (OR) was calculated for continuous and dichotomous outcomes, respectively. GRADE guidelines were used to evaluate the strength of evidence, and trial sequential analysis (TSA) was performed to provide certainty to the conclusion. Twenty-four trials enrolling 1789 patients were included. Moderate strength evidence suggested that SAP provided a significant reduction in 24-hour OME compared with NBC [MD - 24.9 mg (95% CI - 41.54, -8.25; P < 0.001, I2 = 99.68%)]. TSA ruled out the possibility of false-positive results. Subgroup analysis for the SAP demonstrated that the superficial plane approach was more effective in reducing opioid consumption than the deep approach. The odds of developing PONV were significantly lower in SAP compared to NBC. Compared with PVB and PECS, SAP block was not statistically different for 24-hour OME and time to first rescue analgaesia. Single-shot SAP reduced opioid consumption, prolonged analgaesia duration, lowered pain scores, and decreased the incidence of PONV compared to NBC. There was no statistically significant difference in the studied endpoints between SAP, PVB, and PECS blocks.

Measuring the Impact of Augmented Reality in Flipped Learning Mode on Critical Thinking, Learning Motivation, and Knowledge of Engineering Students.

Digital electronics is a fundamental subject for engineering students, and it enables the students to learn design-based approaches and solve complex engineering problems. Students learn about minimization techniques for reducing the hardware components and size of the circuit by solving complex Boolean equations. The Karnaugh map (K-map) is one such technique utilized in digital electronics to solve complex Boolean equations and design AND-OR-INVERT (AOI) logical diagrams. The K-map technique involves several steps to solve the Boolean expression, and students often find it difficult to follow the K-map process. In this study, an AR-based learning system was developed using Unity 3D and Vuforia SDK that aimed to teach the students about the step-wise operation of the K-map technique. An experimental study was conducted with 128 undergraduate engineering students to determine the impact of the AR learning system on the critical thinking skills, learning motivation, and knowledge gain of students. The students were divided into two groups: experimental group (N = 64) and control group (N = 64). The AR learning system was implemented in flipped learning mode and utilized to provide in-class activities during the learning. The experimental group students utilized the AR learning system for in-class activities whereas control group students performed in-class activities using the traditional approach. The experimental outcomes indicate that the use of AR technology has a significant positive impact on the critical thinking skills, learning motivation, and knowledge gain of students. The study also found that critical thinking skills and learning motivation have a significant positive correlation with the knowledge gain of students in the experimental group.

Regulation of Calcium Homeostasis in Acute Kidney Injury: A Prospective Observational Study.

Background: Maintaining homeostasis is an integral part of all physiological processes both in health and disease including critically ill patients and may impact clinical outcomes. The present study was designed to assess prevalence of serum calcium, phosphate, vitamin-D3, FGF-23, and PTH levels abnormalities in AKI. Patients and methods: Single-center, prospective, observational study in a tertiary care hospital. Patients meeting KDIGO criteria for AKI were included. Paired blood samples were drawn from eligible patients-first sample within 24 hours of AKI diagnosis and second after 5 days or at time of hospital discharge, whichever was earlier for measuring serum calcium (albumin corrected), phosphate, PTH, 25(OH)Vit-D, and FGF-23 levels. Clinical outcomes analyzed included survival status, utilization of RRT, and hospital stay. Results: Of the 50 patients with AKI, about three-fourths were males. Mean age of the participants was 57.32 ± 11.47 years. Around half of patients had hypocalcemia and four-fifths had low serum phosphate. Nearly 82% had low 25(OH)Vit-D and 52% cases had high PTH level. Patients who underwent RRT had numerically higher but not significant serum calcium and PTH levels. FGF-23 levels (pg/mL) were significantly higher in patients on RRT (81.70 ± 17.30 vs non-RRT, 72.43 ± 20.27, p = 0.049), nonsurvivors (87.96 ± 18.82 vs survivors 57.11 ± 15.19, p = 0.045), and those hospitalized for time of stay above median (109.67 ± 26.97 vs below median 70.27 ± 20.43, p = 0.046). Among all the bone and mineral parameters analyzed high FGF23 levels were consistently linked with poor clinical outcomes in AKI. Conclusion: The present study found high prevalence of calcium and phosphate disorders in AKI with dysregulated phosphate homeostasis as evidenced from elevated FGF-23 levels linked with morbidity and mortality in AKI. How to cite this article: Singh NP, Panwar V, Aggarwal NP, Chhabra SK, Gupta AK, Ganguli A. Regulation of Calcium Homeostasis in Acute Kidney Injury: A Prospective Observational Study. Indian J Crit Care Med 2022;26(3):302-306.

The analgesic efficacy of intravenous dexamethasone for post-caesarean pain: A systematic review with meta-analysis and trial sequential analysis.

BACKGROUND: Analgesic efficacy of intravenous dexamethasone has not been well defined after caesarean delivery. We performed a systematic review and meta-analysis to evaluate the impact of peri-operative dexamethasone administration on postoperative pain after caesarean delivery. OBJECTIVES: We investigated the impact of perioperative intravenous dexamethasone on postoperative pain after caesarean delivery. The two primary outcomes of interest were early (4 to 6 h) resting pain scores and time to first rescue analgesia. DESIGN: A systematic review and meta-analysis of randomised controlled trials (RCTs). DATA SOURCES: PubMed, EMBASE, Scopus and the Cochrane central registers of controlled trials were searched to identify RCTs from inception to April 2021. ELIGIBILITY CRITERIA: Prospective RCTs comparing the role of intravenous dexamethasone with non-active control were eligible for inclusion. Exclusion criteria included trials comparing various doses of dexamethasone without any control treatment arm, dexamethasone with other active drugs and trials comparing different routes of dexamethasone, for example, wound infiltration. RESULTS: Thirteen RCTs constituting of 988 parturients undergoing caesarean delivery were included. Patients receiving dexamethasone had lower pain scores at rest at 4 to 6 h after surgery, mean difference -1.29 [95% confidence interval (CI), -1.85 to -0.73], P < 0.0001, with low quality of evidence (I2 = 94%). Moderate quality of evidence (I2 = 17%) suggested that the time to first rescue analgesia in the dexamethasone group was significantly longer, mean difference 2.64 h (95% CI, 1.85 to 3.42), P  < 0.0001. Trial sequential analysis for pain scores suggested the benefit of dexamethasone; however, the requisite information size (RIS) could not be reached, whereas RIS was adequate for time to rescue analgesia. Significant reduction in pain scores at all times and opioid consumption at 24 h with dexamethasone were observed with sparse reporting on adverse effects. CONCLUSION: Peri-operative intravenous dexamethasone was associated with a significant decrease in postoperative pain scores at rest and a longer time to first rescue analgesia, along with a small but statistically significantly reduced opioid consumption after caesarean delivery compared with nonactive control.

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials.

BACKGROUND: The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery. METHODS: In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting. RESULTS: Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting. CONCLUSION: Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice. STUDY REGISTRATION: PROSPERO (CRD42020198244); registered 19 October 2020.

RéSUMé: CONTEXTE: La technique régionale optimale pour contrôler la douleur après une chirurgie de cancer du sein n'a pas encore été clairement établie. Nous avons cherché à synthétiser les données disponibles provenant d'études randomisées contrôlées comparant les issues liées à la douleur à la suite de diverses techniques régionales pour la chirurgie mammaire oncologique majeure. MéTHODE: Dans une revue systématique et une méta-analyse de réseau, nous avons recherché les études portant sur les techniques régionales couramment utilisées dans les bases de données PubMed, Embase Scopus, Medline, Cochrane Central et Google Scholar, de leur création au 31 juillet 2020. Le critère d'évaluation principal était le score de douleur au repos à 24 heures mesuré sur une échelle d'évaluation numérique de 0 à 10. Nous avons utilisé la surface sous la courbe de classement cumulatif (SUCRA) afin d'établir la probabilité qu'une intervention soit cotée plus haut. L'analyse a été réalisée à l'aide d'un modèle bayésien à effets aléatoires, et les tailles d'effet sont rapportées comme intervalle crédible à 95 % (ICr). Nous avons effectué une analyse de classement en grappes en combinant le classement de douleur sur 24 heures avec la consommation d'opioïdes sur 24 heures ou l'incidence des nausées et vomissements postopératoires. RéSULTATS: Soixante-dix-neuf études randomisées contrôlées comportant 11 interventions différentes chez 5686 patientes ont été incluses. Les valeurs SUCRA des interventions pour le score de douleur au repos à 24 heures étaient le bloc paravertébral continu (0,83), le bloc du plan antérieur du serratus (0,76), la perfusion continue de la plaie (0,76), le bloc paravertébral à un seul niveau (0,68), le bloc du plan des muscles érecteurs du rachis (0,59), le bloc pectoral modifié (0,49), le bloc intercostal (0,45), le bloc paravertébral multiniveau (0,41), l'infiltration de plaie (0,33), l'absence d'intervention (0,12) et le placebo (0,08). Par rapport au placebo, le bloc paravertébral continu (différence moyenne, 1,26; ICr 95 %, 0,43 à 2,12) et le bloc du plan antérieur du serratus (différence moyenne, 1,12; ICr 95 %, 0,32 à 1,9) ont affiché la probabilité estimée la plus élevée de diminuer les scores de douleur au repos à 24 heures. L'analyse du classement des grappes combinant les scores de douleur au repos et la consommation d'opioïdes à 24 heures a montré que la plupart des techniques d'analgésie régionale étaient plus efficaces que l'absence d'intervention ou un placebo. Néanmoins, l'infiltration de la plaie et la perfusion continue de la plaie semblaient être les interventions actives les moins efficaces pour réduire les nausées et vomissements postopératoires. CONCLUSION: Le bloc paravertébral continu et le bloc du plan antérieur du serratus ont affiché une forte probabilité de réduire la douleur 24 heures après une chirurgie mammaire oncologique majeure. La fiabilité des données probantes allait de modérée à très faible. Les études futures devraient comparer différentes techniques d'anesthésie régionale, y compris les techniques administrées par le chirurgien telles que l'infiltration de plaie ou les cathéters. Il est peu probable que les études comparant une intervention active à un placebo modifient la pratique clinique. Enregistrement de l'étude : PROSPERO (CRD42020198244); enregistrée le 19 octobre 2020.

Can computational fluid dynamic models help us in the treatment of chronic rhinosinusitis.

PURPOSE OF REVIEW: The aim of this study was to review the recent literature (January 2017-July 2020) on computational fluid dynamics (CFD) studies relating to chronic rhinosinusitis (CRS), including airflow within the pre and postoperative sinonasal cavity, virtual surgery, topical drug and saline delivery (sprays, nebulizers and rinses) and olfaction. RECENT FINDINGS: Novel CFD-specific parameters (heat flux and wall shear stress) are highly correlated with patient perception of nasal patency. Increased ostial size markedly improves sinus ventilation and drug delivery. New virtual surgery tools allow surgeons to optimize interventions. Sinus deposition of nasal sprays is more effective with smaller, low-inertia particles, outside of the range produced by many commercially available products. Saline irrigation effectiveness is improved using greater volume, with liquid entering sinuses via 'flooding' of ostia rather than direct jet entry. SUMMARY: CFD has provided new insights into sinonasal airflow, air-conditioning function, the nasal cycle, novel measures of nasal patency and the impact of polyps and sinus surgery on olfaction. The deposition efficiency of topical medications on sinus mucosa can be markedly improved through parametric CFD experiments by optimising nasal spray particle size and velocity, nozzle angle and insertion location, while saline irrigation effectiveness can be optimized by modelling squeeze bottle volume and head position. More sophisticated CFD models (inhalation and exhalation, spray particle and saline irrigation) will increasingly provide translational benefits in the clinical management of CRS.

Chronic Kidney Disease of Unknown Origin - What do we know?

The global burden of CKD is considerable and has risen dramatically over the past 20 years. Recently, CKD of unknown origin (CKDu), a form of CKD among rural agricultural communities has been reported worldwide. There is no strong evidence for a single cause of CKDu. Basically, it is a phenotypic environmentally acquired disease with a combination of occupational and social factors. Across all geographical regions, CKDu was most frequently associated with men, middle age, snake bite, infection, and exposure to agrochemicals, heavy metals, herbal drugs, heat stress, and dietary exposures. CKDu has emerged as a challenge in certain regions of the world as there is no acceptable global definition for CKDu. There is an urgent need for health promotion at individual and community levels for early screening of risk factors and timely management. It is also important to strengthen the health service networks for a better quality of life and patient safety as well as adequate financing. Further etiological and interventional research is needed to reduce preventable regional risk factors as well as to develop proactive and comprehensive approaches to prevent and treat the disease.

A nose out of joint: first reported case of prison-acquired marijuana-based rhinolith.

Rhinoliths are calcareous concretions of the nasal cavity formed around a nidus that may be endogenous (eg, dislodged tooth) or an exogenous foreign body (eg, plastic bead inserted by a child). Rhinoliths are often found incidentally on endoscopy or imaging to assess for other pathologies. The incidence is estimated to be 1 in 10 000 of all otolaryngology outpatient presentations, but this is likely to be an underestimate due to the often asymptomatic nature of this condition. We describe the unique case of a rhinolith that developed from a marijuana-filled balloon that the patient attempted to smuggle into a correctional facility. After inserting the package into his nostril, the patient then mistakenly believed it had been accidentally swallowed. Despite experiencing persistent symptoms of nasal obstruction and recurrent sinonasal infections, the marijuana package was only discovered 18 years after insertion following imaging for an unrelated indication.

Moffett's Solution Causes Significantly Greater Postoperative Throat Pain Compared to Cophenylcaine in Sinonasal Surgery.

AIM: Preoperative decongestion with Moffett's solution is routine practice in sinonasal procedures providing an ideal operative field. Anecdotally, it is related to postoperative throat pain, yet a quantitative relationship has not been established. We compare the incidence and severity of postoperative throat pain after application of Moffett's solution against Cophenylcaine decongestion. METHODOLOGY: A total of thirty patients from two consultants were recruited. The intervention arm (twenty) was decongested with Moffett's solution and the control arm (ten) with Cophenylcaine. The primary outcome was self-reported postoperative throat pain as measured by visual analogue scale (VAS) at 2 hours, 4 hours, 6 hours, and next morning. RESULTS: There was a significantly higher VAS for throat pain in patients decongested with Moffett's solution in the early postoperative period (2 hours p=0.03, 4 hours p=0.04). CONCLUSION: Moffett's solution is associated with a greater severity of transient postoperative throat pain compared to topical Cophenylcaine. We recommend further studies to identify means to minimise this side effect. CLINICAL TRIAL REGISTRATION: This paper has been registered with the Australian and New Zealand Clinical Trials Registry under the registration number: ACTRN12619000772145.

Isolated primary maxillary sinus esthesioneuroblastoma presenting as idiopathic syndrome of inappropriate antidiuretic hormone.

Esthesioneuroblastoma is an uncommon tumour, and isolated primary involvement of the maxillary sinus is exceedingly rare. Esthesioneuroblastoma has infrequently been reported as a source of paraneoplastic ectopic hormone production. We report a case of isolated primary maxillary esthesioneuroblastoma, presenting as idiopathic syndrome of inappropriate antidiuretic hormone (SIADH). A 17-year-old girl presented with symptoms consistent with SIADH and no sino-nasal symptoms. MRI to exclude pituitary tumour revealed an isolated lesion of the right maxillary sinus. Biopsy demonstrated esthesioneuroblastoma. The lesion was removed endoscopically as a single en bloc specimen. Following resection, the sodium level returned to normal. This is only the third report in the literature of a primary maxillary esthesioneuroblastoma presenting as SIADH.

Efficacy of Intraoperative Renal Stone Culture in Predicting Postpercutaneous Nephrolithotomy Urosepsis/Systemic Inflammatory Response Syndrome: A Prospective Analytical Study with Review of Literature.

AIM: To evaluate and study the efficacy of intraoperative renal stone culture (IOSC) in predicting postpercutaneous nephrolithotomy (PCNL) urosepsis (PPS) and systemic inflammatory response syndrome (SIRS). PPS is known to occur in patients despite negative preoperative midstream urine culture (MSUC). METHODS: After obtaining institutional ethics committee approval and informed consent, 78 selected patients undergoing PCNL were evaluated as per protocol for risk factors for SIRS criteria with MSUC, intraoperative renal pelvic urine culture (RPUC), and IOSC. RESULTS: MSUC was positive in six (7.7%) patients. The sensitivity, specificity, PPV, negative predictive value (NPV) and respiratory rate of MSUC for detecting SIRS were 20%, 93.15, 16.67%, 94.44%, and threefold, respectively. RPUC was positive in five (6.9%) patients with a specificity and NPV of 92.64% and 94.02%, respectively. IOSC positivity was seen in four (5.1%) patients with specificity and NPV of 94.5% and 3.2%, respectively. SIRS developed in five (6.4%) patients. MSUC, RPUC, and IOSC could not demonstrate any significant association with the occurrence of SIRS. Postoperative urine culture (POUC) was positive in 1/5 SIRS patients and no significant association (p < 0.182) could be demonstrated between the risk factors and PPS. Most complications were minor, while the mean hospital stay was significantly higher in SIRS patients. CONCLUSIONS: While MSUC, RPUC, and IOSC were less sensitive in predicting the occurrence of SIRS/urosepsis in patients undergoing PCNL, nevertheless, we recommend routine IOSC for stone colonizing bacteria in at-risk select patients to predict potential PPS/SIRS. POUCs could be used in symptomatic SIRS to guide antimicrobial therapy in post-PCNL patients. Positive peri/intraoperative urine cultures may assist the urologist in directing appropriate antibiotics to prevent potential urosepsis in post-PCNL patients. Those with a higher blood transfusion rate and Clavien complications were at increased risk of PPS/SIRS. Escherichia coli was the most frequently isolated microbe followed by Klebsiella and Proteus, which were mostly sensitive to nitrofurantoin.

Unusual case of left atrial myxoma with gastroesophageal junction adenocarcinoma.

Cardiac myxomas are rare tumors. Esophageal adenocarcinomas are common tumors of the gastrointestinal tract. Simultaneous occurrence of these tumors has not been reported. A 52-year-old gentleman presented to our hospital with dysphagia and was diagnosed with esophageal adenocarcinoma. Routine echocardiography discovered a cardiac tumor in the left atrium. The cardiac tumor was surgically removed and biopsy confirmed a myxoma. We removed the cardiac tumor as the first step and then initiated neoadjuvant chemotherapy. It is ideal to constitute a multidisciplinary team to decide on the course of treatment in such cases.

Pulmonary Hypertension in Patients with End Stage Renal Disease on Maintenance Hemodialysis-A Cross-sectional Study.

BACKGROUND: Pulmonary Hypertension (PH) in End Stage Renal Disease (ESRD) on Maintenance Hemodialysis (HD) portends a poor outcome in patients undergoing dialysis. METHODS: 50 patients with ESRD undergoing regular hemodialysis for at least 3 months were included. Biochemical parameters- hemoglobin, urea, creatinine, albumin, calcium, phosphorus and PTH assessed post dialysis. All patients underwent 2D echocardiography one hour after dialysis to avoid overestimation of pulmonary artery pressures. Measurement of various parameters was carried out including right atrial and ventricular dimensions, tricuspid annular plane systolic excursion, flow across tricuspid and pulmonary valves and tissue doppler imaging of the annular plane. PH was defined as mean right ventricular systolic pressure ≥25 mmHg. Variables were compared between two groups- subjects with PH and Non-PH. RESULTS: Seventeen patients were detected to have PH. All baseline biochemical parameters did not show significant difference between two groups. On ECHO, right atrial and ventricular enlargement and pulmonary vascular resistance were significantly higher in PH group. LA vol index greater than 34ml/m2 was detected in 94.1% patients with PH as opposed to 51.5% in non PH. LVEDP was detected to be significantly higher in PH compared to Non PH (p=0.001; 94.1% vs 39.4%). Mean values of ejection fractions were also significantly different. CONCLUSION: This study suggests that up to one third of ESRD patients on HD develop PH. Echocardiography findings reveal a significant association between raised LVEDP and increased pulmonary artery pressures. Thus, volume overload and diastolic dysfunction (heart failure with preserved ejection fraction) appear to be the main contributors to development of PH.

Lymphoma in Rheumatoid Arthritis - Catastrophic Sequela of a Common Disease.

Rheumatoid arthritis (RA) is a common rheumatological condition affecting the joints and has a wide range of extra-articular manifestations. A 69 year old male, known case of rheumatoid arthritis presented to our OPD with right lower limb redness and swelling, and left axillary lymph node swelling. Lymph node biopsy revealed a high grade diffuse large B-cell lymphoma with co-expression of c-myc and bcl-2 (double expressor). RA increases the risk of both Hodgkin's lymphoma (HL) and non-Hodgkin's Lymphoma (NHL). The association with diffuse large B-cell lymphoma (DLBCL) has been found to be particularly strong, however double expressor DLBCL is an extremely uncommon occurrence. High disease activity of rheumatoid arthritis is a major determinant in development of lymphomas.