Tertiary Care Hospital In India Research Articles

Prescription pattern of antimicrobial agents prescribed in outpatient department of dermatology in a tertiary care hospital in India

Background: Skin diseases contribute largely to global disease burden. Antimicrobial agents are used for treatment of various skin diseases of microbial aetiology caused by fungi, bacteria, viruses and ectoparasites. The primary objective of this study was to study the prescription pattern of antimicrobial agents in dermatology, to provide insights into the disease patterns, profile of the drugs used and their rationality. Methods: Cross-sectional observational study was conducted in dermatology outpatient department of T. N. M. C. and B. Y. L. Nair Charitable Hospital, Mumbai for period of 6 months. 372 prescriptions containing an antimicrobial agent (AMA) were analysed. Demographic data, disease pattern, associated comorbidities and prescription details were recorded after taking written informed consent. Results: Fungal infections were the most common (48%) followed by bacterial infections (31%). The most encountered condition was dermatophytosis. Average number of AMA per prescription was 2.33±0.73. Percentage of AMA prescribed by generic name was 48%. Percentage of AMA prescribed from National list of essential medicines 2015 (NLEM) was 32.60%. 87.9% of AMA were prescribed as combination therapy and 12.10% were prescribed as monotherapy. The commonest prescribed drugs were antifungals followed by antibiotics. Topical creams were the commonest prescribed dosage form. Conclusions: The most common class of antimicrobial agents prescribed was antifungal agents. Prescribing combination of oral antimicrobials with topical antimicrobials was found to be high. This study provides a framework for continuous prescription audit of antimicrobials in an outpatient setting and thus can help in rational use of antimicrobials in dermatological prescribing.

#3783 INCIDENCE AND PREDICTORS OF MAJOR ADVERSE KIDNEY EVENTS IN ICU PATIENTS WITH SEPSIS: A PROSPECTIVE COHORT STUDY FROM A DEVELOPING COUNTRY

Abstract Background and Aims Acute kidney injury (AKI) occurs in 15-60% of intensive care unit (ICU) admissions and is associated with higher mortality, morbidity and increased healthcare costs. Major adverse kidney events (MAKE) is a clinically meaningful patient-centred outcome for AKI which includes mortality, need for renal replacement (RRT) and persistent kidney dysfunction. There is a paucity of data on the incidence and risk factors of MAKE, particularly from developing countries. We sought to examine the incidence of MAKE at day 30 (MAKE30) and its predictors in a cohort of critically ill patients with sepsis. Method This was a prospective cohort study conducted in the medical ICUs of a tertiary-care hospital in India. Ethical clearance was obtained from the Institutional Ethics Committee. Adult patients (≥ 18 years) admitted in the medical ICUs between 1st September, 2022 and 31st December, 2022 with sepsis (as defined by Sepsis-3 criteria) were included. Those with chronic kidney disease stage 5/5D, those requiring dialysis within 72 hours of admission and with an ICU stay of <72 hours were excluded. Baseline clinical and demographic data were recorded on the day of admission. AKI was defined as per KDIGO 2012 guidelines. Patients were followed up till hospital discharge or day 30 (whichever was earlier) and clinical outcomes were noted. The primary outcome measure was MAKE30 (defined as a composite of death, provision of RRT, or sustained loss of kidney function i.e., a final inpatient creatinine ≥200% of the baseline value, at hospital discharge or at 30 days, whichever comes first). Results A total of 250 patients admitted in the medical ICUs during the study period were included for analysis. The baseline characteristics are tabulated below (Table 1). Over the 30-day follow-up period, AKI was noted in 185 (74%) patients, with stage 1 AKI in 38 (15.2%), stage 2 AKI in 29 (11.6%) and stage 3 AKI in 118 (47.2%). Renal replacement therapy was initiated in 86 (34.4%) patients. Mortality occurred in 58 (23.2%). Overall, MAKE30 was seen in 102 (40.8%) patients. Serum lactate (OR 1.04, 95% CI:1.01-1.06; P = 0.010) and SOFA score (OR 1.38, 95% CI:1.27-1.56; P <0.001) at admission were independently associated with MAKE30 (Table 2). There was no association with age, gender, diabetes, type of resuscitation fluid or cumulative fluid balance (at 72 hours) with MAKE30. Conclusion In this cohort of critically ill patients with sepsis, MAKE30 was observed in 40.8%. Serum lactate and SOFA score at admission were independent predictors of MAKE30.

Radiotherapy for Geriatric Cancer Patients: Five-year Experience at a North Indian Tertiary Care Hospital

Background: The incidence of malignancy in elderly population in India has risen due to increased life expectancy, health awareness, and access to tertiary health care. Radiotherapy is the primary treatment modality in elderly cancer patients due to morbidity of surgery. We reviewed and analyzed clinical, disease and treatment profiles of geriatric population treated with conventional radiotherapy at our institute. Methodology: The clinical records of patients aged 70 years or more, treated from January 2015 to December 2019 were analyzed for patient characteristics (age, sex & co-morbidities), disease characteristics (site, histology & stage) and treatment characteristics (modality & intent of treatment, radiation dose). Results: A total of 289 patients aged 70 years and above were treated during the study period. 69% were treated with curative intent, of which, 72.4% received definitive, 24.6% received adjuvant, and 3% received neoadjuvant radiotherapy. 31% were given palliative radiotherapy. The median age was 74.6 years with male: female ratio of 4.25:1. 21.4% of the study patients had co-morbidities. 14% patients were of early stage, 57% locally advanced and 29% had metastatic disease. 51% of the study population received concurrent chemotherapy along with Radiotherapy. 87.1% of those treated with curative intent & 93.3% of patients treated with palliative intent, completed the planned radiotherapy regimen. Out of total 200 patients treated at our institute with Radiotherapy, 187 were prescribed concurrent chemotherapy, while it was exhibited to only 103 patients due to various factors like old age, poor performance status and co-morbidities. Conclusion: Our study showed a high degree of compliance amongst geriatric patients receiving radiotherapy treatment. Toxicity rates in geriatric population were not significantly higher than the overall population treated at our centre. Various factors like disease biology and stage and patient’s performance status, co-morbidities and life expectancy affect the decision making in deciding radiotherapy intent and schedules in cancer patients of geriatric age group. Combined decision making between patients, caregivers and oncologists is crucial in geriatric age group keeping in mind above mentioned factors.

Inflammatory Markers for Prognosis of COVID-19 Mortality in Hospitalized Indian Patients: A Single-Center Retrospective Study

Background: Coronavirus disease 2019 (COVID-19) has emerged as a global pandemic associated with poor outcomes and mortality. Therefore, the present study aimed to assess the prognostic value of inflammatory markers in predicting COVID-19 mortality among patients hospitalized at a tertiary care hospital in India. Methods: A retrospective cross-sectional study of 444 hospitalized patients with COVID-19 was conducted in Karnataka state, India from October 2020 to September 2021. Data on inflammatory markers for survivors and non-survivors of COVID-19 were retrieved and analyzed using the receiver operating characteristic (ROC) curve to determine their prognostic value for predicting mortality. Results: Compared to survivors, the median values of all studied serum inflammatory markers were significantly higher in non-survivors of COVID-19. ROC analysis showed that LDH, D-dimer and ferritin were the best predictive markers of COVID-19 mortality. Conclusion: Serum ferritin, LDH, CRP, PCT, IL-6 and D-dimer, are significantly elevated in non-survivors of COVID-19 than in survivors, with all can significantly predict disease mortality. Among these, LDH, D-dimer and ferritin are the best prognostic markers for predicting COVID-19 mortality, with good sensitivity and specificity.

The Evaluation of Laboratory Parameters as Predictors of Disease Severity and Mortality in COVID-19 Patients: A Retrospective Study From a Tertiary Care Hospital in India.

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection affects and alters various laboratory parametersthat are predictors of disease severity and mortality, and hence, their prompt identification can aid in patient triaging and resourceallocation. Objectives A retrospective study was conducted on 7416 admitted coronavirus disease 2019 (COVID-19) patients from 20 March 2020 to 9August 2021 to identify crucial laboratory biomarkers as predictors of disease severity and outcome; also, their optimal cutoffs were also calculated. A comparison of laboratory markers between both COVID-19 waves was also performed. Results The majority of patients had mild disease (4295/7416, 57.92%), whereas 1262/7416 (17.02%) had severe disease. The overall fatal outcome was reported in 461 (6.22%) patients. Predictors for mortality were age (>52 years), albumin/globulin (A/G) ratio (≤1.47), chloride (≤101 mmol/L), ferritin (>483.89 ng/mL), lactate dehydrogenase (LDH) (>393 U/L), procalcitonin (>0.10 ng/mL), interleukin-6 (IL-6) (>8.8 pg/mL), fibrinogen (>403 mg/dL), international normalized ratio (INR) (>1.18), and D-dimer (>268 ng/mL). Disease severity predictors were neutrophils (>81%), lymphocyte (≤25.4%), absolute lymphocyte count (ALC) (≤1.38×103/µL), absolute eosinophilcount (AEC) (≤0.03×103/µL), total bilirubin (TBIL) (≥0.51 mg/dL), A/G ratio (≤1.49), albumin (≤4.2 g/dL), ferritin (≥445.4 mg/dL), LDH (≥479 U/L), IL-6 (≥28.6 pg/mL), C-reactive protein/albumin (CRP/ALB) ratio (≥1.78), D-dimer (≥237 ng/mL), and fibrinogen (≥425 mg/dL). The majority of patients admitted in the second wave were older and had severe disease, increased fatality, and significantly deranged laboratory parameters than first wave patients. Conclusion Our findings suggested that several biomarkers are crucial for both severe disease and mortality in COVID-19 patients. Ferritin, LDH, IL-6, A/G ratio, fibrinogen, and D-dimer are important biomarkers for both severity and mortality, and when combined, they provide valuable information for patient monitoring and triaging. In addition to these, older age, INR, chloride, and procalcitonin are also significant risk factors for mortality. For severe COVID-19, TBIL, CRP/ALB, albumin, neutrophil percentage, lymphocyte percentage, ALC, and AEC are also important biomarkers. According to the study, the majority of the baseline laboratory parameters associated with COVID-19 mortality and severe diseasewere significantly higher during the second wave, which could be one of the possible causes for the high mortality rate in India during the second wave. So, the combination of all these parameters can be a powerful tool in emergency settings to improve the efficacy of treatment and prevent mortality, and the planningof subsequent waves should be done accordingly.

An Indian perspective for umbilical cord blood haematological parameters reference interval

BackgroundThe Haematological Reference Intervals (RIs) are prone to vary on the basis of various factors such as altitude, age, sex, socioeconomic status, etc. These values play a major role in laboratory data interpretation and determine the necessary clinical treatment. Currently, India has no well–established RI for cord blood haematological parameters of newborns. This study aims to establish these intervals from Mumbai, India.MethodA cross sectional study was conducted in a tertiary care hospital of India from October 2022 to December 2022 on healthy and term neonates having normal birth weight and born to healthy pregnant mothers. About 2 – 3 mL of cord blood was collected from the clamped cord into EDTA tubes from 127 term neonates. The samples were analysed in the haematology laboratory of the institute and the data was analysed. The upper and lower limits were determined using non-parametric method. The Mann–Whitney U test was used to compare the distribution of the parameters between sex of infant, modes of deliveries, maternal age and obstetric history. P value less than 0.05 was considered to declare statistical significance.ResultThe median values and 95% RI for umbilical cord blood haematological parameters of newborns were as follows: WBC = 12.35 [2.56–21.19] × 109/L, RBC = 4.34 [2.45–6.27] × 1012/L, HGB = 14.7 [8.08–21.44] g/dL, HCT = 48 [29–67]%, MCV = 109.6 [59.04–159.1] fL, MCH = 34.5 [30.54–37.79] pg, MCHC = 31.3 [29.87–32.75] %, PLT = 249 [16.97–479.46] × 109/L,LYM = 38 [17–62] %, NEU = 50 [26–74] %, EOS = 2.3 [0.1–4.8] %, MON = 7.3 [3.1–11.4], BAS = 0 [0–1]. This study found no statistically significant difference between sex of infants, except MCHC, and obstetric history. A significant difference was observed in WBC, EOS% and absolute NEU, LYM, MON and BAS by delivery type. A higher platelet count and absolute LYM was observed in the cord blood compared to venous blood.ConclusionsFor the first time, haematological reference intervals in cord blood were established for newborns in Mumbai, India. The values are applicable for newborns from this area. Larger study throughout the country is required.

Severity and mortality associated with COVID-19 among children hospitalised in tertiary care centres in India: a cohort study.

It is critical to identify high-risk groups among children with COVID-19 from low-income and middle-income countries (LMICs) to facilitate the optimum use of health system resources. The study aims to describe the severity and mortality of different clinical phenotypes of COVID-19 in a large cohort of children admitted to tertiary care hospitals in India. Children aged 0-19 years with evidence of SARS-CoV-2 infection (real time polymerase chain reaction or rapid antigen test positive) or exposure (anti-SARS-CoV-2 antibody, or history of contact with SARS-CoV-2) were enrolled in the study, between January 2021 and March 2022 across five tertiary hospitals in India. All study participants enrolled prospectively and retrospectively were followed up for three months after discharge. COVID-19 was classified into severe (Multisystem Inflammatory Syndrome in Children (MIS-C), severe acute COVID-19, 'unclassified') or non-severe disease. The mortality rates were estimated in different phenotypes. Among 2468 eligible children enrolled, 2148 were hospitalised. Signs of illness were present in 1688 (79%) children with 1090 (65%) having severe disease. High mortality was reported in MIS-C (18.6%), severe acute COVID-19 (13.3%) and the unclassified severe COVID-19 disease (12.3%). Mortality remained high (17.5%) when modified MIS-C criteria was used. Non-severe COVID-19 disease had 14.1% mortality when associated with comorbidity. Our findings have important public health implications for low resource settings. The high mortality underscores the need for better preparedness for timely diagnosis and management of COVID-19. Children with associated comorbidity or coinfections are a vulnerable group and need special attention. MIS-C requires context specific diagnostic criteria for low resource settings. It is important to evaluate the clinical, epidemiological and health system-related risk factors associated with severe COVID-19 and mortality in children from LMICs. Department of Biotechnology, Govt of India and Department of Maternal, Child and Adolescent Health and Aging, WHO, Geneva, Switzerland.

Intraoral anastomosis for primary microsurgical reconstruction in patients of oral cavity malignancies: Retrospective analysis of 30 cases from a tertiary care center in India

In patients undergoing either robotic neck dissection or no neck dissection, the neck recipient vessels for the free flaps remain unexposed. Intraoral vessels have been successfully used as microvascular recipients but their use in intraoral malignancies is uncommon. We describe our initial experience of using intraoral recipients in 30 patients with oral cavity malignancies. For this retrospective observational study, the hospital records of all patients who underwent microvascular reconstruction using intraoral recipient vessels over a 14-month period at a tertiary care hospital in India were studied. Patient demographics, disease profile, details of oncosurgical resection, reconstructive procedure details, and postoperative recovery data were analyzed. Intraoral anastomosis was successfully performed in 30 patients. The average patient was middle-aged (mean age 54 years) and male (26/30). Location of the postexcision defect was the buccal mucosa in 16/30 and the tongue in 12/30 patients. Anterolateral thigh flap (ALT) was used in 28/30 patients. Recipient vessels were facial vessels in 24/30 patients and lingual vessels in 6/30 patients. Venous anastomotic coupler was used in 27/30 patients. Three patients underwent re-exploration for flap congestion with loss of flap in 2/30 patients. The intraoral approach offers consistent vascular anatomy and can be performed without any external incision and oro-cervical tunneling. Being technically challenging, it has an initial learning phase. Adequate mouth opening and preservation of recipient vessels during excision and neck dissection are important prerequisites. This approach can offer a scarless reconstruction, which can improve the psycho-social rehabilitation of the patients.

Demographic characteristics of patients who underwent anterior cruciate ligament reconstruction at a tertiary care hospital in India.

Anterior cruciate ligament (ACL) tears are common sports-related injuries. Their incidence is not the same either for all the sports or for the same sport across various nations. This information is maintained by many sports leagues in their registries. However, very few nationwide registries exist for such injuries. This study is carried out to know the demographic characteristics of patients who underwent ACL reconstruction at our hospital in India. To know the demographic characteristics of patients who underwent ACL reconstruction at a tertiary care hospital in India. All the patients who underwent ACL reconstruction from January 2020 to December 2021 were retrospectively studied. Patients with multi-ligament injuries or a history of previous knee surgery were excluded. The patients' history was obtained from the hospital records, they were interviewed telephonically, and online questionnaires were given. Their demographic data was analyzed and compared to the existing literature. A total of 124 patients were operated on for ACL reconstruction during this period. The mean age of the patients was 27.97 years. One hundred and thirteen patients (91.1%) were male and 11 (8.9%) were female. The majority of the patients (47.6%) sustained this injury by road traffic accidents (RTA) followed by sports-related injuries (39.5%). The commonest presenting complaint was giving way of the knee in 118 patients (95.2%). The mean duration from the injury to the first hospital visit among the patients was 290.1 d. The mean duration from the injury to surgery was 421.8 d. ACL patients' demography is different in developing nations as compared to the developed world. RTA are the leading cause of ACL injuries and are followed by recreational sports as a cause. There is delayed access to healthcare leading to delayed diagnosis as well as even greater time to surgery. This, in turn, leads to poorer prognosis and longer rehabilitation. National registries for developing nations are the need of the hour due to the different demographics of ACL injuries in developing countries.

A study of benign sino-nasal tumors in rural tertiary care hospital

Background: The sino-nasal unit, although anatomically a very small space, is quite exceptional in the sense that an eclectic mix of neoplastic tumors originate from here. The diverse nature of the neoplastic pathologies and their unique natural histories prompted for this study. Methods: In this prospective study of two years, done in a rural tertiary care hospital of India, 46 patients with benign neoplastic tumors of nasal cavity, sinuses and nasopharynx were analyzed for their clinic-pathological and radiological profile and surgical management. Results: The incidence of benign tumor was predominant in second decade (34.8%) with significant male preponderance (M:F ratio 2.28:1). Unilateral nasal obstruction (100%) and epistaxis (84.8%) were the two most common presenting complaints. Almost half (48%) of the patients presented as late as more than one year after the onset of the symptoms. Nasal cavity was the commonest site of the tumors (50%). The most common benign tumor in present study was capillary hemangioma (41.31%) followed by angiofibroma (26.09%). All tumors were removed by a standard functional endoscopic sinus surgery or combined approach. Except a single case of inverted papilloma, all the other cases showed no recurrence at the end of one year follow up period. Conclusions: It can be concluded from present study that conjoint application of radiology, endoscopy and histopathology is of utmost importance in dealing with benign neoplastic pathology of sino-nasal region. There is significant success in managing benign sino-nasal tumors with functional endoscopic sinus surgery or by combined approach.

Experience of missed nursing care: A mixed method study.

Missed nursing care is a global phenomenon affecting patient safety and quality of care. The working environment of nurses seems to play an important role in missed nursing care. This study was conceptualized to explore the link of environmental constraints with missed nursing care in the Indian context. A convergent mixed-method design was adopted, and data was collected using Kalisch's MISSCARE survey from 205 randomly selected nurses involved in direct patient care in the acute care settings of four tertiary care hospitals in India. In the qualitative phase, in-depth interviews regarding nurses' experience of missed care were performed with 12 nurses chosen by maximum variant sampling from the quantitative sample. The integrated results revealed that nurses experience a sense of competing priority in the environment where curative and prescribed tasks like medication administration get more priority than activities like communication, discharge teaching, oral hygiene, and emotional support, which are frequently missed. The human resource and communication constraints together explained 40.6% of variance in missed nursing care. Human resource inadequacy in times of increased workload was the most frequently cited reason for missed care. Converging with this finding, nurses in the interviews expressed that maintaining a flexible number of staff and catering to the variable workload can effectively reduce missed nursing care. Frequent interruption of nursing activities by medical staff and lack of structure in some activities were cited as important reasons for missed care. Nursing leaders need to acknowledge missed care in nursing and develop policies to maintain flexible staffing based on situational workload. Methods of staffing like NHPPD (Nursing hour per patient day) which are more sensitive to nursing workload, and patient turnover, can be adopted instead of a fixed nurse-patient mandate. Mutual support from team members and multi-professional cooperation can reduce frequent interruption of nursing tasks thereby reducing missed care.

Characterisation of uropathogenic E.coli by detecting the virulence factors and its drug resistance pattern in a tertiary care hospital in India

Urinary tract infections (UTIs) are among the most prevalent nosocomial and community-acquired bacterial diseases in humans, with E.coli being the most typical pathogen isolated. To detect the prevalence of virulence factors like haemolysin, haemagglutination of human erythrocytes with its effect of D-mannose, and cell surface hydrophobicity, the antibiotic sensitivity pattern and ESBL production in urinary isolates of E.coli obtained from clinical samples. We included the E.coli isolates obtained from a midstream urine sample for the study. Virulence factors like haemolysin, hemagglutination and salt aggregation were detected as per standard protocols. Antibiotic sensitivity testing was performed by the Kirby Bauer disc diffusion method. Extended-spectrum beta-lactamase (ESBL) production was seen by the combined disc diffusion method on Muller Hinton agar as per CLSI guidelines. A total of 103 E.coli isolates were tested, and among them, 24(23.30%) produced haemolysin, 65(63.10%) produced hemagglutination and 38(36.89%) had salt aggregation properties. Most isolates obtained were resistant to beta-lactam antibiotics but showed high sensitivity towards antibiotics like chloramphenicol, meropenem, amikacin, imipenem and nitrofurantoin. Around 48% of them were ESBL producers. The common virulence factors associated with UTI were P-fimbriae (MRHA), haemolysin production, cell surface hydrophobicity and type-1 fimbriae. Because of the emerging drug resistance among UPEC, therapy should be advocated as far as possible after obtaining the culture and sensitivity results to determine exact aetiology and susceptibility patterns. The sensitivity to nitrofurantoin is very high, suggesting that antibiotic recycling will help clinicians treat UPEC.

A comparative analysis of the second and third wave of the Covid-19 pandemic: an experience from a tertiary care hospital in Western India.

Introduction. As the world was still recovering from the 2020 pandemic, the devastating impact of Covid-19 driven by the Delta variant shook the world in 2021. As the second wave was declining, there was an unusual surge in Covid-19 positive cases by the end of 2021 which led to global concern about the change in virus characteristics.Hypothesis/gap statement. Whole genome sequencing is critical for understanding a rapidly progressing pandemic.Aim. To provide an insight into the major differences encountered in the changing characteristics between the second and third waves of the pandemic at a tertiary care hospital in India.Methods. A retrospective observational cohort analysis was conducted on Covid-positive patients during the second wave of the Covid-19 pandemic (from March 2021 to April 2021) and the third wave of the Covid-19 pandemic (from December 2021 to January 2022).Results. Out of 303 Covid-19 positive cases, 52 samples were tested by whole genome sequencing during the second wave and 108 during the third wave. A decline of 18.5 % was observed in the case fatality rate from the second wave to the third wave. There was a 5 % decline in the number of patients admitted with ARDS and a 16.3 % decline in the number of patients with co-morbidities.In total, 51.9 percent of cases were due to the Delta variant during the second wave and 95 percent due to the Omicron variant during the third wave. We found that 36.5 % of Covid-positive patients during the second wave had been vaccinated compared to 40 % in the third wave.Conclusion. Whole genome sequencing of clinical samples from a wide range of individuals during a viral epidemic will enable us to develop a more rapid public health response to new variants and identify the required vaccine modifications more quickly.

Feasibility of the International Wealth Index and the Gapminder tool as instruments to assess household income and estimate catastrophic expenditure: A prospective patient-level cohort study in India.

Patient income assessment is required to assess healthcare catastrophic expenditure (Sustainable Development Goal) but self-reported income has several biases. This study aimed to assess the feasibility of the International Wealth Index (IWI) and the Gapminder tool as indirect instruments to assess household income. Prospective cohort study of colorectal cancer patients in five tertiary care hospitals in India (Dec 2020-August 2021). Patient self-reported household income was compared to income estimated from the IWI (twelve questions about household goods) and the Gapminder tool (five pictures of household assets). Agreement between instruments was explored with Bland-Altman methods. Cancer care expenditure from the same cohort was used to illustrate the impact of these tools in catastrophic expenditure rates. From the 226 patients included, 99.5% completed the IWI and the Gapminder tool. Overall, self-reported incomes were lower than the estimated from the IWI and Gapminder tools (median incomes: 17350₹ for self-reported, 37491₹ for IWI and 51520₹ for Gapminder). The IWI showed better agreement with the self-reported income than the Gapminder tool. For both instruments, the agreement was better for low income earning households. Illustrative catastrophic expenditure rates range from 71% to 56% to 43% when using self-reported, IWI and Gapminder incomes respectively. It is feasible to use the IWI and the Gapminder tools to estimate household income although they might overestimate income, with an impact on catastrophic expenditure rates. Further refinement of these tools could enable global monitoring and modelling of catastrophic expenditure from real-world data, at low burden for patients.

Early versus late decompressive craniectomy in large middle cerebral arterial infarct- A stitch in time saves nine

Introduction: The etiology of malignant MCA infarctions is mostly due to thrombosis or embolic occlusion of either the internal carotid artery or the proximal MCA. The cornerstone of ischemic stroke diagnosis remains the history and neurological examination. A prospective study to compare outcome of early verses late decompression craniotomy was done at a tertiary care hospital in India. Materials and methods: A prospective observational study in the neurosurgical department of a tertiary care hospital of India, for a period of 3 years from 2018-2021. A total of 30 patients (15 each for early and late decompressive craniectomy respectively) were included in study after fulfilling inclusion criteria. The patients were followed up for next 6 months with neuro examination and score making done after every 1 month, 3 months and 6 months of-decompressive craniotomy. To find the significance between early and late group of patients we have used 2 independent sample t-test for age. For MRS and Barthal index at 1st month, 3rd month and 6th month, Hospital stay we have used Mann-Whitney U test (Non-parametric test) because the data type is ordinal or not following normal Distribution/ skewed. All statistical test performed at 5% level of significance so the p-value < 0.05 considered as significant. Results: The majority of patients were male in both the groups – early group 9 (60%) and late group 12 (80%). The mean age group for early and late groups was 44.07 and 42.87 years respectively. The comparison of MRS score in early and late group was not statistically significant at 1st month of follow up, however it showed significant difference at 2nd and 6th month respectively. MRS score with respect to affected side, in both the early and late group showed statistically significant difference at 6 months of follow up respectively. The Barthel index with respect to affected side showed significant difference in early group whereas in the late group significant difference was seen at 6th month of follow up only. The outcome of patients was not affected by side of involvement in both groups early as well as late. The mean hospital stay in early group was 14.8 days in comparison to late group where it was 42.47 days. Conclusion: The results of the present study indicate that early surgical intervention for decompression craniectomy in cases of MCA infarct have better outcome than late intervention with shorter hospital stay better functional outcome at discharge and 6 months post discharge.

Diagnostic validity of peptic ulcer perforation scoring system in predicting mortality in patients with perforated peptic ulcer at a tertiary care hospital in India

Background: One of the prevalent ailments impacting the population of India is peptic ulcer. Although generally benign in its course, it can cause dangerous complications such as perforation and bleeding. Perforation is a life-threatening complication of the peptic ulcer. The status of patients may suddenly deteriorate if they wait too long to seek hospital care or if a diagnosis is delayed due to an unusual presentation. For triage and risk classification, it is critical to accurately and promptly identify high-risk surgical perforated peptic ulcer patients. Aims and Objectives: Perforations in peptic ulcer disease are known to cause considerable morbidity and mortality. The objective of this study was to verify the reliability of the peptic ulcer perforation (PULP) score in predicting patient death after surgery for PULP. Materials and Methods: This was a retrospective cross-sectional study included 50 PULP patients who underwent surgery and analyzed the data until discharge or death at tertiary care university hospital in India. Results: The mortality rate observed was 24%. Elderly population, raised serum creatinine, liver cirrhosis, steroid abuse, pre-operative shock, and American Society of Anesthesiologists (ASAs) grade were identified as risk factors for poor post-operative prognosis. The area under curve for mortality prediction was 0.947 for PULP score. Conclusion: Poor outcome was significantly higher in the elderly, patients with raised serum creatinine, pre-operative shock, and ASA. PULP score proved to be a more precise indicator of mortality. A larger study inclusive of other mortality risk prediction models would help formulate a more accurate and population specific scoring system.

Factors Affecting Follow-Up Adherence of Glaucoma Patients

ABSTRACT Purpose The objective of our study is to understand the factors associated with non-adherence to the physician’s follow-up advice by persons with glaucoma. Methods We use a four-year panel dataset containing demographic, clinical, and intervention details and doctor’s advised follow-up date for a random sample of 2,622 glaucoma patients from an Indian tertiary eye care hospital. We model this unique “advised follow-up date” in multivariate logistic regressions to identify factors associated with patients’ coming early or late as against on-time. An OLS regression also examines an association between delayed follow-up and declining visual acuity. Results Demographic variables such as age, gender, distance to hospital, IOP, and visual acuity were not associated with delayed adherence to follow-up. Patients advised to review within 2 months (p < .001), paying patients (p < .001), and those habituated to routine follow-up (diabetes patients) (p < .01) are less likely to delay care-seeking. Patients are more likely to come on-time in visits immediately after clinical interventions relative to later ones (p < .001). Our second analysis reveals the presence of cataract and the very first post-surgery visit as factors influencing patients to come early. Our third analysis reveals that a higher proportion of delayed visits had resulted in worsening of vision in the glaucoma-affected eye. Conclusion Our results suggest that active counselling by doctors, especially for routine follow-up visits, can help in better follow-up adherence and prevention of glaucoma-related visual impairment.

Arrest Outcome Consortium Registry Analysis [AOCRA 2022]: Outcome Statistics of Cardiac Arrest in Tertiary Care Hospitals in India, Analysis of Five Year Data of Indian Online Cardiac Arrest Registry, www.aocregistry.com.

To publish data with outcome statistics from our online cardiac arrest (CA) outcome consortium (AOC) online registry. Data on cardiac arrest (CA) from tertiary care hospitals were collected on the AOC registry online portal from January 2017 to May 2022. Survival endpoints from cardiac arrest events like ROSC, and survival at hospital discharge with neurological status at discharge were analyzed and presented. Studies of demographics, the association of outcome with age, gender, bystander CPR, low and no flow times, and admission lactate were also done along with suitable statistical analysis. Out of 2,235 CA, 2,121 received CPR (1,998 IHCA, 123 Out of hospital Cardiac Arrest (OHCA)) as 114 were DNR. The males-female ratio was 70:30. Average age at arrest was 58.7 years. 26% OHCA received bystander CPR but survival advantage was not significant. (with 16%, without 14% p = 0.78). Asystole (67.7%), Pulseless Electrical Activity (PEA) (25.6%), and VF/pVT (6.7%) as first rhythm significantly influence survival (4.9, 8.6 and 39.4%: p < 0.001) ROSC was achieved in 355 (16.7%), with 173 (8.2%) alive and 141 (6.6%) having good (CPC ≤ 2) neurological state at discharge. At discharge, survival as well as CPC ≤ 2 outcomes were significantly better in females. On multivariate regression analysis, first rhythm and low flow time influence survival at discharge. Admission lactate (available only in 102 OHCA) was lower in survivors than non-survivors 10.3 vs 11.5 mmol/L but the difference was not statistically significant (p = 0.397]. Data from our AOC registry shows poor overall survival from CA. The Female gender had a higher survival rate. Ventricular Fibrillation/Pulseless Ventricular Tachycardia (VF/pVT) as first rhythm and low flow time influence the survival to discharge (CTRI/2022/11/047140). Clerk AM, Patel K, Shah BA, Prajapati D, Shah RJ, Rachhadia J, et al. Arrest Outcome Consortium Registry Analysis [AOCRA 2022]: Outcome Statistics of Cardiac Arrest in Tertiary Care Hospitals in India, Analysis of Five Year Data of Indian Online Cardiac Arrest Registry, www.aocregistry.com. Indian J Crit Care Med 2023;27(5):322-329.

Arrhythmia Profile in Children Presenting at a Tertiary Care Centre in India - From Fetal Life to Fifteen Years of Age Prabhu Shakuntala, Prabhshara

Many of the arrhythmias tend to be asymptomatic and detected incidentally, while some others may be picked up too late after a catastrophic presentation. The goal of this study was to document the arrhythmia profile in children presenting to our tertiary care hospital in India. We also reviewed the early and late outcomes of arrhythmias in these patients (including in isolated and post cardiac surgical patients). Amongst 100 patients with arrhythmias, 35% were detected incidentally for presentations like breathlessness (29%) and refusal to feed. A majority of patients (70%) did not have any underlying structural defect and had no cardiomegaly on chest X-Ray. Of those with structural defects, 90% were congenital with the majority being acyanotic (58%) and would have gone clinically undetected. 19 children (20%) presented with heart failure. Tachyarrhythmias (61%) were more common, and all the immediate deaths were from this group. Bradyarrhythmias were mostly complete heart blocks. Almost half the patients required emergency antiarrhythmics. Holter study was done to check for antiarrhythmic efficacy and to decide regarding pacing. In 48% cases, clinical management was changed based on the Holter report. Almost half the patients required emergency antiarrhythmics (adenosine, isoprenaline, amiodarone). The long-term outcomes were favorable with 50% of the patients not requiring long term antiarrhythmics and most remained asymptomatic. The need for interventional therapy like pacemaker insertion and radiofrequency ablation was less than 2%. Arrythmias in children have varied symptoms and pediatricians need to be aware about this. With optimal management, long term outcomes for these children are usually favorable.

When Do Patients with Breast Cancer Seek Help from Psycho-oncology Services? A 3-Year Retrospective Study from India

Abstract Introduction Breast cancer is the most frequent cancer among women. In the last few decades, the outcome of breast cancer has improved significantly in terms of survivorship and quality of life. However, it is crucial that alongside managing the disease, breast cancer services address and manage associated or co-occurring psychiatric illnesses such as acute stress reactions, procedural anxieties, adjustment issues, depression, and fear of recurrence, which leads to an overall better experience of the patient. Objective There is a paucity of data on the patterns of psychiatric morbidity in patients with breast cancer who access psycho-oncology services in a naturalistic setup outside research studies from India. The current study focused on exploring this alongside reporting the common treatment methods adopted for this group of patients. Materials and Methods Real-life data from electronic patient records were retrospectively reviewed for all patients with breast cancer accessing integrated psycho-oncology services in a tertiary care hospital in India over three 3 years (2018–2020). The various psychiatric morbidities were reported, along with associated cancer demographic data, disease characteristics, and treatment details. Results Of all the breast cancer patients (n = 338) in the calendar years 2018 to 2020 reviewed by psycho-oncology services, the most common psychiatric diagnosis was depressive illness (n = 100, 29.6%), followed by adjustment disorders (n = 68, 20.1%) and anxiety (n = 66, 19.5%). There was a significant minority with serious enduring mental illnesses such as schizophrenia (n = 11, 3.3%) and bipolar disorders (n = 14, 4.1%). On the other hand, 14.2% (n = 48) of the patients with breast cancer who attended Psycho-oncology outpatient department did not have any psychiatric syndrome. Around 16.3% of patients could be managed without a prescription for any medications and almost half of the patients needed only one psychotropic medicine. Psychological interventions were used for 45.6% of patients. Conclusions Integrated psycho-oncology services in a cancer hospital catering to patients with breast cancer help in psychiatric assessment, diagnosis, and addressing the mental health needs of patients. The treatment offered needs to be nuanced and individualized and may require a combination of psychotropic medications and psychological techniques.