Single value of NephroCheck™ performed at 4 hours after surgery does not predict acute kidney injury in off-pump coronary artery bypass surgery.

Background: Quantification of urinary tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein (IFGBP-7), which is commercially known as NephroCheck™(NC) test have been suggested as promising tools for the early detection of acute kidney injury (AKI) after cardiac surgery involving cardio-pulmonary bypass (CPB). Objectives: The aim of the present study was to test the hypothesis that single value of postoperative NC test performed at 4 hours after surgery can predict AKI in off-pump coronary artery bypass grafting (OPCABG) surgery. Setting and Design: This prospective single-center study was conducted at the tertiary cardiac center in India from December 2017 to November 2018. Methods: Ninety adult patients of both sex undergoing elective OPCABG were included. Anesthesia was standardized to all patients. Urine samples were collected preoperatively and at 4 hours after surgery for NC test. Urine output, serum creatinine, estimated glomerular filtration rate (eGFR) were also measured. AKI staging was based on kidney disease improving global outcomes (KDIGO) guidelines. Statistical Analysis: To assess the predictability of NC test for the primary endpoint, area under the receiver operating characteristic curve (ROC), was calculated. Results: Thirteen patients developed AKI in the study cohort (14.4%) out of which 7 patients (7.8%) developed stage 2/3 AKI and the remaining stage 1 AKI. Baseline renal parameters were similar between AKI and non-AKI group. The area under curve (AUC) of NC test at 4 hours after surgery was 0.60 [95% confidence interval (CI): 0.42-0.77]. Postoperative NC test performed at 4 hours after surgery did not predict AKI in this study population (P = 0.24). There were no significant differences in duration of mechanical ventilation, length of intensive care stay and hospital stay between the two groups (P > 0.05). Conclusion: NephroCheck™ test performed at 4 hours after surgery did not identify patients at risk for developing AKI following OPCABG surgery.

Clinical Evaluation of a Wireless Device for Monitoring Vitals in Newborn Babies.

OBJECTIVES: To evaluate the ability of the Nemocare Raksha (NR), an internet of things (IoT)-enabled device, to continuously monitor vitals for 6 h and its safety in newborns. The accuracy of the device was also compared with the readings from the standard device used in the pediatric ward. METHOD: Forty neonates (either gender) weighing ≥ 1.5 kg were included in the study. Heart rate, respiratory rate, body temperature, and oxygen saturation was measured using the NR and compared with standard care devices. Safety was assessed by monitoring for skin changes and local rise in temperature. The neonatal infant pain scale (NIPS) was used to assess pain and discomfort. RESULT: A total of 227 h of observations (5.67 h per baby) were obtained. No discomfort or device-related adverse events were noted during the study period. The mean difference between the NR and the standard monitoring was 0.66 (0.42 to 0.90) for temperature (°C); -6.57 (-8.66 to -4.47) for heart rate (bpm); 7.60 (6.52 to 8.68) for respiratory rate (breaths per minute); -0.79 (-1.10 to -0.48) for oxygen saturation (%). The level of agreement analyzed using the intraclass correlation coefficient (ICC) was good for heart rate [ICC 0.77 (0.72 to 0.82); p value < 0.001] and oxygen saturation [ICC 0.80 (0.75 to 0.84); p value < 0.001]; moderate for body temperature [ICC 0.54 (0.36 to 0.60); p value < 0.001] and poor for respiratory rate [ICC 0.30 (0.10 to 0.44); p value 0.002]. CONCLUSION: The NR was able to seamlessly monitor vital parameters in neonates without any safety concern. The device showed a good level of agreement for heart rate and oxygen saturation among the four parameters measured.

Automated versus manual B-lines counting, left ventricular outflow tract velocity time integral and inferior vena cava collapsibility index in COVID-19 patients.

Background and Aims: The incorporation of artificial intelligence (AI) in point-of-care ultrasound (POCUS) has become a very useful tool to quickly assess cardiorespiratory function in coronavirus disease (COVID)-19 patients. The objective of this study was to test the agreement between manual and automated B-lines counting, left ventricular outflow tract velocity time integral (LVOT-VTI) and inferior vena cava collapsibility index (IVC-CI) in suspected or confirmed COVID-19 patients using AI integrated POCUS. In addition, we investigated the inter-observer, intra-observer variability and reliability of assessment of echocardiographic parameters using AI by a novice. Methods: Two experienced sonographers in POCUS and one novice learner independently and consecutively performed ultrasound assessment of B-lines counting, LVOT-VTI and IVC-CI in 83 suspected and confirmed COVID-19 cases which included both manual and AI methods. Results: Agreement between automated and manual assessment of LVOT-VTI, and IVC-CI were excellent [intraclass correlation coefficient (ICC) 0.98, P < 0.001]. Intra-observer reliability and inter-observer reliability of these parameters were excellent [ICC 0.96-0.99, P < 0.001]. Moreover, agreement between novice and experts using AI for LVOT-VTI and IVC-CI assessment was also excellent [ICC 0.95-0.97, P < 0.001]. However, correlation and intra-observer reliability between automated and manual B-lines counting was moderate [(ICC) 0.52-0.53, P < 0.001] and [ICC 0.56-0.69, P < 0.001], respectively. Inter-observer reliability was good [ICC 0.79-0.87, P < 0.001]. Agreement of B-lines counting between novice and experts using AI was weak [ICC 0.18, P < 0.001]. Conclusion: AI-guided assessment of LVOT-VTI, IVC-CI and B-lines counting is reliable and consistent with manual assessment in COVID-19 patients. Novices can reliably estimate LVOT-VTI and IVC-CI using AI software in COVID-19 patients.

Use of Handheld Ultrasound Device with Artificial Intelligence for Evaluation of Cardiorespiratory System in COVID-19.

BACKGROUND: Coronavirus disease-2019 (COVID-19) causes various cardiopulmonary manifestations. Bedside ultrasound helps in the rapid diagnosis of these manifestations. Vscan Extend™ (GE, Wauwatosa, WI, USA) is a handheld ultrasound device with a dual probe and an artificial intelligence application to detect ejection fraction. It can help in reducing the time for diagnosis, duration, and the number of healthcare workers exposed to COVID-19. This is a prospective observational study comparing the cardiorespiratory parameters and time duration for assessment between Vscan Extend™ and the conventional ultrasound machine. MATERIALS AND METHODS: Paired observations were made in 96 COVID-19 patients admitted to the intensive care unit by two intensivists. Intensivist A used the Vscan Extend™ device to assess the cardiac function, lung fields, diaphragm, deep veins, and abdomen. Intensivist B used clinical examination, X-ray chest, ECG, and conventional echocardiogram for assessment. The agreement between the findings and the time duration required in both the methods was compared. RESULTS: The use of handheld ultrasound has significantly decreased the duration of bedside examination of patients than the conventional method. The median duration of examination using handheld ultrasound was 9 (8.0-11.0) minutes, compared to 20 (17-22) minutes with the conventional method (P < 0.001). The Cohen's kappa coefficient was 1.0 for left ventricular systolic function, most of the lung fields, and diaphragmatic movement. CONCLUSION: Vscan Extend™ helps in the rapid identification and diagnosis of cardiopulmonary manifestations in COVID-19 patients. The agreement between the handheld device and the conventional method proves its efficacy and safety. CTRI NUMBER: CTRI/2020/07/026701. HOW TO CITE THIS ARTICLE: Maheshwarappa HM, Mishra S, Kulkarni AV, Gunaseelan V, Kanchi M. Use of Handheld Ultrasound Device with Artificial Intelligence for Evaluation of Cardiorespiratory System in COVID-19. J Crit Care Med 2021;25(5):524-527.

Effects of genetic polymorphisms in Vitamin D metabolic pathway on Vitamin D level and asthma control in South Indian patients with bronchial asthma.

OBJECTIVES: The study was designed to evaluate the single-nucleotide polymorphisms (SNPs) of genes involved in Vitamin D actions (rs2228570) and metabolic pathways (rs2248137 and rs10766197) and their associations with serum 25-hydroxy Vitamin D (25(OH)D) level and asthma control in South Indian patients with bronchial asthma. MATERIALS AND METHODS: One hundred and two patients of South Indian origin with bronchial asthma either naive to inhaled corticosteroids (ICSs) or not receiving ICS for ≥1 month were included and were treated with ICS (beclomethasone 200 µg twice daily) for 8 weeks. One hundred and one unrelated healthy South Indians were used as controls. Pulmonary function test and fractional exhaled nitric oxide were used to assess asthma control. Serum 25(OH)D levels (chemiluminescence immunoassay) and SNPs in Vitamin D pathway (real-time polymerase chain reaction) were assessed. The associations of SNPs and serum 25(OH)D with asthma control was determined using linear regression. All analyses were performed using SPSS (version 19) and "SNPStats." P < 0.05 was considered as statistically significant. RESULTS: Vitamin D receptor (VDR) polymorphism (rs2228570) was found to be protective against asthma (P = 0.022), while there were no significant associations between the other two SNPs and asthma. Similarly, poor correlation and insignificant associations between the SNPs and serum 25(OH)D levels were observed in both cases and controls. There were also insignificant associations between the SNPs and asthma control. CONCLUSION: VDR polymorphism (rs2228570) was found to be protective against asthma in South Indians, while other genes involved in the metabolic pathway of Vitamin D did not show associations with asthma.

Systematic Review on Vitamin D Level in Apparently Healthy Indian Population and Analysis of Its Associated Factors.

BACKGROUND: Vitamin D which is involved in the maintenance of bone mineral homeostasis has been found to portray various pleiotropic effects. Although it has been widely accepted that serum 25-hydroxy Vitamin D level above 30 ng/ml is considered optimal for the biological actions of Vitamin D, there is a need to explore the levels of Vitamin D reported among Indians from various regions of the country. Hence, this systematic review aims to appraise the status of Vitamin D levels reported from apparently healthy Indians across various parts of India. METHODOLOGY: A comprehensive literature search was carried out to identify the range of Vitamin D levels among apparently healthy individuals from various parts of India, with the search term "Vitamin D and India" in the search portals of PubMed, Google Scholar, Indmed, and ScienceDirect. A total of 2998 articles were retrieved by the above search strategy, of which only forty studies fulfilled the criteria to be included in the systematic review. Studies done in various states were compiled under the respective zones based on the classification of Indian zones as specified in Zonal maps of India. RESULTS: The level of Vitamin D from all the forty included studies ranged from 3.15 ± 1.4 to 52.9 ± 33.7 ng/ml. The effect size of Vitamin D level was higher in the South Zone compared to other zones. CONCLUSION: The present study shows that Vitamin D deficiency is prevalent among apparently healthy Indians living in different regions of India, irrespective of their exposure to sunlight.

The Journey of the Non-Vascular Relief for Migraine: From 'Triptans' To 'Ditans'.

Migraine is a recurrent, disabling, complex and highly prevalent neurological disorder. The mystery behind the cause of migraine is continuously evolving, according to the scientific understanding of the disease. This growing understanding helps to identify novel therapeutic targets for the management of migraine to treat the ailing migraineurs. The role of serotonin (5HT) in migraine is recognized to be the cornerstone for the currently available therapeutic options namely ergot alkaloids and triptans. The role of mediators such as Calcitonin Gene-Related Peptide (CGRP), nitric oxide and excitatory neurotransmitter glutamate, has been realized and ignited the development of drugs targeting these factors. Lasmiditan, known as a Neurally Active Anti- Migraine Agent (NAAMA) is a specific 5HT1F agonist, developed as a new group named as 'ditans'. The drug was designed and developed to meet the unmet needs of currently available medications to circumvent the vascular adverse effects. Having a group of drugs with a nonvascular mechanism of action, devoid of unwanted effects with a different spectrum of indication and contraindications, is the need of the hour to expand the armamentarium available to tackle acute migraine attack.

Effect of metformin on exercise capacity in metabolic syndrome.

OBJECTIVE: Metabolic syndrome is a constellation of risk factors with increased predilection towards occurrence of cardiovascular diseases. Currently physical exercise and management with metformin are the prevailing treatment modalities for metabolic syndrome. Patients with metabolic syndrome have been found to have reduced exercise capacity over a period of time. Likewise metformin has been shown to decrease exercise capacity among healthy volunteers. Hence this study aims to evaluate the effect of metformin on the exercise capacity of patients with metabolic syndrome. DESIGN: Prospective study with 6 weeks follow up. METHODS: Newly diagnosed patients with metabolic syndrome and to be started on Table Metformin 500mg twice a day were recruited for the study after obtaining written informed consent. Cardiopulmonary Exercise Testing (CPET) was done at baseline before the subjects were started on metformin and after 6 weeks of treatment using cardiopulmonary exercise testing apparatus (ZAN600). RESULTS: Fifteen treatment naïve patients with metabolic syndrome completed six weeks of therapy with metformin. In these patients oxygen uptake [VO2] showed statistically significant decrease from 1.10±0.44 at baseline to 0.9±0.39 (l/min) after six weeks of treatment with metformin [mean difference of -0.20 (-0.31 to -0.09); P=0.001]. Similarly oxygen uptake/kg body weight [VO2/Kg] showed a significant decrease from 14.10±4.73 to 11.44±3.81 (mlkg-1min-1) at the end of six weeks of treatment [mean difference of -2.66 (-4.06 to -1.26); P=0.001]. CONCLUSION: Six weeks of treatment with metformin significantly decreases exercise capacity in newly diagnosed patients with metabolic syndrome.

Drug information center as referral service in a South Indian tertiary care hospital.

OBJECTIVE: The objective of this study is to assess the various aspects of drug information services (DISs) provided in the DI center of a tertiary care hospital. MATERIALS AND METHODS: DI queries received from various departments from April 2013 to May 2017 were included in the study. Various aspects such as year- and department-wise distribution, reason for sending the queries, mode of receipt and reply, time taken for reply, number of visit for bedside examination of patients, and number of references given per query were analyzed. All the results are expressed in numbers and percentages. RESULTS: Fifty-five DI queries were received during the study period. Most of the queries were received from Department of Orthopedics (26, 47.27%), followed by Neurology (4, 7.27%). Most common mode of receipt of queries (41, 74.55%) was by Cross-reference form not case record form followed by phone calls (8, 14.55%) and outpatient department (OPD) case sheet (6, 10.9%). CRF with attached opinion was the most common mode of reply (41, 74.55%) followed by phone calls (7, 12.73%), and OPD case sheets (6, 10.9%). The most common reason for sending queries was antimicrobials-related problem (25, 45.46%), followed by the use of anticoagulants (13, 23.63%). Most of the queries were replied within 24 h (31, 56.36%), followed by 48 h (14, 25.45%). Out of 41 CRF received for in-patients, bedside examination was requested in 23 (56.09%) CRF. There was an increasing trend in the number of queries received every year with more queries received during 2016 (23, 41.82%). CONCLUSIONS: DIS if utilized properly can be used as a referral service such as other specialties in a tertiary care hospital.