Safety and Efficacy of Newer Oral Anticoagulants Versus Vitamin K Antagonists in the Management of Cerebral Venous Thrombosis: A Single-Center Ambispective Study from South India.

INTRODUCTION: Cerebral Venous Thrombosis (CVT) poses a rare but life-threatening challenge, warranting meticulous treatment approaches. Traditional therapy involves Vitamin K Antagonists (VKAs), but Newer Oral Anticoagulants (NOACs) offer potential advantages. This study addresses a crucial knowledge gap in the Indian context, analyzing real-world data to guide CVT management decisions. METHODS: A single-center, ambispective cohort study included consecutive adult CVT patients. Data collection encompassed demographics, clinical data, imaging, and treatment details. Patients were categorized into VKA and NOAC groups. Outcomes measured recanalization status, functional outcomes, bleeding events, and adverse drug reactions. RESULTS: Among 181 enrolled patients, NOACtreated (Group B) individuals had significantly higher rates of complete recanalization (58.5% vs. 31.1%) with a similar incidence of adverse events and also displayed better functional outcomes at weeks 8 and 12 compared to VKA-treated (Group A) patients. Recurrent thromboembolic events were absent in both groups during follow-up. CONCLUSION: This study highlights NOACs' potential advantages in CVT management, including improved functional outcomes, enhanced recanalization, and similar bleeding risk. Adverse events were milder with NOACs. While acknowledging limitations, these findings support NOACs as a promising alternative to VKAs, advancing CVT care and outcomes.

Oculomasticatory rhythmic movements, insomnia and stroke-like episodes in a patient with POLG mutation.

The POLG mutation, a leading cause of mitochondrial diseases, exhibits a wide-ranging age of onset and a complex clinical presentation. We encountered an atypical clinical profile in an elderly man with a POLG mutation, characterised by a stroke-like episode, chronic insomnia and transient oculomasticatory rhythmic movement. History revealed chronic constipation since his 50s and progressive bilateral ophthalmoplegia since his early 60s. Subsequently, he had experienced acute encephalopathy and later developed chronic insomnia. The present neurological examination showed bilateral complete ophthalmoplegia, ptosis, and rhythmic ocular and jaw movements. Imaging indicated findings suggestive of a stroke-like episode and eventual genetic analysis revealed a homozygous missense mutation in the POLG gene. This case expands the clinical spectrum of POLG mutations in individuals over 60 years, showcasing the rare combination of a stroke-like episode, chronic insomnia and oculomasticatory rhythmic movement.

Improving Antimicrobial Resistance Awareness Among Medical Students in India: The Sensitization of Medical Students on Antimicrobial Resistance (SOS-AMR) Study.

OBJECTIVES: To evaluate the impact of an online educational intervention on improving knowledge of antimicrobial resistance (AMR) and stewardship among final-year medical students in Chennai, India. METHODS: This was a prospective 'before-after' study conducted across 5 medical colleges in Chennai, India. Participants who were final-year (fourth year) undergraduate medical students were administered a pretest to evaluate baseline knowledge. Students were then provided access to online educational material comprising 20 short lectures. Lectures were delivered by content experts and covered a range of topics which included basics of microbiology, fundamental concepts in AMR and stewardship, diagnosis and management of common infections, basics of antimicrobial pharmacokinetics and pharmacodynamics, and vaccination. Students were required to take a posttest at the end of these modules. Primary outcome was improvement in test scores from pretest baseline which was analyzed using a t test. A 30% improvement in the mean scores from baseline was predefined as a measure of success. RESULTS: A total of 599 students participated from 5 medical colleges among whom 339 (56.6%) were female participants; 542 (90.4%) students completed the posttest. Mean pretest score was 11.6 (maximum possible score of 25) (SD: 4.3) and the mean posttest score was 14.0 (SD: 4.6). Comparing pre and posttest scores, there was an improvement of 2.4 marks (20%) from the baseline (95% confidence interval: 1.9, 2.9) (P < .001). Improvement in scores was similar for male and female participants. CONCLUSIONS: In this before-after study evaluating the impact of an educational intervention on AMR among final-year medical students, there was an improvement in knowledge; however, the extent of improvement did not meet the predefined metric of success.

Expanded spectrum of varicella disease and the need for vaccination in India.

Varicella vaccine was first licensed in Japan and South Korea in 1989 for use in healthy children and was introduced in US in 1995. So far, 29 countries have adopted varicella vaccine in their universal immunization program (UIP). No Asian country, India included, has adopted the varicella vaccine as part of their UIP. The extra-cutaneous sites for VZV diseases are central nervous system and gastrointestinal tract, the expanded disease spectrum includes vasculopathy, myelitis, inflammatory bowel disease, perforated ulcers, and gastritis. The actual disease burden of varicella is not known as most of the infected individuals may not visit the physician. The amplifiable VZV DNA will not always be detectable in cerebrospinal fluid (CSF) samples in protracted illnesses such as vasculopathies, but demonstrable anti-VZV IgG in CSF has diagnostic value. The World Health Organization (WHO) position paper 2014 recommends two doses of varicella and zoster vaccines in targeted population. In India, varicella vaccine is not included in the UIP due to the cost and the belief that lifelong immunity occurs following primary infection. The expanded spectrum of VZV disease and the mounting body of evidence, however, suggest the need for both varicella and zoster vaccines in routine immunization schedule.

Incidence of Cardiovascular Instability in Patients With Guillain-Barré Syndrome: A Retrospective Study.

Introduction Guillain-Barré syndrome (GBS) is an autoimmune disease affecting radicles and peripheral nerves resulting in acute flaccid paralysis. Respiratory failure, autonomic dysfunction, and secondary complications such as pneumonia, and venous thromboembolism are the major causes of death and disability in GBS. Cardiovascular complications play a major role in the prognosis of GBS patients. The aim is to determine the incidence of cardiovascular instability in GBS patients and to see if there are any specific risk groups associated with the development of cardiovascular instability. Methodology This is a retrospective descriptive study conducted in a tertiary care center in South India. Data on 50 consecutive GBS patients were collected from hospital records including case sheets, death summaries, and discharge summaries. Patients with evidence of sepsis, blood loss, heavy alcohol consumption, and chronic liver disease were excluded from the study. Baseline demographic data, symptom onset to admission time, baseline Erasmus Guillain-Barré Syndrome Respiratory Insufficiency Score (EGRIS), and baseline liver function tests were documented. The presence of heart rate and blood pressure fluctuations was noted from the records. Frequency data were calculated from the categorical variables. Analysis of non-parametric variables by chi-square test was done using IBM SPSS Statistics for Windows, Version 25.0 (Released 2017; IBM Corp., Armonk, New York, United States). Results Cardiovascular instability was present in 15 (30%) patients in the study population. It was present in all patients (100%) who require mechanical ventilation. The incidence of cardiovascular instability was higher in patients who had lesser onset to admission times (41.9% vs 10.5%; p=0.019), EGRIS≥4 (40.6% vs 11.1%; p=0.029), and lower cranial nerve involvement (40% vs 6.7%; p=0.018). Conclusion Of patients with GBS, 30% developed cardiovascular instability during their disease course. Patients with lesser onset to admission times, EGRIS ≥4, and those with lower cranial nerve involvement had a greater incidence of cardiovascular instability.

Prevalence of frailty and association with patient centered outcomes: A prospective registry-embedded cohort study from India.

PURPOSE: We aimed to study the prevalence of frailty, evaluate risk factors, and understand impact on outcomes in India. METHODS: This was a prospective registry-embedded cohort study across 7 intensive care units (ICUs) and included adult patients anticipated to stay for at least 48 h. Primary exposure was frailty, as defined by a score ≥ 5 on the Clinical Frailty Scale and primary outcome was ICU mortality. Secondary outcomes included in-hospital mortality and resource utilization. We used generalized linear models to evaluate risk factors and model association between frailty and outcomes. RESULTS: 838 patients were included, with median (IQR) age 57 (42,68) yrs.; 64.8% were male. Prevalence of frailty was 19.8%. Charlson comorbidity index (OR:1.73 (95%CI:1.39,2.15)), Subjective Global Assessment categories mild/moderate malnourishment (OR:1.90 (95%CI:1.29, 2.80)) and severe malnourishment (OR:4.76 (95% CI:2.10,10.77)) were associated with frailty. Frailty was associated with higher odds of ICU mortality (adjusted OR:2.04 (95% CI:1.25,3.33)), hospital mortality (adjusted OR:2.36 (95%CI:1.45,3.84)), development of stage2/3 AKI (unadjusted OR:2.35 (95%CI:1.60, 3.43)), receipt of non-invasive ventilation (unadjusted OR:2.68 (95%CI:1.77, 4.03)), receipt of vasopressors (unadjusted OR:1.47 (95%CI:1.04, 2.07)), and receipt of kidney replacement therapy (unadjusted OR:3.15 (95%CI:1.90, 5.17)). CONCLUSIONS: Frailty is common among critically ill patients in India and is associated with worse outcomes. STUDY REGISTRATION: CTRI/2021/02/031503.

Myasthenia-Like Presentation of Imidacloprid Toxicity.

Imidacloprid is a neonicotinoid insecticide highly specific to nicotinic acetylcholine receptors in insects and other invertebrates. Nicotinic receptors in mammalian species have a low affinity to neonicotinoids. However, cross-reactivity with mammalian nicotinic receptors is a major concern especially due to the propensity of this commonly used agent to persist in environmental water sources for an extended period of time. Here, we present a case report of a patient who presented to the emergency department with features suggestive of neuromuscular junction dysfunction, following exposure to imidacloprid.

Physicians' beliefs about brain surgery for drug-resistant epilepsy: A global survey.

PURPOSE: To investigate the opinions of physicians about brain surgery for drug-resistant epilepsy worldwide. METHODS: Practicing neurologists, psychiatrists, and neurosurgeons from around the world were invited to participate in an online survey. The survey anonymously collected data about demographics, years in clinical practice, discipline, nation, work setting, and answers to the questions about beliefs and attitudes about brain surgery for drug-resistant epilepsy. RESULTS: In total, 1410 physicians from 20 countries and different world regions participated. The propensity to discuss brain surgery with patients, who have drug-resistant seizures, was higher among men (versus women) [Odds Ratio (OR) 1.67, 95% CI 1.20-2.31; p = 0.002]. In comparison to neurologists, psychiatrists were less likely (OR 0.28, 95% CI 0.17-0.47; p < 0.001) and neurosurgeons were more likely (OR 2.00, 95% CI 1.08-3.72; p = 0.028) to discuss about it. Survey participants working in Africa, Asia, the Middle East, and the Former Union of Soviet Socialist Republics showed a lower propensity to discuss epilepsy surgery with patients. CONCLUSION: This study showed that on an international level, there is still a knowledge gap concerning epilepsy surgery and much needs to be done to identify and overcome barriers to epilepsy surgery for patients with drug-resistant seizures worldwide.

Counseling about sudden unexpected death in epilepsy (SUDEP): A global survey of neurologists' opinions.

OBJECTIVE: To investigate the opinions and attitudes of neurologists on the counseling about sudden unexpected death in epilepsy (SUDEP) worldwide. METHODS: Practicing neurologists from around the world were invited to participate in an online survey. On February 18th, 2021, we emailed an invitation including a questionnaire (using Google-forms) to the lead neurologists from 50 countries. The survey anonymously collected the demographic data of the participants and answers to the questions about their opinions and attitudes toward counseling about SUDEP. RESULTS: In total, 1123 neurologists from 27 countries participated; 41.5% of the respondents reported they discuss the risk of SUDEP with patients and their care-givers only rarely. Specific subgroups of patients who should especially be told about this condition were considered to be those with poor antiseizure medication (ASM) adherence, frequent tonic-clonic seizures, or with drug-resistant epilepsy. The propensity to tell all patients with epilepsy (PWE) about SUDEP was higher among those with epilepsy fellowship. Having an epilepsy fellowship and working in an academic setting were factors associated with a comfortable discussion about SUDEP. There were significant differences between the world regions. CONCLUSION: Neurologists often do not discuss SUDEP with patients and their care-givers. While the results of this study may not be representative of practitioners in each country, it seems that there is a severe dissociation between the clinical significance of SUDEP and the amount of attention that is devoted to this matter in daily practice by many neurologists around the world.

Genetics of Ataxias in Indian Population: A Collative Insight from a Common Genetic Screening Tool.

Cerebellar ataxias (CAs) represent a group of autosomal dominant and recessive neurodegenerative disorders affecting cerebellum with or without spinal cord. Overall, CAs have preponderance for tandem nucleotide repeat expansions as an etiological factor (10 TREs explain nearly 30-40% of ataxia cohort globally). The experience of 10 years of common genetic ataxia subtypes for ≈5600 patients' referrals (Pan-India) received at a single center is shared herein. Frequencies (in %, n) of SCA types and FRDA in the sample cohort are observed as follows: SCA12 (8.6%, 490); SCA2 (8.5%, 482); SCA1 (4.8%, 272); SCA3 (2%, 113); SCA7 (0.5%, 28); SCA6 (0.1%, 05); SCA17 (0.1%, 05), and FRDA (2.2%, 127). A significant amount of variability in TRE lengths at each locus is observed, we noted presence of biallelic expansion, co-occurrence of SCA-subtypes, and the presence of premutable normal alleles. The frequency of mutated GAA-FRDA allele in healthy controls is 1/158 (0.63%), thus an expected FRDA prevalence of 1:100 000 persons. The data of this study are relevant not only for clinical decision making but also for guidance in direction of genetic investigations, transancestral comparison of genotypes, and lastly provide insight for policy decision for the consideration of SCAs under rare disease category.

Impact of COVID-19 on non-COVID intensive care unit service utilization, case mix and outcomes: A registry-based analysis from India.

Background: Coronavirus disease 2019 (COVID-19) has been responsible for over 3.4 million deaths globally and over 25 million cases in India. As part of the response, India imposed a nation-wide lockdown and prioritized COVID-19 care in hospitals and intensive care units (ICUs). Leveraging data from the Indian Registry of IntenSive care, we sought to understand the impact of the COVID-19 pandemic on critical care service utilization, case-mix, and clinical outcomes in non-COVID ICUs.  Methods: We included all consecutive patients admitted between 1 st October 2019 and 27 th September 2020. Data were extracted from the registry database and included patients admitted to the non-COVID or general ICUs at each of the sites. Outcomes included measures of resource-availability, utilisation, case-mix, acuity, and demand for ICU beds. We used a Mann-Whitney test to compare the pre-pandemic period (October 2019 - February 2020) to the pandemic period (March-September 2020). In addition, we also compared the period of intense lockdown (March-May 31 st 2020) with the pre-pandemic period. Results: There were 3424 patient encounters in the pre-pandemic period and 3524 encounters in the pandemic period. Comparing these periods, weekly admissions declined (median [Q1 Q3] 160 [145,168] to 113 [98.5,134]; p=0.00002); unit turnover declined (median [Q1 Q3] 12.1 [11.32,13] to 8.58 [7.24,10], p<0.00001), and APACHE II score increased (median [Q1 Q3] 19 [19,20] to 21 [20,22] ; p<0.00001). Unadjusted ICU mortality increased (9.3% to 11.7%, p=0.01519) and the length of ICU stay was similar (median [Q1 Q3] 2.11 [2, 2] vs. 2.24 [2, 3] days; p=0.15096). Conclusion: Our registry-based analysis of the impact of COVID-19 on non-COVID critical care demonstrates significant disruptions to healthcare utilization during the pandemic and an increase in the severity of illness.

Anthelmintics for people with neurocysticercosis.

BACKGROUND: Neurocysticercosis is a parasitic infection of the central nervous system by the larval stage of the pork tapeworm and is a common cause of seizures and epilepsy in endemic areas. Anthelmintics (albendazole or praziquantel) may be given alongside supportive treatment (antiepileptics/analgesia) with the aim of killing these larvae (cysticerci), with or without corticosteroid treatment. However, there are potential adverse effects of these drugs, and the cysticerci may eventually die without directed anthelminthic treatment. OBJECTIVES: To assess the effects of anthelmintics on people with neurocysticercosis. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, the WHO ICTRP, and ClinicalTrials.gov, up to 21 October 2020. SELECTION CRITERIA: Randomized controlled trials comparing anthelmintics and supportive treatment (+/- corticosteroids) with supportive treatment alone (+/- corticosteroids) for people with neurocysticercosis. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the title and abstract of all articles identified by the search. We obtained full-text articles to confirm the eligibility of all studies that passed screening. One review author extracted data, which a second review author checked. Two review authors assessed the risk of bias of each trial and performed GRADE assessments. In cases of disagreement at consensus discussion stage between review authors, we consulted a third review author. We calculated risk ratios (RR) for dichotomous variables, with 95% confidence intervals (CIs) for pooled data from studies with similar interventions and outcomes. MAIN RESULTS: We included 16 studies in the review. Only two studies investigated praziquantel and did not report data in a format that could contribute to meta-analysis. Most results in this review are therefore applicable to albendazole versus placebo or no anthelmintic. The aggregate analysis across all participants with neurocysticercosis did not demonstrate a difference between groups in seizure recurrence, but heterogeneity was marked (RR 0.94, 95% CI 0.78 to 1.14; 10 trials, 1054 participants; I2 = 67%; low-certainty evidence). When stratified by participants with a single cyst or multiple cysts, pooled analysis suggests that albendazole probably improves seizure recurrence for participants with a single cyst (RR 0.61, 95% CI 0.4 to 0.91; 5 trials, 396 participants; moderate-certainty evidence). All studies contributing to this analysis recruited participants with non-viable, intraparenchymal cysts only, and most participants were children. We are uncertain whether or not albendazole reduces seizure recurrence in participants with multiple cysts, as the certainty of the evidence is very low, although the direction of effect is towards albendazole causing harm (RR 2.05, 95% CI 1.28 to 3.31; 2 trials, 321 participants; very low-certainty evidence). This analysis included a large study containing a highly heterogeneous population that received an assessment of unclear risk for multiple 'Risk of bias' domains. Regarding radiological outcomes, albendazole probably slightly improves the complete radiological clearance of lesions (RR 1.22, 95% CI 1.07 to 1.39; 13 trials, 1324 participants; moderate-certainty evidence) and the evolution of cysts (RR 1.27, 95% CI 1.10 to 1.47; 6 trials, 434 participants; moderate-certainty evidence). More adverse events appeared to be observed in participants treated with either albendazole or praziquantel compared to those receiving placebo or no anthelmintic. The most commonly reported side effects were headache, abdominal pain, and nausea/vomiting. AUTHORS' CONCLUSIONS: For participants with a single cyst, there was less seizure recurrence in the albendazole group compared to the placebo/no anthelmintic group. The studies contributing to this evidence only recruited participants with a non-viable intraparenchymal cyst. We are uncertain whether albendazole reduces seizure recurrence for participants with multiple cysts. We also found that albendazole probably increases radiological clearance and evolution of lesions. There were very few studies reporting praziquantel outcomes, and these findings apply to albendazole only.

Preventive Oral Treatment of Episodic Migraine: An Overview.

BACKGROUND: Migraine is a common primary headache disorder and Episodic migraine is characterized by the occurrence of up to 14 headache days in a month. The preventive treatment of migraine is useful in patients with frequent migraine attacks, impaired activities of daily living, failure of acute pain management, disabling aura and limitations in the use of acute treatment. It is aimed at reducing headache frequency and intensity, improve response to acute treatment of migraine and improve the quality of life. AIM: To analyze the evidence for the efficacy and tolerability of preventive oral drugs used in the management of episodic migraine. METHODS: A narrative review of the references were reviewed by searching the literature for the articles published in PubMed in English language using all the following MeSH keywords "preventive treatment", "preventive oral treatment", AND "episodic migraine", "migraine". RESULTS: Out of articles identified in the search, 38 articles were reviewed for evidence and summarized. The various oral drugs used in the prevention of episodic migraine are antihypertensives (beta-blockers, calcium channel blockers and Angiotensin-converting enzyme inhibitors/Angiotensin receptor blockers), antidepressants (tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors), antiepileptic drugs (valproic acid, topiramate, lamotrigine) and other miscellaneous agents. HURT questionnaire and HALT 30 index are useful in assessing response to treatment in the follow up of migraine patients. CONCLUSION: An appropriately chosen oral drug is useful in the preventive treatment of episodic migraine. In patients, who fail to respond to the preventive treatment, it is essential to review the diagnosis of migraine, titrate the dosage and duration of preventive treatment and ensure patient compliance. In those patients who fail to respond to monotherapy, polytherapy is a useful option to be considered.

Feasibility, tolerance and effectiveness of enteral feeding in critically ill patients in prone position.

AIM: To assess the feasibility, tolerance and effectiveness of enteral nutrition in critically ill patients receiving invasive mechanical ventilation in the prone position for severe Acute Respiratory Distress Syndrome (ARDS). METHODS: Prospective observational study conducted in a multidisciplinary critical care unit of a tertiary care hospital from January 2013 until July 2015. All patients with ARDS who received invasive mechanical ventilation in prone position during the study period were included. Patients' demographics, severity of illness (Acute Physiology and Chronic Health Evaluation (APACHE II) score), baseline markers of nutritional status (subjective global assessment (SGA) and body mass index), details of nutrition delivery during prone and supine hours and outcomes (Length of stay and discharge status) were recorded. RESULTS: Fifty-one patients met inclusion criteria out of whom four patients were excluded from analysis since they did not receive any enteral nutrition due to severe hemodynamic instability. The mean age of patients was 46.4 ± 12.9 years, with male:female ratio of 7:3. On admission, SGA revealed moderate malnutrition in 51% of patients and the mean APACHE II score was 26.8 ± 9.2. The average duration of prone ventilation per patient was 60.2 ± 30.7 h. All patients received continuous nasogastric/orogastric feeds. The mean calories (kcal/kg/day) and protein (g/kg/day) prescribed in the supine position were 24.5 ± 3.8 and 1.1 ± 0.2 while the mean calories and protein prescribed in prone position were 23.5 ± 3.6 and 1.1 ± 0.2, respectively. Percentage of prescribed calories received by patients in supine position was similar to that in prone position (83.2% vs. 79.6%; P = 0.12). Patients received a higher percentage of prescribed protein in supine compared to prone position (80.8% vs. 75%, P = 0.02). The proportion of patients who received at least 75% of the caloric and protein goals was 37 (78.7%) and 37 (78.7%) in supine and 32 (68.1%) and 21 (44.6%) in prone position. CONCLUSION: In critically ill patients receiving invasive mechanical ventilation in the prone position, enteral nutrition with nasogastric/orogastric feeding is feasible and well tolerated. Nutritional delivery of calories and proteins in prone position is comparable to that in supine position.

Implementing an intensive care registry in India: preliminary results of the case-mix program and an opportunity for quality improvement and research.

Background: The epidemiology of critical illness in India is distinct from high-income countries. However, limited data exist on resource availability, staffing patterns, case-mix and outcomes from critical illness. Critical care registries, by enabling a continual evaluation of service provision, epidemiology, resource availability and quality, can bridge these gaps in information. In January 2019, we established the Indian Registry of IntenSive care to map capacity and describe case-mix and outcomes. In this report, we describe the implementation process, preliminary results, opportunities for improvement, challenges and future directions. Methods: All adult and paediatric ICUs in India were eligible to join if they committed to entering data for ICU admissions. Data are collected by a designated representative through the electronic data collection platform of the registry. IRIS hosts data on a secure cloud-based server and access to the data is restricted to designated personnel and is protected with standard firewall and a valid secure socket layer (SSL) certificate. Each participating ICU owns and has access to its own data. All participating units have access to de-identified network-wide aggregate data which enables benchmarking and comparison. Results: The registry currently includes 14 adult and 1 paediatric ICU in the network (232 adult ICU beds and 9 paediatric ICU beds). There have been 8721 patient encounters with a mean age of 56.9 (SD 18.9); 61.4% of patients were male and admissions to participating ICUs were predominantly unplanned (87.5%). At admission, most patients (61.5%) received antibiotics, 17.3% needed vasopressors, and 23.7% were mechanically ventilated. Mortality for the entire cohort was 9%.  Data availability for demographics, clinical parameters, and indicators of admission severity was greater than 95%. Conclusions: IRIS represents a successful model for the continual evaluation of critical illness epidemiology in India and provides a framework for the deployment of multi-centre quality improvement and context-relevant clinical research.

Comparison of Epidemiology and Outcomes of Acute Kidney Injury in Critically Ill Patients with and without Sepsis.

OBJECTIVES: In critically ill patients, acute kidney injury (AKI) and sepsis often coexist. This confounds the assessment of outcomes of both sepsis and AKI in these patients. Hence, in this study, we compare the outcomes of AKI with sepsis, AKI without sepsis, and sepsis without AKI against a control cohort comprising patients with neither AKI nor sepsis. MATERIALS AND METHODS: Prospective observational study conducted in our critical care unit (CCU) between January and July 2009. Data including demographic details, acute physiology and chronic health evaluation (APACHE) III score, presence of AKI, presence of sepsis, intensive care unit (ICU) length of stay (LOS), and outcomes were collected for all patients. Acute Kidney Injury Network (AKIN) criteria were used to define the presence of AKI and American College of Critical Care Medicine 2001 definition was used to define the presence of sepsis. RESULTS: A total of 250 patients were included in the study and 8 patients were excluded from analysis as they were discharged from hospital against medical advice. The remaining 242 patients (mean age 52.8 ± 17 years; 61.6% male; APACHE III score: 48.2 ± 24.1) were analyzed, and AKI was seen in 111 patients (45.8%). Among the patients with AKI, 55.8% (62/111) had sepsis and 44.2% (49/111) had nonseptic AKI. There was a higher need for renal replacement therapy (RRT) among patients with septic AKI in comparison to those with nonseptic AKI (19.3% vs 6.1%; p = 0.04), but no mortality difference was seen between the two groups (25.8% vs 20.4%, p = 0.5). Patients with sepsis and AKI had a significantly higher mortality (25.8%) compared to the patients with sepsis alone (5.6%; p < 0.01). CONCLUSION: Patients with septic AKI had a higher RRT requirement compared to patients with nonseptic AKI, but no significant differences in mortality were seen between the groups. Occurrence of AKI in septic patients substantially increases their mortality. HOW TO CITE THIS ARTICLE: Nandagopal N, Reddy PK, Ranganathan L, Ramakrishnan N, Annigeri R, Venkataraman R. Comparison of Epidemiology and Outcomes of Acute Kidney Injury in Critically Ill Patients with and without Sepsis. Indian J Crit Care Med 2020;24(4):258-262.

Therapeutic Plasma Exchange Practices in Intensive Care Unit.

OBJECTIVE: To observe the indications, practices and outcome of therapeutic plasma exchange (TPE) in a tertiary care ICU. MATERIALS AND METHODS: The study involves retrospective analysis of 56 patients who underwent TPE between May 2011 and August 2013. Data relating to demographics, diagnosis, category of indication, number of sessions, volume and type of replacement solutions were collected. RESULTS: Category I indications were 50%, with a mean of 3.32 sessions per patient. Per session volume exchanged was 9775.1 ± 11812.9 mL and replacement volume was 7414 ± 6993.03 mL. Fresh frozen plasma (FFP), crystalloids, cryopoorplasma and PRBC constituted 62.9%, 22%, 9.9% and 5.3% of volume replacement, respectively. TPE was terminated in three patients for Transfusion Associated Acute Lung Injury (TRALI), hypotension and cardiac arrest respectively. Clinical improvement was noted in 82% of patients and overall mortality rate was 12.5%. CONCLUSION: TPE is feasible and well tolerated in ICU with favorable disease resolution and outcome. Common indications included sickle cell and myasthenia crisis and blood products were the most commonly used for volume replacement. HOW TO CITE THIS ARTICLE: Ranganathan L, Menon R, Ramakrishnan N, Venkatraman R, Ramachandran P. Therapeutic Plasma Exchange Practices in Intensive Care Unit. Indian J Crit Care Med 2019;23(7):336-338.

Subpial transection surgery for epilepsy.

BACKGROUND: Nearly 30% of patients with epilepsy continue to have seizures despite using several antiepileptic drugs (AEDs). Such patients are regarded as having refractory, or uncontrolled, epilepsy. While there is no universally accepted definition of uncontrolled, or medically refractory, epilepsy, for the purposes of this review we will consider seizures as drug resistant if they have failed to respond to a minimum of two AEDs. Specialists consider that early surgical intervention may prevent seizures at a younger age, which in turn may improve the intellectual and social status of children. Many types of surgery are available for treating refractory epilepsy; one such procedure is known as subpial transection. OBJECTIVES: To assess the effects of subpial transection for focal-onset seizures and generalised tonic-clonic seizures in children and adults. SEARCH METHODS: For the latest update we searched the following databases on 7 August 2018: the Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid, 1946 to August 06, 2018), ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP). We imposed no language restrictions. SELECTION CRITERIA: We considered all randomised and quasi-randomised parallel-group studies, whether blinded or non-blinded. DATA COLLECTION AND ANALYSIS: Two review authors (BK and SR) independently screened trials identified by the search. The same two review authors planned to independently assess the methodological quality of studies. Had we identified studies for inclusion, one review author would have extracted the data, and the other would have verified the data. MAIN RESULTS: We found no relevant studies. AUTHORS' CONCLUSIONS: We found no evidence to support or refute the use of subpial transection surgery for patients with medically refractory epilepsy. Well-designed randomised controlled trials are needed to guide clinical practice.