Determinants of severity among hospitalised COVID-19 patients: Hospital-based case-control study, India, 2020.

BACKGROUND: Risk factors for the development of severe COVID-19 disease and death have been widely reported across several studies. Knowledge about the determinants of severe disease and mortality in the Indian context can guide early clinical management. METHODS: We conducted a hospital-based case control study across nine sites in India to identify the determinants of severe and critical COVID-19 disease. FINDINGS: We identified age above 60 years, duration before admission >5 days, chronic kidney disease, leucocytosis, prothrombin time > 14 sec, serum ferritin >250 ng/mL, d-dimer >0.5 ng/mL, pro-calcitonin >0.15 µg/L, fibrin degradation products >5 µg/mL, C-reactive protein >5 mg/L, lactate dehydrogenase >150 U/L, interleukin-6 >25 pg/mL, NLR ≥3, and deranged liver function, renal function and serum electrolytes as significant factors associated with severe COVID-19 disease. INTERPRETATION: We have identified a set of parameters that can help in characterising severe COVID-19 cases in India. These parameters are part of routinely available investigations within Indian hospital settings, both public and private. Study findings have the potential to inform clinical management protocols and identify patients at high risk of severe outcomes at an early stage.

Towards Developing a Scoring System for Febrile Thrombocytopenia.

BACKGROUND: The authors wished to develop a scoring system for evaluating patients presenting with febrile thrombocytopenia for risk stratification, predicting patient outcome and optimization of care especially in resource poor countries. OBJECTIVE: 1. To decide a protocol in the management of patients with fever and thrombocytopenia. 2. To develop screening or therapeutic guidelines (early warning score-EWS) in febrile thrombocytopenic patients and decide about therapeutic interventions. METHODS: 1. To decide a protocol in the management of patients with fever and thrombocytopenia. 2. To develop screening or therapeutic guidelines (early warning score-EWS) in febrile thrombocytopenic patients and decide about therapeutic interventions. DESIGN: Retrospective study and development of a bedside scoring system based on Platelet Count, Temperature, Respiratory Rate, Blood Pressure. Pulse, CNS, Respiratory, Hematological, Hepatic and Renal complications in a central civic hospital and teaching institute in India. PARTICIPASNTS: All patients > 18 years presenting with fever and thrombocytopenia with platelet count of < 150 × 109/L. RESULTS: Number of patients requiring platelet transfusions decreases when total risk score is used for risk stratification and for transfusing platelets as against the platelet count at admission. Patients who died in our study had a platelet count at presentation between 20,000- 1,00,000 though their total risk score was 17 and 18 respectively; hence platelet count alone should not be relied upon for platelet transfusion. Irrespective of the number of platelets transfused the prognosis is poor as the total risk score increases. CONCLUSIONS: The platelet count is not the only indicator of transfusion. When we use total risk score instead of platelet count for classifying patients who need transfusions, number of patients who fall in severe risk category needing immediate transfusion reduces and haphazard use of platelets can be avoided. Patient outcome (death/survival), occurrence of complications and hematological manifestations (petechiae/purpura etc) are not dependent on platelet count at presentation. There is a significant association between risk category and patient outcome.

Efficacy of Low-Dose Chlorthalidone and Hydrochlorothiazide as Assessed by 24-h Ambulatory Blood Pressure Monitoring.

BACKGROUND: Thiazide and thiazide-like diuretic agents are being increasingly used at lower doses. Hydrochlorothiazide (HCTZ) in the 12.5-mg dose remains the most commonly prescribed antihypertensive agent in the United States. OBJECTIVES: This study compared chlorthalidone, 6.25 mg daily, with HCTZ, 12.5 mg daily, by 24-h ambulatory blood pressure (ABP) monitoring and evaluated efficacy. Because HCTZ has been perceived as a short-acting drug, a third comparison with an extended-release formulation (HCTZ-controlled release [CR]) was added. METHODS: This 12-week comparative, double-blind, outpatient study randomized 54 patients with stage 1 hypertension to receive either chlorthalidone, 6.25 mg, (n = 16); HCTZ 12.5 mg (n = 18); or HCTZ-CR 12.5 mg (n = 20). ABP monitoring was performed at baseline and after 4 and 12 weeks of therapy. RESULTS: All 3 treatments significantly (p < 0.01) lowered office BP at weeks 4 and 12 from baseline. At weeks 4 and 12, significant reductions in systolic and diastolic 24-h ambulatory and nighttime BP (p < 0.01) were observed with chlorthalidone but not with HCTZ. At weeks 4 (p = 0.015) and 12 (p = 0.020), nighttime systolic ABP was significantly lower in the chlorthalidone group than in the the HCTZ group. With HCTZ therapy, sustained hypertension was converted into masked hypertension. In contrast to the HCTZ group, the HCTZ-CR group also showed a significant (p < 0.01) reduction in 24-h ABP. All 3 treatments were generally safe and well tolerated. CONCLUSIONS: Treatment with low-dose chlorthalidone, 6.25 mg daily, significantly reduced mean 24-h ABP as well as daytime and nighttime BP. Due to its short duration of action, no significant 24-h ABP reduction was seen with HCTZ, 12.5 mg daily, which merely converted sustained hypertension into masked hypertension. Thus, low-dose chlorthalidone, 6.25 mg, could be used as monotherapy for treatment of essential hypertension, whereas low-dose HCTZ monotherapy is not an appropriate antihypertensive drug. (Comparative Evaluation of Safety and Efficacy of Hydrochlorothiazide CR with Hydrochlorothiazide and Chlorthalidone in Patients With Stage I Essential Hypertension; CTRI/2013/07/003793).

Atypical presentation of leptospirosis.

Leptospirosis, a disease of protean manifestations occurs sporadically throughout the year with a peak seasonal incidence during the rainy season. We hereby present a case that had clinical features of nephrotic syndrome with massive proteinuria. Leptospirosis was detected on ELISA testing. Patient was cured with antibiotics and diuretics.