Preoperative C-reactive protein - Albumin ratio as a predictor of requirement for postoperative mechanical ventilation after non-cardiac surgery under general anaesthesia: A prospective observational study (HICARV).

Background and Aims: Mechanical ventilation is an essential but limited resource worldwide. Appropriate perioperative utilisation of such useful resource demands in time prediction where literature does not have enough data. High C-reactive protein (CRP) and low albumin both represent a state of exaggerated inflammation and poor nutrition, the combination of which might represent the sick surgical patients. Therefore, we tried to evaluate the performance of ratio between preoperative CRP and albumin (CAR) for the prediction of postoperative mechanical ventilation. Methods: After approval from the ethics committee and trial registration, the study was carried out over 2 years. It included 580 adults undergoing non-cardiac surgeries under general anaesthesia. Blood samples were collected for estimation of CRP and albumin, and all were followed up for the need of mechanical ventilation in the postoperative period till hospital discharge. Results: Sixty-six of the analysed 569 patients (11.6%) required postoperative mechanical ventilation in whom the median CAR was higher {0.38 (0.10, 1.45)} than those who did not require the same {0.20 (0.07, 0.65)}, although not statistically significant. A ROC curve analysis found that there is a 58% chance that a CAR will distinguish between the patients requiring postoperative mechanical ventilation from those who do not (AUC = 0.58), which is statistically significant (P value = 0.024). Logistic regression did not result in a significant odds of mechanical ventilation with higher ratio {Odds ratio = 1.06 (0.98, 1.16)}. Conclusions: High CRP-albumin ratio was found to be associated with higher need for mechanical ventilation in patients undergoing surgery under general anaesthesia, but failed to predict the need for mechanical ventilation.

Serum levels of osteoprotegerin, RANK-L & vitamin D in different stages of osteoarthritis of the knee.

Background & objectives: Osteoarthritis (OA) is the 11th leading cause of disability in the modern world, but till date, there have been no effective markers for monitoring the progression of OA. The three proteins RANK/RANK-Ligand and Osteoprotegerin (OPG) have been found to be the key regulators of bone metabolism. Interaction of RANK-Ligand with its receptor RANK triggers differentiation of osteoclasts leading to bone resorption. OPG on the other hand is protective as it is expressed by osteoblasts and bind RANKL with higher affinity preventing its interaction with RANK. The levels of these serum proteins are regulated by vitamin D and parathyroid hormones. Therefore, the present study, aimed to study the association of serum RANKL, OPG and vitamin D with disease severity in patients with knee OA. Methods: It was a cross-sectional study where 80 (43 women and 37 men) newly diagnosed subjects with OA knee were recruited. They were classified into four grades based on K-L grading and into two groups as early (grade 1+grade 2) and advanced (grade 3 + grade 4) based on the disease progression. Results: On comparing the biochemical parameters among the four grades decreasing vitamin D levels were seen with increasing severity of knee OA; an increasing trend of RANKL with increase in the severity of OA was seen; OPG was found to be elevated more in the early stages of OA. We also observed a strong association of RANKL/OPG ratio with disease severity. Interpretation & conclusions: Overall the results suggest that OPG may be considered as an early marker of the diseases.

Preventive Epidural Analgesia in Bilateral Single-Stage Knee Arthroplasty: A Randomized Controlled Trial.

INTRODUCTION: Although controversial, pre-emptive analgesia has shown some promise in preventing altered pain perception and reducing pain amplification after surgery. Hence, it has the potential to be more effective than a similar analgesic regimen started after surgery with an appropriate combination of patient category and analgesic modality. Hence, the present study was undertaken to evaluate the effect of preventive epidural analgesia in reducing pain severity and duration after bilateral single-stage knee arthroplasty. METHODS: Fifty patients, 18-70 years, with American Society of Anesthesiologists physical status class I & II posted for bilateral single-stage knee replacement under regional anesthesia were randomly allocated into preventive versus postoperative epidural analgesia group to compare severity of post-operative pain, analgesic consumption, day of mobilization, C-reactive protein (CRP) levels, and hospital stay. RESULTS: The pain score after surgery [2.0 (1.5, 2.0); 3.0 (1.5, 3.0), p = 0.005] and day of mobilization [(2. 92 ± 0. 28; 3. 31 ± 0. 48; p value 0.02)] were significantly lesser in the preventive epidural group. However, there was no difference in the hospital stay (9.92 ± 3.71 and 9.00 ± 2.12, p = 0.95) and analgesic consumption (65.38 ± 37.55 and 73.08 ± 43.85, p = 0.30). The preventive group had a larger drop in CRP and experienced a lesser number of days with pain after surgery as compared to the controls [(64.29 ± 21.29); (142.37 ± 80.04), p = 0.0001]. Six patients in the preemptive group (24%) and 13 of the control group (24 vs. 56.5%; p = 0.02) had chronic postsurgical pain. CONCLUSIONS: Preventive epidural analgesia reduces the severity and number of chronic pain days after bilateral single-stage knee replacement. TRIAL REGISTRATION: The study was registered in the Indian national registry (CTRI/2017/03/008240 on 28/03/2017).

Role of cerebrospinal fluid adenosine deaminase level estimation in diagnosis of tuberculous meningitis.

Five lakh patients of tuberculosis die every year in India. Meningeal tuberculosis is an endemic disease with 7-12% incidence. Delay in diagnosis and in initiating treatment results in poor prognosis and sequelae in upto 25% of cases. The aim of the present study is to look for a simple, rapid, cost effective and non-invasive test for diagnosing this disease. Forty patients between 6-24 months of age having symptoms and signs of meningitis were selected and divided into two groups tuberculous and non-tuberculous, depending upon the accepted criteria. Cerebrospinal fluid (CSF) was drawn and adenosine deaminase (ADA) estimated. Out of 19 tuberculous patients, 18 patients had CSF ADA at or above the cut-off value while 1 had below the cut-off value. Out of 21 non-tuberculous patients, 2 patients had at or above the cut-off value while 19 were below this value. Results of this study indicate that ADA level estimation in CSF is not only of considerable value in the diagnosis of tuberculous meningitis, CSF ADA level of 10 U/L as a cut-off value exhibited 94.73% sensitivity and 90.47% specificity in differentiating tuberculous from non-tuberculous meningitis; it also has 90.00% positive predictive value and 95.00% negative predictive value. ADA estimation in CSF is simple, inexpensive, rapid and fairly specific method for making a diagnosis of tuberculous aetiology in TBM; especially when there is a dilemma of differentiating the tuberculous aetiology from non-tuberculous and for this reason ADA estimation in TBM may find a place as a routine investigation.

Sensitivity, specificity, negative and positive predictive values of adenosine deaminase in patients of tubercular and non-tubercular serosal effusion in India.

BACKGROUND: In India, tuberculosis is an endemic disease. Delay in diagnosis results in poor prognosis and fast spread of the disease. The objective of the present study is to look for an effective and acceptable diagnostic test, which may be helpful to initiate early treatment to improve prognosis and reduce spread. METHODS: Three hundred and thirty patients with pleural, ascitic, meningeal and synovial effusion were selected and divided depending upon the etiology and the involvement of serosal membranes. Serosal aspirated fluid was subjected to biochemical tests and adenosine deaminase estimation. Cutoff taken is above 40 for pleural, peritoneal or synovial fluid and above 10 for CSF. RESULTS: In cases of pulmonary and extra-pulmonary disease, sensitivity was 92.80% and 94.29%; specificity 90.00% and 92.16%; positive predictive value 92.86% and 89.00%; and negative predictive value 90.00% and 95.92% respectively. CONCLUSIONS: Adenosine deaminase estimation is not only a fairly sensitive and specific test (more than 90%), helpful in differentiating tubercular from non-tubercular etiology both in pulmonary and extra-pulmonary disease, but is also simple, inexpensive and rapid. For this reason this test may help in early diagnosis, improve the prognosis and reduce spread of disease and sequlae. KEYWORDS: Adenosine deaminase; Serosal effusion; Tubercular; Non-tubercular; Pulmonary; Extra-pulmonary.

Role of Adenosine Deaminase Estimation in Differentiation of Tuberculous and Non-tuberculous Exudative Pleural Effusions.

BACKGROUND: Tuberculosis kills five lakh patients every year in India, commonest being pulmonary tuberculosis and is often associated with effusion. Delay in diagnosis and treatment results in poor prognosis. Several studies have suggested the role of adenosine deaminase (ADA) in the diagnosis of tuberculous pleural effusions, but false-positive results from lymphocytic effusions have also been reported. The purpose of this study is to find out the role of ADA levels in differentiation of tuberculous and non-tuberculous exudative pleural effusions of different etiologies. METHODS: Ninety-six lymphocytic pleural fluid samples were consecutively selected and divided into two groups: tuberculous (n = 56) and non-tuberculous (n = 40), depending upon the etiology [Malignancy (n = 16), Infectious diseases (n = 18), Pulmonary embolism (n = 1), Collagen vascular diseases (n = 3) and Sarcoidosis (n = 2)]. ADA was estimated in pleural fluid in all the cases. RESULTS: In all 56 samples, ADA level of tuberculous group was above diagnostic cut-off (40 U/L), while only one sample was above cut-off in non-tuberculous group (2.5%). The negative predictive value of ADA for the diagnosis of non-tuberculous etiology was 97.5% (39 of 40) lymphocytic pleural effusion patients. CONCLUSIONS: In this study, ADA levels in nontuberculous exudative pleural effusions rarely exceeded the cut-off; set for tuberculous disease. The pleural fluid ADA levels were significantly higher in tuberculous exudative pleural effusions when compared with non-tuberculous exudative pleural effusions. KEYWORDS: Adenosine deaminase; Tuberculous effusion; Pleural fluid; Exudative pleural effusions.