The Promise of Cilnidipine in Hypertension with Comorbidities: National Consensus Statement: National Consensus Group Comprises Cardiologists, Nephrologists, and Diabetologists from India in a National Meet at New Delhi held on 22nd May 2022.

The rapidly increasing burden of hypertension is responsible for premature deaths from cardiovascular disease (CVD), renal disease, and stroke, with a tremendous public health and financial burden. Hypertension detection, treatment, and control vary worldwide; it is still low, particularly in low- and middle-income countries (LMICs). High blood pressure (BP) and CVD risk have a strong, linear, and independent association. They contribute to alarming numbers of all-cause and CVD deaths. A major culprit for increased hypertension is sympathetic activity, and further complications of hypertension are heart failure, ischemic heart disease (IHD), stroke, and renal failure. Now, antihypertensive interventions have emerged as a global public health priority to reduce BP-related morbidity and mortality. Calcium channel blockers (CCB) are highly effective vasodilators. and the most common drugs used for managing hypertension and CVD. Cilnidipine, with both L- and N-type calcium channel blocking activity, is a promising 4th generation CCB. It causes vasodilation via L-type calcium channel blockade and inhibits the sympathetic nervous system (SNS) via N-type calcium channel blockade. Cilnidipine, which acts as a dual L/N-type CCB, is linked to a reduced occurrence of pedal edema compared to amlodipine, which solely blocks L-type calcium channels. The antihypertensive properties of cilnidipine are very substantial, with low BP variability and long-acting properties. It is beneficial for hypertensive patients to deal with morning hypertension and for patients with abnormal nocturnal BP due to exaggerated sympathetic nerve activation. Besides its BP-lowering effect, it also exhibits organ protection via sympathetic nerve inhibition and renin-angiotensin-aldosterone system inhibition; it controls heart rate and proteinuria. Reno-protective, neuroprotective, and cardioprotective effects of cilnidipine have been well-documented and demonstrated.

Utility and timing of the respiratory rate-oxygenation index in the prediction of high-flow oxygen therapy failure in acute hypoxemic respiratory failure of infective etiology: a prospective observational study.

During and following the COVID-19 pandemic, the world has witnessed a surge in high-flow oxygen therapy (HFOT) use. The ability to provide high oxygenation levels with remarkable comfort levels has been the grounds for the same. Despite the advantages, delays in intubation leading to poor overall outcomes have been noticed in subgroups of patients on HFOT. The respiratory rate-oxygenation (ROX) index has been proposed to be a useful indicator to predict HFOT success. In this study, we have examined the utility of the ROX index prospectively in cases of acute hypoxemic respiratory failure (AHRF) due to infective etiologies. A total of 70 participants were screened, and 55 were recruited for the study. The majority of participants were males (56.4%), with diabetes mellitus being the most common comorbidity (29.1%). The mean age of the study subjects was 46.27±15.6 years. COVID-19 (70.9%) was the most common etiology for AHRF, followed by scrub typhus (21.8%). 19 (34.5%) experienced HFOT failure, and 9 (16.4%) subjects died during the study period. Demographic characteristics did not differ between either of the two groups (HFOT success versus failure and survived group versus expired group). The ROX index was significantly different between the HFOT success versus failure group at baseline, 2, 4, 6, 12, and 24 hours. The best cut-offs of the ROX index at baseline and 2 hours were 4.4 (sensitivity 91.7%, specificity 86.7%) and 4.3 (sensitivity 94.4% and specificity 86.7%), respectively. The ROX index was found to be an efficient tool in predicting HFOT failure in cases of AHRF with infective etiology.

Angiotensin Receptor-Neprilysin Inhibitor Therapy and Cardiac Remodeling in Heart Failure: Consensus Statement from India.

Adverse cardiac remodeling refers to progressive structural and functional modifications in the heart because of increased wall stress in the myocardium, loss of viable myocardium, and neurohormonal stimulation. The guideline-directed medical therapy for Heart failure (HF) includes Angiotensin receptor-neprilysin inhibitor (ARNI) (sacubitril/valsartan), ß-blockers, sodium-glucose co-transporter 2 (SGLT2) inhibitors, and mineralocorticoid receptor antagonists (MRA). ARNI is under-prescribed in India despite its attractive safety and efficacy profile. Therefore, the consensus discusses objectives and topics related to ARNI in the management of cardiac remodeling, and experts shared their views on the early timely intervention of effective dosage of ARNI to improve the diagnosis and enhance mortality and morbidity benefits in cardiac reverse remodeling (CRR).

The Power and Promise of Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure Management: National Consensus Statement.

;Heart failure (HF) is a huge global public health task due to morbidity, mortality, disturbed quality of life, and major economic burden. It is an area of active research and newer treatment strategies are evolving. Recently angiotensin receptor-neprilysin inhibitor (ARNI), a class of drugs (the first agent in this class, Sacubitril-Valsartan), reduces cardiovascular mortality and morbidity in chronic HF patients with reduced left ventricular ejection fraction (LVEF). Positive therapeutic effects have led to a decrease in cardiovascular mortality and HF hospitalizations (HFH), with a favorable safety profile, and have been documented in several clinical studies with an unquestionable survival benefit with ARNI, Sacubitril-Valsartan. This consensus statement of the Indian group of experts in cardiology, nephrology, and diabetes provides a comprehensive review of the power and promise of ARNI in HF management and an evidence-based appraisal of the use of ARNI as an essential treatment strategy for HF patients in clinical practice. Consensus in this review favors an early utility of Sacubitril-Valsartan in patients with HF with reduced EF (HFrEF), regardless of the previous therapy being given. A lower rate of hospitalizations for HF with Sacubitril-Valsartan in HF patients with preserved EF who are phenotypically heterogeneous suggests possible benefits of ARNI in patients having 40-50% of LVEF, frequent subtle systolic dysfunction, and higher hospitalization risk.

Role of Iron Therapy in Heart Failure: A Consensus Statement from India.

Iron deficiency (ID) with or without anemia is frequently observed in patients with heart failure (HF). Uncorrected ID is associated with higher hospitalization and mortality in patients with acute HF (AHF) and chronic HF (CHF). Hence, in addition to chronic renal insufficiency, anemia, and diabetes, ID appears as a novel comorbidity and a treatment target of CHF. Intravenous (IV) ferric carboxymaltose (FCM) reduces the hospitalization risk due to HF worsening and improves functional capacity and quality of life (QOL) in HF patients. The current consensus document provides criteria, an expert opinion on the diagnosis of ID in HF, patient profiles for IV FCM, and correct administration and monitoring of such patients.

Characteristics & outcomes of cancer patients with COVID-19: A multicentre retrospective study from India.

Background & objectives: High mortality has been observed in the cancer population affected with COVID-19 during this pandemic. We undertook this study to determine the characteristics and outcomes of cancer patients with COVID-19 and assessed the factors predicting outcome. Methods: Patients of all age groups with a proven history of malignancy and a recent diagnosis of SARS-CoV-2 infection based on nasal/nasopharyngeal reverse transcriptase (RT)-PCR tests were included. Demographic, clinical and laboratory variables were compared between survivors and non-survivors groups, with respect to observed mortality. Results: Between May 11 and August 10, 2020, 134 patients were included from the three centres and observed mortality was 17.1 per cent. The median age was 53 yr (interquartile range 39-61 yr) and thirty four patients (25%) were asymptomatic. Solid tumours accounted for 69.1 per cent and breast cancer was the most common tumour type (20%). One hundred and five patients (70.5%) had received chemotherapy within the past four weeks and 25 patients (19.3%) had neutropenia at presentation. On multivariate analysis, age [odds ratio (OR) 7.99 (95% confidence interval [CI] 1.18-54.00); P=0.033], haemoglobin [OR 6.28 (95% CI 1.07-37.04); P=0.042] neutrophil-lymphocyte ratio [OR 12.02 (95% CI 2.08-69.51); P=0.005] and baseline serum albumin [OR 18.52 (95% CI 2.80-122.27); P=0.002], were associated with higher mortality. Recent chemotherapy, haematological tumours type and baseline neutropenia did not affect the outcome. Interpretation & conclusions: Higher mortality in moderate and severe infections was associated with baseline organ dysfunction and elderly age. Significant proportion of patients were asymptomatic and might remain undetected.

A Bionic Testbed for Cardiac Ablation Tools.

Bionic-engineered tissues have been proposed for testing the performance of cardiovascular medical devices and predicting clinical outcomes ex vivo. Progress has been made in the development of compliant electronics that are capable of monitoring treatment parameters and being coupled to engineered tissues; however, the scale of most engineered tissues is too small to accommodate the size of clinical-grade medical devices. Here, we show substantial progress toward bionic tissues for evaluating cardiac ablation tools by generating a centimeter-scale human cardiac disk and coupling it to a hydrogel-based soft-pressure sensor. The cardiac tissue with contiguous electromechanical function was made possible by our recently established method to 3D bioprint human pluripotent stem cells in an extracellular matrix-based bioink that allows for in situ cell expansion prior to cardiac differentiation. The pressure sensor described here utilized electrical impedance tomography to enable the real-time spatiotemporal mapping of pressure distribution. A cryoablation tip catheter was applied to the composite bionic tissues with varied pressure. We found a close correlation between the cell response to ablation and the applied pressure. Under some conditions, cardiomyocytes could survive in the ablated region with more rounded morphology compared to the unablated controls, and connectivity was disrupted. This is the first known functional characterization of living human cardiomyocytes following an ablation procedure that suggests several mechanisms by which arrhythmia might redevelop following an ablation. Thus, bionic-engineered testbeds of this type can be indicators of tissue health and function and provide unique insight into human cell responses to ablative interventions.

Metastatic colo-rectal cancer: real life experience from an Indian tertiary care center.

BACKGROUND: No data exist for the long-term outcome of metastatic colorectal cancer (mCRC) from the Southern part of Asia. The primary objective of the study is to evaluate the survival outcome of mCRC from an Indian tertiary care center. The study also aims to highlight the treatment pattern practiced and the unique clinico-pathologic characteristics. METHODS: This is a single-center retrospective observational study done at a large referral tertiary care center in North India. All patients with synchronous or metachronous mCRC who received at least one dose of chemotherapy for metastatic disease, registered between 2003 to 2017 were included. Primary outcome measures were overall survival and progression-free survival and prognostic factors of overall survival. Descriptive analysis was done for the clinicopathological characteristics and treatment patterns. Kaplan Meier method for overall survival and progression-free survival. Cox regression analysis was performed for the determination of the prognostic factors for overall survival. RESULT: Out of 377 eligible patients, 256 patients (68%) had de novo metastatic disease and the remaining 121 (32%) progressed to metastatic disease after initial treatment. The cohort was young (median age, 46 years) with the most common primary site being the rectum. A higher proportion of signet (9%) and mucinous histology (24%). The three common sites of metastasis were the liver, peritoneum, and lung. In the first line, most patients received oxaliplatin-based chemotherapy (70%). Only 12.5% of patients received biologicals in the first-line setting. The median follow-up and median overall survival of study cohort were 17 months and 18.5 months. The factors associated with poor outcome for overall survival on multivariate analysis were ECOG performance status of > 1, high CEA, low albumin, and the number of lines of chemotherapy received (< 2). CONCLUSION: The outcome of mCRC is inferior to the published literature. We found a relatively higher proportion of patients with the following characteristics; younger, rectum as primary tumor location, the signet, and mucinous histology, higher incidence of peritoneum involvement. The routine use of targeted therapies is limited. Government schemes (inclusion of targeted therapies in the Ayushman scheme), NGO assistance, and availability of generic low-cost targeted drugs may increase the availability.

Evaluation of platelet-rich plasma on hair regrowth and lesional T-cell cytokine expression in alopecia areata: A randomized observer-blinded, placebo-controlled, split-head pilot study.

BACKGROUND: Platelet-rich plasma has shown some promise in the treatment of alopecia areata. OBJECTIVE: To evaluate the effect of platelet-rich plasma on hair regrowth and lesional T-cell cytokine expression in alopecia areata. METHODS: This was a randomized, placebo-controlled, split-head study involving 27 patients with alopecia areata (Severity of Alopecia Tool score ≥25%). Alopecia patches on either side of the scalp were randomized to receive 3 intradermal injections of platelet-rich plasma or normal saline at monthly intervals and evaluated 3 months after the last session. Lesional T-cell cytokine messenger RNA expression was compared pre- and posttreatment in the platelet-rich plasma-treated sites. RESULTS: The mean Severity of Alopecia Tool score did not change significantly compared with baseline with either platelet-rich plasma or placebo injections at any visit; however, the mean percentage reduction in the score in the platelet-rich plasma arm was more than in the placebo arm (9.05% ± 36.48% vs 4.99% ± 33.88%; P = .049) at final assessment. The mean interferon gamma (P = .001) and interleukin 17 cytokine (P = .009) messenger RNA expression decreased, whereas the mean interleukin 10 (P = .049) and FOXP3 (P = .011) messenger RNA expression increased significantly after platelet-rich plasma treatment. LIMITATIONS: Small sample size and a relatively short follow-up. CONCLUSION: Platelet-rich plasma was found to have limited efficacy in alopecia areata. However, it may play a role in restoring immune balance in the alopecic patches.

Importance of Imaging in Work up of Cardiovascular Diseases by Using Telemedicine in Rural India.

BACKGROUND: Cardiovascular diseases have emerged as an epidemic in India. Telemedicine is a useful tool for sending ECG, x-ray and ultrasound images to telemedicine centre for diagnosis and management of cardiovascular diseases in rural areas as it overcomes the distance barrier. METHODS: National Heart Institute collaborated with Hospital Guide Foundation (HGF) Jewar, Greater Noida for conducting telemedicine sessions. Two hundred patients were analysed during time span of June 2018 to August 2019. Imaging tools like ECG, Chest X- ray and ultrasound were studied besides usual laboratory parameters. RESULTS: Important ECG abnormalities included LVH (10.9%), ischemia (10.1%), LBBB (2.4%), RBBB (3.9%), p- mitrale (1.5%), hyperkalaemia (2.3%) besides normal ECGs (56.2%). Chest x- ray revealed features of COPD (8.3%), cardiomegaly (6.9%), hilar shadows (6.9%), bronchitis (2.7%) and prominent broncho -vascular markings (6.9%). Ultrasound abdomen showed hepatomegaly (23.2%), fatty liver (15.1%), gallstones (2%). bilateral renal stone / left or right renal stone (42.4 %). CONCLUSION: Telecardiology/ Teleradiology are important and useful imaging tools in the diagnosis and treatment of cardiovascular diseases in rural India.

Genu valgum deformity - correction by a wedgeless implantless femoral "V" osteotomy.

Coronal malalignment of the knee joint is very common in developing countries especially because of nutritional rickets. Significant valgus deformity needs to be treated surgically to improve appearance, gait and function of the patient. The purpose of this prospective study was to evaluate the results of supracondylar "V" osteotomy as a surgical technique for correction of the valgus knee deformity. This study was conducted in a tertiary level teaching hospital and 30 cases were included in the study. For all the patients deformity was assessed using ana- tomical tibiofemoral angle, mechanical axis deviation and intermalleolar distance preoperatively and post- operatively. The average age of our patients was 13.7 years and the average follow up was3.29 years (1.39-14.22 yrs). Clinically the average value of intermalleolar distance preoperatively was 16cm and 3.2 cm postperatively. Average pre-operative tibiofemoral angle was 23° and the average postoperative angle was 6 0 which was found to be statistically significant using the Paired t test (p<0.005). The average value of preoperative mechanical axis deviation was 3.1 cm which decreased to an average value of 1.1 cm postoperatively. The results with this technique have been encouraging. The advantages of this technique are low morbidity, good stability allowing early ambulation, ability to adjust alignment postoperatively by casting and no need for internal fixation. Few studies have been conducted on osteotomies that do not require internal fixation and are inherently stable. This technique has the advantage of practically no occurrence of any infection or a second surgery to remove hardware in children and adolescents. Since no specialized instrumentation, image intensifier and implants are required, it is cost effective and can be used in any primary care or district level surgical setup in a developing country like ours.

Scheduling and Power Control for Wireless Multicast Systems via Deep Reinforcement Learning.

Multicasting in wireless systems is a natural way to exploit the redundancy in user requests in a content centric network. Power control and optimal scheduling can significantly improve the wireless multicast network's performance under fading. However, the model-based approaches for power control and scheduling studied earlier are not scalable to large state spaces or changing system dynamics. In this paper, we use deep reinforcement learning, where we use function approximation of the Q-function via a deep neural network to obtain a power control policy that matches the optimal policy for a small network. We show that power control policy can be learned for reasonably large systems via this approach. Further, we use multi-timescale stochastic optimization to maintain the average power constraint. We demonstrate that a slight modification of the learning algorithm allows tracking of time varying system statistics. Finally, we extend the multi-time scale approach to simultaneously learn the optimal queuing strategy along with power control. We demonstrate the scalability, tracking and cross-layer optimization capabilities of our algorithms via simulations. The proposed multi-time scale approach can be used in general large state-space dynamical systems with multiple objectives and constraints, and may be of independent interest.

Clinical utility of genetic testing in 201 preschool children with inherited eye disorders.

PURPOSE: A key property to consider in all genetic tests is clinical utility, the ability of the test to influence patient management and health outcomes. Here we assess the current clinical utility of genetic testing in diverse pediatric inherited eye disorders (IEDs). METHODS: Two hundred one unrelated children (0-5 years old) with IEDs were ascertained through the database of the North West Genomic Laboratory Hub, Manchester, UK. The cohort was collected over a 7-year period (2011-2018) and included 74 children with bilateral cataracts, 8 with bilateral ectopia lentis, 28 with bilateral anterior segment dysgenesis, 32 with albinism, and 59 with inherited retinal disorders. All participants underwent panel-based genetic testing. RESULTS: The diagnostic yield of genetic testing for the cohort was 64% (ranging from 39% to 91% depending on the condition). The test result led to altered management (including preventing additional investigations or resulting in the introduction of personalized surveillance measures) in 33% of probands (75% for ectopia lentis, 50% for cataracts, 33% for inherited retinal disorders, 7% for anterior segment dysgenesis, 3% for albinism). CONCLUSION: Genetic testing helped identify an etiological diagnosis in the majority of preschool children with IEDs. This prevented additional unnecessary testing and provided the opportunity for anticipatory guidance in significant subsets of patients.

Evaluation of an Integrated Device Diagnostics Algorithm to Risk Stratify Heart Failure Patients　- Results From the SCAN-HF Study.

BACKGROUND: Integrated device diagnostics, Triage-HF, is useful in risk stratifying patients with heart failure (HF), but its performance for Japanese patients remains unknown. This is a prospective study of Japanese patients treated with a cardiac resynchronization therapy defibrillator (CRT-D), with a Medtronic OptiVol 2.0 feature.Methods and Results:A total of 320 CRT-D patients were enrolled from 2013 to 2017. All received HF treatment in the prior 12 months. Following enrollment, they were followed every 6 months for 48 months (mean, 22 months). Triage-HF-stratified patients at low, medium and high risk statuses at every 30-day period, and HF-related hospitalization occurring for the subsequent 30 days, were evaluated and repeated. The primary endpoint was to assess Triage-HF performance in predicting HF-related hospitalization risk. All device data were available for 279 of 320 patients (NYHA class II or III in 93%; mean left ventricular ejection fraction, 31%). During a total of 5,977 patient-month follow-ups, 89 HF-related hospitalization occurred in 72 patients. The unadjusted event numbers for Low, Medium and High statuses were 19 (0.7%), 42 (1.6%) and 28 (4.1%), respectively. Relative risk of Medium to Low status was 2.18 (95% CI 1.23-3.85) and 5.78 (95% CI 3.34-10.01) for High to Low status. Common contributing factors among the diagnostics included low activity, OptiVol threshold crossing, and elevated night heart rate. CONCLUSIONS: Triage-HF effectively stratified Japanese patients at risk of HF-related hospitalization.

Stepwise treatment of primary focal hyperhidrosis with aluminum chloride hexahydrate lotion (20%) and oral glycopyrrolate: a retrospective study from a tertiary care center.

Primary focal hyperhidrosis is a common reason for dermatology outpatient visit and has significant impact on patient's social and professional activities. The study describes the clinical profile of those patients and response with aluminum chloride hexahydrate lotion (ACH 20%) and oral glycopyrrolate (OGP). A retrospective study was carried out at a tertiary care center between the year 2016 and 2018. Details of history, baseline assessment, treatment response recorded in specially designed proformas were analyzed. Initially, the patients received topical ACH daily at night. Non-responders were advised OGP 1 mg BD and increased to 2 mg BD if they did not respond. Response was measured according to patient global assessment and objective evaluation of sweating. Among total 69 patients 57 had onset <10 years of age. There was male preponderance and most common trigger was situations causing anxiety (n = 15). Around 15.3% patients got adequate response with ACH lotion. The cumulative response increased to 45.8% by addition of OGP 1 mg BD and to 55.9% by increasing the dose to 2 mg BD. Addition of OGP to topical ACH increases the treatment efficacy in patients with primary focal hyperhidrosis. Increasing the glycopyrrolate dose augments the response further. However, the current medical treatment options are able to give moderate response.

Effect of Q-switched Nd-YAG laser on the clinical, pigmentary, and immunological markers in patients with lichen planus pigmentosus: A pilot study.

The persistent discoloration in lichen planus pigmentosus (LPP) is secondary to persistent melanophages in the superficial dermis in these patients. We evaluated the effect of Q-switched Nd-YAG laser on the clinical, pigmentary, and immunological markers in patients with LPP. Nine females with a clinical diagnosis of LPP were included in the study. After six sessions of laser with toning protocol, performed over a representative area of 5 × 5 cm2 at 2-weekly intervals, the mean clinical improvement as per the physician assessment was 25.7% (10-40%). There was no significant reduction in melanin and erythema index. On expression analysis using quantitative-polymerase chain reaction, the reduction in tyrosinase (p = 0.03) was statistically significant, though, the reduction in other pigment and immunological markers was not significant. The immunohistochemistry quantification data of corresponding proteins also did not show any significant difference. Post inflammatory hypopigmentation was noted in one patient. Q-switched Nd-YAG laser toning protocol resulted in modest clinical and histological improvement in patients of LPP.

Multivisceral Transplant, The Prince Charles Hospital Experience.

BACKGROUND: Multi-visceral organ transplant is uncommon. As a result of the rarity of these surgeries, there are limited studies, making it difficult to interpret outcomes and identify specific patient complications. We aim to assess the indications for multi-organ transplant, the time on the wait-list and evaluate outcomes including patient survival, graft survival and postoperative complications in an Australian context. METHODS: Patients undergoing multi-organ transplant from 1993 to 2018 at The Prince Charles Hospital, Brisbane, Australia were retrospectively reviewed, looking at baseline characteristics and post-transplant morbidity, mortality and graft survival. RESULTS: A total of 37 patients were included in the study, comprising 22 heart-lung transplants, eight heart-kidney transplants and seven heart-lung-liver transplants. There were six domino heart transplants performed, all in the heart-lung-liver transplant group. The mean age at transplant was 37 years and the mean wait-list time was 10 months. One patient, receiving a heart-lung transplant, required re-transplantation (bilateral lung) at 3 years. One-year (1-year) survival was 91% for heart-lung transplants, 86% for heart-lung-liver transplants and 87.5% for heart-kidney transplants. Five- and ten-year (5- and 10-year) survival was 79% for both in heart-lung transplant, 43% and 29% for heart-lung-liver transplant and 87.5% for both in heart-kidney transplant. CONCLUSION: Patients undergoing multi-organ transplant at our unit had long-term survival and organ function comparable to international data. In addition, waitlist time for multi-organ transplant was not found to be excessive.

Effects of stage-matched repeated individual behavioural counselling session (RIBCS) as an intervention for decreased and stopping smoking.

We aimed to evaluate the effects of stage-matched repeated individual behavioural counselling (RIBCS) on the basis of the transtheoretical model (TTM) as an intervention to reduce and stop smoking. This study was conducted over a period of one year where all smokers presenting to a chest clinic in a tertiary centre were enrolled, each was classified on the basis of stage of readiness to change and underwent repeated counselling for a period of six months and each session was preceded and succeeded with filling of Fagerstorm test for nicotine dependence. Over the period of a year, 207 patients participated in this study, the mean age was 50.74±14.74 years; mean duration of tobacco use was 29.43±14.72 years; 64.3% were illiterate, 11.6% primary education, 14.1% were matric and while 10.1% were graduate. About 73% of smokers reported high level of nicotine dependence (FTND score >5/10). In the present study mean dependence score was 6.0±1.96; 44 (21.3%) were in pre-contemplation stage, 93 (44.9%) were in contemplation, 57 (27.5%) were in preparation and 13 (6.3%) were in action. The point prevalence excellence rate in follow up-I was 15%, follow up-II was 35.3% and follow up-III was 61.9% which was statistically significant. When we took both abstinence and reduction in smoking behaviour as one, p-value was <0.05. The point prevalence of abstinence rate (questionnaire validated) 1 month to 6 months was almost 4 times. Our intervention (RIBCS) succeeded in increasing the abstinence rates during the study period among smokers with a lower motivation to quit (pre-contemplators and contemplators) as well as those ready to quit (preparators). This is significant because of most existing smoking-cessation interventions target only motivated smokers, with few having a positive effect in smokers with a lower motivation to quit.

Indications for Proning in Acute Respiratory Distress Syndrome: Expanding the Horizon!

BACKGROUND: Previously prone positioning (PP) was described in addition to invasive mechanical ventilation and it has been known to reduced mortality and improve oxygenation in patients of ARDS. Recently novel timing of prone positioning was described with the use of high-frequency nasal cannula (HFNC) and noninvasive ventilation (NIV) in patients of acute respiratory distress syndrome (ARDS) to avoid the intubation. Here we would like to share a case of severe ARDS where prone positioning was used in a step further ahead. CASE DESCRIPTION: A 38-year-old gentleman presented with the complaints of progressive breathlessness, dry cough and fever for 7 days. Patient was diagnosed as a case of H1N1 pneumonia with severe ARDS. Patient was initially managed with invasive mechanical ventilation according to ARDS-Net protocol. Despite persistent hypoxia he was put on prone positioning for consecutive 4 days. Patient was extubated after 10 days of mechanical ventilation and put on HFNC in view of persistent high oxygen requirement. At this point of time, we attempted prone positioning in addition to HFNC. Patient was comfortable on prone position and put himself in the same condition for prolonged periods. His oxygenation showed a remarkable improvement from PaO2 of 63 (before prone positioning) to 136 mm Hg (after prone positioning). Oxygen supplementation was later tapered off and subsequently, he improved and was shifted to ward. CONCLUSION: Prone positioning is a harmless and still extremely effective intervention which can and should be utilized at all steps of ARDS-management. HOW TO CITE THIS ARTICLE: Lalwani LK, Sharma V, Chaudhry D, Singh PK. Indications for Proning in Acute Respiratory Distress Syndrome: Expanding the Horizon! Indian J Crit Care Med 2020;24(7):589-591.