A Case of Disseminated Melioidosis With Cerebritis.

Melioidosis is caused by Burkholderia pseudomallei, a Gram-negative, facultative intracellular bacterium. Because melioidosis can mimic many diseases, it requires more advanced laboratory facilities with the necessary expertise and can become an underdiagnosed yet serious infection with high mortality and morbidity. Our patient is a middle-aged male with new-onset uncontrolled type 2 diabetes mellitus who presented with high-grade fever, productive cough and altered mental status. CT thorax showed diffuse middle and lower zone consolidation while MRI brain noted meningitis with cerebritis. Blood culture grew Burkholderia pseudomallei. The patient was started on meropenem for melioidosis, however, no adequate improvement was seen. In view of this inadequate response, parenteral cotrimoxazole was added. Significant improvement was noted and cotrimoxazole was continued for six months.

Aspirin vs Clopidogrel: Antiplatelet Agent of Choice for Those With Recent Bleeding or at Risk for Gastrointestinal Bleed.

Antiplatelet agents are used worldwide mainly for primary and secondary prevention of cardiovascular events on a long-term basis for mortality benefit. Gastrointestinal bleeding is a well-known adverse effect. Various factors are to be considered while choosing antiplatelet agents to prevent the risk of bleed and rebleed incidents. These range from deciding on the agent, timing of therapy, underlying indications, coadministration of proton pump inhibitor, etc. At the same time, one must weigh the risks of cardiovascular events secondary to the stoppage of antiplatelet therapy. With this review, we have tried to guide the clinician on decision-making regarding the care of patients on management of acute upper and lower gastrointestinal bleeding, stoppage, restarting of agents, and measures to prevent a recurrence. We have focused on aspirin and clopidogrel as they are among the most widely used antiplatelet agents.

A Clinical and Demographic Profile of Elderly (>65 Years) in the Medical Intensive Care Units of a Tertiary Care Center.

Background: The elderly population in India is expected to increase to 319 million by 2050. Managing critically ill elderly patients in intensive care units (ICUs) is a difficult task. Proper planning and development of healthcare infrastructure are of prime importance to face this challenge. Objectives: To study the clinical profile and outcomes of elderly patients admitted to the medical ICUs. Materials and methods: A time-bound, prospective observational study on elderly patients admitted to medical ICUs for more than 48 hours was conducted from March 2019 to September 2020. The demographic, biochemical, hematologic, and microbiological data on antibiotic susceptibility patterns on various organisms and procalcitonin (PCT) reports were collected. Acute Physiology and Chronic Health Evaluation II (APACHE II) score was calculated. Various treatment modalities, such as mechanical ventilation, inotropes, hemodialysis, antibiotics, culture report in sepsis patients, and length of ICU stay were collected. Results: The age of the patients and the length of their ICU stay were not significantly associated with outcomes. Sepsis and APACHE II scores are significantly associated with outcomes. Receipt of mechanical ventilation, vasopressor support, and hemodialysis are significantly associated with mortality (p < 0.001). Conclusion: The patients' ages were not significantly associated with outcomes. The most common cause of death among elderly patients was found to be sepsis, followed by pneumonia. In elderly ICU patients, gram-negative organisms are the most common causative agents in bloodstream infections. The APACHE II score, sepsis, receipt of mechanical ventilation, vasopressor support, and hemodialysis are significantly associated with mortality. How to cite this article: Prabhudev P, Ramamoorthi K, Acharya RV. A Clinical and Demographic Profile of Elderly (>65 Years) in the Medical Intensive Care Units of a Tertiary Care Center. Indian J Crit Care Med 2023;27(3):166-175.

Leukocytoclastic Vasculitis: A peculiar presentation of scrub typhus.

Scrub typhus is a disease endemic to the Indian subcontinent caused by the obligate intracellular pleomorphic organism, Orientia tsutsugamushi. Scrub typhus, among other acute febrile illnesses, manifests as prodromal symptoms of fever, malaise, myalgia and anorexia followed by a distinct maculopapular rash, hepatosplenomegaly and lymphadenopathy. We report the case of a patient presenting to tertiary care hospital in southern India in 2021 who developed a rare cutaneous vasculitis secondary to infection with Orientia tsutsugamushi. After performing the Weil-Felix test, a diagnostic titre of >1:640 against OXK was obtained. Furthermore, a skin biopsy was carried out which confirmed the diagnosis of leukocytoclastic vasculitis. The patient was treated with doxycycline and showed drastic improvement in his symptoms.

COVID-19 Palliative and End-of-Life Care Plan: Development and Audit of Outcomes.

Objectives: Palliative care (PC) referral in serious and critical COVID-19 improves decision-making, health resource utilisation, end-of-life symptom management and family support. In this study, we explored developing a systematic decision-making matrix for PC referral in COVID-19 and audited its outcomes. Materials and Methods: A team of interdisciplinary experts developed a hospital COVID-19 PC plan. PC referral and outcomes of PC referral in hospitalised COVID-19 patients were audited. Results: Out of 1575 inpatients, 1066 (67.7%) had mild and 509 (32.3%) had serious and critical COVID-19 illness. Among 50 (3.1%) referred to PC, 5 (0.4%) had mild and 45 (8.8%) had serious and critical COVID-19 illness. Out of 45 serious and critical COVID-19 patients referred to PC, 38 (84%) received end-of-life care (EOLC), 4 (9%) self-discharged against medical advice and 3 (7%) recovered. Forty-seven (94%) were referred for goals-of-care discussion. About 78% received opioids, 70% benzodiazepines and 42% haloperidol for symptom management. Among 45 serious and critical COVID-19 patients referred to PC, foregoing life-sustaining treatment was documented in 43 (96%) but implemented only in 23 (53%). Out of 38 who received EOLC, ICU was the place of death in 31 (82%) and ward in 7 (18%). Conclusion: Despite interdisciplinary experts developing a hospital COVID-19 PC, low referral of serious and critical COVID-19 patients to PC was observed. PC referral enabled access to management of end-of-life symptoms and facilitated limitation of life-sustaining treatment in some COVID-19 patients with serious illness. Educating critical care physicians about the scope of PC in the COVID-19 setting might improve PC referral.

Acute myocardial infarction in a young adult with hyperhomocysteinaemia secondary to tropical sprue.

Coronary heart disease and its complications remain the most common cause of morbidity and mortality throughout the world. In addition, its incidence among adults <45 years of age has also been steadily increasing in the past few decades. Besides the typical aetiology such as coronary artery abnormalities or autoimmune disorders, increasing rates can be attributed to escalating trends of obesity, type 2 diabetes mellitus, and illicit abuse of drugs such as cocaine and amphetamines in the younger population.1 Every cardiovascular event in a young adult must be thoroughly investigated as the aetiology is typically unconventional. Our case reports a young man who developed an acute inferior wall myocardial infarction (IWMI) in the setting of hyperhomocysteinaemia secondary to vitamin B12-folate deficiency itself due to tropical sprue.

Prevalence and Predictors of Potentially Inappropriate Medication Use Among Elderly Patients Using Updated Beers Criteria 2019: A Single Centered Retrospective Analysis.

BACKGROUND: Inappropriate medication use poses a sizable health safety hazard in the elderly owing to aging-associated physiological and anatomic changes. Inappropriate drug prescribing and polypharmacy in this population elevate the risk of adverse drug reactions (ADR). The study aimed at assessing the prevalence and predictors of Potentially Inappropriate Medication (PIM) use in elderly patients according to updated Beers Criteria 2019. METHODS: Medical records of 402 patients aged ≥65 years admitted to a tertiary care hospital from June 2018 to May 2019 were analyzed. The patients who received at least one PIM based on the 2019 Updated Beers Criteria were considered as test cases and others as control. Data were presented as descriptive statistics, and logistic regression was performed to assess the factors affecting the outcomes. RESULTS: The mean age was found to be 73.7 ±6.4 years in the test and 70.5±5.5 years in the control group. The prevalence of PIMs to be used with caution was found to be 54%. Whereas the prevalence of PIMs to be avoided and to be used with reduced dose was found to be 45% and 1%, respectively. The most prescribed PIMs were aspirin, diuretics, long-acting sulfonylureas, and proton pump inhibitors (PPIs). Increasing age, polypharmacy, and the number of drugs in medication history were significantly (p<0.05) correlated with a substantial risk of PIM use. The risk of developing serious and moderate drug-drug interactions (DDIs) was significantly high in the test group (p<0.05) when compared to the control group. CONCLUSION: A high prevalence of PIMs was observed in this study. Age, polypharmacy, and ≥ 3 drugs in medication history were identified as risk factors for PIM use, and at a higher risk of developing DDIs. Continuous medication reviews by clinical pharmacists can aid in reducing the occurrence of PIMs amongst geriatrics.

Factors affecting the outcomes in patients with acute respiratory distress syndrome in a tertiary care setting.

Purpose: The clinical profile and factors affecting outcomes in acute respiratory distress syndrome (ARDS) from adequately sample-sized Indian studies are still lacking. We aimed to investigate the clinical profile, treatment pattern, outcomes; and to assess factors affecting non-recovery in ARDS patients. Patients and methods: A retrospective observational study was conducted among adult ARDS patients admitted during five year period (January 2014-December 2018) in a South Indian tertiary care setting. The relevant data were collected from the medical records to the data collection form. The univariate and multivariate logistic regression analyses were conducted to identify the predictors of outcomes using SPSS v20. Results: A total of 857 participants including 496 males and 361 females with a mean age of 46.86 ± 15.81 years were included in this study. Fever (70.9%), crepitation (58.3%), breathlessness (56.9%), and cough (45%) were the major clinical presentation. Hypertension (25.2%), kidney disease (23.8%), and diabetes (22.3%) were the major comorbidities; and sepsis (37.6%), pneumonia (33.3%), and septic shock (27.5%) were the major etiological factors observed. Antibiotics and steroids were administered to 97.9% and 52.3% of the population, respectively. The recovery rate was 47.49%. The patients with scrub typhus, dengue, pancreatitis, and oxygen supplementation had significantly lower mortality. The factors such as advanced age, sepsis, septic shock, liver diseases, and ventilation requirements were observed to be the independent predictors of non-recovery in ARDS patients. Conclusion: A comparable recovery rate was observed in our population. Advanced age, sepsis, septic shock, liver diseases, and ventilation requirements were the independent predictors of non-recovery.

Efficacy and safety of corticosteroids in acute respiratory distress syndrome: An overview of meta-analyses.

BACKGROUND: Evidence-based recommendations on the efficacy and safety of corticosteroids in acute respiratory distress syndrome (ARDS) remain a therapeutic challenge. Findings from several systematic reviews and meta-analyses are inconsistent. We aimed to assess the published meta-analyses through a systematic review approach and provide further insight into the current uncertainty and also to perform an updated meta-analysis from all the available primary studies. METHODOLOGY: We followed the Preferred Reporting Items for Systematic Review (PRISMA) guidelines to establish the patients, intervention, control and outcome (PICO) for reviewing published meta-analyses. Data sources such as PubMed/MEDLINE, SCOPUS, Cochrane and Google Scholar from inception to February 2021 were accessed. Prevention of ARDS, mortality, ventilator-free days, ICU stay and safety in terms of occurrence of adverse effects were the patient-related outcomes. The review also assessed meta-analysis design-related outcomes which includes the quality of meta-analysis, factors contributing to the risk of bias, extent and sources of heterogeneity, publication bias and robustness of findings. AMSTAR-2 checklist assessed the quality of published meta-analyses. RESULTS: A total of 18 meta-analyses were reviewed comprising a total of 38 primary studies and 3760 patients. Fourteen studies were in ARDS, three in community-acquired pneumonia and one in critical care. The overall quality of meta-analyses was observed to be critically low to high. A non-significant risk of publication bias and non-significant level of heterogeneity was observed in the reviewed meta-analysis. Corticosteroid was significantly effective in preventing ARDS among CAP patients. The effect of corticosteroids on mortality was observed to be still inconsistent, whereas significant improvement was observed with ICU and ventilator outcomes compared with the control group. Our meta-analysis observed a significant reduction of mortality in RCTs (RR: 0.78; 95% CI: 0.61 to 0.99) and the duration of mechanical ventilation (MD: -4.75; 95% CI: -7.63 to -1.88); and a significant increase in ventilator-free days (MD: 6.03; 95% CI: 3.59 to 8.47) and ICU-free days (MD: 8.04; 95% CI: 2.70 to 13.38) in ARDS patients treated with corticosteroids compared with the control group. CONCLUSION: The quality of included studies ranged from critically low to high demonstrating inconsistency in risk of bias. While older studies found no significant effect, recent meta-analyses of RCTs found a significant mortality reduction in the corticosteroid group with considerable levels of heterogeneity. The updated meta-analysis by our team found a significant reduction in mortality in the pooled estimation of RCTs but not in cohort studies. Corticosteroid therapy was effective in terms of ICU and ventilator outcomes with minimal safety concerns. Future meta-analyses should be well executed with specific research questions and well performed with minimal risk of bias to produce good quality evidence.

Association of Vitamin D Deficiency and Newly Diagnosed Pulmonary Tuberculosis.

INTRODUCTION: Vitamin D has a significant role in host immune defense against Mycobacterium tuberculosis. It has been suggested that pulmonary tuberculosis may be associated with lower levels of vitamin D. Present study was therefore undertaken to identify the association between vitamin D deficiency and pulmonary tuberculosis. METHODS: A case-control study was conducted in a tertiary care hospital from 2014 to 2016, including 50 adult newly diagnosed sputum positive pulmonary tuberculosis patients as cases and 50 age and sex-matched healthy participants as control groups. All participants in the study group had undergone detailed clinical examination and routine laboratory investigations, including vitamin D, calcium, and sputum for AFB. The clinical characteristics, X-ray findings, sputum AFB, and vitamin D levels were analyzed and compared with data obtained from healthy controls. RESULTS: In both groups, the majority were men (88%). BMI was significantly (<0.0001∗) lower in the tuberculosis group (19.40 (17.20, 22.0) vs. 24.00 (22.50, 25.47)). Serum vitamin D levels were significantly lower (P = 0.012) in the tuberculosis group (19 (7.75, 27.25) ng/dl) as compared to the control group (25 (19.75, 32.00) ng/dl). Out of 50 TB patients, 27 (54%) had vitamin D deficiency, while among healthy controls, only 13 (26%) had vitamin D deficiency. Among vitamin D deficient PTB patients, 44% had 3+/hpf AFB in sputum smear examination. CONCLUSION: The prevalence of vitamin D deficiency in pulmonary tuberculosis cases is very high. Hypovitaminosis D was associated with more severe clinical symptoms, higher sputum smear positivity, and extensive lesions in chest radiograph among pulmonary tuberculosis patients.

Looking beyond the Obvious: Cefepime-induced Nonconvulsive Status Epilepticus.

Cephalosporins are a commonly used class of antibiotics in various types of infections. Cefepime, a fourth-generation cephalosporin, has been reported to cause neurotoxicity, which can present itself as varied manifestations. Nonconvulsive status epilepticus (NCSE) is a rare manifestation of this neurotoxicity. This condition often proves difficult to diagnose because it is chiefly an electroencephalogram-based diagnosis. The authors report a case of cefepime-induced NCSE in a 57-year-old female patient with compromised renal status.

Performance of the 2010 American College of Rheumatology/European League against Rheumatism (ACR/EULAR) criteria for classification of rheumatoid arthritis in an Indian population: An observational study in a single centre.

BACKGROUND & OBJECTIVES: The 1987 American College of Rheumatology (ACR) criteria were criticised for classifying patients only in the late stage. The 2010 ACR/European League against Rheumatism (ACR/EULAR) classification criteria for rheumatoid arthritis (RA) were thus formulated to recognize the early stage of disease with high sensitivity. This pilot study was designed to estimate and compare the sensitivities of the 1987 ACR and 2010 ACR/EULAR classification criteria for RA. METHODS: In a tertiary care hospital, the medical records of 97 patients diagnosed with RA were reviewed. Case study forms were filled with relevant clinical data and investigation results after reviewing each medical record. The radiographs of hands were also reviewed. To each case, both the 1987 ACR and the 2010 ACR/EULAR criteria were applied and the results of the classification were noted. RESULTS: The sensitivity of the 2010 ACR/EULAR criteria was found to be 79.38 per cent [95% confidence interval (CI) = 71.33-87.43%] and the sensitivity of the 1987 ACR criteria was found to be 63.92 per cent (95% CI = 54.36-73.48%). The difference in the sensitivities was significant (P< 0.01). There was a significant rise in sensitivity of the 2010 ACR/EULAR criteria when patients having anti-cyclic citrullinated peptide (CCP) titres were analysed. INTERPRETATION & CONCLUSIONS: The 2010 ACR/EULAR criteria were found to be more sensitive than the 1987 ACR criteria possibly owing to features of the criteria. Anti-CCP titres were found to increase the sensitivity of the 2010 ACR/EULAR criteria.

Therapeutic assessment of chloroquine-primaquine combined regimen in adult cohort of Plasmodium vivax malaria from a tertiary care hospital in southwestern India.

BACKGROUND: Of late there have been accounts of therapeutic failure and chloroquine resistance in Plasmodium vivax malaria especially from Southeast Asian regions. The present study was conducted to assess the therapeutic efficacy of chloroquine-primaquine (CQ-PQ) combined regimen in a cohort of uncomplicated P. vivax mono-infection. METHODS: A tertiary care hospital-based prospective study was conducted among adult cohort with mono-infection P. vivax malaria as per the World Health Organization's protocol of in vivo assessment of anti-malarial therapeutic efficacy. Participants were treated with CQ 25 mg/kg body weight divided over 3 days and PQ 0.25 mg/kg body weight daily for 2 weeks. RESULTS: Of a total of 125 participants recruited, 122 (97.6%) completed day 28 follow up, three (2.4%) participants were lost to follow-up. Eight patients (6.4%) were ascertained to have mixed P. vivax and Plasmodium falciparum infection by nested polymerase chain reaction test. The majority of subjects (56.8%, 71/125) became aparasitaemic on day 2 followed by 35.2% (44/125) on day 3, and 8% (10/125) on day 7, and remained so thereafter. Overall only one therapeutic failure (0.8%, 1/125) occurred on day 3 due to persistence of fever and parasitaemia. CONCLUSIONS: CQ-PQ combined regimen remains outstandingly effective for uncomplicated P. vivax malaria and should be retained as treatment of choice in the study region. One case of treatment failure indicates possible resistance which warrants constant vigilance and periodic surveillance.