Marching Ahead through the Pandemic: Continuing Anesthesia Services in COVID Era-Our Experience from a Tertiary Care Cancer Centre.

Swati BhanIntroduction This paper aims to provide an overview of the administrative and clinical preparations done in a tertiary care cancer hospital in continuing operation theatre (OT) services through the COVID pandemic. Methods Retrospective data collection, data for the past 1.5 years (COVID period) March 2020 to August 2021 were compared to surgical output for a similar duration of time before the COVID era (September 2018-February 2020). Results A total of 1,022 surgeries were done under anesthesia in the COVID period as against 1,710 surgeries done in a similar time frame in the pre-COVID era. Overall, we saw a 40%drop in the total number of cases. Thorax, abdominal, and miscellaneous surgeries (soft tissue sarcomas, urology, and gyneconcology) saw a maximum fall in numbers; however, head and neck cases saw an increase in numbers during the pandemic. Surgical morbidity and mortality were similar in the COVID and pre-COVID era. No cases of severe COVID infection were reported among the healthcare staff working in OT. Discussion We could successfully continue our anesthesia services with minimal risk to healthcare staff throughout the pandemic by adopting major guidelines in a pragmatic and practical approach with minor changes to suit our setup.

Feasibility of the ERAS (Enhanced Recovery After Surgery) Protocol in Patients Undergoing Gastrointestinal Cancer Surgeries in a Tertiary Care Hospital-A Prospective Interventional Study.

Enhanced Recovery After Surgery (ERAS) protocols have emerged as a promising approach to optimize perioperative care and improve outcomes in various surgical specialties. Despite feasibility studies on ERAS in various surgeries, there remains a paucity of research focusing on gastrointestinal cancer surgeries in the Indian context. The primary objective is to evaluate the compliance rate of the ERAS protocol and secondary objectives include the compliance rate of individual components of the protocol, the complications, the length of hospital stay, and the challenges faced during implementation in patients undergoing gastrointestinal cancer surgeries in our tertiary care cancer center. In this prospective interventional study (CTRI/2022/04/041657; registered on 05/04/2022), we evaluated 50 patients aged 18 to 70 years undergoing surgery for gastrointestinal malignancies and implemented a refined ERAS protocol tailored to our institutional resources and conditions based on standard ERAS society recommendations for gastrointestinal surgeries and specific recommendations for colorectal, pancreatic, and esophageal surgeries.Our study's mean overall compliance rate with the ERAS protocol was 88.54%. We achieved a compliance rate of 91.98%, 81.66%, and 92.00% for pre-operative, intraoperative, and post-operative components respectively. Fourteen (28%) patients experienced complications during the study. The median length of stay was 6.5 days (5.25-8). Challenges were encountered during the preoperative, intraoperative, and postoperative phases. The study highlighted the feasibility of implementing the ERAS protocol in a cancer institute, but specific challenges need to be addressed for its optimal success in gastrointestinal cancer surgeries. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-024-01897-y.

A multicentre, double-blind, placebo-controlled randomized trial of Mycobacterium w in critically ill patients with COVID-19 (ARMY-2).

BACKGROUND: Mycobacterium w (Mw), an immunomodulator, resulted in better clinical status in severe coronavirus infectious disease 19 (COVID-19) but no survival benefit in a previous study. Herein, we investigate whether Mw could improve clinical outcomes and survival in COVID-19. MATERIALS AND METHODS: In a multicentric, randomized, double-blind, parallel-group, placebo-controlled trial, we randomized hospitalized subjects with severe COVID-19 to receive either 0.3 mL/day of Mw intradermally or a matching placebo for three consecutive days. The primary outcome was 28-day mortality. The co-primary outcome was the distribution of clinical status assessed on a seven-point ordinal scale ranging from discharged (category 1) to death (category 7) on study days 14, 21, and 28. The key secondary outcomes were the change in sequential organ failure assessment (SOFA) score on days 7 and 14 compared to the baseline, treatment-emergent adverse events, and others. RESULTS: We included 273 subjects (136 Mw, 137 placebo). The use of Mw did not improve 28-day survival (Mw vs. placebo, 18 [13.2%] vs. 12 [8.8%], P = 0.259) or the clinical status on days 14 (odds ratio [OR], 1.33; 95% confidence intervals [CI], 0.79-2.3), 21 (OR, 1.49; 95% CI, 0.83-2.7) or 28 (OR, 1.49; 95% CI, 0.79-2.8) between the two study arms. There was no difference in the delta SOFA score or other secondary outcomes between the two groups. We observed higher injection site reactions with Mw. CONCLUSION: Mw did not reduce 28-day mortality or improve clinical status on days 14, 21 and 28 compared to placebo in patients with severe COVID-19. [Trial identifier: CTRI/2020/04/024846].

Evaluation of a simple method for testing aztreonam and ceftazidime-avibactam synergy in New Delhi metallo-beta-lactamase producing Enterobacterales.

NDM-producing carbapenem-resistant bacterial infections became a challenge for clinicians. Combination therapy of aztreonam and ceftazidime-avibactam is a prudent choice for these infections. However, there is still no recommendation of a practically feasible method for testing aztreonam and ceftazidime-avibactam synergy. We proposed a simple method for testing aztreonam and ceftazidime-avibactam synergy and compared it with reference broth micro-dilution and other methods. Carbapenem-resistant Enterobacterales clinical isolates were screened for the presence of the NDM gene by the Carba R test. NDM harbouring isolates were tested for aztreonam and ceftazidime-avibactam synergy by broth microdilution (reference method), E strip-disc diffusion, double disc diffusion, and disc replacement methods. In the newly proposed method, the MHA medium was supplemented with ceftazidime-avibactam (corresponding to an aztreonam concentration of 4µg/ml). The MHA medium was then inoculated with the standard inoculum (0.5 McFarland) of the test organism. An AZT disc (30 µg) was placed on the supplemented MHA medium, and the medium was incubated overnight at 37°C. Aztreonam zone diameter on the supplemented MHA medium (in the presence of ceftazidime-avibactam) was compared with that from a standard disc diffusion plate (without ceftazidime-avibactam), performed in parallel. Interpretation of synergy was based on the restoration of aztreonam zone diameter (in the presence of ceftazidime-avibactam) crossing the CLSI susceptibility breakpoint, i.e., ≥ 21 mm. Of 37 carbapenem-resistant NDM-producing isolates, 35 (94.6%) were resistant to aztreonam and tested synergy positive by the proposed method. Its sensitivity and specificity were 97.14% and 100%, respectively. Cohen's kappa value showed substantial agreement of the reference method with the proposed method (κ = 0.78) but no other methods. The proposed method is simple, easily interpretable, and showed excellent sensitivity, specificity, and agreement with the reference method. Therefore, the new method is feasible and reliable for testing aztreonam synergy with avibactam in NDM-producing Enterobacterales.

Clinical Features Predicting COVID-19 Severity Risk at the Time of Hospitalization.

The global spread of COVID-19 has led to significant mortality and morbidity worldwide. Early identification of COVID-19 patients who are at high risk of developing severe disease can help in improved patient management, care, and treatment, as well as in the effective allocation of hospital resources. The severity prediction at the time of hospitalization can be extremely helpful in deciding the treatment of COVID-19 patients. To this end, this study presents an interpretable artificial intelligence (AI) model, named COVID-19 severity predictor (CoSP) that predicts COVID-19 severity using the clinical features at the time of hospital admission. We utilized a dataset comprising 64 demographic and laboratory features of 7,416 confirmed COVID-19 patients that were collected at the time of hospital admission. The proposed hierarchical CoSP model performs four-class COVID severity risk prediction into asymptomatic, mild, moderate, and severe categories. CoSP yielded better performance with good interpretability, as observed via Shapley analysis on COVID severity prediction compared to the other popular ML methods, with an area under the received operating characteristic curve (AUC-ROC) of 0.95, an area under the precision-recall curve (AUPRC) of 0.91, and a weighted F1-score of 0.83. Out of 64 initial features, 19 features were inferred as predictive of the severity of COVID-19 disease by the CoSP model. Therefore, an AI model predicting COVID-19 severity may be helpful for early intervention, optimizing resource allocation, and guiding personalized treatments, potentially enabling healthcare professionals to save lives and allocate resources effectively in the fight against the pandemic.

Quality of life and symptom burden in hematological cancer patients receiving hematopoietic stem cell transplantation: an observational study at Regional Cancer Centre, India.

PURPOSE: Hematopoietic stem cell transplant (HSCT) is an intense form of treatment, resulting in major symptom burden but can prove curative. The quality of life (QOL) is a major endpoint for these patients as the survival rate in them has improved over time. The aim of the study is to assess the QOL and symptom burden of hematological malignancy patients at admission to hospital for HSCT, at 1 month and at 3 months following HSCT. METHODS: This prospective observational study was done on hematological malignancy patients who were admitted for HSCT in a regional cancer center. The study subjects were assessed by the Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale (FACT-BMT Scale), Edmonton Symptom Assessment Scale-revised (r-ESAS), and Depression, Anxiety and Stress Scale-21 Items (DASS-21) at the time of hospital admission for transplantation, on day 30 (~ 1 month) and day100 (~ 3 months) of transplantation. RESULTS: A total of 68 patients were included in this study. FACT-BMT scores have decreased from baseline (F0) to the first follow-up (F1) and then increased in the third follow-up (F2). The maximum r-ESAS mean score was for tiredness among all other symptoms at F0 as well as at F1 and at F2. The DASS 21 scores for depression, anxiety, and stress were maximum during F1 and minimum during F2. CONCLUSION: Symptom burden is maximum during the first month of BMT, which improves later and QOL becomes improved with time.

Demographical and Epidemiological Contribution to Cancer Incidence in Delhi and Its Trends from 1991-2015.

INTRODUCTION: Cancer incidences are rising worldwide, and India ranked third globally in cancer incidence as of 2020, according to estimates from GLOBOCAN. The three components that contributed to changes in cancer incidence include cancer-related risk factors, population size, and population structure. The present study aim is to derive the contribution of these factors to cancer incidence and to evaluate their trend from 1991 to 2015. METHODS: The Data were extracted from the Delhi population-based cancer registry published reports. This longstanding registry covers nearly 100% of the Delhi population. The secular trends of cancer incidence from 1991-2015 were assessed for all sites combined as well as top-five cancer sites among males and females. Joinpoint regression and Riskdiff software were performed to assess the trend among the components of cancer incidence change. RESULTS: Both males and females exhibited nearly equal age-standardised incidence rates over 25 years. Albeit, an overall trend in age-standardised rate was not significant for both sexes (0.68% for males and -0.16% for females) when considering all cancer sites combined. Lung, prostate, oral, and gallbladder cancer exhibits a significant rising trend in the age-standardised rates in males while in females only breast and endometrial cancer showed a rising trend. The cancer counts surged by 252% in males and 208.5% in females from 1991 to 2015. The population size component contributed a 180% increase in males and a 170% increase in females, respectively. The site-specific risk changes were more than 100% for the prostate, oral, and gallbladder cancers in males and endometrial cancer in females. The population structure (aging) contributed to rising cancer incidence varying from 35% to 60% in both genders. CONCLUSION: A significant contribution to new cancer cases was observed due to a demographical shift in both population size and structure, in addition to plausible cancer-specific risk factors. This transformation could surge a potential burden on the Delhi healthcare system. Persistent endeavours are essential to expand and enhance the existing cancer care infrastructure to meet the rising demand driven by aging and population growth. Implementing a stringent population policy can help to mitigate the impact of population growth on cancer incidence.

Comparison of lung aeration loss in open abdominal oncologic surgeries after ventilation with electrical impedance tomography-guided PEEP versus conventional PEEP: a pilot feasibility study.

Background: Existing literature lacks high-quality evidence regarding the ideal intraoperative positive end-expiratory pressure (PEEP) to minimize postoperative pulmonary complications (PPCs). We hypothesized that applying individualized PEEP derived from electrical impedance tomography (EIT) would reduce the severity of postoperative lung aeration loss, deterioration in oxygenation, and PPC incidence. Methods: A pilot feasibility study was conducted on 36 patients who underwent open abdominal oncologic surgery. The patients were randomized to receive individualized PEEP or conventional PEEP at 4 cm H2O. The primary outcome was the impact of individualized PEEP on changes in the modified lung ultrasound score (MLUS) derived from preoperative and postoperative lung ultrasonography. A higher MLUS indicated greater lung aeration loss. The secondary outcomes were the PaO2/FIO2 ratio and PPC incidence. Results: A significant increase in the postoperative MLUS (12 ± 3.6 vs 7.9 ± 2.1, P < 0.001) and a significant difference between the postoperative and preoperative MLUS values (7.0 ± 3.3 vs 3.0 ± 1.6, P < 0.001) were found in the conventional PEEP group, indicating increased lung aeration loss. In the conventional PEEP group, the intraoperative PaO2/FIO2 ratios were significantly lower but not the postoperative ratios. The PPC incidence was not significantly different between the groups. Post-hoc analysis showed the increase in lung aeration loss and deterioration of intraoperative oxygenation correlated with the deviation from the individualized PEEP. Conclusions: Individualized PEEP appears to protect against lung aeration loss and intraoperative oxygenation deterioration. The advantage was greater in patients whose individualized PEEP deviated more from the conventional PEEP.

Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit.

End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs. How to cite this article: Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.

Developing mathematical models to compare and analyse the pharmacokinetics of morphine and fentanyl.

Background and Aims: The two-compartment model is generally used in pharmacokinetics to illustrate the distribution and excretion of drugs. In this study, we evaluated the distribution patterns of morphine and fentanyl by using a two-compartment model. Methods: Using numeric analysis techniques, non-linear ordinary differential equations were used to mathematically analyse drug distribution, transition, and concentration in the body compartments. Math Works, Inc., MATLAB, version 2023a, a programming tool, was used to characterise the impact of initial concentration and rate constants on the kinetics of the drug. For a definite therapeutic concentration of morphine and fentanyl in blood, pharmacokinetic characteristics were plotted. Results: The study results showed the time taken by morphine and fentanyl to reach a target concentration in the blood that is sufficient to generate the preferred therapeutic effects. The mathematical models comparing morphine and fentanyl pharmacokinetics showed that fentanyl reached the target therapeutic concentration 125 minutes earlier than morphine and was metabolised and removed from the body more rapidly (44 minutes earlier than morphine). Conclusion: These comparative mathematical models on morphine and fentanyl enable the determination of drug dosages and understanding of drug efficacy that facilitates optimising dosing regimens. The right choice between them can be made based on the time to reach the target therapeutic concentration in the blood, elimination time, severity of pain, and patient characteristics.

A comparative evaluation of fibreoptic bronchoscopy versus C-MAC® D-BLADE-guided videolaryngoscopy for nasotracheal intubation under general anesthesia in oropharyngeal carcinoma surgery patients.

PURPOSE: Nasotracheal intubation (NTI) is required for surgery in oropharyngeal (OP) carcinoma patients, but it may be challenging because of distorted anatomy, mucosal congestion, and increased risk of bleeding. Flexible bronchoscopy (FB)-guided NTI is preferred in these cases but has limitations. In this randomized controlled study, we sought to compare C-MAC® D-BLADE-guided videolaryngoscopy (VL) (Karl Storz SE & Co. KG, Tuttlingen, Germany) with FB for NTI under general anesthesia in patients with OP carcinomas. METHODS: We randomized a total of 100 patients with OP carcinoma and El-Ganzouri's risk index (EGRI) < 7 to undergo NTI under general anesthesia with FB (n = 50) or C-MAC D-BLADE-guided VL (n = 50). The primary outcome was the total intubation time. We also recorded the time to glottis view, nasal intubation difficulty scale (NIDS) score, best percentage of glottis opening score, and complications. RESULTS: The median [interquartile range (IQR)] total intubation time was shorter with VL than with FB (total intubation time, 38 [26-43] sec vs 60 [52-65] sec; difference, -20 sec [95% confidence interval (CI), -27 to -11]; P < 0.001). Similarly, the median [IQR] time to glottis view was shorter with VL compared to FB (8 [6-9] sec vs 22 [14-25] sec; difference, -13 sec [95% CI, -17 to -10]; P < 0.001). The median NIDS score was higher with VL (difference, 2 [95% CI, 2 to 3]; P < 0.001). The incidences of airway trauma (two cases with FB vs seven with VL; P = 0.30) and postoperative sore throat (ten cases in both groups; P = 0.56) were similar. CONCLUSION: Compared to FB, C-MAC D-BLADE-based VL reduced the total time for nasal intubation oropharyngeal carcinoma patients, potentially representing an acceptable alternative in selected cases. TRIAL REGISTRATION: CTRI.nic.in (2018/11/0162830); first submitted 8 November 2018.

RéSUMé: OBJECTIF: L'intubation nasotrachéale est nécessaire pour la chirurgie chez la patientèle atteinte de carcinome oropharyngé, mais elle peut être difficile en raison d'une anatomie déformée, d'une congestion des muqueuses et d'un risque accru de saignement. Dans ces cas, il est préférable d'utiliser une intubation nasotrachéale guidée par bronchoscopie flexible (BF), mais cette modalité a ses limites. Dans cette étude randomisée contrôlée, nous avons cherché à comparer la vidéolaryngoscopie guidée par lame D-BLADE C-MAC® (VL) (Karl Storz SE & Co. KG, Tuttlingen, Allemagne) à la BF pour réaliser l'intubation nasotrachéale sous anesthésie générale chez les patient·es ayant un carcinome oropharyngé. MéTHODE: Au total, nous avons randomisé 100 personnes atteintes d'un carcinome oropharyngé et présentant un indice de risque d'El-Ganzouri (EGRI) < 7 à bénéficier d'une intubation nasotrachéale sous anesthésie générale par BF (n = 50) ou par VL guidée par lame D-BLADE C-MAC (n = 50). Le critère d'évaluation principal était le temps d'intubation total. Nous avons également enregistré le temps écoulé jusqu'à la visualisation de la glotte, le score sur l'échelle de difficulté de l'intubation nasale (NIDS), le meilleur pourcentage de score d'ouverture de la glotte et les complications. RéSULTATS: La durée totale d'intubation médiane [écart interquartile (ÉIQ)] était plus courte avec la VL qu'avec la BF (durée totale d'intubation, 38 [26­43] sec vs 60 [52 à 65] secondes; différence, −20 sec [intervalle de confiance (IC) à 95 %, −27 à −11]; P < 0,001). De même, le temps médian [ÉIQ] jusqu'à la visualisation de la glotte était plus court avec la VL qu'avec la BF (8 [6­9] sec vs 22 [14 à 25] secondes; différence, −13 sec [IC 95 %, −17 à −10]; P < 0,001). Le score médian sur l'échelle NIDS était plus élevé avec la VL (différence, 2 [IC 95 %, 2 à 3]; P < 0,001). L'incidence des traumatismes des voies aériennes (deux cas avec la BF vs sept avec la VL; P = 0,30) et le mal de gorge postopératoire (dix cas dans les deux groupes; P = 0,56) étaient similaires. CONCLUSION: Par rapport à la BF, la VL guidée par lame D-BLADE C-MAC a réduit le temps total d'intubation nasale pour les personnes atteintes d'un carcinome oropharyngé, ce qui représente potentiellement une alternative acceptable dans certains cas. ENREGISTREMENT DE L'éTUDE: CTRI.nic.in (2018/11/0162830); première soumission le 8 novembre 2018.

Malignant Chest Wall Tumors: Complex Defects and Their Management-A Review of 181 Cases.

BACKGROUND: Chest wall tumors are a heterogeneous group of tumors that are managed by surgeons from diverse specialties. Due to their rarity, there is no consensus on their diagnosis and management. MATERIALS: This retrospective, descriptive analysis includes patients with malignant chest wall tumors undergoing chest wall resection. Tumors were classified as primary, secondary, and metastatic tumors. The analysis includes clinicopathological characteristics, resection-reconstruction profile, and relapse patterns. RESULTS: A total of 181 patients underwent chest wall resection between 1999 and 2020. In primary tumors (69%), the majority were soft tissue tumors (59%). In secondary tumors, the majority were from the breast (45%) and lung (42%). Twenty-five percent of patients received neoadjuvant chemotherapy, and 98% of patients underwent R0 resection. Soft tissue, skeletal + soft tissue, and extended resections were performed in 45%, 70%, and 28% of patients, respectively. The majority of patients (60%) underwent rib resections, and a median of 3.5 ribs were resected. The mean defect size was 24 cm2. Soft tissue reconstruction was performed in 40% of patients, mostly with latissimus dorsi flaps. Rigid reconstruction was performed in 57% of patients, and 18% underwent mesh-bone cement sandwich technique reconstruction. Adjuvant radiotherapy and chemotherapy were given to 29% and 39% of patients, respectively. CONCLUSIONS: This is one of the largest single-institutional experiences on malignant chest wall tumors. The results highlight varied tumor spectra and multimodality approaches for optimal functional and survival outcomes. In limited resource setting, surgery, including reconstructive expertise, is very crucial.

Comparison of sedation efficacy of intravenous infusion of dexmedetomidine versus propofol in terms of opioid consumption in patients requiring postoperative mechanical ventilation after head and neck onco-surgeries - A randomized prospective study.

BACKGROUND: The conventional drug regimen of sedation for patients requiring mechanical ventilation in an intensive care unit (ICU) is propofol or midazolam. Dexmedetomidine is a newer drug for sedation with a better clinical profile. We conducted this study to compare the sedative efficacy of dexmedetomidine versus propofol in patients after head and neck cancer surgeries requiring mechanical ventilation. METHODS: After ethics committee approval and written informed consent, 80 patients undergoing head and neck onco-surgery were recruited. The patients were randomly allocated to group I [1 mg/kg of bolus propofol over 15 minutes followed by infusion of 1 mg/kg/hour titrated by increasing or decreasing the infusion dose to Ramsay Sedation Score (RSS) 2-4] or group II (a loading dose of dexmedetomidine 1 mcg/kg over 15 minutes followed by a maintenance dose of 0.4 µg/kg/hour titrated to desired sedation level). The RSS, behavioral pain scale (BPS), heart rate, blood pressure, fentanyl consumption, additional sedative agent, extubation time, length of ICU stays, mechanical ventilation duration, side effects, and patient's satisfaction were noted. RESULTS: Total fentanyl required was 0.56 ± 0.13 µg/kg/hour in group II and 0.58 ± 0.18 µg/kg/hour in group I (P = 0.75). Extubation time, RSS, BPS, patient satisfaction, and ICU duration were similar in both the groups. The incidence of hemodynamic-related adverse effects were 41.67% in group II and 11.11% in group I (P = 0.006). CONCLUSION: The fentanyl requirement was comparable in both the groups in the postoperative period. Dexmedetomidine was associated with an increased incidence of bradycardia and hypotension as compared to the propofol group. Propofol should be the preferred sedative for postoperative mechanical ventilation after head and neck onco-surgeries.

Breakthrough infection among healthcare personnel following exposure to COVID-19: Experience after one year of the world's largest vaccination drive.

Context: The COVID-19 vaccination drive globally was supposedly a game-changing event. However, the emerging variants of the virus and waning immunity over time posed new challenges for breakthrough infections. Standing at the frontline of defense against COVID-19, healthcare personnel (HCP) were vulnerable to such infections. Aims: This study estimates i) the vaccine breakthrough infections (VBI) among HCP following exposure to COVID-19 cases, and ii) the mean interval between the second dose of vaccine and laboratory-confirmed SARS-CoV-2 infection. Materials and Methods: A cross-sectional study was conducted including 385 HCP with a history of exposure to COVID-19 cases during January and February 2022. Demographic details and clinical and vaccination history were collected from the test forms and the Web-based hospital management system. Laboratory testing of COVID-19 was carried out by real-time RT-PCR test. Results: The majority of the HCP were males (262; 68.05%) and nurses (180; 46.75%) by occupation. Two doses of vaccines were received by 278 (87.7%) HCP. VBI was confirmed in 185 (66.55%) HCP. No significant difference in VBI between the COVAXIN and COVISHIELD recipients (P = 0.69) was observed. The interval between the second dose and confirmed SARS-CoV-2 infection was significantly higher (P < 0.00001) in COVAXIN recipients (median 228 days) than in COVISHIELD recipients (median 95 days). Conclusions: The incidence of VBI was very high among the HCP, but not statistically different among the COVAXIN and COVISHIELD-recipients. Waning immunity over time suggests boosting immunity with a third dose because of emerging variants.

Assessing Awareness and Palliative Care Needs in Rural Haryana, North India: A Community-Based Study.

Background Community-based palliative care offers a solution to ensure continuity of treatment for patients with life illnesses or life-threatening conditions. Hence, to advocate for community-based palliative care services, it is imperative to generate evidence for palliative care needs in the community. This study aimed to assess the need for and awareness of palliative care in rural Haryana, North India. Methods This was a community-based cross-sectional study conducted in six villages of Haryana. A trained investigator conducted house-to-house visits to screen the population for those who require palliative care. The screening was done using three questions, i.e., (1) the presence of a bedridden patient, (2) a person in need of help in activities of daily living, or (3) not able to go to work due to any physical chronic illness. If the answer to any of these questions was positive, a list of patients was prepared, and a community physician trained in palliative care contacted them. Patients and their caregivers were evaluated for their awareness of palliative care through the following question: 'Have you heard about the term palliative care/end-of-life care/home care for bedridden people/community-based care/supportive care?'. Data collection was done using Epicollect5 mobile application, and a descriptive analysis was conducted using the R software. Results A total of 1,983 households were visited, and 152 households were excluded as they were found locked during two separate visits. Therefore, a total of 1,831 households, comprising 9,727 individuals, were screened. The need for palliative care was found to be 3.7 per 1,000 population (95% CI: 2.5 - 4.9) and 18.6 per 1000 households (12.4 - 24.8). The most common diseases requiring palliative care were stroke with a focal neurological deficit (27.8%) and cancer (22.2%). One patient with cancer was receiving palliative care. None of the patients or their caregivers was aware of the terms palliative care/end-of-life care/home care for bedridden people/community-based care/supportive care. Conclusion The need for palliative care in rural Haryana (North India) was found to be 3.7 per 1000 population. Neither the patients nor their caregivers had an awareness of palliative care.

Relevance of Conventional Microscopy in the Diagnosis of Mucormycosis during COVID-19 Pandemic.

Introduction: Mucormycosis is a lethal disease which bewildered the health-care community of India during the ongoing second wave of the COVID-19 pandemic. The diagnosis is challenging considering the poor isolation in culture. Aims: The aim of the study was to emphasize the utility of potassium hydroxide (KOH) mount examination using conventional light microscopy for early diagnosis of mucormycosis in resource-limited settings. Materials and Methods: A retrospective analysis of results for all the samples including tissue biopsies, swabs, and pus received in the laboratory for KOH microscopy was done, and results were recorded. The clinical and demographic details of the patients were collected from the hospital information system. Results: A total of 75 samples from 50 patients were received in the laboratory. Out of these, 43 samples from 35 patients showed fungal hyphae (38 patients with only nonseptate hyaline hyphae, 2 with septate hyaline hyphae, and 3 samples with mixed infections). All patients except one were positive for severe acute respiratory syndrome coronavirus 2 infection. The most common age group was 45-59 years (40%), followed by 30-44 years (34.28%) with a male predominance. There was a significant difference in hemoglobin A1C (P = 0.005) and ferritin (P = 0.017) levels between laboratory-confirmed mucormycosis patients and clinically suspected mucormycosis patients without confirmation. Conclusion: Early diagnosis and initiation of targeted therapy is the cornerstone for treating mucormycosis patients. Hence, a rapid and reliable mode of diagnosis is the need of the hour. Conventional microscopy is such a tool that may be used, especially in resource-limited settings.

Mortality in Two Waves of COVID-19: A Comparative Analysis of a Tertiary Care Hospital in India.

Background COVID-19 has spread as two distinct surges of cases in many countries. Several countries have reported differences in disease severity and mortality in the two waves. Objective Compare the in-hospital mortality in the two COVID-19 waves at a tertiary care hospital in India. Methods We conducted a retrospective data collection. Distinct periods of surges in cases and admissions were defined as the first wave spanning from March 2020 to December 2020 and the second wave from April 2021 to June 21, 2021. The primary outcome of this study was to compare mortality rates in terms of total hospital mortality rate (TMR) and case fatality rate (CFR). Results Mortality rates of wave 2 were approximately 10 times that of wave 1 (TMR of 20.3% in wave 2 versus 2.4% in wave 1 and CFR of 1.5% versus 17.7% in wave 1 and 2, respectively). Mortalities in wave 2 had a larger proportion of severe disease at presentation, faster progression of symptoms to death, and more patients without any chronic comorbid condition dying due to the direct effect of COVID-19 acute respiratory distress syndrome (ARDS). Conclusion Our data matches the worldwide reported pooled hospital mortality figures and shows the comparative difference in disease severity between the two waves.

Development and Validation of Total Pain Scale for Evaluation of Total Pain in Cancer Patients.

Objectives: Cancer pain has all the components of total pain such as physical, social, psychological, and spiritual. These components contribute to the overall pain experience in cancer patients. Many instruments have been developed till date to assess the effect of pain in cancer patients but none of the instruments include all components of total pain. In this article, we describe the development and validation of the total pain scale (TPS) for the evaluation of total pain in cancer patients with pain. This study aimed to develop and validate a questionnaire for the evaluation of total pain in cancer patients with pain. Material and Methods: This study included a review of existing pain questionnaires for cancer pain for item pool generation. Items were generated in the Hindi language by six stakeholders to create 23 items to develop TPS. TPS was applied to 300 Hindi-speaking cancer patients. Bivariate correlation was used to reduce the number of items as well as construction of the domain followed by factor analysis to finalise TPS. Confirmatory factor analysis (CFA) was performed for testing the validity and reliability of TPS. Results: TPS is an 18-item scale composed of four domains (physical, social, spiritual and psychological domain). The internal consistency of TPS and its subscales was found to be very good (a = 0.84-0.88). CFA and structural equation modeling Goodness of fit has confirmed that model 4 is the best fit as it yielded a lesser root-mean-squared error of approximation value of 0.062 and a greater comparative fit index, Tucker-Lewis index value of 0.944. The convergent and divergent validity of TPS and its domain was good. Conclusion: This study reports TPS to be a brief (18-item), valid, and reliable questionnaire in the Hindi language for assessment of all components of total pain in cancer patients with pain.