Impact of intraoperative haemoadsorption on outcomes of patients undergoing aortic surgery: a single-centre, prospective, observational study.

OBJECTIVES: To investigate the impact of a cytokine haemoadsorption (HA) device (CytoSorb®) on inflammatory markers and patients' outcome during aortic root surgery. METHODS: Prospective, observational study including all-comers with quasi-randomization by strictly alternating inclusion (1:1 basis). Sixty patients undergoing elective aortic surgery were assigned to either HA group (n = 30) with intraoperative HA, or a control (C) group (n = 30). Primary outcomes were: (i) impact of HA on haemodynamic stability and need for vasopressors (vasoactive-inotropic score) and (ii) sequential organ failure assessment (SOFA) score. Secondary parameters included the impact of HA on the course of hyperinflammation using interleukin-6 and procalcitonin, duration of mechanical ventilation, and lengths of intensive care unit and hospital stay. RESULTS: Noradrenaline requirement was significantly reduced in the HA group postoperatively compared to the C group (HA: 0.03 µg/kg/min vs C: 0.08 µg/kg/min, P = 0.004 at 2 h, and HA: 0.02 µg/kg/min vs C: 0.04 µg/kg/min, P = 0.004 at 24 h). This translated into a significantly lower vasoactive-inotropic score in the HA group. SOFA score was less in the HA group at all time points and reached statistical significance 2 h postoperatively (HA: 5.77 vs C: 7.43, P < 0.001). Intraoperative HA significantly reduced interleukin-6 levels (P < 0.05) at all time points, and procalcitonin at 2 h after discontinuation from cardiopulmonary bypass (P = 0.005). The duration of ventilation, intensive care unit and hospital stays were shorter in the HA group compared to the C group. CONCLUSIONS: Intraoperative HA has the potential to mitigate hyperinflammatory response leading to improved haemodynamics after aortic root surgery, thereby shortening the duration of ventilation, and lengths of intensive care unit and hospital stay. However, it must be evaluated in larger cohorts.

The feasibility of using of a comprehensive unit-based safety program (CUSP) for improving antimicrobial stewardship at a tertiary care hospital in national capital region of India: A prospective quasi experimental study.

PURPOSE: To examine the feasibility of Comprehensive Unit-based Safety Program (CUSP) as a strategy tool to improve antibiotic stewardship in low and middle income countries (LMIC) in resource limited setting. The primary outcome measure is identification of inappropriate prescriptions. The secondary outcome parameters are App adoption trends and antimicrobial prescription pattern and practices. MATERIAL AND METHODS: A prospective quasi-experimental design was used to operationalizing the CUSP intervention. The project considered the data of 482 patients from two mixed Medical ICUs admitted during June 2019 to April 2020. The information was collected on antimicrobials prescription pattern and practices for identification of inappropriate use as well as app adoption trend with respect to Electronic Medical Record (EMR) Orders Placed, Clinical Notes and Checklist Filled. The intervention in the study comprised of development of an antibiotic monitoring stewardship (AMS) data collection app for ease of use and for Clinical Decision Support System (CDSS) to identify the cases of inappropriate use of antibiotics. RESULTS: Data of patients was reviewed to create algorithms for empirical and directed antibiotic therapy as well as to create a CDSS app. Out of 793 prescriptions initially during July-September 2019, 19 (2.4%) were inappropriate antimicrobial prescription. The continuous monitoring of antimicrobial prescription helped in reducing the irrational use and bring it to level zero at the end. CONCLUSION: It requires commitment from the management, and seamless communication within Clinical, Microbiology, Pharmacology and data management teams to create and run a successful CUSP program towards Antimicrobial Resistance. Tools such as the CDSS can smoothen the process.

Evaluation of T and B cell immunophenotyping and antibody response post Covid-19 vaccination.

PURPOSE: To evaluate T and B cell subsets and IgG antibodies in response to SARS-CoV-2 post COVID-19 vaccination. METHODS: A total of 50 healthy adults (18-60 years) receiving anti-SARS-CoV-2 vaccination (COVISHIELD) were recruited for the study. Blood samples were collected from participants at 3 time points; just before vaccination (Visit 0, V0), just before booster dose (Visit 1, V1) and 6th month after 1st dose (Visit 2, V2). Peripheral blood mononuclear cell isolation was done and evaluated for T and B cell subsets by Flow cytometry. Quantitative determination of IgG antibodies to SARS-CoV-2 was done by Chemiluminescence immunoassay in all samples. Final data for all three visits was available for 37 participants who remained healthy. Ethics approval was obtained from Medanta Institution of Ethics Committee vide MICR No. 1290/2021 dated 24th May 2021. RESULTS: Mean age of the participants was 34.6 â€‹± â€‹5.7 years (Range: 24-45 years). Highly significant improvement in SARS-CoV-2 IgG levels was observed after each visit {Mean IgG: (V0 v/s. V1: 133.8 â€‹± â€‹339.2AU/ml v/s. 434.5 â€‹± â€‹519.2AU/ml; p-value â€‹= â€‹0.003) and V0 v/s. V2: 133.8 â€‹± â€‹339.2AU/ml v/s. 420.9 â€‹± â€‹394.2AU/ml; p-value â€‹= â€‹0.002) Between visits 0 and 1, the mean value for CD4 Naïve T cells showed significant increase, while CD4 central memory (CM) T cells showed significant decrease. Between visits 0 and 2 the mean values for CD4 Naïve T cells, CD8 Naïve T cells and Pre germinal centre (Pre GC) B cells showed significant increase. During the same period the mean values for CD4CM, CD8 effector memory (EM) and CD8 CM T cells showed significant decrease. CONCLUSION: It is concluded that both, humoral and cellular immunity, play an important role in maintaining immunity against COVID-19 infection, following COVISHIELD vaccination. Moreover, in subjects with normalisation of antibody levels post vaccination, persistence of T cell subsets may still offer some immunity.

Safety, immunogenicity & effectiveness of the COVID-19 vaccine among healthcare workers in a tertiary care hospital.

BACKGROUND & OBJECTIVES: The COVID-19 pandemic has caused significant global morbidity and mortality. As the vaccination was rolled out with prioritization on healthcare workers (HCWs), it was desirable to generate evidence on effectiveness of vaccine in prevailing real-life situation for policy planning. The objective of the study was to evaluate the safety, effectiveness and immunogenicity of COVID-19 vaccination among HCWs in a tertiary care hospital. METHODS: This prospective observational study was undertaken on the safety, immunogenicity and effectiveness of the ChAdOx1 nCoV- 19 coronavirus vaccine (Recombinant) during the national vaccine roll out in January-March 2021, in a tertiary care hospital, New Delhi, India. RESULTS: The vaccine was found to be safe, with local pain, fever and headache as the most common adverse events of milder nature which generally lasted for two days. The adverse events following vaccination were lower in the second dose as compared to the first dose. The vaccine was immunogenic, with seropositivity, which was 51 per cent before vaccination, increasing to 77 per cent after single dose and 98 per cent after two doses. Subgroup analysis indicated that those with the past history of COVID-19 attained seropositivity of 98 per cent even with single dose. The incidence of reverse transcription (RT)-PCR positive COVID-19 was significantly lower among vaccinated (11.7%) as compared to unvaccinated (22.2%). Seven cases of moderate COVID-19 needing hospitalization were seen in the unvaccinated and only one such in the vaccinated group. The difference was significant between the fully vaccinated (10.8%) and the partially vaccinated (12.7%). The hazard of COVID-19 infection was higher among male, age >50 yr and clinical role in the hospital. After adjustment for these factors, the hazard of COVID-19 infection among unvaccinated was 2.09 as compared to fully vaccinated. Vaccine effectiveness was 52.2 per cent in HCWs. INTERPRETATION & CONCLUSIONS: ChAdOx1 nCoV-19 coronavirus vaccine (Recombinant) was safe, immunogenic as well as showed effectiveness against the COVID-19 disease (CTRI/2021/01/030582).

Perioperative dexmedetomidine reduces delirium after coronary artery bypass graft surgery: A prospective, single-blind, observational study.

Background: Delirium is a commonly seen complication of cardiac surgery. Dexmedetomidine, by its anti-inflammatory properties and other effects, can attenuate postoperative delirium. Aims: The aim of this work was to study the incidence of delirium after coronary artery bypass graft surgery, and to compare the effects of dexmedetomidine and propofol on the incidence of postoperative delirium in coronary artery bypass graft surgery patients. Materials and Methods: A prospective, observational study was conducted on 180 consecutive patients undergoing off-pump or on-pump coronary artery bypass graft surgery. The patients were administered either intravenous dexmedetomidine (n = 90) or propofol (n = 90) after hemostasis was achieved, till they were ready for weaning from the ventilator. The Confusion Assessment Method was used to assess the incidence of postoperative delirium. Measurements and Main Results: A total of 25 (13.8%) patients developed delirium after coronary artery bypass graft surgery. Sedation with dexmedetomidine was associated with a significantly reduced incidence of postoperative delirium (8.9% v 18.9% propofol, P = 0.049). Subgroup analyses showed reduced incidence of postoperative delirium in off-pump patients compared to on-pump coronary artery bypass graft patients (3.3% vs. 20%, P = 0.009 dexmedetomidine group and 11.6% vs. 33.3%, P = 0.047 propofol group respectively). The mean age of the patients who had delirium was significantly more (64.9 ± 8.1 years vs. 52.5 ± 5.8 years, P = 0.046) compared to those who did not have delirium. Conclusion: Administration of dexmedetomidine-based sedation resulted in the reduced incidence of postoperative delirium compared to propofol-based sedation in patients after coronary artery bypass graft surgery.

Alleviating Work Exhaustion, Improving Professional Fulfillment, and Influencing Positivity Among Healthcare Professionals During COVID-19: A Study on Sudarshan Kriya Yoga.

Demanding work-life and excessive workload, the conflict between professional and personal lives, problems with patients and those related to the occurrence of death and high risk for their own life are a few factors causing burnout, disengagement, and dissatisfaction in the professional lives of healthcare professionals (HCPs). The situation worsened during the COVID-19 pandemic. It is of utmost importance to find effective solutions to mitigate the stress and anxiety adversely affecting the mental well-being and professional lives of HCPs. This study was designed to examine the efficacy of Sudarshan Kriya Yoga (SKY) for alleviating work exhaustion, improving Professional Fulfillment, and influencing positivity among HCPs during COVID-19. In a comparative observation before the intervention (Pre), after the intervention (Post), and 30 days after the intervention (Day 30) in the Experimental Group (29 physicians) and Control Group (27 physicians), it was found that immediately after SKY, HCPs experienced a significant improvement in Professional Fulfillment (p = 0.009), work exhaustion (0.008), positive affect (p = 0.02), and negative affect (p < 0.001) compared to the Control Group. The effect of SKY continued until Day 30 for Professional Fulfillment and had positive and negative effects. Findings suggest that SKY elevated Professional Fulfillment among HCPs during the COVID-19 pandemic and reduced their work exhaustion and the negative effect on their mental health. SKY can aid HCPs in maintaining their well-being when faced with unprecedented challenges.

Seroprevalence of Covid-19 infection among healthcare workers: A study from a tertiary care hospital in the National Capital Region of India.

Background Seroprevalence studies on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can provide information on the target populations for vaccination. We aimed to evaluate the seroprevalence among healthcare workers (HCWs) at our tertiary care institution and to identify parameters that may affect it. Method We assessed seroprevalence of SARS-CoV-2 by the chemiluminescence immunoassay test among 3258 HCW in our hospital and evaluated as per gender, age, their previous Covid-19 diagnosis, role in hospital and type/risk of exposure. Results Of 3258 participants, 46.2% (95% CI 44.4%- 47.9%) were positive for SARS-CoV-2 IgG antibodies (i.e. IgG ≥15 AU/ml). Higher seroprevalence was seen in non-clinical HCWs (50.2%) than in clinical HCWs (41.4%, p=0.0001). Furthermore, people with a history of Covid-19 were found to have significantly higher antibody levels (p=0.0001). Among the HCWs, doctors and nurses had lower relative risk (RR) of acquiring Covid-19 infection (RR=0.82; 95% CI 0.76-0.89) compared to non-clinical HCWs. Conclusion Seroprevalence in HCWs at our hospital was 46.2%. Clinical HCWs had lower seroprevalence compared to non-clinical HCWs. Previous history of Covid-19 almost doubled the seropositivity, particularly in those with current infection.

Ayurvedic clinical profile of COVID-19 - A preliminary report.

BACKGROUND: Ayurvedic clinical profiling of COVID-19 is a pre-requisite to develop standalone and integrative treatment approaches. At present, Ayurvedic clinicians do not have access to COVID-19 patients in clinical settings. In these circumstances, a preliminary clinical profiling of COVID-19 based on review of modern medical and classical Ayurvedic literature with inputs from Allopathic clinicians treating COVID-19 patients assumes significance. OBJECTIVES: This paper aims to develop an Ayurvedic clinical profile of COVID-19 by literature review supported by analysis of clinical data of a cohort of COVID-19 patients. METHODS: The typical clinical presentation of COVID-19 was categorized based on a cluster of symptoms with reference to "Interim Clinical Guidance for Management of Patients with confirmed corona virus disease (COVID-19)" released by the US CDC. As the clinical presentation is found to vary widely, research papers reporting clinical symptoms of patient samples from different parts of the world were also reviewed to identify outliers and atypical presentations. Case records of fourteen COVID-19 patients treated at Medanta Hospital, Gurgaon were analyzed to compare symptomatology with data obtained from published literature. Further, a careful correlation was done with the data collected from selected Ayurvedic classical texts and expert views of clinical practitioners to arrive at a preliminary Ayurvedic clinical profile of COVID-19. RESULTS: COVID-19 can be understood from the Ayurvedic perspective as vatakapha dominant sannipatajvara of agantu origin with pittanubandha. The asymptomatic, presymptomatic, mild, moderate, severe and critical stages of COVID-19 with varying clinical presentations have been analysed on the basis of nidana, dosa, dusya, nidanapañcaka and satkriyakala to present a preliminary clinical profile of the disease. CONCLUSION: In this paper, we have demonstrated that a preliminary clinical profiling of COVID-19 from the Ayurvedic perspective is possible through literature review supported by discussions with Allopathic clinicians as well as examination of patient case records. The provisional diagnosis proposed can be further developed with continued review of literature, wider cooperation and teamwork with Allopathic physicians and access to clinical data as well as direct clinical assessment of COVID-19 patients.

A pilot clinical study of an add-on Ayurvedic formulation containing Tinospora cordifolia and Piper longum in mild to moderate COVID-19.

BACKGROUND: After declaration of COVID- 19 as pandemic by WHO, countries adopted several measures to contain the spread as well as test and treat the patients. Further, as no effective management protocols to address this pandemic were available, a need was felt to explore the integration of modern and traditional medicines to treat COVID- 19 cases. OBJECTIVE: To undertake a study with Ayurveda formulation as add on to existing standard of care (SOC) and to compare the outcomes in terms of patient acceptability, the time to clinical recovery, hospital stay as well as any signs of drug-herb interaction between the Ayurveda formulation and the SOC. MATERIAL AND METHODS: An exploratory nonrandomized prospective study has been undertaken for comparing the outcomes of traditional Ayurvedic classical formulation of Tinospora cordifolia (Guduchi) and Piper longum (Pippali) as an add on to standard of care (SOC) using modern medicine with SOC alone. This has been done in mild and moderate COVID- 19 cases, at a tertiary care integrative Medicine hospital in the National Capital Region, Gurgaon, India. The outcomes have been evaluated in terms of the duration of hospital stay, the time to clinical recovery, safety and non- interference/interaction of Ayurvedic and Further, long term impact of COVID- 19 treatment has been evaluated using quality of life questionnaire after 3 months of discharge. RESULTS: Findings of present study reveals that the Ayurveda add-on formulation of T. cordifolia (Guduchi) and P. longum (Pippali) has reduced the length of hospital stay and improve the recovery time. General feeling of wellbeing and activity levels were better in the 3 month follow-up post discharge in the Ayurveda add-on group. CONCLUSION: Addition of Ayurveda formulation has reduced the time of recovery and duration of hospital stay. However, this formulation needs further investigated to provide more information on effective and safe herbal add-on to SOC for better outcomes to treatment of COVID-19 disease.

Heterotopic caval valve implantation in severe tricuspid regurgitation.

Severe symptomatic tricuspid regurgitation (TR) with right heart failure is associated with significant morbidity and mortality. Medical therapy is often ineffective and surgical correction is not feasible due to prohibitive perioperative risk. Transcatheter caval valve implantation (CAVI) is an evolving therapeutic option for this condition. It refers to the heterotopic placement of a valve into the inferior vena cava alone or with a second valve in the superior vena cava to restrict the backflow from the failing tricuspid valve. We hereby describe a patient with previous mitral valve surgery with chronic severe TR who underwent successful CAVI at our institute.

Combined off pump coronary artery bypass graft and liver transplant.

Background: Prospective recipients of liver transplant (LT) have a high prevalence rate of coronary artery disease (CAD) requiring revascularization. In patients of Child Turcot Pugh Class B and C performing LT prior to cardiac revascularization on cardiopulmonary bypass leads to a high risk of major adverse cardiovascular events (MACE). Whereas, isolated cardiac surgery prior to LT has perioperative risk of coagulopathy, sepsis, and hepatic decompensation. We present four cases of end stage liver disease who underwent concomitant living donor liver transplant (LDLT) with off pump coronary artery bypass graft (OPCAB) in an effort to decrease the morbidity and mortality. Methods: The cases were performed in a tertiary care centre over two years. Four patients scheduled for LDLT, who were diagnosed with significant CAD, underwent single sitting OPCAB and LDLT. Cardiac surgery was performed first and once patient was stable, it was followed by LDLT. The morbidity parameters in terms of duration of intubation, blood transfusion, hospital stay, ICU stay, requirement of dialysis, atrial fibrillation and sepsis was compared with similar studies. Results: The blood transfusion requirement (median 8 units PRBC), incidence of atrial fibrillation (25%), sepsis (25%), and renal dysfunction (0%) was less than the combined surgery conducted on cardiopulmonary bypass. The rate of median intubation time, length of ICU stay, hospital stay, and one year mortality rate was comparable with other studies. Conclusions: Morbidity with combined OPCAB and LDLT is less than combined on pump coronary artery bypass surgery with LDLT. Combined CABG with LDLT may be performed with acceptable outcomes in CTP class B and C cirrhosis.

Mobile digital x-ray and portable cartridge based nucleic acid amplification test machines for point-of-care diagnosis of TB in rural India.

BACKGROUND: There is no experience of point-of-care (POC) microbiological confirmation for TB in India in field settings. METHODS: Under the TB-Free Haryana project, a mobile van-mounted digital x-ray and portable GeneXpert system screened all presumptive TB patients with strong clinic-radiological suspicion for TB. RESULTS: Of 1673 x-rays, 215 (13%) had findings suggestive of TB, 109 had strong clinical suspicion and were eligible for POC GeneXpert, in whom a test was performed in 82 (75%) cases; 59 (72%) tested positive and were initiated on treatment within 24 h. CONCLUSIONS: A mobile van equipped with digital x-ray and POC GeneXpert is feasible and has a good success rate with potential for replication.

Aortic pulse wave velocity and its relationship with transaortic flow and gradients in patients with severe aortic stenosis undergoing aortic valve replacement.

BACKGROUND: Low-flow, low-gradient severe aortic stenosis (LFLGAS) is a common clinical entity and is associated with poor prognosis. Increased left ventricular (LV) afterload is one of the mechanisms contributing to low LV stroke volume index (SVi) in these patients. Aortic stiffness is an important determinant of LV afterload, but no previous study has evaluated its relationship with LVSVi in patients with AS. METHODS: Fifty-seven patients (mean age 66 ± 8 years, 71.9% men) with severe AS [aortic valve area (AVA) < 1.0 cm2] undergoing aortic valve replacement (AVR) were included in this study. Echocardiographic parameters of AS were correlated with carotid-femoral pulse wave velocity (cfPWV), a measure of aortic stiffness, derived using PeriScope® device. RESULTS: Mean AVA was 0.63 ± 0.17 cm2 with mean and peak transvalvular gradient 56.5 ± 18.8 mmHg and 83.2 ± 25.2 mmHg, respectively. Nearly half (26 of 57, 45.6%) of the subjects had SVi <35 mL/m2, indicative of low-flow severe AS. These subjects had lower AVA, lower aortic valve gradient, and LV ejection fraction. CfPWV was numerically lower in these subjects [median 1467 (interquartile range 978, 2259) vs 1588 (1106, 2167)] but the difference was not statistically significant (p = 0.66). However, when analyzed as a continuous variable, cfPWV had significant positive correlation with SVi (Pearson's r 0.268, p = 0.048) and mean aortic valve gradient (Pearson's r 0.274, p = 0.043). CONCLUSIONS: In patients with severe AS undergoing AVR, aortic stiffness measured using cfPWV is not a determinant of low-flow state. Instead, an increasing cfPWV tends to be associated with increasing transvalvular flow and gradient in these patients.

Implementing upfront mobile digital chest x-ray for tuberculosis diagnosis in India-feasibility and benefits.

BACKGROUND: The Tuberculosis (TB) Control Program in India changed the TB diagnostic algorithm and recommended sputum testing and chest x-ray (CXR) for presumptive TB up front. There is no experience of testing this algorithm in routine field settings. METHODS: In a public-private partnership (PPP), a private hospital provided mobile digital CXR services (mounted on a van) to complement the existing diagnostic services of sputum microscopy and GeneXpert testing. All presumptive TB patients (cough >2 weeks) underwent CXR and sputum microscopy, and GeneXpert testing if eligible (smear-negative CXR suggestive of TB). RESULTS: All 2973 presumptive TB patients underwent CXR and sputum microscopy; 471 (15.8%) had abnormal CXR findings suggestive of TB, 129 (4.3%) were smear positive and 17 were extrapulmonary TB. Of the remaining 325 with smear-negative and CXR suggestive of TB, 147 (45.2%) underwent GeneXpert testing, yielding 32 positives (21.8%). Of the remaining 178 with no GeneXpert test done, 106 (60.0%) had CXR definitely suggesting TB (clinically diagnosed TB). Thus a total of 284 cases of TB (161 microbiologically confirmed, 106 clinically diagnosed, 17 extrapulmonary TB) were identified, giving a potential diagnostic yield of 19.6%. CONCLUSIONS: Systematic screening with mobile digital X-ray service via a PPP model integrated into the national program is feasible and scalable with a high yield.

Immediate postoperative complications following coronary artery bypass grafting in patients with type 2 diabetes: A prospective cohort study.

AIMS: Several studies in patients with type 2 diabetes mellitus (T2DM) from the United States and European countries have demonstrated a higher risk of morbidity and mortality than those without T2DM following coronary artery bypass grafting (CABG). The data from Indian patients are scarce. Therefore, this study was carried out to focus on immediate postoperative complications following CABG in Indian patients. METHODS: Eighteen hundred consecutive patients who underwent elective CABG were included. Following exclusion criteria, a total of 1017 subjects were included for final analysis. 692 (68%) patients had T2DM and 325 (32%) patients had no T2DM. Data were obtained by collecting clinical data, routine biochemistry and chest imaging. Patients were followed up to 7 days postoperatively. RESULTS: At baseline, hypertension, triple vessel coronary artery disease, chronic kidney disease and peripheral vascular disease were more common in patients with T2DM. Intraoperatively, use of blood products and intra-aortic balloon pump were more common in T2DM patients. Postoperatively, 13.2% patients with T2DM developed acute kidney injury versus 5.3% in non-T2DM group. Requirement of dialysis was not different between groups (P = 0.394). Pneumonia occurred in 2 patients in both groups (P = 0.370). Catheter-associated urinary tract infections were similar in two groups (P = 0.507). Mortality occurred only in one T2DM patient and none in non-T2DM group (P = 0.618). CONCLUSIONS: A significant number of patients with T2DM developed acute kidney injury following CABG. There was no difference in infective complications such as pneumonia and catheter-associated urinary tract infection, between the two groups.

Fifth year of a public-private partnership to improve the case detection of tuberculosis in India: A role model for future action?

BACKGROUND: There is limited access to radiology facilities in most parts of India leading to significant under diagnosis and underreporting of smear negative clinically diagnosed tuberculosis (CDTB). Public Private Partnership (PPP) has a lot to contribute towards addressing this gap through providing access to chest x-ray (CXR) in far-off locations. METHOD: Mobile vans equipped with digital CXR equipment and support staff were provided by a Corporate Hospital working closely with government, with scheduled visits to government peripheral health institutes. Patients received upfront CXR and sputum microscopy along with GeneXpert in accordance with the revised TB diagnostic algorithm prescribed by the national program, Following a successful pilot in 2014 in district Rewari, "TB free Haryana" was launched in November 2015 with a phased roll out in 16 districts by 2018. RESULTS: The pilot initiative in 2014 confirmed practical and clinical feasibility and revealed a high rate (30% of people screened) of CDTB i.e. symptomatic cases with radiologic abnormalities compatible with Pulmonary TB. In the first year (2016), 5 districts were covered and a total of 3340 CXRs were carried out. There was an increase in the case notification rates of new CDTB (smear negative) in 2016 compared to 2015 (p = 0.036); yielding an additional 180 cases and an 11.67% increase in case detection. Scale up to a total of 13 and 16 districts took place successfully in 2017 and 2018 respectively; with 6268 CXRs and 8021 CXRs done in the respective years. CONCLUSION: PPP can involve Corporate Hospitals to improve the existing diagnostic infrastructure and provides access to CXR in a not-for-profit sustainable collaboration, with scale-up to the state level; and potential to replicate this initiative in other states.

Continuation of Metformin Till Night Before Surgery and Lactate Levels in Patients Undergoing Coronary Artery Bypass Graft Surgery.

BACKGROUND: Lactic acidosis is a rare but serious complication associated with metformin therapy in certain high-risk patients. NICE guidelines and the British National Formulary advise the discontinuation of metformin before surgery. The drug manufacturer's datasheet advises the withdrawal of metformin 48 h before surgery. However, the data regarding perioperative use of metformin is scarce. AIMS: To evaluate the effect of continuation of metformin till night before surgery on lactate levels in patients undergoing coronary artery bypass graft (CABG) surgery. MATERIALS AND METHODS: In this prospective cohort study, 1,800 consecutive patients who underwent CABG between 1st November 2015 and 31st October 2016 were enrolled. Following exclusion criteria, a total of 790 subjects were included for final analysis. Three-hundred and eight seven (48.9%) patients with diabetes received metformin till night before surgery (Met group), 239 (30.3%) patients with diabetes were non-metformin users (Non-Met group), and 164 (20.8%) patients were having no diabetes (Non-Diab group). Lactate levels and arterial pH were measured using arterial blood gas machine. Postoperative morbidity outcome data were obtained by collecting clinical data, routine biochemistry, and chest imaging. RESULTS: The mean metformin dose was 1,124.6 mg/day (SD: 509.3; range: 500-2,500 mg/day). Mean postoperative lactate levels were 1.91 ± 0.7 in Met group, 2.04 ± 0.79 in Non-Met group, and 2.07 ± 0.78 in Non-Diab group. Lactic acidosis occurred in 41 patients and there was no difference among the groups [Met group = 18 (4.7%); Non-Met group = 14 (5.9%)]. Among secondary outcome measures, acute renal failure occurred more frequently in diabetic patients [Met group = 46 (11.9%) and Non-Met group = 32 (13.4%)] as compared with non-diabetic patients. There were no differences with regard to pneumonia, length of ICU stay, and duration of ventilatory support among the three groups. CONCLUSIONS: Continuation of metformin till night before surgery is not associated with significant changes in lactate levels in patients undergoing CABG.