Outcome of individuals with alcoholic cirrhosis hospitalized with first decompensation and their predictors.

BACKGROUND OBJECTIVES: Alcohol is one of most common aetiologies of cirrhosis and decompensated cirrhosis is linked to higher morbidity and death rates. This study looked at the outcomes and mortality associated risk variables of individuals with alcoholic cirrhosis who had hospitalization with their first episode of decompensation. METHODS: Individuals with alcoholic cirrhosis who were hospitalized with the first episode of decompensation [acute decompensation (AD) or acute-on-chronic liver failure (ACLF)] were included in the study and were prospectively followed up until death or 90 days, whichever was earlier. RESULTS: Of the 227 study participants analyzed, 167 (73.56%) and 60 (26.43%) participants presented as AD and ACLF, respectively. In the ACLF group, the mortality rate at 90 days was higher than in the AD group (48.3 vs 32.3%, P=0.02). In the AD group, participants who initially presented with ascites as opposed to variceal haemorrhage had a greater mortality rate at 90 days (36.4 vs 17.1%, P=0.041). The chronic liver failure-consortium AD score and the lactate-free Asian Pacific Association for the study of the Liver-ACLF research consortium score best-predicted mortality in individuals with AD and ACLF. INTERPRETATION CONCLUSIONS: There is significant heterogeneity in the type of decompensation in individuals with alcoholic cirrhosis. We observed significantly high mortality rate among alcoholic participants hospitalized with initial decompensation; deaths occurring in more than one-third of study participants within 90 days.

Clinical Profile and Outcome of Patients presenting with Guillain - Barré Syndrome in a Medical Intensive Care Unit of a Tertiary Care Hospital.

BACKGROUND: Guillain-Barré syndrome (GBS) is an inflammatory, autoimmune disorder of the peripheral nervous system that is acute in onset, self-limited, and can result in significant morbidity, placing a burden on the healthcare system. This study aims to study the clinical profile and outcome of patients with GBS who require intensive care unit (ICU) and mechanical ventilation (MV). MATERIALS AND METHODS: After Institutional Ethics Committee approval, a single-center, prospective, observational study was conducted, recruiting 51 patients from the medical ICU with GBS over 18 months. Patients were categorized into three groups as per the timing of the commencement of immunomodulator therapy. The association between dependent variables like the need for MV, patient outcome, and independent factors like time of initiation of immunomodulator therapy from the time of onset of symptoms and age-groups; were analyzed using the Chi-squared test and the overall disability sum score (ODSS) with Spearman's rank correlation test. RESULTS: Out of 51 patients in the study, (52.94%) were male, with a male:female ratio of 1.12:1. Most of them had quadriparesis (98.04%) or bulbar symptoms (56.86%). A total of 24 (47.05%) patients required MV. The presence of bulbar weakness at admission had a statistically significant positive correlation with the need for MV (Spearman's ρ = 0.663, p = 0.001), the need for prolonged MV (Spearman's ρ = 0.457, p = 0.001), duration of MV (Spearman's ρ = 0.512, p = 0.001) and duration of ICU stay (Spearman's ρ = 0.516, p = 0.001); and a negative correlation with improvement in ODSS (Spearman's ρ = -0.409, p = 0.001). Early commencement of immunomodulator therapy was associated with a significantly decreased probability of requiring ventilatory support (p = 0.001), decreased probability of requiring prolonged MV (p = 0.04), and a decreased duration of ICU stay (p = 0.004). CONCLUSION: Early commencement of immunomodulator therapy decreased the probability of requiring ventilatory support and improved the outcome. Breathlessness and bulbar symptoms at admission were poor prognostic indicators in terms of the need for MV and the duration of both the ICU stay and MV.

Outcome of pharmacological thromboprophylaxis in hospitalized patients with cirrhosis - a systematic review and meta-analysis.

BACKGROUND: Portal hypertension in cirrhosis brings about a complex interplay in the risks of bleeding and thrombosis. It is unclear whether hospitalized patients with cirrhosis need pharmacological prophylaxis for venous thromboembolism (VTE), as it may increase the risk of bleeding. We aimed to compare the outcome of hospitalized patients with cirrhosis with and without pharmacological thromboprophylaxis. METHODS: A comprehensive search of three databases was conducted from inception to August 2022 for studies comparing the outcome of hospitalized patients with cirrhosis with and without pharmacological prophylaxis for VTE. Odds ratios (OR) with 95% confidence intervals (CIs) were calculated for the outcomes of VTE or bleeding. RESULTS: Overall, 12 studies were included in the final analysis. The pooled incidence of VTE in patients with and without thromboprophylaxis was 1.9% (95% CI: 0.8-2.9) and 1.9% (95% CI: 0.9-2.9), respectively. The odds of VTE were comparable between the groups with OR 1.11 (95% CI: 0.76-1.62). The pooled incidence of bleeding events in patients with and without thromboprophylaxis was 6.7% (95% CI: 3.6-9.8) and 10.4% (95% CI: 6.6-14.1), respectively. There was no significant difference in the odds of overall bleeding (OR 0.68; 95% CI: 0.30-1.52) or major bleeding (OR 1.18; 95% CI: 0.55-2.56) between the groups. There was no significant difference in the relative effects on sensitivity analysis. CONCLUSION: The present analysis could not demonstrate the benefit of pharmacological thromboprophylaxis in reducing in-hospital VTE in patients with cirrhosis. Future studies are required to assess the role of risk prediction models in hospitalized patients with cirrhosis.

Magnetic resonance cholangiopancreatography versus endoscopic ultrasound for diagnosis of choledocholithiasis: an updated systematic review and meta-analysis.

INTRODUCTION: Both endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are used for the diagnosis of choledocholithiasis (CDL). Previous studies have shown conflicting results regarding the optimal diagnostic strategy for suspected CDL; hence, this meta-analysis was conducted. METHODS: A comprehensive search of literature from 1990 till April 2022 was done of three databases for studies comparing EUS and MRCP to diagnose CDL. RESULTS: A total of 12 studies were identified. The pooled sensitivity and specificity for EUS were 0.96 [95% confidence interval (CI) 0.92-0.98], and 0.92 (95% CI 0.85-0.96), respectively. The pooled sensitivity and specificity for MRCP were 0.85 (95% CI 0.78-0.90) and 0.90 (95% CI 0.79-0.96), respectively. EUS had a higher relative sensitivity [Relative risk (RR) 1.12, 95% CI 1.05-1.19], a higher diagnostic accuracy (Odds ratio 1.98, 95% CI 1.35-2.90) but comparable specificity (RR 1.02, 95% CI 0.96-1.08) with MRCP. CONCLUSION: There is little difference concerning specificity, although EUS likely provides a higher sensitivity and accuracy for diagnosing CDL, compared to MRCP.

A Clinical Profile of Patients with Hyperuricemia and the Relationship between Hyperuricemia and Metabolic Syndrome: A Cross-sectional Study at a Tertiary Hospital in the Indian Population.

INTRODUCTION: Metabolic syndrome is a constellation of interrelated risk factors that increase the risk of cardiovascular diseases (CVD) and diabetes mellitus. The increase in prevalence of hyperuricemia was considered to be directly related to increasing incidence of obesity and Metabolic Syndrome in developing and developed countries. Hyperuricemia is defined as serum uric acid of 6.0mg/dl and 7.0mg/dl for females and males respectively. AIMS AND OBJECTIVES: To study correlation of hyperuricemia with metabolic syndrome or its components. MATERIALS AND METHODS: An observational, cross sectional single centre study with 316 patients fulfilling inclusion and exclusion criteria was carried out. RESULTS: Out of 316 patients, 202 (63.9%) were males and 114 (36.1%) were females. 138(43.7%) were from rural areas and 178 (56.3%) were from urban areas. 126 (39.9%) patients had an active lifestyle and 190 (60.1%) had a sedentary lifestyle. Mean waist circumference among114 females was 82.10 cm and among men was 87.07cm. 113 patients fulfilled the criteria for central obesity with the mean uric acid level of 8.14 mg/dl (p=0.001); Mean uric acid level of patients without central obesity was 7.36 mg/dl. 99 (31.33%) fulfilled the criteria for hypertriglyceridemia with mean s.uric acid level 8.24mg/dl (p=0.0440). 124 had elevated blood pressure with mean s.uric acid 8.28 mg/dl (p=0.004). Patients with normal blood pressure had a mean value of s. uric acid 7.86 mg/dl. 33.44% fulfilled the criteria for metabolic syndrome (41.23%of total females and 32.10% of total males). Odds ratio was 1.28 and 0.864 for females and males respectively. CONCLUSION: Prevalence of metabolic syndrome in patients with hyperuricemia was 35.4%. More common in females than males. Hyperuricemia is more prevalent in patients with a sedentary lifestyle. Hyperuricemia positively correlates with central obesity, blood pressure, hypertriglyceridemia and hyperglycemia. Hence, it is of utmost importance to screen patients of hyperuricemia for metabolic syndrome or its components to prevent mortality and morbidity associated with CVDs.

Clinical Study of Use of Remdesivir and Tocilizumab in Severely Ill COVID-19 Patients.

Introduction: Remdesivir and Tocilizumab are two experimental drugs used in severely ill COVID-19 patients. Various clinical trials studying these drugs are giving conflicting results. Our aim is to study these two drugs and share the experience in our setting. Methods: Our Study is a retrospective analysis of Clinico-laboratory details and outcome of three groups of patients who were given either (i) Remdesivir or (ii) Tocilizumab or (iii)both Remdesivir and Tocilizumab . We compared the outcome of these patients with other patients who did not receive either of these drugs, when it was not available or not introduced as experimental drugs earlier in treatment guidelines. Results: Out of a total of 521 patients, in the above three groups who received either or both Remdesivir or Tocilizumab, 334 survived. Out of 214 patients who did not receive any of the two drugs only 74 survived. The outcome was better individually for all the three groups of patients receiving either or both of the drugs as compared to neither of the drugs.(p <0.01) Conclusion: Remdesivir and Tocilizumab were useful drugs in treatment of severely ill covid -19 patients as compared with the patients who did not receive any of the above drugs.

Psychiatric Sequelae and COVID Experiences of Post COVID -19 Recovered Resident Doctors and Interns of a Tertiary General Hospital in Mumbai.

Background: The wide and profound psychological impact of the COVID pandemic on people has been demonstrated by several studies. A survey from the Indian Medical Association (IMA) showed that at least 500 doctors have been infected across Maharashtra, with Mumbai doctors making it to the top of the list. The most infected are the resident doctors working in government hospitals. A few doctors also have lost their lives while working in this pandemic. The delicate balance between duty, altruism and fear for oneself and others often causes conflict and feelings of helplessness and dissonance in many health care personnel with a fear to resume back the duty, especially after being a COVID victim. There have been hardly any studies yet, related to understanding the emotional and general well being of COVID-19 positive health care workers who have recovered and resumed their duties. Aims and Objectives: To study in post COVID-19 recovered resident doctors and interns the presence of anxiety and depressive symptoms, sleep changes, general well-being, perceptions of their COVID experience and association of general wellbeing with anxiety, depression and sleep changes. Methods: The study was conducted after institutional ethics committee permission and online informed consent from the participants which included medical interns and resident doctors of our institute. A Google form with questions and scales pertaining to the aims of the study (Patient Health Questionnaire, Zung Self Rating Anxiety Scale, Warwick Edinburgh Mental Well Being Scale and Insomnia Symptom Questionnaire) was sent on the Google link to the 150 interns and resident doctors via whatsapp who had recovered from COVID 19 infection. Their details were taken from hospital database with Dean permission. Results: 79 responded to the link with the mean duration of COVID infection being 16.1 ± 8.59 days. 64 participants were hospitalized and 18 participants had lung parenchymal involvement. 28 participants had depressive symptoms on the patient health questionnaire. Only 4 participants experienced anxiety as per Zung self rating anxiety scale. 69 participants had greater well being with scores higher than 40 on the Warwick Edinburgh mental well being scale. 8 participants had sleep related issues affecting their work. A negative correlation of general well being was seen with depression, anxiety and insomnia which was highly significant. The most distressing of COVID experiences were being isolated in a room, transmitting disease to near and dear ones and possibility of a serious complication. Re infection, workload followed by use of PPE was the major concern.Many described their COVID experience as boring, depressing with feelings of loneliness. Conclusions: Our study is the first of its kind to evaluate the psychiatric sequelae and COVID experiences of post COVID-19 recovered resident doctors and interns. Psychosocial and institutional support will definitely help in improving the post COVID sequelae in the resident doctors and interns.

Prescription pattern & adverse drug reactions of prokinetics.

Background & objectives: Prokinetics are extensively prescribed leading to several adverse events (AEs). The aim of this study was to assess the prescription pattern in patients receiving prokinetics, and characteristics of adverse drug reactions (ADRs) in an outpatient department set up in a tertiary care hospital in western India. Methods: Patients attending outpatient departments of a tertiary care hospital and who had received prokinetic agent for at least seven days over the last one month were enrolled. Causality assessment of AEs was done and assessed for severity, preventability, seriousness and predictability. Results: A total of 304 patients [161 males (52.96%); 143 females (47.04%)] were enrolled. Most prescriptions (299/304, 98%) included domperidone, most commonly prescribed as fixed-dose combination (FDC) with pantoprazole (274/304, 90%). Prokinetic dose was not mentioned in 251/304 (83%) prescriptions, and 18/304 (6%) did not mention frequency. Of the 378 AEs reported from 179 patients (47.35%), 306 (81%) were mild, all non-serious; 272 (72%) not preventable and 291 (77%) predictable in nature. Decreased appetite (n=31, 8.2%) and fatigue (n=27,7.14%) were most commonly reported. Causality assessment by the World Health Organization-Uppsala Monitoring Centre scale showed that 180 AEs were related to suspected drug (17 probable and 163 possible ADRs). Significant correlation was observed for AEs with increasing number of drugs per prescription (Spearman's R=+0.8, P =0.05) and with increasing therapy duration (Spearman's R=+1.00, P <0.001). Interpretation & conclusions: Our findings showed that prokinetics were often prescribed as FDCs, with incomplete prescriptions. Domperidone was found to be associated with multiple AEs. It is suggested that regular prescription monitoring should be done in hospitals to encourage rational use of drugs.