Rapid N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) Kit as a Differentiating Tool for Acute Dyspnea in a Resource-Limited Setting.

Introduction Dyspnea is among the most prevalent symptoms experienced by patients presenting as an emergency. The underlying etiology is often a cardiovascular or pulmonary condition, of which heart failure is recognized as a major contributor. The differentials are primarily established based on the patient's clinical presentation and physical examinations but are not conclusive. Of the various investigations undertaken to determine the cause of dyspnea, the biomarker N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) was found to be significantly associated with heart failure. Its level has been proven to be in direct correlation with the severity of the disease. This study demonstrates the usability of an economical rapid test kit in measuring NT-ProBNP levels to help differentiate the cause of dyspnea in the presenting patient in a resource-limited setting. Methodology We studied 115 participants from a tertiary care center in India, which included 70 males and 45 females aged ≤30 to ≥75 years, presenting with shortness of breath. Rapid NT-ProBNP tests were conducted alongside recording their symptoms, vitals, examination findings, and other parameters. They were also classified according to New York Heart Association (NYHA) Classification, and further investigated. Results The study elucidated the efficacy and accuracy of the rapid kits in determining NT-ProBNP levels, and its relation with the severity and prognosis of heart failure. The kits utilized had a sensitivity of greater than 93% for ruling out heart failure as a cause of dyspnea, and a sensitivity of greater than 96% for ruling out elevated NT-ProBNP levels in general. Other parameters such as presenting symptoms and vitals were also analyzed, establishing a correlation with NT-ProBNP levels.  Conclusion This study guided us in understanding the effective utilization of the rapid testing kits for emergency care, minimizing the burden on other limited resources. The lower cost and ease of use would serve as a quick means of reaching a conclusive diagnosis, especially in an emergency, which in turn would aid in receiving timely and specific treatment. These kits could act as a stepping stone in creating a sustainable and efficient healthcare system for patients as well as healthcare workers.

Analysis of Predictors and Outcomes of COVID-19 Patients Requiring ICU Admission from COVID-19 Registry, India.

Background: Patients admitted to intensive care units (ICUs) with severe coronavirus disease (COVID-19) are associated with high mortality. The present retrospective, multicenter study describes the predictors and outcomes of COVID-19 patients requiring ICU admission from COVID-19 Registry of Indian Council of Medical Research (ICMR), India. Materials and methods: Prospectively collected data from participating institutions were entered into the electronic National Clinical Registry of COVID-19. We enrolled patients aged >18 years with COVID-19 pneumonia requiring ICU admission between March 2020 and August 2021. Exclusion criteria were negative in RT-PCR report, death within 24 hours of ICU admission, or incomplete data. Their demographic and laboratory variables, ICU severity indices, treatment strategies, and outcomes were analyzed. Results: A total of 5,865 patients were enrolled. Overall mortality was 43.2%. Non-survivors were older (58.2 ± 15.4 vs 53.6 ± 14.7 years; p = 0.001), had multiple comorbidities (33.2% vs 29.5%, p = 0.001), had higher median D-dimer (1.56 vs 1.37, p = 0.015), higher CT severity index (16.8 ± 5.2 vs 13.5 ± 5.47, p = 0.001) and longer median hospital stay (10 vs 8 days, p = 0.001) and ICU stay (5 vs 4 days, p = 0.001), compared with survivors.On multivariate analysis, high CRP (HR 1.008, 95% CI: 1.006-1.010, p = 0.001) and high D-dimer (HR 1.089, 95% CI: 1.065-1.113, p < 0.001) were associated with invasive mechanical ventilation while older age (HR 1.19, CI: 1.001-1.038, p = 0.039) and high D-dimer (HR-1.121, CI: 1.072-1.172, p = 0.001) were independently associated with mortality and while the use of prophylactic low molecular weight heparin (LMWH) (HR 0.647, CI: 0.527-0.794, p = 0.001) lowered mortality. Conclusion: Among 5,865 COVID-19 patients admitted to ICU, mortality was 43.5%. High CRP and D-dimers were independently associated with the need for invasive mechanical ventilation while older age and high D-dimer were associated with higher mortality. The use of prophylactic LMWH independently reduced mortality. How to cite this article: Kajal K, Singla K, Puri GD, Bhalla A, Mukherjee A, Kumar G, et al. Analysis of Predictors and Outcomes of COVID-19 Patients Requiring ICU Admission from COVID-19 Registry, India. Indian J Crit Care Med 2023;27(8):552-562.

Evaluation of a Hospitalized Pediatric COVID-19 Cohort from Indian National Clinical Registry of COVID-19.

OBJECTIVE: To evaluate the factors associated with mortality of a multicentric cohort of hospitalized COVID-19 patients, 0-18 y old, from 42 centers across India. METHODS: The National Clinical Registry for COVID-19 (NCRC) is an on-going prospective data collection platform enrolling COVID-19 patients diagnosed by real-time PCR or rapid antigen test. The data are collected in prestructured e-capture forms. The sociodemographic, clinical, laboratory, and hospital outcome data from 1st September 2020 to 20th February 2022 were analyzed. RESULTS: Of the 1244 enrolled hospitalized COVID-19 patients aged 0-18 y, 98 and 124 were infants and neonates, respectively. Only 68.6% children were symptomatic at admission, with fever being the most common symptom. Diarrhea, rash, and neurological symptoms were also noted. At least 1 comorbidity was present in 260 (21%) children. The in-hospital mortality rate was 6.2% (n = 67), the highest in infants (12.5%). Altered sensorium (aOR: 6.8, CI: 1.9, 24.6), WHO ordinal scale ≥ 4 at admission (aOR: 19.6, CI: 8.0, 47.8), and malignancy (aOR: 8.9, 95% CI: 2.4, 32.3) were associated with higher odds of death. Malnutrition did not affect the outcome. Mortality rates were similar across the three waves of the pandemic, though a significant shift towards the under-five group was observed in the third wave. CONCLUSION: This multicentric cohort of admitted Indian children showed that the COVID-19 was milder in children than adults, and the pattern was consistent across all waves of the pandemic.

Intracranial Tuberculoma in a Pregnant Lady: A Hitherto Unknown Case and a Successful Outcome.

Central nervous system tuberculosis (CNS-TB) is rarely suspected in pregnancy because its clinical presentation may masquerade other common conditions in pregnancy, such as eclampsia. In high tuberculosis endemic areas, CNS-TB should be suspected with a high degree of suspicion among unimmunized and immunocompromised individuals. We hereby report a case of a 32-year-old pregnant woman conceived by in vitro fertilization due to tubal blockage causing infertility, probably due to chronic infection, who presented with a history of multiple seizure episodes without a history of similar complaints outside this pregnancy. Obstetric examination revealed a gravid uterus larger than the corresponding gestational age, and an antenatal scan confirmed dichorionic diamniotic twins with the first twin in the breech and the second twin in the cephalic presentation. Magnetic resonance imaging of the brain revealed multiple nodular lesions of varying sizes that were isointense on T1-weighted imaging and hypointense on T2-weighted imaging in multiple regions of the brain, which suggest tuberculomas. A preterm cesarean section was performed at 31 weeks gestational age due to preterm rupture of membranes. We report this case to enlighten the physicians in diagnosing seizures causing intracranial tuberculoma in pregnant women and utilizing the role of imaging in diagnosis.

A comparative study of antibody response, virus neutralization efficiency & metabolites in SARS-CoV-2-infected adults & children.

Background & objectives: COVID-19 has been a global pandemic since early 2020. It has diverse clinical manifestations, but consistent immunological and metabolic correlates of disease severity and protection are not clear. This study was undertaken to compare seropositivity rate, antibody levels against nucleocapsid and spike proteins, virus neutralization and metabolites between adult and child COVID-19 patients. Methods: Plasma samples from naïve control (n=14) and reverse transcription (RT)-PCR positive COVID-19 participants (n=132) were tested for reactivity with nucleocapsid and spike proteins by ELISA, neutralization of SARS-CoV-2 infectivity in Vero cells and metabolites by [1]H nuclear magnetic resonance (NMR) spectroscopy. Results: An ELISA platform was developed using nucleocapsid and spike proteins for COVID-19 serosurvey. The participants showed greater seropositivity for nucleocapsid (72%) than spike (55.3%), and males showed higher seropositivity than females for both the proteins. Antibody levels to both the proteins were higher in intensive care unit (ICU) than ward patients. Children showed lower seropositivity and antibody levels than adults. In contrast to ICU adults (81.3%), ICU children (33.3%) showed lower seropositivity for spike. Notably, the neutralization efficiency correlated with levels of anti-nucleocapsid antibodies. The levels of plasma metabolites were perturbed differentially in COVID-19 patients as compared with the naive controls. Interpretation & conclusions: Our results reflect the complexity of human immune response and metabolome to SARS-CoV-2 infection. While innate and cellular immune responses are likely to be a major determinant of disease severity and protection, antibodies to multiple viral proteins likely affect COVID-19 pathogenesis. In children, not adults, lower seropositivity rate for spike was associated with disease severity.

Subcutaneous Emphysema and Pneumomediastinum Following Non-invasive Ventilation in a Patient With Severe COVID-19 Disease.

Subcutaneous emphysema (SE) and pneumomediastinum are rare complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While SE is often non-fatal and usually self-remitting, pneumomediastinum can be fatal with high mortality rates depending on the underlying etiology. Here, we present the case of a 39-year-old otherwise healthy male who tested positive for SARS-CoV-2. The patient was treated with non-invasive mechanical ventilation (NIMV) and developed severe SE and pneumomediastinum which resulted in a fatal outcome. Although the exact pathogenesis could not be determined, the extensive lung injury caused by SARS-CoV-2 pneumonia along with possible barotrauma secondary to NIMV could have been the culprits in this case. Early detection through careful observation of these potentially fatal complications in patients with severe coronavirus disease 2019 is crucial. Further studies determining the potential risk factors and incidence of SE and pneumomediastinum, especially in patients receiving invasive mechanical ventilation or NIMV, are needed.

Clinical and whole genome characterization of SARS-CoV-2 in India.

We report clinical profile of hundred and nine patients with SARS CoV-2 infection, and whole genome sequences (WGS) of seven virus isolates from the first reported cases in India, with various international travel histories. Comorbidities such as diabetes, hypertension, and cardiovascular disease were frequently associated with severity of the disease. WBC and neutrophil counts showed an increase, while lymphocyte counts decreased in patients with severe infection suggesting a possible neutrophil mediated organ damage, while immune activity may be diminished with decrease in lymphocytes leading to disease severity. Increase in SGOT, SGPT and blood urea suggests the functional deficiencies of liver, heart, and kidney in patients who succumbed to the disease when compared to the group of recovered patients. The WGS analysis showed that these isolates were classified into two clades: I/A3i, and A2a (four according to GISAID: O, L, GR, and GH). Further, WGS phylogeny and travel history together indicate possible transmission from Middle East and Europe. Three S protein variants: Wuhan reference, D614G, and Y28H were identified predicted to possess different binding affinities to host ACE2.