Comparison of a Novel Score "NOD-ACLF" to Other Established Prognostic Scores for Prediction of Mortality in APASL-ACLF Patients: A Cohort Study from a Tertiary Care Center of North India.

Background: Commonly used prognostic scores for acute on-chronic liver failure (ACLF) have complex calculations. We tried to compare the simple counting of numbers and types of organ dysfunction to these scores, to predict mortality in ACLF patients. Methods: In this prospective cohort study, ACLF patients diagnosed on the basis of Asia Pacific Association for Study of the Liver (APASL) definition were included. Severity scores were calculated. Prognostic factors for outcome were analysed. A new score, the Number of Organ Dysfunctions in Acute-on-Chronic Liver Failure (NOD-ACLF) score was developed. Results: Among 80 ACLF patients, 74 (92.5%) were male, and 6 were female (7.5%). The mean age was 41.0±10.7 (18-70) years. Profile of acute insult was; alcohol 48 (60%), sepsis 30 (37.5%), variceal bleeding 22 (27.5%), viral 8 (10%), and drug-induced 3 (3.8%). Profiles of chronic insults were alcohol 61 (76.3%), viral 20 (25%), autoimmune 3 (3.8%), and non-alcoholic steatohepatitis 2 (2.5%). Thirty-eight (47.5%) were discharged, and 42 (52.5%) expired. The mean number of organ dysfunction (NOD-ACLF score) was ->4.5, simple organ failure count (SOFC) score was >2.5, APASL ACLF Research Consortium score was >11.5, Model for End-Stage Liver Disease-Lactate (MELD-LA) score was >21.5, and presence of cardiovascular and respiratory dysfunctions were significantly associated with mortality. NOD-ACLF and SOFC scores had the highest area under the receiver operating characteristic to predict mortality among all these. Conclusion: The NOD-ACLF score is easy to calculate bedside and is a good predictor of mortality in ACLF patients performing similar or better to other scores.

Size and Number of Gastric Varices Decide Amount of Glue Injected during Endoscopic Therapy.

INTRODUCTION: Cyanoacrylate glue injection has become standard of care for acutely bleeding as well as for primary and secondary prophylaxis of high risk gastric varices. There is limited data on safe and effective amount of glue injected. Our study was aimed to fulfill the gap. MATERIALS: It was retrospective analysis of endoscopy laboratory chart, videos and corresponding case sheets of all consecutive endoscopies January to September 2022. Number, type and size of gastric varices, amount of glue injected and outcomes (technical success, intra procedural and post-procedural complications) were noted. RESULT: Among 337 upper gastrointestinal endoscopies performed during the study period, 12 patients had gastric varices. 3 had GOV1F1, 2 had GOV1F2, 8 had GOV2F2, 1 had GOV2F3 and one had isolated gastric varices, IGV2F1. 4 patients had history of upper GI bleed. 3 had one, 4 had two and 3 had three varices. 3 patients had <0.5 cm and 8 had >0.5 cm size varices. Cyanoacrylate glue was injected in 4 patients. Technical success was achieved in all (100%) patients. The amount of Cyanoacrylate glue injected was decided by the size and number of varices and varied between 1-4 ml depending on the above factors. Two patients had intra-procedural, self subsiding bleeding, one patient had severe abdominal pain needing intramuscular analgesic. None had fatal complication. CONCLUSION: Size and numbers of gastric varices are deciding factors for amount of glue injected during endotherapy. References Kumar A, Singh S, Madan K, et al. Undiluted N-butyl cyanoacrylate is safe and effective for gastric variceal bleeding. Gastrointest Endosc 2010;72(4):721-727. Saraswat VA, Verma A. Gluing gastric varices in 2012: lessons learnt over 25 years. J Clin Exp Hepatol 2012;2(1):55-69.

Dengue Encephalitis Versus Japanese Encephalitis in Cases of Dengue Fever With Altered Sensorium: A Diagnostic Dilemma.

Dengue and Japanese encephalitis (JE) are diseases that often conquer the top headlines in the leading newspapers during epidemics. Although recovery is the rule in most dengue cases, some unfortunately land up with multiple organ dysfunction syndromes, get critical, and even succumb to death. The main risk here is bleeding due to thrombocytopenia and platelet dysfunction. On the other hand, JE often presents with acute encephalitis syndrome (AES). We report a confirmed case of dengue (NS1 reactive, IgM dengue positive) by enzyme-linked immunosorbent assay (ELISA) who developed sudden onset altered sensorium. Non-contrast computed tomography (NCCT) head was done, which showed an infarct in the right gangliocapsular region with normal-sized ventricles. The patient had deteriorated in the past four days, which warranted a repeat NCCT head, revealing dilated ventricles and hemorrhagic transformation in the old infarct with surrounding edema. CSF viral markers were suggestive of IgM anti-JE virus positive. An MRI brain was planned but could not be done due to the deteriorating condition of the patient. Unfortunately, the patient landed up with multiple organ dysfunction syndrome and succumbed to death.

Type 2 Diabetes Mellitus in a Young Female Later Diagnosed as​​​​ Pancreatogenic Diabetes: The Dilemma in Classifying Diabetes Mellitus.

Diabetes mellitus type 3c (DM3c) is a diabetes caused by pancreatic pathology. It occurs due to the destruction of the endocrine islet cells. Diabetes diagnosed at the age of 20-30 years share a common dilemma in segregating between the type of diabetes the patient has, as its management varies depending on the type of diabetes the patient is harboring. However, insulin remains the treatment of choice in later decades as the pancreatic reserves of beta cells exhaust, although it takes decades to happen. We report a case of a woman who was diagnosed with diabetes mellitus at the age of 26, was on oral hypoglycemic agents (OHA), and was shifted to insulin therapy as she became non-responsive to OHA in a short span of six years, which was alarming. The patient presented to us with the chief complaints of recurrent abdominal pain that aggravated on taking meals and was associated with multiple episodes of vomiting for two months. Blood gas analysis on admission had no evidence of metabolic acidosis, urine ketones were negative, and a random blood sugar test (RBS:202) excluded the possibility of diabetic ketoacidosis. Serum amylase and serum lipase were within normal limits. Contrast-enhanced computed tomography (CECT) of the abdomen was suggestive of the atrophic pancreas with the non-dilated main pancreatic duct. Magnetic resonance cholangiopancreatography (MRCP) was done to rule out the congenital anomalies of the pancreas responsible for chronic pancreatitis, which showed no structural abnormalities. During our clinical workup, we postulated that the diabetes she was diagnosed with at the age of 26 was DM3c, i.e., pancreatogenic diabetes. The rapid shift of patients from OHA to subcutaneous insulin in a short span must be alarming to the physician managing diabetes and needs extensive workup to look upon the etiology of the same.

Cytomegalovirus Coinfection in Critically Ill Patients with Novel Coronavirus-2019 Disease: Pathogens or Spectators?

Coronavirus disease-2019 (COVID-19) pandemic is raging all over the world. As we are delving more into management of COVID-19, certain new challenges are emerging. One of these is emergence or reactivation of viral infections belonging to Herpesviridae family, especially cytomegalovirus (CMV). Although we have come across the threat of fungal and resistant bacterial infections, experience regarding reactivation or coinfection with concomitant viral infections like CMV during the COVID pandemic is still limited. Whether CMV is a bystander or pathogen is difficult to say categorically and needs further research. In this case series, we intend to describe three patients of COVID-19 with CMV coinfections. To our knowledge, this is the first case series from India. How to cite this article: Siddiqui SS, Chatterjee S, Yadav A, Rai N, Agrawal A, Gurjar M, et al. Cytomegalovirus Coinfection in Critically Ill Patients with Novel Coronavirus-2019 Disease: Pathogens or Spectators? Indian J Crit Care Med 2022;26(3):376-380.

Prognostic Factors in Patients Hospitalized with Diabetic Ketoacidosis.

BACKGROUND: Diabetic ketoacidosis (DKA) is characterized by a biochemical triad of hyperglycemia, acidosis, and ketonemia. This condition is life-threatening despite improvements in diabetic care. The purpose of this study was to evaluate the clinical and biochemical prognostic markers of DKA. We assessed correlations in prognostic markers with DKA-associated morbidity and mortality. METHODS: Two hundred and seventy patients that were hospitalized with DKA over a period of 2 years were evaluated clinically and by laboratory tests. Serial assays of serum electrolytes, glucose, and blood pH were performed, and clinical outcome was noted as either discharged to home or death. RESULTS: The analysis indicated that significant predictors included sex, history of type 1 diabetes mellitus or type 2 diabetes mellitus, systolic blood pressure, diastolic blood pressure, total leukocyte count, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, blood urea nitrogen, serum creatinine, serum magnesium, serum phosphate, serum osmolality, serum glutamic oxaloacetic transaminases, serum glutamic pyruvic transaminases, serum albumin, which were further regressed and subjected to multivariate logistic regression (MLR) analysis. The MLR analysis indicated that males were 7.93 times more likely to have favorable outcome compared with female patients (odds ratio, 7.93; 95% confidence interval, 3.99 to 13.51), while decreases in mean APACHE II score (14.83) and serum phosphate (4.38) at presentation may lead to 2.86- and 2.71-fold better outcomes, respectively, compared with higher levels (APACHE II score, 25.00; serum phosphate, 6.04). CONCLUSION: Sex, baseline biochemical parameters such as APACHE II score, and phosphate level were important predictors of the DKA-associated mortality.

Scorpion bite, a sting to the heart!

Scorpion bites are common in India. Usually, these bites are harmless but sometimes have serious clinical sequelae, including death. We report herein a case of scorpion bite with electrocardiographic abnormalities simulating early myocardial infarction. Pulmonary edema and congestive heart failure accompanied these electrocardiographic changes as well as serum cardiac markers. The etiology of cardiovascular manifestations in severe scorpion sting is related to venom effect on sympathetic nervous system and the adrenal secretion of catecholamines as well as to the toxic effect of the venom on the myocardium itself. It is a rare case of scorpion sting presented as myocardial infarction and heart failure, successfully treated with Intensive Care Unit care, noninvasive ventilation, vasopressors, and antiischemic treatment.