COVID-19: Clinical Course and Outcome of hospitalized Hemodialysis Patients: Single-center Experience.

BACKGROUND: There is a paucity of data regarding the consequences of coronavirus disease 2019 (COVID-19) infection in patients with maintenance hemodialysis (MHD). Our objective was to identify the clinical manifestations and prognostic factors and to assess the impact of treatment schemes on the outcomeMaterials and methods: Here we present retrospectively collected data from medical records of patients on MHD hospitalized with COVID-19 infection from 1st June to 30th November 2020Result: Around 69 patients were admitted with a median age of 51 years. About 81% had hypertension, 41% had diabetes, and 24% had body mass index (BMI) ≥ 23 kg/m2 . Of all who died, 73.33% had dialysis vintage of <12 months (p = 0.06). Common presenting symptoms were fatigue (67%), fever (58%), cough (42%), and dyspnea (35%). Milder, severe, and critical disease was found in 35, 45, and 20% of patients, respectively. About 54 patients were living 4 weeks after discharge. Around 15 patients died, that includes all who received invasive ventilatory support. Nonsurvivors were older and had lower oxygen saturation on admission, lower hemoglobin (Hb), and worst lactate dehydrogenase (LDH), interleukin (IL)-6, and D-dimer values than survivors, which were statistically significant. Use of remdesivir and anticoagulant improves chances of survival (p-value 0.035 and 0.034, respectively) Conclusion: About one-third of patients had mild disease. Those with critical disease displayed high mortality. Older age, male gender, short dialysis vintage, lower oxygen saturation on admission, anemia, leucocytosis, higher inflammatory markers [except C-reactive protein (CRP)], bilateral lung opacity, and requirement of the mechanical ventilator are poor prognostic factors. CRP, ferritin, and lymphopenia are not good prognostic markers unlike in the general population. These findings need to be verified in larger cohorts.

Safety and Tolerability of Remdesivir in Patients with End-stage Renal Disease on Maintenance Hemodialysis.

Introduction: The use of remdesivir is not recommended in patients with end-stage renal disease (ESRD) with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection unless potential advantage offset disadvantage due to limited safety data. Our objective was to assess the safety of remdesivir in patients with end-stage renal failure and evaluate the outcome of this vulnerable group. Methodology: We carried out a retrospective observational study in dialysis-dependent ESRD patients with SARS-CoV-2 infection who received a standard 5-day course of remdesivir (powder form) from June 2020 to December 2020. Oxygen requirement, hemogram, inflammatory markers, and liver function tests before and after remdesivir treatment were compared. Result: We found thirty-nine such patients with mean age of patients 58.79 ± 12.13 years. Diabetes mellitus, hypertension, and cardiac diseases were present in 58.97, 87.17, and 23.07% of patients, respectively. Mean oxygen saturation on admission was 85.41% (±7.73). There were no events of hepatotoxicity, altered behavior, or infusion reaction. There was statistically significant improvement in total leukocyte count, absolute lymphocyte counts, and C-reactive protein (p value <0.001, 0.01, and 0.02, respectively) post remdesivir treatment. A total of 60% of patients had improved oxygenation while 13% of patients had no change in oxygen requirement after completion of remdesivir course. Mortality in our study was 28.21%. We did not find any significant benefit of early remdesivir administration (3-6 days of illness) on mortality or days of hospitalization. Conclusion: The use of remdesivir in end-stage kidney disease is safe. Improvement in oxygenation was significant when baseline oxygen requirement was less. It requires prospective controlled trials with larger population to assess its impact on mortality. How to cite this article: Shah MK, Parikh M, Prajapati D, Kute VB, Bhende P, Prajapati A, et al. Safety and Tolerability of Remdesivir in Patients with End-stage Renal Disease on Maintenance Hemodialysis. Indian J Crit Care Med 2022;26(5):619-625.

Cognitive style assessment among medical students: A step towards achieving meta-cognitive integration in medical education.

Background: Knowledge of cognition and its regulation are important meta-cognitive activities, which are crucial for enhancement of learning. Their explicit teaching is meaningful and necessary yet seldom undertaken systematically in medical education programmes. Methods: We aimed to identify the cognitive styles using the Alert Scale of Cognitive Style among our undergraduate students. Students were also sensitized about different cognitive styles, their implications in strategic learning and the importance of meta-cognitive approach in education. Feedback from students was obtained to understand their awareness, perspectives and relevance of meta-cognitive concepts. Results: The intervention enhanced awareness of students about their own cognitive style and its implications to learning processes. The middle brain cognitive style was the most common (51.2%), followed by the right and the left brain cognitive styles (29.5% and 19.4%, respectively). A significant shift from the left towards the middle or the right cognitive style was observed in clinical years. No significant association was observed between a cognitive style and various variables such as age, gender and handedness. Conclusion: Incorporation of meta-cognitive learning practices in medical education offers a basis for enhancing classroom teaching, thereby making it learner-centric. The study helped students in identifying the way they process information and in identifying their preferred methods of assimilating knowledge. Identification of cognitive diversity is a primary pedagogic act for improving competence in learning. Meta-cognitive skills can be harnessed to bring about consonance of the left, right and middle brain cognitive styles to achieve better learning outcomes.

Critically ill obstetric patients requiring mechanical ventilation in rural western India: A retrospective analysis.

BACKGROUND: There is a dearth of studies on the clinical profile and therapeutic aspects of critically ill obstetric patients from rural areas, especially those requiring tertiary care support and ventilator therapy. METHODS: We retrospectively analysed the aetiological, clinical, interventional and outcome-related factors of obstetric patients requiring mechanical ventilation in western India. We analysed factors that influence seeking of antenatal care, pregnancy and its complications, severity assessment score, indications and initiation of mechanical ventilation, multiorgan failure and their correlation with maternal mortality. RESULTS: Of the 6708 obstetric admissions studied, 1112 were of critically ill (16.5%) patients and 200 (17%) of these required mechanical ventilation. Over three-fourths (77%) of patients were from rural areas, 83.5% were referred and 97% had inadequate antenatal care. Severe pregnancy-induced hypertension/eclampsia, massive haemorrhage and sepsis were the common obstetric complications. Pulmonary oedema (32.5%), acute respiratory distress syndrome (ARDS, 14%) and acute lung injury (22.5%) were the three most common indications for mechanical ventilation. In 26% of patients, mechanical ventilation was initiated early based on a worsening cardiorespiratory profile. A sequential organ failure assessment score of >5 on admission and delay in treatment resulted in multi-organ failure and worsening outcome. The maternal mortality ratio was 32.5%, incidence of multi-organ dysfunction syndrome was 71%, and pregnancy loss was 43.5%. The odds ratio for maternal mortality in patients ventilated early was 0.39 as against 5 in those with ARDS. CONCLUSIONS: Inadequate antenatal care, delayed referral practices, pregnancy-induced hypertension, obstetric haemorrhage and sepsis remain the major causes of complications in obstetric patients from rural areas. The common indications for mechanical ventilation were pulmonary oedema, ARDS and acute lung injury. Early initiation of mechanical ventilation upon detection of imminent.

Comparison of heart rate variability in normotensive and hypertensive Indian adults.

Autonomic imbalance is seen in hypertensive. This study was designed to compare heart rate variability in normotensive and hypertensive Indian adults. HRV records beat to beat variation in R-R intervals in milliseconds in electrocardiogram. Lead II ECG was recorded and a 5 minutes' stationary, artifacts free recording was selected for data analysis. HRV measures like total power was significantly less in hypertensive (303.37 ± 438.1) as compared to normotensive (534.16 ± 818.41). Standard deviation of normal-to-normal RR intervals was significantly reduced in hypertensive. A significant reduction of HRV was seen in hypertensive as compared to normotensive.

Study of effect of guided meditation on quality of life in patients of end stage renal disease (ESRD) on maintenance hemodialysis - a randomised controlled trial.

BACKGROUND: There is paucity of data regarding effects of guided meditation (Yoganidra) on quality of life among patients of chronic kidney disease on maintenance hemodialysis. Our objective was to study effects of guided meditation on physical, emotional, and cognitive dimensions of well-being and quality of life in patients undergoing maintenance hemodialysis. METHOD: We collected baseline and post intervention data in control and intervention groups on hemodialysis and studied the effect of Guided mediation provided for 6 weeks. RESULT: Eighty patients (forty in control and intervention group each) were studied. Mean age was 51 years. Hypertension and Diabetes were the most common etiological condition (28.75%) followed by undermined aetiology (25.00%). 8.75% of the patients had dialysis vintage of less than 1 year. There was statistically significant difference in qualities of happiness and all measures of physical general wellbeing. There was statistically significant difference in burden and effect of kidney disease as well as symptoms of kidney disease post intervention in Kidney Disease Quality of Life score. We carried out Qualitative analysis in our study by maintaining a diary of their subjective experiences related to listening music/guided meditation during the study period in which the feeling of peace and feeling inspired to manage the illness/ do regular work were the most common experiences (97.5%) reported by participants.  CONCLUSION: Guided meditation resulted in statistically significant improvement in happiness, enthusiasm, inspiration, activeness, alertness, awareness, degree of stability, self-confidence, clarity of thoughts, control over anger, self-reflection intervention in the intervention group. It reduced perceived stress. It improved burden and effect of kidney disease, symptoms of kidney disease and total Kidney Disease Quality of Life score. In qualitative dimensions of wellbeing (as emerging from analysis of results of diary), feeling of peace and feeling inspired to manage the illness/ continue regular work, clarity of thoughts, happiness, concentration, reduction of laziness, improved sleep pattern, reduction in anger among other psychological components. TRIAL REGISTRATION: This trial has been registered under clinical trial registry of India. (CTRI number-CTRI/2020/02/023438) (Date: 19/02/2020).

Ofloxacin Induced Hemolysis in G6PD-deficient Patient: A Rare Cause of Pigment Nephropathy.

Thrombotic microangiopathy (TMA) commonly presents as a triad of acute kidney injury (AKI), jaundice, and hemolysis; however, tropical infections such as malaria, dengue, leptospira, and drugs like antimalarials can also have a similar presentation. They can cause AKI for many reasons including pre-renal causes but an important yet not relatively uncommon genetic cause of hemolytic anemia, that is, glucose 6-phosphate deficiency (G6PD) manifesting as jaundice, hemolysis, and AKI secondary to pigment nephropathy after receiving offending drugs needs to be worked up while evaluating such patients. Ofloxacin is not usually included in the lists of unsafe drugs in G6PD deficiency. Herein, we report a patient developing intravascular hemolysis secondary to G6PD deficiency associated with ofloxacin administration presenting as a rare cause for pigment nephropathy.

Clinical Profile and Outcome of Coronavirus Disease-2019 Pneumonia in Kidney Transplant Recipients: A Single-center Study from Western India.

Coronavirus disease-2019 (COVID-19) has become a public health concern and global threat with high morbidity and mortality among kidney transplant recipients. However, risk factors and manifestations in this group of patients remain poorly understood. We aimed to study the clinical characteristics, laboratory parameters, and disease course of kidney transplant recipients with COVID-19 pneumonia. We enrolled 35 kidney transplant patients with COVID-19 pneumonia from March 2020 to November 2020 and studied their clinical records, laboratory results, radiological characteristics, and outcome. Their mean age was 44.82 ± 11.69 years (range: 17-65). The most common symptom was fever (94.28%) followed by cough (54.28%), fatigue (48.57%), shortness of breath (34.28%), and diarrhea/nausea/vomiting (22.85%). Leukopenia was seen in two patients (20.8%), and three patients had leukocytosis, while 75% of the patients had a white cell count in the normal range. Lymphopenia (<1100 per mm3) was seen in 23 patients (79%). All patients had elevated levels of C-reactive protein (CRP) with a range of 6-239.9 mg/L. An increase in serum creatinine from the baseline was seen in 25 patients (71.42%) with a mean of 2.62 mg/dL. Computerized tomography scan of the chest of 30 patients (85.71%) showed typical findings of multifocal ground glass shadows in both lung fields. Injection remdesivir was given in 28 patients (80%), and tocilizumab was given to three patients. Mortality was seen in six patients (17.14%), higher in those with O2 saturation <95% on admission (odds ratio: 6.29). Patients with kidney transplants display a high risk of mortality. The presence of multiple coexisting comorbidities, hypoxia at the time of admission, and high level of inflammatory markers (lactate dehydrogenase, CRP, D-dimer, and ferritin) is predictive of poorer outcomes.

Effect of Yoga-nidra on Adolescents Well-being: A Mixed Method Study.

CONTEXT: Adolescent well-being is a priority area for health-care interventions in the 21st century. Yoga-nidra is an ancient Indian method of enabling individuals to attain a positive state of deep physical, mental, and emotional relaxation. The practice produces a state of simultaneous relaxation and detachment resulting in inner awareness and release of stress on all planes of one's being. AIM: This mixed method study was carried out in adolescent students aged 13-15 years with an aim to assess effects of Yoga-nidra on various dimensions of well-being. MATERIALS AND METHODS: Thirty-six students received Yoga-nidra sessions 30 min daily for 3 days in a week for 1 month. Primary outcome measures were happiness, perceived stress, overall quality of life, and psychological general well-being. These and other experiential dimensions of well-being comprising of enthusiasm, alertness, quietude, clarity of thought, control over anger, self-confidence, and self-awareness were evaluated before and after intervention. Qualitative observations were recorded from participants, their teachers, and parents. Results of quantitative and qualitative methods were analyzed and compared. RESULTS: Yoga-nidra intervention resulted in significant improvement in all primary outcome measures. Participants reported significant improvement in the feelings of happiness, enthusiasm, quietude, being more inspired and alert, active, having clarity of thought, control over anger, and self-confidence at the end of the study period. Mixed method design of the study provided cross-validation and convergence of results obtained from quantitative and qualitative assessment tools. CONCLUSION: Yoga-nidra is beneficial in improving multiple dimensions of adolescent well-being.

Code Krishna: an innovative practice respecting death, dying and beyond.

In moments of grief, human beings seek solace and attempt to discover the meaning of life and death by reaching out to wider and deeper dimensions of existence that stem from their religious, cultural and spiritual beliefs. Conventional patient care fails to consider this vital aspect of our lives. Many hold the view that life and its experiences do not end with death; the body is but a sheath which holds the soul that inhabits it. The use of a protocol-based practice to create a solemn atmosphere around the departed individual can bridge the gap between the materialistic and non-materialistic perceptions of the dimensions of care. The innovative practice, "Code Krishna", is aimed at institutionalising a practice which sensitises and empowers the treating team to address the grief of the relatives of deceased patients, and respect the departed in consonance with the family's cultural, religious and spiritual beliefs. The practice entails the creation of a solemn atmosphere amidst the action-packed environment of the critical care unit at the time of the patient's death, offering of collective prayer and floral tributes, and observation of silence both by the healthcare team and family members. Code Krishna attempts to blend current care practices with spirituality, ensuring that the treating team is the first to commiserate with the grieving family, with warmth and openness. In this piece, we briefly report our first-hand experiences of practising Code Krishna in our hospital [Shree Krishna Hospital, Karamsad, Central Gujarat].

Aspergillus meningoencephalitis in a patient with human immunodeficiency virus infection: Normal cerebrospinal fluid does not mean absence of meningitis.

A male with human immunodeficiency virus infection presented with febrile encephalopathy followed by seizures and left hemiparesis. Initial imaging with contrast computerized tomography (CT) scan brain and cerebrospinal fluid (CSF) examination were normal. Subsequent magnetic resonance imaging brain revealed bilateral parieto-occipital infarcts with bleed. He did not improve on treatment with broad-spectrum antibiotics, anti-tubercular drugs, and antifungals. He finally succumbed to the disease. His CSF culture grew Aspergillus after 2 weeks. Central nervous system (CNS) aspergillosis can present with variable presentations, and initial CT scan and CSF examination can be normal, especially in the immunosuppressed. High index of suspicion is required for the diagnosis of invasive CNS Aspergillus in the immunosuppressed.