Clinical characteristics and outcomes in pseudomonas endocarditis: a systematic review of individual cases : Systematic review of pseudomonas endocarditis.

BACKGROUND: The landscape of Pseudomonas infective endocarditis (IE) is evolving with the widespread use of cardiac implantable devices and hospital-acquired infections. This systematic review aimed to evaluate the emerging risk factors and outcomes in Pseudomonas IE. METHODS: A literature search was performed in major electronic databases (PubMed, Scopus, and Google Scholar) with appropriate keywords and combinations till November 2023. We recorded data for risk factors, diagnostic and treatment modalities. This study is registered with PROSPERO, CRD42023442807. RESULTS: A total of 218 cases (131 articles) were included. Intravenous drug use (IDUs) and prosthetic valve endocarditis (PVE) were major risk factors for IE (37.6% and 22%). However, the prosthetic valve was the predominant risk factor in the last two decades (23.5%). Paravalvular complications (paravalvular leak, abscess, or pseudoaneurysm) were described in 40 cases (18%), and the vast majority belonged to the aortic valve (70%). The mean time from symptom onset to presentation was 14 days. The incidence of difficult-to-treat resistant (DTR) pseudomonas was 7.4%. Valve replacement was performed in 57.3% of cases. Combination antibiotics were used in most cases (77%), with the aminoglycosides-based combination being the most frequently used (66%). The overall mortality rate was 26.1%. The recurrence rate was 11.2%. Almost half of these patients were IDUs (47%), and most had aortic valve endocarditis (76%). CONCLUSIONS: This review highlights the changing epidemiology of Pseudomonas endocarditis with the emergence of prosthetic valve infections. Acute presentation and associated high mortality are characteristic of Pseudomonas IE and require aggressive diagnostic and therapeutic approach.

Abnormal Body Composition Increases the Cardiometabolic Risk in Adolescents and Young Adults With Turner Syndrome.

OBJECTIVE: To determine the cardiometabolic risk of adolescents and adults with Turner syndrome (TS) and whether and how anthropometry and body composition predict this risk. METHODS: We compared the anthropometric, biochemical, and dual-energy x-ray absorptiometry-derived body composition parameters of 103 girls and women with TS aged 12 to 30 years and 103 controls of the same age and body mass index: (1) between TS with and without metabolic syndrome (MetS), (2) between the different karyotypes of TS, and (3) between growth hormone recipients and nonrecipients. RESULTS: Individuals with TS had higher prevalence rates of truncal obesity (57.2%), MetS (37.9%), prediabetes (20.4%), dyslipidemia (73.8%), hypertension (9.7%), and hepatic steatosis (15.5%) and a greater total body fat percentage (38.43% vs 34.26%) and fat mass index (9.15 vs 6.71 kg/m2) but a lower lean mass index (11.05 vs 12.49 kg/m2) than controls (P <.001). Individuals with TS and MetS (n = 39) had a higher total body fat percentage (41.74% vs 36.42%, P <.0001), truncal fat percentage (44.66% vs 36.09%, P <.0001), and visceral adipose tissue mass (495.57 vs 276 g, P <.0001) than those with TS but without MetS. Those with classic TS (45,X) had a higher prevalence of prediabetes (32.6% vs 10.5%, P =.01). Growth hormone recipients had a lower prevalence of MetS and lesser truncal obesity. Altered body composition was significantly correlated with metabolic risk. The truncal fat percentage independently predicted MetS (odds ratio, 1.12; 95% confidence interval, 1.003-1.24; P =.04). Waist circumference and waist-hip ratio predicted metabolic risk with good sensitivity and specificity. CONCLUSION: Adverse cardiometabolic risk and altered body composition start early in life in TS. Postpubertal women with TS should be routinely assessed for truncal obesity, dysglycemia, dyslipidemia, and liver steatosis, irrespective of body mass index and karyotype.

Cutoff values of body fat composition to predict metabolic risk factors with normal waist circumference in Asian Indian population.

OBJECTIVES: The aim of the study is to see if visceral fat volume (VFV), subcutaneous fat volume (SFV), and visceral-subcutaneous fat ratio (VSR) can be used to detect metabolically obese normal weight individuals in Asian Indian population. METHODS: This is a single center prospective cross-sectional study and 80 cases having either hypertension, diabetes, or hyperlipidemia with normal waist circumference and 80 controls having normal metabolic parameters with normal waist circumference were evaluated. Visceral and subcutaneous fat volumes and visceral to subcutaneous fat ratios were determined by computed tomography (CT) at L4-L5 level with a slice thickness of 5 mm. RESULTS: Visceral fat volume, subcutaneous fat volume, and VSR are significantly higher in patients with metabolic risk factors as compared to those without risk factors. Volume of subcutaneous fat is significantly higher in females as compared to males. VSR is higher in males in our study. The cutoff values for VFV, SFV, and VSR to predict at least one metabolic syndrome are 8.5 cm3, 15.7 cm3, and 0.61 in males and 7.0 cm3, 16.5 cm3, and 0.44 in females. CONCLUSIONS: For individuals with normal waist circumference, VFV, SFV, and VSR can effectively predict the presence of one metabolic risk factor. KEY POINTS: • Visceral fat volume, subcutaneous fat volume, and visceral-subcutaneous fat ratio can predict individuals at risk of metabolic syndrome having normal waist circumference. • Higher VSR in Indian population is due to low reservoir of primary adipose tissue fat compartment which leads to diversion of adipocytes into the secondary adipose tissue fat compartment. • This data can be used as a screening tool in preventive radiology for identifying individuals at risk of developing metabolic syndrome.

Musculoskeletal disorders among doctors and nursing officers : an occupational hazard of overstrained healthcare delivery system in western Rajasthan, India.

BACKGROUND: The present study was conducted to estimate the prevalence and distribution of MSDs in different anatomical regions among Doctors and NO and to determine their ergonomic risk factors and predictors. METHODS: This cross-sectional study was conducted in an apex institution in Western India. The socio-demographic information, medical and occupational history, and other personal and work-related attributes were captured using a semi-structured questionnaire, which was developed and finalized by piloting on 32 participants (who were not part of the study). Nordic Musculoskeletal and International Physical Activity Questionnaires were used to assess MSDs and Physical activity. Data were analyzed using SPSS v.23. Prevalence of Musculoskeletal Symptoms (M.S.), Multisite Musculoskeletal Symptoms (MMS), and Widespread Musculoskeletal Symptoms (WMS) were calculated. A comparison was made to estimate the burden and distribution of MSD among Doctors and Nursing officers. Logistic regression was applied to identify the predictors of MSDs and pinpoint the risk factors associated with MSDs. RESULTS: A total of 310 participants, of which 38.7% were doctors, and 61.3% were Nursing Officers (NOs) were included in the study. The mean age of the respondents was 31.63 ± 4.9 years. Almost 73% (95%CI: 67.9-78.1) of participants had MSD in the last 12 months, with approximately 41.6% (95%CI: 36.1-47.3) suffering from MSDs in the previous seven days of the survey. The lower back (49.7%) and the neck (36.5%) were the most affected sites. Working in the same position for a long time (43.5%) and not taking adequate breaks (31.3%) were the highest self-reported risk factors. Females had significantly higher odds of having pain in the upper back [aOR:2.49(1.27-4.85)], neck [aOR:2.15(1.22-3.77)], shoulder [aOR:2.8 (1.54-5.11)], hips [aOR:9.46 (3.95-22.68)] and knee [aOR:3.8(1.99-7.26)]. CONCLUSIONS: Females, who are NOs, work for > 48 h per week, and fall in the obese category were significantly at more risk of developing MSDs. Working in an awkward position, treating an excessive number of patients in a day, working in the same position for a long period, performing repeated tasks, and not having enough rest breaks were significant risk factors for MSDs.

Delayed Compression Paralysis Following an Iliopsoas Hematoma 30 Days After Saw-Scaled Viper (Echis carinatus sochureki) Envenoming: A Case Report.

Snakebite envenoming is a neglected tropical disease disproportionately affecting the rural and marginalized population in low-middle-income countries. The saw-scaled viper (Echis carinatus) is a clinically important snake that causes serious morbidity and mortality in the Indian subcontinent. Even though it is within the so-called big-four snakes against which polyvalent antivenom is available throughout India, reports of antivenom ineffectiveness are emerging in saw-scaled viper envenoming, especially around Jodhpur, Rajasthan, India. This case report highlights a patient with saw-scaled viper envenoming with an ineffective antivenom response complicated by acute kidney injury as well as local and systemic bleeding complications, which subsequently resulted in a pelvic hematoma that compressed the lumbosacral nerves, causing lower-limb weakness and sensory deficits. He was successfully managed with hematoma aspiration and supportive care. This case brings into focus the challenges of managing saw-scaled viper envenoming in this region with antivenom ineffectiveness, resulting in delayed and significant coagulopathy and its complications leading to prolonged hospital stay and morbidity. Our report spotlights less emphasized aspects of long-term morbidity in snakebite survivors, such as loss of working days and productivity. We also highlight the need for an organized system of long-term follow-up of snakebite survivors to screen for possible complications and manage them early.

Outcomes of transcutaneous retrobulbar Amphotericin B (TRAMB) as an adjuvant therapy for rhino-orbital-cerebral mucormycosis (ROCM) following COVID-19.

PURPOSE: To assess the outcomes of transcutaneous retrobulbar Amphotericin B (TRAMB) for rhino-orbital-cerebral-mucormycosis (ROCM) post-COVID-19, as an adjuvant to standard systemic antifungal therapy. METHODS: In this prospective cohort study involving ROCM patients with clinical/radiological orbital involvement, 44 eyes with ROCM stage ≥ 3B received TRAMB for 7 consecutive days with liposomal Amphotericin-B (3.5 mg/ml) with a minimum clinical and radiological follow-up of 3 months. All patients received standard systemic antifungal therapy also as per institutional protocol. Data pertaining to demography, systemic status, clinical involvement, imaging, surgical/medical management were also recorded. Potential eyes for exenteration were excluded. Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 12 Given name: [Mahendra Kumar ] Last name [Garg]. Also, kindly confirm the details in the metadata are correct.All author names are presented accurately. Details in the metadata are correct. Thank you. RESULTS: Forty-four eyes of 42 patients were included, out of which 30 had diabetes mellitus & 22 had received steroid/oxygen treatment during COVID-19 infection. Forty eyes showed improvement or stable disease on follow-up on radiology. Four eyes which showed progression of the disease in orbit were reaugmented with TRAMB. No patient required exenteration. Subconjunctival haemorrhage occurred in six eyes and temporary blurring of vision in four eyes after TRAMB which resolved spontaneously. CONCLUSION: TRAMB, as an adjuvant to standard systemic antifungal therapy, is associated with a significant reduction or stabilisation of orbital involvement. TRAMB should be considered as an adjuvant therapy for ROCM to reduce disease progression as well as to preserve globe or sight. It has a promising role in preventing potential orbital exenterations.

Association of Serum Complement C3 Levels with Severity and Mortality in COVID 19.

The severe acute respiratory distress syndrome-associated coronavirus-2 infection can activate innate and adaptive immune responses which may lead to harmful tissue damage, both locally and systemically. C3, a member of complement system of serum proteins, is a major component of innate immune and inflammatory responses. This study is aimed to assess serum C3 as a marker of COVID-19 severity and a predictor of disease progression. A total of 150 COVID-19 patients, confirmed by RT-PCR, and 50 healthy controls were recruited. Serum C3 levels were determined by using direct colorimetric method. Median levels of serum C3 in total cases and controls were 157.8 and 165.7 mg/dL respectively. Serum C3 although not significantly decreased, they were lower in cases when compared to controls. Similarly, significant differences were found between the groups, with severe group (140.6 mg/dL) having low levels of serum C3 protein when compared to mild (161.0 mg/dL) and moderate group (167.1 mg/dL). Interestingly, during hospitalization, significant difference between baseline (admission) and follow-up (discharge) was observed only in patients with moderate disease. Based on our results, lower levels of C3, with an increase in IL-6 and d-dimer levels, are associated with higher odds of mortality. Therefore, we would like to emphasize that measuring serum C3 levels along with other inflammatory markers might give an added advantage in early identification of patients who are prone to having a severe disease course and can help in a more effective follow-up of disease progression. Supplementary Information: The online version contains supplementary material available at 10.1007/s12291-023-01148-x.

Clinical features, diagnosis and treatment outcome of fungal endocarditis: A systematic review of reported cases.

The landscape of fungal endocarditis (FE) has constantly been evolving in the last few decades. Despite the advancement in diagnostic methods and the introduction of newer antifungals, mortality remains high in FE. This systematic review aimed to evaluate the epidemiology, clinical features, diagnostic and therapeutic interventions in patients with FE. We also aim to examine the aforementioned factors as a determinant of mortality in FE. A literature search was performed in PubMed, Google Scholar and Scopus, and all patients ≥18 years with proven fungal endocarditis were included. A total of 220 articles (250 patients) were included in the final analysis. Candida was the commonest aetiology (49.6%), followed by Aspergillus (30%) and Scedosporium species (3.2%). The proportion of prosthetic valve endocarditis (PVE) and intravenous drug users was 35.2% and 16%, respectively. The overall mortality rate was 40%. On multivariate analysis, Aspergillus endocarditis (HR 3.7, 95% CI 1.4-9.7; p = .009) and immunocompromised state (HR 2.8, 95% CI 1.24-6.3; p = .013) were independently associated with mortality. Patients treated with surgery along antifungals had better survival (HR 0.20, 95% CI 0.09-0.42; p < .001) compared to those treated with antifungals alone. Recurrence of FE was reported in 10.4% of patients. In conclusion, FE carries significant mortality, particularly in immunodeficient and Aspergillus endocarditis. We advocate the use of surgery combined with antifungals to improve clinical outcomes.

Guardian-Reported Impact of the COVID-19 Pandemic on the Lifestyle of Children with Diabetes Mellitus.

INTRODUCTION: The coronavirus disease-2019 (COVID-19) pandemic has had an unprecedented impact on the lives and lifestyles of people of all ages worldwide. Lifestyle has an essential role in the management of diabetes mellitus in children. METHODS: The study was carried out at a tertiary care centre in India. A telehealth survey was conducted among the parents/guardians of children with diabetes to study the impact of the COVID-19 pandemic. The survey evaluated the effects on lifestyle, diabetes management and challenges in connecting to a new telemedicine programme. RESULTS: The survey was completed by guardians of 91 patients. The mean age of the patients was 13.0 ± 3.8 years in boys and 11.9 ± 4.5 years in girls. Fifty-seven per cent of them were boys, and 63.7% stayed in rural areas. The pandemic has resulted in a significant increase in screen time and sleep duration. The median non-educational screen time has gone up from 1.00 (0.5-2.0) to 2.50 (1.0-4.0) h. The mean sleep duration in children increased from 9.1 ± 1.4 to 9.7 ± 1.4 h. Telemedicine services have been established with minimum resources, but they have limitations, and awareness about them is also limited. CONCLUSION: The COVID-19 pandemic has made the lifestyle of children with diabetes more sedentary. Some of them have also faced challenges with regard to diabetes-related supplies and management. It would be fair to anticipate more complications related to this sedentary lifestyle in the future and work towards identifying and treating them.

Integrating health planning and primary care infrastructure for COVID-19 and tuberculosis care in India: Challenges and opportunities.

Tuberculosis (TB) is the leading cause of death from a single infectious agent worldwide. The COVID-19 pandemic has overburdened healthcare services around the world especially in resource constrained settings. It has shaken already unstable foundation of TB control programs in India and other high burden states. A 25% decline is expected in TB detection while estimates suggest 13% increase in TB deaths due to the impact of the pandemic. However, the significant intersections between the two diseases perhaps offer potential opportunities for consolidating the efforts to tackle both. The widespread implementation and acceptance of universal masking and social distancing in India has helped limit transmission of both diseases. Integrating the capacity building strategies for the two diseases, optimizing the existing the surveillance and monitoring systems which have been achieved over the years will result in a single vertically integrated national program addressing both, rather than multiple parallel program which utilize the already sparse primary care manpower and infrastructure. In this article, we explore the impact of the COVID-19 pandemic on tuberculosis in India and offer suggestions on how effective health planning can efficiently integrate infrastructure and manpower at primary level to provide care for both COVID-19 and tuberculosis.

Effectiveness of early awake self proning strategy in non-intubated patients with COVID-19 hypoxemia: an open-labelled randomized clinical trial from Jodhpur, India.

Awake self-proning is being used widely as respiratory support in COVID-19 hypoxemia, in resource-limited settings. We aimed to investigate the effectiveness of early awake self-proning in preventing mortality and the need for intubation in adults with moderate COVID-19 hypoxemia. In this randomized clinical trial with inten-tion-to-treat analysis, we enrolled eligible adults with COVID-19 hypoxemia (SpO2 <94%), requiring supplemental oxygen via nasal prongs or facemask from a tertiary-care setting in Jodhpur, India between June 15 to December 24, 2020. Awake proning comprised of 4-hour cycles with prone position maintained 2 h per cycle. The control group did not maintain any specific position. All participants received standard care. The primary outcomes were 30-day mortal-ity and requirement for mechanical ventilation. Of 502 participants included, mean (SD) age was 59.7 (12.7) years with 124 women (24.6%); 257 were randomized to awake-proning, 245 to control group and all 502 were included for follow-up mortality analysis. Mortality at follow-up was 16.3% in the awake-prone and 15.1% in the control group [OR:1.10 (0.68-1.78), p=0.703). The requirement of mechanical ventilation was 10% in both groups (p=0.974). Survival time (in days) was not significantly different between the groups [Log-rank test, HR: 1.08 (95% CI, 0.70-1.68), p=0.726]. Likewise, time to intubation was comparable (Log-rank test, HR: 0.93 (95% CI, 0.56-1.70), p=0.974). Hence, awake self-proning did not improve survival or requirement of mechanical-ventilation in non-intubated patients with mild to moderate COVID-19 hypox-emia. Trial Registration: Clinical trial registry of India, ID: CTRI/2020/06/025804.   The trial is accessible from WHO's International Clinical Trials Registry Platform (ICTRP) at https://trialsearch.who.int ***************************************************************   *Appendix Authors list  Deepak Kumar1, Gopal Krishna Bohra1, Nishant Kumar Chauhan2, Nikhil Kothari3, Vijaya Lakshmi Nag4 Sanjeev Misra5  1Department of Internal Medicine; 2Department of Pulmonary Medicine; 3Department of Anaesthesiology and Critical Care; 4Department of Microbiology; 5Department of Surgical Oncology, All India Institute of Medical Sciences, Jodhpur, India.

Association of Inflammatory markers with Covid-19 Outcome among Hospitalized adult Patients.

COVID-19 is a highly infectious disease with varied presentation as well as outcome. Inflammation plays a major role in the outcome of COVID-19 infection. This study was aimed to evaluate the role of conventional feasible inflammatory markers in predicting the outcome of COVID-19 in hospitalized adult patients. MATERIAL: A total of 100 confirmed COVID-19 patients were included in the study. Clinical and demographic data were collected. Biochemical, hematological, and inflammatory markers were assessed in all the patients. Disease severity and primary outcome as survival and or mortality were recorded. OBSERVATION: Hematological indices and inflammatory markers were significantly higher among the non-survivor. N/L (Neutrophil/Lymphocyte) ratio and CRP (C-reactive protein) can differentiate non-survivor from survivors with the sensitivity of 85.7%, 85.7%, and specificity of 96.8 %, 77.4% with a cut-off value of 6.44, 23.02 respectively in the receiver operator curve (ROC). N/L ratio and CRP were significantly increased among the patients with severe COVID-19 infection. Cox regression Survival analysis showed that an elevated N/L ratio and CRP were significantly associated with mortality with the Hazard ratio of 1.331 (P <0.001) and 1.014 (P <0.015) respectively. CONCLUSION: The present study implicates that increased N/L ratio and CRP were significantly correlated with severity and mortality in COVID-19 patients. These conventional feasible markers can be useful in predicting the outcome of COVID-19 infection.

Clinical Characteristics and Treatment Outcome of Central Nervous System Nocardiosis: A Systematic Review of Reported Cases.

BACKGROUND: The clinical spectrum of systemic nocardiosis encompasses pulmonary and disseminated disease. Central nervous system (CNS) involvement is an important feature of disseminated disease with significant mortality and high relapse rate, especially in those with suppressed cell-mediated immunity. This systematic review aimed to evaluate the epidemiology, clinical features, diagnosis, therapeutic interventions, and outcome in patients with CNS nocardiosis. METHODS: A literature search was performed in major databases (PubMed, Google Scholar, and Scopus) by using distinct keywords: "CNS disease," "Nocardia," "meningitis," "brain abscess," "disseminated disease," and "Cotrimoxazole." We included all patients ≥18 years with CNS nocardiosis reported between January 2000 and December 2020. RESULTS: A total of 129 papers were included in the final analysis. The mean age of patients was 55 ± 16 years, and the majority were male (70.8%). Nocardia farcinica was the commonest species (39.6%), followed by Nocardia nova (5.9%). Thirty-four percent of the patients were found to be immunocompetent. Corticosteroid use was the most common predisposing factor (55.8%). Among neuroimaging findings, brain abscess was most common (86.9%), followed by leptomeningeal enhancement (12.1%). The overall case-fatality rate in CNS disease was 22.8%. On multivariate analysis, patients who underwent surgery (OR 2.4, 95% CI 0.99-4.11, p value 0.046) had better survival than those treated with antimicrobial therapy alone. Immunodeficient state (OR 0.32, 95% CI 0.15-0.90, p value 0.019) was independently associated with poor outcome. CONCLUSION: CNS nocardiosis carries significant mortality, especially in immunodeficient patients. We advocate the use of surgery combined with antimicrobials to improve clinical outcome.

Use of rotational thromboelastometry to predict the outcome of COVID-19 patients: A retrospective observational study.

Background and Aims: The hypercoagulability occurring in COVID-19 patients is detected only by Rotational thromboelastometry (ROTEM). However, the benefit of performing ROTEM in the management of disease and predicting the outcome of COVID-19 patients is yet to be established. Material and Methods: The data of 23 critically ill and 11 stable COVID-19 adult patients were extracted from the hospital information system admitted between July and August 2020 and patient charts and analyzed retrospectively. The critically ill patients were divided as a survivor and non-survivor groups. The Intrinsic pathway part of ROTEM (INTEM) and Fibrinogen part of ROTEM (FIBTEM) were performed on day 0 for both critically ill and stable patients, and on day 10 for critically ill patients. The statistical package for social science (SPSS) version 26 was used for statistical analysis. Results: The median FIBTEM amplitude at 5 min (A5) and maximum clot firmness (MCF) were elevated in both stable and critically ill patients (24 vs 27 mm, P = 0.46 and 27.5 vs 40 mm, P = 0.011) with a significant difference in FIBTEM MCF. But there was no significant difference between number of survivors and non-survivors with FIBTEM MCF >25 at day 0 and day 10. Conclusion: The Hypercoagulability state as detected by ROTEM parameters at day 0 and day 10 had no association with the outcome (mortality) of critically ill COVID-19 patients. Hence it cannot be used as a prognostic test. The increasing age, comorbidities and D-dimer values were associated with a poor prognosis in COVID-19 patients.

Empyema necessitans with osteomyelitis of fifth rib due to Nocardia farcinica: a case report.

BACKGROUND: Empyema necessitans is a rare pulmonary condition described as the presence of pus in the pleural cavity with insidious extension into the surrounding soft tissue. The common microbial aetiology of empyema necessitans is tuberculosis. Nocardiosis a cause of empyema necessitans is rarely described in the literature. We herein present a case of an 80-year-old male with empyema necessitans with osteomyelitis of rib caused by Nocardia farcinica. CASE PRESENTATION: An 80-year-old male presented with complaints of soft swelling on the left lower posterior chest wall associated with dry cough and breathlessness on exertion. Computed Tomography (CT) thorax demonstrated empyema necessitans with features of left fifth rib osteomyelitis. Radiological guided aspiration of the chest wall collection revealed Nocardia species and surgical drainage of abscess was performed. Matrix-assisted laser desorption/ionization time-of-flight-mass spectrometry (MALDI-TOF-MS) identified the isolate as Nocardia farcinica. He was treated with three-drug regimen: Trimethoprim-sulfamethoxazole, amikacin and ceftriaxone for 2 weeks. After showing improvement patient was discharged and advised to take oral Trimethoprim-sulfamethoxazole for the next 6 months with periodic follow-up. CONCLUSIONS: As our case demonstrates, the possibility of invasive Nocardiosis should not be overlooked even in immunocompetent patients. Clinicians should aware of this rare entity while treating patients with empyema necessitans.

Clinical profile of bloodstream infections in COVID-19 patients: a retrospective cohort study.

BACKGROUND: Bloodstream infections (BSIs) are an emerging cause of significant morbidity and mortality in severe Coronavirus disease 2019 (COVID-19). We aimed to assess the prevalence, clinical profile and outcome of BSIs in critically ill COVID-19 patients. METHODS: This was a single-centre retrospective study conducted at a tertiary care hospital in Western India. All patients (age > 18 years) with reverse-transcription polymerase chain reaction (RT-PCR) confirmed COVID-19 admitted in the intensive care unit (ICU) were included. Hospital electronic records were searched for demographic data, time of bloodstream infection since admission, clinical profile, antimicrobial resistance pattern and clinical outcome of all patients who developed BSIs. RESULTS: Out of 750 patients admitted in COVID ICU, 8.5% developed secondary BSIs. All severe COVID-19 patients who developed BSIs succumbed to illness. A significant proportion of BSIs were Gram-negative pathogens (53/64, 82.8%). Acinetobacter baumannii was the commonest isolate, followed by Klebsiella pneumoniae (32.8% and 21.9%, respectively). Multidrug-resistance organisms (MDRO) were found in 57.8% of the cases. The majority of MDRO belonged to K. pneumoniae and Enterococcus groups. The proportion of Gram-negative bacteria resistant to carbapenems was 47.2% (25/53). On multivariate analysis, raised total leukocyte counts, mechanical ventilation and presence of comorbidities were significantly associated with the incidence of BSIs. CONCLUSION: We found a significant prevalence of Acinetobacter baumannii in COVID-19 associated BSIs. The presence of comorbidities raised leukocyte counts and mechanical ventilation should alarm clinicians for possible BSIs. The timely initiation of empirical antibiotics and rapid de-escalation is vital to improve the outcome. At the same time, strict compliance of infection control practices should be accomplished to reduce the occurrence of MDRO.

Does dehydroepiandrosterone sulfate have a role in COVID-19 prognosis and treatment?

The pathophysiology of COVID comprises an exaggerated pro-inflammatory response. Hypothalamic-pituitary-adrenal (HPA) axis has a crucial role in various inflammatory conditions and modulated immunological response. Limited evidence is available regarding the incidence and the effect of HPA dysfunction in COVID-19. Although the cortisol levels have only been estimated in a few studies, the dehydroepiandrosterone sulfate (DHEAS) release from the adrenal gland has not been explored yet. In this mini review, the authors discuss the role of dehydroepiandrosterone (DHEA) and DHEAS in the acute stress response and immunological modulation. Various effects of DHEAS have been demonstrated in different diseases. The specific inhibitory effect of DHEA on interleukin 6 (IL-6) could be of paramount importance in COVID-19. Further, DHEA supplementation has already been proposed in inflammatory conditions, like rheumatoid arthritis. DHEAS levels in COVID-19 may help to understand the HPA axis dysfunction as well as the possibility of repurposing DHEA as a drug for mitigating the pro-inflammatory COVID-19.

Venom-Induced Consumption Coagulopathy Unresponsive to Antivenom After Echis carinatus sochureki Envenoming.

Snakebite envenoming is a serious and life-threatening but neglected problem in the tropics. The focus in the Indian subcontinent is usually on the Indian cobra (Naja naja), common krait (Bungarus caeruleus), Russell's viper (Daboia russelii), and Indian saw-scaled viper (Echis carinatus). The Indian polyvalent antivenom contains hyperimmunized horse antibodies against only these 4 species. However, regional intraspecific variations are important in viper envenomings, leading to marked differences in clinical presentation and response to the available polyvalent antivenom. Echis carinatus sochureki, a subspecies of Echis carinatus, has been linked to serious morbidity in the Thar Desert regions of Rajasthan, although consistent reports are lacking. We report a patient with prolonged venom-induced consumption coagulopathy owing to Echis carinatus sochureki envenoming who did not respond to Indian polyvalent antivenom in Jodhpur, India. Features of local and hemotoxic envenoming resolved after a week with supportive care. Echis sochureki venom has been shown to be different from Echis carinatus in terms of composition and in vitro neutralization by antivenom. Clinicians in the tropical desert regions must suspect Echis sochureki envenoming in the setting of nonresponsiveness to Indian polyvalent antivenom. This will help optimize antivenom use in these patients, preventing potentially life-threatening antivenom associated reactions. Because the usefulness of Indian polyvalent antivenom appears to be limited in this setting, there is an urgent need to advocate for region-specific antivenom or monovalent antivenom for this area.

Interleukin-6 Perpetrator of the COVID-19 Cytokine Storm.

COVID-19 has emerged as a global pandemic. It is mainly manifested as pneumonia which may deteriorate into severe respiratory failure. The major hallmark of the disease is the systemic inflammatory immune response characterized by Cytokine Storm (CS). CS is marked by elevated levels of inflammatory cytokines, mainly interleukin-6 (IL-6), IL-8, IL-10, tumour necrosis factor-α (TNF-α) and interferon-γ (IFN-γ). Of these, IL-6 is found to be significantly associated with higher mortality. IL-6 is also a robust marker for predicting disease prognosis and deterioration of clinical profile. In this review, the pivotal role played by IL-6 in the immuno-pathology of COVID-19 has been illustrated. The role of IL-6 as a pleiotropic cytokine executing both pro and anti-inflammatory activities has been reviewed. ADAM 10, a metalloproteinase switches the anti-inflammatory pathway of IL-6 to pro inflammatory hence blocking the action of ADAM 10 could be a new therapeutic strategy to mitigate the proinflammatory action of IL-6. Furthermore, we explore the role of anti-IL6 agents, IL-6 receptor antibodies which were being used for autoimmune diseases but now are being repurposed for the therapy of COVID-19.

Impact of three different daily doses of vitamin D3 supplementation in healthy schoolchildren and adolescents from North India: a single-blind prospective randomised clinical trial.

In India, there is a lack of information about the adequate daily dose of vitamin D3 supplementation in school children. Hence, we undertook this study to evaluate the adequacy and efficacy of different doses of vitamin D3 in schoolchildren. A total of 1008 vitamin D-deficient (VDD) children, aged 6-16 years with serum 25-hydroxyvitamin D (25(OH)D) levels <50nmol/l, were cluster randomised into three groups (A-344, B-341 and C-232) for supplementation (600, 1000 and 2000 IU daily) of vitamin D3 under supervision for 6 months. Of the 1008 subjects who completed the study, 938 (93 %) were compliant. Baseline and post-supplementation fasting blood and urine samples were evaluated for Ca, phosphates, alkaline phosphatase, 25(OH)D and parathormone and urine Ca:creatinine ratio. The mean age of the subjects was 11·7 (sd 2·4) years, and the overall mean baseline serum 25(OH)D level was 24·3 (SD 9·5)nmol/l. Post-supplementation rise in serum 25(OH)D in compliant group was maximum with 2000 IU (70·0 (SD 30·0)nmol/l), followed by 1000 IU (46·8 (SD 22·5)nmol/l) and 600 IU (36·5 (SD 18·5)nmol/l), and serum 25(OH)D levels of ≥50nmol/l were achieved in 71·5, 81·8 and 92·9 % by groups A, B and C, respectively. Secondary hyperparathyroidism decreased from 31·7 to 8·4 % post-supplementation. Two participants developed hypercalciuria, but none developed hypercalcaemia. Children with VDD benefit maximum with the daily supplementation of 2000 IU of vitamin D3. Whether recommendations of 400 IU/d by Indian Council of Medical Research or 600 IU by Indian Academy of Pediatrics or Institute of Medicine would suffice to achieve vitamin D sufficiency in children with VDD remains debatable.