Future of Palliative Medicine

A ‘need-supply’ and ‘requirement-distribution mismatch’ along with a continuingneed explosion are the biggest hurdles faced by palliative medicine today. It is the need of the hour to provide an unbiased, equitable and evidence-based palliative care to those in need irrespective of the diagnosis, prognosis, social and economic status or geographical location. Palliative care as a fundamental human right, ensuring provision throughout the illness spectrum, global as well as region-specific capacity building, uniform availability of essential drugs at an affordable price, a multidisciplinary team approachand caregiver-support are some of the achievable goals for the future. This supplanted with a strong political commitment, professional dedication and ‘public-private partnerships’ are necessaryto tackle the existing hurdles and the exponentially increasing future need. For effectively going ahead it is of utmost importance to integrate palliative medicine into medical education, healthcare system and societal framework.     

A multicenter prospective study of infections related morbidity and mortality in cirrhosis of liver

Background and Aims

Infections are a common and serious complication among patients with cirrhosis. We assessed the epidemiology, risk factors, and clinical consequences of bacterial infections in cirrhotic patients.

Methods

In this multicenter prospective study, all patients with cirrhosis of liver with different infections were analyzed. Infections were classified as community-acquired (CA), healthcare-associated (HCA), or hospital-acquired (HA). Site of infection and characteristics of bacteria were recorded; effect on liver function and 30-day survival were evaluated.

Results

One hundred and six out of 420 (25 %) patients with cirrhosis of liver had infection. Infection rate among indoor patients was 37.5 % (92/245) and among outdoor patients was 8 % (14/175). Out of 106 patients, CA, HCA, and HA were seen in 19.8 %, 50 %, and 30.2 %, respectively. Spontaneous bacterial peritonitis (31.1 %), urinary tract infections (22.6 %), and pneumonia and cellulitis (11.3 % each) were common infections. Gram-negative bacteria (54 %) were more common than Gram-positive cocci (46 %). Multidrug resistant (MDR) organisms were seen in 41.7 % of patients. Most of the MDR organisms were seen in HCA and HA patients. The degree of liver impairment was significantly more severe in patients with infection. Independent predictor of infection was high Child-Turcott-Pugh (CTP) class (p?=?0.006, Child B vs. A (odds ratio (OR) 3.04 95 % CI?=?1.63 to 5.68) and Child C vs. A (OR 4.17 95 % CI?=?2.12 to 8.19). Overall in-hospital mortality was 7.6 %. Patients with infection had increased mortality at 30-day follow up compared to those without infection (23.5 % vs. 2.2 %; p<0.001).

Conclusions

Infections are one of the important causes of morbidity and mortality in patients with cirrhosis of liver. The most frequent infections are HCA and HA. Infection predisposes to deterioration of liver function and increases mortality. Cirrhotic patients should be monitored closely for infections especially those with Child class B and C.     

Double-Trouble Doppler: Reduction in Aortic Flow Due to Combined Left Ventricular Outflow Tract Obstruction and Severe Aortic Stenosis, Complete Diagnosis by Transthoracic Doppler Echocardiography

In patients with hypertrophic obstructive cardiomyopathy and dynamic left ventricular outflow tract obstructions, an additional fixed obstruction may uncommonly coexist. In these situations, flow through the aortic valve is usually delayed but typically still throughout the entire ejection period. We describe a case of marked reduction in aortic flow during mid and late systole, diagnosed by Doppler echocardiography, caused by combined hypertrophic obstructive cardiomyopathy and severe calcific bicuspid aortic stenosis.     

Transport Circuit during COVID-19 Crisis: A Simple Modification of the Bain's Circuit for Safety of Healthcare Workers

How to cite this article: Burman S, Sharma PB, Tyagi M, Singh GP, Chaturvedi A. Transport Circuit during COVID-19 Crisis: A Simple Modification of the Bain''s Circuit for Safety of Healthcare Workers. Indian J Crit Care Med 2020;24(12):1281–1283.     

Balance,Falls Risk,and Related Disability in Untreated Vestibular Schwannoma Patients

Background Many vestibular schwannoma (VS) patients complain of balance dysfunction; however, validated standardized assessments are lacking. The relative contribution of imbalance and factors like anxiety to disability is unknown. Because imbalance significantly affects quality of life in this group and vestibular rehabilitation may improve outcomes, determining the severity of balance dysfunction is important to understand long-term rehabilitation needs. Aim To assess functional balance (Vertigo Symptom Scale-Vertigo [VSS-VER] and Functional Gait Assessment [FGA]) and the relative contribution of symptom severity (VSS-VER), ambulant posture (FGA), and anxiety symptoms (Vertigo Symptom Scale-Anxiety [VSS-SA]) to disability in untreated patients. Methods Patients not exposed to surgery completed the VSS, Vertigo Handicap Questionnaire (VHQ), and FGA. VSS scores were compared with migrainous vertigo (MV) patients, a mixed neuro-otological group, and healthy controls. Results A correlation was found between decreased FGA and increasing age (r = − 0.35; p < 0.01), female sex (r = 0.42; p = 0.001), increasing handicap (r = − 0.55; p < 0.001), and symptom severity (r = − 0.52; p < 0.001). In 12 of 21 patients (57%) > 60 years of age the FGA score was ≤ 22 suggesting increased falls risk.VSS-VER scores were higher than in healthy controls (p < 0.001) but lower than MV (p < 0.001) and mixed neuro-otology controls (p < 0.001).VSS-SA scores in VS patients with balance symptoms were higher than normal controls (p < 0.05) and correlated with handicap (r = 0.59; p < 0.001) and symptom severity (r = 0.74; p < 0.001).After controlling for age and sex, the VSS-VER, VSS-SA, and FGA explained 47% of the variation in VHQ scores. Conclusion Older VS patients are at significant risk of falls. Balance symptoms are more severe than in healthy controls but less than other neuro-otological patients. Balance symptom severity, anxiety symptoms, and ambulant posture were significant contributors to disability and should be the focus of vestibular rehabilitation strategies.     

Genetics of platelet traits in ischaemic stroke: focus on mean platelet volume and platelet count

Purpose/Aim of the study: The aim of this review is to summarize the role of genetic variants affecting mean platelet volume (MPV) and platelet count (PLT) leading to higher platelet reactivity and in turn to thrombotic events like stroke and cardiovascular diseases.

Materials and Methods: A search was conducted in PUBMED, MEDLINE, EMBASE, PROQUEST, Science Direct, Cochrane Library, and Google Scholar related to the studies focussing on genome-wide association studies (GWAS), whole exome sequencing (WES), whole genome sequencing (WGS), phenome-wide association studies (PheWAS) and multi-omic analysis that have been employed to identify the genetic variants influencing MPV and PLT.

Results: Antiplatelet agents underscore the crucial role of platelets in the pathogenesis of stroke. Higher platelet reactivity in terms of mean platelet volume (MPV) and platelet count (PLT) contributes significantly to the interindividual variation in platelet reaction at the site of vessel wall injury. Some individuals encounter thrombotic events as platelets get occluded at the site of vessel wall injury whereas others heal the injury without occluding the circulation. Evidence suggests that MPV and PLT have a strong genetic component. High throughput techniques including genome-wide association studies (GWAS), whole exome sequencing (WES), whole genome sequencing (WGS), phenome-wide association studies (PheWAS) and multi-omic analysis have identified different genetic variants influencing MPV and PLT.

Conclusions: Identification of complex genetic cross talks affecting PLT and MPV might help to develop novel treatment strategies in treating neurovascular diseases like stroke.     

Microwave Assisted Extraction, Antioxidant Potential and Chromatographic Studies of Some Rasayana Drugs

Objective:To study and compare the conventional extraction procedure with microwave assisted extraction(MAE) for some Ayurvedic Rasayana drugs and to evaluate their antioxidant potential and carry out the characterization of extracts by thin layer chromatography.Methods:Three Ayurvedic rasayana plants Allium sativum Linn.,Bombax ceiba Linn.and Inula racemosa Hook,were evaluated for an improved MAE methodology by determining the effects of grinding degree,extraction solvent,effect of dielectric constant and duration of time on the extractive value.Antioxidant potential of all three drugs was evaluated with 2,2-diphenyl-1-picrylhydrazyl(DPPH) radical scavenging activity and reducing power was determined by using Gallic acid as standard.Further thin layer chromatographic(TLC) analysis was performed on pre-activated Silica Gel G plates and Rf value were compared with those reported for the important biomarkers.Results:The total extractive value for Allium sativum Linn,was 36.95%(w/w) and 49.95%(w/w) for ethanol extraction respectively.In case of Bombax ceiba Linn,the yield of aqueous extract by MAE was 50%(w/w) compared to 42%(w/w) in ethanol(50%v/v).Percent yield of Inula racemosa Hook,in aqueous extract was found to be 27.55%(w/w) which was better than ethanol extract(50%) where the yield was 25.95%(w/w).Upon antioxidant activity evaluation A.sativum extract showed an absorbance of 0.980 ± 0.92 at concentration of 500 μg with maximum reducing capacity.This was followed by B.ceiba Linn.0.825 ±0.98 and /.racemosa Hook,with 0.799 ±2.01 at a concentration of 500 μg.TLC based standardization of A.sativum Linn,extract shows single spot with Rf value of 0.38,B.ceiba Linn,extract shows Rf values were 0.23,0.58,0.77,0.92 and I.racemosa Hook,extract spot had a Rf value of 0.72.Conclusions:A significant improvement in extractive values was observed as a factor of time and other advantages by using MAE technology.All three drugs have high antioxidant potential and a TLC profiling similar to reported ones.The presence of fructan type polysaccharide can be further utilized for bioactivity directed fractionation and evaluation of immunomodulatory activity.     

Neuronal ceroid lipofuscinosis type-11 in an adolescent

Neuronal ceroid lipofuscinosis (NCL) is a group of progressive neurodegenerative disorders characterized by intracellular accumulation of ceroid lipopigments. Based on gene defect of NCL-associated proteins, 14 types of NCL have been described till date. NCL type 11 was first described in 2014 in two siblings as adult-onset NCL and was found to be due to a homozygous progranulin gene mutation. These siblings had progressive retinopathy, recurrent generalized seizures, moderate ataxia and subtle cognitive dysfunction. Palinopsia was present and MRI showed selective and severe cerebellar atrophy which was progressive with age. There have been no further reports of NCL 11 in literature. We here present a 14-year old girl born to second degree consanguineous couple who presented with gradually increasing frequency of seizures for the past 1?year without any signs of visual abnormalities and dementia. She had an elder sister who had progressive seizures and dementia from 8?years of age and died after few years. Her electroencephalogram showed frequent generalized epileptiform discharges and magnetic resonance imaging (MRI) showed pure cerebellar atrophy mainly affecting the vermis. MRI findings suggested a neurodegenerative disorder like NCL and prompted us to go for whole exome screen which revealed NCL type 11 due to homozygous mutation c.912G>A (p.Trp304Ter) in exon 9 of GRN gene (OMIM#614706). To the best of our knowledge this is the third case of NCL 11 and the first from Asia.