Showing papers by "Max Healthcare published in 2021"

Mucormycosis and COVID-19: An epidemic within a pandemic in India.

Abstract: Importance Coronavirus disease (COVID-19) causes an immunosuppressed state and increases risk of secondary infections like mucormycosis. We evaluated clinical features, predisposing factors, diagnosis and outcomes for mucormycosis among patients with COVID-19 infection. Methods This prospective, observational, multi-centre study included 47 consecutive patients with mucormycosis, diagnosed during their course of COVID-19 illness, between January 3 and March 27, 2021. Data regarding demography, underlying medical conditions, COVID-19 illness and treatment were collected. Clinical presentations of mucormycosis, imaging and biochemical characteristics and outcome were recorded. Results Of the 2567 COVID-19 patients admitted to 3 tertiary centres, 47 (1.8%) were diagnosed with mucormycosis. Mean age was 55 ± 12.8years, and majority suffered from diabetes mellitus (n = 36, 76.6%). Most were not COVID-19 vaccinated (n = 31, 66.0%) and majority (n = 43, 91.5%) had developed moderate-to-severe pneumonia, while 20 (42.6%) required invasive ventilation. All patients had received corticosteroids and broad-spectrum antibiotics while most (n = 37, 78.7%) received at least one anti-viral medication. Mean time elapsed from COVID-19 diagnosis to mucormycosis was 12.1 ± 4.6days. Eleven (23.4%) subjects succumbed to their disease, mostly (n = 8, 72.7%) within 7 days of diagnosis. Among the patients who died, 10 (90.9%) had pre-existing diabetes mellitus, only 2 (18.2%) had received just one vaccine dose and all developed moderate-to-severe pneumonia, requiring oxygen supplementation and mechanical ventilation. Conclusions Mucormycosis can occur among COVID-19 patients, especially with poor glycaemic control, widespread and injudicious use of corticosteroids and broad-spectrum antibiotics, and invasive ventilation. Owing to the high mortality, high index of suspicion is required to ensure timely diagnosis and appropriate treatment in high-risk populations.

High prevalence of diabetes and other comorbidities in hospitalized patients with COVID-19 in Delhi, India, and their association with outcomes.

Abstract: Background and aims To study the prevalence and impact of diabetes mellitus and other comorbidities among hospitalized patients with COVID-19. Methods In a prospective, observational study including consecutive adults hospitalized with COVID-19, clinical outcomes and inflammatory markers were compared in those with and without diabetes. Participants were classified as having mild or severe COVID-19 disease using the WHO ordinal scale. Results 401 patients (125 females) with median age of 54 years (range 19–92) were evaluated. Of them 189 (47.1%) had pre-existing diabetes and21 (5.2%) had new-onset hyperglycaemia. Overall, 344 (85.8%) and 57 (14.2%) cases had mild and severe COVID-19 disease respectively. The group with diabetes had a higher proportion of severe cases (20.1% vs 9%, p-0.002), mortality (6.3 vs 1.4%, p-0.015), ICU admission (24.3 vs 12.3%, p-0.002), and oxygen requirement (53.4 vs 28.3%, p Conclusions We report a high prevalence of diabetes in a hospitalized COVID-19 population. Patients with diabetes or hypertension had more severe disease and greater mortality.

Lack of association of baseline 25-hydroxyvitamin D levels with disease severity and mortality in Indian patients hospitalized for COVID-19.

Abstract: Vitamin D deficiency (VDD) owing to its immunomodulatory effects is believed to influence outcomes in COVID-19. We conducted a prospective, observational study of patients, hospitalized with COVID-19. Serum 25-OHD level < 20 ng/mL was considered VDD. Patients were classified as having mild and severe disease on basis of the WHO ordinal scale for clinical improvement (OSCI). Of the 410 patients recruited, patients with VDD (197,48.2%) were significantly younger and had lesser comorbidities. The levels of PTH were significantly higher in the VDD group (63.5 ± 54.4 vs. 47.5 ± 42.9 pg/mL). The proportion of severe cases (13.2% vs.14.6%), mortality (2% vs. 5.2%), oxygen requirement (34.5% vs.43.4%), ICU admission (14.7% vs.19.8%) was not significantly different between patients with or without VDD. There was no significant correlation between serum 25-OHD levels and inflammatory markers studied. Serum parathormone levels correlated with D-dimer (r 0.117, p- 0.019), ferritin (r 0.132, p-0.010), and LDH (r 0.124, p-0.018). Amongst VDD patients, 128(64.9%) were treated with oral cholecalciferol (median dose of 60,000 IU). The proportion of severe cases, oxygen, or ICU admission was not significantly different in the treated vs. untreated group. In conclusion, serum 25-OHD levels at admission did not correlate with inflammatory markers, clinical outcomes, or mortality in hospitalized COVID-19 patients. Treatment of VDD with cholecalciferol did not make any difference to the outcomes.

Effect of age, comorbidity and remission status on outcome of COVID-19 in patients with hematological malignancies.

Abstract: Background There is scarcity of data on outcome of COVID-19 in patients with hematological malignancies. Primary objective of study was to analyse the 14-day and 28-day mortality. Secondary objectives were to correlate age, comorbidities and remission status with outcome. Methods Retrospective multicentre observational study conducted in 11 centres across India. Total 130 patients with hematological malignancies and COVID-19 were enrolled. Results Fever and cough were commonest presentation. Eleven percent patients were incidentally detected. Median age of our cohort was 49.5 years. Most of our patients had a lymphoid malignancy (n = 91). One-half patients (52%) had mild infection, while moderate and severe infections contributed to one-fourth each. Sixty seven patients (52%) needed oxygen For treatment of COVID-19 infection, half(n = 66) received antivirals. Median time to RT-PCR COVID-19 negativity was 17 days (7–49 days). Nearly three-fourth (n = 95) of our patients were on anticancer treatment at time of infection, of which nearly two-third (n = 59;64%) had a delay in chemotherapy. Overall, 20% (n = 26) patients succumbed. 14-day survival and 28-day survival for whole cohort was 85.4% and 80%, respectively. One patient succumbed outside the study period on day 39. Importantly, death rate at 1 month was 50% and 60% in relapse/refractory and severe disease cohorts, respectively. Elderly patients(age ≥ 60) (p = 0.009), and severe COVID-19 infection (p = 0.000) had a poor 14-day survival. The 28-day survival was significantly better for patients in remission (p = 0.04), non-severe infection (p = 0.00), and age Conclusions Elderly patients with hematological malignancy and severe covid-19 have worst outcomes specially when disease is not in remission.

Low uptake of COVID-19 prevention behaviours and high socioeconomic impact of lockdown measures in South Asia: evidence from a large-scale multi-country surveillance programme

Abstract: Background South Asia has become a major epicentre of the COVID-19 pandemic. Understanding South Asians’ awareness, attitudes and experiences of early measures for the prevention of COVID-19 is key to improving the effectiveness and mitigating the social and economic impacts of pandemic responses at a critical time for the Region. Methods We assessed the knowledge, behaviours, health and socio-economic circumstances of 29,809 adult men and women, at 93 locations across four South Asian countries. Data were collected during the national lockdowns implemented from March to July 2020, and compared with data collected prior to the pandemic as part of an ongoing prospective surveillance initiative. Results Participants were 61% female, mean age 45.1 years. Almost half had one or more chronic disease, including diabetes (16%), hypertension (23%) or obesity (16%). Knowledge of the primary COVID-19 symptoms and transmission routes was high, but access to hygiene and personal protection resources was low (running water 63%, hand sanitisers 53%, paper tissues 48%). Key preventive measures were not widely adopted. Knowledge, access to, and uptake of COVID-19 prevention measures were low amongst people from disadvantaged socio-economic groups. Fifteen percent of people receiving treatment for chronic diseases reported loss of access to long-term medications; 40% reported symptoms suggestive of anxiety or depression. The prevalence of unemployment rose from 9.3% to 39.4% (P Conclusions Our results identified important knowledge, access and uptake barriers to the prevention of COVID-19 in South Asia, and demonstrated major adverse impacts of the pandemic on chronic disease treatment, mental health, health-related behaviours, employment and household finances. We found important sociodemographic differences for impact, suggesting a widening of existing inequalities. Our findings underscore the need for immediate large-scale action to close gaps in knowledge and access to essential resources for prevention, along with measures to safeguard economic production and mitigate socio-economic impacts on the young and the poor.

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID-19 pandemic.

Abstract: BACKGROUND: During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study's objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines. METHODS: We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March-31 May 2020. The prior 1-year control period (1 March-31 May 2019) was obtained to account for seasonal variation. FINDINGS: There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI -24.3% to -20.7%, p<0.0001). Embolisation of ruptured aneurysms declined with 1170-1035 procedures, respectively, representing an 11.5% (95%CI -13.5% to -9.8%, p=0.002) relative drop. Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations, a 24.9% relative decline (95% CI -28.0% to -22.1%, p<0.0001). A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1% (95% CI 32.3% to 50.6%, p=0.008) despite a decrease in SAH admissions in this tertile. INTERPRETATION: There was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

Differentials in the characteristics of COVID-19 cases in Wave-1 and Wave-2 admitted to a network of hospitals in North India

Abstract: Second wave of COVID-19 pandemic in India came with unexpected quick speed and intensity, creating an acute shortage of beds, ventilators, and oxygen at the peak of occurrence. This may have been partly caused by emergence of new variant delta. Clinical experience with the cases admitted to hospitals suggested that it is not merely a steep rise in cases but also possibly the case-profile is different. This study was taken up to investigate the differentials in the characteristics of the cases admitted in the second wave versus those admitted in the first wave. Records of a total of 14398 cases admitted in the first wave (2020) to our network of hospitals in north India and 5454 cases admitted in the second wave (2021) were retrieved, making it the largest study of this kind in India. Their demographic profile, clinical features, management, and outcome was studied. Age-sex distribution of the cases in the second wave was not much different from those admitted in the first wave but the patients with comorbidities and those with greater severity had larger share. Level of inflammatory markers was more adverse. More patients needed oxygen and invasive ventilation. ICU admission rate remained nearly the same. On the positive side, readmissions were lower, and the duration of hospitalization was slightly less. Usage of drugs like remdesivir and IVIG was higher while that of favipiravir and tocilizumab was lower. Steroid and anticoagulant use remained high and almost same during the two waves. More patients had secondary bacterial and fungal infections in Wave-2. Mortality increased by almost 40% in Wave-2, particularly in the younger patients of age less than 45 years. Higher mortality was observed in those admitted in wards, ICU, with or without ventilator support and those who received convalescent plasma. No significant demographic differences in the cases in these two waves, indicates the role of other factors such as delta variant and late admissions in higher severity and more deaths. Comorbidity and higher secondary bacterial and fungal infections may have contributed to increased mortality.

Effectiveness of convalescent plasma in Indian patients with COVID-19.

Abstract: Background Convalescent plasma (CP) is being used as a treatment option in hospitalized patients with COVID-19. Till date, there is conflicting evidence on efficacy of CP in reducing COVID-19 related mortality. Objective To evaluate the effect of CP on 28-day mortality reduction in patients with COVID-19. Methods We did a multi-centre, retrospective case control observational study from 1st May 2020 to 31st August 2020. A total of 1079 adult patients with moderate and severe COVID-19 requiring oxygen, were reviewed. Of these, 694 patients were admitted to ICU. Out of these, 333 were given CP along with best supportive care and remaining 361 received best supportive care only. Results In the overall group of 1079 patients, mortality in plasma vs no plasma group was statistically not significant (22.4% vs 18.5%; p = 0.125; OR = 1.27, 95% CI: 0.94‐–1.72). However, in patients with COVID-19 admitted to ICU, mortality was significantly lower in plasma group (25.5% vs 33.2%; p = 0.026; OR = 0.69, 95%CI: 0.50–0.96). This benefit of reduced mortality was most seen in age group 60 to 74 years (26.7% vs 43.0%; p = 0.004; OR = 0.48, 95% CI: 0.29–0.80), driven mostly by females of this age group (23.1% vs 53.5%; p = 0.013; OR = 0.26, 95% CI: 0.09–0.78). Significant difference in mortality was observed in patients with one comorbidity (22.3% vs 36.5%; p = 0.004; OR = 0.50, 95% CI: 0.31–0.80). Moreover, patients on ventilator had significantly lower mortality in the plasma arm (37.2% vs 49.3%; p = 0.009; OR = 0.61, 95% CI: 0.42–0.89); particularly so for patients on invasive mechanical ventilation (63.9% vs 82.9%; p = 0.014; OR = 0.37, 95% CI: 0.16–0.83). Conclusion The use of CP was associated with reduced mortality in COVID-19 elderly patients admitted in ICU, above 60 years of age, particularly females, those with comorbidities and especially those who required some form of ventilation.

Development of the Asia pacific consortium on osteoporosis (APCO) framework: Clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-pacific region

Abstract: Guidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care. Minimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development. We conducted a structured comparative analysis of existing CPGs in the AP region using a “5IQ” model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards. Eighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines. The 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.

Impact of COVID-19 on medical education: introducing homo digitalis.

Abstract: To determine how members of the Societe Internationale d’Urologie (SIU) are continuing their education in the time of COVID-19. A survey was disseminated amongst SIU members worldwide by email. Results were analyzed to examine the influence of age, practice region and settings on continuing medical education (CME) of the respondents. In total, 2494 respondents completed the survey. Internet searching was the most common method of CME (76%; all ps < 0.001), followed by searching journals and textbook including the online versions (62%; all ps < 0.001). Overall, 6% of the respondents reported no time/interest for CME during the pandemic. Although most urologists report using only one platform for their CME (26.6%), the majority reported using ≥ 2 platforms, with approximately 10% of the respondents using up to 5 different platforms. Urologists < 40 years old were more likely to use online literature (69%), podcasts/AV media (38%), online CME courses/webinars (40%), and social media (39%). There were regional variations in the CME modality used but no significant difference in the number of methods by region. There was no significant difference in responses between urologists in academic/public hospitals or private practice. During COVID-19, urologists have used web-based learning for their CME. Internet learning and literature were the top frequently cited learning methods. Younger urologists are more likely to use all forms of digital learning methods, while older urologists prefer fewer methods.

Joint awareness after unicompartmental knee arthroplasty and total knee arthroplasty: a systematic review and meta-analysis of cohort studies.

Abstract: The purpose of this systematic review and meta-analysis is to evaluate the joint awareness after unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). It was hypothesized that patients with UKA could better forget about their artificial joint in comparison to TKA. A search of major literature databases and bibliographic details revealed 105 studies evaluating forgotten joint score in UKA and TKA. Seven studies found eligible for this review were assessed for risk of bias and quality of evidence using the Newcastle–Ottawa Scale. The forgotten joint score (FJS-12) was assessed at 6 months, 1 year, and 2 years. The mean FJS-12 at 2 years was 82.35 in the UKA group and 74.05 in the TKA group. Forest plot analysis of five studies (n = 930 patients) revealed a mean difference of 7.65 (95% CI: 3.72, 11.57, p = 0.0001; I2 = 89% with p < 0.0001) in FJS-12 at 2 years. Further sensitivity analysis lowered I2 heterogeneity to 31% after exclusion of the study by Blevin et al. (MD 5.88, 95%CI: 3.10, 8.66, p < 0.0001). A similar trend of differences in FJS-12 between the groups was observed at 6 months (MD 32.49, 95% CI: 17.55, 47.43, p < 0.0001) and at 1 year (MD 25.62, 95% CI: 4.26, 46.98, p = 0.02). UKA patients can better forget about their artificial joint compared to TKA patients. III.

Effects of a Technology-Assisted Integrated Diabetes Care Program on Cardiometabolic Risk Factors Among Patients With Type 2 Diabetes in the Asia-Pacific Region: The JADE Program Randomized Clinical Trial.

Abstract: Importance Many health care systems lack the efficiency, preparedness, or resources needed to address the increasing number of patients with type 2 diabetes, especially in low- and middle-income countries. Objective To examine the effects of a quality improvement intervention comprising information and communications technology and contact with nonphysician personnel on the care and cardiometabolic risk factors of patients with type 2 diabetes in 8 Asia-Pacific countries. Design, Setting, and Participants This 12-month multinational open-label randomized clinical trial was conducted from June 28, 2012, to April 28, 2016, at 50 primary care or hospital-based diabetes centers in 8 Asia-Pacific countries (India, Indonesia, Malaysia, the Philippines, Singapore, Taiwan, Thailand, and Vietnam). Six countries were low and middle income, and 2 countries were high income. The study was conducted in 2 phases; phase 1 enrolled 7537 participants, and phase 2 enrolled 13 297 participants. Participants in both phases were randomized on a 1:1 ratio to intervention or control groups. Data were analyzed by intention to treat and per protocol from July 3, 2019, to July 21, 2020. Interventions In both phases, the intervention group received 3 care components: a nurse-led Joint Asia Diabetes Evaluation (JADE) technology-guided structured evaluation, automated personalized reports to encourage patient empowerment, and 2 or more telephone or face-to-face contacts by nurses to increase patient engagement. In phase 1, the control group received the JADE technology-guided structured evaluation and automated personalized reports. In phase 2, the control group received the JADE technology-guided structured evaluation only. Main Outcomes and Measures The primary outcome was the incidence of a composite of diabetes-associated end points, including cardiovascular disease, chronic kidney disease, visual impairment or eye surgery, lower extremity amputation or foot ulcers requiring hospitalization, all-site cancers, and death. The secondary outcomes were the attainment of 2 or more primary diabetes-associated targets (glycated hemoglobin A1c <7.0%, blood pressure <130/80 mm Hg, and low-density lipoprotein cholesterol <100 mg/dL) and/or 2 or more key performance indices (reduction in glycated hemoglobin A1c≥0.5%, reduction in systolic blood pressure ≥5 mm Hg, reduction in low-density lipoprotein cholesterol ≥19 mg/dL, and reduction in body weight ≥3.0%). Results A total of 20 834 patients with type 2 diabetes were randomized in phases 1 and 2. In phase 1, 7537 participants (mean [SD] age, 60.0 [11.3] years; 3914 men [51.9%]; 4855 patients [64.4%] from low- and middle-income countries) were randomized, with 3732 patients allocated to the intervention group and 3805 patients allocated to the control group. In phase 2, 13 297 participants (mean [SD] age, 54.0 [11.1] years; 7754 men [58.3%]; 13 297 patients [100%] from low- and middle-income countries) were randomized, with 6645 patients allocated to the intervention group and 6652 patients allocated to the control group. In phase 1, compared with the control group, the intervention group had a similar risk of experiencing any of the primary outcomes (odds ratio [OR], 0.94; 95% CI, 0.74-1.21) but had an increased likelihood of attaining 2 or more primary targets (OR, 1.34; 95% CI, 1.21-1.49) and 2 or more key performance indices (OR, 1.18; 95% CI, 1.04-1.34). In phase 2, the intervention group also had a similar risk of experiencing any of the primary outcomes (OR, 1.02; 95% CI, 0.83-1.25) and had a greater likelihood of attaining 2 or more primary targets (OR, 1.25; 95% CI, 1.14-1.37) and 2 or more key performance indices (OR, 1.50; 95% CI, 1.33-1.68) compared with the control group. For attainment of 2 or more primary targets, larger effects were observed among patients in low- and middle-income countries (OR, 1.50; 95% CI, 1.29-1.74) compared with high-income countries (OR, 1.20; 95% CI, 1.03-1.39) (P = .04). Conclusions and Relevance In this 12-month clinical trial, the use of information and communications technology and nurses to empower and engage patients did not change the number of clinical events but did reduce cardiometabolic risk factors among patients with type 2 diabetes, especially those in low- and middle-income countries in the Asia-Pacific region. Trial Registration ClinicalTrials.gov Identifier: NCT01631084.

Low FT3 is an independent marker of disease severity in patients hospitalized for COVID-19.

Abstract: Aim To study the prevalence of thyroid dysfunction and its association with disease severity in hospitalized patients of coronavirus disease-19 (COVID-19). Methods In this retrospective cohort study, thyroid function tests (TFT) of 236 hospitalized patients of COVID-19, along with demographic, comorbid, clinical, biochemical, and disease severity records were analysed. Patients were divided into previous euthyroid or hypothyroid status to observe the effect of prior hypothyroidism on severity of COVID-19. Results TFT abnormalities were common. Low free T3 (FT3), high thyroid stimulating hormone (TSH) and low TSH were seen in 56 (23.7%), 15 (6.4%) and 9 (3.8%) patients, respectively. The median levels of TSH (2.06 vs 1.26 mIU/mL, p=0.001) and FT3 (2.94 vs 2.47 pg/mL, p=0.000) were significantly lower in severe disease. Previous hypothyroid status (n=43) was associated with older age, higher frequency of comorbidities, higher FT4 and lower FT3. TFT did not correlate with markers of inflammation (except lactate dehydrogenase), however, FT3 and TSH negatively correlated with outcome severity score and duration of hospital stay. Cox-regression analysis showed that low FT3 was associated with severe COVID-19 (p=0.032, HR 0.302; CI 0.101-0.904), irrespective of prior hypothyroidism. Conclusions Functional thyroid abnormalities (low FT3 and low TSH) are frequently seen in hospitalized patients of COVID-19. Although these abnormalities did not correlate with markers of inflammation, this study shows that low FT3 at admission independently predicts severity of COVID-19.

The Indian Society for Bone and Mineral Research (ISBMR) position statement for the diagnosis and treatment of osteoporosis in adults.

Abstract: The Indian Society for Bone and Mineral Research (ISBMR) has herein drafted clinical practice guidelines for the diagnosis and management of osteoporosis for the people of India. Implementation of the position statement in clinical practice is expected to improve the overall care of patients with osteoporosis in India. In India, osteoporosis is a major public health problem. However, in the absence of any robust regional guidelines, the screening, treatment, and follow-up of patients with osteoporosis are lagging behind in the country. The Indian Society for Bone and Mineral Research (ISBMR), which is a multidisciplinary group of physicians, researchers, dietitians, and epidemiologists and who study bone and related tissues, in their annual meeting, drafted the guidelines for the diagnosis and management of osteoporosis that would be appropriate in a resource constraint setting like India. Diagnosis of osteoporosis can be made in a patient with minimal trauma fracture without the aid of any other diagnostic tools. In others, bone mineral density measured by dual-energy X-ray absorptiometry remains the modality of choice. Data indicates that osteoporotic fractures occur at an earlier age in Indians than in the West; hence, screening for osteoporosis should begin at an earlier age. FRAX can be used for fracture risk estimation; however, it may underestimate the risk of future fractures in our population and still needs validation. Maintaining optimum serum 25-hydroxyvitamin D levels is essential, which, in most cases, would require regular vitamin D supplementation. Pharmacotherapy should be guided by the presence/absence of vertebral/hip fractures or the severity of risk based on clinical factors, although bisphosphonates remain the first choice in most cases. Regular follow-up is essential to ensure adherence and response to therapy. Implementation of the position statement in clinical practice is expected to improve the overall care of patients with osteoporosis in India.

Long Term Health Consequences of COVID-19 in Hospitalized Patients from North India: A follow up study of upto 12 months

Abstract: Purpose: Long COVID syndrome is now a real and pressing public health concern. We cannot reliably predict who will recover quickly or suffer with mild debilitating long COVID 19 symptoms or battle life threatening complications. In order to address some of these questions, we studied the presence of symptoms and various correlates in COVID 19 patients who were discharged from hospital, 3 months and up to 12 months after acute COVID 19 illness. Methods: This is an observational follow up study of RT PCR confirmed COVID 19 patients admitted at 3 hospitals in north India between April August 2020. Patients were interviewed telephonically using a questionnaire regarding the post COVID symptoms. The first tele calling was done in the month of September 2020, which corresponded to 4 to 16 weeks after disease onset. All those who reported presence of long COVID symptoms, were followed up with a second call, in the month of March 2021, corresponding to around 9 to 12 months after the onset of disease. Results: Of 990 patients who responded to the first call, 615 (62.2%) had mild illness, 227 (22.9%) had moderate and 148 (15.0%) had severe COVID 19 illness at the time of admission. Nearly 40% (399) of these 990 patients reported at least one symptom at that time. Of these 399 long COVID patients, 311 (almost 78%) responded to the second follow up. Nearly 8% reported ongoing symptomatic COVID, lasting 1 to 3 months and 32% patients having post COVID phase with symptoms lasting 3 to 12 months. Nearly 11% patients continued to have at least one symptom even at the time of the second interview (9 to 12 months after the disease onset). Overall, we observed Long COVID in almost 40% of our study group. Incidence of the symptoms in both the follow ups remained almost same across age groups, gender, severity of illness at admission and presence of comorbidity, with no significant association with any of them. Most common symptoms experienced in long COVID phase in our cohort were fatigue, myalgia, neuro psychiatric symptoms like depression, anxiety, brain fog and sleep disorder, and breathlessness. Fatigue was found to be significantly more often reported in the elderly population and in those patients who had a severe COVID 19 illness at the time of admission. Persistence of breathlessness was also reported significantly more often in those who had severe disease at the onset. The overall median duration of long COVID symptoms was 16.9 weeks with inter quartile range of 12.4 to 35.6 weeks. The duration of symptom resolution was not associated with age, gender or comorbidity but was significantly associated with severity of illness at the time of admission (P=0.006). Conclusions: Long COVID is now being recognized as a new disease entity, which includes a constellation of symptoms. Long COVID was in almost 40% of our study group with no correlation to age, gender, comorbidities or to the disease severity. The duration of symptom resolution was significantly associated with severity of illness at the time of admission (P = 0.006). In our study, all patients reported minor symptoms such as fatigue, myalgia, neuro psychiatric symptoms like depression, anxiety, brain fog and sleep disorder and persistence of breathlessness. Severe organ damage was not reported by our subjects. This might be the longest post COVID follow up study on a sample of nearly 1000 cases from India.

Dual-Plating in Distal Femur Fracture: A Systematic Review and Limited Meta-analysis

Abstract: Although lateral locking plate has shown promising results in distal femur fracture, there are high rates of varus collapse and implant failure in comminuted metaphyseal and articular fractures. This systematic review evaluates the functional outcomes and complications of dual plating in the distal femur fracture. Manual and electronic search of databases (PubMed, Medline Embase and Cochrane Central Register of Controlled Trials) was performed to retrieve studies on dual plate fixation in the distal femur fracture. Of the retrieved 925 articles, 12 were included after screening. There were one randomized-controlled, four prospective and seven retrospective studies. A total of 287 patients with 292 knees were evaluated (dual plating 213, single plating 76, lost to follow-up 3). The nonunion and delayed union rates following dual plate fixations were up to 12.5% and 33.3%, respectively. The mean healing time ranged from 11 weeks to 18 months. Good to excellent outcome was observed in 55–75% patients. There was no difference between the single plate and dual plate fixation with regards to the functional outcomes (VAS score, Neer Score and Kolmert's standard) and complications. Pooled analysis of the studies revealed a longer surgical duration (MD − 16.84, 95% CI − 25.34, − 8.35, p = 0.0001) and faster healing (MD 5.43, 95% CI 2.60, 8.26, p = 0.0002) in the double plate fixation group, but there was no difference in nonunion rate (9.2% vs. 0%, OR 4.95, p = 0.13) and blood loss (MD − 9.86, 95% CI − 44.97, 25.26, p = 0.58). Dual plating leads to a satisfactory union in the comminuted metaphyseal and articular fractures of the distal femur. There is no difference between the single plate and dual plate with regards to nonunion rate, blood loss, functional outcomes and complications. However, dual fixation leads to faster fracture healing at the cost of a longer surgical duration.

Surgical Management of the Axilla in Clinically Node-Positive Breast Cancer Patients Converting to Clinical Node Negativity through Neoadjuvant Chemotherapy: Current Status, Knowledge Gaps, and Rationale for the EUBREAST-03 AXSANA Study

Abstract: In the last two decades, surgical methods for axillary staging in breast cancer patients have become less extensive, and full axillary lymph node dissection (ALND) is confined to selected patients. In initially node-positive patients undergoing neoadjuvant chemotherapy, however, the optimal management remains unclear. Current guidelines vary widely, endorsing different strategies. We performed a literature review on axillary staging strategies and their place in international recommendations. This overview defines knowledge gaps associated with specific procedures, summarizes currently ongoing clinical trials that address these unsolved issues, and provides the rationale for further research. While some guidelines have already implemented surgical de-escalation, replacing ALND with, e.g., sentinel lymph node biopsy (SLNB) or targeted axillary dissection (TAD) in cN+ patients converting to clinical node negativity, others recommend ALND. Numerous techniques are in use for tagging lymph node metastasis, but many questions regarding the marking technique, i.e., the optimal time for marker placement and the number of marked nodes, remain unanswered. The optimal number of SLNs to be excised also remains a matter of debate. Data on oncological safety and quality of life following different staging procedures are lacking. These results provide the rationale for the multinational prospective cohort study AXSANA initiated by EUBREAST, which started enrollment in June 2020 and aims at recruiting 3000 patients in 20 countries (NCT04373655; Funded by AGO-B, Claudia von Schilling Foundation for Breast Cancer Research, AWOgyn, EndoMag, Mammotome, and MeritMedical).

Notto covid-19 vaccine guidelines for transplant recipients

Abstract: In December 2019, novel coronavirus (SARS-CoV-2) infection started in Wuhan and resulted in a pandemic within a few weeks' time. Organ transplant recipients being at a risk for more severe COVID-19 if they get SARS CoV-2 viral infection, COVID-19 vaccine has a significant role in these patients. The vaccine is a safer way to help build protection and would either prevent COVID-19 infection or at least diminish the severity of the disease. It would also reduce the risk of the continuing transmission and enhance herd immunity. Immuno-compromised patients should not receive live vaccines as they can cause vaccine-related disease and hence the guidelines suggest that all transplant recipients should receive age-appropriate 'inactivated vaccine' as recommended for general population. Though trials have not been undertaken on transplant recipients, efficacy and safety of COVID-19 vaccine have been scientifically documented for few vaccines among the general population.

Complications after bariatric surgery: A multicentric study of 11,568 patients from Indian bariatric surgery outcomes reporting group.

Abstract: Background: Complications after bariatric surgery are not uncommon occurrences that influence the choice of operations both by patients and by surgeons. Complications may be classified as intra-operative, early ( Objectives: To examine the various complications after different bariatric operations that currently performed in India. Materials and Methods: A scientific committee designed a questionnaire to examine the post-bariatric surgery complications during a fixed time period in India. Data requested included demographic data, co-morbidities, type of procedure, complications, investigations and management of complications. This questionnaire was sent to all centres where bariatric surgery is performed in India. Data collected were reviewed, were analysed and are presented. Results: Twenty-four centres responded with a report on 11,568 bariatric procedures. These included 4776 (41.3%) sleeve gastrectomy (SG), 3187 (27.5%) one anastomosis gastric bypass (OAGB), 2993 (25.9%) Roux-en-Y gastric bypass (RYGB) and 612 (5.3%) other procedures. Total reported complications were 363 (3.13%). Post-operative bleeding (0.75%) and nutritional deficiency (0.75%) were the two most common complications. Leaks (P = 0.009) and gastro-oesophageal reflux disease (P = 0.019) were significantly higher in SG, marginal ulcers in OAGB (P = 0.000), intestinal obstruction in RYGB (P = 0.001) and nutritional complications in other procedures (P = 0.000). Overall, the percentage of complications was higher in 'other' procedures (6.05%, P = 0.000). There were 18 (0.16%) reported mortalities. Conclusions: The post-bariatric composite complication rate from the 24 participating centres in this study from India is at par with the published data. Aggressive post-bariatric follow-up is required to improve nutritional outcomes.

Effect of COVID-19 Pandemic-Induced Dietary and Lifestyle Changes and Their Associations with Perceived Health Status and Self-Reported Body Weight Changes in India: A Cross-Sectional Survey.

Abstract: Home confinement during the COVID-19 pandemic is accompanied by dramatic changes in lifestyle and dietary behaviors that can significantly influence health. We conducted an online cross-sectional survey to assess COVID-19 pandemic-induced dietary and lifestyle changes and their association with perceived health status and self-reported body weight changes among 1000 Indian adults in early 2021. Positive improvements in dietary habits, e.g., eating more nutritious (85% of participants) and home-cooked food (89%) and an increase in overall nutrition intake (79%), were observed. Sixty-five percent of participants self-reported increased oat consumption to support immunity. There were some negative changes, e.g., more binge eating (69%), eating more in between meals (67%), and increasing meal portion size (72%). Two-thirds of participants reported no change in lifestyles, whereas 21 and 23% reported an increase, and 13 and 10% reported a decrease in physical activity and sleep, respectively. Overall, 64 and 65% of participants reported an improvement in perceived health and an increase in body weight during the COVID-19 period compared to pre-COVID-19, respectively. The top motivations for improving dietary habits included improving physical and mental health and building immunity. In conclusion, the overall perceived health was improved and there was an increase in self-reported body weight in most participants during COVID-19. Diet emerged as the most crucial determinant for these changes.

Evaluation of Remineralizing Capacity of P11-4, CPP-ACP, Silver Diamine Fluoride, and NovaMin: An In Vitro Study.

Abstract: Aim and objective To determine and compare remineralizing efficacy of NovaMin, CPP-ACP, silver diamine fluoride (SDF), and P11-4. Materials and methods Sixty permanent premolars were divided into four groups with 15 samples in each group; group I: self-assembling peptide (P11-4), group II: SDF, group III: Casein phosphopeptide-stabilized amorphous calcium phosphate (CPP-ACP), and group IV: NovaMin. Mineral content was assessed using a scanning electron microscope at 7, 14, and 21 days after remineralization with each agent. Results The mean remineralization in group I at 7 days was 1.73 ± 0.02, at 14 days was 1.79 ± 0.01, and at 21 days was 1.90±0.03. Mean remineralization in group II was 1.61 ± 0.01, 1.64 ± 0.02, and 1.73 ± 0.03 at 7, 14, and 21 days, respectively. Mean remineralization in group III was 1.62 ± 0.01, 1.65 ± 0.02, and 1.74 ± 0.05 at 7, 14, and 21 days, respectively. Mean remineralization in group IV was 1.59 ± 0.02, 1.62 ± 0.07, and 1.70 ± 0.09 at 7, 14, and 21 days, respectively. The maximum value was obtained on day 21. There was a significant difference in mean remineralization values between group I vs group II, group I vs group III, and group I vs group IV (p Conclusion Self-assembling peptides showed maximum remineralization in tested specimens followed by CPP-ACP, SDF, and NovaMin-containing toothpaste. Clinical significance CPP-ACP, SDF, and NovaMin-containing toothpaste can be indicated for remineralization of initial caries in clinical use.

COVID-19 associated mucormycosis: A Descriptive Multisite Study from India.

Abstract: Background and aims Mucormycosis is an invasive fungal infection and carries a significant morbidity and mortality. A number of cases of mucormycosis have been reported in association with COVID-19. In this study, a consortium of clinicians from various parts of India studied clinical profile of COVID-19 associated mucormycosis (CAM) and this analysis is presented here. Methods Investigators from multiple sites in India were involved in this study. Clinical details included the treatment and severity of COVID-19, associated morbidities, as well as the diagnosis, treatment and prognosis of mucormycosis. These data were collected using google spreadsheet at one centre. Descriptive analysis was done. Results There were 115 patients with CAM. Importantly, all patients had received corticosteroids. Diabetes was present in 85.2% of patients and 13.9% of patients had newly detected diabetes. The most common site of involvement was rhino-orbital. Mortality occurred in 25 (21.7%) patients. On logistic regression analysis, CT scan-based score for severity of lung involvement was associated with mortality. Conclusion Universal administration of corticosteroids in our patients is notable. A large majority of patients had diabetes, while mortality was seen in ∼1/5th of patients, lower as compared to recently published data.

Reliability and Reproducibility of Landmark Identification in Unilateral Cleft Lip and Palate Patients: Digital Lateral Vis-A-Vis CBCT-Derived 3D Cephalograms.

Abstract: Background: The aim of the retrospective observational study was to compare the precision of landmark identification and its reproducibility using cone beam computed tomography-derived 3D cephalograms and digital lateral cephalograms in unilateral cleft lip and palate patients Methods: Cephalograms of thirty-one (31) North Indian children (18 boys and 13 girls) with a unilateral cleft lip and palate, who were recommended for orthodontic treatment, were selected After a thorough analysis of peer-reviewed articles, 20 difficult-to-trace landmarks were selected, and their reliability and reproducibility were studied These were subjected to landmark identification to evaluate interobserver variability; the coordinates for each point were traced separately by three different orthodontists (OBA, OBB, OBC) Statistical analysis was performed using descriptive and inferential statistics with paired t-tests to compare the differences measured by the two methods Real-scale data are presented in mean ± SD A p-value less than 005 was considered as significant at a 95% confidence level Results: When comparing, the plotting of points posterior nasal spine (PNS) (p < 005), anterior nasal spine (ANS) (p < 001), upper 1 root tip (p < 005), lower 1 root tip (p < 005), malare (p < 005), pyriforme (p < 005), porion (p < 001), and basion (p < 005) was statistically significant Conclusion: In patients with a cleft lip and palate, the interobserver identification of cephalometric landmarks was significantly more precise and reproducible with cone beam computed tomography -derived cephalograms vis-a-vis digital lateral cephalograms

Liver Transplant Society of India Guidelines for Liver Transplant during COVID-19 times.

Abstract: COVID-19 pandemic has affected liver transplantation in many ways. There is risk of infection to the transplant recipients; and COVID-19 is associated with significant risk of mortality in patients on wait list. The Liver Transplant Society of India has prepared guidelines regarding selection of adult and pediatric patients for liver transplantation, transplant for acute liver failure, use of deceased donor organs, transplant techniques and minimally invasive donor hepatectomy, pre and post-surgery testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related coronavirus disease 2019 in donors and recipients, role of COVID-19 antibody testing, shifting of recipients from COVID-19 to non-COVID-19 areas after recovery, isolation policy of team members exposed to COVID-19 patients, drug therapy of proven or suspected COVID-19 infection early post-transplant, care of SARS-CoV-2 positive donors and recipients and a separate COVID-19 consent for surgery.

Rhino-orbital-cerebral mucormycosis in times of COVID-19: A neurosurgical experience.

Abstract: Background The gravity of "second wave" of COVID-19 has effaced many new challenges in India; mucormycosis being a recent one. Diabetes mellitus (DM) is a known significant risk factor for mucormycosis. Here, we present our experience with rhino-orbital-cerebral mucormycosis (ROCM) during the "second wave of COVID-19" at a tertiary health care centre in North India. Methods This case series includes four cases of ROCM that were managed by our neurosurgical team in view ofcerebral involvement. Results All the cases with an exception of one (Case 1), had a history of treatment for COVID-19 pneumonia. Case 2, 3 had undergone functional endoscopic sinus surgery (FESS) and orbital decompression before the onset of cerebral involvement; Case 4 underwent FESS and cranial surgery in the same sitting. All the patients had a history of DM and all the cases treated for COVID-19 pneumonia had a history of treatment with corticosteroids. Two patients underwent surgery with the exception of one patient, who did not provide consent for the same. One patient expired before surgical excision could be attempted. Conclusion Regular and intensive follow-up is the key in swift detection and management of ROCM in post-COVID patients. While surgical excision is advisable in the fungal lesion, it must be borne in mind that radical excision of cerebral lesions is associated with morbidity, delayed recovery, and prolonged ICU stay. Culture and sensitivity-based antibiotics should be used judiciously as fever is a common postoperative complication. Blood sugar monitoring and control of DM are paramount in this condition. Steroids should be avoided in the management of cerebral edema with judicious use of hypertonic saline or mannitol.

Early Gestational Diabetes Mellitus: Diagnostic Strategies and Clinical Implications.

Abstract: Preexisting diabetes mellitus (DM) should be ruled out early in pregnancy in those at risk. During screening, a significant proportion of women do not reach the threshold for overt DM but fulfill the criteria used for diagnosing conventional gestational DM (cGDM). There is no consensus on the management of pregnancies with intermediate levels of hyperglycemia thus diagnosed. We have used the term early gestational DM (eGDM) for this condition and reviewed the currently available literature. Fasting plasma glucose (FPG), oral glucose tolerance test, and glycated hemoglobin (HbA1c) are the commonly employed screening tools in early pregnancy. Observational studies suggest that early pregnancy FPG and Hba1c correlate with the risk of cGDM and adverse perinatal outcomes. However, specific cut-offs, including those proposed by the International Association of the Diabetes and Pregnancy Study Group, do not reliably predict the development of cGDM. Emerging data, though indicate that FPG ≥ 92 mg/dL (5.1 mmol/L), even in the absence of cGDM, signals the risk for perinatal complication. Elevated HbA1c, especially a level ≥ 5.9%, also correlates with the risk of cGDM and worsened outcome. HbA1c as a diagnostic test is however besieged with the usual caveats that occur in pregnancy. The studies that explored the effects of intervention present conflicting results, including a possibility of fetal malnutrition and small-for-date baby in the early treatment group. Diagnostic thresholds and glycemic targets in eGDM may differ, and large multicenter randomized controlled trials are necessary to define the appropriate strategy.

Experts’ consensus: pharmaco-invasive therapy for ST‐elevation myocardial infarction along with focus on secondary prevention and cardiac rehabilitation in India

Abstract: In India, patients with acute coronary syndrome (ACS) tend to present with higher percentage of ST-elevation myocardial infarction (STEMI). Numerous existing challenges like patient unawareness, lack of structured STEMI care systems, inadequacy of promptly available facilities and unequipped ambulances for patient transport make it difficult to achieve optimal STEMI treatment. Also, due to socio-economic diversities prevailing in India, a large proportion of the entire population has access to only basic primary healthcare and are unable to afford proper medical facilities. Judicious and timely reperfusion strategy has been the mainstay of STEMI management. Even though, percutaneous coronary intervention (PCI) continues to be the gold standard for treating STEMI worldwide, it is not the ideal strategy in many Indian settings, especially in villages and smaller towns/cities. In such scenarios, pharmaco-invasive approach has proved to be a better reperfusion therapeutic strategy for improving treatment outcomes and subsequently reducing morbidity and mortality. The purpose of this consensus article is to highlight the clinical perspectives of Indian cardiologists at identifying and addressing the need gaps currently existing in India for optimization of STEMI treatment approaches. The experts shared their views on the rationale of pharmaco-invasive approach and highlighted the significance of commonly used thrombolytic agents, STEMI treatment protocols, secondary prevention and cardiac rehabilitation.