Comparative study between effectiveness of low molecular weight heparin injection and unfractionated heparin in terms of morbidity and outcome in COVID-19 cases

Background: The novel coronavirus 2019 presented a variety of disease spectrums that range from asymptomatic to sepsis with multi-organ dysfunction and death. One of the mechanisms being a hypercoagulable state with micro and macro-circulatory thrombosis is found in critically ill COVID-19 patient with ARDS with pathology consistent with a vascular occlusive aetiology of respiratory failure rather than more classic finding of ARDS. Venous thromboembolism, MI, acute peripheral arterial thrombosis is seen in COVID-19. Endothelial cells dysfunction induced by infection causing excess thrombin generation, fibrinolysins shutdown, hypoxia inducible transcription factor dependent signalling pathways, increasing blood viscosity leading to Hypercoagulable state. Early application of anticoagulant therapy in severe COVID-19 was suggested for improving outcome in patients with elevated d-dimer. Aim of study was comparing effectiveness of LMWH with unfractionated heparin in outcome of COVID-19.Methods: This retrospective observational study including 400 patients meeting inclusion criteria were divided 2 groups out of which 200 patients were treated with inj. LMWH and other 200 were treated with injection heparin and various parameters were compared. A probability value (p value) of less than or equal to 0.05 was considered statistically significant.Results: Death rate is seen lower with LMWH in critically ill patients with high discharge rate with minimal lab parameter derangement and high efficacy to lower down inflammatory markers (LDH, ferritin, CRP, D-dimer, ESR) in comparison to unfractionated heparin.Conclusions: Early use of LMWH may be beneficial for the outcome

Life threatening acute kidney injury in a patient of rheumatoid arthritis, is it drug or disease related?

Even low-dose MTX therapy for treatment of rheumatic diseases is claimed to cause impairment in renal function. We report an insidious and progressive deterioration of renal function of patient with RA on low-dose MTX in a 41-year-old woman. We suggest that patients on low-dose MTX therapy should be periodically monitored for creatinine levels

Polymicrobial therapy induced nephrotoxicity: more is not always better

Polymicrobial induced nephrotoxicity (PIN) occurs more commonly in critically ill patients. Exposure to drugs often results in toxicity in kidney which represents a major control system maintaining homeostasis of body and thus is especially susceptible to xenobiotics. We present here an adverse drug reaction which is additive nephrotoxicity with combined antimicrobial use in critically ill patient. Blood urea and serum creatinine levels were raised much above the baseline after a fortnight of therapy. The suspected drugs were withdrawn leading to a gradual improvement and normalization of blood urea and serum creatinine levels This suggested a causal relationship which was possibly due to the administration of nephrotoxic antimicrobials. The present case highlights that critically ill patients on prolonged Polymicrobial therapy should be closely monitored, and dose increments should be made cautiously

Cystathionine Beta-Synthase Deficiency Causes Fat Loss in Mice

Cystathionine beta synthase (CBS) is the rate-limiting enzyme responsible for the de novo synthesis of cysteine. Patients with CBS deficiency have greatly elevated plasma total homocysteine (tHcy), decreased levels of plasma total cysteine (tCys), and often a marfanoid appearance characterized by thinness and low body-mass index (BMI). Here, we characterize the growth and body mass characteristics of CBS deficient TgI278T Cbs−/− mice and show that these animals have significantly decreased fat mass and tCys compared to heterozygous sibling mice. The decrease in fat mass is accompanied by a 34% decrease in liver glutathione (GSH) along with a significant decrease in liver mRNA and protein for the critical fat biosynthesizing enzyme Stearoyl CoA desaturase-1 (Scd-1). Because plasma tCys has been positively associated with fat mass in humans, we tested the hypothesis that decreased tCys in TgI278T Cbs−/− mice was the cause of the lean phenotype by placing the animals on water supplemented with N-acetyl cysteine (NAC) from birth to 240 days of age. Although NAC treatment in TgI278T Cbs−/− mice caused significant increase in serum tCys and liver GSH, there was no increase in body fat content or in liver Scd-1 levels. Our results show that lack of CBS activity causes loss of fat mass, and that this effect appears to be independent of low serum tCys

Piperacillin-tazobactam induced hypokalaemia

Electrolytes imbalance has been reported with the use of several antimicrobials in clinical scenarios. Piperacillin/tazobactam is a commonly used antibiotic with tolerable side effects and broad antimicrobial activity in general practice. Herein we report a case of a 27 year old male presented with Road Traffic Accident with depressed frontal bone fracture, fracture humerus and fracture of great toe complicated with Ventilator associated Pneumonia (VAP) who developed hypokalemia secondary to intravenous piperacillin-tazobactam. Upon withdrawal of the drug, serum potassium normalized in 2 days. There were no other underlying renal or hepatic illness and other causes of hypokalemia. Hypokalemia is a serious adverse effect of piperacillin-tazobactam and should be suspected while treating patients with this drug in clinical practice especially in Intensive Care Units (ICU). We concluded this causality as probable/likely category according to WHO-UMC Causality Categories

Suspected immune mediated response to COVID-19 vaccine: two individual case reports

SARS-CoV-2, the virus that causes coronavirus disease 19 (COVID-19), has spread rapidly around the world. Researchers have been working round the clock to develop effective vaccines, which people started receiving in December 2020. Therefore, careful follow-up and surveillance studies for continued vaccine safety monitoring will be needed to ascertain the potential risks of such adverse events or disease. Here, we present two individual cases of pancreatitis and typhilitis following COVID 19 vaccination. In the first case of a 38 years old male patient developed pancreatitis after 4 days of COVID 19 vaccination and in second case, of a 60 years old female patient developing typhilitis after just one day after vaccination. All possible causes of this occurrence were ruled out. Two main factors suggest a possible link to the vaccine, the chronology of the events and the incongruent immune response to the vaccine component. It is not possible to establish a direct causal relation between vaccination and adverse event following immunization; however, this report can be used to alert practitioners to this possibility of adverse event following immunization after COVID-19 vaccine

Methotrexate induced ventricular arrhythmia as a medication error: a case report

Methotrexate (MTX) is the most widely used drug in clinical practice for long term treatment of connective tissue disorders. As this drug has narrow therapeutic index, if it goes unmonitored can lead to life threatening complications. Herein we are describing the case of a patient who presented with ventricular arrhythmia, due to failure to execute MTX therapy in the prescribed frequency and took daily dose of MTX which was meant to be taken as a weekly dose pointing to failure of patient education or patient comprehension regarding MTX and finally succumbed due to cardiogenic shock. We concluded this causality as probable/likely category according to WHO-UMC causality categories.

Analysis of adverse drug reactions in a tertiary care emergency medicine department: prevalence, preventability and reporting

Background: Adverse drug reactions (ADRs) are negative consequences of drug therapy. ADR results in diminished quality of life, increased physician visits, hospitalizations, and even death. Hence a study was planned to detect and analyze ADR encountered in emergency medicine department.Methods: Data was collected over a period of 1 year after taking approval from IRB (Institutional Review Board) and written informed consent from patients. ADRs presenting as a cause of hospital admission or developed during hospitalization were analyzed.Results: A total of 229 ADRs were analyzed. Majority of ADRs were found in the age group of 40-60 Years. The M: F Ratio was 1.10:1. According to Wills and Brown Classification, majority of the ADRs belonged to Type A. According to Hartwig and Siegel classification of severity of ADRs, 18.78% of the ADRs were severe in nature. According to Schumock and Thornton preventability score, majority (64.19%) of the ADRs were not preventable, whereas 17.03% were definitely preventable. 120 (52.40%) of the ADRs were serious in nature Anti-infective were the most common drug class (30.13%) followed by CVS (24.03%) group of drugs. About (57.64%) ADRs fall in the category of probable/likely. Regarding their Outcome, 44.10% of the ADRs were recovered and 43.23% were recovering.Conclusions: Anti-infective were the most reported drug class to cause ADRs in a tertiary care emergency medicine department. Causality assessment according to WHO-UMC and Naranjo’s causality assessment criteria reported to be Probable. Whereas modified Schumock and Thornton scale preventability scale showed that majority were not preventable

Analysis of drug related electrolyte disturbances in emergency medicine department

Background: Electrolytes play an important role in various physiological functions of the body. Electrolyte disturbances are one of the most common problems encountered in critically ill patients. Drugs are also known to cause adverse electrolyte consequences. These drugs could be anti-hypertensive agents, hormones, antipsychotics or steroids. There is paucity of published literature on electrolyte disturbances caused by drugs. The purpose of our study was to evaluate the electrolyte disturbances caused by various drugs in critically ill patients.Methods: Following approval of the Institutional Ethics Committee, data collection was started. Adverse Drug Reactions (ADRs) presenting as an electrolyte disturbance in emergency medicine department or occurring in hospitalized patients in the Intensive care unit (ICU) of our hospital was be collected. ADRs resulting into electrolyte disturbances were identified and analysed in detail for demographic details, types of electrolyte disturbances, seriousness, severity, causality and preventability of ADRs. Fisher's exact test was done to find out the statistical difference between the electrolyte disturbances and different drugs.Results: Total 58 ADRs were reported as an electrolyte disturbance. Mean age of the patients affected was 52.48 years. Highest number of ADRs were observed in the age group of 61 to 70 years. Hypokalemia constituted 32 cases (55.2%) followed by hyponatremia (25.9%), hyperkalemia (6.9%), hypernatremia (6.9%), hypocalcemia (1.7%), hypomagnesemia (1.7%) and hypophosphatemia (1.7%). Insulin was associated with maximum cases of ADRs (27.6%).Conclusions: Electrolyte disturbances constitutes a major chunk of ADRs especially in critically ill patients. The physicians must be well-versed with the dynamics of fluid-electrolyte balance

Analysis of waiting time for elective surgical procedures in neurosurgery department at a tertiary care teaching hospital in NCT, India

Background: Reported increases in waiting times for publicly-funded elective surgeries have intensified the need to decrease wait by healthcare providers and hence the study.Methods: Descriptive study done in neurosurgery department, to ascertain waiting times for its elective surgeries, included a retrospective analysis of admitted post-surgical patients and a prospective study using interviews with relevant stakeholders to do a process mapping.Results: Median time from decision of surgery to actual date of surgery was found to be 110.5 days. It was calculated that for optimum utilization of present available OTs, 19 extra beds are required and to address the existing load of patients waiting for their respective surgeries there is a need of 63 additional beds with 2 additional OTs functioning per day.Conclusions: The most common cause of waiting time was unavailability of vacant beds due to mismatch in demand-supply. The reason for postponement of surgery after admission was found to be lack of availability of theatre time followed by patient not being fit for surgery. Shortage of operating time was due to delayed start of operation theatre time. The study recommends improving admission process, restricting OPD time, standardized patient prioritization depending on relevant clinical criteria