Journal of Acute Disease

120-126

Authors: Razieh Avan, Afrooz Mazidimoradi, Hamid Salehiniya

Unbalanced magnesium levels in the body, like other minerals, are a factor that is important in the severity and mortality of COVID-19. This study was designed to investigate the relationship between serum magnesium levels and clinical outcomes in COVID-19 patients. In this systematic review, a comprehensive search was performed in PubMed, Scopus, and Web of Science databases until September 2021 by using the keywords COVID-19, severe acute respiratory syndrome coronavirus 2, coronavirus disease, SARS- COV-infection 2, SARS-COV-2, COVID 19, and magnesium. End-Note X7 software was used to manage the studies. Articles that evaluated effect of magnesium on COVID-19 were included in the analysis. After reviewing several articles,12 studies were finally included in the ultimate analysis. The studies show that hypomagnesemia and hypermagnesemia are both factors that increase mortality in patients with COVID-19, even in one study, hypomagnesemia is the cause of doubling thedeaths in COVID-19 patients. Some studies have also found a negative correlation between magnesium deficiency and infectionseverity, while some others have reported no correlation between magnesium level and disease severity. According to the important role of magnesium in the body and its involvement in many physiological reactions, as well as differences in physical and physiological conditions of COVID-19 patients, in addition to the need for studies with larger sample sizes, monitoring and maintaining normal serum magnesium levels during the disease seems necessary as a therapeutic target, especially in patients admitted to the intensive care unit.

133-139

Authors: Aref Zarei, Hesameddin Modir, Behnam Mahmoodiyeh, Alireza Kamali, Farzad Zamani-Barsari

Objective: To compare effect of midazolam, dexmedetomidine, and ketamine as oral premedication on pediatric sedation and ease of parental separation anxiety in anesthesia induction. Methods: This multicenter, prospective, randomized, double-blind, clinical trial focused on a pediatric population aged 2-7 years (n=153) with the American Society of Anesthesiologists I-II who required elective surgery. The patients were stratified into three intervention groups: midazolam, ketamine, and dexmedetomidine. Hemodynamic parameters (blood pressure, heart rate, and oxygen saturation) every 5 min until induction of anesthesia along with non-hemodynamic factors, comprised of sedation score before the administration and at the time of being separated from the parents, as well as parental separation anxiety scale, acceptance of anesthesia induction, and side effects were recorded and compared. Results: No statistically significant difference in oxygen saturation, heart rate, blood pressure, duration of surgery, time to achieve an Aldrete score of 9-10, or sedation score was noted in the study groups. More patients in the dexmedetomidine and midazolam groups could better ease parental separation anxiety than the ketamine group (P=0.001). Moreover, fewer patients accept anesthesia induction (P=0.001) and more had side effects in the ketamine group (P=0.047). Conclusions: Our findings indicate that compared to the ketamine group, dexmedetomidine and midazolam are better in easing parental separation anxiety and accepting induction of anesthesia with fewer side effects. Dexmedetomidine and midazolam may be considered better choices. However, the final choice hinges on the patient's specific physical condition and the anesthesiologist's preference. Clinical registarion: This study is registered in the Iranian Registry Clinical Trial center with the clinical trial code of IRCT20211007052693N1.

150-155

Authors: LA Gauri, Ketan Bhatnagar, Parvez Sameja, Hardeva Ram Nehara, Kuldeep Saini, Ravi Dutt, Bhupen Bhatnagar, Mohit Singh Khokhar, Vikas Kumar, Anjali Garg

Objective: To explore predictive hematological parameters on admission which are associated with mortality in NS1 positive dengue shock syndrome patients. Methods: Demographic characteristics, hematological parameters, and the outcome of NS1 positive dengue shock syndrome patients without any comorbidity and coexisting infections were collected from the Intensive Care Unit and the results were compared between the survivor and non-survivor groups. Results: The mean age was (30.77±11.48) years and 56 (56.6%) patients were males. Out of the total 99 patients, 72 (72.27%) patients were successfully discharged and 27 (27.27%) patients eventually succumbed to death. The most common hematological finding was thrombocytopenia (95.95%), followed by anemia (52.52%) and decreased mean platelet volume (37.37%). After controlling other variables, logistic regression analysis showed that absolute neutrophil count and mean platelet volume were associated with mortality. Conclusions: Total leucocyte count, absolute neutrophil count, and total platelet count are significantly higher, and mean platelet volume is significantly lower in the non-survivor group as compared to the survivor group. Absolute neutrophil count and mean platelet volume are predictors associated with mortality.

161-164

Authors: Neeraj Kumar, Sushant Satyapriya, Shaik Mohammad Tahaseen, Kunal Singh, Abhyuday Kumar

Rationale: The impact of COVID-19 in patients with autoimmune liver disease treated with immunosuppressive therapy has not been described so far. This case report describes the clinical course of a patient with autoimmune hepatitis (AIH) who developed COVID-19 and the features of cytokine syndrome leading to its deterioration in our intensive care unit. Patient’s Concern: A 28-year-old male presented with generalized anasarca for two weeks and chronic liver disease for 8 months. Diagnosis: AIH and Covid-19 with features of cytokine storm syndrome. Interventions: Intravenous furosemide, mannitol, syrup lactulose, steroids (prednisolone 40 mg), azathioprine 1 mg/kg body weight, rifaximin, vitamin K, and blood products. Outcomes: The patient had hepatic encephalopathy and AIH and died on the 10th day after admission despite ventilatory support, sustained low-efficiency hemodialysis, and resuscition. Lessons: The dramatic release of cytokines and the inflammatory-immune responses not only alter the pathophysiology but also affects the onset and severity of disease progression in patients with AIH.

89-93

Authors: Debarshi Guha, Kiran Sheshadri, Shalendra Singh, Sonia Bhan

Objective: To investigate the effects of propofol and ketamine on seizure duration, hemodynamics, and recovery of electroconvulsive therapy (ECT). Methods: This prospective randomized trial included patients who had undergone ECT under anesthesia. Patients received injection of propofol 1.5 mg/kg i.v. (the propofol group) or ketamine 0.8-1.2 mg/kg i.v. (the ketamine group) during ECT. Seizure duration, hemodynamics, and recovery were recorded and compared between the two groups. Results: This trial included 44 patinets with 22 patients receiving propofol and 22 patients receiving ketamine. The total dose of propofol and ketamine was (105.68±25.27) mg and (81.36±24.55) mg, respectively. The motor seizure and electroencephalogram seizure duration were prolonged in the ketamine group (P<0.001). The hemodynamics at the admission of the two groups were comparable (P>0.05); however, the mean systolic blood pressure during the procedure was significantly higher in the ketamine group (P=0.04). Besides, spontaneous eye-opening in the ketamine group took longer than that of the propofol group (P=0.001). Conclusion: Both propofol and ketamine are safe as anesthetic agents for modified ECT, and ketamine provides a longer seizure duration without hemodynamic instability or any significant complication.

101-106

Authors: Navaneetha Krishnan Subramanian, VV Ramesh Chandra, Karthikeyan Elumalai, Narahari N Palei, Tiruveedi Kusuma, Vadlamuri Venkata Prasad, Yellanti Bala Venkata Bhargav Phani, Mungara Yeshwanth Sai, Pradeep Battula, Anna Balaji

Objective: To assess the efficacy of gabapentin in the treatment of low back pain patients. Methods: This prospective observational study was conducted over 6 months to assess the efficacy of gabapentin in patients suffering from low back pain. Past medical history, pain severity by Visual Analogue scale (VAS) and sleep quality by Pittsburgh Sleep Quality Index (PQSI) were collected. VAS scores and PQSI scores before and after gabapentin treatment were compared, and gabapentin satisfaction post treatment were recorded. Results: This study included 100 low back pain patients with 65 males and 35 females, and the mean age was (39.0±10.5) years. The commonest presentation was non-radiating low back pain (40%). The mean VAS score and the mean PQSI score in the study before treatment were 7.70±1.91 and 10.95±5.02, respectively. After treatment with gabapentin, the mean VAS score and the mean PQSI score decreased to 2.75±1.79 and 4.90±2.20, respectively, and the differences before and after the treatment were significantly different (both P=0.001). Overall, 62% of the patients were extremely satisfied with gabapentin because they reported no adverse drug reaction. Besides, 31% of the patients were satisfied and 7%were strongly dissatisfied with the therapy. Conclusion: Gabapentin can improve sleep quality and reduce lower back pain as measured by the VAS and PQSI. The efficacy of this drug is relatively good, but further improvement is required.

115-119

Authors: Chandrakant Waikar, Vinayak Gour, Lal Pranay, Sevras Hingwe

Objectives: To determine the correlation between lymphocyte count and A-DROP score in COVID-19 patients and their role in predicting poor outcomes. Methods: This retrospective observational single-center study was conducted in a tertiary care hospital in Vidisha district, India. COVID-19 patients were included in this study, who were admitted to ICU and the COVID Care Centre from August 2020 to October 2020. Demographic profile, clinical characteristics, medical history, A-DROP score, complete blood counts including lymphocyte counts (on admission), the severity of the disease course, and duration of hospitalization were collected. The correlation between lymphopenia and A-DROP score was determined, and their role in predicting poor outcomes was investigated. Results: This study included 220 patients, among which 134 were male, and 86 were female [mean age (48.98±16.98) years, 95% CI: 46.72-51.23]. Lymphocyte count in COVID-19 patients negatively correlated with the A-DROP score (r=−0.67, P<0.001). The area under the ROC curve was 0.892 (95% CI: 0.80-0.98, P<0.001) for the lymphocyte count, and the area under the ROC curve was 0.93 (95% CI: 0.84-1.00, P<0.001) for lymphocyte count-A-DROP. Conclusion: Lymphocyte count along with the A-DROP score on admission could be used to predict the severity of COVID-19 pneumonia and unfavorable outcome.

123-126

Authors: Neeraj Kumar, Subhajit Ghosh, Abhyuday Kumar, Sanjeev Kumar, Prem Kumar

Rationale: The mechanism of sudden cardiac death in COVID-19 can be multifactorial. Cardiac hypersensitivity to 5-ASA therapy leading to myocarditis has been reported in some cases. Cytokine storm syndrome and idiosyncratic reaction with mesalazine use may lead to sudden cardiac death in COVID-19. Use of immunosuppressants in hospitalized COVID-19 patients should be continued with caution, especially in patients with inflammatory bowel disease. Patient’s concern: A 75-year-old man who was tested positive for SARS-CoV-2 was admitted with a history of shortness of breath for the last two days. He was a known case of Crohn’s disease treated with mesalazine. Diagnosis: COVID-19 pneumonia with underlying Crohn’s disease leading to sudden cardiac death. Intervention: Remdesivir, antibiotics, steroids, low molecular weight heparin, tablet zinc, tab vitamin C, and other supportive treatment were started. Because of increased inflammatory markers, itolizumab was given to the patient on the 2nd day. Outcome: On the 5th day of the intensive care unit, the patient complained of sudden chest pain with respiratory distress leading to bradycardia and asystole and could not be resuscitated. Lessons: Causes for sudden cardiac death in COVID-19 pneumonia patients with Crohn’s disease is multifactorial. Although mesalazine may be a safe and effective drug in the management of inflammatory bowel disease, it can induce sytokine strom syndrome and idiosyncratic reactions that could be one of the reasons of sudden cardic death. Therefore, we should be aware of its serious and potentially life-threatening complications, especially in COVID-19 infected patients.

129-130

Authors: Rabi Narayan Hota, Shalendra Singh, Rakesh Sharma, Pallavi Khandare

NA

45-51

Authors: Gautam Jesrani, Samiksha Gupta, Saurabh Gaba, Monica Gupta

Cardiovascular manifestations and electrocardiographic abnormalities have been reported among some prevalent infections in tropical regions, which lead to a great amount of morbidity and mortality. The major infectious diseases include chikungunya, dengue fever, H1N1 influenza, and coronavirus disease-19 (COVID19) in the viral category, leptospirosis, salmonellosis, scrub typhus and tuberculosis in the bacterial category, and malaria in the protozoan parasite category. All these infirmities constitute a foremost infection burden worldwide and have been linked to the various cardiac rhythm aberrancies. So we aimed to identify and compile different studies on these infections and associated acute electrocardiographic (ECG) changes. The search was made in online international libraries like PubMed, Google Scholar, and EMBASE, and 38 most relevant articles, including original research, systematic reviews, and unique case reports were selected. All of them were evaluated thoroughly and information regarding ECG was collected. Myocarditis is the predominant underlying pathology for rhythm disturbance and can be affected either due to the direct pathogenic effect or the abnormal immune system activation. ECG variabilities in some infections like chikungunya, scrub typhus, and leptospirosis are associated with longer hospital stay and poor outcome. Tropical infective diseases are associated with prominent acute cardiac rhythm abnormalities due to myocarditis, which can be identified preliminarily by ECG changes.

59-64

Authors: Manpreet Singh1 , Awadh Bihari Tiwari1 , Priya Taank2 , Shalendra Singh3 , Amrinder Kaur4 , Munish Sood5 , Rahul Yadav6

Objective: To compare the safety and efficacy of dexmedetomidine and dexamethasone for the prevention of postoperative nausea and vomiting (PONV) in patients scheduled for laparoscopic surgery. Methods: A total of 86 female patients were prospectively administered dexmedetomidine 1 µg/kg i.v. (the group A, n=43), and dexamethasone 8 mg i.v. (the group B, n=43). The two groups were compared in treatment response, hemodynamic changes, and Numerical Analog Scale (NAS). Besides, the relation of PONV with patient baseline characteristics in the perioperative period was determined as well. Results: Patients in group A had lower PONV scores (t=3.1, P<0.002), less needs for rescue anti-emetics (χ 2 =0.47, P<0.001), and decreased intraoperative heart rate (t=9.72, P<0.001) and mean arterial pressure (t=7.58, P<0.001) compared to that of group B. Group A reported lower NAS than group B (t=2.66, P<0.001). In addition, we found no relationship between PONV score and rescue anti-emetic requirement, age, or body mass index (P=0.96, P=0.60, P=0.28, respectively). Conclusion: Dexmedetomidine could be used as an effective antiemetic in laparoscopic surgeries, with better efficacy than dexamethasone. Dexmedetomidine not only can reduce PONV but also is effective in postoperative analgesia.

71-76

Authors: Hardeva Ram Nehara1 , Sahdev Kumawat2 , Rohitash Kularia2 , J Amareshwara2 , Prashant Kumar Batar2 , Vivek Goudgaon2

Objective: To determine the association between body weight and COVID-19 outcomes. Methods: This is a retrospective cohort study of COVID-19 patients admitted in a dedicated COVID-19 hospital, a tertiary health care center, between May and June 2021. Demographic data and baseline variables, including age, sex, body mass index (BMI), and comorbidities were collected. Outcomes (death or mechanical ventilation) of the patients with different BMI, age, comorbidities, and qSOFA scores were compared. Besides, the risk factors for death or mechanical ventilation were determined. Results: The mean age of the subjects was (51.8±14.7) years old, and 233 (74.2%) were male. There were 103 (32.8%) patients with normal weight, 143 (45.5%) patients were overweight, and 68 (21.7%) patients were obese. In-hospital deaths and need of mechanical ventilations were significantly higher in the obese and the overweight group compared to the normal weight group, in age group ≥65 years compared to <65 years, in patients with ≥1 comorbidities compared to patients without comorbidities, in patients with qSOFA scores≥2 compared to patients with qSOFA scores<2. There was a significantly increased risk of death (RR: 4.1, 95% CI 1.0-17.4, P=0.04) and significantly increased need of mechanical ventilation (RR: 5.2, 95% CI 1.8-15.2, P=0.002) in the obese patients compared with those with normal weight after controlling other covariates. Conclusion: Obesity is one of the significant risk factors for adverse outcomes in COVID-19 patients and should be considered during management.

85-87

Authors: De-Gang Wang1 , Jian-Jiao Chen2

Rationale: Emphysematous pyelonephritis is a life-threatening infectious disease that requires early diagnosis and treatment. The disease is often misdiagnosed due to its diversity of clinical manifestations. Patient’s concern: A 62-year-old woman was admitted to the emergency department following a 12-hour history of abdominal pain and dyspnea. Physical examination showed percussion pain on the right costovertebral angle. Besides, she had a history of diabetes mellitus and urinary calculus. Diagnosis: Emphysematous pyelonephritis. Intervention: The patient accepted antishock therapy, tight glucose control, and broad-spectrum anti-infective therapy. After stabilization of the general condition, an ultrasound-guided percutaneous nephrostomy was performed. Outcome: Her conditions became stable over the following days. She presented a favorable clinical course, with normalization of renal function and positive improvements in imaging findings in a month. Lessons: Early diagnosis and rapid medical management are the keys to successful treatment. CT is an important method for the diagnosis of emphysematous pyelonephritis. For patients with severe lesions, percutaneous renal drainage combined with active anti-infection should be given in time.

1-11

Authors: Xin-Xin Wu1#, Jin-Jian Yao2#, Jin Qian3,4, Qi-Feng Huang3,5, Tang Deng3,5, Shuang-Qin Xu3,5, Hang-Fei Wang3,5, Qi Li3,5, Ji-Chao Peng1 , Yang Yi3,5, Nan Li3,5, Yue Huang3,5, Xiao-Ran Liu1,3,5

Objective: To systematically evaluate the incidence of adverse reactions to coronavirus disease 2019 (COVID-19) vaccination. Methods: We systematically searched PubMed, Embase, The Cochrane Library, Web of Science, CNKI, WanFang Data, and VIP Database from the inception of each database to August 31, 2021. Randomized controlled clinical trials (RCTs) on the safety of different types of COVID-19 vaccines were retrieved and analyzed. A random or fixed-effects model was used with an odds ratio as the effect size. The quality of each reference was evaluated. The incidence of the adverse reactions of the placebo group and the vaccination group was compared. Heterogeneity and publication bias were taken care of by meta-regression and sub-group analyses. Results: A total of 13 articles were included, with 81287 subjects. Compared with the placebo group, the vaccination group showed a higher combined risk ratio (RR) of total adverse reactions (RR=1.67, 95% CI: 1.46-1.91, P<0.01), local adverse reactions (RR=2.86, 95% CI: 2.11-3.87, P<0.01), systemic adverse reactions (RR=1.25, 95% CI: 0.92-1.72, P=0.16), pain (RR=2.55, 95% CI: 1.75-3.70, P<0.01), swelling (RR=4.16, 95% CI: 1.71-10.17, P=0.002, fever (RR=2.34, 95% CI: 1.84-2.97, P<0.01), fatigue (RR=1.36, 95% CI: 1.32-1.41, P<0.01) and headache (RR=1.22, 95% CI: 1.18-1.26, P<0.01). The subgroup analysis showed the incidence of adverse reactions of the vaccination group after injection of the three COVID-19 vaccines (inactivated viral vaccines, mRNA vaccines and adenovirus vector vaccines) was higher than that of the placebo group, and the difference between the placebo group and the vaccination group in the mRNA vaccine subgroup and the adenovirus vector vaccine subgroup was statistically significant (P<0.01). The incidence of adverse reactions after injection of COVID-19 vaccine in subgroups of different ages was significantly higher than that in the placebo group (P<0.01). Conclusions: COVID-19 vaccines have a good safety, among which adenovirus vector vaccine has the highest incidence of adverse reactions. Both adolescents and adults vaccinated with novel coronavirus vaccine have a certain proportion of adverse reactions, but the symptoms are mild and can be relieved by themselves. Our meta-analysis can help boost global awareness of vaccine safety, promote mass vaccination, help build regional and global immune barriers and effectively curb the recurrency of COVID-19.

18-25

Authors: Asuman Ahcioglu, Gulay Yilmazel

Objective: To investigate health literacy, behavioral and psychosocial characteristics in coronary artery patients. Methods: Between March 2019 and 2020 years, 275 coronary artery patients aged ≥50 years were included in the study. Turkish Health Literacy Scale-32 and Beck Depression Inventory were used to collect the data. Results: General health literacy index score was 31.7 and the prevalence of limited health literacy was 59.3%. Adequate health literacy was 2.8 fold higher in the 50-64 age group, 3.1 fold higher among men, 3.4 fold higher among married and 5.3 fold higher among those who believed in the necessity of individual protective practices (P<0.05). Significant differences were also found in different working status, living places, perceived economic situation, perceived general health status, comorbidities, family history of coronary artery disease, angiography history, material skills on reading and understanding, level of depressive syptom, commitment to individual protective practices health check-ups, utilizing health services, cigarette and alcohol use, and exercise and nutrition between limited and adequate health literacy (P<0.05). Logistic regression analysis showed that adequate health literacy was significantly higher among younger patients (OR: 2.81; 95% CI: 1.46-5.62), male gender (OR: 3.10; 95% CI: 1.46-6.58), married (OR: 3.42; 95% CI: 1.39-8.44) and those with belief in individual protective practices (OR: 5.3; 95% CI: 1.93-14.96). Conclusions: Health literacy is poor among coronary artery patients and behavioral and psychosocial variables differ with health literacy levels. To keep cardiovascular health among these patients, health literacy-based interventions should be adopted in coronary artery clinics, especially for risky population.

32-41

Authors: Leila Safaeian1 , Behzad Zolfaghari2 , Zahra Haghighatian3 , Mahmoud Etebari1 , Tahereh Nasirimoghadam1

Objective: To assess the potential toxicity of hydroalcoholic extract of Allium affine (A. affine) aerial parts after acute and sub-acute administration in female and male Wistar rats. Methods: For acute toxicity assay, animals orally received the limit test dose of 2 000 mg/kg of A. affine extract and were observed for 2 weeks. For sub-acute toxicity study, rats were orally treated with 125, 250, and 500 mg/kg/day of the extract over 28 days, and hematological, biochemical, and histological evaluations were then conducted. Results: All rats were alive with normal body weight gain over 14 days, with LD50˃2 000 mg/kg. No abnormality in body weight changes but significant increases in the relative weight of spleen and lung were detected after administration of the highest dose of extract for 28 days in sub-acute assay. Hematological analysis showed prominent elevations in total white blood cells in male rats and neutrophils count in female rats after exposure to 500 mg/kg of A. affine extract. In biochemical evaluations, significant increases in serum creatinine level (female rats, 250 and 500 mg/kg) and in aspartate aminotransferase (male and female rate, 500 mg/kg) and alanine aminotransferase (male, 250 and 500 mg/kg and female, 500 mg/kg) activities, however, notable decreases in serum blood glucose (male rats, 125 and 500 mg/kg), triglycerides (male rats, 500 mg/kg and female rates, 250 mg/kg), and low-density lipoprotein cholesterol levels (male, 250 mg/kg) were found. Histological examinations presented slight portal inflammation in liver tissue, moderate pneumocyte hyperplasia, congestion and peri-bronchial inflammation in lung tissue, and mild histiocytosis and lymphoid follicular activation in spleen tissue after exposure to 500 mg/kg of A. affine extract in male and female animals. Conclusions: The present investigation reveals the safety of A. affine extract at doses of lower than 250 mg/kg in rats and monitoring of lung, spleen, and liver functions is suggested during excessive and prolonged uses.