Impact of Hypertension on Cerebral Small Vessel Disease may differ by sex and age at hypertension diagnosis

Recent research delving into the relationship between hypertension, cerebral small vessel disease, and brain health has uncovered intriguing differences based on gender. The study found sex-specific and age-dependent effects of hypertension on cerebral small vessel disease–related brain structural changes underscoring the importance of considering both sex and age at hypertension diagnosis when evaluating the impact on brain health.

The study results were published in the journal Hypertension.

Also Read: Targeting TyG index more effective for primary and secondary prevention of hypertension, study suggests

Differences between genders contribute to the risk of cognitive decline, potentially linked to cerebral small vessel disease. The age at which hypertension is diagnosed uniquely influences structural changes in the brain associated with cerebral small vessel disease. Despite this, it remains uncertain whether this relationship varies between sexes. Consequently, researchers conducted a study to assess the disparities between genders in the connection between the age at hypertension diagnosis and cerebral small vessel disease–related alterations in brain structure.

The study drew upon data from the UK Biobank, focusing on participants with known ages at hypertension diagnosis and undergoing brain magnetic resonance imaging (MRI) scans (n=9430). The cohort was stratified by sex and age at hypertension diagnosis. Randomly selected control participants with MRI scans but no history of hypertension were included using propensity score matching. Generalized linear models were employed to analyze morphological brain structural changes, adjusting for other vascular risk factors. For the assessment of white matter microstructure, principal component analysis was utilized to reduce the number of fractional anisotropy variables, followed by regression analysis with major principal components as outcomes.

Findings:

  • The findings revealed notable distinctions in brain structure between males and females with varying ages at hypertension diagnosis.
  • Males diagnosed with hypertension at a younger age exhibited lower brain gray and white matter volume compared to normotensive controls.
  • Both males and females with hypertension showed greater volume of white matter hyperintensities compared to normotensive controls, with a particularly significant increase in older females with hypertension. Moreover, individuals with hypertension displayed lower white matter microstructural integrity compared to normotensive controls, a trend that became more pronounced with advancing age.
Also Read: Continued tirzepatide treatment enhances weight loss but discontinuation leads to weight regain: JAMA

Thus, the study findings underscore the importance of considering both sex and age at hypertension diagnosis when evaluating the impact on brain health. Understanding these nuances can contribute to more tailored approaches for preventing and managing cognitive decline associated with cerebral small vessel disease.

Understanding the unique effects of hypertension on brain health in both males and females, considering their age at diagnosis, adds a layer of complexity to our understanding of cerebral small vessel disease. Moving forward, these insights could pave the way for more targeted interventions and therapies, ultimately improving outcomes for individuals at risk of cognitive decline related to hypertension and cerebral small vessel disease.

Further reading: Kaur A, Angarita Fonseca A, Lissaman R, Behlouli H, Rajah MN, Pilote L. Sex Differences in the Association of Age at Hypertension Diagnosis With Brain Structure. Hypertension. Published online December 19, 2023. doi:10.1161/HYPERTENSIONAHA.123.22180

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Larger femoral heads in Hip Implants Lower Revision Risk in hip Arthroplasty

A new study published in the The Journal of Arthroplasty found that the size of hip implants used in total hip arthroplasty (THA) can have a substantial impact on patient outcomes. The research spanned over 16 years and included more than 10,000 primary THA cases, compared the clinical results of different head sizes, namely 28, 32, and 36 millimeters.

This retrospective consecutive study, conducted from 2003 to 2019, gathered data from 10,104 primary THAs. The median age of patients was 69 years, with 61.5% being women. The surgeries employed various techniques, including the posterior approach, and were carried out to address a range of primary diagnoses.

The study revealed that the overall rate of revision for THAs was 1.7%. Notably, the group that received 36-millimeter head implants had the lowest revision rate at 1.1%, compared to 1.3% for the 32-millimeter group and 2.7% for the 28-millimeter group. Cox regression analyses indicated a significantly decreased risk of all-cause revision for the 32-millimeter and 36-millimeter head sizes when compared to the 28-millimeter heads.

This difference was particularly noteworthy for the 32-millimeter group, where the risk was significantly reduced (P = 0.01). The risk of revision specifically for dislocation was also significantly reduced in the 32-millimeter (P = 0.03) and 36-millimeter (P = 0.03) head size groups. However, when it came to all-cause revision excluding dislocation, there were no significant differences between head sizes.

This extensive study indicates that using larger head sizes in THA may significantly reduce the risk of revision, particularly for dislocation. The research dismisses concerns related to the increased risk of early revision due to issues like aseptic loosening, polyethylene wear, or taper corrosion associated with larger heads. The results of this study, with a follow-up period of up to 17 years, are expected to have a profound impact on the decision-making process for orthopedic surgeons and could lead to better outcomes and increased patient satisfaction for those undergoing THA.

Source:

Matar, H. E., van Duren, B. H., Bloch, B. V., Berber, R., James, P. J., & Manktelow, A. RJ. (2023). Lower Risk of Revision with 32- and 36-millimeter Femoral Heads Compared with 28-mm heads in Primary Total Hip Arthroplasty: A Comparative Single-Center Study (10,104 Hips). In The Journal of Arthroplasty. Elsevier BV. https://doi.org/10.1016/j.arth.2023.10.042

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Can Mycobacterium indicus pranii improve outcomes of Sepsis patients?

Recently published paper investigates the effectiveness of Mycobacteria indicus pranii (MIP) in enhancing clinical outcomes in sepsis patients. Sepsis is a major health concern, particularly in India. The authors conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) focusing on 28-day mortality as the primary outcome and several secondary outcomes like ICU stay duration, days on vasopressor support, ventilator-associated pneumonia (VAP), secondary infections, and delta sequential organ failure assessment (SOFA) score. The dysregulated host immune response in sepsis and the influence of factors such as pre-morbid conditions and prompt therapeutic interventions are highlighted.

The paper explains that immunomodulatory agents like MIP are potential solutions to counteract the immunosuppressive state caused by sepsis. It details the pathways activated by lipopolysaccharide and the potential of immunomodulatory agents to counteract the immunosuppressive state caused by sepsis. The authors mention that previous studies have shown a significant decrease in mortality, fewer days on mechanical ventilation, and reduced hospital and ICU stay duration with MIP.

The systematic review included two RCTs, enrolling a total of 252 participants and revealed a 43% lower mortality rate in the MIP group than in the control group. Other outcomes such as days on vasopressor, length of ICU stay, secondary infection, VAP, CRBSI, and delta SOFA score were also analyzed. The analysis indicated a trend in the reduction of death and lower secondary infections in the MIP group compared to the control, although statistical significance was not achieved.

The paper acknowledges limitations, including a small number of included studies and a high degree of heterogeneity among them, and highlights the need for well-designed RCTs to further investigate the role of MIP in sepsis patients. The findings suggest preliminary evidence for a positive association of MIP with better outcomes in sepsis patients, indicating the importance of conducting future RCTs to determine its precise role in treating sepsis patients.

Reference –

Saran, Khushboo; Iyengar, Swathy S.1; Sinha, Nitesh2; Abhishek, Kumar3; Kumar, Amit4; Prakash, Jay5. Role of Mycobacterium indicus pranii in clinical outcomes in patients with sepsis: A systematic review and meta-analysis of randomised controlled trials. Indian Journal of Anaesthesia 67(12):p 1029-1035, December 2023. | DOI: 10.4103/ija.ija_726_23

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Digital impressions reduced clinical time for fabricating full-arch implant-supported prostheses

Digital impressions reduced clinical time for fabricating full-arch implant-supported prostheses suggests a new study published in the Journal of Prosthetic Dentistry.

With the growing use of digital scanning, an evaluation of the clinical impact of digital scans versus conventional impressions in complete arch implant-supported prostheses is needed. However, systematic reviews on this subject are lacking.

The purpose of this systematic review was to evaluate the scanning and impression times and the radiographic marginal bone loss over time associated with digital scans and conventional impressions for complete arch implant-supported fixed prostheses.

Material and methods

The search was performed in MEDLINE/PubMed, SCOPUS, EMBASE, and Web of Science. Only randomized clinical trials (RCTs) comparing digital scans and conventional impressions for complete arch prostheses were included in the review. The scan and impression times and marginal bone loss were analyzed through random effects meta-analysis.

Results

Six RCTs were included. The meta-analysis was conducted by using a standardized mean difference (MD) and indicated a statistically significant reduction in time for the digital scan group compared with the conventional group (MD 10.01 [7.46, 12.55], P<.001, I²=80%). The fact that digital scans were used did not lead to significant differences in radiographic marginal bone loss compared with conventional impressions after 6 months (MD −0.03 [−0.14, 0.08], P=.58, I²=0%), after 12 months (MD −0.06 [−0.24, 0.12], P=.12, I²=45%), and after 24 months (MD −0.12 [−0.32, 0.09], P=.28, I²=58%).

Digital scans significantly reduced the time required compared with conventional impressions for complete arch implant-supported prostheses. Nevertheless, additional studies with more consistent methodologies are needed for confirmation. No significant differences were found in radiographic marginal bone loss between treatments performed with digital scans and conventional impressions.

Reference:

Clinical outcomes of digital scans versus conventional impressions for implant-supported fixed complete arch prostheses: A systematic review and meta-analysis. Isabella Neme Ribeiro dos Reis, Camila Nogueira Chamma-Wedemann, Ian Artoni de Oliveira Silva, Rubens Spin-Neto, Newton Sesma, Emily Vivianne Freitas da Silva. Journal of Prosthetic Dentistry. Published:October 20, 2023DOI:https://doi.org/10.1016/j.prosdent.2023.09.023

Keywords:

Digital, impressions, reduced, clinical, time, fabricating, full-arch, implant-supported, prostheses, Isabella Neme Ribeiro dos Reis, Camila Nogueira Chamma-Wedemann, Ian Artoni de Oliveira Silva, Rubens Spin-Neto, Newton Sesma, Emily Vivianne Freitas da Silva, Journal of Prosthetic Dentistry

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Record-breaking six days Doctors’ Strike to pile pressure on England Health Service

London: Junior doctors in England will begin a six-day walkout on Wednesday, the longest strike in the state-run National Health Service’s (NHS) 75-year history which is set to hit patient care during its seasonal winter peak in demand. 

Like in other key sectors over the past year, junior doctors represented by the British Medical Association (BMA) have staged a series of walkouts in demand of better pay in the face of soaring inflation.

Also Read:UK Junior Doctors on 3-day strike over pay dispute

Cumulatively, the NHS, which has provided healthcare free at the point of use since it was founded in 1948, cancelled 1.2 million appointments in 2023 due to strikes.

The BMA abandoned talks with the government after being offered a pay rise of 8-10% and held strikes on Dec. 20-23. The union is seeking a 35% improvement which it says is needed to cover the impact of inflation over several years.

The government, which has agreed new pay deals with other healthcare workers, including nurses and senior doctors in recent months, has resisted hikes it says would worsen inflation.

The strikes threaten to increase the pressure on the health service where over 7.7 million patients are on waiting lists for procedures and appointments.

“This January could be one of the most difficult starts to the year the NHS has ever faced,” NHS National Medical Director Stephen Powis said in a statement.

“The action will not only have an enormous impact on planned care, but comes on top of a host of seasonal pressures such as covid, flu, and staff absences due to sickness.”

Junior doctors are qualified physicians, often with several years of experience, who work under the guidance of senior doctors and represent a large part of the country’s medical community.

A spokesman for Prime Minister Rishi Sunak said deals with other healthcare workers’ unions showed that the striking junior doctors were “outliers”.

“We have sought to come to a fair resolution – fair for the taxpayer, fair for hardworking doctors and health workers. We have achieved that in the majority of cases … we are willing to have further discussions. But obviously the first thing to do is to stop striking,” he told reporters.

The BMA said a record waiting list and underinvestment over the past decade had undermined the NHS.

“As a profession we are exhausted, disenchanted, and questioning whether we want to stay in the health service at all. Add to this years of pay erosion, and it’s no wonder that morale on the frontline has never been lower,” the union said.

Also Read:UK Junior and Senior doctors to go on 4-day joint strike over pay dispute

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Supreme Court Junks Plea Challenging Anti-NEET Signature Campaign

New Delhi: The Public Interest Litigation (PIL) that challenged the signature campaign against the National Eligibility-cum-Entrance Test (NEET) exams has now been Supreme Court.

Dravida Munnetra Khazagam (DMK), the ruling party in Tamil Nadu State, reportedly organized this signature campaign against the centralized common entrance test NEET for admission to undergraduate and postgraduate medical courses.

Rejecting the PIL, the Supreme Court bench comprising Justices Surya Kant and KV Viswanathan observed, “We have heard the petitioner in person at a considerable length. We are of the considered opinion that this is not a fit case to invoke the jurisdiction under Article 32 of the Constitution of India. We therefore decline to entertain this wit petition.”

Although the counsel for the petitioner argued that the students may end up distressed as a result of the campaign, as they may have to face NEET tomorrow, the top court bench noted, “fortunately now we have a very informed generation…our children are not so innocent… they are far ahead of our generation, so they understand everything…that what is the motive, what is the agenda…”

Further, the Apex Court clarified that the common medical entrance test NEET is a competitive exam and it has to be held on pan-India basis. Therefore, it will not be affected by the campaign, opined the Apex Court.

Last year, Medical Dialogues had reported that Tamil Nadu Sports Minister and Dravida Munnetra Kazhagam (DMK) leader Udhayanidhi Stalin had also participated in the ‘signature campaign’ against NEET examination. In this regard, the son of Tamil Nadu Chief Minister MK Stalin observed that DMK plans to get lakhs of signatures in 50 days against the NEET examination.

Also Read: TN: Signature campaign against NEET Exam gathers momentum

As per the latest media report by Live Law, the PIL was filed by Advocate ML Ravi, who argued that even though NEET exams have been allowed by the Supreme Court, DMK was organizing the signature campaign in schools. The plea alleged that during the campaign, school students were being tutored against the NEET exam and they were made to put their signatures. It was also alleged that the concerned exercise was initiated without taking the due permission from the parents of the students.

The PIL highlighted that under Article 19 of the Constitution, any citizen or political party may protest and have the freedom of expression. However, such a right cannot be advanced at schools and with students who do not have voting rights. The PIL argued that such political activity should not be allowed within the school campuses.

Further, the plea expressed concern that the concerned campaign could distress students who have to face NEET exams, and therefore, DMK, the ruling party. should not be given the undue advantage of entering the school campuses to get signature of students against NEET. Further, the PIL mentioned that the campaign had the effect of roping in school students into a political activity.

“We have heard the petitioner in-person at a considerable length. We are of the considered opinion that this is not a fit case to invoke our jurisdiction under Article 32 of the Constitution of India. We, therefore, decline to entertain this writ petition,” observed the top court bench as it dismissed the PIL.

NEET in Tamil Nadu:

NEET was introduced in India as a centralized test for admitting medical students at both undergraduate and postgraduate levels. However, since its inception, Tamil Nadu has been protesting against the same as after the test was introduced more than a dozen students of underprivileged social backgrounds committed suicide. These students belonging to remote areas were unable to access the necessary resources for clearing the entrance examination.

It was on December 21, 2010, the Medical Council of India (now replaced by the National Medical Commission) issued a notification making NEET mandatory for admission to medical courses. A similar notification was issued by the Dental Council of India (DCI) in 2012 and subsequently, a common entrance was brought for admission to homoeopathy and Indian medicine courses as well.

Prior to NEET, Tamil Nadu used to hold its own Common Entrance Test (CET) for admission to medical colleges in the state for filling the state seats.

Several deliberations and protests staged over the years seeking NEET exemption in the state resulted in the formation of the Anti-NEET bill, which was passed in the Tamil Nadu assembly. The Centre had also sought clarifications from the state on the bill.

However, the bill has not come into effect as the Governor forwarded it seeking President’s assent, which has not been granted till date. Last year, the matter reached Supreme Court also as the State of Tamil Nadu filed a lawsuit challenging the validity of the MBBS entrance test. The State had argued that the introduction of NEET is violative of the federal structure, as it takes away the power of the States to admit students to Government Seats in medical colleges.

To view the Supreme Court order, click on the link below:

https://medicaldialogues.in/pdf_upload/anti-neet-supreme-court-229286.pdf

Also Read: NEET ‘violates’ federal Structure: Tamil Nadu moves Supreme Court challenging validity of MBBS entrance test

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AstraZeneca Gets CDSCO Panel Nod to Study anticancer drug Volrustomig

New Delhi: The drug major AstraZeneca has got approval from the Subject Expert Committee (SEC) functional under the Central Drug Standard Control Organisation (CDSCO) to conduct the Phase III clinical trial of the Monoclonal Antibody Volrustomig.

This came after the drug major AstraZeneca presented Phase III clinical trial protocol No. D798AC00001.

The above study is a global study of Volrustomig plus chemotherapy versus Pembrolizumab plus chemotherapy for Participants With Metastatic Non-small Cell Lung Cancer. (eVOLVE-Lung02)

The purpose of the study is to test the efficacy and measure the safety of volrustomig in combination with chemotherapy compared with pembrolizumab in combination with chemotherapy as 1L treatment in participants with mNSCLC in PD-L1 < 50%.

Volrustomig is a bispecific antibody that targets programmed death 1 (PD-1) and cytotoxic T lymphocyte-associated antigen 4 (CTLA-4). This dual-targeting bispecific antibody has the potential to enhance the therapeutic benefit and decrease the risk of toxicity which is typically associated with CTLA-4 inhibitors.

Monoclonal antibodies targeting the immune checkpoint proteins such as PD-1 and CTLA-4 have been around for a long time, however, due to their limited effect on the majority of patients, the idea of dual immune checkpoint inhibitors using bispecific antibodies has been gaining attention from researchers all over the world.

The drug candidate is a bi-specific monoclonal antibody. It is administered through an intravenous route. It acts by targeting programmed cell death protein 1 (PD-1) and Cytotoxic T Lymphocyte Protein 4 (CTLA4).

At the recent SEC meeting for oncology and hematology held on 21st and 22nd December 2023, the expert panel reviewed the Phase III clinical trial protocol No. D798AC00001.

After detailed deliberation, the committee recommended the grant of permission to conduct the clinical trial as presented by the firm.

Also Read: CDSCO Panel Approves AstraZeneca’s Proposal for Protocol Amendment of anti-cancer drug Asciminib

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Topical Vancomycin Effective in Reducing Surgical site Infecitons after Cranial Surgeries

A recent study conducted by researchers based in NIMHANS and AIIMS, and published in Neurology India suggests that topical vancomycin used in cranial neurosurgery procedures is quite effective in reducing post-op surgical site infections (SSIs) , including cases where implants like VP shunts have been placed.

World Health Organization (WHO) has recommended several steps to prevent surgical site infections (SSI) after cranial surgery, which include patient preparation before surgery, handwashing, and surgical site preparation. Despite these, the rate of SSI continues to be still high (1–9%) and it has become the most preventable healthcare-associated infection. A recent study involving 5,463 patients observed that the rate of SSI after common neurosurgical interventions was 1.94%, with the highest rate after vascular (3.4%) and CSF diversion procedures (3%).

A few studies have advised the application of systemic antibiotics for the prevention of SSI, especially in cases of shunts or drain, while other studies disagree stating it does not have an effect in reducing SSIs but also may be harmful as it enhances the possibility of growth of resistant microbes and clostridium difficile.

Topical vancomycin has emerged as an effective approach and several studies have shown that it has good efficacy in preventing SSI following spinal and orthopedic surgical procedures. This is due to its broad spectrum of action which covers almost all gram-positive cocci (Methicillin resistant staphylococcus aureus (MRSA), Methicillin sensitive staphylococcus aureus (MSSA), and Streptococci) which are the usual causes for cranial wound infection. Also, it has limited systemic absorption, thus, maintaining good local wound concentration without the risk of systemic toxicity.

S. aureus has been reported to be present in as many as 48.6% SSI, out of which 56% are resistant to beta-lactams. MRSA has been emerging as an increasingly common pathogen in postoperative infections, and thus, prompts the use of more selective antibiotics for prophylaxis such as vancomycin. In non-spinal neurosurgery, several risk factors have been identified as independently responsible for the increased risk of infections: male gender, age more than 60 years, smoking, lengthier preoperative hospital stay, surgery duration of more than 3 h, emergency surgery or re-exploration surgery, contaminated surgery, the use of implants, and CSF leakage Also, skin flora such as S. aureus, Cutibacterium acnes, and coagulase-negative staphylococcus further increase the applicability of vancomycin in-infection prevention bundles. 

The authors of this study evaluated the role of topical vancomycin in the form of an intrawound powder as a safe and effective modality based on available literature. Their analysisshowed  that only 1.6%  of the patients in the vancomycin group got SSIs as compared to 5.28% in the control group. Systemic vancomycin does not appear to be as beneficial; although studies are limited, available data suggest it to be no more beneficial compared to standard prophylaxis.This is in addition to its safety profile when administered locally as there have been low to non-existent levels of vancomycin detected in the serum. They found that topical vancomycin was useful in decreasing the risk of infections with a pooled risk ratio of 0.29. 

The applicability of topical vancomycin is especially enhanced due to its use in surgeries with deep brain stimulation as the implant infection mandates explanation of the implants. In DBS or IPG placement the pooled risk ratio was 0.24. This finding is understandable as intravenous levels of antibiotics given systematically have no bearing due to the avascular nature of the implants. Moreover, the use of topical vancomycin in pediatric cases is particularly beneficial as local administration reduces the systemic side effects. The pooled risk ratio of infection in the vancomycin group in pediatric patients was 0.09.

Topical vancomycin antibiotics prophylaxis is being currently utilized in various surgical specialties. It is warranted for operational sites where SSIs carry significant morbidity and mortality concerns. Data from neurosurgery has consistently demonstrated that antibiotic prophylaxis with vancomycin in cases where there is MRSA colonization in the anterior nares reduces the risk of SSIs. S. aureus is a skin commensal and colonizer of anterior nares in more than a third of the hospitalized patients and colonization before surgery is associated with an increased risk of postop S. aureus infections. As the most common organism causing SSIs are S. aureus, the efficacy of vancomycin found in our systematic review is understandable.

The authors agree that there are concerns regarding the breeding of antibiotic-resistant S. aureus with the widespread use of prophylactic topical vancomycin. However recent studies have shown that the application of topical vancomycin in spinal surgeries is not related to the growth of vancomycin-resistant bacteria. However, an increased incidence of infections caused by gram-negative bacteria was seen.  The retrieved studies reported no complications commonly associated with vancomycin, such as renal failure, skin rash, red man syndrome, anaphylaxis, seromas, or other local or systematic side effects. Even when the studies directly compared the adverse effects among two randomized groups, there were no differences in the cerebrospinal fluid (CSF) leakage, seroma formation, pseudo-meningocele, bone flap resorption, or seizures.

It can be concluded that the limited systemic absorption of vancomycin and broad-spectrum has led to its widespread applicability in the prevention of SSI in all types of cranial neurosurgery. Cases with implantable pulse generators, cranioplasty, and cerebrospinal fluid (CSF) diversion procedures have all demonstrated their unequivocal effectiveness.

Reference:

Deora H, Nagesh M, Garg K, Singh M, Chandra SP, Kale SS. Topical Vancomycin for Prevention of Surgical Site Infection in Cranial Surgeries: Results of an Updated Systematic Review, Meta-Analysis and Meta-Regression. Neurol India 2023;71:875-83

DOI: 10.4103/0028-3886.388107

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Patient dies due to lack of oxygen: NHRC directs Bihar Govt to submit report in four weeks

Patna: The National Human Rights Commission (NHRC) has issued a notice to the Bihar chief secretary over the death of a heart patient allegedly due to the non-availability of oxygen cylinders at a government health centre in Munger district. 

The NHRC said it has taken suo motu cognisance of a media report of the incident that reportedly happened on December 26.    

The Commission has observed that the contents of the news report, if true, raise a serious issue of violation of human rights, which is a matter of concern.     

Also Read:NHRC notices to Delhi Chief Secretary, DCGI and Police Commissioner after epilepsy drug Sodium Valproate fails quality test

It has issued a notice to the chief secretary, calling for a detailed report within four weeks.       

The report should also include the status of the action taken against the accused as well as relief and rehabilitation provided to the next of kin of the deceased, the notice said.          

According to the media report, carried on December 28, 2023, the doctor posted at the Emergency Ward of the health centre has alleged that the oxygen cylinder for the patient was not available, while, the In-charge Medical Officer has said that there is no scarcity of the oxygen cylinders.        

Medical Dialogues team had earlier reported that the National Human Rights Commission (NHRC) had sought a complete report on the allegation of medical negligence, irregularities and poor administration at MKCG Medical College and Hospital in Odisha. The NHRC issued the reminder to the Principal Secretary, Department of Health and Family Welfare, Odisha government, District Magistrate, Berhampur and Superintendent of Police, Berhampur to file an additional report in light of the complainant’s comments, within four weeks.                                                                             

Also Read:NHRC takes suo moto cognisance of rats gnawing feet of patients at Jodhpur hospital, seeks report from Govt

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Hospitals cannot admit critically ill patients in ICU without consent: GOI ICU Admission guidelines

New Delhi: The Government of India has come up with guidelines for hospitals on ICU admissions and directed that hospitals cannot admit critically ill patients in the ICU without the consent of the patient and family.

According to the latest guidelines, patients who are critically ill should not be admitted to an ICU if they do not give their consent. “Critically ill patients should not be admitted to the ICU; if Patient’s or next-of-kin informed refusal to be admitted in ICU.”

Also Read:NMC issues guidelines for assessment, rating of medical colleges from 2024-25 academic year, key takeaways

The guidelines have also mentioned that the specialist in ICU should also have specific qualifications. The Intensivist should have a postgraduate qualification in Internal Medicine, Anaesthesia, Pulmonary Medicine, Emergency Medicine, or General Surgery with either of the following

“An additional qualification in Intensive Care such as DM Critical Care/Pulmonary Critical Care, DNB/FNB Critical Care (National Board of Examinations), Certificate Courses in Critical Care of the ISCCM (IDCCM and IFCCM), Post-Doctoral Fellowship in Critical Care (PDCC/Fellowship) from an NMC recognised University, or equivalent qualifications from abroad such as the American Board Certification, Australian or New Zealand Fellowship (FANZCA or FFICANZCA), UK (CCT dual recognition), or equivalent from Canada.”

” At least one-year training in a reputed ICU abroad. A few candidates of the ISCCM Certificate Course (CTCCM) who have been certified with a 3-year training programme in Intensive Care after M.B.B.S. are also recognised as Intensivists. In addition, persons so qualified or trained must have at least two-years’ experience in ICU (at least 50% time spent in the ICU).” it said

“In case of doctors not having either of the mentioned qualifications or training, they should have extensive experience in Intensive Care in India after M.B.B.S., quantified as at least three years’ experience in ICU (at least 50% time spent in the ICU).” stated the guidelines

The new guidelines have been developed by doctors with expertise in critical care medicine working in different levels of Hospital and Intensive Care Units (ICU) across the country.

The criteria for admitting a patient to ICU should be based on organ failure and the need for organ support or in anticipation of deterioration in the medical condition.

ICU admission criteria should be based on altered level of consciousness and if a patient requires respiratory support, “Altered level of consciousness of recent onset, Hemodynamic instability (e.g., clinical features of shock, arrythmias), Need for respiratory support (e.g. escalating oxygen requirement, de-novo respiratory failure requiring non-invasive ventilation, invasive mechanical ventilation, etc.).”

“Patients with severe acute (or acute-on-chronic) illness requiring intensive monitoring and/or organ support. Any medical condition or disease with anticipation of deterioration Patients who have experienced any major intraoperative complication (e.g. cardiovascular or respiratory instability).Patients who have undergone major surgery, (e.g. thoracic, thoraco-abdominal, upper abdominal operations, trauma who require intensive monitoring or at a high risk of developing postoperative complications),” stated the guidelines.

“Any disease with a treatment limitation plan . Anyone with a living will or advanced directive against ICU care. Terminally ill patients with a medical judgement of futility. Low priority criteria in case of pandemic or disaster situation where there is resource limitation (e.g. bed, workforce, equipment).”

The ICU discharge criteria guidelines states, “return of physiological aberrations to near normal or baseline status. Reasonable resolution and stability of the acute illness that necessitated ICU admission. Patient/family agrees for ICU discharge for a treatment-limiting decision or palliative care. Based on lack of benefit from aggressive care (should be a medical decision, not obligating family agreement and as far as possible should not be based on economic constraint.”

“For infection control reasons with ensuring appropriate care of the given patient in a non ICU location. Rationing (i.e., prioritisation in the face of a resource crunch). In this event there should be an explicit and transparent written rationing policy that should be fair, consistent and reasonable.”

The minimum patient monitoring required while awaiting an ICU bed include, “Blood pressure (continuous/intermittent), Clinical monitoring (e.g., pulse rate, respiratory rate, breathing pattern, etc.) Heart rate (continuous/intermittent).Oxygen saturation – SpO2 (continuous/intermittent), Capillary refill time, Urine Output (continuous/intermittent) Neurological status e.g. Glasgow Coma Scale (GCS), Alert Verbal Pain Unresponsive (AVPU) scale etc. Intermittent temperature monitoring”

Blood sugar Minimum stabilisation required before transferring a patient to ICU includes “ensuring a secure airway (i.e., tracheal intubation if the patient has a GCS <=8) Ensuring adequate oxygenation and ventilation. Stable haemodynamics, either with or without vasoactive drug infusion. Ongoing correction of hyperglycemia/hypoglycemia and other life-threatening electrolyte/metabolic disturbances Initiation of definitive therapy for life-threatening condition (e.g., external fixation of a fractured limb, administration of antiepileptics for recurrent seizures, antiarrhythmic drug infusion for unstable arrhythmias etc, intravenous antibiotics for sepsis).”

The minimum monitoring required for transferring a critically ill patient (inter-facility transfer to hospital/ICU) includes “Blood pressure (continuous/intermittent), Clinical monitoring (pulse rate, respiratory rate, breathing pattern, etc.), Continuous Heart rate, Continuous SpO2, Neurological status (AVPU, GCS, etc.)”

Also Read:New Govt Guidelines Define Who is an Intensivist

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