Both GA and conscious sedation reasonable anaesthetic approaches for patients undergoing endovascular thrombectomy

Endovascular thrombectomy (EVT) is established as the standard treatment for managing patients with acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). However, the ideal anesthetic approach during EVT remains undetermined.

A study published in the International Journal of Stroke concluded that the choice of anesthetic modality for AIS patients undergoing EVT did not seem to impact their 3-month neurological outcomes. However, regarding successful reperfusion rates, GA was superior to CS. Additionally, patients in the GA group were at a higher risk for developing hypotension and pneumonia. More research is needed to provide additional evidence. 
This systematic review and meta-analysis determined the optimal anesthetic modality for AIS patients undergoing EVT by examining current randomized controlled trials (RCTs).
Researchers evaluated databases Medline (via PubMed), EMBASE, Web of Science, and the Cochrane Library for RCTs comparing general anesthesia (GA) and conscious sedation (CS) in AIS patients undergoing EVT. The primary outcome was a favourable functional outcome at 90 days post-intervention. Review Manager software (RevMan V.5.3) was used for data analysis.
Key findings from the study are:
• Eight RCTs with 1199 patients were included.
• There was no significant difference between these two groups in the rate of functional independence with a risk ratio of 1.10
• Compared with the CS group, the GA group attained a higher successful recanalization rate with an RR of 1.14
• Patients in the GA had higher rates of hypotension and pneumonia incidence with RR of 1.87 and 1.38, respectively.
They said, ‘This systematic review and meta-analysis examined the clinical outcomes of conscious sedation versus general anesthesia during endovascular thrombectomy. Pooling data from eight randomized clinical trials, most of which were single-centre and European studies, the study found no significant difference in 3-month functional outcomes between the two groups. However, the general anaesthesia group had a higher rate of successful reperfusion but also higher rates of periprocedural hypertension and pneumonia. The meta-analysis suggests that both conscious sedation and general anesthesia are reasonable options for patients undergoing endovascular thrombectomy. Centre experience and patient characteristics are also important factors in decision-making.’
Reference:
Jia Y, Feng Y, Ma Y, et al. Type of anaesthesia for endovascular therapy in acute ischemic stroke: A literature review and meta-analysis. International Journal of Stroke. 2024;0(0).
doi:10.1177/17474930241228956

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Alleged delay in treatment lead to paralysis, seizures: Consumer Court absolves Max Hospital, Cardio-Diabetologist of medical negligence

New Delhi: The Delhi State Consumer Disputes Redressal Commission has absolved Max Super Speciality Hospital, a Senior Consultant Physician & Cardio-Diabetologist and others in a case alleging medical negligence over the delay in admitting a patient and not providing timely medical treatment resulting in paralysis on the left side of his body and ongoing seizures.

The commission, led by Justice Sangita Dhingra Sehgal delivered the decision on 12th January 2024 noting that the complainant failed to establish negligence or deficiency in service on the part of Max Super Speciality Hospital and no lackadaisical approach of the treating doctors were found.

The case, initiated on October 3, 2017, concerned Colonel Gulati who alleged deficiency in service and medical negligence by Max Super Speciality Hospital and its doctor. Gulati, a retired officer from the Indian Army, visited Max Super Specialty Hospital, Shalimar Bagh, complaining of disorientation and loss of control in his left hand. The hospital conducted a CT scan, revealing bleeding inside the brain and changes in brain tissue density. Further investigations, including MRI and Venography, were recommended.

He underwent a CT scan that revealed a critical condition requiring immediate attention and admission for treatment/surgery. However, despite repeated requests from the patient’s family, the hospital staff allegedly took no action, leading to a seizure in the reception area. The complainant became unconscious in a wheelchair outside the Emergency Room. After a four-hour delay, the hospital eventually admitted him, resulting in paralysis on the left side of his body and ongoing seizures.

Aggrieved, the patient filed a complaint with the consumer court alleging negligence, deficient services, and financial losses, and sought relief from the commission, including a lump sum of Rs 75,00,000 for income loss, Rs 10,00,000 for mental harassment, and legal costs of Rs 1,00,000, among other demands.

The Opposite Parties (Max Super Speciality Hospital (OP1), the doctor- a Senior Consultant Physician & Cardio-Diabetologist (OP2), the Medical Superintendent (OP3) and OPD Coordinator (OP4) of Max Hospital), in their joint written statement, refuted all allegations in the Complaint. They argued that the Complainant was attempting to shift blame, asserting that he arrived late, around 11:00 am, in the OPD, and underwent consultation with the doctor. The NCCT Scan revealed minimal traces of Subarachnoid Hemorrhage (SAH), leading to the recommendation for admission under the neurology team at the hospital.

The Opposite Parties claimed that proper medical measures were taken per protocol, and there was no negligence by the operating doctors. They allege that the Complainant concealed his medical history, including Paraesthesia in both Upper Limbs, and was already undergoing treatment for it. They argue that the SAH trace was minimal, confirmed by tests on 01.10.2017, and call for the complaint’s dismissal due to the suppression of material facts.

The Complainant filed a rejoinder to counter the Opposite Parties’ written statement. Both parties submitted evidence through affidavits and presented their written arguments.

The Commission perused the material available on record and heard the counsel for the contesting parties. It referred to Seema Garg & Anr. vs. Superintendent, Ram Manohar Lohia Hospital & Anr to discuss the extent of Medical Negligence in the instant case.

Deliberating the case, the Commission found that the complainant did not challenge the competency of the operating doctor, indicating no lack of competence on the part of the medical staff. Medical records demonstrated that the hospital promptly advised admission upon detecting abnormalities in the CT scan. It noted;

“On perusal of the abovementioned OPD sheet, we find that upon examination, the Opposite Party no. 2 advised the Complainant (patient) to go through a CT scan of the brain along with other tests such as CBC, KFT, PLS, LFT and STSH in order to determine the treatment to be followed in case of any emergency. Furthermore, we discover that after reviewing the CT scan report, which revealed a minimal trace of SAH, the Opposite Party no. 2 immediately advised the Complainant to be admitted under the supervision of a Neurosurgeon at Opposite Party no. 1 hospital, Dr. Kumar and the Complainant was admitted at around 3:30 p.m. on 01.10.2015, where further treatment was advised to the Complainant.”

“Even though the Complainant has not spared a word against the operating doctor in his complaint and has challenged the delay in admitting him to the hospital, but has failed to bring on record any substantial evidence, oral or documentary, in support of his contentions. It is further noted that the Complainant failed to establish that there was any breach of duty or omission to do something which a reasonable man would do or would abstain from doing or that the treatment which was given to the Complainant was not acceptable to the Medical Profession at that specific time period and also failed to examine any Expert Witness in support of his case”

The Consumer body further found that the complainant chose the hospital’s Out-Patient Department (OPD), designed for diagnosis and minor treatments, where immediate admission was not required. It observed;

“It was found that the Complainant had chosen Out-Patient Department (OPD) of Opposite Party No. 1 Hospital which is specifically designed for diagnosis, treatment, and care without requiring admission, catering to minor treatments and follow-up appointments. Additionally, in instances where patients face severe issues, they opt for the Emergency Ward, ensuring priority treatment for immediate medical attention.”

Subsequently, the commission ruled that there was no evidence supporting the allegations of negligence against Max Super Speciality Hospital, and the complaint was dismissed on the grounds of insufficient proof. It held;

“in view of the above discussion, we do not find any lackadaisical approach of the treating doctors of the Opposite Party no. 1 Hospital as no substantial evidence has been filed by the Complainant in order to show that the Opposite Parties have delayed the treatment of Complainant due to which, the Complainant has suffered seizure in reception area of the Opposite Party no. 1 Hospital. Additionally, this Commission cannot presume that the allegations in the complaint are inviolable truth even though they remained unsupported by any evidence.”

“Since there exists no evidence to substantiate the submission of the Complainant, we are of the view that there exists no Negligence on part of the Opposite Parties in the present case. Consequently, the present Complaint stands dismissed, with no order as to costs.”

To view the original order, click on the link below:

https://medicaldialogues.in/pdf_upload/max-hospital-no-medical-negligence-233352.pdf

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Private Medical Colleges Wrongfully Denied Admission to Medical Aspirants, HC Directs State to Pay Rs 20 Lakh Compensation each

Mumbai: The Bombay High Court bench recently directed the State Government to pay Rs 20 lakh compensation to three medical aspirants, who were denied admission to medical courses around 12 years ago due to irregularities in the admission process in private medical colleges.

Altogether four aspirants approached the HC bench. All of them were aspiring to pursue medical course and therefore they had appeared in the Common Entrance Test (CET) conducted by the Association of Management of Unaided Private Medical and Dental Colleges, Maharashtra (AMUPMDC) in 2012.

Even though they cleared the exam, due to the irregularities conducted by various medical institutes/colleges, they could not get admitted to medical courses although the students less meritorious than them managed to get admission.

Consequently, the State set up a committee to examine the irregularities. The Committee gave its report and recommended strict action against the institutions/officials who were involved in the irregularities.

Some of the students challenged the admission process before the Bombay HC back in 2013 and after the matter was dismissed by the HC, it reached the Supreme Court. The Apex Court on 2nd September 2014 directed the State Government to compensate the students by paying a sum of Rs 20 lakh towards public law damages and further directed the State to take action against the officers involved in the irregularities which resulted into meritorious students being denied admission.

The four medical aspirants who approached the Bombay HC bench in 2015 were not the petitioners before the Supreme Court. However, based on the Supreme Court’s directions, they approached the HC bench seeking similar relief i.e. Rs 20 lakh compensation on account of public law damages.

It was submitted by the petitioners that they were similarly placed to students who had approached the Supreme Court and therefore the relief granted by the Apex Court should also be granted to them. 

They further submitted that identical relief had been granted to other students who could not get admission for the academic year 2012-2013. The petitioners informed the Court that pursuant to the letter by the State, they had already submitted all the documents including the undertaking but they did not receive Rs 20 lakh compensation.

On the other hand, the State submitted that the petitioners were not before the Supreme Court and therefore they could not seek the relief by filing the plea before the HC bench. Therefore, the State submitted that the petitioners were not entitled to public law damages of Rs 20 lakh and urged the Court to dismiss the plea.

While considering the matter, the bench noted, “Therefore, in our view, if the Petitioners are similarly placed as those who were before the Supreme Court then the Respondent No.6 cannot deny the relief of payment of Rs.20,00,000/- to each Petitioner.”

The HC bench noted that in March 2019, the State had paid Rs 20 lakh to one of the petitioners for the lost opportunity. Referring to this, the bench observed, “If that be so, we failed to understand as to how Respondent No.6-State can submit that since the other three Petitioners were not before the Supreme Court they are not entitled to sum of Rs.20,00,000/-. This stand of Respondent No.6-State is contrary to their own act of making payment of Rs.20,00,000/- to Petitioner No.2. Therefore even on this count, the Respondent No.6-State is not justified in denying payment of Rs.20,00,000/- to other Petitioners.”

Further, the Court took note of the fact that in March 2015, the State issued a letter to the other three petitioners and sought certain documents to process and make the payment as per the Apex Court’s directions.

“We are informed by the Petitioners that they have complied with the said requisition by filing an undertaking and various documents namely Aadhaar card, bank details etc. However, the Petitioners have not received the payment of Rs.20,00,000/- till today. There is no justification given by Respondent No.6-State for having issued such communication and the Petitioner having complied with why the payment was not made from 2015 onward till today. Therefore on this count also, the stand taken by the Respondent No.6-State to deny the payment is contrary to their own stand. However since in the petition there is no averment on the Petitioners having complied with the requisition, we direct Petitioner Nos.1, 3 and 4 to once again file the documents requisitioned by Respondent No.6 vide letter dated 9th March 2015 so that the claim can be processed,” the Court noted at this outset.

Therefore, the bench directed three of the four petitioners to file the details sought via letter dated 9th March 2015 within a period of two weeks and directed the State to process the claim. 

“The Respondent No.6-State is directed to process the claim and make payment of Rs.20,00,000/- each to Petitioner Nos.1, 3 and 4 within a period of eight weeks from the expiry of two weeks as (i) per above,” directed the bench.

To view the order, click on the link below:

https://medicaldialogues.in/pdf_upload/bombay-hc-wrongful-denial-of-admission-233429.pdf

Also Read: 40 years after death of patient, HC upholds conviction of doctor

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Role of Vaccination in Immune Compromised Patients – Dr Dipu TS

Vaccination plays a pivotal role in protecting
immunocompromised individuals from potential infections, given their
compromised immune status. The effectiveness of vaccines, however, largely
depends on the robustness of the immune system, presenting a significant
challenge in this context.

Immunocompromised persons are at an elevated risk of
contracting infections, underscoring the critical need for vaccination as a key
mitigation strategy. Yet, the weakened immune response typical of such
individuals may not suffice to prevent vaccine-preventable diseases,
highlighting a unique and pressing dilemma.

Historical successes in vaccination, such as
the cowpox vaccine’s cross-immunity to smallpox, demonstrate the importance of
a responsive immune system to the effectiveness of vaccinations. This principle
applies equally to the immunocompromised, for whom achieving a sufficient
immune response through vaccination can be particularly challenging.

The
administration of live vaccines, which are attenuated strains designed to
enhance immunity without causing disease in immunocompetent individuals, poses
a significant risk. In immunocompromised patients, the replication of these
strains could proceed unchecked, leading to severe health implications, thereby
rendering live vaccines like MMR, Polio, and Varicella unsuitable for this
population.

The limitations in vaccine options for
immunocompromised individuals further complicate their protection strategy.
Ensuring the persistence of immunity poses an additional hurdle; even when an
immune response is initially achieved, sustaining the vaccine’s effectiveness
over time can be challenging.

This underscores the importance of monitoring
specific immune responses, such as antibodies and T-cell mediated reactions,
and the necessity for repeated vaccine boosters to counteract the decline in
immunity. For certain conditions, such as after a splenectomy, revaccination
protocols are specifically recommended to maintain protective immunity levels.

Preventing vaccine-preventable diseases is
paramount for the immunocompromised, as the failure to do so could lead to
severe consequences, including mortality. The use of non-live vaccines—subunit,
conjugate, and whole killed vaccines—offers a safe alternative for
immunocompromised individuals.

It is crucial for patients to inquire about the
type of vaccine being administered to avoid the risks associated with live
vaccines inadvertently. Such knowledge empowers patients to engage proactively
with their healthcare providers, informing them of their immune status and any
ongoing treatments, thus facilitating informed decision-making regarding
appropriate vaccination strategies.

The complexity of the immunocompromised state
varies widely across individuals, influenced by various conditions and
treatments. For example, the eligibility for vaccination among patients
receiving HIV treatment may hinge on their CD4 cell count. To narrate an example, if their CD4 cell count is more than 200 then we can give live vaccine
to protect against varicella (chickenpox) whereas if their CD4 count is below
200 then we will not able to give the same vaccine.

This emphasises the need
for tailored vaccination approaches. The timing of vaccination is also
critical, especially for patients undergoing treatments such as cancer
chemotherapy or preparing for elective splenectomy. Vaccines should ideally be
administered during periods when the immune system is at its most responsive to
achieve maximum efficacy.

Furthermore, ongoing research and development
efforts are needed to improve vaccination strategies for immunocompromised
patients. This includes investigating alternative vaccine formulations, such as
novel adjuvants or delivery systems, that can enhance immune responses in this
population.

Additionally, studies focusing on immune monitoring techniques can
help tailor vaccination schedules and boosters to optimize protection while
minimizing risks. Education also plays a crucial role in empowering both healthcare
providers and patients.

By raising awareness about the importance of
vaccination in immunocompromised individuals and providing clear guidelines for
vaccination practices, we can improve vaccination rates and ultimately reduce
the burden of vaccine-preventable diseases in this vulnerable population.

In conclusion, both physicians and patients
must recognize the complexities involved in vaccinating immunocompromised
individuals. This understanding is increasingly important in today’s medical
landscape, characterized by the advent of biological therapies, chemotherapy,
and organ transplantation.

By customizing vaccination strategies to meet the
unique needs of this vulnerable group, healthcare providers can offer the best
possible protection against infectious diseases, reflecting the nuanced and evolving
nature of medical care for the immunocompromised.

Disclaimer: The views expressed in this article are of the author and not of Medical Dialogues. The Editorial/Content team of Medical Dialogues has not contributed to the writing/editing/packaging of this article.

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Union Home Minister inaugurates Swaminarayan Institute of Medical Science in Gujarat

Union Home Minister and Minister of Cooperation, Shri Amit Shah inaugurated ‘Swaminarayan Institute of Medical Science and Research’ of Shri Swaminarayan Vishwamangal Gurukul at Kalol in Gandhinagar, Gujarat. On this occasion, Chief Minister of Gujarat Shri Bhupendra Patel and many dignitaries were present.

Addressing the inaugural programme, Shri Amit Shah lauded the Swaminarayan sect and said that Lord Swaminarayan made Gujarat Karmabhoomi, established nine temples and a great tradition. He said that the Swaminarayan sect freed crores of people from addiction, promoted the values ​​of devotion in every home, and taught them how to live a smooth life. Shri Shah said the Swaminarayan sect started setting up Gurukuls across Gujarat since the 1960s.

For more information click on the link below:

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Post-traumatic stress disorder trajectories in sepsis survivors

Recently published study identified and predict trajectories of post-traumatic stress symptoms in sepsis survivors up to two years after discharge from the ICU. It addressed the limited research on long-term trajectories of post-traumatic stress and potentially modifiable risk factors following the ICU stay. The study included data on post-traumatic stress symptoms collected from sepsis survivors at one, six, 12, and 24 months after ICU discharge. The results identified three distinct trajectories of post-traumatic stress symptoms: stable low symptoms (59% of patients), increasing symptoms (26%), and recovering from symptoms (15%). Patients with initially high post-traumatic symptoms were more likely to show a decrease. Females and patients reporting early traumatic memories of the ICU were at higher risk for increasing post-traumatic stress symptoms.

Implications of Findings

The findings suggest that post-traumatic stress is a relevant long-term burden for sepsis patients after ICU stay and highlight the importance of regular screening for post-traumatic stress, especially in patients with few initial symptoms. The study suggests the need for timely screening for early traumatic memories after ICU discharge and regular monitoring of post-traumatic stress symptoms in the long term. Additionally, it indicates that women may be at a higher risk of increasing symptom severity and emphasizes the importance of screening and monitoring, particularly in general practice settings.

Limitations and Recommendations

The study provides valuable insights into the long-term trajectories of post-traumatic stress symptoms in sepsis survivors and identifies potential risk factors for adverse mental health outcomes. However, it also acknowledges certain limitations, such as the exploratory nature of the analysis and the need for replication in larger prospective cohorts with more measurement points. Overall, the study contributes to the understanding of post-traumatic stress in ICU survivors and emphasizes the need for ongoing monitoring and support for sepsis survivors.

Reference –

Schmidt, K.F.R., Gensichen, J.S., Schroevers, M. et al. Trajectories of post-traumatic stress in sepsis survivors two years after ICU discharge: a secondary analysis of a randomized controlled trial. Crit Care 28, 35 (2024). https://doi.org/10.1186/s13054-024-04815-4.

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Prostate cancer test may lead to harmful overdiagnosis in Black men

A new study from experts at the University of Exeter has found that a widely used test for prostate cancer may leave Black men at increased risk of overdiagnosis.

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UK’s General Medical Council urged to revise terminology for international medical graduates

The General Medical Council (GMC) should revise its terminology regarding international medical graduates (IMGs) in the UK, argues a new commentary published in the Journal of the Royal Society of Medicine (JRSM).

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Loneliness found to increase the risk of health deterioration in older adults

The loneliness often experienced by older people in our society has a negative effect on their physical health, according to researchers from Amsterdam UMC and the University of Glasgow. Emiel Hoogendijk, epidemiologist at Amsterdam Public Health, analyzed research results from more than 130 studies and found that loneliness led to an increase in physical frailty, which in turn increases the risk of adverse health outcomes such as depression, falls and cognitive decline. These results are published today in The Lancet Healthy Longevity.

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More than one billion people in the world are now living with obesity, global analysis suggests

The total number of children, adolescents and adults worldwide living with obesity has surpassed one billion, according to a global analysis published in The Lancet. These trends, together with the declining prevalence of people who are underweight since 1990, make obesity the most common form of malnutrition in most countries.

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