Nguyen H.B.,Loma Linda University |
Kuan W.S.,National University of Singapore |
Batech M.,Loma Linda University |
Shrikhande P.,Fortis Flt Lt Rajan Dhall Hospital |
And 5 more authors.
Critical Care | Year: 2011
Introduction: Implementation of the Surviving Sepsis Campaign (SSC) guidelines has been associated with improved outcome in patients with severe sepsis. Resolution of lactate elevations or lactate clearance has also been shown to be associated with outcome. The purpose of the present study was to examine the compliance and effectiveness of the SSC resuscitation bundle with the addition of lactate clearance.Methods: This was a prospective cohort study over 18 months in eight tertiary-care medical centers in Asia, enrolling adult patients meeting criteria for the SSC resuscitation bundle in the emergency department. Compliance and outcome results of a multi-disciplinary program to implement the Primary SSC Bundle with the addition of lactate clearance (Modified SSC Bundle) were examined. The implementation period was divided into quartiles, including baseline, education and four quality improvement phases.Results: A total of 556 patients were enrolled, with median (25th to 75th percentile) age 63 (50 to 74) years, lactate 4.1 (2.2 to 6.3) mmol/l, central venous pressure 10 (7 to 13) mmHg, mean arterial pressure (MAP) 70 (56 to 86) mmHg, and central venous oxygen saturation 77 (69 to 82)%. Completion of the Primary SSC Bundle over the six quartiles was 13.3, 26.9, 37.5, 45.9, 48.8, and 54.5%, respectively (P <0.01). The Modified SSC Bundle was completed in 10.2, 23.1, 31.7, 40.0, 42.5, and 43.6% patients, respectively (P <0.01). The ratio of the relative risk of death reduction for the Modified SSC Bundle compared with the Primary SSC Bundle was 1.94 (95% confidence interval = 1.45 to 39.1). Logistic regression modeling showed that the bundle items of fluid bolus given, achieve MAP >65 mmHg by 6 hours, and lactate clearance were independently associated with decreased mortality - having odds ratios (95% confidence intervals) 0.47 (0.23 to 0.96), 0.20 (0.07 to 0.55), and 0.32 (0.19 to 0.55), respectively.Conclusions: The addition of lactate clearance to the SSC resuscitation bundle is associated with improved mortality. In our study patient population with optimized baseline central venous pressure and central venous oxygen saturation, the bundle items of fluid bolus administration, achieving MAP >65 mmHg, and lactate clearance were independent predictors of outcome. © 2011 Nguyen et al.; licensee BioMed Central Ltd.
Goel K.,Mayo Medical School |
Misra A.,Fortis Flt Lt Rajan Dhall Hospital |
Misra A.,National Foundation for Diabetes |
Misra A.,Diabetes Foundation India |
And 3 more authors.
Heart | Year: 2010
Hypothesis: Subcutaneous abdominal adipose tissue (SCAT) compared with intra-abdominal adipose tissue (IAAT) would be more significantly associated with the metabolic syndrome in Asian Indians. Design: Cross-sectional study. Setting: Tertiary care medical institution. Subjects: 100 healthy adults without known heart disease or diabetes. Interventions: Magnetic resonance imaging to measure cross-sectional areas of abdominal adipose tissue compartments at the L3-L4 intervertebral level. Dual energy x-ray absorptiometry to measure fat percentage (BF%) and lean mass of total body, trunk, legs and arms. Results: Subjects with the metabolic syndrome (n=35) had a significantly higher BF%, SCAT and IAAT than those without it. Both SCAT and IAAT showed a significant correlation with blood pressure and triglycerides. One SD increase in IAAT (odds ratio (OR) 3.43; 95% CI 1.78 to 6.63) or SCAT area (OR 6.35; 95% CI 2.75 to 14.7) was significantly associated with the metabolic syndrome. On comparing them in the same model, SCAT was the only significant factor associated with the metabolic syndrome (OR 4.92; 95% CI, 1.95 to 12.38). In receiver operating characteristic curve analysis, significant areas under the curves (AUC) were noted for IAAT (0.77) and SCAT (0.89). On comparing the equality of AUC by C statistics, SCAT was a more significant predictor of the metabolic syndrome than IAAT (p=0.009). Only SCAT was significantly associated with the metabolic syndrome after adjusting for BF%, lean body mass or trunk lean mass. Conclusion: SCAT is a more important predictor of the metabolic syndrome in Asian Indians than IAAT. The significance of SCAT in the pathogenesis of atherosclerosis and diabetes needs to be investigated further in Asian Indians.
Misra A.,Fortis Flt Lt Rajan Dhall Hospital |
Misra A.,National Foundation for Diabetes Obesity and Cholesterol Disorders N DOC |
Misra A.,Diabetes Foundation India
Expert Opinion on Biological Therapy | Year: 2010
Importance of the field: Ever since the formation of the first biotechnology company almost three decades ago, more than 150 biopharmaceutical products have been marketed across the globe. The oldest of these biotechnology-derived products are now at the end of their patent lives, as a result of which, the development of 'biosimilars' is increasing. Areas covered in the review: The review highlights aspects in which biosimilars differ from generic drugs. What the reader will gain: The active substance of a biosimilar medicine is similar to the one of the biological reference medicine; however, biosimilars differ from generics of pharmacological drugs in aspects like size and complexity of the active substance, and the nature of the manufacturing process. The manufacture of a biopharmaceutical product is complex and involves several isolation and purification steps. These procedures are proprietary to the manufacturer of the originator product and hence even minor changes in production can have serious implications in terms of safety and efficacy of the product. Take home message: Biosimilars should not be brought to market using the same procedure applied to generics, and existing and future regulation should prevent inappropriate and automatic substitution of a biosimilar for a reference biopharmaceutical product. © 2010 Informa UK Ltd.
Negi S.,National Institute of Immunology |
Kumar A.,Fortis Flt Lt Rajan Dhall Hospital |
Thelma B.K.,University of Delhi |
Juyal R.C.,National Institute of Immunology
Pharmacogenetics and Genomics | Year: 2011
Aberrations in ubiquitin pathway have been implicated in many diseases and drug response. In a previous study on rheumatoid arthritis (RA) in Japanese population, significant association of Cullin1 gene (CUL1), an ubiquitin E3 ligase, was observed. CUL1 also mediates degradation of IκBα and p27, levels of which has been associated with RA etiology and drug response, respectively. We carried out a replication study of association of CUL1 polymorphisms with RA in a north Indian population. Allelic, genotypic, and haplotypic associations of a promoter and two intronic polymorphisms of CUL1 with RA and with methotrexate response in patients with RA, were tested. A significant association (P=0.00056, adjusted) of a haplotype A-T-T with RA (odds ratio=3.68; 95% confidence interval=1.86-7.27) and in patients with RA poorly responding to methotrexate treatment (P=0.04, adjusted) was observed. Association with CUL1 haplotype indicates a possible role of CUL1 variation(s) in RA and its response to methotrexate. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Prasad P.,University of Delhi |
Kumar A.,All India Institute of Medical Sciences |
Kumar A.,Fortis Flt Lt Rajan Dhall Hospital |
Gupta R.,All India Institute of Medical Sciences |
And 3 more authors.
PLoS ONE | Year: 2012
Genome-wide association studies and meta-analysis indicate that several genes/loci are consistently associated with rheumatoid arthritis (RA) in European and Asian populations. To evaluate the transferability status of these findings to an ethnically diverse north Indian population, we performed a replication analysis. We investigated the association of 47 single-nucleotide polymorphisms (SNPs) at 43 of these genes/loci with RA in a north Indian cohort comprising 983 RA cases and 1007 age and gender matched controls. Genotyping was done using Infinium human 660w-quad. Association analysis by chi-square test implemented in plink was carried out in two steps. Firstly, association of the index or surrogate SNP (r2>0.8, calculated from reference GIH Hap-Map population) was tested. In the second step, evidence for allelic/locus heterogeneity at aforementioned genes/loci was assessed for by testing additional flanking SNPs in linkage equilibrium with index/surrogate marker. Of the 44 European specific index SNPs, neither index nor surrogate SNPs were present for nine SNPs in the genotyping array. Of the remaining 35, associations were replicated at seven genes namely PTPN22 (rs1217407, p = 3×10 -3); IL2-21 (rs13119723, p = 0.008); HLA-DRB1 (rs660895, p = 2.56×10 -5; rs6457617, p = 1.6×10 -09; rs13192471, p = 6.7×10 -16); TNFA1P3 (rs9321637, p = 0.03); CCL21 (rs13293020, p = 0.01); IL2RA (rs2104286, p = 1.9×10 -4) and ZEB1 (rs2793108, p = 0.006). Of the three Asian specific loci tested, rs2977227 in PADI4 showed modest association (p<0.02). Further, of the 140 SNPs (in LE with index/surrogate variant) tested, association was observed at 11 additional genes: PTPRC, AFF3, CD28, CTLA4, PXK, ANKRD55, TAGAP, CCR6, BLK, CD40 and IL2RB. This study indicates limited replication of European and Asian index SNPs and apparent allelic heterogeneity in RA etiology among north Indians warranting independent GWAS in this population. However, replicated associations of HLA-DRB1, PTPN22 (which confer ∼50% of the heritable risk to RA) and IL2RA suggest that cross-ethnicity fine mapping of such loci is apposite for identification of causal variants. © 2012 Prasad et al.
Bedi G.,Fortis Flt Lt Rajan Dhall Hospital
Journal of Clinical Orthopaedics and Trauma | Year: 2011
Shoulder injuries are extremely common in sportspeople involved in overhead sports and even in casual sportspersons. With increasing interest in activities such as tennis, golf, squash, badminton not to mention cricket, many of our colleagues are seeing a lot of these individuals with disabling pains. Many unnecessary investigations are being done where most diagnosis can be made by good clinical examination and knowledge of pathology. Therapy plays a very important part in the rehabilitation of these injuries, although again certain protocols have to be followed. The review will look at some of the common pathologies and also treatment options and also some specific injuries related to few sports. © 2011 Delhi Orthopedic Association.
Kumar A.,Fortis Flt Lt Rajan Dhall Hospital |
Abrol A.,Fortis Hospital
Indian Journal of Rheumatology | Year: 2015
Granulomatosis with polyangiitis (GPA) is now a well-recognised clinical entity in India. The earliest description of GPA in India (then called Wegener's granulomatosis) appeared as a single case in a series of 108 cases of systemic vasculitis published in 1985. Later, several short case-series (mostly from northern India) and a number of case reports were published. The number of published cases of GPA from India till date is about 130 (actual burden of disease is certainly much larger as only a few cases get published). The overall clinical profile, response to treatment and long-term outcome of GPA do not differ significantly from what is described in western literature. A female preponderance has been noted in the Indian series, whereas no gender predilection was seen in western series. Although many cases used to masquerade as pulmonary tuberculosis in the past, the situation has improved considerably, with better awareness about the disease and availability of ANCA as a diagnostic test. High relapse rate and significant organ damage continue to pose a challenge. Cyclophosphamide combined with prednisolone is the standard induction regimen. Rituximab and its two biosimilars are being increasingly used in the management of refractory cases as well as for induction of remission in certain situations. © 2015 Indian Rheumatology Association
Sharma P.R.,Fortis FLT LT Rajan Dhall Hospital |
Barman P.,Fortis FLT LT Rajan Dhall Hospital
Indian Journal of Pharmacology | Year: 2010
Objective : To study the antimicrobial (AM) consumption, record the AM sensitivity pattern, and evaluate impact of "Reserve AM indent form" in the intensive care unit (ICU). Materials and Methods : The study was carried out in medical ICU over 4 months period at a tertiary care hospital. AM consumption was determined by defined daily dose (DDD) per 100 bed days for each month for consecutive 4 months. The average total AM consumption was calculated. The laboratory samples were processed, and the sensitivity pattern was determined. Some of the newer AM were categorised as "Reserve" and an indent form was made mandatory to be filled up prior to prescription. Results : The total AM consumption was 232 per 100 bed days. The commonly used AM were penicillin with β-lactamase inhibitor (21%) followed by antifungal drugs (13.4%), cephalosporins and macrolides (11.7%) each. The most common organism isolated was Acinetobacter (26.1%) followed by Candida (23.8%) and Pseudomonas (21.4%). The average occupancy index was 0.53, and the average duration of ICU stay was 6 days. The consumption of carbapenems (new AM) and antifungals decreased from 18.8/100 to 10.6/100 and 56.1/100 to 22.1/100 bed days, respectively, after the introduction of indent form. Conclusion : The "Reserve AM indent form" was helpful in reducing the AM consumption during the study period. The AM indent form can be used as an important tool to combat irrational use, AM resistance and can be implemented in AM stewardship programmes.
Kumar A.,Fortis Flt Lt Rajan Dhall Hospital
Best Practice and Research: Clinical Rheumatology | Year: 2014
Polyarthritis comprises a large number of conditions ranging from rheumatoid arthritis (RA) to metabolic conditions such as ochronosis. Differential diagnosis begins with delineation of inflammatory from non-inflammatory disorders using laboratory markers of inflammation. The latter are good but they can be misleading. Laboratory tests help in the diagnosis of rheumatic diseases as well as their prognostication. The choice of serological tests should be based on clinical differential diagnosis and not 'arthritis panels'. The point of time when the test is performed in the clinical course of disease can have an important influence on the result obtained. Anti-citrullinated protein antibody (ACPA), rheumatoid factor, human leucocyte antigen (HLA) B27 and imaging are routinely employed for the early diagnosis of RA and spondyloarthritis (SpA). Despite advances in musculoskeletal imaging modalities such as ultrasonography (USG) with power Doppler, conventional as well as extremity magnetic resonance imaging (MRI) and dual-energy computed tomography (DECT), their exact place in clinical rheumatology remains to be defined. Synovial fluid examination has only a limited role in the investigations of new-onset polyarthritis. © 2015 Elsevier Ltd. All rights reserved.
PubMed | Lok Nayak Jai Prakash Hospital, Fortis Flt Lt Rajan Dhall Hospital, Southwestern Medical Center, Mayo Medical School and University of Iowa
Type: | Journal: The British journal of radiology | Year: 2016
The stomach may be involved by a myriad of pathologies ranging from benign aetiologies like inflammation to malignant aetiologies like carcinoma or lymphoma. Multidetector CT (MDCT) of the stomach is the first-line imaging for patients with suspected gastric pathologies. Conventionally, CT imaging had the advantage of simultaneous detection of the mural and extramural disease extent, but advances in MDCT have allowed mucosal assessment by virtual endoscopy (VE). Also, better three-dimensional (3D) post-processing techniques have enabled more robust and accurate pre-operative planning in patients undergoing gastrectomy and even predict the response to surgery for patients undergoing laparoscopic sleeve gastrectomy for weight loss. The ability of CT to obtain stomach volume (for bariatric surgery patients) and 3D VE images depends on various patient and protocol factors that are important for a radiologist to understand. We review the appropriate CT imaging protocol in the patients with suspected gastric pathologies and highlight the imaging pearls of various gastric pathologies on CT and VE.