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A pregnant mother undergoes significant changes in acid-base status as well as sodium and calcium metabolism to combat her physiological needs of pregnancy. Pregnant patients experience mild respiratory alkalosis due to the stimulation of the respiratory center by progesterone. This is associated with a corresponding increase in bicarbonate excretion by kidneys; as a result, the pH remains slightly high (7.40-7.45) but within the normal range. Pregnant women are predisposed to starvation ketosis as compared to nonpregnant states due to relative insulin resistance and increased production of the counter-regulatory hormone. Physiological mild hyponatremia occurs during pregnancy due to increased AVP secretion caused by resetting of osmoreceptors in the hypothalamus at a lower osmolality, but values below 130 mEq/L require a diagnostic workup and intervention. Gestational diabetes insipidus can occur due to increased production or decreased destruction of enzyme vasopressinase. Secretion of parathyroid hormone-related peptide by the placenta and breasts and two- to three-fold increased calcium and phosphate absorption in the maternal gut are the key changes in calcium metabolism during pregnancy. Though rare, both hypo- and hypercalcemia in pregnancy are associated with significant maternofetal morbidity and mortality.Ahmed A. Fetomaternal Acid-Base Balance and Electrolytes during Pregnancy. Indian J Crit Care Med 2021; 25(Suppl 3):S193-S199.

Among the various strategies for the prevention of airborne transmission, engineering measures are placed high in the hierarchy of control. Modern hospitals in high-income countries have mechanical systems of building ventilation also called HVAC (heating, ventilation, and air-conditioning) but installation and maintenance of such systems is a challenging and resource-intensive task. Even when the state-of-the-art technology was used to build airborne infection isolation rooms (AIIRs), recommended standards were often not met in field studies. The current coronavirus disease-2019 pandemic has highlighted the need to find cost-effective and less resource-intensive engineering solutions. Moreover, there is a need for the involvement of interdisciplinary teams to find innovative infection control solutions and doctors are frequently lacking in their understanding of building ventilation-related problems as well as their possible solutions. The current article describes building ventilation strategies (natural ventilation and hybrid ventilation) for hospitals where HVAC systems are either lacking or do not meet the recommended standards. Other measures like the use of portable air cleaning technologies and temporary negative-pressure rooms can be used as supplementary strategies in situations of demand surge. It can be easily understood that thermal comfort is compromised in buildings that are not mechanically fitted with HVAC systems, therefore the given building ventilation strategies are more helpful when climatic conditions are moderate or other measures are combined to maintain thermal comfort. How to cite this article Zia H, Singh R, Seth M, Ahmed A, Azim A. Engineering Solutions for Preventing Airborne Transmission in Hospitals with Resource Limitation and Demand Surge. Indian J Crit Care Med 2021;25(4):453–460.

Objective: Invasive candidiasis is associated with increased morbidity and mortality in critically ill patients. Current study was undertaken to study the colonization trend in critically ill patients admitted to a medical /surgical ICU of a tertiary care teaching hospital. Methodology: Data for the current study has been derived from a larger database generated for external validation of risk prediction scores for invasive candidiasis conducted in a 12 bedded medical/surgical ICU of a tertiary care hospital of North India. Non neutropenic adult patients with >48 hours of ICU stay were included in the study. Colonization surveillance samples were collected from oral cavity, endotracheal aspirates, axilla, perineum and urine at the time of admission and then on 3rd, 7th, 14th and 21st day of ICU stay. Blood culture samples were taken at admission and then as per physician’s discretion. Results: Total 200 patients were enrolled from July 2013 to November 2014. Ninety five percent patients were colonized with Candida either at admission or during their stay in ICU. The most common species responsible for colonization was Candida glabrata (27%) followed by C. tropicalis (20.5%) and C. auris (18%). Seventeen patients developed Candida blood stream infection. C. tropicalis was the most common species causing candidemia. C.auris was most frequent colonizer of axilla (54.2%), while rectal swabs had high growth of C. glabrata (44.9%). Conclusion: Our study population had high rate of Candida colonization. C. glabrata was the most common colonizer followed by C. tropicalis. J Microbiol Infect Dis 2018; 8(4):147-152.

How to cite this article: Siddiqui S, Ahmed A, Azim A. Selecting Journal for Publication in the Era of “Haste Predatory Journals and COVID-19”. Indian J Crit Care Med 2020;24(12):1284–1285.

Emergency laparotomies have remained a challenging entity since many decades. Only during the past 10 years, serious efforts have been made to improve their outcome by conducting audits and designing care pathways. Indications for emergency laparotomies can be broadly classified into trauma and non-trauma surgeries, which are either done for control of hemorrhage or/and done for control of sepsis and organ dysfunction. Goal-directed resuscitation for septic/hemorrhagic shock, consultant-led multidisciplinary teams, and timely transfer to intensive care units form core principles of management for these patients. Global inequity in access to standard and affordable emergency surgeries is an area of concern requiring integrated efforts at international level. How to cite this article: Ahmed A, Azim A. Emergency Laparotomies: Causes, Pathophysiology, and Outcomes. Indian J Crit Care Med 2020;24(Suppl 4):S183–S189.

How to cite this article: Siddiqui S, Ahmed A, Azim A. Selecting Journal for Publication in the Era of "Haste Predatory Journals and COVID-19". Indian J Crit Care Med 2020;24(12):1284-1285.

Background The aim of this study was to conduct external validation of risk prediction scores for invasive candidiasis. Methods We conducted a prospective observational study in a 12-bedded adult medical/surgical Intensive Care Unit (ICU) to evaluate Candida score >3, colonization index (CI) >0.5, corrected CI >0.4 (CCI), and Ostrosky's clinical prediction rule (CPR). Patients' characteristics and risk factors for invasive candidiasis were noted. Patients were divided into two groups; invasive candidiasis and no-invasive candidiasis. Results Of 198 patients, 17 developed invasive candidiasis. Discriminatory power (area under receiver operator curve [AUROC]) for Candida score, CI, CCI, and CPR were 0.66, 0.67, 0.63, and 0.62, respectively. A large number of patients in the no-invasive candidiasis group (114 out of 181) were exposed to antifungal agents during their stay in ICU. Subgroup analysis was carried out after excluding such patients from no-invasive candidiasis group. AUROC of Candida score, CI, CCI, and CPR were 0.7, 0.7, 0.65, and 0.72, respectively, and positive predictive values (PPVs) were in the range of 25%-47%, along with negative predictive values (NPVs) in the range of 84%-96% in the subgroup analysis. Conclusion Currently available risk prediction scores have good NPV but poor PPV. They are useful for selecting patients who are not likely to benefit from antifungal therapy.

Hypocalcemia is a frequent finding in acute pancreatitis. Severe hypocalcemia can present with neurological as well as cardiovascular manifestations. Correction of hypocalcemia by parenteral calcium infusion remains a controversial topic as intracellular calcium overload is the central mechanism of acinar cell injury in pancreatitis. The current article deals with the art and science of calcium correction in pancreatitis patients.

Use of antifungal agents has increased over past few decades. A number of risk factors such as immunosuppression, broad spectrum antibiotics, dialysis, pancreatitis, surgery, etc., have been linked with the increased risk of invasive candidiasis. Though there are various guidelines available for the use of antifungal therapy, local/regional epidemiology plays an important role in determining the appropriate choice of agent in situations where the offending organism is not known (i.e. empirical, prophylactic or preemptive therapy). Developing countries like India need to generate their own epidemiological data to facilitate appropriate use of antifungal therapy. In this article, the authors have highlighted the need for region-specific policies/guidelines for treatment of invasive candidiasis. Currently available Indian literature on candidemia epidemiology has also been summarized here.

Background: Invasive candidiasis (IC) is associated with increased morbidity in severe acute pancreatitis (SAP). There is limited information regarding the predisposing factors, Candida species distribution and in vitro susceptibility. Methodology: Current data have been derived from a larger prospective nonintervention study conducted on 200 critically ill patients which was done to study the antifungal prescription practices, collect epidemiological data, and perform an external validation of risk prediction models for IC under senior research associateship program of Council of Scientific and Industrial Research New Delhi. Of these critically ill patients, thirty had SAP and were included for analysis. Results: There were 23 males and 7 females. Out of eight patients (27%) who developed IC, three had isolated candidemia, two had isolated deep-seated candidiasis while three had both candidemia and deep-seated candidiasis. SAP patients with IC had a longer duration of Intensive Care Unit stay, hospital stay, days on mechanical ventilation and duration of shock. Mortality was not different between SAP patients with or without IC. Conclusion: There is a high rate of Candida infection in SAP. More studies are needed to generate epidemiological data and develop antifungal stewardship in this subset of high-risk population.

Acute respiratory distress syndrome (ARDS) contributes substantially to mortality and morbidity in USA and worldwide. Due to limitations in early diagnostics of ARDS by classical methods, there has been need for discovery of novel methods and biomarkers for its characterization. We present here first high-resolution 1H nuclear magnetic resonance (NMR) metabolic profiling of serum from ARDS patients and non ARDS (NARDS) controls to search for novel biomarkers in blood serum for better diagnostics and prognostics. We have carried out study with serum samples from a total of 45 subjects, which included 26 ARDS patients and 19 NARDS controls. Principal component analysis (PCA) and partial least square discriminant analysis (PLS-DA) were performed on 1H NMR spectra of serum for group discrimination between the two. PCA and PLS-DA on 1H NMR spectra of serum clearly discriminated between NARDS control and ARDS diseased samples. In our study, lipid resonances showed major contribution for this separation in loading plots. In order to highlight role of other small molecular weight metabolites, the analysis was also carried out after removing lipids resonances from NMR spectrum. There was significant increase in concentrations of N-acetylglycoproteins (NAC) (p = 0.001), acetoacetate (p = 0.001), lactate (p = 0.001), creatinine (p = 0.003), histidine (p = 0.03), formate (p = 0.04) and aromatic amino acids serum of ARDS patients. Along with small metabolites, lipids play a very important role in this discrimination and can differentiate between two classes. Our study has given new avenue in the metabolic profiling of lung injuries.

We present a method for identifying biomarkers in human lung injury. The method is based on high-resolution nuclear magnetic resonance (NMR) spectroscopy applied to bronchoalveolar lavage fluid (BALF) collected from lungs of critically ill patients. This biological fluid can be obtained by bronchoscopic and non-bronchoscopic methods. The type of lung injury in acute respiratory failure presenting as acute lung injury (ALI) and its severe form, acute respiratory distress syndrome (ARDS), continues to challenge critical care physicians. We characterize different metabolites in BAL fluid by non-bronchoscopic method (mBALF) for better diagnosis and understanding of ALI/ARDS by NMR spectroscopy. NMR spectra of mBALF collected from 30 patients (9 controls, 10 ARDS and 11 ALI) were analyzed for the identification of biomarkers. Statistical methods such as principal components analysis and partial least square discriminant analysis were carried out on 1H NMR spectrum of mBALF to identify biomarker responsible for separation among different lung injuries classes (ALI and ARDS) and normal lungs. The corresponding correlation of biomarkers with metabolic cycle has given insight into metabolism of lung injuries in critically ill patients. Our study shows statistically significant differentiation of various metabolites concentration in mBALF collected from lungs of ALI, ARDS and healthy control patients, making NMR spectroscopy as a possible new method of characterizing human lung injury.

A recently published article on corruption in Indian healthcare in the BMJ has triggered a hot debate and numerous responses (1, 2, 3, 4). We do agree that corruption in Indian healthcare is a colossal issue and needs to be tackled urgently (5). However, we want to highlight that corruption in healthcare is not a local phenomenon confined to the Indian subcontinent, though India does serve as a good case study and intervention area due to the magnitude of the problem and the country's large population (6). Good governance, strict rules, transparency and zero tolerance are some of the strategies prescribed everywhere to tackle corruption. However, those entrusted with implementing good governance and strict rules in India need to go through a process of introspection to carry out their duties in a responsible fashion. At present, it looks like a no-win situation. In this article, we recommend education in medical ethics as the major intervention for dealing with corruption in healthcare.

Over past few years, treatment of invasive candidiasis (IC) has evolved from targeted therapy to prophylaxis, pre-emptive and empirical therapy. Numerous predisposing factors for IC have been grouped together in various combinations to design risk prediction models. These models in general have shown good negative predictive value, but poor positive predictive value. They are useful in selecting the population which is less likely to benefit from empirical antifungal therapy and thus prevent overuse of antifungal agents. Current article deals with various risk prediction models for IC and their external validation studies.

Widespread emergence of multidrug resistant (MDR) bacterial pathogens is a problem of global dimension. MDR infections are difficult to treat and frequently associated with high mortality. More than one antibiotic is commonly used to treat such infections, but scientific evidence does not favor use of combination therapy in most cases. However, there are certain subgroups where combination therapy may be beneficial, e.g. sepsis due to carbapenem-resistant Enterobacteriaceae (CRE), bacteremic pneumococcal pneumonia, and patients with multiple organ failure. Well-designed prospective studies are needed to clearly define the role of combination therapy in these subgroups.

Sir, The article “Candida glabrata candidemia; An emerging threat in critically ill patients” very well highlights the importance of this emerging species.[1] Due to delay in time to positivity for blood culture, empirical antifungal therapy is an important strategy in the management of invasive candidiasis, more so for C. glabrata infection. Appropriate empirical therapy requires identification of high risk group. In the present study, authors have reported broad spectrum antibiotic, mechanical ventilation, central venous catheter, diabetes mellitus and age >65 years as risk factors for C. glabrata candidemia. We agree with Chakrabarti's view that due to lack of control group in the study, it is difficult to draw any inference regarding the risk factors.[2] At least two authors have attempted to develop risk model to predict C. glabrata candidemia. Tapia et al. studied 246 cases of candidemia, out of which 68 cases were due to C. glabrata.[3] Four factors independently associated with C. glabrata candidemia were absence of renal failure, 60 years, recent abdominal surgery, interval from intensive care unit admission to first positive blood culture

Background Limited studies are available on prevalence and severity of vitamin D deficiency in a critically ill population. To the best of our knowledge, this the first study of its kind in an Indian intensive care set-up. Methods One hundred fifty-eight critically ill patients were prospectively enrolled for over 2 years. Demographic profile and clinical characteristics were noted. Blood sample for serum 25 (OH) D was collected on admission (4 ml). Serum 25 (OH) D was measured using radioimmunoassay kit. Vitamin D deficiency was labelled as insufficient (31–60 nmol/l), deficient (15–30 nmol/l) and undetectable (

Sir, We read the article “Nosocomial candiduria in chronic liver disease patients at a hepatobiliary center”[1] with great interest. This article clearly highlights the importance of repeat sampling in patients who are reported as having candiduria. Candiduria can occur due to contamination, colonization (of the indwelling catheter or bladder), and infection (Candida cystitis or ascending pyelonephritis or renal candidiasis) as discussed in this article. Taking a repeat sample after insertion of fresh catheter eliminates the chances of contamination, but colonization can still be present without any clinical manifestation of disease.[2,3] Differentiation between the colonization and infection is difficult one and should be interpreted in the light of clinical features. Frequently, due to the presence of multiple co morbidities the line of demarcation between Candida colonization and infection is blurred, more so in critically ill patients. Pathogenesis of urinary tract and renal infections caused by Candida involves hematogenous spread as well ascending infection. When suspecting hematogenous spread various risk prediction scores (colonization index, Candida score) have been designed to guide therapy.[3,4] Candida colonization has been shown to be a risk factor for invasive candidiasis, but multiple site colonization and heavy colonization is considered more significant than single site colonization.[5] Candiduria represents single site colonization and should not trigger initiation of treatment unless other symptoms are also present. When suspecting ascending infection, one should look for predisposing factors like presence of stone or presence of obstruction, urinary drainage devices, prior surgical procedures, broad spectrum antibiotic use, old age, and diabetes mellitus. Infectious Disease Society of America 2009 guidelines recommends that asymptomatic candiduria should not be treated unless the patient is at high risk of invasive candidiasis (neutropenia, low birth weight, and patients who undergo urologic procedures).[6] The reason for treating asymptomatic candiduria in high risk patients is mainly prophylaxis. Chronic liver disease is a very broad terminology and includes various etiologies and stages of evolution in its natural history. Whether all chronic liver disease patients should be included in the high risk remains to be established. Currently, there is a paucity of literature regarding predisposition for invasive Candida infections among chronic liver disease patients. It would have been enlightening if the patient characteristics and stages/classification of liver disease were also mentioned in this study. The study also reports that 11 (3.5%) patients of candiduria evolved to candidemia. Though it is difficult to perform, genotypic identification is ideally required before one can say that species colonizing is the same as the species responsible for blood stream infection.