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SATGURU PARTAP SINGH HOSPITALS

Volume :1 Issue : 3July-Sept. 2020

Blessing 04

From the desk of the Managing Director 05

From the desk of Chief Operating Officer 06

From the desk of Medical Superintendent 07

• How to make homes safe for HCW's and their families

Dr. Vikas Sikri & Dr. Seema Singhal 08

• Antibody detection (seroconversion) and future protection??

- Dr. Seema Singhal 10

• Pregnancy in COVID-19 Times

- Dr. Zeenie Sarda Girn 15

• Saving Newborn Lives

- Dr. Pradeep Kumar Sharma 18

• Case Report: Two complex Balloon Angioplasty Procedures in

Children in COVID Times

-Dr. Navdeep singh 19

• Primary Angioplasty with Bifurcation stenting in Acute

MI with Pulmonary oedema

-Dr. Ravninder Singh Kuka 20

• Removal of impacted foreign body by flexible

bronchoscopy using dormia basket in children

-Dr. Vikas Bansal & Dr. Mehak Bansal 23

• COVID-19 Angels and experimental plasma therapy

-Dr. Aikaj Jindal 26

• Blonanserin Overdose: A Case Report

-Dr. Sandeep Goyal & Dr. Parambir Singh 28

• Glimpses (past three months) 30-31

3

Editorial Disclaimer Content: All content found on this publication - MedTalk, including: text, images or other formats were created for informational and scientific purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment.Contents and any information provided by Contributors in this publication, are provided on an "as is" basis. The Contributors are solely responsible for the respective content and it's authenticity and MedTalk is not responsible for any such content.Images: The images used are either provided by Contributors (all photos of patients used in the articles have been obtained after "written informed consent" from the patient to be used only for scientific research purpose.) or are royalty free images or are legally procured stock images. The scientific articles that are included in the news letter are already published in scientific journals. The authors of the articles are clinicians in SPS Hospitals and consent has been taken from them to publish these articles in our newsletter with proper citation of the article giving due diligence to give credit to the journal in which original article was published.

Meet the Medtalk Team

Executive Board

Mr. Jai Singh: Managing DirectorDr. Jatinder Arora: Chief Operating OfficerDr. Rajiv Kundra: Medical Superintendant

Contributors

Dr. Vikas Sikri Dr. Seema SinghalDr. Zeenie Sarda GirnDr. Pradeep Kumar SharmaDr. Navdeep SinghDr. Ravninder Singh Kuka

Dr. Rajiv Kundra (Editor)

Dr. Vikas Sikri

Dr. Seema Singhal

Dr. Zeenie Sarda Girn

Dr. Pradeep Kumar Sharma

Dr. Navdeep Singh

Dr. Ravninder Singh Kuka

Dr. Vikas Bansal

Dr. Mehak Bansal

Dr. Aikaj Jindal

Dr. Sandeep Goyal

Dr. Parambir Singh

Dr. Akriti Gupta

2

Dr. Vikas BansalDr. Mehak BansalDr. Aikaj JindalDr. Sandeep GoyalDr. Parambir Singh

Satguru Partap Singh Hospital has completed 15 years of service since its inception. This hospital was startedby Satguru Jagjit SIngh Ji in the loving memory of his father, Sri Satguru Partap Singh Ji. Satguru Ji always had apassion to get good treatment for the people who are in need and who cannot afford it. Before the hospital

started we always remember how Satguruji used to sponsor different patients in different hospitals throughdifferent entrepreneurs. Even as Namdhari Seeds we had the opportunity to serve some patients whom he sent toBangalore. I feel fortunate since Satguru Ji gave me this opportunity to establish this hospital under their blessings.and guidance. We all feel fortunate as over the years we have been able to treat a lot of patients who are in needand could not have afforded treatment in another hospital.

Still the quality medical care is unaffordable to all Indians and especially the rural population of India. Oneimportant reason is that awareness about medical insurance in rural India is still very low. Unfortunately theGovernment hospitals have not been able to provide quality care which they were supposed to do and it is creatinga large gap. The different Government schemes for the daily wage earners are not very popular with the privatehospitals due to difficulty in getting the payments. In this challenging environment I would like to motivate andinspire our staff that we should provide good and affordable health care to live the dream of Satguru Jagjit Singh Ji.Management is happy that we are working for a good cause and we are also able to treat large number of patientswho are needy and who cannot afford their own treatment where we are able to do it through different schemes,sponsorships, donations and from the hospital discounts.

I feel we have a huge opportunity and responsibility where I would like to inspire our consultants, Resident Doctors,OT Staff, Nurses and other staff in the administration. Keep in mind you are working for one of the most noblecauses and you are serving the patients who are in need. We should work with the spirit that we are serving ourown family members. Our service will make us different from the other hospitals and we have had many exampleswhere the patients from here had gone to the big institutions but they have come back and applauded our service.We should continue and strive to further improve our service.

My best wishes for the future growth of the hospital and a humble prayer to Satguruji to give us the strength to

Best Wishes

Uday Singh

4 5

Satguru Partap Singh (SPS) Hospital is all about friendly vibes and caring professionals with a genuine desire to facilitate full and speedy pa�ent diagnosis, preven�on as well as recovery.

The greatest honour one can receive is being given the opportunity to serve one's community. I am proud to have been given the chance by HH Satguru Uday Singh Ji (Spiritual Head of the Namdhari Sikhs) for leading SPS Hospital, a health care ins�tu�on par excellence with a proud heritage.

In 2005 His Holiness Satguru Jagjit Singh Ji founded the SPS Hospital with a vision to serve and provide the community with world class healthcare services both preven�ve as well as cura�ve. I look forward to con�nuing that tradi�on. Our team's goal is to strengthen the trust and confidence that our pa�ents have in us.

In the challenging �mes of the Covid-19 Pandemic, with the blessings of HH Satguru Uday Singh Ji, I would like to reassure and put forth our resolve to lock every fear and worry away by taking the challenge head on and defea�ng Covid-19.

While SPS hospitals, Ludhiana has always been at the fore front in providing interna�onal healthcare services to the people of Punjab. We have always been front runners in challenging �mes as well and have stood by the people.

SPS hospital is fully geared up with our steel resolve to take on the Pandemic head on. We acknowledge and appreciate the efforts of the front line warriors of the Pandemic - our government officials, Police personnel, Doctors and Healthcare staff who are displaying exemplary courage and doing their du�es with utmost devo�on.

I wish to assure the family members of Government officials that SPS hospital resolves and commits to treat 'ALL' frontline government officials performing their du�es as 'Security Personnel' of the general public free of cost, who are diagnosed and affected due to the Covid-19 illness.

SPS hospitals is and will always be commi�ed to provide quality healthcare services to the people of Punjab.

Nanak Naam Chardi Kala, Tere Bhaney SARBAT DA BHALA !

Jai SinghManaging Directormd@spshospitals.com

The field of Healthcare is continuously changing and evolving with new technologies, practices and innovations. Almost every day we see a new medical study is published or advancements are made in the industry. These findings and innovations impact how patients with certain medical conditions should be assessed, treated and cared for. As a result, medical professionals have a responsibility to their patients to continue their education and stay on top of these changes. Only by doing so can they confidently provide patients with the level of care they deserve.

Last three months we have seen Corona spreading throughout the country. These have been tough times for the general population and especially health care workers who have risked their lives as well the lives of their near & dear ones and have not restrained from taking good care of the patients.

At SPS Hospitals, we thank those Covid warriors who have stayed with the patients in these tough times. In this issue special articles have been put to educate the medical professionals about the preventive measures which need to be taken.

Third edition of MedTalk is another step towards enhancing continued medical education at our hospitals.

RegardsDr. Rajiv Kundra

Medical Superintendent

7

Dr. Rajiv Kundra

6

From The Desk of Chief Operating Ofcer

Chief Operating Officer

Best regards,Dr. Jatinder Arora

SPS Hospitals stands tall as one of the leading health care ins�tu�ons in Punjab. The hospital aspires to excel in its facili�es, offering various

opera�onal for over fourteen years now and our team of renowned specialists and medical personnel has successfully been trea�ng pa�ents with complex ailments and extending cri�cal care at crucial �mes to save lives. Access to latest technological know-how and equipment enables us to accept the most cri�cal medical emergencies and treat them sa�sfactorily.

SPS hospitals is coming up with this latest edi�on when the world is dealing with corona virus. SPS hospitals, Ludhiana has always been a healthcare organisa�on, people can depend upon. The outbreak of Covid-19, a global pandemic has given SPS hospitals once again an opportunity as a healthcare organiza�on, to show its resolve to fight and overcome all odds mankind is challenged with.

Community of healthcare experts suggest that the society will have to learn to live with corona as a 'New Normal' just like anybody have been doing for other viral diseases like Measeles etc. Since the virus is immunogenic and it would take some �me for the vaccine to be available people would have to work on the principle of “SMS” that is S- Sani�za�on, M – Mask and S- Social Distancing.

Going forward we need to act on the public health by doing extensive tes�ng, including an�body tes�ng of work places and containment of virus at primary level and con�nuously educa�ng the public.

As we move forward, we would like to take this opportunity to share with you all, significant informa�on of high-risk and excep�onal cases treated right from day one at SPS. 'MedTalk' is a magazine exclusively highligh�ng and sharing these excep�onal case studies. This is a clinical magazine for the doctors by the doctors. We hope you will gain from the knowledge of these case studies and contribute to the communi�es by stepping forward and engaging with us on any interes�ng insights you may have for us to deliberate on.

health care services to the community at large. The hospital has been

Health Care Workers (HCW) have dual responsibility, not only to take care of patients in hospital, but also look after their respective families once they are off duty. It really pays heavy on their minds so as to not harm/infect their family who are the backbone of their support system.There is limited guidance available for HCW’s as to effectively take care of their moral and personal responsibilities. However, the risk of exposure should be gauged by individuals as per CDC recommendations. It is know a well established fact that the major route of transmission of COVID -19 is through aerosol generation. So, the most important factor for HCW is prevention of generation of such aerosols and avoidance of it from suspected patients.There are various methods through which HCW can at least try to decrease the guilt of taking infection home. The for-most is extreme hygiene. The HCW tend to carry least things from home to hospital, like pens, bottles, stethoscope, bags, laptop etc. so as to decrease the contaminated objects brought back home. It’s also prudent to change to hospital dress/scrubs, put on disposable cap, mask and shoe covers on reaching the hospital and take a shower before changing back and returning home .Repeated hand washing with soap and water/alcohol based solutions both at workplace and home should be a routine practice. Also, clean the phone, stethoscope etc with alcohol based solutions prior to returning home.Some HCW also tend to isolate themselves from their families at their home itself or have moved to hotels for the period of quarantine. If it’s a shared space, ensure good airflow in the room, windows

should be kept open and fans switched on for good air circulation. If the bathroom is shared then the HCW should clean and disinfect it after every use. (CDC recommendations)Routine cleaning of frequently touched surfaces at home is also recommended. Surfaces like door knobs, handles, switches, table tops, sinks, toilets etc should be initially cleaned with soap and water then with disinfectant (where applicable).Diluted home based bleaches can be used if appropriate for the surface. Alcohol based solutions with 70% concentrat ion can also be used. (CDC Recommendations) Electronic surfaces can be covered with wipeable material for easy cleaning e.g. Touch screen monitors, keyboards, remote controls etc. Laundry should be cleaned separately using the warmest appropriate water for the clothes. Do not shake dirty laundry.(CDC recommendations)The HCW should not let their guard down or decrease the level of precautions to be taken as the time passes, as it looks like virus is here to stay for some time, before an actual antidote or vaccine is commercially gets available in the market.

8 9

How to make homes safe for HCW's and their families

Methods for Isolation

Home(Separateroom with attached

bathroom)

Home(Separateroom with

shared bathroom

Disinfect after every use )

Designated Quarentine

centre

REQULAR HAND WASHING CHARGE TO HOSPITAL SCRUBS HOME ISOLATIO IN SEPRATE ROOM

MAINTAIN SOCIAL DISTANCING MUST FOLLOW AND KNOW COUGH/SNEEZING ETIQUETTE

Don't’s

DO’s

AVOID CLOSE CONTACT PANIC

SPREAD MISINFORMATION INFORMATION BOMBARDMENT CREATE PROBLEMS FOR HCWÊS

Dr. Vikas Sikri is a Consultant in the Department of Pulmonary Medicine,Dr. Seema Singhal is a Senior Consultant & Infec�on Control Officer in the Department of Microbiology

SPS Hospitals, Ludhiana. For Consulta�on & Appointment Contact : 8872027456

Dr. Vikas Sikri Dr. Seema Singhal

10 11

Antibody detection (seroconversion) and future protection??

Dr. Seema Singhal

SARS-CoV-2 Structure, Epidemiology and Clinical Features of the Disease

The severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) (also referred as 2019 novel coronavirus, 2019-nCoV) is the causative agent of a new outbreak emerged in Wuhan City, Hubei province of China, in December 2019, and rapidly spreading all over the world . Till mid June2020, 7,998,006 confirmed cases of novel coronavirus disease 2019 (COVID-19) are documented by the World Health Organization (WHO), with 435697 deaths globally.SARS-CoV-2 belongs to the beta-coronavirus genus of the Coronaviridae family, which includes SARS-CoV, MERS-CoV, bat SARS-related coronaviruses (SARSr-CoV).Coronaviruses are enveloped, single-stranded

positive-sense RNA (+ssRNA) viruses encoding the spike (S), envelope (E), membrane (M), and nucleocapsid (N) structural proteins, 16 non-structural proteins (nsp1–16), and 5–8 accessory proteins . The SARS-CoV spike (S) protein is composed of two subunits: the N-terminal S1 subunit contains a receptor-binding domain (RBD) that engages with the angiotensin-converting enzyme 2 (ACE2) receptor on human alveolar epithelial cells of the low respiratory tract. This interaction determines a conformational change in the C-terminal S2 subunit of the S protein that mediates fusion between the viral and host cell membranes. The S protein, particularly its S1 subunit, is highly immunogenic. The N protein,

abundantly expressed during the infection and h igh ly immu n o gen ic , i s invo lved in th e transcription and replication of the RNA and in the packaging of the encapsidated genome into virions. The M and E proteins are necessary for virus assembly.Phylogenetically, SARS-CoV-2 shares 79.6% sequence identity to SARS-CoV and 96% identity to a bat coronavirus, indicating that it may have a zoonotic origin.The majority of Coronaviruses infecting humans are mild, with the exception of SARS-CoV and MERS-CoV, which caused the outbreaks in 2002 and 2012, respectively. The current mortality rate of SARS-CoV-2 is lower than that of SARS-CoV and MERS. However, different from the viruses of the previous outbreaks, SARS-CoV-2 has a higher human-to-human transmission rate. The SARS-CoV-2 S protein binds ACE2 with higher affinity than SARS-CoV, probably leading to the higher transmission across the population.The confirmed transmission modes of SARS-CoV-2 include respiratory droplets and physical contact. The first occurs when the mouth and nose mucosa or conjunctiva are exposed to potentially infective respiratory droplets of someone with respiratory symptoms and in close contact (within 1 m). Transmission can occur through contact with contaminated surfaces as well. To date, there have been no reports of fecal–oral transmission of SARS-CoV-2, although a study highlighted that 8 children persistently tested positive on rectal swabs even after nasopharyngeal testing was negative. No evidences for intrauterine infection caused by vertical transmission come from the analysis of pregnant women with laboratory-confirmed COVID-19 pneumonia in the late pregnancy and their newborns. Currently, real time reverse transcriptase polymerase reaction (RT-PCR) is the primary diagnostic tool to detect cases of SARS-CoV-2 infection from nasopharyngeal, oropharyngeal swabs and bronchoalveolar lavage

(BAL) fluids. In addition, computed tomography imaging and some hematology parameters complement the diagnosis.Typical clinical symptoms of COVID-19 range from asymptomatic state to fever, cough, shortness of breath, fatigue and headache, loss of taste and smell, generalized myalgia, malaise, drowsy, diarrhea, and confusion. Some patients experience more serious illness requiring hospital care, including severe pneumonia symptoms and complications such as acute respiratory distress syndrome (ARDS), which leads to pulmonary edema and lung failure, acute kidney injury, or multiple organ dysfunction and, finally, death. Lymphopenia probably related to lymphocyte a p o pto s i s a n d i nte rst i t i a l m o n o n u c l e a r inflammatory infiltrates in lung tissues are common clinic-pathological characteristic in COVID-19 patients. Men seem to be at higher risk to develop more severe symptoms as well as subjects suffering from co-morbidities such as cardiovascular and cerebrovascular disease, diabetes and cancer.Development of Antibodies and Immunity Nearly all immune competent individuals will develop an immune response following SARS-CoV-2 infection. Like infections with other pathogens, SARS-CoV-2 infection elicits development of IgM and IgG antibodies, little is known about IgA response in the blood. The dynamics of the antibody response against SARS-CoV-2 are currently under investigation, as antibodies may be considered potent diagnostic tools to complement RT-PCR based diagnosis.SARS-CoV-triggered humoral S- and N-specific IgM response reached a peak within 4 weeks and was no more detectable 3 months post symptoms onset; the switch to IgG often occurred around day 14, and IgGs were detectable up to 36 months.In addition, development of neutralizing antibodies can also be assessed. Neutralizing antibodies inhibit viral replication in vitro, and as with many infectious diseases, their presence correlates with

immunity to future infection, at least temporarily.Recurrence of COVID-19 illness appears to be very uncommon, suggesting that the presence of antibodies could confer at least short-term immunity to infection with SA RS-CoV-2. Additionally, antibody development in humans correlates with a marked decrease in viral load in the respiratory tract. Taken together, these observations suggest that the presence of antibodies may decrease a person’s infectiousness and offer some level of protection from reinfection. However, definitive data are lacking, and it remains uncertain whether individuals with antibodies (neutralizing or total) are protected against reinfection with SARS-CoV-2, and if so, what concentration of antibodies is needed to confer protection.Detection of AntibodiesAntibodies most commonly become detectable 1-3 weeks after symptom onset, at which time evidence suggests that infectiousness likely is greatly decreased and that some degree of immunity from future infection has developed. However, additional data are needed before modifying public health recommendations based on serologic test results, including decisions on discontinuing physical distancing and using personal protective equipment.Serologic assays for SARS-CoV-2, now broadly available, can play an important role in understanding the virus’s epidemiology in the general population and identifying groups at higher risk for infection. Unlike viral direct detection methods such as nucleic acid amplification or antigen detection tests that can detect acutely infected persons, antibody tests help determine whether the individual being tested was ever infected—even if that person never showed symptoms. Serologic tests detect waning or past SARS-CoV-2 virus infection indirectly, by measuring the host humoral immune response to the virus. Therefore,

serology assays do not typically replace direct detection methods as the primary tool for diagnosing an active SARS-CoV-2 infection, but they do have several important applications in monitoring and responding to the COVID-19 pandemic.Current Status of Antibody Testing Antigenic targetsThe two major antigenic targets of SARS-CoV-2 virus against which antibodies are detected are spike glycoprotein (S) and nucleocapsid phosphoprotein (N). While S protein is essential for virus entry and is present on the viral surface, N protein is the most abundantly expressed immunodominant protein that interacts with RNA. Multiple forms of S protein — full-length (S1+S2) or partial (S1 domain or receptor binding domain [RBD]) — are used as antigens. The protein target determines cross-reactivity and specificity because N is more conserved across coronaviruses than S, and within S, RBD is more conserved than S1 or full-length S.Types of Antibody TestingDifferent types of assays can be used to determine different aspects of immune response and functionality of antibodies. The tests can be broadly classified to detect either binding or neutralizing antibodies.• Binding antibody detection: These tests use

purified proteins of SARS-CoV-2, not live virus, and can be performed in lower biosafety level laboratories (e.g., BSL-2). With specific reagents, individual antibody types, like IgG, IgM, and IgA, can be determined. In general, IgM is one of the first types of antibodies produced after infection and is most useful for determining recent infection, while IgG generally develops after IgM and may remain detectable for months or years. IgA is important for mucosal immunity and can be detected in mucous secretions like saliva in addition to blood, though its significance in

this disease is still to be determined. Depending on the complexity of assays, these tests can be performed rapidly (less than 30 minutes) in a field setting or in a few hours in a laboratory.

Tests that detect binding antibodies fall into two broad categories.

Point-of-care (POC) tests generally are lateral flow devices that detect IgG or IgG and IgM, or total antibody in serum, plasma, whole blood, and/or saliva. An advantage of some point-of-care tests using whole blood is that they can be performed on blood samples obtained by fingerstick rather than venipuncture.

Laboratory tests use ELISA (Enzyme-Linked Immunosorbent Assay) or CIA

(chemiluminescent immunoassay) methods for antibody detection, which for some assays may require trained laboratorians and specialized instruments. Based on the reagents, IgG, IgM, and IgA can be detected separately or combined as total antibody.

ICMR has developed a sensitive (92.37%) and specific (97.9%) assay based on whole virus antigen that could be produced at lower manufacturing cost and provide easy to use and affordable kit to resource-limited settings. Negative predictive value of this assay is 98.14% a n d p o s i t i v e p re d i c t i v e va l u e 9 4 . 4 4 % . Use of whole cell antigen instead of recombinant nucleocapsid antigen or spike protein antigen, provided a broad sensitivity to the assay. In brief, SARS CoV-2 was isolated from throat/nasal swab specimen in Vero CCL-81 cells. Stock was prepared by propagating the virus in Vero C C l-81 cel ls , then t itrated, gamma inactivated, twice confirmed by inoculating Vero CCl-81 cells then concentrated and used as antigen for coating ELISA plates. Sensitivity and specificity was determined using virus neutralization test as gold standard. The ELISA results correlate strongly with virus neutralizing antibodies and this assay may be used to ascertaining the seroprevalence

against SARS-CoV-2 in a population and for epidemiological studies.ICMR transferred this CovidKavach ELISA IgG technology to 7 pharma companies. Name and contact detai ls of the manufacturers of CovidKavach IgG ELISA are listed on ICMR site.• Neutralizing antibody detection: FDA has not

yet authorized the use of neutralization tests for SARS-CoV-2. Neutralization tests determine the functional ability of antibodies to prevent infection of virus in vitro. The test involves incubating serum or plasma with live virus followed by infection and incubation of cells. Testing will require either BSL-3 or BSL-2 laboratories, depending on what form of the SARS-CoV-2 virus is used.

Two types of neutralization tests are conducted. Virus neutralization tests (VNT), such as the

plaque-reduction neutralization test (PRNT) and micro neutralization, use a SARS-CoV-2 virus from a clinical isolate or recombinant SARS-CoV-2 expressing reporter proteins. This testing requires BSL-3 laboratories and may take up to 5 days to complete.

Pseudo virus neutralization tests (pVNT) use recombinant pseudoviruses (like vesicular stomatitis virus, VSV) that incorporate the S protein of SARS-CoV-2. This testing can be performed in BSL-2 laboratories depending on the VSV strain used

Limitations of Serologic TestsAt present, the immunologic correlates of immunity from SARS-CoV-2 infection are not well defined. Few question cannot be answered are• The level of antibodies required for protection

from reinfection• The duration of that protection• The protective titre of neutralizing antibody• The correlation of binding antibody titres to

neutralization ability Hence, the presence of antibodies cannot be equated with an individual’s immunity from SARS-CoV-2

12 13

infection.• Some tests may exhibit cross-reactivity with

other coronaviruses, resulting in false-positive test results.

• Some persons may not develop detectable antibodies after coronavirus infection.

Choice of test and testing strategy• Serologic assays that have validation from

ICMR or US-FDA and DCGI approved for marketing in India.

• Serologic test results should be interpreted in the context of the expected positive and negative predictive values.

• Currently, there is no substantive performance advantage of assays whether they test for IgG, IgM and IgG, or total antibody. Thus, immunoglobulin class should not determine the assay chosen in most circumstances. The detection of IgM antibodies may indicate a more recent infection, but the dynamics of the IgM antibody response are not well defined at present. Over time, it may be important to characterize and evaluate the performance of assays in samples that are IgM negative and IgG positive to ensure that assays remain fit for purpose in population studies as the pandemic progresses and more individuals are expected to have lower IgM levels.

Recommendations for persons who test positive for anti-SARS-CoV-2 antibodies• Although the presence of anti-SARS-CoV-2

antibodies when detected using a testing algorithm with high positive predictive value likely indicates at least some degree of immunity, i t cannot be assumed that individuals are protected from future infection.

• Asymptomatic persons who test positive by serologic testing and who are without recent history of a COVID-19 compatible illness have a low likelihood of active infection and should follow Precautions to prevent infection with SARS-CoV-2 and otherwise continue with normal activities, including work.

• Persons who have had a COVID-19-compatible o r c o n f i r m e d i l l n e s s s h o u l d f o l l o w quarantine/isolat ion recommendation regarding resumption of normal activities, including work.

• There should be no change in clinical practice or use of personal protective equipment (PPE) by health care workers and first responders who test positive for SARS-CoV-2 antibody.

Reference:1. SiracusanoG,Pastori C and Lopalco L(2020)

Humoral immune response in COVID-19 patients: A window on the state of the art. Front.Immunol.11:1049.doi:10.3389/fimmu.2020.01049

2. https://www.cdc.gov>lab>resources Interim g u i d e l i n e s f o r C O V I D - 1 9 A n t i b o d y testing/CDC23-may-2020

3. Advisory on List of IgG ELISA kits for COVID-19 validated BY ICMR identified validation centres. Dated 03.06.2020

4. Gajanan Sapkal et a l .Development of indigenous IgG ELISA for the detection of anti-SARS-CoV-2 IgG. IJMR, Epub ahead of print DOI:10.4103/ijmr_2232_20

Pregnancy in COVID-19 Times

Novel coronavirus (SARS-CoV-2) is a new strain of coronavirus causing COVID-19, first identified in Wuhan City, China towards the end of 2019. Other human coronavirus (HCoV) infections include HCoV 229E, NL63, OC43 and HKU1, which usually cause mild to moderate upper-respiratory tract illnesses, like the common cold, Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). Most global cases of COVID-19 have evidence of human-to-human transmission. This virus can be readily isolated from respiratory secretions, faeces and fomites (objects). Transmission of the virus is known to occur through close contact with an infected person (within 2 metres) or from contaminated surfaces. Due to the duration and rapidly evolving nature of the COVID-19 pandemic, there is a current lack of high-quality evidence. Using a conventional grading system for guideline development, many of the studies would be classed as level 3 or 4 (non-analytical studies, e.g. case series/reports and expert opinion), with a few recent studies being classed as level 2 (systematic reviews of cohort studies). The advice based on this evidence would therefore be graded D, and in some cases, graded as good practice points. Good practice points are defined based on expert consensus opinions of senior clinicians across a variety of disciplines reviewing the available data from case series, ongoing studies and clinical practice.Pregnant women do not appear more likely to contract the infection than the general population. Pregnancy itself alters the body’s immune system and response to viral infections in general, which

can occasionally cause more severe symptoms. This may be the same for COVID-19 but there is currently no evidence that pregnant women are more likely to be severely unwell needing admission to intensive care or die from the illness than non-pregnant adults.

Data from the UK Obstetric Surveillance System (UKOSS) in 427 pregnant women admitted to hospital with coronavirus shows• Most women required only ward treatment

and were discharged home well• Around one in ten women required intensive

care• Five women with coronavirus died, although it

is currently unclear if coronavirus was the cause of their death.

• Majority of women who did become severely ill were in their third trimester of pregnancy, emphasising the importance of social distancing from 28 weeks of pregnancy.

FAQs ADDRESSING DOCTORS, MEDICAL AND PARAMEDICAL STAFF

Effect of COVID-19 on pregnant women

• Pregnant women are not necessarily more susceptible to viral illness

• Physiological pregnancy related changes to their immune system in pregnancy can be associated with more severe symptoms, particularly true in the third trimester.

• Most pregnant women will experience only mild or moderate cold/flu-like symptoms

14 15

Dr. Zeenie Sarda Girn

Dr. Seema Singhal is a Senior Consultant & Infec�on Control Officer in the Department of Microbiology SPS Hospitals, Ludhiana. For Consulta�on & Appointment Contact : 8872027456

• Cough, fever, shortness of breath, headache, anosmia and loss of taste are other relevant symptoms

• The symptoms of severe infection are no different in pregnant women and early identification and assessment for prompt supportive treatment is key risk factors that appear to be associated with hospital admission with COVID-19 illness include:

Overweight or obesity Pre-existing co morbidity for example

diabetes, hypertension, heart disease (congenital or acquired), respiratory illnesses, immune compromise

Maternal age >35 years Vitamin D deficiencyEffect of COVID-19 on the fetus• There are currently no data suggesting

an increased risk of miscarriage in relation to COVID-19

• Reports from early pregnancy studies with SARS-CoV and MERS-CoV have not demonstrated a significant relationship between infection and increased risk of miscarriage or second trimester loss

• With regard to vertical transmission (transmission from woman to her baby antenatally orintrapartum), emerging evidence now suggests that vertical transmission is possible. There are, however, serious limitations to the available evidence.

Two reports have published evidence of IgM for SARS-CoV-2 in neonatal serum at birth. Assuming that IgM does not cross the placenta, this would suggest a neonatal immune response to in utero infection. It is uncertain in these cases whether the IgM levels resulted from cross reactivity as there was no evidence of SARS-CoV-2 in the infant’s nasopharyngeal swabs or in the mother’s vaginal secretions or breast milk on PCR testing. Moreover, the proportion of

pregnancies affected and the significance to a neonate has yet to be determined.

In a systematic review of 24 pregnant women with COVID-19, there was no evidence of SARS-CoV-2 on PCR testing of placenta, amniotic fluid, and cord blood or breast milk. Further research is required and is ongoing on this subject.

• In all reported cases of new-born babies developing coronavirus very soon after birth, the babies were well

• PREMATURITY: Across the world, emerging reports suggest some babies have been born prematurely to women who were very unwell with coronavirus. It is unclear whether coronavirus caused these premature births, or whether it was recommended that their babies were born early for the benefit of the women’s health and to enable them to recover.

What should pregnant women be advised to reduce the risk of catching coronavirus• Wash hands regularly• Use a tissue when you or anyone in your

family coughs or sneezes, discard it and wash your hands

• Avoid contact with someone who is displaying symptoms of coronavirus (these symptoms include high temperature and/or new and continuous cough)

• Avoid non-essential use of public transport when possible

• Work from home, when possible• Avoid large and small gatherings in public

spaces, noting that malls, restaurants, leisure centres and similar venues are currently shut as infections spread easily in closed spaces where people gather together

• Avoid gatherings with friends and family; keep in touch using remote technology such as phone, internet and social media

• Use telephone or online services to contact

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Dr. Zeenie Sarda Girn is a Senior Consultant in the department of Obstetrics and Gynaecology SPS Hospitals, Ludhiana. For Consulta�on & Appointment Contact : 8872027456

your doctor or other essential servicesEspecially in the third trimester (more than 28 weeks’ pregnant) women should be particularly attentive to social distancing and minimise any contact with others.Guidance for individuals and households with

possible coronavirus infection• Keep mobile and hydrated to reduce the risk of

blood clots in pregnancy• Exercise regularly• Additional shielding measures • Stay at home and not allow visitors• Open windows to ventilate rooms• Separate themselves from other members of

their household as far as possible, using their own towels, crockery and utensils and eating at different times

Guidance for pregnant ladies who develop a fever or temperature, or both

• Isolation is a must• Be alert to the other possible causes of fever in

pregnancy. In particular, these include urine infections, malaria, dengue, and ruptured membranes.

• Women have any burning or discomfort when passing urine, or any unusual vaginal discharge, or having any concerns about baby’s movements, should contact the doctor or the hospital over the phone. These women should be seen in isolation or triage areas with FULL PPE.

 

Dr. Pradeep K. Sharma

Children are not small adults and newborns are not small children. Their requirements for survival differ from the adults and children. Some simple and easy to do interventions can make a huge difference in the survival of the newborn babies. Before the baby gets born the health of the mother makes a significant impact on the growth of the fetus. If the mother is undernourished or obese it has a negative impact on the pregnancy outcome. So the pregnant ladies should get good food, a healthy atmosphere and optimal medical care including regular blood pressure check up, hemoglobin level check and various supplements like iron, calcium and vitamin D. They should also get themselves vaccinated against diseases like tetanus and whooping cough so that the newborns are protected during the early phase of infancy. Vaccines like that for swine flu are important for their own health as this disease has a worse outcome in pregnant ladies. The couple should visit the doctor before conception as folic acid tablet if started three months before conception can decrease the risk of neural tube defects. These are defects in the backbone and later on may require surgery to repair the defect. So prevention is better than cure.Just like we make preparation for marriage in advance similarly preparation for delivery should start in advance much before the baby is born. Arrangements should be made for the finances and transport in case a complicated or pre mature delivery happens. So that the family is well prepared to handle the emergency. It should also be pre-decided where to take the pregnant lady in case of emergency, this is called as birth preparednessAlthough the delivery is a natural process, it should be conducted in a center well equipped to handle

the complications. There should be facilities to take care of the newborn and a proper referral system should be in place in case required. At birth it is preferred to delay the clamping of the umbilical cord so that the newborn gets more blood from the placenta and later on has better iron stores and lesser risk of anemia. All stable term newborns should be started on breast feeding as soon as possible. Vitamin K injection should be given at birth.If preterm delivery is anticipated, the pregnant lady should be shifted to a hospital where neonatal ICU facility is available. Breast feeding is the single most important intervention that decreases neonatal mortality. Infants should be on exclusive breast feeding till six months of age. After that breast feeding should be continued and semisolids should be added to the diet. Infants should receive vitamin D3 and iron supplements at least till two years of age. Infections are an important cause of childhood deaths. So all the children should receive appropriate immunization to reduce the incidence of vaccine preventable diseases. Hands should be washed with soap and water and food should be prepared in good hygienic conditions.Children not only need food, medical supplements and vaccines but also tender loving care, a healthy environment where they can play and learn as the early stimulation has long term imprinting on their future development.

Saving Newborn Lives

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Dr. Pradeep Kumar Sharma is a Senior Consultant in the department of Peadiatric & Neonatology SPS Hospitals, Ludhiana. For Consulta�on & Appointment Contact : 8872027456

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Case Report: Two complex Balloon Angioplasty Procedures in Children in COVID Times

Presenting two cases of balloon angioplasties done back to back in Covid era. The first child was a 2yr old with critical Pulmonary Valve stenosis which was so severe that it resulted in momentary asystole during balloon inflation due to near complete cessation of cardiac output but recovered well post deflation of balloon. Second case was of a 6 months old infant with a Bicuspid Aortic Valve with severe Aortic stenosis. Bicuspid Aortic Valve is the most common congenital heart anomaly present in about 2% of the general population and the valve frequently become increasingly stenosed or regurgitant as the child

grows up. Balloon angioplasty is the only option available to rescue these babies. Post intervention both the respective valves opened up well and they were discharged the very next day. The post procedure echocardiography revealed significant decrease in the gradients across the individual valves.Balloon angioplasty in small children is a complex procedure and may occasionally result in even

fatal outcomes specially when associated with co-morbid conditions like congestive heart failure, acute renal failure, broncho-pneumonia and sepsis. Cardiac interventions done in this scenario may result in procedural complications and prolonged hospital stay. For this reason, these procedures are generally performed in limited centers in the country equipped with a highly specialized and experienced team well versed with dealing with children suffering from congenital heart problems and with adequate surgical back up on stand by.

Both these children had a murmur picked up early by their respective Pediatricians and had only minimal signs of early heart failure which resulted in a rapid recovery and discharge in both these patients. Symptoms in valvular lesions develop only when left or right ventricular failure has set in and these are as follows- frequent respiratory tract infections, breathing difficulty, early tiring during feeding, excessive crying and sweating and failure

Dr. Navdeep Singh

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Dr. Navdeep Singh is a Senior Consultant in the Department of Pediatric and Fetal Cardiology SPS Hospitals, Ludhiana. For Consulta�on & Appointment Contact : 8872027456

to gain weight. So an early referral after detection of a murmur, even in the absence of symptoms, and echocardiography done by an experienced Pediatric Cardiologist is imperative. A timely

cardiac intervention done in relatively well preserved child has decisively favorable prognosis and outcomes.

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Coronary bifurcations remain one of the most fascinating and challenging lesion subsets in interventional cardiology. These procedures are renowned for being technically challenging and historically have been associated with lower procedural success rates and worse clinical outcomes compared with non-bifurcation lesions.A bifurcation lesion is a lesion occurring at, or adjacent to, a significant division of a major epicardial coronary artery. Pathological studies and intravascular ultrasound evaluation demonstrate that atherosclerosis occurs predominantly in low shear-stress regions at lateral walls of bifurcation opposite to the carina, but carina involvement in atherosclerosis is extremely unusual. As a result, main branch stenting creates worsening of side branch ostial lesions due to a combination of MB plaque and carina shift. Therefore, no two bifurcations are identical, and no single strategy exists that can be applied to every bifurcation. With this background we are going to discuss a challenging case of bifurcation stenting done at our institute few days ago.A 39 years old male presented to our emergency department with complaints of severe chest painassociated with breathlessness for the last 3 hours. On examination patient was found to be in respiratory distress acute pulmonary oedema. ECG was done which revealed Acute Posterior wall MI. As per Thomas Killip’s bedside risk stratification in acute MI, this patient was in Killip Class III with estimated mortality of 38%.He was started on diuretics and put on non-invasive ventilation support for respiratory distress. After explaining the high risk to life and benefits of re-perfusion to the attendants, he was loaded with anti-platelets and taken up for urgent coronary angiography and primary angioplasty. CAG revealed proximal Left circumflex artery (LCX) 100% thrombotic occlusion

along with moderate disease (60-70%) in LAD as well as RCA. (Figure.1)

Right femoral artery access was taken and left coronary tree was engaged with catheter. LCX artery was wired following which lesion was dilated with a balloon residual 80% stenosis in LCX artery. (Figure.2)

A 3.0X36mm drug eluting stent (DES) was introduced and deployed in the LCX artery. (Figure.3)

(Figure.1)

(Figure.2)

Dr. Gurkirat Singh

Primary Angioplasty with Bifurcation Stenting in Acute MI with Pulmonary Oedema

Dr. Ravninder Singh Kuka

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Removal of impacted foreign body by flexible bronchoscopy using dormia basket in children

Dr. Mehak Bansal

Introduction - Foreign body aspiration in children is a potentially life-threatening emergency. Patient may be asymptomatic or present with choking or cough attacks with inspiratory stridor. Sometimes the foreign body aspiration may go unnoticed and the child presents with chronic nonspecific symptoms like cough and recurrent wheeze. A delay in the diagnosis of an aspirated foreign body can increase morbidity and mortality, ranging from life-threatening airway obstruction to recurrent infection and wheezing [1] Therefore, strong suspicion and prompt diagnosis and treatment is imperative if the clinical history or signs and symptoms suggest foreign body aspiration. Rigid bronchoscopy has been the gold standard for extraction of airway foreign bodies in children [2-4].Recently, extraction of tracheobronchial foreign body by flexible bronchoscopy is gaining popularity as it is less traumatic as compared to rigid bronchoscopy and can be done under moderate or deep sedation. Also, the length of hospitalization post flexible bronchoscopy is less as opposed to rigid procedure. This case report demonstrates that, with skilled personnel and perfect equipment, flexible bronchoscopy is a safe and feasible procedure for retrieving foreign bodies from the trachea and proximal bronchus. Case Report 6-year-old male child weighing 26 kg was admitted with history of aspiration of temporary tooth after shedding, followed by cough. Chest X-Ray (Figure 1A) confirmed tooth in right bronchus

intermedius. Rigid bronchoscopy was tried outside in a hospital but failed. Patient was referred to our centre to remove the foreign body with flexible scope. On admission, child had cough, but had no respiratory distress and was maintaining saturation in room air. The foreign body had been impacted in the trachea for 5 days. Removal of foreign body with flexible bronchoscopy was tried under moderate sedation with midazolam and ketamine, but child didn't tolerate sedation due to severe laryngospasm, owing to long standing impacted foreign body and airway edema. Our routine practice is to remove foreign body with flexible bronchoscope under moderate sedation, but this patient required rapid sequence intubation using sedation and muscle relaxation. Tooth was located in the right lower lobe segmental bronchus and it was successfully removed with the flexible bronchoscope using dormia basket. It was a very tedious procedure and required few attempts before we could successfully remove the tooth, as it was deeply impacted in the mucosa. Check bronchoscopy showed no foreign body in the airways. Post procedure, child was successfully extubated within half an hour on to room air. He was administered corticosteroids for one day to alleviate the airway edema. Chest X-ray done 4 hours later showed no foreign body and no air leak (Figure 1B). Patient was monitored for 24 hours in pediatric intensive care unit and was discharged the following day.

Dr. Vikas Bansal

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When flow was checked after stent deployment, spasm of distal vasculature was noted. Therefore intra-coronary NTG was injected. But we were in for a surprise as a large dominant LCX artery appeared jailed across the stent. (Figure.4)

The origin of distal LCX was critically diseased with 99% stenosis; therefore another wire was introduced into the jailed LCX artery through the struts of existing stent. After wiring the distal LCX, a small balloon was taken to open up the struts of the stent at the site of bifurcation. The process was repeated with a larger balloon so that adequate opening is created to allow a stent to enter the jailed artery through the 1st stent. Now the 2nd stent, was introduced through the 1st stent into the jailed LCX artery. Over the other wire a balloon was introduced into other branch through the 1st stent. Now the 2nd stent was

deployed in the distal LCX. After this both the stent and the balloon were simultaneously inflated to create a neo-carina at the bifurcation site. (Figure.5)

This was followed by proximal optimization with a larger balloon in proximal LCX. Finally both the wires were withdrawn with normal flow in both LCX and OM1 arteries. (Figure.6)

Patient stabilized haemodynamically within next few hours and was discharged after 2 days. ConclusionBifurcation stenting with 2 stents strategy is one of the most challenging and skilled procedures of interventional cardiology. However this case is even more remarkable as it was performed during primary angioplasty in a critical patient with unstable hemodynamic where time is of essence.

(Figure.5)

Dr. Ravninder Singh Kuka is a Senior Consultant in the Department of Interven�onal Cardiology

SPS Hospitals, Ludhiana. For Consulta�on & Appointment Contact : 8872027456

(Figure.4)

(Figure.3)

(Figure.6)

Dr. Gurkirat Singh is a Consultant in the Department of Interven�onal Cardiology

Figure 1A- Chest X-Ray showing foreign body (tooth) in the right lower bronchus. 1B Post procedure chest x-ray showing fully expanded lung, no foreign body and no air leak.

Figure 2A- Bronchoscopy view of foreign body (tooth) impacted in the right lower segmental bronchus. 2B – Bronchoscopy view of the tooth caught in the dormia basket before pulling it out of the airways. Discussion- Recent studies demonstrate that flexible bronchoscopy is helpful, with high success rates, in airway foreign body retrieval in children (5, 6, 7, 8, and 9). Foreign body aspiration is more frequently seen in children less than three years of age. Commonly nuts and organic foreign bodies are located at the carina or in right main stem bronchus in this age group. In this case, the age of the child was 6 years and the size of the deciduous tooth was small, so it went deep into the right lower lobe sub segmental bronchus, where it is difficult to reach with the

rigid bronchoscope. Flexible bronchoscopes of small diameter can easily reach right lower lobe sub segmental bronchus and retrieve the foreign bodies located there. Our case report is the first to demonstrate that flexible bronchoscopy could successfully remove foreign body after failed rigid bronchoscopy procedure. We believe that the case presented demonstrates that flexible bronchoscopy is a novel and safe approach for performing difficult foreign body retrievals in pediatric patients. We also wish to highlight that although rigid bronchoscopy is considered as gold standard for foreign body removal, and many a times failed flexible bronchoscopy foreign bodies are ultimately removed with rigid scope, but with advent of better instruments we were able to remove this tooth with flexible bronchoscope after a failed rigid bronchoscopy. Bibliography 1. Swanson KL, Prakash UB, Midthun DE, Edell

ES, Utz JP, McDougall JC, et al. Flexible bronchoscopic management of airway foreign bodies in chi ldren. Chest. 2002;121:1695–700.

2. Faro A, Wood RE, Schechter MS, Leong AB, Wittkugel E, Abode K, et al. Official American Thoracic Society Technical Standards: Flexible Airway Endoscopy in Children. American J Respiratory Crit Care Med.

2015;191:1066-80.3. Ernst E, Antón-Pacheco JL, Blic JD, Doull I,

Faro A, Nenna R, et al. E R S s t a t e m e n t : I n t e r v e n t i o n a l

bronchoscopy in children. Eur Respir J. 2017;50:1700901.

4. Schramm D,　Ling K,　Schuster A,　Nicolai T. Foreign body removal in children: Recommendations versus real life – a survey of current clinical management in Germany. PediatrPulmonol. 2017;52:656-61.

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Dr. Vikas Bansal is a Senior Consultant -in the Department of Peadiatrics, Peadiatric Pulmonology and Peadiatric Intensive Care

Dr. Mehak Bansal is a Consultant in the Department of Peadiatric

SPS Hospitals, Ludhiana. For Consulta�on & Appointment Contact : 8872027456

5. Kim K, Lee HJ, Yang EA, Kim HS, Chun YH, Yoon J-S, et al. Foreign body removal by flexible bronchoscopy using retrieval basket in children. Ann Thorac Med. 2018;13: 82-5.

6. Hata A, Nakajima T, Ohashi K, Inage T, Tanaka K, Sakairi Y, et al. Mini grasping basket forceps for endobronchial foreign body removal in

pediatric patients, Pediatr Int. 2017;59:1200-04.7. Tenenbaum T, Kähler G, Janke C, Demirakca S.

Management of foreign body removal in children by flexible bronchoscopy.

J BronchologyIntervPulmonol. 2017;24:21-8. 

Figure 1-A Figure 1-B

Figure 2-A Figure 2-B

Dr. Aikaj Jindal

COVID-19 Angels and experimental plasma therapy

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Dr. Aikaj Jindal is a Senior Consultant in the Department of Transfusion Medicine SPS Hospitals, Ludhiana. For Consulta�on & Appointment Contact : 8872027456

The Pandemic COVID-19 has redefined our perspective of life. This yet-incurable disease has not only changed our way of life completely but also has led to stigma being associated with COVID positive patients. COVID-19 Angels are those recovered patients from coronavirus infection who have beaten this disease and have developed antibodies against this virus and are willing to donate their plasma. In these tough times where the entire humanity is searching for a cure for this yet-incurable disease, the plasma from these recovered patients has shown us a ray of hope. Although experimental at this stage, this therapy has shown promise in some individual cases. Indian Council of Medical Research (ICMR) has started a clinical trial for the use of this plasma from recovered patients in moderately affected COVID patients in hope to assess and find authentic evidence of its success.Q1. What is Convalescent Plasma (CP) therapy for COVID-19? It is the administration of plasma which is rich in antibodies against the coronavirus in a patient who has COVID-19 disease. We can understand these antibodies as 'soldiers' that can kill the virus. These 'soldiers' are formed naturally in human body in response to virus. In this therapy we take these 'soldiers' out of the body of a recovered patient and put them in a current patient who still requires time to produce his/her own 'soldiers' in the required amount. It is also called as passive immunity.Q2. Is it a new/novel therapy?No; passive antibody therapy has a long history going back to the 1890s and was the only means of

treating certain infectious diseases prior to the development of antimicrobial therapy in the 1940s. Over the last two decades, Convalescent Plasma therapy was used in the treatment of SARS, MERS, and Ebola pandemic. Q3. Is Convalescent Plasma therapy a vaccine?No, this therapy is different from vaccines. Vaccines lead to the development of patient's own 'soldiers' (antibodies) in patient's body whereas in this plasma therapy we take the already made soldiers from another recovered patient and put them in current patient to fight the virus. Research is going on to use this experimental therapy till a vaccine can be developed for this disease.Q4. How this convalescent plasma does acts

against COVID 19?Convalescent plasma has been found to contain virus-neutralizing antibodies which have the capability to block the viral infection.Q5. What is the source of this convalescent

plasma?Source of this convalescent plasma is COVID ANGELS – the recovered patients of COVID who have beaten the disease and their plasma can now be used to save other COVID patients. As per ICMR guidelines, any medically fit COVID angel can donate this plasma after• Complete resolution of symptoms at least 28

days prior to donation.• Complete resolution of symptoms at least 14

days prior to donation with two negative real time PCR test for COVID-19 from nasopharyngeal swab, collected 24 hours apart.

Q6. What is the procedure of plasma collection?

It is as simple as a blood donation. After the mandatory medical fitness, the COVID angel is attached to an aphaeresis machine which will take out the plasma from his/her body. Total 400-500 ml plasma has to be collected from a COVID recovered individual in a single sitting. The individual can donate again after two weeks of first plasma donation.Q7. What are the tests to be done before

collecting plasma from a donor?All the tests which are routinely done for normal aphaeresis donor in a blood bank plus two new tests called titration of anti-COVID-19 (both IgG and IgM) antibodies and SARS-CoV-2 neutralizing antibodies. Desired titres for IgG antibodies are 1:1024 and for neutralizing antibodies are 1:40 as per the available data.Q8. Is it safe to donate plasma after a short

interval of recovery from COVID 19?Yes, absolutely; all the parameters will be checked before plasmapheresis by the medical personnel in blood center and then the final decision will be taken. The procedure is done through a sterile kit which is completely safe and used only for one donor.Q9. When and how the collected plasma will be

transfused to patient?Since it is an experimental clinical trial therapy,

after proper permission from the competent authorities, it is advisable to start the therapy at earliest in patients within 14 days after the diagnosis of COV I D 19. The first plasma transfusion of 200 ml will be followed by one additional dose of 200 ml at 24 hours interval under medical supervision.Q10. Is there any chance of adverse reaction in

patient after transfusion of convalescent plasma?

The known side effects have been similar like those associated with normal plasma transfusion which is minor and medically treatable.Q11. Is convalescent plasma the miracle cure for

COVID-19?No. Currently this is one of the experimental treatment which is under research. In this pandemic, each and every option of a potential cure is being evaluated and plasma therapy is also one of them. This therapy also has many questions associated with it the answers to which shall require more research.

Dr. Parambir Singh

Blonanserin Overdose: A Case Report

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Blonanserin is an “atypical antipsychotic” which is indicated for the treatment of schizophrenia. It is

[1] approved for use in Japan and South Korea. In India, it was approved as a second line drug for the

[2]use in adults who have schizophrenia in 2012. In a meta-analysis, blonanserin was found to have a lower risk (0.31) of hyperprolactinemia than haloperidol and risperidone. Blonanserin had a lower risk of akathisia (Risk ratio (RR) 0.54) as compared to haloperidol, whereas it had a higher

[3]risk (RR 1.62) as compared to risperidone.Blonanserin-induced dyskinesia and akathisia are reported, but on detailed search, we could not find

[4, 5] any case report of an overdose of blonanserin. We describe a case report of blonanserin overdose.Case ReportA 23-year-old female patient with a diagnosis of schizophrenia since 2014 was on treatment from our department since May 2018. She was started on blonanserin and clonazepam. She showed significant improvement with treatment and was doing well on 8 mg of blonanserin and0.25 of clonazepam. She had no suspiciousness, auditory hallucinations, self muttering, or self smiling. She had no sialorrhea, slurring of speech, tremors of body, or akathisia. She had no family history of psychiatric illness.In August 2018, she presented to the emergency room with an alleged history of ingestion of 12 tablets of blonanserin 8 mg. She was conscious, oriented, talking relevantly. As per patient, her parents stopped her medicines, and she was taken to various faith healers. The patient admitted auditory hallucinations and suicidal thoughts, and

she reported that someone was controlling her thoughts. Systemic examination was normal, her pulse rate was 116/min, blood pressure 130/90 mm of Hg, and respiratory rate 18/min, and she was afebrile. Electrocardiogram was normal. She was admitted for observation, and baseline creatine phosphokinase was done which came out to be 28 U/L (reference range 26–140 U/L). The patient was managed conservatively and was discharged on the 3rd day in a stable condition. She had no sialorrhea, slurring of speech, tremors of body, or akathisia at the time of discharge. On the 4th day, she presented in the outpatient department (OPD) with a history of restlessness andInability to sit or lie down due to restlessness since last evening. She was weeping due to restlessness and was pacing in the room. Based on the history and clinical examination, a diagnosis of akathisia was made, and she was started on trihexyphenidyl 4 mg/day and amantadine 100 mg/day. Akathisia resolved in 2 days. Seven days later, she presented to OPD with weeping, sadness of mood, not feel like doing work or studying, and she had no psychotic symptoms. She was started on paroxetine 12.5 mg/day and blonanserin 4 mg/day, and trihexyphenidyl was stopped. Amantadine was stopped in the next visit. At present, she is doing well at blonanserin 4 mg and paroxetine 12.5 mg/day. No further episodes of akathisia were reported.DiscussionThe amount of blonanserin ingested was four times the recommended maximum dose of 24 mg. Blonanserin-induced akathisia at overdose is

Dr. Sandeep K Goyal

29

Dr. Sandeep K Goyal is a Senior Consultant in the Department of Psychiatry & Behavioral Sciences,Dr. Parambir Singh is a Senior Consultant in the Department of Internal Medicine

SPS Hospitals, Ludhiana For Consulta�on & Appointment Contact : 8872027456

understandable as blonanserin is associated with akathisia at therapeutic doses also, and the risk of akathisia is higher as compared to risperidone.[3,5] Blonanserin overdose was not associated with hemodynamic changes, neurolept malignant syndrome, dystonia, sedation, sialorrhea, slurring of speech, or tremors of the body. To the best of our knowledge, this is the largest single dose ingestion of blonanserin reported in the literature.

Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest.References

1. Wang SM, Han C, Lee SJ, Patkar AA, Masand PS, Pae CU, et al. Asenapine, blonanserin, iloperidone, lurasidone, and sertindole:

Distinctive clinical characteristics of 5 novel atypical antipsychotics. Clin Neuropharmacol 2013;36:223-38.2. Available from http://www.medlineindia.com/list%20of%20

approved%20drugs%20in%202012%20India.html [Last accessed on 2019 Sep 03].

3. Tenjin T, Miyamoto S, Ninomiya Y, Kitajima R, Ogino S, Miyake N, et al. Profile of blonanserin fo r t h e t reat ment o f s ch i zo p h ren ia . Neuropsychiatr Dis Treat 2013;9:587-94.

4. Chaudhari D, Shanker G, Gupta K. Two cases of blonanserin induced dyskinesia. Indian J Priv Psychiatry 2018;12:29-30.

5. Nath S, Saraf AS, Mukherjee D. Blonanserin induced akathisia: A case report. Indian Med Case Rep 2015; 4:13-5.

How to cite this article: Goyal SK, Singh P. Blonanserin overdose:A case report. CHRISMED J Health Res 2019;6:272-3.

© 2019 CHRISMED Journal of Health and Research | Published by Wolters Kluwer -Medknow

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GLIMPSE -BLOOD DONATION CAMP AND BLS TRAINING

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