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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

ANNEXURE-11

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE

CANDIDATE AND

DR. KAVYA K

POST GRADUATE

DEPT OF GENERAL MEDICINE ,

ESIC MEDICAL COLLEGE AND PGIMSR ,

RAJAJINAGAR,

BENGALURU-560010

2. NAME OF THE

INSTITUTION

3. COURSE OF THE

STUDY AND SUBJECT M.D. – GENERAL MEDICINE

4. DATE OF ADMISSION

TO COURSE 31-05-2012

5. TITLE OF TOPIC

“AN OBSERVATIONAL STUDY OF ANAEMIA AND ITS

UNDERLYING CAUSES IN MEDICAL INTENSIVE CARE UNIT.”

BRIEF RESUME OF THE INTENDED STUDY:

6.1 NEED FOR THE STUDY:

Anemia is common in critically ill patients and appears early during their intensive

care unit (ICU) course. By day 3 after ICU admission, almost 95% of patients are anemic.[1–3] The anemia in these critically ill patients persists throughout their ICU and hospital

stay, with or without red blood cell (RBC) transfusion.[3]

Delivery of oxygen to tissues depends upon hemoglobin level and tissue perfusion

by oxygenated blood; anemia will lead to a decreased capacity of oxygen transport, which

is compensated by cardiac compensatory mechanisms. In critically ill patients these

mechanisms might not be sufficient eventually resulting in tissue hypoxia and progression

to multiple organ dysfunction syndromes. The presence of anemia patients in ICU has been

associated with worse outcomes including increased lengths of stay and increased

mortality.[4]

Anemia is a hemoglobin concentration in blood that is below the expected value,

when age, gender, pregnancy and certain environmental factors, such as altitude, are taken

into account. The World Health Organization (WHO) defines anemia as a hemoglobin

<13 g/dl (hematocrit <39%) for adult males and <12 g/dl (hematocrit <36%) for adult non-

pregnant females. [5, 6] There are no universally agreed grades of severity for anemia during

critical illness.

Among the causes of anemia in the critically ill, important are sepsis (inflammation)

induced bone marrow suppression, blood loss especially gastrointestinal bleeding, blood

sampling, chronic renal failure, drug-induced hemolytic anemia, nutritional deficiencies

and worm infestation.[7,8] Anemia of critical illness is similar as anemia of Inflammation

and anemia of chronic disease as it develops acutely in states of inflammation. Anemia of

inflammation is the second most common cause of anemia after iron deficiency.[9]

A proper identification of anemia and its underlying causes in ICU patients is required

because various disorders may necessitate different diagnostic and therapeutic management

strategies. It will be helpful to select appropriate treatment options like blood transfusion,

erythropoietin therapy, and iron supplementation which influence the outcome in these

critically ill patients.

6.2 REVIEW OF LITERATURE Corwin et. al study in the USA examined 489 admissions to ICUs the mean hemoglobin

concentration at ICU admission was 11.0 g/dl. Almost two-thirds of patients had a

hemoglobin concentration <12 g dl at ICU admission.[3]

Vincent et. al in a cohort study of 3534 patients admitted to 146 Western European

ICUs with varying case mix found that the mean hemoglobin concentration at ICU

admission was 11.3 g/dl. Sixty-three per cent of patients had a hemoglobin concentration

<12 g/dl on ICU admission and 29% of patients had an admission hemoglobin

concentration <10 g/dl.[4]

A cohort study by Bahlas S et. al., out of the 100 patients, 82% (82 patients) were

anemic with Hb average of 10.06 + 0.28, 48 of whom had blood transfusion. Sepsis was

the most common clinical setting associated with anemia in 72% of the patients followed

by Chronic Renal Failure in 56% of the patients. The others being gastrointestinal

bleeding, hemolysis and internal hemorrhage. [9]

Anemia is common in heart failure populations, with the majority of studies indicating

prevalence >20%. In most reported studies anemia is an independent predictor of increased

mortality risk and increased risk of hospitalization for heart failure.[10]

In a prospective cohort study by N Manchal, S Jayaram causes identified for anemia in

ICU were 33% due to sepsis, 9% due to chronic kidney disease,8% each for GI bleed,

internal bleed and protozoa infections.[11]

Tanne D et. al concluded in a cohort study as WHO-defined anemia was common in both

men and women among patients with acute stroke and predicted poor outcome.[12]

Hebert et al. studied 4,470 patients Critically ill patients admitted to ICU; survivors:

(n = 3,469), non-survivors: (n = 1,001) Survivors had higher Hb levels than non-survivors.[13]

6.3 OBJECTIVES OF THE STUDY1. To study occurrence of anemia among critically ill patients and its contribution to ICU

related morbidity.

2. To study the etiological factors that contributes to anemia in critically ill patients.

7 MATERIALS AND METHODS

7.1 SOURCE OF THE DATA The study includes patient selected from ICU at Employees State Insurance Corporation-

Medical Collage- Post Graduate Institute of Medical Sciences and Research [ESIC-MC-

PGIMSR] over a period of 18 months.

7.2 METHOD OF COLLECTION OF DATA Patients satisfying inclusion criteria are enrolled within 24 hours of admission to ICU

after informed consent.

Complete hemogram noted on first day, third day and at the time of discharge or transfer

from ICU.C-reactive protein measured on first day and at the time of discharge or transfer

Other investigations as advised by attending physician based on primary diagnosis are

noted as relevant to the study.

Sample size: 60

Study design: observational study

Statistical analysis: The data collected in this study will be analyzed statistically using

descriptive statistics.

INCLUSION CRITERIA:1. Patients aged above 18 years admitted under medicine department.[11]

2. Males with hemoglobin <13 g/dl (hematocrit <39%) and females with<12g/dl

(hematocrit <36%) [5,6]

3. APACHE II SCORE ≥ 20 on the day of admission[4,12] or Patient on mechanical

ventilator[13]

EXCLUSION CRITERIA:1. Patient under age 18 years

2. Patient with known congenital anaemias

3. HIV positive patients

4. Patient with known malignancy and on chemotherapy

5. Pregnant patients

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR

INTERVENTIONS TO BE CONDUCTED IN PATIENTS OR OTHER

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION :YES

8. REFERENCES:

1. Corwin HL, Gettinger A, Rodriguez RM, Pearl RG, Gubler KD, Enny C, Colton T,

Corwin MJ: Efficacy of recombinant human erythropoietin in the critically ill patient: a

randomized, double-blind, placebo-controlled trial. Crit Care Med 1999; 27:2346-2350.

2. Rodriguez RM, Corwin HL, Gettinger A, Corwin MJ, Gubler D, Pearl RG. Nutritional

deficiencies and blunted erythropoietin response as causes of the anemia of critical illness.

J Crit Care 2001; 16:36-41.

3. Corwin HL, Gettinger A, Pearl RG, Fink MP, Levy AM, Abraham E, MacIntyre NR,

Shabot M, Dun MS, Shapiro MJ. The CRIT study: Anemia and blood transfusion in the

critically ill: current clinical practice in the United States. Crit Care Med 2004; 32:39-52.

4. Vincent JL, Baron JF, Reinhart K, et al. Anaemia and blood transfusions in critically ill

patients. JAMA 2002; 288:1499–507.

5. Longo D L et al. Harrison´s Principles of Internal Medicine. 18 th edition. Vol.I. New

York: McGraw-Hill; 2012: 448-9.

6. Nutritional anaemia’s. Report of WHO scientific group. World Health Organ Tech Rep

Ser1968; 405:5-37.

7. Walsh T.S, Ezz-El-Din Saleh. Anaemia during critical illness. British Journal of

Anaesthesia 2006; 97 (3): 278–91.

8. Irwin, Richard S., Rippe, James M. Irwin and Rippe's Intensive Care Medicine. 7th

Edition. Lippincott Williams & Wilkins: 2011; Sec IX Chap 112:1253-4.

9. Bahlas S, Faydhi A , Ahmed M.A. Prospective Study on Anemia and Blood Transfusion

in Critically ill Patients.WebmedCentral GENERAL MEDICINE 2011; 2(4):WMC001836.

10. Tang Y, Katz SD. The prevalence of anemia in chronic heart failure and its impact on

the clinical outcomes. Heart Fail Rev. 2008 Dec; 13(4):387-92

11. Manchal N, Jayaram S. A prospective cohort study on anemia and blood transfusion in

critically ill patients. Indian J Crit Care Med 2007; 11:182-5.

12. Tanne D, Molshatzki N, Merzeliak O, Tsabari R, Toashi M, Schwammenthal Y.

Anaemia status, haemoglobin concentration and outcome after acute stroke: a cohort study.

BMC Neurol 2010; 10:22.

13. Hebert PC, Wells G, Tweeddale M, et al. Does transfusion practice affect mortality in

critically ill patients? Transfusion Requirements in Critical Care (TRICC) Investigators and

the Canadian Critical Care Trials Group. Am J Resp Crit Care Med 1997; 155:1618–1623.

14. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. "APACHE II: a severity of

disease classification system". Critical Care Medicine 1985; 13 (10): 818–29.

15. Wang MP, Jiang L, Zhu B, Jiang Q, Xi XM. Clinical observational study of anemia in

mechanically ventilated patients. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 2012 Feb;

24(2): 70-3.

9. SIGNATURE OF CANDIDATE

10.REMARKS OF THE GUIDE:

Anemia in ICU has diagnostic and therapeutic implications. Hence study is relevant with practical implications.

11. 11.1 NAME AND DESIGNATION( IN BLOCK LETTERS) OFGUIDE

DR.T.ANIL KUMAR, MDPROFESSOR AND HEAD OF THE DEPARTMENT,DEPARTMENT OF GENERAL MEDICINE,ESIC-MC PGIMSR,RAJAJINAGAR,BENGALURU-560010

11.2 CO-GUIDE ( if any ) DR.V.SRINIVASA MURTHY, MDPROFESSOR AND HEAD OF THE DEPARTMENT,DEPARTMENT OF PATHOLOGY,ESIC-MC PGIMSR,RAJAJINAGAR,BENGALURU-560010

11.3 HEAD OF THE DEPARTMENT

11.4 SIGNATURE

11.5 REMARKS OF THE CHAIRMAN & PRINCIPAL

11.6 SIGNATURE

11.7 PRINCIPAL OF THE INSTITUTTION

Dr. B. RAJEEVA SHETTY, MSDEAN, ESIC MEDICAL COLLEGE & POSTGRADUATE INSTITUTE OF MEDICAL SCIENCE AND RESEARCH, RAJAJINAGAR, BENGALURU-560010

Case No: Hospital- IP / OP No:

Address: Occupation:

History of fever – type Duration Degree Associated factors History of cough –productive Non – productive History of burning micturition History of pain abdomen/ vomiting/loose stoolsHistory of blood in vomitus / stools / black tarry stoolsHistory of recent bleeding from any orifices- menstrual, gum bleeding or othersHistory of headache / altered sensorium

Co-morbidities- Hypertension/ diabetes/ chronic renal failure/ chronic obstructive pulmonary disease/ ischemic heart disease/ tuberculosis/ epilepsy/ cirrhosis of liver

PAST HISTORY -

GPE- General Physical Examination:

General appearance:

Height / weight Temperature

Pallor: Clubbing: Icterus: Cyanosis: Edema:

Pulse: BP: Respiratory rate: Saturation:

Systemic examination:

Investigations:

APACHE II score-Arterial blood gas analysis-

Mechanical ventilation-

1. Complete Hemogram:On day 1On day 3On day of discharge or transfer

On day 1On day of discharge or transfer

Other investigations as ordered by attending physician based on primary diagnosis:

PT, aPTT, INR Smear for MP, Serological tests for dengue, leptospirosis Liver function tests Renal function tests Thyroid function tests Iron studies Serum B12, Folic acid levels Bone marrow aspiration & biopsy Blood culture & sensitivity Urine routine analysis Urine culture & sensitivity Sputum gram stains & culture sensitivity Chest x ray Ultra sonogram

Other relevant investigations as required;

TREATMENT GIVEN;

Number of units of blood transfused:

CONSENT FORM

Participant’s name: Age: Sex:

Title of the study: AN OBSERVATIONAL STUDY OF ANAEMIA AND ITS ETIOLOGICAL PROFILE IN MEDICAL INTENSIVE CARE UNIT.

The details of the study have been provided to me in writing and explained to me/us in my/our own language. I/we confirm that I have understood the above study and had the

opportunity to ask questions. I/we understand that my participation in the study is voluntary and that I/we am free to withdraw at any time, without giving any reason, without the medical care that will normally be provided by the hospital being affected. I/we agree not to restrict the use of any data or results that arise from this study provided such a use is only for scientific purpose(s). I/we have been given an information sheet giving details of the study. I/we fully consent for detailed examination, investigations and to participate in the above study.

Signature of the participant/ next of kin: ______________________ Date: _____________

Signature of the witness ________________________ Date: _____________

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May 17, 2024

This article has been reviewed according to Science X's editorial process and policies . Editors have highlighted the following attributes while ensuring the content's credibility:

fact-checked

trusted source

More leptospirosis cases occur after floods, study shows

by K. W. Wesselink, University of Twente

A recent study, published by researchers at the Faculty of ITC in the International Journal of Health Geographics , has shown that flooding leads to increased leptospirosis cases.

First author, John Ifejube is a recent graduate of the master's program in Spatial Engineering. This publication is a direct result of his thesis on GeoHealth.

Flooding is a climate-related disaster that impacts not only the environment but also the well-being of people. Leptospirosis is a blood infection caused by the bacteria Leptospira. People become infected through interaction with contaminated water or urine.

Infected humans can get headaches, muscle pains, and fevers, but severe forms can lead to kidney failure. More and more studies link the spread of leptospirosis with floods, but it has not been extensively studied, until now.

Master's thesis

For his master's thesis, Ifejube conducted a study on the association between the incidence of leptospirosis and the occurrence of multiple floods in Kerala, India. He found that flooding leads to an increase in leptospirosis cases. His study reveals that flood duration is the most important characteristic of floods that can be used to predict the number of infections. According to his research, severe floods lead to more leptospirosis cases than moderate floods.

He compared leptospirosis cases across three different years in time and space. Specifically, he compared the number of cases in 2018 and 2019, which were years with heavy and moderate flooding respectively, to the number of cases in 2017, a year that did not experience any floods.

For each flood year, he looked at the reported cases three months before, during and three months after the flood. To assess the severity of floods, he determined the population exposed to each flood event using high-resolution satellite images. Finally, he used spatial regression to examine the relationship between post-flood cases and flood extents.

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Student research day scientific poster session, student research day, shelli farhadian, md, phd, and john k. forrest, md, peter aronson, md, c.n.h. long professor of medicine (nephrology) and professor of cellular and molecular physiology.

On May 7, 2024, students and faculty mentors were celebrated at Yale School of Medicine’s (YSM) Student Research Day (SRD), an annual tradition at YSM since 1988. Five medical students (Chinye Ijile, Amanda Lieberman, Kingson Lin, Victoria Marks, and Jamieson O’Marr) made thesis presentations, and over 75 students, from across Yale’s health profession schools, displayed scientific posters and engaged with attendees during the poster session.

“Today we’re showcasing a diverse range of mentored research—spanning from fundamental basic science, to implementation science—performed by student investigators from across the health professions schools,” Associate Dean for Student Research Sarwat Chaudhry, MD, professor of medicine (general medicine), said in opening remarks. Associate Dean for Student Research Erica Herzog, MD, PhD, John Slade Ely Professor of Medicine (pulmonary) and professor of pathology, added, “We take immense pride in Yale’s deep-rooted tradition of embedding research within medical education. For our students, experience in scientific investigation isn't merely a stepping stone towards a successful residency match or a career in academic research; it's foundational training for their lifelong commitment to medicine.”

Farr Lecture

The Lee E. Farr MD Endowed Lectureship and the presentation of the Dr. John N. Forrest, Jr., Mentorship Award, which bookended the student thesis presentations, honored YSM faculty for their outstanding mentorship. In introducing Peter Aronson, MD, C.N.H. Long Professor of Medicine (Nephrology) and professor of cellular and molecular physiology, as the Farr lecturer, Nancy J. Brown, MD, Jean and David W. Wallace Dean and C.N.H. Long Professor of Internal Medicine, explained that the lecture aims to stimulate thinking and to inspire students to strive to achieve more effective leadership and educational roles in society. Brown said that Aronson, who has been at YSM for 50 years since joining as a nephrology fellow in 1974, “epitomizes these qualities as a physician-scientist, educator, mentor, and colleague. As such, there is no one more fitting to speak at today’s event.”

As chief of the Section of Nephrology from 1987-2002, Brown said, Aronson nurtured the development of numerous physician-scientists, both as faculty and fellows, many of whom became recognized leaders—and many of whom remain at Yale and were present on SRD. “It goes without saying” Brown concluded, “that Dr. Aronson’s stewardship is one reason for the enduring strength of Yale’s 200-year tradition of medical student research,” noting he had been part of the tradition for one quarter of the 200 years. (In comments after Aronson spoke, Herzog noted several of his student evaluations simply said GOAT: “Greatest Of All Time.”)

Using his own experiences as examples in his lecture titled From Sugar to Salt to Stones: Serendipitous Journey as Mentee and Mentor, Aronson noted the importance of chance events and serendipitous research findings in determining the course of his academic development and research career. ( This article describes his remarks in detail .) In closing, Aronson honored the late John N. Forrest, Jr., professor emeritus of medicine and the founding director of YSM’s Office of Student Research (OSR). Forrest, he said, “exemplified extraordinary commitment to the process of education and mentorship,” adding “we should all be inspired by his example of what is most gratifying in academic medicine.”

Dr. John N. Forrest, Jr., Mentorship Award

Chaudhry similarly honored John N. Forrest, Jr. in introducing the mentorship award established to recognize his legacy. “As many of you know, Dr. Forrest died earlier this year, and so this year’s Forrest Prize holds special meaning.” OSR “was his pride and joy,” Chaudhry said, adding that since starting their roles as associate deans of student research in 2020, “Dr. Herzog and I have continually been impressed by Dr. Forrest’s care and foresight in establishing the Office of Student Research. Dr. Forrest’s legacy lives on in the enduring strength of YSM’s medical student research program.”

Before Forrest’s son, John K. Forrest, MD, associate professor of medicine (cardiovascular medicine), announced the award recipient— Shelli Farhadian, MD, PhD, assistant professor of medicine (infectious diseases); assistant professor, epidemiology of microbial diseases —he shared, “My family and I are grateful to the numerous people who reached out after our father’s passing. Some of the most touching correspondence we received were from medical students, residents, and fellows whom he had mentored while at Yale. There is no greater evidence of the lasting impact that mentorship plays in the lives of young physicians that the words contained in those letters.”

Turning to the awardee, Forrest said, “Dr. Farhadian is an exemplary mentor,” and pointed to her role “in shaping the careers of her mentees, many of whom have garnered multiple awards and recognition, and published first author manuscripts under her tutelage.”

He then shared what a student wrote about Farhadian: “Dr. Farhadian is such a fantastic mentor and person. As my mentor she encouraged me to apply for grants and submit to conferences and journals and has always made herself available to answer any questions that I have. She also facilitates an environment in which her mentees feel comfortable coming to her with questions and offers help in connecting me with doctors in my fields of interest. Beyond my research with Dr. Farhadian, she has also proved to be an invaluable resource in terms of developing as a student and a future doctor. She is an inspiring woman in medicine, and I hope to become as caring and capable as a doctor and mentor as she models.”

Upon receiving the award, Farhadian said, “It means a great deal for me to receive this award in Dr. Forrest’s name. I was lucky to cross paths with Dr. Forrest when I was an intern, and I will always remember how kind he was to everyone in the hospital, no matter how small their role.” Farhadian added, “I feel very lucky to have had my own exceptional research mentors along the way, and I have tried to emulate them when mentoring my own trainees.”

Student Thesis Presentations

Chinye Ijile

Medicaid Coverage for Undocumented Children in Connecticut: A Political History

Faculty mentor: Naomi Rogers, PhD, professor in the history of medicine and of history; acting chair, Spring 2024, History of Medicine

Amanda Lieberman

Multilevel Barriers to Methadone for HIV Prevention Among People Who Inject Drugs in Kazakhstan

Faculty mentor: Frederick Altice, MD, MA, professor of medicine (infectious diseases) and of epidemiology (microbial diseases)

Kingson Lin, MD-PhD

Design, Synthesis, and Characterization of Novel MGMT-Dependent, MMR-Independent Agents for the Treatment of Glioblastoma Multiforme (GBM)

Faculty mentors: Ranjit Bindra, MD, PhD, Harvey and Kate Cushing Professor of Therapeutic Radiology and professor of pathology; and Seth Herzon, PhD, Milton Harris ’29 Ph.D. Professor of Chemistry

• Victoria Marks

Association between Medical Insurance, Access to Care, and Clinical Outcomes for Patients with Uveal Melanoma in the United States

Faculty mentor: Michael Leapman, MD, MHS, associate professor of urology; assistant professor, chronic disease epidemiology

Jamieson O’Marr

Ballistic and Explosive Orthopaedic Trauma Epidemiology and Outcomes in a Global Population

Faculty mentor: Brianna Fram, MD, assistant professor of orthopaedics & rehabilitation

Featured in this article

• Frederick Lewis Altice, MD, MA
• Peter S. Aronson, MD
• Ranjit S. Bindra, MD, PhD
• Nancy J. Brown, MD
• Sarwat Chaudhry, MD
• Shelli Farhadian, MD, PhD
• John K Forrest, MD, FACC, FSCAI
• Brianna R. Fram, MD
• Erica Herzog, MD, PhD
• Seth Herzon, PhD
• Chinye Ijeli
• Michael S. Leapman, MD, MHS
• Amanda Liberman
• Kingson Lin
• Jamieson O'Marr, MS
• Naomi Rogers, PhD

Related Links

• Student Research Day Program