Search

Introduction: The incidence of stroke is increasing in India. Prehospital stroke care is crucial for reducing stroke morbidity and mortality, but its implementation in India faces several challenges. Limited original research exists on prehospital stroke care in India, making it essential to identify the problems in implementing effective prehospital stroke care. Methods: A web-based survey was conducted among registered medical practitioners in India who treat acute stroke. The survey questionnaire was developed in English and included 26 questions divided into five parts: questions about the physician's practice setup/hospital in India, perception of community awareness, existing prehospital care/systems, in-hospital stroke care availability, and specific issues faced. Results: Eighty-three doctors in India participated in the survey (43% response rate). Most of the respondents worked in private hospitals (68%) and urban areas (76%). While 89% of hospitals had ambulance services, over 33% reported that patients had to pay for ambulance transport. Among respondents, 12% reported a community stroke care network, with infrequent prehospital procedures such as random blood glucose measurement (22%), stroke identification (15.7%), "last seen normal" documentation (14.5%), and low prehospital notification to hospitals (5%). Delays in referral from peripheral centers were reported by 73% of respondents. Most hospitals had standard operating procedures (SOPs) (84%), computed tomography (CT) (94%), magnetic resonance imaging (MRI) (85%), and offered intravenous thrombolysis (IVT) (77%). However, 24 h availability of CT was reported only by 6%, MRI by 19% and IVT by 12%. Nearly half (45%) reported treatment with thrombolysis was not covered by insurance. Mechanical thrombectomy was available in 34% of hospitals and 63% of hospitals conducted in-hospital audits for stroke patients. Conclusions: The capabilities of stroke-catering hospitals in urban settings are encouraging, with many having SOPs, imaging capabilities, and thrombolysis and mechanical thrombectomy services. However, there is much room for improvement, in making the essential stroke care services financially accessible to all and available around the clock. [ABSTRACT FROM AUTHOR]

Ruptured sinus of Valsalva aneurysm (RSOV) is a less commonly encountered acquired defect that is often related to the underlying congenital deficiency in structural integrity of aortic sinuses in association with other congenital heart diseases. Surgical RSOV repair (SRR) has been traditionally the treatment of choice for symptomatic patients. However, with the advent of modern percutaneous techniques and refinement in hardware device closure is a safe and effective treatment in selected patients. We herein report a case of RSOV device closure related complication in which the continuous intra-procedural electrocardiogram monitoring assisted in rapid identification of the problem that was resolved successfully in a timely fashion. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The objective of the study is to test the efficacy of high-dose methylprednisolone in the prevention of esophageal stricture after corrosive ingestion. METHODS: This study was a single-center, randomized controlled single-blinded study. Simple randomization was done with 15 adult patients (>18 years) in each arm, who presented with a history of corrosive ingestion within the past 24 h and had esophageal injury of Zargar Grade IIB on endoscopy. Intravenous methylprednisolone 1 g/day for 3 days was given to the intervention arm while 100 mL of normal saline was given as placebo in control arm. Follow-up to diagnose esophageal stricture was done at 8 weeks. RESULTS: Thirty patients (15 in each arm) were recruited for the study. As per the intention to treat analysis, 33% and 46.6% developed stricture in the intervention and control arm, respectively (relative risk [RR] = 0.714; 95% confidence interval 0.29-1.75; P = 0.462). 40% patients in control group and 7.7% in intervention group had undergone feeding jejunostomy, which was statistically significant with a p-value of 0.048. Airway injury showed significant clinical improvement in the intervention arm but the difference was nonsignificant statistically (P = 0.674). There was no increased incidence of hypertension, hyperglycemia, hyponatremia, hyperkalemia, or infections in intervention arm. CONCLUSION: Methylprednisolone does not help in the prevention of stricture formation in corrosive esophageal injury, but it significantly reduces the requirement of feeding jejunostomy and has a beneficial role in treating airway injury. [ABSTRACT FROM AUTHOR]

Objectives: The reported incidence of coronary artery disease (CAD) is on the upsurge in middle-aged women of 35-54 years, whereas decreasing in similar aged matched men. The current clinical trial studies have revealed that attention is drawn away from estrogens and shifted toward androgens and sex hormone-binding globulin considered potential mediators of increasing cardiovascular risk in women at midlife. Data evaluating the endocrinological basis for CAD in premenopausal Indian women is infrequent. We aimed to assess the incidence of CAD among premenopausal women undergoing coronary angiography, identify the prevalence of various risk factors for CAD, and compare clinical characteristics and hormonal levels among premenopausal women with and without CAD to elucidate endocrinological explanations for CAD in premenopausal women. Materials and Methods: Ninety-nine consecutive premenopausal women undergoing coronary angiography between January 2014 and January 2017 were enrolled in this single-center and cross-sectional study. The reproductive hormone levels were quantified using commercially available electrochemiluminescence immunoassay. Results: Sixty-six (66.7%) premenopausal women had CAD on coronary angiography. Multivariate linear regression analysis was used, for diabetes mellitus (adjusted odds ratio [AOR] 16.46; P = 0.006 [95% confidence interval, CI: 2.21-122.41]), triglycerides (AOR 1.05; P = 0.002 [95% CI: 1.02-1.10]), progesterone (AOR 0.68; P = 0.015 [95% CI: 0.50-0.93]), and insulin (AOR 0.51; P < 0.0001 [95% CI: 0.38-0.70]) were observed to independently anticipate the development of CAD in premenopausal women. Conclusion: Approximately two-thirds of premenopausal women undergoing coronary angiography are detected to have CAD. Patients having diabetes, high serum triglyceride levels, low progesterone, and low insulin levels are considered in the high-risk category for developing CAD, thereby in premenopausal women providing a hormonal basis for the development of CAD. [ABSTRACT FROM AUTHOR]

We express recent double-sums studied by Wang, Yee, and Liu in terms of two types of Hecke-type double-sum building blocks. When possible we determine the (mock) modularity. We also express a recent q -hypergeometric function of Andrews as a mixed mock modular form. [ABSTRACT FROM AUTHOR]

Adult presentation of unilateral pulmonary artery atresia in association with contralateral branch pulmonary stenosis is rare. We present the case of a quadragenarian, who manifested with right ventricular failure and hemoptysis. This report discusses the diagnostic workup and therapeutic options along with a brief overview of the concerned literature. [ABSTRACT FROM AUTHOR]

Aims Assessment of pulmonary vascular dimensions (PVDs) in Tetralogy of Fallot (TOF) is an integral part of planning transcatheter and surgical interventions. We sought to examine the reliability and correlation of echocardiography (ECHO) and computed tomography angiography (CTA) measurements with those obtained by cardiac catheterization and angiography (CCA). Methods and results Tetralogy of Fallot physiology patients undergoing ECHO, CTA, and CCA within a month prior to surgical correction during 2018–2020 were retrospectively enrolled. Indexed diameter of pulmonary annulus (iPAnn), indexed right pulmonary artery (iRPA), indexed left pulmonary artery (iLPA) and indexed descending aorta (iDA) were measured using ECHO and CTA followed by derivation of Nakata index (NI), McGoon's ratio (MGR), ratio of predicted peak right ventricular (RV) and left ventricular (LV) pressures (pRV/pLV) and Z -scores. Comparison with CCA-derived measurements was made and correlational equations were subsequently deduced. Pulmonary vascular dimensions for 54 patients with mean age of 15.5 ± 9.3 years (range: 3–34 years) were analysed. Computed tomography angiography and CCA measurements for iPAnn, iRPA, NI, MGR, pRV/pLV, and Z -score were comparable with each other while ECHO parameters were significantly lower than CCA. However, iLPA diameter was significantly underestimated by ECHO and overestimated by CTA. Correlational analysis showed stronger correlation between CTA- and CCA-derived PVD as against ECHO measurements except for iDA, pRV/pLV, and Z -score. Conclusions For unrepaired TOF physiology patients weighing more than 10 kg, CTA-acquired PVD are reliable and comparable with CCA except for DA for which ECHO is non-inferior. Non-invasive modalities though are inferior to CCA for LPA sizing. Utilizing derived equations, precise estimation of PVD can be carried out using non-invasive tools. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study was conducted to investigate the association between visible cardiac activity in point-of-care ultrasound (POCUS) and outcomes of cardiac arrest such as the return of spontaneous circulation (ROSC), survival to inpatient admission (SIA), and survival to hospital discharge (STHD). METHODS: This was a single-center, prospective cohort study conducted in the emergency department (ED). Adult (age >18 years) patients in cardiac arrest were included in the study. Exclusion criteria of the study were - traumatic arrest, out-of-hospital cardiac arrest resuscitated before ED admission, and patients presenting with initial shockable rhythm. Patients whose ultrasound images could not be obtained and whose resuscitation stopped following POCUS were also excluded from the study. POCUS examination was done after 2 min of initiation of cardiopulmonary resuscitation (CPR) and visible cardiac activity was defined as any visible movement of the myocardium, excluding movement of blood within cardiac chambers, or isolated valve movement. The duration of POCUS examinations was limited to 10 s. The association of initial cardiac activity in POCUS with the outcomes of cardiac arrest was investigated. RESULTS: Out of 140 patients screened, 84 patients were included in the study. Rates of ROSC, SIA, and STHD were found in 23 (27.4%), 9 (10.7%), and 2 (2.4%) patients, respectively. Only 15 out of 84 (17.9%) patients had cardiac activity on the initial POCUS examination. Cardiac activity was seen in 52.2% of patients with ROSC, which was significantly higher (P < 0.001) as compared with the no-ROSC group (4.9%). Unlike the above association, there was no difference in the incidence of initial cardiac activity in patient groups who got admitted (SIA) and discharged (STHD) versus those who died. In the multivariate regression analysis, the duration of CPR and initial cardiac activity significantly predicted the rate of ROSC, with an adjusted odds ratio of 0.93 (95% confidence interval [CI]: 0.86-0.99, P = 0.04) and 24.8 (95% CI: 3.17-89.41, P = 0.002), respectively. None of the variables predicted SIA and STHD. The positive likelihood ratio of cardiac activity for predicting ROSC, SIA, and STHD were 10.6, 2.1, and 2.9, respectively. CONCLUSION: Integration of POCUS in cardiac arrest resuscitation was shown to be helpful in terms of prognostic significance of the presence of initial cardiac activity in terms of ROSC. [ABSTRACT FROM AUTHOR]

Introduction: Sepsis is the leading cause of mortality, and various scoring systems have been developed for its early identification and treatment. The objective was to test the ability of quick sequential organ failure assessment (qSOFA) score to identify sepsis and predict sepsis-related mortality in the emergency department (ED). Methods: We conducted a prospective study from July 2018 to April 2020. Consecutive patients with age ≥18 years who presented to the ED with a clinical suspicion of infection were included. Sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV), and odds ratio (OR) for sepsis related mortality on day 7 and 28 were measured. Results: A total of 1200 patients were recruited; of which 48 patients were excluded and 17 patients were lost to follow-up. 54 (45.4%) of 119 patients with positive qSOFA (qSOFA >2) died at 7 days and 76 (63.9%) died at 28 days. A total of 103 (10.1%) of 1016 patients with negative qSOFA (qSOFA score <2) died at 7 days and 207 (20.4%) died at 28 days. Patients with positive qSOFA score were at higher odds of dying at 7 days (OR: 3.9, 95% confidence interval [CI]: 3.1–5.2, P < 0.001) and 28 days (OR: 6.9, 95% CI: 4.6–10.3, P < 0.001). The PPV and NPV with positive qSOFA score to predict 7- and 28-day mortality were 45.4%, 89.9% and 63.9%, 79.6%, respectively. Conclusion: The qSOFA score can be used as a risk stratification tool in a resource-limited setting to identify infected patients at an increased risk of death. [ABSTRACT FROM AUTHOR]

Introduction: Cardiovascular implantable electronic device (CIED) infection contributes to a significant clinical and financial burden. We sought to assess CIED postimplant infection rates and the effect of different treatment modalities on reinfection over a long-term follow-up. Methods: We retrospectively analyzed CIED recipients presenting with complications during 2010-2019 at our center. Data related to the different management modalities used as per the discretion of treating physician, were collected and patients were followed up telephonically. Results: A total of 3394 patients underwent CIED implantation of which 122 (3.5%) patients developing complications were included in the study. Mean age of the patients was 66.4 ± 12.5 years. Single-chamber ventricular pacing (VVI), dual-chamber (DDD) pacing, and biventricular pacing were seen in 68 (56.2%), 51 (41%), and 3 (2.8%) patients, respectively. CIED infection was seen in 61 patients (1.8%). Strategies used for CIED infection management included: new device implantation on contralateral side (n = 34; 55.7%), old device repositioning on same side (n = 14; 22.8%), antibiotic therapy alone (n = 5; 8.5%), resterilized device implantation on contralateral side (n = 3; 4.9%), epicardial lead placement (n = 3; 4.9%), and permanent device removal (n = 2; 3.3%). The CIED reinfection rates for the above strategies were 2.9%, 71.4%, 80%, 100%, 0% and 0%, respectively. Conclusion: Multiple strategies are being used in real-world practice for the management of CIED infection. Previously advocated strategy of reimplanting resterilized CIED is associated with high recurrence rates. The best practice still remains to implant a new device on the contralateral side post extraction of infected hardware. [ABSTRACT FROM AUTHOR]

Background: There is a need to identify novel markers for CAD, independent of traditional CV risk factors. One of these is gamma-glutamyl transferase (GGT), a marker of increased oxidative stress. Given the high prevalence of CAD in Asian Indians, the link of GGT and CAD in them needs to be studied.Aim: To assess GGT in patients with angiographically documented CAD.Methods and Results: Two hundred patients aged 58.1 ± 9.95 years, 73% males, hypertension 56%, diabetes 40% were included. Mean GGT was 63.6 ± 44.33 (10-269 U/L). The levels of GGT progressively increased in those with single/double or triple-vessel CAD (36.5, 61.5, and 87 U/L, respectively, P < 0.001). Using objective criteria of CAD burden (SYNTAX and Gensini scores), we reaffirmed these findings. GGT in patients with SYNTAX tertiles 0-22, 23-32, and ≥ 33 was 33, 62, and 97 U/L, respectively and in Gensini tertiles 0-17.65, 17.66-56.65, ≥56.66 was 32, 52, and 88 U/L, respectively, all P < 0.001. SYNTAX score ≥ 23 was present in only 23% patients in GGT tertile 1 (<41 U/L), whereas60% and 94% in GGT tertiles 2 and 3 had SYNTAX ≥ 23. Significant positive correlation was seen between GGT and SYNTAX (r = 0.634) and Gensini score (r = 0.772).Conclusions: In this study, GGT had an independent correlation with angiographic severity of CAD and SYNTAX and Gensini scores. Although the existing evidence seems biologically plausible, more studies are needed to explore the potential role of this inexpensive marker for predicting disease burden in patients with CAD. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Emergency airway management is an integral part of patient stabilization. It is an essential skill for an emergency physician to master. There is a paucity of literature on airway management from low-to-middle-income countries like India where emergency medicine (EM) specialty is still in its infancy. We conducted this study to identify the existing airway management practices among emergency physicians in our tertiary care center. This study could pave the way for national airway registries. METHODS: This prospective, observational study was conducted in the emergency department (ED) of a tertiary care center in India for 16 months. We included 166 patients who underwent emergency endotracheal intubation in the ED, irrespective of their age or underlying condition. The patients were observed for 15 min after intubation to identify any associated adverse events. We collected data about patients' demographic profile, indication for intubation, techniques of airway management, medications used, specialty of the physician performing intubation, use of preintubation and postintubation checklists, vitals before and after intubation, and any adverse events following intubation. RESULTS: A total of 166 patients who required definite airway management in the ED were recruited for the study. The mean age of patients was 45.5 ± 20.1 years. Males comprised 61.4% of the patients. One hundred and forty-four patients were nontrauma cases and the remaining 22 cases were related to trauma. The most common indication for emergency airway management was altered mental status among nontrauma encounters and traumatic brain injury among trauma patients. Rapid sequence intubation (RSI) was the most common method employed (72.9% of cases). The most common agents used for induction and paralysis were etomidate and rocuronium, respectively. Direct laryngoscope was used in about 95% of cases. The first pass success rate in our study was 78.3%. EM residents were able to perform orotracheal intubation for all patients and none required a surgical airway. The incidence of adverse events within 15 min of intubation was 58.4%. Common complications observed were desaturation, right mainstem bronchus intubation, and equipment failure. Postintubation cardiac arrest occurred in around 5% of cases. CONCLUSION: RSI remains the most common method employed for emergency airway management. There exists heterogeneity in the practice and its associated complications. Hence, regular surveillance, quality improvement, and training are imperative to provide good patient care. [ABSTRACT FROM AUTHOR]