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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 Text classification plays a major role in research such as sentiment analysis, opinion mining, and customer feedback analysis. Text classification using hypergraph algorithms is effective in capturing the intricate relationships between words and phrases in documents. The method entails text preprocessing, keyword extraction, feature selection, text classification, and performance metric evaluation. Here, we proposed a Hypergraph Attention Layer with Logistic Regression (HGATT_LR) for text classification in the Amazon review data set. The essential keywords are extracted by utilizing the Latent Dirichlet Allocation (LDA) technique. To build a hypergraph attention layer, feature selection based on node-level and edge-level attention is assessed. The resultant features are passed as an input of Logistic regression for text classification. Through a comparison analysis of different text classifiers on the Amazon data set, the performance metrics are assessed. Text classification using hypergraph Attention Network has been shown to achieve 88% accuracy which is better compared to other state-of-the-art algorithms. The proposed model is scalable and may be easily enhanced with more training data. The solution highlights the utility of hypergraph approaches for text classification as well as their applicability to real-world datasets with complicated interactions between text parts. This type of analysis will empower the business people will improve the quality of the product.

In this paper, an advanced and optimized Light Gradient Boosting Machine (LGBM) technique is proposed to identify the intrusive activities in the Internet of Things (IoT) network. The followings are the major contributions: i) An optimized LGBM model has been developed for the identification of malicious IoT activities in the IoT network; ii) An efficient evolutionary optimization approach has been adopted for finding the optimal set of hyper-parameters of LGBM for the projected problem. Here, a Genetic Algorithm (GA) with k-way tournament selection and uniform crossover operation is used for efficient exploration of hyper-parameter search space; iii) Finally, the performance of the proposed model is evaluated using state-of-the-art ensemble learning and machine learning-based model to achieve overall generalized performance and efficiency. Simulation outcomes reveal that the proposed approach is superior to other considered methods and proves to be a robust approach to intrusion detection in an IoT environment.

Point-of-care ultrasound (PoCUS) has a potentially vital role to play in emergency medicine (EM), whether it be in high-, medium-, or low-resourced settings. However, numerous barriers are present which impede EM PoCUS implementation nationally and globally: (i) lack of a national practice guideline or scope of practice for EM PoCUS, (ii) resistance from non-PoCUS users of ultrasound imaging (USI) and lack of awareness from those who undertake parallel or post-EM patient care, and (iii) heterogeneous pattern of resources available in different institutes and settings. When combined with the Indian Preconception and Prenatal Diagnostic Techniques (PCPNDT) Act, this has led to the majority of India's 1.4 billion citizens being unable to access EM PoCUS. In order to address these barriers (globally as well as with specific application to India), this article outlines the three core principles of EM PoCUS: (i) the remit of the EM PoCUS USI must be well defined a priori, (ii) the standard of EM PoCUS USI must be the same as that of non-PoCUS users of USI, and (iii) the imaging performed should align with subsequent clinical decision-making and resource availability. These principles are contextualized using an integrated PoCUS framework approach which is designed to provide a robust foundation for consolidation and expansion across different PoCUS specialisms and health-care settings. Thus, a range of mechanisms (from optimization of clinical practice through to PoCUS educational reform) are presented to address such barriers. For India, these are combined with specific mechanisms to address the PCPNDT Act, to provide the basis for influencing national legislation and instigating an addendum to the Act. By mapping to the recent Lancet Commission publication on transforming access to diagnostics, this provides a global and cross-discipline perspective for the recommendations.

The basic amenity for a highly civilized community needs water and drainage facilities; with uncontrolled population outrage, there arises demand for water consumption which naturally leads to effluent discharge. Even though the district has ample landscape, smart drainage facilities, the rainwater and storm runoff are still collected as pumped source for treatment to a long distance. These wastewaters diverted to the river surface due to insufficient retention time for treatment that naturally grounds a serious ecological damage. The concentration of organic and inorganic heavy metals determines the nature of contamination whether lighter low concentrated or severe high concentrated, meanwhile the level get diluted with streaming in the river surface. Deposited contaminants along the Porunai river basin are in dissolved stages that naturally lead to eutrophication which will cause pollution risk and indirectly affects the dependents covering three districts. With the support of GIS, online monitoring is incorporated to check the gathering of phosphorus, removal of phosphorus from the soil and nitrogen removal. The aim of the research focus is to study eutrophic nutrient limits in river Porunai which is a streaming of Thamirabarani and manimuthar. Nutrient removals from the designed reactors express the available measure of pollution risk. Life cycle study gives the life term of river front and a blueprint is framed based on reducing the mixing of unwanted water sources. In due course make it a place of recreation prevailing with current scenario and future prediction by means of statistical data compared with navigation studies.

The components of each stage have similarities as well as differences, which make each unique in its own right. As the film-making and the movie industry may have much we can learn from, some of these will be covered under the different sections of the paper, for example, “Writing Powerful Narratives,” depiction of emotional elements, specific industry-driven developments as well as the “cultural considerations” in both. For medical simulation and simulation-based education, the corresponding stages are as follows: Development Preproduction Production Postproduction and Distribution. The art of sim-making has many similarities to that of film-making. In fact, there is potentially much to be learnt from the film-making process in cinematography and storytelling. Both film-making and sim-making can be seen from the artistic perspective as starting with a large piece of blank, white sheet of paper, which will need to be colored by the “artists” and personnel involved; in the former, to come up with the film and for the latter, to engage learners and ensure learning takes place, which is then translated into action for patients in the actual clinical care areas. Both entities have to go through a series of systematic stages. For film-making, the stages are as follows: Identification of problems and needs analysis Setting objectives, based on educational strategies Implementation of the simulation activity Debriefing and evaluation, as well as Fine-tuning for future use and archiving of scenarios/cases.

Introduction: Chest compression fraction (CCF) is the cumulative time spent providing chest compressions divided by the total time taken for the entire resuscitation. Targeting a CCF of at least 60% is intended to limit interruptions in compressions and maximize coronary perfusion during resuscitation. We aimed to identify the mean CCF and its relationship with various factors affecting it. Methods: Patients presenting to the emergency department in cardiac arrest at a single center were prospectively included in this study. Resuscitation was provided by trained health-care providers. The feedback device Cprmeter2™ was placed on the patient's sternum at the beginning of resuscitation. The total time taken for the entire resuscitation was noted by the device and CCF calculated. Results: The mean CCF was analyzed using descriptive statistics and was found to be 71.60% ± 7.52%. The total duration of resuscitation (R = −0.55, P = < 0.001, min-max, 2.02–34.31, mean 12.25 ± 6.54), number of people giving chest compressions (R = −0.48, P = < 0.001, min-max, 1–6, mean 4.04 ± 1.12), and total number of team members in resuscitation (R = −0.50, P = < 0.001, min-max, 4–10, mean 6.65 ± 1.32) had negative correlation with CCF. Diurnal variation (day, n = 35; mean 69.20% ± 7% and night, n = 20; mean 75.80% ± 5.6%, P = 0.001) and patients receiving defibrillation (receiving n = 10 mean 67.00% ± 4.11% and not receiving n = 45 mean 72.62 ± 7.42%, P = 0.005) were found to significantly affect CCF. Conclusion: The mean CCF for cardiac arrest patients was well within the targets of guideline recommendation. CCF decreased when resuscitation lasted longer, during daytime when the defibrillator was used, the total team members increased, and also when the number of people giving chest compressions increased. CCF during resuscitation may improve if there is a focus on improving these factors and requires validation in multicentric settings.

The optical communication system is preferred over microwave and radio frequency communication systems because of license free operation. Simulative analysis of 10gbps bandwidth using different optical communication channels have been performed in this paper. The different modulation formats of QAM and PSK have been compared for its performances under all the three optical channels OWC, FSO, and LOS-FSO which are an unguided form of optical communication. The optical channels under these modulation formats are extensively used in Digital Video Broadcasting Communication. The parameters such as Q-factor, BER and Eye height can be obtained by varying the wavelengths in the range of 850 nm 1064 nm, 1330 nm and 1550 nm. From the design and performance analysis, the system with the maximum Q-factor and minimum BER can be found for the wavelength of 1064 nm.

Evaporation from open water is among the most rigorously studied problems in hydrology. Robert E. Horton, unbeknownst to most investigators on the subject, studied it in great detail by conducting experiments and heuristically relating his observations to physical laws. His work furthered known theories of lake evaporation, but it appears that it was dismissed as simply empirical. This is unfortunate because Horton's century-old insights on the topic, which we summarize here, seem relevant for contemporary climate-change-era problems. In rediscovering his overlooked lake evaporation works, in this paper we (1) examine several of his publications in the period 1915–1944 and identify his theory sources for evaporation physics among scientists of the late 1800s, (2) illustrate his lake evaporation formulae, which require several equations, tables, thresholds, and conditions based on physical factors and assumptions, and (3) assess his evaporation results over the continental U.S. and analyze the performance of his formula in a subarctic Canadian catchment by comparing it with five other calibrated (aerodynamic and mass transfer) evaporation formulae of varying complexity. We find that Horton's method, due to its unique variable vapor pressure deficit (VVPD) term, outperforms all other methods by ∼3 %–15 % of R2 consistently across timescales (days to months) and at an order of magnitude higher at subdaily scales (we assessed up to 30 min). Surprisingly, when his method uses input vapor pressure disaggregated from reanalysis data, it still outperforms other methods which use local measurements. This indicates that the vapor pressure deficit (VPD) term currently used in all other evaporation methods is not as good an independent control for lake evaporation as Horton's VVPD. Therefore, Horton's evaporation formula is held to be a major improvement in lake evaporation theory which, in part, may (A) supplant or improve existing evaporation formulae, including the aerodynamic part of the combination (Penman) method, (B) point to new directions in lake evaporation physics, as it leads to a “constant” and a nondimensional ratio (the former is due to Horton, John Dalton (1802), and Gustav Schübler (1831) and the latter to Jožef Štefan (1881) and Horton), and (C) offer better insights behind the physics of the evaporation paradox (i.e., globally, decreasing trends in pan evaporation are unanimously observed, while the opposite is expected due to global warming). Curiously, Horton's rare observations of convective vapor plumes from lakes may also help to explain the mythical origins of the Greek deity Venus and the dancing Nereids.

Background: The commercially available training phantoms being expensive, homemade models are popular surrogates for training. We intended to study how comparable our indigenously developed ultrasound phantom (IDUP) was with the commercially available model for ultrasound-guided vascular access (USGVA) training. We also assessed the change in confidence among trainees using a 21-h standardized program. Methods: A prospective randomized double-blinded, parallel design study, with sequential allocation, was done after a standardized point of care ultrasound training course. Over three consecutive courses, 48 trainees volunteered to take part in the study. The models (IDUP and commercial phantom) were allocated as model A and model B. In each course, participants were also allotted sequentially to either perform in-plane or out of plane approach first, at the testing stations. Wilcoxon signed-rank test was used to compare pretest with posttest scores. Results: There was a statistically significant difference between IDUP and commercial phantom with respect to the resemblance to human tissue on tactile feedback and ease to perform the procedure. However, both models did not show a statistically significant difference in terms of ease of use, visual resemblance to human tissue, needle visualization, and artifacts on ultrasonography display. A significant change in the confidence levels of participants was seen postcourse. Conclusion: IDUP was a comparable alternative to the commercial model for USGVA training in a resource-limited setting. A 21-h standardized training program improved the trainee's confidence in performing and teaching USGVA.

Background: Central venous catheter (CVC) placement is a frequently performed procedure in the emergency department (ED). We aim to compare two different ultrasound (US)-guided techniques, the short-axis (SAX) approach and the oblique axis (OAX) approach for the insertion of internal jugular vein (IJV) catheters in an ED setting. Methods: This prospective, observational study was conducted in the ED of a single tertiary care teaching hospital on patients requiring IJV cannulation. CVC placement was done using both the SAX and OAX approaches as per the ED physician's discretion. Outcome measures included acute complications, successful insertion of an IJV catheter, number of attempts, and access times. The Chi-square test was used to compare the study variables (acute complications, number of cannulation attempts, and successful cannulation) between the two approaches. Mann–Whitney U-test was applied to compare the mean differences of flash time and cannulation time. Results: Sixty patients were enrolled, of which 30 underwent IJV cannulation by the SAX technique and 30 by the OAX technique. We noted a total of 22 acute complications, 56.7% in the SAX group and 16.7% in the OAX group. A significant incidence of posterior venous wall puncture was noted in the SAX group (50.0%). No significant statistical differences were noted on analysis of other outcome measures. Conclusion: The OAX approach is a useful alternative technique to IJV cannulation in the ED setting. Further multicentric studies in this domain will be required to consider this technique as the primary approach to US-guided IJV cannulation in the ED setting.

The Coronavirus, known as COVID-19, which appeared in 2019 in China, has significantly affected the global health and become a huge burden on health institutions all over the world. These effects are continuing today. One strategy for limiting the virus's transmission is to have an early diagnosis of suspected cases and take appropriate measures before the disease spreads further. This work aims to diagnose and show the probability of getting infected by the disease according to textual clinical data. In this work, we used five machine learning techniques (GWO_MLP, GWO_CMLP, MGWO_MLP, FDO_MLP, FDO_CMLP) all of which aim to classify Covid-19 patients into two categories (Positive and Negative). Experiments showed promising results for all used models. The applied methods showed very similar performance, typically in terms of accuracy. However, in each tested dataset, FDO_MLP and FDO_CMLP produced the best results with 100% accuracy. The other models' results varied from one experiment to the other. It is concluded that the models on which the FDO algorithm was used as a learning algorithm had the possibility of obtaining higher accuracy. However, it is found that FDO has the longest runtime compared to the other algorithms. The link to the Covid 19 models is found here: https://github.com/Tarik4Rashid4/covid19models

With the prevalence of Aerospace Technologies, the regulations of cybersecurity are becoming smarter, assured, and long-lasting. Modern communication network technologies have enormous growth in the cyber threats and masquerading attacks to steal data. Hence concepts and mechanisms are built and made into regulations for a safer environment. Unmanned aerial vehicles (UAVs), often known as drones, are becoming increasingly common, posing new problems in areas such as monitoring, agriculture, weather prediction, surveillance and other fields. This includes a large number of devices that, owing to a lack of energy or a system shutdown, might occasionally send incorrect signals and must be monitored autonomously by drones in remote regions. In this paper, we propose a energy intensive blockchain-based platform for controlling drone operations while ensuring trust and security for all parties involved. The goal of this paper is to explore the extent of Unmanned Aerial Vehicle (UAV) vulnerability to deceptive (Global Navigation Satellite System) GNSS signals by establishing the necessary conditions for UAV via GPS (Global Positioning System) spoofing. The existing algorithms used to mitigate spoofing attacks have unbounded long-term errors, which increase in time during its performance. An innovative idea is necessitating to eliminate those errors, thereby in the proposed work, Ethereum Blockchain has been implemented to create a blockchain network to mitigate the spoofing attacks. Blockchains are incredibly popular nowadays and is the basic technology for cryptocurrencies. Blockchain technology greatly impacts the applications in UAVs. The proposed methodology uses the network that has to be registered in the aerospace components through the ledger associated with relevant data communication in the Blockchain. When an intruder gets acquired with the data in the network with a single block, it cannot affect the entire network due to the data integrity in the ledgers that has been cryptographically assigned. The blockchain network intermittently verifies the geolocation data so that any outlying data would be detected and eliminated quickly. The data that has been verified is made available for the view of aviation and spacecraft operations through the distributed network. The proposed methodology outperforms the existing methods in intense drift error and, in the case of confidentiality and integrity, it has very low risk when compared to existing methods.

Background: Disaster preparedness is one of the critical strategies for effectively managing disasters and has been an area of high focus in the healthcare sector over the past few decades. The current Indian medical undergraduate curriculum does not describe any novel methods for disaster preparedness training. There is a need for a better understanding of novel teaching-learning methods and modes for administering disaster preparedness training among Indian medical students. Objectives: Describe the undergraduate medical students' baseline knowledge and confidence level of disaster preparedness. Compare undergraduate medical students' knowledge scores and confidence levels on disaster preparedness after online and onsite delivery of the disaster preparedness module. Methods: In this educational interventional study, 103 medical students were divided into two groups and subjected to an online or onsite session of the validated disaster preparedness module (based on the COVID-19 pandemic), encompassing a simulation-based tabletop exercise. Baseline testing was done for 52 participants in the online group and 51 in the onsite group of the study. Post-intervention, they were assessed with single-response type MCQs for knowledge and Likert scale-based questions for confidence scores. The pretest and posttest scores were collected, and the data were analysed using two-tailed t-tests for paired analysis of within-group (online group or onsite group) and heteroscedastic analysis of between-group datasets. Results: One hundred and three participants completed the exercise—52 participants were from the online group, and 51 were from the onsite group. After the intervention, there was a statistically significant increase in knowledge and confidence in both online and onsite groups. There is, however, no significant difference in the 'percentage change' in 'knowledge' or 'confidence' between the groups. Conclusions: Our study indicates that the disaster preparedness module, delivered online and onsite, improves knowledge and confidence among undergraduate medical students. However, there is no superiority between one mode of delivery and the other. We conclude that online training can facilitate disaster preparedness training as a corollary to the prescribed traditional training methods for undergraduate medical students in India. [ABSTRACT FROM AUTHOR]

The authors of this toolkit focus on children under the age of 18 comprising approximately 41% of the total population in India. This toolkit has been created with an objective to prepare, mitigate the effects of any surge of COVID-19 in our communities, and help to optimally utilize the scarce resources. The toolkit design suggests the manpower, equipment, laboratory support, training, consumables, and drugs for a 10-bedded pediatric emergency room, 25-bedded COVID pediatric intensive care unit, and 75-bedded COVID pediatric high dependency unit/ward as defined for a 100-bedded facility. A dedicated and detailed chapter is included to address the psychological needs of the children. These data can be modified for other department sizes based on the facilities, needs, local environment, and resources available.

Coronavirus disease 2019 (COVID-19) was an impetus for a multitude of transformations – from the ever-changing clinical practice frameworks, to changes in our execution of education and research. It called for our decisiveness, innovativeness, creativity, and adaptability in many circumstances. Even as care for our patients was always top priority, we tried to integrate, where possible, educational and research activities in order to ensure these areas continue to be harnessed and developed. COVID-19 provided a platform that stretched our ingenuity in all these domains. One of the mnemonics we use at SingHealth in responding to crisis is PACERS: P: Preparedness (in responding to any crisis, this is critical) A: Adaptability (needed especially with the ever-changing situation) C: Communications (the cornerstone in handling any crisis) E: Education (must continue, irrespective of what) R: Research (new opportunities to share and learn) S: Support (both physical and psychological). This article shares our experience integrating the concept of simulation-based training, quality improvement, and failure mode analysis.

Covid-19 has once again brought into focus our limited preparedness to deal with epidemics. Most nations, across the globe, have responded with a resolve to come stronger out of this crisis and leaderships across the world have shown great commitment to protecting its people from Covid-19. Covid-19 has also taught us a few things for the future. One such learning has been that a strong shift in focus towards non-communicable diseases driving health infrastructure across the globe for the last few decades has come at neglect of communicable diseases. In that sense, therefore, the current pandemic has been a wake-up call. Organised Medicine Academic Guild (OMAG), an umbrella organization of professional associations gathered a group of health experts to develop a policy document on epidemic preparedness to limit the influence of epidemics like Covid-19.

The outer surface of the building is the same size as its premises, with greater heat loss. Therefore, when building, renovating, or expanding apartment, if possible, avoid all kinds of spaces, ledges, and lodges in the walls. It makes sense to build unheated exterior buildings on the north side of the apartment. The storage rooms for garden tools and bicycles, technical buildings protect the warm part of the house from wind and cold. In the most common design of a private apartment, the energy consumption for heating is 110-130 kW per 1 m2 per year. In this paper, an energy distribution model was proposed to estimate the photo energy with the help of deep learning model. A small apartment not only uses less energy but also requires lower construction costs. An energy-efficient apartment is a building with a low-energy consumption and comfortable microclimate. Energy savings in such homes can be up to 90%. Annual heat demand can be less than 15 kWh per square meter of energy-efficient home.

Organized medicine is the academic guild of professional medical organizations in India. It was founded at the annual conference of Indian Academy of Pediatrics (PEDICON) on January 7, 2018. Organized medicine is constituted by leading professional medical organizations and mandated to support the sustainability of health agenda of the Government of India. A group of experts on behalf of Organized Medicine Academic Guild (OMAG) of India was constituted to facilitate adequate theories and models on how to make primary care integral to participation of people and intersectoral collaboration in equitable delivery of health care. A subtle, flexible, and comprehensive approach instead of a “compartmentalized existing in silos” approach is likely to be needed. This paper is a formal recommendation on behalf of OMAG with an aspiration to deliver to the people of India, what they need, focusing on discrete objectives with long-term plans.

Aim: Lung ultrasound (LUS) has been extensively used in the evaluation of acute respiratory distress syndrome (ARDS) in the critical care setting. In our study, we aim to assess the utility of point-of-care ultrasound (POCUS)-LUS in the initial assessment of ARDS patients presenting to the emergency department (ED). Subjects and Methods: We evaluated a prospective convenience sample of 73 adult patients presenting to the ED. The bedside LUS was performed by the trained emergency physician on patients with undifferentiated dyspnea with a clinical diagnosis of ARDS according to the Berlin's criteria. The four major LUS findings were examined on structured 12-zone LUS. The observed profile consisted of A lines, well-separated B lines, coalescent B lines, and consolidation among patients who were clinically diagnosed as ARDS. These LUS findings may vary depending on the severity of ARDS. The findings were analyzed using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY, USA). Results: Of the 73 study individuals, majority were male 46 (63%). The distributions of study individuals were as follows: 27% – mild ARDS, 37% – moderate ARDS, and 36% – severe ARDS. Coalescent B lines are present in about 70.4% and 92.3% of moderate and severe ARDS patients, respectively. Consolidations are predominantly present in moderate (100%) and severe (92.3%) ARDS. Conclusion: LUS in the initial assessment of patients' with ARDS yielded significant findings in the three clinically designated categories. This study opens up the possibility of using POCUS as an adjunct in the initial assessment of ARDS patient in the ED.

INDUSEM was established as an INDO-US Satellite Knowledge Network in 2005. It brought together the academic leaders and innovators from India and the US with the goal of creating collaborative synergies and creative solutions to advance the knowledge and science of emergency medicine (EM) in India. Since 2005, the leadership of INDUSEM devoted substantial resources, effort, and expertise to ensure that newly implemented clinical institutes and training programs have the necessary resources and logistical support to effectively advance EM and Traumatology Sciences in India. As a result, significant synergies and progress were achieved toward establishing EM training programs and building clinical infrastructure through education, grant funding, research, skills development, bidirectional collaborations, and sustained influence on public health policy development. As INDUSEM's mission matures, its efforts will increasingly focus on creating long-term sustainability across clinical, didactic, educational, outreach, health policy, and research domains. In this joint statement, the authors describe the evolution of INDUSEM's institution of INDO-US Summit into the World Academic Congress of EM , with the parallel inception of an India-centric academic enterprise, EMINDIA.

Introduction: In Russell's viper bites, due to the lack of a better alternative, whole blood clotting test (WBCT) remains the standard test even though its reliability and sensitivity has been shown to be low. Activated partial thromboplastin time (aPTT)-based clot waveform analysis (CWA) is an optic absorbance assay that can be used as a global clotting test. In this study, the objective was to assess the changes in CWA and to compare CWA to WBCT and aPTT in patients with Russell's viper envenomation. Methods: The datum was collected prospectively over 2 months as a pilot observational study in a tertiary care center. All proven cases of Russell's viper-envenomated individuals with preliminary CWA data and WBCT were included in the study. The clot wave (CW) of the five individuals, which met all the stringent inclusion criteria, was analyzed and interpreted. Results: CW absorbance sigmoid waveform was deranged in all 5 cases, of which 4 showed a change in CWA even before an abnormal aPTT. Three of the 5 had a normal WBCT but showed early changes in CWA. Atypical biphasic waveform reported in disseminated intravascular coagulation in other prior studies is seen in venom-induced consumptive coagulopathy also. In all patients where a second derivative was plotted, the second (lower) phase of the second derivative showed a slow rise to baseline. Conclusion: CWA showed changes which provided information earlier than the conventional coagulation studies in the snakebite victims studied. While aPTT or WBCT reflects clotting time, CWA conveys the dynamic process of clot formation and stabilization. CWA may reveal disorders of clotting in snakebite victims before the conventional tests become abnormal. Future research should assess the speed and accuracy of the test in diagnosing hemotoxic envenomation and its potential role in guiding antivenom therapy.

Context: The guideline recommended dose of intravenous (i.v) recombinant tissue-type plasminogen activator (rt-PA) for acute ischemic stroke is 0.9 mg/kg in the European and American populations. In Asiatic population, some studies have shown that a lower dose of i.v rt-PA is equally efficacious. Aims: To assess if there is a need for a dose optimization for i.v rt-PA study among Indians. Setting and Design: A prospective, observational database of acute stroke cases that presented to a tertiary care institute over a period of 1 year was made. Methods: The data procured using a prestructured elaborate pro forma. Based on the dose of rt-PA received, the individuals were divided into three groups; Group 1 (0.6–0.7 mg/kg), Group 2 (0.7–0.8 mg/kg), and Group 3 (0.8–0.9 mg/kg). Improvement was assessed in each group and between the thrombolysed and nonthrombolysed individuals. Statistical Analysis Used: The nonparametric Mann–Whitney U-test (Wilcoxon rank-sum test) was applied for assessing improvement of National Institutes of Health Stroke Scale score with significance level of α < 0.05 (P < 0.012) and compliance level at 95%. Results: Between the thrombolysed (n = 46) and nonthrombolysed (n = 113) group, there was a statistically significant neurological improvement in the thrombolysed group. Clinical improvement was noted in 75%, 85.7%, and 66.7% of individuals receiving rt-PA in Groups 1, 2, and 3, respectively. Four out of the five who developed a clinically significant intracranial hemorrhage were thrombolysed at a dose of 0.8–0.9 mg/kg rt-PA (Group 3). Conclusion: There is a need for a properly randomized, dose optimization study of i.v rt-PA in the Indian subcontinent.

The government of India has done remarkable work on commissioning a government funded prehospital emergency ambulance service in India. This has both public health implications and an economic impact on the nation. With the establishment of these services, there is an acute need for standardization of education and quality assurance regarding prehospital care provided. The International Joint Working Group has been actively involved in designing guidelines and establishing a comprehensive framework for ensuring high-quality education and clinical standards of care for prehospital services in India. This paper provides an independent expert opinion and a proposed framework for general operations and administration of a standardized, national prehospital emergency medical systems program. Program implementation, operational details, and regulations will require close collaboration between key stakeholders, including local, regional, and national governmental agencies of India.

OBJECTIVE: Cardiovascular disease is the leading cause of death worldwide. As there is an increase in the global burden of ischemic heart disease, there are multiple scoring systems established in the emergency department (ED) to risk stratify and manage acute coronary syndrome (ACS) in patients with chest pain. The objective of this study was to integrate point-of-care echo into the existing history, electrocardiogram, age, risk factors, and troponin (HEART) score and evaluate a novel scoring system, the echo HEART (E-HEART) score in risk stratification of patients presenting with undifferentiated chest pain to the ED. The E-HEART Score was also compared with existing traditional scoring systems for risk-stratifying acute chest pain. METHODS: A diagnostic accuracy study involving 250 patients with chest pain at the ED of a single tertiary care teaching hospital in India was conducted. The emergency physicians assessed the E-HEART score after integrating their point-of-care echo/focused echo findings into the conventional HEART score on presentation. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE) within 4 weeks of initial presentation. The accuracy of the E-HEART score was compared with other conventional risk stratification scoring systems such as the thrombolysis in myocardial infarction (TIMI), history, electrocardiogram, age, and risk factors, Troponin Only Manchester ACS (T-MACS), and HEART scores. RESULTS: A total of 250 patients with a median age of 53 years (42.25-63.00) were part of the study. Low E-HEART scores (values 0-3) were calculated in 121 patients with no occurrence of MACE in this category. Eighty-one patients with moderate E-HEART scores (4-6) were found to have 30.9% MACE. In 48 patients with high E-HEART scores (values 7-11), MACE occurred in 97.9%. The area under receiver operating characteristics (AUROC) of E-HEART score is 0.992 (95% confidence interval: 0.98-0.99), which is significantly higher than AUROC values for HEART (0.978), TIMI (0.889), T-MACS (0.959), and HEAR (0.861), respectively (P < 0.0001). At a cutoff of E-HEART score >6, it accurately predicted ACS with a sensitivity of 92% and a specificity of 99% with a diagnostic accuracy of 97%. CONCLUSION: The E-HEART score gives the clinician a quick and accurate forecast of outcomes in undifferentiated chest pain presenting to the ED. Low E-HEART scores (0-3) have an extremely low probability for short-term MACE and may aid in faster disposition from the ED. The elevated risk of MACE in patients with high E-HEART scores (7-11) may facilitate more aggressive workup measures and avoid disposition errors. E-HEART is an easily adaptable scoring system with improved accuracy compared to conventional scoring systems. [ABSTRACT FROM AUTHOR]