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Background: Acute diarrhoeal diseases (ADD) account for a large number of preventable deaths in India, especially in children less than five years who are more at risk than adults with respect to the degree of dehydration and complications. (1) To measure the incidence of ADD among children under 5 years; (2) Determine risk factors associated among children; (3) Study treatment-seeking behaviour of their mothers. Community-based, prospective, longitudinal study conducted in an urban area of Goa. Material and Methods: 250 children enrolled in the study with their mothers by stratified random sampling technique, conducted house-to-house visits every three months and mothers were interviewed with pre-tested semi-structured questionnaire. The duration of study was one year from January to December 2018. Data entered using EpiData Entry Client®, Analysed using SPSS® software version 22. Student's t-tests and Chi-square tests were used. Results: The incidence of ADD was 0.124 episodes/child/year. Significant association was noted between ADD in children and certain socio-demographic factors like child's sex, birth order, birth weight, immunization status, malnutrition, mother's age group, mother's education, and mothers' hygiene practices. Conclusions: Efforts should be made to educate all mothers about the seeking timely treatment, awareness about home-based management and their types, awareness of ORS, zinc, importance of hygienic practices like hand washing for mother and child. [ABSTRACT FROM AUTHOR]

Aim: The aim of the study was to highlight the pathology, clinical spectrum, and approach considerations in abdominoscrotal hydrocele (ASH). Materials and Methods: Our study included eight children with ASH from 2015 to 2022. The demographics, clinical presentation, investigations, operative details, and postoperative outcome were collected retrospectively from case files. Results: The age of presentation ranged from 11 months to 2 1/2 years. Six lesions were on the right side and two were on the left side. One child presented with an acute scrotum and underwent emergency inguinal exploration, revealing hemorrhagic fluid after trauma. Others presented with tense inguinoscrotal swelling, which was fully reducible but refilled promptly after emptying. Preoperative ultrasound showed the abdominal component in 50%, while others were detected intraoperatively. All of them were approached inguinally, and the hydrocele sac was traced proximally to the abdominal component through the internal ring. This was drained and a partial excision of the extraperitoneal sac was done. An additional patent processus vaginalis (PPV) was identified in 87%, dissected up to the deep ring, and ligated. On follow-up, there was no recurrence. Conclusion: ASH is an uncommon condition that should be identified and dealt with appropriately. Physical examination and ultrasonography are usually sufficient for diagnosis. The inguinal approach is a safe, simple method and an extension of the standard operation for the hydrocele. One must keep in mind to explore for an additional narrow PPV to prevent the recurrence of hydrocele. [ABSTRACT FROM AUTHOR]

Introduction: Despite advances in medical therapy, liver replacement continues to be the only definitive mode of therapy for children with end-stage liver disease (ESLD). However, its acceptance in India has been discouraging more due to financial and logistic reasons than the availability of expertise. This report outlines our journey and highlights issues pertinent to circumstances in an emerging economy like India. Aim: The aim is to review a single center's 100 case experience with liver transplantation (LT). Materials and Methods: A prospective analysis of all children who underwent LT since 2005 at our institute was done. The data were collated from a maintained structured database. Results: Hundred children underwent LT. Sixty-four were boys. Age ranged from 5 to 144 months, with a median of 17 months. The mean weight of the cohort was 7.5 kg (ranging from 3.7 to 31.5 kg), with 60% of our children weighing between 5 and 10 kg. Biliary atresia is the most common indication (57%); others include metabolic disorders, progressive familial intrahepatic cholestasis, and hepatoblastoma. Two patients were for acute liver failure. Ninety-one children underwent live donor LT (mothers being the majority of the donors). None of the donors had any major postoperative complications. Major intraoperative complications include sepsis (39%), vascular complications (17%), biliary leak (11%), and intestinal complications (11%). Early postoperative deaths occurred in 18% of patients with sepsis being most common cause. The mean follow-up was 8.5 years and the overall survival is 70%. The mean survival is time (months) = 176.1. All surviving patients were followed up and had achieved good catch up growth by 3rd and 5th years posttransplant. The long-term sequalae include recurrent intercurrent infections, graft rejection (9%), posttransplant lymphoproliferative disease (5%), and portal vein stenosis (5%). Conclusion: 0ur experience demonstrates the feasibility of LT in children with ESLD in India. With longer-living grafts, patients often struggle with other issues such as compliance with follow-up, financial issues, recurrent infections, and neurological problems. Close monitoring with regular follow-up of patients helps in early recognition and treatment of late-onset complications, thus helping the overall long-term outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To describe the subretinal hyporeflective globule in cases of central serous chorioretinopathy (CSC). Methods: A retrospective analysis of consecutive cases of CSC presenting to a tertiary eye care center in eastern India was conducted. Subretinal hyporeflective globules were identified as small globular lesions below the external limiting membrane/ellipsoid zone, but above the RPE layer. They had a hyperreflective border with a hyporeflective core and a clear posterior tail of hyper-transmission. Results: The present study analyzed 137 eyes of 137 patients. Eighty (58.4%) eyes had acute disease at presentation, 48 (35%) eyes had chronic disease, and eight (5.8%) eyes had resolved CSC. Subretinal hyporeflective globules were seen in 27 (21.8%) eyes, of which choroidal caverns were seen in seven (5.1%) eyes. Twenty-five eyes with chronic CSC and only two eyes with acute CSC had subretinal hyporeflective globules. Three eyes with resolved CSC had subretinal hyporeflective globules. Conclusion: We describe subretinal hyporeflective globule as a novel optical coherence tomography (OCT) finding in cases of CSC and describe its clinical correlates. [ABSTRACT FROM AUTHOR]

Background: With the provision of a small positive end-expiratory pressure (PEEP) effect, high-flow nasal oxygen (HFNO) therapy carries a risk of stomach distension. The present study was conducted to find out the air leak in the gastric antrum leading to gastric distension in adult patients with acute respiratory failure receiving HFNO therapy. Materials and methods: Adult patients with early hypoxemic respiratory failure requiring HFNO therapy were enrolled in this trial. Before initiation of HFNO therapy, baseline gastric volume (GV) and the average number of peristaltic contractions over one minute were measured using ultrasound. Once the patient was stabilized on HFNO therapy, a 2nd, 3rd, and 4th ultrasound scans were acquired at 10, 20, and 30 minutes respectively. Vitals and blood gas values were recorded at the baseline and after 30 min of initiation of HFNO therapy. Patient comfort, duration of HFNO therapy, and outcome were also recorded. Results: The GV at 10, 20, and 30 minutes were significantly larger (p < 0.001) compared to baseline. This increase in GV was associated with a significantly increased number of peristaltic contractions and had a significant positive correlation with the HFNO flow (r = 0.541; p < 0.001). The HFNO therapy was well tolerated by most of the patients and led to a significant improvement in the vitals and blood gas parameters at 30 minutes after initiation of HFNO therapy. Conclusion: In adult patients with hypoxemic respiratory failure, the use of HFNO therapy produces gas leaks into the stomach leading to increased gastric volume. The gastric distension increases the peristaltic contraction and higher flows result in more distension. [ABSTRACT FROM AUTHOR]

Introduction: Intestinal obstruction has emerged as a challenging emergency putting unwanted financial as well as clinical burden globally. A study on etiology, symptoms, and management could benefit in treating larger population of the region. Aim: The study aimed to study the demography, etiology, symptoms, and management of intestinal obstruction among a population in central India. Materials and Methods: A single-center prospective observational study of intestinal obstruction was done among patients admitted to various surgical wards, during the period from January 1, 2018, to May 31, 2019. Here, we studied 50 cases of intestinal obstruction. Patients belonged to the age groups ranging from 15 to 85 years were included. Patients were selected on the basis of clinical history, physical findings, and radiological and hematological investigations. For statistical analysis, Chi-square and Fisher exact tests were performed. Results: There were a total of 12,233 admissions among which 228 cases were acute intestinal obstruction, we randomly selected 50 cases for the present study. Males were 72% (n = 36) and females were 28% (n = 14). The age groups 31-40 (20%) and 51-60 (20%) showed the highest incidence. Postoperative adhesions (40%), obstructive hernia (30%), and malignancy (14%) were the major causes of obstruction. Surgical intervention was carried out with release of adhesions in majority of cases (40%), resection anastomosis in 22%, and release of adhesions with herniorrhaphy in 18% of cases. Pain in the abdomen was a major symptom (88%) among the cases. The mortality rate was 14% of the total subjects involved in the study. Conclusion: Acute intestinal obstruction remains an important surgical emergency in the surgical field, success in the treatment depends largely upon early diagnosis and proper management and treatment of pathological effects of the obstruction. Postoperative adhesions are one of the main causes responsible for intestinal obstruction. [ABSTRACT FROM AUTHOR]

Background: Stroke is a leading cause of long-term disability worldwide, resulting in significant physical impairments, including hemiparesis and loss of motor control. Rehabilitation plays a crucial role in aiding stroke patients' recovery, and various approaches have been used to improve their functional abilities. Two widely practiced methods are Proprioceptive Neuromuscular Facilitation (PNF) exercises and focused regimen programs. Purpose: To compare the effectiveness of PNF exercises and focused regimen programs in improving motor function, mobility and quality of life in stroke patients. Materials and Methods: The total of 30 subjects with acute stroke were taken from Saicharan physio Center- Arakkonam. The subjects are selected based on inclusion and exclusion criteria The intervention was given for 6 weeks. The entire process was performed from November 2022 to February 2023. Result: According to the statistical analysis, PNF exercises revealed significant in improving both balance and quality of life measures for acute stroke patients compared to focused regimen program. Conclusion: This study finally concluded that the PNF exercises has a high impact in improving both balance and may enhance neuroplasticity. [ABSTRACT FROM AUTHOR]

Objectives: To determine post‐COVID syndromes in the Indian population, correlating a wide spectrum of post‐COVID manifestations with acute disease severity and associated risk factors. Background: Post‐COVID Syndrome (PCS) is defined as signs and symptoms that develop during or after acute COVID‐19 infection. Design of Study: This is a prospective observational cohort with repetitive measurements. Methods: The study followed RT‐PCR confirmed COVID‐19‐positive survivors discharged from HAHC Hospital, New Delhi, for a period of 12 weeks. The patients were interviewed over the phone at 4 weeks and 12 weeks from the onset of symptoms for evaluation of clinical symptoms and health‐related quality of life parameters. Results: A total of 200 patients completed the study. At the baseline, 50% of the patients were categorised as severe based on their acute infection assessment. At 12 weeks after symptom onset, fatigue (23.5%), hair loss (12.5%) and dyspnea (9%) were the main persistent symptoms. The incidence of hair loss (12.5%), memory loss (4.5%) and brain fog (5%) were found to be increased as compared to the acute infection period. Severity of the acute COVID infection behaved as an independent predictor for the development of PCS, with high odds of experiencing persistent cough (OR = 13.1), memory loss (OR = 5.2) and fatigue (OR = 3.3). Further, 30% of subjects in the severe group experienced statistically significant fatigue at 12 weeks (p <.05). Conclusion: From the results of our study, it can be concluded that there is a huge disease burden of post‐COVID Syndrome (PCS). The PCS comprised multisystem symptoms ranging from serious complaints of dyspnea, memory loss and brain fog to non‐serious complaints of fatigue and hair loss. Severity of the acute COVID infection behaved as an independent predictor for the development of PCS. Our findings strongly recommend vaccination against COVID‐19, for protection from disease severity as well as prevention of PCS. Relevance to Clinical Practice: The findings of our study support the multidisciplinary approach required for the management of PCS with a team comprising of physicians, nurses, physiotherapists and psychiatrists working in close coordination for the rehabilitation of these patients. As nurses are considered the most trusted professionals in the community and the class of health workers associated with rehabilitation, focus should be given to educating them on PCS, which would prove to be an important strategy for efficient monitoring and long‐term management of COVID‐19 survivors. [ABSTRACT FROM AUTHOR]

One of the most performed emergency abdominal surgeries is appendicectomy. Studies show that serum bilirubin is raised in acute appendicitis and appendicular perforation, the significance of which has not been stressed. The purpose of the study is to find the relation between them. To study the relationship between hyperbilirubinemia and acute appendicitis; and to evaluate its credibility as a diagnostic marker for acute appendicitis and perforation. Case series analysis. This study was conducted in a tertiary hospital S.C.B. Medical College, Cuttack from October 2019 to October 2021. One hundred-fifty patients with clinical diagnosis acute appendicitis or appendicular perforation were randomly sampled. Serum bilirubin and liver function tests were carried out in the patients opting for the study. The mean total serum bilirubin was 1.771 SD0.92mg/dl which was above >1.0 mg/dl representing hyperbilirubinemia. Amongst the 117 patients diagnosed with acute appendicitis, 74 patients (63.24%) were found to have elevated bilirubin (mean 1.49 SD0.63 mg/dl) whereas in patients diagnosed with appendicular perforation (n = 33), 28 patients (84.8%) had bilirubin elevated (mean 2.77 SD1.08 mg/dl). The cut-off value of serum bilirubin was found to be 2.15 mg/dl above which complications occur. The sensitivity and specificity of bilirubin in diagnosing acute appendicitis and appendicular perforation were 71.96% and 38.88% respectively. The p-value is 0.001 suggesting a positive correlation. Serum bilirubin can be a useful investigation as it can be done easily and is less expensive. Patients with raised bilirubin of three or more times the normal bilirubin value and clinical signs of appendicitis and appendicular perforation have a higher probability of having complicated appendicitis on histopathological report. [ABSTRACT FROM AUTHOR]

In September 2022, Panchkula Civil Hospital reported an outbreak of acute febrile illness (AFI) in Pinjore, located in the Himalayan foothills, Haryana, North India. There was an upsurge of fever cases. Blood samples were taken from suspected patients (n = 58) with AFI and subjected to serology of dengue, chikungunya, Japanese encephalitis, leptospira and scrub typhus. The samples were also screened for West Nile & Zika virus RNA using real-time PCR. Viral strains were characterized by sequencing. Of the 58 cases of AFI, Dengue could be identified in 45 (77.58%) followed by JE and Chikungunya in 2 cases each (3.44%), respectively. Among Dengue positive cases, 44 had monoinfection (97.77%) and 1 patient had dengue and JE. None were positive for Zika, West Nile, Scrub typhus, and Leptospira with the testing protocol. Four patients developed dengue with warning signs, such as abdominal pain in one patient and recurrent vomiting in the remaining three. The dengue serotype could be determined in 17 samples and revealed serotype 2. Molecular evolution analysis based on the complete envelope gene revealed that all DENV-2 strains (n = 13) circulated in the outbreak area belonged to the DENV-2 cosmopoliton genotype. In the early stages of infection, relying only on clinical manifestations is ineffective, so both molecular and serological assays along with clinical diagnosis are noteworthy for determining the aetiology of AFI. [ABSTRACT FROM AUTHOR]

Background: Acute respiratory infections (ARIs) are an important cause of pediatric mortality–morbidity worldwide, the most common etiology being viral. This study aims to identify causative organisms for ARIs admitted in pediatric intensive care unit (PICU), when multiplex polymerase chain reaction (PCR) testing of respiratory secretions was sent; any seasonal trends detect microbiological correlation when co-infections. Subjects and Methods: This was a retrospective observational study, from July 2021 to December 2022, of children aged 1 month–18 years, whose multiplex PCR tests (nasopharyngeal, endotracheal [ET] secretion or bronchoscopic alveolar lavage [BAL]) were sent when admitted for ARI to tertiary care PICU. Results: In the study period, 372 of 1492 medical PICU admissions were ARI. Multiplex PCR of 81 respiratory secretions was sent, of which 69 (85%) were positive. Multiplex pcr sample positivity : 83% for nasopharyngeal aspirate, 78% for ET secretions, 100% for BAL samples. Forty-one percent of samples detected >1 organism. Respiratory syncytial virus (RSV)-A was the most common virus (18); other organisms included adenovirus (n = 5), influenza (n = 9), parainfluenza (n = 5), rhinovirus: 13, Pneumocystis Jerovecci (PCP): 4, Streptococcus pneumoniae: 17, pertussis: 1, and Haemophilus influenzae B: 9. ARIs were seen throughout the year with peaks in monsoon season and a peak in cases of ARI due to RSV from July to October. Of co-infections with bacteria in ET secretions and BAL samples via multiplex PCR, bacterial culture reports were sterile. Conclusions: Multiplex PCR detected organisms in 85% of ARI patients tested. Most of the ARIs getting admitted to PICU were viral in origin. RSV was the most common virus isolated showing peak from July to October, local monsoon season. With extended viral and bacterial PCR being available, mixed infections/colonization with uncertain significance are being detected. [ABSTRACT FROM AUTHOR]

Background: Malnutrition is a major public health problem and leading determinant of morbidity and mortality in under-five children in India. Aim & Objective: To assess determinants of Severe Acute Malnutrition (SAM) in under-five children of Dibrugarh district, to assess knowledge and practice of Infant, Young Child Feeding Practices (IYCF) and to assess the knowledge and practice of identification of SAM of Anganwadi workers. Settings and Design: Dibrugarh district, Assam. Mixed method study. Methods and Material: It was a case-control study that interviewed mothers of children between 6- 59 months between June 2021 to May 2022. Using a pre-tested semi-structured questionnaire Interviews of a total of 164 under-five children's mothers (82 cases and 82 controls)] were done. Qualitative data was also collected by in-depth interviews of Anganwadi workers (AWWs). Statistical analysis used: SPSS version 25.0. Chi-Square test, unadjusted OR for Bivariate analysis and adjusted odds ratio using Multiple logistic regression was calculated. Results: Determinants of severe acute malnutrition were joint family (AOR 3.08, 95% CI 1.02-9.31, p= 0.046); birth weight less than 2.5 kg (AOR 20.6, 95% CI 4.50-94.03, p=<0.0001); mothers with less than 4 antenatal check-ups (AOR 5.13, 95% CI 1.28-29.47, p=0.021); partial immunization (AOR 9.2, 95%CI 1.83-46.59, p=0.007); and irregular utilization of ICDS services (AOR 27.36, 95%CI 5.73-130.66, p=<0.0001). Problems faced by AWWs during service delivery were communication barriers, community resistance during home visits, and increased workload during COVID-19. Conclusions: IYCF practices need to be promoted with screening and growth monitoring for early detection and timely referral of malnutrition along referred back and linkages of services so that home-based and community-based management can be done to prevent severe acute malnutrition. [ABSTRACT FROM AUTHOR]

Background: Regular epidemiological investigations are essential for gaining insights into the incidence of poisoning in various geographical areas. The purpose of this study was to assess the characteristics and trends of deaths due to poisoning in Gandhi Medical College, Secunderabad. Methods: Hospital records, inquest reports, post-mortem reports and toxicological analysis reports were analysed among various age groups, sex, type and manner of poisoning. Snake bite poisoning cases were excluded. Results: Out of 318 cases, we got positive toxicological analysis report for 287 (90.2%) cases. In our study predominance of male cases 259(81.45%) compared to female cases 59(18.55%) reported. In the age group most involved was 21-30 yrs 107 cases (34%) followed by 31-40 yrs 82 (26%), 41-50 yrs 49 (15%). Organophosphate poisoning reported in high number of cases 189(65.85%) followed by paraquat poisoning 44(15.33%), tablet poisoning 23(2.01%), Sulphuric acid poisoning 22(7.67%) and others 9 (3.14%) (Rodenticide, phenol, pyrethroid, nitrite). In manner of death suicidal cases 311(97.80%) reported more followed by accidental cases 7 (2.20%). In suicidal cases, economic constraints as a reason were outnumbered 209 cases (67.20%) followed by health issues 52(16.72%), academic failure 35(11.25%), love failure 15(4.82%). In region wise, rural areas reported more cases 244(76.73%) when compared to urban area 74 (23.27%). In season wise, more cases reported in April to July 148 cases (46.50%) followed by December to March 97 cases (30.5%), August to November 73 (23%). Zero homicidal poisoning noted. Conclusion: Organophosphate poisoning in active male population of rural areas with economic constraints were reported to be predominant. [ABSTRACT FROM AUTHOR]

Background: Acute and transient psychotic disorder (ATPD) was recognized as separate from other psychotic disorders and described in the International Classification of Diseases (ICD) tenth revision for the first time. A lot of research on ATPD has been conducted in India over the last six decades, but a review focusing exclusively on Indian research on ATPD is not available. Aim: This paper aims to review the literature on ATPD emerging from India. Methodology: A combination of search terms "Acute and Transient Psychosis," "acute psychosis," "non-affective psychosis," "non-affective psychotic disorder," "reactive psychosis," "first-episode psychosis," and "India" were searched on various search engines like PUBMED, Medknow, Hinari, and Google Scholar. We also did a hand search for additional relevant articles, including published abstracts of the Indian Journal of Psychiatry from 2007 to 2023. Relevant papers were selected. Results: The prevalence of ATPD varies across different study settings, and it tends to have an abrupt to acute onset, and is primarily associated with stress. Few studies have assessed the subtypes of ATPD, and symptom profile has been inconsistently reported. There is a lack of trials on the effectiveness or efficacy of antipsychotics in ATPD patients. In a large proportion of patients initially diagnosed with ATPD, the diagnosis remains stable, with recurrence varying from 10% to 46.6% based on the duration of follow-up. Conclusion: There is a need for more multicentric studies, studies with larger sample sizes, and consistency in data about risk factors. There is a need to evaluate symptom profile, course, outcome, and treatment outcomes in patients with ATPD using validated instruments to improve our understanding. Further, there is a need for comparative studies to evaluate the risk factors for ATPD. [ABSTRACT FROM AUTHOR]

Background: This research aimed to evaluate the clinico-epidemiological profile and short-term outcomes of patients admitted to the emergency department of a tertiary hospital. Materials and Methods: This prospective observational cross-sectional study was conducted between January 1, 2021, and June 30, 2022, in the Emergency Department of a tertiary hospital. Patients of either gender of any age attending the emergency department with acute poisoning were included. These cases were analyzed for their epidemiological profiles, poisoning characteristics, and various clinical variables influencing patient outcomes. Results: Out of a total of 236 patients, 190 patients (80.5%) were aged more than 18 years. Comorbidities were present in 32 (13.5%) patients, and psychiatric illness was the most common comorbidity. The intention of poisoning was suicidal in 185 patients (78.4%) and accidental in 51 patients (21.6%). Organophosphate was the most common poisoning seen in 55 patients (23.3%), followed by drug ingestion seen in 44 patients (18.6%). Twenty-eight patients (11.8%) were transferred to the intensive care unit. Nineteen patients (8.1%) required mechanical ventilation. There were ten deaths (4.2%) in the study population. Aluminum phosphide poisoning was associated with the highest mortality rate, followed by organophosphate poisoning. Conclusions: This study indicates that most poisoning cases involved young people, mainly males. Organophosphorus poisoning was one of the most common poisonings, followed by the ingestion of drugs in this part of the world. Aluminum phosphide had the highest fatality rate. [ABSTRACT FROM AUTHOR]

Zika virus (ZIKV) is an arthropod-borne flavivirus that presents with acute febrile illness associated with rash, arthralgia and conjunctivitis. After years of sporadic reports in Africa, the three major outbreaks of this disease occurred in Yap Islands (2007), French Polynesia (2013–14) and South Americas (2015–16). Although, serological surveys suggested the presence of ZIKV in India in 1950s, cross-reactivity could not be ruled out. The first four proven cases of ZIKV from India were reported in 2017. This was followed by major outbreaks in the states of Rajasthan and Madhya Pradesh in 2018. Fortunately, the outbreaks in India were not associated with neurological complications. These outbreaks in India highlighted the spread of this disease beyond geographical barriers owing to the growing globalization, increased travel and ubiquitous presence of its vector, the Aedes mosquito. In this review, we discuss the epidemiology, clinical features and management of ZIKV in India. [ABSTRACT FROM AUTHOR]

Acute paraplegia in pregnancy is uncommon but can result from pathology including Guillain-Barre syndrome, acute transverse myelitis, and spinal tuberculosis, also known as Pott's disease of the spine. India has a high incidence of tuberculosis (2.8 million cases annually) therefore spinal tuberculosis is a particularly important disease to consider during pregnancy. Management of spinal tuberculosis in pregnancy poses a challenge especially at term gestation as immobilization of the spine and maintaining supination is difficult, particularly at delivery. [ABSTRACT FROM AUTHOR]

Introduction and Aims : Dilated cardiomyopathy (DCM) is an important cause of heart failure (HF) among children. Research on pediatric DCM remains surprisingly scarce. The primary objective of the study was to evaluate the clinical profile and outcomes of pediatric DCM and the secondary objective was to study the predictors of outcome. Methods and Results : We enrolled all patients with cardiomyopathy who presented to us between 1990 and 2020 and were younger than 18 years. During the 30-year study period, we identified 233 cases of pediatric cardiomyopathy. One hundred and nineteen (51%) cases had DCM. This retrospective cohort was analyzed to study their outcome and the possible predictors of outcome. Nearly, 8% presented in the neonatal period, and 37% in infancy. The most common mode of presentation was dyspnea on exertion (71%). Ninety-three patients presented in heart failure (78%). The median left ventricular dimension z-score in diastole was 4.3 (range 2.5--9.06). The median left ventricle (LV) ejection fraction was 31%. Seventy-two percent of this cohort were on angiotensin-converting-enzyme inhibitors, 40% on aldosterone antagonists, and 47% on beta-blockers. One-third had syndromic, metabolic, genetic, or any secondary cause identified. Twenty-seven patients satisfied the three-tiered clinical classification for the diagnosis of probable acute myocarditis. Over a mean follow-up of 3.29 years, 27% were lost to follow-up. Among the remaining patients who were on follow-up (n = 86), 39 (45%) died, 31 (36%) recovered, and 16 (18%) had persistent LV dysfunction. Heart Failure was the most common cause of death. Eight patients in this cohort (4.2%) had thromboembolic phenomena. Nine had sustained ventricular arrhythmias and six had atrial/junctional arrhythmias. Among the various risk factors studied, only infantile onset had a significant relationship with death or ventricular arrhythmias (P value-- 0.05). The 5-year survival rate of DCM patients was 59%. Conclusion : A reasonably good percentage of our population showed recovery of the left ventricular function (36%). Only infantile onset had a significant relationship with death or ventricular arrhythmias. The outcome in our DCM cohort is similar to other population cohorts. [ABSTRACT FROM AUTHOR]

Background: Post-acute COVID symptoms have become a major health concern and one of the most important causes of morbidity throughout the world. Hence, it is important to document the pattern of presentation in post-COVID syndrome patients in India, which has been one of the countries with the largest acute COVID-19 infections. Aims and Objectives: This study was done to estimate the prevalence of post-acute COVID syndrome in patients recovered from acute COVID infection and to determine the factors influencing with its incidence. Materials and Methods: Community-based observational study in which patients who have recovered from acute COVID infection 3–6 months before the study period were selected using multistage sampling. Data were collected through house visits using a prevalidated questionnaire containing details of acute COVID-19 infection, treatment taken, vaccination status before the infection, symptoms in the period between 4 and 12 weeks, and symptoms after 12 weeks of acute COVID infection. Results: Out of the 265 patients studied, 14.34% had ongoing symptomatic COVID-19 in the first 3 months of acute illness and 9.81% had post-COVID symptoms even after 3 months. 17.74% of the patients had a history of pre-existing comorbid illnesses and 31.32% had received two doses of vaccination before acquiring COVID-19 infection. 92.83% were treated in home quarantine, 4.91% needed hospitalization without oxygen supplementation, and 2.26% required oxygen or ventilatory support. The most common post-COVID symptoms reported were tiredness, easy fatiguability, breathlessness, and body ache. Female gender, presence of comorbidities, and mode of treatment had a significant role in predicting the incidence of post-COVID symptoms. Conclusion: The study clearly showed that the severity of acute COVID infection has a significant correlation with the incidence of both ongoing symptomatic COVID and post-COVID syndrome. Other factors that increased the incidence included female gender and pre-existing comorbidities. [ABSTRACT FROM AUTHOR]

BACKGROUND In 2017, more than half the cases of typhoid fever worldwide were projected to have occurred in India. In the absence of contemporary population-based data, it is un-clear whether declining trends of hospitalization for typhoid in India reflect in-creased antibiotic treatment or a true reduction in infection. METHODS From 2017 through 2020, we conducted weekly surveillance for acute febrile illness and measured the incidence of typhoid fever (as confirmed on blood culture) in a prospective cohort of children between the ages of 6 months and 14 years at three urban sites and one rural site in India. At an additional urban site and five rural sites, we combined blood-culture testing of hospitalized patients who had a fever with survey data regarding health care use to estimate incidence in the community. RESULTS A total of 24,062 children who were enrolled in four cohorts contributed 46,959 child-years of observation. Among these children, 299 culture-confirmed typhoid cases were recorded, with an incidence per 100,000 child-years of 576 to 1173 cases in urban sites and 35 in rural Pune. The estimated incidence of typhoid fever from hospital surveillance ranged from 12 to 1622 cases per 100,000 child-years among children between the ages of 6 months and 14 years and from 108 to 970 cases per 100,000 person-years among those who were 15 years of age or older. Salmonella enterica serovar Paratyphi was isolated from 33 children, for an overall incidence of 68 cases per 100,000 child-years after adjustment for age. CONCLUSIONS The incidence of typhoid fever in urban India remains high, with generally lower estimates of incidence in most rural areas. (Funded by the Bill and Melinda Gates Foundation; NSSEFI Clinical Trials Registry of India number, CTRI/2017/09/009719; ISRCTN registry number, ISRCTN72938224.) [ABSTRACT FROM AUTHOR]

Scrub typhus is a disease endemic to the Indian subcontinent caused by the obligate intracellular pleomorphic organism, Orientia tsutsugamushi. Scrub typhus, among other acute febrile illnesses, manifests as prodromal symptoms of fever, malaise, myalgia and anorexia followed by a distinct maculopapular rash, hepatosplenomegaly and lymphadenopathy. We report the case of a patient presenting to tertiary care hospital in southern India in 2021 who developed a rare cutaneous vasculitis secondary to infection with Orientia tsutsugamushi. After performing the Weil-Felix test, a diagnostic titre of >1:640 against OXK was obtained. Furthermore, a skin biopsy was carried out which confirmed the diagnosis of leukocytoclastic vasculitis. The patient was treated with doxycycline and showed drastic improvement in his symptoms. [ABSTRACT FROM AUTHOR]

Introduction: In recent years, scrub typhus has rapidly emerged to become the major cause of acute febrile illness (AFI) in India. The commonest tests used for diagnosis are serology and PCR. Therefore, the present study was planned to compare these two techniques in the diagnosis of scrub typhus. Aim of the study: To compare IgM ELISA and PCR for diagnosis of scrub typhus as a causative agent of AFI. Material and Methods: Patients with acute undiagnosed febrile illness presenting to the outpatient (OPD) or inpatient services of PGIMER Chandigarh between August 2013 and March 2014 were included in this study. Blood was collected for further analysis by IgM ELISA and nested PCR followed by Sanger sequencing. Result: Of 176 patients, 29 (16.4%) were positive for scrub typhus by nested PCR while 162 (92%) were positive by IgM ELISA. There was 59 % concordance between the two tests. Conclusion: This study report shows that the concordance between PCR and ELISA for the diagnosis of scrub typhus is less than 60%. Ideally, both tests should be performed to diagnose scrub typhus depending on the day of presentation to hospital. [ABSTRACT FROM AUTHOR]

Background: Early hospital presentation is critical in the management of acute ischemic stroke. The effectiveness of stroke treatment is highly dependent on the amount of time lapsed between onset of symptoms and treatment. This study was aimed to identify the factors associated with prehospital delay in patients with acute stroke. Material and Methods: A cross-sectional descriptive study was conducted in Sri Ramachandra University Hospital, India. A total of 210 patients hospitalized in the stroke unit were included. Patients' data were obtained by interviewing the patient and/or accompanying family member and by reviewing their medical records using a standard questionnaire. Associations were determined between prehospital delay (≥4.5 h) and variables of interest by using univariate and multivariate logistic regression analyses. Results: The prehospital delay was observed in 154 patients (73.3%) and the median prehospital delay was 11.30 h. The following are the factors significantly (P < 0.05) attributed for the delay in presenting to the hospital: contextual factors like using public transport (bus), taxi, time of onset of symptoms, 7 pm–3 am; family history of stroke, perceived cognitive and behavioral factors like, wishing or praying for the symptoms to subside on its own, hesitation to travel due to long distance, delay in arranging transport, and arranging money for admission and wasting time by shopping for general practitioners, nursing homes, and hospitals. The presence of stroke symptom, headache, significantly decreased the prehospital delay. Conclusions: Prehospital delay is high in South India and influenced by clinical, contextual, and cognitive/behavioral factors. [ABSTRACT FROM AUTHOR]

Hyperacute GVHD (HaGVHD) is a rare complication of hematopoietic stem cell transplantation (HSCT) occurring before engraftment, a syndrome commonly involving skin and/or gut and/or liver, with increased morbidity and mortality. Myeloablative conditioning (MAC) regimes and mismatched donor transplants have an increased risk for HaGVHD. There is a higher chance of steroid-refractoriness and chronic GVHD in those who develop HaGVHD. There is limited literature about HaGVHD, especially in the paediatric age group. This retrospective single-centre case series included five paediatric patients who underwent HSCT between 1st April 2013 and 31st July 2015 at a tertiary care centre in South India, who fulfilled the criteria for HaGVHD as per criteria by Kim et al. and whose follow up data was available. We noted their risk factors, clinical course and prognosis. There were five paediatric HaGVHD patients. The risk factors noted among them were MAC regimen in three and mismatched unrelated donor sources in three. Two had steroid-refractory disease, four went on to develop chronic GVHD and three died of GVHD or treatment-related complications. A high index of suspicion is necessary to recognize HaGVHD, especially in patients with known risk factors developing a fever with rash post-HSCT. [ABSTRACT FROM AUTHOR]

Background: There is inconclusive evidence on the role of nebulized magnesium sulphate (MgSO4) in the management of acute asthma in paediatric population.Objectives: Whether the use of nebulized salbutamol with or without MgSO4 in the management of acute asthma results in clinically significant improvement in lung function in Indian children? The primary outcome measure was to assess improvements in peak expiratory flow rate (PEFR), heart rate, respiratory rate and SpO2.Methods: This was a single centre; prospective double-blind randomized control trial conducted in paediatric intensive care unit of a tertiary care centre. Ninety children of 6-14 years with acute exacerbations of bronchial asthma were enrolled to receive either inhaled magnesium sulphate (95 mg) with salbutamol (5 mg) or inhaled salbutamol (5 mg) alone. All patients got three nebulizations done during the first hour at 20 min intervals, two nebulizations during the second hour at 30 min intervals, hourly for the next 2 h and then at 24 and 48 h.Results: Eighty-five patients were finally analysed as per protocol analysis. The trial showed that PEFR increased gradually in both groups over the study duration, but it was statistically not significant. Heart rate decreased significantly in both groups over the study duration. Respiratory rate decreased significantly between the groups at 24 and 48 h only. SpO2 improved too in both groups but was not significant statistically.Conclusion: The addition of nebulized MgSO4 to salbutamol does not seem to result in improvement in lung function in the management of acute asthma in Indian children. [ABSTRACT FROM AUTHOR]

Introduction: Movement disorders can present in emergency services in an acute severe form which can be life threatening if not recognized. The relative frequency and spectrum of movement disorder emergencies have not been studied extensively. We studied the frequency, spectrum, and outcome of patients presenting with movement disorders emergencies. Methods: This was a prospective, descriptive single center study. Patients presenting with acute movement disorders to the neurology emergency services of the institute during the study period from April 2019 to June 2021 were analyzed. Results: A total of 71 patients presented with acute movement disorders during the study period. Out of them, 65 patients had hyperkinetic and 6 patients had hypokinetic movement disorders emergencies. Fifteen patients were below the age of 18 years. Chorea (59.1%) was the most common movement disorder emergencies followed by dystonia and myoclonus in adults. Dystonia (33.3%) was the common movement disorder emergencies in children. Hyperglycemia followed by stroke was the most common etiology of acute movement disorders. Conclusion: This study brings out some novel findings on the movement disorders emergencies in Indian scenario. Chorea was the most common movement disorder emergencies presenting to the neurology emergency services. Early recognition and management of movement disorders emergencies help in reducing morbidity. [ABSTRACT FROM AUTHOR]

Acute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis. [ABSTRACT FROM AUTHOR]

Objective: The effect of vitamin D, which is a steroid hormone, on bone health has long been known. Vitamin D is also found to be associated with various diseases such as diabetes, hypertension, chronic kidney disease, coronary artery disease, and cancer. Neuroprotective effect of vitamin D makes it an important marker in clinical course of neurological diseases such as cognitive impairment, dementia and Alzheimer's disease. Vitamin D deficiency is also associated with increased risk of stroke. In this study, we aimed to show the effect of vitamin D levels on severity and prognosis of stroke. Materials and Methods: This was a prospective, observational study conducted in a tertiary medical center in Rohtak on 200 stroke patients admitted in Medicine ward. The National Institute of Health Stroke scale (NIHSS) and modified Rankin Scale were used to assess the severity of stroke at admission and functional outcome at 3 months, respectively. The patients were divided into 4 groups on the basis of vitamin D levels. Results: Vitamin D deficiency was associated with higher NIHSS score and independently associated with poor functional outcome. Patients with severe and mild vitamin D deficiency, and vitamin D insufficiency had 9, 6.7, and 3.9 times higher adjusted odds of poorer functional outcomes at 3 months in comparison to the patients with normal vitamin D levels (p<0.01) when adjusted for age, sex, alcohol, smoking, body mass index, NIHSS score, and co-morbidities. Conclusion: Vitamin D is associated with severe stroke and poor functional outcome at 3 months. However, further studies need to be carried out to evaluate whether supplementation of vitamin D can help prevent stroke or associated morbidity and mortality. [ABSTRACT FROM AUTHOR]

Introduction: Leptospirosis is an anthropozoonotic disease; it occurs worldwide but is most common in tropical and subtropical countries. It is usually underreported due to a lack of awareness, atypical presentations and lack of diagnostic facilities, especially in a resource-limited setting like India. Knowing the local prevalence of such infections is of utmost importance for appropriate control and management. Aim: To estimate the seroprevalence of leptospirosis among suspected Acute Febrile Illness (AFI) cases and to assess the clinicoepidemiological profile of leptospirosis cases presented at Government Medical College, Amritsar, Punjab, India. Materials and Methods: This hospital-based cross-sectional study was conducted at Government Medical College, Amritsar, Punjab, India. A total of 360 clinically suspected AFI cases were enrolled in the study. The demographic and clinical profile of the cases was taken on a semistructured predesigned proforma. Blood sample was collected from the patients, and an Immunoglobulin M (IgM) Enzyme-linked Immunosorbent Assay (ELISA) was done for diagnosis. Data analysis was done using International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) statistical package for windows. Results: Out of 360 AFI cases suspected of leptospirosis, 62 (17.2%) were positive for leptospirosis IgM ELISA. The majority of AFI cases and leptospirosis cases belonged to the 21-40 years age group followed by the 41-60 years age group. Seroprevalence was found to be higher in males (20.8%) as compared to females (12.7%). Maximum seroprevalence (20.1%) was seen during the monsoon season followed by the autumn, summer and winter season. The association between risk exposure to risk factors and leptospirosis seroprevalence was found to be statistically significant (p=0.034). Fever, myalgia, headache, nausea/vomiting, icterus and hepatomegaly were common clinical features observed in leptospirosis cases. Conclusion: Leptospirosis has rapidly emerged to become the major cause of AFI in many parts of India. High seroprevalence of leptospirosis was reported among undifferentiated AFI cases in the present study. A programmatic approach towards the prevention, control and management of these emerging diseases in Punjab is highly recommended. [ABSTRACT FROM AUTHOR]

Scrub typhus infections caused by Orientiatsutsugamushi (OT), continue to remain underdiagnosed globally, due to the lack of distinctive symptoms. The elusive nature of the Acute Encephalitis Syndrome (AES) outbreak in Gorakhpur, Uttar Pradesh that claimed numerous pediatric lives was the driving force of this study which involved serological diagnosis (IgM-ELISA), isolation of OT in cell culture, confirmation by PCR, and characterization by Sanger sequencing. In total, 12 out of 36 patients were seropositive, of which 4 were positive by PCR. Upon enrichment in cell culture, additional 3 patients (including two seronegative) were detected positive by PCR. In total, three of these 7 patients were found to be infected with two strains of OT. Taken together, this study for the first time reports the occurrence of dual infections in addition to three circulating OT genotypes (Gilliam, Kato, and Karp-like) and highlights the significance of enriching OT in cell culture systems for efficient molecular detection. [ABSTRACT FROM AUTHOR]

Background: The primary central nervous system (CNS) demyelinating disorders are witnessing significant advancement in terms of treatment options and the diagnostics. However, a resource poor country like ours has to rely more on our clinical findings. Aims and Objectives: To study the spectrum of different clinical manifestations in patients of various primary CNS demyelinating disorders in the hospital setting; categorizing them to the most possible extent into its various types viz. multiple sclerosis(MS), neuromyelitis optica spectrum disorder (NMOSD), acute disseminated encephalomyelitis(ADEM), idiopathic optic neuritis(ON). Metarials and Methods: An observational study was conducted for 2 years including old and newly diagnosed cases in whom detailed clinical assessment was done for every attack including the previous and subsequent ones. Statistical analysis was done using SPSS version 21. Results: Of the 47 patients included, 26 (55.3%) were cases of NMOSD, 12 (25.5%) of MS, 4 (8.5%) of ADEM and 5 (10.6%) were isolated cases of ON. 30 were female and 17 were male (ratio 1:0.6). The total mean age for primary CNS demyelinating disorders at presentation was 27.09 ± 13.44 years. Maximum patients fell in the age range of 11-20 years. Among the clinical manifestations, motor abnormalities (97.6%), sensory abnormalities (69%), bladder dysfunction (59.5%), visual manifestations (54.8%) (Unilateral in all MS patients, both bilateral and unilateral in NMOSD) were the most common presentations. In MS, the most common manifestations were motor dysfunction followed by sensory symptoms, optic neuropathy (mostly unilateral), and bladder dysfunction. In NMOSD, the most common clinical manifestations were motor dysfunction, followed by bladder dysfunction, optic neuropathy and then sensory abnormalities. In ADEM, most common manifestations were motor abnormalities, acute encephalopathy, headache, optic neuropathy. Among idiopathic ON, most patients presented with painful diminution of vision (80%). Mean number of attacks was 2.53. Conclusion: A wide spectrum of clinical presentations in various disorders of primary CNS demyelination was found with maximum patients presenting with motor dysfunction in various forms. [ABSTRACT FROM AUTHOR]

Introduction: Fever is a common symptom with multifactorial etiologies. In tropical country like India, most of the cases of acute febrile illness are due to seasonal viral diseases and vector-borne infections. Aim: To know the causes of acute onset fever in immunocompetent adults and to study the prevalence of neutropaenia. Materials and Methods: A cross-sectional study was done on 403 patients presenting with Acute Febrile Illness (AFI) of <14 days duration admitted to a tertiary care hospital, Pune, Maharashtra, India from January 2019 to January 2020. Total Leukocyte Count (TLC), Absolute Neutrophil Count (ANC) and investigations for dengue, malaria, leptospirosis, enteric fever, atypical infections like brucella, rickettsia and relevant body fluid cultures were done. The categorical and continuous variables were expressed as frequency, percentage, and standard deviation. Results: Out of 403 patients, 214 were males (53.1%) and 189 females (46.9%) with mean age of 28.57±11.26 years. Cause of fever was found in 254 (63%) patients. Dengue fever was the most common cause in 221 (54.8%) followed by Acute Undifferentiated Febrile Illness (AUFI) in 149 (37%). Transient neutropaenia was present in 38.5% cases, mostly with dengue. Only 5.2% patients with AFI required antibiotics. Conclusion: Dengue fever, the most common cause of AFI chiefly affecting young adults. Neutropaenia in AFI in immunocompetent adult is transient and benign. Antibiotics are not required in majority of the cases of AFI without organ specific aetiologies. [ABSTRACT FROM AUTHOR]

Background: One of the major challenges is to deliver adequate health care in rural India, where more than two-thirds of India's population lives. There is a severe shortage of specialists in rural areas with one of the world's lowest physician/population ratios. There is only one neurologist per 1.25 million population. Stroke rehabilitation is virtually nonexistent in most district hospitals. Two innovative solutions include training physicians in district hospitals to diagnose and manage acute stroke ('Stroke physician model') and using a low-cost Telestroke model. We will be assessing the efficacy of these models through a cluster-randomized trial with a standard of care database maintained simultaneously in tertiary nodal centers with neurologists. Methods: SMART INDIA is a multicenter, open-label cluster-randomized trial with the hospital as a unit of randomization. The study will include district hospitals from the different states of India. We plan to enroll 22 district hospitals where a general physician manages the emergency without the services of a neurologist. These units (hospitals) will be randomized into either of two interventions using computer-generated random sequences with allocation concealment. Blinding of patients and clinicians will not be possible. The outcome assessment will be conducted by the blinded central adjudication team. The study includes 12 expert centers involved in the Telestroke arm by providing neurologists and telerehabilitation round the clock for attending calls. These centers will also be the training hub for "stroke physicians" where they will be given intensive short-term training for the management of acute stroke. There will be a preintervention data collection (1 month), followed by the intervention model implementation (3 months). Outcomes: The primary outcome will be the composite score (percentage) of performance of acute stroke care bundle assessed at 1 and 3 months after the intervention. The highest score (100%) will be achieved if all the eligible patients receive the standard stroke care bundle. The study will have an open-label extension for 3 more months. Conclusion: SMART INDIA assesses whether the low-cost Telestroke model is superior to the stroke physician model in achieving acute stroke care delivery. The results of this study can be utilized in national programs for stroke and can be a role model for stroke care delivery in low- and middle-Income countries. (CTRI/2021/11/038196) [ABSTRACT FROM AUTHOR]

Acute encephalitis syndrome (AES) refers to an acute onset of fever and clinical neurological manifestation that includes mental confusion, disorientation, delirium, or coma, which may occur because of infectious or non-infectious causes. Cerebrospinal fluid (CSF) pleocytosis generally favors infectious etiology, and a normal CSF favors an encephalopathy or non-infectious AES. Among the infectious AES, viral, bacterial, rickettsial, fungal, and parasitic causes are the commonest. Geographical and seasonal clustering and other epidemiological characteristics are important in clinical decision making. Clinical markers like eschar, skin rash, myalgia, hepatosplenomegaly, thrombocytopenia, liver and kidney dysfunction, elevated serum CK, fronto-temporal or thalamic involvement on MRI, and anterior horn cell involvement are invaluable clues for the etiological diagnosis. Categorizing the AES cases into neurologic [Herpes simplex encephalitis (HSE), Japanese encephalitis (JE), and West Nile encephalitis (WNE)] and systemic (scrub typhus, malaria, dengue, and Chikungunya) helps in rational utilization of diagnostic and management resources. In neurological AES, cranial CT/MRI revealing frontotemporal lesion is consistent with HSE, and thalamic and basal ganglia lesions are consistent with JE. Cerebrospinal fluid nucleic acid detection test or IgM antibody for JE and HSE are confirmatory. Presence of frontotemporal involvement on MRI indicates acyclovir treatment pending virological confirmation. In systemic AES, CT/MRI, PCR for HSE and JE, and acyclovir therapy may not be useful, rather treatable etiologies such as malaria, scrub typhus, and leptospirosis should be looked for. If smear or antigen for malaria is positive, should receive antimalarial, if negative doxycycline and ceftriaxone should be started pending serological confirmation of scrub typhus, leptospira, or dengue. A syndromic approach of AES based on the prevalent infection in a geographical region may be developed, which may be cost-effective. [ABSTRACT FROM AUTHOR]

Antibiotic resistance is a naturally occurring phenomenon, but the misuse and overuse of antibiotics is accelerating the process. This study aimed to quantify and compare antibiotic use before, during, and after seeking outpatient care for acute febrile illness in Ujjain, India. Data were collected through interviews with patients/patient attendants. The prevalence and choice of antibiotics is described by the WHO AWaRe categories and Anatomical Therapeutic Chemical classes, comparing between age groups. Units of measurement include courses, encounters, and Defined Daily Doses (DDDs). The antibiotic prescription during the outpatient visit was also described in relation to the patients' presumptive diagnosis. Of 1000 included patients, 31.1% (n = 311) received one antibiotic course, 8.1% (n = 81) two, 1.3% (n = 13) three, 0.4% (n = 4) four, 0.1% (n = 1) five, and the remaining 59.0% (n = 590) received no antibiotics. The leading contributors to the total antibiotic volume in the DDDs were macrolides (30.3%), combinations of penicillins, including β-lactamase inhibitors (18.8%), tetracyclines (14.8%), fluoroquinolones (14.6%), and third-generation cephalosporins (13.7%). 'Watch' antibiotics accounted for 72.3%, 52.7%, and 64.0% of encounters before, during, and after the outpatient visit, respectively. Acute viral illness accounted for almost half of the total DDDs at the outpatient visit (642.1/1425.3, 45.1%), for which the macrolide antibiotic azithromycin was the most frequently prescribed antibiotic (261.3/642.1, 40.7%). [ABSTRACT FROM AUTHOR]

Background and Aims: Heart-type fatty acid-binding protein (H-FABP) is a novel marker of myocardial injury, released rapidly (<1 h) after the onset of myocardial injury and plays an important role in both early diagnoses of high-risk patients presenting with chest pain as well as an early reperfusion marker in post-thrombolytic patients. We aim to assess and compare the efficacy of H-FABP as an early marker of cardiac injury with Troponin I (cTnI) and creatinine Phospholinase Kinase (CPK-MB) and to correlate it with Left ventricular Ejection Fraction (LVEF)and percentage of stenosis in Coronary arteries. Material and Methods: Total of 300 patients (STEMI 150 and NSTEMI 150) with acute chest pain attending the emergency department within 6 hours after the onset of chest pain were included. Peripheral venous blood samples were obtained on admission, post thrombolysis at 60 minutes, and after 6 and 12 hours to measure a panel of conventional biomarkers FABP, cTnI and CPK. Echocardiography assessed Simpson’s LVEF and Trans mitral Doppler flow and the spectrum of coronary artery disease was defined by Coronary Angiography. Conclusion: FABP could reliably diagnose AMI patients 1 to 3 hours after admission over CPK MB and Troponin I and could also assess post-thrombolysis reperfusion in STEMI patients noninvasively over coronary angiography. [ABSTRACT FROM AUTHOR]

Pain following traumatic rib fractures is one of the most common symptoms and requires adequate management initiated in the emergency department (ED). Many strategies for in-patient management of rib fracture pain have been discussed in literature, but a standardized algorithm to provide uniform care is not available. We hereby propose a multimodal "AIIMS-TRAP" (Traumatic Rib fracture Acute Pain management) algorithm to achieve pain-free experience for chest injury patients and also reduce further complications resulting as a consequence of severe pain such as limited chest expansion, reduced tidal volumes, risk of atelectasis, and respiratory infections. [ABSTRACT FROM AUTHOR]

Introduction: Catastrophic health expenditure (CHE) is a reliable measure of the financial unpreparedness of the studied population to meet unexpected health issues. The alarming proportion of patients who incur CHE in the wake of an acute neurological illness like Guillain Barre Syndrome (GBS) is of serious concern in a country like India where a large majority of households are uninsured. Methodology: Medical records of patients diagnosed with at a tertiary care centre in Delhi were analysed retrospectively to determine the rate of CHE. Clinical details and other contributory variables were also recorded. Results: 53 patients with a median age of 29 years (10.5–46.5) were included in the study. Tow‐ third of patients were less than 40 years of age and 58.5% were male. 90.6% of patients incurred CHE with a median amount INR 273 300 spent out of pocket. Conclusion: The enormous magnitude of financial distress and crisis emerging out of an acute neurological illness needs to be addressed with urgency to prevent impoverishment of already weakened households. [ABSTRACT FROM AUTHOR]

Background: Stroke patients experience a variety of physical problems which affect their activities of daily life. As there is need for identifying the physical problems of patients with acute stroke in the initial stage, the present study was undertaken to identify the physical problems of patients with acute stroke. Objectives: the objectives of the study were to identify the physical problems of patients with acute stroke. Methods: This descriptive study was conducted at neurology department of a tertiary care hospital in Kerala. 60 patients with acute stroke was selected by consecutive sampling technique. Physical problems of stroke patients were identified by standardised tools; National Institute of Health Stroke Scale (NIHSS) and Barthel index. Appropriate descriptive and inferential statistical methods were used to analyze the data. Results: The major physical problems identified were immobility (81.7%), lower extremity weakness (75%), upper extremity weakness (71.6%), loss of bladder control (66.7%), loss of bowel control (65%), feeding problem (63.3%) and communication problems like dysarthria (55%) and aphasia (53.3%). Conclusion: The study stresses the importance of identification of various existing and emerging physical problems encountered by acute stroke patients and the preparation of a nursing care protocol, which can be utilized in future, for managing the major physical problems. [ABSTRACT FROM AUTHOR]

Introduction: In India, infectious Hepatitis is one of the major health care burdens, with viral hepatitis being the most common culprit, followed by dengue, typhoid, and malarial hepatitis. Fulminant hepatitis manifests as a sudden abnormality in liver function enzymes in a child with no prior hepatic pathology. Aims and Objects: This study was aimed at identifying the various etiological factors and correlating clinical features of viral hepatitis, and fulminant liver failure. Materials and Methods: This observational study was conducted in the paediatrics in-patient department of S.P. Medical College & P.B.M. Associated Group of Hospitals, Bikaner (Rajasthan) over a period of one year. A total of 125 children with a clinical and lab-confirmed diagnosis of acute infective hepatitis were included. Data including clinical signs, symptoms, and laboratory parameters were obtained and analyzed. Results: Most commonly affected age group was between 5-10 years with the mean age being 7.1±4.6 years. The most common etiology was hepatitis A (n=39), followed by hepatitis E (n=24) and mixed hepatitis A virus (HAV)/hepatitis E virus (HAE) infection (n=20). Other causative organisms were dengue virus (n=16), typhoid (n=13), malaria (n=9), and hepatitis B. The most common clinical symptoms were fever, jaundice, loss of appetite, and vomiting/nausea. There were some clinical features seen more commonly in case of infection with certain organisms. High frequency of diarrhoea, arthralgia, and thrombocytopenia was seen with HAV. Neurological, renal complications and high mortality were associated with HEV or HAV/HEV coinfection. While retroorbital pain and purpuric rash were exclusive with dengue, malarial hepatitis was strongly associated with pallor and altered sensorium. Conclusion: Acute infective hepatitis is most commonly caused by HAV and HEV in Western Rajasthan. It is imperative to educate the masses regarding the prevention of common infections transmissible by infected drinking water, poor hand hygiene, improper waste disposal, and open defecation. [ABSTRACT FROM AUTHOR]

Objectives: The objective of the study was to describe the clinico-virological profile, treatment details, intensive care needs, and outcome of infants with acute viral bronchiolitis (AVB). Methodology: In this prospective observational study, 173 infants with AVB admitted to the pediatric emergency room and pediatric intensive care unit (PICU) of a tertiary care teaching hospital in North India during November 2019 to February 2020 were enrolled. The data collection included clinical features, viruses detected [respiratory syncytial virus (RSV), rhinovirus, influenza A virus, parainfluenza virus (PIV) 2 and 3, and human metapneumovirus (hMPV)], complications, intensive care needs, treatment, and outcomes. Multivariate analysis was performed to determine independent predictors for PICU admission. Results: Most common symptoms were rapid breathing (98.8%), cough (98.3%), and fever (74%). On examination, tachypnea (98.8%), chest retractions (93.6%), respiratory failure (84.4%), wheezing (49.7%), and crepitations (23.1%) were observed. RSV and rhinovirus were the predominant isolates. Complications were noted in 25% of cases as encephalopathy (17.3%), transaminitis (14.3%), shock (13.9%), acute kidney injury (AKI) (7.5%), myocarditis (6.4%), multiple organ dysfunction syndrome (MODS) (5.8%), and acute respiratory distress syndrome (ARDS) (4.6%). More than one-third of cases required PICU admission. The treatment details included nasal cannula oxygen (11%), continuous positive airway pressure (51.4%), high-flow nasal cannula (14.5%), mechanical ventilation (23.1%), nebulization (74%), antibiotics (35.9%), and vasoactive drugs (13.9%). The mortality was 8.1%. Underlying comorbidity, chest retractions, respiratory failure at admission, presence of shock, and need for mechanical ventilation were independent predictors of PICU admission. Isolation of virus or coinfection was not associated with disease severity, intensive care needs, and outcomes. Conclusion: Among infants with AVB, RSV and rhinovirus were predominant. One-third infants with AVB needed PICU admission. The presence of comorbidity, chest retractions, respiratory failure, shock, and need for mechanical ventilation independently predicted PICU admission. [ABSTRACT FROM AUTHOR]

Objectives: Emergency department (ED) length of stay (LOS) is defined as the time a patient is registered to the time the patient is shifted to a hospital bed or discharged. Increasing demand for quality emergency care has resulted in increased wait times due to demand and supply mismatch. It is perceived that longer LOS in the ED of critical patients leads to poor outcomes. Our goal was to study the impact of LOS in the ED on the patients who required critical care admissions. Methods: This was a retrospective study conducted in the ED of a tertiary center. Data were collected using electronic health records (EHR) for patients admitted to the intensive care units (ICUs). Patient's LOS in ED was divided into 0--4, 4--8, 8--12, 12--24, and >24 hours. ED LOS was calculated from the registration time to the time patient was handed over in the ICU. Patients were divided into four categories (1--4) based on their criticality. LOS in ED, mortality, and total hospital LOS were analyzed in the study. Results: Three thousand four hundred and twenty-nine patients were enrolled in the study. Mean age was 62.69 years (95% CI 62.11--63.26). A total of 42.09% (95% CI 40.5--43.8) were Category 1 patients. Overall mortality rate was 52.46% (95% CI 50.79--54.13). LOS of 48.15% (95% CI 46.54--49.88) patients in the ED was between 0 and 4 hours, 19.90% (95% CI 18.62--21.29) between 4 and 8 hours, 8.21% (95% CI 7.35--9.19) between 8 and 12 hours, 15.50% (95% CI 14.34--16.77) between 12 and 24 hours, and 8.13% (95% CI 7.27--9.10) >24 hours. Mortality for LOS of 0--4 hours was 51.30% (95% CI 48.89--53.70), 54.03% (95% CI 50.28--57.73) for 4--8 hours, 48.94% (95% CI 43.16--54.75) for 8--12 hours, 51.50% (95% CI 47.26--55.72) for 12--24 hours, and 60.57% (95% CI 54.73--66.13) for >24 hours. Conclusion: We concluded that the longer the critically ill patients are boarded in the ED, the higher is the chance for mortality. Processes should be implemented to ease the throughput from the ED. [ABSTRACT FROM AUTHOR]

Background: COVID-19 is a novel acute infection that is mainly manifested as acute respiratory disease. Information on coronavirus disease-2019 (COVID-19) in CKD patients who are not on dialysis is very limited. We are reporting a single-center observational study on the effect of COVID-19 in CKD patients. Methods: A single-center retrospective study with consecutive patients who had eGFR <60 mL/min/1.73 m2 (CKD-EPI) admitted with COVID-19, from April to July 2020 were included. Result: A total of 30 patients were included in the study. Patients of CKD stage 5, 4 and 3 were 50%, 13.3%, and 36.6%, respectively. The mortality rate was 53.3%. Category wise, 9 were in mild; 3 in moderate, and 18 were in the severe COVID category. Twenty-five patients (83.3%) developed acute on CKD. Twenty patients (67%) required renal replacement therapy (RRT). The prognosis of patients who required RRT was poor. High LDH and IL-6 were significantly associated with mortality. Lymphopenia, present in 50% of cases was associated with fatal outcome. There was a 100% survival rate in mild to moderate cases and 11% in severe cases. Conclusion: Mortality among hospitalized CKD patients is high. [ABSTRACT FROM AUTHOR]

Introduction: Dearth in the literature pertaining to natural history of acute pancreatitis (AP) necessitates further studies to evaluate the outcome of local pancreatic complications using the revised Atlanta classification.Objective: To evaluate the outcomes of local pancreatic complications after first episode of AP, risk factors for their development and predictors of need for intervention.Methodology: A prospective study was carried out on 50 consecutive cases of AP who developed local pancreatic complications from January 2015 to July 2016. After imaging, they were categorised into acute pancreatic fluid collection (APFC) and acute necrotic collection (ANC). The risk factors for their development and the need for intervention were assessed.Results: Of 50 patients, 20 developed APFC and 30 ANC. Of ANC cases, 27 progressed into walled-off necrosis (WON), of which 4 were managed conservatively and 18 collections were drained percutaneously, 3 underwent endotherapy (transmural drainage and endoscopic necrosectomy) and 2 died following percutaneous drainage (PCD) and surgery. Ten WON collections persisted at the end of 3rd month. Collections resolved in 6 of 20 APFC patients, 14 formed pseudocysts, of which 10 showed resolution with or without intervention and only 4 of them persisted at the end of study. Size of collection ≥6 cm was independent predictor of intervention irrespective of type of collections while in cases of ANC, extensive necrosis (>30%) and multiple collections were more likely to require intervention.Conclusion: Incidence of ANC is more common than APFC when local pancreatic fluid collections develop most of which develop WON and require intervention. [ABSTRACT FROM AUTHOR]

To investigate the diagnostic value of total leucocyte counts, plasma lactate dehydrogenase (LDH), and serum lactate levels in combination for diagnosing acute mesenteric ischemia (AMI). This cross-sectional observation study included patients presenting to a tertiary care hospital of Indian Armed Forces with acute abdomen and were found to have mesenteric ischemia at laparotomy. A total of thirty cases of acute abdomen found to have mesenteric ischemia at laparotomy were studied over a period from September 2016 to December 2019. Preoperative leukocytosis, serum lactate levels, and LDH levels were observed in the study population and correlated with intraoperative findings to see whether a preoperative raised value were indicators of mesenteric ischemia when used in combination. A total of 30 patients were observed. Twenty-seven patients were male and 3 were females. Diagnosis was verified at laparotomy. It was observed that 43.3% of the patients had all the three variables positive (raised LDH, lactate, and leukocytosis). At least two of the three variables were positive in 83.3% of the patients of mesenteric ischemia. At least one variable was positive in all patients of mesenteric ischemia. The findings indicate that raised plasma LDH levels, leukocytosis, and serum lactate levels are better predictors of mesenteric ischemia if taken in combinations. In a clinical setting where mesenteric ischemia is suspected, raised levels of at least two of the three markers are indicators of mesenteric ischemia in more than 80% of cases. In case all three markers are negative, mesenteric ischemia is unlikely and alternative diagnosis needs consideration. [ABSTRACT FROM AUTHOR]

Background: Scrub typhus, a vector-borne zoonotic infection caused by the bacteria Orientia tsutsugamushi, is one of the most common and clinically important rickettsial infections worldwide. An estimated one million cases occur annually with a high case fatality rate. Although scrub typhus is a major public health threat in India, the burden and distribution remains unclear. We aimed to estimate the burden of scrub typhus in India. Methodology: We performed a systematic review of published literature on scrub typhus from India to extract information on epidemiology, morbidity, and mortality. Important databases were searched using keywords and appropriate combinations. We identified observational, interventional, and population-based studies and extracted the data to evaluate the number of cases diagnosed using serology or PCR and the number of deaths due to scrub typhus. We conducted a systematic narrative synthesis to summarize included studies. Principal findings: In the last decade, there were 18,781 confirmed scrub typhus cases reported in 138 hospital-based studies and two community-based studies. IgM ELISA was used in 122 studies to confirm the cases in majority (89%). The proportion of scrub typhus among acute undifferentiated febrile illness (AUFI) studies was 25.3%, and community seroprevalence was 34.2%. Ninety studies had data published on multiple organ involvement out of which 17.4% of cases had multiple organ dysfunction syndromes, 20.4% patients required ICU admission, and 19.1% needed ventilation. The overall case-fatality rate was 6.3%, and the mortality among those with multi-organ dysfunction syndrome was as high as 38.9%. Conclusion/significance: Scrub typhus, a common acute febrile illness in India causing severe morbidity, accounts for a large number of deaths. The burden of the disease has been underappreciated. Early diagnosis and prompt treatment can significantly reduce complications and mortality. Establishing good surveillance and instituting appropriate control measures are urgently needed. Author summary: Scrub typhus is an infection that is caused by a rickettsial bacteria called Orientia tsutsugamushi and transmitted to humans through chigger mites. Scrub typhus has re-emerged as one of the most common life-threatening rickettsial infections accounting for a million cases annually. However, it is a largely overlooked public health problem in India. This systematic review aims to integrate data obtained from medical literature over the past 10 years to estimate the burden of scrub typhus in India. It also intends to summarize the diagnostic tests that are most commonly used to confirm scrub typhus cases and to map the distribution of cases across India. The insights provided from this review will further enable policymakers to establish a surveillance system to observe this disease and initiate strategies to effectively control, and prevent the spread of, this neglected disease. In this review, we found that scrub typhus is very common in India and affects multiple organs in the majority of positively tested patients. This increases complications and the risk of death. Improving awareness about this disease, increasing access to testing and initiating appropriate therapy early can help reduce this public health threat in the future. [ABSTRACT FROM AUTHOR]

Background: As the COVID-19 pandemic continues with its high mortality in older adults, there is a need to find better outcome predictors in such patients. The use of frailty as outcome predictors in the acute-care settings may help in providing more care to the high-risk patients. The aim of this pilot study was to assess the use of frailty measurement in the emergency department as an in-hospital and short-term outcome predictor in older patients admitted with severe acute respiratory illness (SARI). Subjects and Methods: The study was conducted in the emergency department of a tertiary care hospital in India from May 1, 2020 to July 31, 2020. All older patients presenting with SARI were assessed using the Clinical Frailty Scale at presentation by the emergency medicine residents who were trained by a geriatrician. Patients were followed up telephonically till January 31, 2021. Results: A total of 100 patients were recruited (mean age-71.5 years, males-61%, and 75 years or older-40%). Of these patients, 44% were found to be frail. Overall, 50% were SARS-CoV-2 positive. Frail patients had higher in-hospital (47.7% vs. 41.1%) and short-term mortality (67.6% vs. 54.7%); however, the difference was not statistically significant. Duration of hospitalization was also not significantly different between the two groups. Conclusions: Frailty among older SARI patients (with or without COVID-19 infection) was associated with higher in-hospital and long-term mortality, although the results were not statistically significant. Larger multicentric studies are needed to further explore this. [ABSTRACT FROM AUTHOR]

Introduction: As regard to all pandemics, the current COVID-19 pandemic, could also have been better managed with prudent use of preventive measures coupled with rapid diagnostic tools such as rapid antigen tests, but their efficacy is under question because of projected lower sensitivity as compared to Real Time Reverse Transcriptase Polymerase Chain Reaction, which although considered gold standard has its own limitations. Methodology: A prospective, single centre study was carried out to evaluate the performance of Standard Q COVID-19 Ag, a rapid immunochromatographic assay for antigen detection, against TrueNat, a chip-based, point-of-care, portable, Real-Time PCR analyzer for diagnosis of COVID-19; on 467 nasal swab samples from suspected subjects at a fever clinic in North India in month of July 2020. Results: Of the 467 specimens tested, TrueNat showed positive result in 29 (6.2%), majority of whom were asymptomatic (72.4%) while 4/29 (13.9%) had influenza like illness and 2/29 (6.8%) presented with severe acute respiratory illness. Compared to TrueNat, Rapid antigen test gave concordance for 26 samples, while for 2 samples the result was false positive; giving an overall sensitivity of 89.7% (95% CI = 72.6-97.8) and a specificity of 99.5%, indicating strong agreement between two methods. Conclusion: Community prevalence plays an important role is choosing the laboratory test and result interpretation. Rapid antigen detection tests definitely have a big role to play, especially in resource limited setting, for early diagnosis as well as for source control to halt the spread. [ABSTRACT FROM AUTHOR]

Background: Scrub typhus (ST) is a common Rickettsial infection which has been increasingly reported from the various states of southern part of India. Aims and Objective: With very few reports from Central Kerala, we aimed to study the seroprevalence of scrub typhus and its clinical profile. Materials and Methods: Patients presenting with acute undifferentiated febrile illness and other symptoms and signs of Rickettsial infections during a period of two years were included in this prospective study. Serodiagnosis of ST was based on a positive Scrub typhus IgM Enzyme Linked Immunosorbent Assay (ELISA) and/or agglutination for OXK in Weil Felix test. The cut-off for ELISA was calculated. The clinical and laboratory details of the positive patients were obtained and bivariate analysis was performed. Results: The cutoff for ST IgM ELISA was calculated and found to be 0.38. Of the 636 samples screened, 34 (5.3%) were positive for ST IgM ELISA. Out of the 34 positive samples, only 5 (0.8%) were positive by Weil Felix test. Most of the ST patients presented during the months of May to January. Rashes were observed in 8.8% of the ST patients and none had signs of eschar. The commonest clinical features included fever, myalgia (52.9%), nausea & vomiting (32.4%), headache (29.4%) and hepatosplenomegaly (29.4%). The commonest abnormal laboratory finding and complication observed were elevated serum transaminases (52.9%) and acute respiratory distress syndrome (17.6%) respectively. Conclusion: The seroprevalence of ST in Central Kerala was 5.3% using Weil Felix test and ST IgM ELISA. [ABSTRACT FROM AUTHOR]