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Since the diagnosis of the first case of COVID-19 in December 2019, there have been reports of several healthcare workers infected with COVID-19. It has changed the infection control practices of most ICUs all over the world. Prevention is better than cure is definitely proven true as there is no definite cure for COVID-19 yet. Personal protective equipment and hand hygiene are a must while handling any suspected COVID-19 patient. Apart from that, there are several other things, which should be followed in ICU and specifically while caring for a patient on ventilator. There are a large number of interventions done while treating any critically ill patient in ICU, which can generate aerosols and exaggerate spread of COVID-19, which include high-flow nasal cannula, NIV, nebulization, suctioning, bag and mask ventilation, endotracheal intubation, and bronchoscopy. We will be reviewing those things beyond PPE and hand hygiene along with the rationale of each of them, which can help to minimize the risk of exposure to healthcare workers and other patients in the surrounding. It will help not only to prevent COVID-19 transmission but also to reduce overall nosocomial infection rate. As per our knowledge, this will be the first paper reviewing innovative ideas to minimize the risk of infection in a comprehensive manner. How to cite this article: Shah V, Tyagi N, Trivedi D. Extra Precautions while Caring for a Suspected COVID-19 Patient in an ICU beyond PPE and Hand Hygiene. Indian J Crit Care Med 2021;25(3):331–336.

Objectives The aim of this study is to report a case series of atypical presentations of intracranial dysgerminoma in which the diagnosis was delayed due to clinical and radiographic findings initially suggestive of CNS inflammatory or demyelinating diseases, such as MS. Methods This study is a case series detailing the history, clinical presentations, radiographic and laboratory results, and management of three patients with biopsy-proven intracranial dysgerminoma. Results All three patients demonstrated hyperintense lesions on MRI that were more suggestive of demyelinating or inflammatory diseases, including lesions involving the midbrain and corpus callosum. All three patients were serum positive for oligoclonal bands and negative for both AFP and beta-hCG (these two markers are commonly seen in dysgerminoma cases). One case involved a steroid-responsive tumor whereas the other two cases either did not respond to steroids or steroids were withheld due to uncertainty of etiology. Following biopsy, all three results were consistent with dysgerminoma. Conclusion Clinicians should be aware that dysgerminoma may mimic the clinical and radiographic presentations of demyelinating diseases such as MS. These lesions can cause acute visual loss or diplopia, have MRI and CSF findings that might mimic MS, and have been shown to respond to steroids. Atypical clinical (e.g., headache, dorsal midbrain syndrome, bilateral optic neuropathy) or atypical radiographic features (e.g., mass effect, hydrocephalus) should prompt consideration for repeat imaging and possible biopsy even if serum or CSF tumor markers (beta-hCG and AFP) are negative for dysgerminoma.

Introduction: We report 2 cases of medulloblastoma maturing into gangliocytoma after receiving multimodal therapy. Here we present 2 cases of diagnosed medulloblastoma which on re-resection were noted to be gangliocytoma without heterogeneity, which is an extremely rare occurrence. Case Presentation: The first patient, an 11-year-old boy diagnosed with high-risk (non-WNT, non-SHH) medulloblastoma, was treated with near-total surgical resection followed by craniospinal radiation therapy with weekly vincristine. He then received maintenance chemotherapy with vincristine, cyclophosphamide, and cisplatin. On surveillance MR imaging studies residual tumor in the lateral aspect of the tumor bed was noted to be slowly growing, eliciting gross-total resection of the residual tumor. Histopathology showed benign gangliocytoma without residual medulloblastoma. The second patient, a 3-year-old girl, was diagnosed with medulloblastoma, desmoplastic nodular variant. She was initially treated with gross total resection and chemotherapy with etoposide, carboplatin, and high-dose methotrexate. At 4 months off therapy, she was noted to have local recurrence along the resection cavity. Second-line therapy was started with irinotecan and temozolomide, but MRI assessment during treatment showed further disease progression. She then received craniospinal radiation. Eleven months off therapy, further radiographic progression was noted, and the patient underwent second-look surgery, with pathology showing gangliocytoma and treatment-related gliosis. Discussion/Conclusion: The maturation of medulloblastoma into a ganglion cell-rich lesion is very rare, with few well-characterized previous reports. Given the rare nature of this entity, it would be of great value to understand the process of posttreatment maturation and the genetic and treatment factors which contribute to this phenomenon.

The central nervous system plays an important role in essential hypertension in humans and in animal models of hypertension through modulation of sympathetic activity and Na+and body fluid homeostasis. Data from animal models of hypertension suggest that the renin-angiotensin system in the subfornical organ (SFO) of the brain is critical for hypertension development. We recently reported that the brain (pro)renin receptor (PRR) is a novel component of the brain renin-angiotensin system and could be a key initiator of the pathogenesis of hypertension. Here, we examined the expression level and cellular distribution of PRR in the SFO of postmortem human brains to assess its association with the pathogenesis of human hypertension. Postmortem SFO tissues were collected from hypertensive and normotensive human subjects. Immunolabeling for the PRR and a retrospective analysis of clinical data were performed. We found that human PRR was prominently expressed in most neurons and microglia, but not in astrocytes, in the SFO. Importantly, PRR levels in the SFO were elevated in hypertensive subjects. Moreover, PRR immunoreactivity was significantly correlated with systolic blood pressure but not body weight, age, or diastolic blood pressure. Interestingly, this correlation was independent of antihypertensive drug therapy. Our data indicate that PRR in the SFO may be a key molecular player in the pathogenesis of human hypertension and, as such, could be an important focus of efforts to understand the neurogenic origin of hypertension.NEW & NOTEWORTHY This study provides evidence that, in the subfornical organ of the human brain, the (pro)renin receptor is expressed in neurons and microglia cells but not in astrocytes. More importantly, (pro)renin receptor immunoreactivity in the subfornical organ is increased in hypertensive humans and is significantly correlated with systolic blood pressure.

A 53 year-old Vietnamese male presented with a complaint of a left buttock mass which had grown to 8.0 cm during the past three years. A CT scan revealed the gluteal lesion and a large mass of the stomach. A biopsy of the gluteal skin lesion was diagnosed as a high grade neuroendocrine carcinoma consistent with Merkel cell carcinoma. Tumor cells in the gastric biopsy showed the same morphology and immunophenotype as seen in the skin biopsy, and expressed synaptophysin, chromogranin, CD56, and cytokeratin (CK) 20 with perinuclear dot-like staining. The diagnosis of gastric metastasis of Merkel cell carcinoma was further confirmed by immunohistochemistry for Merkel cell polyomavirus (MCPyV). The patient underwent one cycle of chemotherapy until he presented with a perforation of the gastric lesion. Surgical resection was performed, with subsequent pathologic analysis of the stomach lesion interpreted as metastatic Merkel cell carcinoma. Herein we describe the first case of perforated gastric metastasis of Merkel cell carcinoma. Histopathological diagnosis of perforated gastric metastasis of Merkel cell carcinoma was established by characteristic immunostains for CK20 and MCPyV in addition to the positive stains for neuroendocrine markers (synaptophysin, chromogranin and CD56). Keywords: Merkel cell carcinoma, Gastric metastasis, Perforation, Merkel cell polyomavirus, Immunohistochemistry

A 7-month-old boy presented with gastrointestinal disturbance, mild neurologic deficit of the left lower extremity and levo-scoliosis of the thoracic spine. Magnetic resonance imaging demonstrated a large intramedullary lesion involving the thoracic spine, from level T1 to T11. Histologic analysis showed a glial tumor with fibrillary processes arranged in radial pattern around mucoid fibrovascular cores with a high proliferative index (focally up to 80%) and prominent vascular endothelial hyperplasia. These findings were consistent with an anaplastic myxopapillary ependymoma. Subtotal resection was performed via a T3-T10 laminoplasty. A ventricular shunt was placed, and the patient subsequently received chemoradiation therapy. To date, this is the second case of a myxopapillary ependymoma with high-grade anaplastic features and the first case in an infant reported in the literature.

This paper presents the experimental and numerical results for a two stage combustor capable of achieving flameless combustion mode with 20 kW thermal input and heat release density up to 5 MW/m(3). The fuel and oxidizer are supplied at ambient conditions. The concept of high swirl flows has been adopted to achieve high internal recirculation rates, residence time and increased dilution of the fresh reactants in the primary combustion zone, resulting in flameless combustion mode. Air is injected through four tangential injection ports located near the bottom of the combustor and liquid fuel is injected through a centrally mounted pressure swirl injector. Preliminary computational analysis of the flow features shows that decrease in the exit port diameter of the primary chamber increases the recirculation rate of combustion products and helps in achieving the flameless combustion mode. Based on preliminary computational studies, a 30 mm primary chamber exit port diameter is chosen for experimental studies. Detailed experimental investigations show that flameless combustion mode was achieved with evenly distributed combustion reaction zone and uniform temperature distribution in the combustor. The CO and NOx emissions are reduced from 350 to 11 ppm and 45 to 12 ppm respectively at an equivalence ratio of 0.92, as operation of the combustor changes from conventional to flameless combustion mode. Measurement of CO and NOx emissions show that these emissions are reduced by an order of magnitude when operated in flameless combustion mode. The acoustic emission levels are reduced by 6-8 dB as combustion mode shifts from conventional mode to flameless combustion mode. (C) 2012 The Combustion Institute. Published by Elsevier Inc. All rights reserved.

A range of processed cheese spread samples containing starch were prepared on a Rapid Visco Analyser (RVA). The starches used were waxy cornstarch, high-amylose cornstarch, rice starch, potato starch, wheat starch and acid-converted starch. Incorporation of the starches at different levels produced marked differences in the rheological, microstructural and functional properties of the processed cheese spreads. Rheological attributes such as complex modulus and viscosity increased; the extent of increase depended on the starch type and the starch level. Starch incorporation at reduced protein levels demonstrated the possibility of maintaining satisfactory rheological properties at lower ingredient cost.

Flameless combustion is an effective method to suppress CO and NOX emissions from combustion systems with improved combustion efficiency. Flameless combustion is achieved through simultaneous preheating and dilution of fresh reactants with internal recirculation of hot combustion products leading to a distributed reaction zone and uniform temperature distribution throughout the volume of the combustor. In the present study, a high-intensity swirl-based combustor operating with liquid fuel in a flameless combustion mode is developed for industrial applications and designed to run at atmospheric pressure conditions. Detailed investigations on the emission characteristics for various operating conditions in flameless combustion mode have been reported. The experiments have been carried out for a range of heat release rates varying from 5 to 10 MW/m(3). Swirl flow pattern is achieved through tangential air injection to enhance the internal recirculation of hot combustion products into fresh reactants. Preliminary numerical studies aimed at understanding flow pattern in four different combustor configurations show that recirculation rate increases with an increase in the divergence angle of the combustor. This helps achieve flameless combustion mode. Recirculation rate increases with a decrease in the outlet diameter from 80 mm to 25 mm. Based on the degree of the combustion completeness, extended frustum of the cone-based configuration (60.) has been proposed to obtain low emission combustion mode with liquid fuels. Temperature distribution and emissions are measured and compared for different thermal inputs (heat release intensities) and air-preheat temperatures. Measurements of acoustic, CO, and NOX emissions show that these emissions are reduced by an order of magnitude when the combustor is operated in flameless combustion mode as compared to conventional combustion mode.

Background: A prospective randomized study was undertaken to evaluate the efficacy of intrathecal morphine along with bupivacaine for post-operative analgesia in patients undergoing vaginal hysterectomy. Materials and methods: The study was conducted on 80 female patients in the age group of 18 to 60 years, belonging to ASA grade I to III scheduled for vaginal hysterectomy. Patients were randomly divided in to two equal groups,one receiving morphine(group M) and other normal saline(group B). Baseline pulse rate, blood pressure, respiratory rate, Visual analogue scale and sedation score were recorded & monitored at regular intervals. Result: Respiratory rate & Oxygen saturation remained normal in both groups. Fall in pulse rate was more in group M Blood pressure was lower in group M as compared to group B. Higher sedation score in group M, sensory and motor blockade achieved was faster in group M with improved VAS score and less serious side effects. Conclusion: We thus conclude that intrathecal administration of 0.1mg preservative free morphine along with 0.5% bupivacaine (17.5mg) significantly prolongs the duration of post-operative analgesia up to 14 hours. It also reduces postoperative analgesic requirement in first 24 hours.

Objective: To provide psychiatrists with relevant, up to date information about sporadic Creutzfeldt-Jakob disease. Conclusions: A 59-year-old bookkeeper presented with psychiatric symptoms in the context of stressors and past history of depression, for which her GP prescribed sertraline and olanzapine. Following a further deterioration in her mental state she was referred to acute psychiatric services, and there found to have dementia and myoclonus, and investigations supported a diagnosis of probable Creutzfeldt-Jakob disease, sporadic type (sCJD). This paper serves to outline the emerging literature challenging the notion that suggests psychiatric symptoms are uncommon in the presentation of sCJD.

In the present work, the effect of coflow conditions and fuel injection pressure on flame lift-off height, flame stabilization, and flame fluctuations in liquid spray flames has been experimentally investigated for three different coflow cases: (1) cold flow, (2) cold flow with nitrogen dilution, and (3) preheated and diluted coflow. It has been observed that the flame lift-off height is proportional to the coflow velocity and inversely proportional to the injection pressure. The dependence of flame lift-off height on the fuel mass flow rate has been investigated using fuel injectors of identical spray cone angles, mean droplet diameter, and different fuel mass flow rates. It has been observed that the flame lift-off height decreases with an increase in the fuel flow rate. Mean droplet diameter (SMD) has a dominating effect on flame lift-off height and flame stability. An increase in the SMD increases the fluctuations in the stabilization point of the lifted flame and vice versa. For N(2) dilution cas, (21%-17% O(2) in coflow stream), the lift-off height increases with dilution as compared to ambient air coflow. The flame blows-off at lower coflow velocities due to reduced oxidizer concentration in the coflow. Preheating of the coflow stream enhances the droplet evaporation rate and mixing, thus leading to a significant increase in the stability of lifted spray flames.

We have been following the proposed diagnostic criteria for Alzheimer's disease (AD) closely over the past few years. 1 Recent revisions of the AD criteria proposed by Dubois and colleagues 2 represent a clear improvement on their previously published Position Paper. 3 In the new revision, Dubois and colleagues propose an important distinction between the clinical disorder (AD) and the neuropathological condition (“Alzheimer's pathology”). They also describe several distinctions within the clinical disorder, including two preclinical conditions (“asymptomatic at-risk for AD” and “presymptomatic AD”), a prodromal condition (“prodromal AD”), and AD dementia with varying presentations (“typical AD,” “atypical AD”, and “mixed AD”)...