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AbstractBackgroundFor antiretroviral therapy (ART) naive human immunodeficiency virus (HIV) infected adults suffering from tuberculosis (TB), there is uncertainty about the optimal time to initiate highly active antiretroviral therapy (HAART) after starting antituberculosis treatment (ATT), in order to minimize mortality, HIV disease progression, and adverse events.MethodsIn a randomized, open label trial at All India Institute of Medical Sciences, New Delhi, India, eligible HIV positive individuals with a diagnosis of TB were randomly assigned to receive HAART after 2-4 or 8-12 weeks of starting ATT, and were followed for 12 months after HAART initiation. Participants received directly observed therapy short course (DOTS) for TB, and an antiretroviral regimen comprising stavudine or zidovudine, lamivudine, and efavirenz. Primary end points were death from any cause, and progression of HIV disease marked by failure of ART.FindingsA total of 150 patients with HIV and TB were initiated on HAART: 88 received it after 2-4 weeks (early ART) and 62 after 8-12 weeks (delayed ART) of starting ATT. There was no significant difference in mortality between the groups after the introduction of HAART. However, incidence of ART failure was 31% in delayed versus 16% in early ART arm (p = 0.045). Kaplan Meier disease progression free survival at 12 months was 79% for early versus 64% for the delayed ART arm (p = 0.05). Rates of adverse events were similar.InterpretationEarly initiation of HAART for patients with HIV and TB significantly decreases incidence of HIV disease progression and has good tolerability.Trial registrationCTRI/2011/12/002260

Abstract Background Rifampicin reduces the plasma concentrations of nevirapine in human immunodeficiency virus (HIV) and tuberculosis (TB) co-infected patients, who are administered these drugs concomitantly. We conducted a prospective interventional study to assess the efficacy of nevirapine-containing highly active antiretroviral treatment (HAART) when co-administered with rifampicin-containing antituberculosis treatment (ATT) and also measured plasma nevirapine concentrations in patients receiving such a nevirapine-containing HAART regimen. Methods 63 cases included antiretroviral treatment naïve HIV-TB co-infected patients with CD4 counts less than 200 cells/mm3 started on rifampicin-containing ATT followed by nevirapine-containing HAART. In control group we included 51 HIV patients without tuberculosis and on nevirapine-containing HAART. They were assessed for clinical and immunological response at the end of 24 and 48 weeks. Plasma nevirapine concentrations were measured at days 14, 28, 42 and 180 of starting HAART. Results 97 out of 114 (85.1%) patients were alive at the end of 48 weeks. The CD4 cell count showed a mean increase of 108 vs.113 cells/mm3 (p=0.83) at 24 weeks of HAART in cases and controls respectively. Overall, 58.73% patients in cases had viral loads of less than 400 copies/ml at the end of 48 weeks. The mean (± SD) Nevirapine concentrations of cases and control at 14, 28, 42 and 180 days were 2.19 ± 1.49 vs. 3.27 ± 4.95 (p = 0.10), 2.78 ± 1.60 vs. 3.67 ± 3.59 (p = 0.08), 3.06 ± 3.32 vs. 4.04 ± 2.55 (p = 0.10) respectively and 3.04 μg/ml (in cases). Conclusions Good immunological and clinical response can be obtained in HIV-TB co-infected patients receiving rifampicin and nevirapine concomitantly despite somewhat lower nevirapine trough concentrations. This suggests that rifampicin-containing ATT may be co administered in resource limited setting with nevirapine-containing HAART regimen without substantial reduction in antiretroviral effectiveness. Larger sample sized studies and longer follow-up are required to identify populations of individuals where the reduction in nevirapine concentration may result in lower ART response or shorter response duration.

Background: The main objective is to detect clinically significant conditions by transcranial ultrasound (TCS) in post-decompressive craniectomy (DC) patients who come to the emergency department. Materials and methods: This was a cross-sectional observational study. We studied 40 post-DC patients. After primary stabilization, TCS was done. Computer tomography of head was done within 2 hours of performing TCS. The correlation between both modalities were assessed by the measurement of lateral ventricle (LV) (Bland-Altman plot), Midline shift and mass lesion. Additionally, normal cerebral anatomy, 3rd and 4th ventricles and external ventricular drainage (EVD) catheter visualization were also done. Results: About 14/40 patients came with non-neurosurgical complaints and 26/40 patients came with neurosurgical complaints. Patients with non-neurosurgical complaints (4/14) had mass lesions and 1/14 had MLS. Patients with neurosurgical complaints (11/26) had mass lesions and about 5 patients had MLS. A good correlation was found between TCS and CT of head in measuring LV right (CT head = 17.4 ± 13.8 mm and TCS = 17.1 ± 14.8 mm. The mean difference (95% CI) = [0.28 (--1.9 to 1.33), ICC 0.93 (0.88--0.96)], Left [CT head = 17.8 ± 14.4 mm and TCS = 17.1 ± 14.2 mm, the mean difference (95% CI) 0.63 (--1.8 to 0.61), ICC 0.96 (0.93--0.98)], MLS [CT head = 6.16 ± 3.59 (n = 7) and TCS = 7.883 ± 4.17 (n = 6)] and mass lesions (kappa 0.84 [0.72--0.89] [95% CI] p-value < 0.001). The agreement between both modalities for detecting mass lesions is 93.75%. Conclusion: Point of care ultrasound (POCUS) is a bedside, easily operable, non-radiation hazard and dynamic imaging tool that can be used for TCS as a supplement to CT head in post-DC patients in emergency as well as in ICU. However, assessment of the ventricular system (pre/post-EVD insertion), monitoring of regression/progression of mass lesion, etc. can be done with TCS. Repeated scans are possible in less time which can decrease the frequency of CT head. [ABSTRACT FROM AUTHOR]

Background: Pupillary assessment is an important part of the neurological assessment which provides vital information in critically ill patients. However, clinical pupillary assessment is subjective. The ultrasound‐guided pupillary examination is objective. There are limited pieces of literature regarding its use in assessing patients with altered mental status. So, we studied the extent of agreement of B‐mode ultrasound with clinical examination for assessment of the pupillary size and reflex in patients with altered mental status. Objectives: The primary objective was to determine the extent of agreement between clinical examination and ultrasound‐based examination for assessing pupillary reflex and size in patients with altered mental status in two settings (trauma and non‐trauma patients). Methods: Exactly 200 subjects (158 males, mean [range] age 43.56 [18–92 years]) with no history of partial globe rupture or dementia were included in this cross‐sectional study from March 2019 to March 2020. B‐mode ultrasound was performed with the subject's eyes closed using a 7–12 MHz linear probe and a standardized light stimulus. ICC score, paired t‐test, kappa, Wilcoxon signed‐rank test, and Bland–Altman plots were used for statistical analysis. Results: The clinical‐USG agreement for pupillary light reflex examination (Pupillary Diameter [PD] at rest, after direct light stimulation [Dstim] and consensual light stimulation [Cstim]) was excellent (ICC, 0.93–0.96). The Kappa coefficient (0.74 ± 0.07) showed an agreement of 87.36% between clinical and USG examination for pupillary reflex (reactive or non‐reactive). Conclusion: USG‐guided pupillary examination proves to be a better adjunct to neurological assessment in patients with altered mental status. [ABSTRACT FROM AUTHOR]

This document provides abstracts from studies presented at the Middle East and North Africa Clinical Toxicology Association Meeting in Abu Dhabi. The studies cover a range of topics, including the presence of warning labels on energy drinks in Kuwait, snakebites in Saudi Arabia, the efficacy of high-dose Methylprednisolone in preventing esophageal stricture formation, medical toxicology knowledge in Oman, and patterns of telephone enquiries related to suicide attempts in Sudan. The document also includes case reports of toxic exposures and poisonings, highlighting the importance of recognizing toxic exposures and providing appropriate treatment. Additionally, there are cases discussing different types of poisonings and their treatment, including colchicine overdose, radiation emergencies, envenomation medical care in zoos, monitoring viperine venom-induced consumptive coagulopathy, and the economic impact of managing paracetamol poisoning in Algeria. These cases underscore the significance of proper treatment and preparedness in handling various types of poisonings. [Extracted from the article]

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

Introduction: Triage is a crucial process not only to identify sick patients and prioritize prompt management but also to foster efficient resource utilization. In low-and middle-income countries (LMICs) most emergency departments (ED) still have an informal triage process. Although an important element of emergency care, triage research has not been a priority in LMICs, and hence, very few triage systems have been validated. The All India Institute of Medical Sciences (AIIMS) triage protocol or ATP for adult patients was developed by expert consensus at AIIMS using the Delphi method. We attempted a prospective validation of the ATP in terms of mortality and intensive care unit (ICU)/hospital admission at 24 h. Methods: Patients presenting to the ED, who were 14 years and above were included in the study. The patients were followed up at 24 h and their outcome documented on a standardized data collection form. Mortality and ICU admission were noted at 24 h. Results: A total of 15,505 patients were recruited. After exclusion, among 13,754 patients, 6303 (45.83%) were triaged red and 7451 (54.17%) were triaged yellow. Mortality at 24 h was 10.31% (650) in red triaged patients and 0.35% (26) in yellow triaged patients. The 24-h mortality of red triaged patients was significantly higher (P <0.001) than that of yellow triaged patients. The presence of one or more ATP "Red" criteria was 96.2% (95% confidence interval [CI]: 94.42%–97.47%) sensitive and 56.8% (95% CI: 55.92%–57.63%) specific in predicting 24-h mortality. The sensitivity and specificity of ATP "Red" criteria for 24-h ICU admission were 98.5% (95% CI: 97.7%–99.1%) and 59.6% (95% CI: 58.8%–60.5%), respectively. Conclusion: When applied to adult nontrauma patients, ATP had a high accuracy in recognizing sick patients presenting to the ED. A time-tested and validated triage system like ATP may be a good starting point for public hospital EDs in LMICs. [ABSTRACT FROM AUTHOR]

Background: COVID 19 resurgence in multiple waves and the highly infectious variant of SARS-CoV-2 (B.1.617) has wreaked havoc across healthcare systems in India. We conducted a study to delineate the clinico-epidemiological profile of COVID-19 patients in this second wave of the pandemic. Methods: This was a retrospective, single centre, observational study at the Emergency Department(ED) of a teaching institute in North India. The ED health records were screened for patient files with the diagnosis of COVID -19, age > 14 years, presenting from 10th April to 30th of May. ED clinical notes, disposition, and mortality data were retrieved and analysed. Results: 1647 files were screened and 253 eligible patients of COVID-19 were included in the study. 60% patients were male, mean age (+ SD) was 54 (+ 14.8 years). Shortness of breath (74.7%), fever (71.9%), cough (57.7%) were the common presenting symptoms. 20% of patients were nil comorbid; Diabetes (44.7%) and Hypertension (41.5%) were the common comorbid illnesses. 73.1% patients had severe COVID illness, 39.9% had oxygen saturation <90% on arrival and 33.2% had <70%. More than 90% patients required respiratory support on arrival. 25% of people presented to hospital after home isolation, of which 81% had severe COVID at presentation. 39 % patients of mild illness had received corticosteroids. Conclusion: The second wave of COVID-19 with rapid upsurge of cases overwhelmed the healthcare system with a higher proportion of severe COVID-19 cases and higher mortality, thus stressing the need for prior planning, preparation and strengthening healthcare systems across tiers. [ABSTRACT FROM AUTHOR]

Bee sting can lead to allergic reactions which can present as life-threatening emergencies. Kounis syndrome is an acute coronary syndrome caused by mast cell activation after exposure to an allergen. Atrial fibrillation (AF) along with Kounis syndrome after allergen exposure is a rare presentation. A 40-year-old male patient presented to the emergency department (ED) with multiple bee stings to the face and neck. He complained of retrosternal chest pain along with facial pain and swelling. An electrocardiogram (ECG) showed AF with ST elevation in aVR and generalized ST segment depression. Troponin levels were elevated. He was diagnosed with Kounis syndrome along with AF secondary to a bee sting. The patient improved symptomatically with removal of stings and conservative management (steroids, antihistamines, antiplatelet drugs). ECG reverted to sinus rhythm and resolution of ST-T changes. He was discharged from the ED in stable condition. The bee sting may lead to significant cardiovascular events such as AF and Kounis syndrome, which require a high index of suspicion and prompt treatment. Kounis syndrome should be suspected in the ED in young patients with no cardiovascular risk factors after exposure to an allergen. [ABSTRACT FROM AUTHOR]

We conducted a prospective, observational study to assess the serum chymase level, a mast cell derived protease, as a predictor of dengue severity. NS1‐positive non‐severe dengue patients of age ≥14 years with duration of fever ≤4 days were included in the study. At the time of admission, the serum sample was taken for chymase estimation. Patients were followed up to four days after they became afebrile to find out the final diagnosis. Total of 338 non‐severe dengue patients were recruited (mean age: 29.15 years; male: 66%). On follow‐up, 26 patients (7.8%) developed severe dengue. Only chymase level (adjusted odds ratio [aOR]: 1.787; 95% confidence interval [CI]: 1.309–2.440) and platelet count at admission (aOR: 0.981; 95% CI: 0.968–0.993) were able to predict the severity after adjustment for all variables. But, for prediction of severe dengue, the area under receiver′s operating curve of chymase was 0.835 (95% CI: 0.765–0.905), which was significantly higher than that of the platelet count at admission (0.760, 95% CI: 0.650–0.870) (p <.001). Patients who developed severe dengue in due course of illness had significantly higher serum chymase level at admission as compared with the rest of the patients. Similar findings were noted across all age‐groups. At an optimum cut‐off value of 1.35 ng/ml, chymase had a positive likelihood ratio (LR) of 3.5 and a negative LR of 0.15, for predicting severe dengue. This study demonstrated the potential ability of serum chymase levels at admission, as a biomarker for prediction of severe dengue in due course of illness. Highlights: Prediction of severe dengue disease by serum chymase assay was investigated in this prospective study. It was found that patients with initial higher serum chymase levels were more likely to develop severe dengue in due course of illness, as compared to that of lower chymase level. [ABSTRACT FROM AUTHOR]

Background: A systematic review and meta-analysis of available studies was performed to investigate the clinical characteristics that can predict COVID-19 disease severity. Materials and Methods: Databases including PubMed, Embase, and Web of Science were searched from December 31, 2019, to May 24, 2020. Random-effects meta-analysis was used for summarizing the Pooled odds ratio (pOR) of individual clinical characteristics to describe their association with severe COVID-19 disease. Results: A total of 3895 articles were identified, and finally, 22 studies comprising 4380 patients were included. Severe disease was more common in males than females (pOR: 1.36, 95% confidence interval [CI]: 1.08–1.70). Clinical features that were associated with significantly higher odds of severe disease were abdominal pain (pOR: 6.58, 95% CI: 1.56–27.67), breathlessness (pOR: 3.94, 95% CI: 2.55–6.07), and hemoptysis (pOR: 3.35, 95% CI: 1.05–10.74). pOR was highest for chronic obstructive pulmonary disease (pOR: 2.92, 95% CI: 1.70–5.02), followed by obesity (pOR: 2.84, 95% CI: 1.19–6.77), malignancy (pOR: 2.38, 95% CI: 1.25–4.52), diabetes (pOR: 2.29, 95% CI: 1.56–3.39), hypertension (pOR: 1.72, 95% CI: 1.23–2.42), cardiovascular disease (pOR: 1.61, 95% CI: 1.31–1.98) and chronic kidney disease (pOR: 1.46, 95% CI: 1.06–2.02), for predicting severe COVID-19. Conclusion: Our analysis describes the association of specific symptoms and comorbidities with severe COVID-19 disease. Knowledge of these clinical determinants will assist the clinicians in the risk-stratification of these patients for better triage and clinical management. [ABSTRACT FROM AUTHOR]

Background and Objectives: As the number of COVID-19 cases keeps on rising, a better awareness of the nature and severity of the disease will aid in clinical decision-making and management. Hence, this study was conducted to find the predictors of mortality and the need for mechanical ventilation in COVID-19 patients. Methods: This was a single centre, prospective observational study conducted in a tertiary care centre in north India. We included patients with influenza like illness who tested positive for COVID-19. Information regarding patient demography, symptoms, and vital signs on presentation, laboratory values, chest imaging findings, and disease severity was collected by the emergency physician. QSOFA score and National early warning score (NEWS) score were calculated using initial vital signs. Each patient was followed up till discharge or death. Results: We included 116 COVID-19 patients with 33 patients having mild, 46 patients with severe and 37 patients with critical disease. The median age of our patients was 47 years (39–59) with 63% males. About 58% of patients had at least one comorbidity and shortness of breath was the most common presenting feature. The patients with severe and critical disease had a significantly higher respiratory rate and heart rate as compared to mild disease (p < 0.05). SpO2 of those with critical disease was significantly lower as compared to those with mild disease. Mechanical ventilation was required in around 36% of patients which included 67% of patients with critical disease. The overall mortality was 51% with 90% among critical disease. Lower SpO2 and GCS were the only parameters that showed a significant association with mortality and need for mechanical ventilation. The receiver operating characteristics analysis showed NEWS score as a better predictor of mortality and need for mechanical ventilation as compared to qSOFA score. Conclusion: NEWS and qSOFA scores are useful tools in predicting fatal outcomes in COVID patients with NEWS score being a better score than qSOFA. [ABSTRACT FROM AUTHOR]

Vertigo is not an uncommon presenting symptom in patients presenting to the emergency department (ED) and primary physician's clinic, and around one-tenth of these patients have a central cause, i.e., posterior circulation stroke. HINTS, the acronym for head impulse (HI) test, nystagmus (N), and test of skew (TS), is a neurological examination utilized for differentiating a peripheral cause of vertigo from a sinister central cause. It is a simple, easy-to-do, inexpensive, and less time-consuming test. Here, we present a 27-year young male case without any known comorbidity or trauma, presented to the ED, with complaints of sudden onset isolated vertigo for 2 hours. HINTS examination pointed towards a central cause (normal head impulse test and direction-changing nystagmus). Other neurological and systemic examinations were normal. Non-contrast computed tomography of the brain was normal. Further, computed tomography angiography of head and neck vessels was performed, showing left vertebral artery dissection (VAD). The patient's neurological status deteriorated in the next 8 hours. The patient underwent decompressive craniotomy and got discharged after two weeks. Early performance of the HINTS examination by the primary care physicians and emergency physicians lead to early diagnosis and treatment of this common cause of posterior circulation stroke in young patients. Essential take-home points are the importance of the HINTS test and not to forget VAD as a cause of isolated vertigo without any neck manipulation or trauma. [ABSTRACT FROM AUTHOR]

Emergency department (ED), the specialty of undifferentiated resuscitation and care, caters all patients irrespective of their age, gender, social status, or disease condition. Yearly, we receive approximately 1.5 lakh patients in our ED (trauma and nontrauma patients). Prehosp Disaster Med 1996;11:117-24. 11 Kumar R, Bhoi S, Chauhan S, Sinha TP, Adhikari G, Sharma G, et al. (A264) Does the Implementation of START Triage Criteria in the Emergency Department Reduce Over-and under-Triage of Patients?. [Extracted from the article]