Acute Stroke in the Emergency Department: Profiles of Patients and Obstacles to Acute Intervention.

AIMS: To build a demographic profile of patients presenting to the emergency department (ED) with stroke, determine the proportion who successfully undergo thrombolysis and active interventions, and study their outcomes up to discharge or death in the hospital. METHODS AND MATERIALS: A sample size of 215 was calculated and patients were recruited consecutively on presentation to the ED after obtaining consent. Data was collected and they were followed up till the outcome. Data was tabulated and analyzed both as a whole and after further categorization into infarction, hemorrhagic stroke, and cerebral venous thrombosis (CVT). Mean and standard deviation were used for continuous variables and chi-square for categorical variables. RESULTS: A total of 216 patients were recruited, 156 (72%) male and 60 (28%) female. There were 135 (63%) ischemic strokes, 67 (31%) hemorrhagic, and 14 (6%) CVT. The mean age was 56.57 years (SD 14.22 years). A total of 12 patients (5.5%) presented within the 'golden hour' and 28 ischemic strokes presented within the thrombolysis window, of which nine were thrombolyzed. In total, 39 patients were intubated in the ED, of which 10 (7.41%) had ischemic strokes, 27 (40.3%) had hemorrhagic strokes and two (14.29%) had CVTs. There were 192 patients admitted to in-patient care, while 24 (11%) were discharged against medical advice. A further 14 patients were intubated during admission. Nine patients (13.43%) with hemorrhagic strokes underwent surgical decompression, five (7.46%) had an external ventricular drain (EVD) placed, six (8.96%) underwent aneurysm clipping, and two (2.99%) underwent aneurysm coiling. One case of CVT underwent surgical decompression. CONCLUSIONS: Stroke is a highly heterogeneous clinical entity with nuanced differences between the different subtypes. There appear to be significant obstacles regarding the early presentation of strokes to hospitals and the initiation of thrombolysis in the case of acute interventions.

Critical insights into ensemble learning with decision trees for the prediction of biochar yield and higher heating value from pyrolysis of biomass.

Pyrolysis is an efficient thermochemical conversion process, but accurate prediction of yield and properties of biochar presents a significant challenge. Three prominent ensemble learning methods, viz. Random Forest (RF), eXtreme Gradient Boosting (XGB), and Adaptive Boosting (AdaBoost) were utilized to develop models to predict yield and higher heating value (HHV) of biochar. Dataset comprising 423 observations from 44 different biomasses was curated from peer-reviewed journals for predicting biochar yield. RF regressor achieved a test R2 of 0.86 for biochar yield, while XGB regressor achieved a test R2 of 0.87 for biochar HHV prediction. The SHapley Additive exPlanations (SHAP) analysis was conducted to assess influence of each feature on the model's output. Pyrolysis temperature and ash content of biomass were identified as the most influential features for the prediction of both yield and HHV of biochar. The partial dependence plots (PDPs) revealed nonlinear relationships, interpreting how the model formulates its predictions.

Revealing an Uncommon Presentation of Chiari I Malformation With Diverse Craniovertebral Anomalies in the Absence of Syringomyelia and Atlanto-Occipital Subluxation: A Case Report.

A Chiari I malformation is a frequently encountered anomaly of the posterior fossa, occurring in a notable percentage of the population. It often coexists with various other craniovertebral junction abnormalities, albeit less frequently with Klippel-Feil syndrome. Interestingly, the majority of individuals with Chiari I malformation do not exhibit any symptoms. We present a rare case of a 25-year-old male with chronic neck and occipital pain, along with progressive weakness and sensory disturbances in all four limbs, urinary urgency, and elevated left shoulder. Examination unveiled spasticity, weakness, and brisk reflexes. On extensive radiological evaluation (X-ray, CT, and MRI), findings revealed various anomalies in the craniovertebral junction, including complete atlanto-occipital assimilation, basilar invagination, and platybasia. Furthermore, cervical segmentation abnormalities indicative of Klippel-Feil syndrome were observed, along with Sprengel's deformity. MRI confirmed Chiari I malformation with tonsillar herniation and myelomalacia, as well as compression at the cervico-medullary junction. This patient underwent a surgical procedure that included transoral odontoidectomy combined with occipito-cervical fixation, after which a good clinical response was observed. It emphasizes the necessity of radiological imaging for the diagnosis of Chiari and other associated abnormalities in the craniovertebral junction.

A Case of Lymphangioma of the Calf Region: Imaging Spectrum With Histopathological Correlation.

Lymphangioma, also known as cystic hygroma are benign malformations arising from abnormal development of the lymphatic system. Most often these lesions are found in the pediatric population, having a predilection for the neck/axilla, and are less common in extremities. Symptoms can vary based on size and location. Treatment is not usually indicated until they start impacting life due to deformity or symptoms such as pain, paraesthesia, etc. Here, we report a case report of lymphangioma located in the calf region of the right lower limb presenting in adult age.

Chondrosarcoma of Iliac Bone Imaging Spectrum With Histopathological Correlation: A Case Report.

Chondrosarcoma is a rare form of carcinoma that originates in the cells of cartilage, the flexible tissue that cushions the joints and gives structure to various parts of the body. This malignant tumour primarily affects adults and is most commonly found in the bones of the arms, legs, pelvis, and ribs. The severity and prognosis of chondrosarcoma can vary widely depending on factors such as tumour size, location, and grade. We are reporting a case of an 83-year-old male patient who presented with swelling over the left hip joint. A mass was detected on radiograph and ultrasound that was further characterized using contrast-enhanced CT and MRI. Imaging findings suggested chondrosarcoma. The patient was diagnosed on histopathological examination.

Budd Chiari Syndrome: A Case Report on Classic Imaging Findings With Successful Intervention.

Budd Chiari syndrome is an unusual vascular disease involving the hepatic vasculature and has significant mortality and morbidity if not treated early. Ultrasonography (USG), Doppler, computed tomography (CT), and magnetic resonance imaging (MRI) have classical imaging findings that can help make a reliable and quick diagnosis. Intervention radiology plays an important role in the treatment of these patients, helping avoid various complications and proper patient management. We are presenting a case report with classical imaging spectrum and highlighting successful intervention with hepatic vein stenting.

Valorization of millet agro-residues for bioenergy production through pyrolysis: Recent inroads, technological bottlenecks, possible remedies, and future directions.

Millets are receiving increasing attention, lately, in view of their preeminent agronomic traits, nutritional significance, and renewed emphasis on highlighting their health benefits through national and international programs. As a consequence, a variety of millets are being cultivated in different parts of the world resulting in significant amount of millet agro-residues. Present study comprehends critical analysis of reported investigations on pyrolysis of different millet agro-residues encompassing (i) physico-chemical characterization (ii) kinetics and thermodynamic parameters (iii) reactors employed and (iv) relationship between the reaction conditions and characteristics of millets-derived biochar and its prospective applications. Based on the analysis of reported investigations, specific research gaps have been figured out. Finally, future directions for leveraging the energy potential of millet agro-residues are also discussed. The analysis elucidated is expected to be useful for the researchers for making further inroads pertaining to sustainable utilization of millet agro-residues in tandem with other commonly employed agro-residues.

The Diagnosis and Treatment of Rasmussen's Encephalitis: A Case Report.

Rasmussen's encephalitis is a very rare type of chronic inflammatory disease of the brain. We report a case of a nine-year-old male patient who presented with seizures and cognitive impairment for six years. An MRI of the brain revealed significant cerebral hemiatrophy. The patient was on immunoglobulin therapy. We also engage in a review of the existing literature on Rasmussen's encephalitis.

Evaluation of Regional Myocardial Work Indices in Pediatric Essential and Renal or Renovascular Hypertension.

BACKGROUND: Myocardial work (MW) is an index of LV function based on pressure-strain loops and brachial cuff pressure measurement. MW has been proposed as more sensitive than conventional functional parameters, as it accounts for afterload and myocardial deformation. However, many studies have been limited to assessment of global MW indices, neglecting regional differences in cardiac associated with hypertension and consequent cardiac remodeling. We aimed to quantify regional MW in pediatric hypertension and compare the findings in renal or renovascular hypertension (RHTN) with essential hypertension (EHTN). METHODS: We retrospectively assessed conventional markers of LV function, and both global and regional MW indices in 78 patients (49 males, 15.4 ± 2.94 years) with EHTN and RHTN. RESULTS: Peak systolic strain (PSS) in the basal septal segment was significantly impaired in patients with RHTN compared to EHTN (-13.00% [-15.50%; -13.00%] vs. -15.00% [-17.50%; -13.50%], P = 0.034). Similarly, basal septal MW indices were significantly elevated in patients with EHTN compared to RHTN, including MW efficiency (MWE) (95.0% [93.0%; 98.0%] vs. 94.0% [89.0%; 95.0%], P = 0.004) and constructive work (CW) (1700 mm Hg% (409 mm Hg%) vs. 1520 mm Hg% (336 mm Hg%), P = 0.037). Wasted work (WW) was significantly elevated in the RHTN group (79.0 mm Hg% [28.5 mm Hg%; 104 mm Hg%] vs. 105 mm Hg% [62.0 mm Hg%; 164 mm Hg%], P = 0.010). CONCLUSION: Significant differences in basal septal PSS and MW indices were observed between EHTN and RHTN. These findings highlight the usefulness of regional MW indices in assessing disease and may help differentiate between etiologies of pediatric hypertension.

Rasmussen's Aneurysm: A Rare Case.

Rasmussen's aneurysm is a very uncommon condition occurring in post-pulmonary tuberculosis patients. We are presenting a case of a young male patient with the chief complaints of hemoptysis, breathlessness on exertion, cough with expectoration and fever, and weight loss. A thorough radiological examination revealed multiple cavitary lesions, bronchiectasis, tree-in-bud appearance and pulmonary nodules, and areas of air-spaced opacities, indicating a likely diagnosis of post-primary pulmonary tuberculosis with stages of active infection and healed infection. The post-contrast study revealed a well-defined dilated vascular channel arising from a branch of the right pulmonary artery indicating pseudo-aneurysm formation, i.e., Rasmussen's aneurysm, within a large cavity in the right middle lobe. The patient underwent emergency trans-arterial embolization successfully and he was stable postoperatively.

Real-Time Prediction of Mortality, Cardiac Arrest, and Thromboembolic Complications in Hospitalized Patients With COVID-19.

Background: COVID-19 infection carries significant morbidity and mortality. Current risk prediction for complications in COVID-19 is limited, and existing approaches fail to account for the dynamic course of the disease. Objectives: The purpose of this study was to develop and validate the COVID-HEART predictor, a novel continuously updating risk-prediction technology to forecast adverse events in hospitalized patients with COVID-19. Methods: Retrospective registry data from patients with severe acute respiratory syndrome coronavirus 2 infection admitted to 5 hospitals were used to train COVID-HEART to predict all-cause mortality/cardiac arrest (AM/CA) and imaging-confirmed thromboembolic events (TEs) (n = 2,550 and n = 1,854, respectively). To assess COVID-HEART's performance in the face of rapidly changing clinical treatment guidelines, an additional 1,100 and 796 patients, admitted after the completion of development data collection, were used for testing. Leave-hospital-out validation was performed. Results: Over 20 iterations of temporally divided testing, the mean area under the receiver operating characteristic curve were 0.917 (95% confidence interval [CI]: 0.916-0.919) and 0.757 (95% CI: 0.751-0.763) for prediction of AM/CA and TE, respectively. The interquartile ranges of median early warning times were 14 to 21 hours for AM/CA and 12 to 60 hours for TE. The mean area under the receiver operating characteristic curve for the left-out hospitals were 0.956 (95% CI: 0.936-0.976) and 0.781 (95% CI: 0.642-0.919) for prediction of AM/CA and TE, respectively. Conclusions: The continuously updating, fully interpretable COVID-HEART predictor accurately predicts AM/CA and TE within multiple time windows in hospitalized COVID-19 patients. In its current implementation, the predictor can facilitate practical, meaningful changes in patient triage and resource allocation by providing real-time risk scores for these outcomes. The potential utility of the predictor extends to COVID-19 patients after hospitalization and beyond COVID-19.

Insights into kinetic and thermodynamic analyses of co-pyrolysis of wheat straw and plastic waste via thermogravimetric analysis.

This work studied the co-pyrolysis of wheat straw (WS) and polyethylene (PE) via thermogravimetric experiments from room temperature to 1000 °C at various heating rates (10, 20, and 30 °C/min). Thermal behavior revealed that the maximum decomposition of WS, PE, and their blend occurred in three temperature ranges, viz. 250 - 496, 200 - 486, and 200 - 501 °C. Kinetic parameters were determined using model-free isoconversional methods. Activation energy from KAS (163.56, 220.26 and 196.78 kJ/mol for WS, PE, and blend), FWO (165.97, 222.05, 198.86 kJ/mol for WS, PE, and blend), and Starink (163.45, 220.05, 196.46 kJ/mol for WS, PE, and blend) method was estimated. From among various solid-state kinetic models, first-order reaction kinetics and one and two-dimensional diffusion models dominated co-pyrolysis of WS and PE. Thermodynamic parameters confirmed the feasibility of co-pyrolysis of WS and PE while differential thermal analysis signified that endothermic and exothermic reactions occur simultaneously.

Pyrolysis of pigeon pea (Cajanus cajan) stalk: Kinetics and thermodynamic analysis of degradation stages via isoconversional and master plot methods.

Detailed analysis of thermo-kinetics, reaction mechanism, and estimation of thermodynamic parameters are imperative for the design of reactor systems in thermochemical conversion processes. Present investigation was aimed at exploring the pyrolysis potential of pigeon pea stalk (PPS) by thermogravimetric experiments at 10, 20, and 30 °C/min heating rates. Maximum devolatilization of PPS was found to take place below 480 °C. The average activation energy for PPS pyrolysis was found to be 95.97, 100.74, 96.24, and 96.64 kJ/mol by Kissinger-Akahira-Sunose, Flynn-Wall-Ozawa, Starink, and Friedman method, respectively. Statistical analysis by one way analysis of variance method by employing Tukey test revealed that the difference in activation energy estimated from different methods was insignificant. Thermodynamic parameters (ΔH, ΔS, and ΔG) together with reaction mechanisms were also evaluated. Difference in the activation energy and enthalpy was found to be less than 5 kJ/mol. R2 and R3 models were found best fitted with experimental PPS pyrolysis data.

A Unique Case of Unicornuate Uterus With a Non-communicating Rudimentary Horn and Hematometra.

Congenital uterine anomalies are a rare type of malformation involving female genitalia caused by abnormal development of the Mullerian duct system. Patients having an obstructive type of uterine anomalies are very much likely to develop obstetric and gynecological complications usually at the age of menarche or later in the course of life. In this case report, we present a case of a young female patient having severe dysmenorrhea which is caused by obstructive hematometra in the rudimentary horn which is not communicating with the uterine cavity. Ultrasonography (USG) was used to make a differential diagnosis of a probable congenital abnormality, which was subsequently validated by magnetic resonance imaging (MRI), which revealed a uterine cavity having a single cornu on the left side seen to be connecting with the cervix and a dilated rudimentary horn on the right side. The patient underwent the excision of the rudimentary horn laparoscopically. This case emphasizes the importance of identifying patients having anomalies involving the uterus to provide appropriate treatment to the patient and to prevent adverse outcomes for her reproductive potential.

Co-pyrolysis of petroleum coke and banana leaves biomass: Kinetics, reaction mechanism, and thermodynamic analysis.

Insights into thermal degradation behaviour, kinetics, reaction mechanism, possible synergism, and thermodynamic analysis of co-pyrolysis of carbonaceous materials are crucial for efficient design of co-pyrolysis reactor systems. Present study deals with comprehensive kinetics and thermodynamic investigation of co-pyrolysis of petroleum coke (PC) and banana leaves biomass (BLB) for realizing the co-pyrolysis potential. Thermogravimetric non-isothermal studies have been performed at 10, 20, and 30 °C/min heating rates. Synergistic effect between PC and BLB was determined by Devolatilization index (Di) and mass loss method. Kinetic parameters were estimated using seven model-free methods. Standard activation energy for PC + BLB blend from FWO, KAS, Starink, and Vyazovkin methods was ≈165 kJ/mol and that from Friedman and Vyazovkin advanced isoconversional methods was ≈171 kJ/mol. The frequency factor calculated for the blend from Kissinger method was found to be in the range of 106-1016s-1. Devolatilization index (Di) showed synergistic effect of blending. The data pertaining to co-pyrolysis was found to fit well with R2 (second order) and D3 (three dimensional) from Z(α) master plot. Thermodynamic parameters, viz. ΔH ≈ 163 kJ/mol and ΔG ≈ 151 kJ/mol were calculated to determine the feasibility and reactivity of the co-pyrolysis process. The results are expected to be useful in the design of petcoke and banana leaves biomass co-pyrolysis systems.

P-Null Phenotype Due to a Rare Frame-Shift Mutation and with Allo-Anti-PP1Pk Causing a Severe Hemolytic Transfusion Reaction: A Case Report with Clinical Management.

INTRODUCTION: The identification of alloantibodies to high-frequency antigens (HFA) and subsequent transfusion management can be challenging and often poses a problem in finding the compatible blood for transfusion. The aim of this study was to investigate the specificity of the antibody to the HFA causing a hemolytic transfusion reaction (HTR) and procure the compatible blood unit for future transfusion. CASE PRESENTATION: A 4-year-old female met with a head injury that led to intracranial bleeding and surgical intervention was required to remove blood clots. In the face of anemia, blood transfusion was planned. The pretransfusion tests on her blood sample revealed the presence of a pan-reactive alloantibody with hemolytic properties. She was transfused with 10 mL of the least incompatible red blood cells (RBCs) to which she reacted with signs of clinical hemolysis, i.e., chill, rigor, fever, and hemoglobinuria, on 3 different occasions. Despite her anemia, she was managed by medical intervention only. Her antibody reacted with all RBCs tested, except autologous and P-null (p phenotype) cells. Her RBCs did not react with anti-PP1Pk, which corroborated her phenotype as P-null. The genomic study revealed she was hemi- or homozygous or for a deletion of 26-bp in A4GALTexon 3, previously reported as causing the P-null phenotype and designated A4GALT*01N.019. CONCLUSION: This report documents a rare case of the P-null phenotype with an alloanti-PP1Pk causing a severe HTR to transfusion of the trial dose of the least incompatible blood. The case is the first example of this specific A4GALTmutation found in India.

A novel observation on grouping anomaly: The phenomena mimicking the Bel genetic variant of the ABO blood groups.

BACKGROUND: Discrepancy in "forward/reverse" grouping leads to confusion in assigning ABO group to a person. It could be genetic in nature and classified according to the presence/absent of antigen on red blood cell (RBC) vis-a-vis corresponding alloantibody in plasma. AIM: The aim of the study was to investigate the grouping anomaly found in a recently delivered woman who required transfusion. MATERIALS AND METHODS: A standard protocol for investigation was followed. RESULTS: A 27-year-old female, gravida 4, para 3, was grouped O on forward grouping, but her serum did not agglutinate Group B RBCs tested. Absorption-elution study gave an active eluate from her sensitized RBCs with anti-B or anti-A+B. Saliva showed H, but no B antigens indicating to her Bel phenotype. However, 2-week latter in the follow-up study, her serum revealed a presence of complement binding high titer anti-B. The problem of missing anti-B on the previous occasion was attributed to hemagglutination inhibition caused by accumulated complement macromolecules on RBCs that gave rise to physical hindrance in the formation hemagglutination clumps. CONCLUSION: The unusual case of erroneous reversed grouping was attributed to complement-mediated hemagglutination inhibition. The positive eluate obtained from sensitized RBCs of the mother was considered to be due to a contamination of fetal RBCs in maternal circulation entered during her postpartum phase of pregnancy. It could also be due to a conversion of H to B antigen no matter in trace amount by the fetal B group-specific transferase percolated into maternal circulation.

Pyrolysis of mustard oil residue: A kinetic and thermodynamic study.

Critical analysis of thermogravimetric data, characterization of the biomass, and kinetic and thermodynamic analyses are crucial in the design of efficient biomass pyrolysis systems. In this study, characterization, kinetic and thermodynamic analysis was performed for pyrolysis of mustard oil residue (MOR). Thermogravimetric analysis (TGA) with differential thermal analysis (DTA) was applied to study thermal decomposition behaviour of MOR at 10, 20, and 30 °C/min. FTIR and XRD analyses were used to characterize MOR. Average activation energy estimated from employed isoconversional methods was ≈155 kJ/mol. Variation in activation energy was found to be statistically insignificant as suggested by p-value of 0.992 by one-way ANOVA method. The pyrolytic temperature for MOR ranged from 234 to 417 °C. Reaction mechanism predicted as R3 (third order) and D3 (three dimensional). Thermodynamic parameters (ΔHα, ΔGα, and ΔSα) showed that endothermicity increased from 0.2 to 0.8 conversion and product had highest energy at 0.8 conversion.

Studies on individual pyrolysis and co-pyrolysis of corn cob and polyethylene: Thermal degradation behavior, possible synergism, kinetics, and thermodynamic analysis.

The knowledge on thermo-kinetics, synergistic effect, and reaction mechanism of pyrolysis/co-pyrolysis of biomass with plastics is crucial for designing efficient reactor system and subsequently the pyrolysis/co-pyrolysis process. The present work explores thermal response, kinetics, reaction mechanism and thermodynamic analysis of pyrolysis and co-pyrolysis of individual corn cob (CC) and polyethylene (PE), and their blend in the ratio of 3:1 (w/w). Thermogravimetric analysis (TGA) data was obtained under inert atmosphere at various heating rates of 10, 20, and 30 °C/min and synergistic effect in the co-pyrolysis of CC and PE is discussed. The obtained TGA data was processed using various model-free isoconversional methods like KAS, FWO, Friedman, Starink, and Vyazovkin for determination of kinetics of pyrolysis/co-pyrolysis process of CC and PE. Average activation energy for CC pyrolysis was estimated to be 240 ± 51.25 kJ/mol, 240 ± 51.51 kJ/mol, 237 ± 49.67 kJ/mol, and 245 ± 52.10 kJ/mol according to KAS, Starink, FWO, and Vyazovkin models, respectively. Statistical analysis showed that the variation in reported values of activation energy was not significantly different (p = 0.994). Similar statistically insignificant difference was also observed for pyrolysis of PE and co-pyrolysis of CC and PE. Results showed that co-pyrolysis (CC + PE) requires 10% less activation energy than pyrolysis of CC alone. For the co-pyrolysis process, the extent of synergistic effect was discussed by difference in mass loss (ΔW). Investigation also revealed that residue left for co-pyrolysis of CC and PE is 50% less than pyrolysis of CC alone showing synergistic effect during co-pyrolysis. Thermodynamic parameters were calculated to illustrate complex mechanism of the process. Third order reaction, 3D diffusion Jander, and Ginstling-Brounshtein (D4) models were found to be best fitted for CC pyrolysis, PE pyrolysis, and co-pyrolysis, respectively. Results obtained are expected to be useful in the design of corn cob and waste polyethylene co-pyrolysis systems.

Reducing rates of discharge against medical advice in the neonatal intensive care unit in a tertiary care hospital in South India: a mixed-methods study.

OBJECTIVE: To elucidate characteristics among neonates and their mothers who were discharged against medical advice (DAMA), providers' perspectives on DAMA and the effect of an intervention to reduce DAMA in a tertiary care hospital in South India. METHODS: We conducted a mixed-methods study to identify neonates at risk of DAMA. We reviewed charts of neonates and their mothers who were DAMA and conducted logit regression analysis to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) to determine associations with DAMA. We conducted focus group discussions with nurses and doctors. We developed an intervention that included family counselling, supplemental funds for hospital bills and involving family members to reduce DAMA. RESULTS: Of 10 834 neonates, 179 (1.7%) were DAMA over the study period. Maternal characteristics associated with DAMA included higher previous parity (aOR 1.9, 95% CI 1.1-2.3, P = 0.001). Mothers who received antenatal care had lower odds of DAMA (aOR 0.2, 95% CI 0.1-0.7, P = 0.039). Neonates with lower birth weight (aOR 2.1, 95% CI 1.7-9.4, P = 0.002) and congenital malformations (aOR 3.3, 95% CI 1.1-5.3, P = 0.005) also had higher odds of DAMA. The most commonly cited reasons for DAMA were financial constraints, inadequate counselling and perceived poor prognosis. The average monthly number of neonates who were DAMA decreased from 3.6 (1.6%) to 1.5 (0.6%) after our multi-pronged intervention. CONCLUSIONS: Neonates with severe illness and poor prognosis had higher odds of DAMA. A multi-pronged intervention demonstrated reductions in the rates of DAMA. This intervention may be trialled in similar settings to reduce DAMA.