Surgical interventions for intractable migraine: a systematic review and meta-analysis.

BACKGROUND: Migraine affects approximately 14-15% of the global population, contributing to nearly 5% of the world's health burden. When drug treatments prove ineffective for intractable migraines, highly specific surgical interventions emerge as potential solutions. We aimed to analyze surgical approaches for these refractory or intractable migraines through a systematic review and meta-analysis. METHODS: We conducted a literature search across databases such as PubMed, Scopus, Web of Science, and Embase, focusing on studies related to migraines and surgical outcomes. We considered clinical trials or observational studies that included any surgical intervention for refractory or intractable migraines, emphasizing key outcomes such as reductions in migraine intensity, Migraine Disability Assessment scores (MIDAS), and 50% Migraine Headache Index (MHI) reduction rates. Statistical analyses were performed using R version 4.3. RESULTS: Eleven studies were included in the systematic review. A meta-analysis of four studies involving overall 95 patients showed a significant reduction in mean migraine intensity scores using ONS (-2.27, 95% CI: -3.92 to -0.63, P=0.021). Three studies with 85 patients showed an average MIDAS score reduction of -52.3, though this was not statistically significant (95% CI: -136.85 to 32.19, P=0.116). Two additional studies corroborated these reductions in MIDAS scores. Nerve decompression surgery showed a substantial decrease in the average migraine intensity (from 8.31 down to 4.06). Median MIDAS score dropped from 57 to 20. Two studies indicated a success rate of 40% and 82%, respectively, in achieving a 50% reduction in the Migraine MHI through nerve decompression. Findings from two studies suggest that septorhinoplasty and sinus surgery effectively decrease migraine intensity scores. CONCLUSION: The existing evidence emphasizes the potential advantages of surgical interventions as a promising approach to managing intractable or refractory migraines. However, robust and comprehensive research is crucial to refine and solidify the efficacy of these surgical methods, aiming for widespread benefits for patients, considering cost-effectiveness factors.

Performance of ChatGPT on the India Undergraduate Community Medicine Examination: Cross-Sectional Study.

BACKGROUND: Medical students may increasingly use large language models (LLMs) in their learning. ChatGPT is an LLM at the forefront of this new development in medical education with the capacity to respond to multidisciplinary questions. OBJECTIVE: The aim of this study was to evaluate the ability of ChatGPT 3.5 to complete the Indian undergraduate medical examination in the subject of community medicine. We further compared ChatGPT scores with the scores obtained by the students. METHODS: The study was conducted at a publicly funded medical college in Hyderabad, India. The study was based on the internal assessment examination conducted in January 2023 for students in the Bachelor of Medicine and Bachelor of Surgery Final Year-Part I program; the examination of focus included 40 questions (divided between two papers) from the community medicine subject syllabus. Each paper had three sections with different weightage of marks for each section: section one had two long essay-type questions worth 15 marks each, section two had 8 short essay-type questions worth 5 marks each, and section three had 10 short-answer questions worth 3 marks each. The same questions were administered as prompts to ChatGPT 3.5 and the responses were recorded. Apart from scoring ChatGPT responses, two independent evaluators explored the responses to each question to further analyze their quality with regard to three subdomains: relevancy, coherence, and completeness. Each question was scored in these subdomains on a Likert scale of 1-5. The average of the two evaluators was taken as the subdomain score of the question. The proportion of questions with a score 50% of the maximum score (5) in each subdomain was calculated. RESULTS: ChatGPT 3.5 scored 72.3% on paper 1 and 61% on paper 2. The mean score of the 94 students was 43% on paper 1 and 45% on paper 2. The responses of ChatGPT 3.5 were also rated to be satisfactorily relevant, coherent, and complete for most of the questions (>80%). CONCLUSIONS: ChatGPT 3.5 appears to have substantial and sufficient knowledge to understand and answer the Indian medical undergraduate examination in the subject of community medicine. ChatGPT may be introduced to students to enable the self-directed learning of community medicine in pilot mode. However, faculty oversight will be required as ChatGPT is still in the initial stages of development, and thus its potential and reliability of medical content from the Indian context need to be further explored comprehensively.

The continuum of liver injury with severity of dengue fever: A retrospective observational study.

BACKGROUND: Dengue is a major international health concern prevalent in tropical and sub-tropical countries. There are a paucity of studies on the relationship of hepatic complications with inflammatory parameters in dengue infection. METHODS: Single-centre observational study was conducted at the tertiary care centre in North India. Patients (>12 years) diagnosed with dengue infection between August and November 2021 were enrolled in the study. The frequency of hepatic derangements and their associations with inflammatory severity was analysed. RESULTS: Based on the clinical symptoms, 170 patients were classified into three categories, namely, dengue fever, warning dengue and severe dengue. Higher incidence of liver dysfunction was observed in severe dengue patients with median values of aspartate aminotransferase (AST) (3051 U/L, p < 0.001), alanine aminotransferase (ALT) (1792 U/L, p = 0.009), alkaline phosphatase (172 U/L, p = 0.001), T.Bil (34.2 µmol/L, p < 0.001), albumin (30 g/L, <0.001), and gamma-glutamyl transferase (152 U/L, p < 0.001) along with inflammatory marker C-reactive protein (CRP) (43 mg/dL, p < 0.001) highly deranged, in comparison to patients with/without warning signs. Median levels of CRP were found to be positively and significantly correlated with the median levels of AST and ALT (p < 0.05, r = 0.99) in all three categories of dengue patients. Liver injury was noted in 107 (63%) of the cohort, and mixed type of liver injury involving both hepatocellular and cholestatic patterns was observed as the most common type of injury (n = 50, 29.4%). Liver injury correlated with the severity of dengue illness as about 85% of severe dengue patients had significant liver injury (p = 0.014). CONCLUSION: In dengue patients, the association of the liver injury with inflammatory severity suggests that the mechanism of liver injury may be related to inflammatory response apart from the hepatotropic nature of the virus.

Efficacy and safety of the Arctic Sun device for hypoxic-ischemic encephalopathy in adult patients following cardiopulmonary resuscitation: A systematic review and meta-analysis.

AIM: The principal objective of this study was to carry out a comprehensive and thorough analysis to compare the safety and effectiveness of the Arctic Sun, a servo-controlled surface cooling device, with conventional cooling techniques for providing therapeutic hypothermia in adult patients who had experienced hypoxic-ischemic brain injury following cardiopulmonary resuscitation. METHODS: In order to achieve our goal, we conducted an extensive search of multiple databases including PubMed, Embase, Cochrane, and ClinicalTrials.gov up to the date of July 30, 2021. We only included studies that compared the safety and efficacy of the Arctic Sun surface cooling equipment with standard cooling approaches such as cooling blankets, ice packs, and intravenous cold saline for treating comatose adult patients who had recovered after experiencing cardiac arrest. We evaluated various outcomes, including all-cause mortality, good neurological outcome at 1 month, and the occurrence of adverse effects such as infections, shock, and bleeding. We employed a random-effects meta-analysis to estimate the odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous outcomes. RESULTS: One hundred and fourteen records were identified through our search; however, only three studies met our eligibility criteria, resulting in overall 187 patients incorporated in the meta-analysis. The findings indicated no significant difference in mortality rates among the Arctic Sun device and conventional cooling techniques (OR: 0.64; 95% CI: 0.34-1.19; P = 0.16; I2 = 0%). In addition, we found no significant difference in occurrence of good neurological outcomes (OR: 1.74; 95% CI: 0.94-3.25; P = 0.08; I2 = 0%) between the two cooling methods. However, the application of the Arctic Sun device was associated with increased incidence of infections compared to standard cooling methods (OR: 2.46; 95% CI: 1.18-5.11; P = 0.02; I2 = 0%). While no significant difference occurred in the incidence of shock (OR: 0.29; 95% CI: 0.07-1.18; P = 0.08; I2 = 40%), the use of the Arctic Sun device was linked to significantly fewer bleeding complications compared to standard cooling methods (OR: 0.11; 95% CI: 0.02-0.79; P = 0.03; I2 = 0%). CONCLUSIONS: After analyzing the results of our meta-analysis, we concluded that the use of the Arctic Sun device for targeted temperature management following cardiopulmonary resuscitation did not result in significant differences in mortality rates or improve neurological outcomes when compared to standard cooling techniques.

Evaluation of Mycobacterium tuberculosis derived cell-free DNA using pleural fluid and paired plasma samples for the diagnosis of pleural tuberculosis.

Pleural tuberculosis (pTB) is a grave clinical challenge. A novel cell-free M. tuberculosis DNA (cfM.tb-DNA) probe-based-qPCR assay was developed for the diagnosis of pTB. Total cell-free DNA was extracted from pleural fluid (PF) and paired plasma samples and cfM.tb-DNA was quantified by probe-based qPCR targeting devR (109-bp) gene of M. tuberculosis in patients with pleural effusion. Patient categorization was done using 'Composite-Reference-Standard' formulated for the study. Assay cut-offs were determined from samples in the 'Development set' (n = 17; 'Definite & Probable' pTB; n = 9 and 'Non-TB'; n = 8) by ROC-curve analysis and applied to 'Validation set' (n = 112; 'Definite' pTB; n = 8, 'Probable' pTB; n = 34, 'Possible' pTB; n = 28 and 'Non-TB'; n = 42). cfM.tb-DNA qPCR had a sensitivity of 62.5% (95%CI; 24.4,91.4) in 'Definite' pTB category and 59.5% (95%CI; 43.2,74.3) in 'Definite & Probable' pTB category with 95.2% (95%CI; 83.8,99.4) specificity using PF. In plasma (n = 85), the assay had a sub-optimal sensitivity of 7.6% (95%CI; 0.95,25.1) with 88.2% (95%CI; 72.5,96.7) specificity in 'Definite & Probable' pTB group. Xpert MTB/RIF assay detected only six-samples in the 'Validation set'. Logistic regression analysis indicated that PF-cfM.tb-DNA qPCR provided incremental advantage over existing pTB diagnostic algorithms. To the best of our knowledge, this is the first report describing the utility of cfM.tb-DNA for pTB diagnosis in India.

Monocyte Distribution Width (MDW) as an Early Investigational Marker for the Diagnosis of Sepsis in an Emergency Department of a Tertiary Care Hospital in North India.

Background Sepsis is an emergency state in response to an infectious process ultimately leading to multiorgan dysfunction and death. There is an urgent need for sepsis detection methods, especially in emergency settings. To fill this gap, monocyte distribution width (MDW) was studied as an early indicator of sepsis. Aim To evaluate MDW as an early marker of sepsis. Material and methods This was a prospective observational study including critically ill adult patients who presented to the emergency department. MDW was measured using a DxH 900 Hematology Analyser (Beckman Coulter Inc., Miami, FL). Abnormal MDW (>20.0) was considered a predictor of sepsis. Results A total of 148 patients were included and categorized according to the Sepsis-2 and Sepsis-3 criteria, as having sepsis (25.6%), sepsis with shock (21.6%), and non-sepsis (52.8%). In patients with sepsis with and without shock, MDW was 28.28 ± 9.20 and 28.02 ± 9.01, respectively, significantly higher than in patients without sepsis (p < 0.001). The diagnostic accuracy value of MDW testing for early sepsis detection was highly significant (0.74, p < 0.000). Conclusion MDW can be used as a marker for the early prediction of sepsis.

Clinical Profile of Patients Admitted With Mucormycosis During the COVID-19 Pandemic in Medicine Emergency of a Tertiary Care Hospital in North India.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has taken the world as a storm, has been indisputably found to be associated with mild to life-threatening pneumonia in the majority of patients. Mucormycosis emerged as a life-threatening complication of coronavirus disease 2019 (COVID-19) in India during the second wave of the COVID-19 pandemic. There lies a large lacuna in the understanding of the disease progression and the association of mucormycosis with COVID-19 and the various predisposing factors. AIM: To assess the pattern, risk factors, and outcome of mucormycosis cases reported to hospitals in North India during the second wave of the COVID-19 pandemic. MATERIAL AND METHODS: An observational, prospective study was conducted for 109 patients reporting to a medical emergency with a history of suspected or confirmed mucormycosis from May 2021 to July 2021. Obtained data were analysed using descriptive statistics and results were expressed as a percentage and mean. RESULTS: Out of 109 patients, 75 were male and 34 were female with a mean age of 50.6 years, most cases belong to the rural background. The most common types of mucormycosis were rhino-orbital (34.8%), rhino-orbital cerebral (20.18%), and pulmonary (23.8%). The most common risk factors were uncontrolled diabetes (80 %), use of steroids (68.8%), diabetic ketoacidosis (42%), and COVID-19 positive status (66.9%). High mortality of 33.9% was seen in our study. CONCLUSIONS: The most vulnerable group in our study were patients with pulmonary manifestations (51.4%) and patients requiring oxygen therapy (94.6%). Our study found that scoring systems namely the quick sequential organ failure assessment (q SOFA) scoring system (p-value <0.001) along with the Glasgow Coma Scale (p-value <0.038) can be used as a prognostic indicator and good assessment tools for the degree of severity of disease at an early stage.

Paradigm Shift in Pattern & Prevalence of Poisoning During Covid-19 Pandemic.

Poisoning and drug overdose are the medical emergencies in which it is important to identify the incidence, pattern and the outcome in order to take relevant steps for stringent planning not only at the hospital level but also at the community level for its prevention and management. The current pandemic of COVID-19 has had a tremendous effect on the psychological state of the people. MATERIAL: An observational, prospective study was conducted for 100 patients reporting to medical emergency with history of poisoning intake from April 2020 to January 2021. Age range was 14-85 years. Obtained data were analysed using descriptive statistics and results were expressed as percentage and mean. OBSERVATION: Out of 100 patients (77M,33F), mean age of 32.6 years, most cases belong to age group of 20-30 years and 50% were matriculates and majority of the patients belonged to Punjab and Himachal Pradesh. The most common poisoning agents consumed were corrosives (34%) followed by cellular toxins (24%). Respiratory distress (53%), loss of consciousness (43%), acute kidney injury (36%) were the common clinical presentations. PSS (Poisoning Severity Score) was moderate in 52% of patients, 14% had severe, 16% of patients had fatal PSS scores and 18% of patients had minor PSS. 16 patients with fatal PSS and 16 patients with moderate to severe PSS got expired. High mortality of 33% was seen in our study. CONCLUSION: The most vulnerable group in our study was of young males in age group of 21-30 years and less educated, who had lost their jobs due to Covid-19 pandemic lockdown. Corrosives were the most commonly consumed poison during lockdown. Our study found that scoring systems PSS and GCS were good assessment tools for degree of severity of poisoning at an early stage.

Paradigm shift in pattern and prevalence of poisoning during COVID-19 pandemic.

Objective: To assess the pattern, prevalence and outcome of poisoning cases reporting to hospital in North India during COVID-19 pandemic. Material and Methods: An observational, prospective study was conducted for 100 patients reporting to medical emergency with history of poisoning intake from April 2020 to January 2021. Age range was 14-85 years. Obtained data were analysed using descriptive statistics and results were expressed as percentage and mean. Results: Out of 100 patients (77M, 33F), mean age of 32.6 years, most cases belong to age group of 20-30 years and 50% were matriculates and majority of the patients belonged to Punjab and Himachal Pradesh. The most common poisoning agents consumed were corrosives (34%) followed by Aluminium Phosphide (24%). Respiratory distress (53%), loss of consciousness (43%), acute kidney injury (36%) were the common clinical presentations. PSS (Poisoning Severity Score) was moderate in 52% of patients, severe in 14%, fatal in 16% and minor PSS in 18% of patients. 16 patients with fatal PSS and 16 patients with moderate to severe PSS got expired. High mortality of 33% was seen in our study. Conclusions: The most vulnerable group in our study was of young males in age group of 21-30 years and less educated, who had lost their jobs due to COVID-19 pandemic lockdown. Corrosives were the most commonly consumed poison during lockdown. Our study found that scoring systems PSS and GCS were good assessment tools for degree of severity of poisoning at an early stage.

Quantification of chronic diseases presenting in the Emergency Department and their disposition outcomes: A hospital-based cross-sectional study in north India.

A knowledge of the extent and distribution of chronic comorbidity plays an essential role in providing appropriate care, and allocating health resources to the patients admitted to the emergency department. We performed a cross-sectional study to quantify the chronic diseases presenting in the Emergency Department of PGIMER, Chandigarh (India). Out of 205 patients, 133 (64.9%) had pre-existing comorbidity. Common were chronic kidney disease (29, 14.1%), chronic liver disease (23, 11.2%), diabetes mellitus (21, 10.2%), malignancy (20, 9.8%), cardiac diseases (17, 8.3%), and chronic obstructive pulmonary disease (9, 4.4%). The median Charlson comorbidity index score was 2 (range, 0-9). In-hospital mortality was 43 (21%) and was predicted by older age (median, 60 v. 50 years; p-value, 0.017). Deaths with previous stroke (66.6%), chronic obstructive pulmonary disease (55.6%), and diabetes (28.6%) were higher than cardiac (2.3%) and renal (6.9%) comorbidity. Increasing comorbidity requires a shift in existing models of emergency care.

Clinical spectrum and outcomes of geriatric tuberculosis emergencies in North India.

OBJECTIVES: Despite the acute and life-threatening repercussions that tuberculosis (TB) may have on the burgeoning older population in endemic countries like India, the spectrum of geriatric TB emergencies is not adequately understood. METHODS: We performed a prospective observational study at the emergency department of an academic hospital in north India between January 2019 and June 2020, investigating the clinical and laboratory features and outcomes of active TB in older patients aged 60 years and above. RESULTS: Out of 71 geriatric TB emergencies, central nervous system disease predominated (n = 41, 57.7%), followed by pulmonary (n = 16, 22.5%), pleural TB (n = 8, 11.3%), and multisite involvement (n = 6, 8.4%). Nearly 71.8% were male, and 77.4% belonged to low socioeconomic status (lower-middle or lower class). Usual predisposing factors were tobacco smoking (38.0%), chronic alcohol use (27.0%), and diabetes mellitus (23.9%). Atypical features were more frequent with extrapulmonary TB. Only 28.2% were microbiologically confirmed cases, and rifampicin resistance was seen in only one case. The mortality rate was considerably high (24.0%), highest with pulmonary TB (37.0%). CONCLUSION: Older patients with TB emergencies have atypical presentations, diagnostic difficulties, and high mortality.

Severe Acute Respiratory Infection Surveillance during the Initial Phase of the COVID-19 Outbreak in North India: A Comparison of COVID-19 to Other SARI Causes.

INTRODUCTION: World Health Organization proposes severe acute respiratory infection (SARI) case definition for coronavirus disease 2019 (COVID-19) surveillance; however, early differentiation between SARI etiologies remains challenging. We aimed to investigate the spectrum and outcome of SARI and compare COVID-19 to non-COVID-19 causes. PATIENTS AND METHODS: A prospective cohort study was conducted between March 15, 2020, to August 15, 2020, at an adult medical emergency in North India. SARI was diagnosed using a "modified" case definition-febrile respiratory symptoms or radiographic evidence of pneumonia or acute respiratory distress syndrome of ≤14 days duration, along with a need for hospitalization and in the absence of an alternative etiology that fully explains the illness. COVID-19 was diagnosed with reverse transcription-polymerase chain reaction testing. RESULTS: In total, 95/212 (44.8%) cases had COVID-19. Community-acquired pneumonia (n = 57), exacerbation of chronic lung disease (n = 11), heart failure (n = 11), tropical febrile illnesses (n = 10), and influenza A (n = 5) were common non-COVID-19 causes. No between-group differences were apparent in age ≥60 years, comorbidities, oxygenation, leukocytosis, lymphopenia, acute physiology and chronic health evaluation (APACHE)-II score, CURB-65 score, and ventilator requirement at 24-hour. Bilateral lung distribution and middle-lower zones involvement in radiography predicted COVID-19. The median hospital stay was longer with COVID-19 (12 versus 5 days, p = 0.000); however, mortality was similar (31.6% versus 28.2%, p = 0.593). Independent mortality predictors were higher mean APACHE II in COVID-19 and early ventilator requirement in non-COVID-19 cases. CONCLUSIONS: COVID-19 has similar severity and mortality as non-COVID-19 SARI but requires an extended hospital stay. Including radiography in the SARI definition might improve COVID-19 surveillance. HOW TO CITE THIS ARTICLE: Pannu AK, Kumar M, Singh P, Shaji A, Ghosh A, Behera A, et al. Severe Acute Respiratory Infection Surveillance during the Initial Phase of the COVID-19 Outbreak in North India: A Comparison of COVID-19 to Other SARI Causes. Indian J Crit Care Med 2021;25(7):761-767.