Utility of ED triage tools in predicting the need for intensive respiratory or vasopressor support in adult patients with COVID-19.

BACKGROUND: Serum and radiological parameters used to predict prognosis in COVID patients are not feasible in the Emergency Department. Due to its damaging effect on multiple organs and lungs, scores used to assess multiorgan damage and pneumonia such as Pandemic Medical Early Warning Score (PMEWS), National Early Warning Score 2 (NEWS2), WHO score, quick Sequential Organ Failure Assessment (qSOFA), and DS-CRB 65 can be used to triage patients in the Emergency Department. They can be used to predict patients with the highest risk of seven-day mortality and need for intensive respiratory or vasopressor support (IRVS). PURPOSE: The primary purpose was to find the score with the highest AUC in predicting IRVS and mortality at seven days. Additional objective was to find out any independent factors associated with IRVS and mortality. METHODS: The data of adult patients who presented to the Emergency Department (ED) between April 1, 2021 and June 30, 2021 were collected. The WHO score, CRB-65, DS-CRB 65, PMEWS, NEWS2, and qSOFA score were calculated for all patients. Statistical analysis was done and an ROC curve was calculated for all the tools for mortality and need for IRVS at seven days. FINDINGS: 677 patients presented to the Emergency Department with COVID-19 during the period above. Presence of Diabetes Mellitus (p = 0.001), Hypertension (p = 0.001), and chronic kidney disease(CKD) (p = 0.04) was significantly associated with need for IRVS. Age, duration of symptoms, pulse rate, respiratory rate, room air saturation, mental status at admission, and time to IRVS need were identified as independent predictors of in-hospital mortality. The longer the time to IRVS need from ED arrival, the higher the likelihood of mortality. PMEWS (0.830) had the highest AUC, followed by NEWS2 (0.805). A PMEWS cut-off of 6.5 was 74.2% sensitive and 78.3% specific in predicting the need for IRVS. ROC analysis to predict 7-day mortality showed that PMEWS had an AUC of 0.802 (0.766-0.839). QSOFA performed poorly in predicting IRVS (AUC 0.645) and 7-day mortality (AUC 0.677). CONCLUSION: PMEWS may be used for triaging patients presenting to the Emergency Department with COVID-19 and accurately predicts the need for IRVS and seven day mortality.

Clinically available immunosuppression averts rejection but not systemic inflammation after porcine islet xenotransplant in cynomolgus macaques.

A safe, efficacious, and clinically applicable immunosuppressive regimen is necessary for islet xenotransplantation to become a viable treatment option for diabetes. We performed intraportal transplants of wild-type adult porcine islets in 25 streptozotocin-diabetic cynomolgus monkeys. Islet engraftment was good in 21, partial in 3, and poor in 1 recipient. Median xenograft survival was 25 days with rapamycin and CTLA4Ig immunosuppression. Adding basiliximab induction and maintenance tacrolimus to the base regimen significantly extended median graft survival to 147 days (p < .0001), with three animals maintaining insulin-free xenograft survival for 265, 282, and 288 days. We demonstrate that this regimen suppresses non-Gal anti-pig antibody responses, circulating effector memory T cell expansion, effector function, and infiltration of the graft. However, a chronic systemic inflammatory state manifested in the majority of recipients with long-term graft survival indicated by increased neutrophil to lymphocyte ratio, IL-6, MCP-1, CD40, and CRP expression. This suggests that this immunosuppression regimen fails to regulate innate immunity and resulting inflammation is significantly associated with increased incidence and severity of adverse events making this regimen unacceptable for translation. Additional studies are needed to optimize a maintenance regimen for regulating the innate inflammatory response.

An Unusual Cause of Bulbar Palsy in the Emergency Department.

BACKGROUND: Osmotic demyelination syndrome commonly occurs after rapid correction of hyponatremia. But it has also been reported after graded correction of hyponatremia in the presence of other risk factors like chronic alcoholism, malnutrition, liver disease, and hypokalemia. CASE REPORT: We report a case of a 67-year-old man who presented with dysphagia and nasal regurgitation and had features suggestive of bulbar palsy on neurological examination. He had spontaneous rapid correction of hyponatremia from a serum sodium level of 122 mEq/L to 132 mEq/L after discharge from our hospital. Neuroimaging was suggestive of extrapontine myelinolysis involving the basal ganglia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: An emergency physician should be aware of this because osmotic demyelination syndrome should also be considered in the differential diagnosis of patients presenting with bulbar palsy to the emergency department.

Brugada phenocopy induced by consumption of yellow oleander seeds - A case report.

Brugada phenocopy is a brugada-like pattern in ECG seen in some diseases without an inherited channelopathy. The causes of brugada phenocopy are usually reversible. Once the reversible condition resolves, the ECG pattern disappears. There are many conditions that cause brugada phenocopy like myocardial infarction, hyperkalemia etc. Here we report a case of brugada phenocopy induced by consumption of yellow oleander seeds (T. Peruviana).

Carcinoma Prostate Presenting as Multiple Cranial Nerve Palsy.

Metastatic prostatic carcinoma commonly involves bones and extra pelvic lymph nodes. CNS involvement is unusual and particularly the occurence of leptomeningeal metastasis is extremely rare, with few cases described in the literature.1 The reported incidence at autopsy vary from 0.6 to 4.4 percent.2 We report a 65 year old male who presented with multiple cranial nerve palsies due to leptomeningeal metastasis in carcinoma prostate treated with orchidectomy and planned for radiotherapy and antiandrogen therapy.

Natural Bond Orbitals (NBO), Natural Population Analysis, Mulliken Analysis of Atomic Charges of 2-[(2, 3-Dimethylphenyl) Amino] Benzoic Acid.

The spectroscopic properties of the FT-IR and FT-Raman spectra of the 2-[(2,3-dimethylphenyl)amino]benzoic acid (DMPABA) compound have been recorded in the region 4 000～400 cm-1. The molecular structure, vibrational wavenumbers were calculated using DFT (B3LYP) method with 6-31G(d,p) and 6-311++G(d,p) basis sets. The Geometrical structure, vibrational frequencies, corresponding vibrational assignments of 2-[(2,3-dimethylphenyl)amino]benzoic acid (DMPABA) have been investigated experimentally and theoretically using Gaussian03 software package. The detailed Molecular orbital calculation such as Natural Bond Orbitals (NBO), Natural Population Analysis (NPA) and Mulliken analysis of atomic charges is also calculated.

Natural Bond Orbitals (NBO), Natural Population Analysis, Mulliken Analysis of Atomic Charges of L-Alaninium Oxalate.

The Fourier Transform Infrared and Raman spectra of the L-Alaninium oxalate (LAO) have been recorded and analyzed. The fundamental vibrational wave numbers intensities of vibrational bands and optimized geometrical parameters of the compound were evaluated using DFT (B3LYP) method with 6-31+G(d,p) basis set. Natural Bond Orbital (NBO) and Natural Population Analysis (NPA) analysis for the LAO compound was carried out. Mulliken population analyses on atomic charges were also calculated.

Vibrational Spectroscopic Study of N-[4-[1-Hydroxy-2-[(1-Methyl Ethyl) Amino] Ethyl] Phenyl] Methane Sulfonamide.

The vibrational spectral analysis was carried out by using FT-Raman and FT-IR spectroscopy in the range 4 000-400 and 4 000-400 cm(-1) respectively, for N-[4-[1-hydroxy-2-[(1-methyl ethyl) amino] ethyl] phenyl] methane sulfonamide (HPAEPMS) molecule. Theoretical calculations were performed by ab initio Density Functional Theory (DFT) method using 6-31G(d, p) basis set. The complete vibrational assignments of wavenumbers were made on the basis of potential energy distribution (PED). The results of the calculations were applied to simulated spectra of the title compound, which show excellent agreement.

Early/Subtle Electrocardiography Features of Acute Coronary Syndrome and ST-Segment Elevation Myocardial Infarction.

Chest pain is one of the most common presenting complaints in the emergency department. Interpreting a 12-lead electrocardiography (ECG) for evidence of ischemia is always challenging. Frank ECG changes such as ST-segment elevation and ST-segment depression can be easily identified by emergency physicians. However, identifying subtle or early features of ACS in the 12-lead ECG is essential in preventing significant mortality and morbidity from ACS. In the following case series, we describe five of the subtle/early ECG changes of ACS, namely (1) T-wave inversion in lead aVL; (2) terminal QRS distortion; (3) hyperacute T-waves; (4) negative U-waves in precordial leads; and (5) loss of precordial T-wave balance. In all these cases, the initial 12-lead ECG showed only subtle/early ECG changes which were followed up with serial ECGs which progressed to STEMI.

The Alpha-bent and Tunneling: A Novel Technique for Fixing the Transvenous Pacer Lead during Temporary Transvenous Pacing in the Emergency Department.

The last step in the management of symptomatic bradycardia according to the advanced cardiac life support algorithm is temporary transvenous pacemaker insertion (TPI). TPI done by an emergency physician in the emergency department (ED) is on the rise particularly in South India owing to the increased incidence of yellow oleander poisoning. As in ED, we use passive fixation leads, fixation of a transvenous pacer lead is very important. In the following case series, we describe two novel techniques namely, "the alpha-bent" and "tunneling" for fixing the transvenous pacer lead. This technique of fixing the lead reduces lead displacement thus minimizing the potential complications.

Association of serum regenerating islet-derived protein 3-beta and oncostatin-M levels with the risk of acute coronary syndrome in patients with type 2 diabetes mellitus - A pilot study.

BACKGROUND AND AIMS: Regenerating islet-derived protein 3-beta (Reg3ß) and oncostatin-M (OSM), an inducer of Reg3ß, are important for the recruitment of macrophages, tissue repair and survival after myocardial infarction. The study was planned to elucidate the diagnostic utility of serum Reg3ß and OSM levels for the acute coronary syndrome (ACS). METHODS: Forty-two type 2 diabetes mellitus (T2DM) patients with ACS as cases and forty-two T2DM patients as controls were recruited. Routine biochemical investigations, creatine kinase-total (CK-T), and creatine kinase-MB (CK-MB) levels were estimated. Serum Reg3ß and OSM levels were analysed by enzyme-linked immunosorbent assay. RESULTS: Serum Reg3ß and OSM levels were significantly higher in cases as compared to controls. Serum Reg3ß and OSM levels were positively correlated with random blood glucose, serum CK-total, CK-MB levels, and negatively correlated with serum high-density lipoprotein cholesterol (HDL-C) levels. Receiver operating characteristics curve analysis showed that serum OSM and Reg3ß levels can be used for the diagnosis of ACS in patients with T2DM as compared to CK-MB levels. On regression analysis, serum Reg3ß level was positively associated with body mass index and negatively with serum HDL-C levels and serum OSM level was positively associated with waist circumference and random blood glucose and negatively with serum HDL-C levels. CONCLUSION: Serum Reg3ß and OSM levels may be used as complementary markers besides traditional cardiac markers for the diagnosis of ACS in patients with T2DM. However, further studies are still needed to verify our claim.

Memory T-Waves, a Rare Cause of T-Wave Inversion in the Emergency Department.

One of the rare causes of diffuse T-wave inversion (TWI) in electrocardiogram (ECG) is memory T-waves. This should be considered among the differentials of diffuse TWI in ECG of patients presenting to the emergency department (ED), especially when they have previous episodes of ventricular tachycardia (VT) or pacemaker implantation or Wolff-Parkinson-White syndrome. These TWIs are benign and do not require any treatment. However, it is of paramount importance for the emergency physician to differentiate it from ischemia-related T-wave changes. In the following case series, we report three cases of memory T-waves. Two of the cases had TWI in leads II, III, aVF, and V3 to V6 following reversion of VT. The other patient, with a VVI (Left ventricle paced, Left ventricle sensed, Inhibition to sensing) pacemaker, had memory T-waves in the ECG taken during normal sinus rhythm. In all the three patients, we considered memory T-waves to be the possible cause of TWI. The electrocardiographic diagnostic criteria for memory T-waves are positive T in lead aVL and positive/isoelectric T in the lead I; and precordial TWI >inferior TWI. These criteria are 92% sensitive and 100% specific. In the following case series, we also provide an algorithmic approach for patients with suspected memory T-waves in their 12-lead ECG when they present to the ED.