Role of high-dose methylprednisolone in Zargar Grade IIB corrosive esophageal burns: A randomized control study.

OBJECTIVE: The objective of the study is to test the efficacy of high-dose methylprednisolone in the prevention of esophageal stricture after corrosive ingestion. METHODS: This study was a single-center, randomized controlled single-blinded study. Simple randomization was done with 15 adult patients (>18 years) in each arm, who presented with a history of corrosive ingestion within the past 24 h and had esophageal injury of Zargar Grade IIB on endoscopy. Intravenous methylprednisolone 1 g/day for 3 days was given to the intervention arm while 100 mL of normal saline was given as placebo in control arm. Follow-up to diagnose esophageal stricture was done at 8 weeks. RESULTS: Thirty patients (15 in each arm) were recruited for the study. As per the intention to treat analysis, 33% and 46.6% developed stricture in the intervention and control arm, respectively (relative risk [RR] = 0.714; 95% confidence interval 0.29-1.75; P = 0.462). 40% patients in control group and 7.7% in intervention group had undergone feeding jejunostomy, which was statistically significant with a p-value of 0.048. Airway injury showed significant clinical improvement in the intervention arm but the difference was nonsignificant statistically (P = 0.674). There was no increased incidence of hypertension, hyperglycemia, hyponatremia, hyperkalemia, or infections in intervention arm. CONCLUSION: Methylprednisolone does not help in the prevention of stricture formation in corrosive esophageal injury, but it significantly reduces the requirement of feeding jejunostomy and has a beneficial role in treating airway injury.

High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial.

OBJECTIVES: Sympathetic crashing acute pulmonary edema (SCAPE) is a subset of heart failure with a dramatic presentation. The unique physiology of this condition requires a different management strategy from the conventional practice. The trial objective was to compare the efficacy of high-dose and low-dose GTN in patients with SCAPE. METHODS: This was an open-label randomised control trial conducted in a tertiary care teaching hospital in India from 11 November 2021 to 30 November 2022. Consenting participants were randomised to high-dose GTN or conventional low-dose GTN. The primary outcome was symptom resolution at 6 hours and 12 hours. Secondary outcomes included intubation rates, admission rates, length of hospital stay, and any short-term adverse effects of GTN and major adverse cardiac events (MACE) at 30 days. RESULTS: Fifty-four participants were included (26 high-dose GTN, 26 low-dose GTN). At 6 hours, symptom resolution was seen in 17 patients (65.4%) in the 'high-dose' group, compared with 3 (11.5%) in the 'low-dose' group (p<0.001). At 12 hours, 88.5% of patients had a clinical resolution in the 'high-dose' arm versus 19.5% in 'low-dose' arm . The low-dose group had longer median hospital stay (12 hours vs 72 hours), more frequent MACE (3.8% vs 26.9%, p=0.02) and a higher intubation rate (3.8% vs 19.2%, p=0.08). The only short-term adverse effect seen was a headache in both the groups. CONCLUSION: In SCAPE, patients receiving high-dose GTN (>100 mcg/min) had earlier symptom resolution compared with the conventional 'low dose' GTN without any significant adverse effects. TRIAL REGISTRATION: Clinical trial registry of India (CTRI/2021/11/037902).

Isolated unilateral pulmonary artery atresia with contralateral pulmonary artery branch stenosis: A "window" for intervention.

Adult presentation of unilateral pulmonary artery atresia in association with contralateral branch pulmonary stenosis is rare. We present the case of a quadragenarian, who manifested with right ventricular failure and hemoptysis. This report discusses the diagnostic workup and therapeutic options along with a brief overview of the concerned literature.

Emergency Department Point-of-Care Tests during Cardiopulmonary Resuscitation to Predict Cardiac Arrest Outcomes.

Introduction: This study evaluated the role of point-of-care tests (POCT) such as blood lactate, anion gap (AG), base deficit, pH, N-terminal pro B-type natriuretic peptide (NT-proBNP), and troponin as the predictors of cardiac arrest outcomes in the emergency department (ED). Methods: We conducted a prospective, observational study in the ED of a tertiary care hospital in India. All the adult patients who received cardiopulmonary resuscitation (CPR) in the ED were included in the study. Blood samples were collected within 10 min of initiation of CPR for assay of POCTs. Outcomes assessed were the return of spontaneous circulation (ROSC), 24-h survival, survival to hospital discharge (STHD), survival at 7 days, and favorable neurological outcome (FNO) at day 7 of admission. Results: One hundred and fifty-one patients were included in the study (median age: 50 years, 65% males). Out of 151 cases, ROSC, survival at 7 days, STHD, and FNO was observed in 86 patients, six patients, five patients, and two patients, respectively. "No-ROSC" could be significantly predicted by raised lactate (odds ratio [OR]: 1.14, 95% confidence interval: 1.07-1.22) and NT-proBNP (OR: 1.05, 1.01-1.09) values at the time of cardiac arrest. "24-h mortality" could be significantly predicted by the raised lactate (OR: 1.14, 1.01-1.28), low arterial pH (OR: 0.05, 0.01-0.52), raised AG (OR: 1.08, 1.01-1.15), and lower base deficit (<-15) (OR: 1.07, 1.01-1.14). None of the other POCTs was found to be a predictor of other cardiac arrest outcomes. Conclusion: Among various POCTs, raised lactate assayed within 10 min of cardiac arrest can predict poor outcomes like "no-ROSC" and 24-h mortality.

Performance of qSOFA Score as a Screening Tool for Sepsis in the Emergency Department.

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.

Taming the Tiger: Ultra high dose nitroglycerin in managing sympathetic crashing acute pulmonary edema patient.

INTRODUCTION: Sympathetic Crashing Acute Pulmonary Edema (SCAPE) lies on the end of the acute heart failure syndrome spectrum with pulmonary edema in all lung zones. NTG at lower doses (10-20 µg/min) cause preload reduction, and at higher doses (> 100 µg/min) causes after-load reduction by arterial dilatation. The main aim is to decrease the afterload at the earliest to cut the vicious cycle caused by sudden sympathetic upsurge. To our knowledge, this is the highest nitroglycerin dose usage in the literature. CASE: A 60-year-old male with no known prior co-morbidities presented to our Emergency with complaints of acute onset severe shortness of breath, which was also associated with extreme diaphoresis, agitation, anxiety, and palpitations. On Examination, the patient was hypoxic and hypertensive with severe tachypnea and tachycardia. On Auscultation, diffuse bilateral crackles in all areas were heard. Point of care ultrasound showed bilateral B-profile in all lung zones, inferior vena cava was >50% collapsible. We managed the patient with non-invasive ventilation and ultrahigh dose nitroglycerin/ highest ever- 9 mg intravenous bolus with 76 mg infusion. The patient had improved within hours and did not require oxygen. The patient was discharged from the emergency after a few hours of observation. DISCUSSION: SCAPE occurs due to a vicious spiral involving increasing sympathetic outflow, excessive afterload, and worsening heart failure. The central, defining pathophysiological feature of SCAPE is pathologically elevated afterload due to systemic vasoconstriction and hypertension. SCAPE patients may be euvolemic, hypovolemic or hypervolemic. The problem is shift of fluid into the lungs rather than hypervolemia. The emphasis on treating pulmonary edema has shifted from diuretics to vasodilators, especially high-dose nitrates, combined with non-invasive positive pressure ventilation. CONCLUSION: This is the first report describing the safe and effective administration of ultra-high dose bolus/ highest dose ever and prolonged high-dose infusion for SCAPE, along with Non-invasive ventilation, which has prevented mechanical ventilation and mortality. High doses of intravenous NTG are extremely effective and safe for SCAPE patients.

Is it Worthy Enough to Revascularize Chronically Occluded Coronaries?

Chronic total occlusions (CTOs) represent the "final frontier" of coronary interventions with the lowest procedural success rates and the most common reason for incomplete revascularization and referral to coronary artery bypass graft surgery (CABG). CTO lesions are not an infrequent finding during coronary angiography. They are often responsible for enhancing the complexity of the coronary disease burden thereby affecting the final interventional decision in the process. Notwithstanding the modest technical success of CTO-PCI, most of the earlier observational data demonstrated a clear survival benefit free of major cardiovascular events (MACE) in patients undergoing successful CTO revascularization. However, data from recent randomized trials fail to uphold the same survival advantage albeit, showing some trend toward improvement in left ventricular function, quality of life indicators and freedom from fatal ventricular arrythmia. Various guidance statements propose a well-defined role for CTO intervention in specific situations provided criterions for patient selection, appreciable inducible ischemia, myocardial viability and cost-risk-benefit analysis are met.

Role of initial cardiac activity assessed by point-of-care ultrasonography in predicting cardiac arrest outcomes: A prospective cohort study.

OBJECTIVES: This study was conducted to investigate the association between visible cardiac activity in point-of-care ultrasound (POCUS) and outcomes of cardiac arrest such as the return of spontaneous circulation (ROSC), survival to inpatient admission (SIA), and survival to hospital discharge (STHD). METHODS: This was a single-center, prospective cohort study conducted in the emergency department (ED). Adult (age >18 years) patients in cardiac arrest were included in the study. Exclusion criteria of the study were - traumatic arrest, out-of-hospital cardiac arrest resuscitated before ED admission, and patients presenting with initial shockable rhythm. Patients whose ultrasound images could not be obtained and whose resuscitation stopped following POCUS were also excluded from the study. POCUS examination was done after 2 min of initiation of cardiopulmonary resuscitation (CPR) and visible cardiac activity was defined as any visible movement of the myocardium, excluding movement of blood within cardiac chambers, or isolated valve movement. The duration of POCUS examinations was limited to 10 s. The association of initial cardiac activity in POCUS with the outcomes of cardiac arrest was investigated. RESULTS: Out of 140 patients screened, 84 patients were included in the study. Rates of ROSC, SIA, and STHD were found in 23 (27.4%), 9 (10.7%), and 2 (2.4%) patients, respectively. Only 15 out of 84 (17.9%) patients had cardiac activity on the initial POCUS examination. Cardiac activity was seen in 52.2% of patients with ROSC, which was significantly higher (P < 0.001) as compared with the no-ROSC group (4.9%). Unlike the above association, there was no difference in the incidence of initial cardiac activity in patient groups who got admitted (SIA) and discharged (STHD) versus those who died. In the multivariate regression analysis, the duration of CPR and initial cardiac activity significantly predicted the rate of ROSC, with an adjusted odds ratio of 0.93 (95% confidence interval [CI]: 0.86-0.99, P = 0.04) and 24.8 (95% CI: 3.17-89.41, P = 0.002), respectively. None of the variables predicted SIA and STHD. The positive likelihood ratio of cardiac activity for predicting ROSC, SIA, and STHD were 10.6, 2.1, and 2.9, respectively. CONCLUSION: Integration of POCUS in cardiac arrest resuscitation was shown to be helpful in terms of prognostic significance of the presence of initial cardiac activity in terms of ROSC.

Comparison of non-invasive assessment for pulmonary vascular indices by two-dimensional echocardiography and cardiac computed tomography angiography with conventional catheter angiocardiography in unrepaired Tetralogy of Fallot physiology patients weighing more than 10 kg: a retrospective analysis.

AIMS: Assessment of pulmonary vascular dimensions (PVDs) in Tetralogy of Fallot (TOF) is an integral part of planning transcatheter and surgical interventions. We sought to examine the reliability and correlation of echocardiography (ECHO) and computed tomography angiography (CTA) measurements with those obtained by cardiac catheterization and angiography (CCA). METHODS AND RESULTS: Tetralogy of Fallot physiology patients undergoing ECHO, CTA, and CCA within a month prior to surgical correction during 2018-2020 were retrospectively enrolled. Indexed diameter of pulmonary annulus (iPAnn), indexed right pulmonary artery (iRPA), indexed left pulmonary artery (iLPA) and indexed descending aorta (iDA) were measured using ECHO and CTA followed by derivation of Nakata index (NI), McGoon's ratio (MGR), ratio of predicted peak right ventricular (RV) and left ventricular (LV) pressures (pRV/pLV) and Z-scores. Comparison with CCA-derived measurements was made and correlational equations were subsequently deduced. Pulmonary vascular dimensions for 54 patients with mean age of 15.5 ± 9.3 years (range: 3-34 years) were analysed. Computed tomography angiography and CCA measurements for iPAnn, iRPA, NI, MGR, pRV/pLV, and Z-score were comparable with each other while ECHO parameters were significantly lower than CCA. However, iLPA diameter was significantly underestimated by ECHO and overestimated by CTA. Correlational analysis showed stronger correlation between CTA- and CCA-derived PVD as against ECHO measurements except for iDA, pRV/pLV, and Z-score. CONCLUSIONS: For unrepaired TOF physiology patients weighing more than 10 kg, CTA-acquired PVD are reliable and comparable with CCA except for DA for which ECHO is non-inferior. Non-invasive modalities though are inferior to CCA for LPA sizing. Utilizing derived equations, precise estimation of PVD can be carried out using non-invasive tools.

An Unusual Hemodynamic Pressure Trace Mimicking Aortic Stenosis: A Decepti "Con".

We report an abnormal hemodynamic pressure tracing taken during pullback from the left ventricle. This report emphasizes the careful observation of hemodynamic tracing relative to continuous electrocardiographic monitoring for identifying potentially pathological vascular phenomena that may have detrimental outcomes on the clinical management of the underlying condition.

Airway management practices among emergency physicians: An observational study.

OBJECTIVES: Emergency airway management is an integral part of patient stabilization. It is an essential skill for an emergency physician to master. There is a paucity of literature on airway management from low-to-middle-income countries like India where emergency medicine (EM) specialty is still in its infancy. We conducted this study to identify the existing airway management practices among emergency physicians in our tertiary care center. This study could pave the way for national airway registries. METHODS: This prospective, observational study was conducted in the emergency department (ED) of a tertiary care center in India for 16 months. We included 166 patients who underwent emergency endotracheal intubation in the ED, irrespective of their age or underlying condition. The patients were observed for 15 min after intubation to identify any associated adverse events. We collected data about patients' demographic profile, indication for intubation, techniques of airway management, medications used, specialty of the physician performing intubation, use of preintubation and postintubation checklists, vitals before and after intubation, and any adverse events following intubation. RESULTS: A total of 166 patients who required definite airway management in the ED were recruited for the study. The mean age of patients was 45.5 ± 20.1 years. Males comprised 61.4% of the patients. One hundred and forty-four patients were nontrauma cases and the remaining 22 cases were related to trauma. The most common indication for emergency airway management was altered mental status among nontrauma encounters and traumatic brain injury among trauma patients. Rapid sequence intubation (RSI) was the most common method employed (72.9% of cases). The most common agents used for induction and paralysis were etomidate and rocuronium, respectively. Direct laryngoscope was used in about 95% of cases. The first pass success rate in our study was 78.3%. EM residents were able to perform orotracheal intubation for all patients and none required a surgical airway. The incidence of adverse events within 15 min of intubation was 58.4%. Common complications observed were desaturation, right mainstem bronchus intubation, and equipment failure. Postintubation cardiac arrest occurred in around 5% of cases. CONCLUSION: RSI remains the most common method employed for emergency airway management. There exists heterogeneity in the practice and its associated complications. Hence, regular surveillance, quality improvement, and training are imperative to provide good patient care.

Neutrophil Gelatinase-Associated Lipocalin as a Marker for Contrast-Induced Nephropathy in Patients Undergoing Percutaneous Coronary Intervention: A Prospective Observational Analysis.

Introduction: Incidence of contrast-induced nephropathy (CIN) post percutaneous coronary intervention (PCI) varies between 5% and 20%. Neutrophil gelatinase-associated lipocalin (NGAL) is a sensitive marker for acute kidney injury. Data regarding the predictive accuracy of NGAL in Indian patients undergoing PCI is sparse. Methods: A total of 212 consecutive "all-comer" patients, undergoing PCI from March 2015 to April 2016 were recruited in this single-center observational study. Plasma NGAL levels were measured at 4 hours post PCI using commercially available enzyme-linked immunosorbent assay (Triage® Alere™, San Diego, CA, USA). Results: Twenty-five (11.8%) patients developed CIN. The 4-hour post-PCI plasma NGAL levels were significantly higher in patients with CIN than without (400.6 ± 269.3 ng/mL vs. 109.8 ± 68.0 ng/mL, P < 0.0001). Patients developing CIN had higher age, low estimated glomerular filtration rate (eGFR), and higher contrast volume usage during PCI. After adjusting for confounding factors, diabetes mellitus (adjusted odds ratio [AOR] 3.04; P = 0.039; 95% confidence interval [CI]: 1.06-8.73), hypotension at presentation (AOR 24.84; P < 0.0001; 95% CI: 4.65-132.83), and multi-staged PCI (AOR 13.45; P < 0.0001; 95% CI: 4.54-39.79) were found to independently predict the development of CIN. NGAL levels significantly correlated with age (r = 0.149, P = 0.031), eGFR (r = -0.385, P < 0.0001), hemoglobin (r = -0.214, P = 0.002), contrast volume (r = 0.185, P = 0.007), and 48-hour post-PCI serum creatinine levels (r = 0.334, P < 0.0001). At a cutoff of 256.5 ng/mL, plasma NGAL had a sensitivity of 68% and a specificity of 95.2% (area under the curve = 0.878; P < 0.0001; 95% CI: 0.801-0.955) to predict the occurrence of CIN. Conclusions: Plasma NGAL is an early and highly predictive biomarker of CIN in patients undergoing PCI. Patients having diabetes, hypotension at presentation and those undergoing second-stage procedures are at a high risk of developing CIN after PCI.

Isolated vertigo in a young male, HINTS examination and vertebral artery dissection in emergency department - A case report.

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.

Anti-mitochondrial antibodies in Indian patients with idiopathic inflammatory myopathies.

AIMS: Anti-mitochondrial antibodies (AMAs) are associated with distinct clinical phenotypes including cardiac and hepatic manifestations in idiopathic inflammatory myopathies (IIMs). This article studies the prevalence, clinical characteristics and outcomes of AMA in Indian patients with IIM. METHODS: Patients (97: 81 adult, 16 juvenile) clinically diagnosed with polymyositis or antibody-negative IIM were retrieved from the MyoCite bio-archive. They were tested for myositis-specific autoantibodies / myositis autoantibodies (MSAs/MAAs) using line immunoassay and antinuclear antibodies and AMAs using immunofluorescence assay (IFA). Patients were also screened for cardiac biomarkers (cardiac troponin I [c-TnI] and N terminal-pro brain natriuretic peptide [NT-pro-BNP] using immunometric immunoassay technique and enhanced chemiluminescence assay testing respectively) and hepatic manifestations using AMA testing. Results were formulated after carrying out analytical tests. RESULTS: Of the cohort, 5 adults (6.2%) (M:F 0:1) with a median age and disease duration of 37 years and 2 months respectively, tested AMA+ while the children tested negative. Dermatomyositis was the commonest phenotype, with amyopathic forms being common, often with MSA positivity. Cancer-associated myositis and polymyositis were also seen. AMA positivity is associated with Gottron's sign and calcinosis. Comparable levels of C-TnI and NT-pro-BNP and AMA testing in patients help to rule out subclinical cardiac and hepatic involvement respectively. CONCLUSION: Anti-mitochondrial antibodies are rare (6.2%) in different subtypes of IIM in the Indian population, and often coexist with MSAs. Their negative association with cardiac and hepatic involvement and probable association with Gottron's sign and calcinosis merit further investigation and long-term follow-up to understand the entire spectrum of the disease.

Guiding Principles for the Clinical Use and Selection of Microcatheters in Complex Coronary Interventions.

The use of microcatheters as a coronary interventional tool for a therapeutic approach to complex coronary interventions like bifurcation lesions, ostial location, tortuous anatomy, angled takeoffs, coronary calcification, and chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is growing among cardiologists across the country. During the treatment of such complex lesions, microcatheters play an essential part of the tool kit with both single-lumen and double-lumen microcatheters (DLMs) having their specific niche areas. The selection of microcatheters involves a detailed understanding of the microcatheter specification, lesion anatomy, lesion location, vessel tortuosity and trajectory, and crossing techniques. The selection of appropriate crossing techniques with different microcatheters increases success rates of PCI, reduces procedural time and contrast use, and lowers the radiation. However, the use of microcatheters and their technicalities have not yet fully realized by many operators and their true scope has not been fully explored. This article discusses and summarizes the thoughts and key opinions of experts in this field.

Cardiovascular Diseases in Pregnancy - A Brief Overview.

Even though, there have been many advances in maternal medical care and fertility treatments, the presence of cardiovascular disease has a significant impact on pregnancy. In pregnant women, several heart conditions, such as valvular heart disease, chronic hypertension, congenital heart defects and non-ischemic cardiomyopathies are linked to increased risk of fetal as well as maternal morbidity and mortality. To date, the management of the co-existing conditions of pregnancy and heart disease has been challenging. Therefore, in-depth information may be beneficial to tackle a difficult case scenario. Towards this end, this paper provides an overview of the recent updated knowledge of pregnancy-related cardiovascular diseases in women.

Simultaneous radio-ulnar cannulation: shifting gears from 'feasibility' to 'applicability'.

Conventionally, routes of vascular access commonly include femoral and radial arteries with brachial, ulnar and subclavian arteries being rarely used for coronary interventions. Non-femoral arterial access is being increasingly preferred to minimise groin puncture site complications, prolonged immobilization and duration of hospital stay. However, radial artery cannulation is also fraught with fears of tortuosity, loops, vascular spasm, perforation, pseudoaneurysm formation, arm hematoma and arterial occlusion. In contemporary practice when most of the coronary procedures are being done via transradial access, encountering one of the above-mentioned hurdles often forces the operator to switchover to femoral access. Here, we explore the rationale, feasibility, operational logistics, clinical implications and future directions for using simultaneous radio-ulnar arterial access in the same extremity.

Study of pre-hospital care of out of hospital cardiac arrest victims and their outcome in a tertiary care hospital in India.

BACKGROUND: India does not have a formal cardiac arrest registry or a centralized emergency medical system. In this study, we aimed to assess the prehospital care received by the patients with OHCA and predict the factors that could influence their outcome. METHODS: Out-of-hospital cardiac arrest patients presenting to the emergency department in a tertiary care centre were included in the study. Prehospital care was assessed in terms of bystander cardiopulmonary resuscitation (CPR), mode of transport, resuscitation in ambulance. OHCA outcomes like Return of spontaneous circulation (ROSC), survival to hospital discharge and favourable neurological outcome at discharge were assessed. RESULTS: Among 205 patients, the majority were male (71.2%) and were above 60 years of age (49.3%); Predominantly non-traumatic (82.4%). 30.7% of the patients had sustained cardiac arrest in transit to the hospital. 41.5% of patients reached hospital by means other than ambulance. Only 9.8% patients had received bystander CPR. Only 12.5% ambulances had BLS trained personnel. AED was used only in 1% of patients. The initial rhythm at presentation to the hospital was non-shockable (96.5%). Return of spontaneous circulation (ROSC) was achieved in 17 (8.3%) patients, of which only 3 (1.4%) patients survived till discharge. The initial shockable rhythm was a significant predictor of ROSC (OR 18.97 95%CI 3.83-93.89; p < 0.001) and survival to discharge (OR 42.67; 95%CI 7.69-234.32; p < 0.001). CONCLUSION: The outcome of OHCA in India is dismal. The pre-hospital care received by the OHCA victim needs attention. Low by-stander CPR rate, under-utilised and under-equipped EMS system are the challenges.

Is this the beginning of end for warfarin in bioprosthetic mitral valve recipients with atrial fibrillation? - New insights from RIVER trial.

Novel oral anticoagulants, with dabigatran in particular have failed in their quest to replace the traditional anticoagulation in the form of vitamin K antagonist in patients with mechanical valvular implants. However, the same had not been tried in bioprosthetic valve recipients until recently in a large trial where rivaroxaban was found to be non-inferior to warfarin on head-to-head basis. This commentary discusses the various aspects related to oral anticoagulation in bioprosthetic valve recipients in the light of recent clinical evidence.