Comparing commercial versus low-cost gelatinous phantoms for ultrasound-guided needle tracking: A randomized crossover trial, among emergency medicine residents.

OBJECTIVES: The objective of this study was to devise a low-cost indigenous gelatin-based vascular phantom and to compare this newly constructed phantom with a commercially available phantom. METHODS: This was a randomized crossover study conducted at a tertiary care hospital of India. The aim of the study was to develop a prototype low-cost gelatin-based vascular phantom and compare it with a commercially available phantom. Gelatin, psyllium husk, corn starch, antiseptic liquid, food-coloring agent, latex balloons, and metallic containers were used to prepare the gelatin phantom. The newly prepared gelatin model was labeled "Model A" and the commercially available gelatin model was labeled "Model B." Emergency medicine residents (n = 34) who routinely perform ultrasound (USG)-guided invasive procedures were asked to demonstrate USG-guided in-plane and out-of-plane approach of needle-tracking in both the models and fill out a questionnaire on a Likert scale (1-5). An independent supervisor assessed the image quality. RESULTS: The cost of our phantom was USD 6-8 (vs. USD 1000-1200 for commercial phantom). The participants rated the ease of performance and tissue resemblance as 4 (interquartile range [IQR]: 4-5) for both the models "A" and "B." The supervisor rated the overall performance as 4 (IQR: 3-4) for both the models. In all the parameters assessed, model A was noninferior to model B. CONCLUSION: The indigenously developed vascular phantom was noninferior to the commercially available phantom in terms of tissue resemblance and overall performance. The cost involved was a fraction of that incurred with the currently available commercial model. The authors feel that gelatin-based models can be easily prepared in resource-constraint settings which may be used for USG-guided training and medical education in low- and middle-income countries.

Feasibility of USG-Guided Objective Initial Assessment of Pupillary Size and Pupillary Reflexes Versus Clinical Examination in Patients With Altered Mental Status: A Cross-Sectional Study.

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

IMPETUS Stroke: Assessment of hospital infrastructure and workflow for implementation of uniform stroke care pathway in India.

BACKGROUND: India accounts for 13.3% of global disability-adjusted life years (DALYs) lost due to stroke with a relatively younger age of onset compared to the Western population. In India's public healthcare system, many stroke patients seek care at tertiary-level government-funded medical colleges where an optimal level of stroke care is expected. However, there are no studies from India that have assessed the quality of stroke care, including infrastructure, imaging facilities, or the availability of stroke care units in medical colleges. AIM: This study aimed to understand the existing protocols and management of acute stroke care across 22 medical colleges in India, as part of the baseline assessment of the ongoing IMPETUS stroke study. METHODS: A semi-structured quantitative pre-tested questionnaire, developed based on review of literature and expert discussion, was mailed to 22 participating sites of the IMPETUS stroke study. The questionnaire assessed comprehensively all components of stroke care, including human resources, emergency system, in-hospital care, and secondary prevention. A descriptive analysis of their status was undertaken. RESULTS: In the emergency services, limited stroke helpline numbers, 3/22 (14%); prenotification system, 5/22 (23%); and stroke-trained physicians were available, 6/22 (27%). One-third of hospitals did not have on-call neurologists. Although non-contrast computed tomography (NCCT) was always available, 39% of hospitals were not doing computed tomography (CT) angiography and 13/22 (59%) were not doing magnetic resonance imaging (MRI) after routine working hours. Intravenous thrombolysis was being done in 20/22 (91%) hospitals, but 36% of hospitals did not provide it free of cost. Endovascular therapy was available only in 6/22 (27%) hospitals. The study highlighted the scarcity of multidisciplinary stroke teams, 8/22 (36%), and stroke units, 7/22 (32%). Lifesaving surgeries like hematoma evacuation, 11/22 (50%), and decompressive craniectomy, 9/22 (41%), were performed in limited numbers. The availability of occupational therapists, speech therapists, and cognitive rehabilitation was minimal. CONCLUSION: This study highlighted the current status of acute stroke management in publicly funded tertiary care hospitals. Lack of prenotification, limited number of stroke-trained physicians and neurosurgeons, relatively lesser provision of free thrombolytic agents, limited stroke units, and lack of rehabilitation services are areas needing urgent attention by policymakers and creation of sustainable education models for uniform stroke care by medical professionals across the country.

Gender-based Assessment of Survival in Trauma-hemorrhagic Shock: A Retrospective Analysis of Indian Population.

INTRODUCTION: Trauma-hemorrhagic shock (THS) is a leading cause of death. Female rats and women experience better outcomes in terms of survival after major trauma as compared to males. There are limited data in Indian population. Authors studied the gender-based outcome of patients with Class IV hemorrhagic shock due to blunt trauma and the distribution of factors among males and females which are known to affect outcome. MATERIALS AND METHODS: It was a retrospective study with data of trauma victims between January 2008 and July 2013. Road traffic crash (RTC), fall, or assault of all ages with Class IV hemorrhagic shock on arrival was included in the study, and data were collected on demographic, clinical, and laboratory parameters. Drowning, burns, penetrating injuries, and septic, neurogenic, and cardiogenic shock were excluded from the study. RESULTS: Seven hundred and eighty-one patients were analyzed under three groups: (i) overall group including all patients (n = 781), (ii) male group (n = 609), and (iii) female group (n = 172). After adjusting all variables, mortality was significantly lower in females as compared to males following THS (P < 0.05). Age, blood pressure, pulse, male gender, and fall and RTC as mode of injury (MOI) were independent predictors of mortality (P < 0.05) in overall group. Among males, age, pulse, and RTC as a MOI were significant (P < 0.05), while in females, only systolic blood pressure (SBP) was independent predictor of mortality. CONCLUSION: Females had better survival as compared to males following THS. SBP was an independent predictor of mortality in females with THS.

Direct and indirect cost of myasthenia gravis: A prospective study from a tertiary care teaching hospital in India.

Myasthenia gravis (MG) requires lifelong treatment. The cost of management MG is very high in developed countries but there is no information on the cost of management of MG in the developing countries. This study reports the direct and indirect cost and predictors of cost of MG in a tertiary care teaching hospital in India. In a prospective hospital based study, from a tertiary hospital in India 66 consecutive patient during 2014-2015 were included. The age of the patients ranged between 6 and 75years. The severity of MG was assessed by myasthenia gravis foundation association (MGFA) class (MGFA) I-V. The patient data was collected s and their direct cost was calculated from the computerized Hospital information system. The indirect cost was calculated from patient's memory, checking the bills of transportation and wages loss by the patient or the care giver. Total annual cost of MG ranged between INR (4560-532227) with median INR 61390.5 (US$911.64). The median cost of outpatient department (OPD) consultation of 16 patients was INR 20439.9 (US$303.53), of 50 admitted patients was INR 44311.8 (US$658.03) and 21 intensive care unit (ICU) patients was INR 59574.3 (US$ 884.6) and the direct cost of thymectomy was INR 45000 (US$ 668.25). Direct cost was related to indirect cost (r=0.55; p=0.0001). Predictors of patient outcome were severity of MG, ICU admission, and thymectomy. The total median cost for management of myasthenia gravis was INR 61390.5 (4560-532227, US$911.64) per year, and the cost was mainly determined by the severity of MG.

Role of 18F-FDG PET in demonstrating disease burden in patients with tuberculous meningitis.

OBJECTIVE: To study the role of 18fluoro-deoxy glucose positron emission tomography/computed tomography (18F-FDG PET/CT) scan in documenting the disease burden in patients with tuberculous meningitis (TBM), and compare these findings with conventional imaging and magnetic resonance imaging (MRI). SUBJECTS AND METHODS: Ten patients with definite TBM were prospectively recruited. The severity of TBM was graded into stage I to III. The patients were subjected to whole body 18F-FDG PET/CT imaging and MRI brain. 18F-FDG PET/CT results were compared with the findings of brain MRI and other convectional imaging modalities (ultrasonography of abdomen and chest radiograph). RESULTS: There were ten patients with TBM whose median age was 27 (14-55) years, and the median duration of illness was 4 (0.5-8.0) months. Two patients were in stage I, six in stage II, and two in stage III meningitis. 18F-FDG PET/CT confirmed the cranial MRI findings in six patients, revealed additional brain lesion in one and did not detect the existing MRI lesions in three patients. 18F-FDG PET/CT however detected additional lesions in vertebrae, spinal cord and lymph nodes which were not seen on the conventional imaging. CONCLUSION: 18F-FDG PET/CT has a complementary role to MRI for detection of cranial lesions and is more sensitive in detecting the extra cranial tuberculosis burden in the patients with TBM.

Cost of status epilepticus in a tertiary care hospital in India.

PURPOSE: Status epilepticus (SE) is one of the most important neurological emergencies. The present study evaluated both direct cost of SE and predictors of cost in an Indian tertiary care teaching hospital in Lucknow India. METHODS: SE was defined as continuous seizure for ≥ 5 min or recurrent seizures without regaining consciousness. Etiologies of SE were categorized as acute central nervous system (CNS) pathology, acute non-CNS pathology, chronic CNS pathology, congenital disorders and others. Patients requiring mechanical ventilation (MV) received ventilators free of cost. Mortality and disability on discharge were noted. RESULTS: Fifty-five patients aged 8-90 years were included (males, 33). Fifty (89.3%) patients had generalized convulsive SE. The severity of SE as assessed by Status Epilepticus Scoring Scale was unfavorable (score, 3-6) in 41 (74.5%) patients. The etiology of SE was categorized as acute CNS pathology in 28 (51%) patients, non-CNS and chronic CNS pathology in 11 (19.6%) patients each, remote congenital pathology in 2 (3.6%), and others in 3 (5.6%). Thirty (53.6%) patients had comorbidities. Median duration of hospitalization was 7 (range, 1-72) days.Twenty six patients were hospitalized for >7 days. SE was controlled by 2 drugs in 47 (85.5%) patients and refractory to 2 intravenous antiepileptic drugs in 8 (14.5%). Nineteen (34.5%) patients died, and 29 (51.8%) showed favorable outcomes on discharge. Median hospital expenditure per case was INR 19,900 ($309.87; range, INR 1600-574,000). On multivariate analysis, SE hospitalization costs were determined by refractoriness of SE and mechanical ventilation (MV). Hospitalization cost of SE was lower than those of stroke. CONCLUSION: Acute non-CNS pathology is largely responsible for the high cost of SE, particularly refractory SE requiring mechanical ventilation.

Assessment of ultrasound as a diagnostic modality for detecting potentially unstable cervical spine fractures in pediatric severe traumatic brain injury: A feasibility study.

BACKGROUND: Early cervical spine clearance is extremely important in unconscious trauma patients and may be difficult to achieve in emergency setting. OBJECTIVES: The aim of this study was to assess the feasibility of standard portable ultrasound in detecting potentially unstable cervical spine injuries in severe traumatic brain injured (TBI) patients during initial resuscitation. MATERIALS AND METHODS: This retro-prospective pilot study carried out over 1-month period (June-July 2013) after approval from the institutional ethics committee. Initially, the technique of cervical ultrasound was standardized by the authors and tested on ten admitted patients of cervical spine injury. To assess feasibility in the emergency setting, three hemodynamically stable pediatric patients (≦18 years) with isolated severe head injury (Glasgow coma scale ≤8) coming to emergency department underwent an ultrasound examination. RESULTS: The best window for the cervical spine was through the anterior triangle using the linear array probe (6-13 MHz). In the ten patients with documented cervical spine injury, bilateral facet dislocation at C5-C6 was seen in 4 patients and at C6-C7 was seen in 3 patients. C5 burst fracture was present in one and cervical vertebra (C2) anterolisthesis was seen in one patient. Cervical ultrasound could easily detect fracture lines, canal compromise and ligamental injury in all cases. Ultrasound examination of the cervical spine was possible in the emergency setting, even in unstable patients and could be done without moving the neck. CONCLUSIONS: Cervical ultrasound may be a useful tool for detecting potentially unstable cervical spine injury in TBI patients, especially those who are hemodynamically unstable.

To determine the accuracy of focused assessment with sonography for trauma done by nonradiologists and its comparative analysis with radiologists in emergency department of a level 1 trauma center of India.

BACKGROUND: Focused assessment with sonography for trauma (FAST) is an important skill during trauma resuscitation. Use of point of care ultrasound among the trauma team working in emergency care settings is lacking in India. OBJECTIVE: To determine the accuracy of FAST done by nonradiologists (NR) when compared to radiologists during primary survey of trauma victims in the emergency department of a level 1 trauma center in India. MATERIALS AND METHODS: A prospective study was done during primary survey of resuscitation of nonconsecutive patients in the resuscitation bay. The study subjects included NR such as one consultant emergency medicine, two medicine residents, one orthopedic resident and one surgery resident working as trauma team. These subjects underwent training at 3-day workshop on emergency sonography and performed 20 supervised positive and negative scans for free fluid. The FAST scans were first performed by NR and then by radiology residents (RR). The performers were blinded to each other's sonography findings. Computed tomography (CT) and laparotomy findings were used as gold standard whichever was feasible. Results were compared between both the groups. Intraobserver variability among NR and RR were noted. RESULTS: Out of 150 scans 144 scans were analyzed. Mean age of the patients was 28 [1-70] years. Out of 24 true positive patients 18 underwent CT scan and exploratory laparotomies were done in six patients. Sensitivity of FAST done by NR and RR were 100% and 95.6% and specificity was 97.5% in both groups. Positive predictive value among NR and RR were 88.8%, 88.46% and negative predictive value were 97.5% and 99.15%. Intraobserver performance variation ranged from 87 to 97%. CONCLUSION: FAST performed by NRs is accurate during initial trauma resuscitation in the emergency department of a level 1 trauma center in India.