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.

Application of phytoaccumulation perspective of Monochoria hastate L. on fluoride contaminated water in hydroponic treatment: its statistical design and characterization studies.

The present research work approaches the accumulation of fluoride ions from contaminated water using an aquatic plant Monochoria hastate L. in hydroponic culture. A design of experiment (DOE) has been adopted and an analysis of variance has been conducted to establish the statistical significance of various process parameters. The different experimental factors are root and shoot (Factor A), fluoride concentration (Factor B), and experimental days (Factor C) largely influence the output response. Plants treated with 5 mg/L of fluoride solutions accumulated the highest concentration in root biomass 1.23 mg/gm, and shoot biomass 0.820 mg/gm, dry weight after 21 days' experimentation. The accumulation mechanism and potentiality of treated plants depend on root cells of the plasma membrane and energy-capturing molecules of adenosine triphosphate. Monochoria hastate L. root biomass was characterized to confirm the accumulation of fluoride ions in the experimented plants using scanning electron micrographs-energy dispersive spectrum (SEM-EDS), and Fourier transforms infrared analysis (FTIR) analysis.

The novelty of this study is the high fluoride accumulation efficiency in hydroponic treatment by Monochoria hastate L an excellent choice for phytoremediation technique. The Design of Experiment (DOE) has a good approach for the optimization of fluoride in the accumulation process. The maximum absorption of fluoride ions in root biomass is 1.23 mg/gm, and shoot biomass is 0.820 mg/gm, dry weight after 21 days of treatment. To know the fluoride ions in shoot and root biomass are characterized using scanning electron micrographs-energy dispersive spectrum (SEM-EDS), and Fourier transforms infrared analysis (FTIR).

Correlation between Transcranial Ultrasound and CT Head to Detect Clinically Significant Conditions in Post-craniectomy Patients Performed by Emergency Physician: A Pilot Study.

Background: The main objective is to detect clinically significant conditions by transcranial ultrasound (TCS) in post-decompressive craniectomy (DC) patients who come to the emergency department. Materials and methods: This was a cross-sectional observational study. We studied 40 post-DC patients. After primary stabilization, TCS was done. Computer tomography of head was done within 2 hours of performing TCS. The correlation between both modalities were assessed by the measurement of lateral ventricle (LV) (Bland-Altman plot), Midline shift and mass lesion. Additionally, normal cerebral anatomy, 3rd and 4th ventricles and external ventricular drainage (EVD) catheter visualization were also done. Results: About 14/40 patients came with non-neurosurgical complaints and 26/40 patients came with neurosurgical complaints. Patients with non-neurosurgical complaints (4/14) had mass lesions and 1/14 had MLS. Patients with neurosurgical complaints (11/26) had mass lesions and about 5 patients had MLS. A good correlation was found between TCS and CT of head in measuring LV right (CT head = 17.4 ± 13.8 mm and TCS = 17.1 ± 14.8 mm. The mean difference (95% CI) = [0.28 (-1.9 to 1.33), ICC 0.93 (0.88-0.96)], Left [CT head = 17.8 ± 14.4 mm and TCS = 17.1 ± 14.2 mm, the mean difference (95% CI) 0.63 (-1.8 to 0.61), ICC 0.96 (0.93-0.98)], MLS [CT head = 6.16 ± 3.59 (n = 7) and TCS = 7.883 ± 4.17 (n = 6)] and mass lesions (kappa 0.84 [0.72-0.89] [95% CI] p-value < 0.001). The agreement between both modalities for detecting mass lesions is 93.75%. Conclusion: Point of care ultrasound (POCUS) is a bedside, easily operable, non-radiation hazard and dynamic imaging tool that can be used for TCS as a supplement to CT head in post-DC patients in emergency as well as in ICU. However, assessment of the ventricular system (pre/post-EVD insertion), monitoring of regression/progression of mass lesion, etc. can be done with TCS. Repeated scans are possible in less time which can decrease the frequency of CT head. How to cite this article: Chouhan R, Sinha TP, Bhoi S, Kumar A, Agrawal D, Nayer J, et al. Correlation between Transcranial Ultrasound and CT Head to Detect Clinically Significant Conditions in Post-craniectomy Patients Performed by Emergency Physician: A Pilot Study. Indian J Crit Care Med 2024;28(3):299-306.

How Do Self-Interaction Errors Associated with Stretched Bonds Affect Barrier Height Predictions?

Density functional theory (DFT) suffers from self-interaction errors (SIEs) that generally result in the underestimation of chemical reaction barrier heights. This is commonly attributed to the tendency of density functional approximations to overstabilize delocalized densities that typically occur in the stretched bonds of transition state structures. The Perdew-Zunger self-interaction correction (PZSIC) and locally scaled self-interaction correction (LSIC) improve the prediction of barrier heights of chemical reactions, with LSIC giving better accuracy than PZSIC on average. These methods employ an orbital-by-orbital correction scheme to remove the one-electron SIE. In the context of barrier heights, this allows an analysis of how the self-interaction correction (SIC) for each orbital contributes to the calculated barriers using Fermi-Löwdin orbitals (FLOs). We hypothesize that the SIC contribution to the reaction barrier comes mainly from a limited number of orbitals that are directly involved in bond-breaking and bond-making in the reaction transition state. We call these participant orbitals (POs), in contrast to spectator orbitals (SOs) which are not directly involved in changes to the bonding. Our hypothesis is that ΔETotalSIC ≈ ΔEPOSIC, where ΔETotalSIC is the difference in the SIC corrections for the reactants or products and the transition state. We test this hypothesis for the reaction barriers of the BH76 benchmark set of reactions. We find that the stretched-bond orbitals indeed make the largest individual SIC contributions to the barriers. These contributions increase the barrier heights relative to LSDA, which underpredicts the barrier. However, the full stretched-bond hypothesis does not hold in all cases for either PZSIC or LSIC. There are many cases where the total SIC contribution from the SOs is significant and cannot be ignored. The size of the SIC contribution to the barrier height is a key indicator. A large SIC correction is correlated to a large LSDA error in the barrier, showing that PZSIC properly gives larger corrections when corrections are needed most. A comparison of the performance of PZSIC and LSIC shows that the two methods have similar accuracy for reactions with large LSDA errors, but LSIC is clearly better for reactions with small errors. We trace this to an improved description of reaction energies in LSIC.

Purification and characterization of a high molecular weight serine protease from Microbacterium paraoxydans sp. SKS10.

Alkaline proteases from microbial sources have been found suitable for diverse industrial applications, with serine proteases being the most common enzymes used in the detergent industry. In the present study, we have purified and characterized an extracellular alkaline serine protease from Microbacterium paraoxydans sp. SKS10. The protease was purified using ammonium sulfate precipitation followed by different chromatography techniques (fold purification 6.919). Km and Vmax for the protease were determined to be 0.183 mg/mL and 4.904 U/mL, respectively. This enzyme is a thermostable high molecular weight (∼109.4 kDa) protease which has maximal activity at 60°C, and above pH 10. Inhibitor assays revealed the enzyme to be a serine protease whose activity increased by 2.5-fold in the presence of EDTA. This enzyme remained active in the presence of various metal salts and organic solvents and was compatible with commercially available laundry detergents highlighting its potential for use in the detergent industry.

Study of Self-Interaction Errors in Density Functional Calculations of Magnetic Exchange Coupling Constants Using Three Self-Interaction Correction Methods.

We examine the role of self-interaction error (SIE) removal on the evaluation of magnetic exchange coupling constants. In particular, we analyze the effect of scaling down the self-interaction correction (SIC) for three nonempirical density functional approximations (DFAs) namely, the local spin density approximation, the Perdew-Burke-Ernzerhof generalized gradient approximation, and the recent SCAN family of meta-GGA functionals. To this end, we employ three one-electron SIC methods: Perdew-Zunger SIC [Perdew, J. P.; Zunger, A. Phys. Rev. B, 1981, 23, 5048.], the orbitalwise scaled SIC method [Vydrov, O. A. et al. J. Chem. Phys. 2006, 124, 094108.], and the recent local scaling method [Zope, R. R. et al. J. Chem. Phys. 2019, 151, 214108.]. We compute the magnetic exchange coupling constants using the spin projection and nonprojection approaches for sets of molecules composed of dinuclear and polynuclear H···He models, organic radical molecules, and chlorocuprate and compare these results against accurate theories and experiment. Our results show that for the systems that mainly consist of single-electron regions, PZSIC performs well, but for more complex organic systems and the chlorocuprates, an overcorrecting tendency of PZSIC combined with the DFAs utilized in this work is more pronounced, and in such cases, LSIC with kinetic energy density ratio performs better than PZSIC. Analysis of the results in terms of SIC corrections to the density and to the total energy shows that both density and energy correction are required to obtain an improved prediction of magnetic exchange couplings.

Study of self-interaction-errors in barrier heights using locally scaled and Perdew-Zunger self-interaction methods.

We study the effect of self-interaction errors on the barrier heights of chemical reactions. For this purpose, we use the well-known Perdew-Zunger self-interaction-correction (PZSIC) [J. P. Perdew and A. Zunger, Phys. Rev. B 23, 5048 (1981)] as well as two variations of the recently developed, locally scaled self-interaction correction (LSIC) [Zope et al., J. Chem. Phys. 151, 214108 (2019)] to study the barrier heights of the BH76 benchmark dataset. Our results show that both PZSIC and especially the LSIC methods improve the barrier heights relative to the local density approximation (LDA). The version of LSIC that uses the iso-orbital indicator z as a scaling factor gives a more consistent improvement than an alternative version that uses an orbital-dependent factor w based on the ratio of orbital densities to the total electron density. We show that LDA energies evaluated using the self-consistent and self-interaction-free PZSIC densities can be used to assess density-driven errors. The LDA reaction barrier errors for the BH76 set are found to contain significant density-driven errors for all types of reactions contained in the set, but the corrections due to adding SIC to the functional are much larger than those stemming from the density for the hydrogen transfer reactions and of roughly equal size for the non-hydrogen transfer reactions.

Sensitivity and specificity of waterbath ultrasound technique in comparison to the conventional methods in diagnosing extremity fractures.

INTRODUCTION: Point of care ultrasound (POCUS) has variable diagnostic accuracy in diagnosing fractures. Waterbath technique is a modification of the conventional ultrasound technique which may improve diagnostic accuracy by enhancing image quality. Authors studied the diagnostic accuracy of waterbath technique compared to the final diagnosis based on clinical examination and radiology in the identification of fractures of hand and foot. METHODS: Patients of >18 yrs. age with suspected distal hand and foot fractures presenting to the emergency department of a level 1 trauma center were recruited after informed consent. Unconscious and hemodynamically unstable patients, injuries >72 h old, open fractures, obvious deformities, and old fractures at the affected site were excluded. Cases were subjected to waterbath technique performed by an academic emergency medicine resident and relevant radiographs were ordered and interpreted by an orthopedic specialist. CT/MRI, if done in case of discrepancy, was interpreted by radiologist. The findings of both waterbath technique and radiology were blinded to each other and compared to the final diagnosis made by a cumulative assessment of clinical examination, radiographs, and CT/MRI of the discrepant cases. RESULTS: Waterbath technique identified fractures of hand and foot with sensitivity of 97% (95% CI 90%-100%), specificity 94% (95%CI 81%-99%), PPV 98% (95%CI 91%-99%), NPV 94% (95%CI 79%-98%), LR+ 17.5(95% CI 4.5-67.2), LR- 0.03(95% CI 0.01-0.12) and diagnostic accuracy 96% (95%CI 91%-99%). CONCLUSION: This pilot study has demonstrated the utility of Waterbath technique in the diagnosis of fractures of hand and foot in adults in the ED setting. Future well designed studies are required to explore the potential of this novel technique in both adult and pediatric population.

Optimization of multiple parameters for adsorption of arsenic (III) from aqueous solution using Psidium guajava leaf powder.

The conventional method of water treatment using activated carbon from several sources has been focused on extensively in the last two decades. However, rare attention has been noticed on natural adsorbents such as plant leaves. Therefore, the Psidium guajava (guava) leaf has been investigated to understand its adsorption efficacy for Arsenic (III) [As(III)] in this study. The effect of process variables, e.g., pH, concentration of metal ion, adsorbent's particle size, and dosages, are evaluated. Experiments are carried out in batch mode, and the individual and combined parameter's impact on adsorption have been discussed. Fourier transform infrared spectroscopy (FTIR) and scanning electron microscopy (SEM) is used to characterize the adsorbent's surface. Freundlich and Langmuir's isotherms are used for adsorption equilibrium study. The adsorption parameters are optimized by establishing a regression correlation using central composite design (CCD) of response surface methodology (RSM). The analysis of variance (ANOVA) suggests a high regression coefficient (R2 = 0.9249) for the removal of As(III). Particle size of 0.39 mm; adsorbent's height of 10 cm; metal ion concentration of 30 ppm, and pH 6 are optimized to remove 90.88% As(III) from aqueous solution. HCl is evaluated as a potential solvent for desorption of arsenic from the desorption study.

Mobile phone ingestion requiring endoscopic retrieval.

A 24-year-old male was brought to our emergency with complaints of abdominal pain for two days. There was a history of foreign body ingestion five days earlier, details of which he refused to reveal. After investigation with abdominal X ray and ultrasound, the foreign body was detected to be a mobile phone containing a battery. Clinical evaluation revealed no signs of lithium toxicity due to battery leak. The patient underwent endoscopy for removal of the mobile phone. The case shows the importance of thorough investigation and prompt attempt at endoscopic removal in the event of ingestion of foreign bodies containing batteries.

Removal of Cr (VI) from aqueous solution by activated charcoal derived from Sapindus trifoliate L fruit biomass using continuous fixed bed column studies.

In this study, the removal of hexavalent chromium from aqueous solution were examined using activated charcoal derived from Sapindus trifoliate L fruit biomass in continuous fixed-bed column studies. The activated S. trifoliate L fruit charcoal was prepared by treating the fruit powder using concentrated nitric acid solution. Experiments were performed to investigate the effect of bed height and initial concentration on the breakthrough and saturation times. The breakthrough and saturation time increases with increase in bed height and initial concentration of chromium solutions. The maximum adsorption capacity of S. trifoliate L charcoal for hexavalent chromium was found to be 1.719 mg/g in the bed height 15 cm and initial concentration 10 mg/L, respectively. Column data required at various conditions were explained using Bohart-Adams and Thomas model. Two models were found to be suitable to describe the definite part of the dynamic behaviour of the column with regard to bed-height and initial concentration of hexavalent chromium. On comparison of Adjusted R2 and estimated standard error, the Thomas model was found to best-fitted model and can be used to predict the adsorption of the hexavalent chromium in fixed-bed column studies. Activated S. trifoliate L fruit charcoal was characterised by SEM-EDX and FTIR analysis.

Endotracheal Tube Placement Confirmation by Ultrasonography: A Systematic Review and Meta-Analysis of more than 2500 Patients.

BACKGROUND: The integration of point-of-care ultrasound in endotracheal tube placement confirmation has been focus of many recent studies. OBJECTIVES: We sought to determine the diagnostic accuracy of ultrasonography in confirmation of endotracheal intubation compared with standard confirmatory methods. METHODS: We completed an extensive search of PubMed, EMBASE, Cochrane Central, Web of Science, and bibliographies of the selected articles from inception to October 2019. The search was limited to prospective studies conducted in human adults that compared the accuracy of ultrasonography in confirming the endotracheal tube position with a reference standard. The methodologic quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A bivariate random-effects model summarized diagnostic accuracy statistics. Subgroup analyses by ultrasonographic signs, study location, the operator's specialty, types of transducer, the technique of ultrasound confirmation, and clinical setting (cardiac arrest vs. non-cardiac arrest) were performed. RESULTS: Thirty studies involving 2534 patients were selected for this meta-analysis. The estimated pooled sensitivity and specificity for ultrasonography were 0.982 (95% confidence interval [CI] 0.971-0.988) and 0.957 (95% CI 0.901-0.982), respectively. Subgroup analyses did not reveal significant difference by ultrasonographic sign used, location, the sonographer's specialty, transducer type, or ultrasound technique used. Ultrasound was also found to be a useful adjunct in confirming endotracheal tube position in the subgroup of patients with cardiac arrest, with sensitivity of 0.99 (95% CI 0.98-1.00) and specificity of 0.84 (95% CI 0.67-1.00), respectively. CONCLUSIONS: Ultrasonography is a valuable and reliable adjunct for endotracheal tube confirmation, including during cardiac arrest resuscitation.

Point-of-care Ultrasound in Lingual Hematoma.

Isolated tongue hematoma following direct trauma to face is not a common finding. It can cause life-threatening airway obstruction and needs prompt diagnosis and early intervention. We report the case of a 40-year-old male who presented to our hospital with a large tongue swelling after a fall. Bedside point-of-care ultrasound (POCUS) of the tongue revealed a hematoma. This case highlights the use of POCUS for early diagnosis of tongue hematomas.

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.

Extended Synaptotagmin Interaction with the Fibroblast Growth Factor Receptor Depends on Receptor Conformation, Not Catalytic Activity.

We previously demonstrated that ESyt2 interacts specifically with the activated FGF receptor and is required for a rapid phase of receptor internalization and for functional signaling via the ERK pathway in early Xenopus embryos. ESyt2 is one of the three-member family of Extended Synaptotagmins that were recently shown to be implicated in the formation of endoplasmic reticulum (ER)-plasma membrane (PM) junctions and in the Ca(2+) dependent regulation of these junctions. Here we show that ESyt2 is directed to the ER by its putative transmembrane domain, that the ESyts hetero- and homodimerize, and that ESyt2 homodimerization in vivo requires a TM adjacent sequence but not the SMP domain. ESyt2 and ESyt3, but not ESyt1, selectively interact in vivo with activated FGFR1. In the case of ESyt2, this interaction requires a short TM adjacent sequence and is independent of receptor autophosphorylation, but dependent on receptor conformation. The data show that ESyt2 recognizes a site in the upper kinase lobe of FGFR1 that is revealed by displacement of the kinase domain activation loop during receptor activation.

Cerebral malaria--clinical manifestations and pathogenesis.

One of the most common central nervous system diseases in tropical countries is cerebral malaria (CM). Malaria is a common protozoan infection that is responsible for enormous worldwide mortality and economic burden on the society. Episodes of Plasmodium falciparum (Pf) caused CM may be lethal, while survivors are likely to suffer from persistent debilitating neurological deficits, especially common in children. In this review article, we have summarized the various symptoms and manifestations of CM in children and adults, and entailed the molecular basis of the disease. We have also emphasized how pathogenesis of the disease is effected by the parasite and host responses including blood brain barrier (BBB) disruption, endothelial cell activation and apoptosis, nitric oxide bioavailability, platelet activation and apoptosis, and neuroinflammation. Based on a few recent studies carried out in experimental mouse malaria models, we propose a basis for the neurological deficits and sequelae observed in human cerebral malaria, and summarize how existing drugs may improve prognosis in affected individuals.

Epidemiology of traumatic cardiac arrest in patients presenting to emergency department at a level 1 trauma center.

INTRODUCTION: There is a paucity of literature on prehospital care and epidemiology of traumatic cardiac arrest (TCA) in India. This study highlights the profile and characteristics of TCA. METHODS: A retrospective cohort study was conducted to study epidemiological profile of TCA patients ≥1 year presenting to a level 1 trauma center of India. RESULTS: One thousand sixty-one patients were recruited in the study. The median age (interquartile range) was 32 (23-45) years (male:female ratio of 5.9:1). Asystole (253), pulseless electrical activity (11), ventricular fibrillation (six), and ventricular tachycardia (five) were initial arrest rhythm. Road traffic crash (RTC) (57.16%), fall from height (18.52%), and assault (10.51%) were modes of injury. Prehospital care was provided by police (36.59%), ambulance (10.54%), relatives (45.40%), and bystanders (7.47% cases). Return of spontaneous circulation was seen in 69 patients, of which only three survived to hospital discharge. CONCLUSION: RTC in young males was a major cause of TCA. Asystole was the most common arrest rhythm. Police personnel were major prehospital service provider. Prehospital care needs improvement including the development of robust TCA registry.

Variable Surface Antigens of Plasmodium falciparum: Protein Families with Divergent Roles.

Malaria caused by Plasmodium falciparum (Pf) is an illness that contributes significantly to the global health burden. Pf makes significant alterations to the host cell to meet its metabolic demands and escape the immune response of the host. These include the export of a large number of parasite proteins to the infected Red Blood Cells (iRBC). Variable Surface Antigens (VSAs), which are highly polymorphic protein families with important roles in immune evasion, form an important component of the exported proteins. A total of five protein families constitute the VSAs, viz. PfEMP1 (Pf erythrocyte membrane protein 1), RIFIN (repetitive interspersed family), STEVOR (sub-telomeric open reading frame), SURFIN (surface-associated interspersed gene family), and PfMC-2TM (Pf Maurer's cleft two transmembrane). With orthologues present in various simian-infecting species, VSAs take up a variety of domain topologies and organizational structures while exhibiting differential expressions throughout the parasite life cycle. Their expression varies across clinical isolates and laboratory strains, which suggests their crucial role in host cell survival and defense. Members of VSAs are reported to contribute significantly to disease pathogenesis through immune evasion processes like cytoadherence, iRBC sequestration in the host vasculature, rosetting, reduced erythrocyte deformability, and direct immunosuppression. In this study, we have gathered information on various aspects of VSAs, like their orthologues, domain architecture, surface topology, functions and interactions, and three-dimensional structures, while emphasizing discoveries in the field. Considering the vast repertoire of Plasmodial VSAs with new emergent functions, a lot remains unknown about these families and, hence, malaria biology.