Prognostic biomarkers of intracerebral hemorrhage identified using targeted proteomics and machine learning algorithms.

Early prognostication of patient outcomes in intracerebral hemorrhage (ICH) is critical for patient care. We aim to investigate protein biomarkers' role in prognosticating outcomes in ICH patients. We assessed 22 protein biomarkers using targeted proteomics in serum samples obtained from the ICH patient dataset (N = 150). We defined poor outcomes as modified Rankin scale score of 3-6. We incorporated clinical variables and protein biomarkers in regression models and random forest-based machine learning algorithms to predict poor outcomes and mortality. We report Odds Ratio (OR) or Hazard Ratio (HR) with 95% Confidence Interval (CI). We used five-fold cross-validation and bootstrapping for internal validation of prediction models. We included 149 patients for 90-day and 144 patients with ICH for 180-day outcome analyses. In multivariable logistic regression, UCH-L1 (adjusted OR 9.23; 95%CI 2.41-35.33), alpha-2-macroglobulin (aOR 5.57; 95%CI 1.26-24.59), and Serpin-A11 (aOR 9.33; 95%CI 1.09-79.94) were independent predictors of 90-day poor outcome; MMP-2 (aOR 6.32; 95%CI 1.82-21.90) was independent predictor of 180-day poor outcome. In multivariable Cox regression models, IGFBP-3 (aHR 2.08; 95%CI 1.24-3.48) predicted 90-day and MMP-9 (aOR 1.98; 95%CI 1.19-3.32) predicted 180-day mortality. Machine learning identified additional predictors, including haptoglobin for poor outcomes and UCH-L1, APO-C1, and MMP-2 for mortality prediction. Overall, random forest models outperformed regression models for predicting 180-day poor outcomes (AUC 0.89), and 90-day (AUC 0.81) and 180-day mortality (AUC 0.81). Serum biomarkers independently predicted short-term poor outcomes and mortality after ICH. Further research utilizing a multi-omics platform and temporal profiling is needed to explore additional biomarkers and refine predictive models for ICH prognosis.

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.

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.

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).

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.

Assessment of Troponin I Levels as a Predictor of Mortality in Acute Decompensated Heart Failure.

BACKGROUND: Acute decompensated heart failure (ADHF) is a highly prevalent diagnosis in the emergency department and is associated with high morbidity and mortality. As mortality remains high even in patients discharged from the emergency, it becomes mandatory to identify markers predictive of mortality in order to guide the disposition of such patients. No literature is available on the prognostic significance of Troponin I in ADHF patients in an emergency setting from an Indian standpoint. OBJECTIVES: This study was aimed at identifying the ability of Troponin I levels at presentation to predict one-month mortality in patients with ADHF. METHODS: The study was conducted in the emergency department of a tertiary healthcare center in north India. Serum cardiac Troponin I (cTnI) levels at presentation were assayed in 101 patients and a one-month follow-up was done. RESULTS: cTnI levels were > 0.02 ng/mL in 51 patients (50.5%). ROC analysis showed an accuracy of 63% in predicting mortality (p < 0.05). Univariate and multivariate analysis showed an OR of 2.58 and 2.74, respectively (p - 0.037 and 0.047, respectively), suggesting cTnI to be a significant predictor of mortality in ADHF. N-terminal proBNP (NT-proBNP) (OR - 2.09; p - 0.229) and left ventricular ejection fraction (OR - 2.01; p - 0.157) were not found to be significant predictors of mortality on regression analysis. CONCLUSION: cTnI levels at presentation are a significant predictor of short-term mortality in ADHF and can be used in an emergency setting to guide treatment, disposition, and follow-up plans of these patients.

Diagnostic accuracy of drooling, reluctance, oropharynx, others, and leukocytosis score as a predictor of mortality and complications following acute corrosive ingestion.

OBJECTIVES: Esophagogastroduodenoscopy is considered the gold standard in assessing the severity of injury to the gastrointestinal tract following corrosive ingestion. Zargar's endoscopic grading of injury helps in prognostication as well as guiding management. Since the major burden of cases lies in resource-limited settings, the availability of endoscopic evaluation is a limiting factor. Hence, it is prudent to develop bedside tools that can be used as screening tools to identify patients at high risk of mortality and complications so that timely referrals and judicious utilization of resources can be made. Literature in this regard is limited and published studies have shown that clinical features fail to predict the severity of injury. We aimed our study to find the role of Drooling, Reluctance, Oropharynx, Others, and Leukocytosis (DROOL) score as a predictor of mortality and complications following acute corrosive ingestion. METHODS: This was a diagnostic accuracy study conducted in the emergency department (ED) of a tertiary care hospital in North India. We screened all cases of acute corrosive ingestion presented to our ED. We collected the data on demographic profile, clinical features, investigations, endoscopy findings, treatment, and DROOL score. We followed patients for up to 12 weeks for outcomes including mortality and complications. RESULTS: We studied 79 patients of acute corrosive ingestion. The median age was 26 years with a female predominance. Nausea, vomiting, and pain abdomen were the common symptoms. The median DROOL score was 4. The majority of our patients had normal to Zargar grade 1 injury to the stomach and esophagus. Out of 79 patients, 27 patients developed some complications. The overall mortality up to 12 weeks was 10%. The receiver operating characteristics (ROC) analysis was performed, and the area under the ROC (AUROC) curve of Zargar classification in predicting overall complications was 0.909 (96% confidence interval [CI]: 0.842-0.975) and it was 0.775 (95% CI: 0.553-1.000) in predicting mortality. The AUROC of DROOL score in predicting overall complications was 0.932 (95% CI: 0.877-0.987) and the AUROC of DROOL score in predicting mortality was 0.864 (95% CI: 0.758-0.970). The ROC analysis showed that a DROOL score ≤4 has a sensitivity of 96.2% and a specificity of 77.8% in predicting overall complications. Similarly, DROOL score ≤5 has a sensitivity of 81.7% and a specificity of 62.5% in predicting the development of mortality. Delong test showed that there was no statistically significant difference in Zargar versus DROOL score in terms of prediction of mortality and overall complications (P > 0.05). CONCLUSION: DROOL score is comparable to Zargar score in identifying patients at high risk of mortality and complications. Hence, DROOL score can be used for risk stratification of patients presenting with corrosive ingestion.

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.

Phylogeny and evolution of SARS-CoV-2 during Delta and Omicron variant waves in India.

SARS-CoV-2 evolution has continued to generate variants, responsible for new pandemic waves locally and globally. Varying disease presentation and severity has been ascribed to inherent variant characteristics and vaccine immunity. This study analyzed genomic data from 305 whole genome sequences from SARS-CoV-2 patients before and through the third wave in India. Delta variant was reported in patients without comorbidity (97%), while Omicron BA.2 was reported in patients with comorbidity (77%). Tissue adaptation studies brought forth higher propensity of Omicron variants to bronchial tissue than lung, contrary to observation in Delta variants from Delhi. Study of codon usage pattern distinguished the prevalent variants, clustering them separately, Omicron BA.2 isolated in February grouped away from December strains, and all BA.2 after December acquired a new mutation S959P in ORF1b (44.3% of BA.2 in the study) indicating ongoing evolution. Loss of critical spike mutations in Omicron BA.2 and gain of immune evasion mutations including G142D, reported in Delta but absent in BA.1, and S371F instead of S371L in BA.1 could explain very brief period of BA.1 in December 2021, followed by complete replacement by BA.2. Higher propensity of Omicron variants to bronchial tissue, probably ensured increased transmission while Omicron BA.2 became the prevalent variant possibly due to evolutionary trade-off. Virus evolution continues to shape the epidemic and its culmination.Communicated by Ramaswamy H. Sarma.

Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial.

OBJECTIVE: To determine if initial fluid resuscitation with balanced crystalloid (e.g., multiple electrolytes solution [MES]) or 0.9% saline adversely affects kidney function in children with septic shock. DESIGN: Parallel-group, blinded multicenter trial. SETTING: PICUs of four tertiary care centers in India from 2017 to 2020. PATIENTS: Children up to 15 years of age with septic shock. METHODS: Children were randomized to receive fluid boluses of either MES (PlasmaLyte A) or 0.9% saline at the time of identification of shock. All children were managed as per standard protocols and monitored until discharge/death. The primary outcome was new and/or progressive acute kidney injury (AKI), at any time within the first 7 days of fluid resuscitation. Key secondary outcomes included hyperchloremia, any adverse event (AE), at 24, 48, and 72 hours, and all-cause ICU mortality. INTERVENTIONS: MES solution ( n = 351) versus 0.9% saline ( n = 357) for bolus fluid resuscitation during the first 7 days. MEASUREMENTS AND MAIN RESULTS: The median age was 5 years (interquartile range, 1.3-9); 302 (43%) were girls. The relative risk (RR) for meeting the criteria for new and/or progressive AKI was 0.62 (95% CI, 0.49-0.80; p < 0.001), favoring the MES (21%) versus the saline (33%) group. The proportions of children with hyperchloremia were lower in the MES versus the saline group at 24, 48, and 72 hours. There was no difference in the ICU mortality (33% in the MES vs 34% in the saline group). There was no difference with regard to infusion-related AEs such as fever, thrombophlebitis, or fluid overload between the groups. CONCLUSIONS: Among children presenting with septic shock, fluid resuscitation with MES (balanced crystalloid) as compared with 0.9% saline resulted in a significantly lower incidence of new and/or progressive AKI during the first 7 days of hospitalization.

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.

Learning to switch gears - Steering palliative care into emergency medicine.

Emergency care is largely seen as synonymous with resuscitation and saving lives. In most of the developing world where Emergency Medicine (EM) is still evolving, the concept of EM palliative care is alien. Provision of palliative care in such settings poses its own challenges in terms of knowledge gaps, socio-cultural barriers, dismal doctor-to-patient ratio with limited time for communication with patients, and lack of established pathways to provide EM palliative care. Integrating the concept of palliative medicine is crucial for expanding the dimension of holistic, value-based, quality emergency care. However, glitches in decision-making processes, especially in high patient volume settings, may lead to inequalities in care provision, based on socio-financial disparities of patients or premature termination of challenging resuscitations. Pertinent, robust, validated screening tools and guides may assist physicians in tackling this ethical dilemma.

The Role of Triple Rule-out CT in an Indian Emergency Setting.

Background: Emergency physicians are acutely aware of the consequences of missing fatal diagnoses for acute non-traumatic chest pain and subjecting patients to over-testing. In the large arsenal of tests that are available to us, a triple rule-out computed tomography (TRO-CT) Angiography is often less pursued, due to concerns about their efficacy and safety or because of nescience. We aim to find the yield of the test in an Indian emergency setting and impart some knowledge about it along the way. Materials and methods: Twenty-six patients who presented to the emergency department of our institute with acute chest pain, with non-specific electrocardiogram (ECG) findings and negative serial troponin I, underwent TRO-CT. HEART scores of all patients, calculated at their presentation, were correlated with TRO-CT findings. Results: Triple rule-out computed tomography angiography was positive in 5 patients (20%), of which 4 cases (16%) were diagnosed to have significant coronary artery disease and one had an acute pulmonary embolism. All 4 patients who had significant coronary artery disease (CAD) diagnosed by TRO-CT had a HEART score of intermediate risk. The mean effective radiation dose of the entire TRO study was 19.024 ± 3.319 mSv (range = 13.89-25.95 mSv). Conclusion: Triple rule-out CT angiography is a useful tool in the evaluation of patients presenting with acute chest pain in the emergency and can be an important adjunct in ruling out significant CAD in intermediate-risk patients. Emergency physicians and young residents need to know about this tool in their armamentarium to tackle doubtful cases. How to cite this article: Pattereth N, Chaliyadan S, Mathew R, Kumar S, Das CJ, Aggarwal P. et al. The Role of Triple Rule-out CT in an Indian Emergency Setting. Indian J Crit Care Med 2023;27(3):190-194.

Nebulized vs IV Tranexamic Acid for Hemoptysis: A Pilot Randomized Controlled Trial.

BACKGROUND: Tranexamic acid (TA) is used to control bleeding in patients with hemoptysis. However, the effectiveness of the different routes of TA administration has not been studied. RESEARCH QUESTION: Does the nebulized route of TA administration reduce the amount of hemoptysis compared with the IV route in patients presenting to the ED with hemoptysis? STUDY DESIGN AND METHODS: This was a pragmatic, open-label, randomized, parallel, single-center, pilot trial of nebulized TA (500 mg tid) vs IV TA (500 mg tid) in adult patients presenting to the ED with active hemoptysis. The primary outcome was cessation of bleeding at 30 min. Secondary outcomes included amount of hemoptysis at 6, 12, and 24 h; interventional procedures; and side effects of TA. Patients who were hemodynamically unstable or requiring immediate interventional procedure or mechanical ventilation were excluded from the study. RESULTS: Of the 55 patients in each arm, hemoptysis cessation at 30 min following TA administration was significantly higher in the nebulization arm (n = 40) compared with the IV arm (n = 28): χ2 (1, n = 110) = 5.55; P = .0019. Also, hemoptysis amount was reduced significantly in the nebulization arm at all time periods of observation (P value at 30 min = .011, at 6 h = .002, 12 h = .0008, and at 24 h = .005). Fewer patients in the nebulization arm required bronchial artery embolization (13 vs 21; P = .024) and thereby had higher discharge rates from the ED (67.92% vs 39.02%; P = .005). Two patients in the nebulization arm had asymptomatic bronchoconstriction that resolved after short-acting beta-agonist nebulization. No patient discharged from the ED underwent any interventional procedure or revisited the ED with rebleed during the 72 h follow-up period. INTERPRETATION: Nebulized TA may be more efficacious than IV TA in reducing the amount of hemoptysis and need for ED interventional procedures. Future larger studies are needed to further explore the potential of nebulized TA compared with IV TA in patients with mild hemoptysis. CLINICAL TRIAL REGISTRATION: Clinical Trials Registry-India; No.: CTRI/2019/05/019337; URL: http://ctri.nic.in/Clinicaltrials/advancesearchmain.php.

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.

Prospective Validation of a Novel Triage System Developed in a Middle Income Country - AIIMS Triage Protocol.

Introduction: Triage is a crucial process not only to identify sick patients and prioritize prompt management but also to foster efficient resource utilization. In low-and middle-income countries (LMICs) most emergency departments (ED) still have an informal triage process. Although an important element of emergency care, triage research has not been a priority in LMICs, and hence, very few triage systems have been validated. The All India Institute of Medical Sciences (AIIMS) triage protocol or ATP for adult patients was developed by expert consensus at AIIMS using the Delphi method. We attempted a prospective validation of the ATP in terms of mortality and intensive care unit (ICU)/hospital admission at 24 h. Methods: Patients presenting to the ED, who were 14 years and above were included in the study. The patients were followed up at 24 h and their outcome documented on a standardized data collection form. Mortality and ICU admission were noted at 24 h. Results: A total of 15,505 patients were recruited. After exclusion, among 13,754 patients, 6303 (45.83%) were triaged red and 7451 (54.17%) were triaged yellow. Mortality at 24 h was 10.31% (650) in red triaged patients and 0.35% (26) in yellow triaged patients. The 24-h mortality of red triaged patients was significantly higher (P <0.001) than that of yellow triaged patients. The presence of one or more ATP "Red" criteria was 96.2% (95% confidence interval [CI]: 94.42%-97.47%) sensitive and 56.8% (95% CI: 55.92%-57.63%) specific in predicting 24-h mortality. The sensitivity and specificity of ATP "Red" criteria for 24-h ICU admission were 98.5% (95% CI: 97.7%-99.1%) and 59.6% (95% CI: 58.8%-60.5%), respectively. Conclusion: When applied to adult nontrauma patients, ATP had a high accuracy in recognizing sick patients presenting to the ED. A time-tested and validated triage system like ATP may be a good starting point for public hospital EDs in LMICs.

Blood-based protein biomarkers for the diagnosis of acute stroke: A discovery-based SWATH-MS proteomic approach.

Background and purposes: Recent developments in high-throughput proteomic approach have shown the potential to discover biomarkers for diagnosing acute stroke and to elucidate the pathomechanisms specific to different stroke subtypes. We aimed to determine blood-based protein biomarkers to diagnose total stroke (IS+ICH) from healthy controls, ischemic stroke (IS) from healthy controls, and intracerebral hemorrhage (ICH) from healthy control subjects within 24 h using a discovery-based SWATH-MS proteomic approach. Methods: In this discovery phase study, serum samples were collected within 24 h from acute stroke (IS & ICH) patients and healthy controls and were subjected to SWATH-MS-based untargeted proteomics. For protein identification, a high-pH fractionated peptide library for human serum proteins (obtained from SCIEX) comprising of 465 proteins was used. Significantly differentially expressed (SDE) proteins were selected using the following criteria: >1.5-fold change for upregulated, < 0.67 for downregulated, p-value < 0.05, and confirmed/tentative selection using Boruta random forest. Protein-protein interaction network analysis and the functional enrichment analysis were conducted using STRING 11 online tool, g:Profiler tool and Cytoscape 3.9.0 software. The statistical analyses were conducted in R version 3.6.2. Results: Our study included 40 stroke cases (20 IS, 20 ICH) within 24 h and 40 age-, sex-, hypertension-, and diabetes-matched healthy controls. We quantified 375 proteins between the stroke cases and control groups through SWATH-MS analysis. We observed 31 SDE proteins between total stroke and controls, 16 SDE proteins between IS and controls, and 41 SDE proteins between ICH and controls within 24 h. Four proteins [ceruloplasmin, alpha-1-antitrypsin (SERPINA1), von Willebrand factor (vWF), and coagulation factor XIII B chain (F13B)] commonly differentiated total stroke, IS, and ICH from healthy control subjects. The most common significant pathways in stroke cases involved complement and coagulation cascades, platelet degranulation, immune-related processes, acute phase response, lipid-related processes, and pathways related to extracellular space and matrix. Conclusion: Our discovery phase study identified potential protein biomarker candidates for the diagnosis of acute stroke and highlighted significant pathways associated with different stroke subtypes. These potential biomarker candidates warrant further validation in future studies with a large cohort of stroke patients to investigate their diagnostic performance.