Efficacy of a low dose of antivenom for severe neuroparalysis in Bungarus caeruleus (common krait) envenomation: a pilot study.

Introduction: Despite the widespread use of antivenom for the treatment of snakebite envenoming in the Indian subcontinent, the ideal dose of antivenom has been a point of contention. Low-dose regimens can economize on a scarce resource in low- and middle-income countries. This study assessed the effectiveness of a low-dose (10 vials) antivenom regimen compared to the usual 20 vials in patients with krait bite neuroparalysis requiring mechanical ventilation. Methods: This study was a prospective controlled pilot study conducted in a tertiary-care hospital in north India. Participants were eligible if they were ≥12 years old, had krait bite neurotoxicity, showed severe paralysis requiring mechanical ventilation, and had access to antivenom therapy within 24 h of the bite. The primary outcome was the duration of mechanical ventilation, and the secondary outcomes were the length of hospital stay and in-hospital survival. Results: Fifteen patients received 10 vials of antivenom, and 25 received 20 vials. The two treatment groups had similar baseline demographics, clinical and laboratory features, snakebite severity scores, and median time from snakebite to initiation of antivenom therapy. The low-dose regimen was as effective as the standard dose concerning the median duration of mechanical ventilation (41 h vs. 55 h, P = 0.094), the median length of stay (78 h vs. 85.5 h, P = 0.360), and in-hospital deaths (1 vs. 3, P = 1.000). The incidence of ventilator-associated pneumonia was similar between the two groups (1 vs 3, P = 1.000). Conclusion: A low dose of antivenom effectively treats patients with severe krait bite neuroparalysis.

The Utility of Quantitative D-Dimer Assay as a Biomarker in the Diagnosis and Exclusion of Cerebral Venous Sinus Thrombosis.

The utility and sensitivity of quantitative D-Dimer assay to rule out the diagnosis of deep vein thrombosis is well established. We extrapolated this principle to evaluate the utility of D-Dimer assay in exclusion of cerebral venous sinus thrombosis (CVST). As advanced imaging modalities required for the diagnosis of CVST might not be available everywhere, it is important to have a sensitive biomarker and a clinical decision rule which can assist in the diagnosis. Patients undergoing CT/MR Venography of the brain with the suspicion of CVST were enrolled. Quantitative D-Dimer assay was performed in those who had CVST on CT/MR Venography and was compared with those who did not. A Clinical decision rule for the diagnosis of CVST was formulated using logistic regression analysis. Receiver operating characteristic analysis evaluating the diagnostic accuracy of D Dimer for patients with CVST as compared to those who did not revealed an AUROC of 0.694. D-Dimer levels of < 300 ng/mL had a sensitivity of 90% for the exclusion of CVST. After logistic regression analysis, a clinical decision rule with a total score of 16 and individual components of Female gender (2 points), Headache (7 points), D-Dimer levels of ≥ 792 ng/mL (7 points) was proposed. D-Dimer had a poor diagnostic accuracy for differentiation of patients who had CVST from those who did not, however, had a high sensitivity at values < 300 ng/mL. The proposed clinical decision rule with a score of ≥ 9 had a good diagnostic accuracy in prediction of CVST (AUROC = 0.809).

Changing spectrum of primary pyomyositis in North India.

Recent data have demonstrated the changing epidemiology of primary pyomyositis worldwide. Our hospital-based retrospective study investigated the clinical and microbiological spectrum of primary pyomyositis between 2013 and 2021 in PGIMER (Chandigarh), India. Over a quarter had predisposing conditions, mainly diabetes mellitus and immunosuppressive therapy. Fever, muscle pain, local swelling and breathlessness were the usual presentations, with quadriceps, iliopsoas and gluteal muscles commonly affected. Staphylococcus aureus was the predominant cause, with c.50% methicillin-resistant strains. Almost two-thirds presented with metastatic infection (stage 3 pyomyositis), frequently with septic lung emboli. Patients with methicillin-sensitive and resistant Staphylococcus aureus had a similar incidence of metastatic infection. In-hospital mortality was c.10% and was strongly associated with a high international normalised ratio. Primary pyomyositis remains a significant problem, with a dramatic increase in community-associated methicillin-resistant Staphylococcus aureus.

Occult paraquat poisoning causing pneumomediastinum and organizing pneumonia.

Pneumomediastinum is not an uncommon manifestation of lung toxicity in acute paraquat ingestion. The condition is almost invariably seen with other lung parenchymal abnormalities such as consolidations, ground-glass opacities and interlobular septal thickening. The diagnosis may be challenging in cases with no history of toxin exposure, presentation with a subacute illness and/or absence of typical local or systemic features of paraquat toxicity.

Severe pulmonary-renal syndrome in honeybee sting envenomation - A case report.

Honeybee stings with features of envenomation (either local or allergic and rarely systemic toxicity) are often seen in agriculture workers. An initial presentation with severe diffuse alveolar hemorrhage or pulmonary-renal syndrome is rare and only confined to a few case reports. Herein, we describe a case of a 45-year-old male who presented with multiple bee stings and subsequently developed acute kidney injury and pulmonary hemorrhage. He was managed with hemodialysis, invasive mechanical ventilation, red-cell transfusion, and pulse methylprednisolone. However, he developed cardiac arrhythmias with ventricular tachycardia and died.

Efficacy and safety of the Arctic Sun device for hypoxic-ischemic encephalopathy in adult patients following cardiopulmonary resuscitation: A systematic review and meta-analysis.

AIM: The principal objective of this study was to carry out a comprehensive and thorough analysis to compare the safety and effectiveness of the Arctic Sun, a servo-controlled surface cooling device, with conventional cooling techniques for providing therapeutic hypothermia in adult patients who had experienced hypoxic-ischemic brain injury following cardiopulmonary resuscitation. METHODS: In order to achieve our goal, we conducted an extensive search of multiple databases including PubMed, Embase, Cochrane, and ClinicalTrials.gov up to the date of July 30, 2021. We only included studies that compared the safety and efficacy of the Arctic Sun surface cooling equipment with standard cooling approaches such as cooling blankets, ice packs, and intravenous cold saline for treating comatose adult patients who had recovered after experiencing cardiac arrest. We evaluated various outcomes, including all-cause mortality, good neurological outcome at 1 month, and the occurrence of adverse effects such as infections, shock, and bleeding. We employed a random-effects meta-analysis to estimate the odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous outcomes. RESULTS: One hundred and fourteen records were identified through our search; however, only three studies met our eligibility criteria, resulting in overall 187 patients incorporated in the meta-analysis. The findings indicated no significant difference in mortality rates among the Arctic Sun device and conventional cooling techniques (OR: 0.64; 95% CI: 0.34-1.19; P = 0.16; I2 = 0%). In addition, we found no significant difference in occurrence of good neurological outcomes (OR: 1.74; 95% CI: 0.94-3.25; P = 0.08; I2 = 0%) between the two cooling methods. However, the application of the Arctic Sun device was associated with increased incidence of infections compared to standard cooling methods (OR: 2.46; 95% CI: 1.18-5.11; P = 0.02; I2 = 0%). While no significant difference occurred in the incidence of shock (OR: 0.29; 95% CI: 0.07-1.18; P = 0.08; I2 = 40%), the use of the Arctic Sun device was linked to significantly fewer bleeding complications compared to standard cooling methods (OR: 0.11; 95% CI: 0.02-0.79; P = 0.03; I2 = 0%). CONCLUSIONS: After analyzing the results of our meta-analysis, we concluded that the use of the Arctic Sun device for targeted temperature management following cardiopulmonary resuscitation did not result in significant differences in mortality rates or improve neurological outcomes when compared to standard cooling techniques.

Comparative study of diabetic ketoacidosis in the elderly and non-elderly patients: A nine-year experience from an academic hospital in North India.

BACKGROUND AND AIMS: Despite an increasing prevalence of the aged population with diabetes in low-middle-income countries, there is limited literature on geriatric hyperglycemic emergencies. The present study aimed to compare the spectrum and outcomes of diabetic ketoacidosis (DKA) between elderly and non-elderly adult patients in India. METHODS: Seventy-seven elderly patients (≥60 years) were compared to 477 non-elderly patients (13-59 years) with DKA admitted to the medical emergency, Postgraduate Institute of Medical Education and Research, Chandigarh, India, between January 2014 and December 2022. Clinical features, laboratory parameters, precipitating factors, and in-hospital outcomes were reviewed. RESULTS: Elderly patients less commonly had vomiting and abdominal pain than non-elderly patients (31.3 % vs. 66.2 %, 27.3 % vs. 60.1 %, respectively) and typically presented with dyspnea (48.5 %), altered mental status (47.8 %), and fever (46.3 %). Ketonemia and metabolic acidosis were significantly more marked in non-elderly patients, whereas elderly patients frequently had anemia, hypoalbuminemia, and renal dysfunction. The most common precipitations of geriatric DKA were infections (70.1 %), followed by treatment non-adherence (66.2 %) and non-infectious disorders (35.1 %). Infections and non-infectious disorders were significantly more frequent in elderly patients than in non-elderly patients. Respiratory and urinary tract infections were prevalent in both age groups. In-hospital survival was 74.9 % (n = 415) and remained lower in older patients (48.1 % vs. 79.2 %, P-value <0.001). The independent prognostic factors were age (OR 1.030, 95 % CI 1.006-1.054, P = 0.014), Glasgow coma scale (OR 0.789, 95 % CI 0.717-0.869, P <0.001), and infection trigger (OR 6.635, 95 % CI 2.852-15.441, P <0.001). CONCLUSION: Older patients with DKA present atypically, frequently have precipitation with infections and noninfectious disorders, and have poor outcomes.

Circulatory shock in adults in emergency department.

Circulatory shock is a common condition that carries high morbidity and mortality. This review aims to update the critical steps in managing common types of shock in adult patients admitted to medical emergency and intensive care units. A literature review was performed by searching PubMed, EMBASE Ovid, and Cochrane Library, using the following search items: ("shock" OR "circulatory shock" OR "septic shock" OR "cardiogenic shock") AND ("management" OR "treatment" OR "resuscitation"). The review emphasizes prompt shock identification with tissue hypoperfusion, knowledge of the underlying pathophysiological mechanism, initial fluid resuscitation with balanced crystalloids, norepinephrine as the preferred vasopressor in septic and profound cardiogenic shock, and tailored intervention addressing specific etiologies. Point-of-care ultrasound may help evaluate an undifferentiated shock and determine fluid responsiveness. The approach to septic shock is improving; however, confirmatory studies are required for many existing (e.g., amount of initial fluids and steroids) and emerging (e.g., angiotensin II) therapies. Knowledge gaps and wide variations persist in managing cardiogenic shock that needs urgent addressing to improve outcomes.

Diagnostic utility of procalcitonin for bacterial infections in diabetic ketoacidosis.

Procalcitonin is a widely used infection biomarker; however, its utility in identifying bacterial infection in diabetic ketoacidosis (DKA) is unclear. We aimed to evaluate its diagnostic performance for detecting DKA cases triggered by bacterial infections. We reviewed 303 case records of patients aged ≥ 13 years with DKA admitted to the emergency department, PGIMER (Chandigarh), between 2017 and 2022. Baseline procalcitonin was measured by electrochemiluminescence immunoassay, and a value > 0.5 ng/mL was considered elevated. Both microbiological reference standard (MRS) and composite reference standard (CRS) were used to evaluate the diagnostic performance of procalcitonin. 151/303 (49.8%) DKA cases had infection precipitations. Bacterial infections were present in 98 patients (53 microbiologically confirmed), of which urinary tract infection (n = 42), pneumonia (n = 19), skin and soft-tissue infection (n = 13), and bacteremia (n = 11) were common. The median value of procalcitonin was higher with bacterial infections than in patients without (3.68 vs. 1.00, P-value < 0.001). An elevated procalcitonin to detect bacterial infections in DKA had sensitivity 84.69%, specificity 34.15%, positive likelihood ratio (LR +) 1.29, and negative likelihood ratio (LR -) 2.44, against CRS. Against MRS, both LR + and LR - further decreased to 1.23 and 1.81, respectively. Using the receiver-operating-characteristic curve, an optimal cut-off of procalcitonin was calculated at 1.775 ng/ml against both CRS (area under curve 0.655, sensitivity 68.37%, specificity 59.02%, LR + 1.67, LR - 1.86, Yoden's index 0.274) and MRS (area under curve 0.616, sensitivity 67.92%, specificity 59.02%, LR + 1.66, LR - 1.84, Yoden's index 0.269). Procalcitonin does not help detect bacterial infections in patients with DKA at admission.

Prognostic significance of poison-related factors and consumption patterns in acute aluminum phosphide poisoning.

OBJECTIVES: The prognosis of acute aluminum phosphide poisoning is usually based on toxidrome features, with little focus on poison-related factors. We aimed to study the prognostic significance of poison-related factors, consumption patterns, and time delays to treatment. METHODS: We performed a prospective cohort study in an academic hospital in North India in patients aged ≥ 13 with aluminum phosphide poisoning from July 2019 to December 2020. During data collection, a particular emphasis was made on the poison formulation, the ingested dose, the reconstitution of poison, vomiting, and time intervals to initiate various treatments. The primary outcome was inhospital mortality. RESULTS: Fifty-eight patients were enrolled (median age, 32 years; 37 males). The mean dose of the ingested poison was 6.56 (±5.42) g. The predominant formulation of poison was pellet (n = 41), followed by powder (n = 16). Twenty patients performed reconstitution of poison before consumption, and 13 stirred the poison while reconstituting. All patients but three developed vomiting after consumption. Inhospital mortality (n = 23, 39%) was significantly high with a higher ingested dose (P < 0.001), nonstirred reconstitution before consumption (P = 0.042), fewer vomiting episodes (P = 0.010), a delay in detection of the victim by someone (P = 0.001), and delayed initiation of intravenous fluids (P = 0.043). The secondary outcomes (shock and requirement of vasopressor or ventilation) remained unaffected by the stirring in the reconstitution group. CONCLUSIONS: Poison-related factors and time intervals determine early risk stratification at admission in aluminum phosphide poisoning.

A young boy with severe pulmonary-renal syndrome: Will you suspect IgA nephropathy?

IgA nephropathy is a renal-limited form of systemic vasculitis, and pulmonary manifestations are uncommon. An initial presentation with severe diffuse alveolar hemorrhage (DAH) or pulmonary-renal syndrome is rare and only confined to a few case reports. Herein, we present a young male admitted with acute-onset dyspnea, hemoptysis, and rapidly progressive renal failure. With an initial diagnosis of an immune-mediated pulmonary-renal syndrome, he was treated with high-dose corticosteroids and therapeutic plasmapheresis along with intensive organ support (including hemodialysis, red cell transfusion, and high-flow oxygen). After a detailed laboratory evaluation and kidney biopsy, IgA nephropathy was diagnosed. The patient continued to worsen with persistent DAH and died. IgA nephropathy-associated severe DAH or pulmonary-renal syndrome is rare but increasingly recognized. The condition is difficult to diagnose early and has no proven disease-targeted therapy.

Severe copper sulphate poisoning: A case rescued with plasmapheresis.

Acute copper sulphate poisoning is associated with multi-organ failure and high mortality. Patients typically present with gastrointestinal symptoms, haemolysis, methaemoglobinaemia, acute liver injury, rhabdomyolysis and renal failure. Management is usually supportive, and the role of chelation therapy has not been established. Copper is not dialysable. Plasmapheresis has been shown to remove protein-bound copper, reducing plasma and intracellular concentrations. We present a case of severe copper sulphate poisoning, who did not improve with chelation therapy with D-penicillamine and supportive care, but with therapeutic plasma exchange (four cycles) showed rapid clinical recovery.

Role of bone marrow examination in pyrexia of unknown origin.

A stepwise approach is essential to evaluating pyrexia of unknown origin (PUO). When other investigations are negative, bone marrow examination is a valuable diagnostic tool in PUO. It is particularly helpful in patients with involvement of reticuloendothelial organs (e.g. cytopenia, splenomegaly), immunodeficiency states, or older age.

Adult-onset Still's disease and fever of unknown origin in India.

Despite an essential differential diagnosis for fever of unknown origin (FUO) in young adults, adult-onset Still's disease (AOSD) is infrequently considered and remained underdiagnosed in low-middle-income countries. The present study analyzed the clinical, serological, radiological, and pathological characteristics of AOSD presented as FUO in India. A hospital-based retrospective study of patients aged > 13 years admitted with FUO and later diagnosed with AOSD in Postgraduate Institute of Medical Education and Research, Chandigarh (India), was conducted between January 2014 and December 2020. Petersdorf and Beeson's criteria were used to define FUO. The diagnosis of AOSD was made based on Yamaguchi's criteria. Twenty-seven patients (median age 26 years, 14 females) were enrolled. All presented with intermittent fever with a median duration of 10 weeks. The typical features of AOSD at admission were arthralgia (n = 24), hepatosplenomegaly (n = 21), spiking fever ≥ 39 °C (n = 19), lymphadenopathy (n = 18), typical rash (n = 17), and sore throat (n = 11). Leukocytosis (n = 25) and neutrophilia (n = 19) were frequent. Hyperferritinemia was universal (range, 700-145,003 ng/ml; ≥ 2000, n = 23). At admission, AOSD was suspected in only nine FUO cases, while tuberculosis (n = 16), undifferentiated connective tissue disorder (n = 14), and lymphoproliferative disorder (n = 11) were common diagnostic possibilities. Crispin et al. clinical scale detected AOSD in only 15 (55.5%) FUO patients. Whole-body imaging (n = 27), including fluorodeoxyglucose positron emission tomography (n = 12), demonstrated reticuloendothelial organ-system involvement and serositis. Seventeen (63%) patients had macrophage activation syndrome at the time of AOSD diagnosis. AOSD FUO presents with typical but nonspecific features; thus, early differentiation from common causes (e.g., tuberculosis, lymphoma) is difficult. Macrophage activation syndrome is common in AOSD with FUO presentation.

Sepsis screening tools for predicting infection triggers and outcomes in diabetic ketoacidosis.

Background: An early prediction of infection is challenging in diabetic ketoacidosis (DKA). Methods: This prospective cohort study aimed to assess effectiveness of various sepsis screening tools in predicting infections and prognosis in DKA. Results: Among 141 cases, infection (44.0%) was the commonest precipitating factor. A Sequential Organ Failure Assessment score ≥4 showed high specificity (82.28%) and high positive likelihood ratio (2.64) but limited sensitivity (46.77%). Conversely, Systemic Inflammatory Response Syndrome ≥2 exhibited good sensitivity (95.16%) but a high false-positive rate (84.28%). National Early Warning Score ≥7 and Quick Sequential Organ Failure Assessment ≥2 had low sensitivity and specificity. These sepsis tools also demonstrated low prognostic accuracy for mortality. Conclusion: Sepsis screening tools have limited predictive accuracy for infections and mortality in DKA.

Various clinical tools, including the Sequential Organ Failure Assessment score, Quick Sequential Organ Failure Assessment score, Systemic Inflammatory Response Syndrome criteria and the National Early Warning Score, are used to identify serious infections. This study examined the effectiveness of these tools in patients with diabetic ketoacidosis (DKA), a serious diabetes complication. The study involved 141 patients from north India, and nearly half of them had infections such as pneumonia and urinary tract infections. The researchers found that these tools were not highly effective in identifying infections or predicting deaths among DKA patients at the time of hospital admission. The study suggests that doctors need better ways to diagnose infections in DKA, including more thorough clinical evaluations and advanced tests.

Changing spectrum of acute poisoning in North India: A hospital-based descriptive study.

OBJECTIVES: Evaluating local trends and continued monitoring of patterns of acute poisoning are essential for prompt recognition of the toxidromes, the establishment of immediate treatment facilities (e.g., antidote availability), and effective preventive strategies (e.g., governmental regulation on hazardous substances marketing). We aimed to describe the prevalence of the various types of poisoning and associated case fatality in our academic hospital in North India. METHODS: A prospective observational descriptive study was conducted, enrolling patients aged ≥13 years with acute poisoning for 17 months from December 2016 to December 2017 and from September 2019 to December 2019, for a total of 17 months. RESULTS: Four hundred and two patients were enrolled (median age 28 years; 63.2% males). Majority of the acute poisoning cases resulted from ingestion (n = 391, 97.3%) and the primary intention was most commonly self-harm (n = 314, 78.1%). The major types of poisoning were pesticide (n = 264, 65.7%), drug overdose (n = 77, 19.2%), and corrosive ingestion (n = 31, 7.7%). Pesticides included insecticides (n = 146, 36.3%; cholinesterase inhibitors, n = 91), fungicides (n = 76, 18.9%; all aluminum phosphide), herbicides (n = 22, 5.5%; paraquat, n = 19), and rodenticides (n = 20, 5.0%; coumarin-derived substances, n = 12). Benzodiazepines (n = 33) and opioids (n = 25) were frequent causes of drug overdose. 95.3% (n = 379) received preliminary treatment at the previous health-care center, including gastric lavage (n = 239) and antidotes (n = 73). In-hospital case fatality rate was 17.3% (n = 58). CONCLUSION: Herbicide ingestion and opioid overdose are emerging threats with a gradual decline in organophosphate and aluminum phosphide poisoning. Despite improving management of acute poisoning, the overall case fatality rate remains substantial.

Magnesium sulfate in organophosphorus compound poisoning: A prospective open-label clinician-initiated intervention trial with historical controls.

Background: The addition of magnesium sulfate (MgSO4) to standard treatment has improved mortality and morbidity associated with organophosphorus compound (OPC) poisoning. We aimed to assess the effectiveness of adjunctive intravenous MgSO4 (IV MgSO4) in poisoning from OPCs. Methods: Forty-seven cases and 72 controls were recruited to this prospective open-label clinician-initiated intervention trial after admitting OPC poisoning. All patients received standard treatment for anticholinesterase poisoning, and oximes were not used. Cases were divided into two groups. Group A (22 patients) received IV MgSO4 at 4 g/day in four divided doses (1 g every 6 h) on day 1. Group B (25 patients) received the same daily dose of IV MgSO4 throughout the hospital stay. Group C (72 patients) represents historical controls who did not receive IV MgSO4. The primary outcome was inhospital mortality. The secondary outcomes included the development of intermediate syndrome (IMS), the requirement of mechanical ventilation (MV), duration of MV, and length of hospital stay. Results: Baseline parameters in both groups were comparable. There is no statistically significant difference in mortality among three groups (Group A: 2/22, 9.1%; Group B: 5/25, 20% and Group C: 6/72, 8.3%). Results were similar for the development of IMS, the requirement of MV, length of MV, and duration of hospital stay. Conclusion: IV MgSO4 did not result in better outcomes compared with standard care alone in OPC poisoning.