Does apneic oxygenation with nasopharyngeal cannula during intubation improve the oxygenation in patients with acute hypoxemic respiratory failure compared to the standard bag valve mask preoxygenation? An open-labeled randomized control trial.

OBJECTIVES: In the context of acute hypoxemic respiratory failure (AHRF), ensuring effective preoxygenation and apneic oxygenation emerges as the pivotal approach ensuring for averting hypoxemic adverse events during endotracheal intubation. To investigate this, we conducted an open-label randomized controlled trial, aiming to assess the comparative effectiveness of nasopharyngeal high-flow oxygenation in conjunction with Bag-Valve-Mask (BVM) versus standard BVM preoxygenation in patients experiencing AHRF within the emergency department (ED). METHODS: This prospective single-center, open-labeled, randomized controlled trial enrolled patients aged 18 years and above requiring rapid sequence intubation due to AHRF in the ED. Participants were randomly assigned in a 1:1 ratio to either the intervention arm (involving nasopharyngeal high-flow oxygenation and BVM preoxygenation) or the control arm (involving BVM preoxygenation alone). RESULTS: A total of 76 participants were enrolled in the study, evenly distributed with 38 individuals in each arm. Median (interquartile range [IQR]) SpO2 at 0 min postintubation was 95.5 (80%-99%) versus 89 (76%-98%); z-score: 1.081, P = 0.279 in the intervention and control arm, respectively. The most common postintubation complications included hypoxia (intervention arm: 56.7% vs. control arm: 66.7%) and circulatory/hypoxic arrest (intervention arm: 39.5% vs. control arm: 44.7%). There were no adverse complications in 36.7% (n = 11) of patients in the intervention arm. Despite the best possible medical management, almost half (52.6%) of patients in the intervention arm and 47.4% of patients in the control arm succumbed to their illnesses in the ED. CONCLUSION: The primary outcome revealed no statistically significant difference between the two arms. However, patients in the intervention arm exhibited fewer intubation-related adverse effects.

Effectiveness of a monitored home isolation program for COVID-19 infection during the second wave of the pandemic.

Background: The rapidity of spread of COVID-19 infection during the second wave of the pandemic placed tremendous stress on healthcare resources. This study evaluated the effectiveness of a monitored home isolation (HI) program. Methods: In this descriptive longitudinal study, symptomatic patients were screened in the HI clinic and eligible patients were followed up at home using tele-consultation, until recovery or hospitalization. HI failure was defined as need for hospitalization. Factors associated with HI failure were assessed using logistic regression analysis and expressed as odds ratio (OR) with 95% confidence interval (CI). Results: During April and May 2021, 1957 RT-PCR confirmed patients (984 male) with mean (SD) age 40 (13.5) years were enrolled; 93.3% (n = 1825) were successfully managed at home. Of the 132 patients (6.7%) who failed HI, 57 (43.2%) required oxygen therapy and 23 needed intensive care admissions. Overall mortality was 0.4% (7/1957). On adjusted analysis, factors associated with HI failure were age ≥60 years (OR 2.24; 95%CI 1.26-3.99), male gender (OR 2.26; 95%CI 1.44-3.57), subjective reporting of breathing difficulty (OR 3.64; 95%CI 2.08-6.37), history of cough (OR 2.08; 95%CI 1.37-3.17), and higher heart rate (OR 1.04; 95%CI 1.02-1.05). Although patient status (non-healthcare workers), no prior vaccination and ≥2 comorbidities were associated with HI failure on unadjusted analysis, these were non-significant on adjusted analysis. Conclusion: Monitored HI program can be used successfully during a pandemic wave to judicially use scare hospital resources. Older male patients presenting with breathlessness or cough may warrant closer monitoring.

Three waves, three vaccines, three COVID-19 infections - Saga of a frontline health care worker during the pandemic.

The COVID-19 pandemic affected millions around the globe, with front line healthcare workers (HCW) amongst the most vulnerable. The Emergency Department (ED) was the first line of care for all patients infected with the virus, making HCWs in the ED one of the most exposed populations during the pandemic. We highlight the case of a 35-year-old ED physician who developed COVID-19 infections on three separate instances during the peaks of each wave despite the usage of personal protective equipment and being triple vaccinated.

Medication - A boon or bane: Emergencies due to medication-related visits.

BACKGROUND: Medication-related visits (MRV) to the Emergency Department (ED) are substantial though weakly recognized and intervened. Data from developing countries on the prevalence of MRV-related ED admissions are scanty. This study is first of its kind in India to estimate the prevalence of MRV, its severity and the factors contributing to these visits. METHODOLOGY: This prospective observational study was done in the ED of an apex tertiary care center in August 2018. A convenient cross-sectional sample of patients presenting with emergencies regarding drug use or ill-use were included and a questionnaire filled after obtaining a written informed consent. RESULTS: During the study period, a cross-sectional sample of 443 patients was studied and the prevalence of MRV was 27.1% (120/443). The mean age was 55 (standard deviation: 15) years with a male preponderance (60.8%). Triage priority I patients comprised 39.1%. Common presenting complaints included vomiting (25%), seizure (20.8%), giddiness (20%), and abdomen pain (17.5%). Less than ½ (43.3%) were compliant to prescribed medication. The most common reasons for MRV were failure to receive drugs/noncompliance (47.5%), subtherapeutic dosage (25%), and adverse drug reaction (16.7%). Severity of MRV was classified as mild (50%), moderate (38.3%), and severe (11.7%). Out of these visits, 71 (59.2%) were deemed preventable. Three-fourths (73.3%) were stabilized and discharged from the ED. CONCLUSION: The fact that a quarter of the ED visits are due to MRV and that more than half of them are preventable is quite alarming. Diligent patient education by the treating physicians may perhaps help in decreasing the incidence of this deleterious event.

A prospective cohort study of patients presenting to the emergency department with upper gastrointestinal bleeding.

BACKGROUND: Upper gastrointestinal (UGI) bleeding is a common presentation to the Emergency Department (ED), and is associated with re-bleeding and significant mortality. Although several studies have described etiology and outcome of UGI bleeding, few have been done in the EDs. MATERIALS AND METHODS: This prospective observational cohort study included all patients presenting with hematemesis or melena, between June 2016 and January 2017 to the ED. Demographic data, risk factors, endoscopy findings and prognosticating scores were noted. Patients were followed up through telephonic communication after 3 months to assess re-bleeding rate and mortality. RESULTS: The study cohort included 210 patients with a male predominance (76.2%). The mean (SD) age was 51 (16.8) years. They presented with either hematemesis (33.8%), melena (28.6%), or both (37.6%). One third (35.7%) had variceal bleed, 21% had peptic ulcer disease (PUD), and 43.3%bled due to other etiology. UGI scopy was performed in 85.2% of patients with banding (25.1%) and sclerotherapy (14%) being the most frequently performed procedures. Endoscopic intervention was not required in 58.6%of patients. Packed red cells were transfused in 46.7% patients. The 48-h re-bleed rate among variceal bleeders was 5.3% and 11.4% among peptic ulcer bleeders. The 3-month re-bleeding rate was 42.9% and the 3-month mortality rate was 17.5% among the variceal bleeders and the same was 5.6% and 2.8%, respectively, among the peptic ulcer bleeders. The overall mortality was 12.4%. CONCLUSIONS: Variceal bleeding and PUD were the predominant causes of UGI bleeding. Overall, a quarter of our patients had a re-bleed within 3 months, with majority being variceal bleeds.

Blood alcohol levels in road traffic accidents: Factors associated and the relationship between history of alcohol consumption and blood alcohol level detection.

INTRODUCTION: Alcohol consumption contributes to a significant number of road traffic accidents (RTAs), and data regarding the reliability of history and blood alcohol content (BAC) in RTA victims are scant. METHODOLOGY: This retrospective study was conducted in the emergency departments (EDs) over 6 weeks. All adult RTAs presenting within 12 h of the incident were included for analysis. RESULTS: The study cohort included 369 RTA patients, with the mean interval before presentation being 3 h (standard deviation: 2.22). Two-wheeler accidents (77.2%) were the predominant mode of injury. Usage of a helmet and seat belt was documented in a meager (6.4% [17/267] and 8.8% [3/34], respectively). A positive history of alcohol consumption was reported by 19.5% of cases (72/369). However, BAC was detectable in 30.1% of cases (111/369), with an alarming 19.78% (73/369) being above the legal limit for driving. Nearly 77.5% (86/111) of those who tested positive for alcohol consumption were driving the vehicle involved. Positive BAC levels showed a significant association with young age (18-39 years), male gender, two-wheeler usage, and between 5 PM and 12 AM. CONCLUSION: A history of alcohol consumption leading to an RTA is not reliable in the ED. Hence, measuring BAC levels in all RTA patients provides an objective and reliable form of documentation for medico-legal purposes.

Utility of Loop-mediated Isothermal Amplification Assay, Polymerase Chain Reaction, and ELISA for Diagnosis of Leptospirosis in South Indian Patients.

BACKGROUND: Leptospirosis is a zoonotic disease which requires laboratory diagnosis for confirmation. MATERIALS AND METHODS: In this study serum samples from adults with acute undifferentiated fever (duration ≤15 days) were tested for IgM antibodies to Leptospira by ELISA, PCR for rrs gene and loop-mediated isothermal amplification (LAMP) assay for LipL32 and LipL41. RESULTS: Among the 150 sera tested, three were positive by PCR, LAMP and IgM ELISA/modified Faines' criteria, two by only PCR; seven only by LAMP assay and forty fulfilled modified Faine's criteria (illness clinically compatible and IgM ELISA positive for leptospirosis). Clinical correlation revealed renal compromise, low platelet count and severe jaundice were significantly related to leptospirosis (P < 0.05). CONCLUSION: This study suggests that LAMP assay could be useful for diagnosis of leptospirosis during the 1st week of illness whereas IgM ELISA forms the mainstay of diagnosis from the 2nd week onward. Further studies especially community based, comparing ELISA, PCR, LAMP, culture and microscopic agglutination test are required to evaluate the veracity of these findings.

Clinical presentation, etiology, management, and outcomes of iliopsoas abscess from a tertiary care center in South India.

INTRODUCTION: Iliopsoas abscess (IPA) is the collection of pus in the iliopsoas compartment. The etiology of IPA is variable and depends on the geographical area and the antibiotic usage prevalence in that area. This study attempts to evaluate the etiology, clinical features, risk factors, management modalities, and outcomes in patients with IPA from a tertiary care center in South India. MATERIALS AND METHODS: This was a retrospective study done in a tertiary care center in South India. Patient details were obtained from electronic medical records. RESULTS: A total of 43 patients were enrolled in the study, the causative organism could be identified in 20 (46.5%) patients. The most common etiology was tuberculosis (TB). Most (23 [56.5%]) patients were treated conservatively, 20 (46.5%) patients were treated with percutaneous drainage (PCD), and 2 (4%) patients required surgery. CONCLUSION: The most common cause of IPA is TB. PCD was successful in 95% of the patients with complete resolution of symptoms.

Profile of deliberate self-harm patients presenting to Emergency Department: A retrospective study.

BACKGROUND: Deliberate self-harm (DSH) is a major under-recognized epidemic in the low- and middle-income countries. This is a large retrospective study form the Emergency Department (ED) of Tertiary Care Center of South India to describe the clinicodemographic features of DSH cases. MATERIALS AND METHODS: This is a retrospective study conducted at ED of Christian Medical College, Vellore, India from January 01, 2011 to December 31, 2013. All cases of DSH were included in the study. The demographic details, mode of DSH and clinical outcome were extracted from the electronic medical record. Descriptive statistics are presented. Chi-square test was used to compare categorical variables. For all tests, a two-sided P ≤ 0.05 was considered statistically significant. RESULTS: Total of 1228 patients were admitted to ED for DSH during the study period. Male and female occurred in equal ratio. More than half of the cases occurred among age group below 30 years. Consumption of pesticides (agricultural chemicals) was the single most common mode of DSH (46%), especially among men, followed by medication overdose (29.8%). Consumption of plant poison and tablet overdose was higher among women. Overall mortality due to DSH was low (1.5%) in our study. CONCLUSION: DSH is under-recognized major public health problem in low-middle income countries like India. Most cases occur among young and productive age group and in equal frequencies among men and women. Timely and the appropriate institution of treatment can decrease the morbidity and mortality due to DSH remarkably.

Duodenal Perforation Precipitated by Scrub Typhus.

Scrub typhus is an acute febrile illness usually presenting with fever, myalgia, headache, and a pathognomonic eschar. Severe infection may lead to multiple organ failure and death. Gastrointestinal tract involvement in the form of gastric mucosal erosions and ulcerations owing to vasculitis resulting in gastrointestinal bleeding is common. This process may worsen a pre-existent asymptomatic peptic ulcer, causing duodenal perforation, and present as an acute abdomen requiring surgical exploration. We report the case of a patient with no previous symptoms or risk factors for a duodenal ulcer, who presented with an acute duodenal perforation, probably precipitated by scrub typhus infection.

Prevalence of musculoskeletal disorders among brick kiln workers in rural Southern India.

BACKGROUND: A variety of musculoskeletal disorders and discomfort are seen among brick kiln workers, where heavy physical work is associated with awkward working postures and manual handling of materials, leading to significant morbidity. MATERIALS AND METHODS: This cross-sectional study was conducted in unorganized brick kiln industries in villages of Vellore district of Tamil Nadu and included 310 brick kiln workers. Modified Nordic Questionnaire was used to survey the prevalence of musculoskeletal disorders and the intensity of pain was assessed by the body pain discomfort scale. RESULTS: The mean age of the workers was 37 ± 13.2 years with a range of 18-85 years. 62% (n = 192) had normal body mass index, whereas 27% (n = 85) were undernourished. The commonest posture adopted at work was squatting (67%) followed by standing (14%). Majority of workers (87%, n = 269) reported to having symptoms of pain currently of which 51% (n = 158) had pain during work. Chronic low back ache (LBA) (1 year prevalence -59%) and acute LBA (1 week prevalence-33%) were the commonest followed by chronic knee pain. More than 10 years of work was significantly associated (P < 0.05) with acute LBA and acute and chronic knee pain. Severity of the pain was also significantly (t statistic 2.476, P < 0.05) associated with job dissatisfaction. CONCLUSION: Long-term brick kiln workers, who adopt a specific posture for prolonged periods, have severe musculoskeletal pain that interferes with activities of daily living and reduces job satisfaction. Health education on frequent postural change, implementation and monitoring of laws among unorganized industries are recommended to bring down morbidity due to musculoskeletal disorders (MSD).