Prospective observational study on clinical and epidemiological profile of adult patients presenting to the emergency department with suspected upper gastrointestinal bleed.

BACKGROUND AND OBJECTIVE: Bleeding from the upper gastrointestinal (GI) tract is one of the common medical emergencies. In this study, we assessed patients' socio-demographic and clinical characteristics and the association of clinical characteristics with treatment outcomes among patients with suspected upper gastrointestinal bleed (UGIB) presenting to the emergency department (ED). At present, there is a scarcity of data on UGIB in Northern part of India. MATERIAL AND METHOD: The study was a single-center, prospective observational study conducted at an urban tertiary care center. Consecutive patients with suspected UGIB were enrolled in the study from August 2020 to February 2022. A detailed history was obtained, including demographic data such as age and sex, presenting complaints, history of presenting illness, history related to co-morbidities, addiction, and drug history. Pre-endoscopic Rockall and Glasgow-Blatchford Score were calculated for each patient. The patients were subsequently followed up till discharge from the hospital. The final outcomes with regard to mortality, need for blood transfusion, length of emergency department stay, and discharge were noted. RESULT: 141 patients were included in the study. The mean age of the patients with suspected UGIB was 48 ± 14 years. 115 (81.6%) patients were male. The most common co-morbidity was chronic liver disease (40;28.4%). The most frequent presenting complaint in this study was hematemesis (96; 68.1%), followed by melena (76;53.9%). The mean (Standard Deviation, SD) of the Rockall Score was 2.46 ± 1.75. The mean (SD) of the Glasgow Blatchford Score was 12.46 ± 3.15 in patients with UGIB. CONCLUSION: In our study, hematemesis was the most prevalent symptom of suspected UGIB, followed by melena. Portal hypertension was the most common cause of UGIB. Most frequent comorbidities in patients suspected of UGIB were alcohol intake, Nonsteriodal Antiinflammatory Drugs (NSAIDs) abuse, and co-morbidities such as underlying chronic liver disease, hypertension, and diabetes. Early endoscopy can be of great utility to reduce morbidity and mortality.

CMIP6 models informed summer human thermal discomfort conditions in Indian regional hotspot.

The frequency and intensity of extreme thermal stress conditions during summer are expected to increase due to climate change. This study examines sixteen models from the Coupled Model Intercomparison Project Phase 6 (CMIP6) that have been bias-adjusted using the quantile delta mapping method. These models provide Universal Thermal Climate Index (UTCI) for summer seasons between 1979 and 2010, which are regridded to a similar spatial grid as ERA5-HEAT (available at 0.25° × 0.25° spatial resolution) using bilinear interpolation. The evaluation compares the summertime climatology and trends of the CMIP6 multi-model ensemble (MME) mean UTCI with ERA5 data, focusing on a regional hotspot in northwest India (NWI). The Pattern Correlation Coefficient (between CMIP6 models and ERA5) values exceeding 0.9 were employed to derive the MME mean of UTCI, which was subsequently used to analyze the climatology and trends of UTCI in the CMIP6 models.The spatial climatological mean of CMIP6 MME UTCI demonstrates significant thermal stress over the NWI region, similar to ERA5. Both ERA5 and CMIP6 MME UTCI show a rising trend in thermal stress conditions over NWI. The temporal variation analysis reveals that NWI experiences higher thermal stress during the summer compared to the rest of India. The number of thermal stress days is also increasing in NWI and major Indian cities according to ERA5 and CMIP6 MME. Future climate projections under different scenarios (SSP1-2.6, SSP2-4.5, and SSP5-8.5) indicate an increasing trend in thermal discomfort conditions throughout the twenty-first century. The projected rates of increase are approximately 0.09 °C per decade, 0.26 °C per decade, and 0.56 °C per decade, respectively. Assessing the near (2022-2059) and far (2060-2100) future, all three scenarios suggest a rise in intense heat stress days (UTCI > 38 °C) in NWI. Notably, the CMIP6 models predict that NWI could reach deadly levels of heat stress under the high-emission (SSP5-8.5) scenario. The findings underscore the urgency of addressing climate change and its potential impacts on human well-being and socio-economic sectors.

Atypical Presentation of Aortic Dissection in a Young Female and the Utility of Point-of-Care Ultrasound in Identifying Aortic Dissection in the Emergency Department.

In the absence of prompt diagnosis and treatment, aortic dissection is an extremely dangerous and often fatal medical condition, of which acute coronary syndrome, stroke, limb ischemia, pulmonary embolism, and acute mesenteric ischemia are all possible manifestations. Neurological manifestations of aortic dissection are often missed at presentation. We report a case of a 23-year-old female without any prior characteristics of connective tissue disorder presenting to the emergency department with headache and right upper limb weakness and the utility of bedside point-of-care ultrasound (POCUS) for diagnosing aortic dissection.

Point of care ultrasound as initial diagnostic tool in acute dyspnea patients in the emergency department of a tertiary care center: diagnostic accuracy study.

BACKGROUND: Dyspnea is one of the common symptoms patients present to the emergency department (ED). The broad spectrum of differentials often requires laboratory and radiological testing in addition to clinical evaluation, causing unnecessary delay. Point of care ultrasound (PoCUS) has shown promising results in accurately diagnosing patients with dyspnea, thus, becoming a popular tool in ED while saving time and maintaining safety standards. Our study aimed to determine the utilization of point of care ultrasound in patients with acute dyspnea as an initial diagnostic tool in our settings. METHODOLOGY: The study was conducted at the emergency department of a tertiary healthcare center in Northern India. Adult patients presenting with acute dyspnea were prospectively enrolled. They were clinically evaluated and necessarily investigated, and a provisional diagnosis was made. Another EP, trained in PoCUS, performed the scan, blinded to the laboratory investigations (not the clinical parameters), and made a PoCUS diagnosis. Our gold standard was the final composite diagnosis made by two Emergency Medicine consultants (who had access to all investigations). Accuracy and concordance of the ultrasound diagnosis to the final composite diagnosis were calculated. The time to formulate a PoCUS diagnosis and final composite diagnosis was compared. RESULTS: Two hundred thirty-seven patients were enrolled. The PoCUS and final composite diagnosis showed good concordance (κ = 0.668). PoCUS showed a high sensitivity for acute pulmonary edema, pleural effusion, pneumothorax, pneumonia, pericardial effusion, and low sensitivity for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and acute respiratory distress syndrome (ARDS)/acute lung injury (ALI). High overall specificity was seen. A high positive predictive value for all except left ventricular dysfunction, pericardial effusion, non-cardiopulmonary causes of dyspnea, and a low negative predictive value was seen for pneumonia. The median time to make a PoCUS diagnosis was 16 (5-264) min compared to the 170 (8-1346) min taken for the final composite diagnosis. Thus, time was significantly lower for PoCUS diagnosis (p value <0.001). CONCLUSION: By combining the overall accuracy of PoCUS, the concordance with the final composite diagnosis, and the statistically significant reduction in time taken to formulate the diagnosis, PoCUS shows immense promise as an initial diagnostic tool that may expedite the decision-making in ED for patients' prompt management and disposition with reliable accuracy.

Rupture of sinus of Valsalva aneurysm: a rare cause of acute ischaemic chest pain in the emergency department.

Acute chest pain is a leading cause of emergency department (ED) visits in the adult population. However, patients with a life-threatening cause of chest pain comprise only a small fraction, hence identification of those who need immediate intervention is very important. One rare cause is rupture of the aneurysm, which may present with a wide variety of symptomatology, including anginal chest pain. In a busy ED, evaluation of chest pain suggestive of myocardial ischaemia needs to cater to early identification of acute coronary syndrome (ACS), limit over investigating patients for low or intermediate probability of ACS and appropriate decision making for discharge, to reduce ED over boarding. Validated scores for evaluating the low or intermediate probability chest pain like the HEART pathway may miss such rare diagnoses in the absence of ECG changes, requiring high degree of suspicion and individualisation of patient care.

An Evaluation of the Predictive Value of Sepsis Patient Evaluation in the Emergency Department (SPEED) Score in Estimating 28-Day Mortality Among Patients With Sepsis Presenting to the Emergency Department: A Prospective Observational Study.

Background and objective Sepsis is a life-threatening medical emergency and a significant cause of mortality. Risk stratification scores for sepsis can be unsuitable for use in the emergency department (ED) due to their complexity, and an appropriate solution has yet to be found. In this study, the predictive value of the Sepsis Patient Evaluation in the Emergency Department (SPEED) score in estimating 28-day mortality was assessed among patients with sepsis presenting to the ED, in order to determine its suitability as an efficient risk stratification system. Materials and methods This was a single-center, prospective observational study conducted at an urban tertiary care center. We included patients presenting to the ED with suspected or confirmed sepsis who met the inclusion and exclusion criteria of our study. The patients were evaluated with the following scoring systems on arrival: the SPEED score; Predisposition, Infection, Response, and Organ dysfunction (PIRO) score; and Mortality in Emergency Department Sepsis (MEDS) score; the patients were subsequently followed up on the 28th day to record the final outcomes with regard to mortality and discharge rates. Results This study included 127 patients in total. The median age of the study population was 49 years, and the 28-day mortality rate was 50.4%. The area under the receiver operating characteristic (AUROC) curve for the SPEED score for predicting mortality was 0.899 (95% CI: 0.847-0.951). In comparison, the AUROC for MEDS and PIRO scores was 0.857 (95% CI: 0.793-0.92) and 0.895 (95% CI: 0.838-0.951), respectively. Based on the DeLong test, no significant difference was found in the diagnostic performances with respect to these scores. Conclusion The SPEED score is a simple and handy parameter that can be used for the early and appropriate risk stratification of patients with sepsis in the ED.

An ultrafast programmable electrical tester for enabling time-resolved, sub-nanosecond switching dynamics and programming of nanoscale memory devices.

Recent advancements in commercialization of high-speed non-volatile electronic memories including phase change memory (PCM) have shown potential not only for advanced data storage but also for novel computing concepts. However, an in-depth understanding on ultrafast electrical switching dynamics is a key challenge for defining the ultimate speed of nanoscale memory devices that demands for an unconventional electrical setup, specifically capable of handling extremely fast electrical pulses. In the present work, an ultrafast programmable electrical tester (PET) setup has been developed exceptionally for unravelling time-resolved electrical switching dynamics and programming characteristics of nanoscale memory devices at the picosecond (ps) time scale. This setup consists of novel high-frequency contact-boards carefully designed to capture extremely fast switching transient characteristics within 200 ± 25 ps using time-resolved current-voltage measurements. All the instruments in the system are synchronized using LabVIEW, which helps to achieve various programming characteristics such as voltage-dependent transient parameters, read/write operations, and endurance test of memory devices systematically using short voltage pulses having pulse parameters varied from 1 ns rise/fall time and 1.5 ns pulse width (full width half maximum). Furthermore, the setup has successfully demonstrated strikingly one order faster switching characteristics of Ag5In5Sb60Te30 (AIST) PCM devices within 250 ps. Hence, this novel electrical setup would be immensely helpful for realizing the ultimate speed limits of various high-speed memory technologies for future computing.

Redefining the Speed Limit of Phase Change Memory Revealed by Time-resolved Steep Threshold-Switching Dynamics of AgInSbTe Devices.

Although phase-change memory (PCM) offers promising features for a 'universal memory' owing to high-speed and non-volatility, achieving fast electrical switching remains a key challenge. In this work, a correlation between the rate of applied voltage and the dynamics of threshold-switching is investigated at picosecond-timescale. A distinct characteristic feature of enabling a rapid threshold-switching at a critical voltage known as the threshold voltage as validated by an instantaneous response of steep current rise from an amorphous off to on state is achieved within 250 picoseconds and this is followed by a slower current rise leading to crystallization. Also, we demonstrate that the extraordinary nature of threshold-switching dynamics in AgInSbTe cells is independent to the rate of applied voltage unlike other chalcogenide-based phase change materials exhibiting the voltage dependent transient switching characteristics. Furthermore, numerical solutions of time-dependent conduction process validate the experimental results, which reveal the electronic nature of threshold-switching. These findings of steep threshold-switching of 'sub-50 ps delay time', opens up a new way for achieving high-speed non-volatile memory for mainstream computing.