Clinico-epidemiological profile & outcome of patients presenting with cerebral venous thrombosis to emergency department.

OBJECTIVES: To better understand the clinical and radiological characteristics of Cerebral Venous Thrombosis (CVT), we conducted a study focusing on the assessment of neurological outcomes and factors associated with poor prognosis in patients with CVT. METHODS: This prospective, observational study took place over two years (July 2020 to June 2022) in a tertiary care teaching hospital in South India, encompassing adults aged 18 years and over. Key data points included demographic information, symptomatology, physical and neurological examinations, neuroimaging findings, hospital interventions, and neurological outcomes at discharge and at a six-week telephonic follow-up. RESULTS: A total of 140 patients with CVT, median age 34 years, were studied. 61.4 % were males. The most common symptoms and signs were headaches (70.7 %) and papilledema (60.7 %). Hemorrhagic infarct was the most prevalent finding on the non-contrast computed tomography (NCCT) of the brain, involving 39.4 % of patients. The most commonly affected sinus was the superior sagittal sinus. Risk factors most often observed were alcoholism (45 %), smoking (21.4 %), anemia (27.1 %), oral contraceptive pill usage (12.1 %), and hypertension (12.1 %). Deep vein thrombosis or pulmonary embolism was present in 5 % of the patients. The mean hospital stay was 13.9 days, with 6.4 % of patients requiring endotracheal intubation at presentation and 22.9 % during their stay. The observed in-hospital mortality rate was 17.9 %, increasing to 22.4 % at the six-week follow-up. Morbidity (mRS 3-5) was 24.3 % at discharge, decreasing to 8.2 % at six-week follow-up. Favorable outcomes were reported in 57.9 % of cases at discharge, rising to 69.4 % at six weeks. CONCLUSIONS: Our study underscores the importance of recognizing cardinal symptoms and diverse risk factors of CVT, including alcoholism and anemia. Majority of CVT occurrences were observed in males aged 18-29. Critical determinants of heightened morbidity and mortality were identified, including lower GCS scores and the necessity for advanced interventions. Notably, majority of patients presented favorable neurological outcomes at six-week follow-up.

Hyperglycemia and steroid use increase the risk of rhino-orbito-cerebral mucormycosis regardless of COVID-19 hospitalization: Case-control study, India.

BACKGROUND: In the ongoing COVID-19 pandemic, an increased incidence of ROCM was noted in India among those infected with COVID. We determined risk factors for rhino-orbito-cerebral mucormycosis (ROCM) post Coronavirus disease 2019 (COVID-19) among those never and ever hospitalized for COVID-19 separately through a multicentric, hospital-based, unmatched case-control study across India. METHODS: We defined cases and controls as those with and without post-COVID ROCM, respectively. We compared their socio-demographics, co-morbidities, steroid use, glycaemic status, and practices. We calculated crude and adjusted odds ratio (AOR) with 95% confidence intervals (CI) through logistic regression. The covariates with a p-value for crude OR of less than 0·20 were considered for the regression model. RESULTS: Among hospitalised, we recruited 267 cases and 256 controls and 116 cases and 231 controls among never hospitalised. Risk factors (AOR; 95% CI) for post-COVID ROCM among the hospitalised were age 45-59 years (2·1; 1·4 to 3·1), having diabetes mellitus (4·9; 3·4 to 7·1), elevated plasma glucose (6·4; 2·4 to 17·2), steroid use (3·2; 2 to 5·2) and frequent nasal washing (4·8; 1·4 to 17). Among those never hospitalised, age ≥ 60 years (6·6; 3·3 to 13·3), having diabetes mellitus (6·7; 3·8 to 11·6), elevated plasma glucose (13·7; 2·2 to 84), steroid use (9·8; 5·8 to 16·6), and cloth facemask use (2·6; 1·5 to 4·5) were associated with increased risk of post-COVID ROCM. CONCLUSIONS: Hyperglycemia, irrespective of having diabetes mellitus and steroid use, was associated with an increased risk of ROCM independent of COVID-19 hospitalisation. Rational steroid usage and glucose monitoring may reduce the risk of post-COVID.

Early/Subtle Electrocardiography Features of Acute Coronary Syndrome and ST-Segment Elevation Myocardial Infarction.

Chest pain is one of the most common presenting complaints in the emergency department. Interpreting a 12-lead electrocardiography (ECG) for evidence of ischemia is always challenging. Frank ECG changes such as ST-segment elevation and ST-segment depression can be easily identified by emergency physicians. However, identifying subtle or early features of ACS in the 12-lead ECG is essential in preventing significant mortality and morbidity from ACS. In the following case series, we describe five of the subtle/early ECG changes of ACS, namely (1) T-wave inversion in lead aVL; (2) terminal QRS distortion; (3) hyperacute T-waves; (4) negative U-waves in precordial leads; and (5) loss of precordial T-wave balance. In all these cases, the initial 12-lead ECG showed only subtle/early ECG changes which were followed up with serial ECGs which progressed to STEMI.

Effectiveness of Multimodal Intervention to Improve Blood Culture Collection in the Emergency Department.

Introduction: The blood culture (BC) contamination was a significant problem in our hospital, especially in the emergency department (ED). The study, therefore, was undertaken to improve the BC collection in the ED. Methods: The study was conducted for 1 year divided into two phases of 6 months each: Preintervention phase and intervention phase (regular and phlebotomist groups). The interventions comprised implementing standard protocol for BC collection and conducting educational sessions. In preintervention and regular groups, the BCs were collected by interns and technicians, while dedicated phlebotomist did so in the phlebotomist group. Data were analyzed and interpreted for the contamination rate as well as compliance in adequate filling of the requisition form. Statistical Package for the Social Sciences (SPSS) version 22. A value of P < 0.005 was considered statistically significant, and P < 0.01 was considered statistically significant. Results: In the preintervention group, 13.7% of specimens were reported as contaminated which was reduced to 4.2% and 3.2% in the regular and phlebotomist group, respectively, after intervention. Compliance of health-care workers to various elements of BC collection protocol was also found to be significantly improved in the intervention phase compared to the preintervention phase (P < 0.001). Conclusions: Implementation of this multimodal intervention resulted in a drastic reduction in BC contamination and improvement in compliance to BC collection protocol and filling of various parameters in the BC requisition form, thus improving the overall effectiveness of BC testing. It was also noted that the contamination rate was further reduced by implementing dedicated phlebotomist.

Isolation of Corynebacterium freneyi from a case of exudative pharyngitis, a close mimicker of Corynebacterium diphtheriae.

Corynebacterium freneyi is a recently described coryneform bacteria. It is only rarely identified from clinical specimens and its pathogenic significance has not been well studied. Here we report the isolation of the species from the throat swab of a patient with suspected diphtheria. The morphology on direct microscopy and culture also closely resembled Corynebacterium diphtheriae, which almost led to misidentification. The prompt clinical and microbiological response suggests a probable pathogenic role. This is the first report of the isolation of this species from an oropharyngeal sample.

An Unusual Cause of Bulbar Palsy in the Emergency Department.

BACKGROUND: Osmotic demyelination syndrome commonly occurs after rapid correction of hyponatremia. But it has also been reported after graded correction of hyponatremia in the presence of other risk factors like chronic alcoholism, malnutrition, liver disease, and hypokalemia. CASE REPORT: We report a case of a 67-year-old man who presented with dysphagia and nasal regurgitation and had features suggestive of bulbar palsy on neurological examination. He had spontaneous rapid correction of hyponatremia from a serum sodium level of 122 mEq/L to 132 mEq/L after discharge from our hospital. Neuroimaging was suggestive of extrapontine myelinolysis involving the basal ganglia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: An emergency physician should be aware of this because osmotic demyelination syndrome should also be considered in the differential diagnosis of patients presenting with bulbar palsy to the emergency department.

Memory T-Waves, a Rare Cause of T-Wave Inversion in the Emergency Department.

One of the rare causes of diffuse T-wave inversion (TWI) in electrocardiogram (ECG) is memory T-waves. This should be considered among the differentials of diffuse TWI in ECG of patients presenting to the emergency department (ED), especially when they have previous episodes of ventricular tachycardia (VT) or pacemaker implantation or Wolff-Parkinson-White syndrome. These TWIs are benign and do not require any treatment. However, it is of paramount importance for the emergency physician to differentiate it from ischemia-related T-wave changes. In the following case series, we report three cases of memory T-waves. Two of the cases had TWI in leads II, III, aVF, and V3 to V6 following reversion of VT. The other patient, with a VVI (Left ventricle paced, Left ventricle sensed, Inhibition to sensing) pacemaker, had memory T-waves in the ECG taken during normal sinus rhythm. In all the three patients, we considered memory T-waves to be the possible cause of TWI. The electrocardiographic diagnostic criteria for memory T-waves are positive T in lead aVL and positive/isoelectric T in the lead I; and precordial TWI >inferior TWI. These criteria are 92% sensitive and 100% specific. In the following case series, we also provide an algorithmic approach for patients with suspected memory T-waves in their 12-lead ECG when they present to the ED.

Sclerosterosis (Truswell-Hansen disease).

Sclerosteosis or Truswell-Hansen disease is a rare autosomal recessive disorder characterized by dense bones, tall stature, and syndactyly. Most of the reports are from South Africa. Here we report the first such case from India.

Extension of molecular similarity analysis approach to classification of DNA sequences using DNA descriptors.

Several alignment-free sequence comparison methods are available which use similarity, based on a particular numerical descriptor of biological sequences. Any loss of information incurred in the transformation of a sequence into a numerical descriptor affects the results. A pool of descriptors that use different algorithms in their computation is expected to suffer minimum loss of information and an attempt is made in this direction to study the similarity of DNA sequences. A number of descriptors based on information theory and connectivity were computed for DNA sequences. Principal component analysis (PCA) was used to extract minimum number (N) of orthogonal descriptors, principal components (PCs). Similarity/dissimilarity clustering of DNA sequences were carried out in the N-dimensional similarity space constructed using the PCs extracted from the DNA descriptors. The paper explains the extension of quantitative molecular similarity analysis (QMSA) from the prediction of physicochemical properties and toxicity of chemicals to bioinformatics for the classification of DNA sequences.

Outbreak of scrub typhus in Pondicherry.

AIM: To describe the diverse clinical and laboratory manifestations of scrub typhus diagnosed in Pondicherry Institute of Medical Sciences, Pondicherry. MATERIALS AND METHODS: All cases of febrile illness diagnosed as scrub typhus over a period of 2 years were analysed. Diagnosis was based on the presence of the eschar and/or positive Weil Felix test with a titre of > 1:80. RESULTS: Fifty cases of scrub typhus were seen over a period of 2 years (April 2006 and April 2008). Common symptoms were high grade fever of 7-14 days duration, nausea, vomiting, headache, myalgia, cough and breathlessness. Eschar was seen in 23 cases (46%) and the common sites were axilla, breast and groin. Weil Felix test was positive in 39 cases (78%). Liver enzymes were elevated in nearly all cases (95.9%). Multiple Organ Dysfunction Syndrome (MODS) was present in one third of our patients (17 out of 50, 34%). Hypotension (8 patients, 16%), renal impairment (6 patients, 12%), ARDS (4 patients, 8%) and meningitis (7 patients, 14%) were some of the important complications. There was a dramatic response to doxycycline in nearly all the patients. CONCLUSION: Scrub typhus has emerged as an important cause of febrile illness in Pondicherry. Empirical treatment with doxycycline is justified in endemic areas.

Reclamation of tannery polluted soil through phytoremediation.

The huge volume of sludge emanating from the tannery effluent treatment plants poses a serious environmental problem. Phytoremediation is an emerging technology in which the plants are employed to reclamate the contaminated soil strewn with heavy metals (metalloids) and toxic compounds. This work focuses the impact of application of tannery sludge on biochemical properties of 6 months old tree saplings of Azadirachta indica A. Juss. (Neem), Melia azedarach Linn. (Wild Neem) and Leucaena leucocephala (Lam) de Wit (Subabool) raised over the tannery sludge in an attempt to use these plants for phytoremediation. The plants raised over the garden soil served as the control. The porosity and water holding capacity of the tannery sludge were higher. The plant growth supporting elements such as Ca, total N2, NO3 and Mg were higher in the sludge. The plants raised over the sludge were found to be dark green with increased morphometric parameters. Electrophoretic profile revealed amplification of a few polypeptides (100, 105, 49 and 55 KDa). The levels of biomolecules and the CO2 absorption increased in 6 months old plants. There was a significant uptake and transport of chromium in all the three tree species suggesting that these plants could be employed in phytoremediation of soils contaminated with heavy metals.

Photosynthetic Potential and Accumulation of Assimilates in the Developing Chloroembryos of Cyamopsis tetragonoloba (L.) Taub.

The photosynthetic potential of leaves and chloroembryos of Cyamopsis tetragonoloba (L.) Taub as measured by (14)C-bicarbonate fixation, Hill activity, and in vivo fluorescence transients is compared. On a chlorophyll basis, dark fixation of NaH(14)CO(3) in chloroembryos was 1.5 times higher than that of the leaf, whereas carbon fixation under illumination was threefold higher in the leaf than in the embryos. Rates of O(2) evolution were four times more in embryo than in leaf chloroplasts. Shading of developing fruits on the day of anthesis for 10 days induced a 65% reduction in dry matter accumulation in the etiolated embryos, as compared to the normal green embryos of the same fruit half covered by a transparent Polythene sheet. The reduction in dry weight, size of the embryos, and levels of assimilates after shading the developing fruits may be ascribed to partial autotrophy of the chloroembryos.

Activation of NADP-malate dehydrogenase in C3 plants by reduced glutathione.

NADP-malate dehydrogenase extracted from darkened leaves of the C3 plants pea, barley, wheat and spinach was activated by reduced glutathione, a monothiol, as well as by dithiothreitol (DTT). However, in the C4 plants maize and Flaveria trinervia, only dithiothreitol could effectively activate the enzyme. There was no activation of the maize enzyme and little or no activation of the F. trinervia enzyme by glutathione. The failure of glutathione to activate NADP-MDH in leaf extracts of maize and F. trinervia may indicate there is some difference in disulfide groups of the protein compared to the C3 plant enzyme. Both DTT and glutathione could activate NADP-malate dehydrogenase in a partially purified enzyme preparation from pea leaves with or without addition of partially purified thioredoxin. However, the required concentration of reductant was lower with addition of thioredoxin than in its absence. In extracts of C3 species and the partially purified pea enzyme the level of activation after 40 to 60 min under aerobic conditions was higher (up to twofold) with DTT than with glutathione. Under anaerobic conditions, the initial rate of activation was about twice as high with DTT as with glutathione, but the total activation after 40 to 60 min was similar. Ascorbate was totally ineffective as a reducing agent in activating NADP-MDH from C3 or C4 plants, possibly due to its more positive redox potential.