A rare co-occurrence of spontaneous pneumomediastinum,pneumothorax,and pneumoperitoneum:Macklin effect

Spontaneous pneumomediastinum (SPM) is characterized by free air or gas located within the mediastinum that is not associated with any noticeable cause,such as chest trauma,intrathoracic infections,surgery,other organ rupture or mechanical ventilation.

Systematic review with expert consensus on use of extracorporeal hemoadsorption in septic shock:An Indian perspective

BACKGROUND Septic shock is a severe form of sepsis characterised by deterioration in circulatory and cellular-metabolic parameters.Despite standard therapy,the outcomes are poor.Newer adjuvant therapy,such as CytoSorb®extracorporeal haemoadsorption device,has been investigated and shown promising outcome.However,there is a lack of some guidance to make clinical decisions on the use of CytoSorb®haemoadsorption as an adjuvant therapy in septic shock in Indian Setting.Therefore,this expert consensus was formulated.AIM To formulate/establish specific consensus statements on the use of CytoSorb®haemoadsorption treatment based on the best available evidence and contextualised to the Indian scenario.METHODS We performed a comprehensive literature on CytoSorb®haemoadsorption in sepsis,septic shock in PubMed selecting papers published between January 2011 and March 20232021 in English language.The statements for a consensus document were developed based on the summarised literature analysis and identification of knowledge gaps.Using a modified Delphi approach combining evidence appraisal and expert opinion,the following topics related to CytoSorb®in septic shock were addressed:need for adjuvant therapy,initiation timeline,need for Interleukin-6 levels,duration of therapy,change of adsorbers,safety,prerequisite condition,efficacy endpoints and management flowchart.Eleven expert members from critical care,emergency medicine,and the intensive care participated and voted on nine statements and one open-ended question.RESULTS Eleven expert members from critical care,emergency medicine,and the intensive care participated and voted on nine statements and one open-ended question.All 11 experts in the consensus group(100%)participated in the first,second and third round of voting.After three iterative voting rounds and adapting two statements,consensus was achieved on nine statements out of nine statements.The consensus expert panel also recognised the necessity to form an association or society that can keep a registry regarding the use of CytoSorb®for all indications in the open-ended question(Q10)focusing on“future recommendations for CytoSorb®therapy”.CONCLUSION This Indian perspective consensus statement supports and provides guidance on the use of CytoSorb®haemoadsorption as an adjuvant treatment in patients with septic shock to achieve optimal outcomes.

Surgical decompression for the management of abdominal compartment syndrome with severe acute pancreatitis: A narrative review

Intra-abdominal hypertension(IAH)and abdominal compartment syndrome(ACS)play a pivotal role in the pathophysiology of severe acute pancreatitis(SAP)and contribute to new-onset and persistent organ failure.The optimal management of ACS involves a multi-disciplinary approach,from its early recognition to measures aiming at an urgent reduction of intra-abdominal pressure(IAP).A targeted literature search from January 1,2000,to November 30,2022,revealed 20 studies and data was analyzed on the type and country of the study,patient demographics,IAP,type and timing of surgical procedure performed,post-operative wound management,and outcomes of patients with ACS.There was no randomized controlled trial published on the topic.Decom-pressive laparotomy is effective in rapidly reducing IAP(standardized mean difference=2.68,95%confidence interval:1.19-1.47,P<0.001;4 studies).The morbidity and complications of an open abdomen after decompressive laparotomy should be weighed against the inadequately treated but,potentially lethal ACS.Disease-specific patient selection and the role of less-invasive decompressive measures,like subcutaneous linea alba fasciotomy or component separation techniques,is lacking in the 2013 consensus management guidelines by the Abdominal Compartment Society on IAH and ACS.This narrative review focuses on the current evidence regarding surgical decompression techniques for managing ACS in patients with SAP.However,there is a lack of high-quality evidence on patient selection,timing,and modality of surgical decompression.Large prospective trials are needed to identify triggers and effective and safe surgical decompression methods in SAP patients with ACS.

Extracorporeal blood purification strategies in sepsis and septic shock:An insight into recent advancements

BACKGROUND Despite various therapies to treat sepsis,it is one of the leading causes of mortality in the intensive care unit patients globally.Knowledge about the pathophysiology of sepsis has sparked interest in extracorporeal therapies(ECT)which are intended to balance the dysregulation of the immune system by removing excessive levels of inflammatory mediators.AIM To review recent data on the use of ECT in sepsis and to assess their effects on various inflammatory and clinical outcomes.METHODS In this review,an extensive English literature search was conducted from the last two decades to identify the use of ECT in sepsis.A total of 68 articles from peer-reviewed and indexed journals were selected excluding publications with only abstracts.RESULTS Results showed that ECT techniques such as high-volume hemofiltration,coupled plasma adsorption/filtration,resin or polymer adsorbers,and CytoSorb®are emerging as adjunct therapies to improve hemodynamic stability in sepsis.CytoSorb®has the most published data in regard to the use in the field of septic shock with reports on improved survival rates and lowered sequential organ failure assessment scores,lactate levels,total leucocyte count,platelet count,interleukin-IL-6,IL-10,and TNF levels.CONCLUSION Clinical acceptance of ECT in sepsis and septic shock is currently still limited due to a lack of large random clinical trials.In addition to patient-tailored therapies,future research developments with therapies targeting the cellular level of the immune response are expected.

Tension urinothorax as a reversible cause of cardiac arrest:a case report

Urinothorax, is the accumulation of urine in the pleural space, and is a rare and unusual condition.[1]Several etiologies are responsible for this, with trauma being the most common,[2] along with, surgical renal procedures(percutaneousnephrolithotomy,PCNL),retroperitoneal inflammation, urinary obstruction and malignancies.[3,4] Massive collections of a urinothorax or a hydrothorax can lead to tension, mediastinal shifts andcardiacarrests. Wedescribeacaseoftension urinothorax that led to cardiac arrest and was resuscitated successfully in the emergency department (ED).

Fungal arthritis:A challenging clinical entity

There has been an increasing incidence of fungal infections in recent years.Rarely joints are also affected by fungal infections.Mainly,these infections develop in prosthetic joints,but sometimes native joints are also involved.Candida infections are mostly reported,but patients may also develop infections secondary to non-Candida fungi,especially Aspergillus.Diagnosis and management of these infections is challenging and may involve multiple surgical interventions and prolonged antifungal therapy.Despite this,these infections are associated with high morbidity and mortality.This review described the clinical features,risk factors,and therapeutic interventions required to manage fungal arthritis.

Liver injury from direct oral anticoagulants

BACKGROUND Drug-induced liver injury(DILI)can be caused by any prescribed drug and is a significant reason for the withdrawal of newly launched drugs.Direct-acting oral anticoagulants(DOACs)are non-vitamin K-based antagonists recently introduced and increasingly used for various clinical conditions.A meta-analysis of 29 randomised controlled trials and 152116 patients reported no increased risk of DILI with DOACs.However,it is challenging to predict the risk factors for DILI in individual patients with exclusion of patients with pre-existing liver disease from these studies.AIM To determine the risk factors and outcomes of patients who developed DILI secondary to DOACs by systematic review and meta-summary of recent case reports and series.METHODS A systematic search was conducted on multiple databases including PubMed,Science Direct,Reference Citation Analysis,and Google Scholar.The search terms included“Acute Liver Failure”OR“Acute-On-Chronic Liver Failure”OR“Acute Chemical and Drug Induced Liver Injury”OR“Chronic Chemical and Drug Induced Liver Injury”AND“Factor Xa Inhibitors”OR“Dabigatran”OR“Rivaroxaban”OR“apixaban”OR“betrixaban”OR“edoxaban”OR“Otamixaban”.The results were filtered for literature published in English and on adult patients.Only case reports and case studies reporting cases of DILI secondary to DOACs were included.Data on demographics,comorbidities,medication history,laboratory investigations,imaging,histology,management,and outcomes were extracted.RESULTS A total of 15 studies(13 case reports and 2 case series)were included in the analysis,comprising 27 patients who developed DILI secondary to DOACs.Rivaroxaban was the most commonly implicated DOAC(n=20,74.1%).The mean time to onset of DILI was 40.6 d.The most common symptoms were jaundice(n=15,55.6%),malaise(n=9,33.3%),and vomiting(n=9,33.3%).Laboratory investigations showed elevated liver enzymes and bilirubin levels.Imaging studies and liver biopsies revealed features of acute hepatitis and cholestatic injury.Most patients had a favourable outcome,and only 1 patient(3.7%)died due to liver failure.CONCLUSION DOACs are increasingly used for various clinical conditions,and DILI secondary to DOACs is a rare but potentially serious complication.Prompt identification and cessation of the offending drug are crucial for the management of DILI.Most patients with DILI secondary to DOACs have a favourable outcome,but a small proportion may progress to liver failure and death.Further research,including post-marketing population-based studies,is needed to better understand the incidence and risk factors for DILI secondary to DOACs.

Acute Aortic Occlusion in a Critically Ill Adult Presenting to the Emergency Department

Acute Aortic Occlusion (AAO) is a rare, life-threatening event so far described mainly in small-scale series. The most common causes of AAO are large saddle emboli to the aortic bifurcation, in-situ thrombosis of an atherosclerotic aorta, and occlusion of previous surgical reconstruction. We present the case of a 52-year-old female with rheumatic heart disease, ischemic cardiomyopathy with restricted left ventricular function, atrial fibrillation, and previous cardio-embolic stroke, who was brought to the Emergency Department (ED) with sudden-onset dyspnea and lower backache radiating to both the legs. On arrival at the ED, the patient was electively intubated and mechanically ventilated in view of hypoxia and altered mental status, attributed to respiratory failure secondary to acute cardiogenic pulmonary oedema. The secondary survey revealed absence of bilateral femoral and popliteal artery pulsations. A computed tomography (CT) aortogram showed a complete lumen occlusion thrombus in the infra-renal region of the abdominal aorta at the level of L3-L4 lumbar vertebrae. An emergency embolectomy was performed successfully, following which the patient was started on heparin infusion and managed in the Intensive Care Unit (ICU). In the ICU, she suffered a torsade-cardiac arrest, with return of spontaneous circulation (ROSC) following rapid defibrillation. She was extubated on Day 3. Three weeks later, she was discharged from the hospital. At the time of discharge, she had developed ischemic lumbosacral radiculoplexus neuropathy, for which neuro-rehabilitation was advised. In our case report, we would like to highlight the following key points: 1) The importance of a detailed secondary survey in the Emergency Department (ED). 2) An inter-disciplinary approach to a complex syndrome that ensures the highest probability of a good outcome. .

Bitter Bottle Gourd Toxicity

Bottle gourd (Lagenaria siceraria), colloquially known as “lauki” or “doodhi” in India, is an edible plant in the Cucurbitaceae family. Consumption of raw bottle gourd juice is common practice in India. However, little known is the fact that ingestion of raw bottle gourd juice that is extremely bitter tasting is associated with cucurbitacin toxicity. Cucurbitacin is a pheromone produced by the plant as a defense mechanism against insects and herbivores. It is responsible for imparting the bitter taste, and the associated toxicity. The exact mechanism of cucurbitacin toxicity is not well understood, however it is suspected to result in gastric erosions and increased capillary permeability, resulting in rapid onset of vomiting, diarrhea, gastrointestinal bleeding, hypotension and shock. As serum and urine concentration measurements of cucurbitacin are not readily available, bottle gourd toxicity remains a clinical diagnosis based largely on the temporal association of ingestion of unusually bitter tasting vegetable or its juice with rapid onset of symptoms. Physician awareness is therefore of paramount importance in the diagnosis of this unusual entity. We present the case of a 78-year-old woman, with no comorbid conditions, who presented to the Emergency Department (ED) with three episodes of vomiting and multiple episodes of watery loose stools soon after ingestion of extremely bitter tasting, fresh bottle gourd juice. A prompt diagnosis of cucurbitacin toxicity was made in the ED and fluid resuscitation was commenced expeditiously. However, it was noted that most physicians were unfamiliar with this entity, and therefore skeptical of the diagnosis. Our rationale in presenting this clinical case report is three-fold: 1) To create physician awareness regarding this unique clinical entity, especially among emergency physicians, as they are the first point of contact for a critically ill patient. 2) To highlight the rapid onset and progression of symptoms in cucurbitacin toxicity. 3) To emphasize aggressive fluid resuscitation and symptomatic management as the mainstay of clinical treatment.

Nimotuzumab with Concurrent Chemoradiation in Inoperable Locally Advanced Squamous Cell Carcinoma of Head and Neck: An Indian Experience

Background: The prognosis of patients with Epidermal Growth Factor Receptor (EGFR) overexpression in inoperable Locally Advanced Squamous Cell Carcinoma of Head and Neck (LASCCHN) remains poor. Nimotuzumab is an Anti EGFR humanized monoclonal antibody approved for treatment of LASCCHN, with concurrent chemoradiation. Objective: To assess the efficacy and safety of nimotuzumab with concurrent chemoradiation in inoperable LASCCHN patients. Methodology: This is a single-centre, single arm, retrospective study evaluating 35 patients with histologically confirmed inoperable LASCCHN (stages III-IV). The patients were administered IV cisplatin 50 mg/m2 and IV nimotuzumab 200 mg for 6 - 7 weeks, along with radiotherapy of 6600 - 7000 cGy over 35 fractions. Patients were evaluated over response evaluation criteria in solid tumors (RECIST) criteria 12 weeks after the last cycle of chemotherapy. They were also followed up for overall survival and relapse free survival. Results: The median duration of follow-up was 20 months. The most common site of cancer was oropharynx (68.6%). One patient was lost to follow up. Objective Response Rate (ORR) was observed in 97% of the patients with 17 patients (48.6%) achieving complete response (CR) and 17 patients (48.6%) achieving partial response (PR). The median overall survival was 22.7 months (95% CI: 21.30, 34.27). The median relapse free survival was 16.7 months (95% CI: 9.80, 24.50). Nimotuzumab was safe and well tolerated with few mild, self-limiting adverse events. Conclusion: Nimotuzumab with chemoradiation is a safe and efficacious option in patients with LASCCHN. Larger studies are needed to verify the same.

The relative value of education of emergency physicians in patient outcome: A retrospective analysis at a single center in developing India

BACKGROUND: There is a considerable paucity with regards to the research available on the quality and quantity of clinical teaching in the national emergency department(ED) setups. With the onset of the age of modern medicine, the outlook towards to the time worn tradition of triage and detailed medical evaluation must be revoked. Despite the variety of programs being conducted in the country, a comparable entity common to all is patients' clinical outcomes which can be measured using simple parameters which can be easily acquired compiling hospital registry entries.METHODS: A retrospective observational study was conducted in the emergency department of Max Hospital, Saket, New Delhi. A period of 22 months prior to the start of the program and like-wise 22 months after initiation of the program was collected from the hospital registry. The Emergency Medicine program in consideration was the Masters in emergency Medicine(MEM) Program affiliated with George Washington University, NY, USA. Patients of all age groups and gender registering in the Emergency Department and so were all the doctors working in the ED before and after initiation of the program.RESULTS: An improvement was noted in terms of total admissions through the ED per month, average length of stay of admitted as well as discharged patients; return to ED within 24 hours; leave against medical advice and patient complaints. A reduction was noted in number of discharges from the ED. Despite a numerical worsening on the patient's death in ED a graphical improvement can be noted considering the month wise representation of data.CONCLUSION: We can make a coherent conclusion that there is an improvement in the outcome of the entire patient related aspects in the Emergency Department considering the all two time frames included in the study. The difference can be very well attributed to the integration of the structural Academic Program in the development of the Emergency Physicians. This leads us to make a conclusive analysis regarding a positive impact of the Relative Value of Education of Emergency Physicians not only in patient outcome but also in physicians and administrative outlook towards an overall better emergency care.

Change in pulse rate with Enviro Chip and dummy chip fixed on radiation emitting devices like mobile phones/computers/laptops of users—A double blind crossover study

Use of Electronic gadgets such as mobile phones, computers/laptops constitutes an integral part of human day-to-day activity in offices and businesses. Therefore, their use cannot be stopped. These electronic gadgets emit electromagnetic radiations, which are believed to be hazardous to human health. World Health Organization/International Agency for Research on Cancer has classified radiofrequency electromagnetic fields as possibly carcinogenic to humans (Group B). The Enviro Chip developed by Synergy Environics, India, is a radiation harmonizing chip which when fixed on electronic gadgets at specific locations claims to reduce stress level by reducing the pulse rate of users which may also result in improvement of other health parameters. In this study, we have tested the ability of the Enviro Chip to reduce pulse rate of people who may have developed high pulse rate due to prolonged use of electronic gadgets. This was the double blind crossover study conducted in 205 healthy volunteers having an average pulse rate of above 82 per Minute at Max Healthcare India. The primary objective of the study was to evaluate and compare the change in pulse rate over 14 measurements with the use of both the Enviro Chip and a Dummy chip from average pulse rate at baseline without the Placebo effect. The secondary objective was to evaluate the change in pulse rate gender-wise. Data analysis was done using Wilcoxon Sign Rank test. The study demonstrated statistical significant reduction in pulse rate over 14 measurements with the use of Enviro Chip in both male and female healthy volunteers

Bradycardia Secondary to Negative Suction Pressure Applied to Chest Drain

Positive pressure generated in peritoneal cavity by gas insufflation during laparoscopic procedures can cause hemodynamic instability. There are a few case reports suggesting similar occurrences during thoracoscopic procedures as well. The mechanism behind the conditions above is explained to be due to stretch force applied to peritoneum and pleura which causes vagal stimulation. We wish to present a case where a high negative pressure applied to pleural cavity lead to treatment-resistant bradycardia. The possible mechanism behind this occurrence was traction pressure on pleura which triggered vagal activity. The bradycardia subsided on reducing or discontinuing negative suction pressure. To best of our knowledge this the first case report on bradycardia associated with high negative suction pressure applied to inter costal drain.

COVID-19 and hemolysis,elevated liver enzymes and thrombocytopenia syndrome in pregnant women-association or causation?

Pregnant women are among the high-risk population for severe coronavirus disease 2019(COVID-19)with unfavorable peripartum outcomes and increased incidence of preterm births.Hemolysis,the elevation of liver enzymes,and low platelet count(HELLP)syndrome and severe preeclampsia are among the leading causes of maternal mortality.Evidence supports a higher odd of pre-eclampsia in women with COVID-19,given overlapping pathophysiology.Involvement of angiotensin-converting enzyme 2 receptors by severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)for the entry to the host cells and its downregulation cause dysregulation of the renin-angiotensin-aldosterone system.The overexpression of Angiotensin II mediated via p38 Mitogen-Activated Protein Kinase pathways can cause vasoconstriction and uninhibited platelet aggregation,which may be another common link between COVID-19 and HELLP syndrome.On PubMed search from January 1,2020,to July 30,2022,we found 18 studies on of SARS-COV-2 infection with HELLP Syndrome.Most of these studies are case reports or series,did not perform histopathology analysis of the placenta,or measured biomarkers linked to pre-eclampsia/HELLP syndrome.Hence,the relationship between SARS-CoV-2 infection and HELLP syndrome is inconclusive in these studies.We intend to perform a mini-review of the published literature on HELLP syndrome and COVID-19 to test the hypothesis on association vs causation,and gaps in the current evidence and propose an area of future research.

Spindle cell tumor of the lung: A rare case

Spindle cell carcinoma of the lung is a rare,aggressive lung malignancy(non-small cell carcinoma)with a poor prognosis.This tumor accounts for approximately 0.4%of all lung malignancies,and due to its rarity,standard therapy is yet to be established for its management and treatment.The prevalence of this tumor is more common in males as compared to females(ratio of 4:1)and usually occurs in the sixth/seventh decade of life,more so in smokers.The authors report a case of a 79-year-old male patient who was incidentally detected and diagnosed with this rare lung carcinoma proven with a lung biopsy.

Myocardial tuberculosis: A rare case report

Tuberculosis(TB)is one of the most common causes of mortality and morbidity globally,with Indian subcontinent having quite a large number of TB cases.TB can involve any organ system in humans;however,the disease affecting the cardiovascular system is rare.On the other hand,myocardial tuberculosis is a serious entity and can,unfortunately,be fatal if the diagnosis is missed or delayed.Therefore,the possibility of TB involving the myocardium should always be considered in areas with a high prevalence of TB,like the Indian subcontinent.Anti-TB therapy(with corticosteroids in some cases),along with early detection and suspicion,is proven to be quite effective in management and cure in most cases.We describe a case of sputum AFB(acid-fast bacilli)positive pulmonary TB with dilated cardiomyopathy,and impaired/decreased left ventricular systolic function,which gradually improved after anti-tubercular decongestive therapy.

General-motors diet: A quick fix for steatotic live liver donors

Background and aims:GM(General-Motors)diet is a low-calorie 7-day diet plan using complex carbohydrates used for quick weight loss.Dietary optimisation is known to decrease steatosis and improve outcomes in liver donors.We evaluated the efficacy and feasibility of using GM diet in steatotic live liver donors(LLD).Methods:LLDs who either had BMI>30 kg/m^(2),Computerised tomography liver attenuation index(CT-LAI)<0 HU,Magnetic resonance(MR)fat-fraction of>10%were started on GM diet for 1 week.Records of these LLDs and their recipients were retrieved retrospectively and analysed.Weight,liver function tests(LFT),MR fat-frac-tion,CT-LAI,hospital-stay and complications were analysed in LLDs while early graft dysfunction(EGD)and complications were assessed in recipients.Results:A total of 51 LLDs with mean age of 34.6?9.5 years with baseline mean weight of 80.6±10.8 kg and BMI of 29.1±2.78 kg/m^(2) were started on GM diet.After a week of following the GM diet,there was an average weight loss of 3.46±2.1 kg,a decrease in fat-fraction by 3.8%±2.7,and an improvement in CT-LAI by 6.7?3.7 HU.All patients could successfully undergo donor hepatectomy with an average postoperative ICU stay of 2.86±0.8 days and hospital stay of 6.82?0.81 days.No donor had steatosis>10% on intraoperative Tru-cut biopsy and their post-operative outcomes were similar to normal liver donors.There were intra-abdominal collections in 2 donors requiring drainage and one required re-exploration for intestinal obstruction.There was EGD in 8 recipients(15.6%)and mortality in 1(1.9%)recipients.Conclusion:GM diet is safe and effective regimen to reduce steatosis and increase healthy LLD pool without compromising donor or recipient safety.