Utility of Dyspnea Discrimination Index and Ultrasonography in discriminating between a Cardiac and Pulmonary Cause for Dyspnea in the Emergency Department

INTRODUCTION: Acute breathlessness is one of the main causes for admission into the emergency department of a hospital. Casualty medical officers often need to make rapid and accurate diagnosis so as to devise a treatment plan. This can be challenging as the information available at presentation is usually limited. It is particularly difficult in heart failure syndromes and exacerbation of reactive airway disease as history and examination may not clearly demarcate the actual pathology. The typical example is that of cardiac asthma, where examination findings reveal bilateral wheeze with scattered crepitation‟s. Here the patient is dyspneic and the dilemma is whether it is due to cardiac asthma or reactive airway disease. Often chest X rays take a long time and a silent chest can imply very severe chronic obstructive pulmonary disease or a pneumothorax. The time lag in waiting for a definitive diagnosis can cost a life. In patients with cardiac failure as a cause for breathlessness, chest x ray, ECG and laboratory tests that are available in the emergency department may have variable diagnostic value as cardiac failure syndromes are a heterogeneous set of clinical syndromes. Typically diagnosis is made with history and clinical examination is such cases but studies have proven that this yields very poor sensitivity with good specificity. To improve this, there have been many bed side maneuvers and tests postulated and studied. Bedside tests that deliver rapid and reliable results are a cornerstone of diagnostics in the emergency set up. AIM OF THE STUDY: To assess the utility of the Dyspnea discrimination index along with a multifactorial ultrasound screening tool to differentiate between a cardiac and pulmonary cause for breathlessness in patients who present with acute or acute on chronic breathlessness to the emergency department. OBJECTIVES: 1. To calculate the Dyspnea discrimination Index (DDI) and Percentage Dyspnea Discrimination Index (%DDI) for all patients presenting to the emergency department with dyspnea. 2. To assess the sensitivity, specificity, positive and negative predictive values of Dyspnea Discrimination Index and Percentage Dyspnea Discrimination Index in identifying pulmonary and cardiac causes for dyspnea. 3. To do a discriminate analysis on factors evaluated at admission like PaCO2, PaO2, Peak expiratory flow rate, Percentage peak expiratory flow rate which would help identify the factors with discriminative power between a cardiac and pulmonary etiology. 4. To assess the utility of a screening lung and cardiac plus IVC ultrasound in distinguishing a cardiac and pulmonary etiology for the dyspnea. METHODOLOGY: The study protocol was approved by the Institution Regional Board on 19/3/2013. It was reviewed and approved of by the ethical board. Patient Population: Patients where admitted to the emergency department of our hospital with acute or acute on chronic breathing difficulty, who fit into the inclusion criteria and gave written consent were included. As our hospital has patients from all over the country, consent was taken in the regional language. Inclusion Criteria: 1. Men and women who present to the emergency department with acute onset breathlessness or acute worsening of a chronic breathlessness. 2. Age above 18 years. 3. No other obvious non cardiac or non-pulmonary cause for breathlessness like trauma, organophosphorus poisoning or snake bite induced muscle weakness. Exclusion Criteria: 1. Patients not requiring hospitalization, who get discharged from the emergency department. 2. Those who have an obvious non-cardiac, non-pulmonary cause for dyspnea like trauma induced, poisoning or snake bite induced muscular weakness. 3. Inability to perform peak expiratory flow rate. 4. Patients who refuse consent. CONCLUSION: The bedside tools assessed in this study showed good discriminative power between cardiac and pulmonary causes of breathlessness. As the diagnostic accuracy in our emergency department is good, the dyspnea discrimination index may not help differentiate the cause further. The ultrasound tool on the other hand has a very high sensitivity and specificity and will be ideal in a tertiary care emergency set up where it can be used in the emergency department to identify the exact cause for breathlessness

A single - center retrospective observational study on patients undergoing Encephalo-Duro-Arterio -Myo-Synangiosis in patients with moyamoya disease

BACKGROUND: Many cases of moyamoya disease are refractory to conventional medical therapy, hence surgical revascularization techniques have emerged as one of the primary choices of treatment. In this study, we present the functional and angiographic outcomes of patients undergoing encephalo-duro-arterio-myo-synangiosis (EDAMS). METHODS: This is a retrospective observational cohort study, done over 8 years (2012–2020) in a neurological center in Eastern India. Data were retrieved from the hospital's electronic system, recorded in a standard data abstract sheet, and analyzed. RESULTS: This study included 75 patients, with a male (n = 42; 56.0%) preponderance. Majority belonged to the pediatric age group (≤18 years) (n = 70; 93.3%); remaining adult population included 5 (6.6%) patients. The most common presenting complaint was that of an ischemic cerebrovascular accident (CVA) (n = 57; 76.0%). Symptomatic hemispheres (n = 69; 92.0%) were treated and later followed if they had progressed to bilateral disease formation. Preoperative DSA showed 50 (71.4%) to have Suzuki grade 3 type of angiographic findings. Postoperative complications included worsening unilateral hemiparesis 4 (40%), slurring of speech (n = 2; 20.0%), hematoma (n = 2; 20.0%), and surgical site infection (n = 2; 20.0%). One patient succumbed to his illness on the second postoperative day. A postoperative angiogram showed regression of moyamoya vessels in the majority (n = 69; 93.3%) of patients. All (n = 74; 100%) had an intensification of transdural vessels; none had a regression. None of the study participants showed an intensification of moyamoya vessels. Many of our patients (83.8%) had a good grade of revascularization (modified Matsushima and Inaba A and B), while 16.2% had low-grade revascularization (grade C). On assessing outcomes using a modified Rankin Score, a large number of our patients had an excellent (n = 45, 60%) neurological outcomes. CONCLUSION: There was a bimodal age distribution with most of them presenting with ischemic CVA. This procedure (EDAMS) had good angiographic (Matsushima and Inaba) and functional (modified Rankin Score) outcomes

Changes in the emergency department dynamics during COVID-19 pandemic

In the past 20 years, several viral epidemics such as the severe acute respiratory syndrome coronavirus (SARS-CoV) in 2002 and 2003, H1N1 influenza in 2009, and Middle East Respiratory Coronavirus in 2012 have been recorded. The COVID-19 pandemic caused by SARS-CoV-2 has infected millions across the globe and has been a unique public health challenge with its increased rates of contagion and transmission. This outbreak was likely to have started from a zoonotic transmission event associated with a large sea-food market that also traded live wild animals. An exponential increase in the number of nonzoonotic cases in late December 2019, pointed toward the risk of human-to-human transmission. This led to a faster spread of infection and made the outbreak difficult to contain. The situation was unique in the busy Emergency Department (ED) of our institution, where regular emergency care could not be halted but had to be modified to accommodate COVID-19 confirmed and suspect patients. The ED needed to develop standard operating protocols to isolate and manage these patients, without putting other patients and health-care workers at risk of infection. This is a story of evolving practices in the ED of a leading tertiary care center of South India

A clinico-epidemiological profile, coinfections and outcome of patients with Influenza Like Illnesses (ILI) presenting to the emergency department during the COVID-19 pandemic

Background: During the COVID-19 pandemic, many patients presented to the emergency department (ED) with features of Influenza-like illnesses (ILI) and with other atypical presentations. This study was done to determine the etiology, co-infections, and clinical profile of patients with ILI. Methods: This prospective observational study included all patients presenting to the ED with fever and/or cough, breathing difficulty, sore throat, myalgia, gastrointestinal complaints (abdominal pain/vomiting/diarrhea), loss of taste and altered sensorium or asymptomatic patients who resided in or travelled from containment zones, or those who had contact with COVID-19 positive patients during the first wave of the pandemic between April and August 2020. Respiratory virus screening was done on a subset of COVID-19 patients to determine co-infection. Results: During the study period, we recruited 1462 patients with ILI and 857 patients with the non-ILI presentation of confirmed COVID-19 infection. The mean age group of our patient population was 51.4 (SD: 14.9) years with a male predominance (n-1593; 68.7%). The average duration of symptoms was 4.1 (SD: 2.9) days. A sub-analysis to determine an alternate viral etiology was done in 293 (16.4%) ILI patients, where 54 (19.4%) patients had COVID 19 and co-infection with other viruses, of which Adenovirus (n-39; 14.0%) was the most common. The most common symptoms in the ILI-COVID-19 positive group (other than fever and/or cough and/or breathing difficulty) were loss of taste (n-385; 26.3%) and diarrhea (n- 123; 8.4%). Respiratory rate (27.5 (SD: 8.1)/minute: p-value < 0.001) and oxygen saturation (92.1% (SD: 11.2) on room air; p-value < 0.001) in the ILI group were statistically significant. Age more than 60 years (adjusted odds ratio (OR): 4.826 (3.348-6.956); p-value: <0.001), sequential organ function assessment score more than or equal to four (adjusted OR: 5.619 (3.526-8.957); p-value: <0.001), and WHO critical severity score (Adjusted OR: 13.812 (9.656-19.756); p-value: <0.001) were independent predictors of mortality. Conclusion: COVID-19 patients were more likely to present with ILI than atypical features. Co-infection with Adenovirus was most common. Age more than 60 years, SOFA score more than or equal to four and WHO critical severity score were independent predictors of mortality

Factors associated with unexplained sudden deaths among adults aged 18-45 years in India – A multicentric matched case–control study

Background & objectives: In view of anecdotal reports of sudden unexplained deaths in India's apparently healthy young adults, linking to coronavirus disease 2019 (COVID-19) infection or vaccination, we determined the factors associated with such deaths in individuals aged 18-45 years through a multicentric matched case–control study. Methods: This study was conducted through participation of 47 tertiary care hospitals across India. Cases were apparently healthy individuals aged 18-45 years without any known co-morbidity, who suddenly (<24 h of hospitalization or seen apparently healthy 24 h before death) died of unexplained causes during 1st October 2021-31st March 2023. Four controls were included per case matched for age, gender and neighborhood. We interviewed/perused records to collect data on COVID-19 vaccination/infection and post-COVID-19 conditions, family history of sudden death, smoking, recreational drug use, alcohol frequency and binge drinking and vigorous-intensity physical activity two days before death/interviews. We developed regression models considering COVID-19 vaccination ≤42 days before outcome, any vaccine received anytime and vaccine doses to compute an adjusted matched odds ratio (aOR) with 95 per cent confidence interval (CI). Results: Seven hundred twenty nine cases and 2916 controls were included in the analysis. Receipt of at least one dose of COVID-19 vaccine lowered the odds [aOR (95% CI)] for unexplained sudden death [0.58 (0.37, 0.92)], whereas past COVID-19 hospitalization [3.8 (1.36, 10.61)], family history of sudden death [2.53 (1.52, 4.21)], binge drinking 48 h before death/interview [5.29 (2.57, 10.89)], use of recreational drug/substance [2.92 (1.1, 7.71)] and performing vigorous-intensity physical activity 48 h before death/interview [3.7 (1.36, 10.05)] were positively associated. Two doses lowered the odds of unexplained sudden death [0.51 (0.28, 0.91)], whereas single dose did not. Interpretation & conclusions: COVID-19 vaccination did not increase the risk of unexplained sudden death among young adults in India. Past COVID-19 hospitalization, family history of sudden death and certain lifestyle behaviors increased the likelihood of unexplained sudden death