To evaluate the diagnostic and prognostic accuracy of nCD64, mHLA-DR and sepsis Index (SI), ratio of nCD64 and mHLA-DR, in patients with sepsis. Prospective observational study was undertaken among 50 cases diagnosed with sepsis, 25 non-septic patients, and 25 healthy individuals as controls. Participants underwent flowcytometric estimation of nCD64 and mHLA-DR on the day of admission. The sepsis cohort had significantly higher nCD64 and lower mHLA-DR expression than both control groups (p-value: < 0.001). The sensitivity and specificity of nCD64 ABC (Antibodies Bound per Cell) for diagnosis of sepsis with a cut-off of 1152.16 was 94

DVT and/or PE collectively constitute what is known as venous thromboembolism (VTE).Data on the clinical presentation, risk factors, and short-term outcomes of VTE in the Indian emergency care setting are limited.This observational prospective study recruited patients > 18 years with diagnosis of deep vein thrombosis and cerebral venous thrombosis confirmed on duplex ultrasonography and MRI/MR venography respectively over period of 15 months. Among 96 patients with radiologically proven acute DVT or CVT; 81.2

How to cite this article: Pannu AK, Bhalla A. Paraquat Poisoning: When Intensive Care Meets the Limits of Medicine. Indian J Crit Care Med 2026;30(2):88-89.

Background Snakebite envenoming causes an estimated 138,000 deaths and more than 400,000 cases of permanent disability each year, disproportionately affecting low-resource regions. Antivenom is the only treatment but requires intravenous administration. We evaluated intravenous followed by oral varespladib as adjunctive therapy to antivenom in hospitalized patients with snakebite envenoming. Methods and findings In this multicenter, randomized, double-blind, placebo-controlled phase II trial in India (CTRI/2023/10/058782) and the USA ( NCT05717062 ), patients with snakebite envenoming were randomly assigned (1:1) to receive varespladib or placebo in addition to standard of care. For elapid envenoming, the primary endpoint was time to recovery of 5-second head-lift. For viper envenoming, the primary endpoint was area under the curve (AUC) from baseline to Day 14 of a 3-item Snakebite Severity Score (SSS). Between June 3 rd , 2023 and October 19 th , 2024, 140 patients were randomized and 139 were analyzed (73 varespladib; 66 placebo). Study drug was initiated a mean of 7.3 hours after the bite and 3.3 hours after antivenom. Among elapid-bite patients, mean time to head-lift recovery was 27.6 hours with varespladib vs. 36.2 hours with placebo (p = 0.6). Among viper-bite patients, SSS AUC to Day 14 was 660 vs. 629 in varespladib vs. placebo (p = 0.7). No serious adverse event occurred with varespladib. Conclusions In this trial in which varespladib was initiated on average 7 hours after snakebite and several hours after antivenom, adjunctive varespladib did not improve the primary endpoints. Other study designs and settings will be needed to assess the effect of varespladib when initiated prior to antivenom. Synopsis Snakebite envenoming causes more than 100,000 deaths and hundreds of thousands of cases of long-term disability each year, primarily in low- and middle-income countries. Antivenom is the only specific treatment currently available, but it must be administered intravenously in a healthcare facility and may not fully neutralize venom toxins that have already entered tissues. Varespladib is a small-molecule drug that inhibits secretory phospholipase A2, a toxin family found in many medically important snakes. Animal studies suggest that varespladib may reduce the harmful effects of snake venom, but its effectiveness in patients remains uncertain. We conducted a randomized, placebo-controlled clinical trial in India and the United States to evaluate intravenous followed by oral varespladib as a late adjunctive treatment given in addition to standard care, including antivenom. Outcomes were analyzed in 139 patients with snakebite envenoming. Study drug began, on average, more than 7 hours after the bite and in all cases after treatment with antivenom. Varespladib was generally safe and well tolerated but did not improve the trial’s prespecified primary outcomes. These findings suggest that adjunctive varespladib does not provide an overall benefit when initiated several hours after snakebite and after antivenom administration. The study provides information to guide future research on direct toxin inhibitors for snakebite.

Background Vaccination is an important method of preventing infectious diseases. Due to waning immunity in the older age group, there are chances of acquiring vaccine-preventable diseases. The present study was undertaken to assert the seroprevalence of protective immunoglobulin G antibodies to measles, mumps, and rubella (MMR) among the healthy adult population and health care workers. Methods This prospective observational study was conducted at the outpatient Department of Internal Medicine and Blood Donation Center of the Department of Transfusion Medicine of a tertiary care center in North India over 18 months. Healthy adults without comorbidities of >18 years of age were included in the study. The levels of immunoglobulin G antibodies against MMR were tested using commercially available enzyme-linked immunosorbent assay kits (Euroimmun, Germany) by following the manufacturer's instructions. The OD ratios were calculated as per kit instructions. Results A total of 207 healthy adults were enrolled in this study. There were 175 (84.5%) males and 32 (15.5%) females. They were divided into 4 groups, group A (n = 50) adults between 18 and 39 years, group B (n = 55) adults between 40 and 59 years, and group C (n = 52) adults >60 years and group D (n = 50) health care workers (HCWs). One hundred ninety-eight (95.5%) subjects had protective antibody titers against measles. One hundred ninety-one (92.3%) subjects had protective antibody titers against rubella. One hundred seventy-one (82.5%) subjects had protective antibody titers against mumps. Eighty percent of participants reported vaccination history of measles as compared with 10% in both mumps and rubella. Around 12% and 8% of HCWs were also found to be susceptible to measles and rubella. Conclusion Overall protective immunity among adults against MMR is 95.5%, 82.5%, and 92.3%, respectively.

INTRODUCTION:Paracetamol (acetaminophen) poisoning is common, and many publications describe various outcomes and treatments. As internationally agreed definitions are non-existent to describe patterns of paracetamol overdose (acute, repeated supratherapeutic, chronic, or staggered), it is difficult to analyze outcomes between studies. The Clinical Toxicology Recommendations Collaborative was tasked to provide guidance on the management of paracetamol poisoning and formed the Paracetamol Workgroup. The Workgroup concluded that an agreed set of terms was needed to perform the systematic review and categorize the evidence. METHODS:A modified Delphi process was employed to establish uniform definitions to categorize various patterns of paracetamol overdose. RESULTS:Group consensus was reached for each one of the following standard definitions for each pattern of poisoning: acute, staggered, repeated supratherapeutic ingestions, and chronic for use in their upcoming systematic review. "Acute" ingestion represents an excessive amount of paracetamol ingested over a total time (from first paracetamol dose ingested to last paracetamol dose ingested) of less than 8 h. "Staggered" ingestion involves an excessive amount of paracetamol ingested over a total time period of between 8 h and 24 h. "Repeated supratherapeutic ingestion" describes ingestions exceeding the recommended daily dose for more than 24 h, and "chronic" ingestion includes both staggered or repeated supratherapeutic ingestions. "High-risk overdoses" are defined by either an ingested dose, that is greater than 500 mg/kg or 30 g (whichever is less), or an initial serum or plasma paracetamol concentration of greater than 300 mg/L (1,985 µmol/L) at 4 h on the Rumack-Matthew nomogram line. DISCUSSION:The definitions established by the Paracetamol Workgroup will structure the upcoming systematic review, ensuring consistent categorization of studies within each ingestion pattern to enable clearer comparisons of treatments and outcomes. CONCLUSION:We encourage researchers to define overdose patterns and patients at increased risk of hepatotoxicity consistently and to include these definitions in publications to improve research reliability and comparability.

Background and aims: Hepatic infarcts are uncommon vascular lesions due to dual vascular supply of the liver characterized by the peripherally-located wedge-shaped large zones of necrosis in the hepatic parenchyma. They are commonly seen as a complication of liver transplant. Material and methods: The cases of hepatic infarcts of the native liver detected in medical autopsies were searched in the archives and their clinical, biochemical, gross, and histomorphological details were retrieved. Results: Three cases of hepatic infarct of the native liver were detected from among 1865 consecutive cases of adult and pediatric autopsies (0.2%). These cases were caused by hornet stings, acute pancreatitis, and hemolysis, elevated liver enzymes, low platelet syndrome (HELLP) in a 24-year-old male, 19-year-old male, and a 28-year-old postpartum female, respectively. The first two cases showed 50-150 times elevated transaminases and conjugated hyperbilirubinemia. All cases showed hyperemic to pale subcapsular infarcts. The HELLP syndrome case showed intrasinusoidal fibrin-rich microthrombi, while the other two cases showed the presence of fibrin-rich/organized microthrombi involving variable-sized portal and central venous radicles. Two of these cases (hornet sting and HELLP syndrome) did not show any macroscopic thrombi in the portal vein, hepatic artery, or hepatic veins. Conclusion: Hepatic infarcts are rare vascular lesions found in the nontransplant liver. The gross and histomorphology of these lesions depend on the age of these lesions. They can occur in the presence of vascular microthrombi in the absence of any documented macroscopic thrombus.

18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) has been used previously for the diagnosis of sepsis of unknown focus and pyrexia of unknown origin. Its use in the diagnosis of pyomyositis has not been fully explored. Pyomyositis was found to be an important cause of sepsis, but its cause has not been fully elucidated in previous studies exploring the role of PET. We studied the role of whole-body 18 F-FDG PET/CT in the diagnosis and management of 10 patients with suspected multifocal pyomyositis. In our study, we were able to find a distant focus in 7 out of 10 patients, which led to changes in treatment and outcome.

Introduction:Aluminum phosphide(AlP) insecticide is India's leading cause of poisoning-related mortality. Limited information is available about its mortality burden, common presentation type, and exposure(suicidal/accidental) characteristics. There exists no definite antidote for AlP poisoning management. The study was planned to systematically review the exact mortality burden, type of exposure- accidental/suicidal, commonest presentation in emergency department(ED), and gender difference in poison exposure, if any. Methods:We conducted comprehensive search in Scopus, PubMed, Web of Science, and Embase, and cross-referencing relevant articles from 1982 to 31 January 2025. Prospective, retrospective, and cross-sectional Indian studies that provided information on mortality data, common clinical presentation, and exposure type-accidental/suicidal were included. Study details- time to reach ED, duration of hospital-stay, average dose consumed, gender distribution in poison exposure, and other relevant information, were also assessed. Random-effects meta-analysis with DerSimonian & Laird estimator, meta-regression, and subgroup analyses were conducted using R. Results:Forty-two studies involving 3449 Indian patients were included in the analysis. Pooled mortality prevalence was 54 %(95 % CI- 48-61 %) in the primary endpoint evaluation. In secondary endpoints analysis, it was observed that 94 %(95 % CI- 88-97) of the AlP poisonings were intentional(suicide), while accidental exposure accounted for 5 %(95 % CI- 2-12) of cases presenting to ED. Hypotension, with odds of 78 %(95 % CI- 64-88)(p < 0.01) was observed as common presentation type. Odds ratio for male-to-female gender among patients exposed to AlP was not significant, at 89 %(95 % CI- 61-129)(p = 0.86). Conclusion:Death of every second patient with AlP poisoning in ED room underscores the urgent need for stringent regulatory measures to control its access in India.

Background:Antimicrobial resistance (AMR) poses a global health threat, emphasizing the need for Point Prevalence Surveys (PPS) to understand antibiotic use and resistance. This study assesses antibiotic use patterns and resistance in tertiary care hospitals across India to inform AMR interventions. Methods:This cross-sectional survey was conducted over two weeks between May and August 2023 in eight Indian tertiary care hospitals. The survey comprised two parts: the ward form, which captured ward details (name, specialty, bed count, and antibiotic use), and the patient form, which documented demographics, antimicrobial therapy, and microbiological data, including redundant coverage and designated antibiotics. Rationality was assessed using 50 forms from each site. Data were collected digitally by trained team of surveyors. The study included hospitalized patients on systemic antimicrobials, excluding outpatient, day-care dialysis patients, and those on topical antibiotics. Findings:Among 3974 patients in eight hospitals, adult surgical and pediatric medical wards had the highest antibiotic usage. Of 4248 prescriptions, the most common antibiotics were ceftriaxone (14.9%, 95% CI: 10.4%, 18.4%), metronidazole (10.2%, 95% CI: 6.0%-11.2%), amikacin (8.7%, 95% CI: 6.3%-11.3%), piperacillin/tazobactam (8.7%, 95% CI: 9.1%-10.5%), and meropenem (7.1%, 95% CI: 5.2%-9.5%). Antibiotics were categorized as 'Watch' (57.03%), 'Access' (32.67%), and 'Reserve' (5.08%). Primary indications were community-acquired infections (30.6%, 95% CI: 25.1%-32.5%) and surgical prophylaxis (31%, 95% CI: 29.8%-36.9%). HAIs prevalence was 13.3% (95% CI: 9.3%-15.4%), with majority of use being empiric (48.96%, 95% CI: 35.1%-58.8%). Common isolates included Escherichia coli, Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus. Assessment of rationale of antibiotic use was assessor dependent and variable (0-50% irrational prescriptions, majority due to prolonged duration of prophylaxis/treatment) across sites. Interpretation:The SASPI (Society of Antimicrobial Stewardship Practices in India)-led survey underscores the high use of antibiotics in the included tertiary care centers emphasizing the need for point prevalence surveys to guide antimicrobial stewardship programs. It highlights the importance of ongoing AMR surveillance, improved stewardship, and education to refine prescribing practices, targeting hospital-acquired infections, and reducing unnecessary treatments. Funding:None.

Objective: Despite a recent rise in incidence, varicella in adults remains under-recognized, particularly in tropical regions, where prevalence is high. This study aims to delineate the clinical spectrum, evaluate organ involvement, and assess outcomes in adult Indian patients with varicella. Methods: A hospital-based retrospective study was conducted at Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, between March 2016 and February 2020. Adult patients aged ≥15 years diagnosed with varicella were included. Diagnosis was based on the presence of a characteristic vesicular rash, epidemiological history of the recent exposure, and exclusion of alternative etiologies. Results: Fifty patients (mean age 32 years, 31 males) were included. Organ dysfunction was seen in 34 (68%) patients, most commonly pneumonia (n = 17), hepatitis (n = 12), hemorrhagic complications (n = 12), acute meningoencephalitis or myelitis (n = 10). Multi-organ involvement was present in 12 (24%). In-hospital mortality was 18% (n = 9), highest among patients with pneumonia (41.2%) and hemorrhagic complications (41.7%). Advanced age was the only independent predictor of mortality (OR 1.144, P value 0.034). Twenty-three (46%) patients had underlying predisposing conditions, most commonly immunosuppressive therapy (n = 9) and hematological malignancy (n = 5). However, organ complications and outcomes were comparable regardless of the immune status. Only one case of breakthrough varicella was detected. Admissions peaked in March and April (n = 15), although cases were seen throughout the year. Conclusion: Varicella in adults is frequently associated with severe organ complications, particularly pneumonia, and substantial in-hospital mortality. These adverse outcomes occur even in previously healthy individuals, underscoring the need for heightened clinical vigilance, timely antiviral therapy, and strengthened preventive strategies in the adult population.