Introduction: Cardiovascular implantable electronic device (CIED) infection contributes to a significant clinical and financial burden. We sought to assess CIED postimplant infection rates and the effect of different treatment modalities on reinfection over a long-term follow-up. Methods: We retrospectively analyzed CIED recipients presenting with complications during 2010–2019 at our center. Data related to the different management modalities used as per the discretion of treating physician, were collected and patients were followed up telephonically. Results: A total of 3394 patients underwent CIED implantation of which 122 (3.5%) patients developing complications were included in the study. Mean age of the patients was 66.4 ± 12.5 years. Single-chamber ventricular pacing (VVI), dual-chamber (DDD) pacing, and biventricular pacing were seen in 68 (56.2%), 51 (41%), and 3 (2.8%) patients, respectively. CIED infection was seen in 61 patients (1.8%). Strategies used for CIED infection management included: new device implantation on contralateral side (n = 34; 55.7%), old device repositioning on same side (n = 14; 22.8%), antibiotic therapy alone (n = 5; 8.5%), resterilized device implantation on contralateral side (n = 3; 4.9%), epicardial lead placement (n = 3; 4.9%), and permanent device removal (n = 2; 3.3%). The CIED reinfection rates for the above strategies were 2.9%, 71.4%, 80%, 100%, 0% and 0%, respectively. Conclusion: Multiple strategies are being used in real-world practice for the management of CIED infection. Previously advocated strategy of reimplanting resterilized CIED is associated with high recurrence rates. The best practice still remains to implant a new device on the contralateral side post extraction of infected hardware.

Vertigo is not an uncommon presenting symptom in patients presenting to the emergency department (ED) and primary physician’s clinic, and around one-tenth of these patients have a central cause, i.e., posterior circulation stroke. HINTS, the acronym for head impulse (HI) test, nystagmus (N), and test of skew (TS), is a neurological examination utilized for differentiating a peripheral cause of vertigo from a sinister central cause. It is a simple, easy-to-do, inexpensive, and less time-consuming test. Here, we present a 27-year young male case without any known comorbidity or trauma, presented to the ED, with complaints of sudden onset isolated vertigo for 2 hours. HINTS examination pointed towards a central cause (normal head impulse test and direction-changing nystagmus). Other neurological and systemic examinations were normal. Non-contrast computed tomography of the brain was normal. Further, computed tomography angiography of head and neck vessels was performed, showing left vertebral artery dissection (VAD). The patient’s neurological status deteriorated in the next 8 hours. The patient underwent decompressive craniotomy and got discharged after two weeks. Early performance of the HINTS examination by the primary care physicians and emergency physicians lead to early diagnosis and treatment of this common cause of posterior circulation stroke in young patients. Essential take-home points are the importance of the HINTS test and not to forget VAD as a cause of isolated vertigo without any neck manipulation or trauma.

Introduction: Sepsis is the leading cause of mortality, and various scoring systems have been developed for its early identification and treatment. The objective was to test the ability of quick sequential organ failure assessment (qSOFA) score to identify sepsis and predict sepsis-related mortality in the emergency department (ED). Methods: We conducted a prospective study from July 2018 to April 2020. Consecutive patients with age ≥18 years who presented to the ED with a clinical suspicion of infection were included. Sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV), and odds ratio (OR) for sepsis related mortality on day 7 and 28 were measured. Results: A total of 1200 patients were recruited; of which 48 patients were excluded and 17 patients were lost to follow-up. 54 (45.4%) of 119 patients with positive qSOFA (qSOFA >2) died at 7 days and 76 (63.9%) died at 28 days. A total of 103 (10.1%) of 1016 patients with negative qSOFA (qSOFA score <2) died at 7 days and 207 (20.4%) died at 28 days. Patients with positive qSOFA score were at higher odds of dying at 7 days (OR: 3.9, 95% confidence interval [CI]: 3.1–5.2, P < 0.001) and 28 days (OR: 6.9, 95% CI: 4.6–10.3, P < 0.001). The PPV and NPV with positive qSOFA score to predict 7- and 28-day mortality were 45.4%, 89.9% and 63.9%, 79.6%, respectively. Conclusion: The qSOFA score can be used as a risk stratification tool in a resource-limited setting to identify infected patients at an increased risk of death.