Presence of a mutant allele of VKORC1 (-1639A & 1173T) and CYP2C9 genes increased the odds of requiring a lower mean dosage of acenocoumarol. Studying the combination of genotypes in RHD patients could predict acenocoumarol dose requirement more accurately.

BackgroundAirway management is a life-saving procedure in the emergency department (ED). Hypoxia during rapid sequence intubation (RSI) is associated with high morbidity and mortality.AimTo decrease the median time of intubation (time from administration of paralytic agent to the successful passage of endotracheal tube) by 40% from baseline 300 s in patients undergoing RSI in the ED.MethodsA multidisciplinary quality improvement team worked to improve the airway management. The bottle necks identified using process mapping and fish bone analysis were lack of formal training of residents and nursing officers, and communication gap between residents and nursing officers. Change ideas focused on training residents in laryngoscopy and intubation and nursing officers in facilitating airway management by preparation of drugs and equipment; on-site awareness of logistical issues to the residents and nursing officers, introducing airway drug checklist and ensuring availability of difficult airway equipment.ResultsAfter implementation of change ideas there was a significant reduction in intubation time. At the end of first Plan-Do-Study-Act (PDSA) cycle median intubation time was 165 s (IQR 125 s). By the end of last PDSA cycle, median intubation time reduced to 157 s (IQR 66 s). A shift was obtained on the run chart with a new median time of 141.5 s from mid-PDSA 1. The 8-week data after the end of PDSA 3 showed sustainability with median time of 126 s (IQR 42 s).ConclusionA well organised team effort, simple change ideas such as structured training of residents and nursing officers, introduction of airway drug checklist and improved communication can decrease the intubation time in a chaotic ED.

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Acute abdominal pain is a common presentation to the emergency department (ED). Ruling out life-threatening causes and giving pain relief are the most important tasks in ED. We describe a 32-year-old man who presented to ED with abdominal pain and vomiting which was unrelieved by usual doses of analgesic. Extensive investigations revealed no significant abnormalities. On further probing, he admitted taking traditional medications for infertility. The toxicological panel revealed a high blood lead level, leading to a diagnosis of acute lead toxicity. Chelation therapy with D-penicillamine was initiated and the patient’s abdominal pain resolved within 4 days.

Background/objectives: Acute liver failure (ALF) is rare and associated with poor outcomes. The outcomes of ALF and predictors of outcome may vary as per the etiology. There are limited data on the predictors of spontaneous survival among patients with ALF of non-A-E hepatitis or cryptogenic etiology. We aimed to assess clinical course, complications, and outcome of non-A-E etiology ALF. Methods: In this prospective analysis, all consecutive ALF patients (n = 1555; January 1986-June 2018) were analyzed. Non-A-E-ALF was defined as ALF that could not be attributed to known etiologies such as drugs, viral hepatitis, autoimmune hepatitis, and Wilson's disease. Clinical course, complications, and outcomes of non-A-E-ALF patients who did not undergo liver transplantation were analyzed. Unadjusted and adjusted odds ratios (ORs) were calculated. Results: Non-A-E-ALF constituted 34.6% (n = 538) of all ALF patients, whereas hepatitis E virus (HEV), hepatitis B virus (HBV), and antituberculosis therapy (ATT) accounted for 29.5% (n = 459), 8.6% (n = 134), and 7.4% (n = 115), respectively. Among non-A-E-ALF patients, mean age was 28.8 ± 12.0 years, 50.9% females, majority (63.1%) had hyperacute presentation, and 79.2% had advanced encephalopathy at presentation. The frequency of cerebral edema in non-A-E-ALF (53.3%) was higher than that in HEV-ALF (41.2%) and ATT-ALF (44.2%), P < 0.001. The survival rate in non-A-E-ALF (37.5%) was poorer than HEV-ALF (54.9%) and was comparable to that in HBV (35.8%) and ATT (29.6%) induced ALF. The baseline prothrombin time prolongation (odds ratio [OR] 1.