What started as a cluster of patients with a mysterious respiratory illness in Wuhan, China, in December 2019, was later determined to be coronavirus disease 2019 (COVID-19). The pathogen severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel Betacoronavirus , was subsequently isolated as the causative agent. SARS-CoV-2 is transmitted by respiratory droplets and fomites and presents clinically with fever, fatigue, myalgias, conjunctivitis, anosmia, dysgeusia, sore throat, nasal congestion, cough, dyspnea, nausea, vomiting, and/or diarrhea. In most critical cases, symptoms can escalate into acute respiratory distress syndrome accompanied by a runaway inflammatory cytokine response and multiorgan failure. As of this article's publication date, COVID-19 has spread to approximately 200 countries and territories, with over 4.3 million infections and more than 290,000 deaths as it has escalated into a global pandemic. Public health concerns mount as the situation evolves with an increasing number of infection hotspots around the globe. New information about the virus is emerging just as rapidly. This has led to the prompt development of clinical patient risk stratification tools to aid in determining the need for testing, isolation, monitoring, ventilator support, and disposition. COVID-19 spread is rapid, including imported cases in travelers, cases among close contacts of known infected individuals, and community-acquired cases without a readily identifiable source of infection. Critical shortages of personal protective equipment and ventilators are compounding the stress on overburdened healthcare systems. The continued challenges of social distancing, containment, isolation, and surge capacity in already stressed hospitals, clinics, and emergency departments have led to a swell in technologically-assisted care delivery strategies, such as telemedicine and web-based triage. As the race to develop an effective vaccine intensifies, several clinical trials of antivirals and immune modulators are underway, though no reliable COVID-19-specific therapeutics (inclusive of some potentially effective single and multi-drug regimens) have been identified as of yet. With many nations and regions declaring a state of emergency, unprecedented quarantine, social distancing, and border closing efforts are underway. Implementation of social and physical isolation measures has caused sudden and profound economic hardship, with marked decreases in global trade and local small business activity alike, and full ramifications likely yet to be felt. Current state-of-science, mitigation strategies, possible therapies, ethical considerations for healthcare workers and policymakers, as well as lessons learned for this evolving global threat and the eventual return to a “new normal” are discussed in this article.

Pre-hospital delay was long, and use of reperfusion therapy was significantly lower. The in-hospital death rates are higher.

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Background The Himachal Pradesh state acute coronary syndrome registry recorded a median delay of 13 h between the time of onset of pain to the time of making the diagnosis and giving treatment for acute coronary syndrome. We conducted a pilot study on providing 24-h tele-electrocardiography (Tele-ECG) services in the district Kangra of Himachal Pradesh, with the aim to reduce the time taken for diagnosis of acute coronary syndrome. Methods The intervention group for the study included eight rural community health centres, each with one to three primary care physicians, who were all unskilled in electrocardiogram interpretation. We provided them with 24-h Tele-ECG support. The primary care physicians used their smartphones to transmit the electrocardiogram image to the command centre, which was then read by the skilled specialist physicians in our medical college hospital and the report sent back within five minutes of having received the electrocardiogram. Antiplatelets were given by the primary care physician to patients diagnosed with acute coronary syndrome, who was then transported to the medical college hospital. The urban sub-divisional hospitals ( n = 6) formed the control group for the study. These hospitals had five to fifteen unskilled primary care physicians and one to two skilled specialist physicians; no intervention was done in this group. A pilot was run from February 2015-January 2016. Results We received 819 Tele-ECG consultations within the intervention group; 157 cases of acute coronary syndrome were confirmed and transferred to our medical college hospital facility. Similarly, we admitted 177 cases of acute coronary syndrome at the medical college hospital, who were first attended to by the primary care physician in the control group. Aspirin was administered to 91% and 58% of patients with acute coronary syndrome in the intervention and the control groups, respectively ( p < 0.0001). The median hospital-to-aspirin time (h) in the intervention and the control groups was 0.7 ± 1.45 h and 3.5 ± 10 h, respectively ( p < 0.0001). In the intervention group, 72% of the ST elevation myocardial infarction patients were diagnosed within 12 h by the primary care physician using Tele-ECG support. Interpretation and conclusions Smartphone-based Tele-ECG support for primary care physicians reduced the hospital-to-aspirin time in acute coronary syndrome significantly ( p < 0.0001). This is an effective low cost strategy and is easily replicable anywhere in the world.

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Intestinal stomas have been performed for hundreds of years for both benign and malignant disorders of the large and small bowel. Complications of stomas like stomal prolapse, parastomal hernia, and retraction are well-known. The evisceration of intra-abdominal contents is a very rare occurrence, carrying a high burden of morbidity. The etiology, timing, and treatment of this complication are not adequately described in the literature. We report two patients who were operated and in whom ostomy was fashioned; parastomal evisceration occurred in the early postoperative period in both cases. Both of these patients were operated emergently, and reduction of eviscerated contents followed by stoma refashioning was performed. One patient survived; whereas, the other patient who presented with septic shock expired due to multiorgan dysfunction syndrome. This report describes a rare and possibly fatal complication of ostomy and highlights the importance of meticulous operative technique in ensuring safety in this procedure.

Snake bite envenomations are common in rural areas and the incidence peaks during monsoons in India. Prominent venomous species have been traditionally labeled as the ‘big four’ that includes Cobra, Krait, Russel's viper and Saw scaled viper. Systematic attempts for identification and classification of prevalent snakes in various states of India are missing till now and there is no concrete data on this aspect. The published literature however shows that some species of snakes are more prevalent in a particular region than the other parts of India e.g. Saw scaled vipers in Rajasthan. We reviewed the published literature from various parts of India and found that there is a North-South divide in the snake bite profile from India. Neurotoxic envenomations are significantly higher in North India compared to South India where Hematotoxic envenomations are prevalent. Russel's viper causes local necrosis, gangrene and compartment syndrome. These manifestations have never been reported in North Indian snake bite profile in the published literature. Early morning neuroparalysis caused by Krait is a common problem in North India leading to high mortality after snake bite. This review presents supporting evidence for the North-South divide and proposes a way forward in formulation and revision of guidelines for snake bite in India.