Thoracic trauma trends in Northern India- single center experience

Introduction

Thoracic trauma comprises 10–15 % of all traumas. The incidence and etiological pattern of chest trauma varies from region to region and is related to cultural and socio-political circumstances. This paper details our experience with thoracic trauma in a North Indian state.

Material & methods

All patients who were hospitalized for thoracic trauma from June 2010 to June 2012 in our hospital were enrolled. Data was collected prospectively and analysed. Factors analysed were age, gender, mode of injury, type of thoracic injury, associated injuries, management modalities, and outcome.

Results

The total number of patients was 250. The male to female ratio was about 10:1. The mean age of patients was 36.62 years. Road Traffic Accident (RTA) was the most common mode of chest injury. Motor-bike accident was the most common type of RTA. Majority of patients were managed with tube thoracostomy (183, 73.2 %). One hundred and eighty nine (75.6 %) patients were discharged after recovery. Ten (4.0 %) patients absconded. In all, 29 (11.6 %) patients died, while 22 (8.8 %) patients left the hospital against medical advice. A significant association between presence of associated injury and outcome was observed (p?<?0.001). We found mortality rate was significantly higher in chest injury associated with neurotrauma and abdominal visceral injury.

Conclusion

Chest trauma is a major health problem since it has high morbidity and mortality rate. The majority of patients with simple chest injuries can be managed by tube thoracostomy. According to our analysis; mortality predictors were: RTAs, blunt chest trauma, unstable hemodynamic status upon arrival, neurotrauma, abdominal visceral injury, flail chest, ventilator use, cardiac contusion and complications of therapy.     

Thrombotic microangiopathy and acute kidney injury following vivax malaria

Background

Infection with Plasmodium vivax, a common human parasite, is occasionally recognized to cause severe organ dysfunction similar to P. falciparum infection. Acute kidney injury (AKI) in malaria is attributed to acute tubular necrosis; thrombotic microangiopathy is not described.

Methods

This observational study includes patients referred to a tertiary care center in North India during June to September 2011 with severe AKI, anemia, and thrombocytopenia following vivax malaria. Renal biopsies were processed by light, immunofluorescence, and electron microscopy.

Results

Nine patients (including 5 children) had persistent AKI with thrombocytopenia and variable anemia following the diagnosis of malaria. Based on peripheral smear, eight patients were diagnosed with vivax malaria and had received antimalarial therapy prior to referral; a laboratory diagnosis of P. vivax infection was made for one patient at this center. Renal histology in all cases showed features of thrombotic microangiopathy, including fibrin thrombi, subendothelial widening, and mesangiolysis, along with variable tubulointerstitial nephritis and acute tubular or cortical necrosis. Ultrastructural examination confirmed endothelial injury and subendothelial widening. All patients required hemodialysis, and six were dialysis dependent at four weeks. Delayed presentation to the hospital (P = 0.019), hemolysis on peripheral smear (P = 0.083), and prolonged oligoanuria (P = 0.036) were associated with dialysis dependence.

Conclusion

The association of anemia, thrombocytopenia, and renal histological evidence of thrombotic microangiopathy with vivax malaria is novel, and suggests the presence of severe endothelial injury. Further studies are necessary to confirm the association and examine the factors associated with its occurrence.     

Simultaneous progression of oxidative stress,angiogenesis, and cell proliferation in prostate carcinoma

ObjectivesTo understand the association between markers of oxidative stress, levels of vascular endothelial growth factor (VEGF), and cell proliferation index in relation to disease progression, clinical stage, and cytologic grade in pathophysiology of prostate carcinoma.Patients and methodsCase control study comprised of 40 prostate carcinoma patients along with 40 age- and sex-matched healthy subjects as controls. Levels of 8-hydroxy-2-deoxy guanosine, protein carbonyl, and malondialdehyde along with total antioxidant status were measured to study the oxidative stress status in the study subjects. Angiogenesis was evaluated by studying the VEGF level and cell proliferation index.ResultsThe levels of markers of oxidative stress along with VEGF and cell proliferation index were found to be significantly higher with significantly decreased levels of antioxidant activity in the study subjects in comparison with healthy controls. The results indicate oxidative stress, angiogenesis, and cell proliferation activity increase progressively with the increase in staging and progression of disease.ConclusionsOxidative stress parameters, angiogenesis, and cell proliferation activity point clearly that with the progression of oxidative stress there is a simultaneous progression of angiogenesis, regulation and control of endothelial cell proliferation in relation to disease progression, clinical stage, and cytologic grade in the pathophysiology of prostate carcinoma.     

Anterior cervical discectomy plus intervertebral polyetheretherketone cage fusion over three and four levels without plating is safe and effective long-term

Anterior cervical discectomy and fusion (ACDF) is an established treatment for single-level cervical spondylotic myelopathy and radiculopathy, yet its stand-alone use for multi-level disease of the subaxial cervical spine remains controversial. We report a prospectively studied case series of 30 patients receiving polyetheretherketone (PEEK) cage fusion over three and four cervical levels without anterior plating. Seven (23.3%) four-level procedures (all C3 to C7) were performed, the other 23 (76.7%) being three-level, with 19 (64.4%) at C4 to C7 and four (12.3%) at C3 to C6. Long-term follow-up of more than 2 years was available in 67% of patients. This cohort showed statistically significant improvements in visual analogue score for neck pain (p = 0.0006), arm pain (p = 0.0003) and Japanese Orthopaedic Association myelopathy score (p = 0.002). Fused segment heights increased by 0.6–1.1%. Adjacent segment disease requiring ACDF at C3–4 was seen in 6.7% of patients (one after trauma) at a mean follow-up of 62 months. Same segment recurrence requiring posterior decompression with instrumented fusion was found in 10% of patients at a mean follow-up of 49 months, only one of whom had radiological evidence of cage subsidence. The results suggest the procedure is safe and effective with potentially less morbidity than anterior plating, shorter inpatient stays than posterior approaches, acceptable same segment recurrence and lower than predicted adjacent segment disease rates.     

Phenotype of dent disease in a cohort of Indian children

Objective

To describe the clinical and genotypic features of Dent disease in children diagnosed at our center over a period of 10 years.

Design

Case series.

Setting

Pediatric Nephrology Clinic at a referral center in Northern India.

Methods

The medical records of patients with Dent disease diagnosed and followed up at this hospital from June 2005 to April 2015 were reviewed. The diagnosis of Dent disease was based on presence of all three of the following: (i) low molecular weight proteinuria, (ii) hypercalciuria and (iii) one of the following: nephrolithiasis, hematuria, hypophosphatemia or renal insufficiency, with or without mutation in CLCN5 or OCRL1 genes.

Results

The phenotype in 18 patients diagnosed with Dent disease during this period was characterized by early age at onset (median 1.8 y), and polyuria, polydipsia, salt craving, hypophosphatemic rickets and night blindness. Rickets was associated with severe deformities, fractures or loss of ambulation in six patients. Nephrocalcinosis was present in three patients, while none had nephrolithiasis. Generalized aminoaciduria was seen in 13 patients, two had glucosuria alone, and one had features of Fanconi syndrome. Over a median follow up of 2.7 years, one patient developed renal failure. Genetic testing (n=15) revealed 5 missense mutations and 3 nonsense mutations in CLCN5 in 13 patients. Five of these variations (p.Met504Lys, p.Trp58Cys, p.Leu729X, p.Glu527Gln and p.Gly57Arg) have not been reported outside the Indian subcontinent.

Conclusion

Our findings suggest a severe phenotype in a cohort of Indian patients with Dent disease.

     

Possible role for interactions between 5-lipoxygenase (5-LOX) and AMPA GluR1 receptors in depression and in antidepressant therapy

Emerging evidence suggests that 5-lipoxygenase (5-LOX) plays a role in central nervous system functioning. It has been shown that 5-LOX metabolic products can decrease the phosphorylation of the glutamate receptor subunit GluR1, and that this effect can be antagonized by 5-LOX inhibitors. Recent concepts about the pathobiological mechanisms of depression and the molecular mechanisms of antidepressant activity postulate a significant role for glutamatergic neurotransmission and the GluR1 receptor. Regulation of GluR1 phosphorylation, i.e., enhancement of this phosphorylation, may be a part of antidepressant activity. On the other hand, reduced GluR1 phosphorylation may be a pathobiological mechanism contributing to depression. Since 5-LOX inhibitors, along with antidepressants share the capacity to increase GluR1 phosphorylation, we hypothesize that they may also have antidepressant properties. Furthermore, we postulate that increased brain 5-LOX expression may lead to decreased GluR1 phosphorylation and favor the development of depression. For example, brain 5-LOX expression is stimulated by stress hormone glucocorticoids, and stress is a known contributing factor in depression.     

Facilitators and barriers in implementing the Minimum Initial Services Package (MISP) for reproductive health in Nepal post-earthquake

Background

Following the Nepal earthquake in April 2015, UNFPA estimated that 1.4 million women of reproductive age were affected, with approximately 93,000 pregnant and 28,000 at risk of sexual violence. A set of priority reproductive health (RH) actions, the Minimum Initial Services Package (MISP), was initiated by government, international and local actors. The purpose of this study was to identify the facilitators and barriers affecting the implementation of priority RH services in two districts.

Methods

In September 2015, a mixed methods study design was used in Kathmandu and Sindhupalchowk districts to assess the implementation of the priority RH services five months post-earthquake. Data collection activities included 32 focus group discussions with male and female participants aged 18–49; 26 key informant interviews with RH, gender-based violence (GBV), and human immunodeficiency virus (HIV) experts; and 17 health facility assessments.

Results

The implementation of priority RH services was achieved in both districts. In Kathmandu implementation of emergency RH services started within days of the earthquake. Facilitating factors for successful implementation included disaster preparedness; leadership and commitment among national, international, and district level actors; resource mobilization; strong national level coordination; existing reproductive and child health services and community outreach programs; and supply chain management. Barriers included inadequate MISP training for RH coordinators and managers; weak communication between national and district level stakeholders; inadequate staffing; under-resourced and fewer facilities in rural areas; limited attention given to local GBV and HIV organizations; low availability of clinical management of rape services; and low awareness of GBV services and benefits of timely care.

Conclusion

Ensuring RH is included in emergency preparedness and immediate response efforts and is continued through the transition to comprehensive care is critical for national governments and humanitarian response agencies. The MISP for RH remains a critical component of response efforts, and the humanitarian community should consider these learnings in future emergency response.

     

Phenolic amides from <Emphasis Type="Italic">Tribulus terrestris</Emphasis> and their inhibitory effects on nitric oxide production in RAW 264.7 cells

A new phenolic amide, named cis-terrestriamide (7), together with ten known compounds (1–6, 8–11), were isolated from the methanolic extract of the fruits of Tribulus terrestris. The structure of 7 was elucidated on the basis of extensive analyses of 1D and 2D nuclear magnetic resonance spectroscopic and high resolution mass spectrometry data. Compounds 1, 2, 5, 6, 8, 9, and 11 exhibited inhibitory effects on the lipopolysaccharide-stimulated nitric oxide production in RAW 264.7 cells, with IC₅₀ values of 18.7–49.4 μM.     

State insurance mandates and off‐label use of chemotherapy

Access to cancer drugs used off‐label is important to cancer patients but may drive up healthcare costs with little evidence of clinical benefit. We hypothesized that state health insurance mandates for private insurers to provide coverage for off‐label use of cancer drugs cause higher rates of off‐label use. We used Truven MarketScan data from 1999 to 2007 on utilization of 35 infused chemotherapy drugs in private health plans in the United States, covering the period when eight states implemented off‐label coverage laws. We studied trends in off‐label use of drugs, distinguishing between appropriate and inappropriate off‐label use according to drug compendia, and estimated difference‐in‐difference regressions of the effect of state laws on off‐label use. We estimate 41% of utilization was off‐label, including 17% of use conservatively defined as inappropriate. Trends show gradual declines in off‐label use over time. We also find no discernable effect of state laws mandating coverage of off‐label use of cancer drugs on utilization patterns under multiple empirical specifications. Our conclusion is that policymakers should consider shifting away from mandating coverage as a way to ensure access to drugs off‐label and towards incentivizing adherence to clinical practice guidelines to improve the quality and value of off‐label use.