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   2015| January-March  | Volume 5 | Issue 1  
    Online since March 2, 2015

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Severe hemophagocytic lymphohistiocytosis as a complication of drug-induced hypersensitivity syndrome
Dron Gauchan, Hamid Shaaban, Neil Parikh, Nai-Lun Chang, Zaid Altheeb, Michael Maroules
January-March 2015, 5(1):60-61
DOI:10.4103/2229-5151.152349  PMID:25810969
  7 2,600 54
Analysis of pediatric trauma data from a hospital based trauma registry in Qatar
Khalid A Alyafei, Fatihi Toaimah, Ayman El Menyar, Hassan Al Thani, Bashir Youssef, Muneera Mollazehi, Rafael Consunji
January-March 2015, 5(1):21-26
DOI:10.4103/2229-5151.152312  PMID:25810960
Background: Trauma is the leading killer in the young age children, but data about the injury burden on pediatric population are lacking. The aim of this study is to describe the epidemiology and outcome of the traumatic injuries among children in Qatar. Materials and Methods: This is a retrospective analysis of a trauma registry database, which reviewed all cases of serious traumatic injury (ISS ≥ 9) to children aged 0-18 years who were admitted to the national pediatric Level I trauma center at the Hamad General Hospital (HGH), over a period of one year. Data included demographics, day of injuries, location, time, type and mechanism of injuries, co-morbidity, safety equipment use, pre-hospital intubation, mode of pre-hospital transport, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), emergency department (ED) intervention, hospital length of stay and mortality outcome. Results: The incidence of severe pediatric trauma was 163 per 280,000 children who visited the ED of HGH in 2011. Out of them, 83% were male, mean age was 9.6 ± 5.9 years and mortality rate was 1.8%. On presentation to the ED, the mean ISS was 13.9 ± 6.6 and GCS was 13.4 ± 3.8. Over half of the patients needed ICU admission. For the ages 0-4 years, injuries most frequently occurred at home; for 5-9 years (59%) and 15-18 years (68%), the street; and for 10-14 years (50%), sports and recreational sites. The most common mechanisms of injury for the age groups were falls for 0-4 years, motor vehicle collision (MVC) or pedestrian injury for 5-9 years, all-terrain vehicle (ATV)/bicycle injuries for 10-14 years, and MVC injuries for 15-18 years. Head (34%) and long bone (18%) injuries were the most common, with 18% suffering from polytrauma. None of the patients were using safety equipment when injured. Conclusion: Traumatic injuries to children have an age- and mechanism-specific pattern in Qatar. This has important implications for the formulation of focused injury prevention programs for the children of Qatar.
  6 2,126 92
A comparative evaluation of magnesium sulphate and nitroglycerine as potential adjuncts to lidocaine in intravenous regional anaesthesia
Pooja Bansal, Neha Baduni, Jyoti Bhalla, Bablesh Mahawar
January-March 2015, 5(1):27-31
DOI:10.4103/2229-5151.152324  PMID:25810961
Introduction: This randomized control trial was carried out to evaluate and compare the efficacy of magnesium sulphate and nitroglycerine (NTG) as adjuncts to lidocaine in intravenous regional anesthesia (IVRA). Materials and Methods: Seventy-five, ASA grade I and II patients, aged between 20-50 years, scheduled for hand and forearm surgery were selected and entered randomly into three study groups. Patients in group C received 3 mg/kg of preservative free lidocaine 2% diluted with saline to a total volume of 40 ml. Patients in group M received 3 mg/kg of preservative free lidocaine 2% mixed with 6 ml of 25% magnesium sulphate (1.5 g) diluted with saline to a total volume of 40 ml. Patients in group N received 3 mg/kg of preservative free lidocaine 2% mixed with 200 ΅g of nitroglycerine diluted with saline to a total volume of 40 ml. Sensory and motor block onset and recovery time, tourniquet pain onset time, intraoperative fentanyl requirement, the total number of patients requiring rescue analgesia and the time to first analgesia requirement, intra-operative and postoperative degree of analgesia were evaluated. Results: The sensory and motor block onset times were shorter in group M and N as compared to group C (P- = 0.004, 0.0036 for sensory block, 0.021, 0.038 for motor block. The mean time of onset of sensory block was earliest in group M and the mean time of onset of motor block was earliest in group N. Mean time of onset of tourniquet pain in the three groups was similar in groups M and N. The sensory and motor block recovery time were significantly prolonged in M and N group as compared to group C (P < 0.001). Intraoperative fentanyl requirement (P value- = 0.041), the total number of patients requiring rescue analgesia (P value = 0.009) and the time to first analgesia requirement (P value = 0.038) were lower in group M. Conclusion: The addition of both magnesium suphate and nitroglycerin (NTG) to lidocaine for intravenous regional anesthesia (IVRA) leads to early onset of sensory block and prolonged postoperative analgesia, with no side effects.
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Seatbelt versus seatbelt and airbag injuries in a single motor vehicle crash
Ibrahim Afifi, Ayman El-Menyar, Hassan Al-Thani, Ruben Peralta
January-March 2015, 5(1):46-49
DOI:10.4103/2229-5151.152344  PMID:25810964
Seatbelt restraints are important for occupant safety which substantially reduces morbidity and mortality in severe motor vehicle crashes (MVC). Though, it has been established that the air bag and seatbelt use reduce injury severity and mortality but still there is limited information on the pattern of injury by restraint type. Herein, we presented two case reports which describe the injury pattern of two patients (both were restrained but only driver had airbag) involved in a single MVC. Both of them had severe traumatic injuries, however, the restrained passenger without airbag, sustained more severe injuries of intestine, kidney and spinal cord. In addition to seatbelt, airbag provides considerable protection against severe blunt abdominal trauma. Therefore, installation of airbags especially for front seat passenger is imperative for minimizing the risk of significant traumatic injuries.
  3 3,260 72
Cerebral venous sinus thrombosis with nontraumatic subdural hematoma
Ranjan Kumar Sahoo, Pradipta Tripathy, HN Praharaj
January-March 2015, 5(1):59-59
DOI:10.4103/2229-5151.152348  PMID:25810968
  3 1,911 75
Massive intracardiac thrombosis during coronary artery bypass grafting surgery
Sujatha P Bhandary, Thomas J Papadimos, Michael K Essandoh, John Apostolakis
January-March 2015, 5(1):56-58
DOI:10.4103/2229-5151.152347  PMID:25810967
Thrombosis is a potential life-threatening complication in patients undergoing cardiac surgery. Various clinical and heritable conditions, like cancer, trauma, immobilization, the presence of factor V Leiden or prothrombin 20210A, deficiency of or resistance to the inhibitor proteins C, S, or antithrombin, elevated levels of coagulation proteins, antiphospholipid antibody syndrome, pregnancy, and the use of exogenous hormones, may contribute to catastrophic thrombosis. Massive thrombi with cerebrovascular and cardiovascular events develop in patients with polycythemia vera (PV). However, thrombus formation in the cardiac chambers is extremely rare. We report a case of massive intracardiac thrombosis in a patient undergoing coronary artery bypass grafting.
  2 1,916 52
Impact of acetazolamide use in severe exacerbation of chronic obstructive pulmonary disease requiring invasive mechanical ventilation
Mabrouk Bahloul, Anis Chaari, Ahmed Tounsi, Olfa Turki, Kamilia Chtara, Chokri Ben Hamida, Hatem Ghadhoune, Hassen Dammak, Hedi Chelly, Mounir Bouaziz
January-March 2015, 5(1):3-8
DOI:10.4103/2229-5151.152296  PMID:25810957
Purpose: To analyse the impact of acetazolamide (ACET) use in severe acute decompensation of chronic obstructive pulmonary disease requiring mechanical ventilation and intensive care unit (ICU) admission . Patients and Methods: Retrospective pair-wise, case-control study with 1:1 matching. Patients were defined as cases when they had received acetazolamide (500 mg per day) and as controls when they did not received it. Patients were matched according to age , severity on admission (pH, PaO 2 /FiO 2 ratio) and SAPSII score. Our primary endpoint was the effect of ACET (500 mg per day) on the duration of mechanical ventilation. Our secondary endpoints were the effect of ACET on arterial blood gas parameters, ICU length of stay (LOS) and ICU mortality. Results: Seventy-two patients were included and equally distributed between the two studied groups. There were 66 males (92%). The mean age (± SD) was 69.7 ± 7.4 years ranging from 53 to 81 years . There were no differences between baseline characteristics of the two groups. Concomitant drugs used were also not significantly different between two groups. Mean duration of mechanical ventilation was not significantly different between ACET(+) and ACET(-) patients (10.6 ± 7.8 days and 9.6 ± 7.6 days, respectively; P = 0.61). Cases had a significantly decreased serum bicarbonate, arterial blood pH, and PaCO 2 levels . We did not found any significant difference between the two studied groups in terms of ICU LOS. ICU mortality was also comparable between ACET(+) and ACET(-) groups (38% and 52%, respectively; P = 0.23). Conclusion: Although our study some limitations, it suggests that the use of insufficient acetazolamide dosage (500 mg/d) ACET (500 mg per day) has no significant effect on the duration of mechanical ventilation in critically ill COPD patients requiring invasive mechanical ventilation. Our results should be confirmed or infirmed by further studies.
  2 3,093 154
Diagnosing bacterial peritonitis made easy by use of leukocyte esterase dipsticks
Kiran Chugh, Yuthika Agrawal, Vipin Goyal, Vinod Khatri, Pradeep Kumar
January-March 2015, 5(1):32-37
DOI:10.4103/2229-5151.152337  PMID:25810962
Introduction: Spontaneous bacterial peritonitis (SBP) requires rapid diagnosis for the initiation of antibiotics. Its diagnosis is usually based on manual examination of ascitic fluid (AF) having long reporting time. AF infection is diagnosed when the fluid polymorphonuclear leukocyte (PMNL) concentration ≥250 cells/mm 3 . Aims and Objectives: Aim was to evaluate the diagnostic utility of leukocyte esterase (LE) reagent strip for rapid diagnosis of SBP in patients who underwent abdominal paracentesis and to calculate the sensitivity, specificity, positive, and negative predictive values. Materials and Methods: The study was carried out on 103 patients with ascites. Cell count of AF as determined by colorimetric scale of Multistix 10 SG reagent strip was compared with counting chamber method (PMNL count ≥250 cells/mm 3 was considered positive). Results and Observations: Of the 103 patients SBP was diagnosed in 20 patients, 83 patients were negative for SBP by manual cell count. The sensitivity and specificity of the LE test for detecting neutrocytic SBP taking grade 2 as cut off were 95% and 96.4% respectively, with a positive predictive value of 86.4% and a negative predictive value of 98.8%. Diagnostic accuracy of LE test was 96.1%. Discussion: There was a good correlation between the reagent strip result and PMNL count. The LE strip test is based on the esterase activity of activated granulocytes which reacts with an ester-releasing hydroxyphenylpyrrole causing a colour change in the azo dye of reagent strip. It is a very sensitive and specific method for the prompt detection of elevated PMNL count, and represents a convenient, inexpensive, simple, and bedside method for diagnosis of SBP. A negative LE test result excludes SBP with a high degree of certainty.
  2 2,571 106
An uncommon pulmonary embolism
Renaud Prevel, Philippe Garcon, François Philippart
January-March 2015, 5(1):50-52
DOI:10.4103/2229-5151.152345  PMID:25810965
Objectives: To report an unusual case of suicide attempt secondary complicated of pulmonary and systemic embolisms. Data Source: A 49-year-old-woman, with a factor V Leiden mutation and a notion of chronic depression, admitted to our intensive care unit for a suicide attempt by ingestion ofmepronizine and lormetazepam. Data Extraction: We report the rare evolution of this patient with a persistent alteration of consciousness associating a respiratory degradation. Despite the drug intoxication and possibility of aspiration, we performed a computed tomography (CT) angiography which confirmed the presence of a bilateral, proximal, pulmonary embolism suspected on transthoracic echocardiography. A cerebral CT showed left sylvian and cerebellar infarctions complicated of perilesional edema. Association of stroke and pulmonary embolism led us to suspect a patent foramen ovale (PFO). There was also a context of genetical perturbation of hemostasis. Transesophageal echocardiography confirmed the presence of a PFO undiagnosed by transthoracic echography. The PFO was complicated by an entrapped thrombus. The thrombotic complications were treated by unfractionated heparin. Data Synthesis: Neurological and respiratory degradation following voluntary drug intoxication led to the discovery of both a pulmonary and cerebral embolism secondary to a PFO entrapped thrombus. Conclusions: An entrapped thrombus in a PFO is a rare and dangerous situation, associated with many complications. Association of systemic and pulmonary embolisms should lead to PFO detection to guide therapeutic interventions.
  1 1,836 59
Metastatic transitional cell carcinoma presenting with skin metastasis
Onur Açikgöz, Erkan Ölçücüoglu, Yusuf Kasap, Metin Yigman, Zeki Ender Günes, Eymen Gazel
January-March 2015, 5(1):53-55
DOI:10.4103/2229-5151.152346  PMID:25810966
Transitional cell carcinomas (TCC) of upper urinary system account for 5% of all TCCs. The incidence of such metastases ranges from 0.18% to 2%. Experimental studies reported a general unsatisfactory survival time following skin metastasis. We report in this paper a case of metastatic urinary system TCC, which had become evident with a skin lesion in the right hypogastric region. A 60-year-old female patient with a history of being operated upon due to renal pelvic TCC was admitted to our outpatient clinic with complaints of red skin lesion in the near vicinity of the operational incision scar for 3 months. Her medical history revealed nothing but nephroureterectomy operation on the upper urinary system; moreover, it was learned that she had been ignoring what was recommended to her for routine controls. Thoraco-abdominal computed tomographic (CT) examination performed on the basis of aforementioned findings depicted a mass lesion of 24*20 mm dimension with high contrast uptake detected within the subcutaneous fat tissue in the right abdominal wall. The skin lesion depicted in CT was surgically excised. The pathological examination of the excised material was reported to be compatible with TCC. The patient was referred due to abdominal lesion to medical oncology after the operation. Followed up under chemotherapy protocol, the patient died 3 months after the metastasectomy operation. Skin metastasis of upper urinary system TCCs, especially renal pelvic TCCs, are quite rare conditions. Among the likely skin sites of metastasis for genitourinary system TCCs are head, face, extremities, suprapubic region and abdomen. Taking into consideration the low survival rates, the importance of early diagnosis of recurrences and/or distant metastases should be better appreciated. These patients die soon after the skin metastasis even with the administration of aggressive therapy. Similarly, our patient died 90 days after the diagnosis of skin metastasis despite the oncologic therapy.
  1 625 33
Mid-gestational serum uric acid concentration effect on neonate birth weight and insulin resistance in pregnant women
Khadijeh Nasri, Maryamsadat Razavi, Mohammad Reza Rezvanfar, Esmat Mashhadi, Ali Chehrei, Abolfazl Mohammadbeigi
January-March 2015, 5(1):17-20
DOI:10.4103/2229-5151.152309  PMID:25810959
Objective : To investigate the relationship between mid-gestational serum uric acid and birth weight in diabetic pregnant women with or without insulin resistance. Methods: In a prospective cohort study, fasting uric acid, blood glucose, and serum insulin were measured in 247 pregnant women between 20-22 weeks of gestational period. Insulin resistance was estimated using the homeostasis model assessment-insulin resistance (HOMA-IR). Stratification analysis and independent t-test was used to assess the association between uric acid and birth weights regarding to insulin resistance. Results : The means of the mid-gestational serum uric acid concentrations were not significantly different in women with and without insulin resistance. But stratification analysis showed that there was a significant difference between uric acid concentration and macrosomic birth in diabetic women without insulin resistance. Conclusions: Higher mid - gestation serum uric acid concentration, even if it does not exceed the normal range, is accompanied by lower birth weight only in non-insulin resistance women. Insulin resistance could have a negative confounding effect on hyperuriemia and birth weight.
  1 2,119 105
The assessment of an in-vitro model for evaluating the role of PARP in ethanol-mediated hepatotoxicity
Jayme P Coyle, A Mayo-Perez, M Bourgeois, G Johnson, S Morris, RD Harbison
January-March 2015, 5(1):9-16
DOI:10.4103/2229-5151.152300  PMID:25810958
This investigation aims to assess whether the hepatocellular carcinoma cell line, HepG2, is an appropriate model to assess the role of poly (ADP-ribose) polymerase (PARP) during acute ethanol toxicosis. HepG2 cells were dosed with graded concentrations of ethanol, ranging from 100 mM to 800 mM, for 6 hours to assess PARP activity induction, while another parallel experiment examined cellular damage via medium aspartate aminotransferase activity and cellular viability via MTT reduction. Aspartate aminotransferase activity was significantly elevated at 600 mM ethanol (FOLD; P < 0.01), with further increases at the 800 mM dose (1.43 fold; P < 0.001), compared to controls. Cellular viability was not significantly decreased compared to controls among all dose groups. PARP activity measured in total cell lysates showed a significant decreasing trend with respect to ethanol dose, reaching statistical significance at the 100 mM dose group (P < 0.05). Paradoxically, exposure to 50 μM etoposide (Positive apoptosis-inducing control) did not demonstrate significant PARP activity ablation. When analyzing PARP activity observation temporally, a significant correlation (R΂ =0.5314) was observed between activity and assay sequence. Overall, a clear HepG2 insensitivity to ethanol was observed.
  1 2,325 76
What is new in critical illness and injury science? Acetazolamide in decompensated respiratory failure!
Jacopo Colombo
January-March 2015, 5(1):1-2
DOI:10.4103/2229-5151.152293  PMID:25810956
  - 1,616 80
A letter in response to"Thoracostomy tubes: A comprehensive review of complications and related topics"
Animesh Ray
January-March 2015, 5(1):61-62
DOI:10.4103/2229-5151.152350  PMID:25810970
  - 1,129 54
Predictors of mortality in poisonous snake bite
Sim Sai Tin, Viroj Wiwanitkit
January-March 2015, 5(1):62-62
DOI:10.4103/2229-5151.152351  PMID:25810971
  - 1,204 75
Guillain-Barré syndrome presenting as Bell's palsy with crossed hemiparesis
Vivek Chauhan, G Sharma, BS Rana, V Jearth, J Sandhu
January-March 2015, 5(1):62-63
DOI:10.4103/2229-5151.152352  PMID:25810972
  - 1,588 56
Partial optic atrophy and homonymous quadrantanopia in a patient with occipital encephalomalacia
Ali Akal, Tugba Goncu, Nurefsan Boyaci, Bahattin Celik, Ozcan Kocaturk
January-March 2015, 5(1):63-64
DOI:10.4103/2229-5151.152353  PMID:25810973
  - 1,443 53
Child-witnessed domestic violence: An epidemic in the shadows
Areti Tsavoussis, Stanislaw PA Stawicki, Thomas J Papadimos
January-March 2015, 5(1):64-65
DOI:10.4103/2229-5151.152354  PMID:25810974
  - 1,454 45
A crying shame: Battered baby
Shasanka Shekhar Panda, Pankaj Kumar Mohanty, Meely Panda, Rashmi Ranjan Das, Arundeep Arora
January-March 2015, 5(1):65-66
DOI:10.4103/2229-5151.152355  PMID:25810975
  - 1,239 40
New year's eve pediatric celebratory gunshot wound
Jonathan W Meadows, Veronica T Tucci, Dainius A Drukteinis, Kevin Farquharson
January-March 2015, 5(1):66-68
DOI:10.4103/2229-5151.152356  PMID:25810976
  - 1,376 35
Concomittant chronic lymphocytic leukemia and colon cancer a patient presenting with ileus
Zerrin Demirturk, Tuba Hacibekiroglu, Ayhan Akpinar
January-March 2015, 5(1):68-68
DOI:10.4103/2229-5151.152357  PMID:25810977
  - 1,177 44
Prevalence of derangement of coagulation profile in surgical patients and its outcome in India
Iftikaar Ahmad, Akshay Anand, Jitendra Kumar Kushwaha, Abhinav A Sonkar
January-March 2015, 5(1):68-69
DOI:10.4103/2229-5151.152358  PMID:25810978
  - 1,281 58
Clinical conundrums and challenges during geriatric orthopedic emergency surgeries
Sukhminder Jit Singh Bajwa
January-March 2015, 5(1):38-45
DOI:10.4103/2229-5151.152342  PMID:25810963
Despite so many advancements and innovations in anesthetic techniques, expectations and challenges have also grown in plenty. Cardiac, pediatric, obstetric and neuro-anesthesia have perfectly developed to fulfill the desired needs of respective patient population. However, geriatric anesthesia has been shown a lesser interest in teaching and clinical practices over the years as compared with other anesthetic sub-specialties. The large growing geriatric population globally is also associated with an increase number of elderly patients presenting for orthopedic emergency surgeries. Orthopedic emergency surgery in geriatric population is not only a daunting clinical challenge but also has numerous socio-behavioral and economic ramifications. Decision making in anesthesia is largely influenced by the presence of co-morbidities, neuro-cognitive functions and the current socio-behavioral status. Pre-anesthetic evaluation and optimization are extremely important for a better surgical outcome but is limited by time constraints during emergency surgery. The current review aims to highlight comprehensively the various clinical, social, behavioral and psychological aspects during pre-anesthetic evaluation associated with emergency orthopedic surgery in geriatric population.
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