Rapid sequence induction (RSI) in trauma patients:Insights from healthcare providers / 世界急诊医学杂志（英文）

BACKGROUND@# We aimed to describe the current practice of emergency physicians and anaesthesiologists in the selection of drugs for rapid-sequence induction (RSI) among trauma patients.@*METHODS@# A prospective survey audit was conducted based on a self-administered questionnaire among two intubating specialties. The preferred type and dose of hypnotics, opioids, and muscle relaxants used for RSI in trauma patients were sought in the questionnaire. Data were compared for the use of induction agent, opioid use and muscle relaxant among stable and unstable trauma patients by the intubating specialties.@*RESULTS@#A total of 102 participants were included; 47 were anaesthetists and 55 were emergency physicians. Propofol (74.5%) and Etomidate (50.0%) were the most frequently used induction agents. Significantly higher proportion of anesthesiologist used Propofol whereas, Etomidate was commonly used by emergency physicians in stable patients (P=0.001). Emergency physicians preferred Etomidate (63.6%) and Ketamine (20.0%) in unstable patients. The two groups were comparable for opioid use for stable patients. In unstable patients, use of opioid differed significantly by intubating specialties. The relation between rocuronium and suxamethonium use did change among the anaesthetists. Emergency physicians used more suxamethonium (55.6% vs. 27.7%, P=0.01) in stable as well as unstable (43.4 % vs. 27.7%, P=0.08) patients.@*CONCLUSION@# There is variability in the use of drugs for RSI in trauma patients amongst emergency physicians and anaesthesiologists. There is a need to develop an RSI protocol using standardized types and dose of these agents to deliver an effective airway management for trauma patients.

Predisposing factors, clinical assessment, management andoutcomes of agitation in the trauma intensive care unit / 世界急诊医学杂志（英文）

BACKGROUND: Agitation occurs frequently among criticaly il patients admitted to the intensive care unit (ICU). We aimed to evaluate the frequency, predisposing factors and outcomes of agitation in trauma ICU. METHODS: A retrospective analysis was conducted to include patients who were admitted to the trauma ICU between April 2014 and March 2015. Data included patient's demographics, initial vitals, associated injuries, Ramsey Sedation Scale, Glasgow Coma Scale, head injury lesions, use of sedatives and analgesics, head interventions, ventilator days, and ICU length of stay. Patients were divided into two groups based on the agitation status. RESULTS: A total of 102 intubated patients were enrolled; of which 46 (45％) experienced agitation. Patients in the agitation group were 7 years younger, had significantly lower GCS and sustained higher frequency of head injuries (P<0.05). Patients who developed agitation were more likely to be prescribed propofol alone or in combination with midazolam and to have frequent ICP catheter insertion, longer ventilatory days and higher incidence of pneumonia (P<0.05). On multivariate analysis, use of propofol alone (OR=4.97; 95％CI=1.35–18.27), subarachnoid hemorrhage (OR=5.11; 95％CI=1.38–18.91) and ICP catheter insertion for severe head injury (OR=4.23; 95％CI=1.16–15.35) were independent predictors for agitation (P<0.01). CONCLUSION: Agitation is a frequent problem in trauma ICU and is mainly related to the type of sedation and poor outcomes in terms of prolonged mechanical ventilation and development of nosocomial pneumonia. Therefore, understanding the main predictors of agitation facilitates early risk-stratification and development of better therapeutic strategies in trauma patients.

Renal cell carcinoma metastasizing to parotid gland

Renal cell carcinoma [RCC] has diverse behaviour. At the time of diagnosis, many patients are found to have metastases. Bones, lungs, liver and brain are the frequent homing sites of metastases. Parotid gland metastasis is the rarest manifestation of RCC. Here-in we report a case of a 70 year old Saudi male who underwent radical left nephrectomy in February 1997 for renal cell carcinoma [RCC] pT2N0M0. After remaining asymptomatic for 15 years, in January 2012, he presented with four months history of left cheek mass. Subsequent computed tomography [CT] and CT- positron emission tomography [PET] imaging showed left parotid lesion of size 1.3 cm. Patient underwent left parotidectomy. Histopathology was consistent with metastatic RCC. At nine months after metastatectomy, patient was doing well without any disease recurrence

Dust mites in a routine clinical stool sample

We report a case of dust mite carriage in a 56-year-old gentleman. Dust mites eggs and larvae were found in a stool sample which was taken for a routine clinical examination. He was completely asymptomatic with no history of rash, airway disease or other allergic manifestations associated with dust mites. We noticed that the oval structure of mite eggs resembled helminth eggs and therefore may be misidentified during routine clinical analysis. As the patient was otherwise healthy, it was concluded that no rigorous antiparasitic therapy was necessary to eliminate dust mites from his system.

Human ophthalmomyiasis externa caused by the sheep botfly Oestrus ovis：a case report from Karachi, Pakistan

Ocular myiasis due to Oestrus ovis larvae infestation is an eye infection in humans. A case of ophthalmomyiasis externa in a young male from Karachi, Pakistan in winter (December 2012), without history of close proximity to domestic animals or visit to any rural area was reported. The condition is self-limiting and the disease is confined to the conjunctiva. The eye was locally anesthetized and washed with 5% povidine iodine solution. A total number of 27 first instar larvae of Oestrus ovis were removed with fine forceps. The patient received 0.5% moxifloxacin and diclofenac eye drops for one week. His eye was examined after one day, one week and one month and the recovery status was favorable. The present case raise the awareness among ophthalmologists regarding larval conjunctivitis as one of the causes of conjunctivitis and it can occur throughout the year in any season including winter. Moreover, it can occurr in any area either rural or urban with or without close proximity to domestic animals especially in subtropical regions with high parasitic burden.

Promoter region polymorphism & expression profile of toll like receptor-3 (TLR-3) gene in chronic hepatitis C virus (HCV) patients from India.

Background & objectives: Hepatitis C virus (HCV) induces an immune response of the host, manifested by the formation of anti-HCV antibodies mediated by adaptive and innate immunity. Toll-like receptors (TLRs) play a pivotal role in innate immunity system. This study was aimed to investigate the promoter region polymorphism and expression of TLR3 gene in patients with chronic HCV infection. Methods: Patients with chronic HCV infection (N=180) and an equal number of age-sex matched controls were included in the study. Patients positive for HCV-RNA were subjected to analysis of TLR3 polymorphism by direct sequencing of PCR products verified by comparing with the sequences reported in the National Centre for Biotechnology Information (NCBI) database (accession number: NT 022792). Expression of TLR3 gene was analyzed by semiquantitative RT-PCR using housekeeping β-actin gene as the internal control. Results: Polymorphisms at position -288G/A and -705A/G were identified. The results were significant in -705 allele (P=0.004) OR 2.79(1.46-5.42) and were associated with high risk of HCV infection. In silico sequence analysis showed the presence of ectropic viral integration site 1 encoded factor, in which G at -705 results in the loss of this site. The -7C/A polymorphism was not seen in our study cohort. The expression of TLR3 was upregulated in chronic HCV patients compared to healthy controls. Interpretation & conclusions: Polymorphism in the -705A/G allele at the promoter region of the TLR3 gene may predispose individual to HCV infection. However association of TLR3 expression with polymorphism of TLR3 promoter was not found.

Evaluation of adefovir & lamivudine in chronic hepatitis B: correlation with HBV viral kinetic, hepatic-necro inflammation & fibrosis.

Background & objectives: Chronic hepatitis B is an important cause of morbidity and mortality. We conducted a study comparing the efficacy of adefovir and lamivudine with respect to their impact on serum and hepatic viral DNA clearance, and improvement in hepatic necro-inflammatory score, in naive patients of chronic hepatitis B. Methods: This prospective randomized pilot study was conducted in Lok Nayak Hospital, New Delhi, involving 30 patients of chronic hepatitis B (both e antigen positive and negative); 15 were randomly selected to receive either adefovir or lamivudine for a period of 6 months. Quantification of serum and hepatic HBV DNA levels was done by real time PCR and liver biopsy was done at the beginning and end of 6 months. Results: Serum ALT was elevated to 2 or more times normalized in both the groups. In the adefovir group, two patients became HBeAg negative. In the lamivudine group, one patient became HBeAg negative. After therapy HBV DNA was negative in 26.7 per cent patients from adefovir group and 13.3 per cent patients from lamivudine group. Serum HBV DNA levels were correlated with the hepatic levels before therapy (r=0.843; P<0.001) and after therapy (r=0.713, P<0.001) showing strong correlation. There was a median reduction of 1.92 and 2.06 log copies per ml in serum HBV DNA load after adefovir and lamivudine therapy, respectively. The mean reduction in the histotogy activity index (HAI) score was 2 and 1.53, fibrosis score was 2.33 and 3.06 after adefovir and lamivudine therapy respectively. Interpretation & conclusions: Adefovir and lamivudine treatment caused biochemical and serological improvement when administered for about 6 months with significant reduction in HBV DNA, serum and hepatic viral load without completely clearing the virus from either serum or liver. It also helped in reduction of the necro-inflammatory and fibrosis score of patients with chronic hepatitis B. Our study also showed significant correlation between serum and hepatic HBV DNA levels both before and after therapy. There was not enough evidence to show therapeutic advantage of one drug over the other in any of the parameters measured.

Significance of anti-HBc screening of blood donors & its association with occult hepatitis B virus infection: Implications for blood transfusion.

Background & objective: Expansions of blood donor screening and improved laboratory detection of viral markers have remarkably reduced the risk for infection with transfusion-transmitted viruses. This study was aimed to evaluate the presence of anti-HBc and to determine the presence or absence of HBV DNA in the serum samples from HBsAg negative, anti-HBc positive blood donors in a tertiary care hospital blood bank from Delhi. Methods: A total of 2175 HBsAg negative, first time volunteer blood donors were included in the study from blood bank, Lok Nayak Hospital, New Delhi. The blood specimens from all these subjects were evaluated for anti-HBV-core antigen (anti-HBc) serology, anti-HBV-surface antigen (anti-HBs) titres and HBeAg. The presence of HBV DNA was evaluated by testing, through polymerase chain reaction (PCR) techniques. Results: Of the 2175 HBsAg negative voluntary blood donors, 413 (19.8%) were tested to be positive for anti-HBc alone. Of these, 153 (group-I) were anti-HBs negative whereas group-II comprises a total of 260 anti-HBs positive cases i.e. 89 out of 413 had anti-HBs titres of 10-99 IU/l and the remaining 171 had anti-HBs titres of 100-500 IU/l. HBV DNA was detected in 7.5 per cent anti-HBc positive samples irrespective of anti-HBs status. Interpretation & conclusions: Our results showed that 18.9 per cent of our donor population was anti-HBc reactive, and hence inclusion of anti-HBc testing will lead to a high discard rate. The presence of HBV DNA in fairly high percentage of anti-HBc positive samples highlighted the need for a stringent and better screening system to prevent occult HBV infection.

Clinical & molecular characterization of human TT virus in different liver diseases.

Background & objectives: TT virus (TTV) is a newly discovered non-enveloped, single stranded DNA virus of high genotypic variability, found frequently in patients with acute or chronic hepatitis of non A-G aetiology. This study was carried out to look for the presence of TTV and its genotypes in patients with different types of liver diseases from northern India. Methods: A total of 262 serum samples from patients of acute viral hepatitis (AVH; n=72), fulminant hepatic failure (FHF; n=49), chronic active hepatitis (CAH; n=93) and liver cirrhosis (LC; n=48), were analyzed for hepatitis A-G viral markers. TTV DNA was detected in all cases by nested polymerase chain reaction (PCR) using the primers from N22 and untranslated (UTR) region. TTV-DNA was also tested in 150 volunteer blood donors. Direct nucleotide sequencing of N22 amplicons were carried out to look into the prevalent TTV genotypes. Results: TTV-DNA was detected in 73.6, 59.2, 21.5 and 29.1 per cent cases with AVH, FHF, CAH and cirrhosis, respectively. In AVH and FHF groups, TTV showed co-infection with all A-G hepatitis cases whereas in CAH and cirrhosis groups, TTV co-infection observed with HBV, HCV and HGV. TTV-DNA was detected in 45.3 per cent volunteer blood donors. No statistically significant difference was observed amongst the mean liver function profile of UTR PCR positive and negative cases in different liver disease groups except AVH cases, in whom the various biochemical parameters between TTV positive and TTV negative patients were marginally significant. However, no significant evidence of biochemical or histological deterioration of the liver was observed in TTV positive cases amongst FHF, CAH and cirrhosis. Predominance of genotype 1a was observed in all the cases from north India. Interpretation & conclusions: TTV is a frequent virus isolated from patients with various types of liver diseases as well as in healthy individuals from northern India. TTV has no effect on biochemical markers of associated liver diseases. Genotype 1a was the most predominant type in different liver disease groups. The occurrence of TTV did not further influence the course of the disease.