Lambda-cyhalothrin ingestion: an infrequent yet concerning presentation of pyrethroid poisoning.

Introduction and importance: Lambda-cyhalothrin is a type II pyrethroid compound commonly used as a pesticide, with the potential to cause life-threatening toxicity in humans. Furthermore, among cases of pesticide poisoning in Nepal, organophosphates are most frequently implicated. Case presentation: A 40-year-old female presented to our hospital after ingesting a pesticide compound with suicidal intent. She also admitted to alcohol intoxication and exhibited symptoms of confusion, abdominal pain, nausea, and vomiting. An atropine challenge test yielded negative results. Therefore, conservative management was continued. It was discovered later that the ingested pesticide was lambda-cyhalothrin. The patient's condition eventually improved with supportive treatment. Clinical discussion: Several reports have highlighted the overlapping clinical features between organophosphorus and pyrethroid poisoning. In some cases of pyrethroid poisoning, misdiagnosis as organophosphorus poisoning has occurred, leading to the inappropriate administration of atropine. In our case, initial management was challenging owing to the lack of accurate information about the ingested compound. On further evaluation, cholinergic clinical features were absent and the atropine challenge test was negative. This was suggestive of nonorganophosphorus compound poisoning. Conclusion: This case illustrates that managing pesticide poisoning becomes challenging when the nature of the pesticide is unknown. Patients suffering from poisoning caused by pyrethroid compounds like lambda-cyhalothrin can present with features resembling organophosphorus poisoning. In such circumstances, a comprehensive clinical evaluation should guide the management. Clinical features and an atropine challenge test can aid in differentiating organophosphorus from nonorganophosphorus compound poisoning. This distinction facilitates therapeutic decision-making, including the consideration of atropine administration.

Effect of obesity on autonomic functions of Heart among healthy volunteers at a teaching Institute.

Background: Obesity usually results from an imbalance between energy intake and energy expenditure, that is, energy homeostasis, which is controlled by the autonomic nervous system. This imbalance results from multifaceted interactions of genetic, physiological, behavioral, environmental, endocrine, nervous, metabolic factors, which lead to hemodynamic and metabolic alteration. Objective: To study the effect of obesity on the autonomic functions of the heart. Methods: An observational analytical study was carried out among 100 subjects. All healthy volunteers of 30-50 years were included. The subjects were grouped into two categories of body mass index (BMI): 30-39.99 kg/m2 as Obese group and BMI: 18.50-24.99 kg/m2 as Non -Obese group. Out of 100 subjects, 50 were obese and 50 were non-obese. The interview was taken. General physical examination and anthropometric measurements were recorded. The assessment of various cardiac autonomic function tests was carried out. Results: Both groups were comparable for age and sex (P = 0.754). The resting heart rate, SBP, and DBP in the obese group were significantly higher compared to the non-obese group (P < 0.05). All values of autonomic function tests in the non-obese group were significantly higher compared to the obese group (P < 0.05) except for the Standing to lying ratio (P > 0.05). The values of SBP and DBP increased significantly in the non-obese people after the isometric handgrip test and cold press test compared to the obese people (P < 0.05). Conclusion: We conclude that the resting HR, SBP, and DBP were higher in obese people. However, after applying autonomic function tests, non-obese people respond better to these tests compared to obese people in the form of an increase in these parameters. Obesity is, thus, found to affect the autonomic function tests.

Emergency medical dispatcher training as a strategy to improve pre-hospital care in low- and middle-income countries: the case study of Nepal.

BACKGROUND: Low- and middle-income countries (LMICs) often face significant challenges related to providing effective pre-hospital care services. Barriers to providing care include lack of financial resources, poor road infrastructure, lack of trained first responders and ambulance staff, and issues regarding coordination/communication between different entities involved in Emergency Medical Services. Prior initiatives to characterize and improve the state of pre-hospital care in LMICs have largely focused on improving access to high-quality ambulance services by providing training programs to community first responders and ambulance staff on how to recognize and manage key emergency conditions. In this article, we discuss an alternative strategy for improving pre-hospital care: the creation of a context-specific Emergency Medical Dispatcher (EMD) training curriculum and program. METHODS: We describe the current pre-hospital care setting in Nepal, the process of creating and piloting the Nepal-specific EMD training manual, and the early impact of its implementation. RESULTS: The 30-h EMD training was designed, piloted, and revised in collaboration with the three largest EMS organizations in Nepal. The training is now required for all dispatchers at the Dhulikhel Hospital Dispatch Center, one of the largest ambulance dispatch networks in Nepal. Dispatchers are trained in the following knowledge and skill areas: telecommunication guidelines, triaging and documentation procedures, delivery of Basic Life Support instructions to callers, other medical and trauma-condition specific instructions, and limited resource management. The short-term positive impacts of the training's implementation include improved documentation procedures, better prioritization of ambulance resources, delivery of Basic Life Support instructions to callers, and improved communication between dispatch, responders, and healthcare facilities. CONCLUSIONS: Context-specific Emergency Medical Dispatch training programs, which aim to optimize the emergency resources available in resource-limited settings, present a promising low-cost, high-impact interventional strategy to strengthen the pre-hospital care systems in low- and middle-income countries.

Plasma Free Homocysteine Levels in Children with Idiopathic Nephrotic Syndrome.

Altered metabolism of homocysteine in children with idiopathic nephrotic syndrome leads to raised plasma-free homocysteine levels. Elevated free homocysteine causes endothelial cell dysfunction and promotes early atherosclerosis and glomerulosclerosis. In this analytical study with a longitudinal follow-up, 29 children with first episode of nephrotic syndrome (FENS) aged 1-16 years along with 30 age andgender-matched healthy controls were enrolled. Plasma-free homocysteine was measured using high-performance liquid chromatography (HPLC). Other variables were measured using standard biochemical methods. The primary outcome measure was plasma-free homocysteine level in children with FENS and in controls. The secondary outcome measure was to observe the levels of plasma-free homocysteine in children with FENS at 12 weeks in remission and in steroid resistant states. Plasma-free homocysteine levels were significantly elevated in children with FENS at disease onset [Median (IQR) 2.170 (1.54-2.71); N = 29; P < 0.001], at 12 weeks of steroid-induced remission [Median (IQR) 1.946 (1.53-2.71); N = 22; P < 0.001], and in steroid-resistant states [Median (IQR) 2.262 (1.53-2.74); N = 7; P < 0.001] compared to controls. The levels did not decrease significantly at 12 weeks of steroid-induced remission compared to onset of nephrotic syndrome. Plasma-free homocysteine levels correlated positively with serum total cholesterol (P = 0.005; r = 0.362) and negatively with serum albumin (P = 0.032; r = 0.281). Plasma-free homocysteine levels are raised in children with FENS posing a risk of endothelial dysfunction which persists at least in short term. Long-term effects of raised plasma-free homocysteine needs to be studied.

On the relation between fluvio-deltaic flood basin geomorphology and the wide-spread occurrence of arsenic pollution in shallow aquifers.

Pollution of groundwater with natural (geogenic) arsenic occurs on an enormous, world-wide scale, and causes wide-spread, serious health risks for an estimated more than hundred million people who depend on the use of shallow aquifers for drinking and irrigation water. A literature review of key studies on arsenic concentration levels yields that Holocene fluvial and deltaic flood basins are the hotspots of arsenic pollution, and that the dominant geomorphological setting of the arsenic-polluted areas consists of shallow-depth meandering-river deposits with sand-prone fluvial point-bar deposits surrounded by clay-filled (clay plug) abandoned meander bends (oxbow lakes). Analysis of the lithofacies distribution and related permeability contrasts of the geomorphological elements in two cored wells in a point bar and adjacent clay plug along the Ganges River, in combination with data of arsenic concentrations and organic matter content reveals that the low-permeable clay-plug deposits have a high organic matter content and the adjacent permeable point-bar sands show high but spatially very variable arsenic concentrations. On the basis of the geomorphological juxtaposition, the analysis of fluvial depositional processes and lithofacies characteristics, inherent permeability distribution and the omnipresence of the two geomorphological elements in Holocene flood basins around the world, a generic model is presented for the wide-spread arsenic occurrence. The anoxic deeper part (hypolimnion) of the oxbow lake, and the clay plugs are identified as the loci of reactive organic carbon and microbial respiration in an anoxic environment that triggers the reductive dissolution of iron oxy-hydroxides and the release of arsenic on the scale of entire fluvial floodplains and deltaic basins. The adjacent permeable point-bar sands are identified as the effective trap for the dissolved arsenic, and the internal permeability heterogeneity is the cause for aquifer compartmentalization, with large arsenic concentration differences between neighboring compartments.

Trauma team discord and the role of briefing.

BACKGROUND: Briefing of the trauma team before patient arrival is unstructured in many centers. We surveyed trauma teams regarding agreement on patient care priorities and evaluated the impact of a structured, physician-led briefing on concordance during simulated resuscitations. METHODS: Trauma nurses at our Level II center were surveyed, and they participated in four resuscitation scenarios, randomized to "briefed" or "nonbriefed." For nonbriefed scenarios, nurses independently reviewed triage sheets with written information. Briefed scenarios had a structured 4-minute physician-led briefing reviewing triage sheets identical to nonbriefed scenarios. Teams included three to four nurses (subjects) and two to four confederates (physicians, respiratory therapists). Each team served as their own control group. Confederates were blinded to nurses' briefed or nonbriefed status. Immediately before, and at the midpoint of each scenario, nurses estimated patients' morbidity and mortality and ranked the top 3 of 16 designated immediate care priorities. Briefed and nonbriefed groups' responses were compared for (1) agreement using intraclass correlation coefficient, (2) concordance with physicians' responses using the Fisher exact test, (3) teamwork via T-NOTECHS ratings by nurses and physicians using t-test, and (4) time to complete clinical tasks using t test. RESULTS: Thirty-eight nurses participated. Ninety-seven percent "agreed/strongly agreed" briefing is important, but only 46% agreed briefing was done well. Comparing briefed versus nonbriefed scenarios, nurses' estimation of morbidity and mortality in the briefed scenarios showed significantly greater agreement with each other and with physicians' answers (p < 0.01). Rank lists also better agreed with each other (intraclass correlation coefficient, 0.64 vs 0.59) and with physicians' answers in the briefed scenarios. T-NOTECHS Leadership ratings were significantly higher in the briefed scenarios (3.70 vs 3.39; p < 0.01). Time to completion of key clinical tasks was significantly faster for one of the briefed scenarios. CONCLUSIONS: Discordant perceptions of patient care goals was frequently observed. Structured physician-led briefing seemed to improve interprofessional team concordance, leadership, and task completion in simulated trauma resuscitations.

Role confusion and self-assessment in interprofessional trauma teams.

BACKGROUND: Trauma care requires coordinating an interprofessional team, with formative feedback on teamwork skills. We hypothesized nurses and surgeons have different perceptions regarding roles during resuscitation; that nurses' teamwork self-assessment differs from experts', and that video debriefing might improve accuracy of self-assessment. METHODS: Trauma nurses and surgeons were surveyed regarding resuscitation responsibilities. Subsequently, nurses joined interprofessional teams in simulated trauma resuscitations. After each resuscitation, nurses and teamwork experts independently scored teamwork (T-NOTECHS). After video debriefing, nurses repeated T-NOTECHS self-assessment. RESULTS: Nurses and surgeons assumed significantly more responsibility by their own profession for 71% of resuscitation tasks. Nurses' overall T-NOTECHS ratings were slightly higher than experts'. This was evident in all T-NOTECHS subdomains except "leadership," but despite statistical significance the difference was small and clinically irrelevant. Video debriefing did not improve the accuracy of self-assessment. CONCLUSIONS: Nurses and physicians demonstrated discordant perceptions of responsibilities. Nurses' self-assessment of teamwork was statistically, but not clinically significantly, higher than experts' in all domains except physician leadership.

Electric stimulations mediated beta lactam resistance reversal and correlation with growth dynamics of community acquired methicillin resistant Staphylococcus aureus.

The community associated methicillin resistant Staphylococcus aureus (CA-MRSA) is a serious issue of public health. Here, we conducted an experimental approach to determine: (i) the optimal significant stimulation range of electrical current for effective checking of CA-MRSA growth; (ii) the effect of electrical stimulations on methicillin susceptibility and possible beta lactam resistance reversal; and (iii) the variation in the level of ATP as function of exposure to electric current. An 8 chambered electrical system was developed for DC flow in control and test sets, with and without drug (oxacillin 4 mg/ml). Measurement of growth by CFU/ml and spectrometry, susceptibility and ATP levels were calculated and interpreted. Linear pattern in reduction of ATP was observed with respect to the intensity of electric current (EC) and an enhanced inhibitory effect was explicit with 1000 microampere (µA) with 30 min exposure. At 4000 µA exposure to DC at 180 min and in combination of drug (µA+D), the growth of CA-MRSA was substantially checked to 0.23 absorbance in comparison to current without drug and the effect of DC electrical current to the culture showed that 10 µA, 100 µA and 4000 µA current exposure in combination of oxacillin (µA+D), markedly reduced the CFU to an average of 256.4. ATP level was linearly reduced with exposure to EC.

Homocysteine metabolism in children with idiopathic nephrotic syndrome.

BACKGROUND: Homocysteine metabolism is altered in children with idiopathic nephrotic syndrome. Hyperhomocysteinemia is a risk factor of early atherosclerosis and glomerulosclerosis and may occur at time of first occurrence of idiopathic nephrotic syndrome. METHODS: Thirty children with first episode of idiopathic nephrotic syndrome (FENS) aged 1-16 years along with 30 age- and sex-matched healthy controls were enrolled in this study. Homocysteine and cysteine were measured with HPLC; vitamin B12 and folic acid were measured with electro-chemilumiscence immunoassay. Primary outcome measure was plasma homocysteine level in children with FENS and in controls. Secondary outcome measures were (1) plasma and urine homocysteine and cysteine levels in children with FENS at 12 weeks and 1 year (remission) and (2) plasma and urine levels of vitamin B12 and folic acid in children with FENS, at 12 weeks and 1 year (remission). RESULTS: Plasma homocysteine and cysteine levels were comparable to controls in children with FENS, at 12 weeks and 1-year remission. Plasma levels of vitamin B12 and folic acid were significantly decreased compared to controls in FENS due to increased urinary excretion, which normalize during remission at 12 weeks and 1 year. Urinary homocysteine and cysteine levels were significantly raised in FENS compared to controls and continued to be raised even at 12-week and 1-year remission. CONCLUSION: Homocysteine metabolism is deranged in children with FENS. Renal effects of long-term raised urinary homocysteine levels need to be studied.

Two cases of restavek-related illness: clinical implications of foster neglect in Haiti.

Restaveks, or indentured foster children, are a poorly understood, vulnerable subclass of Haitian society. From 2001 to the present, a partnership between multiple US academic medical centers and Project Medishare for Haiti has held an ongoing series of mobile clinics in rural Haiti. Multiple cases of restavek-related illness were identified. At a recent pair of mobile clinics, the authors identified two restavek cases that were significantly worse off than their communal peer groups and required immediate care. Given the lack of a robust legal support to protect orphaned children in Haiti, clinicians have an important role in advocating for restaveks at the bedside. The plight of Haiti's restaveks is widely reported in the human rights literature but is not publicly recognized as an issue for community health and wellbeing among physicians. To address these health disparities, the health consequences of an entire class of neglected children must be further explored.

Uterine artery pseudoaneurysm rupture: a life-threatening presentation of vaginal bleeding.

Uterine artery pseudoaneurysm rupture is a rare, yet life-threatening, cause of postpartum hemorrhage. Prompt recognition and management are critical in severe vaginal bleeding. In this case, diagnosis by bedside ultrasonography and initial management with vaginal packing and fluid resuscitation were performed in the emergency department. Definitive treatment by selective arterial embolization was performed to achieve hemostasis. This article discusses options available in the diagnosis, management, and treatment of uterine artery pseudoaneurysm hemorrhage.