Prevalence of Atrial Fibrillation on a 24-hour Holter in Adult Indians.

OBJECTIVE: To evaluate paroxysmal atrial fibrillation (AF) prevalence in Indian adults who completed 24-Hour Holter monitoring. METHODS: A total of 23,847 patients (36.9% women) were analyzed for AF duration using using a software algorithm. RESULTS: AF was diagnosed in 4,153 (17.4%) patients with a median AF duration of 13 minutes and 55 seconds. CONCLUSION: AF prevalence was high and largely untreated. The short duration of AF episodes indicates a low likelihood of detection during clinical visits, highlighting its potential underestimation in Indian healthcare.

Successful management of a thoracoabdominal impalement injury.

A 63-year-old female presented to the hospital with a history of alleged accidental fall onto a rusted iron rod. She was hypotensive but stable. Cooling of the rod while cutting the protruding part was performed as per basic trauma life support (BTLS) access. Following resuscitation, she was re-evaluated clinically and radiologically, and prepared for surgery. The iron rod trajectory was shown on computed tomography (CT) scan to be entering through the left popliteal fossa, then traversing the abdominal cavity with injury to the descending colon and the left dome of the diaphragm. At laparotomy the iron rod was removed under vision. The laceration to the left dome of the diaphragm was repaired. The perforation of the descending colon was identified and repaired. Colostomy was deferred as there was no peritoneal contamination. The penetrating thigh wound was debrided. Her recovery was uneventful. She was discharged on postoperative day 15. She came for follow-up as out-patient after 3 weeks and the thigh wound had healed. Impalement injuries are rare and often severe. Most impalement injuries require a multidisciplinary approach. Adequate early resuscitation, proper evaluation and early surgical management is ideal. Immediate stabilisation of the foreign body from the time of encounter is essential. Removal under anaesthesia is mandatory.

Successful management of a thoracoabdominal impalement injury.

A 63-year-old female presented to the hospital with a history of alleged accidental fall onto a rusted iron rod. She was hypotensive but stable. Cooling of the rod while cutting the protruding part was performed as per basic trauma life support (BTLS) access. Following resuscitation, she was re-evaluated clinically and radiologically, and prepared for surgery. The iron rod trajectory was shown on computed tomography (CT) scan to be entering through the left popliteal fossa, then traversing the abdominal cavity with injury to the descending colon and the left dome of the diaphragm. At laparotomy the iron rod was removed under vision. The laceration to the left dome of the diaphragm was repaired. The perforation of the descending colon was identified and repaired. Colostomy was deferred as there was no peritoneal contamination. The penetrating thigh wound was debrided. Her recovery was uneventful. She was discharged on postoperative day 15. She came for follow-up as out-patient after 3 weeks and the thigh wound had healed. Impalement injuries are rare and often severe. Most impalement injuries require a multidisciplinary approach. Adequate early resuscitation, proper evaluation and early surgical management is ideal. Immediate stabilisation of the foreign body from the time of encounter is essential. Removal under anaesthesia is mandatory.

Profile of Pediatric Trauma among the Patients Attending Emergency Department in a Tertiary Care Hospital in South India.

BACKGROUND: Pediatric trauma is emerging as an epidemic worldwide; the epidemiology of pediatric trauma is different in different parts of the world. There are very few studies describing the pediatric trauma in developing countries. OBJECTIVES: The objectives of this study were to assess the type, mechanism, and extent of trauma among pediatric trauma patients and its association with clinical outcome. METHODOLOGY: This was a prospective observational study conducted in the department of emergency medicine and trauma at a tertiary care hospital in South India from September 2015 to March 2017. All children aged <12 years with a history of injuries irrespective of the cause for attending our trauma center were included in the study. OBSERVATIONS AND RESULTS: Of the 911 children enrolled, 63.9% sustained injuries at home. The leading modes of injury were fall at level ground (26.9%), road traffic accidents (RTAs) (25.5%), and fall from height (16.8%). Majority of RTA victims were two-wheeler pillion riders (40.5%) and pedestrians (31.9%). Nearly 49% of children had head and maxillofacial injuries. Polytrauma was found in 3.6% of children. Based on the Pediatric Trauma Score (PTS), 72.6% of children had mild trauma and 6.1% severe trauma. Totally, 18.9% of children required inpatient management, 7.5% surgical intervention, and 1.8% expired. CONCLUSIONS: Most of injuries in children occurred at home. This was followed by injuries on road. The leading cause of polytrauma was RTA. RTA victims were more likely to have severe injuries and poor outcome. They were more likely to require inpatient management compared to those who fell from height or fell at level ground. Glasgow Coma Scale and PTS may be used reliably to assess the severity of injuries sustained by children.

Clinical Profile and Autopsy Findings in Fatal Head Injuries.

AIMS: This study aims to correlate the autopsy findings with the clinical picture and imaging report in fatal head injury patients. SETTINGS AND DESIGN: A descriptive study conducted at tertiary care hospital in South India from July 2015 to December 2016. PATIENTS AND METHODS: All patients with head injuries who were admitted to our Emergency and Trauma Centre and underwent autopsy were included in the study. A structured pro forma was used for collecting information. Autopsy findings were considered as a gold standard to correlate with antemortem findings in fatal head injury. The data were analyzed with EpiData and OpenEpi statistical analyzing software. RESULTS: Of the 303 fatal head injury patients, a majority were males and age group between 21 and 40 years. Eighty-eight percent (267/303) of fatal head injuries were due to road traffic accidents. Twenty-five of the 303 patients reached our center within 1 h (golden hour) of trauma. Of the 303 fatal head injuries, 153 (50.5%) died within 24 h of reaching our center. The most common autopsy finding in this study was subarachnoid hemorrhage (SAH) (247/303, 81.3%). Diagnostic accuracy of Epi dural hemorrhage (EDH) antemortem had the highest value (98.35%). SAH had least diagnostic accuracy value (45.72). subdural hemorrhage (SDH) had highest sensitivity (57.02%). EDH had higher specificity (100%). Significant SDH, SAH, and brain contusions were not detected during antemortem evaluation. CONCLUSIONS: Our study revealed that among fatal head injury patients, half of them died within first 24 h after reaching to tertiary care center. Diagnostic accuracy to detect extradural hemorrhage antemortem had the highest value and SAH had least diagnostic accuracy value. Significant subdural hemorrhage, subarachniod hemorrhage, and brain contusion were not detected during antemortem evaluation. Expertise in interpretation of imaging, adequate clinical examination, proper documentation, and early resuscitation may reduce the chances of missed injuries in head injury patients.

Pediatric Trauma - An Emerging Epidemic.

We enrolled 911 children aged <12 years presenting to the trauma center of a tertiary-care hospital (over a period of 18 months) with history of injuries. Majority (582; 63.9%) of children had sustained injuries at home; 56 (6.1%) had severe injuries based on Pediatric Trauma Score. Of road traffic accidents victims (n=232), majority (40.5%) were two-wheeler pillion riders or pedestrians (31.9%). More Indian data are required and efforts are needed to prioritize injury prevention efforts in children.

Adjuvant therapy for intra oral surgical oncological defect with ancillary prosthesis: A literature review.

The role of a maxillofacial prosthodontist in the treatment of facial defects cannot be underestimated. A multidisciplinary approach is required during the rehabilitation procedure to bring out effective results. Ancillary maxillofacial prostheses limit the patient's disability and improve function. These prostheses are inevitable in restoring the function, esthetics, general, and psychological health of the patients. This article reviews the various ancillary-maxillofacial prostheses and throws light on their historical development.

Impact of embryo co-culture with cumulus cells on pregnancy & implantation rate in patients undergoing in vitro fertilization using donor oocyte.

BACKGROUND & OBJECTIVES: Cumulus cell co-culture of embryo had been found to be beneficial for achieving better pregnancy and implantation rate (IR). The present study was aimed to evaluate efficiency of cumulus co-culture technique over simple culture of embryo in terms of pregnancy rate (PR) and IR in patients undergoing treatment for infertility using donor oocytes fertilized by intracytoplasmic sperm injection. METHODS: This was a quasi-experimental study between control and study groups. The primary endpoint was achievement of pregnancy. Control group included 508 women who underwent embryo development without cumulus cell co-culture and study group included 394 women who underwent embryo development with cumulus cell co-culture using donor's cumulus cells. RESULTS: The present study demonstrated a significant increase in the IR (37.2 vs 24.2%, P<0.001) and in PR (45.7 vs 37.8%, P<0.05) in study group than in control group. The PR and IR were found to be higher in study group, among all groups of women, grouped on the basis of different indications for use of donor oocytes. INTERPRETATION & CONCLUSIONS: Cumulus cell co-culture technique was found to be more effective than simple culture technique for embryo development in women undergoing treatment for infertility using donor oocytes fertilized by intracytoplasmic sperm injection.

A History of Intravenous Anesthesia in War (1656-1988).

The practice of anesthesia in war places significant restraints on the choice of anesthetic technique used; these include, but are not limited to, safety, simplicity, and portability. Ever since intravenous anesthesia became a practical alternative, there have been military doctors who felt that this technique was particularly suited to this environment. The challenge, as in civilian practice, has been to find the appropriate drugs as well as simple and safe delivery systems. The urgency of war has always stimulated innovation in medicine to counteract the ongoing development of weapons of war and their effects on the human body and to achieve improved survival as public expectations rise. This article traces the development of and the use of intravenous anesthesia by military physicians for battle casualties. The story starts long before the era of modern anesthesia, and the discussion concludes in the dog days of the cold war. The rapidly increasing interest in intravenous anesthesia in both civilian and military practice since the early 1990s is left for other authors to examine.

Biodegradable Gelatin Methacrylate Gel as a Potential Scaffold for Bone Tissue Engineering of Canine Adipose-Derived Stem Cells.

Therapeutic potential of adipose derived stem cells (ADSCs) has widely been explored for treatment of orthopedic ailments. Transplantation of cells encapsulated in a scaffold facilitates 3 dimensional modelling of the tissue for the cases where well-defined spatial distribution of cells is desired for implantation. Present study aims to encapsulate canine ADSCs (cADSCs) in biodegradable methacrylated gelatin gel (GelMA) scaffold followed by their osteogenic differentiation for fabrication of a three dimensional bone tissue construct. Different percentages (5, 10 and 20%) and different methacrylation levels of gel (GelMAhigh and GelMAlow) were tested for degradation. Porosity of 10% GelMA was compared by SEM imaging. Gels with the fastest degradation rate (5% GelMAhigh and GelMAlow) were chosen for cell encapsulation since degradation of scaffold is of prime importance when the gel is intended to be used for implantation. Finally, cADSCs encapsulated in 5% GelMAlow demonstrated best morphology and were differentiated osteogenically. We developed a modified protocol for isolation of RNA from cells encapsulated in GelMA. Osteogenic differentiation was affirmed by the presence of osteo-specific gene expression by reverse transcriptase PCR in addition to von Kossa staining of the construct. GelMA is an excellent biodegradable scaffold for encapsulation of cADSCs without altering their osteogenic potential. This osteo-induced cellular scaffold implant opens a new therapeutic horizon in the area of tissue engineering in orthopedics.

Current Practice of Hypertension in India: Focus on Blood Pressure Goals.

INTRODUCTION: Recommended Blood Pressure (BP) goals in elderly and those with co-morbid conditions like Diabetes Mellitus (DM) and Chronic Kidney Disease (CKD) vary in different Hypertension (HTN) management guidelines. AIM: To understand currently followed BP goals and practices among the physicians involved in management of HTN in India. MATERIALS AND METHODS: A cross-sectional, observational survey was conducted at 66th annual conference of Cardiological Society of India (CSICON-2014, Hyderabad). A structured questionnaire related to the BP goals and HTN practices was provided and responses from voluntarily participating physicians were collected. Data was analysed with descriptive statistics. RESULTS: Two-hundred sixty physicians completed this survey. In their routine clinical practice, physicians most frequently referred to Joint National Committee (JNC) guidelines (63.85%) followed by Indian guidelines on HTN (14.23%). In patients aged 60 years and above, BP goal <140/90mmHg and <150/90mmHg was aimed by 43.46% and 33.85% of the physicians respectively. In HTN with Type 2 DM (T2DM), most physicians (61.92%) had a BP goal of <130/80mmHg. A target BP <130/80mmHg was aimed by 48.08% physicians in CKD without proteinuria and 68.85% physicians in CKD with proteinuria. In newly diagnosed hypertensives, treatment modification was practiced after 15, 20 and 30 days by 37.31%, 16.15% and 35.77% of the physicians respectively. Beta-blockers were considered as third-line agents in HTN without co-morbidities by 45% physicians. Ambulatory BP Monitoring (ABPM) is practiced only in few patients (<5%) by most (71.93%) physicians. CONCLUSION: In practice, Indian physicians follow lower BP goals when compared to the recommendations from the most referred JNC guidelines. Increasing physicians' awareness to the changes in recommendations is the need.

Cellular Effect of Curcumin and Citral Combination on Breast Cancer Cells: Induction of Apoptosis and Cell Cycle Arrest.

PURPOSE: The unmanageable side effects caused by current chemotherapy regimens to treat cancer are an unresolved problem. Although many phytonutrients are useful as chemoprevention without side effects, their effects are slower and smaller than conventional chemotherapy. In the present work, we examined the cumulative effect of two phytonutrients, curcumin and citral, on breast cancer cell lines and compared their effect with the known chemotherapy regimen of cyclophosphamide, methotrexate, and 5-fluorouracil. METHODS: Using cultured breast cancer and normal epithelial cells, the cytotoxic and apoptotic effect of curcumin and citral was evaluated in vitro. The synergistic effect of curcumin and citral was calculated by a combination index study using the method by Chou and Talalay. Cell death pathways and mechanisms were analyzed by measuring intracellular reactive oxygen species (ROS) and apoptotic protein levels. RESULTS: Curcumin and citral caused dose and time dependent cell death and showed a synergistic effect at effective concentration EC50 and above concentrations in breast cancer cells without disturbing normal breast epithelial cells. With combination curcumin and citral treatment, apoptosis induction and cell cycle arrest at G0/G1 phase in breast cancer cells were observed. Curcumin and citral generated ROS and activated p53 and poly (ADP-ribose) polymerase-1 mediated apoptotic pathways. CONCLUSION: The results of this study suggest that curcumin and citral in combination may be a useful therapeutic intervention for breast cancer.

Optimization of cellulase production by Penicillium oxalicum using banana agrowaste as a substrate.

The purpose of this study was to produce a higher amount of cellulase by using an alternative carbon source, such as banana agrowaste, and to optimize the fermentation parameters for a high yield. In the present study, cellulase-producing Penicillium was isolated from a decaying wood sample. Different nutritional and environmental factors were investigated to assess their effect on cellulase production. The highest crude enzyme production was observed at a pH 6.0 and a temperature of 28°C in a medium that was supplemented with banana agrowaste as the carbon source. Pretreatment with 2N NaOH, at 7% substrate (banana agrowaste) concentration yielded the highest cellulase activity. Further to this, the effect of other parameters such as inoculum age, inoculum size, static and agitated conditions were also studied. It is concluded that Penicillium oxalicum is a powerful cellulase-producer strain under our tested experimental conditions using banana agrowaste as the carbon source.

Cellular Effect of Curcumin and Citral Combination on Breast Cancer Cells: Induction of Apoptosis and Cell Cycle Arrest / 한국유방암학회지

PURPOSE: The unmanageable side effects caused by current chemotherapy regimens to treat cancer are an unresolved problem. Although many phytonutrients are useful as chemoprevention without side effects, their effects are slower and smaller than conventional chemotherapy. In the present work, we examined the cumulative effect of two phytonutrients, curcumin and citral, on breast cancer cell lines and compared their effect with the known chemotherapy regimen of cyclophosphamide, methotrexate, and 5-fluorouracil. METHODS: Using cultured breast cancer and normal epithelial cells, the cytotoxic and apoptotic effect of curcumin and citral was evaluated in vitro. The synergistic effect of curcumin and citral was calculated by a combination index study using the method by Chou and Talalay. Cell death pathways and mechanisms were analyzed by measuring intracellular reactive oxygen species (ROS) and apoptotic protein levels. RESULTS: Curcumin and citral caused dose and time dependent cell death and showed a synergistic effect at effective concentration EC50 and above concentrations in breast cancer cells without disturbing normal breast epithelial cells. With combination curcumin and citral treatment, apoptosis induction and cell cycle arrest at G0/G1 phase in breast cancer cells were observed. Curcumin and citral generated ROS and activated p53 and poly (ADP-ribose) polymerase-1 mediated apoptotic pathways. CONCLUSION: The results of this study suggest that curcumin and citral in combination may be a useful therapeutic intervention for breast cancer.

The fentanyl 'lozenge' story: from books to battlefield.

This article outlines the process that led to the introduction of the fentanyl lozenge for acute pain management. It starts with the historical context before discussing the recognition of an ongoing problem and then identifies the options that were considered. There follows a description of the pharmacology of fentanyl before describing the trial of concept that was conducted. This leads into an outline of the meetings and committees that had to be engaged with before the final acceptance and subsequent ushering in. The final section describes an option that was unsuccessful.

A survey of post-amputation pains in serving military personnel.

INTRODUCTION: Amputation is a common injury in survivors of current military conflicts. The primary aim of this study was to establish the prevalence rate of phantom limb pain (PLP) in military personnel undergoing rehabilitation at the UK's Defence Medical Rehabilitation Centre. The secondary aims were to establish treatment failure rates and prevalence rates of phantom limb sensations (PLS) and residual limb pains (RLP). METHOD: A questionnaire survey was developed from that used in a previous study of pains in veterans. Questions were asked of the intensity of PLP, RLP and PLS over the previous month and the entire time since amputation. Treatment failure was defined as greater than 'mild' pain. A literature review for similar studies was undertaken. RESULTS: There were 48 responders with 65 amputations. PLP in the previous month was reported by 49% of respondents and 20% were classed as treatment failures; 76% had PLP at some point and 56% were analgesic failures. PLS was commoner with 70% reported over the previous month and 66% at any time. 65% had RLP over the previous month, 31% were treatment failures and 80% had experienced RLP at some point and 63% of these were failures of treatment. Eight other papers were found for comparison. CONCLUSIONS: This is the first paper that describes prevalence of pains associated with amputation in a serving military population. It also describes the use of analgesic failure as a concept and provides an encouraging rate of as low as 20% in this population.

Identification of Helicobacter pylori by different conventional staining techniques and its comparison with polymerase chain reaction.

OBJECTIVE: To evaluate Helicobacter pylori (H. pylori) detection by histological staining methods, and to compare with those of Gram staining and polymerase chain reaction (PCR). METHODS: This is a cross-sectional study conducted at the Department of Microbiology, Shree P. M. Patel Paramedical College, Anand, Gujarat, India on 436 patients attending the Deep Surgical Hospital, Anand, Gujarat between February 2008 and October 2011. Biopsies were subjected to histological staining using Hematoxylin & Eosin (H&E), Giemsa, and Warthin-Starry stains, as well as with Gram staining. The PCR was performed on 71 biopsy samples. RESULTS: Sensitivity and negative predictive values of all 3 histological stains (Warthin-Starry, H&E, and Giemsa) were excellent. Gram staining showed excellent results pertaining to sensitivity, specificity, positive predictive value, and accuracy. Sensitivity of PCR was remarkably low compared to all the staining methods. The sensitivity of all histological stains was found better than PCR. CONCLUSION: From the findings in our study, we conclude that in a mediocre laboratory, where PCR facility is not available, histological stain can be a better substitute for the diagnosis of H. pylori. Our findings also confirm the assertion that Gram staining is a preferred stain, affordable, reliable, and simple means for identifying H. pylori compared with both histology and PCR.

Effect of exendin (exenatide)--GLP 1 receptor agonist on the thyroid and parathyroid gland in a rat model.

Exenatide or Exendin-4 is a 39-amino acid agonist of the glucagon like peptide (GLP-1) receptor approved for the adjunctive treatment for type 2 diabetes. Recent reports suggest that GLP-1 agonists may also have distant effects including C-cell thyroid hyperplasia. The aim of this study was to evaluate the effect of exendin-4 on the thyroid and parathyroid cells in a rat model. Rat thyroids were stained for calcitonin, H&E and for carcinoembryonic antigen (CEA). Thyroid C-cell hyperplasia was graded on H&E stained slides using cell size and secretory granule numbers, morphological features of the parathyroid glands and the serum calcium concentrations of the rats were also evaluated. Counts of stained cells/high power field and intensity of staining were recorded by two pathologists. Data were analyzed by ANOVA/post-tests. C cell hypertrophy was elevated in exenatide-treated vs. untreated animals (22.5 ± 8.7 vs. 10.5 ± 2.7 cells/HPF). CEA staining failed to show effects by exendin. Calcitonin staining was significantly elevated in exenatide treated controls (P<0.001). Parathyroid glands were histologically normal in both groups, and serum calcium levels were within normal range in all animals. In summary, exenatide was associated with C cell hyperplasia and increased calcitonin staining of thyroids, but was unrelated to CEA levels. These data raise important concerns about the effects of exenatide which, given its wide clinical use, should be clarified with urgency.

Evaluation of the effect of presence of blood in the stomach on endoscopic diagnostic tests for Helicobacter pylori infection.

INTRODUCTION: Presence of blood in the stomach has been thought to affect the performance of diagnostic tests used in detecting Helicobacter pylori (H. pylori) in the stomach. This study evaluated the effect of blood on the efficacy of rapid urease test (RUT) and microscopic appearance of the biopsy after staining with Giemsa stain. MATERIALS AND METHODS: Patients with bleeding oesophageal varices who met the inclusion criteria were tested for H. pylori by RUT and microscopic examination of the biopsy. A repeat endoscopy, RUT and histology were done one month following initial presentation. The performance of the diagnostic tests was evaluated with and without the presence of intraluminal blood. A combined result of the two tests, RUT and histology, carried out in presence or absence of blood for the diagnosis of H. pylori, when considered together was considered as the gold standard. RESULTS: Thirty six patients included in the study were in the ages ranging between 15-60 years (mean age = 44.14 years ± 2.1). The combination of tests at both visits showed 20/36 (55.6%) patients were positive for H. pylori. The decrease in H. pylori positivity in the presence of blood was significant for RUT (8.3% vs. 38.9%; P=0.005) and combined test (19.4% vs. 47.2%; P=0.02) but the decrease in positivity for histology (11.1% vs 30.6%) was not significant (P=0.08). In the presence of blood, the sensitivity of RUT, histology and combined tests were 15%, 20% and 35%, respectively. In the absence of blood, the sensitivity of RUT, histology and combination of tests was 70%, 55% and 85%, respectively. CONCLUSION: Blood in the stomach significantly decreased the sensitivity of RUT, histology and the combination of both. Negative results of these tests in acute upper gastro intestinal (GI) bleeding should therefore be interpreted carefully.