Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying.

A decision by a society to sanction assisted dying in any form should logically go hand-in-hand with defining the acceptable method(s). Assisted dying is legal in several countries and we have reviewed the methods commonly used, contrasting these with an analysis of capital punishment in the USA. We expected that, since a common humane aim is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress, there might be a single technique being used. However, the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined. In voluntary assisted dying (in some US states and European countries), the common method to induce unconsciousness appears to be self-administered barbiturate ingestion, with death resulting slowly from asphyxia due to cardiorespiratory depression. Physician-administered injections (a combination of general anaesthetic and neuromuscular blockade) are an option in Dutch guidelines. Hypoxic methods involving helium rebreathing have also been reported. The method of capital punishment (USA) resembles the Dutch injection technique, but specific drugs, doses and monitoring employed vary. However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness. This raises a concern that some deaths may be inhumane, and we have used lessons from the most recent studies of accidental awareness during anaesthesia to describe an optimal means that could better achieve unconsciousness. We found that the very act of defining an 'optimum' itself has important implications for ethics and the law.

Acute myocardial infarction in yellow oleander poisoning.

Self-harm by consuming yellow oleander seeds has become more frequent in South Asian countries, especially Sri Lanka and in southern parts of India. Yellow oleander poisoning usually presents with gastrointestinal, cardiovascular, and neurological manifestations as well as electrolyte abnormalities. Cardiac effects can manifest as nearly any type of dysrhythmia and sudden death with very few premonitory signs. To our knowledge yellow oleander poisoning related acute myocardial infarction has not yet been reported. We report a 37-year-old man with yellow oleander poisoning who had normal sinus rhythm at presentation but within few hours developed acute ST-segment myocardial infarction.

A 2-Dof LQR based PID controller for integrating processes considering robustness/performance tradeoff.

This paper focuses on the analytical design of a Proportional Integral and Derivative (PID) controller together with a unique set point filter that makes the overall Two-Degree of-Freedom (2-Dof) control system for integrating processes with time delay. The PID controller tuning is based on the Linear Quadratic Regulator (LQR) using dominant pole placement approach to obtain good regulatory response. The set point filter is designed with the calculated PID parameters and using a single filter time constant (λ) to precisely control the servo response. The effectiveness of the proposed methodology is demonstrated through a series of illustrative examples using real industrial integrated process models. The whole range of PID parameters is obtained for each case in a tradeoff between the robustness of the closed loop system measured in terms of Maximum Sensitivity (Ms) and the load disturbance measured in terms of Integral of Absolute Errors (IAE). Results show improved closed loop response in terms of regulatory and servo responses with less control efforts when compared with the latest PID tuning methods of integrating systems.

Assessing the national trends in colon cancer among Native Americans: A 12 year SEER database study.

INTRODUCTION: Native Americans (NA) form a unique cohort of colon cancer (CC) patients among whom the variability in demographics and cancer characteristics remains unclear. METHODS: We abstracted the national estimates for NA with CC using the Surveillance, Epidemiology, and End Result (SEER) database. Trend analysis of incidence, variation in location and patient demographic analysis were performed. RESULTS: A total number of 26,674 NA with CC were reported during the 12-year study period. While the overall incidence of CC decreased by 12% during the study period, incidence increased by 38% in NA. Incidence of CC was more prevalent and higher increase (42%) seen in NA females than males (p = 0.02; 34%). Stage III tumors represented 29% of all CC, sigmoid colon the most common site location (38%) with 72% of all tumors being moderately differentiated. 55% tumors were localized in left, 36% in right and 9% in transverse colon. 92% of the NA were insured. CONCLUSION: Incidence of CC continues to rise in NA with majority of CC presented at higher stage and moderate differentiation.

An optimal PID controller via LQR for standard second order plus time delay systems.

An improved tuning methodology of PID controller for standard second order plus time delay systems (SOPTD) is developed using the approach of Linear Quadratic Regulator (LQR) and pole placement technique to obtain the desired performance measures. The pole placement method together with LQR is ingeniously used for SOPTD systems where the time delay part is handled in the controller output equation instead of characteristic equation. The effectiveness of the proposed methodology has been demonstrated via simulation of stable open loop oscillatory, over damped, critical damped and unstable open loop systems. Results show improved closed loop time response over the existing LQR based PI/PID tuning methods with less control effort. The effect of non-dominant pole on the stability and robustness of the controller has also been discussed.

Studies on space charge neutralization and emittance measurement of beam from microwave ion source.

A 2.45 GHz microwave ion source together with a beam transport system has been developed at VECC to study the problems related with the injection of high current beam into a compact cyclotron. This paper presents the results of beam profile measurement of high current proton beam at different degrees of space charge neutralisation with the introduction of neon gas in the beam line using a fine leak valve. The beam profiles have been measured at different pressures in the beam line by capturing the residual gas fluorescence using a CCD camera. It has been found that with space charge compensation at the present current level (∼5 mA at 75 keV), it is possible to reduce the beam spot size by ∼34%. We have measured the variation of beam profile as a function of the current in the solenoid magnet under the neutralised condition and used these data to estimate the rms emittance of the beam. Simulations performed using equivalent Kapchinsky-Vladimirsky beam envelope equations with space charge neutralization factor are also presented to interpret the experimental results.

Studies on the coupling transformer to improve the performance of microwave ion source.

A 2.45 GHz microwave ion source has been developed and installed at the Variable Energy Cyclotron Centre to produce high intensity proton beam. It is operational and has already produced more than 12 mA of proton beam with just 350 W of microwave power. In order to optimize the coupling of microwave power to the plasma, a maximally flat matching transformer has been used. In this paper, we first describe an analytical method to design the matching transformer and then present the results of rigorous simulation performed using ANSYS HFSS code to understand the effect of different parameters on the transformed impedance and reflection and transmission coefficients. Based on the simulation results, we have chosen two different coupling transformers which are double ridged waveguides with ridge widths of 24 mm and 48 mm. We have fabricated these transformers and performed experiments to study the influence of these transformers on the coupling of microwave to plasma and extracted beam current from the ion source.

Effect of various physical stress models on serum cortisol level in wistar rats.

BACKGROUND: Stress indicates the response or reaction of an organism to the environmental circumstances and their outcomes. Acute stress is well known to trigger several hormonal alterations in animals. An increase in glucocorticoid concentration can represent intensity of discomfort or distress experienced by an animal. The study was undertaken to evaluate the effects of various physical stress models on serum cortisol level in Wistar male rats. METHODOLOGY: In this study six Wistar male rats weighing 150-200 gm were randomly selected. Animals were exposed to 'forced swim test' and 'restraint test'. Their serum cortisol level was measured by ELISA test using alpha prime ELISA system before and after the tests respectively. RESULTS: RESULTS were analyzed by students paired t-test. Serum cortisol level was significantly higher after forced swim test as well as after restraint test. When both the physical activities were compared, serum cortisol level was increased more after restraint stress than after forced swim test however, the difference was not significant statistically. INTERPRETATION AND CONCLUSION: The rise in serum cortisol level was observed in both the physical activity models . Rise in serum cortisol level was significantly higher after restraint test than exposing them to forced swim test. This indicates that restraining the rats produced more stress than making them forcefully swim.

Age and mortality after injury: is the association linear?

INTRODUCTION: Multiple studies have demonstrated a linear association between advancing age and mortality after injury. An inflection point, or an age at which outcomes begin to differ, has not been previously described. We hypothesized that the relationship between age and mortality after injury is non-linear and an inflection point exists. METHODS: We performed a retrospective cohort analysis at our urban level I center from 2007 through 2009. All patients aged 65 years and older with the admission diagnosis of injury were included. Non-parametric logistic regression was used to identify the functional form between mortality and age. Multivariate logistic regression was utilized to explore the association between age and mortality. Age 65 years was used as the reference. Significance was defined as p < 0.05. RESULTS: A total of 1,107 patients were included in the analysis. One-third required intensive care unit (ICU) admission and 48 % had traumatic brain injury. 229 patients (20.6 %) were 84 years of age or older. The overall mortality was 7.2 %. Our model indicates that mortality is a quadratic function of age. After controlling for confounders, age is associated with mortality with a regression coefficient of 1.08 for the linear term (p = 0.02) and a regression coefficient of -0.006 for the quadratic term (p = 0.03). The model identified 84.4 years of age as the inflection point at which mortality rates begin to decline. CONCLUSIONS: The risk of death after injury varies linearly with age until 84 years. After 84 years of age, the mortality rates decline. These findings may reflect the varying severity of comorbidities and differences in baseline functional status in elderly trauma patients. Specifically, a proportion of our injured patient population less than 84 years old may be more frail, contributing to increased mortality after trauma, whereas a larger proportion of our injured patients over 84 years old, by virtue of reaching this advanced age, may, in fact, be less frail, contributing to less risk of death.

Rethinking bicycle helmets as a preventive tool: a 4-year review of bicycle injuries.

INTRODUCTION: Traumatic brain injury is a leading cause of disability in bicycle riders. Preventive measures including bicycle helmet laws have been highlighted; however, its protective role has always been debated. The aim of this study was to determine the utility of bicycle helmets in prevention of intra-cranial hemorrhage. We hypothesized that bicycle helmets are protective and prevent the development of intra-cranial hemorrhage. METHODS: We performed a 4-year (2009-2012) retrospective cohort analysis of all the patients who presented with traumatic brain injury due to bicycle injuries to our level 1 trauma center. We compared helmeted and non-helmeted bicycle riders for differences in the patterns of injury, need for intensive care unit admissions and mortality. RESULTS: A total of 864 patients were reviewed of which, 709 patients (helmeted = 300, non-helmeted = 409) were included. Non-helmeted bicycle riders were more likely to be young (p < 0.001) males (p = 0.01). There was no difference in the median ISS between the two groups (p = 0.3). Non-helmeted riders were more likely to have a skull fracture (p = 0.01) and a scalp laceration (p = 0.01) compared to the helmeted riders. There was no difference in intra-cranial hemorrhage between the two groups (p = 0.1). Wearing a bicycle helmet was not independently associated (p = 0.1) with development of intra-cranial hemorrhage. CONCLUSION: Bicycle helmets may have a protective effect against external head injury but its protective role for intra-cranial hemorrhage is questionable. Further studies assessing the protective role of helmets for intra-cranial hemorrhage are warranted.

Lower extremity fractures in falls.

INTRODUCTION: Lower extremity fractures are very common in victims of falls. These fractures are usually associated with other bodily injuries and can lead to permanent disability if appropriate management is not provided. The aim of this study was to evaluate the incidence and outcomes of associated injuries in victims of falls with lower extremity fractures. METHODS: This is a retrospective review (1995-2006) of all fall-related trauma patients evaluated at our Level I trauma center. Injuries were categorized as: isolated femur fractures (FF), isolated tibia fractures (TF), and both femur and tibia fractures (FTF). Data were analyzed for differences in patterns of injury, associated fractures and injuries, and mortality and morbidity according to age groups within patients with minor body injuries expressed by Abbreviated Injury Score (AIS) < 3. RESULTS: Three hundred and thirty-two patients (64.8 %) had FF, 164 patients (32 %) had TF, and 16 patients (3.2 %) presented with FTF. The incidence of severe trauma was 9.4 % (Injury Severity Score, ISS > 25). A higher incidence of ISS > 25 was observed in patients with FF. Increased mortality was observed in the elderly group, especially in patients with an isolated femur fracture. CONCLUSION: Patients with a combination of femur and tibia fractures have a significantly higher risk of associated injuries compared to patients with either a femur or a tibia fracture. Elderly patients (≥65 years of age) have higher morbidity and mortality compared to younger patients after falls. Clinicians evaluating these patients should be aware of these injury patterns. Further studies assessing the impact of age and pattern of injury in patients following falls are warranted.

Preparation and characterization of pioglitazone cyclodextrin inclusion complexes.

Pioglitazone, a class II Biopharmaceutical Classification System drug having poor water solubility and slow dissolution rate may have a negative impact on its subtherapeutic plasma drug levels leading to therapeutic failure. In order to improve its water solubility and thus dissolution, cyclodextrin complexation technique was followed. The phase solubility studies were carried using three different types of cyclodextrins viz., ß, methyl-ß and γ-cyclodextrins. The Gibbs free energy was calculated in order to determine ease of the complexation. Binary systems of pioglitazone with cyclodextrins were prepared by kneading method and spray drying method. The phase solubility profiles with all the three cyclodextrins were classified as A(L)-type, indicating the formation of 1:1 stoichiometric inclusion complexes. The complexation capability of cyclodextrins with pioglitazone increased in the order of methyl-ß > ß > γ-cyclodextrin. The Gibbs free energy was found to be in the order γ > methyl-ß > ß cyclodextrin. Characterization of inclusion complexes was done by solubility studies, in vitro dissolution studies, Fourier transformation-infrared spectroscopy, scanning electron microscopy, differential scanning calorimetry and X-ray powder diffractometry studies. Inclusion complexes exhibited higher rates of dissolution than the corresponding physical mixtures and pure drug. Greater solubility was observed with spray-dried methyl-ß cyclodextrin complexes (2.29 ± 0.001 mg/ml) in comparison to the kneaded methyl-ß cyclodextrin complexes (1.584 ± 0.053 mg/ml) and pure drug (0.0714 ± 0.0018 mg/ml).

Symptomatic hypocalcemia in primary hyperaldosteronism: a case report.

The metabolic alterations caused by hyperaldosteronism are being increasingly recognized and have generated considerable interest among the medical fraternity. Hyperaldosteronism is suspected to have a pivotal role in the patho-physiology of congestive cardiac failure where it has been studied extensively. But its effects on calcium metabolism, parathyroid metabolism and renal handling of calcium are less well described. Recent experimental models have shed light into the roles played by previously unknown mechanisms in causing these metabolic alterations. We hereby report a case of primary hyperaldosteronism due to adrenal adenoma (Conn's syndrome) who presented with a myriad of clinical features including symptomatic hypocalcemia, significant weight loss along with uncontrolled hypertension for a prolonged period before eventually detected to have primary hyperaldosteronism. Surgical removal of the causative tumor resulted in prompt disappearance of all the symptoms and signs and regain of lost weight.

False-positive widal in melioidosis.

Enteric fever is endemic in this part of the world, and Widal test is one of the time-honored laboratory tests that are being used for years to diagnose the disease. On the other hand, melioidosis is a newly emerging disease from this region, which is most often misdiagnosed or underdiagnosed by clinicians. It is well accepted that false-positive Widal reactions following certain non-typhoid Salmonella infections may occur commonly. Three cases of high titers of Widal test are described, where melioidosis was the actual diagnosis in every occasion and was never suspected until diagnosed microbiologically. All the patients had shown a partial response to ceftriaxone. Blood and pus cultures grew Burkholderia pseudomallei, whereas Salmonella typhi was not isolated from blood in any patient. With appropriate antibiotics, the patients showed clinical and microbiological improvement with lowering of Widal titers. These 3 cases show that high Widal titer in any patient may mislead the diagnosis of melioidosis, and further laboratory workup should always be done to rule out melioidosis, especially in cases with nonresponsiveness to treatment.

Seasonal variation of toxic benzene emissions in petroleum refinery.

Petroleum refineries are largest chemical industries that are responsible for the emission of several pollutants into the atmosphere. Benzene is among the most important air pollutants that are emitted by petroleum refineries, since they are involved in almost every refinery process. Volatile organic compounds (VOCs) are a major group of air pollutants, which play a critical role in atmospheric chemistry. These contribute to toxic oxidants, which are harmful to ecosystem, human health and atmosphere. The variability of pollutants is an important factor in determining human exposure to these chemicals. The ambient air concentrations of benzene were measured in several sites around the Digboi petroleum refinery, near the city of Gowahati in northeast India, during winter and summer 2004. The seasonal and spatial variations of the ambient air concentrations of this benzene were investigated and analyzed. An estimation of the contribution of the refinery to the measured atmospheric levels of benzene was also performed. The ambient air mixing ratios of benzene in a large area outside the refinery was generally low, in ppbv range, much lower than the ambient air quality standards. This article presents the temporal and spatial variation of air pollution in and around petroleum refinery and showed that no health risk due to benzene is present in the areas adjacent to the refinery.

Monitoring of hydrocarbon emissions in a petroleum refinery.

In a petroleum refinery the hydrocarbon emissions which are mostly fugitive in nature are emitted from process, offsites and periodic accidental releases such as: materials storage & handling, process, equipment leaks, solvent evaporation, combustion sources, waste treatment etc. In India, the monitoring of such emissions in a refinery are limited as also the standards are not set for its limit in ambient air. Hence there is an urgent need for generating a database for such emissions. Recently in India, MoEF/CPCB has set some guidelines under CREP rules for monitoring such emissions in a refinery. A detailed monitoring of the hydrocarbon emissions from different sources in a typical 10.5 MMTPA Indian refinery is undertaken during 1999-2001 and the results are presented. It is observed that the storage tank emissions alongwith process leaks form the major contributor towards fugitive hydrocarbon emissions.