Toxico-epidemiology of acute poisoning; an exploratory study from a tertiary care hospital in South India along with global comparisons and solutions.

BACKGROUND: Poisoning has been and still is a major problem faced throughout the globe. But its patterns are different and changing in different parts of the world due to local influences. This calls for a study to explore the issue in this unique South Indian state. METHODS: A cross-sectional exploratory study was conducted to analyse the patterns of poisoning and the socio-demographic characteristics of the patients. Subgroups were compared using Fisher-Freeman-Halton exact test and further analysed by multivariate logistic regression. RESULTS: 48% of cases were of pharmaceutical drug poisoning. 27.5% of these cases involved polymedication and Paracetamol (Acetaminophen) turned out to be the single most drug used. Suicide was the most common circumstance. 10% of patients had co-diagnoses of psychiatric disorders. Univariate analysis separately showed that females (p < 0.001), higher educated (p = 0.149), higher socioeconomic strata (p = 0.136) and non-addicts (p = 0.002) were more exposed to drugs whereas males, lower educated, lower socioeconomic strata and addicts are skewed to pesticides for poisoning. Most repeat suicide attempts were with the same poisonous agent. 70% of patients with a diagnosed psychiatric disorder have attempted suicide before using some drugs (p < 0.001). CONCLUSION: Our study highlights the importance of a region-wise, targeted approach in policymaking to curb poisoning.

Etiology and Outcomes of ARDS in a Resource Limited Urban Tropical Setting.

BACKGROUND: Several studies have been published in the western literature on the incidence, clinical course and outcome of patients with ARDS. However, there is limited data about ARDS in the tropics and moreover, the etiology and outcomes of ARDS in tropical countries are different from those of western nations. In tropical countries like India, resources are limited and costs of therapy play a major role in deciding treatment options. This prospective observational study was designed to analyze the clinical profile, outcomes and predictors of mortality of patients with ARDS in an urban tropical setting. METHODS: 75 patients ≥13 years, admitted in the medical intensive care unit of a teaching hospital in Kerala, India between March 2013 and February 2014, satisfying Berlin definition for ARDS were enrolled in the study. Lung protective ventilation strategy as laid by ARDS Network protocol was followed for every patient on mechanical ventilation. Due to scarcity of ventilators in our institution, invasive ventilation could not be provided for all ARDS patients. The criteria used for patient selection for non-invasive ventilation were hemodynamic stability, well compliant to the use of NIV mask and PaO2/FiO2 ratio >180 at the time of admission. RESULTS: Out of the 75 patients, 51% were females and the mean age of the study population was 39.8 ± 3.3 years. Common aetiologies were leptospirosis (18.7%), bronchopneumonia (17.3%), scrub typhus and dengue (12% each). Lung injury score and sequential organ failure assessment score scores had statistically significant association with the severity of ARDS. Forty patients (53.3%) received invasive mechanical ventilation and 35 patients were managed with non-invasive ventilation at the time of admission. The mortality in our study was 45%. Altered sensorium (p-0.002), central cyanosis (p-0.024), elevated creatinine (p-0.036), acidosis (p < 0.001), hypotension (p < 0.001), multiorgan dysfunction (p-0.017), PEEP >12 cm H2O (p-0.036), days on ventilator <7 (p-0.014), PaO2/FiO2 Ratio <100 (p < 0.001), LIS>2.5 (p < 0.001) and SOFA score>11 (p < 0.001) were individual predictors of mortality. CONCLUSION: Tropical infections form a major etiological component of ARDS in a developing country like India. More studies are required for determining criteria for using NIV in mild ARDS patients which would be helpful in resource limited countries. Timely administration of effective antimicrobial therapy in patients in the rural tropics may help to reduce mortality and financial burden due to ARDS.

Use of leucocyte esterase reagent strips in the diagnosis or exclusion of prosthetic joint infection.

Infection is a leading indication for revision arthroplasty. Established criteria used to diagnose prosthetic joint infection (PJI) include a range of laboratory tests. Leucocyte esterase (LE) is widely used on a colorimetric reagent strip for the diagnosis of urinary tract infections. This inexpensive test may be used for the diagnosis or exclusion of PJI. Aspirates from 30 total hip arthroplasties (THAs) and 79 knee arthroplasties (KA) were analysed for LE activity. Semi-quantitative reagent strip readings of 15, 70, 125 and 500 white blood cells (WBC) were validated against a manual synovial white cell count (WCC). A receiver operating characteristic (ROC) curve was constructed to determine the optimal cut-off point for the semi-quantitative results. Based on established criteria, six THAs and 15 KAs were classified as infected. The optimal cut-off point for the diagnosis of PJI was 97 WBC. The closest semi-quantitative reading for a positive result was 125 WBC, achieving a sensitivity of 81% and a specificity of 93%. The positive and negative predictive values of the LE test strip were 74% and 95% respectively. The LE reagent strip had a high specificity and negative predictive value. A negative result may exclude PJI and negate the need for further diagnostic tests.

The use of ultrasound-guided wire localisation in orthopaedics.

The use of ultrasound-guided wire localisation of lesions is not well described in the orthopaedic literature. We describe a case of an impalpable schwannoma of the femoral nerve and another of sacroiliitis with an associated pelvic abscess. In both, surgical localisation was difficult. Peri-operative ultrasound-guided wire localisation was used to guide surgery and minimise tissue damage, thereby optimising the results and recovery of the patient.

Supracondylar periprosthetic femoral fractures following total knee arthroplasty: treatment with a retrograde intramedullary nail.

Total knee replacement surgery is occasionally complicated by a supracondylar periprosthetic fracture, and this presents a challenging problem in an often frail population. Multiple nonoperative and operative treatments have been described which have the aim of restoring the patient to their pre-injury status. This study retrospectively reviews the results of the largest series to date of 14 such fractures treated by retrograde intramedullary supracondylar nailing and is supportive of its continued use with good functional outcomes, low complication rates, and 100% fracture union.

Case report: overnight hospital stay for minimally invasive bilateral total hip arthroplasty.

Bilateral total hip arthroplasty was performed on a 58-year-old man. He was successfully discharged home from hospital the following morning, 23 hours post surgery. A direct anterior, minimally invasive approach was used which avoided detachment of hip musculature. Preoperative assessment was carried out, with early multidisciplinary team input. Modified anaesthetic techniques with an ambulatory pain pump were employed. Follow-up in the community was carried out by an outreach team. All these factors were important in a successful early supported discharge. We believe this to be the first such case reported.

Morphine disrupts long-range synchrony of gamma oscillations in hippocampal slices.

Oscillations in neuronal population activity within the gamma frequency band (>25 Hz) have been correlated with cognition: Gamma oscillations could bind together features of a sensory stimulus by generating synchrony between discrete cortical areas [Eckhorn, R., Bauer, R., Jordan, W., Brosch, M., Kruse, W., Munk, M. & Reitboeck, H. J. (1989) Biol. Cybern. 60, 121-130; Singer, W. & Gray, C. M. (1995) Annu. Rev. Neurosci. 18, 555-556]. Herein we demonstrate that morphine and beta-endorphin disrupt this long-range synchrony of gamma oscillations while leaving the synchrony of local oscillations relatively intact. The effect is caused by a decrease in type A gamma-aminobutyric acid receptor-mediated inhibition of both excitatory pyramidal cells and inhibitory interneurons. The effects of morphine on gamma oscillations were blocked by mu-opioid receptor antagonists but not by antagonists of delta or kappa receptors. Morphine also produced burst firing in interneurons, because synaptic excitation from pyramidal cells was no longer balanced by synchronous inhibitory postsynaptic potentials. The loss of synchrony of gamma oscillations induced by morphine may constitute one mechanism involved in producing the cognitive deficits that this drug causes clinically.