Blunt Trauma Neck with Complete Tracheal Transection - A Diagnostic and Therapeutic Challenge to the Trauma Team.

Survival following trachea-esophageal transection is uncommon. Establishing a secure airway has the highest priority in trauma management. Airway management is a unique and a defining element to the specialty of emergency medicine. There is no doubt regarding the significance of establishing a patent airway in the critically ill patient in the emergency department. Cannot intubate and cannot ventilate situation is a nightmare to all emergency physicians. The most important take-home message from this case report is that every Emergency physician should have the ability to predict "difficult airway" and recognize "failed airway" very early and be skilled in performing rescue techniques when routine oral-tracheal intubation fails. Any delay at any step in the "failed airway" management algorithm may not save the critically ill dying patient. Here, we report a case of blunt trauma following high-velocity road traffic accident, presenting in the peri-arrest state, in whom we noticed "failed airway" which turned out to be due to complete tracheal transection. In our patient, although we had secured the airway immediately, he had already sustained hypoxic brain damage. This scenario emphasizes the importance of prehospital care in developing countries.

Demographics, clinical characteristics and management of herbicide poisoning in tertiary care hospital.

Herbicide poisoning is most common method of suicide in India and it is associated with high morbidity and mortality. Among different herbicidal poisonings the most predominantly found poisonings are paraquat and glyphosate. These compounds are highly toxic and their poisonings require proper management techniques. High fatality is seen in these cases which are mainly due to its inherent toxicity and lack of effective treatment. Common symptoms of these poisonings includes gastrointestinal corrosive effects with mouth and throat, epigastric pain and dysphagia, acid-base imbalance, pulmonary edema, shock and arrhythmia. Long term health effects include pulmonary fibrosis, renal failure, hepatic failure, heart failure, multi-organ failure or death. No proven antidote exists for these poisonings. So the treatment is mainly supportive. Initially gastric lavage or whole-gut irrigation using adsorbents such as Fuller's earth, bentonite or activated charcoal is recommended. In case of renal failure hemodialysis or hemoperfusion may be considered. However novel approaches like treatment with N-acetylcysteine, vitamin C, vitamin E, cyclophosphamide may also be helpful.

Gold Nanoparticle-Based Drug Delivery System for the Diagnosis and Treatment of Bacterial Meningitis.

Managing bacterial pathogens in the central nervous system is an immense issue for researchers all around the globe. The problem of these infections remains throughout the population, regardless of the discovery of several possible medicines. The major obstacle to drug delivery is the BBB, but only a few medicines that fulfill demanding requirements can penetrate it. Considering inadequate antibiotic alternatives and the increasing development of resistance, it is more important than ever to find new approaches to address this worldwide problem. Medical nanotechnology has evolved as a cutting-edge and effective means of treating many of the most difficult CNS illnesses, including bacterial meningitis. Various metallic nanoparticles, such as gold, silver, and titanium oxide, have shown bactericidal potential. Gold nanoparticles have gotten a great deal of interest due to their excellent biocompatibility, simplicity of surface modification, and optical qualities. The current study described AuNP-based detection and therapy options against meningitis-- causing bacteria, including bacterial pathogens' mechanisms for crossing BBB and AuNPs' mode of Action against those bacteria. The current study looked into green synthesized bactericidal gold nanoparticles-based therapy techniques for diagnosing and intervening in bacterial meningitis. Nevertheless, more research is needed before these laboratory findings can be translated into therapeutic trials. Nonetheless, we can confidently assert that the knowledge acquired and addressed in this study will benefit neuro-nanotechnology researchers.

Clinical and Epidemiological Study of Poisoning Cases Presenting to the Emergency Department of a Tertiary Care Center in Central India.

Objective To analyze the clinical and epidemiological characteristics of acute cases of poisoning and the pre-hospital measures that the patient receives before seeking care in an emergency department at a tertiary care center in Central India. Methods An observational prospective study was carried out over 18 months, and the relevant findings were documented using a predesigned data collection form. All patients who presented to the emergency department and were 18 years of age or older were recruited, and consent was sought. Data analysis was performed using the SPSS software. Results A total of 102 patients diagnosed with poisoning were taken for this study, and data were collected and analyzed. The mean age was 32.8 ± 13.75 years. Of the study population, 63 (61.8%) patients were males. In our study, the most common cause of poisoning was impulsive intake of poison (n = 22, 21.5%) and suicidal ingestion in patients with depression (n = 18, 17.6%). In the emergency department, 61 patients (59.8%) received gastric lavage, and 37 patients (36.3%) received an antidote. The most common agent of poisoning was pesticide ingestion, accounting for 45 (44%) of the total cases. Prescribed drugs were the second-largest group (n = 19, 18.6%). Other common poisoning agents were rodenticides (n = 12, 11.7%), corrosives (n = 8, 7.8%), and aluminum phosphide (n = 3, 2.9%). Out of 102 patients, 82 patients survived, 15 patients died, and five patients left against medical advice (LAMA). One patient had residual comorbidity and was discharged with jejunostomy. The maximum mortality (22.5%) was due to organophosphorus compounds. Conclusions While accidental encounters are also common, intentional self-harm accounts for the majority of poisonings; homicidal motives are less likely. Pesticides were the most often used poisoning agents, followed by prescribed and over-the-counter drugs, rodenticides, corrosive agents, and aluminum phosphide. Of the poisoned cases, 69.6% had a full recovery, 22.54% of them died, and eight (7.84%) among them left against medical advice (LAMA). Organophosphorus chemicals were the cause of the highest mortality (22.5%).

Hospitalization Events Among Adolescents and Adults With Sickle Cell Disease in a Tertiary Care Center in Central India.

BACKGROUND: Sickle cell disease (SCD) is an inherited red blood cell disorder, wherein mutation causes the substitution of glutamic acid to valine at the sixth position of the ß-globin chain. These include sickle cell anemia (homozygous sickle mutation), sickle-beta thalassemia, and hemoglobin SCD. The clinical manifestations of SCD are protean. Individuals with SCD suffer from both acute and chronic complications, which include recurring episodes of pain commonly called vaso-occlusive crisis (VOC) - acute chest syndrome (ACS); aseptic necrosis of the bone; micro-infarction of the spleen, brain, and kidney; infections; stroke; and organ damage affecting every part of the body. SCD necessitates frequent hospitalizations because of severe complications, which pose a significant burden on caregivers and economic strain on healthcare systems. The pattern of hospital admission with SCD varies in different parts of the world. OBJECTIVE: This study aimed to determine the causes of hospitalization among adolescent and adult patients with SCD and to determine factors associated with their hospital stay. METHODS: The study was a hospital-based prospective observational study comprising adolescent and adult patients diagnosed with SCD, aged 15-45 years, who were hospitalized in the Department of General Medicine at All India Institute of Medical Sciences in Raipur from August 2021 to August 2022. RESULT: According to our study, the primary reason for hospitalization was a painful crisis, accounting for 63% of cases, followed by infection (17%), ACS (11%), and acute hemolytic crisis (9%). Notably, we did not observe any significant differences between genders and causes of admission (p > 0.05). Joint pain (p = 0.005), back pain (p = 0.001), and chest pain (p = 0.001) were more frequently reported by adults over the age of 19. In addition, our analysis of the duration of hospital stays and various factors revealed that patients admitted for infections had a significantly longer mean hospital stay duration (p = 0.040). CONCLUSION: Acute painful crises were the primary cause of hospital admission among individuals with SCD; many patients also encountered infections and ACS. Furthermore, patients who experienced infections and VOC had a lengthier duration of hospital stay. Therefore, it is essential to provide them with comprehensive instructions on various preventive measures against infections and the factors that trigger painful crises.

Deciphering the Neuropsychiatric Lupus Enigma: Navigating the Intersection of Acute Inflammatory Demyelinating Polyneuropathy (AIDP), Infection, and Flare.

A 17-year-old male diagnosed with systemic lupus erythematosus (SLE), showing poor compliance with medication, presented to our facility with a 20-day history of fever, polyarthritis, and cough. Additionally, he had experienced a seizure episode, followed by a one-day history of altered mentation. Subsequently, he developed pneumonia, respiratory distress, and shock, necessitating ventilator and inotropic support. Neuropsychiatric lupus (NP-lupus) was suspected, and hence high-dose steroids, hydroxychloroquine, and broad-spectrum antibiotics were initiated. Following successful extubation, he manifested ascending flaccid paralysis. The presence of albumin-cytological dissociation and axonal neuropathy confirmed the diagnosis of acute inflammatory demyelinating polyneuropathy (AIDP). He underwent further management with pulse steroids and plasmapheresis. Upon recovery, he was discharged on a regimen of steroids, cyclophosphamide, and hydroxychloroquine. During follow-up, he maintained ambulatory status with no residual neurological sequelae.

Pharmacokinetic and pharmacodynamic evaluation of floating microspheres of metformin hydrochloride.

Metformin hydrochloride (MH), a biguanide antidiabetic, is the drug of choice in obese patients. It is well absorbed from the upper part of gastrointestinal tract and has oral bioavailability of 50% to 60%. The objective of this study was to formulate MH into floating microspheres in order to increase its residence time at the site of absorption and thus improve its bioavailability; and to extend the duration of action along with possibilities of dose reduction. Microspheres were prepared by emulsion solvent evaporation method and evaluated for particle size, entrapment efficiency, buoyancy, and in vitro release; and further characterized by powder X-ray diffraction, Fourier transform infrared spectroscopy, scanning electron microscopy, and differential scanning calorimetry. The pharmacokinetic and pharmacodynamic evaluation of selected formulation was carried out in male Wistar diabetic rats. The data was statistically analyzed by unpaired t-test. A 3.5-fold increase in relative bioavailability was observed. The prolongation of half-life (t(1/2)) from 4.5 ± 2.41 h to 14.12 ± 4.81 h indicated extended duration of action. Oral glucose tolerance test (OGTT) was analyzed by one-way analysis of variance followed by Dunnet multiple comparison test, a significant decrease (p < 0.05) in the blood glucose levels was observed when formulations were compared with control rats. Hence, MH floating microspheres were tested at 50 mg/kg and 100 mg/kg body weight, OGTT data showed nonsignificant difference (p >0.05). In conclusion, an effective oral antidiabetics treatment can be achieved by formulating MH into floating microspheres which results in increase in bioavailability along with extended duration of action resulting in possible reduction in dose.

Glycopyrrolate-induced polyuria: An unexpected side effect.

Polyuria is urine output exceeding 3 L/d in adults, primarily due to solute and water diuresis. In a hospital setting, mannitol and diuretics commonly lead to polyuria. We have found an interesting association of polyuria with glycopyrrolate; to the best of our knowledge, no case is reported in the literature. Here, we are describing a case of Guillain-Barre Syndrome, which developed polyuria during the hospital stay, which was secondary to glycopyrrolate.

Recent Trends in Nanocarriers for the Management of Atopic Dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a pruritic inflammatory skin condition with increasing global prevalence, almost affecting 15% to 30% of children and 5% of adults. AD results due to a complex interaction between the impaired skin barrier function, allergens, and immunological cells. Topical corticosteroids or calcineurin inhibitors in the form of creams or ointments are the mainstay of therapy, but they have low skin penetration and skin barrier repair efficiency. OBJECTIVE: The above limitations of conventional dosage forms have motivated the development of nanoformulations of drugs for improved penetration and deposition in the skin for better management of AD. METHODS: Databases, such as Pubmed, Elsevier, and Google Scholar, were reviewed for the investigations or reviews published related to the title. RESULTS: The present review discusses the advantages of nanoformulations for the management of AD. Further, it also discusses the various types of topically investigated nanoformulations, i.e., polymeric nanoparticles, inorganic nanoparticles, solid lipid nanoparticles, liposomes, ethosomes, transfersomes, cubosomes, and nanoemulsion for the management of atopic dermatitis. In addition, it also discusses advancements in nanoformulations, such as nanofibres, nanosponges, micelles, and nanoformulations embedded textiles development for the management of AD. CONCLUSION: The nanoformulations of drugs can be a better alternative for the topical management of AD with enhanced skin penetration and deposition of drugs with reduced systemic side effects and better patient compliance.

Steroid and sphingomonas.

Sphingomonas paucimobilis is a Gram-negative bacteria identified as a rare infectious agent, more commonly seen among immune-compromised hosts. Infections include bacteremia, septicemia leading to septic shock, bone and soft-tissue infections such as septic arthritis, osteomyelitis, infection of shunts, and implantable devices. Although the organism has been reported to have low pathogenicity, infections in the immune compromised can be devastating leading to even death.

Résumé Sphingomonas paucimobilis est une bactérie Gram-négative identifiée comme un agent infectieux rare, plus fréquemment observé chez les hôtes immunodéprimés. Les infections comprenaient la bactériémie, la septicémie entraînant un choc septique, les infections des os et des tissus mous telles que l'arthrite septique, l'ostéomyélite, l'infection des shunts et des dispositifs implantables. Bien que l'organisme ait été signalé comme ayant une faible pathogénicité, les infections chez les personnes immunodéprimées peuvent être dévastatrices et même entraîner la mort. Mots clés: Sphingomonas, stéroïdes, antibiotiques.

Diagnosing Joubert Syndrome in Two Adult Siblings: A Very Rare Case Report.

Joubert syndrome (JS) is a rare genetic disorder usually diagnosed during childhood. Adult Joubert syndrome is rare, and that too in siblings from a non-consanguineous marriage in their adulthood is extremely rare, with very few cases reported worldwide. The need for expensive imaging modality to aid diagnosis has also been cited as a drawback in diagnosing the condition in resource-poor areas. We describe the case of two adult siblings who came for other diseases and were diagnosed with Joubert syndrome.

Pre-hospital care and its association with clinical outcome of snakebite victims presenting at a tertiary care referral hospital in South India.

Most snakebite victims in low- and middle-income countries continue to seek many forms of first aid therapy before reaching hospital, the commonest being the application of a tourniquet. Our study looked at a prospective cohort of 382 such patients to ascertain the association of pre-hospital care with clinical outcome, and found that 60% developed complications as compared to 36% who had no pre-hospital care (p < 0.001), with 10 fatalities in the former compared to only one in the latter. Pre-hospital care remains very common and definitely increases morbidity and mortality.

Gaucher's Disease in an Adult Female: A Rare Entity.

Gaucher's disease is a rare inborn error of metabolism with an autosomal recessive pattern of inheritance. With over 26 million births occurring per annum, extrapolation of this figure would give us an estimated burden of 17,000 babies born with lysosomal storage disorder (LSD). Given the large population of India and the high rates of consanguineous marriage that takes place in the subcontinent, LSD might not be as rare as we perceive it to be. We report a rare occurrence of type-1 Gaucher's disease in an adult female patient born of a non-consanguineous marriage, belonging to the tropical area of Chhattisgarh, India where there is a predominance of malaria, thalassemia, and sickling. The diagnosis was challenging in this case since we needed to work out all the differential diagnoses of pancytopenia with hepatomegaly and massive splenomegaly. The key part was her medical history where there was documentation of her elder brother's death due to some mental illness of undiagnosed etiology. Being a difficult time due to coronavirus disease 2019 ( COVID-19) , we were able to diagnose the patient with a bone marrow biopsy followed by glucocerebrosidase enzyme level suggestive of Gaucher's disease.

Wilson's Disease: Diagnosis in Novel Way.

Wilson's disease first described by Kinnier Wilson in 1912, is a rare autosomal recessive genetic disorder involving a defect in copper metabolism. This disease affects between one in 30,000 to one in 100,000 individuals and has a carrier frequency of one in every 90. It is characterized by hepatic and neurological symptoms. The usual age of presentation is 4 to 40 years but this disorder has been detected in children as young as three years and adults as old as 70 years with males and females being equally affected. Diagnosing Wilson's disease at the earliest is crucial as it is not only progressive and fatal if untreated, but also responds promptly to medication. Here we are going to present a novel way to diagnose a case of Wilson disease in a resource-limited setting. The diagnosis was possible with detailed present and past history raising strong clinical suspicion of environmental or genetically related disease. The diagnosis was done in a novel way by first diagnosing in daughter thereafter confirming the same diagnosis in patient.

A study on treatment outcome of registered tuberculosis cases under RNTCP in Udupi Taluk, Karnataka.

Directly Observed Treatment Short Course is the internationally recommended strategy to ensure cure of tuberculosis. However, it is equally important to review the shortcomings if any of such an important strategy against tuberculosis to make it more useful. This Descriptive study carried in a Tuberculosis Unit was to find out the treatment outcome of patients registered under Revised National Tuberculosis Control Program. The data was collected from the tuberculosis register and was analyzed using SPSS 13.0 version. Study included 563 patients, 68% were males and 32.0% were females. Category I had majority of the patients 307 (54.52%); Category II had 133 (23.6%), and Category III had 116 (20.6%) patients. In Category I, 175 (57.0%) patients were cured and 13(4.2%) had treatment failure. In Category II, 61 (45.9%) were cured and 11(8.3%) had treatment failure. In Category III, 105 (90.5%) had complet treatment. Out of 236 patients who were cured, majority were under the care of government health workers 125(53%), followed by anganwadi 32(13.6%) and social workers 27(11.4%). Joint efforts of DOTS providers cured 53 (22.4%) patients. Ensuring early diagnosis and high cure rate of Tuberculosis cases is the only effective way to stop the spread of Tuberculosis.

Assessment of serum tenascin-C and growth differentiation factor-15 among type 2 diabetes mellitus patients with and without acute coronary syndrome.

BACKGROUND: High prevalence of type 2 diabetes mellitus (T2DM) is associated with a higher prevalence of acute coronary syndrome (ACS). Inflammation is one of the important contributors to the pathogenesis and complications of coronary atherosclerotic plaque. Growth Differentiation Factor-15 (GDF-15) and Tenascin-C (TNC) play an important role in the initiation of atherosclerotic plaque as well as its rupture. The aim of the study was to evaluate the association between serum GDF-15, TNC, and the risk of ACS among T2DM patients. METHODS: Anthropometric parameters, routine biochemical investigations like liver and renal function tests, lipid profile, and Creatine Kinase-Total (CK-T), Creatine Kinase-MB (CK-MB) were measured in 42 T2DM patients with ACS and 42 T2DM patients. Serum GDF-15 and TNC were measured by Human Sandwich-ELISA kits. RESULTS: Serum GDF-15 and TNC levels were significantly higher in T2DM patients with ACS as compared to T2DM patients. Serum GDF-15 was significantly correlated with waist circumference, diastolic blood pressure, pulse, serum CK-T, and CK-MB. Serum TNC was significantly correlated with the pulse, serum CK-T, CK-MB, high-density lipoprotein-cholesterol, and blood urea nitro GEN. Multivariate linear regression analysis showed that waist circumference was independently positively associated with serum GDF-15. CONCLUSIONS: T2DM patients with higher serum GDF-15 and TNC levels were at higher risk of acute coronary syndrome independent of other cardiovascular risk factors.

Association between carbonyl stress markers and the risk of acute coronary syndrome in patients with type 2 diabetes mellitus-A pilot study.

BACKGROUND AND AIMS: Carbonyl stress is one of the mechanisms responsible for diabetes and its complications. The study was planned to examine the relationship between carbonyl stress markers and the risk of acute coronary syndrome (ACS) in patients with type 2 diabetes mellitus (T2DM). METHODS: Forty T2DM patients with ACS and forty T2DM patients without ACS participated in this cross-sectional pilot study. Routine biochemical investigations, creatine kinase-total (CK-T), and creatine kinase-MB (CK-MB) levels were estimated. Serum carbonyl stress markers were analysed by enzyme-linked immunosorbent assay. Binary logistics regression was done to determine the predictive value of carbonyl stress markers for ACS. RESULTS: Fasting plasma glucose, serum total methylglyoxal (MG), methylglyoxal derived hydroimidazolones-1 (MG-H1), and Nε-carboxymethyl-lysine (CML) levels were significantly higher in T2DM patients with ACS than in those without ACS. Serum glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and glyoxalase-1 (GLO1) levels were significantly lower in T2DM patients with ACS than in those without ACS. Fasting plasma glucose level was significantly positively correlated with serum MG (r = 0.441, P < 0.001), CML (r = 0.649, P < 0.001), MG-H1 (r = 0.725, P < 0.001), and negatively correlated with serum GAPDH (r = - 0.268, P = 0.012) and GLO1 (r = - 0.634, P = 0.016). Receiver operating characteristic curve analysis showed that serum GAPDH and GLO1 could predict the risk of ACS in T2DM patients. CONCLUSION: These findings revealed that high carbonyl stress due to lower levels of GAPDH and GLO1 may predispose patients with T2DM for more risk of ACS.

Incidence and outcome of peripartum cardiomyopathy from a tertiary hospital in South India.

There is very little literature regarding peripartum cardiomyopathy (PCM) from Asian countries. A study of PCM was conducted at Kasturba Medical College Hospital, Manipal, with special reference to incidence and outcome. The incidence of PCM was 1 case per 1374 live births. Major risk factors for the development of PCM were multiparity and advanced maternal age. Echocardiography is useful in early diagnosis and for follow-up assessment of left ventricular function. Most of the patients noticed good symptomatic improvement at time of discharge and during the follow-up with standard therapy. Clinical improvement was well correlated with improvement of LV function by echocardiography. Significant thrombotic complications were noticed. None of the patients died during the study and follow-up period.

Cardiac arrhythmias, electrolyte abnormalities and serum cardiac glycoside concentrations in yellow oleander (Cascabela thevetia) poisoning - a prospective study.

BACKGROUND: Consumption of yellow oleander (Cascabela thevetia) is a popular method of intentional self-harm in South India. OBJECTIVES: The objectives of this study were to identify the cardiac arrhythmias and electrolyte abnormalities in yellow oleander poisoning and to identify the association between electrolyte abnormalities, cardiac glycoside concentrations at admission and the severity of cardiotoxicity. This study was also designed to identify clinical and biochemical parameters at presentation which predict serious arrhythmias and determinants of mortality. MATERIALS AND METHODS: This was a prospective study among 192 patients who attended our Emergency department after consuming yellow oleander seeds. Patients were monitored with serial ECGs. Serious cardiac arrhythmias included sinus bradycardia <40/min, sinus arrest/exit block, second or third degree AV block, atrial tachyarrhythmias and ventricular tachyarrhythmias. Serum sodium, potassium, magnesium, total calcium and cardiac glycoside concentrations were measured at presentation for all 192 patients. Serial estimation of cardiac glycoside concentration was done in 43 patients who presented within 24 hours of consuming at least five seeds. RESULTS: At presentation, 46 patients had serious arrhythmias and on follow-up, 11 developed new-onset serious arrhythmia. Sinus bradycardia (27%) was the most common arrhythmia followed by second-degree AV block (17%); multiple arrhythmias were observed in 18%. Digoxin effect in ECG correlated significantly with hyperkalemia. Mortality rate was 5%. Serum sodium, total calcium and magnesium levels did not correlate with cardiotoxicity. Cardiac glycoside concentration was of relatively modest clinical utility to discriminate patients with serious dysrhythmias (AUC: 0.719, 95% CI: 0.63-0.81). Prolonged PR interval and digoxin effect in ECG were significantly associated with an increased likelihood of serious dysrhythmias. Increase in 0.4 number of seed intake increased the odds of mortality by 1.5 times when all other independent variables were kept constant. CONCLUSION: Cardiac glycoside concentration at the time of presentation predicted the development of new-onset serious arrhythmias. Although serum potassium correlated significantly with cardiac glycoside concentration at admission and overall serious dysrhythmias, it did not predict the development of new-onset serious arrhythmia. On the whole, serious dysrhythmias were significantly associated with higher number of seeds ingested, hypotension at admission, PR interval prolongation, presence of digoxin effect in ECG, hyperkalemia and higher cardiac glycoside concentration. The independent determinants of mortality were larger number of seeds ingested and hypotension at admission. Cardiac glycoside concentration and hyperkalemia failed to be independent markers of serious dysrhythmias as well as mortality.