Identificação da velocidade anormal da dilatação de pupila como biomarcador de lesão cerebral em pacientes neurocríticos / Identification of abnormal pupil dilation velocity as a biomarker of cerebral injury in neurocritically ill patients

RESUMO Objetivo: Calcular as velocidades médias da dilatação de pupila para classificar a gravidade da lesão derivada da escala de coma de Glasgow, estratificada por variáveis de confusão. Métodos: Neste estudo, analisaram-se 68.813 exames das pupilas para determinar a velocidade normal de dilatação em 3.595 pacientes com lesão cerebral leve (13 - 15), moderada (9 - 12) ou grave (3 - 8), segundo a escala de coma de Glasgow. As variáveis idade, sexo, raça, tamanho da pupila, tempo de permanência na unidade de terapia intensiva, pressão intracraniana, uso de narcóticos, classificação pela escala de coma de Glasgow e diagnóstico foram consideradas confundidoras e controladas para análise estatística. Empregou-se regressão logística com base em algoritmo de classificação com aprendizado de máquina para identificar os pontos de corte da velocidade de dilatação para as categorias segundo a escala de coma de Glasgow. Resultados: As razões de chance e os intervalos de confiança desses fatores se mostraram estatisticamente significantes em sua influência sobre a velocidade de dilatação. A classificação com base na área sob a curva mostrou que, para o grau leve, na escala de coma de Glasgow, o limite da velocidade de dilatação foi de 1,2mm/s, com taxas de falsa probabilidade de 0,1602 e 0,1902 e áreas sob a curva de 0,8380 e 0,8080, respectivamente, para os olhos esquerdo e direito. Para grau moderado na escala de coma de Glasgow, a velocidade de dilatação foi de 1,1mm/s com taxas de falsa probabilidade de 0,1880 e 0,1940 e áreas sob a curva de 0,8120 e 0,8060, respectivamente, nos olhos esquerdo e direito. Mais ainda, para o grau grave na escala de coma de Glasgow, a velocidade de dilatação foi de 0,9mm/s, com taxas de falsa probabilidade de 0,1980 e 0,2060 e áreas sob a curva de 0,8020 e 0,7940, respectivamente, nos olhos esquerdo e direito. Esses valores foram diferentes dos métodos prévios de descrição subjetiva e das velocidades de dilatação previamente estimadas. Conclusão: Observaram-se velocidades mais lentas de dilatação pupilar em pacientes com escores mais baixos na escala de coma de Glasgow, indicando que diminuição da velocidade pode indicar grau mais grave de lesão neuronal.

ABSTRACT Objective: To calculate mean dilation velocities for Glasgow coma scale-derived injury severity classifications stratified by multiple confounding variables. Methods: In this study, we examined 68,813 pupil readings from 3,595 patients to determine normal dilation velocity with brain injury categorized based upon a Glasgow coma scale as mild (13 - 15), moderate (9 - 12), or severe (3 - 8). The variables age, sex, race, pupil size, intensive care unit length of stay, intracranial pressure, use of narcotics, Glasgow coma scale, and diagnosis were considered as confounding and controlled for in statistical analysis. Machine learning classification algorithm-based logistic regression was employed to identify dilation velocity cutoffs for Glasgow coma scale categories. Results: The odds ratios and confidence intervals of these factors were shown to be statistically significant in their influence on dilation velocity. Classification based on the area under the curve showed that for the mild Glasgow coma scale, the dilation velocity threshold value was 1.2mm/s, with false probability rates of 0.1602 and 0.1902 and areas under the curve of 0.8380 and 0.8080 in the left and right eyes, respectively. For the moderate Glasgow coma scale, the dilation velocity was 1.1mm/s, with false probability rates of 0.1880 and 0.1940 and areas under the curve of 0.8120 and 0.8060 in the left and right eyes, respectively. Furthermore, for the severe Glasgow coma scale, the dilation velocity was 0.9mm/s, with false probability rates of 0.1980 and 0.2060 and areas under the curve of 0.8020 and 0.7940 in the left and right eyes, respectively. These values were different from the previous method of subjective description and from previously estimated normal dilation velocities. Conclusion: Slower dilation velocities were observed in patients with lower Glasgow coma scores, indicating that decreasing velocities may indicate a higher degree of neuronal injury.

Obstetrics outcome in pregnant women with cardiac disease in tertiary care center, Dehradun, India

Background: Incidence of heart disease in pregnancy is about 1%. Pregnant patient with cardiac disease can present with lot of challenges for the obstetrician, paediatrician and the cardiologist. With improvement in diagnostic, medical, surgical management, more patient with cardiac diseases especially congenital are able to reach reproductive age. Therefore, still a cardiac disease remains a significant cause of maternal death. Maternal and fetal prognosis both is affected by the care given and the skills used in the treatment of the individual patient. Hospital has resulted in majority of cardiac disease patient being managed in a tertiary care center and this provide an opportunity to report on clinical experiences of pregnancy with cardiac disease, their management and obstetrical outcomes.Methods: This was a retrospective study, with all the patients detailed demographic information, diagnosis, course in the hospital, management, maternal and fetal outcome was obtained from the medical records and files.Results: Incidence of cardiac disease was found to be 0.7%, 47% of pregnant women fell in age group of 26-30 years, 38.2% were primigravida, only 23.53% were booked, and half of them belonged to NYHA II class. 73.5% had Rheumatic heart disease and the most common obstetrics complications were preterm labor and anemia. LSCS was done in 29.4% cases and 38.2% of the newborns were premature.Conclusions: Prematurity anaemia, IUGR, are the common obstetrical complication in pregnant patient with cardiac disease which can be taken care with increased awareness and pre-conceptional counselling especially in patient with congenital heart disease. For optimization of maternal and neonatal outcomes in these patients, dedicated team of obstetrician, fetal medicine specialist, pediatricians, cardiologist and anesthesiologist is the prime requirement.

Cardiovascular consequences of obstructive sleep apnoea.

Obstructive sleep apnoea (OSA) is a form of sleep disordered breathing with a high prevalence rate and is often underdiagnosed. OSA is associated with hypertension, coronary artery disease, stroke, peripheral vascular disease, heart failure, and arrhythmias. The presence of OSA may be a strong predictor of fatal cardiovascular events in patients with cardiovascular disease (CVD). Increased sympathetic drive, activation of metabolic and inflammatory markers, and impaired vascular function are some of the proposed mechanisms that could explain the association between OSA and cardiovascular diseases. Understanding these mechanisms is important for identifying treatment strategies. The presence of OSA should be considered in clinical practice, especially in patients with CVD. Randomized intervention studies are needed to establish whether early identification and treatment of OSA patients reduces cardiovascular morbidity.

Symbiotic characterization of isoleucine+valine and leucine auxotrophs of Sinorhizobium meliloti.

Ten isoleucine+valine and three leucine auxotrophs of Sinorhizobium meliloti Rmd201 were obtained by random mutagenesis with transposon Tn5 followed by screening of Tn5 derivatives on minimal medium supplemented with modified Holliday pools. Based on intermediate feeding, intermediate accumulation and cross-feeding studies, isoleucine+valine and leucine auxotrophs were designated as ilvB/ilvG, ilvC and ilvD, and leuC/leuD and leuB mutants, respectively. Symbiotic properties of all ilvD mutants with alfalfa plants were similar to those of the parental strain. The ilvB/ilvG and ilvC mutants were Nod-. Inoculation of alfalfa plants with ilvB/ilvG mutant did not result in root hair curling and infection thread formation. The ilvC mutants were capable of curling root hairs but did not induce infection thread formation. All leucine auxotrophs were Nod+ Fix-. Supplementation of leucine to the plant nutrient medium did not restore symbiotic effectiveness to the auxotrophs. Histological studies revealed that the nodules induced by the leucine auxotrophs did not develop fully like those induced by the parental strain. The nodules induced by leuB mutants were structurally more advanced than the leuC/leuD mutant induced nodules. These results indicate that ilvB/ilvG, ilvC and one or two leu genes of S. meliloti may have a role in symbiosis. The position of ilv genes on the chromosomal map of S. meliloti was found to be near ade-15 marker.