Perforated gastric ulcer in severe dengue infection: A case report.

Abdominal pain is one of the common presentations in severe dengue infection. We report a rare case of perforated gastric ulcer in a young man diagnosed with severe dengue infection and the challenges we faced in managing this patient. Perforated gastric ulcer need to be considered if there are signs of peritonitis and persistent abdominal pain that does not conform to the natural history of dengue. Proper imaging and early surgical intervention in perforated gastric ulcer is vital in preventing further complication and reducing the risk of mortality.

Intravenous immunoglobulin suppresses NLRP1 and NLRP3 inflammasome-mediated neuronal death in ischemic stroke.

Multi-protein complexes called inflammasomes have recently been identified and shown to contribute to cell death in tissue injury. Intravenous immunoglobulin (IVIg) is an FDA-approved therapeutic modality used for various inflammatory diseases. The objective of this study is to investigate dynamic responses of the NLRP1 and NLRP3 inflammasomes in stroke and to determine whether the NLRP1 and NLRP3 inflammasomes can be targeted with IVIg for therapeutic intervention. Primary cortical neurons were subjected to glucose deprivation (GD), oxygen-glucose deprivation (OGD) or simulated ischemia-reperfusion (I/R). Ischemic stroke was induced in C57BL/6J mice by middle cerebral artery occlusion, followed by reperfusion. Neurological assessment was performed, brain tissue damage was quantified, and NLRP1 and NLRP3 inflammasome protein levels were evaluated. NLRP1 and NLRP3 inflammasome components were also analyzed in postmortem brain tissue samples from stroke patients. Ischemia-like conditions increased the levels of NLRP1 and NLRP3 inflammasome proteins, and IL-1ß and IL-18, in primary cortical neurons. Similarly, levels of NLRP1 and NLRP3 inflammasome proteins, IL-1ß and IL-18 were elevated in ipsilateral brain tissues of cerebral I/R mice and stroke patients. Caspase-1 inhibitor treatment protected cultured cortical neurons and brain cells in vivo in experimental stroke models. IVIg treatment protected neurons in experimental stroke models by a mechanism involving suppression of NLRP1 and NLRP3 inflammasome activity. Our findings provide evidence that the NLRP1 and NLRP3 inflammasomes have a major role in neuronal cell death and behavioral deficits in stroke. We also identified NLRP1 and NLRP3 inflammasome inhibition as a novel mechanism by which IVIg can protect brain cells against ischemic damage, suggesting a potential clinical benefit of therapeutic interventions that target inflammasome assembly and activity.

The comparison of discomfort level between upper arm and forearm tourniquet.

The conventional upper arm tourniquet used for hand and wrist operations may cause significant discomfort to patient when the procedure is performed under local anaesthesia. Forearm tourniquet causes less muscle ischeamia and pain. The discomfort experienced while using a forearm and upper arm tourniquet was assessed in 96 healthy subjects. Tourniquet placed on both sides was inflated sequentially to 250mmhg for five minutes on different hand. The discomfort level was assessed using a small visual analogue scale and complications were recorded. In the upper arm tourniquet, 24.9% had mild, 60.5% had moderate and 14.6% had severe pain whereas with forearm tourniquet, 99% had mild pain and only 1% had moderate pain. Seventy-nine percent of the subjects tested with forearm tourniquet had no discomfort at all. The average discomfort level for upper arm and forearm tourniquet was 4.72 and 0.39 respectively, which is statistically significant. Complications that were observed only in upper arm tourniquet included prolonged tingling, burning sensation and discomfort and stiffness of the upper limb. We concluded that forearm tourniquet was safe and well tolerated and should be used more often when indicated.