Association between admission systolic blood pressure and outcomes in patients with isolated traumatic brain injury: A cross-national multicentre cohort study.

BACKGROUND: The optimal prehospital blood pressure in patients following traumatic brain injury (TBI) remains controversial. We aimed to assess the association between the systolic blood pressure (SBP) at emergency department triage and patient outcomes following isolated moderate-to-severe TBI. METHODS: We conducted a cross-national multicentre retrospective cohort study using the Pan-Asia Trauma Outcomes Study database from January 1, 2016, to November 30, 2018. The enrollees were adult patients with isolated moderate-to-severe TBI defined by the International Classification of Diseases code, a Glasgow Coma Scale (GCS) < 13 at triage, and a non-head Abbreviated Injury Scale ≤ 3. The studied variables were SBPs at triage categorised into different ranges. The primary outcome was 30-day mortality and the secondary outcome was poor functional status at hospital discharge defined by the modified Rankin Scale ≥ 4. Multivariable logistic regression were applied to adjust for confounders including country, sex, age, mechanism of injury, prehospital vascular access, respiratory rate, GCS, oxygen saturation, intubation, Injury Severity Score, head surgery, intensive care unit admission, and length of hospital stay. Subgroup analyses were performed on different severity of TBI. RESULTS: A total of 785 patients (median age, 42 years; male patients 77.5%; mean SBP at triage, 136.3 ± 33.1 mmHg) were included in the primary analysis. The lowest 30-day mortality rate existed in patients with SBP of 100-119 mmHg. Taking it as baseline, the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of SBP < 100 mmHg, 120-139 mmHg, 140-159 mmHg, and ≥ 160mmHg were 7.05 (2.51-19.78), 3.14 (1.14-8.65), 2.91 (1.04-8.17), and 3.28 (1.14-9.42). As for the secondary outcome, the aORs and 95% CIs were 1.36 (0.68-2.68) of < 100 mmHg, 0.99 (0.57-1.70) of 120-139 mmHg, 1.23 (0.67-2.25) of 140-159 mmHg, and 1.52 (0.78-2.95) of ≥ 160 mmHg. Subgroup analyses revealed trends of the best outcomes in both moderate and severe TBI patients with SBP 100-119 mmHg, while statistical significance appeared only in patients with severe TBI. CONCLUSIONS: SBP of 110-119 mmHg at triage is associated with the lowest 30-day mortality in patients following isolated moderate-to-severe TBI, and possibly related to a better functional outcome.

Development of a prediction model for emergency medical service witnessed traumatic out-of-hospital cardiac arrest: A multicenter cohort study.

BACKGROUND/PURPOSE: To develop a prediction model for emergency medical technicians (EMTs) to identify trauma patients at high risk of deterioration to emergency medical service (EMS)-witnessed traumatic cardiac arrest (TCA) on the scene or en route. METHODS: We developed a prediction model using the classical cross-validation method from the Pan-Asia Trauma Outcomes Study (PATOS) database from 1 January 2015 to 31 December 2020. Eligible patients aged ≥18 years were transported to the hospital by the EMS. The primary outcome (EMS-witnessed TCA) was defined based on changes in vital signs measured on the scene or en route. We included variables that were immediately measurable as potential predictors when EMTs arrived. An integer point value system was built using multivariable logistic regression. The area under the receiver operating characteristic (AUROC) curve and Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration in the derivation and validation cohorts. RESULTS: In total, 74,844 patients were eligible for database review. The model comprised five prehospital predictors: age <40 years, systolic blood pressure <100 mmHg, respiration rate >20/minute, pulse oximetry <94%, and levels of consciousness to pain or unresponsiveness. The AUROC in the derivation and validation cohorts was 0.767 and 0.782, respectively. The HL test revealed good calibration of the model (p = 0.906). CONCLUSION: We established a prediction model using variables from the PATOS database and measured them immediately after EMS personnel arrived to predict EMS-witnessed TCA. The model allows prehospital medical personnel to focus on high-risk patients and promptly administer optimal treatment.

Effect of Non-Surgical Periodontal Therapy on Systemic Inflammatory Markers, Glycemic Status and Levels of Proteinuria in Type 2 Diabetic and Non-Diabetic Patients With Chronic Periodontitis.

AIMS AND OBJECTIVES:  The present study aimed to evaluate the effect of non-surgical periodontal therapy (NSPT) on systemic inflammatory markers, glycemic status, and levels of proteinuria in Type 2 diabetic and non-diabetic individuals with chronic periodontitis. METHODOLOGY: A total of 120 patients, categorized into three groups of 40 each, were included in this randomized observational study. Group 1 comprised patients with chronic periodontitis; Group 2 had chronic periodontitis with controlled diabetes; and Group 3 represented patients with chronic periodontitis with uncontrolled diabetes based on fasting blood sugar (FBS) and glycated hemoglobin (HbA1c) levels. Periodontal clinical parameters like plaque index, gingival index, bleeding on probing, pocket depth, and clinical attachment levels were evaluated. Blood samples and urine samples were collected and assessed for the levels of FBS, HbA1c, total protein, albumin, globulin, and proteinuria. All parameters recorded at baseline and three months after non-surgical periodontal therapy were analyzed for statistical significance at p <.05 using SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc. RESULTS: A significant reduction in the periodontal clinical parameters within the groups, except for the clinical attachment level in Group 1 patients (p = 0.05), was observed. Glycemic status revealed a significant reduction after non-surgical periodontal therapy (p < 0.001), and on intragroup comparison, the total protein, albumin, globulin, and microprotein blood and urine levels showed significance among the evaluated groups (p < 0.001). CONCLUSION: Non-surgical periodontal treatment can effectively improve the periodontal and circulating inflammatory status. Results of our study showed improved glycemic control and a reduction in systemic inflammatory markers and proteinuria after performing non-surgical periodontal treatment in patients with type 2 diabetes.

Superfluid density in conventional superconductors: from clean to strongly disordered.

The highly convergent form of superfluid density in disordered conventional superconductors available in the literature and independently obtained by us following the approach of an earlier paper (Mandal and Ramakrishnan 2020Phys. Rev.B102024514) has been reformulated to separate out the generally used so-called 'dirty-limit' term and an additional term. We use this new expression for making an extensive comparison with previously published experimental data and show that the former, generally used, term isnotsufficient for analyzing these results. We point out that consequently, there is a large regime (disordered superconductors with moderate to no disorder) where theoretical predictions need to be confronted with experiment.

Microscale heterogeneous pore occupancy with variable background resistance.

Fluid flow through porous media often involves the spontaneous displacement of one immiscible fluid by another. On the level of adjacent channels, a pore doublet model can estimate the relative flow rates in the two channels and the final fluid occupancy of the pair. Pore doublet models nominally capture the dominant roles of capillarity and viscosity, by describing the flow using hydraulic circuit theory. However, this approach neglects the more complex fluid flow in the region where the immiscible fluids meet, and therefore the applicability of this model for low aspect-ratio pores commonly seen in natural media is questionable. We show that for large channel aspect ratios, the numerical results replicate the traditional pore doublet models; however, as the aspect ratio approaches unity, the accuracy of these models break down. We quantify the effect of complex flow on the final fluid occupancy, which we link to the excess energy dissipation rate from the flow near the immiscible interface. Our results indicate that a minimal 1D pore doublet model may be sufficient to model global dynamics, including the fraction of residual oil that remains trapped in a reservoir, where the pore diameter and length are comparable.

Indian Resuscitation Council (IRC) suggested guidelines for Comprehensive Cardiopulmonary Life Support (CCLS) for suspected or confirmed coronavirus disease (COVID-19) patient.

Management of the recent outbreak of the novel coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) remains challenging. The challenges are not only limited to its preventive strategies, but also extend to curative treatment, and are amplified during the management of critically ill patients with COVID-19. Older persons with comorbidities like diabetes mellitus, cardiac diseases, hepatic impairment, renal disorders and respiratory pathologies or immune impairing conditions are more vulnerable and have a higher mortality from COVID-19. Earlier, the Indian Resuscitation Council (IRC) had proposed the Comprehensive Cardiopulmonary Life Support (CCLS) for management of cardiac arrest victims in the hospital setting. However, in patients with COVID-19, the guidelines need to be modified,due to various concerns like differing etiology of cardiac arrest, virulence of the virus, risk of its transmission to rescuers, and the need to avoid or minimize aerosolization from the patient due to various interventions. There is limited evidence in these patients, as the SARS-CoV-2 is a novel infection and not much literature is available with high-level evidence related to CPR in patients of COVID-19. These suggested guidelines are a continuum of CCLS guidelines by IRC with an emphasis on the various challenges and concerns being faced during the resuscitative management of COVID-19 patients with cardiopulmonary arrest.

Marginally Self-Averaging One-Dimensional Localization in Bilayer Graphene.

The combination of a field-tunable band gap, topological edge states, and valleys in the band structure makes insulating bilayer graphene a unique localized system, where the scaling laws of dimensionless conductance g remain largely unexplored. Here we show that the relative fluctuations in lng with the varying chemical potential, in strongly insulating bilayer graphene (BLG), decay nearly logarithmically for a channel length up to L/ξ≈20, where ξ is the localization length. This "marginal" self-averaging, and the corresponding dependence of ⟨lng⟩ on L, suggests that transport in strongly gapped BLG occurs along strictly one-dimensional channels, where ξ≈0.5±0.1 µm was found to be much longer than that expected from the bulk band gap. Our experiment reveals a nontrivial localization mechanism in gapped BLG, governed by transport along robust edge modes.

Enhanced oil displacement by nanofluid's structural disjoining pressure in model fractured porous media.

Nanofluids for improved oil recovery has been demonstrated through laboratory corefloods. Despite numerous experimental studies, little is known about the efficacy of nanofluids in fractured systems. Here, we present studies of nanofluid injection in fractured porous media (both water-wet and oil-wet) formed by sintering borosilicate glass-beads around a dissolvable substrate. The fracture inside the porous medium is characterized and visualized using a high resolution X-ray microtomography. Based on a simple displacement theory, the nanofluid injection is conducted at a rate where structural disjoining pressure driven oil recovery is operational. An additional 23.8% oil was displaced using nanofluid after brine injection with an overall recovery efficiency of 90.4% provided the matrix was in its native wettability state. But only 6% additional oil was displaced by nanofluid following brine injection when the bead-pack was rendered oil-wet. Nanofluids appear to be a good candidate for enhanced oil recovery (EOR) in fractured water-wet to weakly water-wet media but not necessarily for strongly oil-wet systems. Our laboratory studies enable us to understand limitations of nanofluids for improving oil recovery in fractured media.

Primary Tubercular Abscess of the Axilla-a Rare Case.

Tuberculosis can be broadly classified as pulmonary and extrapulmonary. Though pulmonary tuberculosis is the most common presentation, extrapulmonary tuberculosis is also an important entity. A tubercular cold abscess secondary to involvement of an adjacent bone or suppuration of lymph nodes is a well-known entity; however, a primary cold abscess is rare. We report a case of a young girl who presented with an axillary swelling which turned out to be a primary tubercular abscess of the axilla. To the best of our knowledge, this is the first reported case of a primary tubercular abscess presenting in the axilla. A primary tubercular abscess, though rare, should be considered as a possible diagnosis in appropriate clinical settings backed by evidence of Mycobacterium tuberculosis in form of AFB microscopy, L-J culture, BACTEC culture, or PCR test.

Faciobrachial dystonic seizures result from fronto-temporo-basalganglial network involvement.

•Faciobrachial dystonic seizures (FBDS) are caused by autoantibodies to leucine-rich glioma-inactivated1 proteins, a component of the voltage-gated potassium channel complex (VGKC-complex) and precede the clinical presentation of limbic encephalitis.•The exact pathophysiology of FBDS is not known and whether they are seizures or movement disorder is still debated.•We suggest the fronto-temporo-basal ganglia network involving the medial frontal and temporal regions along with the corpus striatum and substantia nigra being responsible for the clinical phenomenon of FBDS.•The varied clinical, electrical and imaging features of FBDS in our cases and in the literature are best explained by involvement of this network.•Entrainment from any part of this network will result in similar clinical expression of FBDS, whereas other electro-clinical associations and duration depends on the extent of involvement of the network.

Necrotizing Fasciitis: A Rare Complication of Acute Necrotizing Pancreatitis.

Necrotizing pancreatitis occurs in 10 to 25% of patients requiring hospital admission for acute pancreatitis and carries a high mortality rate. Necrotizing pancreatitis can cause a spectrum of complications. However, we report an extremely rare complication of necrotizing pancreatitis: necrotizing fasciitis of the abdominal wall. A 56-year-old male patient presented to our center with discoloration of skin over left flank of 15 days duration and pus discharge from it since three days. Two months back he was managed at a private hospital as a case of acute necrotizing pancreatitis and was discharged after one week of inpatient treatment. After discharge patient continued to have malaise and weakness but was able to do his routine day to day activity. On presentation at our hospital, patient was in septic shock and was taken emergently to operating theatre for debridement. However, later, the patient succumbed to his illness. Necrotizing fasciitis is an extremely uncommon complication of necrotizing pancreatitis and has a fulminant course. Timely detection and debridement can avert a potential mortality.

Colistin Nephrotoxicity in Adults: Single Centre Large Series from India.

CONTEXT: Limited Indian data are available on the rate of colistin nephrotoxicity and other risk factors contributing to the development of this important side effect. AIM: This study aims to generate data on colistin nephrotoxicity from a large cohort of Indian patients. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: Case record analysis of patients who received colistin, in an oncology center in India, between January 2011 and December 2015. Nephrotoxicity was assessed using risk, injury, failure, loss, and end-stage (RIFLE) criteria. STATISTICAL ANALYSIS: P < 0.05 was considered as statistically significant. RESULTS: Out of the 229 patients, 13.1% (30/229) developed abnormal RIFLE. Abnormal RIFLE group (n = 30), in comparison to the normal renal function group (n = 199), had higher number of patients in intensive care unit (ICU) (96% vs. 79%, P = 0.02), higher Acute Physiology and Chronic Health Evaluation (APACHE II) score (23 vs. 19 P = 0.0001), Charlson score (5.9 vs. 4.3, P = 0.001), mechanical ventilation (90% vs. 67%, P = 0.016), 28 days mortality (63% vs. 25%, P = 0.0001), and abnormal baseline creatinine (36% vs. 8%, P = 0.001). Coadministration of vancomycin had higher rates of nephrotoxicity (P = 0.039). There was no significant difference in nephrotoxicity between 6 and 9 MU/day dosing pattern (8.8% vs. 13.8%, P = 0.058). CONCLUSION: Nephrotoxicity rate in our retrospective single center large series of patients receiving colistin was 13.1%. Patients with abnormal baseline creatinine, ICU stay, and higher disease severity are at higher risk of nephrotoxicity while on colistin. A daily dose of 9 million does not significantly increase nephrotoxicity compared to the 6 million. Concomitant administration of vancomycin with colistin increases the risk of nephrotoxicity.

Evaluation of Micronutrient (Zinc, Magnesium, and Copper) Levels in Serum and Glycemic Status after Nonsurgical Periodontal Therapy in Type 2 Diabetic Patients with Chronic Periodontitis.

AIMS AND OBJECTIVES: To find out the effect of nonsurgical periodontal therapy on serum zinc (Zn), magnesium (Mg), and copper (Cu) concentration and glycemic status in type 2 diabetes with chronic periodontitis (CP). MATERIALS AND METHODS: One hundred and twenty patients were included in this study, which was further divided into three groups. Group 1 consisted of forty patients with CP, Group 2 consisted of forty patients of CP with controlled diabetes, and Group 3 consisted of forty patients of CP with uncontrolled diabetes. Periodontal parameters such as plaque index, gingival index, bleeding on probing, pocket depth, and clinical attachment levels (CALs) were evaluated. Blood samples were collected to assess the levels of fasting blood sugar, glycosylated hemoglobin, Zn, Mg, and Cu. All parameters were evaluated at baseline and 3 months after nonsurgical periodontal therapy. RESULTS: The results showed statistically significant reduction in all the clinical parameters within the groups except for the CAL in group 1 patients (P = 0.05). The glycemic status also showed a statistically significant reduction after treatment (P < 0.001). The intragroup comparison was taken between the values of micronutrients, showed substantial increase in the levels of both Zn and Mg and decrease in the level of Cu after nonsurgical periodontal treatment (P < 0.001). CONCLUSION: Patients with diabetes and periodontitis had altered metabolism of Zn, Mg, and Cu contributing to the progression and complication of diabetes mellitus and periodontitis. Nonsurgical periodontal treatment improved the variation and concentration of plasma micronutrients and also the periodontal status and glycemic level.

Herpes Simplex 1 and Periopathogen Role in Peri-implantitis.

INTRODUCTION: The objectives of this study were to compare the qualitative and quantitative profiles of herpes simplex virus type I (HSV-1) in implant surfaces between participants with peri-implantitis (PI) and Healthy peri-implant tissues and to quantitatively assess the relation between HSV-1 and periopathogens inside the microbiological profile associated with PI. MATERIALS AND METHODS: A total of 40 patients with PI and 40 with healthy peri-implant tissues (HI) were recruited. Plaque samples from peri-implant sulcus and internal implant connections were analyzed using quantitative real-time polymerase chain reaction to detect and quantify HSV-1 and periodonto-pathogens. Frequencies of detection and levels of microorganisms were compared between PI and HI; the frequencies and levels of periodontopathogens were compared between HSV-1+ and HSV-1- PI to assess qualitative relations between HSV-1 and bacteria. Correlation between HSV-1 and periodontopatho-gens levels was assessed in PI and HI. RESULTS: A total of 77 dental implants affected by PI, and 113 HIs were included. The HSV-1 prevalence was slightly higher in PI compared with controls (33.3 vs 23.8%; p > 0.05); HSV-1 was detected in external samples more frequently compared with internal samples. The HSV-1-positive patients revealed higher median loads of Prevotella intermedia (Pi) and Campylobacter rectus (Cr) compared with HSV-1-negative patients. In the PI group, a significant positive correlation was evidenced between HSV-1 and Tannerella forsythia, Parvimonas micra (Pm), Fusobacterium nucleatum, and Cr levels, while in the HI, positive correlation between HSV-1 and Aggregatibacter actinomycetemcomitans, Pi, and Pm was established. CONCLUSION: The HSV-1 prevalence cannot be used to identify PI. The HSV-1 was found in similar levels of PI and HI patients after an average of 6 years of loaded implants. The HSV-1 prevalence cannot be used to identify implants with or without the presence of PI. CLINICAL SIGNIFICANCE: Although HSV-1 is detected in PI site, HSV-1 may represent an unspecific indicator for the host response to the bacterial challenge observed in PI.

Computer-Based CPR Simulation Towards Validation of AHA/ERC Guidelines.

As per the AHA 2015 and ERC 2015 guidelines for resuscitation, chest compression depth should be between 5 and 6 cm with a rate of 100-120 compressions per minute. Theoretical validation of these guidelines is still elusive. We developed a computer model of the cardiopulmonary resuscitation (CPR) system to validate these guidelines. A lumped element computer model of the cardiovascular system was developed to simulate cardiac arrest and CPR. Cardiac output was compared for a range of compression pressures and frequencies. It was observed from our investigation that there is an optimum compression pressure and rate. The maximum cardiac output occurred at 100 mmHg, which is approximately 5.7 cm, and in the range of 100 to 120 compressions per minute with an optimum value at 110 compressions per minute, validating the guidelines. Increasing the pressure or the depth of compression beyond the optimum, limits the blood flow by depleting the volume in the cardiac chambers and not allowing for an effective stroke volume. Similarly increasing the compression rate beyond the optimum degrades the ability of the chambers to pump blood. The results also bring out the importance of complete recoil of the chest after each compression with more than 400% increase in cardiac output from 90% recoil to 100% recoil. Our simulation predicts that the recommendation to compress harder and faster is not the best counsel as there is an optimum compression pressure and rate for high-quality CPR.

Management of gingival recession with acellular dermal matrix graft: A clinical study.

AIMS AND OBJECTIVES: Obtaining root coverage has become an important part of periodontal therapy. The aims of this studyare to evaluate the clinical efficacy of acellular dermal matrix graft in the coverage of denuded roots and also to examine the change in the width of keratinized gingiva. MATERIALS AND METHODS: A total of 20 sites with more than or equal to 2 mm of recession depth were taken into the study, for treatment with acellular dermal matrix graft. The clinical parameters such as recession depth, recession width, width of keratinized gingiva, probing pocket depth (PD), and clinical attachment level (CAL) were measured at the baseline, 8th week, and at the end of the study (16th week). The defects were treated with a coronally positioned pedicle graft combined with acellular dermal matrix graft. RESULTS: Out of 20 sites treated with acellular dermal matrix graft, seven sites showed complete root coverage (100%), and the mean root coverage obtained was 73.39%. There was a statistically significant reduction in recession depth, recession width, and probing PD. There was also a statistically significant increase in width of keratinized gingiva and also gain in CAL. The postoperative results were both clinically and statistically significant (P < 0.0001). CONCLUSION: The results of this study were esthetically acceptable to the patients and clinically acceptable in all cases. From this study, it may be concluded that acellular dermal matrix graft is an excellent substitute for autogenous graft in coverage of denuded roots.

Emergency medicine as a specialty in Asia.

Aim: We aim to examine the similarities and differences in areas of EM development, workload, workforce, and capabilities and support in the Asia region. Emerging challenges faced by our EM community are also discussed. Methods: The National Societies for Emergency Medicine of Hong Kong, India, Japan, Malaysia, Philippines, Singapore, South Korea, Taiwan, Thailand and Turkey participated in the joint Japanese Association of Acute Medicine (JAAM) and Asian Conference of Emergency Medicine (ACEM) Special Symposium held in October 2013 at Tokyo, Japan. The findings are reviewed in this paper. Results: Emergency medicine (EM) has over the years evolved into a distinct and recognized medical discipline requiring a unique set of cognitive, administrative and technical skills for managing all types of patients with acute illness or injury. EM has contributed to healthcare by providing effective, safe, efficient and cost-effective patient care. Integrated systems have developed to allow continuity of emergency care from the community into emergency departments. Structured training curriculum for undergraduates, and specialty training programs for postgraduates are in place to equip trainees with the knowledge and skills required for the unique practice of EM. Conclusion: The practice of EM still varies among the Asian countries. However, as a region, we strive to continue in our efforts to develop the specialty and improve the delivery of EM.

Changes in Transforming Growth Factor-ß1 in Gingival Crevicular Fluid of Patients with Chronic Periodontitis Following Periodontal Flap Surgery.

INTRODUCTION: The aim of the study was to assess changes in Transforming Growth Factor- ß1 (TGF-ß1) levels in gingival crevicular fluid (GCF) and examine correlation of TGF-ß1 levels and periodontal parameters: probing pocket depth (PPD) and clinical attachment level (CAL) in sites with chronic periodontitis at various time intervals before and after periodontal surgery. MATERIALS AND METHODS: The effects of non-surgical and surgical therapy on periodontal parameters and GCF TGF-ß1 levels in 18 sites affected with chronic periodontitis were assessed upto 6 weeks post conventional flap surgery. GCF was collected and PPD, CAL recorded at Baseline. GCF was collected and PPD, CAL recorded at Pre-surgery and flap surgery performed. GCF was collected from all sites at Two Weeks Post-surgery. GCF was collected and PPD, CAL recorded at Six Weeks Post-surgery. The concentration of TGF-ß1 in GCF was determined using a human TGF-ß1 enzyme immunometric assay kit. RESULTS: Mean TGF-ß1 concentrations were significantly reduced at Pre-surgery, at Two Weeks Post-surgery and at Six Weeks Post-surgery (p<0.05) when compared to Baseline TGF-ß1 values. There was a statistically significant reduction in PPD and gain in CAL following non-surgical and surgical therapy when compared to baseline (p<0.05). CONCLUSION: RESULTS indicate that TGF-ß1 may play a role in the pathogenesis and diagnosis of periodontal disease and could be considered as a disease predictive biomarker.