Tuberculous Meningitis Presenting as Cerebral Salt Wasting Syndrome: A Review of Literature with Clinical Approach to Hyponatremia.

Hyponatremia in the neurocritical care patients is commonly encountered in the setting of either syndrome of inappropriate ADH secretion or cerebral salt wasting. However, differentiation of SIADH and CSW is paramount in view of their divergent treatment strategies.

Effects of circadian restricted feeding on parameters of metabolic syndrome among healthy subjects.

Experimental studies indicate that energy homeostasis to the circadian clock at the behavioral, physiological, and molecular levels, emphasize that timing of food intake may play a significant role in the development of obesity and central obesity. Therefore, resetting the circadian clock by circadian energy restriction via food intake in the morning or evening, may be used as a new approach for prevention of obesity, metabolic syndrome and related diseases. After ethical clearance and written, informed consent, free living subjects were included if they volunteered to take most of the total daily meals (approximately 2000 Kcal./day) in the evening (4 weeks) or morning (4 weeks). Of 22 adults, half were randomly selected by computer generated numbers to eat in the morning and the other half in the evening, after 8.00 PM. The eating pattern was changed after 4 weeks of intervention and a 4-week washout period, those who ate in the morning were advised to eat in the evening and vice versa. Validated questionnaires were used to assess food intakes, physical activity, and intake of alcohol and tobacco. Physical examination included measurement of body weight, height, and blood pressure (BP) by sphygmomanometer. Data were regularly recorded blindly, in all subjects at start of study and during follow-up. Blood samples were collected after an overnight fast for analysis of blood glucose and Hb1c. Feeding in the evening was associated with significant increase in body weight by 0.80 kg (P < .001), body mass index (BMI) by 0.30 kg/m2 (P < .001) and waist circumference by 1.13 cm (P < .05). Feeding the same amount of energy in the morning was not associated with any significant change in weight, BMI or waist circumference (P > .500). Lesser increases in all three variables were associated with AM versus PM feeding (P < .05). Systolic BP slightly increased on PM and decreased on AM feeding, with a difference between the two responses of 1.55 mmHg (P < .05). Fasting blood glucose was lower on AM than on PM feeding (74.86 vs. 77.95 mg/dl, paired t = 4.220, P < .001). Hb1C increased on PM feeding by 0.28 (from 4.45 to 4.73; t = 9.176, P < .001), but decreased on AM feeding by 0.077 (from 4.53 to 4.45; t = -6.859, P < .001). The difference in Hb1C response between AM and PM feeding is also statistically significant (t = -11.599, P < .001). Eating in the evening can predispose to obesity, central obesity and increases in fasting blood glucose and Hb1c that are indicators of the metabolic syndrome. By contrast, eating in the morning can decrease Hb1c and systolic BP, indicating that it may be protective against the metabolic syndrome.

Chronomics of Circulating Plasma Lipid Peroxides and Antioxidant Enzymes in Renal Stone Formers.

The chronome of lipid peroxidation and anti-oxidant defense mechanisms may relate to the efficacy and management of time qualified preventive therapeutic and dietary interventions. One hundred renal stone patients, 20-60 years of age, and 50 clinically healthy volunteers, 21-45 years, were synchronized for 1 week with diurnal activity from 06:00 to 22:00 and nocturnal rest. All subjects took their usual meals three times daily (breakfast around 08:30, lunch around 13:00, and dinner around 20:30) with usual fluid intake. Drugs known to affect free radical system were not taken. Blood samples were collected at 6-h intervals for 24-h under standardized, presumably 24-h synchronized conditions. Determinations included plasma lipid peroxides, in terms of malondialdehyde (MDA) and blood superoxide dismutase (SOD), glutathione peroxidase (GPx), glutathione reductase (GR) and catalase (CAT) activities. A marked circadian variation was demonstrated for each studied variable by population-mean cosinor in renal stone patients and healthy participants (p < 0.001). By comparison to healthy subjects, parameter tests indicate that the stone formers had a higher MESOR of MDA, but a lower MESOR of SOD, GPx, GR and CAT. Furthermore, the patients also differed from the healthy controls in terms of their circadian amplitude and acrophase (tested jointly) of all variables (p < 0.001). Mapping the broader time structure with multifrequency circadian characteristics of oxidants and anti-oxidants is needed for exploring their role as marker in the treatment and management of urolithiasis.

Retrospective Evaluation of Patients Who Leave against Medical Advice in a Tertiary Teaching Care Institute.

CONTEXT: Discharge against medical advice or leave against medical advice (DAMA or LAMA) is a global phenomenon. The magnitude of LAMA phenomenon has a wide geographical variation. LAMA reasons are an area of concern for all involved in health-care delivery system. AIMS AND OBJECTIVES: The study aimed to evaluate cases of LAMA retrospectively in a tertiary teaching care institute (1) to find the magnitude of LAMA cases (2) to evaluate demographic and patient characteristics of these cases. SUBJECTS AND METHODS: We screened hospital record of a referral institute over 1 year after approval from IEC and ICMR, New Delhi. Patient demographics and disease characteristics were noted and statistically analyzed after compilation. RESULTS: A total of 47,583 patients were admitted in the year 2015 through emergency and outpatient department. One thousand five hundred and fifty-six (3.3%) patients got DAMA. The mean age of patient excluding infants was 46.64 ± 20.55 years. There were 62.9% of males. Average hospital stay of these cases was 4.09 ± 4.39 days. Most of the patients (70%) belonged to medical specialties and had longer stay as compared to surgical specialties. Most of LAMA patients were suffering from infections, trauma, and malignancies. Most of the patients had LAMA from ward (62%) followed by Intensive Care Unit (ICU) (28.8%) and emergency (9.2%). In 592 (38%) of LAMA patients, the reason for leaving was not clear. The common cited reasons for LAMA were financial (27.6%) and poor prognosis (20.5%). CONCLUSIONS: About 3.3% of patients left hospital against medical advice in our retrospective analysis. Most of these cases did so from ward followed by ICU. Financial reasons and expected poor outcome played a significant role.

Circadian Periodicity of Circulating Plasma Lipid Peroxides, Uric Acid and Ascorbic Acid in Renal Stone Formers.

Circadian periodicity of plasma lipid peroxides and serum ascorbic acid and uric acid levels were studied in one hundred renal stone formers (55 women and 45 men; age 20-60 years) and 50 clinically healthy volunteers (21 women and 29 men; age 21-45 years) with diurnal activity from 06:00 to 22:00 and nocturnal rest. A marked circadian variation was demonstrated by population-mean-cosinor for all studied variables in stone formers and healthy subjects. By comparison to the healthy controls, parameter tests indicate that the stone formers had a higher MESOR (±SE) of MDA (2.90 ± 0.03 vs. 2.28 ± 0.06; F = 94.929, p < 0.001), a lower MESOR of serum ascorbic acid (0.722 ± 0.010 vs. 0.839 ± 0.10; F = 32.083, p < 0.001), and a similar MESOR of serum uric acid. Furthermore, the patients also differed from the healthy subjects in terms of their circadian amplitude and acrophase (tested jointly) of all three variables (p < 0.001). The demonstration herein of a circadian rhythm in MDA, serum ascorbic and uric acid suggests that these variables could also serve as markers to optimize the timing of treatment and to assess the patient's response to treatment for further management.

A cat has 9 lives: The dilemma of diagnosing non hodgkin's lymphoma in intensive care unit.

Non hodgkins lymphoma is a common haematological malignancy characterized by abnormal clonal proliferation of T-cells, B-cells or both. The incidence of non hodgkins lymphoma is rapidly rising. The diagnosis and management of NHL presents as a challenge in developing countries like India due to high prevalence of tuberculosis, cost and poor patient compliance. We describe an unusual case of a patient who presented as a diagnostic dilemma and took 8 diagnosis before finally being confirmed as a case of NHL. A suspicion for NHL should always be kept in mind in a patient presenting with pneumonia, bilateral pulmonary infiltrates and eosinophilia.

Efficacy of lipophilic vs lipophobic opioids in addition to hyperbaric bupivacaine for patients undergoing lower segment caeserean section.

BACKGROUND: Subarachnoid block is the preferred technique for providing anesthesia for patients undergoing cesarean section. Various pharmacological agents in added to local anesthetics (LA) modify their original effects in terms of block characteristics and quality of analgesia. However, there is ongoing debate about this practice of using adjuncts with LA. We tested whether addition of lipophilic versus lipophobic opioids to LA gives any clinical benefits to maternal and fetal outcome when used in these patients requiring spinal anesthesia. SUBJECTS AND METHODS: Sixty American Society of Anesthesiologists I and II parturients, undergoing elective cesarean section requiring subarachnoid block, were included in our study. The parturients were allocated randomly to three groups of 20 each to receive bupivacaine 12.5 mg (Group I), bupivacaine 12.5 mg + morphine 0.2 mg (Group II), bupivacaine 12.5 mg + fentanyl 25 µg (Group III), preservative free physiological saline 0.9% was added to all the solutions to achieve a total volume of 4 ml. The parameters studied were the time of onset, sensory level of the block achieved, total duration of analgesia, any need of rescue analgesics, maternal side effects, and fetal outcome. RESULTS: Onset of block was early 4.30 ± 0.12 min in Group III as compared to Group I 4.64 ± 0.28 min and Group II 4.505 ± 0.22 min. Mean duration of analgesia (hours) was higher in Group II 15.91 ± 0.96 h as compared to Group I 1.95 ± 0.55 h and Group III 4.39 ± 0.2 h. Incidence of nausea, vomiting, and shivering was more in the control group as compared to study groups, whereas sedation and pruritus were seen more in the study groups. No adverse effects on fetus were seen with use of opioids and comparable Apgar scores were noted. CONCLUSION: Addition of intrthecal fentanyl causes rapid onset of block whereas intrathecal morphine provides prolonged analgesia with comparable neonatal wellbeing.

Secalonic Acid-D Represses HIF1α/VEGF-Mediated Angiogenesis by Regulating the Akt/mTOR/p70S6K Signaling Cascade.

Tumor angiogenesis is a validated target for therapeutic intervention, but agents that are more disease selective are needed. Here, we report the isolation of secalonic acid-D (SAD), a mycotoxin from a novel source that exhibits potent antiangiogenic antitumor activity. SAD inhibited multiple HIF1α/VEGF-arbitrated angiogenesis dynamics as scored in human umbilical vascular endothelial cells and human MCF-7 breast tumor xenografts. Similarly, SAD suppressed VEGF-induced microvessel sprouting from rat aortic ring and blood vessel formation in the Matrigel plug assay in C57/BL6J mice. Under normoxic or hypoxic conditions, SAD inhibited cell survival through the Akt/mTOR/p70S6K pathway, with attendant effects on key proangiogenesis factors, including HIF1α, VEGFR, and MMP-2/MMP-9. These effects were reversed by cotreatment with the Akt inhibitors perifosine and GSK69069 or by the addition of neutralizing VEGF antibodies. The apoptotic properties of SAD were determined to be both extrinsic and intrinsic in nature, whereas the cell-cycle inhibitory effects were mediated by altering the level of key G1-S transition-phase proteins. In experimental mouse models of breast cancer, SAD dosing produced no apparent toxicities (either orally or intraperitoneal) at levels that yielded antitumor effects. Taken together, our findings offered a preclinical validation and mechanistic definition of the antiangiogenic activity of a novel mycotoxin, with potential application as a cancer-selective therapeutic agent.

Anesthesia for opioid addict: Challenges for perioperative physician.

Opioid addiction is on a rise globally. Such a patient presents to an anesthesiologist as well as to the surgeon with an array of challenges. We present the case of an opioid addict (pentazocine) who presented for debridement and grafting of eschars and old healed scars. Initially he was medically managed for opioid addiction followed by a planned anesthesia. We hereby discuss the challenges faced during perioperative period.

A retrospective analysis of anesthetic experience in 2917 patients posted for cleft lip and palate repair.

CONTEXT: Anaesthesia during cleft lip and palate surgery carries a high risk and difficult airway management in children. AIM: to study the perioperative anesthetic complications in poor children with cleft abnormalities. SETTINGS AND DESIGN: Retrospective analysis. MATERIALS AND METHODS: This retrospective audit was conducted on 2917 patients of smile train project under going general anesthesia for cleft lip and palate from January 2007 to December 2010. Demographic, pre-anesthetic status, anesthetic management and anesthesia complications were recorded. Chi-square test was used to assess the relation between patient factors and occurrence of complications. RESULTS: Of the 3044, we were able to procure complete data of 2917 patients. Most of children presented with anemia 251 (35%), 202 (29%) had eosinophilia while 184 (26%) had upper respiratory tract infection. The incidence of perioperative complications was 8.19% of which 33.7% critical incidents occurred during the induction time. The most common complication was laryngospasm 77 (40.9%) followed by difficult intubation 64 (30.9%). There was no mortality. CONCLUSION: Since these procedures do not characterize an emergency, most of the perioperative complications can be prevented by following the routine installed by the institute and smile train protocols.

Intra and postoperative outcome of adding clonidine to bupivacaine in infraorbital nerve block for young children undergoing cleft lip surgery.

UNLABELLED: AIMS AND CONTEXT: To evaluate the efficacy of adding clonidine to bupivacaine in bilateral infraorbital nerve block for hemodynamic changes, requirement of opioids, volatile agent, and muscle relaxants intraoperatively and relief of pain postoperatively SETTING AND DESIGN: Prospective, randomized, double-blind study. METHODS: Fifty pediatric patients aged less than 24 months undergoing elective cleft lip repair were randomly allocated to two groups of 25 each. After tracheal intubation, group A received bilateral infraorbital nerve block with 1 ml solution of clonidine (1 µg/kg) and bupivacaine 0.25%, and group B received 1 ml of 0.25% bupivacaine. Hemodynamic parameters, intraoperative requirement of volatile anesthetic agent, muscle relaxant, and analgesic were recorded. Pain was assessed postoperatively using the Face, Legs, Activity, Cry, Consolability scale till the first rescue drug was given. STATISTICAL ANALYSIS: Two sample unpaired t-test and the correlation r test. RESULTS: The duration of analgesia from the time of administration of block in group A was 667.72 ± 210.74 min compared to 558.48 ± 150.28 min in group B (P<0.05). CONCLUSION: Addition of clonidine as an adjunct to local anesthetic significantly decreased the requirement of other anesthetic drugs and significantly prolonged the duration of postoperative analgesia without any adverse effects.

Study of post dural puncture headache with 27G Quincke & Whitacre needles in obstetrics/non obstetrics patients.

UNLABELLED: The proposed study was carried out in the department of Anaesthesiology, Intensive care & Pain management, Himalayan Institute of Medical Sciences. Swami Rama Nagar, Dehradun. A total of 120 patients of ASA I & II obstetric & non-obstetric undergoing elective/emergency surgery under subarachnoid block were included under the study. AIM: To evaluate the frequency of PDPH during spinal anaesthesia using 27 gauge Quincke vs 27G whitacre needle in obstetric/non obstetric patient. OBSERVATION: In our study patients were in the age group of 15-75 years. Most of the patients in our study belong to ASA Grade I. There was 2%, 1%, 4% and 3% hypotension in-group A, B, C, D respectively. There was 2%, 4% shivering in-group A, C respectively and 1% each in group B, D. In our study failed spinal with 27G Quincke needle was in one case (3.33%) in-group C where successful subarachnoid was performed with a thicken spinal needle 23G Quincke. There was no incidence of PDPH in-group A and D, while 1 (2%) patient in-group B and 2 (4%) in group C. RESULTS: All the three patients were for lower section caesarean section and were young and had undergone more than one attempt to perform spinal block. The headache severity was from mild to moderate and no epidural blood patch was applied.

Is I-gel a new revolution among supraglottic airway devices?--a comparative evaluation.

In an attempt to reduce the pressor responses subsequent to laryngoscopy and intubation in normotensive anesthetized paralysed patients, the hemodynamic effects of three supraglottic devices were compared: I-gel, SLIPA, and LMA, The I-gel produced the least hemodynamic changes.

Taylor's approach in an ankylosing spondylitis patient posted for percutaneous nephrolithotomy: A challenge for anesthesiologists.

We describe a patient with long-standing ankylosing spondylitis who underwent percutaneous nephrolithotomy under spinal anesthesia. At preoperative assessment, it was considered that intubation of the trachea was likely to be difficult. Fiberoptic bronchoscopy was attempted, but without success. As the standard technique for spinal anesthesia failed, a variation of the paramedian approach in the lumbosacral approach, also known as Taylor's approach was successfully attempted. This resulted in adequate sensory and motor blockade for the surgical procedure. The patient did not require airway interventions, but equipment and aids to secure airway were available.

Idiopathic recurrent stupor mimicking status epilepticus.

Stupor is defined as a deep sleep or behaviourally similar unresponsiveness from which the subject can be aroused only by vigorous repeated stimuli. Causes of stupor may be related to brain damage, toxic or metabolic encephalopathies. Idiopathic recurring stupor is a stupurous condition of unknown aetiology, unrelated to structural, toxic or metabolic disturbance. This condition responds to flumazenil, a benzodiazepine antagonist. We describe a 60-year-old man presenting with abnormal jerky movements of the body and who was wrongly treated as status epilepticus. He responded to flumazenil which confirmed the diagnosis.

Montgomery T-tube: anesthetic management.

The Montgomery T-tube is a device used as a combined tracheal stent and airway after laryngotracheoplasty. It is a valuable option in the management of upper and mid-tracheal lesions. Because its use is sporadic, many anesthesiologists may not be familiar with this device, and its anesthetic management may pose a challenge. Safe management of such patients requires careful planning. We describe different techniques of anaesthetic management in two cases of injuries to the throat, for which this tube was inserted as a tracheal stent.

A clinicomicrobiological study on the importance of pseudomonas in nosocomially infected ICU patients, with special reference to metallo beta1-lactamase production.

The present study was conducted with a view to assess the burden of pseudomonal infection in ICU patients of a tertiary care teaching hospital in Uttaranchal. Of the 525 patients selected for the study, during a 1-year period, 60 patients developed features of nosocomial infection and among them Pseudomonas was isolated from one or more samples in 18 patients. The isolated strains were speciated and further characterized for determining their antibiogram and for production of beta-lactamase, extended spectrum beta-lactamase and metallo-beta-lactamase enzymes. Pseudomonas aeruginosa was the commonest species isolated (54.54%) and endotracheal suction material showed the highest bacterial yield. Polymyxin B was found to be the most effective antibiotic followed by imipenem and carbenicillin. Though no strain was found to be producing beta-lactamase and extended spectrum beta-lactamase enzymes, a total of 12 strains (54.54%) were metallo-beta-lactamase producers. For all the beta lactam antibiotics, excepting aztreonam, the metallo-beta-lactamase producers showed more resistance compared to the non-producers.