Experience with paraquat poisoning in a respiratory intensive care unit in North India

INTRODUCTION

Paraquat poisoning is an uncommon entity in India. We report our experience of managing five patients with paraquat poisoning using immunosuppressive therapy.

METHODS

Retrospective analysis of 84 patients admitted with a diagnosis of poisoning over the last eight years was performed. The data were presented in a descriptive fashion.

RESULTS

Five (5.9 percent) out of the 84 patients were admitted with a diagnosis of paraquat poisoning. All patients were mechanically ventilated. All patients had hepatic failure with median peak bilirubin being 22.1 +/- 15.1 mg/dL (range 8.4-45.5). Four of the five patients had renal failure (median peak creatinine 3.8 +/- 1.5 mg/dL; range 3.4-11.1) requiring renal replacement therapy. All patients were treated with intravenous methylprednisolone 15 mg/kg/day for three consecutive days and intravenous cyclophosphamide 10 mg/kg/ day for two consecutive days, followed by intravenous dexamethasone 4 mg thrice a day until recovery or death. Two out of the five patients survived. Three died because of severe acute respiratory distress syndrome and multiorgan dysfunction syndrome.

CONCLUSION

Paraquat poisoning is an uncommon entity in India, and is associated with a high mortality rate. There is a potential role for immunosuppressive therapy in patients with moderate to severe poisoning.

Intrapleural fibrinolysis in clotted haemothorax

The immediate treatment of haemothorax is thoracostomy tube insertion. One complication of haemothorax is retained blood and if improperly managed, this can lead to complications such as empyema and fibrothorax. The ideal management of clotted haemothorax is a matter of controversy. Video-assisted thoracoscopic surgery (VATS) is believed to be the best available modality for the management of clotted haemothorax. However, VATS is not routinely available in many centres. One easily available and effective alternative to VATS is the use of intrapleural fibrinolysis. We report the successful management of a post-traumatic clotted haemaothorax in a 34-year-old man, using intrapleural instillation of streptokinase, and review the literature on the management of clotted haemothorax.

Clinical characteristics and outcomes of empyema thoracis in 117 patients: a comparative analysis of tuberculous vs. non-tuberculous aetiologies

BACKGROUND

Empyema thoracis remains a major problem in developing countries. Clinical outcomes in tuberculous empyema are generally believed to be worse than in non-tuberculous aetiologies because of the presence of concomitant fibrocavitary parenchymal disease, frequent bronchopleural fistulae and poor general condition of patients. We performed a prospective study over a 2-year period with the objective of comparing the clinical characteristics and outcomes of patients with tuberculous vs. non-tuberculous empyema.

METHODS

Prospective study of all cases of non-surgical thoracic empyema seen at a tertiary care centre in North India over a 2-year period. A comparative analysis of clinical characteristics, treatment modalities and outcomes of patients with tuberculous vs. non-tuberculous empyema was carried out. Factors associated with poor outcomes were analysed using multivariate logistic regression.

RESULTS

One hundred and seventeen cases of empyema were seen in the study period of which 95 had non-tuberculous and 41 had tuberculous empyema. Malnutrition and bronchopleural fistulae (BPF) were more common and duration of symptoms longer in the tuberculous empyema group. Time to resolution of fever, duration of pleural drainage and pleural thickening >2 cm were significantly greater as well. Eight (10.5%) patients with non-tuberculous empyema and four (9.8%) with tuberculous empyema succumbed. Presence of a BPF was significantly associated with poor outcomes on multivariate logistic regression analysis.

CONCLUSIONS

Tuberculous empyema remains a common cause of thoracic empyema in India though it ranked second amongst all causes of empyema after community acquired lung infections in this study. Tuberculous empyema is associated with longer duration of symptoms, greater duration of pleural drainage and more residual pleural fibrosis.

E2F4 regulates a stable G2 arrest response to genotoxic stress in prostate carcinoma

The retinoblastoma (pRB) family proteins regulate the E2F transcription factors; their complexes regulate critical transitions through the cell cycle. The function of these pRB family/E2F complexes, which includes p130/E2F4, in response to genotoxic agents, is not well understood. We investigated the role of E2F4 in the genotoxic stress response. Following radiation treatment, E2F4 colocalized with p130 in the nucleus during a radiation-induced stable G(2)-phase arrest. Arrested cells had significantly decreased expression of Cyclins A2 and B1 and decreased phosphorylation of mitotic protein monoclonal-2 (MPM-2) mitotic proteins. Small interference RNA (siRNA)-mediated knockdown of E2F4 sensitized cells to subsequent irradiation, resulting in enhanced cellular DNA damage and cell death, as determined by caspase activation and decreased clonogenic cell survival. Downstream E2F4 targets potentially involved in the progression from G(2) into M phase were identified by oligonucleotide microarray expression profiling. Chromatin immunoprecipitation localized E2F4 at promoter regions of the Bub3 and Pttg1 mitotic genes following irradiation, which were among the downregulated genes identified by the microarray. These data suggest that in response to radiation, E2F4 becomes active in the nucleus, enforces a stable G(2) arrest by target gene repression, and thus provides increased cell survival ability by minimizing propagation of cells that have irreparable DNA damage.

An unusual case of mediastinal mass due to Fonsecaea pedrosoi

Phaeohyphomycosis is a disease caused by dematiaceous fungi. Here, the first culture-proven case of mediastinal mass due to Fonsecaea pedrosoi is reported. The patient was a 40-yr-old male who had presented with history of dyspnoea and dysphagia. Computed tomography of the chest disclosed a mediastinal mass. Cultures of a specimen from the mediastinum grew Fonsecaea pedrosoi. The patient received amphotericin B and itraconazole and showed a remarkable recovery. Repeat computed tomography revealed a reduction in the mediastinal mass. The case highlights the need for a high degree of clinical suspicion and appropriate histopathological and mycological examination of clinical specimens.

Clinical implication of routine bacterial culture from epidural catheter tips in postoperative cancer patients: a prospective study

We conducted a prospective study to determine the epidural tip culture pattern and its clinical implication in postoperative cancer patients. All patients scheduled to undergo various cancer surgeries requiring epidural analgesia were included. Epidural catheter tips were sent for culture on removal. Of the 466 epidural catheter tips sent for culture, 27 showed a positive culture (5.7%). The commonest organism identified was Staphylococcus aureus. There were no signs of local or epidural space infection in any of the patients. The rates of epidural catheter tip cultures in cancer patients are comparable to those in the general patients and the presence of a positive tip culture is not a predictor of epidural space infection. Hence, we recommend that even in cancer patients, routine culture of epidural catheters is not advisable, provided strict asepsis is maintained at the time of insertion, and patients are constantly monitored for early signs of epidural infection.

Prognostic significance of quality of life index in breast cancer

6135

Background: Quality of Life (QoL) is a multidimensional construct. There is extensive data showing that QoL tools measuring the activities of daily life provide prognostic information in cancer. However, similar information on QoL tools measuring patient satisfaction with their life is sparse. The Ferrans and Powers Quality of Life Index (QLI) is one such instrument. The goal of this study was to evaluate the statistical strength of association between QLI and survival in breast cancer patients undergoing care in a non-clinical trial setting. Methods: We examined a case series of 251 breast cancer patients treated at Cancer Treatment Centers of America between 04/01 and 11/04. QLI defines QoL in terms of satisfaction with the aspects of life that are important to the patient. QLI measures overall QoL and QoL in four major subscales: health and physical, social and economic, psychological and spiritual, and family. All scores range from 0 to 30 with higher scores indicating better QoL. Study patients were dichotomized into 2 groups based on median scores for all QoL subscales. Kaplan Meier method was used to calculate survival. Log-Rank test was used to study the equality of survival distributions. Results: Of 251 patients, 74 were newly diagnosed and 177 had prior treatment history. The median age was 48 years (range 25 - 74 years). 45 patients had stage I disease, 105 stage II, 38 stage III, and 32 stage IV. The table describes the median survival for all QLI subscales. Health and physical functioning subscale and QLI subtotal subscale were significantly associated with survival. Conclusions: This study shows that baseline levels of patient satisfaction with their QoL provide useful prognostic information in breast cancer. While these findings need to be evaluated further to ascertain which subscales of QoL have a role in predicting patients’ prognosis, they have important implications for patient stratification in clinical trials and may aid decision-making in clinical practice.

[Table: see text]

No significant financial relationships to disclose.

A prospective survey evaluating the use of soy products in breast cancer

10562

Background: Many studies have evaluated the potential role of soy in the prevention of breast cancer. A number of components in soy appear to have anticancer properties, including isoflavones, genistein and daidzein. The use of soy by women with breast cancer is now being questioned because of the estrogen-like effects of isoflavones and possible interactions with tamoxifen. Clinicians providing nutrition counseling to these women are concerned because the availability of soy foods has increased dramatically in the past few years. The goal of this study was to quantify the intake of isoflavones in women with breast cancer to determine if their intake is of clinical significance. Methods: We evaluated a consecutive case series of 100 women with breast cancer treated at Cancer Treatment Centers of America between 09/03 and 02/04. After obtaining informed consent, each patient was asked to complete a soy food frequency questionnaire (FFQ) that was scored by Fred Hutchinson Cancer Research Center, the institute that developed and validated FFQ. Results: Mean age was 50.5 years (std. dev. = 9.4; range 31–70) and mean BMI was 27.3kg/m2 (std. dev. = 6.75; range 17–59). Table 1 shows detailed characteristics of our patients. Genistein and Daidzein consumption was limited to 65 patients with a mean intake of 81.5 mg/week (std. dev. = 153; range 0.02–682) and 52.9 mg/week (std. dev. = 98.8; range 0.02–482) respectively. Soy foods with highest reported consumption were soy sauce (37%), soy milk (23%), soy bars (18%), roasted soy nuts (13%) and tofu (13%). Conclusions: Our study suggests that the isoflavone intake of breast cancer patients at our hospital was quite variable. Thirty-five patients reported no soy intake. The mean daily intake translates into 11.6 mg genistein and 7.4 mg daidzein, which is equivalent of less than ¼ cup of tofu per day. This amount is slightly higher than what has been previously reported in non-Asian American women.

[Table: see text]

No significant financial relationships to disclose.

Quality-of-life index: Implications for prognosis in colorectal cancer

16032

Background: Quality of Life (QoL) assessment is important to evaluate the impact of disease and treatment in patients with advanced cancer. Recently, it has been hypothesized that patient satisfaction with their QoL may have a prognostic role in cancer, however, there is little evidence in the literature to support this view. The Ferrans and Powers Quality of Life Index (QLI) is one such instrument. QLI defines QoL as a person’s sense of well-being that stems from satisfaction or dissatisfaction with the areas of life that are important to him/her. The purpose of this study was to determine whether baseline QLI would predict length of survival in patients with colorectal cancer undergoing care in a non-clinical trial setting. Methods: We examined a case series of 177 colorectal cancer patients treated at Cancer Treatment Centers of America between 04/01 and 11/04. QLI measures global QoL and QoL in four major subscales: health and physical, social and economic, psychological and spiritual, and family. All scores range from 0 to 30 with higher scores indicating better QoL. QLI subscales were dichotomized at the median to split the patient population into 2 distinct groups. Kaplan Meier method with Log Rank test was used to calculate survival. Results: Of 177 patients, 46 were newly diagnosed and 131 had prior treatment history. The median age was 53 years (range 25– 85 years). 8 patients had stage I disease, 16 stage II, 51 stage III, and 77 stage IV. Table 1 describes the median survival for all QLI subscales. Conclusions: Baseline levels of patient satisfaction with their health and physical functioning provided useful prognostic information in colorectal cancer. Interestingly, the other subscales that evaluate various existential and economic issues did not provide statistically significant differences in survival. These findings need to be evaluated further to ascertain which subscales of QLI have a role in predicting patients’ prognosis.

[Table: see text]

No significant financial relationships to disclose.

A prospective study evaluating the relationship between fatigue and patient satisfaction in advanced cancer

16025

Background: Fatigue is the most common and disabling symptoms experienced by cancer patients. No study has prospectively quantified the relationship between fatigue and patient satisfaction (PS) in advanced cancer. We therefore assessed this relationship before the start of chemotherapy and at 3 and 6 months after treatment at our integrative cancer treatment center. Methods: 294 cancer patients treated at Cancer Treatment Centers of America between 04/01 and 11/04. Of 954 patients at baseline, only 294 were available for follow-up at 6 months. Fatigue was measured using the EORTC QLQ-C30 3-item fatigue subscale. Scores ranged from 0–100, higher scores indicating more fatigue. PS was measured using Ferrans & Powers Quality of Life Index (QLI). Scores ranged from 0–30, higher scores indicating better QoL. The mean fatigue scores were compared using ANOVA across the 3 time periods at baseline, 3 and 6 months. The relationship between fatigue and QLI was evaluated using multiple linear regression at all 3 time points. Results: Of 294 patients, 106 were males and 188 females. 91 had breast ca, 52 colorectal, 43 lung, 25 pancreas, 13 prostate, and 70 had other cancers. 112 were newly diagnosed and 182 had received prior treatment elsewhere. The mean fatigue scores at baseline, 3 and 6 months were 43.6, 37.3, and 41.8 respectively; the scores at baseline and 3 months were significantly different (p = .009). At baseline, after controlling for age, gender, prior treatment history, and tumor stage at diagnosis, every 10 unit increase in fatigue was significantly associated with 1.3 units decrease in QLI health subscale. Similarly at 3 and 6 months after treatment, every 10 unit increase in fatigue was significantly associated with 1.2 and 1.4 units decrease in QLI health subscale. Conclusions: In our study, we found that fatigue is a strong correlate of PS independent of the effects of age, gender, prior treatment history and tumor stage at diagnosis during the first 6 months of treatment. Interestingly, fatigue showed a significant improvement after 3 months of treatment and returned back to baseline levels at 6 months. This finding needs to be investigated further to evaluate the impact of integrative cancer care services on PS.

No significant financial relationships to disclose.

Mucosal tear in the oropharynx leading to pneumopericardium and pneumomediastinum: An unusual complication of blunt trauma to the face and neck

Pneumomediastinum and pneumopericardium are very rare complications resulting from blunt trauma to the head and neck. We report the case of a 40-year-old male who had been assaulted. He presented to the Emergency Department with bruises to the face and neck and complained of dysphagia. He was found to have extensive subcutaneous emphysema of the face and neck. Imaging revealed the presence of a mucosal tear in the oropharynx leading to pneumomediastinum and pneumopericardium. He was managed conservatively and made an uneventful recovery. This is a very rare but potentially life-threatening complication of blunt trauma to the head and neck. It poses diagnostic difficulties and treatment dilemmas, which are discussed.

Ketamine for treatment of catheter related bladder discomfort: a prospective, randomized, placebo controlled and double blind study

BACKGROUND

Intraoperative urinary catheterization might cause postoperative catheter related bladder discomfort (CRBD). We evaluated the efficacy of ketamine as a treatment modality for CRBD.

METHODS

Fifty-four, ASA physical status I and II, male and female adult patients, having CRBD after elective percutaneous nephrolithotomy were randomized into two equal groups of 27 each. In the postoperative period, patients who complained of CRBD received medication depending upon group allocation. Group 1 (Control) received placebo, Group II (Ketamine) received i.v. ketamine 250 microg kg(-1). After induction of anaesthesia patients were catheterized with a 16 Fr Foley's catheter and the balloon was inflated with 10 ml distilled water. Grading of CRBD was done as none, mild, moderate and severe by a blinded observer at 0, 1, 2 and 6 h after operation.

RESULTS

Ketamine reduced the incidence of CRBD (P<0.001) at 2 and 6 h along with reduction in severity (P<0.05) at 1 h compared with control. Higher incidence of mild sedation was observed in the ketamine group (P<0.05) which was not associated with any untoward effects. Operative time and intraoperative fentanyl requirement were similar in both the groups.

CONCLUSION

I.V. ketamine (250 microg kg(-1)) is an effective treatment for reducing the incidence and severity of postoperative CRBD.

Failure of NIV in acute asthma: case report and a word of caution

Noninvasive ventilation (NIV) is the provision of ventilatory support without the need for an invasive airway, and has revolutionized the management of patients with diverse forms of respiratory failure. The advantages of NIV include improved patient comfort and reduced need for sedation, while avoiding the complications of endotracheal intubation, including upper airway trauma, sinusitis, otitis, and nosocomial pneumonia. In selected patients, NIV has also been shown to improve survival. The role of NIV in acute severe asthma is at best controversial. In this case report, we describe a patient with acute severe asthma who was initially managed and failed with NIV, and was successfully managed with invasive ventilation. We also review the pathophysiological mechanisms of benefit of NIV in acute severe asthma, and the current literature on the use of NIV in acute asthma. In conclusion, a trial of NIV in acute asthma may be justified in carefully selected and monitored patients who do not respond to initial medical therapy. However, as its role is not clear and as the condition of an asthmatic patient may deteriorate abruptly, extreme caution is advisable to recognize failure of NIV as in the case presented here. Facilities for immediate endotracheal intubation and next level of treatment should be readily available.

Non-invasive ventilation in acute cardiogenic pulmonary oedema

Non-invasive ventilation (NIV) is the delivery of assisted mechanical ventilation to the lungs, without the use of an invasive endotracheal airway. NIV has revolutionised the management of patients with various forms of respiratory failure. It has decreased the need for invasive mechanical ventilation and its attendant complications. Cardiogenic pulmonary oedema (CPO) is a common medical emergency, and NIV has been shown to improve both physiological and clinical outcomes. From the data presented herein, it is clear that there is sufficiently high level evidence to favour the use of continuous positive airway pressure (CPAP), and that the use of CPAP in patients with CPO decreases intubation rate and improves survival (number needed to treat seven and eight respectively). However, there is insufficient evidence to recommend the use of bilevel positive airway pressure (BiPAP), probably the exception being patients with hypercapnic CPO. More trials are required to conclusively define the role of BiPAP in CPO.

Flexible naso-endoscopic decontamination—rationalizing the next step forward

Naso-endoscopes are important tools in the everyday practice of otolaryngology. However, cleaning methods have not yet been standardized. The aims of this article are to assess the degree of variation in practice both within and outside the UK, and to propose explanations why standard national and international guidelines have not been forthcoming. It is hoped that the systematic identification of the problems facing health authorities will lead to a better understanding of the task at hand, and bring us closer to drawing up a more specific standard for 'best possible' practice.

Circadian function in patients with advanced non-small-cell lung cancer

This study aimed to evaluate whether patients with advanced non-small-cell lung cancer experience disrupted rest–activity daily rhythms, poor sleep quality, weakness, and maintain attributes that are linked to circadian function such as fatigue. This report describes the rest–activity patterns of 33 non-small-cell lung cancer patients who participated in a randomised clinical trial evaluating the benefits of melatonin. Data are reported on circadian function, health-related quality of life (QoL), subjective sleep quality, and anxiety/depression levels prior to randomisation and treatment. Actigraphy data, an objective measure of circadian function, demonstrated that patients' rest–activity circadian function differs significantly from control subjects. Our patients reported poor sleep quality and high levels of fatigue. Ferrans and Powers QoL Index instrument found a high level of dissatisfaction with health-related QoL. Data from the European Organization for Research and Treatment for Cancer reported poor capacity to fulfil the activities of daily living. Patients studied in the hospital during or near chemotherapy had significantly more abnormal circadian function than those studied in the ambulatory setting. Our data indicate that measurement of circadian sleep/activity dynamics should be accomplished in the outpatient/home setting for a minimum of 4–7 circadian cycles to assure that they are most representative of the patients' true condition. We conclude that the daily sleep/activity patterns of patients with advanced lung cancer are disturbed. These are accompanied by marked disruption of QoL and function. These data argue for investigating how much of this poor functioning and QoL are actually caused by this circadian disruption, and, whether behavioural, light-based, and or pharmacologic strategies to correct the circadian/sleep activity patterns can improve function and QoL.