Massive Spontaneous Hemothorax as a Complication of Apixaban Treatment

INTRODUCTION

Hemothorax is usually related to chest or iatrogenic trauma from procedures such as central lines and thoracentesis. Spontaneous hemothorax is defined as pleural fluid hematocrit greater than 50% of serum hematocrit in absence of natural or iatrogenic trauma affecting the lung or pleural space. Coagulopathy secondary to anticoagulant use has been associated with spontaneous hemothorax. We present a case of spontaneous hemothorax in a patient taking apixaban for venous thromboembolism disease. To our knowledge, this is the first case report of apixaban as a cause of spontaneous hemothorax.

CASE PRESENTATION

A 56-year-old woman with end-stage renal disease (ESRD) was diagnosed with upper extremity deep vein thrombosis (DVT) one month prior to presentation and was started on apixaban presented with dyspnea and left-sided pleuritic chest pain for two weeks. She was found to have left-sided large pleural effusion which was diagnosed as hemothorax. Other etiologies for spontaneous hemothorax were excluded and drainage by 12-French pigtail catheter achieved total resolution of hemothorax in three days.

DISCUSSION

Apixaban is a DOAC used to prevent stroke or thromboembolic events in patients with nonvalvular atrial fibrillation and to prevent recurrent venous thromboembolic disease. Events such as gastrointestinal, intracranial, and soft tissue bleeding have been well-documented. However, bleeding manifestation as hemothorax is seldom reported. Our patient presented with isolated left-sided large pleural effusion which was diagnosed as spontaneous hemothorax. 12-Fr pigtail catheter drainage was effective in the management of our patient and provided total resolution in three days.

CONCLUSION

Spontaneous hemothorax is a rare complication of anticoagulant therapy and might not exhibit the usual radiological signs of traumatic hemothorax. Health care providers should have high index of suspicion for spontaneous hemothorax when evaluating new pleural effusion in patients receiving DOACs therapy. Drainage by small bore pigtail catheter might be as effective as larger chest tubes.

Third molar in the orbital floor: A precarious presentation of odontogenic keratocyst-A case report and review of literature

The case illuminates the likelihood of a dental pathology presenting with discrete signs and symptoms and the importance of the differential diagnosis of some incongruent clinical entities. The purpose of this article was to present a case report of odontogenic keratocyst (OKC) arising in the orbital floor, finding the common thread in rare pathology, and highlighting the aberration in our treatment plan by collating all the wealth of information published in the literature.

Outcomes in juvenile onset lupus: single center cohort from a developing country

Introduction

About 10–20% of systemic lupus erythematosus (SLE) patients have onset in childhood and have more severe organ involvement. Survival of juvenile SLE patients is improving worldwide. Long-term data of childhood onset SLE from developing countries is scarce.

Methods

Clinical and laboratory data at initial presentation and follow-up visits were retrieved from clinic files, hospital information system and personal interviews. Treatment received, complications, flares, outcomes and death were recorded. Survival was calculated using Kaplan–Meier survival curves and regression analysis was done for predictors of mortality.

Results

Children with SLE ( n = 273, 250 girls) had a median age at onset of 14 years and duration of illness prior to diagnosis at our hospital of 1 year. Fever and arthritis were the most common presenting manifestations. Renal disease was seen in 60.5% and central nervous system (CNS) disease in 29%. The median follow-up period in 248 patients was 3.5 years. Fourteen children died, and 10 of these had active disease at the time of death. The mean actuarial survival was 24.5 years and survival rates at 1, 5 and 10 years were 97.9%, 95% and 89% respectively. Fever, CNS disease, anti-dsDNA levels and serious infections predicted death on univariate and multivariate analysis. Infections were seen in 72 children (26.3%), and 38 of these infections were serious. One-third of the patients had damage on the last follow-up. Flares were seen in 120 children, the majority being major flares.

Conclusion

Outcomes of pediatric SLE in North Indian children are similar to those seen in developed countries. Infections pose a major challenge in these patients.

Secretome of Differentiated PC12 Cells Restores the Monocrotophos-Induced Damages in Human Mesenchymal Stem Cells and SHSY-5Y Cells: Role of Autophagy and Mitochondrial Dynamics

A perturbed cellular homeostasis is a key factor associated with xenobiotic exposure resulting in various ailments. The local cellular microenvironment enriched with secretory components aids in cell-cell communication that restores this homeostasis. Deciphering the underlying mechanism behind this restorative potential of secretome could serve as a possible solution to many health hazards. We, therefore, explored the protective efficacy of the secretome of differentiated PC12 cells with emphasis on induction of autophagy and mitochondrial biogenesis. Monocrotophos (MCP), a widely used neurotoxic organophosphate, was used as the test compound at sublethal concentration. The conditioned medium (CM) of differentiated PC12 cells comprising of their secretome restored the cell viability, oxidative stress and apoptotic cell death in MCP-challenged human mesenchymal stem cells and SHSY-5Y, a human neuroblastoma cell line. Delving further to identify the underlying mechanism of this restorative effect we observed a marked increase in the expression of autophagy markers LC3, Beclin-1, Atg5 and Atg7. Exposure to autophagy inhibitor, 3-methyladenine, led to a reduced expression of these markers with a concomitant increase in the expression of pro-apoptotic caspase-3. Besides that, the increased mitochondrial fission in MCP-exposed cells was balanced with increased fusion in the presence of CM facilitated by AMPK/SIRT1/PGC-1α signaling cascade. Mitochondrial dysfunctions are strongly associated with autophagy activation and as per our findings, cellular secretome too induces autophagy. Therefore, connecting these three potential apices can be a major breakthrough in repair and rescue of xenobiotic-damaged tissues and cells.

Comparison of Surgical Outcome after Impacted Third Molar Surgery Using Piezotome and a Conventional Rotary Handpiece

Background and Aim:

One of the most commonly performed surgical procedures by oral and maxillofacial surgeons all over the world is the removal of impacted teeth. The most critical and important steps in third molar extraction are bone cutting or osteotomy. Many techniques are used for this purpose including chisels and mallet, rotary instruments, and ultrasonic-based bone cutting instruments. Piezotome is newer and innovative device for osteotomy based on piezoelectric vibrations. Piezotome is considered very efficient in performing osteotomy because of its selective cutting; being inert against soft tissues, including nerves and blood vessels. The aim of this study was to compare the surgical outcome of third molar surgery using conventional handpiece and piezotome with all other criteria remaining same for all the individuals.

Materials and Methods:

All patients reporting to the Department of Oral and Maxillofacial surgery, Manipal College of Dental Sciences, Mangalore, for impacted mandibular third molar removal were screened. A total of 30 patients with same Pederson difficulty index for bilateral impacted third molar were selected for the study. The study involved the use of piezotome on one side (Side A) and rotary technique (Side B) on the other side for osteotomy on the same patient with an interval of 1 month. Therapeutic management was same for both the sides. Operating time was recorded in each surgery. Patients were examined postoperatively on 1^st, 3^rd, and 7^th day and pain, edema, trismus, paresthesia, and dry socket were evaluated and compared on both the sides. Data collected were analyzed statistically.

Results:

The mean operating time was 48.13 min in piezotome (Side A) and 32.90 min in conventional handpiece (Side B) which was statistically significant (P < 0.001). Furthermore, there was statistically significant difference (P < 0.001) in the level of pain (P < 0.001), number of analgesics taken (P < 0.001), and trismus (P < 0.01) on 1^st, 3^rd, and 7^th days postoperatively. There was no statistically significant difference in edema between the two sides. Paresthesia was present in one patient (3.3%) in Side B, while no paresthesia was present in Side A. No incidence of alveolar osteitis was reported on both the sides.

Conclusion:

Operating time with piezotome was more than that of conventional handpiece, but the postoperative responses such as pain, trismus, and edema were less in piezotome. Hence, despite being a slower procedure, piezotome can be an effective alternative for osteotomy in impacted third molar surgery. We recommend using piezotome for bone cutting and conventional rotary handpiece for tooth sectioning in order to obtain favorable outcomes as well as decreasing the operating time.

Comparison of Visual Inspection with Acetic Acid and the Pap Smear for Cervical Cancer Screening

OBJECTIVE

To evaluate the efficacy of visual inspection with acetic acid (VIA) in the early detection of cervical cancer and compare it with the Pap smear.

STUDY DESIGN

This was a cross-sectional study conducted over a period of 3 months. A total of 316 patients who attended the Gynecology Outpatient Department of Era's Lucknow Medical College and Hospital, fulfilled the inclusion criteria, and gave their informed consent were included.

RESULTS

VIA was found positive in 38 patients (12.6%). Pap smear was positive in 31 patients (10.3%). Twenty-eight patients had a positive VIA and a positive Pap smear, 3 had a negative VIA and a positive Pap smear, 10 had a positive VIA and a negative Pap smear, and 34 had a negative VIA and a negative Pap smear.

CONCLUSION

The sensitivity of VIA and the Pap smear was found to be nearly equal, 93.3 and 93.8%, respectively. The Pap smear was found to be more specific than VIA, i.e., 72.9 versus 60%. In terms of test accuracy, the Pap smear was found to have greater test accuracy, i.e., 77.3 versus 66.7% for VIA.

Effect of immobilisation on production of rapamycin by Streptomyces hygroscopicus

Numerous antibiotics as secondary metabolites have been isolated from microbes specifically Streptomyces sp. Rapamycin is one of these, which exhibits many roles as immunosuppressant, antifungal antibiotic, anti-tumour etc. Constant thrust has been put by many researchers to improve the production of rapamycin by Streptomyces hygroscopicus. Past research show that whole cell immobilisation is a useful strategy for antibiotic production with economical advantage. This study is another attempt in this direction which involves immobilisation of producer organism on various supports such as polyutherane foam, sintered beads, glass beads and foam peanuts. These support materials have been selected based on their availability and were pre-treated chemically to improve their adsorption capacity. Comparative profiles have been studied to identify the most suited support for the growth of Streptomyces sp. Variation of biomass immobilisation on various support materials with respect to time in batch culture was studied. Cell release study for the carriers was carried out in production medium to evaluate the performance of beads. Also, scanning electron microscopy (SEM) has been employed for visualisation and analysis of immobilised biomass and measurement of pore size. This study aims to determine a suitable support for immobilisation of Streptomyces hygroscopicus which could be used for rapamycin production in batch and continuous mode.

A novel heterozygous missense mutation in uromodulin gene in an Indian family with familial juvenile hyperuricemic nephropathy

Familial juvenile hyperuricemic nephropathy (FJHN), characterized by early-onset hyperuricemia, reduced fractional excretion of uric acid, and chronic renal failure is caused due to mutation in uromodulin (UMOD) gene. We identified a novel mutation in a family with multiple members affected with FJHN. Ten coding exons of UMOD gene in three family members with clinical and biochemical features of FJHN and one unaffected family member were sequenced, and sequence variants were analyzed for the pathogenicity by bioinformatics studies. A heterozygous novel missense mutation (c. 949 T >G) in exon 5 leading to the replacement of cysteine by glycine at position 317 was identified in all three affected family members. This mutation has not been reported earlier in Human Gene Mutation Database, Human Genome Variation, Clinvar, and 1000 Genome. The mutation lies in the cysteine-rich 2 domain of the protein, and the affected residue is evolutionary conserved in other species. To our knowledge, this is the first report of the identification of UMOD mutation in an Indian family.

Unraveling The Origin of Enhanced Field Emission from Irradiated FeCo-SiO2 Nanocomposites: A Combined Experimental and First-Principles Based Study

This work is driven by the vision of engineering planar field emitters with ferromagnetic metal-insulator nanocomposite thin films, using swift heavy ion (SHI) irradiation method. FeCo nanoparticles inside SiO2 matrix, when subjected to SHI get elongated. Using this, we demonstrate here a planar field emitter with maximum current density of 550 μA/cm(2) at an applied field of 15 V/μm. The film, irradiated with 5 × 10(13) ions/cm(2) fluence (5e13) of 120 MeV Au(9+) ions, shows very high electron emitting quantum efficiency in comparison to its unirradiated counterpart. Surface enhanced Raman spectroscopy analysis of unirradiated and 5e13 films further confirms that the field emission (FE) enhancement is not only due to surface protrusions but also depends on the properties of entire matrix. We find experimental evidence of enhanced valence band density of states (VB DOS) for 5e13 film from XPS, which is verified in the electronic structure of a model FeCo cluster from first-principles based calculations combining density functional theory (DFT) and molecular dynamics (MD) simulations. The MD temperature is selected from the lattice temperature profile inside nanoparticles as deduced from thermal spike model. Increasing the irradiation fluence beyond 5e13, results in reduced VB DOS and melting of surface protrusions, thus causing reduction of FE current density. We finally conclude from theoretical analysis that change in fluence alters the co-ordination chemistry followed by the charge distribution and spin alignment, which influence the VB DOS and concurrent FE as evident from our experiment.

Outcome of lupus nephritis in childhood onset SLE in North and Central India: single-centre experience over 25 years

INTRODUCTION

Childhood SLE (cSLE) has a higher prevalence of lupus nephritis (LN), and there are ethnic variations in response to treatment as well as outcome of LN. There are limited data on long-term outcome of LN in cSLE from the Indian subcontinent.

METHODS

Retrospective analysis of case records of patients with cSLE (satisfying revised American College of Rheumatology (ACR) 1997 criteria for diagnosis) and age of onset <18 years was conducted from 1989 to 2013. Data on clinical features, renal involvement and biopsy findings, treatment, renal outcome, damage accrual and mortality were collected. End-stage renal disease (ESRD) was defined as the need for renal replacement therapy. Actuarial ESRD-free survival was studied as the primary outcome measure using Kaplan-Meier analysis.

RESULTS

Among 205 children with cSLE, 134 (121 girls) had evidence of LN. The mean age at disease onset was 13.7 ± 3.5 years and the mean disease duration at presentation was 1.9 ± 2.5 years. Kidney biopsy was available for 92 patients, and histology included: 13 (14.2%) Class II, 24 (26%) Class III, 43 (46.7%) Class IV and 12 (13.1%) Class V LN. The mean follow-up period was 6.75 ± 5.7 years. At last visit, 81 (60.4%) children were in complete remission, 28 (20.9%) were in partial remission, 15 (11.2%) still had active nephritis and 10 (7.4%) had progressed to ESRD. Almost two-thirds (62.9%) of patients experienced lupus flares, and mean flare rate was 0.09 flares/patient follow-up year. Fifty-six (43.8%) children accrued damage and the mean Systemic Lupus International Collaborating Clinics (SLICC)/ACR damage score was 0.79 ± 1.13. Actuarial ESRD-free survival at five, 10 and 15 years was 91.1%, 79% and 76.2%, and five-, 10- and 15-year renal survival was 93.8%, 87.1% and 84%, respectively. Although multiple factors individually predicted poor outcome (death/ESRD), only raised serum creatinine at onset (R square = 0.65, p ≤ 0.0001) and damage accrual (R square = 0.62, p ≤ 0.0001) remained significant on multivariate analysis. Eleven (8.2%) children died during the follow-up period, and infections were the leading cause of mortality.

CONCLUSIONS

Long-term outcome of LN in cSLE in our cohort was better than previous reports from India. However, a high rate of major infection still remains the leading cause of mortality.

Achiral, acyclic nucleic acids: synthesis and biophysical studies of a possible prebiotic polymer

The search for prebiotic, nucleic acid precursors is, at its best, a speculative undertaking.

Spectral weight shift in the valence band density of states and concurrent increase in field emission by hydrogenation of FeCo–SiO2 nanocomposites

Roughened surface and enhanced valence electronic states of hydrogen plasma treated FeCo–SiO₂ nanogranular films has made it an efficient field emitter in comparison to its as-grown and furnace annealed counterparts.