Findings of the first ANZICS conference on the role of intensive care in Rapid Response Teams

Rapid Response Teams (RRTs) are specialised teams introduced into hospitals to improve the outcomes of deteriorating ward patients. Although Rapid Response Systems (RRSs) were developed by the intensive care unit (ICU) community, there is variability in their delivery, and consultant involvement, supervision and leadership appears to be relatively infrequent. In July 2014, the Australian and New Zealand Intensive Care Society (ANZICS) convened the first conference on the role of intensive care medicine in RRTs in Australia and New Zealand. The conference explored RRSs in the broader role of patient safety, resourcing and staffing of RRTs, effect on ICU workload, different RRT models, the outcomes of RRT patients and original research projects in the area of RRSs. Issues around education and training of both ICU registrars and nurses were examined, and the role of team training explored. Measures to assess the effectiveness of the RRS and RRT at the level of health system and hospital, team performance and team effectiveness were discussed, and the need to develop a bi-national ANZICS RRT patient database was presented. Strategies to prevent patient deterioration in the 'pre-RRT' period were discussed, including education of ward nurses and doctors, as well as an overarching governance structure. The role of the ICU in deteriorating ward patients was debated and an integrated model of acute care presented. This article summarises the findings of the conference and presents recommendations on the role of intensive care medicine in RRTs in Australia and New Zealand.

A putative corticosteroid hormone in Pacific lamprey, Entosphenus tridentatus

Great efforts have been put forth to elucidate the mechanisms of the stress response in vertebrates and demonstrate the conserved response across different vertebrate groups, ranging from similarities in the activation of the hypothalamic-pituitary-adrenal axis to the release and role of corticosteroids. There is however, still very little known about stress physiology in the Pacific lamprey (Entosphenus tridentatus), descendants of the earliest vertebrate lineage, the agnathans. In this paper we demonstrate that 11-deoxycortisol, a steroid precursor to cortisol in the steroidogenic pathway, may be a functional corticosteroid in Pacific lamprey. We identified the putative hormone in Pacific lamprey plasma by employing an array of methods such as RIA, HPLC and mass spectrometry analysis. We demonstrated that plasma levels of 11-deoxycortisol significantly increased in Pacific lamprey 0.5 and 1 h after stress exposure and that lamprey corticotropin releasing hormone injections increased circulating levels of 11-deoxycortisol, suggesting that the stress response is under the control of the HPA/I axis as it is in higher vertebrates. A comprehensive understanding of vertebrate stress physiology may help shed light on the evolution of the corticosteroid signaling system within the vertebrate lineage.

Comparison of reliability of lateral cephalogram and computed tomography for assessment of airway space

BACKGROUND AND AIMS

The oropharyngeal (OP) and nasopharyngeal structures seems to play roles in the development of the dentofacial complex. Soft palate as a part of nasopharyngeal and OP apparatus has an important role in phonation, deglutition and respiration. The aim of this study was to find whether any correlation exists between the three types of malocclusion and airway space using lateral cephalogram and computed tomography (CT) and to compare its reliability. To obtain important information on the morphology of the soft palate on lateral cephalogram and to determine its etiopathogenesis in obstructive sleep apnea (OSA).

MATERIALS AND METHODS

Lateral cephalogram of 45 subjects were used to measure the pharyngeal airway. The subjects were divided into three groups (each group included 15 subjects) according to ANB angle: Class I (ANB angle 2-4°), Class II (ANB angle > 4°), Class III (ANB angle ≤ 2°).

RESULTS

The result showed a significant reduction in pharyngeal airway in ANB Class II. Type I soft palate, leaf-shape was found in maximum subjects. The volume of airway size showed higher statistical significance with the greater coefficient of variation on CT in relation to corresponding cephalometric airway area.

CONCLUSION

The sagittal skeletal pattern is a contributory factor in variations in the upper airway dimensions. The measurements acquired from both the modalities are reliable and reproducible, but CT gives the better assessment of cross-sectional dimensions of airway space. Morphology of the soft palate can be used as references for etiological research of OSA.

Genome sequence of vanilla distortion mosaic virus infecting Coriandrum sativum

The 9573-nucleotide genome of a potyvirus was sequenced from a Coriandrum sativum plant from India with viral symptoms. On analysis, this virus was shown to have greater than 85 % nucleotide sequence identity to vanilla distortion mosaic virus (VDMV). Analysis of the putative coat protein sequence confirmed that this virus was in fact VDMV, with greater than 91 % amino acid sequence identity. The genome appears to encode a 3083-amino-acid polyprotein potentially cleaved into the 10 mature proteins expected in potyviruses. Phylogenetic analysis confirmed that VDMV is a distinct but ungrouped member of the genus Potyvirus.

Social marketing of water and sanitation products: a systematic review of peer-reviewed literature

Like commercial marketing, social marketing uses the 4 "Ps" and seeks exchange of value between the marketer and consumer. Behaviors such as handwashing, and products such as those for oral rehydration treatment (ORT), can be marketed like commercial products in developing countries. Although social marketing in these areas is growing, there has been no systematic review of the current state of practice, research and evaluation. We searched the literature for published peer-reviewed studies available through major online publication databases. We identified manuscripts in the health, social science, and business literature on social marketing that used at least one of the 4 Ps of marketing and had a behavioral objective targeting the behaviors or products related to improving water and sanitation. We developed formalized decision rules and applied them in identifying articles for review. We initially identified 117 articles and reviewed a final set of 32 that met our criteria. Social marketing is a widespread strategy. Marketing efforts have created high levels of awareness of health threats and solutions, including behavior change and socially marketed products. There is widespread use of the 4 Ps of marketing, with price interventions being the least common. Evaluations show consistent improvements in behavioral mediators but mixed results in behavior change. Interventions have successfully used social marketing following widely recommended strategies. Future evaluations need to focus on mediators that explain successful behavior change in order to identify best practices and improve future programs. More rigorous evaluations including quasi-experimental designs and randomized trials are needed. More consistent reporting of evaluation results that permits meta-analysis of effects is needed.

Regulation of a putative corticosteroid, 17,21-dihydroxypregn-4-ene,3,20-one, in sea lamprey, Petromyzon marinus

In higher vertebrates, in response to stress, the hypothalamus produces corticotropin-releasing hormone (CRH), which stimulates cells in the anterior pituitary to produce adrenocorticotropic hormone (ACTH), which in turn stimulates production of either cortisol (F) or corticosterone (B) by the adrenal tissues. In lampreys, however, neither of these steroids is present. Instead, it has been proposed that the stress steroid is actually 17,21-dihydroxypregn-4-ene-3,20-dione (11-deoxycortisol; S). However, there have been no studies yet to determine its mechanism of regulation or site of production. Here we demonstrate that (1) intraperitoneal injections of lamprey-CRH increase plasma S in a dose dependent manner, (2) intraperitoneal injections of four lamprey-specific ACTH peptides at 100μg/kg, did not induce changes in plasma S concentrations in either males or females; (3) two lamprey-specific gonadotropin-releasing hormones (GnRH I and III) and arginine-vasotocin (AVT), all at single doses, stimulated S production as well as, or to an even greater extent than CRH; (4) sea lamprey mesonephric kidneys, in vitro, converted tritiated 17α-hydroxyprogesterone (17α-P) into a steroid that had the same chromatographic properties (on HPLC and TLC) as S; (5) kidney tissues released significantly more immunoassayable S into the incubation medium than gill, liver or gonad tissues. One interpretation of these results is that the corticosteroid production of the sea lamprey, one of the oldest extant vertebrates, is regulated through multiple pathways rather than the classical HPI-axis. However, the responsiveness of this steroid to the GnRH peptides means that a reproductive rather than a stress role for this steroid cannot yet be ruled out.

Effect of Tribulus terrestris on Haloperidol-induced Catalepsy in Mice

Haloperidol, an antipsychotic drug, leads to the development of a behavioural state called catalepsy, in which the animal is not able to correct an externally imposed posture. In the present study we have attempted to evaluate the anticataleptic effect of Tribulus terrestris on haloperidol-induced catalepsy in albino mice. Mice were allocated to four groups, each group containing six animals. Both, the test drug, Tribulus terrestris and the standard drug trihexyphenidyl were uniformly suspended in 1% gum acacia solution. Catalepsy was induced in mice with haloperidol (1.0 mg/kg, intraperitoneally). The first group received the vehicle (10 ml/kg, orally), the second group received trihexyphenidyl (10 mg/kg, orally) and the remaining two groups received Tribulus terrestris (100, 200 mg/kg, orally). The animals were assessed after single and repeated dose administration for ten days, 30 min prior to haloperidol, using standard bar test. The result of the present study demonstrates Tribulus terrestris has a protective effect against haloperidol-induced catalepsy, which is comparable to the standard drug used for the same purpose. Our study indicates Tribulus terrestris can be used to prevent haloperidol-induced extrapyramidal side effects.

"Left-sided" Chilaiditi sign? A large gastric perforation with secondary pancreatitis

BACKGROUND

Although the Chilaiditi sign correctly underestimates the radiological presence of air-under-the-diaphragm, in few cases it has lead to delays in the diagnosis of underlying pneumoperitoneum. In this article we report the case of a young lady presenting with acute pancreatitis and radiographic findings of "left-sided" Chilaiditi sign with underlying a large gastric perforation.

CASE REPORT

A 35 year old Caucasian female presented to the Emergency Department with a twenty-four hour history of severe epigastric pain radiating into her back. Stable observations, mildly raised white cell count, increased amylase and subdiaphragmatic radiolucency were interpreted as acute pancreatitis with Chilaiditi sign and treated accordingly. Twenty-four hours later the deterioration of the clinical conditions required a CT scan and an emergency laparotomy that lead to the diagnosis of a large gastric perforation. However, after several days she died of a disseminated intravascular coagulation in the Intensive Care Unit.

CONCLUSIONS

In our case the young age of the patient and lack of underlying comorbidities initially compensated the severity of the perforation until it became evident from the absent resolution of the pancreatitis. Bearing this in mind, radiological appearances similar to Chilaiditi sign with significant symptoms or signs should be investigated with a CT scan in order to reach promptly a correct diagnosis.

Treatment of refractory keloids with pulsed dye laser alone and with rotational pulsed dye laser and intralesional corticosteroids: A retrospective case series

BACKGROUND AND AIMS

The limited available effective treatments make the management of keloids challenging. Intralesional triamcinolone and pulsed dye laser have been used for the treatment of keloids. We sought to assess the efficacy of a treatment regime using rotational intralesional triamcinolone and pulsed dye laser in the management of keloids. Materials (Subjects) and Methods: Case notes and photographic records of 99 patients with keloids treated with pulsed dye laser (PDL) alone or rotational PDL and intralesional triamcinolone (ILT) at our centre between 2005 and 2010 were reviewed. Patients with raised, erythematous and/or symptomatic keloids unresponsive to ILT alone (usually 6 treatments) are referred for consideration of PDL. Patients are offered repeated rotational treatments of three PDL (4-15 J/cm(2), 7 mm spot, 1.5 msec pulse duration, 595 nm wavelength, DCD, 30 msec spray: 20 msec delay; spaced at 6-8 weeks intervals) followed by one ILT (10 mg or 40 mg/dl). ILT-treated flat but erythematous and/or symptomatic keloids are treated with PDL alone at 6-8 week intervals. Response after each laser treatment is documented as a percentage improvement from baseline. Based on the improvement in redness, thickness and pruritus the operator classified the response to treatment as mild (0-49%), moderate (50-75%) or excellent (>75%). Patients are reviewed at 6 months following last treatment. A patient satisfaction questionnaire was also sent out to all patients who received treatments between 2005 and 2010 and this was compared with the information gathered from the notes.

RESULTS

Of the 99 patients, 58 were women and 41 were men and most were Caucasian (n=84). A total of 755 keloids were treated. The average number of PDL treatments to achieve a moderate-excellent result was 14 in male and 12 in females. Moderate-excellent improvement was seen in 76% patients. The average number of ILT required to achieve a moderate-excellent result was 5 in males and 4 in females. All patients were sent a satisfaction questionnaire and 33 responses were received wherein patients reported an average of 70% improvement in the redness and thickness of the keloids. Localised cutaneous atrophy, self-limiting erythema and injection site discomfort were noted in 3 female patients whilst no side-effects noted in the male cohort.

CONCLUSIONS

Pulsed dye laser with or without intralesional triamcinolone is a moderately effective treatment of keloid scars with a very good side-effect profile and high patient satisfaction.

Spontaneous Bilateral Simultaneous Tubal Pregnancy

Bilateral tubal pregnancy in absence of ovulation induction represents the rarest form of ectopic pregnancies. Among the variant of twin ectopic pregnancy, heterotopic or twin pregnancy in the same tube is higher compared to that of bilateral tubal pregnancy. Till date around 250 cases of simultaneous bilateral tubal pregnancy have been detected and many occur following assisted reproductive treatment. Preoperative diagnosis is uncommon. It is usually detected intraoperatively and so necessitates careful examination of both the adnexa. We report a case where in one tube showed ruptured tubal pregnancy and in the other tube, a mass was noticed which was suspected to be a hydrosalphnix or a pyosalphinx. Since patient had already consented for tubectomy, a bilateral salphingectomy was done. Histopathology showed bilateral tubal pregnancy. Nepal Journal of Obstetrics and Gynaecology / Vol 8 / No. 1 / Issue 15 / Jan- June, 2013 / 41-42 DOI: http://dx.doi.org/10.3126/njog.v8i1.8863

Applications of stem cells in interdisciplinary dentistry and beyond: an overview

In medicine stem cell–based treatments are being used in conditions like Parkinson's disease, neural degeneration following brain injury, cardiovascular diseases, diabetes, and autoimmune diseases. In dentistry, recent exciting discoveries have isolated dental stem cells from the pulp of the deciduous and permanent teeth, from the periodontal ligament, and an associated healthy tooth structure, to cure a number of diseases. The aim of the study was to review the applications of stem cells in various fields of dentistry, with emphasis on its banking, and to understand how dental stem cells can be used for regeneration of oral and non-oral tissues conversely. A Medline search was done including the international literature published between 1989 and 2011. It was restricted to English language articles and published work of past researchers including in vitro and in vivo studies. Google search on dental stem cell banking was also done. Our understanding of mesenchymal stem cells (MSC) in the tissue engineering of systemic, dental, oral, and craniofacial structures has advanced tremendously. Dental professionals have the opportunity to make their patients aware of these new sources of stem cells that can be stored for future use, as new therapies are developed for a range of diseases and injuries. Recent findings and scientific research articles support the use of MSC autologously within teeth and other accessible tissue harvested from oral cavity without immunorejection. A future development of the application of stem cells in interdisciplinary dentistry requires a comprehensive research program.

Evaluation of amentoflavone isolated from Cnestis ferruginea Vahl ex DC (Connaraceae) on production of inflammatory mediators in LPS stimulated rat astrocytoma cell line (C6) and THP-1 cells

ETHNOPHARMACOLOGICAL RELEVANCE

Cnestisferruginea (CF) Vahl ex DC (Connaraceae) is a shrub widely used in traditional African medicine for the treatment of various psychiatric illness and inflammatory conditions.

AIM OF THE STUDY

This study was carried out to investigate the effect of amentoflavone isolated from methanolic root extract of CF on lipopolysaccharide (LPS)-induced neuroinflammatory cascade of events associated to the oxidative and nitrative stress, and TNF-α production in rat astrocytoma cell line (C6) and human monocytic leukemia cell line (THP-1), respectively.

MATERIALS AND METHODS

Rat astrocytoma cells (C6) were stimulated with LPS (10μg/ml) alone and in the presence of different concentrations of amentoflavone (0.1-3μg/ml) for 24h incubation period. Nitrite release, reactive oxygen species (ROS), malondialdehyde (MDA) and reduced-glutathione (GSH) in C6 cells were estimated; while the TNF-α level was estimated in THP-1 cell lysate. In vivo analgesic activity was evaluated using mouse writhing and hot plate tests while the anti-inflammatory effect was investigated using carrageenan-induced oedema test.

RESULTS

LPS (10μg/ml) significantly (P<0.05) stimulated C6 cells to release nitrite, ROS, MDA, and TNF-α generation while GSH was down regulated in comparison to control. However, amentoflavone significantly (P<0.05) attenuated nitrite, ROS, MDA and TNF-α generation and also up regulated the level of GSH. Amentoflavone per se did not have any significant effect on C6 and THP-1 cells. Amentoflavone (6.25-50mg/kg) significantly (P<0.05) reduced number of writhes and also increase pain threshold in hot plate test. It produced time course significant (P<0.05) decrease in oedema formation in rodents.

DISCUSSION AND CONCLUSION

Findings in this study demonstrate the anti-neuroinflammatory and antinoceptive effects of amentoflavone which may suggest its beneficial roles in neuroinflammation associated disorders.

Breast cancer surgery without suction drainage: the impact of adopting a 'no drains' policy on symptomatic seroma formation rates

AIM

To determine the effect of a 'no drains' policy on seroma formation and other complications in women undergoing breast cancer surgery.

MATERIALS AND METHODS

Before May 2010 drains were routinely used in our unit following mastectomy ± axillary surgery and axillary lymph node dissection (ALND) ± wide local excision (WLE). Since then, a 'no drains' policy has been adopted. Data was collected prospectively between 01/12/06 and 30/11/11 to compare symptomatic seroma, wound infection, re-admission and re-operation rates in women treated with a drain and those without.

RESULTS

596 women were included in the study. 247 women underwent modified radical mastectomy (MRM) and ALND (Group 1), 184 MRM ± sentinel lymph node biopsy (SLNB)/axillary node sampling (ANS) (Group 2) and 165 ALND ± WLE (Group 3). In group 1, 149 had a drain, in group 2, 62, and in group 3, 50. Within each group, the presence or absence of a drain did not significantly affect the rate of symptomatic seroma, number of aspirations performed, wound infection rates or the incidence of complications requiring re-admission. Having a drain was associated with lower volumes of seroma aspirated. In all three groups, the presence of a drain was associated with a longer hospital stay (p < 0.001).

CONCLUSION

This study suggests that MRM ± ALND/SLNB/ANS and ALND ± WLE can be performed without the use of suction drains without increasing seroma formation and other complication rates. Adopting a 'no-drains' policy may also contribute to earlier hospital discharge.

Combined Spinal Epidural Anesthesia for Total Hip Replacement Surgery in Birendra Army Hospital

Introduction: Total Hip Replacement surgery is one of the most commonly performed surgeries worldwide. Epidural anaesthesia have shown decrease incidence of DVT in these patient. Hence, combined spinal epidural spinal anesthesia is now a preferred technique over spinal anesthesia alone. We have been practicing combined spinal epidural anesthesia routienely in total joint replacement, but have not analyzed the result. The aim of this study was to analyse various aspect of combined spinal epidura anesthesia. Methods: thirteen cases of ASA I and II who underwent Total Hip Arthroplasty under combined spinal epidural anesthesia were analysed. First epidural was given in space L2-3/L3-4 and patency was confirmed with test dose with InjXylocaine 2% with Adrenaline 3 ml, followed by Spinal anesthesia one space below with Bupivacaine 0.5% 3 ml. Results: Intra operative Mean Blood Pressure had dropped up to 55 mm of Hg.To maintain Blood pressure, Intravenous Fluid was given in average is 2423.077 ml and Vasopressure drug (Mephenteramine Maleate) was given in average of14.769 mg. Dura was accidentally puncture in one patient during epidural insertion and two epidural failed to provide post operative analgesia. Post operative rehabilitation was easy, one one patient developed DVT after 4 weeks of surgery. Conclusion: Combined epidural analgesia effectively manages postoperative pain, allows early ambulation and reduces the risk of deep vein thrombosis and thromboembolism, Although significant drop of Blood pressure was noted in all cases. DOI: http://dx.doi.org/10.3126/mjsbh.v10i1.6447 Medical Journal of Shree Birendra Hospital Jan-June 2011 10(1) 32-36