Cost and resource implications with serum angiogenic factor estimation in the triage of pre-eclampsia

OBJECTIVES

To analyse the economic and resource implications of using plasma soluble fms-like tyrosine kinase-1 s(Flt1) and placenta growth factor (PlGF) measurements in pre-eclampsia evaluation and management.

DESIGN

Retrospective cost analysis of our prospective cohort study.

SETTING

Boston, Massachusetts (USA).

POPULATION

Women (n = 176) presenting to the hospital at <34 weeks of gestation for evaluation of possible pre-eclampsia during 2009-10. Cases without complete cost or outcome data (n = 9) and re-enrolments (n = 18) were excluded.

METHODS

Modelled comparisons between the standard approach (combination of blood pressure, urinary protein excretion, alanine aminotransferase and platelet counts) and a novel approach (ratio of plasma sFlt1 and PlGF) using actual hospital data converted to 2012 US dollars in accordance with the Centers for Medicare and Medicaid Services.

MAIN OUTCOME MEASURES

Direct 2-week costs and resource use by groups having true or false positive and negative test results for adverse outcomes according to approach.

RESULTS

The improved specificity of the novel approach decreased the proportion of women falsely labelled as test-positive from 42.3% (34.4-50.2%) to 4.0% (0.85-7.15%) and increased the proportion correctly labelled as test-negative from 23.5% (16.7-30.3%) to 61.7% (53.9-69.5%). This could potentially reduce average per-patient costs by $1215. Substantial quantities of resources [47.2% (35.7-58.7%) of antenatal admissions and 72.5% (68.0-77.0%) of tests for fetal wellbeing] were unnecessarily used for women who were truly negative. A proportion of iatrogenic preterm deliveries among women with negative results was potentially avoidable representing further cost and resource savings.

CONCLUSIONS

Clinical use of the plasma sFlt1 and PlGF ratio improves risk stratification among women presenting for pre-eclampsia evaluation and has the potential to reduce costs and resource use.

Bone marrow negative visceral leishmaniasis in an adolescent male

Visceral Leishmaniasis or Kala Azar is endemic in certain regions of India. In endemic areas, the constellation of fever, progressive weight loss, weakness, pronounced splenomegaly, anemia, leukopenia, and hypergammaglobulinemia is highly suggestive of visceral leishmaniasis. Demonstration of the parasite in liver, splenic or bone marrow aspirates is confirmatory. We present a case in which Leishmania donovani (LD) bodies were demonstrated on splenic aspirate. We were unable to demonstrate LD bodies on bone marrow aspiration.

Reduction of Acute Anterior Shoulder Dislocation Using Intraarticular Lidocaine(IAL) and Stimson’s Technique

Introduction: Shoulder dislocation is common injury requiring urgent reduction. For the reason that patient is not nill orally and anesthetists are not available, reduction under intra venous anaesthesia is not possible. This study was aimed to evaluate the effectiveness of intraarticular lidocaine and stimson’s technique of shoulder dislocation, which could be performed without anesthetist and irrespective of nill orally status. Methods: A prospective observational study was performed from December 2009 to December 2010. Under all antiseptic precautions 20 ml of Lidocaine was injected intraarticularly and reduction was performed by Stimson’s technique. Visual Analogue Score, time for reduction and failure to reduction by this technique was recorded. Results: Out of 27 dislocations 22 were successfully reduced and remaining required added scapular manipulation. The mean VAS scor was 2.3±1.26 and the mean time of reduction was 17.96±1.9 minutes. Conclusion: Stimson’s method with Intraarticular Lidocaine is effective, safe, less costly and can be performed in periphery where anesthetist and monitoring facilities are not available. DOI: http://dx.doi.org/10.3126/mjsbh.v10i1.6406 Medical Journal of Shree Birendra Hospital Jan-June 2011 10(1) 6-8

OS094. Subclinical left ventricular dysfunction in preeclamptic women with preserved left ventricular ejection fraction: A 2D speckle tracking imaging study

INTRODUCTION

Patients with preeclampsia are at risk for cardiovascular disease [1,2]. Changes in cardiac function are subtle in preeclampsia and are quantitatively difficult with conventional imaging. Strain measurements using speckle-tracking echocardiography have been used to sensitively quantifyabnormalities in other disease settings [3].

OBJECTIVES

The objective of this study was to evaluate changes in myocardial strain using speckle tracking echocardiography in women with and without preeclampsia. We hypothesized that global left systolic strain measures would prove more sensitive than conventional left ventricular ejection fraction in detecting early changes in systolic LV function manifesting as subclinical disease prior to overt progression.

METHODS

We evaluated the feasibility and sensitivity of strain imaging using speckle tracking echocardiography. Thirty-six women were enrolled in this pilot study; 28 were analyzed: 11 with preeclampsia and 17 without preeclampsia. Echocardiographic Ejection fraction and global peak longitudinal ,radial and circumferential strain were measured.

RESULTS

Global Median longitudinal strain was significantly worsened in women with preeclampsia compared to women without preeclampsia (P<0.0001). Similar results were observed for global radial strain (P=0.006) and circumferential strain (P=0.03). There was no significant difference in ejection fraction between the groups (P=0.52) (Table 1). Data are presented as median (interquartile range).

CONCLUSION

Myocardial strain imaging using speckle tracking is more sensitive than left ventricular ejection fraction to detect differences in left ventricular systolic function in women with and without preeclampsia.

Imaging assessment of desmoid tumours in familial adenomatous polyposis: is state-of-the-art 1.5 T MRI better than 64-MDCT?

OBJECTIVE

Desmoid tumour is a common extraintestinal manifestation of patients with familial adenomatous polyposis (FAP) who have undergone prophylactic colectomy. We aimed to determine whether MRI provides equivalent or better assessment of desmoid tumours than CT, the current first-line investigation.

METHODS

Following ethics approval and informed consent, FAP patients with known desmoid tumour underwent contrast-enhanced 64-slice multidetector CT (MDCT) and 1.5 T MRI (incorporating T(1) weighted, T(2) weighted, short tau inversion-recovery and T(1) weighted with contrast, axial, sagittal and coronal sequences). The number, site, size, local extent, tumour signal intensity and desmoid-to-aorta enhancement ratio were analysed.

RESULTS

MRI identified 23 desmoid tumours in 9 patients: 9 intra-abdominal desmoid (IAD) tumours, 10 abdominal wall desmoid (AWD) tumours and 4 extra-abdominal desmoid (EAD) tumours. CT identified only 21 desmoids; 1 EAD and 1 AWD were not identified. The two modalities were equivalent in terms of defining local extent of desmoid. Five IAD tumours involved the bowel, six caused ureteric compression and none compromised the proximal superior mesenteric artery. There was no difference in median desmoid size: 56.7 cm(2) (range 2-215 cm(2)) on MDCT and 56.3 cm(2) (3-215 cm(2)) on MRI (p=0.985). The mean MRI enhancement ratio, at 1.12 (standard deviation 0.43), was greater than the CT enhancement ratio, which was 0.48 (0.16) (p<0.0001). High signal intensity on T(2) MRI was associated with increased MRI enhancement ratio (p=0.006).

CONCLUSIONS

MRI is at least equivalent (and may be superior) to MDCT for the detection of desmoid tumours in FAP. Coupled with the advantage of avoiding radiation, it should be considered as the primary imaging modality for young FAP patients.

Use of human urine in phytoplankton production as a tool for ecological sanitation

Measurements of primary productivity of phytoplankton and enumeration of the counts of coliform and heterotrophic bacteria (HB) were made in the water of 12 experimental tanks used for 3 treatments and control in triplicate as follows: (a) fresh human urine (0.02%), (b) stored human urine (0.02%), (c) mixed urine of fresh and stored human urine (0.02%) and (d) control without input of urine. The gross primary productivity of phytoplankton was highest in the stored urine treated tanks (508 mg C m(-2) h(-1)) followed by fresh urine (353 mg C m(-2) h(-1)), mixed urine (303 mg C m(-2) h(-1)) and control (215 mg C m(-2) h(-1)). Similar was the response of net primary production of phytoplankton. The mean count of HB observed in stored urine fed tanks was significantly higher (59-184%) than the remaining urine fed treatments. The mean count of Escherichia coli did not differ from urine treated tanks to control implying the good quality of water. The concentration of dissolved oxygen of water (7.6 to 12.8 mg L(-1)) in these tanks remained satisfactory for aquaculture. The mean concentration of ammonium-N observed in fresh urine treated tanks was more than 10 times higher than the remaining treatments employed. In contrast, the level of phosphate and electrical conductivity in the stored urine treated tanks were significantly higher than the remaining treatments. It is proposed that stored urine with a significantly reduced load of E. coli might be an effective low cost liquid fertilizer for algal biomass production.

Leptin deficiency and leptin gene mutations in obese children from Pakistan

BACKGROUND

Congenital leptin deficiency is a rare human genetic condition clinically characterized by hyperphagia and acute weight gain usually during the first postnatal year. The worldwide data on this disorder includes only 14 cases and four pathogenic mutations have been reported in the leptin gene.

STUDY OBJECTIVE

The objectives of this study were to measure serum leptin levels in obese children and to detect leptin gene mutations in those found to be leptin deficient.

PATIENTS AND RESULTS

A total of 25 obese children were recruited for the study. Leptin deficiency was detected in nine of them. Leptin gene sequencing identified mutations in homozygous state in all the leptin deficient children. Two cases carried novel mutations (c.481_482delCT and c.104_106delTCA) and each of the remaining seven the previously reported frameshift mutation (c.398delG).

CONCLUSION

The results suggest that leptin deficiency caused by mutations in the leptin gene may frequently be seen in obese Pakistani children from Central Punjab.

Status Epilepticus in Children

Status epilepticus (SE) is a life-threatening emergency that requires prompt treatment, including basic neuroresuscitation principles (the ABCs), antiepileptic drugs to stop the seizure and identification of etiology. It results from an inability to normally abort an isolated seizure either due to ineffective inhibition, or due to abnormally persistent excessive excitation. Symptomatic SE is more common in younger children and the likely etiology depends on the age of the child. Treating the precipitating cause may prevent ongoing neurologic injury and facilitates seizure control. Benzodiapenes, phenytoin and phenobarbital form the mainstay of treatment. A systematic treatment regimen, planned in advance, is needed, including one for refractory status epilepticus (RSE). Patient education and home management of seizures is important to reduce the morbidity and mortality associated with SE.

Circadian rhythm and its role in malignancy

Circadian rhythms are daily oscillations of multiple biological processes directed by endogenous clocks. The circadian timing system comprises peripheral oscillators located in most tissues of the body and a central pacemaker located in the suprachiasmatic nucleus (SCN) of the hypothalamus. Circadian genes and the proteins produced by these genes constitute the molecular components of the circadian oscillator which form positive/negative feedback loops and generate circadian rhythms. The circadian regulation extends beyond clock genes to involve various clock-controlled genes (CCGs) including various cell cycle genes. Aberrant expression of circadian clock genes could have important consequences on the transactivation of downstream targets that control the cell cycle and on the ability of cells to undergo apoptosis. This may lead to genomic instability and accelerated cellular proliferation potentially promoting carcinogenesis. Different lines of evidence in mice and humans suggest that cancer may be a circadian-related disorder. The genetic or functional disruption of the molecular circadian clock has been found in various cancers including breast, ovarian, endometrial, prostate and hematological cancers. The acquisition of current data in circadian clock mechanism may help chronotherapy, which takes into consideration the biological time to improve treatments by devising new therapeutic approaches for treating circadian-related disorders, especially cancer.

Investigation of Burkholderia cepacia complex in septicaemic patients in a tertiary care hospital, India

Burkholderia cepacia complex (BCC) is being increasingly recognized as an important pathogen of humans. During the year 2007-8, 39 putative BCC isolates were obtained from 21 cases and subjected to recA PCR RFLP. Twenty-four isolates were confirmed as Burkholderia cenocepacia IIIA (nineteen isolates, recA PCR RFLP type G and five isolates, recA PCR RFLP type I), six were confirmed as B. cepacia (recA PCR RFLP type E). BCC were isolated from inpatients of different wards of Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh with increased isolation from children admitted to different wards of Advanced Pediatric Centre (11/21 cases). BCC isolates are often resistant to most commonly used antibiotics and an early use of effective antimicrobial therapy can decrease morbidity and mortality.

Specific post-transcriptional inhibition of mRNA for ligand binding chain of IgE high affinity receptor

IgE high affinity receptor (FcεRI) plays an important role in triggering type I allergic reactions. In this study, we have investigated the ability of four synthetic and sequence-specific RNA interfering antisense oligodeoxynucleotides (AS-ODNs) to reduce the expression of FcεRIα gene in granulocytes of allergy sufferers in vitro. Only AS1 out of four AS-ODNs specifically inhibited the FcεRIα gene expression and the dose response assay revealed that AS1 was capable of specific inhibition of target mRNA expression over a linear concentration range without affecting the expression of house keeping genes such as glyceraldehyde-3-phosphate dehydrogenase (GAPDH). Together, these results indicate that sequence-specific RNA interfering ODNs can be effectively used to silence the expression of key genes like IgE high affinity receptor that are involved in chronic inflammatory diseases.

Pulmonary hypertension in children and adolescents with sickle cell disease

The prevalence of pulmonary hypertension (PHTN) in the pediatric sickle cell disease (SCD) population is not known despite its high prevalence in adult patients. Our hypothesis was that increased pulmonary artery pressures (PAPs) would be found in SCD children and adolescents, especially those with a history of pulmonary complications: acute chest syndrome, obstructive sleep apnea, asthma, and reactive airway disease. Fifty-two SCD children, 23 of whom had underlying pulmonary disease, were screened for PHTN, which was defined as a tricuspid regurgitant jet velocity (TRV) of at least 2.5 m/s. Twenty-four (46.15%) SCD patients had increased PAP (i.e., TRV > or =2.5 m/s), and 6 (11.5%) had significant PHTN (i.e., TRV > or =3.0 m/s). Pulmonary disease was marginally associated with PHTN (odds ratio 2.80 and confidence interval 0.88 to 8.86; p = 0.0795). As in adult SCD patients with PHTN, this complication was correlated with the degree of hemolysis as manifested by significantly higher lactate dehydrogenase and bilirubin, lower hemoglobin and hematocrit levels, and a strong association with Hb-SS phenotype. However, after statistical adjustment for age and sex, increased serum LDH was not associated with the development of PHTN. Further studies are needed to clarify the prevalence and mechanisms of PHTN in pediatric and adolescent patients with SCD.

On the chemical synthesis and drug delivery response of folate receptor-activated, polyethylene glycol-functionalized magnetite nanoparticles

We describe here the chemical synthesis and in vitro drug delivery response of polyethylene glycol (PEG)-functionalized magnetite (Fe(3)O(4)) nanoparticles, which were activated with a stable ligand, folic acid, and conjugated with an anticancer drug, doxorubicin. The functionalization and conjugation steps in the chemical synthesis were confirmed using Fourier transform infrared spectroscopy. The drug-release behavior of PEG-functionalized and folic acid-doxorubicin-conjugated magnetic nanoparticles was characterized by two stages involving an initial rapid release, followed by a controlled release.

On the suitability of nanocrystalline ferrites as a magnetic carrier for drug delivery: functionalization, conjugation and drug release kinetics

Superparamagnetic nickel ferrite nanoparticles functionalized with polyvinyl alcohol, polyethylene oxide and polymethacrylic acid (PMAA) polymers and subsequently conjugated with doxorubicin anti-cancer drug are studied for their use as a magnetic carrier for drug delivery. Fourier transform infrared spectroscopy enabled examination of the ability of the nanoparticles to be functionalized with polymers and conjugated with doxorubicin drug. The functionalized polymer-coated nanocrystalline nickel ferrites retain the magnetic characteristics of non-functionalized nanocrystalline nickel ferrites (superparamagnetism, absence of hysteresis, remanence and coercivity at room temperature), encouraging their application as a magnetic carrier for drug delivery. The PMAA-coated nanoferrites are demonstrated as being a potentially superior magnetically targeted drug carrier based on FTIR results and drug release kinetics in the absence and presence of an external magnetic field.

Antimicrobial function of Nd3+-doped anatase titania-coated nickel ferrite composite nanoparticles: a biomaterial system

The present study describes and makes a relative comparison of the antimicrobial function of undoped and neodymium-doped titania coated-nickel ferrite composite nanoparticles processed by uniquely combining the reverse micelle and chemical hydrolysis approaches. This methodology facilitates the formation of undoped and doped photocatalytic titania shells and a magnetic ferrite core. The ferrite core is needed to help in the removal of particles from the sprayed surface using a small magnetic field. Doping of the titania shell with neodymium significantly enhances the photocatalytic and anti-microbial function of the core-shell composite nanoparticles without influencing the magnetic characteristics of the nickel ferrite core. The increased performance is believed to be related to the inhibition of electron-hole recombination and a decrease in the band gap energy of titania. The retention of magnetic strength ensures controlled movement of the composite nanoparticles by the magnetic field, facilitating their application as removable anti-microbial photocatalyst nanoparticles. The consistent behavior of the composite nanoparticles points to the viability of the synthesis process adopted.

Stability of Delta(9)-tetrahydrocannabinol (THC) in oral fluid using the Quantisal collection device

This article details the stability of Delta(9)-tetrahydrocannabinol (THC) in oral fluid during collection, extraction and storage. Oral fluid is being increasingly used as the specimen of choice for the detection of drug use in various applications. Studies to determine the extraction efficiency of THC from the collection buffer and stability under various laboratory storage conditions were carried out. THC was extracted from the collection pad and buffer with an average efficiency over 80% and was stable in Quantisal oral fluid extraction buffer when stored at refrigerated temperatures. Fluorescent lighting caused THC losses of over 50%, however the presence of the pad reduced the loss. In the dark, the loss of THC at room temperature was approximately 20% over 14 days. When stored with the serum separators in place, THC losses were significant. After 3 days, THC concentration was reduced by almost 30%, and after 14 days, 60% of the drug was lost and the losses were not concentration dependent.

Anti-microbial active composite nanoparticles with magnetic core and photocatalytic shell: TiO2-NiFe2O4 biomaterial system

Reverse micelle and chemical hydrolysis techniques have been successfully combined to synthesize composite nanoparticles consisting of a photocatalytic shell of titania and a magnetic core of nickel ferrite. The nature of titania shell, i.e. anatase or brookite, depends on the TiO2 and NiFe2O4 molar ratio. The work presented here describes the photocatalytic and anti-microbial activity of the composite nanoparticles together with the magnetic characteristics of the nickel ferrite core. The TiO2-coated NiFe2O4 nanoparticles retain the magnetic characteristics of uncoated nanocrystalline nickel ferrites (superparamagnetism; absence of hysteresis, remanence and coercivity at 300 K) encouraging their application as removable anti-microbial photocatalyst nanoparticles that can be extracted from the sprayed surface (human body or environment) after exposure.

Ketamine anaesthesia for paediatric ophthalmology surgery

AIMS

Children with treatable, vision impairing conditions may not have access to surgical care when they live in regions where anaesthesia is unavailable. The use of ketamine anaesthesia in a developing region was studied to determine its safety and effectiveness.

METHODS

This is a consecutive series of 679 children who had a variety of paediatric eye disorders necessitating a short general anaesthesia. Ketamine was administered intravenously by a paediatrician with training in paediatric resuscitation procedures. Both intraocular and extraocular procedures were performed. The location of treatment was the Tilganga Eye Hospital in Kathmandu, Nepal, a developing region of the world. The study took place over a 5 year period.

RESULTS

All procedures were performed without any anaesthetic complications. No child required unanticipated resuscitation or laryngeal intubation. Postoperative dysphoria occurred occasionally and was difficult to measure quantitatively. This side effect of ketamine resolved by the first postoperative day.

CONCLUSION

Ketamine is an effective agent for both intraocular and extraocular surgery in the paediatric age group. None of the children in this series needed resuscitation or intubations, and the ophthalmic surgery was carried out safely. Ketamine can be used safely in any ophthalmic procedure of short duration by a person having some training in anaesthetic resuscitation procedures. Because of its simplicity and safety, ketamine may be useful in a simple ophthalmic setup in the developing word.

Sero-prevalence and mother-to-infant transmission of hepatitis E virus among pregnant women in the United Arab Emirates

OBJECTIVES

(1) To study the prevalence of HEV infection in a cohort of pregnant women in the United Arab Emirates (UAE). (2) The rate of mother-to-infant transmission.

METHOD

Sera of 469 pregnant women residing in the UAE was tested for anti-HEV with ELISA and for HEV-RNA by polymerase chain reaction (PCR). Neonatal cord-blood and infant blood was similarly tested for anti-HEV and HEV-RNA. Out of these 469 women, 33% were UAE nationals (Group A) and Egyptians (Group B), respectively, and 34% were from the Indian sub-continent (Group C).

RESULTS

Out of 469 mothers 93 (20%) were anti-HEV positive and 28 (30%) of these 93 were HEV-RNA positive and symptomatic with on-going infection. The prevalence of anti-HEV was significantly increased amongst Groups B and C (Group A:B, P<0.001; Group A:C, P<0.001). Twelve of these 28 symptomatic women developed acute hepatic disease and two died undelivered, thus, were excluded from further study. Six of the remaining 10 women had non-fulminant acute viral hepatitis and four developed fulminant hepatic failure, of which one died in the early post-partum period. The remaining 16 women had mild symptomatic disease with complete recovery as did the remaining nine women with acute illness. Of the 10 babies born to mothers with acute disease, two were pre-term, three had anicteric hepatitis and two babies were born with hypothermia and hypoglycaemia and died within 48h. Noteworthy is the fact that, the 26 infants born to the 26 HEV-RNA positive mothers developed acute/on-going clinical infection and were HEV-RNA positive. Apart from the two early neonatal deaths, the remaining 24 infants had full recovery. No infant of the other mothers were symptomatic or had HEV-RNA. Thus, the mother-to-infant transmission was 100%. The remaining 65 sero-positive women remained asymptomatic with no evidence of clinical infection, continued to be HEV-RNA negative and delivered at term. Their infants had no evidence of infection and were sero-negative by 9 months of age, suggesting transplacental transmission of IgG antibodies.

CONCLUSIONS

There is a high prevalence of anti-HEV among pregnant women residing in the UAE. Twelve of infected women developed fulminant/acute hepatitis resulting in three fatalities. Evidence suggests significant vertical transmission of HEV among HEV-RNA positive mothers with appreciable perinatal morbidity and mortality. Excluding mothers with acute hepatic disease, Breast-feeding appears to be safe in HEV sero-positive mothers.

Plasma S-adenosylhomocysteine is a more sensitive indicator of cardiovascular disease than plasma homocysteine

BACKGROUND

Although plasma total homocysteine has been identified as an independent risk factor for vascular disease in a multitude of studies, there is a considerable overlap in values between patients at risk and control subjects. The difference in values can be used to distinguish statistically between the 2 groups, provided each group is large enough; however, discriminating between individual patients at risk and control subjects is difficult.

OBJECTIVE

We investigated whether the precursor of homocysteine, S-adenosylhomocysteine, is a more sensitive indicator of risk.

DESIGN

We measured plasma total homocysteine, S-adenosylhomocysteine, S-adenosylmethionine, creatinine, folate, and vitamin B-12 in 30 patients with proven cardiovascular disease and 29 age- and sex-matched control subjects.

RESULTS

The homocysteine values (+/-SD) were 12.8 +/- 4.9 (95% CI: 11.0, 14.7) micromol/L for patients and 11.0 +/- 3.2 (9.8, 12.2) micromol/L for control subjects. The S-adenosylhomocysteine values were 40.0 +/- 20.6 (32.3, 47.7) nmol/L for patients and 27.0 +/- 6.7 (24.5, 30.0) nmol/L for control subjects (P = 0.0021). The S-adenosylmethionine values were 121.8 +/- 42.9 (105.8, 137.8) nmol/L for patients and 103.9 +/- 21.8 (95.6, 112.2) nmol/L for control subjects (P = 0.0493). The creatinine values were 110 +/- 27 (97, 120) micromol/L for patients and 97 +/- 9 (80, 100) micromol/L for control subjects (P = 0.0025). Values for folate and vitamin B-12 did not differ significantly between groups.

CONCLUSIONS

Plasma S-adenosylhomocysteine appears to be a much more sensitive indicator of the difference between patients with cardiovascular disease and control subjects than is homocysteine. Both plasma total homocysteine and S-adenosylhomocysteine are significantly correlated with plasma creatinine in patients.