End-of-life decisions in an Indian intensive care unit

BACKGROUND

There is a paucity of data on end-of-life decisions (EOLD) for patients in Indian intensive care units (ICUs).

OBJECTIVE

To document the end-of-life and full-support (FS) decisions among patients dying in an ICU, to compare the respective patient characteristics and to describe the process of decision-making.

DESIGN

Retrospective, observational.

PATIENTS

Consecutive patients admitted to a 12-bed closed medical-surgical ICU.

EXCLUSIONS

Patients with EOLD discharged home or transferred to another hospital.

MEASUREMENTS AND RESULTS

Demographic profile, APACHE IV at 24 h, ICU outcome, type of limitation, disease category, pre-admission functional status, reasons for EOLD, interventions and therapies within 3 days of death, time to EOLD, time to death after EOLD and ICU length of stay. Out of 88 deaths among 830 admissions, 49% were preceded by EOLD. Of these 58% had withholding of treatment, 35% had do-not-resuscitate orders (DNR) and 7% had a withdrawal decision. Mean age and APACHE IV scores were similar between EOLD and FS groups. Functional dependence before hospitalization favored EOLD. Patients receiving EOLD as opposed to FS had longer stays. Fifty-three percent of limitations were decided during the first week of ICU stay well before the time of death. Escalation of therapy within 3 days of death was less frequent in the EOLD group.

CONCLUSIONS

Despite societal and legal barriers, half the patients dying in the ICU received a decision to limit therapy mostly as withholding or DNR orders. These decisions evolved early in the course of stay and resulted in significant reduction of therapeutic burdens.

No association of Methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism in susceptibility to gallbladder cancer

Gallbladder carcinoma (GBC) is a leading cause of cancer deaths in north India. Evidence has highlighted the role of abnormal DNA methylation patterns on inappropriate gene expression in development and progression of various cancers. 5,10-Methylenetetrahydrofolate reductase (MTHFR) plays a major role in provision of methyl groups for DNA methylation. A C/T substitution in MTHFR at nucleotide 677 results in replacement of ala222-to-val in the N-terminal catalytic domain of protein, and causes considerable decrease in enzymatic activity. Thus, MTHFR C677T polymorphism may influence genetic susceptibility to GBC. The present study aimed to examine the role of C677T MTHFR polymorphism in conferring genetic susceptibility to GBC. The present study included 146 proven GBC patients and 210 healthy controls. Genotyping was done by PCR-RFLP method. The MTHFR C677T genotypes in control population were in Hardy-Weinberg equilibrium (p = ns). No statistically significant difference was observed in frequency of variant TT genotype in GBC patients in comparison to healthy controls (4.1% and 2.9%). Stratification of GBC patients on the basis of presence or absence of gallstones showed no significant association with the disease. Further, gender and age of onset of the disease did not show any significant association. In conclusion, the present study indicates that the genetic risk for GBC is not modulated by MTHFR C677T polymorphism.

Abscess-a rare fourth ventricular mass

Midline posterior fossa mass lesions in young adults are usually medulloblastomas, pilocytic astrocytomas, haemangioblastomas or ependymomas. We present clinical, imaging and intraoperative findings of an abscess occurring within the fourth ventricle which was associated with right chronic suppurative otitis media and right transverse sinus thrombosis. The possible pathogenesis is discussed.

Detoxification reactions of sulphur mustard on the surface of zinc oxide nanosized rods

Detoxification reactions of sulphur mustard, a deadliest chemical warfare agent were studied on the surface of zinc oxide nanorods at room temperature (32+/-2 degrees C) and the data was compared with that of the bulk ZnO. Prior to the reaction, the nanorods of zinc oxide were synthesized by the hydrothermal method and subsequently characterized by XRD, SEM, TG, N(2) BET, FT-IR. The data revealed the formation of nanorods with diameter ranging from 100 nm to 500 nm with length in microns. Obtained nanomaterial along with bulk ZnO were tested as reactive sorbent for the detoxification of sulphur mustard. Reaction was monitored by GC-FID technique and the reaction products were characterized by GC-MS. Data explores the role of hydrolysis and elimination reactions in the detoxification of sulphur mustard and it also reveals that zinc oxide nanorods and bulk ZnO show the half lives of 8.48 h, 24.75 h in the first 12h and 122.47 h, 177.29 h from 12h to 48 h of the reaction.

Predictable and avoidable human errors in phlebotomy area ? an exclusive analysis from a tertiary health care system blood bank

Error is a direct reflection of system deficiency. Errors occurring in the phlebotomy area are grossly unreported. Though most of these errors does not lead to catastrophic outcome yet indicate system failure. The aim of the study was to identify errors that took place in phlebotomy area, analysing and classifying them. A prospective audit was conducted during an observational period of 8 months, in an overall cohort of 11 260 donors. The incidence of errors was 3.1%. Fifty-five percent errors were technical and remaining 44.9% were clerical. Of all the technical errors, 57.7% were classified as minor, whereas remaining 42.3% were of major category. Similarly, majority of clerical errors (89.9%) were of minor category. The trained staff accounted for all major events (27.8%). In the minor category, technical errors (73.2%) were more commonly done by trained staff, whereas for clerical errors (58.5%), newly recruited staff was responsible. Errors in phlebotomy area are benign but can compromise donor safety. The study helped to develop a consistent and straightforward classification system for errors and to reduce them by basic interventions. Errors committed mostly by our trained staff indicate the need of regular competency testing and an active system for detection of these deviations.

Microbial decolorization and bioremediation of melanoidin containing molasses spent wash

Molasses spent wash from cane-molasses based distilleries contains a brown coloured recalcitrantpolymer melanoidin, which if disposed untreated poses a great threat to environment. Microbial decolorization and chemical oxygen demand (COD) reduction was found to be dependent on specific carbon and nitrogen source. Under optimal condition of pH, carbon and nitrogen concentration for each treatment, it was found that Bacillus sp isolated from soil was capable of removing COD (85. 35%) and colour (81.10%) from distillery waste to the maximum extent after 9 days atpH 7 in the medium containing 0.5% peptone, 2% glucose and 10% (v/v), followed by Phanerochaete chrysosporium and lowest reduction was obtained by using native microbial consortium.

A prospective comparison of four techniques for diagnosis of paroxysmal nocturnal hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal stem cell disorder with altered expression of glycosylphosphatidylinositol (GPI)-anchored proteins, resulting in the increased susceptibility of erythrocytes to complement-mediated lysis. This study compared the available laboratory methods for detection of PNH cells and evaluated their utility in routine clinical practice. Fifty patients were evaluated by flow cytometric immunophenotyping (FCMI) using CD55 and CD59 monoclonal antibodies, PNH gel card test (GCT), Ham test and sucrose lysis test (SLT). A PNH clone was detectable in erythrocytes in 14 (28%) patients by FCMI, 13 (26%) by GCT and 10 (20%) by Ham test and SLT. The GCT and lytic tests showed 100% specificity and sensitivity was 92.8% and 71.1%, respectively. The GCT results correlated with type III cells (positive for > or =3.21% type III cells) and lytic test results correlated with CD59(-) type III cells (positive for > or =5% CD59(-) type III cells). The GCT and lytic tests were comparable in their sensitivity to detect type II cells (positive for > or =18.5% type II cells). Among the available methods, FCMI is most sensitive, can quantify and delineate PNH cells with differential expression of GPI-anchored proteins. The GCT is a useful screening tool as it is fairly sensitive, easy to perform and interpret. Well-standardized lytic tests are fairly reliable as screening tests.

Foot drop after spinal anesthesia in a patient with a low-lying cord

Damage to the spinal cord/conus medullaris due to incorrect identification of the lumbar space is a known complication of lumbar puncture. However, damage to a low-lying cord using an appropriate interspace is extremely rare. We describe a 26-year-old woman who underwent emergency caesarean section under spinal anesthesia. She developed right foot drop immediately after surgery, which gradually recovered over the next 10 months. Magnetic resonance imaging revealed a low lying cord with a fatty filum terminale and intramedullary T2 hyperintensity, suggestive of needle damage.

Pediatric pituitary adenoma: a series of 42 patients

Pituitary adenomas are uncommon in childhood. This report describes the presentation, endocrinological profile, management and outcome of 42 children with pituitary adenomas. The majority of the tumors were functioning adenomas (40/42, 95.2%). Only two patients (4.8%) had non-functioning tumors. Amongst the functioning tumors, there were 20 patients (47.6%) with prolactinomas, 11 patients (26.2%) with Cushing's disease and nine patients (21.4%) with growth hormone (GH)-secreting adenomas. The most common presenting features were endocrinopathy and visual disturbances. The majority of tumors were macroadenomas, with only eight patients (all with Cushing's disease) having a microadenoma. Transsphenoidal tumor decompression was performed in most cases (71.4%). Complications following transcranial surgery were more frequent when compared to transsphenoidal surgery. There was one death following surgery. Response to radiotherapy was satisfactory. Overall, 67.6% of patients achieved endocrinological remission. Of these, 89% of the children with GH-secreting tumors and 100% of the children with Cushing's disease achieved remission. We conclude that the transsphenoidal approach is effective and safe in surgery for pituitary adenomas in children and is the procedure of choice if there is no contraindication. The combination of surgery and radiotherapy, as well as medical therapy with bromocriptine, achieves good results in the management of these uncommon tumors.

Brain abscess--an unusual complication of ventriculo-peritoneal shunt

The authors report a case of a 10-year-old boy, who was operated for a craniopharyngioma with hydrocephalus. He succumbed to delayed development of brain abscess and its consequence, secondary to incompletely treated shunt tract infection. This unfortunate complication developed, despite the fact that conventional steps (removal of VP shunt and intravenous antibiotics) recommended for the treatment of VP shunt infection were adopted. The pathogenesis, management and review of literature of this extremely rare clinical entity is presented.

Rhizobia as a biological control agent against soil borne plant pathogenic fungi

Rhizobia promote the growth of plants either directly through N2 fixation, supply of nutrients, synthesis of phytohormones and solubilization of minerals, or indirectly as a biocontrol agent by inhibiting the growth of pathogens. The biocontrol effect of rhizobia is due to the secretion of secondary metabolites such as antibiotics and HCN. Siderophore production in iron stress conditions provides rhizobia an added advantage, resulting in exclusion of pathogens due to iron starvation.

Subarachnoid hemorrhage and intracereebral hematoma following lumboperitoneal shunt for pseudotumor cerebri: a rare complication

Placement of lumboperitoneal (LP) shunt as a surgical treatment for benign intracranial hypertension (BIH) is generally a safe procedure, with complications like mechanical failure, overdrainage and infections. Subarachnoid hemorrhage and intracerebral hematoma were seen after lumboperitoneal shunt in a patient having BIH. These complications were the cause of the patient's deterioration. After removal of the hematoma and performing a decompressive procedure, patient's neurological condition improved. The clinical features, investigations and clinical course are described and the literature reviewed.

Spontaneous decompression of a posterior fossa arachnoid cyst: a case report

The authors present a case of spontaneous regression of a posterior fossa, supracerebellar arachnoid cyst causing hydrocephalus in a 7-month-old male child. The patient presented with macrocrania, bulging fontanelle and upgaze paresis of the eyes. There was complete improvement of these symptoms on the morning of the day of surgery without any obvious precipitating factors, including trauma. CT scan showed complete resolution of the cyst and hydrocephalus. The child was doing well at 1 year of follow-up. To the best of our knowledge, this is the first case report of spontaneous resolution of a posterior fossa arachnoid cyst.

Targeting of the c-Abl tyrosine kinase to mitochondria in endoplasmic reticulum stress-induced apoptosis

The ubiquitously expressed c-Abl tyrosine kinase localizes to the nucleus and cytoplasm. Using confocal microscopy, we demonstrated that c-Abl colocalizes with the endoplasmic reticulum (ER)-associated protein grp78. Expression of c-Abl in the ER was confirmed by immunoelectron microscopy. Subcellular fractionation studies further indicate that over 20% of cellular c-Abl is detectable in the ER. The results also demonstrate that induction of ER stress with calcium ionophore A23187, brefeldin A, or tunicamycin is associated with translocation of ER-associated c-Abl to mitochondria. In concert with targeting of c-Abl to mitochondria, cytochrome c is released in the response to ER stress by a c-Abl-dependent mechanism, and ER stress-induced apoptosis is attenuated in c-Abl-deficient cells. These findings indicate that c-Abl is involved in signaling from the ER to mitochondria and thereby the apoptotic response to ER stress.

Interaction of hematopoietic progenitor kinase 1 and c-Abl tyrosine kinase in response to genotoxic stress

The c-Abl protein tyrosine kinase is activated by certain DNA-damaging agents and regulates induction of the stress-activated protein kinase/c-Jun N-terminal kinase (SAPK/JNK). The hematopoietic progenitor kinase 1 (HPK1) has also been shown to act upstream to the SAPK/JNK signaling pathway. We report here that exposure of hematopoietic Jurkat T cells to genotoxic agents is associated with activation of HPK1. The results demonstrate that exposure of Jurkat cells to DNA-damaging agents is associated with translocation of active c-Abl from nuclei to cytoplasm and binding of c-Abl to HPK1. Our findings also demonstrate that c-Abl phosphorylates HPK1 in cytoplasm and stimulates HPK1 activity. The functional significance of the c-Abl-HPK1 interaction is supported by the demonstration that this complex regulates SAPK/JNK activation. Overexpression of c-Abl(K-R) inhibits HPK1-induced activation of SAPK/JNK. Conversely, the dominant negative mutant of HPK1 blocks c-Abl-mediated induction of SAPK/JNK. These findings indicate that activation of HPK1 and formation of HPK1/c-Abl complexes are functionally important in the stress response of hematopoietic cells to genotoxic agents.