Interventions to promote cost-effectiveness in adult intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study

BACKGROUND

There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources.

METHODS

A three-round modified online Delphi process, using a web-based platform, sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilized a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. Thereafter, the steering committee endorsed interventions that were identified as 'critical' by more than 50% of steering committee members. These interventions and experts' comments were summarized as final considerations for best practice.

RESULTS

At the conclusion of round 3, consensus was obtained on 50 best practice considerations for cost-effectiveness in adult ICU. Finally, the steering committee endorsed 9 'critical' best practice considerations. This included adoption of a multidisciplinary ICU model of care, focus on staff training and competency assessment, ongoing quality audits, thus ensuring high quality of critical care services whether within or outside the four walls of ICUs, implementation of a dynamic staff roster, multidisciplinary approach to implementing end-of-life care, early mobilization and promoting international consensus efforts on the Green ICU concept.

CONCLUSIONS

This Delphi study with international experts resulted in 9 consensus statements and best practice considerations promoting cost-effectiveness in adult ICUs. Stakeholders (government bodies, professional societies) must lead the efforts to identify locally applicable specifics while working within these best practice considerations with the available resources.

Reply to Letter to the Editor: A Fatal Case of Acute Disseminated Encephalomyelitis—A Diagnosis to Ponder in Pandemic

How to cite this article: Kumar A, Sabharwal P, Gupta P, Singh VK, Rao BK. Reply to Letter to the Editor: A Fatal Case of Acute Disseminated Encephalomyelitis—A Diagnosis to Ponder in Pandemic. Indian J Crit Care Med 2022;26(9):1062.

Agroforestry for controlling soil erosion and enhancing system productivity in ravine lands of Western India under climate change scenario

Soil erosion in semi-arid climate leading to the development of ravine lands is the most severe form of land degradation. Ravine lands are formed when soil is not fully covered by the vegetation throughout the year and sporadic vegetation is not able to bind the soil particles from being washed away by rainfall. Throughout the globe, ravine lands have severe limitations for their rehabilitation and sustainable utilization as a consequence of its unique topographical features. Climatic and edaphic stresses make crop production extremely challenging in these lands. Practicing sole cropping promotes erosion, produces low crop yield, utilizes high energy, and emits greenhouse gasses (GHGs). Tree cultivation either sole or in combination with crops (agroforestry) has a strong potential to control erosion, produce sustainable economic yield, reduce energy consumption, and sequester greater amount of atmospheric carbon dioxide in biomass and soil carbon pools besides providing various ecosystem services. Therefore, practicing agroforestry could be a promising approach to obtain the greater environmental and economic benefits in the ravine lands. The present study was conducted on three systems, i.e., sole crop cultivation (cowpea + castor), agroforestry (sapota + cowpea + castor), and sole sapota plantation, to evaluate their impact on soil erosion, runoff, system productivity, profitability, energetics, and carbon sequestration during the 4-year period (2017-2020). The results revealed that agroforestry reduced the total soil loss and runoff by 37.7% and 19.1%, respectively, compared to the sole crop cultivation. Likewise, the highest system productivity as cowpea equivalent yield (CEY) was obtained under agroforestry system that increased the CEY by 162% and 81.9%, compared to sole crop and sole tree plantation, respectively. The climate change mitigation potential in terms of net carbon balance was observed highest in sole tree plantation (8.4 t/ha) followed by agroforestry system (5.9 t/ha) and lowest in sole cropping system (-2.8 t/ha). Therefore, an agroforestry system could be recommended for controlling soil erosion, improving system productivity and profitability, and reducing energy consumption as well as mitigating climate change in ravine lands.

Critical Care for COVID-19 Affected Patients: Position Statement of the Indian Society of Critical Care Medicine

The global pandemic involving severe acute respiratory syndrome-coronavirus-2 (SARS-COV-2) has stretched the limits of science. Ever since it emerged from the Wuhan province in China, it has spread across the world and has been fatal to about 4% of the victims. This position statement of the Indian Society of Critical Care Medicine represents the collective opinion of the experts chosen by the society.

HOW TO CITE THIS ARTICLE

Mehta Y, Chaudhry D, Abraham OC, Chacko J, Divatia J, Jagiasi B, et al. Critical Care for COVID-19 Affected Patients: Position Statement of the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2020;24(4):222-241.

Critical Care for COVID-19 Affected Patients: Updated Position Statement of the Indian Society of Critical Care Medicine

The management of coronavirus disease-2019 (COVID-19) is witnessing a change as we learn more about the pathophysiology and the severity of the disease. Several randomized controlled trials (RCTs) and meta-analysis have been published over the last few months. Several interventions and therapies which showed promise in the initial days of the pandemic have subsequently failed to show benefit in well-designed trials. Understanding of the methods of oxygen delivery and ventilation have also evolved over the past few months. The Indian Society of Critical Care Medicine (ISCCM) has reviewed the evidence that has emerged since the publication of its position statement in May and has put together an addendum of updated evidence.

How to cite this article: Mehta Y, Chaudhry D, Abraham OC, Chacko J, Divatia J, Jagiasi B, et al. Critical Care for COVID-19 Affected Patients: Position Statement of the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2020;24(Suppl 5):S225–S230.

Indian Society of Critical Care Medicine Experts Committee Consensus Statement on ICU Planning and Designing, 2020

BACKGROUND

Indian Society of Critical Care Medicine (ISCCM) guidelines on Planning and Designing Intensive care (ICU) were first developed in 2001 and later updated in 2007. These guidelines were adopted in India, many developing Nations and major Institutions including NABH. Various international professional bodies in critical care have their own position papers and guidelines on planning and designing of ICUs; being the professional body of intensivists in India ISCCM therefore addresses the subject in contemporary context relevant to our clinical practice, its variability according to specialty and subspecialty, quality, resource limitation, size and location of the institution. Aim: To have a consensus document reflecting the philosophy of ISCCM to deliver safe & quality Critical Care in India, taking into consideration the requirement of regulatory agencies (national & international) and need of people at large, including promotion of training, education and skill upgradation. It also aiming to promote leadership and development and managerial skill among the critical care team. Material and Methods: Extensive review of literature including search of databases in English language, resources of regulatory bodies, guidelines and recommendations of international critical care societies. National Survey of ISCCM members and experts to understand their viewpoints on respective issues. Visiting of different types and levels of ICUs by team members to understand prevailing practices, aspiration and Challenges. Several face to face meetings of the expert committee members in big and small groups with extensive discussions, presentations, brain storming and development of initial consensus draft. Discussion on draft through video conferencing, phone calls, Emails circulations, one to one discussion Result: Based upon extensive review, survey and input of experts' ICUs were categorized in to three levels suitable in Indian setting. Level III ICUs further divided into sub category A and B. Recommendations were grouped in to structure, equipment and services of ICU with consideration of variation in level of ICU of different category of hospitals. Conclusion: This paper summarizes consensus statement of various aspect of ICU planning and design. Defined mandatory and desirable standards of all level of ICUs and made recommendations regarding structure and layout of ICUs. Definition of intensive care and intensivist, planning for strength of ICU and requirement of manpower were also described.

HOW TO CITE THIS ARTICLE

Rungta N, Zirpe KG, Dixit SB, Mehta Y, Chaudhry D, Govil D, et al. Indian Society of Critical Care Medicine Experts Committee Consensus Statement on ICU Planning and Designing, 2020. Indian J Crit Care Med 2020;24(Suppl 1):S43-S60.

Antimicrobial prescribing patterns of surgical speciality in a tertiary care hospital in India: Role of persuasive intervention for changing antibiotic prescription behaviour

BACKGROUND

Inappropriate use of antibiotics globally has been linked to increase in antibiotic resistance.

OBJECTIVES

This interventional study assessed the impact of antibiotic prescription feedback and focus group discussions (FGD) on hospital-based prescribers before and after the FGD.

STUDY DESIGN

The present study was performed at a tertiary care centre in New Delhi, wherein 45 units from surgical specialities were included for FGD. Thirty-five units were assessed for the antibiotic usage during 12 months pre-intervention and 3 and 6 months post-intervention period. The outcome measured was a change in antibiotic prescription rates reflected as daily defined doses per 100 bed days as defined by the World Health Organisation.

RESULTS

Reduction in the level of antibiotic consumption was observed in 15 of 35 units (42.85%) during the 3 months post-intervention period, which was significant (P < 0.05) in 3/35 (8.57%) surgical units. A significant reduction (P < 0.05) was observed for the units of endoscopic gynaecology, super-speciality and transplant surgery units B and C, and orthopaedic unit C during the 6 months period. Decreasing trend (P < 0.05) was observed in 2/35 (5.71%) units during the entire period. Overall reduction of antibiotic consumption (1.88%) was observed, with an increase in the use of low-end antibiotics and a decrease in the use of high-end antibiotics.

CONCLUSION

The present study clearly demonstrates a weak impact of FGD in changing antibiotic prescribing behaviour. Further analysis of the sustainability of FGD and its long-term impact on antimicrobial resistance needs to be evaluated. The effect of continuous educational sessions and multifaceted interventions cannot be ignored.

Diurnal variation in hand hygiene compliance in a tertiary level multidisciplinary intensive care unit

BACKGROUND

Hand hygiene compliance among health care providers is considered to be the single most effective factor to reduce hospital acquired infections. Despite continuous education and awareness, compliance with hand hygiene guidelines has remained low, particularly during evening shifts.

OBJECTIVE

Our objective was to determine the compliance with hand hygiene guidelines among doctors, nurses, and paramedical staff during day and night duties in a multidisciplinary intensive care unit (ICU).

METHODS

We used a prospective, observational, 6-month study conducted in a 34-bed ICU within a tertiary care teaching hospital. All doctors, nurses, and paramedical staff in the ICU were included. An investigator, placed within the ICU setting, observed the hand hygiene practices during day and night. Day and night shift change times were 08:00 and 20:00 hours, respectively.

RESULTS

Of the 5639 opportunities for hand hygiene, 3383 (59.9%) were properly performed. Overall rates of compliance were 66.1% for doctors, 60.7% for nurses, and 38.6% for paramedical staff. Hand hygiene compliance dropped during the night for doctors (81% vs 46%, respectively, P < .001), for nurses (64% vs 55%, respectively, P = .02), and for paramedical staff (44% vs 31%, respectively, P = .01). Characterization of noncompliance is as follows: "No handwashing after procedure" in 41%, "improper duration of handwashing" in 32%, and "no handwashing done at all" in 27% of the events. "No handwashing done at all" occurred in 55% of the time at night with doctors having the highest rate of noncompliance, making 163 (34%) contacts without handwashing.

CONCLUSION

Whereas compliance with hand hygiene guidelines was lower at night compared with day, irrespective of discipline in all 3 groups of health care providers, both periods of compliance would benefit from additional training focusing on the importance of hand hygiene around the clock.

Geometry and electronic structure of Vn(Bz)m complexes

First-principles calculations based on the generalized gradient approximation to the density functional theory are performed to explore the global geometries, ground-state spin multiplicities, relative stabilities, and energetics of neutral and anionic V(n)(Bz)(m) (n=1-3, m=1-4, with n<m) complexes. The calculated results show that the V(n)(benzene)(m) complexes clearly prefer sandwich structures to rice-ball structures. The ground-state spin multiplicities of the V(n)(benzene)(n+1) complexes increased linearly with the size of the system (i.e., n). In the anionic complexes, the V(benzene)(2) complex is found to be unstable against the autodetachment of the extra electron. The energy difference between adiabatic and vertical electron affinities is found to be very less, indicating negligible ionization-induced structural changes in the ground-state geometries of V(n)(benzene)(n+1) complexes.

Outcome predictors for non-invasive positive pressure ventilation in acute respiratory failure

BACKGROUND

Noninvasive positive pressure ventilation (NIPPV) has emerged as a significant advancement in the management of acute respiratory failure.

OBJECTIVE

To identify factors, based on clinical and laboratory parameters, for predicting the outcome of NIPPV in patients with acute respiratory failure.

MATERIALS AND METHODS

Fifty patients were included in the study. Inclusion criteria were RR>30 breaths/ min, PaO2<60mmHg, PaO2/FiO2<300, pCO2< or = 45mmHg and signs of increased work of breathing. Baseline clinical parameters and arterial blood gas (ABG) were recorded before initiating NIPPV. Clinical parameters including heart rate, respiratory rate, oxygen saturation and ABG was revaluated at 1, 4, 12, 24 hrs after initiation of NIPPV. Change in these parameters and need for intubation was evaluated.

RESULTS

Of the 50 patients, 37 (74%) showed clinical and ABG improvement. Out of 13 (26%) patients who failed to respond, 7 (52%) needed endotracheal intubation within 1 hr. There was significant improvement in clinical and ABG parameters within 1st hr in success group and these parameters continues to improve even after 4 hrs of NIPPV treatment (p<0.05). Failure group had higher baseline heart rate than success group (p<0.05).

CONCLUSION

Determination of baseline clinical factors such as heart rate and respiratory rate, available at the time of initiation and after a short period, can predict the likelihood of success or failure of NIPPV. As a result, delay in intubation can be avoided which itself is associated with significant mortality.

Interaction of Pd and PdCl2 with cellulose: a theoretical investigation

The pyrolytic fragmentation of cellulose in the presence of atomic palladium (Pd) and palladium(II) chloride (PdCl2) has been studied with use of hybrid density functional theory and cellobiose as a model for cellulose. The configuration changes in the host, rearrangement of geometries of the products, and the respective reaction energetics for different fragmentation pathways are analyzed. While Pd is found to undergo insertion at the beta-1,4-linkage oxygen (O1)-carbon (C-1) of the rings, Pd(II) chloride is observed to promote the cleavage of the chain as well as rearrangement of the rings. A detailed mechanism for the formation of levoglucosan from one of the fragments following the interaction with PdCl2 is also highlighted.

DFT Study of Structure and Binding Energies of Fe−Corannulene Complex

Density functional theory (DFT) based theoretical calculations are performed to identify the ground-state geometries, the spin multiplicities, and the relevant energetics of neutral and positively charged Fe-corannulene complexes. Our calculations show that the on-top site of the six-membered ring (eta(6)) of corannulene molecule is the most preferred binding site for both Fe atom and Fe(+) ion. The electrostatic potential (ESP) surface picture is employed to explain the preference of the eta(6)- over the eta(5)-binding site (on-top site of central pentagon) of corannulene. Though in both neutral and cationic species the eta(6)-site is the most preferred binding site, the ground-state geometries of these complexes are different. The Fe(+) cation prefers to bind to the convex face of the corannulene, whereas the neutral Fe atom prefers slightly the concave to the convex face. The ionization-induced structural changes are reflected in the large energy difference between the vertical and adiabatic ionization potential values. We also show that the dissociation of Fe(+)-corannulene complex to corannulene + Fe(+) is just as likely as that to Fe + (corannulene)(+).

Evolution of the electronic structure of Be clusters

Using a modified symbiotic genetic algorithm approach and many-body interatomic potential derived from first principles, we have calculated equilibrium geometries and binding energies of the ground-state and low-lying isomers of Be clusters containing up to 41 atoms. Molecular-dynamics study was also carried out to study the frequency of occurrence of the various geometrical isomers as these clusters are annealed during the simulation process. For a selected group of these clusters, higher-energy isomers were more often found than their ground-state structures due to large catchment areas. The accuracy of the above ground-state geometries and their corresponding binding energies were verified by carrying out separate ab initio calculations based on molecular-orbital approach and density-functional theory with generalized gradient approximation for exchange and correlation. The atomic orbitals were represented by a Gaussian 6-311G** basis, and the geometry optimization was carried out using the GAUSSIAN 98 code without any symmetry constraint. While the ground-state geometries and their corresponding binding energies obtained from ab initio calculations do not differ much from those obtained using the molecular-dynamics approach, the relative stability of the clusters and the energy gap between the highest occupied and the lowest unoccupied molecular orbitals show significant differences. The energy gaps, calculated using the density-functional theory, show distinct shell closure effects, namely, sharp drops in their values for Be clusters containing 2, 8, 20, 34, and 40 electrons. While these features may suggest that small Be clusters behave free-electron-like and, hence, are metallic, the evolution of the structure, binding energies, coordination numbers, and nearest-neighbor distances do not show any sign of convergence towards the bulk value. We also conclude that molecular-dynamics simulation based on many-body interatomic potentials may not always give the correct picture of the evolution of the structure and energetics of clusters although they may serve as a useful tool for obtaining starting geometries by efficiently searching a large part of the phase space.

Appearance of bulk properties in small tungsten oxide clusters

Contrary to the conventional understanding that atomic clusters usually differ in properties and structure from the bulk constituents of which they are comprised, we show that even a dimer of tungsten oxide (WO(3))(2) possesses bulklike features and the geometry of a small cluster containing only 4 tungsten and 12 oxygen atoms bears the hallmarks of crystalline tungsten oxide, WO(3). This observation, based on a synergistic approach involving mass distributions under quasisteady state conditions, photoelectron spectroscopy, and first principles molecular orbital theory, not only illustrates the existence of a class of strongly covalent or ionic materials whose embryonic forms are tiny clusters but also lends the possibility that a fundamental understanding of complex processes such as catalytic reactions on surfaces may be achieved on an atomic scale with clusters as model systems.

Electronic structure and bonding of Au on a SiO2 cluster: a nanobullet for tumors

The binding of gold atoms to a small silica cluster has been studied by using density functional theory with generalized gradient approximation for exchange and correlation. It is shown that gold atoms bind to silicon atoms with dangling bonds and serve as seeds for the growth of Au islands. The large electron affinity of gold causes a significant change in the electronic structure of silica resulting in a substantial reduction in the highest occupied and the lowest unoccupied molecular orbital and the optical gap, thus allowing it to absorb near infrared radiation. This suggests that a small cluster can have a similar functionality in the treatment of cancer as the large size nanoshell, but for a different mechanism.

Stabilization of Si60 cage structure

A comprehensive search for the stable geometries of bare Si60 and Si60 supported on a C60 fullerene was carried out using first principles calculations based on density functional theory. In contrast to previous theoretical studies and in agreement with recent experiments, we show that Si60 and C(60)@Si(60) clusters are unstable in the fullerenelike cage structure. However, Si60 cage can be stabilized by including within it, as endohedral units, small magic clusters such as Al12X (X=Si, Ge, Sn, Pb) and Ba@Si(20).

Antidiabetic activity of Terminalia pallida fruit in alloxan induced diabetic rats

Different doses of ethanolic fraction of fruits of Terminalia pallida were evaluated for hypoglycemic and antihyperglycemic activity in normal and alloxan diabetic rats. The oral administration of ethanolic extract at a dosage of 0.5 g/kg body weight exhibited a significant antihyperglycemic activity in alloxan diabetic rats, whereas in normal rats no hypoglycemic activity was observed.

Percutaneous tracheostomy

The purpose of this review is to discuss the various techniques of percutaneous tracheostomy and to assess their safety and efficacy profile, indications and contraindications, early and late complications. Literature was reviewed from Medline and MD Consult databases. Early techniques by Sheldon, toye and Schachner have been abandoned due to their high complication rates. Percutaneous dilational tracheostomy using the Ciaglia kit (Wiliam Cook Europe Bjaeverskov) and a Griggs kit (Portex PDT kit, POrtex, Hythe, Kent, UK) has been used most often. Griggs guide Wire Dilator Forceps kit (SIMS, Portex, Hythe, Kent, UK) is the next most common in use but its long-term studies are few. Fantoni (TLT set, Mallinckrodt Medical) and PercuTwist device (Riisch, Kernen, Germany) are two new techniques currently under study. Percutaneous dilational tracheostomy and conventional surgical tracheostomy are still competing methods to provide an airway for intensive care patient requiring assisted ventilation. Review of literature shows that percutaneous tracheostomy is safe, cost-effective and compares favourably with the open surgical tracheostomy. Many intensive care units now use the percutaneous tracheostomy as a procedure of choice. Percutaneous tracheostomy has a learning curve and requires appropriate case selection and meticulous attention to the technique by all those who want to use this method.

Giant magnetic moments of nitrogen-doped Mn clusters and their relevance to ferromagnetism in Mn-doped GaN

Calculations based on density-functional theory show that the stability and magnetic properties of small Mn clusters can be fundamentally altered by the presence of nitrogen. Not only are their binding energies substantially enhanced, but also the coupling between the magnetic moments at Mn sites remains ferromagnetic irrespective of their size or shape. In addition, these nitrogen-doped Mn clusters carry giant magnetic moments ranging from 4mu(B) in MnN to 22mu(B) in Mn5N. It is suggested that the giant magnetic moments of MnxN clusters may play a key role in the ferromagnetism of Mn-doped GaN which exhibit a wide range (10-940 K) of Curie temperatures.

Magic numbers in metallo-inorganic clusters: chromium encapsulated in silicon cages

A systematic theoretical study of the equilibrium geometries and total energies of Cr encapsulated in Si clusters reveals that Cr@Si(12) is more stable than its neighbors. The origin of this enhanced stability is consistent with the 18-electron sum rule commonly used in the synthesis of stable chemical complexes, and may provide a criterion for a systematic search of magic numbers in metalloinorganic clusters. The 6 mu(B) magnetic moment of the caged Cr atom, the largest among the 3d transition metal atoms, is completely quenched. This effect of caging on the properties of transition metal atoms may lead to the synthesis of novel cluster based materials.

Antihyperglycemic activity of Momordica cymbalaria in alloxan diabetic rats

Aqueous, ethanolic and hexane fractions of Momordica cymbalaria fruits were prepared and given individually at different doses to different batches of rats (both normal and alloxan diabetic rats) after an overnight fast. The blood glucose levels were measured at 0, 1, 3, 5 and 7 h after the treatment. The aqueous extract of Momordica cymbalaria at a dosage of 0.5 g/kg b.w. is showing maximal blood glucose lowering effect in diabetic rats. The same dosage did not produce any hypoglycemic activity in normal rats. The antihyperglycemic activity of Momordica cymbalaria fruit was compared with the treatment of Glibenclamide, an oral hypoglycemic agent.

Lipid peroxidation and antioxidant enzyme status in Type 2 diabetics with coronary heart disease

Lipid peroxides are thought to be formed by free radicals and may play an important role in the development of atheromatous vascular diseases. The relationship between serum lipids, lipoproteins, lipid peroxides [thiobarbituric acid reactive substances (TBARS)] and erythrocyte antioxidant enzymes [catalase (CAT), glutathione peroxidase (GPx) and superoxide dismutase (SOD)] was investigated in non-insulin-dependent diabetic patients with and without coronary heart disease (CHD), and a comparison was made for all the above parameters with non-diabetic patients with CHD. Lipid peroxide concentrations were significantly increased in both groups of diabetic patients and also in non-diabetic patients with CHD, compared to those in control subjects. Diabetic patients with CHD had higher levels of TBARS compared to those diabetics without CHD. Hyperlipidaemia and abnormal lipoprotein levels were observed in all three groups of patients. Increased total cholesterol and LDL-cholesterol were observed in diabetics with CHD compared to those without CHD. Among the erythrocyte antioxidant enzymes, CAT activity was increased, GPx activity was decreased and no change was observed in SOD activity in both groups of diabetic patients and non-diabetic patients with CHD compared to those in controls. A clear correlation was observed between the CAT activity and lipid peroxide concentrations in all the diabetic patients. These observations suggest that there are similar abnormalities in lipid metabolism and erythrocyte antioxidant enzymes in diabetic patients and non-diabetic patients with CHD.

Pyoderma vegetans

BACKGROUND

Pyoderma vegetans is a rare condition that is clinically characterized by large verrucous plaques with elevated borders and multiple pustules. The etiology of this disorder remains unknown.

OBJECTIVES

We describe a 24-year-old woman with rapidly evolving pyoderma vegetans. Our patient had the unique additional findings of a highly elevated serum IgE level and a history of hidradenitis suppurativa.

CONCLUSIONS

Pyoderma vegetans is diagnosed on clinical and histological criteria. Differentiation must be made from disorders such as pyoderma gangrenosum, Sweet's syndrome, and deep fungal infections. We illustrate a case of pyoderma vegetans and review the literature on this rare disorder. Clinical and histological criteria for diagnosis are presented, as well as differentiation from some mimicking disorders.

Electronic structure and properties of transition metal-benzene complexes

A comprehensive theoretical study of the geometries, energetics, and electronic structure of neutral and charged 3d transition metal atoms (M) interacting with benzene molecules (Bz) is carried out using density functional theory and generalized gradient approximation for the exchange-correlation potential. The variation of the metal-benzene distances, dissociation energies, ionization potentials, electron affinities, and spin multiplicities across the 3d series in MBz complexes differs qualitatively from those in M(Bz)(2). For example, the stability of Cr(Bz)(2) is enhanced over that of CrBz by almost a factor of 30. On the other hand, the magnetic moment of Cr(Bz)(2) is completely quenched although CrBz has the highest magnetic moment, namely 6 mu(B), in the 3d metal-benzene series. In multidecker complexes involving V(2)(Bz)(3) and Fe(2)(Bz)(3), the metal atoms are found to couple antiferromagnetically. In addition, their dissociation energies and ionization potentials are reduced from those in corresponding M(Bz)(2) complexes. All of these results agree well with available experimental data and demonstrate the important role the organic support can play on the properties of metal atoms/clusters.

Typical dermoscopic patterns of benign melanocytic nevi

Dermoscopy often is an effective diagnostic tool for differentiating benign and malignant pigmented skin lesions. The observed dermoscopic structures and patterns of lesions provide valuable sources of information that are not accessible by routine clinical examination. Recognition and interpretation of these dermoscopic structures and patterns require training and experience. Mentioned here are some fundamental guidelines for differentiating malignant and benign lesions. Some of the classic patterns associated with a list of benign melanocytic nevi also have been illustrated. Additional research is needed to identify other patterns of these benign lesions. More importantly, analysis of the prevalence of various patterns associated with the various benign lesions will be helpful to clinicians having the responsibility of making in vivo diagnoses of benign compared with malignant melanocytic neoplasms.

Hypoglycemic and antihyperglycemic activity of Syzygium alternifolium (Wt.) Walp. seed extracts in normal and diabetic rats

Aqueous, ethanolic and hexane fractions of Syzygium alternifolium seeds were prepared and given different doses of these extracts individually to different batches of rats (both normal and alloxan diabetic rats) after an overnight fast. The blood glucose levels were measured at 0, 1, 3, 5 and 7 hours after the treatment. The aqueous extract of Syzygium alternifolium at a dosage of 0.75 g/kg b.w. is showing maximum blood glucose lowering effect in both normal and alloxan diabetic rats. The ethanol and hexane fractions are also showing hypoglycemic and antihyperglycemic activity, but the effect is significantly less than that of aqueous extract. The antihyperglycemic activity of Syzygium alternifolium seed was compared with the treatment of Glibenclamide.

AlH(3) and Al(2)H(6): magic clusters with unmagical properties

Enhanced stability, low electron affinity, and high ionization potential are the hallmarks of a "magic" cluster. With an electron affinity of 0.28 eV, ionization potential of 11.43 eV, and a large binding energy, AlH(3) satisfies these criteria. However, unlike other magic clusters that interact only weakly with each other, two AlH(3) clusters bind to each other with an energy of 1.54 eV. The resulting Al(2)H(6), while also a magic cluster in its own right, possesses the most unusual property that the difference between its adiabatic and vertical detachment energy is about 2 eV--the largest of any known cluster. These results, based on density functional theory, are verified experimentally through photodetachment spectroscopy.

Effect of oral administration of bark extracts of Pterocarpus santalinus L. on blood glucose level in experimental animals

The effect of administration of different doses of Pterocarpus santalinus L. bark extracts in normal and diabetic rats, on blood glucose levels was evaluated in this study. Among the three fractions (aqueous, ethanol and hexane), ethanolic fraction at the dose of 0.25 g/kg body weight showed maximum antihyperglycemic activity. The same dose did not cause any hypoglycemic activity in normal rats. The results were compared with the diabetic rats treated with glibenclamide and the antihyperglycemic activity of ethanolic extract of PS bark at the dose of 0.25 g/kg b.w. was found to be more effective than that of glibenclamide.

A case of cutaneous Mycobacterium chelonae abscessus infection in a renal transplant patient

BACKGROUND

Mycobacterium chelonae is an atypical "fast-growing Mycobacteria" that is a rare cause of human infection. There have been several reports of cutaneous infection among immunosuppressed patients, as well as in immunocompetent individuals following trauma. Most cases to date seem to have occurred among renal transplant recipients, raising the possibility that there is something inherent to the renal transplant patient that increases their susceptibility more than other immunocompromised patients.

OBJECTIVE

The differential diagnosis of subcutaneous nodules distributed in a sporotrichoid pattern is extensive, particularly in an immunocompromised host. Although several cases of cutaneous M. chelonae abscessus infection have been reported among both immunosuppressed and immunocompetent patients, the clinical presentation has varied, and few cases have reported the appearance of lesions in a sporotrichoid pattern. We present a case of a renal transplant patient with a reported history of trauma to the lower extremities, who presents with subcutaneous nodules distributed in a sporotrichoid pattern. The patient is found to have M. chelonae abscessus infection, fails several treatment regimens, and presents with a recurrence. The literature of M. chelonae infection is reviewed, and the various treatment options are discussed.

METHODS

An initial skin biopsy was stained with Hematoxylin and Eosin and revealed deep dermal abscesses with acid-fast bacilli in clusters. The culture became positive for Mycobacterium chelonae abscesses in four days and was found to be sensitive to multiple antibiotics. The patient underwent surgical excision of 14 nodules, which revealed findings consistent with the skin biopsy, and was subsequently treated with the appropriate antibiotics.

RESULTS

Despite treatment with a full course of an organism-sensitive antibiotic regimen, the patient returned with persistent and recurrent nodules six weeks later. The patient was then treated as an inpatient with a seven-week course of intravenous antibiotics and was discharged home on a combined intravenous and oral regimen.

CONCLUSION

Although M. chelonae abscessus is an extremely rare cause of infection among humans, there seems to be a predominance of cases reported among renal transplant patients. The explanation for this is not entirely clear; however, the organism must be considered as a cause of infection in any renal transplant recipient who presents with subcutaneous nodules. Eradication of the organism presents a tremendous challenge to the clinician, and, as presented here, even with appropriate antibiotics, there is a high rate of recurrence.

Lipid peroxidation and antioxidant enzyme levels in type 2 diabetics with microvascular complications

Serum levels of total cholesterol, triglycerides, lipoproteins, lipid peroxides (TBARS) and erythrocyte antioxidant enzyme activities were measured in 105 non insulin dependent diabetic patients, among whom 38 had microvascular complications (MVC) of diabetes. All the diabetic patients had higher concentrations of glycated hemoglobin (HbA1) compared to controls (10.51 +/- 2.42% vs 6.31 +/- 0.85% P <0.001). Significant increase of serum triglycerides (TG), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C) and very low density lipoprotein cholesterol (VLDL-C) and a significant decrease of high density lipoprotein cholesterol (HDL-C) were observed in the diabetic patients compared to controls (TG: 2.31 +/- 0.9 mmol/l vs 1.53 +/- 0.48 mmol/l P <0. 001; TC: 5.94 +/- 1.4 mmol/l vs 4.3 +/- 0.85 mmol/l P <0.001; LDL-C: 3.96 +/- 1.33 mmol/l vs 2.39 +/- 0.8 mmol/l P <0.001; VLDL-C: 0.46 +/- 0.2 mmol/l vs 0.3 +/- 0.09 mmol/l P <0.001; HDL-C: 0.81 +/- 0.24 mmol/l vs 1.04 +/- 0.18 mmol/l P <0.001). Significantly increased levels of serum TBARS were observed in diabetic patients compared to those in controls (TBARS: 6.7 +/- 1.5 mmol/l vs 5.14 +/- 0.61 mmol/l P <0.001). Erythrocyte catalase (CAT) activity was increased and Glutathione peroxidase (GPx) activity was decreased in diabetic patients compared to controls, but no significant change in Superoxide dismutase (SOD) activity was observed in diabetic patients (CAT: 104.94 +/- 37.1 KU/g Hb vs 85.8 +/- 23.6 KU/g Hb, P <0.01; GPx: 30 +/- 9.7 U/g Hb/min vs 40.84 +/- 12.3 U/g Hb/min, P <0. 001; SOD: 2.4 +/- 1.2 U/mg Hb/min vs 2.55 +/- 0.84 U/mg Hb/min, P=NS). In comparison with the diabetic group without MVC, the diabetic group with MVC had decreased GPx and SOD activities, while no difference was observed between these two groups regarding CAT activity (GPx: 25.32 +/- 8.4 U/g Hb/min vs 34.5 +/- 8.8 U/g Hb/min, P <0.001; SOD: 1.83 +/- 0.53 U/mg Hb/min vs 2.84 +/- 1.4 U/mg Hb/min, P<0.001; CAT: 106.3 +/- 39.9 KU/g Hb vs 103 +/- 34.9 KU/g Hb, P =NS). TBARS concentrations were significantly increased in the group with MVC compared to the group without these complications, indicating a positive relationship between TBARS and MVC of diabetes (7.05 +/- 1.23 mmol/l vs 6.3 +/- 1.02 mmol/l, P <0.001). Serum triglycerides, LDL and VLDL cholesterol concentration were significantly higher in diabetics with MVC than in diabetics without the complications (TG: 2.7 +/- 0.98 mmol/l vs 2.13 +/- 0.82 mmol/l, P<0.01; LDL - C: 4.45 +/- 1.3 mmol/l vs 3.67 +/- 1.3 mmol/l, P <0. 02; VLDL-C: 0.53 +/- 0.19 mmol/l vs 0.43 +/- 0.16 mmol/l, P <0.01), and the serum levels of TC in the group with MVC showed a positive correlation with their lipid peroxide levels (r =0.368, P <0.001). The increase in TBARS and the decreased GPx and SOD activities in diabetics with MVC in this study indicate that these factors may contribute to the occurrence of micro vascular complications in NIDDM patients.

Inhibitory copper binding site on the spinach cytochrome b6f complex: implications for Qo site catalysis

The isolated cytochrome (cyt) b(6)f complex from spinach is inhibited by Cu(2+) with a K(D) of about 1 microM at pH 7.6 in the presence of 1.6 microM decyl-plastoquinol (C(10)-PQH(2)) as a substrate. Inhibition was competitive with respect to C(10)-PQH(2) but noncompetitive with respect to horse heart cyt c or plastocyanin (PC). Inhibition was also pH-sensitive, with an apparent pK at about 7, above which inhibition was stronger, suggesting that binding occurred at or near a protonatable amino acid residue. Equilibrium binding titrations revealed ca. 1.4 tight Cu(2+) binding sites with a K(D) of about 0.5 microM and multiple (>8) weak (K(D) > 50 microM) binding sites per complex. Pulsed electron paramagnetic resonance (EPR) techniques were used to identify probable binding sites for inhibitory Cu(2+). A distinct enhancement of the relaxation time constant for the EPR signal from bound Cu(2+) was observed when the cyt f was paramagnetic. The magnitude and temperature-dependence of this relaxation enhancement were consistent with a dipole interaction between Cu(2+) and the cyt f (Fe(3+)) heme at a distance of between 30 and 54 A, depending upon the relative orientations of Cu(2+) and cyt f heme g-tensors. Two-pulse electron spin-echo envelope modulation (ESEEM) and 4-pulse 2-dimensional hyperfine sublevel correlation (2D HYSCORE) measurements of Cu(2+) bound to isolated cyt b(6)f complex indicated the presence of a weakly coupled nitrogen nucleus. The nuclear quadrupole interaction (NQI) and the hyperfine interaction (HFI) parameters identified one Cu(2+) ligand as an imidazole nitrogen of a His residue, and electron-nuclear double resonance (ENDOR) confirmed the presence of a directly coordinated nitrogen. A model of the 3-dimensional structure of the cytochrome b(6)f complex was constructed on the basis of sequences and structural similarities with the mitochondrial cyt bc(1) complex, for which X-ray structures have been solved. This model indicated three possible His residues as ligands to inhibitory Cu(2+). Two of these are located on the "Rieske" iron-sulfur protein protein (ISP) while the third is found on the cyt f protein. None of these potential ligands appear to interact directly with the quinol oxidase (Q(o)) binding pocket. A model is thus proposed wherein Cu(2+) interferes with the interaction of the ISP protein with the Q(o) site, preventing the binding and subsequent oxidation of plastoquinonol. Implications for the involvement of ISP "domain movement" in Q(o) site catalysis are discussed.

Wrinkling due to mid-dermal elastolysis: two cases and literature review

BACKGROUND

Mid-dermal elastolysis is an acquired disorder of elastic tissue clinically characterized by diffuse fine wrinkling, most often of the trunk and arms. Histologically, a clear band of elastolysis is present in the mid-dermis.

OBJECTIVE

Although examples of diffuse elastolysis are well known, only a small number of patients with mid-dermal elastolysis have been reported to date. We present two patients with clinical and histological evidence of mid-dermal elastolysis, review the literature, and summarize the salient features of some common disorders of elastic tissue.

METHODS

The first patient presented with fine wrinkles and papules over the upper arms, upper chest, and axillae, and demonstrated increased laxity of the eyelids. The second patient had striking wrinkles extending in a band-like pattern on her arms, upper chest, back, and abdomen. Neither one of our patients had a previous history of skin inflammation, urticaria, or any other underlying diseases related to their skin changes. Skin biopsies were taken from lesional and perilesional skin of both patients, and were stained with hematoxylin and eosin, and with elastic tissue stain. In addition, a tissue sample from Patient 1 was fixed for electron-microscopy.

RESULTS

Hematoxylin and eosin stains did not demonstrate specific changes or diagnostic patterns. However, elastic tissue stains revealed a band-like loss of elastic tissue in the mid-dermis. Elastic tissue in the remaining superficial and deep dermis stained normally. Electron-microscopy was consistent with these findings and revealed significant loss of elastic tissue limited to the mid-dermis.

CONCLUSION

We have presented two cases of mid-dermal elastolysis and reviewed the literature. To date, the pathophysiology of mid-dermal elastolysis had not been elucidated and no definitive therapy exists.

Antidiabetic and hypolipidemic effects of Momordica cymbalaria Hook. fruit powder in alloxan-diabetic rats

This study was undertaken to investigate the effect of Momordica cymbalaria fruit powder on blood glucose and other biochemical parameters in alloxan-induced diabetic rats. The treatment was given for 15 days. After the treatment, a significant reduction was observed in fasting blood glucose levels in the treated diabetic rats, but no hypoglycaemic activity in the treated normal rats. M. cymbalaria treatment showed considerable lowering of serum cholesterol and triglycerides in the treated diabetic group. There was a significant improvement in hepatic glycogen level in treated diabetic rats close to normal level after the treatment with M. cymbalaria. These results suggest that the M. cymbalaria fruit powder possesses antidiabetic and hypolipidemic effects in alloxan-induced diabetic rats.

Hyperlipidemia, increased lipid peroxidation and changes in antioxidant enzymes, Na(+)-K(+)-ATPase in erythrocytes of type 2 diabetic patients in andhra pradesh

Plasma levels of lipids, lipoproteins and lipid peroxides and erythrocyte Na(+)-K(+) ATPase, Mg(2+)ATPase and antioxidant enzymes were measured in type-2 diabetic patients. A significant decrease in Na(+)-K(+)-ATPase activity was observed in diabetic patients which was negatively correlated with blood glucose and lipid peroxides, while the Mg(2+)-ATPase activity was increased. In the diabetic subjects the plasma concentrations of Na(+) and K(+) were increased where as erythrocyte levels of Na(+) were increased and K(+) were decreased. Hyperlipidaemia and increased levels of lipid peroxides were observed in the diabetic subjects. There was a significant increase in erythrocyte catalase activity in diabetics which positively correlated with their lipid peroxides. There was no change in GPx activities between controls and diabetics.

Involvement of nitric oxide (NO) in hypoglycaemic activity of tolbutamide

The study was conducted to find the involvement of Nitric Oxide (NO) using L-arginine, a NO precursor and NG-methyl L-arginine a nitric oxide synthase inhibitor on tolbutamide activity in normal rabbits. L-arginine (25-300 mg/kg, body weight, oral) produced transient and dose dependent hypoglycaemia. When combined with tolbutamide (40 mg/kg, oral) it produced early and prolonged action. The effect of tolbutamide was blocked by NG-methyl L-arginine (5 mg/kg, body weight, oral). The results confirm the involvement of NO in tolbutamide activity and the possibility of using L-arginine as a supplement to antidiabetic drugs in blood glucose control.

Risk of melanoma in medium-sized congenital melanocytic nevi: a follow-up study

BACKGROUND

The risk of the occurrence of malignant melanoma (MM) in medium-sized (1.5 to 19.9 cm in diameter) congenital melanocytic nevi (CMN) is the subject of controversy. Universally accepted recommendations regarding the management of such lesions have not been made.

OBJECTIVE

Our purpose was to assess the risk of MM arising in medium-sized CMN.

METHODS

The study included 230 medium-sized CMN in 227 patients, first seen in a private dermatology practice from 1955 to 1996, who were followed up for MM arising within their CMNs. Criteria for entry into the study included (1) a clinically diagnosed medium-sized CMN, (2) minimum follow-up period of 1 year, and (3) a photograph of the lesion in the patient's medical record.

RESULTS

No MM occurred in a medium-sized CMN during an average follow-up of 6.7 years (median, 5.8 years) to an average age of 25.5 years (median, 19.1 years).

CONCLUSION

The results of this short-term follow-up study do not support the view that there is a clinically significantly increased risk for MM arising in banal-appearing medium-sized CMN or that prophylactic excision of all such lesions is mandatory. Lifelong medical observation seems a reasonable alternative for many medium-sized CMN.

Carcinoid tumour: laser therapy

A 31-year-old female, pregnant (I trimester), presented with symptoms and signs of bronchial asthma. Chest roentgenogram and computerized tomography of the chest revealed right mid and lower zone opacity (collapse). Bronchoscopic examination revealed intrabronchial growth in the right middle and lower lobe bronchus. Biopsy and histopathological examination confirmed carcinoid tumour. These symptoms and signs disappeared after laser therapy. The lesion, however, recurred two years later.

A study of large congenital melanocytic nevi and associated malignant melanomas: review of cases in the New York University Registry and the world literature

BACKGROUND

Patients with large congenital melanocytic nevi (LCMN) are at greater risk for the development of malignant melanoma (MM) than are persons in the general population.

OBJECTIVE

Our purpose was to identify the clinical features of LCMN in those patients in whom MMs actually developed.

METHODS

The records of 117 patients in the New York University Registry of LCMN and the reports of 172 cases of LCMN in the world literature were studied.

RESULTS

Of the 289 cases of LCMN studied, 34 patients (12%) had primary cutaneous MMs within their nevi; in two additional patients, MMs developed at cutaneous sites other than within their nevi. All patients in whom MM developed within LCMN had nevi in axial locations; however, 91% of the LCMN were axial. No MM was found that had arisen in any of the 26 LCMN confined to the extremities. In addition, no MM was found that had arisen in thousands of satellite nevi.

CONCLUSION

When MM develops within an LCMN, it generally does so in those LCMN in an axial location. The absence of cases of MM arising in LCMN confined to the extremities suggests that such nevi represent lower risk lesions, but the number of extremity nevi analyzed was too small to allow definitive conclusions. A striking finding was the absence of MMs arising in satellite nevi.