Exploring urinary extracellular vesicles for organ transplant monitoring: A comprehensive study for detection of allograft dysfunction using immune-specific markers

BACKGROUND

Allograft dysfunction (AGD) is a common complication following solid organ transplantation (SOT). This study leverages the potential of urinary extracellular vesicles (UEVs) for the non-invasive detection of AGD.

AIM

We aimed to assess the diagnostic value of T-cell and B-cell markers characteristic of T-cell-mediated and antibody-mediated rejection in UEV-mRNA using renal transplantation as a model.

MATERIALS AND METHODS

UEVs were isolated from 123 participants, spanning healthy controls, functional transplant recipients, and biopsy-proven AGD patients. T-cell and B-cell marker mRNA expressions were evaluated using RT-qPCR.

RESULTS

We observed significant differences in marker expression between healthy controls and AGD patients. ROC analysis revealed an AUC of 0.80 for T-cell markers, 0.98 for B-cell markers, and 0.94 for combined markers. T-cell markers achieved 81.3 % sensitivity, 80 % specificity, and 80.4 % efficiency. A triad of T-cell markers (PRF1, OX40, and CD3e) increased sensitivity to 87.5 % and efficiency to 82.1 %. B-cell markers (CD20, CXCL3, CD46, and CF3) delivered 100 % sensitivity and 97.5 % specificity. The combined gene signature of T-cell and B-cell markers offered 93.8 % sensitivity and 95 % specificity.

CONCLUSION

Our findings underscore the diagnostic potential of UEV-derived mRNA markers for T-cells and B-cells in AGD, suggesting a promising non-invasive strategy for monitoring graft health.

Successful Renal Transplant in Castleman Disease - First Case Report from India

Castleman disease (CD) comprises a rare group of heterogenous benign lymphoproliferative disorders with pathologic similarities. However, they present with diverse clinical manifestations. Renal involvement is rare in CD and is mainly reported with plasma cell type of multicentric disease. Various glomerular pathologies, interstitial involvement, or thrombotic microangiopathies have all been reported, some of which progress to end-stage renal disease (ESRD). Progression of CD to ESRD is well documented; however, a patient on dialysis developing CD is rare. Moreover, kidney transplantations have seldom been performed on patients with CD. We report a patient with ESRD of unknown etiology who developed multicentric CD while on dialysis. He was treated with four doses of rituximab and later underwent a living kidney transplant with his wife as a donor. He has been clinically well ever since. We believe that this is possibly the first successful case of renal transplantation in CD with ESRD being reported from India.

Correlation between BISAP score and D-dimer level on their predictive ability to determine the severity of acute pancreatitis at 24-hours of hospital admission: an observational study

Background: Early prediction of severity of acute pancreatitis (AP) is important for management of AP patients with escalation of care and aggressive therapy which can reduce complications. Bedside index of severity in AP (BISAP) score is helpful in early diagnosis of severe AP. D-dimer, a biomarker of secondary fibrinolysis may be helpful in predicting the severity of pancreatitis. Aims and Objectives: The objective of this study was to evaluate the two scoring systems - the BISAP score and D-dimer in early prediction (within 24 h) on the severity of AP and to analyze how D-dimer correlates with BISAP score. Materials and Methods: Seventy-five patients, aged 18–70 years, suffering from AP due to any cause were included for this prospective, observational study. Within 24 h of admission D-dimer was estimated and BISAP score was calculated. The severity was assessed based on D-dimer level and BISAP scoring systems within 24 h of hospital admission and data were tabulated for analysis. The D-dimer level >2.5 mg/L was considered to be suggestive of severe pancreatitis. The BISAP score >2 in first 24 h was defined as predictive of severe pancreatitis. Spearman rank correlation was used for an analysis of the association between two set of data (BISAP scores and d-dimer levels) and thus to measure the strength and direction of the relationship between the two variables. Results: In the present study, 37.3% of the patients had D-dimer ≤2.5 mg/L and 62.7% had D-dimer>2.5 mg/L’ on calculating the Pearson’s correlation on the ranked values of the data (BISAP scores and D-dimer levels), the correlation coefficient (Spearman’s Rho, designated as “rs”) was found to be 0.406 which indicates about moderate positive correlation. Conclusion: D-dimer testing can be used as an alternative test to predict the severity of AP. It shows a moderate correlation with BISAP scoring.

Nasogastric tube insertion in anesthetized, intubated adult patients: A comparison between conventional blind insertion technique and “throat pack in situ” technique

Background: Correct placement of nasogastric tube (NGT) placement often becomes difficult in anesthetized, intubated adult patients due to lack of cooperation from patient and the propensity of the tube to travel the same course of path. Preexisting throat pack is supposed to resist the normal passage of the NGT as per common belief. Only one study has evaluated this in pediatric population and the result is encouraging. Aims and Objectives: Hence, the present study has been carried out in adult population to compare the success rate of correct placement of NGT in anesthetized intubated adult patients with the pharyngeal (throat) pack in its position in comparison with no throat pack. This is to examine the effect of preexisting throat pack whether it assists or resists the normal passage of the NGT. Materials and Methods: One hundred and eighty patients were recruited for this interventional and single-blind study. After induction of anesthesia and intubation, the patients were randomized to receive NGT insertion following either blind insertion of the NGT without a pharyngeal pack (group A, n=90) or receive the NGT placement in the same technique but after placement of a pharyngeal pack. The success rate of correct placement of NGT in the first attempt (primary outcome), the procedure time, and adverse events was recorded. Results: Successful insertion of NGT in first attempt was considerably higher in throat pack in situ group compared to blind insertion without a throat pack 81 (90%) versus 63 (70%), respectively (P=0.001). The procedure time for successful placement of NGT was found comparable between the two groups. Significant decrease in coiling is seen in “throat pack in situ” group compared with blind insertion technique (P=0.003). Conclusion: In view of considerable higher success rate and reduced adverse events, it can be concluded that the pre-existing appropriately placed throat pack can facilitate the placement of NGT instead of putting any hindrance.

Attenuation of hemodynamic pressor response to laryngoscopy and endotracheal intubation by intravenous fentanyl in elective surgery under general anesthesia: A randomized controlled trial using three different doses

Background: Direct laryngoscopy and endotracheal intubation elicit hemodynamic pressor responses which may be hazardous in high risk patients. Fentanyl, a low cost synthetic opioid, when used judiciously, may be a good option to attenuate this stress response. Aims and Objectives: The present study has been conducted to compare the efficacy of three different doses of intravenous fentanyl in attenuation of hemodynamic pressor response to laryngoscopy and endotracheal intubation in elective surgery under general anesthesia. Materials and Methods: It was a double-blinded randomized controlled trial. A total of 90 patients of American Society of Anesthesiologists physical status I and II, 55 male and 35 female, aged between 20 and 55 years, were randomized into three groups receiving 2, 3, and 4 μg/kg of injection fentanyl, respectively, administered intravenously 5 min before direct laryngoscopy and endotracheal intubation. Results: There were significant differences in hemodynamic variables among all three groups at 1, 3, 5, and 10 min after endotracheal intubation. Just after endotracheal intubation; heart rate, mean arterial pressure, and diastolic arterial pressure – all these variables showed significance between 3 μg/kg and 4 μg/kg groups only. Incidence of nausea/vomiting showed statistical significance between 2 μg/kg and 4 μg/kg groups only. Conclusion: In our double-blinded randomized controlled trial, 4 μg/kg of injection fentanyl administered 5 min before laryngoscopy and intubation, has showed superior efficacy in suppressing hemodynamic stress responses associated with it. Further, larger trials are needed to confirm our findings.

Nasogastric tube insertion in anesthetized intubated adult patients: A comparison between the “reverse Sellick’s maneuver with throat pack in situ” and reverse Sellick’s maneuver alone

Background: Nasogastric tube (NGT) insertion is an essential procedure in the operating room for which the anesthesiologists often take the responsibility. This simple procedure often becomes difficult in anesthetized patients. Literature reveals the flooding of studies and novel techniques are in the pipeline, indicating that quest for the best is still on. Aims and Objectives: The aim of the study was to determine the proportion of patients in whom successful NGT insertion would be possible in the first attempt using either the “Reverse Sellick’s maneuver (RSM) with throat pack in situ” technique or RSM alone; and to compare the proportions between the two groups. Materials and Methods: This interventional study was performed on 222 adult patients (≥18 years), undergoing abdominal surgeries requiring intraoperative NGT insertion. Patients received NGT insertion using the combined RSM with “throat pack in situ” technique (Group A, n=111) or RSM alone (Group B, n=111). The proportion of patients in whom successful NGT insertion was possible in the first attempt using either of the techniques and the time taken for correct placement of NGT in both the groups. In addition, the incidence of adverse events was noted. Results: Although, NGT placement was possible in higher proportions of patients in Group A in first attempt compared with Group B (91% vs. 83.8%), it was not significant on analysis (P=0.106). The procedure time in both the groups was comparable (30.0±4.0 vs. 29.9±4.3, P=0.859). Coiling was found to be significantly more in the RSM alone technique as compared to the combined method. (P=0.04). Conclusion: With comparable success rate and lesser incidence of adverse events, it can be commented that the RSM with throat pack in situ technique appears to be a better alternative to RSM alone.

Effects of intrathecal dexmedetomidine coadministered with hyperbaric bupivacaine in the lower abdominal surgery: Results of a double-blind, randomized, and controlled trial between two different doses

Background: Although various adjuvants have been added to local anesthetic agents to potentiate its effect, dexmedetomidine is a relatively new drug with only a fewer studies. Aims and Objectives: The present study has been conducted to compare the efficacy of intrathecal hyperbaric bupivacaine alone with dexmedetomidine of two different doses as adjuvants in spinal anesthesia for the lower abdominal surgery. Materials and Methods: This was a double-blinded, randomized, and controlled trial. Total 120 patients of American Society of Anesthesiologists physical status I and II, 70 male and 50 female, aged between 20 and 60 years, were randomized into three groups receiving 15 mg 0.5% hyperbaric bupivacaine with normal saline, 4 μg (microgram) dexmedetomidine, and 2 μg dexmedetomidine, respectively, administered intrathecally. Results: There was significant difference among all three groups with regard to the onset of sensory block and time to reach the highest level of sensory block. Time to reach T10 dermatome, time to reach Bromage 3 motor block, the mean regression time to S1 dermatome level, the mean regression time to reach Bromage 0, and time to first requirement of rescue analgesia – all these variables showed significance when 4 μg dexmedetomidine additive group was compared with 2 μg dexmedetomidine additive group and bupivacaine alone group. Conclusion: In our double-blinded, randomized, and controlled trial, 4 μg intrathecal dexmedetomidine coadministered with 0.5% hyperbaric bupivacaine showed superior efficacy. Further, larger trials are needed to confirm our findings.

Cardiorenal disease management in type 2 diabetes: An expert consensus

BACKGROUND AND AIM

The interplay between cardiovascular disease (CVD), chronic kidney disease (CKD) and type 2 diabetes (T2D) is well established. We aim at providing an evidence-based expert opinion regarding the prevention and treatment of both heart failure (HF) and renal complications in people with T2D.

METHOD

ology: The consensus recommendations were developed by subject experts in endocrinology, cardiology, and nephrology. The criteria for consensus were set to statements with ≥80% of agreement among clinicians specialized in endocrinology, cardiology, and nephrology. Key expert opinions were formulated based on scientific evidence and clinical judgment.

RESULTS

Assessing the risk factors of CVD or CKD in people with diabetes and taking measures to prevent HF or kidney disease are essential. Known CVD or CKD among people with diabetes confers a very high risk for recurrent CVD. Metformin plus lifestyle modification should be the first-line therapy (unless contraindicated) for the management of T2D. Glucagon-like peptide 1 (GLP-1) agonists can be preferred in people with atherosclerotic cardiovascular disease (ASCVD) or with high-risk indicators, along with sodium-glucose cotransporter-2 inhibitors (SGLT2i), whereas SGLT2i are the first choice in HF and CKD. The GLP-1 agonists can be used in people with CKD if SGLT2i are not tolerated.

CONCLUSION

Current evidence suggests SGLT2i as preferred agents among people with T2D and HF, and for those with T2D and ASCVD. SGLT2i and GLP-1RA also lower CV outcomes in those with diabetes and ASCVD, and the treatment choice should depend on the patient profile.

Evaluation of diabetic foot ulcer with reference to demography, clinical presentation, and imaging modalities for diagnosis: An observational study

Background: Demography and clinical presentation of diabetic foot ulcer varies across geographical location. Multiple imaging modalities such as plain radiography and magnetic resonance imaging (MRI) are used to evaluate osteomyelitis or neuroarthropathy in diabetic foot. Plain radiography is a low cost and easily available test while MRI is reported to be of higher sensitivity and specificity for delineating the extent of soft tissue and bone involvement. Aims and Objectives: The study was designed to determine the spectrum of demographic and clinical findings and to find the utility of different diagnostic modalities such as clinical, plain radiography, and MRI that were used to differentiate between osteomyelitis and neuroarthropathy. Materials and Methods: After obtaining permission of Institute’s Ethics Committee’s permission, this observational study was carried out among patients, males and females aged 13 years and above, who presented with diabetic foot ulcer for treatment. The study spanned from March 2020 to August 2021 to reach a sample of 50 patients following non-random purposive sampling. A pro forma (containing history, physical examination findings, and laboratory investigations) was used to explore patient data. Besides clinical diagnosis, plain radiography and MRI were used to evaluate the clinical findings. Results: In the study, most of the subjects were between 51 and 70 years of age having diabetes for a duration of 5–15 years. The basis of complications observed is infections, ischemia, and neuroarthropathy. Among the diagnostic modalities used to reach a diagnosis of osteomyelitis or neuroarthropathy, MRI was able to pick up the diagnosis in a greater number of patients for above two entities. Osteomyelitis was identified in 24 (48%) patients and neuroarthropathy was identified in 22 (44%) patients. Use of plain radiography helped in reaching diagnosis in 30% of patients for each category. Clinical diagnosis about osteomyelitis or neuroarthropathy was made in 22% and 26% of patients, respectively. However, on analysis, it was not significant. Conclusion: The present study showed a male preponderance. Moreover, MRI was able to categorically diagnose different pathological parameters of osteomyelitis and neuroarthropathy. Marrow edema was detected in a larger proportion of patients among the MRI-diagnosed cases of osteomyelitis and neuroarthropathy. MRI appears to be more useful than plain radiography for clinical diagnosis.

Comparison Between the Reverse Sellick’s and SORT Manoeuvres of Nasogastric Tube Insertion in Anaesthetised, Intubated, Adult Patients- A Randomised Clinical Study

Introduction: In the perioperative period and critical care unit, nasogastric tube (NGT) placement is a simple procedure which turns in to a difficult one in anaesthetized, intubated patient. The SORT manoeuvre (a combination of Sniffing position, Orientation of nasogastric tube, Rotating the patient’s head to the contralateral side, and Twisting movements of operator’s hand) has been studied sparingly. Reverse Sellick’s manoeuvre is a commonly applied method for NGT placement where cricoid cartilage is lifted by the performer with non-dominant hand during placement of NGT. Aim: To ascertain the success rate of SORT manoeuvre in comparison with the reverse Sellick’s manoeuvre for NGT placement in anaesthetized and intubated adults. Materials and Methods: This single-blinded, randomised study was conducted in N.R.S. Medical College and Hospital (tertiary care centre), Kolkata, West Bengal, India, from March 2020 to August 2021. Total 102 adults patients, scheduled for abdominal surgeries under general anaesthesia with intubation, were included. The patients received NGT placement either by applying reverse Sellick’s manoeuvre (group A, n=51) or using SORT manoeuvre (group B, n=51), following a random allocation method. The number and percentage of patients having successful NGT placement within first attempt in each group was recorded. The time to perform the procedure and any incidence of adverse event were recorded. Quantitative variables were compared using Independent t-test between the two groups. Qualitative variables were compared using Chisquare test/Fisher’s exact test, as appropriate. A p-value ≤0.05 was considered statistically significant. Results: Successful placement of NGT within single attempt was feasible in 48 patients (94.2%) using the SORT manoeuvre in contrast with 38 (74.5%) applying the reverse Sellick’s manoeuvre (p-value=0.006). Longer procedure time was observed with the SORT manoeuvre compared to the reverse Sellick’s manoeuvre (22.3±4.4 vs 20.1±3.8 seconds), respectively; p-value=0.008). Use of SORT manoeuvre in comparison with reverse Sellick’s manoeuvre resulted in apparently lower incidence of adverse events (Coiling 1.96% vs 19.6%; Kinking 1.96% vs 3.92%, respectively); however, found statistically not significant (p-value=0.305). However, overall incidence of adverse events was considerably more in reverse Sellick’s manoeuvre compared with the SORT manoeuvre (25.5 % and 5.8%, respectively, p-value=0.006). Conclusion: The SORT manoeuvre appears to be advantageous over the reverse Sellick’s manoeuvre for NGT placement in adult patients undergoing surgery under general anaesthesia with intubation, in terms of higher success rate and lower incidence of adverse events.

Aqueous Mg-Ion Supercapacitor and Bi-Functional Electrocatalyst Based on MgTiO₃ Nanoparticles

Supercapacitor and hydrogen-based fuel cells are cheap and environmental-friendly next-generation energy storage devices that are intended to replace Lithium-ion batteries. Metal oxide nanostructures having perovskite crystal structure have been found to exhibit unique electrochemical properties owing to its unique electronic band structure and multiple redox-active ions. Herein, MgTiO₃ nanoparticles (MTO-1) were synthesized by wet-chemical sol-gel technique with an average particle size of 50-55 nm, which exhibited superior supercapacitor performance of capacitance (C) = 25 F/g (at 0.25 A/g), energy density (E_D) = 17 Wh/kg, power density (P_D) = 275 W/kg and 82.41% capacitance retention (after 1000 cycles). Aqueous 1 M Mg(ClO₄)₂ solution was used as the electrolyte. MTO-1 revealed an overpotential () = 1.329 V and Tafel slope (b) = 374 mV/dec towards Oxygen Evolution Reaction (OER) electrocatalyst and exhibited = 0.914 V and b = 301.4 mV/dec towards Hydrogen Evolution Reaction (HER) electrocatalyst, both in presence of alkaline 1 M KOH solution, making these MgTiO₃ nanoparticles very promising for potential use in various technologically important electrochemical applications.

Molten Salt Synthesized MgNiO₂ Micro/Nano-Particles for High Energy Density Supercapacitor and Electrocatalyst for Hydrogen Evolution Reaction in Alkaline Medium

In recent years, solid solutions have shown promising results as functional materials for different applications. These materials have tunable physiochemical properties and electronic properties, and are being intensively studied for next generation electrochemical charge storage as well as noble metal free low cost electrocatalyts. In the present work, Magnesium Nickel Oxide (MgNiO₂) solid solution is prepared by molten salt synthesis. MgNiO₂ particles having octahedron shaped morphology with size of 550 nm with an agglomerative behavior was observed through morphological studies. Raman studies revealed presence of three two-phonon modes as well as two one-phonon modes, which confirm the phase purity of MgNiO₂ sample. MgNiO₂ particles behaved as a promising supercapacitor candidate by exhibiting a large specific capacitance of 76 F/g. It also revealed electrochemical stability over an expansive potential range under the presence of 0.5 mol L^-1Sodium Sulfate (Na₂SO₄) electrolyte, having a high energy density of nearly 51 Wh/kg with a power density of nearly 825 w/kg. Further, MgNiO₂ particle showed improved electrocatalytic potential towards Hydrogen Evolution Reaction (HER) in 1 mol L^-1 Potassium Hydroxide (KOH) alkaline medium, by demonstrating an overpotential of 0.636 V with a Tafel slope of 0.22205 v/dec. Based on these observed promising results, it can be conclusively inferred that MgNiO₂ solid solution is a potential candidate for environmental friendly high voltage supercapacitor and HER electrocatalyst applications.

Anti-glomerular Basement Membrane Disease with Atypical Associations

Anti-glomerular basement membrane (anti-GBM) disease is a systemic autoimmune disorder characterized by circulating immunoglobulin (Ig) G antibodies to carboxy-terminal, noncollagenous 1 domain of type IV collagen of GBM. Patients typically present with rapidly progressive glomerulonephritis and pulmonary hemorrhage. Anti-GBM disease has been reported to coexist with pauci-immune antineutrophil cytoplasmic autoantibody-positive glomerulonephritis and membranous glomerulopathy. The presentation of anti-GBM disease with thrombotic microangiopathy (TMA) and IgA nephropathy has been rarely described. We herein report two cases of anti-GBM antibody disease, both with crescentic glomerulonephritis and peripheral linear deposits of IgG, one case with clinical and histological findings of associated TMA and other with findings of extensive mesangial IgA deposits. Both the patients were treated with corticosteroid, intravenous cyclophosphamide, and plasma exchange but had poor renal recovery. Association of anti-GBM disease with TMA or IgA nephropathy could open up new pathogenetic mechanism and may help us to prognosticate anti-GBM disease.

P1616ASSESSMENT OF SEQUENTIAL CHANGES OCCURRING IN THE BODY FLUID COMPOSITION BY BIO-IMPEDANCE ANALYSER IN PRE AND EARLY POST RENAL TRANSPLANT PATIENTS

Background and Aims

Chronic kidney disease is now recognized as major causes of death in India. The Global Burden of Disease (GBD) study 2015, ranked chronic kidney disease as 17th among the causes of deaths globally (age standardized annual death rate of 19·2 deaths per 100 000 population). Deaths due to renal failure constituted 2·9% of all deaths in 2010–13 among 15–69 year-olds, an increase of 50% from 2001–03. These are varies metabolic derangements in CKD patients, among which volume overload is the major problem contributing uncontrolled hypertension and increases cardiovascular mortality. There will be increased total body water (TBW) and extracellular water (ECW) at the expense of reduced intracellular water (ICW). Renal replacement therapies such as dialysis or kidney transplantation are the major treatment modalities. Renal transplantation is the treatment of choice for end stage renal failure patients. Despite improving renal dysfunction, patients are at risk for existing or new onset of conditions after transplantation and may alter the body fluid physiology. Till date, renal transplant patients received little attention towards fluid balance and nutritional status. There are many studies supporting the use of bioimpedance analyzer as a reliable tool in assessing the fluid status in haemodialysis patients, but there are very few studies done in post renal transplant patients to know their fluid status with single functioning kidney where Glomerular filtration rate are generally much lower than normal.

Method

fifty renal transplant recipients were followed in our centre for 6 months (68 males, maximum were in 31-45years of age). Biochemical parameters like haemoglobin, urea, creatinine, electrolytes, albumin, estimated glomerular filtration rate (eGFR); TBW, ECW, ICW and over hydration (OH) measured using bioimpedance analysis (BCM, Fresenius) were evaluated at baseline (pre-transplant) and after transplant at 3 and 6 months. Baseline biochemical and bio-impedance values were compared with 3 and 6 months post transplant. Patients were divided into 3 sub-groups based on eGFR: good graft function (eGFR >60 ml/min), borderline graft function (eGFR 30-60 ml/min) and severe graft dysfunction (eGFR >30 ml/min/1.73m2). TBW, ECW, OH and ICW were compared between the sub groups of eGFR at 3 and 6 months post transplant.

Results

Comparing before transplant with 3 and 6 months post-transplant, TBW, ECW and OH were reduced while ICW increased significantly with good graft function. On comparing 3 months to 6 months post-transplant, ECW, TBW, OH reduced further but there was not much difference in ICW. OH at 6 months post-transplant was 0.6 L (within normal range of gender-matched individuals from the reference population, that is, −1.1 to 1.1 L). In patients with severe graft dysfunction (<30ml/min), TBW, ECW and OH were remained high when compared to borderline (31-60ml/min) and with good graft function group (>60ml/min). Biochemical improvement was comparable with bio-impedance parameters at 3 months and 6 months post transplant with good graft function.

Conclusion

The BIA showed significant reduction in TBW, ECW and OH by 6 months post transplant and ICW increased as graft function improved post transplantation by 3 months and thereafter, change was not significant. Parameters of Bio-impedance analyzer of well-functioning kidney transplant recipients showed that the altered body water compartments quickly normalizes which is never achieved by a hemodialysis session. We found that Bio-impedance analyzer was useful to know the changes in body fluid composition in post renal transplant patients.

Patients on Chronic Peritoneal Dialysis for Ten Years or More in North America

Thirty-six patients on peritoneal dialysis (PD) for more than ten years in six North American centers were analyzed retrospectively. In the six centers, the percentage of patients surviving for more than ten years varied between 0.8% and 7.3%. The study group included 27 females and 9 males aged 38.6 ± 14.2 years [mean ± standard deviation (SD)] at the start of treatment. Of the 36 patients, 28 were Caucasian.

The most common cause of end-stage renal disease (ESRD), present in 12 patients, was chronic glomerulonephritis. Only 4 patients had diabetes. At the beginning of the study, 19 patients had hypertension (the most common comorbid condition); 11 had no comorbid conditions at the start.

Creatinine clearance at the start was 4.12 ± 3.5 mL per minute, and the mean duration to anuria was 51 ± 25 months. Mean initial body weight was 55 ± 9 kg, and mean body surface area was 1.5 ± 0.2 m2. Serum albumin levels showed an increase from 33.8 ± 3.6 g/L at the start of the study to 38.2 ± 3.9 g/L at the end.

Hospitalization rate was low at 0.5 ± 0.3 admissions per patient–year, and duration of hospitalization was 4.8 ± 3.7 days per patient–year. Peritonitis was the most common cause of hospitalization. The mean peritonitis rate was 1 episode every 52 ± 48 patient–months.

There were 36 catheter changes in 18 patients; 16 patients had a single PD catheter throughout the period of study. Autonomous hyperparathyroidism was the most common long-term complication.

At the end of the study period, 11 patients were still on PD, 9 had died, 5 had been transferred to hemodialysis (HD), 1 was alive with a functioning allograft, and 1 was lost to follow-up.

We conclude that patients who survive longer than ten years on PD are most likely to be young Caucasian females, small in body size, who are non diabetic, with few comorbid conditions. These long-term survivors have few hospitalizations, and their peritonitis rate is low. In this group of patients, severe autonomous hyperparathyroidism is the most common long-term complication.

Accuracy of quick Sequential Organ Failure Assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria for predicting mortality in hospitalized patients with suspected infection: a meta-analysis of observational studies

OBJECTIVE

To identify sensitivity, specificity and predictive accuracy of quick sequential organ failure assessment (qSOFA) score and systemic inflammatory response syndrome (SIRS) criteria to predict in-hospital mortality in hospitalized patients with suspected infection.

METHODS

This meta-analysis followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group consensus statement for conducting and reporting the results of systematic review. PubMed and EMBASE were searched for the observational studies which reported predictive utility of qSOFA score for predicting mortality in patients with suspected or proven infection with the following search words: 'qSOFA', 'q-SOFA', 'quick-SOFA', 'Quick Sequential Organ Failure Assessment', 'quick SOFA'. Sensitivity, specificity, area under receiver operating characteristic (ROC) curves with 95% confidence interval (CI) of qSOFA and SIRS criteria for predicting in-hospital mortality was collected for each study and a 2 × 2 table was created for each study.

RESULTS

Data of 406 802 patients from 45 observational studies were included in this meta-analysis. Pooled sensitivity (95% CI) and specificity (95% CI) of qSOFA ≥2 for predicting mortality in patients who were not in an intensive care unit (ICU) was 0.48 (0.41-0.55) and 0.83 (0.78-0.87), respectively. Pooled sensitivity (95% CI) of qSOFA ≥2 for predicting mortality in patients (both ICU and non-ICU settings) with suspected infection was 0.56 (0.47-0.65) and pooled specificity (95% CI) was 0.78 (0.71-0.83).

CONCLUSION

qSOFA has been found to be a poorly sensitive predictive marker for in-hospital mortality in hospitalized patients with suspected infection. It is reasonable to recommend developing another scoring system with higher sensitivity to identify high-risk patients with infection.

Purification and development of ELISAs for two forms of vitellogenin in Indian walking catfish, Clarias batrachus (L.)

Two forms of vitellogenin (Vg: Vg1 and Vg2) were purified from the plasma of estradiol-17β (E₂)-treated Indian walking catfish, Clarias batrachus, by gel filtration and adsorption chromatography. Native Vg1 and Vg2 had apparent molecular masses of 375 and 450 kDa, respectively, and both Vgs resolved into two similar major bands (95 and 67 kDa) in SDS-PAGE under reducing condition. Polyclonal antisera raised against each form of Vg were absorbed with a combination of hypophysectomized male catfish serum proteins and alternate Vg to ensure specificity. Immunological analyses verified the presence of Vg1 and Vg2 in the plasma of female catfish. Homologous ELISAs were developed for Vg1 and Vg2 using their respective harvested antisera, which exhibited the detection limit of 100 ng ml^-1 for Vg1 and 40 ng ml^-1 for Vg2, and low level of cross-reactivity (not parallel to the standard) was found with alternate Vg in each assay. Treatment of male catfish with E₂ induced both Vgs showing a proportionate ratio of Vg1 to Vg2 at 5.6:1. Plasma concentrations of both Vgs measured by ELISAs at different reproductive phases of field collected female catfish increased in accordance with the ovarian development, keeping the proportionate ratio of Vg1 to Vg2 at about 2:1 in fish undergoing vitellogenesis during prespawning period and 1:20 during spawning period, suggesting that Vg1 may be the major Vg to contribute in yolk formation, whereas Vg2, besides its role in yolk formation, may facilitate other physiological functions. The present study, thus, demonstrates the occurrence of two unequally synthesized Vgs in the catfish.

Efficacy of epidural local anesthetic and dexamethasone in providing postoperative analgesia: A meta-analysis

BACKGROUND

Dexamethasone is a potent anti-inflammatory, analgesic, and antiemetic drug. Individual randomized controlled trials found a possible benefit of epidural dexamethasone. The purpose of this meta-analysis is to estimate the benefit of epidural dexamethasone on postoperative pain and opioid consumption and to formulate a recommendation for evidence-based practice.

MATERIALS AND METHODS

Prospective, randomized controlled trials comparing the analgesic efficacy of epidural local anesthetic and dexamethasone combination, with local anesthetic alone for postoperative pain management after abdominal surgery, were planned to be included in this meta-analysis. PubMed, PubMed Central, Scopus, and Central Register of Clinical Trials of the Cochrane Collaboration (CENTRAL) databases were searched for eligible controlled trials using the following search words: "Epidural", "dexamethasone", and "postoperative pain", until February 20, 2015.

RESULTS

Data from five randomized control trials have been included in this meta-analysis. Epidural dexamethasone significantly decreased postoperative morphine consumption (mean difference -7.89 mg; 95% confidence interval [CI]: -11.66 to -3.71) and number of patients required postoperative rescue analgesic boluses (risk ratio: 0.51; 95% CI: 0.41-0.63).

CONCLUSION

The present data shows that the addition of dexamethasone to local anesthetic in epidural is beneficial for postoperative pain management.

The effect of noggin interference in a rabbit posterolateral spinal fusion model

STUDY DESIGN

Noggin protein levels and spinal fusion rates were compared in a rabbit model after application of siRNA against BMP antagonist noggin in paraspinal muscle.

OBJECTIVE

To test whether endogenous BMPs are sufficient to form bone in the absence of their antagonists, using noggin siRNA to interrupt the negative feedback loop on endogenous BMP within the paraspinal muscles in rabbits. Unused Posterolateral lumbar fusion is a standard surgical treatment for many spinal disorders, yet even under ideal conditions the rate of non-fusion approaches 25 %. BMPs are effective in promoting bone formation, and are inhibited by antagonists such as noggin. We have previously shown that in this model, endogenous BMPs are present and endogenous BMP antagonist noggin is strongly increased during spinal fusion. Previous studies have found that noggin siRNA enhanced spinal fusion in combination with supra-physiological amounts of exogenous BMP; however, the effect of the siRNA alone remains unknown.

METHODS

A posterolateral intertransverse rabbit lumbar fusion was utilized, as established by Boden et al. SiRNA against noggin was electroporated into paraspinal muscle to determine its effect on fusion. Outcome measures included noggin protein expression, and assessment of spinal fusion at 6 weeks.

RESULTS

SiRNAs were effective in reducing overexpressed noggin in vitro. Noggin protein was successfully knocked down in vivo for the initial 7 days in our rabbit model and returned to detectable levels by 4 weeks and to normal levels by 6 weeks. The overall fusion rate was not significantly enhanced compared to established controls from our earlier work (Tang et al.).

CONCLUSIONS

Early noggin suppression does not appear to enhance the BMP activity sufficiently to significantly affect final fusion rates in our model.

Potential contribution of monoamine oxidase a gene variants in ADHD and behavioral co-morbidities: scenario in eastern Indian probands

Attention deficit hyperactivity disorder (ADHD) is the most frequently diagnosed behavioral disorder in children with a high frequency of co-morbid conditions like conduct disorder (CD) and oppositional defiant disorder (ODD). These traits are controlled by neurotransmitters like dopamine, serotonin and norepinephrine. Monoamine oxidase A (MAOA), a mitochondrial enzyme involved in the degradation of amines, has been reported to be associated with aggression, impulsivity, depression, and mood changes. We hypothesized that MAOA can have a potential role in ADHD associated CD/ODD and analyzed 24 markers in a group of Indo-Caucasoid subjects. ADHD probands and controls (N = 150 each) matched for ethnicity and gender were recruited following the Diagnostic and Statistical Manual for Mental Disorders-IV. Appropriate scales were used for measuring CD and ODD traits. Markers were genotyped by PCR-based methods and data obtained analyzed using the Cocaphase program under UNPHASED. Only eight markers were found to be polymorphic. rs6323 "G" allele showed higher frequencies in ADHD (P = 0.0023), ADHD + CD (P = 0.03) and ADHD + ODD (P = 0.01) as compared to controls. Haplotype analysis revealed statistically significant difference for three haplotypes in ADHD cases (P < 0.02). Statistically significant differences were also noticed for haplotypes in ADHD + CD and ADHD + ODD cases (P < 0.01). LD analysis showed significant variation in different groups. Multidimensionality reduction analysis showed independent as well as interactive effects of markers. Genotypes showed correlation with behavioral problems in ADHD and ADHD + CD. We interpret that MAOA gene variants may contribute to the etiology of ADHD as well as associated co-morbid CD and ODD in this ethnic group.

Dengue: a growing menace -- a snapshot of recent facts, figures & remedies

Dengue is specially owing to inadequate water supply and poor solid waste management , which are favorable for multiplication of the main vectors including the Aedes ageypti coupled with lack of proven anti viral therapy and no proven efficient vaccine .there are many cases of both dengue shock syndrome and dengue haemmorhagic fever making it a major public health burden sending ominous signal resulting both rising morbidity & mortality, deleterious effect on DALY [disability adjusted life year] & QALY [quality adjusted life year] & though it affect all section of society ,still it affect the poor & underprivileged section more, thereby growing menace in public health in general & in developing countries in particular.

Sociodemographic profile of breast cancer patients diagnosed by FNAC

The study included 431 patients who underwent breast FNAC over a period of five years between 2003 and 2008. The required clinical details were obtained from the requisition forms. The Information about the level of education and occupation were collected by interviewing the subjects. The number of cases of breast carcinoma was significant constituting 14.84% (n = 64). The study showed that the peak age for breast carcinoma was between 41 and 50 years. This correlates with the national figure where most of the cases observed belonged to the reproductive age group. Most of the females were married (93.75%) and were multiparous (92.18%). Maximum number of patients had only received primary education. There was not much difference in the number regarding whether they lived in urban or rural areas. Middle and lower socioeconomic class contributed the bulk of the cases and it were the housewives who were in majority (85.93%).

Participation of cAMP-dependent protein kinase and MAP kinase pathways during Anabas testudineus oocyte maturation

Possible involvement of cyclic nucleotide dependent protein kinase (PKA) and MAP kinase (MAPK) pathways during oocyte maturation in Anabas testudineus was investigated. Pre-incubation with phosphodiesterase (PDE) inhibitor, 3-isobutyl-1-methylxanthine (IBMX), inhibited 17α, 20β-DHP-induced GVBD dose dependently. PKA inhibitor, H89 could induce resumption of meiosis independent of 17α, 20β-DHP, in dose and duration dependent manner. The maximum response was obtained with the dose of 10 μM of H89 and 95% of cells underwent GVBD within 18 h. Moreover, stimulation with 17α, 20β-DHP inhibited endogenous PKA activity significantly within first hour and this effect was attenuated by PDE inhibitor IBMX at all time points. The pattern of PKA inhibition corresponded well with kinetics of histone H1 kinase activation and p34cdc2 phosphorylation. These results suggest physiological relevance of cAMP/PKA signaling in perch oocytes undergoing G2/M transition. MAPK was demonstrated as two distinct isoforms (ERK1 and ERK2) which resolved in the range of 42-44 kDa in immunoblot. Though total protein content did not show significant variation, H89 stimulation was able to stimulate phosphorylation of ERK1/2 from 5h onwards and the strongest response was observed between 10 and 18 h. MEK inhibitor, U0126 completely blocked PKA inhibition induced MAPK activation and GVBD. In addition, inhibition of endogenous PKA by a more selective peptide inhibitor [PKI-(6-22)-amide] was sufficient to resume GVBD and MAPK activation in intact perch oocytes. Also, significant ERK1/2 phosphorylation could be stimulated in cell-free extracts of perch oocytes supplemented with PKI-(6-22)-amide. The results suggest an interaction between cAMP/PKA and MAPK pathways in mediating meiosis resumption in perch oocyte.

A clinical and pathological study of triple negative breast carcinoma: experience of a tertiary care centre in eastern India

Breast cancers which do not express oestrogen, progesterone, or HER-2 neu receptors are known as triple negative breast carcinomas. In western literature they have been found to be extremely aggressive with a poor prognosis. However there is scarcity of data regarding this variety of breast cancer in India.To examine the clinical and pathological character of triple negative breast carcinomas and to compare their characteristics with other variants of breast carcinomas which presented to Medical College, Kolkata, a randomised sample of 72 patients were included with breast cancer attending the department of surgery from January 2008 to June 2008.The clinical and histopathological data along with ER/PR status and HER-2 neu expression examined by immunohistochemical methods were recorded.Twenty patients (27.78%) were found to be triple negative.The mean age at presentation was 35.4 +/- 1.95 years with 17 (85%) out of 20 being premenopausal. At presentation, mean tumour size was 4.7 +/- 0.21 cm. Though 15 patients (75%) presented with stage III disease and 16 patients (80%) had grade III histology, 14 (70%) were node negative and 20 (80%) did not have involvement of nipple areola complex and 19(95%) did not have multicentric disease. Triple negative breast cancer is prevalent in eastern India.They are locally aggressive, common in premenopausal women, but strangely do not tend to present with lymph node involvement or involvement of nipple areola complex. Therefore a more conservative approach might have a role in these seemingly aggressive tumours.

Management of large amoebic liver abscess--a comparative study of needle aspiration and catheter drainage

Amoebiasis in endemic in the tropical countries with amoebic liver abscesses being a common complication. Different modalities of treatment of amoebic liver abscess are conservative (medical management), percutaneous needle aspiration, percutaneous catheter drainage, surgical drainage and endoscopic drainage. This study was carried out to compare the efficacy, safety and outcome of needle aspiration comparing with percutaneous catheter drainage of large (> or = 5cm diameter) amoebic liver abscesses. This was a prospective study carried over a period of two years (2006-2008) at the general surgery department of Calcutta National Medical College and Hospital, Kolkata. A total of 45 patients were included in this study. All of them had amoebic liver abscess with diameter of abscess cavity > or = 5cm. They were divided into two groups. Group A included 22 patients and they were treated with needle aspiration. Group B included 23 patients and they were treated by catheter drainage. Improvement in clinical features, liver function tests, ultrasonic evidence of decrease in the size of abscess cavity was considered as criteria for successful treatment. The sex ratio and the age incidence in the two groups were similar. In about 80% patients the right lobe was affected, in about 18% the left lobe was affected and in rest the abscess involved both lobes. Needle aspiration was successful in 15 (68.2%) and catheter drainage was successful in 23 patients (100%). The mean hospital stay of patients treated with needle aspiration was more than those treated with catheter drainage. The mean time in days taken for 50% decrease in the size of abscess cavity was significantly greater in group treated with needle aspiration than in those treated with catheter drainage (9 days versus 4 days). It is concluded that percutaneous catheter drainage is more effective in management of large amoebic liver abscess than needle aspiration.

Efferent loop gastrojejunal intussusception: a case report

Gastrojejunal intussusception is a rare complication of gastric surgery. It can occur in cases with gastrojejunostomy done after partial gastric resection or in cases of simple gastrojejunostomy. There are only few cases reported worldwide, Review of literature showed about 200 cases reported till 2006 and a few more cases reported after that. A rare case of retrograde gastrojejunal intussusception is reported. The patient presented in the emergency with severe pain upper abdomen and haematemesis. Contrast enhanced CT scan of abdomen showed hugely distended stomach with retrograde gastrojejunal intussusception on laparotomy, the intussusception was reduced. A jejunojejunostomy was done. The patient is doing well after 1 1/2, months.

Kikuchi-fujimoto disease from eastern India

Kikuchi’s disease, a rare disorder which usually presents with fever painful lymphadenopathy, rash and arthritis, all of which are close mimickers of infective and immunological disorders. It is essentially a histopathological diagnosis and tests to rule out other connective tissue disorders or infective etiology must be undertaken. We present a series of two cases of kikuchi-fujimoto’s disease presenting primarily with lymphadenopathy and fever in all cases. The first is a case of generalized lymphadenopathy and the second case of kikuchi’s disease with SLE, a rare association. Lymph node excision biopsy and histopathology documented Kikuchi Fujimoto disease in above cases. All the cases improved on follow up and had no residual stigmata.

The impact of vitamin D status on periodontal surgery outcomes

Vitamin D regulates calcium and immune function. While vitamin D deficiency has been associated with periodontitis, little information exists regarding its effect on wound healing and periodontal surgery outcomes. This longitudinal clinical trial assessed outcomes of periodontal surgery and teriparatide administration in vitamin-D-sufficient and -insufficient individuals. Forty individuals with severe chronic periodontitis received periodontal surgery, daily calcium and vitamin D supplements, and self-administered teriparatide or placebo for 6 wks to correspond with osseous healing time. Serum 25(OH)D was evaluated at baseline, 6 wks, and 6 mos post-surgery. Clinical and radiographic outcomes were evaluated over 1 yr. Placebo patients with baseline vitamin D deficiency [serum 25(OH)D, 16-19 ng/mL] had significantly less clinical attachment loss (CAL) gain (-0.43 mm vs. 0.92 mm, p < 0.01) and probing depth (PPD) reduction (0.43 mm vs. 1.83 mm, p < 0.01) than vitamin-D-sufficient individuals. Vitamin D levels had no significant impact on CAL and PPD improvements in teriparatide patients at 1 yr, but infrabony defect resolution was greater in teriparatide-treated vitamin-D-sufficient vs. -deficient individuals (2.05 mm vs. 0.87 mm, p = 0.03). Vitamin D deficiency at the time of periodontal surgery negatively affects treatment outcomes for up to 1 yr. Analysis of these data suggests that vitamin D status may be critical for post-surgical healing. (ClinicalTrials.gov number, CT00277706).

Nephrogenic systemic fibrosis following hair-dye ingestion induced acute renal failure

We report a patient who developed acute renal failure following the ingestion of a hair-dye with a suicidal intent. He was managed by hemodialysis and other symptomatic measures. He developed generalized seizures and underwent MRI scan of the brain using gadolinium containing contrast material followed by development of bilateral and symmetrical thickening and induration of the skin over the extremities and verrucous papules and plaques over the lower back. Skin biopsy and immunohistochemistry showed typical features of nephrogenic fibrosing dermopathy as well as deposits of calcium. Successful management of renal failure resulted in clearing of all skin lesions except a small bony hard plate like area overt the left leg, the biopsy of which showed features of osseous metaplasia.

Anti-tissue transglutaminase antibodies in the follow-up of adult coeliac disease

BACKGROUND

The detection of auto antibodies directed against tissue transglutaminase (anti-tTG antibodies) has a well-established role in the diagnosis of coeliac disease, but the value of these antibodies in long-term follow-up is controversial.

AIMS

To determine if serial anti-tTG antibody measurements could confirm adherence to a gluten-free diet (GFD) and identify patients at risk of disease complications.

METHODS

In a 54-month cohort follow-up study, 182 adult patients were assessed. Data recorded included self-assessment of GFD adherence; anti-tTG antibody concentration and serum ferritin, vitamin B12 and folate. Where available, bone mineral density (BMD) and duodenal histology data were retrieved.

RESULTS

Persistently elevated anti-tTG antibody levels were significantly associated with abnormal duodenal histology (P < 0.001), low ferritin (P < 0.01) and poor adherence to the GFD (P < 0.001). The specificity was >85% while the sensitivity was 39-60%. Anti-tTG antibody concentrations fell rapidly following successful initiation of a GFD, and maintenance of normalization identified those who continued to be adherent to the diet.

CONCLUSIONS

This study supports a strategy of using anti-tTG antibody concentrations to monitor newly diagnosed and established patients with coeliac disease, and to target dietetic intervention to reduce the risk of complication.

Anti-GBM antibody disease sans crescents with thrombotic microangiopathy

We report a case of a 38-year-old male with acute renal failure, elevated anti-glomerular basement membrane (anti-GBM) antibody titres, bilateral nodular lung opacities and hypertension. In the renal biopsy examination, whereas direct immunofluorescence revealed significant peripheral linear deposits of IgG typical of anti-GBM antibody disease (Goodpasture's disease), eosin–haemotoxylin staining showed glomerular and vascular changes typical of thrombotic microangiopathy (TMA) and without crescents. We postulate that the TMA was responsible for the acute renal failure and that antibodies, though demonstrable, were not adequate at the site of the glomerular basement membrane to elicit a crescentic response, because of occlusion of the vascular lumina by the thrombotic process. The patient remained dialysis dependent at a 3-month follow-up.

The risk of sympathetic ophthalmia following evisceration for penetrating eye injuries at Groote Schuur Hospital

BACKGROUND/AIMS

The aim of this study was to assess the incidence of sympathetic ophthalmia following evisceration for penetrating eye injuries and to assess whether evisceration is safe in this setting.

METHODS

Data were obtained retrospectively from patients who were admitted to a tertiary hospital following penetrating ocular trauma over a 10-year period.

RESULTS

A total of 1392 patients were included in the study. Of these, 1283 (99.4%) underwent surgery on admission (primary repair or primary removal of the globe). Of the surgical group 889 (64.3%) underwent primary repair, 491(35.5%) had primary eviscerations and three (0.2%) had primary enucleations. Secondary eviscerations were performed on 11 patients who had undergone primary repair. Two cases of sympathetic ophthalmia were identified in the non-surgical group and none in the surgical group. The incidence of sympathetic ophthalmia following penetrating trauma was 0.14%.

CONCLUSION

The incidence of sympathetic ophthalmia was low, as found in previous studies. The lack of follow-up, as well as the statistically insufficient number of patients, did not provide conclusive proof that sympathetic ophthalmia does not occur after evisceration. It would appear, however, that evisceration after severe ocular trauma is an acceptable option with a low risk of sympathetic ophthalmia.

Descending thoracic aortic aneurysm presenting as left sided hemorrhagic pleural effusion

Aneurysm of descending thoracic aorta, in majority of cases is diagnosed either by chance in routine chest imaging for some other reasons or rarely due to it's symptomatic presentation like chest pain and other mediastinal compression symptoms. In this case report we present a case of 69 year old smoker who presented with cough, hemoptysis and left sided massive painless hemorrhagic pleural effusion. Further investigation revealed a large aneurysm of descending thoracic aorta which infiltrated the left lung. We suggest descending thoracic aneurysm be included in the differential diagnosis of this sort of clinical presentation which otherwise imperative with the clinical scenario of bronchogenic carcinoma.

Causes of death in older peritoneal dialysis patients--can we depend on registry reports?

OBJECTIVES

Despite significant improvements in renal management the mortality associated with dialysis care remains high. Many renal registries report mortality statistics on an annual basis. The objectives of this study were (1) to establish the accuracy of the registered cause of death (CoD) against that determined by a panel of physicians; and (2) to test the feasibility of using the HEMO study CoD classification system in patients on peritoneal dialysis (PD).

SETTING

Single centre tertiary-care hospital.

PATIENTS AND METHODS

Patients were selected from those aged > or = 65 years who died while receiving PD. The CoD was identified from that registered with the local renal registry, and from clinical records.

MAIN OUTCOME MEASURES

(1) Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and kappa score comparing registered and extracted CoD. (2) The proportions of deaths in seven categories using two classification systems.

RESULTS

A total of 51 patient charts were reviewed. The agreement between the registered and extracted CoD was poor for all causes of death except malignancy. Kappa scores ranged from 0.55 to 1.0 for different causes. PPV were poor for all except malignancy. Comparison of the CoD was highly dependent on the classification method used (e.g., death secondary to infection was 4% and 25% for CORR and HEMO, respectively).

CONCLUSIONS

The registered CoD for patients who die while on PD is often inaccurate. Different policies for classifying deaths can have a significant effect on the final reports, which show the proportion of deaths attributed to different diseases. Standardization across registries is required.

Foreign body mimicking a nasal bone fracture

Nasal foreign bodies are common in young children and are typically the result of intranasal placement by the child. The authors report a case of an extranasal foreign body in an adult, which presented as a nasal fracture following trauma to the nose. This uncommon presentation, previously unreported in the literature, highlights the importance of careful history taking in cases of nasal trauma and of thorough wound exploration if any penetrative injury is found.