COPD exacerbation rates are higher in non-smoker patients in India

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is common among non-smokers exposed to solid fuel combustion at home. Different clinical characteristics in these patients may have significant therapeutic and prognostic implications.METHODS: We used medical record review and a questionnaire among COPD patients at 15 centres across India to capture data on demographic details, different types of exposures and clinical characteristics. Chest radiography and pulmonary function testing were performed in all 1984 cases; C-reactive protein and exhaled breath nitric oxide were measured wherever available.RESULTS: There were 1388 current or ex-smokers and 596 (30.0%) non-smokers who included 259 (43.5%) male and 337 (56.5%) female patients. Sputum production was significantly more common in smokers with COPD (P < 0.05). The frequency of acute symptomatic worsening, emergency visits and hospitalisation were significantly higher (P < 0.05) in non-smokers with COPD; however, intensive care unit admissions were similar in the two groups. There was no significant difference with respect to the use of bronchodilators, inhalational steroids or home nebulisation among smoker and non-smoker patients. The mean predicted forced expiratory volume in 1 sec in smokers (43.1%) was significantly lower than in non-smokers (46.5%).CONCLUSION: Non-smoker COPD, more commonly observed in women exposed to biomass fuels, was characterised by higher rate of exacerbations and higher healthcare resource utilisation.

Haemorrhagic shock from solid tumours of the adrenal gland: a case of bleeding primary adrenal lymphoma

Suprarenal or adrenal gland haemorrhage is an uncommon but potentially lethal condition if unrecognised. Adrenal masses rarely present with haemorrhage, but they remain an important differential aetiology for adrenal bleeding. We present a novel case of primary adrenal lymphoma with adrenal haemorrhage in a middle-aged woman who presented with right-sided abdominal pain and class 1 haemorrhagic shock. She was found to have spontaneous unilateral adrenal gland haemorrhage in the absence of any underlying previous pathology. Presenting features, diagnosis and subsequent oncological management are reported.

Robotic vs. Laparoscopic Splenectomy in Management of Non-traumatic Splenic Pathologies: A Systematic Review and Meta-Analysis

We aimed to evaluate comparative outcomes of robotic and laparoscopic splenectomy in patients with non-traumatic splenic pathologies. A systematic search of electronic databases and bibliographic reference lists were conducted, and a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in electronic databases were applied. Intraoperative and post-operative complications, wound infection, haematoma, conversion to open procedure, return to theatre, volume of blood loss, procedure time and length of hospital stay were the evaluated outcome parameters. We identified 8 comparative studies reporting a total of 560 patients comparing outcomes of robotic (n = 202) and laparoscopic (n = 258) splenectomies. The robotic approach was associated with significantly lower volume of blood loss (MD: -82.53 mls, 95% CI -161.91 to -3.16, P = .04) than the laparoscopic approach. There was no significant difference in intraoperative complications (OR: 0.68, 95% CI .21-2.01, P = .51), post-operative complications (OR: .91, 95% CI .40-2.06, P = .82), wound infection (RD: -.01, 95% CI -.04-.03, P = .78), haematoma (OR: 0.40, 95% CI .04-4.03, P = .44), conversion to open (OR: 0.63; 95% CI, .24-1.70, P = .36), return to theatre (RD: -.04, 95% CI -.09-.02, P = .16), procedure time (MD: 3.63; 95% CI -16.99-24.25, P = .73) and length of hospital stay (MD: -.21; 95% CI -1.17 - .75, P = .67) between 2 groups. In conclusion, robotic and laparoscopic splenectomies seem to have comparable perioperative outcomes with similar rate of conversion to an open procedure, procedure time and length of hospital stay. The former may potentially reduce the volume of intraoperative blood loss. Future higher level research is required to evaluate the cost-effectiveness and clinical outcomes.

Anastomotic dehiscence following retroflexion in surveillance colonoscopy: a case report

Anastomotic dehiscence following colonoscopy for routine surveillance after anterior resection for colorectal cancer is unreported in the English literature. It is a potentially fatal complication requiring awareness, quick recognition and management. We present the case of a 45-year-old woman who presented 12 hours after a routine follow-up colonoscopy with peritonitis due to anastomotic rupture diagnosed on computed tomography. The patient was taken to theatre for emergency laparotomy and formation of an end colostomy. Her postoperative recovery and follow-up were optimal.

Diaphragm disease in emergency surgery

BACKGROUND/AIMS

Diaphragm disease of the small bowel has been described in the literature over the last three decades. The pathognomonic characteristic of multiple circumferential stenosis is noted on gross examination of the bowel. It is a severe form of non-steroidal anti-inflammatory drug-induced enteropathy, often presenting as acute small bowel obstruction. A systematic review was performed to identify risk factors and patient outcomes in histologically-proven diaphragm disease of the small intestine in patients undergoing emergency operation for small bowel obstruction.

METHODS

A comprehensive search was performed between January 1975 and March 2019 using relevant MeSH terms. Studies were chosen based on predefined inclusion criteria. Diaphragm disease of the small intestine was defined as macroscopically detected thin diaphragm-like mucosal folding inside the lumen of the bowel. The parameters assessed included patient characteristics, duration of use of non-steroidal anti-inflammatory drugs, type of emergency surgery performed, complications, recurrence, presentation and diagnosis of diaphragm disease.

RESULTS

A total of 21 studies were analysed which included 17 case reports, one case series, and three retrospective comparative studies. Overall 29 patients with diaphragm disease of the small bowel were reported following emergency laparotomy for small bowel obstruction. Use of non-steroidal anti-inflammatory drugs was noted in all cases with an average duration of 3-5 years. All patients presented acutely with features of small bowel obstruction and had emergency laparotomy, except one who underwent laparoscopic resection. In the comparative studies patients were more likely to be female and to have been taking non-steroidal anti-inflammatory drugs for more than 7 years.

CONCLUSIONS

This is a rare disease, difficult to diagnose and often confirmed by the intra-operative macroscopic appearance of circumferential stenosis of the bowel. Risk factors for developing small bowel diaphragm disease include long-term use of non-steroidal anti-inflammatory drugs, and female gender. Patients with this disease are at increased risk of developing acute small bowel obstruction, so early identification is important.

Microsatellite Instability in Chronic Myeloid Leukemia using D17S261 and D3S643 markers: A Pilot Study in Gujarat Population

CONTEXT

Tumor progresses through a series of genetic alterations that involve proto-oncogenes and tumor suppressor genes - the gatekeeper, caretakers, and landscaper genes. Microsatellites are short tandem repeat sequences, present over the span of human genome and are known to be variable at multiple loci due to errors in DNA Mismatch Repair machinery.

AIM

The present study was aimed to evaluate the association between Microsatellite Instability (MSI) and evolution of Chronic Myeloid Leukemia (CML) - genetically a rare event but profound in this pilot study.

SETTINGS AND DESIGNS

We explore the possibility of MSI in primary CML patients confirmed by t(9;22) using capillary electrophoresis. Fifteen CML patients and healthy individual samples, respectively, were used to study the markers D17S261 and D3S643.

MATERIALS AND METHODS

The DNA was amplified using tagged and nontagged primers and further subjected to bioanalysis and fragment analysis.

RESULTS

While the results from bioanalyzer fluctuated, fragment analysis indicated the presence of microsatellite variability in 80% of the patients' samples as compared to no MSI in normal individuals for both the markers.

CONCLUSION

These findings suggest that MSI is a genetic event that may have a role in CML progression or evolution. Further studies are warranted to understand the plausible underlying causes.

A novel digital method to assess air space loss associated with acute lung injury in experimental acute pancreatitis

BACKGROUND/OBJECTIVES

Respiratory dysfunction and/or failure from acute lung injury (ALI) are common in acute pancreatitis (AP), but assessment of ALI in experimental AP has lacked standardisation.

METHODS

A range of experimental AP models induced in C57BL/6 mice with corresponding controls (n = 6/group). Full double lung or right lung specimens were taken for histopathological assessment and slides analysed by a pre-set pipeline using Aperio Scanner (Leica), ImageJ software and CellProfiler software. Findings were compared to other routinely assessed parameters.

RESULTS

Overall histopathological changes were similar between both lungs. Mean lung field occupancy was significantly different between moderate and severe CER-AP (21.9% v 27.5%, p < 0.05) and corresponded with lung MPO and local injury severity parameters and was mirrored for all models tested.

CONCLUSION

We have developed a novel, simple method for assessment of ALI to improve measurement of systemic organ injury in experimental AP and contribute to preclinical drug development.

Improved UV Photodetection by Indium Doped TiO₂ Thin Film Based Photodetector

Indium (In) was doped into TiO2 thin film (TF) using the electron beam evaporation technique followed by an annealing process. The high resolution X-ray diffraction (HRXRD) analysis revealed lower angle diffraction peak (2) shifting of Rutile (002) phases of TiO2 from 61.9 to 61.56 for an increased In doped samples. Calculated average grain size from FESEM (field emission scanning electron microscope) gradually decreased from 21.12 nm to 17.03 mm with an increase in In content ranging from 1.45~17.30 at%. HRXRD data revealed that crystallite sizes also reduced from 21.79 nm to 16.93 nm with an increased In doping concentration. Doping of In leads to the formation of inhomogeneous InxTiy O2 alloy that enhances the transition between 3.3-3.42 eV energy levels with variation in doping concentration. The photo-efficiencies for increased doping concentration of In with 3.47 at% and 17.30 at% were enhanced by 2.56 and 2.76 times, respectively, compared to the undoped TiO2 TF detector and both were larger than low doped In with 1.45 at% sample. The ratio of main band detection intensity to oxygen defect level was also increased from 0.22 to 2.22 with the gradual increase in In content.

Epidemiology of Acquired Immune Deficiency Syndrome and Cerebrovascular Disease in a Post Antiretroviral Era

BACKGROUND

People with acquired immune deficiency syndrome (AIDS) develop ischemic stroke through distinct mechanisms. These include infections such as syphilis, tuberculosis, varicella, and other conditions such as cocaine abuse, endocarditis, and hypercoagulability. The effect of improved awareness, detection, and treatment with highly active antiretroviral therapy (HAART) on the incidence and outcome of AIDS patients with stroke is unknown.

METHODS

Data from the Nationwide Inpatient Sample from 1995 to 2010 were analyzed. Patients with ischemic stroke and AIDS were identified using ICD-9 (International Classification of Diseases) codes. Time trends for demographics, survival, and frequency of AIDS-associated conditions were analyzed.

RESULTS

Proportion of AIDS among stroke patients increased significantly during the study. Median age of all strokes decreased from 75 years in 1995 to 72 years in 2010. Conversely, median age for men with stroke and AIDS increased from 43 years to 53 years; and for women with stroke and AIDS, from 41 years to 51 years. Death rates from stroke in the AIDS patients declined. In recent years, the death rates from stroke are similar to patients without HIV/AIDS. Stroke patients with AIDS had increased odds of syphilis (odds ratio [OR]: 33.50), varicella (OR: 48.34), tuberculosis (OR: 137.48), endocarditis (OR: 5.19), cocaine abuse (OR: 26.05), and hypercoagulability (OR: 4.82).

CONCLUSIONS

In the HAART era, the median age of incident stroke in AIDS has increased and the mortality from stroke has improved. Research should focus on optimal management of dyslipidemia while on HAART. Whether HAART can reduce the incidence and improve survival of stroke needs to be explored.

Positive association between serum silicon levels and bone mineral density in female rats following oral silicon supplementation with monomethylsilanetriol

Observational (epidemiological) studies suggest the positive association between dietary silicon intake and bone mineral density may be mediated by circulating estradiol level. Here, we report the results of a silicon supplementation study in rats that strongly support these observations and suggest an interaction between silicon and estradiol.

INTRODUCTION

Epidemiological studies report strong positive associations between dietary silicon (Si) intake and bone mineral density (BMD) in premenopausal women and indicate that the association may be mediated by estradiol. We have tested this possibility in a mixed-gender rodent intervention study.

METHODS

Tissue samples were obtained from three groups of 20-week-old Sprague Dawley rats (five males and five females per group) that had been supplemented ad libitum for 90 days in their drinking water with (i) <0.1 mg Si/L (vehicle control), (ii) 115 mg Si/L (moderate dose) or (iii) 575 mg Si/L (high dose). All rats received conventional laboratory feed, whilst supplemental Si was in the form of monomethylsilanetriol, increasing dietary Si intakes by 18 and 99 %, for the moderate- and high-dose groups, respectively.

RESULTS

Fasting serum and tissue Si concentrations were increased with Si supplementation (p < 0.05), regardless of gender. However, only for female rats was there (i) a trend for a dose-responsive increase in serum osteocalcin concentration with Si intervention and (ii) strong significant associations between serum Si concentrations and measures of bone quality (p < 0.01). Correlations were weaker or insignificant for tibia Si levels and absent for other serum or tibia elemental concentrations and bone quality measures.

CONCLUSIONS

Our findings support the epidemiological observations that dietary Si positively impacts BMD in younger females, and this may be due to a Si-estradiol interaction. Moreover, these data suggest that the Si effect is mediated systemically, rather than through its incorporation into bone.

Gender-specific brain regional variation of neurons, endogenous estrogen, neuroinflammation and glial cells during rotenone-induced mouse model of Parkinson's disease

Rotenone (RT) produces reactive oxygen species (ROS) by inhibiting the mitochondrial electron transport chain; causing dopaminergic (DA) cell death in the substantia nigra (SN) and simulates other models of induced Parkinson's disease (PD). There is a sincere dearth of knowledge regarding the status of glial cells, neuroprotective estrogen and the status of neuroinflammatory TNF-α in the different brain regions in either sex during healthy, as well as during PD conditions. In the present study of RT-induced mouse model of PD, we have selected the frontal cortex (FC), hippocampus (HC) and SN from either sex of Swiss albino mice as these are the major regions involved during PD pathogenesis. During non pathogenic conditions, the ROS-scavenging enzyme activity varied among the brain regions and also in between genders. The number of DOPA decarboxylase-positive cells, astrocytes and microglia was similar in the respective regions of the brain in both the sexes. The level of proinflammatory cytokine TNF-α was same in the respective FC and HC in either sex except that of SN. The expression level of estrogen and its receptors varied among the three brain regions. During RT treatment, ROS-scavenging enzyme activities increased, DOPA decarboxylase-positive neurons and fibers in DA as well as in norepinephrinergic (NE) systems become degenerated, number of astrocytes decreased and microglial cells increased in those specific brain regions in either of the sexes except in the SN region of males where astrocyte number remained unaltered and microglial cell percentage decreased. TNF-α increased in the FC and SN but remained unaltered in the HC of both sexes. Estradiol level decreased in the HC and SN but the level unevenly varied in the FC. Similarly, the estrogen bound and nuclear-cytosolic receptor α and β also varied differentially among the brain regions of the two sexes. Therefore our present study depicts that there exists a clear variation of neuronal and astroglial cell population, estrogen and its receptor levels in different brain regions of both the sexes during control and RT-treated pathogenic condition and these variations have major implication in PD pathogenesis and progression.

Evaluation of Documentation Patterns of Trainees and Supervising Physicians Using Data Mining

BACKGROUND

The electronic health record (EHR) includes a rich data set that may offer opportunities for data mining and natural language processing to answer questions about quality of care, key aspects of resident education, or attributes of the residents' learning environment.

OBJECTIVE

We used data obtained from the EHR to report on inpatient documentation practices of residents and attending physicians at a large academic medical center.

METHODS

We conducted a retrospective observational study of deidentified patient notes entered over 7 consecutive months by a multispecialty university physician group at an urban hospital. A novel automated data mining technology was used to extract patient note-related variables.

RESULTS

A sample of 26 802 consecutive patient notes was analyzed using the data mining and modeling tool Healthcare Smartgrid. Residents entered most of the notes (33%, 8178 of 24 787) between noon and 4 pm and 31% (7718 of 24 787) of notes between 8 am and noon. Attending physicians placed notes about teaching attestations within 24 hours in only 73% (17 843 of 24 443) of the records. Surgical residents were more likely to place notes before noon (P < .001). Nonsurgical faculty were more likely to provide attestation of resident notes within 24 hours (P < .001).

CONCLUSIONS

Data related to patient note entry was successfully used to objectively measure current work flow of resident physicians and their supervising faculty, and the findings have implications for physician oversight of residents' clinical work. We were able to demonstrate the utility of a data mining model as an assessment tool in graduate medical education.

Large artery atherosclerosis: carotid stenosis, vertebral artery disease, and intracranial atherosclerosis

PURPOSE OF REVIEW

Large artery atherosclerosis is an important cause of ischemic stroke. Recent randomized clinical trials have helped clarify the treatment options for conditions such as carotid stenosis and intracranial atherosclerosis. This review outlines the primary findings of these trials and provides current recommendations for treatment.

RECENT FINDINGS

Carotid revascularization is preferred in patients with severe symptomatic carotid stenosis. Carotid endarterectomy achieves lower rates of stroke or death than carotid artery stenting. The risk of stroke or death with stenting is higher among older patients and women. Intensive medical therapy achieves low stroke and death rates in asymptomatic stenosis. Medical therapy and treatment of atherosclerotic risk factors are the mainstay of therapy for intracranial atherosclerosis, and medical therapy is recommended for patients with vertebral artery origin atherosclerosis.

SUMMARY

Contemporary medical therapy is paramount in large artery atherosclerosis. Patient demographics, comorbidities, and the periprocedural risks of stroke and death should be carefully weighed while choosing a revascularization procedure for carotid stenosis.

Abstract T P203: Areas of Cerebral Ischemia Have Increased Propensity to Convert to Infarct Among Diabetics

Diabetes influences ischemic stroke outcome. While several theories are proposed, the mechanism for worse outcomes is unclear. Perfusion computed tomography (PCT) helps identify stroke patients who would benefit from endovascular therapy. Our hypothesis was that PCT could potentially be used to elucidate the biological basis of poor outcomes among diabetics with stroke

Methods: Patients with ischemic stroke that underwent PCT at admission from August 2011 to March 2012 were reviewed. PCT protocol included 4 supratentorial slices, 8mm thick. Areas of increased mean transit time(MTT) were traced and marked as ischemic area. Area of preserved cerebral blood volume(CBV) was penumbra. CBV and MTT were compared among diabetics and non-diabetics.

Results: The study included 44 patients: 15 diabetic and 29 non-diabetics. The age, sex, race distributions and NIH stroke scale in both groups were similar. There were no differences in risk factors such as hypertension, atrial fibrillation and smoking. The average MTT was similar for both groups in the ischemic area (8.1ml/100g in diabetics and 8.7ml/100g in non diabetics, p=0.43) and within penumbra (8.4ml/100g in diabetics and 9.2 in non diabetics, p=0.32). The CBV was significantly lower among diabetics within the ischemic area (2.8sec vs.3.5sec among nondiabetics, p=0.04) as well as penumbra (2.8sec vs. 3.6sec in nondiabetics, p=0.03). This suggests an increased propensity for penumbra to convert to infarct among diabetics. In conclusion, PCT evaluation suggests that a lower CBV could explain worse outcomes among diabetics with stroke. Microvascular disease and endothelial dysfunction should be investigated as potential mechanisms for lower CBV and worse outcomes among diabetics.

Abstract W P193: Early Involvement of Stroke Neurologist Allows Efficient Tissue Plasminogen Activator Administration in Member Hospitals of a Telemedicine Network

The Michigan Stroke Network provides telestroke services at 32 hospitals across Michigan. These include several critical access hospitals and free standing emergency rooms (ERs). The network conducts ongoing education of member hospitals, emphasizing rapid recognition of symptoms and early activation of the stroke network. Our hypothesis was that prompt communication with a stroke neurologist will facilitate processes and decision making; reducing door to needle times for patients receiving tPA

Methods: Data was collected for all video consultations. For patients who received tPA, time of symptom onset, time of arrival at member hospital, time of call to network and door to needle times were recorded. Data from January 2012-March 2013 are presented in this abstract; further prospective data collection is ongoing.

Results: Over 15 months, 249 consultations were performed, resulting in 42(16.8%) tPA administrations and 110(44.2%) transfers for endovascular therapy or post tPA care. A door to needle time<60 min was achieved in 17 of 42(40.4%). Three patients received tPA for symptoms starting within the hospital. Of 33 patients who arrived within 2 hours of symptom onset, 27(81.8%) received tPA within 3 hours.

When the stroke network was activated within 20min of patient arrival, 9/10 patients received tPA within 60 min; whereas if the network was not activated within 20min, only 8/29 achieved this target(p=0.0009). In conclusion, involving the on-call neurologist in a telemedicine network facilitates early decision making and results in shorter door to needle times. Quality improvement initiatives within a hospital network should concentrate on improving front end processes for early identification of stroke symptoms and prompt communication with the stroke neurologist.