Case Report on Morbidly Obese Patient with Cervical Spine Ankylosing Spondylitis Presenting with Acute Spinal Shock and Complex Airway Management

A 67 year old morbidly obese male presented to the ER with weakness in both lower extremities after a fall at home. The patient sustained a T12/ L1 unstable vertebral fractures and cord compression at the thoracolumbar junction with acute traumatic paraplegia. The patient arrived in the PACU on a backboard and with a cervical collar in place directly from the ER. The review of the patient’s chart revealed that he had a history of hypertension, PE / DVT on coumadin, hypothyroidism, NIDDM, bipolar disorder and cervical spine ankylosing spondylitis of his neck. On physical exam the patient was sleepy, but arousable and unable to move his lower extremities, with loss of bladder and bowel control. There was one 20 G IV in place. The airway exam revealed Mallampati Class 4. The patient was hemodynamically unstable with BP ~80/~40 mm HG; HR ~70’s/min; SpO2 ~86-88%. Resuscitation commenced immediately. The patient was started on face mask @ 10 l/m O2. One liter of normal saline was administered with minimal effect. A phenylephrine infusion was started. The blood pressure improved to SBP of 120’s mm Hg. The O2 saturation increased to 95%. A methylprednisone drip (30mg/kg iv bolus) was started for treatment of his spinal cord injury. For additional IV access, another 20G IV was placed. Two units of FFP were given to normalize the INR of 2.4. After multiple attempts, a right radial arterial catheter was successfully placed. A right internal jugular (RIJ) central venous catheter was inserted under ultrasound guidanc

AN OPEN-LABEL RANDOMIZED CLINICAL STUDY OF TOPICAL NANOPARTICULATE ANTIPSORIATIC POLYHERBAL CREAM

Objective: Objective of the study was to investigate the safety, efficacy, and antipsoriatic activity of topical cream enriched with Nanostructured Lipid Carriers (NLC) of Azadirachta indica, Lawsonia inermis, and Mallotus philippensis through the controlled clinical study. Methods: The randomized controlled trial was performed for 12 months on 65 adult patients between the age group 20 and 60 years of either sex of diagnosed, uncomplicated cases of psoriasis Vulgaris. The Test group received a local application of the herbal antipsoriatic NLC enriched cream, while the Control group was treated with Clobetasol propionate 0.05% cream twice daily for 3 months. Both groups were assessed for parameters of skin and nail examinations, lab investigation, and Psoriasis Area and Severity Index (PASI) score. The data were analyzed and interpreted statistically. Results: Significant improvement in itching and PASI score was seen during successive visits in both groups. However, recurrence of mild itching and erythema in a few patients of the control group was seen after 2 weeks, whereas no such recurrence is seen in the test group. Statistically significant reduction in eosinophilia in the control group was observed before and after treatment. The efficacy of clobetasol in the control group and the prepared formulation in the test group both show statistical efficacy at par. Conclusion: The data suggest that the NLC enriched cream exhibited significant relief in all the symptoms of psoriasis and therefore can be used as a potent antipsoriatic agent due to the easy availability of the drugs and cultural affinity for herbal formulations

Histomorphometric Effcets of Oral use of Tobacco in Testes of Offsprings of Swiss Albino Mice

Objective: To study the gross micro structural changes in the testis of the offspring of Swiss albino mice exposed to oral use of tobacco during pregnancy. Study Design: Experimental Duration and Setting of Study: This study was conducted from July 2017 to December 2017 at Isra University Hyderabad  Methodology: ­­20 female albino mice were mated. After confirmation of pregnancy by vaginal plug they were divided into two groups; experimental A and control B of 10 each. Experimental mice of group A were given 5% tobacco in their chow diet and0water ad libitum; however, control group B were given only normal chow0diet and0water0ad libitum. After 15 days of birth the 10 male offsprings each of control and experimental mice were randomly selected. Their initial and final body weight was recorded.  They were sacrificed0by cervical dislocations and0their testes were taken away for further gross & histological0analysis.  Results: Noticeable changes were observed in the body weight and weight of testes. The mean initial weight of experimental male offspring was found to be 1.76 ± 0.33 g, while in control group it was 2.60± 0.45 g. The final weight in experimental offspring was 9.38± 0.59 g and in control group it was 12.75±0.96 g.  Statistically the difference of body weight in offspring was found to be significant (p value <0.05). The testes weight was markedly decreased in experimental group as compared to control group.  The mean testes weight in experiment group was recorded as 0.03 ± 0.004 g however in control group it was recorded as   0.07 ± 0.004 g. Simultaneously, 5 micro structural variations were also observed in the testes of off-springs of mice. In0the0experimental group0of off-springs, very few0layers and decreased number of spermatocytes were noticed in seminiferous tubules of 9 testes.  Sperm degenerative changes, cellular inflammation and mild to massive hyalinization were noticed in 9, 6, and 9 testes of experimental group respectively. Loss of architecture of seminiferous tubules in 8 testes as well as destruction of the basement membrane in 7 testes were also observed in experiment group testes. However, the decreased number of spermatocytes in only 1 testes and mild hyalinization in 2 testes of control group were observed. Conclusion: The consumption of smokeless tobacco has vital effects on the body weight, micro structure  and weight of testes of offsprings of mice given with cellular injury of seminiferous tubules especially decreased sperm count, cellular inflammation, destruction of basement membrane as well as massive hyalinization. &nbsp

UNDERGROUD COAL GASIFICATION AND UTILIZATION OF SYNGAS IN VARIOUS FIELDS

Coal is the most widely deposited fossil fuel on our planet. That is the reason why it plays a key role in the energy sector. Underground coal gasification (UCG) is a technique that is used in those areas where we cannot getcoal by mining. Those coal reserves having a water layer cannot be extracted by mining easily. So this technique is used where we convert coal in to gas called syngas. This is an atmosphere clean process to reduce 90% Sulphur and CO2in the air called green technology. Thar Desert (Pakistan) has world’s 2nd largest coal reserve of 175 billion ton. In this paper energy scarcity issue in Pakistan has been addressed with focus on thermal psychiatry of Thar coal reserves. The syngas can be utilized for power generation or as feedstock in the production of liquid fuels, fertilizers, or other chemical products.Main benefit for coal gasification in underground is the fact that it is a clean form of energy, because most pollutants remain underground

Structural, surface morphology, dielectric and magnetic properties of holmium doped BiFeO3 thin films prepared by pulsed laser deposition

In this work, Bi1-xHoxFeO3 (with x = 0, 0.05, 0.10, 0.15 and 0.20) thin films were successfully grown on Si (100) substrates using pulsed laser deposition and the effect of Ho doping on the crystal structure, dielectric and magnetic properties were studied. X-ray diffraction studies on undoped BiFeO3 confirmed the presence of a rhombohedral phase with crystallite sizes in the 14–24 nm range. The surface morphology and microstructure of the thin films were analysed by field emission scanning electron microscopy and atomic force microscopy. The results reveal that the grain size decreases as the Ho doping concentration increases. X-ray photoemission spectroscopy was used to identify the chemical bonding, valance band and core levels of Ho doped BiFeO3 thin films. Dielectric constant and loss in Ho doped samples has been measured using a vector network analyzer and shows good dielectric behaviour compared to undoped BiFeO3. A vibrating sample magnetometer was used to investigate the magnetic properties for Ho doping with concentrations of x ≥ 0.15. In comparison to undoped BiFeO3, the doped films exhibited larger remanence and saturation magnetization. The enhancement of these properties due to Ho doping is discussed along with their relevance in designing multiferroic materials based on Bi1-xHoxFeO3 films for magnetic field sensors, multiple-state memories and spintronic elements

Fludrocortisone-a treatment for tubulopathy post-paediatric renal transplantation : a national paediatric nephrology unit experience

Calcineurin inhibitors post-renal transplantation are recognized to cause tubulopathies in the form of hyponatremia, hyperkalemia, and acidosis. Sodium supplementation may be required, increasing medication burden and potentially resulting in poor compliance. Fludrocortisone has been beneficial in addressing tubulopathies in adult studies, with limited paediatric data available. A retrospective review of data from an electronic renal database from December 2014 to January 2016 was carried out. Forty-seven post-transplant patients were reviewed with 23 (49%) patients on sodium chloride or bicarbonate. Nine patients, aged 8.3 years (range 4.9-16.4), commenced fludrocortisone 22 months (range 1-80) after transplant and were followed up for 9 months (range 2-20). All patients stopped sodium bicarbonate; all had a reduction or no increase in total daily doses of sodium chloride. Potassium levels were significantly lower on fludrocortisone, 5.2 vs 4.5 mmol/L, P = .04. No difference was noted in renal function (eGFR 77.8 vs 81.7 mL/min/1.73 m2 , P = .45) and no significant increase in systolic blood pressure (z-scores 0.99 vs 0.85, P = .92). No side effects secondary to treatment with fludrocortisone were reported. A significant proportion of renal transplant patients were on sodium supplementation and fludrocortisone reduced sodium supplementation without significant effects on renal function or blood pressure. Fludrocortisone appears to be safe and effective for tubulopathies in children post-transplantation

Pulmonary Embolism in COVID-19 Patients: Facts and Figures

COVID-19 infection affects many systems in the body including the coagulation mechanisms. Imbalance between pro-coagulant and anticoagulant activities causes a roughly nine times higher risk for pulmonary embolism (PE) in COVID-19 patients. The reported incidence of PE in COVID-19 patients ranges from 3 to 26%. There is an increased risk of PE in hospitalized patients with lower mobility and patients requiring intensive care therapy. Obesity, atrial fibrillation, raised pro-inflammatory markers, and convalescent plasma therapy increases the risk of PE in COVID-19 patients. Endothelial injury in COVID-19 patients causes loss of vasodilatory, anti-adhesion and fibrinolytic properties. Viral penetration and load leads to the release of cytokines and von Willebrand factor, which induces thrombosis in small and medium vessels. D-dimers elevation gives strong suspicion of PE in COVID-19 patients, and normal D-dimer levels effectively rule it out. Point of care echocardiogram may show right heart dilatation, thrombus in heart or pulmonary arteries. DVT increases the risk of developing PE. The gold standard test for the diagnosis of PE is CTPA (computerized tomographic pulmonary angiography) which also gives alternative diagnosis in the absence of PE. Therapeutic anticoagulation is the corner stone in the management of PE and commonly used anticoagulants are LMWH (low molecular weight heparin) and UFH (unfractionated heparin). Mortality in COVID-19 patients with PE is up to 43% compared to COVID patients without PE being around 3%

Diet and asthma: looking back, moving forward

Asthma is an increasing global health burden, especially in the western world. Public health interventions are sought to lessen its prevalence or severity, and diet and nutrition have been identified as potential factors. With rapid changes in diet being one of the hallmarks of westernization, nutrition may play a key role in affecting the complex genetics and developmental pathophysiology of asthma. The present review investigates hypotheses about hygiene, antioxidants, lipids and other nutrients, food types and dietary patterns, breastfeeding, probiotics and intestinal microbiota, vitamin D, maternal diet, and genetics. Early hypotheses analyzed population level trends and focused on major dietary factors such as antioxidants and lipids. More recently, larger dietary patterns beyond individual nutrients have been investigated such as obesity, fast foods, and the Mediterranean diet. Despite some promising hypotheses and findings, there has been no conclusive evidence about the role of specific nutrients, food types, or dietary patterns past early childhood on asthma prevalence. However, diet has been linked to the development of the fetus and child. Breastfeeding provides immunological protection when the infant's immune system is immature and a modest protective effect against wheeze in early childhood. Moreover, maternal diet may be a significant factor in the development of the fetal airway and immune system. As asthma is a complex disease of gene-environment interactions, maternal diet may play an epigenetic role in sensitizing fetal airways to respond abnormally to environmental insults. Recent hypotheses show promise in a biological approach in which the effects of dietary factors on individual physiology and immunology are analyzed before expansion into larger population studies. Thus, collaboration is required by various groups in studying this enigma from epidemiologists to geneticists to immunologists. It is now apparent that this multidisciplinary approach is required to move forward and understand the complexity of the interaction of dietary factors and asthma

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015

SummaryBackground The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context. Methods We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors—the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI). Findings Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6–58·8) of global deaths and 41·2% (39·8–42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa. Interpretation Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden. Funding Bill & Melinda Gates Foundation

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London