Risk factors for complications and in-hospital mortality: An analysis of 19,834 open pelvic ring fractures

BackgroundOpen pelvic fractures are rare injuries, associated with high patient morbidity and mortality. Few studies have investigated the impact of patient demographics, comorbidities, and injury related factors on complication and mortality rates. The purpose of this study was to: (1) identify the overall incidence of complications and mortality after open pelvic fractures, (2) compare patient factors between those who did and did not develop complications, (3) identify perioperative independent risk factors for complications and mortality.MethodsA query was performed for patients with open pelvic fractures between 2007 and 2017 using the American College of Surgeons National Trauma Data Bank. Patient and injury specific variables were collected and complications were identified using International Classification of Disease Ninth and Tenth edition Codes. Patient demographic and perioperative data was compared using Fisher’s exact test and chi-square test for categorical variables, and Welch’s t-test for continuous variables. Using pooled data from multiple imputations, logistic regressions were used to calculate odds ratios and confidence intervals of independent risk factors for complications.ResultsA total of 19,834 open pelvic fracture cases were identified, with 9622 patients (48.5%) developing at least one complication. Patients who developed complications were older (35.0 vs 38.1 years), and had higher Injury Severity Scores (17.7 vs 26.5), lower Glasgow Coma Scores (14.2 vs 11.7), and a larger proportion presenting with hypotension (21% vs 6.9%). After pooled regression involving 19 factors, these were the strongest independent predictors of inpatient complication and mortality.ConclusionWe report a mortality rate of 14%, with an inclusive complication rate of 48.5%. Evaluating risk factors for morbidity and mortality for this devastating orthopaedic injury provides knowledge of an inherently sparse population.Level of EvidenceLevel II, Retrospective study.     

Frontal osteomyelitis presenting as upper eyelid ectropion: A cautionary tale

Frontal osteomyelitis is a rare clinical entity that can occur as sequelae to frontal sinusitis, head trauma, as a postoperative complication following sinus surgery or due to haematogenous spread. It usually presents with a soft, fluctuant forehead swelling with pain and fever. Cicatricial ectropion is an extremely rare feature of frontal osteomyelitis. We present a young male patient presenting with cicatricial ectropion that occurred as the sole manifestation of an underlying frontal osteomyelitis. Extensive Medline search did not find any such reported case. We feel that frontal osteomyelitis should be kept in mind as a possible etiology when considering the differential diagnosis of cicatricial ectropion.     

Neurological manifestations in m.3243A>G-related disease triggered by metformin

Introductionm.3243A>G-related disease has multi-systemic manifestations including diabetes mellitus. It is uncertain whether metformin would trigger neurological manifestations of this disease. This study aims to review the diagnosis and management of m.3243A>G-related diabetes genetically confirmed by our laboratory and to evaluate the risk of metformin use triggering neurological manifestations.MethodsCases with m.3243A>G detected between 2009 and 2020 were reviewed. Cases with diabetes mellitus were included. Cases with mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) before diabetes onset were excluded. Odds ratio was calculated for association between metformin use and newly developed neurological manifestations.ResultsSixteen patients were identified. Odds ratio for metformin use was 3.50 [0.37–33.0; p = 0.3287]. One illustrative case with clear causal relationship between metformin use and neurological manifestations was described in detail.Conclusionm.3243A>G-related diabetes mellitus is underdiagnosed. Red flags including positive family history, short stature, low body weight and hearing loss are often overlooked. Early diagnosis allows regular systemic assessment. In the era of precision medicine and novel therapies, it is prudent to avoid metformin as it could trigger neurological manifestations in this condition. Coenzyme Q10, DPP-IV inhibitors, SGLT2 inhibitors and GLP-1 receptor agonists may be considered.     

Isolation and study of insulin activated nitric oxide synthase inhibitory protein in acute myocardial infarction subjects

Insulin inhibits platelet aggregation through nitric oxide synthesis by stimulating platelet insulin activated nitric oxide synthase. Impaired platelet insulin activated nitric oxide synthase in acute myocardial infarction (AMI) patients had been reported and thus our aim was to identify and isolate the factors impairing insulin activated nitric oxide in acute myocardial infarction patients’ plasma and study its effect on platelets aggregation in vitro. The insulin activated nitric oxide synthase inhibitor was identified as a protein and was purified from the plasma of AMI subjects using DEAE cellulose and Sephadex G-50 column, molecular weight determined by SDS-PAGE, nitric oxide quantified by methaemoglobin method, inhibitor protein quantified in plasma by immunoblot and ELISA, platelet aggregation studies done using an aggregometer, thromboxane-A2 in the platelets determined by radioimmunoassay, ¹²⁵I-insulin radioligand binding studies done using normal subject platelets. The purified nitric oxide synthase inhibitor protein was ~66 kDa, concentration in AMI subjects’ plasma varied from 114 to 9,090 μM and was undetected in normal subjects’ plasma. The inhibitor protein competes with insulin for insulin receptor binding sites. The Incubation of the normal subject PRP with 5.0 μM inhibitor for 30 min followed by 0.4 μM ADP addition caused platelet aggregation in vitro, 130 μM aspirin or 400 μU insulin/ml addition was able to abrogate 0.4 μM ADP induced platelet aggregation even in the presence of 5.0 μM inhibitor. A potent inhibitory protein against insulin activated nitric oxide synthase in platelets appears in circulation of AMI subjects impairing nitric oxide production, potentiating ADP induced platelet aggregation and increasing the thromboxane-A2 level in platelets.     

Oral hypoglycaemic agent failure

Type 2 diabetic patients initially respond satisfactorily to diet, exercise and oral hypoglycaemic agents (OHA), but a fraction of them acquires resistance to drugs, right from the beginning (primary OHA failure) or in due course of time (secondary OHA failure) and becomes insulin requiring ultimately. Poor diet compliance and deterioration of beta-cell function are major causes of OHA failure and annual incidence is 3 to 30%. Keeping in mind the benefit of organ salvage in diabetes, failure with OHA treatment should be detected earliest and necessary measures adopted as early as possible. Recognition, appraisal and assessment of total problem can help a diabetic to enjoy a normal life.     

A case of chronic chest wall sinus

A 17-year-old Muslim female presented with a swelling over the chest wall underneath her left breast. The swelling was aspirated and the cytology report of the aspirated material showed it to be of pyogenic origin. An incision and drainage was done, after which the patient presented with a non-healing discharging sinus at the same site. The exact nature of the disease was known only after excising the sinus tract with the affected rib.     

Clinical pattern of ocular manifestations in vitiligo

To study the ocular abnormalities in cases of vitiligo, 100 patients were examined who underwent a series of investigations e.g., complete haemogram, urine analysis, blood biochemistry and chest x-ray and 70 cases were taken as control. Patients with systemic diseases such as diabetes mellitus, thyroid and auto-immune disorders were excluded. Detailed ocular examinations including recording of vision, slit-lamp biomicroscopy, gonioscopy, ophthalmoscopy and examination of fundus by 90 D lens were done. Of 100 vitiligo patients, 23% showed hypopigmented sports on the iris, 18% pigmentation on anterior chamber, 9% retinal pigment epithelium hypopigmentation, 5% uveitis, 11% had chorioretinal degeneration and 34% had no ocular findings. There lies a strong association of ocular disorder in patients with vitiligo.     

Novel treatment of atrophic rhinitis: early results

The aim of this randomized control trial, performed at a tertiary referral hospital, was to compare the therapeutic effectiveness of two novel treatment modalities, oral rifampicin and submucosal placentrex injection, in randomly selected patients of primary atrophic rhinitis regarding objective, subjective and histopathological improvement. Patients treated with oral rifampicin showed most promising results regarding objective, subjective and histopathological improvement with maximum disease-free interval on regular follow-up as compared to submucosal placentrex injections.     

Population genetic data for 11 X-STR loci in eleven populations of India

Allele frequencies and forensic parameters were estimated for 11 X chromosome STRs (DXS9898, DXS7424, DXS981, DXS8377, DXS9895, DXS10161, DXS10164, DXS6800, DXS6801, DXS9902 and DXS7423) from 749 samples of unrelated male individuals belonging to eleven populations of India.