Changing clinico-laboratory profile of encephalitis patients in the eastern Uttar Pradesh region of India

A cross-sectional study was done on 100 consecutive paediatric patients presenting with acute encephalitis syndrome. The clinico-laboratory features of all patients were recorded in a prestructured performa. Cerebrospinal fluid and serum samples were tested for: Japanese encephalitis (JE) virus; Chandipura virus; coxsackie virus; dengue virus; enterovirus 76; and West Nile virus. Twenty-two (22.0%) patients were confirmed JE cases and 17% had parasitic or bacteriological aetiology. The remaining 61 cases (61.0%) in which no viral aetiological agent was found were grouped as non-JE cases. Peripheral vascular failure, splenomegaly and hypotonia were distinguishing clinical features found in the non-JE patients. A high mortality of 26.5% was seen in patients with confirmed or presumptive viral encephalitis (22/83). A fatal outcome was independently associated with peripheral vascular failure and pallor at the time of admission. Early recognition of these signs may help clinicians to manage these cases.     

Anticoagulants for the treatment of acute coronary syndrome in the era of new oral agents

Acute coronary syndromes (ACS) cause cessation of myocardial blood flow leading to coronary ischemia. The standard medical treatment includes heparin or low molecular weight heparin in the hospital, antiplatelet agents in the hospital and long term, and occasionally warfarin long term. All of these therapies are associated with bleeding complications. Furthermore, warfarin, with its narrow therapeutic window and need for frequent laboratory monitoring, poses several disadvantages. The development of novel oral factor Xa inhibitors and oral direct thrombin inhibitors may provide an alternative to warfarin. In this review, we discuss the new agents, rivaroxaban, apixaban, and dabigatran, for the potential treatment of ACS. We also review the relevant clinical trials evaluating their effects in ACS. These novel anticoagulants allow convenience of use with no requirement for laboratory monitoring and limited drug interactions, which may provide multifaceted treatment options for ACS and anticoagulation in the future.     

Impact of a Recent Lead Recall on Utilization of Implantable Cardioverter Defibrillators: Data from the NCDR ICD Registry™

Impact of Recalls on ICD Utilization . Introduction: Underutilization of ICDs is well documented. It has been hypothesized that device recalls, and the resultant negative publicity, may contribute. Methods and Results: To determine if the October 2007 recall of the Medtronic Fidelis lead was associated with a decrease in volume of ICD procedures in the United States, we analyzed data submitted to the ICD Registry? between July 2006 and December 2008. Time‐series analyses were performed comparing actual and predicted implant volumes following the recall, using monthly data from July 2006 to September 2007 to establish a trend line. Observed data points falling outside the 95% CIs from the trend line were considered statistically significant. The study cohort includes 173,616 implantations in 658 hospitals. Before October 2007, an average of 5,952 devices, 4,910 for primary prevention, were implanted per month. Following the recall, the average monthly number of implants was modestly lower at 5,623 (P = 0.05), 4,601 for primary prevention (P = 0.01.) However, as volume was decreasing prior, in time‐series analysis, the observed monthly implant volume for primary prevention devices differed from expected based on the trend line for only 1 month. The proportion of Medtronic implants declined from 51.1% in the 15 months prior to the recall to 45.8% in the 15 months of the recall or after (P < 0.01), falling outside the 95% CI of the trend line for 3 months in time‐series analysis. Conclusions: A recent well‐publicized lead recall had minimal impact on ICD utilization either overall or for primary prevention. (J Cardiovasc Electrophysiol, Vol. 23, pp. 861‐865, August 2012)     

Comparison of total body irradiation versus non-total body irradiation containing regimens for de novo acute myeloid leukemia in children

With limited data comparing hematopoietic cell transplant outcomes between myeloablative total body irradiation (TBI) containing and non-TBI regimens in children with de novo acute myeloid leukemia, the aim of this study was to compare transplant-outcomes between these regimens. Cox regression models were used to compare transplant-outcomes after TBI and non-TBI regimens in 624 children transplanted between 2008 and 2016. Thirty two percent (n=199) received TBI regimens whereas 68% (n=425) received non-TBI regimens. Five-year non-relapse mortality was higher with TBI regimens (22% vs. 11%, P<0.0001) but relapse was lower (23% vs. 37%, P<0.0001) compared to non-TBI regimens. Consequently, overall (62% vs. 60%, P=1.00) and leukemia-free survival (55% vs. 52%, P=0.42) did not differ between treatment groups. Grade 2-3 acute graft versus host disease was higher with TBI regimens (56% vs. 27%, P<0.0001) but not chronic graft versus host disease. The 3-year incidence of gonadal or growth hormone deficiency was higher with TBI regimens (24% vs. 8%, P<0.001) but there were no differences in late pulmonary, cardiac or renal impairment. In the absence of a survival advantage, the choice of TBI or non-TBI regimen merits careful consideration with the data favoring non-TBI regimens to limit the burden of morbidity associated with endocrine dysfunction.     

Passage through the carotid sheath: An alternative path to the pre-spinal route for direct repair of contralateral C7 to the lower trunk in total brachial plexus root avulsion injury

Context:In surgical management of global brachial plexus injuries, direct repair of contralateral C7 (cC7) to the anterior division of the lower trunk, can produce good extrinsic finger flexion. The pitfalls associated with the pre-spinal passage have, perhaps, proved to be a deterrent for using this technique routinely.Aims:The aim of this study is to demonstrate an alternative to pre-spinal route for cC7 transfer in brachial plexus avulsion injuries.Methods:We noted that the mobilised lower trunk, which reaches the level of the scalenus anterior by passage deep to the clavicle, can be brought to the suprasternal notch when brought out from below the clavicle. This area was dissected in two cadavres, and safe passage was found through the carotid sheath with the common carotid artery medially and the internal jugular vein with the vagus nerve laterally. The cC7 root dissected medial to the scalenus anterior muscle can be directly transferred along this path to the subcutaneous plane at the suprasternal notch. This study allowed us to execute a direct repair in ten clinical cases of global brachial plexus injuries. In each case, the passage was prepared rapidly and uneventfully. The repair was technically simple and could be performed comfortably using suitable fine suture materials. In none of these cases, did we need to shorten the humerus.Results:The clinical outcome of this technique is awaited.Conclusions:We advocate carotid sheath route to approximate the cC7 to the injured lower trunk in global palsies, as the risks associated with the pre-spinal route can be readily avoided.KEY WORDS: Anterior division of lower trunk, brachial plexus injury, carotid sheath route, contralateral C7, direct repair, finger flexion