Clinical Predictors of Fulminant Colitis in Patients with Clostridium difficile Infection

Background/Aim:

Clostridium difficile infection (CDI) can affect up to 8% of hospitalized patients. Twenty-five percent CDI patients may develop C. difficile associated diarrhea (CDAD) and 1–3% may progress to fulminant C. difficile colitis (FCDC). Once developed, FCDC has higher rates of complications and mortality.

Patients and Methods:

A 10-year retrospective review of FCDC patients who underwent colectomy was performed and compared with randomly selected age- and sex-matched non-fulminant CDAD patients at our institution. FCDC (n=18) and CDAD (n=49) groups were defined clinically, radiologically, and pathologically. Univariate analysis was performed using Chi-square and Student''s t test followed by multivariate logistic regression to compute independent predictors.

Results:

FCDC patients were significantly older (77 ± 13 years), presented with triad of abdominal pain (89%), diarrhea (72%), and distention (39%); 28% had prior CDI and had greater hemodynamic instability. In contrast, CDAD patients were comparatively younger (65 ± 20 years), presented with only 1 or 2 of these 3 symptoms and only 5% had prior CDI. No significant difference was noted between the 2 groups in terms of comorbid conditions, use of antibiotics, or proton pump inhibitor. Leukocytosis was significantly higher in FCDC patients (18.6 ± 15.8/mm³ vs 10.7 ± 5.2/mm³; P=0.04) and further increased until the point of surgery. Use of antiperistaltic medications was higher in FCDC than CDAD group (56% vs 22%; P=0.01).

Conclusions:

Our data suggest several clinical and laboratory features in CDI patients, which may be indicative of FCDC. These include old age (>70 years), prior CDI, clinical triad of increasing abdominal pain, distention and diarrhea, profound leukocytosis (>18,000/mm³), hemodynamic instability, and use of antiperistaltic medications.     

Penile Incarceration with Metallic Foreign Bodies: Management and Review of Literature

Introduction

Penile strangulation from constricting metallic objects disorders is an uncommon urological emergency which requires prompt intervention to prevent complications. The treatment modalities are diverse and characterized by lack of consensus.

Material and Methods

Three cases with penile incarceration due to constricting metallic objects who presented to our department were included in this study. All 3 patients required different management options highlighting the diversity of clinical presentation and need for customization of treatment as per the clinical scenario.

Results

The 3 patients required different approach for treatment. First patient could be managed by degloving of penile skin while second patient required mechanical removal of the foreign body and debridement of local necrotic tissues. The third patient had to undergo excision of gangrenous penile skin and skin grafting.

Conclusion

The study emphasizes the diversity of clinical presentations and the need for employing different surgical techniques to achieve the desired results.Key Words: Penile strangulation, Constricting objects, Penile amputation     

Cardiorespiratory fitness is not associated with risk of venous thromboembolism: a cohort study

Abstract

Objectives. The inverse and independent association between cardiorespiratory fitness (CRF) and arterial thrombotic disease is well established. However, the potential association between CRF and venous thromboembolism (VTE) is not well known. We aimed to assess the prospective association of CRF with the risk of VTE. Design. Cardiorespiratory fitness, as measured by maximal oxygen uptake (VO_2max), was assessed using a respiratory gas exchange analyser in 2,249 men aged 42–61 years without a history of VTE at baseline in the Kuopio Ischemic Heart Disease prospective cohort. Cox-regression models were used to calculate hazard ratios (HR) with 95% confidence interval (CI) for VTE. We corrected for within-person variability in CRF levels using data from repeat measurements taken several years apart. Results. There were 144 (6.4%) incident VTE events recorded during a median follow-up of 25.2 years. The age-adjusted regression dilution ratio of CRF was 0.58 (95% CI: 0.53–0.64). The risk of VTE did not significantly decrease per 1 standard deviation increase in CRF in age-adjusted analysis (HR 0.90; 95% CI 0.75–1.08). The association remained consistent in analyses adjusted for several established and emerging risk factors (HR 0.90; 95% CI 0.73–1.12). The corresponding adjusted HRs were 0.80 (95% CI: 0.52–1.23) and 0.82 (95% CI: 0.51–1.32) respectively, when comparing the extreme tertiles of CRF levels. Conclusions. In a middle-aged Caucasian male population, CRF was not associated with future risk of VTE. Further studies are required to confirm and to generalize these findings, particulary in women and other age groups.     

Alcohol consumption and the risk of stroke among hypertensive and overweight men

High blood pressure and overweight are risk factors for stroke. The aim of the present study was to examine the association between alcohol consumption and the risk of stroke according to the level of blood pressure and body weight. This study is a population-based sample of men with an average follow-up of 14.9 years from eastern Finland. A total of 2,599 men with no history of stroke at baseline participated. During the follow-up period, 224 strokes occurred, of which 181 were ischemic strokes. After adjustment for age, year of examination, socioeconomic status, serum LDL cholesterol, body mass index, smoking and energy expenditure of physical activity (kcal/day), there was a significant trend of an increased risk for any and ischemic stroke among hypertensive men. Hypertensive (blood pressure of over 140/90 mm Hg) men, who did not consume alcohol had a 1.72-fold (95 % CI 1.12–2.66; p = 0.014) relative risk (RR) for any stroke and a 1.90-fold (95 % CI 1.15–3.13; p = 0.012) RR for ischemic stroke. Among hypertensive men who consumed alcohol RR was 1.86-fold (95 % CI 1.20–2.89; p = 0.005) for any stroke and 2.02-fold (95 % CI 1.21–3.35; p = 0.007) for ischemic stroke. Men who did not consume alcohol with elevated BMI (≥26.4 kg/m²) had a 1.63-fold RR (95 % CI 1.11–2.40; p = 0.013) for any stroke and a 1.33-fold RR (95 % CI 0.87–2.04; p = 0.199) for ischemic stroke after adjusting for risk factors. Overweight men (≥26.4 kg/m²) who consumed alcohol had a 1.73-fold RR (95 % CI 1.18–2.54; p = 0.005) for any stroke and a 1.71-fold RR (95 % CI 1.14–2.57; p = 0.010) for ischemic stroke after being adjusted for risk factors. In conclusion, this population-based prospective study shows that hypertensive and overweight men who consumed alcohol had an increased risk for stroke.     

The Mental Health Country Profile: background,design and use of a systematic method of appraisal

This article describes the construction and use of a systematic structured method of mental health country situation appraisal, in order to help meet the need for conceptual tools to assist planners and policy makers develop and audit policy and implementation strategies. The tool encompasses the key domains of context, needs, resources, provisions and outcomes, and provides a framework for synthesizing key qualitative and quantitative information, flagging up gaps in knowledge, and for reviewing existing policies. It serves as an enabling tool to alert and inform policy makers, professionals and other key stakeholders about important issues which need to be considered in mental health policy development. It provides detailed country specific information in a systematic format, to facilitate global sharing of experiences of mental health reform and strategies between policy makers and other stakeholders. Lastly, it is designed to be a capacity building tool for local stakeholders to enhance situation appraisal, and multisectorial policy development and implementation.     

India mental health country profile

India, the second most populated country of the world with a population of 1.027 billion, is a country of contrasts. It is characterized as one of the world's largest industrial nations, yet most of the negative characteristics of poor and developing countries define India too. The population is predominantly rural, and 36% of people still live below poverty line. There is a continuous migration of rural people into urban slums creating major health and economic problems. India is one of the pioneer countries in health services planning with a focus on primary health care. Improvement in the health status of the population has been one of the major thrust areas for social development programmes in the country. However, only a small percentage of the total annual budget is spent on health. Mental health is part of the general health services, and carries no separate budget. The National Mental Health Programme serves practically as the mental health policy. Recently, there was an eight-fold increase in budget allocation for the National Mental Health Programme for the Tenth Five-Year Plan (2002–2007). India is a multicultural traditional society where people visit religious and traditional healers for general and mental health related problems. However, wherever modern health services are available, people do come forward. India has a number of public policy and judicial enactments, which may impact on mental health. These have tried to address the issues of stigma attached to the mental illnesses and the rights of mentally ill people in society. A large number of epidemiological surveys done in India on mental disorders have demonstrated the prevalence of mental morbidity in rural and urban areas of the country; these rates are comparable to global rates. Although India is well placed as far as trained manpower in general health services is concerned, the mental health trained personnel are quite limited, and these are mostly based in urban areas. Considering this, development of mental health services has been linked with general health services and primary health care. Training opportunities for various kinds of mental health personnel are gradually increasing in various academic institutions in the country and recently, there has been a major initiative in the growth of private psychiatric services to fill a vacuum that the public mental health services have been slow to address. A number of non-governmental organizations have also initiated activities related to rehabilitation programmes, human rights of mentally ill people, and school mental health programmes. Despite all these efforts and progress, a lot has still to be done towards all aspects of mental health care in India in respect of training, research, and provision of clinical services to promote mental health in all sections of society.     

Clinical profile and outcome of myasthenic crisis in a tertiary care hospital: A prospective study

Background:

The present understanding of the clinical course, complications, and outcome of myasthenic crisis (MC) is based chiefly on observational studies and retrospective case series.

Aim:

To study the baseline demographic and clinical variables, risk factors, complications, outcome, and mortality in patients of MC.

Materials and Methods:

All patients of myasthenia gravis (MG) who presented with myasthenic crisis between July 2009 and December 2010 were included.

Results:

Ten patients of MC were included in this study. The median age of the patients was 40.5 years (range 14-71 years). Seven were females and three were males. Nine had generalized MG and one patient had oculobulbar involvement only. Median duration of disease was 3 years (range 1 month to17 years). Two patients had thymoma. Two patients had history of thymectomy in the past. Infection was the most common triggering factor accounting for five cases (50%) followed by inadequate treatment/drug withdrawal in three (30%) and steroid initiation and hypokalemia in the remaining two patients (20%). Median duration of MC was 12 days (range 3-28 days). Mortality was in 3 out of 10 (30%) during MC. Management in the intensive care unit (ICU) and treatment with plasma exchange/intravenous immunoglobulins were associated with good outcome.

Conclusions:

Ventilator support and management in intensive care unit are the most important components in the management of MC. The high mortality rate seen in present study may be more reflective of the actual ground reality in resource constrained developing countries, however, larger prospective studies are needed to confirm these findings.     

Muscle-Directed Anti-Aβ Single-Chain Antibody Delivery via AAV1 Reduces Cerebral Aβ Load in an Alzheimer’s Disease Mouse Model

We previously reported that anti-amyloid-beta (Aβ) single-chain antibody (scFv59) brain delivery via recombinant adeno-associated virus (rAAV) was effective in reducing cerebral Aβ load in an Alzheimer’s disease (AD) mouse model without inducing inflammation. Here, we investigated the prophylactic effects and mechanism of a muscle-directed gene therapy modality in an AD mouse model. We injected rAAV serotype 1 encoding scFv59 into the right thigh muscles of 3-month-old mice. Nine months later, high levels of scFv59 expression were confirmed in the thigh muscles by both immunoblotting and immunohistochemistry. As controls, model mice were similarly injected with rAAV1 encoding antihuman immunodeficiency virus Gag antibody (scFvGag). AAV1-mediated scFv59 gene delivery was effective in decreasing Aβ deposits in the brain. Compared with the scFvGag group, levels of Aβ in cerebrospinal fluid (CSF) decreased significantly while Aβ in serum tended to increase in the scFv59 group. AAV1-mediated scFv59 gene delivery may alter the equilibrium of Aβ between the blood and brain, resulting in an increased efflux of Aβ from the brain owing to antibody-mediated sequestration/clearance of peripheral Aβ. Our results suggest that muscle-directed scFv59 delivery via rAAV1 may be a prophylactic option for AD and that levels of CSF Aβ may be used to evaluate the efficacy of anti-Aβ immunotherapy.