What does adolescent undiagnosed wheeze represent? Findings from the Isle of Wight Cohort

We sought to characterise adolescent wheeze in the absence of asthma, which we termed "undiagnosed wheeze". The Isle of Wight Birth Cohort (n=1,456) was reviewed at 1, 2, 4, 10 and 18 yrs. Using questionnaire responses, "asthma" was defined as "ever had asthma" plus either "wheezing in the last 12 months" or "taking asthma treatment in the last 12 months"; "undiagnosed wheeze" as "wheeze in the last 12 months" but "no" to "ever had asthma"; and remaining subjects termed "non-wheezers". Undiagnosed wheeze (prevalence 4.9%) accounted for 22% of wheezing at 18 yrs. This was largely adolescent-onset with similar symptom frequency and severity to diagnosed asthma. However, undiagnosed wheezers had significantly higher forced expiratory volume in 1 s to forced vital capacity ratio, less bronchodilator reversibility and bronchial hyperresponsiveness, and were less frequently atopic than asthmatics. Undiagnosed wheezers had earlier smoking onset, higher smoking rates and monthly paracetamol use than non-wheezers. Logistic regression identified paracetamol use (OR 1.11, 95% CI 1.01-1.23; p=0.03), smoking at 18 yrs (OR 2.54, 95% CI 1.19-5.41; p=0.02), rhinitis at 18 yrs (OR 2.82, 95% CI 1.38-5.73; p=0.004) and asthmatic family history (OR 2.26, 95% CI 1.10-4.63; p=0.03) as significant independent risk factors for undiagnosed wheeze. Undiagnosed wheeze is relatively common during adolescence, differs from diagnosed asthma and has strong associations with smoking and paracetamol use. Better recognition of undiagnosed wheeze and assessment of potential relevance to adult health is warranted.     

Comparative evaluation of VATS assisted combined mechanical and chemical pleurodesis with chemical pleurodesis—is it worthwhile?

Introduction

Malignant Pleural Effusion (MPE) is a common terminal clinical problem in patients with advance cancer. Treatment options for MPE include observation, thoracocentesis, or pleurodesis. In the current study, we compared the effectiveness and safety of combined mechanical and chemical pleurodesis by Video Assisted Thoracoscopic Surgery (VATS) with chemical pleurodesis via intercostals tube alone, using talc as pleurodesis agent in both.

Material and methods

In this prospective study, diagnosed patients of MPE having Eastern Cooperative Oncology Group (ECOG) performance score 3 or less 3, expected life expectancy of more than 3 months, and having lung re-expansion after drainage were selected for pleurodesis. Patients with ability to undergo general anesthesia were considered for VATS assisted combined mechanical & chemical pleurodesis (Group A). In the remaining chemical pleurodesis was performed at bedside (Group B).

Results

The duration of this study was 1 year. The total number of patients was 30. There were 15 patients each in both the groups. Pleurodesis was achieved in 4.47?±?0.92 days in group A and 6.33?±?0.90 days in group B. This difference was highly significant (p?<?0.0001). Post procedural complaints were more or less same in both the groups.

Conclusion

Combined mechanical and chemical pleurodesis (VATS assisted) appears to be superior to chemical pleurodesis, as it offers less morbidity, lesser hospital stay, and complete response in follow up. This modality may be used in patients of MPE for palliation, who are fit for general/ regional anesthesia.     

Thoracic trauma trends in Northern India- single center experience

Introduction

Thoracic trauma comprises 10–15 % of all traumas. The incidence and etiological pattern of chest trauma varies from region to region and is related to cultural and socio-political circumstances. This paper details our experience with thoracic trauma in a North Indian state.

Material & methods

All patients who were hospitalized for thoracic trauma from June 2010 to June 2012 in our hospital were enrolled. Data was collected prospectively and analysed. Factors analysed were age, gender, mode of injury, type of thoracic injury, associated injuries, management modalities, and outcome.

Results

The total number of patients was 250. The male to female ratio was about 10:1. The mean age of patients was 36.62 years. Road Traffic Accident (RTA) was the most common mode of chest injury. Motor-bike accident was the most common type of RTA. Majority of patients were managed with tube thoracostomy (183, 73.2 %). One hundred and eighty nine (75.6 %) patients were discharged after recovery. Ten (4.0 %) patients absconded. In all, 29 (11.6 %) patients died, while 22 (8.8 %) patients left the hospital against medical advice. A significant association between presence of associated injury and outcome was observed (p?<?0.001). We found mortality rate was significantly higher in chest injury associated with neurotrauma and abdominal visceral injury.

Conclusion

Chest trauma is a major health problem since it has high morbidity and mortality rate. The majority of patients with simple chest injuries can be managed by tube thoracostomy. According to our analysis; mortality predictors were: RTAs, blunt chest trauma, unstable hemodynamic status upon arrival, neurotrauma, abdominal visceral injury, flail chest, ventilator use, cardiac contusion and complications of therapy.     

Median nerve compression by a large cephalic vein aneurysm—a case report

The term aneurysm is derived from the Greek word aneurysma, meaning “a widening.” In current vascular surgery practice, an aneurysm is defined as a permanent localized dilatation of any vessel, having at least a 50 % increase in diameter compared with the expected normal diameter (Suggested standards for reporting on arterial aneurysms; Johnston et al., J Vasc Surg, 13: 452–458, 1991). Generally, this term is used for arteries as it is more common in them, but it can also be used for veins which are extremely rare presentation. In our case, a middle-aged female presented with complaints of swelling over the right mid-forearm flexor aspect with difficulty in flexing her wrist and paraesthesia over the right index finger and thumb. The patient was examined and diagnosed as a case of cephalic vein aneurysm compressing the median nerve. She underwent surgical resection of the involved segment of the cephalic vein. Venous aneurysm is a rare disorder and till date only few cases have been reported in English literature; however, its possibility should be kept when dealing with a subcutaneous mass in upper limb.     

Dual inhibition of cyclooxygenase and lipoxygenase enzymes by human cerebrospinal fluid

Thromboxane A₂ (TXA₂) formed in damaged brain tissue and after thromboembolism and subarachnoid haemorrhage is responsible for cerebral vasospasm. In the present study, we examined the effect of human cerebrospinal fluid (CSF) on the production of thromboxane-A₂ (TXA₂) and 12-hydroxy-eicosatetraenoic acid (12-HETE) by human blood platelets. CSF was drawn by lumbar puncture from normal healthy volunteers (n = 17) and samples judged to be normal after routine examination in the clinical laboratories and were used fresh. We found that CSF inhibited the production of TXA₂ and 12-HETE by blood platelets incubated with C¹⁴ labelled arachidonic acid (AA) in a concentration-related manner. Further biochemical analysis using proteolytic enzymes, gel filtration and membrane partition chromatography showed that the inhibitory activity was peptidic in nature and associated with a peptide of low molecular weight (1,400 Da). This study is the first to demonstrate that human CSF contains a dual inhibitor of cyclooxygenase (COX) and lipoxygenase enzymes in CSF.     

In silico and in vitro evaluation of two novel oximes (K378 and K727) in comparison to K-27 and pralidoxime against paraoxon-ethyl intoxication

Organophosphate (OP) poisoning is a major global health issue; while compounds from this group have been used intensively over the last century, an effective antidote is still lacking. Oxime-type acetylcholinesterase (AChE) reactivators are used to reactivate the OP inhibited AChE. Pralidoxime is the only US Food and Drug Administration approved oxime for therapeutic use but its efficacy has been disappointing. Two novel oximes (K378 and K727) were investigated in silico and in vitro and compared with an experimental oxime (kamiloxime; K-27) and pralidoxime. In silico the molecular interactions between AChE and oximes were examined and binding energies were assessed. LogP (predicted log of the octanol/water partition coefficient) was estimated. In vitro the intrinsic ability of the oximes to inhibit AChE (IC₅₀) and their reactivation potency (R₅₀) when used in paraoxon inhibited human RBC-AChE was determined. Molecular docking revealed that K378 and K727 bind to the peripheral site(s) with high binding energies in contrast to the central binding of K-27 and pralidoxime. LogP values indicating that the novel compounds are significantly less hydrophilic than K-27 or pralidoxime. IC₅₀ of K378 and K727 were comparable (0.9 and 1?µM, respectively) but orders of magnitude lower than comparators. R₅₀ values revealed their inability to reactivate paraoxon inhibited AChE. It is concluded that the novel oximes K378 and K727 are unlikely to be clinically useful. The in silico and in vitro studies described allow avoidance of unnecessary in vivo animal work and contribute to the reduction of laboratory animal use.     

Massive repeated nose bleeding after bimaxillary osteotomy

In LeFort I surgery, the separation of the pterygomaxillary junction is done by osteotomy. Although the osteotome is positioned too close to the maxillary artery and its branches during pterygomaxillary separation, postoperative complications from vascular injuries are uncommon. We describe an unusual occurrence of a maxillary artery pseudoaneurysm after LeFort I and bilateral sagittal split osteotomies for maxillary advancement and mandibular setback as well as (anterior sliding) genioplasty. In a patient with class III occlusion and midface retrusion, the significant bleeding began 10 days postoperatively, which was controlled by anterior and posterior nasal packing. The bleeding recurred 28 days after surgery; thus, vascular anatomy in the pterygomaxillary area is reviewed, pseudoaneurysm was diagnosed on selective carotid angiography and successfully treated by embolization; and 2-year follow up was uneventful.