Neurotoxic and cardiotoxic effects of cocaine and ethanol

Introduction

Concurrent abuse of alcohol and cocaine results in the formation of cocaethylene, a powerful cocaine metabolite. Cocaethylene potentiates the direct cardiotoxic and indirect neurotoxic effects of cocaine or alcohol alone.

Case Report

A 44-year-old female with history of cocaine and alcohol abuse presented with massive stroke in the emergency department. CT scan revealed extensive left internal carotid artery dissection extending into the left middle and anterior cerebral arteries resulting in a massive left hemispheric infarct, requiring urgent decompressive craniectomy. The patient had a stormy hospital course with multiple episodes of torsades de pointes in the first 4 days requiring aggressive management. She survived all events and was discharged to a nursing home with residual right hemiplegia and aphasia.

Conclusion

The combination of ethanol and cocaine has been associated with a significant increase in the incidence of neurological and cardiac emergencies including cerebral infarction, intracranial hemorrhage, myocardial infarction, cardiomyopathy, and cardiac arrhythmias. The alteration of cocaine pharmacokinetics and the formation of cocaethylene have been implicated, at least partially, in the increased toxicity of this drug combination.

     

Fasting times in caregivers of children presenting for ambulatory surgery

Background:  It has been the anecdotal experience in this unit that many parents and guardians of children presenting for day-case surgery also fast along with their child for prolonged periods of time. There have been several episodes of parents feeling dizzy or nauseated on leaving the anesthetic room after induction of anesthesia, and many incidents of fainting in recovery when collecting their child. Our purpose was to investigate this theme further, by auditing the fasting times of caregivers coming to the induction room over a 3-month period. This information has not been previously described in the literature.
Methods:  We carried out a prospective audit of current practice. Data were collected by questionnaire, which caregivers were requested to complete in the holding area, after the child was checked in for theatre.
Results:  Two hundred and fifty-seven caregivers fasted for 0–6 h and 223 fasted for >6 h. One hundred and fourteen caregivers fasted for 7–12 h and 109 caregivers fasted between 13 and 19 h.
Conclusions:  A large proportion of parents choose to fast with their children. Some caregivers fast for long periods. In general, this does not cause any ill effects, although some parents missed routine medications while fasting.     

Endoscopic removal of bullet from orbital apex

Penetrating injuries of face are not uncommon. Bullets or pallets may be lodged anywhere in the cavities of skull as a result of firearm injury. Lodgment of a bullet within the orbit through nose is uncommon. An eighteen 18 years old married woman sustained a bullet injury, which entered through lateral wall of the nose and lodged at left orbital apex area. The bullet was removed endoscopically via left nostril without any damage to the eye or disturbance in vision.     

Is unpredictable chronic mild stress (UCMS) a reliable model to study depression-induced neuroinflammation?

Unipolar depression is one of the leading causes of disability. The pathophysiology of depression is poorly understood. Evidence suggests that inflammation is associated with depression. For instance, pro-inflammatory cytokines are found to be elevated in the peripheral blood of depressed subjects. Cytokine immunotherapy itself is known to induce depressive symptoms. While the epidemiological and biochemical relationship between inflammation and depression is strong, little is known about the possible existence of neuroinflammation in depression. The use of animal models of depression such as the Unpredictable Chronic Mild Stress (UCMS) has already contributed to the elucidation of the pathophysiological mechanisms of depression such as decreased neurogenesis and HPA axis alterations. We used this model to explore the association of depressive-like behavior in mice with changes in peripheral pro-inflammatory cytokines IL-1β, TNFα and IL-6 level as well as the neuroinflammation by quantifying CD11b expression in brain areas known to be involved in the pathophysiology of depression. These areas include the cerebral cortex, the nucleus accumbens, the bed nucleus of the stria terminalis, the caudate putamen, the amygdala and the hippocampus. The results indicate that microglial activation is significantly increased in the infralimbic, cingulate and medial orbital cortices, nucleus accumbens, caudate putamen, amygdala and hippocampus of the mouse brain as a function of UCMS, while levels of pro-inflammatory cytokines did not differ among the groups. This finding suggests that neuroinflammation occurs in depression and may be implicated in the subject's behavioral response. They also suggest that UCMS could be a potentially reliable model to study depression-induced neuroinflammation.     

Usability Evaluation of Paper-based “Hajji” Health Record Format

The study objective was the development and content evaluation of the paper-based Hajji Health Record (PHHR) instrument to make it appropriate for developmental phases of web based electronic Hajji (Pilgrim) Health Record (WEHHR) implementation. A qualitative and quantitative survey was done on 13 December 2008G in Alnoor Specialist Hospital, Makkah, Saudi Arabia. Twenty-two physicians of 19 countries were given a preliminary questionnaire containing basic sociodemographic information, followed by Hajjis’ health information sheet (HHIS) with a sample scenario of a case history. A structured evaluation questionnaire about HHIS was given afterwards. Five point Likert scaling was used starting from strongly agree to strongly disagree as 1 to 5. Data was analyzed by using SPSS programme version 16. Two tailed p-value <0.05 was considered as significant. Mean age was 48.6 years with range (35–64). Specialists were 10(45.5%) and teaching hospitals’ physicians were 11(50%). Twelve (54.5%) physicians had concept about EHR, while the same number had their Hajjis’ health record but only 33.3% (4/12) had sufficient health information. Response rate was 91.9% with average rating of 2.2 ± 1. Agreement response (78.8%) was noted for “medical history” category followed by “medication history” (76.2%). Average rating of consultants was (2 ± 0.88), while specialists, residents and general practitioners had 2.3 ± 1.2, 2.7 ± 1, 2.1 ± 0.58, respectively. Physicians without EHR concept had average rating 2.1 ± 1.16 than other group (2.3 ± 0.92). Majority of physicians were specialists. Overall response rate was superb with agreement response. No significant difference in rating was found among all categories of physicians.     

Audit of an urban paediatric emergency department visits

Background:

This study aimed to highlight the health seeking behavior of children in an Emergency Department (ED).

Materials and Methods:

Retrospective files review of ED was done for the month of July, 2008. Data about the children ≤12 years of age was gathered.

Results:

In one month period a total 21000 patients visited our ED, out of them 6120 (29%) were children. Males, Saudis and children of (1-6 years) were more frequent, i.e., 3540 (57.8%), 5760 (94.1%) and 3180 (52%), respectively. Majority of patients visited in shift “2”, i.e., 15:30 hours to 23:30 hours. Among the patients “diseases of respiratory system” were found more frequent 4170 (68.1%) and main diagnosis was “acute upper respiratory tract infection” 3300 (53.9%). Non-urgent cases were 2020 (33%) while 244 (4%) were admitted.

Conclusion:

Young children as well as non-urgent cases were predominant. Evening shift was the busiest one.     

Risk stratification and prognosis in octogenarians undergoing stress echocardiographic study

BACKGROUND: The prognostic value of stress echocardiography (SE) for the diagnosis and risk stratification of coronary artery disease in octogenarians is not well defined. METHODS: Follow-up of 5 years (mean 2.9 +/- 1.0 years) for confirmed nonfatal myocardial infarction (n = 17) and cardiac death (n = 37) was obtained in 335 patients, age > or =80 years (mean age 84 +/- 3 years, 44% male), undergoing SE (33% treadmill, 67% dobutamine). Left ventricular (LV) regional wall motion was assessed by a consensus of two echocardiographers and scored as per standard five-point scale, 16-segment model of wall motion analysis. Ischemic LV wall segment was defined as deterioration in the thickening and excursion during stress (increase in wall-motion score index (WMSI) > or =1). RESULTS: By univariate analysis, inducible ischemia (chi-square = 38.4, P < 0.001), left ventricular ejection fraction (chi-square = 41.2, P < 0.001), a history of previous myocardial infarction (chi-square = 22.3, P < 0.01), hypertension (chi-square = 33, P < 0.01), and age (chi-square = 27.7, P < 0.01) were significant predictors of future cardiac events. WMSI, an index of inducible ischemia, provided incremental prognostic information when forced into a multivariable model where clinical and rest echocardiography variables were entered first. WMSI effectively stratified octogenarians into low- and high-risk groups (annualized event rates of 1.2 versus 5.8%/year, P < 0.001). CONCLUSIONS: Stress echocardiography yields incremental prognostic information in octogenarians and effectively stratifies them into low- and high-risk groups. Precise therapeutic decision making in very elderly patients should incorporate combined clinical and stress echocardiography data.     

Moringa oleifera: a food plant with multiple medicinal uses

Moringa oleifera Lam (Moringaceae) is a highly valued plant, distributed in many countries of the tropics and subtropics. It has an impressive range of medicinal uses with high nutritional value. Different parts of this plant contain a profile of important minerals, and are a good source of protein, vitamins, beta-carotene, amino acids and various phenolics. The Moringa plant provides a rich and rare combination of zeatin, quercetin, beta-sitosterol, caffeoylquinic acid and kaempferol. In addition to its compelling water purifying powers and high nutritional value, M. oleifera is very important for its medicinal value. Various parts of this plant such as the leaves, roots, seed, bark, fruit, flowers and immature pods act as cardiac and circulatory stimulants, possess antitumor, antipyretic, antiepileptic, antiinflammatory, antiulcer, antispasmodic, diuretic, antihypertensive, cholesterol lowering, antioxidant, antidiabetic, hepatoprotective, antibacterial and antifungal activities, and are being employed for the treatment of different ailments in the indigenous system of medicine, particularly in South Asia. This review focuses on the detailed phytochemical composition, medicinal uses, along with pharmacological properties of different parts of this multipurpose tree.