Acute pulmonary embolism in elderly: clinical characteristics and outcome

OBJECTIVE: To evaluate the clinical characteristics and outcome of acute pulmonary embolism in elderly in comparison to the younger patients. METHODS: Study population consisted of 136 patients with a confirmed diagnosis of acute pulmonary embolism. Clinical characteristics and thromboembolic risk factors were analyzed between the elderly (> or =65 years of age) and the younger (<65 years of age) patients. In-hospital mortality was used as a measure of outcome. RESULTS: Elderly group consisted of 70 patients (age 76.4+/-8.3 years, range 65-96 years; females 58%) and younger group of 66 patients (age 48.5+/-12 years, range 18-64 years, females 59%). Syncope was more frequent in elderly group (19% vs. 6%, P=0.03) but the symptoms of shortness of breath and pleuritic chest pain were not significantly different between groups. Malignancy was the most common risk factor for thrombo-embolism, but immobilization predominated among patients in elderly group (21% vs. 6%, P=0.01). Tachycardia was common in younger patients compared to the elderly. Ventilation-perfusion scan was used more commonly in younger patients (76% vs. 57%, P=0.02), whereas, helical computed-tomography scan was used equally in both groups. Most of the patients had lower extremity duplex study (97% in each group). Inferior vena cava filter placement was common and thrombolytic therapy rare among elderly patients. Patients in elderly group had higher in-hospital mortality (17% vs. 5%, P=0.02). CONCLUSIONS: Syncope is a more frequent presenting symptom and immobilization a common risk factor in elderly patients with acute pulmonary embolism. In addition, they have higher in-hospital mortality.     

Diffusion of responsibility attenuates altruistic punishment: A functional magnetic resonance imaging effective connectivity study

Humans altruistically punish violators of social norms to enforce cooperation and pro‐social behaviors. However, such altruistic behaviors diminish when others are present, due to a diffusion of responsibility. We investigated the neural signatures underlying the modulations of diffusion of responsibility on altruistic punishment, conjoining a third‐party punishment task with event‐related functional magnetic resonance imaging and multivariate Granger causality mapping. In our study, participants acted as impartial third‐party decision‐makers and decided how to punish norm violations under two different social contexts: alone (i.e., full responsibility) or in the presence of putative other third‐party decision makers (i.e., diffused responsibility). Our behavioral results demonstrated that the diffusion of responsibility served as a mediator of context‐dependent punishment. In the presence of putative others, participants who felt less responsible also punished less severely in response to norm violations. Our neural results revealed that underlying this behavioral effect was a network of interconnected brain regions. For unfair relative to fair splits, the presence of others led to attenuated responses in brain regions implicated in signaling norm violations (e.g., AI) and to increased responses in brain regions implicated in calculating values of norm violations (e.g., vmPFC, precuneus) and mentalizing about others (dmPFC). The dmPFC acted as the driver of the punishment network, modulating target regions, such as AI, vmPFC, and precuneus, to adjust altruistic punishment behavior. Our results uncovered the neural basis of the influence of diffusion of responsibility on altruistic punishment and highlighted the role of the mentalizing network in this important phenomenon. Hum Brain Mapp 37:663–677, 2016. © 2015 Wiley Periodicals, Inc .     

Criteria for management of calcific metamorphosis: review with a case report.

Calcific metamorphosis is seen commonly in the dental pulp after traumatic tooth injuries and is characterized by deposition of hard tissue within the root canal space. Opinion differs among practitioners as to whether to treat these cases upon early detection of calcific metamorphosis or to observe them until symptoms or radiographic signs of pulpal necrosis are detected. In this article, the clinical, radiographic, and histopathologic appearance of calcific metamorphosis is described; a review of the literature is presented to address these issues in an attempt to establish sound rationale for treatment. Approximately 3.8% to 24% of traumatized teeth develop varying degrees of calcific metamorphosis. Studies indicate that of these, approximately 1% to 16% will develop pulpal necrosis. Most of the literature does not support endodontic intervention unless periradicular pathoses is detected or the involved tooth becomes syptomatic. It may be advisable to manage cases demonstrating calcific metamorphosis through observation and periodic examination. A report of a case where in non-surgical endodontic intervention was successfully carried out a patient suffering from calcific metamorphosis with periapical pathoses is also presented.     

Comparative study of ankle arthrodesis using cross screw fixation versus anterior contoured plate plus cross screw fixation

Arthrodesis of the ankle joint is still the traditional treatment for symptomatic osteoarthritis. This comparative study was done to assess the functional outcome of open ankle fusion using either cross screw fixation (group A) or anterior contoured plate and cross screw fixation (group B) in a consecutive series of 22 patients. All the patients had the same inclusion criteria. All the patients in both groups underwent the same operative technique and were operated by the same surgeon. Mean follow-up was 26.8 months. The mean time to fusion was 18.8 weeks in group A and 16.8 weeks in group B (p = 0.046). The mean American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hind foot score at the final follow-up was 79 in group A and 86 in group B (p = 0.23). Two patients in group A that went to non-union required re-arthrodesis using contoured plate and cross screw fixation; both attained eventual union. We conclude that anterior contoured plate plus cross screw fixation is a simple and reproducible technique for ankle arthrodesis that gives stable internal fixation and excellent clinical results.     

Fatal re-expansion pulmonary oedema in a mechanically ventilated patient

Fatal course of re-expansion pulmonary oedema (REPO) is infrequent and very rarely documented in mechanically ventilated patients. We report a case of fatal REPO following tube thoracostomy for a right-sided pneumothorax in an elderly patient of chronic obstructive pulmonary disease (COPD) with respiratory failure on mechanical ventilation.     

Comparison of coconut water, propolis, HBSS, and milk on PDL cell survival

Coconut water is biologically pure and sterile, with a rich presence of amino acids, proteins, vitamins, and minerals. The purpose of this study was to use a collagenase-dispase assay to investigate the potential of a new storage medium, coconut water, in comparison with propolis, Hank's balanced salt solution (HBSS), and milk in maintaining viable periodontal ligament (PDL) cells on simulated avulsed teeth. Seventy freshly extracted human teeth were divided into 4 experimental groups and 2 control groups. The positive and negative controls corresponded to 0-minute and 8-hour dry times, respectively. The experimental teeth were stored dry for 30 minutes and then immersed in 1 of the 4 media (coconut water, propolis, HBSS, and milk). The teeth were then treated with dispase grade II and collagenase for 30 minutes. The number of viable PDL cells was counted with a hemocytometer and analyzed. Statistical analysis showed that coconut water kept significantly more PDL cells viable compared with propolis, HBSS, or milk. Coconut water can be used as a superior transport medium for avulsed teeth.     

Effective connectivity of brain regions underlying third-party punishment: Functional MRI and Granger causality evidence

Third-party punishment (TPP) for norm violations is an essential deterrent in large-scale human societies, and builds on two essential cognitive functions: evaluating legal responsibility and determining appropriate punishment. Despite converging evidence that TPP is mediated by a specific set of brain regions, little is known about their effective connectivity (direction and strength of connections). Applying parametric event-related functional MRI in conjunction with multivariate Granger causality analysis, we asked healthy participants to estimate how much punishment a hypothetical perpetrator deserves for intentionally committing criminal offenses varying in levels of harm. Our results confirmed that TPP legal decisions are based on two domain-general networks: the mentalizing network for evaluating legal responsibility and the central-executive network for determining appropriate punishment. Further, temporal pole (TP) and dorsomedial prefrontal cortex (PFC) emerged as hubs of the mentalizing network, uniquely generating converging output connections to ventromedial PFC, temporo-parietal junction, and posterior cingulate. In particular, dorsomedial PFC received inputs only from TP and both its activation and its connectivity to dorsolateral PFC correlated with degree of punishment. This supports the hypothesis that dorsomedial PFC acts as the driver of the TPP activation pattern, leading to the decision on the appropriate punishment. In conclusion, these results advance our understanding of the organizational elements of the TPP brain networks and provide better insights into the mental states of judges and jurors tasked with blaming and punishing legal wrongs.     

Clinical profile of carcinoma stomach at a tertiary care hospital in south India.

Carcinoma of the stomach is an important cause of mortality due to cancer. Carcinoma of the stomach is common in the southern region of India. We conducted a retrospective study on the epidemiological, clinical and survival patterns among the patients with carcinoma of the stomach, attending our hospital from June 19, 1995 to 1st January 2003. All the patients had histopathological confirmation of malignancy. Patients with gastrooesophageal junction lesions were excluded. Surgery was performed with curative as well as palliative intent in suitable patients. Chemotherapy has been incorporated in to the combined modality treatment in our hospital since July 2000. Postoperative chemotherapy comprised commonly used intravenous chemotherapy regimens, while oral chemotherapy (etoposide) was given to patients with disease not amenable to surgery, and those having poor performance and nutritional status. Oral etoposide was given in a dose of 50 mg/day for 14 days, in a 28 day cycle. Quality of life was assessed in the oral chemotherapy group. Out of the 1749 cancer patients seen during the period, 151 had gastric malignancy (8.6%). The median age was 55 years (range 15-84 years). The male to female ratio was 4:1. Adenocarcinoma was found in 148 patients, 2 had stromal tumours and 1 had non-Hodgkin lymphoma. Stage disribution was as follows; stage 2-1 patient , stage 3a-25, stage3b-49, stage4-3 1, Metastatic-28. Staging was not completed in 17 patients. Eighty-nine patients underwent surgery. Fifty-nine patients (39%) did not have surgery. One patient underwent polypectomy. Curative gastrectomy was performed in 11 patients. Thirty-nine patients underwent palliative tumour resection. Palliative gastro-jejunostomy for relief of symptoms was performed in 26 patients and exploratory laparotomy alone was perforaied in 13. Thirty-eight patients received chemotherapy. Out of these, only 2 patients had prior complete resection of the tumour and 36 received palliative chemotherapy. Intravenous chemotherapy was given to 17 patients and oral chemotherapy to 19; All the patients who received oral etoposide did not experience any toxicity. Patients who received intravenous chemotherapy (n=17) had the following toxicities: grade 3 emesis in 4 (20%), discoloration of the skin and nails in 6(31%), alopecia in 8 (50%), grade 3 diarrhoea in 3 (15%) and neutropenic fever in 4 patients (20%). Median survival for the cohort was 10.4 months. Quality of life parameters, such as sleep, appetite, weight, pain, work and general sense of ill health showed improvement. In conclusion, 8.6% of all cancers at our hospital were due to cancer of stomach, in whom distal gastric tumor were more frequent and most were non-resectable. Median survival was 10.4 months. Oral etoposide was found to be safe, improved the quality of life and may play a role in the palliative management of advanced carcinoma of the stomach.     

QT Interval Prolongation with Global T‐Wave Inversion: A Novel ECG Finding in Acute Pulmonary Embolism

Objective: The purpose of this study was to report a novel electrocardiographic (ECG) phenomenon in acute pulmonary embolism characterized by QT interval prolongation with global T‐wave inversion. Methods: Among a total of 140 study patients with a confirmed diagnosis of acute pulmonary embolism, patients who fulfilled the inclusion criteria for QT interval prolongation with global T‐wave inversion were examined. Each of these patients had undergone a detailed clinical evaluation including testing for myocardial injury and echocardiography. Results: QT interval prolongation with global T‐wave inversion was found in five patients (age 51–68 years) with acute pulmonary embolism. Four were women. Acute pulmonary embolism was diagnosed by ventilation‐perfusion scan in three patients and by spiral computed tomography in other two patients. None of the patients had any right or left ventricular regional wall motion abnormalities on echocardiography. All patients had changes characteristic of hemodynamically significant pulmonary embolism, including right ventricular stunning or hypokinesis and dilatation in five patients with paradoxical septal motion in four. Acute coronary syndrome was ruled out in each patient by clinical evaluation, serial ECGs and cardiac markers, and lack of regional wall motion abnormalities on echocardiography. Prolongation of QT intervals (QTc 456–521 ms) with global T‐wave inversion was noted on presentation. The ECG changes gradually resolved in 1 week in all patients with appropriate treatment of acute pulmonary embolism. One patient died. None of the patients developed torsade de pointes. Conclusions: Acute pulmonary embolism may occasionally result in reversible QT interval prolongation with deep T‐wave inversion, and, thus should be considered among the acquired causes of the long QT syndrome.