Management Of Other Complications Research Articles

Novaluron and indoxacarb induced methemoglobinemia – unveiling a rare poisoning

Introduction and aim. In India, the utilization of agricultural pesticides for intentional self-poisoning is a prevalent method, and it is associated with substantially higher fatality rates compared to other self-poisoning approaches. Plethora, an agricultural insecticide containing novaluron (5.25%) and indoxacarb (4.5%), has recently been introduced and widely used in India and various other regions for its broad-spectrum lepidopteran control. While there have been documented cases of isolated self-poisoning involving indoxacarb, there is currently no literature reporting incidents of human poisoning specifically related to novaluron. Description of the case. An 83-Year-old male was presented to the emergency department (ED) with a history of consumption of 50 mL of an insecticide suspension concentrate called ‘PLETHORA’ to commit suicide. He had one episode of vomiting and dizziness after the ingestion. There was associated cyanosis, and the patient was put on high-flow oxygen at 10 L/min through a face mask. The patient was diagnosed to have methemoglobinemia and was successfully treated with methylene blue and ascorbic acid. One hour post methylene blue injection showed a methemoglobin level of 1%, and the patient gradually improved. Patients presenting with novaluron and indoxacarb poisoning require supportive treatment as there is no specific antidote. There should be a high index of suspicion for methemoglobinemia in such patients, and timely management is necessary to prevent further complications. The patient was successfully managed and discharged after the 3rd day of admission. Conclusion. The management of patients with novaluron and indoxacarb poisoning primarily involves supportive care, as there is currently no specific antidote available for these substances. Maintaining a high suspicion index for the development of methemoglobinemia and timely management of other complications is crucial for the best possible patient outcomes.

Resurgence of diphtheria in Northern Gujarat: A retrospective study done in Banas Medical College and Research Centre, Palanpur, Gujarat.

A diphtheria outbreak occurred in Banaskantha district in the northern part of Gujarat in 2019-2020. This study was undertaken to study and generate information on the resurgence of the disease in this region and to generate information regarding the status of vaccination in this region and what strategies can be adopted to avoid re-emergence of the disease in the future. This is a hospital-based, retrospective, descriptive study done on patients of diphtheria who were admitted in Banas Medical College and Research Institute, Palanpur from September 2019 to January 2020. Throat swab was taken from all the patients and information regarding symptoms, vaccination, and demographic characteristic was collected. Treatment in the form of ADS, injection crystalline penicillin/erythromycin and other supportive treatment was given. Out of 188 patients, 27 patients (14.36%) were less than 5 years of age, 118 patients (62.76%) and 38 patients (20.21%) were of age group 5-10 and 11-18 years, respectively. Total of five patients (2.66%) were of age more than 18 years. Out of 188 patients, 102 (54.25%) were males and 86 patients (45.74%) were females. All the patients (188) were found to be unvaccinated. Among 188 throat swabs that were tested, 21 samples (11.17%) were found to be culture positive for Corynebacterium diphtheriae. Antidiphtheric serum was given in 181 patients (96.27%) according to the requirement. Out of 188 patients, 155 patients (82.44%) improved with treatment and were discharged. Total of 23 patients (12.23%) were referred to higher center for tracheostomy and for management of other complications. Six patients (3.19%) left against medical advice and four patients (2.12%) expired despite all measures taken. Diphtheria is a disease that can easily be prevented by vaccination. Our study highlights need to increase awareness about vaccination among people of Banaskatha district and all measures should be taken to give full vaccination to children less than 5 years of age and booster vaccination should be encouraged in adolescents and adults so that future resurgence of disease can be prevented.

The role of radiology in addressing the challenge of lung cancer after lung transplantation.

The importance of lung cancer as a complication of lung transplantation is increasingly recognised. It may become an important survival-limiting factor in lung transplant patients as management of other complications continues to improve and utilisation of extended criteria donors grows. Radiology can play a key role in tackling this issue at multiple stages in the transplantation pathway and follow-up process. Routine chest CT as part of pre-transplant recipient assessment (and donor assessment if available) can identify suspicious lung lesions with high sensitivity and detect chronic structural lung diseases such as pulmonary fibrosis associated with an increased risk of malignancy post-transplant. Pre-transplant CT also provides a comparison for later CT studies in the assessment of nodules or masses. The potential role of regular chest CT for lung cancer screening after transplantation is less certain due to limited available evidence on its efficacy. Radiologists should be cognisant of how the causes of pulmonary nodules in lung transplant patients may differ from the general population, vary with time since transplantation and require specific recommendations for further investigation/follow-up as general guidelines are not applicable. As part of the multidisciplinary team, radiology is involved in an aggressive diagnostic and therapeutic management approach for nodular lung lesions after transplant both through follow-up imaging and image-guided tissue sampling. This review provides a comprehensive overview of available clinical data and evidence on lung cancer in lung transplant recipients, and in particular an assessment of the current and potential roles of pre- and post-transplant imaging. KEY POINTS: • Lung cancer after lung transplantation may become an increasingly important survival-limiting factor as mortality from other complications declines. • There are a number of important roles for radiology in tackling the issue which include pre-transplant CT and supporting an aggressive multidisciplinary management strategy where lung nodules are detected in transplant patients. • The introduction of routine surveillance chest CT after transplant in addition to standard clinical follow-up as a means of lung cancer screening should be considered.

Effect of Paracetamol versus Ibuprofen in Adenotonsillectomy.

Introduction:The present study aimed to compare the effects of paracetamol and ibuprofen on pain, bleeding, nausea, and vomiting following adenotonsillectomy in children.Materials and Methods:This was a prospective, double-blinded, randomized clinical trial. Block randomization was used to assign 50 patients to two groups of paracetamol and ibuprofen. In the paracetamol group, subjects received 15 mg/kg oral paracetamol 30 minutes before the induction of anesthesia, followed by the same dosage every 6 hours postoperatively. Meanwhile, the ibuprofen-treated group took 10 mg/kg oral ibuprofen 30 minutes before and every 6 hours after the operation. The subjects in both groups received the medication for three postoperative days. The postoperative pain score was assessed 6 hours after the surgery and during the second and the third postoperative days. Nausea and vomiting episodes were recorded in the first postoperative day and first postoperative week. Results:Based on the results, intraoperative and postoperative bleeding in both groups was not significantly different. The mean score of pain in the first postoperative day (6 hours after the surgery) and the second and the third postoperative days did not show any statistical difference. The ibuprofen group experienced fewer vomiting episodes, compared to the paracetamol group during the first postoperative day (P=0.011). Vomiting episodes in the first postoperative week did not illustrate any significant difference.Conclusion:As evidenced by the results of the current study, Ibuprofen had the same effect on the alleviation of postoperative pain, caused fewer vomiting episodes, and did not cause excessive bleeding as an NSAID. Therefore, oral administration of ibuprofen is suggested for pain relief and management of other complications following adenotonsillectomy in children.

SERUM LIPOPOLYSACCHARIDE BINDING PROTEIN AS A PREDICTOR AND PROGNOSTIC BIOMARKER FOR CIRRHOSIS RELATED ACUTE KIDNEY INJURY

• Acute kidney injury (AKI), defined as an increase in serum creatinine ≥ 0.3 mg/dL (26.5 µmoL/L) ≤ 48 hours, or a 50% increase from baseline, is one of the most serious complications of liver cirrhosis. It occurs in about 19% of hospitalized cases with liver cirrhosis and it carries a bad prognosis. The acute kidney dysfunction is associated with mortality in cases with cirrhosis. Moreover, it usually occurs concomitantly with other cirrhosis related complications like spontaneous bacterial peritonitis (SBP) and bleeding varices.• Multiple factors could increase the risk for this complication including infections, hypovolemia, use of vasodilators, and non-steroidal anti-inflammatory drugs. Because of its unfavorable prognosis, potential triggers for AKI should be identified and removed in such cases. This includes correction of hypovolemia, discontinuation of nephrotoxic drugs, eradication of infections and management of other complications like variceal bleeding.• Lipopolysaccharide binding protein (LBP) is an acute phase protein that is synthesized by the liver. It is secreted into the blood stream in response to infection with Gram-negative bacteria. Recent studies have reported that LBP is an important mediator of AKI in critically ill patients. However, after intensive online research, the current literature had poor data regarding the role of that biomarker in AKI in cirrhotic patients.

Use of artificial intelligence for management and identification of complications in diabetes

Artificial intelligence (AI) can play an important role is in early diagnosis of complications, adherence to a healthy lifestyle and medication, real-time monitoring for optimal glycemic status and predictive prognostic model for the diabetic status of a patient. The early recognition and management of the complications (acute as well as chronic) in diabetes predict the quality of life (QoL) of a patient. The promising results of AI in the early diagnosis of diabetic retinopathy have opened the frontiers for management of other complications as well. Although flash glucose monitoring (FGMs) and continuous glucose monitoring(CGMs) are yet to be used in routine clinical practice but these modalities do hold promise in future for management of diabetes. Automated diagnosis of diabetic retinopathy (DR) and cardiovascular risk factor monitoring are now possible based on the large retinal fundus imag-ing datasets with improved sensitivity and specificity. Smart-phones and smart devices do have the potential to bring the monitoring and early diagnosis of complications of diabetes into the patient’s domain with the use of applications on their smart devices which will make future management of diabetes as an “e-disease management”. AI applications offer greater accuracy, efficiency, ease of use and satisfaction and can complement the management and early identifi-cation of complication of diabetes in long run.

Clinical Evaluation of the Efficacy of Saubhagyashunthi Paka and Dashamularishta in Sutika Paricharya (Postnatal Care)

Background: The postnatal period begins immediately after the separation of the placenta extending up to 6 weeks, otherwise called as the puerperium or puerperal period. The care given during this period is called as Sutika Paricharya (postnatal care) in Ayurveda. During the time of labor, the mother undergoes tremendous physical exertion and becomes extremely debilitated, physically and mentally, which leads to derangement of Dosha especially Vatadosha in the mother. These factors cause general weakness, pain in the abdomen, low back pain, loss of appetite, dysfunction of the bladder, postnatal psychosis, etc. Apart from these, the mother also suffers with Dhatukshaya (weakness of body tissue). Prevention of puerperal sepsis, management of other complications, proper involution of genital organs, and proper lactation need to be well managed during the puerperal period. Based on the information available in the Ayurvedic texts regarding the management during Sutika Kala (postnatal phase), this study has been designed to assess the clinical efficacy of two Ayurvedic classical formulations, viz., Saubhagyashunthi Paka and Dashamularishta for the effective management of the puerperal phase. Materials and methods: A single-center, noncontrolled, open-label clinical trial as a means of assessing the therapeutic efficacy of Saubhagyashunthi Paka and Dashamularishta will be conducted. A total of 40 participants will be recruited for the study. The study period is 12 months, during which all the participants will be given the trial drugs for a duration of 8 weeks along with the standard care as recommended by established guidelines. Outcome measures: The primary outcome measure is to restore the strength of the mother and minimize the complications and establishment of sufficient lactation. The secondary outcomes are improvement in the quality of life and clinical safety of the trial drugs. Statistical evaluation would be done at the end of the trial period to compare the changes in the assessment parameters from the baseline. Discussion: The study will generate the preliminary evidence of the efficacy of Saubhagyashunthi Paka and Dashamularishta in Sutika Paricharya (w.s.r. to postnatal care), which will validate the Ayurvedic therapeutic approach for the management of Sutika Paricharya and will also help to design a randomized controlled trial. Trial registration: Clinical Trials Registry—India [CTRI/2020/01/022935]

Risk Factors for Common Bile Duct Stent Occlusion after Endoscopic Retrograde Cholangiopancreatography

Introduction: Endoscopic biliary stenting is a common procedure performed in gastrointestinal endoscopy to manage various bile duct disorders. The safety and efficacy of common bile duct (CBD) stenting for relieving CBD obstruction and management of other complications is well established. One of the common complications of CBD stent placement is stent occlusion. The risk factors which can predict stent occlusion are not well studied in literature. Aim of our study was to identify potential risk factors that are associated with stent occlusion in patients with CBD stents. Methods: This case control study included all patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with CBD stent placement at our institution from January 2009 to December 2014. The study group included all patients with CBD stents who were subsequently found to have an occluded stent. A control group was randomly selected in 1:1 ratio, and included all patients with CBD stent placement but without stent occlusion during the course of their management. Descriptive statistics were computed for all variables including means, medians, ranges for continuous variables. Data is presented as mean ± standard deviation, median [25th, 75th percentiles or interquartile range, IQR] or N (%). A univariate and multivariate analysis was performed to compare the groups; Results: A total of 394 patients were included in the analysis of which 197 were in the study group and 197 in the control group. Average age of the study cohort was 63.5 ± 14.8 years and 215 (54.8%) were males. The baseline and demographic data was similar in the two groups. On univariate analysis, patients with history of smoking were 1.52 times (1.14-2.04) more likely to have stent occlusion (p=0.04). Patients with cirrhosis were 1.91 times (1.42-2.57, p On multivariate analysis, history of smoking, pancreatic mass causing CBD obstruction, length of stricture and plastic stent placement were all associated with stent occlusion (Table 1).Table 1: Cox Proportional Hazards AnalysisConclusion: Patients with history of smoking, presence of pancreatic mass, and longer strictures are at higher risk for CBD stent occlusion after ERCP. Plastic stents are also at higher risk of stent occlusion compared to metal stents. Patients with these risk factors should have their follow-up ERCP scheduled appropriately early to prevent complications.

Low level laser therapy/photobiomodulation in the management of side effects of chemoradiation therapy in head and neck cancer: part 1: mechanisms of action, dosimetric, and safety considerations.

There is a large body of evidence supporting the efficacy of low level laser therapy (LLLT), more recently termed photobiomodulation (PBM), for the management of oral mucositis (OM) in patients undergoing radiotherapy for head and neck cancer (HNC). Recent advances in PBM technology, together with a better understanding of mechanisms involved, may expand the applications for PBM in the management of other complications associated with HNC treatment. This article (part 1) describes PBM mechanisms of action, dosimetry, and safety aspects and, in doing so, provides a basis for a companion paper (part 2) which describes the potential breadth of potential applications of PBM in the management of side-effects of (chemo)radiation therapy in patients being treated for HNC and proposes PBM parameters. This study is a narrative non-systematic review. We review PBM mechanisms of action and dosimetric considerations. Virtually, all conditions modulated by PBM (e.g., ulceration, inflammation, lymphedema, pain, fibrosis, neurological and muscular injury) are thought to be involved in the pathogenesis of (chemo)radiation therapy-induced complications in patients treated for HNC. The impact of PBM on tumor behavior and tumor response to treatment has been insufficiently studied. In vitro studies assessing the effect of PBM on tumor cells report conflicting results, perhaps attributable to inconsistencies of PBM power and dose. Nonetheless, the biological bases for the broad clinical activities ascribed to PBM have also been noted to be similar to those activities and pathways associated with negative tumor behaviors and impeded response to treatment. While there are no anecdotal descriptions of poor tumor outcomes in patients treated with PBM, confirming its neutrality with respect to cancer responsiveness is a critical priority. Based on its therapeutic effects, PBM may have utility in a broad range of oral, oropharyngeal, facial, and neck complications of HNC treatment. Although evidence suggests that PBM using LLLT is safe in HNC patients, more research is imperative and vigilance remains warranted to detect any potential adverse effects of PBM on cancer treatment outcomes and survival.

Do the epidemiology, physiological mechanisms and characteristics of hepatocellular carcinoma in HIV-infected patients justify specific screening policies?

Reducing the incidence of hepatocellular carcinoma (HCC) in HIV-infected patients has become a serious problem when managing these patients. There are many explanations for this disease evolution, which notably include their longer survival under effective antiviral therapy and also the more rapid evolution of chronic liver disease. Despite recent advances in the management of hepatitis B (HBV) and hepatitis C (HCV) viral diseases, which will probably increase the number of patients achieving a virological response, HIV-infected patients with cirrhosis are still at risk of the onset of HCC. This evolution to HCC is also correlated to other comorbidities such as excessive alcohol consumption and nonalcoholic steatohepatitis (NASH). HCC thus remains a public health issue in this population. The poor prognosis and aggressiveness of HCC have been fully demonstrated, but the mechanisms underlying this aggressiveness are not yet well defined. As well as underlying mechanisms that contribute to accelerating hepatocarcinogenesis in HIV-infected patients, there are other reasons why HIV-infected patients should be considered a higher risk population. This review discusses the principal epidemiological determinants; the mechanisms of pathogenesis; and the treatment of HCC in HIV/HBV and HIV/HCV coinfected patients. It also discusses the probable need to develop a specific screening policy for HCC in this population in order to prevent the rapid development and to make them more amenable to a curative treatment.

What are the essential components of HIV treatment and care services in low and middle-income countries

To review and summarize the essential components of HIV treatment and care services in low and middle-income countries (LMICs). Literature review and reflection on programmatic experience. There is increasing recognition that the essential 'package' of HIV care must include early identification of HIV-positive people in need of care, appropriate initial and continued counselling, assessment of HIV disease stage, treatment with HAART for those who need it, monitoring while on treatment for efficacy, adherence and side-effects, detection and management of other complications of HIV infection, provision of sexual and reproductive health services as well as careful record-keeping. The impressive scale-up of HIV treatment and care services has required decentralization of service provision linked to task-shifting. But the future holds even greater challenges, as the number of people in need of HIV care continues to rise at a time when many traditional donors and governments in the most-affected regions have reduced budgets. In the long-term, the increased demand for HIV-care services can only be satisfied through increased decentralisation to peripheral health units, with the role of each type of unit being appropriate to the human and material resources available to it.HIV-care services can also naturally integrate with the care of chronic noncommunicable diseases and with closely related services like mother and child health, and thus should promote a shift from vertical to integrated programming. Staff training and support around a set of evidence-based policies and guidelines and a reliable supply of essential medicines and supplies are further essential components for a successful programme.

Intraoperative and postoperative complications of laser in situ keratomileusis

Laser in situ keratomileusis for the treatment of myopia, hyperopia and astigmatism is one of the most widely performed ophthalmic surgical procedures in the world. The quest for a safer, more precise and effective refractive procedure has led to many strides in the technology and the procedure itself. With significant advancements in technology, the complications associated with this procedure have declined significantly. However, complications do occur, both intra- and post-operatively. In this article we review some of the more commonly encountered intraoperative, early postoperative and late postoperative complications. Some of these complications are preventable, and we discuss safeguards that can be utilized to avoid them. We further discuss the management of other complications and review current literature regarding technologies and treatments on the horizon.

Multiple Myeloma: Most Common End-Organ Damage and Management

End-organ damage is the factor that differentiates plasma cell dyscrasia requiring therapy (active multiple myeloma [MM]) from disease that does not require therapy (monoclonal gammopathy of undetermined significance and smoldering [asymptomatic] MM). Progressive skeletal destruction is the hallmark of MM and responsible for principle morbidity in the disease. The spine is the most afflicted skeletal organ, and vertebral fractures have significantly contributed to its poor prognosis. Early mortality in MM is usually attributed to the combined effects of active disease and comorbid factors. Infection and renal failure are the main direct causes of early mortality. Using bisphosphonates to manage skeletal events mainly by preventing or slowing the destructive process has become an important adjunctive treatment in MM. Advances in minimally invasive surgical techniques, such as percutaneous vertebroplasty and kyphoplasty, offer these patients less-invasive options for treating vertebral collapse and restoring function. The aggressive management of other complications of the disease through more effective and less toxic therapy that targets the primary disease, in addition to supportive care, is resulting in patients experiencing less morbidity and probably lower mortality. This article reviews recent advances in the understanding of bone disease in MM, the role of bisphosphonates in preventing skeletal events, and available data on percutaneous vertebroplasty and kyphoplasty, and discusses the management of infection and renal failure, which seem to be responsible for high initial mortality and thereby compromise the current advances in therapy.

Guillain-Barré syndrome.

GBS is an acquired, monophasic illness of the peripheral nervous system that usually presents with a gait disturbance and clinical features of pain, weakness, and areflexia. The etiology of the disease is immune-mediated and directed against the peripheral nervous system myelin, axon, or both. A careful history, physical examination, and routine laboratory tests are necessary to make a clinical diagnosis and to exclude other disorders that cause acute weakness. Laboratory tests that support the diagnosis, such as an increased CSF protein and abnormal electrodiagnostic studies, may be normal early in the illness. The most serious complications during the acute phase of the disease are respiratory failure and autonomic disturbances. Plasma exchange or IVIG shortens the duration and severity of the disease significantly. The prognosis for children who have GBS generally is excellent for full and functional recovery, using modern intensive care for respiratory support and the management of other complications.

Guillain-Barré Syndrome in Children

The Guillain-Barré syndrome is an acquired, monophasic illness of the peripheral nervous system. The etiology is an autoimmune attack directed against peripheral nervous system myelin, although the exact mechanism of the immunologic injury is unknown. The major clinical features are rapidly progressive weakness and hyporeflexia, and the most serious complications during the acute phase of the disease are respiratory failure and autonomic cardiovascular disturbances. A careful history, physical examination, and routine laboratory tests are necessary to make a clinical diagnosis and to exclude other disorders that cause acute weakness. Results of laboratory studies that aid in the diagnosis, CSF protein and electrodiagnostic studies, are usually normal during the first week of the illness. The prognosis for children with Guillian-Barré syndrome is excellent for full recovery using modern intensive care therapy for respiratory support and management of other complications.

Guillain-Barré syndrome in children.

The Guillain-Barre syndrome is an acquired, monophasic illness of the peripheral nervous system. The etiology is an autoimmune attack directed against peripheral nervous system myelin, although the exact mechanism of the immunologic injury is unknown. The major clinical features are rapidly progressive weakness and hyporeflexia, and the most serious complications during the acute phase of the disease are respiratory failure and autonomic cardiovascular disturbances. A careful history, physical examination, and routine laboratory tests are necessary to make a clinical diagnosis and to exclude other disorders that cause acute weakness. Results of laboratory studies that aid in the diagnosis, CSF protein and electrodiagnostic studies, are usually normal during the first week of the illness. The prognosis for children with Guillian-Barre syndrome is excellent for full recovery using modern intensive care therapy for respiratory support and management of other complications.