Gut microbiota links with cognitive impairment in amyotrophic lateral sclerosis: A multi-omics study

Recently, cognitive impairments(CI) and behavioral abnormalities in patients with amyotrophic lateral sclerosis(ALS) have been reported. However, the underlying mechanisms have been poorly understood. In the current study, we explored the role of gut microbiota in CI of ALS patients. We collected fecal samples from 35ALS patients and 35 healthy controls. The cognitive function of the ALS patients was evaluated using the Edinburgh Cognitive and Behavioral ALS Screen. We analyzed these samples by using 16S rRNA gene sequencing as well as both untargeted and targeted(bile acids) metabolite mapping between patients with CI and patients with normal cognition(CN). We found altered gut microbial communities and a lower ratio of Firmicutes/Bacteroidetes in the CI group, compared with the CN group. In addition, the untargeted metabolite mapping revealed that 26 and 17 metabolites significantly increased and decreased, respectively, in the CI group, compared with the CN group. These metabolites were mapped to the metabolic pathways associated with bile acids. We further found that cholic acid and chenodeoxycholic acid were significantly lower in the CI group than in the CN group. In conclusion, we found that the gut microbiota and its metabolome profile differed between ALS patients with and without CI and that the altered bile acid profile in fecal samples was significantly associated with CI in ALS patients. These results need to be replicated in larger studies in the future.

神经鞘磷脂合成酶2基因敲除对小鼠血清高密度脂蛋白3功能的影响

背景和目的已有报道显示，神经鞘磷脂合成酶2基因缺失（sphingomyelinsynthase2knockout，SMS2。一）有抗动脉粥样硬化及抗炎作用。本文以SMS2I／一小鼠为研究对象，旨在探讨神经鞘磷脂（sphingomyelin，sM）代谢与血清高密度脂蛋白（high—den—sitylipoprotein，HDL）抗氧化、抗炎症、保护内皮能力之间的关系。方法雄性28周龄SMS2-/-小鼠16只为实验组，同性别同周龄C57BL／6J（wild—type，wT）小鼠16只为对照组。禁食12h后眼球取血，酶学方法检测血脂，超速离心法提取血清HDL3，测定HDl3抗铜离子诱导脂蛋白氧化的能力（以生成TBARS含量表示）、

紫外线照射对成纤维细胞染色体端粒DNA复制的影响

目的:旨在DNA水平探讨紫外线启动人皮肤光老化的机制,以加深对光老化的理解,并为减缓光老化进程提供新靶点。方法:紫外线照射原代人成纤维细胞,用比色法测定成纤维细胞的增殖活性;用1000 mJ/cm^2紫外线照射细胞,采用实时定量PCR方法测定照射与未照射细胞不同代数的端粒长度;不同剂量紫外线照射同代细胞,并测定端粒长度。结果:紫外线照射与未照射细胞的端粒长度均有随着细胞的复制传代而逐渐缩短趋势;在不同剂量紫外线照射的同一代细胞之间,紫外线剂量越高,端粒长度则越短,高剂量组与未照射组相比有统计学差异(P<0.05)。结论:单次大剂量紫外线照射可以使端粒长度变短,急性光损伤可能启动光老化的早期进程。

Endoscopic and non-endoscopic approaches for the management of radiation-induced rectal bleeding

Pelvic radiation is a commonly utilized treatment for malignancy of the genitourinary and lower gastrointestinal tract. Radiation proctitis and the resultant clinical picture varies from asymptomatic to potentially life threatening. Similarly, treatment options also vary greatly, from medical therapy to surgical intervention. Commonly utilized medical therapy includes sucralfate enemas, antibiotics, 5-aminosalicylic acid derivatives, probiotics, antioxidants, short-chain fatty acids, formalin instillation and fractionated hyperbaric oxygen. More invasive treatments include endoscopic-based, focally ablative interventions such as dilation, heater and bipolar cautery, neodymium/yttrium aluminum garnet argon laser, radiofrequency ablation or argon plasma coagulation. Despite its relatively common frequency, there is a dearth of existing literature reporting headto-head comparisons of the various treatment options via a randomized controlled approach. The purpose of our review was to present the reader a consolidation of the existing evidence-based literature with the goal of highlighting the comparative effectiveness and risks of the various treatment approaches. Finally, we outline a pragmatic approach to the treatment of radiation proctitis. In light of the lack of randomized data, our goal is to pursue as least invasive an approach as possible, with escalation of care tailored to the severity of the patient's symptoms. For those cases that are clinicallyasymptomatic or only mildly symptomatic, observation or medical management can be considered. Once a patient fails such management or symptoms become more severe, invasive procedures such as endoscopically based focal ablation or surgical intervention can be considered. Although not all recommendations are supported by level I evidence, reported case series and single-institutional studies in the literature suggest that successful treatment with cessation of symptoms can be obtained in the majority of cases.

MicroRNA signature and function in retinal neovascularization

Ischemic retinopathies are clinically well-defined chronic microvascular complications characterized by gradually progressive alterations in the retinal microvasculature and a compensatory aberrant neovascularization of the eye. The subsequent metabolic deficiencies result in structural and functional alterations in the retina which is highly susceptible to injurious stimuli such as diabe-tes, trauma, hyperoxia, inflammation, aging and dys-plipidemia. Emerging evidence indicates that an effec-tive therapy may require targeting multiple components of the angiogenic pathway. Conceptually, mircoRNA(miRNA)-based therapy provides the rationale basis for an effective antiangiogenic treatment. miRNAs are an evolutionarily conserved family of short RNAs, each regulating the expression of multiple protein-coding genes. The activity of specific miRNAs is important for vascular cell signaling and blood vessel formation and function. Recently, important progress has been made in mapping the miRNA-gene target network andmiRNA-mediated gene expression control. Here wehighlight the latest findings on angiogenic and antian-giogenic miRNAs and their targets as well as potentiaimplications in ocular neovascular diseases. Emphasis isplaced on how specific vascular-enriched miRNAs regu-late cell responses to various cues by targeting severafactors, receptors and/or signaling molecules in orderto maintain either vascular function or dysfunction. Fur-ther improvement of our knowledge in not only miRNAspecificity, turnover, and transport but also how miRNAsequences and functions can be altered will enhancethe therapeutic utility of such molecules.

Treating comorbid anxiety and depression: Psychosocial and pharmacological approaches

Comorbid anxiety with depression predicts poor outcomes with a higher percentage of treatment resistance than either disorder occurring alone. Overlap of anxiety and depression complicates diagnosis and renders treatment challenging. A vital step in treatment of such comorbidity is careful and comprehensive diagnostic assessment. We attempt to explain various psychosocial and pharmacological approaches for treatment of comorbid anxiety and depression. For the psychosocial component, we focus only on generalized anxiety disorder based on the following theoretical models:(1) "the avoidance model";(2) "the intolerance of uncertainty model";(3) "the meta-cognitive model";(4) "the emotion dysregulation model"; and(5) "the acceptance based model". For depression, the following theoretical models are explicated:(1) "the cognitive model";(2) "the behavioral activation model"; and(3) "the interpersonal model". Integration of these approaches is suggested. The treatment of comorbid anxiety and depression necessitates specific psychopharmacological adjustments as compared to treating either condition alone. Serotonin reuptake inhibitors are considered first-line treatment in uncomplicated depression comorbid with a spectrum of anxiety disorders. Short-acting benzodiazepines(BZDs) are an important "bridging strategy" to address an acute anxiety component. In patients with comorbid substance abuse, avoidance of BZDs is recommended and we advise using an atypical antipsychotic in lieu of BZDs. For mixed anxiety and depression comorbid with bipolar disorder, we recommend augmentation of an antidepressant with either lamotrigine or an atypical agent. Combination and augmentation therapies in the treatment of comorbid conditions vis-à-vis monotherapy may be necessary for positive outcomes. Combination therapy with tricyclic antidepressants, gabapentin and selective serotonin/norepinephrine reuptake inhibitors(e.g., duloxetine) are specifically useful for comorbid chronic pain syndromes. Aripiprazole, quetiapine, risperidone and other novel atypical agents may be effective as augmentations. For treatment-resistant patients, we recommend a "stacking approach" not dissimilar from treatment of hypertension In conclusion, we delineate a comprehensive approach comprising integration of various psychosocial approaches and incremental pharmacological interventions entailing bridging strategies, augmentation therapies and ultimately stacking approaches towards effectively treating comorbid anxiety and depression.

Mechanisms of interleukin-22's beneficial effects in acutepancreatitis

Acute pancreatitis(AP) is a disorder characterized by parenchymal injury of the pancreas controlled by immune cell-mediated inflammation. AP remains a significant challenge in the clinic due to a lack of specific and effective treatment. Knowledge of the complex mechanisms that regulate the inflammatory response in AP is needed for the development of new approaches to treatment, since immune cell-derived inflammatory cytokines have been recognized to play critical roles in the pathogenesis of the disease. Recent studies have shown that interleukin(IL)-22, a cytokine secreted by leukocytes, when applied in the severe animal models of AP, protects against the inflammation-mediated acinar injury. In contrast, in a mild AP model, endogenous IL-22 has been found to be a predominantly antiinflammatory mediator that inhibits inflammatory cell infiltration via the induction of Reg3 proteins in acinar cells, but does not protect against acinar injury in the early stage of AP. However, constitutively over-expressed IL-22 can prevent the initial acinar injury caused by excessive autophagy through the induction of the antiautophagic proteins Bcl-2 and Bcl-XL. Thus IL-22 plays different roles in AP depending on the severity of the AP model. This review focuses on these recently reported findings for the purpose of better understanding IL-22's regulatory roles in AP which could help to develop a novel therapeutic strategy.

Acinar cell injury induced by inadequate unfolded protein response in acute pancreatitis

Acute pancreatitis (AP) is an inflammatory disorder of pancreatic tissue initiated in injured acinar cells. Severe AP remains a significant challenge due to the lack of effective treatment. The widely-accepted autodigestion theory of AP is now facing challenges, since inhibiting protease activation has negligible effectiveness for AP treatment despite numerous efforts. Furthermore, accumulating evidence supports a new concept that malfunction of a self-protective mechanism, the unfolded protein response(UPR), is the driving force behind the pathogenesis of AP. The UPR is induced by endoplasmic reticulum(ER) stress, a disturbance frequently found in acinar cells, to prevent the aggravation of ER stress that can otherwise lead to cell injury. In addition, the UPR's signaling pathways control NFκB activation and autophagy flux, and these dysregulations cause acinar cell inflammatory injury in AP, but with poorly understood mechanisms. We therefore summarize the protective role of the UPR in AP, propose mechanistic models of how inadequate UPR could promote NFκB's pro-inflammatory activity and impair autophagy's protective function in acinar cells, and discuss its relevance to current AP treatment. We hope that insight provided in this review will help facilitate the research and management of AP.

Sleep disorders and chronic kidney disease

Sleep disorders have a profound and well-documented impact on overall health and quality of life in the general population. In patients with chronic disease, sleep disorders are more prevalent, with an additional morbidity and mortality burden. The complex and dynamic relationship between sleep disorders and chronic kidney disease(CKD) remain relatively little investigated. This article presents an overview of sleep disorders in patients with CKD, with emphasis on relevant pathophysiologic underpinnings and clinical presentations. Evidence-based interventions will be discussed, in the context of individual sleep disorders, namely sleep apnea, insomnia, restless leg syndrome and excessive daytime sleepiness. Limitations of the current knowledge as well as future research directions will be highlighted, with a final discussion of different conceptual frameworks of the relationship between sleep disorders and CKD.

Drug induced acute pancreatitis: Does it exist?

As the incidence of acute pancreatitis continues to rise, establishing the etiology in order to prevent recurrence is important. Although the etiology of acute pancreatitis is not difficult in the majority of patients, almost a quarter of patients are initially labeled as having idiopathic acute pancreatitis. When confronted with a patient with acute pancreatitis and no clear etiology defined as an absence alcoholism, gallstones(ultrasound and/or MRI), a normal triglyceride level, and absence of tumor, it often appears reasonable to consider a drug as the cause of acute pancreatitis. Over 100 drugs have been implicated by case reports as causing acute pancreatitis. While some of these case reports are well written, many case reports represent poorly written experiences of the clinician simply implicating a drug without a careful evaluation. Over-reliance on case reports while ignoring randomized clinical trials and large pharmacoepidemiologic surveys has led to confusion about drug induced acute pancreatitis. This review will explain that drug induced acute pancreatitis does occur, but it is rare, and over diagnosis leads to misconceptions about the disease resulting in inappropriate patient care, increased litigation and a failure to address the true entity: idiopathic acute pancreatitis.

Dexamethasone mediates protection against acute pancreatitis via upregulation of pancreatitis-associated proteins

AIM: To examine the influence of dexamethasone on pancreatitis-associated protein (PAP) gene expression using both in vitro and in vivo models of acute pancreati- tis and to study how PAP gene expression correlates with severity of pancreatitis. METHODS: In vitro, IL-6 stimulated pancreas acinar AR42J cells were cultured with increasing concentrations of dexamethasone and assayed for PAP expression (RT-PCR). In vivo , pancreatitis was induced in rats by retrograde injection of 40 g/L taurocholate into the pancreatic duct. Animals were pretreated with dexamethasone (2 mg/kg) daily or saline for 4 d. Pancreata and serum were harvested after 24 h and gene expression levels of PAPⅠ, Ⅱ and Ⅲ were measured by RT-PCR. Severity of pancreatitis was based on serum amylase, pancreatic wet weight, and histopathological score. RESULTS: In vitro, dexamethasone and IL-6 induced a marked transcription of PAPⅠ, Ⅱ and Ⅲ genes in AR42J cells at 24 h (P < 0.05 for all comparisons). In vivo, pancreas mRNA levels of PAPⅠ, Ⅱ or Ⅲ increased by 2.6-fold, 1.9-fold, and 1.3-fold respectively after dexa- methasone treatment, compared with saline treated ani- mals. Serum amylase levels and edema were significantly lower in the dexamethasone group compared with the saline group. Histopathologic evaluation revealed less inflammation and necrosis in pancreata obtained from dexamethasone treated animals (P < 0.05). CONCLUSION: Dexamethasone significantly decreases the severity of pancreatitis. The protective mechanism ofdexamethasone may be via upregulating PAP gene ex- pression during injury.

The risk of wound infection after simple hand laceration

BACKGROUND: This prospective observational study aimed to determine the infection rate of simple hand laceration(SHL), and to compare infection rates between patients who were prescribed antibiotics and those who were not.METHODS: The study was performed at two urban hospitals enrolling 125 emergency department(ED) patients with SHL. Exclusion criteria included patients with lacerations for more than 12 hours, immunocompromized patients, patients given antibiotics, and patients with gross contamination, bites or crush injuries. Wound infection was defined as clinical infection at a follow-up visit(10–14 days) or wound was treated with antibiotics. Patient satisfaction was also measured using a visual analogue scale 1–10, asking the patients about wound appearance. Demographic data and wound characteristics were compared between the infected and non-infected wounds. The infection rates were also compared between patients who received prophylactic antibiotics and those who did not. The results were presented with medians and quartiles or percentages with 95% confidence intervals(CI).RESULTS: In the 125 patients with SHL [median age: 28(18, 43); range: 1–102 years old; 36% female], 44(35%, 95% CI: 27%–44%) were given antibiotics in the ED. Wound infection was reported in 6 patients(4.8%, 95% CI: 2%–10%). Age, gender, history of diabetes and wound closure were not associated with wound infection(P>0.05). The infection rate was not significantly different between patients with or without antibiotic prophylaxis [7%(3/44), 95% CI: 2%–10% vs. 4%(3/81), 95% CI: 1%–11%, P=0.66]. Patient's satisfaction with appearance ofinfected and non-infected wounds were significantly different [7.5(6, 8) vs. 9(8, 10), P=0.01].CONCLUSION: Approximately 5% of simple hand lacerations become infected. Age, gender, diabetes, prophylactic antibiotics and closure technique do not affect the risk ofinfection.

Could the number of CT angiograms be reduced in emergency department patients suspected of pulmonary embolism?

This study was undertaken to identify the prevalence of pulmonary embolism （PE） in the emergency department （ED） of an urban teaching hospital and also to test a Bayesian model in estimating the number of CT pulmonary angiography （CTA） expected to be performed in an emergency department. The data for this study was obtained through a retrospective review of electronic medical records for all ED patients suspected of PE who underwent chest CTA or ventilation perfusion scanning （V/Q） between 2009 and 2010. The data is presented as means and standard deviation for continuous variables and percentages with 95% confidence intervals （95%CI） for proportions. The prevalence of PE was used as pre-test probability in the Bayesian model. Post-test probability was obtained using a Fagan nomogram and likelihood ratios for CTA. A total of 778 patients （560 females） with mean age of 50 years （range 18-98 years） were enrolled （98.3% underwent chest CTA and 1.7% underwent V/Q scan）. A total of 69 patients had PE, rendering an overall prevalence of 8.9% （95%CI, 7.1% to 11.1%） for PE. We calculated that 132 CTA＇s per year could be avoided in our institution, without compromising safe exclusions of PE （keeping post-test probability of PE below 2%）. Despite differences in our patient populations and/or study designs, the prevalence of PE in our institution is about average compared to other institutions. Our proposed model for calculating redundant chest CTA is simple and can be used by institutions to identify overuse of CTA.

Pharmacological management of behavioral symptoms associated with dementia

Dementia is a clinical syndrome with features of neurocognitive decline. Subtypes of dementia include Alzheimer's, frontotemporal, Parkinson's, Lewy body disease, and vascular type. Dementia is associated with a variety of neuropsychiatric symptoms that may include agitation, psychosis, depression, and apathy. These symptoms can lead to dangerousness to self or others and are the main source for caregiver burnout. Treatment of these symptoms consists of nonpharmacological and pharmacological interventions. However, there are no Food and Drug Administration-approved medications for the treatment of behavioral and psychological symptoms of dementia. Pharmacological interventions are used off-label. This article reviews the current evidence supporting or negating the use of psychotropic medications along with safety concerns, monitoring, regulations, and recommendations.

Psychiatric aspects of brain tumors:A review

Infrequently, psychiatric symptoms may be the only manifestation of brain tumors. They may present with mood symptoms, psychosis, memory problems, personality changes, anxiety, or anorexia. Symptoms may be misleading, complicating the clinical picture. A comprehensive review of the literature was conducted regarding reports of brain tumors and psychiatric symptoms from 1956-2014. Search engines used include Pub Med, Ovid, Psych Info, MEDLINE, and Med Scape. Search terms included psychiatric manifestations/symptoms, brain tumors/neoplasms. Our literature search yielded case reports, case studies, and case series. There are no double blind studies except for post-diagnosis/-surgery studies. Early diagnosis is critical for improved quality of life. Symptoms that suggest work-up with neuroimaging include: new-onset psychosis, mood/memory symptoms, occurrence of new or atypical symptoms, personality changes, and anorexia without body dysmorphic symptoms. This article reviews the existing literature regarding the diagnosis and management of this clinically complex condition.

Risk for emerging bipolar disorder, variants, and symptoms in children with attention deficit hyperactivity disorder, now grown up

AIM: To determine the prevalence of bipolar disorder(BD) and sub-threshold symptoms in children with attention deficit hyperactivity disorder(ADHD) through 14 years' follow-up, when participants were between 21-24 years old.METHODS: First, we examined rates of BD type Ⅰ?and Ⅱ diagnoses in youth participating in the NIMH-funded Multimodal Treatment Study of ADHD(MTA). We used the diagnostic interview schedule for children(DISC), administered to both parents(DISC-P) and youth(DISCY). We compared the MTA study subjects with ADHD(n = 579) to a local normative comparison group(LNCG, n = 289) at 4 different assessment points: 6, 8, 12, and 14 years of follow-ups. To evaluate the bipolar variants, we compared total symptom counts(TSC) of DSM manic and hypomanic symptoms that were generated by DISC in ADHD and LNCG subjects. Then we sub-divided the TSC into pathognomonic manic(PM) and non-specific manic(NSM) symptoms. We compared the PM and NSM in ADHD and LNCG at each assessment point and over time. We also evaluated the irritability as category A2 manic symptom in both groups and over time. Finally, we studied the irritability symptom in correlation with PM and NSM in ADHD and LNCG subjects.RESULTS: DISC-generated BD diagnosis did not differ significantly in rates between ADHD(1.89%) and LNCG 1.38%). Interestingly, no participant met BD diagnosis more than once in the 4 assessment points in 14 years. However, on the symptom level, ADHD subjects reported significantly higher mean TSC scores: ADHD 3.0; LNCG 1.7; P < 0.001. ADHD status was associated with higher mean NSM: ADHD 2.0 vs LNCG 1.1; P < 0.0001. Also, ADHD subjects had higher PM symptoms than LNCG, with PM means over all time points of 1.3 ADHD; 0.9 LNCG; P = 0.0001. Examining both NSM and PM, ADHD status associated with greater NSM than PM. However, Over 14 years, the NSM symptoms declined and changed to PM over time(df 3, 2523; F = 20.1; P < 0.0001). Finally, Irritability(BD DSM criterion-A2) rates were significantly higher in ADHD than LNCG(χ2 = 122.2, P < 0.0001), but irritability was associated more strongly with NSM than PM(df 3, 2538; F = 43.2; P < 0.0001).CONCLUSION: Individuals with ADHD do not appear to be at significantly greater risk for developing BD, but do show higher rates of BD symptoms, especially NSM. The greater linkage of irritability to NSM than to PM suggests caution when making BD diagnoses based on irritability alone as one of 2(A-level) symptoms for BD diagnosis, particularly in view of its frequent presentation with other psychopathologies.

Lipogenesis in Huh7 cells is promoted by increasing the fructose: Glucose molar ratio

AIM: To determine whether hepatocyte lipogenesis, in an in vitro cell culture model, is modulated by adjusting culture media monosaccharide content and concentration.METHODS: Hepatocytes(Huh7), demonstrating glucose and fructose uptake and lipid biosynthesis, were incubated in culture media containing either glucose alone(0.65-0.72 mmol/L) or isosmolar monosaccharide(0.72 mmol/L) comprising fructose:glucose(F:G) molar ratios ranging from 0.58-0.67. Following a 24-h incubation, cells were harvested and analyzed for total protein, triglyceride(TG) and cholesterol(C) content. Significant differences(P < 0.05) among groups were determined using analysis of variance followed by Dunnett's test for multiple comparisons.RESULTS: After a 24 h incubation period, Huh7 cell mass and viability among all experimental groups were not different. Hepatocytes cultured with increasing concentrations of glucose alone did not demonstrate a significant change either in C or in TG content. However, when the culture media contained increasing F:G molar ratios, at a constant total monosaccharideconcentration, synthesis both of C and of TG increased significantly [F:G ratio = 0.58, C/protein(μg/μg) = 0.13;F:G = 0.67, C/protein = 0.18, P < 0.01; F:G ratio = 0.58,TG/protein(μg/μg) = 0.06; F:G ratio = 0.67, TG/protein= 0.11, P < 0.01]. CONCLUSION: In an in vitro hepatocyte model, glucose or fructose plus glucose support total cell mass and lipogenic activity. Increasing the fructose:glucose molar ratio(but not glucose alone) enhances triglyceride and cholesterol synthesis. These investigations demonstrate fructose promotes hepatocellular lipogenesis, and they provide evidence supporting future, in vivo studies of fructose's role in the development of hepatic steatosis and non-alcoholic fatty liver disease.

Large ulcerated cecal lipoma mimicking malignancy

Colonic lipomas are relatively uncommon tumors of mesenchymal origin,composed of well-differentiated adipose tissue supported by fibrous tissue,that usually occur in cecum and ascending colon.Colonic lipomas rarely cause symptoms and are usually detected incidentally. However,if the lesion is large,it may produce symptoms, such as abdominal pain,rectal bleeding,obstruction, intussusception,and even weight loss.Large colonic lipomas can be mistaken for malignancy,which may result in extensive surgical operations.We report a large broadbased ulcerated cecal lipoma in a 68-year-old woman, who presented with abdominal pain and weight loss.The ulcerated lesion was highly suspicious for malignancy radiologically and endoscopically.The patient underwent laparoscopic right-hemicolectomy,and the lesion was diagnosed as a cecal submucosal lipoma.The surgical approach remains the treatment of choice for large and complicated cases.

Correction of Severe Anemia in a Patient with End Stage Renal Disease and Myelodysplastic Syndrome

Background: Anemia is a common complication of end-stage renal disease (ESRD) and is effectively managed by Erythropoietin Stimulating Agents (ESAs) and intravenous iron therapy. Management of anemia in ESRD patients with myelodysplastic syndrome (MDS) poses a unique challenge. ESAs even at extremely high doses do not result in a desired response, especially if the patients are iron-overloaded. Case: A 72-year-old man with history of ESRD and MDS on hemodialysis since September 2009 was severely anemic requiring massive doses of ESA in excess of 90,000 units/week. Iron saturation was consistently >60%;ferritin was >2500. Desferrioxamine (DFO) 125 mg IV/week was begun in November 2010. His PRBC transfusion and ESA requirements declined after the initiation of this therapy. He had 33 ER visits for PRBC transfusions (1 - 3 transfusions/visit) from September 2009 to November 2010 (average: 2.35/month), which decreased to 18 visits in 20 months (average: 0.9/month) after getting DFO. Conclusion: We report a case of MDS with ESRD on hemodialysis where anemia was managed with Desferrioxamine therapy along with ESA, after which it was noted that there was a significant reduction in the number of PRBC transfusions that the patient received along with a decrease in ESA requirements and a decrease in number of hospitalizations, which in the long term could be cost effective.

Survey of the current state of emergency care in Chennai, India

BACKGROUND：On July 21, 2009, the Medical Council of India officially recognized the specialty of emergency medicine in India. The city of Chennai with over six and a half million people is the fourth largest on the subcontinent and has already been a prominent city of interest in the specialty＇s development. However, there is no standardization of the resources found in the city＇s emergency departments. This study was to survey the equipment, training, and certification of Chennai area emergency departments and their staff. METHODS：We conducted a cross-sectional survey of emergency department staff from 38 Chennai area hospitals. The survey instrument contained 44 questions pertaining to hospital demographics, staff training and certification, and ED equipment and supplies. The items on the survey were specifically chosen to represent only the most basic and common resources necessary to practise emergency medicine. RESULTS： The survey found a majority of hospitals are privately operated but there is a wide range in terms of size and volume of patients. A minority of both doctors and nurses are certified in BLS, ACLS, PALS, and ATLS. While almost all departments surveyed had the basic code medications, a number of basic equipment items were lacking from a large percentage of the EDs surveyed. CONCLUSION：The newly established EP community in Chennai will have the responsibility to establish standards for both training and resources so that the specialty may grow and provide a higher standard of emergency care moving into the future.