admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

Curcumin, a polyphenolic compound derived from dietary spice turmeric, possesses diverse pharmacologic effects including anti-inflammatory, antioxidant, antiproliferative and antiangiogenic activities. Phase I clinical trials have shown that curcumin is safe even at high doses (12 g/day) in humans but exhibit poor bioavailability. Major reasons contributing to the low plasma and tissue levels of curcumin appear to be due to poor absorption, rapid metabolism, and rapid systemic elimination. To improve the bioavailability of curcumin, numerous approaches have been undertaken. These approaches involve, first, the use of adjuvant like piperine that interferes with glucuronidation; second, the use of liposomal curcumin; third, curcumin nanoparticles; fourth, the use of curcumin phospholipid complex; and fifth, the use of structural analogues of curcumin (e.g., EF-24). The latter has been reported to have a rapid absorption with a peak plasma half-life. Despite the lower bioavailability, therapeutic efficacy of...

Bioavailability of curcumin: problems and promises.

Curcumin (diferuloylmethane) is a polyphenol derived from the plant Curcuma longa, commonly called turmeric. Extensive research over the last 50 years has indicated this polyphenol can both prevent and treat cancer. The anticancer potential of curcumin stems from its ability to suppress proliferation of a wide variety of tumor cells, down-regulate transcription factors NF- κB, AP-1 and Egr-1; down-regulate the expression of COX2, LOX, NOS, MMP-9, uPA, TNF, chemokines, cell surface adhesion molecules and cyclin D1; down-regulate growth factor receptors (such as EGFR and HER2); and inhibit the activity of c-Jun N-terminal kinase, protein tyrosine kinases and protein serine/threonine kinases. In several systems, curcumin has been described as a potent antioxidant and anti-inflammatory agent. Evidence has also been presented to suggest that curcumin can suppress tumor initiation, promotion and metastasis. Pharmacologically, curcumin has been found to be safe. Human clinical trials indicated no dose-limiting toxicity when administered at doses up to 10 g/day. All of these studies suggest that curcumin has enormous potential in the prevention and therapy of cancer. The current review describes in detail the data supporting these studies. Curcumin, derived from turmeric (vernacular name: Haldi), is a rhizome of the plant Curcuma longa. The medicinal use of this plant has been documented in Ayurveda (the Indian

Anticancer potential of curcumin: preclinical and clinical studies.

Curcumin as “Curecumin”: From kitchen to clinic

Potential Therapeutic Effects of Curcumin, the Anti-inflammatory Agent, Against Neurodegenerative, Cardiovascular, Pulmonary, Metabolic, Autoimmune and Neoplastic Diseases

Anti-thrombotic effect of curcumin.

Background
Animal, epidemiologic, and human clinical studies suggest a putative role for vitamin D in osteoarthritis (OA) Inadequate sunlight exposure and lower serum levels of 25(OH)D appear in some reports to be associated with an increased risk for progression of knee OA

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Does Vitamin D Improve Osteoarthritis of the Knee: A Randomized Controlled Pilot Trial

Background: Triage at emergency department is performed to identify those patients who are relatively more serious and require immediate attention and treatment. Despite current methods of triage, trauma continues to be a leading cause of morbidity and mortality. Aims: This study was to evaluate the predictive value of shock index (SI) and modified shock index (MSI) for hospital mortality among adult trauma patients. Materials and Methods: In this prospective longitudinal study, all adult patients who sustained trauma enrolled as per as inclusion/exclusion criteria. After the collection of data, SI and MSI were calculated accordingly. All parameters were again recorded hourly and calculations were done at six-hour intervals. Further, to achieve a value that can be analyzed, we determined threshold value for vital signs, which set the threshold values as heart rate at 120 beats per minute, systolic blood pressure at less than 90, and SI at cut-off 0.5-0.9 and MSI at less than 0.7 to more than 1.3. Results: We analyzed 9860 adult trauma patients. Multivariate regression analysis demonstrated that heart rate more than 120 beats per minute, systolic blood pressure less than 90 mmHg, and diastolic blood pressure (DBP) less than 60 mmHg correlate with hospital stay and mortality rate. MSI 1.3 had higher odds of mortality as compared to other predictors. Conclusions: MSI is an important marker for predicting the mortality rate and is significantly better than heart rate, systolic blood pressure, DBP and SI alone. Therefore, modified SI should be used in the triage of serious patients, including trauma patients in the emergency room.

Correlation of shock index and modified shock index with the outcome of adult trauma patients: A prospective study of 9860 patients

Background Animal, epidemiologic, and human clinical studies suggest a putative role for vitamin D in osteoarthritis (OA). Inadequate sunlight exposure and lower serum levels of 25(OH)D appear in some reports to be associated with an increased risk for progression of knee OA. Questions/purposes We asked whether treatment with vitamin D would (1) reduce knee pain (WOMAC and VAS), (2) improve function (WOMAC), and (3) change levels of relevant biochemical markers in patients with knee OA with vitamin D insufficiency. Methods This randomized controlled pilot trial prospectively enrolled 107 patients with knee OA with vitamin D insufficiency (25(OH)D B 50 nmol/L) to receive oral vitamin D or placebo. The primary outcome measures were pain and function, and the secondary were biochemical markers. At baseline, the two groups were comparable. The patients were followed for 1 year. Results At 12 months, knee pain had decreased in the vitamin D group by mean 0.26 (95% CI, 2.82 to 1.43) on VAS and 0.55 (95% CI, 0.07 to 1.02) on the WOMAC, whereas in the placebo group, it increased by mean 0.13 (95% CI, 0.03 to 0.29) on the VAS and 1.16 (95% CI, 0.82 to 1.49) on the WOMAC (effect size = 0.37 and 0.78). Likewise knee function improved in the vitamin D group by mean 1.36 (95% CI, 1.87 to 0.85) over the placebo group which had a mean 0.69 (95% CI, 0.03 to 1.41; effect size = 0.06). There were significant biochemical changes in serum total calcium, 25(OH)D and alkaline phosphatase. Conclusions The results above suggest there is a small but statistically significant clinical benefit to vitamin D treatment in patients with knee OA, although we recommend a long-term study to determine whether these changes are clinically important and whether they will be sustained with time. Further studies with long-term radiologic evaluations are needed. Level of Evidence Level I, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence. Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. This work was performed at King George Medical University, Lucknow, India. D. Sanghi, A. Mishra, A. C. Sharma, A. Singh, R. N. Srivastava (&) Department of Orthopaedic Surgery, King George’s Medical University, Nabiullah Road, near Daliganj Chauraha, Lucknow, India e-mail: drrnsrivastava@yahoo.com; drrnsrivastava@rediffmail.com S. M. Natu Department of Pathology, KG Medical University, Lucknow, India S. Agarwal Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India 123 Clin Orthop Relat Res (2013) 471:3556–3562 DOI 10.1007/s11999-013-3201-6 Clinical Orthopaedics and Related Research® A Publication of The Association of Bone and Joint Surgeons®

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Rajeshwar Nath Srivastava

Papers

Anti-thrombotic effect of curcumin.

Does Vitamin D Improve Osteoarthritis of the Knee: A Randomized Controlled Pilot Trial

Correlation of shock index and modified shock index with the outcome of adult trauma patients: A prospective study of 9860 patients

Reply to the Letter to the editor: Does vitamin D improve osteoarthritis of the knee: a randomized controlled pilot trial.

TNF-α, IL-6, and IL-8 cytokines and their association with TNF-α-308 G/A polymorphism and postoperative sepsis.