Open grade III fractures of femoral shaft: Outcome after early reamed intramedullary nailing

BACKGROUND

Open grade III fractures of femur are a challenging therapeutic problem as most of them are associated with multiple trauma. Method used for skeletal stabilization of these fractures should limit further soft tissue damage, bacterial spread and morbidity in addition to its ease of application, providing mechanical support and restoring normal alignment.

METHODS

Forty-six patients with open grade III fractures of femoral shaft were included in the study. There were 10 grade IIIA, 34 grade IIIB and two grade IIIC fractures that were treated with early reamed intramedullary nailing with adequate management of soft tissue. Patients were reviewed retrospectively.

RESULTS

Mean time of union was 27 weeks. Infection rate was 4% and non-union rate was 9%. There were two cases (4%) with limb shortening. No case of angular or rotational deformity was noted.

CONCLUSION

Early reamed intramedullary nailing for open grade III fractures of femoral shaft, after giving due respect to the soft tissue injury, gives satisfactory results with proper alignment, good range of motion, short rehabilitation period and low infection rate.

LEVEL OF EVIDENCE

Level IV. Retrospective therapeutic study.

Allergic bronchopulmonary aspergillosis: A review of 42 patients from a tertiary care center in India

Objective:

To study the clinical, radiological, and laboratory profile in patients of allergic bronchopulmonary aspergillosis (ABPA).

Materials and Methods:

Retrospective analysis of 42 cases of ABPA, diagnosed over a period of 10 years from 1995 to 2005, for their clinical, radiological, and laboratory profiles.

Results:

Of 42 ABPA patients, 27 were men and 17 were women. Their mean age at the time of diagnosis was 31.2 years and mean duration of illness was 12.2 years. Breathlessness was the chief symptom. Other allergic disorders existed in 17 (40.5%) patients, and family history suggestive of allergic disease was present in 22 (52.4%) patients. Most common chest radiographic finding was fleeting pulmonary shadows in 28 (66.7%) patients. High resolution CT thorax revealed central bronchiectasis as predominant finding. Peripheral blood eosinophilia more than 1000 cells/μl, Type I and type III cutaneous reactivity to Aspergillus antigen, elevated serum titers of total IgE antibody, A. fumigatus specific IgE and IgG antibodies, and serum precipitin against A. fumigatus were positive in majority of patients, who underwent these tests. Thirty eight (90.5%) patients had had history of antitubercular treatment during the course of their illness. All 42 patients met at least four criteria for the diagnosis of ABPA.

Conclusion:

Any patient of bronchial asthma, presenting with recurrent shadows in chest radiograph and high peripheral blood eosinophilia, should be investigated for ABPA. Efforts need to be intensified to improve the awareness level among general physicians for early diagnosis and prompt treatment of this disease to avoid misuse of antitubercular drugs.

Low- versus high-dose combination of midazolam-ketamine for oral premedication in children for ophthalmologic surgeries

INTRODUCTION

Midazolam and ketamine are useful for oral premedication in children to allay anxiety. We compared the effects of midazolam with a combination of high- and low-dose ketaminemidazolam as an oral premedication.

METHODS

This is a randomised, controlled prospective study conducted in 87 children who were scheduled for ophthalmologic surgeries. Group M received oral midazolam 0.5 mg/kg, Group MKL received oral midazolam 0.25 mg/kg and ketamine 3 mg/kg, and Group MKH received midazolam 0.5 mg/kg and ketamine 6 mg/kg. Standard general anaesthesia technique was used. Sedation levels and ease of parental separation were noted.

RESULTS

A linear increasing trend in sedation was seen in the preoperative sedation scores of all the three groups. At 30 minutes, 23 children in Group MKH had good sedation scores as opposed to 20 in Group MKL and 12 in Group M. The best parental separation time was much shorter in the combination groups. There were no statistically significant differences in the parental separation scores, mean response to induction and mask acceptance. The time to reach Aldrete score of 10 was shorter in Group MKL (22 +/- 5 min) and Group M (36 +/- 1 min) compared to Group MKH (52 +/- 2 min). Group MKH had a higher incidence of excessive salivation compared to the other groups.

CONCLUSION

A combination of low-dose midazolam and ketamine is as effective as high-dose midazolam and ketamine for achieving optimum anxiolysis and a faster recovery, with a lower incidence of excessive salivation in children undergoing ophthalmic surgery.

Effects of intrathecal midazolam in spinal anaesthesia: a prospective randomised case control study

INTRODUCTION

Subarachnoid block with local anaesthetics and adjuvants has been extensively used for surgery. Intrathecal midazolam produces antinociception and potentiates the effect of local anaesthetics. We compared intrathecal bupivacaine with and without midazolam to assess its effect on the duration of sensory block, motor block and pain relief.

METHODS

A total of 100 patients scheduled for elective lower abdominal, lower limb and gynaecological procedures were selected to participate in this prospective, randomised, double-blind study. Patients were randomly allocated into two groups for intrathecal drug administration. Group B received 3 mL 0.5 percent bupivacaine with 0.4 mL saline, and group BM received 3 mL 0.5 percent bupivacaine and 0.4 mL (2 mg) midazolam mixture. The onset, duration of sensory/motor block, time to first rescue analgesia and side effects were noted.

RESULTS

Demographic profile and duration of surgery were comparable between the two groups. The onset of sensory (4.8 versus 4.6 min) and motor block (5.9 versus 6 min) was also comparable between the groups. The duration of sensory blockade was prolonged in the midazolam group (90.8 versus 115.8 min, p-value is 0.001), while the duration of motor blockade was comparable (151.8 versus 151.3 min, p-value is 0.51). The duration of effective analgesia was significantly longer in the midazolam group compared to the control group (121.3 versus 221.1 min, p-value is 0.001). Sedation score was comparable in the two groups.

CONCLUSION

The addition of preservative-free midazolam to bupivacaine intrathecally resulted in prolonged postoperative analgesia without increasing motor block.

Changing trends of services used as first contact by patients with mental health problems

BACKGROUND

In the past, traditional faith healers and practitioners of alternative medicine have often been reported to be the first source of contact for Indian patients with mental health problems. However, over the past few decades, this trend seems to be changing.

METHOD

Using a semi-structured questionnaire, we assessed 200 new patients at a psychiatric outpatient service in a general hospital for the first service contact used by them for their mental health problems.

RESULTS

Psychiatrists, non-psychiatric physicians, traditional faith healers and practitioners of alternative medicine were the first service contact for 91 (45.5%), 88 (44%), 16 (8%) and 5 (2.5%) patients, respectively. Patients suffering from severe mental illnesses were more likely to choose a psychiatrist as the first contact, whereas those with neurotic, stress-related and organic mental disorders contacted a non-psychiatric physician.

CONCLUSION

In the current scenario, psychiatrists and nonpsychiatric physicians serve as the first service contact for most patients with mental health problems in India, though traditional faith healers and practitioners of alternative medicine are contacted by a minority.

Intraoperative anaphylaxis caused by a hepatic hydatid cyst

Anaphylactic and anaphylactoid reactions during anaesthesia are a major cause of concern for anaesthesiologists. During the perioperative period, any symptomatology relating to sudden-onset haemodynamic collapse or increased airway pressures during certain surgical procedures should raise suspicion of anaphylaxis. We report a case of anaphylaxis during pericystectomy for hydatid cyst of the liver intraoperatively in a 29-year-old Indian woman. Although a rare occurrence, reporting of such perioperative events is crucial for future references. Anaphylactic reactions should be seriously considered whenever a hydatid cystectomy is performed, especially in the event of a sudden haemodynamic collapse. Early diagnosis and correct treatment are essential to ensure a favourable patient outcome.

Has the quality of serosurveillance in low- and middle-income countries improved since the last HIV estimates round in 2007? Status and trends through 2009

BACKGROUND

HIV surveillance systems aim to monitor trends of HIV infection, the geographical distribution and its magnitude, and the impact of HIV. The quality of HIV surveillance is a key element in determining the uncertainty ranges around HIV estimates. This paper aims to assess the quality of HIV surveillance systems in low- and middle-income countries in 2009 compared with 2007.

METHODS

Four dimensions related to the quality of surveillance systems are assessed: frequency and timeliness of data; appropriateness of populations; consistency of locations and groups; and representativeness of the groups. An algorithm for scoring the quality of surveillance systems was used separately for low and concentrated epidemics and for generalised epidemics.

RESULTS

The number of countries categorised as fully functioning in 2009 was 35, down from 40 in 2007. 47 countries were identified as partially functioning, while 56 were categorised as poorly functioning. When compared with 2007, the quality of HIV surveillance remains similar. The number of ANC sites in sub-Saharan Africa has increased over time. The number of countries with low and concentrated epidemics that do not have functioning HIV surveillance systems has increased from 53 to 56 between 2007 and 2009.

CONCLUSION

Overall, the quality of surveillance in low- and middle-income countries has remained stable. Still too many countries have poorly functioning surveillance systems. Several countries with generalised epidemics have conducted more than one population-based survey which can be used to confirm trends. In countries with concentrated or low-level epidemics, the lack of data on high-risk populations remains a challenge.

Perceived psychosocial benefits associated with perceived restorative potential of wilderness river-rafting trips

Analysis of the restorative experiences and psychosocial benefits of wilderness river rafting trips of varying difficulty with 186 Canadian participants of different ages supported the restorative potential of natural settings for all age groups as measured by the Perceived Restorativeness Scale. The two-factor structure (General Restorativeness and Coherence) was confirmed. Significant associations were found between scores on the General Restorative subscale and perceived psychosocial benefits (relaxation, nature appreciation or kinship, and physical fitness or achievement) and positive affect. However, the findings associated with the Coherence subscale were not conclusive.

Leprosy: a precipitating factor for complex regional pain syndrome

Complex regional pain syndrome (CRPS) usually develops after trauma. We are reporting the first case of CRPS with leprosy as a precipitating cause. A fifty-five-year male presented in the pain clinic with complaint of pain and swelling in the right arm. There was no history of trauma to the limb. On reviewing the history, patient was found to be on treatment for leprosy. X-ray of the right hand showed severe osteoporosis. A diagnosis of CRPS associated with leprosy was made. A diagnostic stellate ganglion block relived his pain completely. Thereafter patient is on treatment with tablet etoricoxib 90 mg once a day, gabapentin 100 mg twice a day and continuing to have 100% pain relief. The diagnosis of the type of CRPS was difficult in our case as no history of trauma or neurological injury was present. The presence of leprosy along with ulnar nerve thickening may be the precipitating factor for CRPS, this has not been reported so far in the literature. We managed the patient with sympathetic block along with medical therapy for chronic pain and leprosy chemotherapy.

A study to evaluate asbestos fiber burden in lung and pleural malignancies

BACKGROUND

There is scarcity of data on asbestos fiber burden in lung and pleural malignancies.

AIM

To evaluate asbestos fiber burden in biopsy samples of suspected lung and pleural malignancies.

STUDY DESIGN

This was a single-centre, observational study.

STUDY PERIOD

From August 2010 to July 2010.

SETTING

Department of Pulmonary Medicine, CSMMU, UP, Lucknow, a tertiary care hospital in India.

STUDY POPULATION

Suspected cases of lung and pleural malignancy.

MATERIALS AND METHODS

Biopsy tissues taken by computed tomography (CT)-guided biopsy, bronchoscopic biopsy, and pleural biopsy by Cope's needle were analyzed for histopathology and asbestos burden by Haq et al.'s method.

RESULTS

20 patients were studied. Mean fiber burden was 9.25 × 10 4 fibers/g. Average burden in lung malignancies (11 patients) was 9.178 × 10 4 fibers/g and in pleural tissue (9 patients) was 9.332 × 10 4fibers/g. Among the different cell types, mean fiber burden in squamous cell carcinoma was 8.99 × 10 4 fibers/g, in adenocarcinoma was 9.71 × 10 4 fibers/g, and in small cell carcinoma was 7.54 × 10 4 fibers/g. Mean fiber burden in bronchoscopic endobronchial biopsy tissue was 10.69 × 10 4 fibers/g, while in CT-guided biopsy was 8.60× 10 4fibers/g.

CONCLUSION

Maximum number of fibers was found in adenocarcinoma.

Low-dose spinal anaesthesia for a parturient with Takayasu's arteritis undergoing emergency caesarean section

Takayasu's arteritis is a rare form of nonspecific obliterative panarteritis of unknown aetiology. Anaesthesia for patients with Takayasu's arteritis is complicated by severe uncontrolled hypertension leading to end-organ dysfunction, stenosis of major blood vessels affecting regional circulation, and difficulties in the monitoring of arterial blood pressure. The anaesthetic approach for parturients with Takayasu's arteritis has not been standardised in the literature, and previous reports have documented the use of general as well as regional anaesthesia. There are few instances in the literature where low-dose spinal anaesthesia alone is used in patients with Takayasu's arteritis undergoing emergency caesarean section. We present a case of the successful management of a parturient with Takayasu's arteritis, who underwent an emergency caesarean section under low-dose spinal anaesthesia.

The role of CD40L and VEGF in the modulation of angiogenesis and inflammation

Recently, there has been growing interest in deciphering the role of angiogenesis in the progression of atherogenesis. Importantly, CD40-CD40L interactions are of significant relevance because of their involvement in both angiogenesis and atherosclerotic development. Previously, we have shown that recombinant soluble CD40 ligand (rsCD40L) stimulates auto-inflammatory CD40L synthesis and reactive oxygen species (ROS) generation in vascular cells. In the current study, we demonstrate that redox-mediated CD40-CD40L interaction can enhance vascular endothelial growth factor (VEGF)-induced angiogenesis, endothelial migration, and actin polymerization processes. Interestingly, the addition of exogenous VEGF leads to cleavage of de novo CD40L produced in endothelial cells following rsCD40L treatment. Using inhibitor and silencing RNA-based experiments, it was observed that VEGF-induced protease, calpain 2, was responsible for the cleavage of de novo CD40L. While our in vivo experiments using a matrigel plug assay indicate a VEGF and CD40L induced enhancement of angiogenesis, our studies also identify a novel mechanism by which VEGF can abrogate CD40L-mediated inflammation. Together, these studies reveal a new pathway by which VEGF-CD40L interactions can regulate the angiogenic and inflammatory process depending on the specific environment.

Perianesthetic management of the first robotic partial cystectomy in bladder pheochromocytoma. A case report

The authors report the perianesthetic considerations of a rare case of pheochromocytoma of the urinary bladder for which the first reported robotic partial cystectomy and ureteric reimplantation were performed. A 59-year-old male patient, known to be hypertensive, was posted for transurethral resection of a bladder tumor. In the operation room, after attaching the monitors, a subarachnoid block was given. Upon manipulation of the tumor, the blood pressure and heart rate increased markedly. A pheochromocytoma was suspected and was later confirmed by raised urine catecholamine levels and meta-iodobenzyl-guanidine scan. The patient was started on tablet prazosin and atenolol. After optimization, a robotic partial cystectomy was planned. In the operating room, an epidural catheter and a radial artery cannula were inserted. After the induction of anesthesia and the securing of the airway, surgery was started. After the insertion of the verres needle, pneumoperitoneum was created very slowly, and then the patient was positioned in 40 degrees Trendelenburg. Surges in arterial blood pressure (ABP) were managed with titrated doses of sodium nitroprusside and nitroglycerine and boluses of esmolol and labetalol. ABP drops postoperatively were managed with fluid and dopamine infusion. Robotic surgery is a safe alternative to the open technique for pheochromocytoma of the urinary bladder. Care should be taken during the positioning of the patient for robot placement and during pneumoperitoneum creation.

Possible role of trazodone and imipramine in sleep deprivation-induced anxiety-like behavior and oxidative damage in mice

Sleep is one of the key regulators for maintaining physical, mental and emotional health. Nonrefreshing sleep and depression are common problems nowadays. The present study was designed to explore the protective effects of trazodone and imipramine on 72-h sleep deprivation-induced anxiety-like behavior and oxidative damage in mice. Albino mice were sleep-deprived for a period of 72 h using the grid suspended over water method. Animals were divided into different groups, each consisting of six animals. Trazodone (5 and 10 mg/kg i.p.) and imipramine (10 and 20 mg/kg i.p.) were administered for 5 days starting 2 days before 72-h sleep deprivation. Various behavioral tests (elevated plus maze, zero maze, mirror chamber for anxiety and actophotometer), followed by oxidative parameter tests (malondialdehyde, glutathione, catalase, nitrite and protein), were assessed in sleep-deprived animals. Treatment with trazodone and imipramine significantly improved locomotor activity and exerted anxiolytic-like effects in all paradigm tasks (mirror chamber, elevated plus maze, zero maze) as compared to untreated 72-h sleep-deprived animals (P < 0.05). Biochemically, both trazodone and imipramine significantly restored depleted reduced glutathione (GSH) levels and catalase activity and attenuated raised lipid peroxidation and nitrite concentrations as compared to untreated sleep-deprived animals. The results of the present study suggest a protective effect for trazodone and imipramine on sleep deprivation-induced anxiety-like behavior and oxidative damage in mice.

Unpredicted neurological complications after robotic laparoscopic radical cystectomy and ileal conduit formation in steep trendelenburg position: two case reports

Robotic surgery is becoming popular for minimally invasive surgical evolution as robotic devices allow unprecedented control and precision in minimally invasive procedures. Two cases of robotic radical cystectomy with ileal conduit urinary diversion surgeries having perioperative neurologic complications related to prolonged surgery in steep head down position are presented. In these patients, neurological deterioration occurred after extubation probably due to cerebral edema. We suggest the duration and positioning should be optimized for such prolonged surgery in steep head down position and some recommendations should be made. Moreover, in such surgeries a great vigilance has to be observed in the perioperative period.

Combined spinal epidural anesthesia with epidural volume extension technique for hysterectomy in patient with unpalliated cyanotic heart disease--a case-report

Adults with unrepaired cyanotic heart disease scheduled for a non-cardiac surgery present serious concerns for the anesthesiologists. Both general and regional anesthetic techniques have been safely reported in Eisenmenger's syndrome and adults with Tetralogy of Fallot (TOF) for non-cardiac surgery. The safety of low-dose sequential combined spinal epidural (CSE) technique in high-risk cardiac cases has recently been emphasized in obstetric anesthetic practice but to our knowledge, this technique has not been reported for hysterectomy in cyanotic heart disease patients in anesthetic literature. We report the successful management of hysterectomy in a patient with ventricular septal defect and pulmonary atresia (VSD-PA) using CSE anesthesia with epidural volume extension (EVE) technique.