Assessment of stress response due to C-Mac D-blade guided videolaryngoscopic endotracheal intubation and docking of da Vinci surgical robot using perfusion index in patients undergoing transoral robotic oncosurgery

Clinical utility of perfusion index (PI) has entered a new realm as a non-invasive, quantitative index of stress response to endotracheal intubation. Transoral robotic surgery (TORS) involves F-K retractor aided docking of the surgical robot producing haemodynamic and stress responses akin to laryngoscopy. We compared the stress response to videolaryngoscopy with that due to docking of da Vinci surgical robot using PI, heart rate and mean arterial pressure evaluated at specific time points post-laryngoscopy and post-docking. Twenty-six adult patients, scheduled for TORS under general endotracheal anaesthesia were included in this prospective, observational, single-centric cohort study. Statistical analysis included paired samples t-test, dotted box-whisker plots, trendlines and correlograms for comparative analysis of two stressors, laryngoscopy and docking. Baseline PI was 4.14. PI values increased post-midazolam (4.23), 1 min (5.69) and 3 min (6.25) post anaesthetic-induction, plummeted at laryngoscopy (3.24), remained low at 1 min (3.68), 3 min (4.69) thereafter, and were highest at 10 min (6.17) post-laryngoscopy and predocking (6.84). Docking witnessed a fall in PI (4.1), which remained low at 1 min (4.02), 3 min (4.31) and 10 min (4.79) post-docking. PI was significantly higher at laryngoscopy compared with PI at docking (p = 0.0044). At 1 min and 3 min post-laryngoscopy and post-docking, respectively, the differences in PI were statistically insignificant. PI at 10 min post-laryngoscopy was significantly lower than PI at 10 min post-docking (p < 0.0001). As non-invasively quantified by PI, videolaryngoscopic stress response is more intense but shorter-lived versus that due to docking. PI displays a negative correlation with haemodynamic variables. PI at laryngoscopy is a good predictor of PI at docking, enabling pre-emptive measures (fentanyl bolus; deepening of volatile anaesthesia from MAC-maintenance to MAC-intubation) anticipating the docking-induced stress response.Trial registration http://ctri.nic.in ; Identifier: CTRI/2019/11/022091.

Supraclavicular block evaluation in oncoorthopedic patients under general anesthesia using perfusion index: A prospective cohort study

Background

Supraclavicular brachial plexus blocks (SCBPB) are routinely placed prior to anaesthetic induction for post-operative pain relief after prolonged orthopaedic oncosurgery, since patients are required to remain awake for sensorimotor evaluation of block. If the window period after surgery but before anesthesia-reversal is employed for administering SCBPB, it bestows the quadruple advantage of being painless, not augmenting surgical bleed, longer post-operative analgesia and reduced opioid-related side effects. The problem spot is assessing SCBPB-efficacy under general anesthesia.

Methods

This prospective, single-centric, observational cohort study included 30 patients undergoing upper limb orthopaedic oncosurgery under general anesthesia. Perfusion index (PI) was assessed using two separate units of Radical-7™ finger pulse co-oximetry devices simultaneously in both the upper limbs and PI ratios calculated. Skin temperature was noted.

Results

After successful block, PI values in blocked limb suddenly increased after 5 min, progressively increasing for next 10 min, whereas PI failed to increase further above that attained post anaesthetic-induction in unblocked limb. PI values in the blocked limb were 4.32, 4.49, 4.95, 7.25, 7.71, 7.90, 7.94, 7.89, and 7.93 at 0, 2, 3, 5, 10, and 15 min post block-institution at reversal and 2 min, 5 min post-reversal, respectively. PI ratios at 2, 3, 5, 10, and 15 min post block-administration in the blocked limb, taking PI at local anaesthetic injection as denominator were 1.04, 1.15, 1.67, 1.78, and 1.83, respectively. Correlation between PI and skin temperature in the blocked limb gave a repeated measures correlation coefficient of 0.79.

Conclusion

Monitoring trends in PI and PI-ratio in the blocked limb is a quantitative, non-invasive, inexpensive, simple, effective technique to monitor SCBPB-onset in anaesthetised patients.

Choosing the correct-sized adult double-lumen tube: Quest for the holy grail

Appropriate size selection of double-lumen tubes (DLTs) for one-lung ventilation (OLV) in adults is still a humongous task. Several important factors are to be considered like patient height, gender, tracheal diameter, left main bronchial diameter, and cricoid cartilage transverse diameter. In addition to radiological assessment of the airway diameters, the manufacturing details of the particular DLT being used also play a significant role in size selection. Optimal positioning of the appropriately sized DLT is indispensable to avoid complications like airway trauma, cuff rupture, hypoxemia, and tube displacement. It is imperative to know whether the one-size-fits-all dictum holds for DLT size selection as claimed by certain studies. Further randomized studies are required for crystallizing standard protocols ascertaining the correct DLT size. This systematic review article highlights the various parameters employed for DLT size selection and explores the newer DLTs used for adult OLV.

Cancer in corona times

Humanity is witnessing an unprecedented tsunami of corona virus disease 2019 (COVID-19) patients. Till date, India houses 10,453 confirmed COVID-19 patients with a death toll of 358 nationwide and the number is steadily rising with each passing day. The capital city of Delhi, harbouring 1510 patients, has the dubious distinction of being the second largest hotspot for COVID positive patients in India, second only to the state of Maharashtra. Being immuno-compromised, cancer patients are first more susceptible to catch this virus and secondly may witness a more devastating course. Having cancer is a bigger risk factor for contracting COVID-19 than even old age. "Death due to untreated cancer is a much bigger reality than death due to COVID-19," is one perspective that advocates continuation of cancer therapy in corona times albeit by converting cancer hospitals into virtual corona-free fortresses with several tiers of barriers against corona. The immediate, short and long term implications of the corona pandemic and a nationwide lockdown to curtail it, on cancer patients and their caregivers is discussed at length here tempered with experience from the largest tertiary care oncology setup of Northern India. Rigorous literature review based on Medline, Google scholar, Embase, Cochrane and Scopus database search was utilized.

Goal-directed fluid therapy using transoesophageal echocardiographic inferior venacaval index in patients with low left ventricular ejection fraction undergoing major cytoreductive surgery: A clinical trial

Background and Aims:

This study aims to trans oesophageal echo cardiographically (TOE) measure inferior venacava diameter (IVCD) during inspiration and expiration in poor left ventricular ejection fraction (LVEF) patients undergoing cytoreductive oncosurgery, to ascertain if any correlation exists between, caval index (DeltaIVCD), and stroke volume variation (SVV), and to compare DeltaIVCD-guided versus SVV-guided fluid therapy.

Methods:

In this prospective, parallel group, interventional study, seventy American Society of Anesthesiologists-III patients, aged 30-75 years, weighing 40-90 kg, with LVEF ≤40% undergoing cytoreductive surgery were included and randomised to group-D (DeltaIVCD-guided fluid therapy) and group-S (SVV-guided fluid therapy). Patients with oesophageal lesions were excluded. After standard endotracheal anaesthesia, arterial and internal jugular vein catheters were placed. A TOE probe was inserted in the interventional group-D. Quantification of IVCD respiratory variations was done. Heart rate (HR), arterial oxygen saturation (SPO₂), mean arterial pressure, end tidal carbondioxide (EtCO₂), central venous pressure, SVV, IVCD, and urine output (UO) were recorded every 30 min. Post-operative arterial blood gas analysis, lung-ultrasound, chest-radiograph, and serum creatinine were done.

Statistical Analysis:

Pearson's correlation coefficient as measure of strength of linear relationship, calculation of regression equation, and unpaired t-test for normally distributed continuous variables were used.

Results:

A positive correlation between DeltaIVCD and SVV (r = 0.751) was observed. A regression equation was obtained for SVV (SVV = [0.317 × DeltaIVCD] + 5.877). Serum lactate, estimated glomerular filtration rate, HR, and UO were within normal limits in group-D. There was no pulmonary oedema.

Conclusion:

DeltaIVCD-guided intravenous fluid therapy is valuable in low LVEF patients where tight fluid control is essential and any fluid overload may precipitate cardiac failure.

Society of Onco-Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for primary peritoneal malignancies or peritoneal spread of malignant neoplasm is being done at many centres worldwide. Perioperative management is challenging with varied haemodynamic and temperature instabilities, and the literature is scarce in many aspects of its perioperative management. There is a need to have coalition of the existing evidence and experts' consensus opinion for better perioperative management. The purpose of this consensus practice guideline is to provide consensus for best practice pattern based on the best available evidence by the expert committee of the Society of Onco-Anaesthesia and Perioperative Care comprising perioperative physicians for better perioperative management of patients of CRS-HIPEC.

Integrating perioperative medicine with anaesthesia in India: Can the best be achieved? A review

Integrating perioperative medicine with anaesthesia is the need of the hour. Evolution of a new superspeciality called perioperative anaesthesia can improve surgical outcomes by quality perioperative care and guarantee imminent escalation of influence and power for anaesthesiologists. All original peer-reviewed manuscripts pertaining to surgery-specific perioperative surgical home models involving preoperative, intraoperative and postoperative initiatives spanning the past 5 years have been reviewed using PubMed and Google Scholar. Whether the perioperative surgical home model is feasible or still a distant dream in the Indian perspective has been analysed.

Robotic hysterectomy in Trendelenburg position in a severely anaemic JKa alloimmunised patient with impending high-output cardiac failure: An anaesthetic challenge

Kidd blood group alloimmunisation, though extremely rare, may produce considerable morbidity, and even mortality. Severe anaemia and impending high-output cardiac failure requiring blood transfusion should be weighed against the risk of severe transfusion reactions even with fully cross-matched blood. Kidd antibodies are a common cause of delayed haemolytic transfusion reaction (DHTR) since they have a tendency remain undetectable in plasma. A low -grade DHTR (second hit) was grossly amplified by a second DHTR (third hit) superimposed on it in our patient leading to severe haemolysis with serum bilirubin reaching 68 mg%. Indirect antiglobulin test (indirect Coombs reaction) should ideally be performed in all patients (scheduled for major surgery requiring blood transfusion) who have experienced a previous pregnancy or blood transfusion. Non-invasive continuous haemoglobin monitoring and non-invasive cardiac output monitoring can prove invaluable tools in management.

Saline conditions alter morpho-physiological intensification in purslane (Portulaca oleracea l.)

In this study, primary investigations of selected cultivar of purslane named as Tall Green under articular salinity stress were evaluated to understand the basic concept of different mechanisms of physiological attributes which will play an important role for molecular and proteomic level research. The evaluation of morphological and physiological attributes under 0 mM (without salt addition) 100 mM and 200 mM salt stress changed dramatically. The results showed high salt stress at 200 mM significantly decreasing the morphological attributes and performance of leaves, stems, and roots. At moderate salt stress levels, 100 mM, the ratio of Fv/Fm slightly increased compared to high stress. In addition, salt stress significantly decreased the total chlorophyll content (chl a+b) at 200 mM. The relative water content percentage was high at 0 mM. Moreover, the electrolyte leakage (EL) significantly increased with increasing salinity stress compared to control 0 mM.

Cardiac output monitoring: A comparative prospective observational study of the conventional cardiac output monitor Vigileo™ and the new smartphone-based application Capstesia™

Background and Aims:

Capstesia is a software designed for smartphones (Android^TM/iOS^TM) to estimate the cardiac output and other haemodynamic variables from the waveform obtained from an invasive arterial cannula. The technology has been validated by studies in simulated environmental conditions. We compared the cardiac output (CO) and stroke volume variation (SVV) obtained by conventional cardiac output monitor Vigileo^TM with CO and pulse pressure variation (PPV) extracted from Capstesia^TM, under clinical conditions, intraoperatively.

Methods:

In a Samsung smartphone in which the Capstesia software had been downloaded, the application was opened and a snapshot of the arterial waveform from the monitor screen of anaesthesia workstation was taken. The application instantaneously calculates the CO and PPV after inputting the heart rate and the systolic and diastolic blood pressure variables. These values were then compared with readings from the Vigileo^TM monitor. Data was collected from 53 patients and analysed.

Results:

Five hundred and thirty data pairs of CO and an equal number of SVV and PPV pairs were analysed. Cardiac index by Capstesia (CIcap) was found to have a positive correlation with cardiac index by Vigileo (CIvig) using the intraclass correlation for raters, the strength of correlation being 0.757. Upper and lower 95% confidence limits were 1.43 l/min/m² and − 1.14 l/min/m² (Bland Altman's plot). A positive correlation was found between SVV and PPV using the Pearson's correlation (r = 0.732).

Conclusion:

Capstesia^TM is a reliable and feasible alternative to Vigileo^TM for intraoperative CO monitoring in oncosurgical patients.

Anesthesia for minimally invasive chest wall reconstructive surgeries: Our experience and review of literature

Minimal access procedures have revolutionized the field of surgery and opened newer challenges for the anesthesiologists. Pectus carinatum or pigeon chest is an uncommon chest wall deformity characterized by a protruding breast bone (sternum) and ribs caused by an overgrowth of the costal cartilages. It can cause a multitude of problems, including severe pain from an intercostal neuropathy, respiratory dysfunction, and psychologic issues from the cosmetic disfigurement. Pulmonary function indices, namely, forced expiratory volume over 1 s, forced vital capacity, vital capacity, and total lung capacity are markedly compromised in pectus excavatum. Earlier, open surgical correction in the form of the Ravitch procedure was followed. Currently, in the era of minimally invasive surgery, Nuss technique (pectus bar procedure) is a promising step in chest wall reconstructive surgery for pectus excavatum. Reverse Nuss is a corrective, minimally invasive surgery for pectus carinatum chest deformity. A tailor-made anesthetic technique for this new procedure has been described here based on the authors’ personal experience and thorough review of literature based on Medline, Embase, and Scopus databases search.

Ceric-induced grafting of acrylonitrile onto sodium alginate: kinetics and mechanism and effects of the reaction medium

The kinetic scheme of free radical graft copolymerization of acrylonitrile (AN) onto sodium alginate, using ceric ammonium nitrate as an initiator, has been proposed and equations relating the values of Rp, Rr and Rh are also suggested. The results have been found to be in good agreement with the proposed mechanism. The per cent grafting of AN onto sodium alginate has also been determined as a function of composition of the mixed solvents comprising methanol: water, ethanol: water, n-propanol:water and n-butanol: water systems. The reaction medium has been found to play an important role in graft copolymerization. The results of the effect of the reaction medium on grafting are also discussed.

A Randomized Clinical Trial Comparing the Standard Mcintosh Laryngoscope and the C-Mac D blade Video laryngoscope™ for Double Lumen Tube Insertion for One Lung Ventilation in Onco surgical Patients

Background and Aims:

Several devices enabling double-lumen tube (DLT) placement for thoracic surgeries are available, but there are no studies for D-blade video laryngoscope-guided DLT insertion. We compared the CMac D-blade videolaryngoscope™ and the Macintosh laryngoscope for DLT endobronchial intubation using parameters of time and attempts required for intubation, glottic view, incidence of complications and haemodynamic changes.

Methods:

Prospective, parallel group, randomised controlled clinical trial where sixty American Society of Anesthesiologists I and II patients aged 18-80 years scheduled for thoracic surgeries entailing DLT placement were randomly allocated in two groups based on the laryngoscopic device used for endobronchial intubation. Data were subjected to statistical analysis SPSS (version 17), the paired and Student's t-test for equality of means. Nominal categorical data between the groups were compared using Chi-squared test or Fisher's exact test as appropriate. P ˂ 0.05 was considered statistically significant.

Results:

Time required for intubation was comparable (37.41 ± 18.80 s in Group-M and 32.27 ± 11.13 s in Group-D). Number of attempts and incidence of complications (trauma, DLT cuff rupture, oesophageal intubation) was greater in the Macintosh group, except malpositioning into the wrong bronchus (easily rectified fibre-optic bronchoscopically), which was greater with the D-blade. Greater haemodynamic changes were observed during Macintosh laryngoscopy.

Conclusion:

D-blade videolaryngoscope™ is a useful alternative to the standard Macintosh laryngoscope for routine DLT insertion.

Acoustic puncture assist device versus loss of resistance technique for epidural space identification

Background and Aims:

The conventional techniques of epidural space (EDS) identification based on loss of resistance (LOR) have a higher chance of complications, patchy analgesia and epidural failure, which can be minimised by objective confirmation of space before catheter placement. Acoustic puncture assist device (APAD) technique objectively confirms EDS, thus enhancing success, with lesser complications. This study was planned with the objective to evaluate the APAD technique and compare it to LOR technique for EDS identification and its correlation with ultrasound guided EDS depth.

Methods:

In this prospective study, the lumbar vertebral spaces were scanned by the ultrasound for measuring depth of the EDS and later correlated with procedural depth measured by either of the technique (APAD or LOR). The data were subjected to descriptive statistics; the concordance correlation coefficient and Bland-Altman analysis with 95% confidence limits.

Results:

Acoustic dip in pitch and descent in pressure tracing on EDS localisation was observed among the patients of APAD group. Analysis of concordance correlation between the ultrasonography (USG) depth and APAD or LOR depth was significant (r ≥ 0.97 in both groups). Bland-Altman analysis revealed a mean difference of 0.171cm in group APAD and 0.154 cm in group LOR. The 95% limits of agreement for the difference between the two measurements were − 0.569 and 0.226 cm in APAD and − 0.530 to 0.222 cm in LOR group.

Conclusion:

We found APAD to be a precise tool for objective localisation of the EDS, co-relating well with the pre-procedural USG depth of EDS.

Anaesthesia for robotic thyroidectomy for thyroid cancer and review of literature

Robotic thyroidectomy (RT) is a new gasless, scarless technique which utilises the da Vinci™ surgical robot to excise thyroid tumours. Anaesthetic management must be modified according to the patient position and robotic surgery equipment. Anaesthesiologists need to be geared up to face the new challenges posed by advancements in surgical techniques in order to maintain patient safety. Another vital aspect of this surgery is documenting possible recurrent laryngeal nerve palsy, for which a C-Mac D-Blade™ video laryngoscope serves as a valuable tool. Post-operative pain management in RT also merits special attention.

Noninvasive intracranial pressure monitoring via optic nerve sheath diameter for robotic surgery in steep Trendelenburg position

Background:

Recent reports of increased intracranial pressure (ICP) due to steep Trendelenburg (ST) position causing neurological deterioration, decreased regional cerebral oxygen saturation and postoperative visual loss after robotic urological and gynecological surgeries led us to consider a simple technique of ICP monitoring. Ours is one of the first instances reported of quantitative noninvasive measurement of increase in ICP with ST position by serial measurement of binocular optic nerve sheath diameter (ONSD) in patients undergoing robot assisted urological and gynecological oncosurgery. We tested whether ONSD values rose to above the upper limits of normal and for what length of time they remained elevated.

Materials and Methods:

Prospective, randomized, interventional, parallel group, active control study conducted on 252 American Society of Anesthesiologists I and II patients. ONSD was measured using 7.5 MHz linear ultrasound probe in supine and Trendelenburg positions.

Statistics:

Student's t-test to compare the inter-group mean ONSD and the repetitive t-test for intra-group analysis.

Result:

Comparison of the mean ONSD values of both groups yielded a 2-tailed significance P <0.01 at all compared time points intra- and post-operatively. In Group-O (open surgery; supine position), the baseline mean bilateral ONSD was 4.36 mm, which did not show any statistically significant change throughout open surgery and postoperative period. On de-docking the robot, 6.2 mm was the mean ONSD value in Group-R (robotic group) while 4.3 mm was the corresponding value in control Group-O.

Conclusion:

ONSD evaluation is a simple, quick, safe, readily available, reliable, cost effective, noninvasive, potential standard of care for screening and monitoring of patients undergoing robotic surgery in ST position.

Comparison of hemodynamic effects of intravenous etomidate versus propofol during induction and intubation using entropy guided hypnosis levels

Background and Aims:

This study aimed to compare the hemodynamic responses during induction and intubation between propofol and etomidate using entropy guided hypnosis.

Material and Methods:

Sixty ASA I & II patients in the age group 20-60 yrs, scheduled for modified radical mastectomy were randomly allocated in two groups based on induction agent Etomidate or Propofol. Both groups received intravenous midazolam 0.03 mg kg^-1 and fentanyl 2 μg kg^-1 as premedication. After induction with the desired agent titrated to entropy 40, vecuronium 0.1 mg kg^-1 was administered for neuromuscular blockade. Heart rate, systolic, diastolic and mean arterial pressures, response entropy [RE] and state entropy [SE] were recorded at baseline, induction and upto three minutes post intubation. Data was subject to statistical analysis SPSS (version 12.0) the paired and the unpaired Student's T-tests for equality of means.

Results:

Etomidate provided hemodynamic stability without the requirement of any rescue drug in 96.6% patients whereas rescue drug ephedrine was required in 36.6% patients in propofol group. Reduced induction doses 0.15mg kg^-1 for etomidate and 0.98 mg kg^-1 for propofol, sufficed to give an adequate anaesthetic depth based on entropy.

Conclusion:

Etomidate provides more hemodynamic stability than propofol during induction and intubation. Reduced induction doses of etomidate and propofol titrated to entropy translated into increased hemodynamic stability for both drugs and sufficed to give an adequate anaesthetic depth.

Anesthesia for hemicolectomy in a known porphyric with cecal malignancy

Intraoperative management of a known acute intermittent porphyria patient is a challenge requiring awareness of factors, which trigger an acute crisis, clinical features of a porphyric attack, knowledge of safe pharmacologic intervention, and preparedness for reintubation and ventilatory support. The classical signs of a porphyric crisis such as pain abdomen, vomiting and neuropsychiatric symptoms are masked under general anesthesia and can be confused with postoperative pain and vomiting and postoperative cognitive dysfunction, especially for intra-abdominal surgeries. Eternal vigilance for onset of an acute crisis is imperative. After a crisis of acute intermittent porphyria, residual paresis may persist for years in the absence of further attacks.

Outcome of treatment of nonunion tibial shaft fracture by intramedullary interlocking nail augmentated with autogenous cancellous bone graft

To assess results of operative treatment of non union fracture shaft of Tibia by intramedullary interlocking nail augmented with autogenous cancellous bone graft in our setup. A total of 25 nonunion tibial shaft fractures were evaluated among which 20 cases were male and 5 female with the mean age 31.84 years. Hypertrophic non-union were 14 and atrophic non union were 11. Upper one third of tibial diaphysis was involved in 4 cases, middle one third in 14 cases and lower one third in 7 cases. In all cases open reduction, interlocking nailing and autogenous cancellous bone graft was applied. The mean follow up was one year. Mean time for healing was 8.08 months. Mean operation time was 110 minutes (range 70 to 160 minutes). Satisfactory results (excellent and good) were achieved in 88% cases and unsatisfactory (fair and poor) results in 12% cases. This operative treatment option appears to have a high success rate and should be considered in nonunion of tibial diaphysis.

Outcome of Minimal Invasive Percutaneous Plate Osteosynthesis in closed fractures of distal tibia

Background: The limited soft tissue, subcutaneous location and poor vascularity render the dista tibial fractures very challenging. Treatment of distal tibial fractures using minimally invasive percutaneous plate osteosynthesis technique may minimise damage to soft tissues and vascular integrity of bony fragments, leaving comminuted fragments out of the mechanical construct, preserving soft tissues with limited operative exposure. Objective: To assess the outcome of patients treated with minimally invasive percutaneous plate osteosynthesis technique for closed distal tibial fractures. Methods: The study included total of 30 patients (24males and 6females) with close distal tibia fracture, which were treated with distal tibia locking plate using minimally invasive percutaneous plate osteosynthesis technique. Results: The mean ages of the patient were 44.23 years (30 to58 years). Patients were followed up at 2 weeks, 6weeks, 12weeks, 24weeks and 1 year after the operation and evaluated clinically and radiologically. Among 30 pateints, all fractures went to union. The mean American orthopaedic foot and ankle score was 89.23% (SD-3.92). There was 2case of superficial infection and 3 case of plate impingement with no intraoperative complication and mortality rates. Conclusion: Minimally invasive percutaneous plate osteosynthesis is an effective technique for the management of distal tibial fractures. It is minimally invasive, though technically demanding, but preserves the biological environment by preserving the soft tissue with better outcome in terms of radiological union and functional outcome. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-2, 38-44 DOI: http://dx.doi.org/10.3126/jcmsn.v9i2.9686

Diaphyseal femoral fractures in children treated with titanium elastic nail system

Femur fractures are common long bone injuries in children which account for less than 2% of all paediatric fractures. Although these fractures are dramatic and disabling injuries for the child and parent, the good part is that they unite rapidly with minimal complications if aligned well. Various methods have been used successfully to treat these fractures, but they differ in their stability and potential for complications. The aim of our study was to see the outcome of titanium elastic nailing system in diaphyseal femoral fracture in children. The study included total of 30 children's (19 boys and 11 girls) of diaphyseal femoral fracture treated with titanium elastic nailing system and they were followed up at 2, 6, 12 and 24 weeks. The average duration of callus formation was 3.5 weeks with radiological union mean time of 9.5 weeks. Full weight bearing was possible in a mean time of 10 weeks. According to flynn's scoring criteria, excellent and good results were in 24 cases (80%) and 6 cases (20%) respectively. The nail irritation was present in 3 childrens and there was no post operative infection, physeal injury and implant failure. Titanium elastic nail is a safe and satisfactory mode of treatment and is relatively easy to perform in disphyseal fracture of femur in children. It avoids the chances of physeal injury, infection and offers rapid healing.

The treatment of trigger thumb in children: conservative or surgical?

The trigger thumb is an uncommon condition in infants and children which occurs due to pathology of flexor pollicis longus or A1 pulley. The objectives in our study were to determine the treatment outcome of trigger thumb. The study included total of 45 patients (24 males and 21 females) with trigger thumb. The mean age of onset was 28.5 months (3 months -7 years). There was overall success rate of 72.41% following conservative treatment and the success rate appears to be higher in the younger age group. The outcome of children who underwent surgery was 91.66% with recurrence rate of 8.33% and superficial wound infection rate of 4.16%. Our study suggests that surgery is not urgent, postponing surgery does not interfere with the result, trying conservative methods to get a higher chance of recovery is reasonable before the elective surgery. So conservative approach should be adopted in treating trigger thumb.

Comparative study in surgical outcome of intracapsular fracture neck of femur in active elderly patients treated with hemiarthroplasty with Austin Moore's and bipolar prosthesis

Fracture neck of femur is most commonly encountered fractures in elderly population. Hemiarthroplasty is generally considered to be the treatment of choice in most active elderly patients. However, there is inadequate evidence to support the choice between unipolar or bipolar prosthesis. This study was conducted to analyze the outcome regarding pain, hip function, complication and acetabular erosion in patients randomly selected and treated with Austin Moore's or Bipolar hemiarthroplasty in our setup. The study included total of 40 patients (17 males and 23 females) with intracapsular neck of femur fractures with mean age of 67 years (55-85 years). 20 patients each were treated with Hemiarthroplasty using Austin Moore's and Bipolar prosthesis. The patients were followed up at intervals of 2 weeks, 6 weeks, 24 weeks and 1 year after the operation and evaluated clinically and radiologically. There were no significant differences between the groups regarding complication. The Harris hip score were 81.95% (SD - 2.99) in Austin Moore's hemiarthroplasty and 79.15% (SD - 2.94) in Bipolar hemiarthroplasty (p = 0.812), whereas acetabular erosion was 20.05% in Austin Moore's hemiarthroplasty and 5% in Bipolar hemiarthroplasty (p = 0.758) with no mortality seen during lyear follow up. The intracapsular neck of femur fracture in active elderly patients treated with Austin Moore's hemiarthroplasty had better outcome regarding pain and hip function whereas high acetabular erosion compared to patients treated with Bipolar hemiarthroplasty though the difference is statistically insignificant.

Outcome of pertrochantric fracture of the femur treated with proximal femoral locking compression plate

Pertrochantric femoral fractures are one of the most common fracture in old patients with variety of complications. However fixing Pertrochantric femoral fractures properly is clinically challenging. We report the outcome of pertrochantric femoral fractures treated with Proximal Femoral Locking Compression Plate (PFLCP) using Minimal Invasive Percutaneous Plate Osteosynthesis (MIPPO) techniques which were evaluated clinically by Harris hip score and radiologically for a union at fracture site and implant related complication. The study included total of 33 patients (20 males and 13 females) with Pertrochantric femoral fractures. The mean ages of the patients were 57 years (23-88 years). Pertrochantric femoral fractures included both Intertrochantric and Subtrochantric femoral fractures. Patients were followed up at 2 weeks, 6 weeks, 3 months, 6 months and 1 year after the operation. Among the 33 patients, the union rate was 95% (31 patients). However there were 1 case of implant breakage and 1 case of non union. According to Harris Hip score the excellent and good results were 87.87% with no mortality during 1 year follow up period. The PFLCP can be feasible alternative to the treatment of Pertrochantric femoral fractures by providing biological healing and mechanical stability with limited occurrence of complications.

Staple versus locking compression plate fixation after lateral closing wedge high tibial osteotomy

PURPOSE

To compare the results of staple versus locking compression plate fixation after closing wedge high tibial osteotomy.

METHODS

A group of 23 patients (24 knees) who underwent box high tibial osteotomy and staple fixation was compared with another group of 19 patients (22 knees) who underwent a similar procedure but with locking compression plate fixation. Both groups were followed up for 3 years. The range of movement, Hospital for Special Surgery (HSS) Knee Score, time to full weight bearing, incidence of delayed union, femorotibial angle, and stage of osteoarthritis were compared.

RESULTS

At 6 months after the operation, the median HSS score and the proportion of patients with excellent or good scores were significantly higher in the locking compression plate than the staple fixation group (76 vs 62, p=0.003; 75% vs 42%, p=0.0354), but not at one and 3 years. The range of movement was significantly greater in the locking compression plate fixation group in the short term (6 weeks, 3 and 6 months), but not after one year. The median time to full weight bearing was significantly shorter in the locking compression plate fixation group (86 vs 116 days, p<0.001). There were fewer delayed unions in the locking compression plate fixation group but not significantly (1 vs 5, p=0.198), possibly because of the small numbers involved. There was no difference, within the limits of measurement error, in the femorotibial angle or correction loss between the 2 groups.

CONCLUSION

Locking compression plate fixation obviates the use of plaster casts, enables early mobilisation and bone union, and reduces the numbers with delayed union and the time to full weight bearing. Longer-term studies are needed to evaluate its effect on revarisation and arthropathy.

In vivo expression of myosin essential light chain using plasmid expression vectors in regenerating frog skeletal muscle

It is well established that mutations in specific structural elements of the motor protein myosin are directly linked to debilitating diseases involving malfunctioning striated muscle cells. A potential way to study the relationship between myosin structure and function is to express exogenous myosin in vivo and determine contractile properties of the transgenic muscle cells. However, in vivo expression of functional levels of contractile proteins using transient transgenesis in skeletal muscle has not been demonstrated. Presently, we used in vivo gene transfer to express high levels of full-length myosin light chain (MLC) in skeletal muscle fibers of Rana pipiens. Anterior tibialis (AT) muscles were injected with cardiotoxin to cause degeneration and then injected at various stages of regeneration with plasmid expression vectors encoding full-length MLC1(f). In fibers from the most robustly transfected muscles 3 weeks after plasmid injections, trans-MLC1(f) expression averaged 22-43% of the endogenous MLC1(f). Trans-MLC1(f) expression was the same whether a small epitope tag was placed on the C- or N-terminus and was highly variable along individual fibers. Confocal microscopy of skinned fibers showed correct sarcomeric incorporation of trans-MLC1(f). The expression profile of myosin heavy chain isoforms 21 days after transfection was similar to normal AT muscle. These data demonstrate the feasibility of using in vivo gene transfer to probe the structural basis of contractile protein function in skeletal muscle. Based on these promising results, we discuss how further improvements in the level and consistency of myosin transgene expression may be achieved in future studies, and the therapeutic potential of plasmid gene transfer in regenerating muscle.

Bench-scale biofilter for removing ammonia from poultry house exhaust

A bench-scale biofilter was evaluated for removing ammonia (NH3) from poultry house exhaust. The biofilter system was equipped with a compost filter to remove NH3 and calcium oxide (CaO) filter to remove carbon dioxide (CO2). Removal of NH3 and CO2 from poultry house exhaust could allow treated air with residual heat to be recirculated back into the poultry house to conserve energy during winter months. Apart from its use as a plant nutrient, NH3 removal from poultry house exhaust could lessen the adverse environmental impacts of NH3 emissions. Ammonia and CO2 were measured daily with gas detector tubes while temperatures in the poultry pen and compost filter were monitored to evaluate the thermal impact of the biofilter on treated air. During the first 37 days of the 54-day study, exhaust air from 33 birds housed in a pen was treated in the biofilter; for the final 17 days, NH3-laden exhaust, obtained by applying urea to the empty pen was treated in the biofilter. The biofilter system provided near-complete attenuation of a maximum short-term NH3 concentration of 73 ppm. During the last 17 days, with a mean influent NH3 concentration of 26 ppm, the biofilter provided 97% attenuation. The CaO filter was effective in attenuating CO2. Compared with a biofilter sized only for NH3 removal, an oversized biofilter would be required to provide supplemental heat to the treated air through exothermic biochemical reactions in the compost. The biofilter could conserve energy in poultry production and capture NH3 for use as plant nutrient. Based on this study, a house for 27,000 broilers would require a compost filter with a volume of approximately 34 m3.

Sarcomere number regulation maintained after immobilization in desmin-null mouse skeletal muscle

The serial sarcomere number of skeletal muscle changes in response to chronic length perturbation. The role of the intermediate filament desmin in regulating these changes was investigated by comparing the architectural adaptations of the tibialis anterior, extensor digitorum longus (EDL) and soleus from wild-type mice with those of homozygous desmin knockout mice after hindlimb immobilization. After 28 days, serial sarcomere number increased significantly in the lengthened wild-type tibialis anterior (by approximately 9 %) and EDL (by approximately 17 %). Surprisingly, muscles from desmin knockout mice also experienced significant serial remodeling, with the serial sarcomere number of the tibialis anterior increasing by approximately 10 % and that of the EDL by approximately 27 %. A consistent result was observed in the shortened soleus: a significant decrease in sarcomere number was observed in the muscles from both wild-type (approximately 26 %) and knockout (approximately 12 %) mice. Thus, although desmin is not essential for sarcomerogenesis or sarcomere subtraction in mouse hindlimb muscles, the results do suggest subtle differences in the nature of sarcomere number adaptation. We speculate that desmin may play a role in regulating the optimal arrangement of sarcomeres within the muscle or in sensing the magnitude of the immobilization effect itself.

Chronic rhinosinusitis: allergy and sinus computed tomography relationships

The management of chronic or recurrent rhinosinusitis problems is multifaceted and should include consideration of contributory and potentially correctable medical and anatomic factors. To date, the relationship between allergy and rhinosinusitis has not been clearly defined. The purpose of this study is to improve understanding of the relative roles of perennial and seasonal allergens in the cause of chronic rhinosinusitis. A retrospective review of 200 consecutive patients was carried out on patients who had chronic rhinosinusitis refractory to medical therapy and who subsequently underwent functional endoscopic sinus surgery. All of these patients had allergy testing for common perennial and seasonal inhalant allergens before surgery. Each patient had sinus CT imaging before undergoing the surgery. The CT scans of each patient were staged according to a validated, standardized grading system by investigators blinded to allergic profile. Allergy testing indicated that 84% of all patients tested positive for allergies. Moreover, 60% of all patients had significant allergic sensitivity; 52% of all patients had multiple allergen sensitivities. Furthermore, there was a predominance of perennial allergens, especially house dust mite over seasonal allergens. The vast majority of our patients undergoing functional endoscopic sinus surgery had concomitant allergy. This study highlights the potential contribution of perennial allergies to the development of rhinosinusitis. Given this direction, future studies may reveal that in the care of patients with perennial allergic rhinitis, early intervention with identification of the offending allergen(s), and subsequent treatment through avoidance, pharmacotherapy, and/or immunotherapy may help in the prevention of recurrent and chronic rhinosinusitis.

Laser in situ keratomileusis to correct residual myopia and astigmatism after radial keratotomy

PURPOSE

To evaluate the safety and efficacy of laser in situ keratomileusis (LASIK) in selected post-radial-keratotomy (RK) eyes with residual myopia and astigmatism.

SETTING

TLC-The Brea Laser Eye Center, Brea, California, USA.

METHODS

Nine eyes of 6 patients who had had RK but had residual myopia and/or astigmatism had LASIK. All RK eyes had 8 radial incisions, were more than 1 year post-RK, had no epithelial inclusion cysts or corneal disease, and had had no subsequent ocular surgery. Follow-up was a minimum of 13 months, at which time uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), manifest refraction, cycloplegic refraction, keratometry, central and peripheral pachymetries, intraocular pressure, and a subjective assessment of visual function were obtained.

RESULTS

At the last follow-up, the mean spherical equivalent (SE) was -0.156 diopter (D) +/- 0.174 (SD). All eyes treated for distance vision had a UCVA of 20/25 or better. No patient lost BCVA. No intraoperative or postoperative complications occurred. Seven eyes had morning and evening measurements. The mean change in manifest SE from morning to evening was -0.143 D. Six of the 7 eyes (86%) had 0 to 1 Snellen line change in UCVA from morning to evening. The subjective questionnaire revealed a high degree of satisfaction with overall vision, minimal glare, and less fluctuation in daily vision than before LASIK.

CONCLUSION

Laser in situ keratomileusis is safe and efficacious for reducing residual myopia and astigmatism in properly selected RK patients.

Nontraumatic nasal septal abscesses in the immunocompromised: etiology, recognition, treatment, and sequelae

Proper management of a nasal septal abscess requires prompt diagnosis, adequate surgical drainage, and antibiotics to prevent the potentially dangerous spread of infection and the development of severe functional and cosmetic sequelae. Most septal abscesses are the result of trauma to the nose with septal hematoma and subsequent infection. We present our experience with nasal septal abscesses in five immunocompromised patients without history of nasal trauma. All patients were treated with surgical drainage and antibiotics. The infections in four patients resolved, whereas in the fifth, the infection led to death. We report these cases to depict alternate etiologies of nasal septal abscess, particularly in the immunocompromised patient. Our review illustrates the wide spectrum of disease presentation, provides treatment strategies, and emphasizes the potentially catastrophic sequelae of this disease when unrecognized. With the growing number of immunocompromised individuals, it is important to recognize the potential for immunocompromise to influence the development of septal abscess.

Transmucosal fine-needle aspiration diagnosis of intraoral and intrapharyngeal lesions

OBJECTIVES

The effectiveness of fine-needle aspiration biopsy (FNAB) for the diagnosis of neck, thyroid, and salivary gland masses is well documented. Very few reports explore the potential of an intraoral FNAB approach for the diagnosis of submucosal lesions. We describe our technique and present case examples of pertinent differential diagnostic entities. We recommend an expanded role for FNAB of the oral cavity and oropharynx.

STUDY DESIGN

Retrospective review.

METHODS

A uniform technique was employed for transmucosal FNAB of 76 patients with intraoral masses. In applicable cases, cytology results were compared with traditional biopsy methods and permanent histopathologic specimens for accuracy.

RESULTS

Our experience demonstrates the high sensitivity (93%) and specificity (86%) of intraoral FNAB when compared with biopsy by conventional means. FNAB provides distinct advantages for the cytologic diagnosis of submucosal lesions, which may be difficult to reach and adequately sample through conventional biopsy. FNAB of the tonsil and tonsillar fossa provides a safe and effective means of diagnosing both lymphoma and squamous cell cancer. Transmucosal FNAB via the mouth led to rapid diagnosis of a number of benign and malignant lesions. Applying this uniform FNAB technique, we had no significant complications.

CONCLUSION

We recommend transmucosal FNAB as an effective means for highly accurate diagnosis of submucosal lesions of the oral cavity and oropharynx.

CLINICAL RELEVANCE

Traditional biopsy techniques in the oral cavity may require anesthesia and may have diagnostic difficulties, particularly for submucosal lesions. Transmucosal FNAB overcomes these shortcomings by providing a minimally invasive means to rapid diagnosis of intraoral lesions.