A&A Practice

Percutaneous Peripheral Nerve Stimulation of the Brachial Plexus for Intractable Phantom Pain of the Upper Extremity: A Case Report Phantom limb pain is a common condition occurring after amputations. Percutaneous peripheral nerve stimulation (PNS) has been reported to provide analgesia for established lower extremity phantom pain. However, this modality has never been applied to upper extremity phantom pain. A patient presented with acute exacerbation of established upper extremity phantom pain 2 years following forequarter amputation. A percutaneous PNS lead placed adjacent to the patient's brachial plexus under ultrasound guidance provided analgesia of the phantom pain for several weeks. PNS of the brachial plexus may provide analgesia for patients with upper extremity phantom pain.

Serratus Anterior Plane Block for Awake Breast Surgery: A Case Report Thoracic fascial blocks have been included in multimodal analgesia for breast surgery. Fewer studies demonstrate its use as a regional anesthesia technique. The serratus anterior plane (SAP) block provides anesthesia to the lateral thoracic wall and the axilla, the surgical area of some breast surgeries, with a single injection.

Intraoperative Management of Carotid Endarterectomy in Patients With Left Ventricular Assist Devices—The Challenge of Continuous Flow: A Case Report Symptomatic carotid artery disease stenosis warrants open surgical carotid endarterectomy (CEA). However, patients with continuous-flow left ventricular assist devices (CF-LVADs) present unique challenges when vasopressors and volume are used to maintain cerebral perfusion pressure after carotid cross-clamping. This report describes patients with CF-LVADs who underwent CEA. We identify how preload, contractility, afterload, pump speed, mean arterial pressure, and anticoagulation should be addressed to maintain CF-LVAD outflow and cerebral perfusion during the procedure. Anesthesiologists can combine an understanding of continuous-flow physiology with invasive monitors to optimize cardiac output and cerebral blood flow during CEA procedures.

Intraoperative Hemostatic Management of a Cardiohepatic Transplant With Rotational Thromboelastometry: A Case Report Cardiohepatic transplantation represents a double hemostatic challenge. Given the absence of specific guidelines and current evidence, we designed a 5-step approach based on rotational thromboelastometry (ROTEM). A 60-year-old male patient with cirrhosis and myocarditis underwent a 9-hour transplantation. Bleeding occurred after weaning from extracorporeal circulation. Evidence of reduced clot strength triggered fibrinogen and platelet replacement therapy. During liver transplant, only hemoglobin optimization was necessary. In conclusion, hemostatic management protocols for cardiohepatic transplants should consider the specific coagulopathy mechanisms underlying each surgical phase. Because whole blood testing is essential for their diagnosis, we recommend using ROTEM for optimal coagulation management.

High-Frequency Jet Ventilation for a Patient With Tracheomediastinal Fistula, Tension Pneumomediastinum, and Pneumothorax: A Case Report Tracheomediastinal fistula (TMF) is an uncommon condition and carries a high mortality. We report the anesthetic management of a patient with TMF using stent insertion via rigid bronchoscopy. The TMF was a complication of double-lumen endotracheal tube insertion resulting in a tension pneumomediastinum. Initial intraoperative attempts to ventilate the lungs and overcome the air leak with high gas flow of 45 L/min via the side port of the bronchoscope resulted in a pneumothorax. This case report demonstrates that high-frequency jet ventilation can minimize the air leak and avoid barotrauma during anesthesia for TMF repair.

Misinterpreting Paced Heart Rhythms: A Case Report We describe 2 cases in which failure to properly interpret paced heart rhythms in patients with cardiac implantable electronic devices (CIEDs) undergoing surgery resulted in adverse consequences including unnecessary invasive procedures, surgical delays, and patient dissatisfaction. Both cases occurred even though experienced clinicians were involved, and all perioperative recommendations were followed. Although it is sometimes argued that anesthesiologists are not directly responsible for CIED management, they are often held accountable when problems arise. These cases reinforce the need for anesthesiologists to not only adhere to all key practice recommendations but to also understand CIED functions and common pitfalls.

Scapular Block: An Innovative Procedure-Specific Regional Anesthesia Technique for Scapula Surgery—A Case Report A 40-year-old healthy male patient underwent open reduction and internal fixation with screws and plate for a comminuted fracture of the right scapula under ultrasound-guided "scapular block" with optimal sedation. We coined the term "scapular block" for an innovative combination of previously described regional anesthesia techniques to cover all dermatomes, myotomes, and osteotomes involved in scapula surgery. It is a combination of 5 target blocks (selective superior trunk block, selective supraclavicular nerve block, subclavian perivascular block, suprascapular nerve block, and erector spinae plane block) via 3 approaches (interscalene, supraclavicular, and paraspinal).

Two-Stage Fiberoptic Intubation in an Infant With a Rare Congenital Laryngopharyngo-Cutaneous Fistula: A Case Report Branchial arches represent embryological precursors of the face, neck, and pharynx, and developmental abnormalities of these branchial arch derivatives can lead to airway anomalies. We report definitive repair of the fistula in an infant with a rare congenital laryngopharyngo-cutaneous fistula. This is the first report that describes a 2-stage fiberoptic intubation, a challenging technique performed for airway management of the aforementioned fistula in a patient with a difficult airway.

Right Ventricular Epicardial Pacing Postcardiac Surgery Can Cause Dynamic Right Ventricular Outflow Tract Obstruction: A Case Report Dynamic right ventricular outflow tract obstruction is rare in the cardiac surgical population. Significant obstruction developing in the perioperative period can contribute to systemic hemodynamic instability. We describe 2 cases of dynamic right ventricular outflow tract obstruction that developed immediately after separation from cardiopulmonary bypass, due to temporary right ventricular epicardial pacing. Both patients had systemic hypotension which improved once ventricular pacing was discontinued. We discuss the recognition of right ventricular outflow tract obstruction as a contributing factor to hemodynamic instability, as well as the importance of identifying the underlying cause such as to institute appropriate management in these patients.

Retrospective Analysis of Peri-Intubation Hypoxemia During the Coronavirus Disease 2019 Epidemic Using a Protocol for Modified Airway Management This single-center retrospective study evaluated a protocol for the intubation of patients with confirmed or suspected coronavirus disease 2019 (COVID-19). Twenty-one patients were intubated, 9 of whom were found to have COVID-19. Adherence to the airway management protocol was high. COVID-19 patients had lower peripheral capillary oxygen saturation by pulse oximetry (Spo2) nadirs during intubation (Spo2, 73% [72%–77%] vs 89% [86%–94%], P = .024), and a greater percentage experienced severe hypoxemia defined as Spo2 ≤80% (89% vs 25%, P = .008). The incidence of severe hypoxemia in COVID-19 patients should be considered in the development of guidelines that incorporate high-flow nasal cannula and noninvasive positive pressure ventilation.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Sports Medicine and Arthroscopy Review

Hip Arthroscopy, Editorial No abstract available

Make the Right Diagnosis: My Pearls for Working Up Hip-related Pain The origin of pain around the hip is commonly more elusive than other joints; often obscured by compensatory disorders. Hip problems tend to be multifactorial and require a multidisciplinary approach in the evaluation. The best strategy is to team with a capable physical therapist to unveil the layers of problems. Ultrasonography and imaging/ultrasound-guided injections can be the most valuable adjunct to the history and physical examination. Plain radiographs are an essential element in the workup. Magnetic resonance imaging can underestimate damage in the joint, but positive findings can sometimes be the normal consequence of age and activity. Magnetic resonance imaging is often as important for what it rules out as much as what it rules in. Computed tomography scans with 3-dimensional reconstructions can be especially helpful in surgical planning but are not used in routine screening, being thoughtful of radiation exposure even with low-dose protocols. Arthroscopic access to the hip is more challenging than other joints, and similarly, unlocking its clinical secrets can be more imposing as well.

Femoroacetabular Impingement and Core Muscle Injury in Athletes: Diagnosis and Algorithms for Success Athletic hip injuries account for a substantial portion of missed time from sports in high-level athletes. For both femoroacetabular impingement (FAI) and core muscles injuries, a thorough history and physical examination are paramount to guide the treatment. While advanced imaging including computed tomography and magnetic resonance imaging are frequently obtained, a wealth of information can be ascertained from standard radiographs alone. For patients with isolated or combined FAI and core muscle injuries (CMIs), the initial treatment is often nonoperative and consists of rest, activity modification, and physical therapy of the hips, core, and trunk. Injections may then aid in both confirming diagnosis and temporary symptom abatement. Arthroscopic procedures for refractory FAI in experienced hands have been shown to be both safe and efficacious. While surgical repair options for CMIs are significantly more variable, long-term studies have demonstrated the rapid resolution of symptoms and high return to play rates. More recently, anatomic and clinical correlations between FAI and CMIs have been identified. Special attention must be paid to elite athletes as the incidence of concurrent FAI with CMI is extremely high yet with significant symptom variability. Predictable return to play in athletes with coexisting symptomatic intra-articular and extra-articular symptomatology is incumbent upon the treatment of both pathologies.

Decision-making in the Borderline Hip Borderline acetabular dysplasia represents a "transitional acetabular coverage" pattern between more classic acetabular dysplasia and normal acetabular coverage. Borderline dysplasia is typically defined as a lateral center-edge angle of 20 to 25 degrees. This definition of borderline dysplasia identifies a relatively narrow range of lateral acetabular coverage patterns, but anterior and posterior coverage patterns are highly variable and require careful assessment radiographically, in addition to other patient factors. Treatment decisions between isolated hip arthroscopy (addressing labral pathology, femoroacetabular impingement bony morphology, and capsular laxity) and periacetabular osteotomy (improving osseous joint stability; often combined with hip arthroscopy) remain challenging because the fundamental mechanical diagnosis (instability vs. femoroacetabular impingement) can be difficult to determine clinically. Treatment with either isolated hip arthroscopy or periacetabular osteotomy (with or without arthroscopy) appears to result in improvements in patient-reported outcomes in many patients, but with up to 40% with suboptimal outcomes. A patient-specific approach to decision-making that includes a comprehensive patient and imaging evaluation is likely required to achieve optimal outcomes.

Capsular Management Techniques and Hip Arthroscopy There has been an increased emphasis on capsular management during hip arthroscopy in the literature in recent years. The capsule plays a significant role in the hip joint stability and studies have demonstrated that capsular closure can restore the biomechanics of the hip back to the native state. Capsular management also affects functional outcomes with capsular repair resulting in better clinical outcomes in some studies. Management of the capsule has evolved in recent years with more surgeons performing routine capsular closure. Management techniques and degree of capsular closure, however, can be quite variable between surgeons. This review will discuss hip capsular anatomy, the importance of the capsule in hip biomechanics, management of the capsule during arthroscopy, and functional outcomes as it relates to the various capsular closure techniques versus leaving the capsulotomy unrepaired.

Surgical Treatment of Labral Tears: Debridement, Repair, and Reconstruction Advances in hip preservation surgery have to lead to increased utilization of hip arthroscopy. With this, there has also been a growth in the understanding of various hip conditions, therefore, leading to an increase in hip conditions amenable to arthroscopic intervention. The acetabular hip labrum has been at the forefront of arthroscopic advances in the hip. The labrum is important for hip stability, provision of the suction seal, and joint proprioception. Given the labrum's central role in hip biomechanics, there is increasing emphasis on labral preservation in the form of debridement and repair. In revision settings, advanced techniques such as labral augmentation and reconstruction may play a role in the management of labral pathology. Appropriate management of the hip labrum at the time of surgery can be an important mediator of the outcome. As such, an understanding of the evolving evidence base and surgical indications and techniques are integral to the treatment and management of labral pathology.

Femoral Version in Hip Arthroscopy: Does it Matter? Femoral version is extremely variable between patients presenting with femoroacetabular impingement (FAI). Careful and routine measurement of femoral anteversion is essential in comprehensive preoperative planning. In general, low degrees of femoral version can lead to anterior impingement (especially on the subspine and distal medial femoral neck). High degrees of anteversion can be seen in the setting of acetabular dysplasia and can lead to anterior hip instability and or posterior impingement. In this article, the authors will discuss the role of routine femoral version management for optimal outcomes after hip arthroscopy for FAI.

Acetabular Rim Disorders/Pincer-type Femoroacetabular Impingement and Hip Arthroscopy Femoroacetabular impingement (FAI) can lead to acetabular impaction, chondral injury, and labral pathology secondary to deformities of the proximal femur (CAM-type FAI), acetabulum (pincer-type FAI), or with combined FAI. While the majority of cases are of the combined type, this paper focuses on acetabular overcoverage/pincer-type deformities. Various pincer subtypes include focal anterior overcoverage, global retroversion, global overcoverage/profunda, protrusio, subspine impingement, and os acetabuli/rim fracture variants. A thorough history and physical examination, plain radiographs, magnetic resonance imaging, 3-dimensional computerized tomography, and diagnostic injections can lead to an accurate assessment of pincer-type variants. Appropriately indicated arthroscopic management techniques and pearls for the various pincer subtypes can lead to improved patient-related outcome measures and a high rate of return to athletic activity for the majority of these patients.

Why Does Hip Arthroscopy Fail? Indications and PEARLS for Revision Success The surgical treatment of femoroacetabular impingement has been shown to have successful early and mid-term clinical outcomes. Despite these favorable clinical outcomes that have been published in the literature, there is a subgroup of patients that present with continued or recurrent symptoms after surgical treatment. Not only has there been an increase in the number of hip arthroscopy procedures, but also there has been a corresponding increase in the number of revision hip arthroscopy and hip preservation surgeries. Previous studies have reported residual deformity to be the most common reason for revision hip arthroscopy. However, chondral, labral, and capsular considerations also are important when addressing patients not only in the primary but also, the revision setting. In this review, we outline the evaluation and treatment of the patient that presents with continued hip and groin pain after undergoing a hip.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,

Critical Illness and Injury Science

What's new in critical illness and injury science? Intravenous immunoglobulin for COVID-19 with severe or critical illness Andrew C Miller, Shobi Venkatachalam International Journal of Critical Illness and Injury Science 2020 10(4):159-162

Fentanyl and clonidine as adjuncts to a mixture of local anesthetics in potentiating postoperative analgesia in supraclavicular block: A randomized controlled study Anisha Puri, Gurchand Singh, Anita Madan International Journal of Critical Illness and Injury Science 2020 10(4):163-169 Background: Brachial plexus block is popular for upper limb surgeries as it is effective for postoperative analgesia. Aims: The aim of the study was to compare fentanyl and clonidine as adjuncts to a mixture of local anesthetics in potentiating postoperative analgesia in the supraclavicular block. Materials and Methods: Sixty patients of the American Society of Anesthesiologist I and II undergoing upper limb surgeries lasting more than 30 min were included and randomly divided into two groups of 30 each. In clonidine (C) group, patients received 10 ml of 0.5% bupivacaine + 20 ml of 2% lignocaine with adrenaline (1:200,000) and 1 μg/kg clonidine diluted till 35 cc with normal saline. In fentanyl (F) group, patients received 10 ml of 0.5% bupivacaine + 20 ml of 2% lignocaine with adrenaline (1:200,000) and 1 μg/kg fentanyl diluted till 35 cc with normal saline. Patients were observed for onset and duration of sensory and motor blockade, duration of analgesia, postoperative pain, and adverse effects. Results: The mean onset of sensory block was faster in Group F (8.43 ± 2.897 min) as compared to 13.17 ± 2.451 min in Group C. The difference between the two groups was statistically strongly significant (P < 0.0001). There was a significant reduction in the onset of motor block in Group F (14.67 ± 1.84 min) compared to (18.17 ± 2.45 min) Group C with P < 0.0001 (statistically strongly significant). There was a significant increase in the duration of analgesia in Group C (16.63 ± 2.04 h) compared to Group F (8.79 ± 1.50 h) with P < 0.0001. There was bradycardia (pulse did not fall below 60) in two patients of Group C (treated with atropine intravenous [i.v.]). Two patients of Group F complained of nausea and vomiting once in the early hours of surgery for which ondansetron i.v. was given. There were no significant side effects in either of the groups. Conclusion: Both clonidine and fentanyl establish a good safety profile. Fentanyl ensures a faster onset of sensory and motor blockade, while clonidine ensures a longer duration of sensory and motor blockade as well as prolonged analgesia.

Clinical implications of serum myoglobin in trauma patients: A retrospective study from a level 1 trauma center Khalid Ahmed, Husham Abdelrahman, Ayman El-Menyar, Mahmoud Saqr, Ashwin D Silva, Sherif M Alkahky, Jowhara Al Qahtani, Ahammed Mekkodathil, Hassan Al-Thani, Ruben Peralta International Journal of Critical Illness and Injury Science 2020 10(4):170-176 Background: We aimed to study the clinical implication of high serum myoglobin levels in trauma patients. Methods: A retrospective analysis was conducted on data from trauma patients who were admitted to a level 1 trauma center between January 2012 and December 2015. A receiver operating characteristic (ROC) curve analysis was performed for the optimum myoglobin cutoff plotted against hospital length of stay of >1 week. Patients were divided into two groups (Group 1; low vs. Group 2; high myoglobin), and a comparative analysis was performed. Results: There were 898 patients who met the inclusion criteria with a mean age of 35.9 ± 14.6 years. Based on ROC, the myoglobin optimum cutoff was 1000 ng/ml (64% of patients were in Group 1 and 36% in Group 2). The mean myoglobin level was 328 ng/ml in patients with the Injury Severity Score (ISS) <15 versus 1202 ng/ml in patients with ISS ≥15 (P < 0.001). Patients in Group 2 had higher ISS (22.2 ± 10 vs. 18.8 ± 10), more musculoskeletal injuries (18.3% vs. 4.2%), more blood transfusion (74% vs. 39%), intubation (57% vs. 46.5%), and sepsis (12% vs. 7.3%). The length of hospital stays was significantly higher in Group 2, but mortality was comparable. High myoglobin levels had a crude odd ratio 2.41; 95% confidence interval (1.470–3.184) for a longer hospital stay with a positive predictive value of 89% and a specificity of 77%. Conclusions: One-third of the admitted trauma patients have elevated serum myoglobin level, which is associated with the prolonged hospital stay. The discriminatory power of myoglobin value of 1000 in trauma is fair, and further prospective assessments are needed.

Effect of using a head injury fast-track system on reducing the mortality rate among severe head injury patients in Southern Thailand: A retrospective study with historical control Kanitha Arundon, Narumon Anumas, Phakawat Chunthong, Autthapol Cheevarungrod, Thanom Phibalsak, Apiradee Lim International Journal of Critical Illness and Injury Science 2020 10(4):177-181 Context: Head injuries are the leading cause of traumatic morbidity and mortality. Timely proper management can reduce the mortality rate. Aims: This study aimed to examine the effects of a fast-track system on reducing head injury mortality using the data in Southern Thailand. Settings and Design: A retrospective study of data from the medical records of severe head injury patients admitted to Hatyai Hospital from October 2012 to May 2017. Subjects and Methods: The records of subjects were selected for participants aged more than 11 years, having Glasgow Coma Score (GCS) <9, no injuries in other organs, and neither hypoxemia nor hypotension. A total of 193 participants fulfilling these criteria were analyzed. Of these, 108 participants were managed in the fast track. Statistical Analysis Used: The fast-track group was compared with normal track participants by using logistic regression after preliminary analysis to identify the risk factors using the Chi-squared tests. Results: After adjustment for confounders, namely acute subdural hematoma, linear skull fracture and diffuse brain injury, and mortality in the fast-track group (13%) was significantly lower than that in the nonfast track group (22.4%). Conclusions: Using the fast-track system can reduce mortality from severe head injuries and should be implemented in the health services system.

Epidemiology and cost-analysis of emergency department patients treated following traffic accidents in Iran: A retrospective cross-sectional study Anahita Behzadi, Mohsen Shahba, Sina Etemadi, Behzad Mohamadi, Mehran Karvar, Yahya Jafari, Marjan Hedayatipour International Journal of Critical Illness and Injury Science 2020 10(4):182-188 Introduction: Epidemiological analysis of traffic accidents can provide information for future plans to lower the cost and burden of road traffic accidents (RTAs). This study was aimed to determine the epidemiological characteristics of patients with RTAs. Methods: We conducted a retrospective cross-sectional study of RTA patients presenting in 2016 to the Emergency Department at Shahid Bahonar Medical Education Center in Kerman, Iran. A checklist including variables such as age, sex, month, in which the patient referred, final outcome, overall cost and the site of injury used to collect data. The diagnostic criteria were in accordance to ICD 10. Results: Of the total of 3277 patients who were studied, 2713 (82.78%) were men and 564 (16.66%) were women. Most of the accidents occurred at the age group of 16–30 years and the average cost of treatment in the hospital was 2152.45 USD. The most affected area was the lower limb. The majority of accidents occurred in spring and summer. The mortality rate was (2.74%). Discussion: Injuries and deaths due to RTAs are a major public health problem, especially in young age groups. Therefore, more preventive programs targeting young adults should be considered to reduce the burden of RTAs. Conclusion: Epidemiology and cost analysis of results showed that men caused more accidents and costs burden for both health system and society. Considering they have a more share of activity, economy and workforce, it will cause more damage and adverse consequences for economy and social life of the society.

Complications following chest tube insertion pre-and post-implementation of guidelines in patients with chest trauma: A retrospective, observational study Ahmed El-Faramawy, Gaby Jabbour, Ibrahim Afifi, Husham Abdelrahman, Amjad S Qabbani, Mohammad Al Nobani, Ahammed A Mekkodathil, Hassan Al-Thani, Ayman El-Menyar International Journal of Critical Illness and Injury Science 2020 10(4):189-194 Background: The need to evacuate the chest after a penetrating wound was first recognized in the 18th century. Most thoracic injuries are treated with tube thoracostomy (TT) which refers to the insertion of a TT into the pleural cavity to drain air, blood, pus, or other fluids. However, TT has been challenged in the trauma care due to insertional, positional, or infective complications. Methods: A retrospective study of all trauma patients who had TT insertion from 2008 to 2014 was conducted based on the trauma registry data to describe patient characteristics, injury characteristics, management, and outcomes. The complication incidences per TT before (2008) and after (2009–2014) the implementation of standard protocol were compared. Results: During the study period, 804 patients were managed with 1004 TT procedures. The mean age was 34 years, and majority (91%) was males. Motor vehicle crash (43%) was the main mechanism of injury. Mean injury severity score was 22. The rib fractures (68%) were more frequent followed by pneumothorax (49%). Nearly 72% of patients received antibiotic coverage before insertion. The complications developed per TT reduced over the years from 2008 to 2014 (12.6% to 4.4%). The average complication per TT after the protocol implementation (2009–2014) reduced by 7% when compared to the duration before implementation (2008). Conclusions: The present study shows that standardized management of trauma patients who undergo TT results in a reduction in complications, helps improve patient flow, and ensures the proper management of resources in our high-volume trauma center.

Tracheostomy in critically ill liver disease patients with coagulopathy: A retrospective study at a tertiary center Vandana Saluja, Shilpa Tiwari, Lalita Gouri Mitra, Guresh Kumar, Rakhi Maiwall, V Rajan International Journal of Critical Illness and Injury Science 2020 10(4):195-199 Introduction: Critically ill patients with liver disease commonly present to the intensive care unit (ICU) with need for prolonged ventilation, difficult weaning, and refractory coagulopathy. These patients experience both bleeding and thrombotic complications with a precariously balanced state of coagulopathy. The purpose of this study was to assess the bleeding complications of tracheostomy in critically ill patients with liver disease. Methods: A retrospective study was conducted in liver ICU of a tertiary teaching institute. Medical records were analyzed to assess postprocedure complication rate among 73 critically ill liver disease patients who had undergone tracheostomy during the period of October 2017 to September 2018. Results: Ten out of 73 patients (13%) required transfusion of blood products after 12 h of procedure, despite thromboelastography (TEG)-based correction prior to procedure. Of these, 7 patients (9%) underwent surgical tracheostomy (ST) and three patients (4%) underwent percutaneous tracheostomy. Statistically no significant difference in bleeding was seen among the two groups, but a rising trend was seen with the ST group (P = 0.52). None of the patients experienced procedure-related pneumothorax and subcutaneous emphysema, as observed in the chest X-ray. Conclusion: We conclude that coagulopathy should not be deterrence for the performance of tracheostomy in critically ill patients with liver disease. Adequate clotting support guided by the global tests of coagulation, such as TEG, ensures lesser incidence of bleeding.

Intermittent gastric feeds lower insulin requirements without worsening dysglycemia: A pilot randomized crossover trial Tyson J Sjulin, Richard J Strilka, Nikhil A Huprikar, Lisa A Cameron, Parker W Woody, Scott B Armen International Journal of Critical Illness and Injury Science 2020 10(4):200-205 Introduction: We hypothesized that critically ill medical patients would require less insulin when fed intermittently. Methods: First, 26 patients were randomized to receive intermittent or continuous gastric feeds. Once at goal nutrition, data were collected for the first 4-hr data collection period. Next, the enteral feed type was switched, goal nutrition was repeated, and a second 4-h data collection period was completed. The primary endpoint was the total amount of insulin infused; secondary endpoints were glucose concentration mean, maximum, minimum, and standard deviation, as well as episodes of hypoglycemia. Results: Sixteen of the 26 patients successfully completed the protocol. One patient experienced a large, rapid, and sustained decline in insulin requirement from liver failure, creating a bias of lesser insulin in the intermittent arm; this patient was removed from the analysis. For the remaining 15 patients, the average total amount of insulin infused was 1.4 U/patient/h less following intermittent feeds: P =0.027, 95% confidence interval (0.02, 11.17), and effect size 0.6. Secondary endpoints were statistically similar. Conclusions: Critically ill medical patients who require an insulin infusion have a reduced insulin requirement when fed intermittently, whereas dysglycemia metrics are not adversely affected. A larger clinical study is required to confirm these findings.

Protocolized ventilator weaning verses usual care: A randomized controlled trial Amir Vahedian-Azimi, Farshid Rahimi Bashar, Mohammad A Jafarabadi, Jennifer Stahl, Andrew C Miller International Journal of Critical Illness and Injury Science 2020 10(4):206-212 Background: Protocolized ventilator weaning (PW) strategies utilizing spontaneous breathing trials (SBTs) result in shorter intubation duration and intensive care unit (ICU) length of stay (LOS). We compared respiratory therapy (RT)-driven PW versus usual care (UC) as it pertains to physiologic respiratory parameters, intubation duration, extubation success/reintubation rates, and ICU LOS. Methods: prospective, multicentric, randomized controlled trial was performed in closed medical and surgical ICUs with 24/7 in-house intensivist coverage at six academic medical centers in a resource-limited setting from October 18, 2007, to May 03, 2014. Extubation readiness was determined by the attending physician (UC) or the respiratory therapist (PW) using predefined criteria and SBT. Physiologic variables, serial blood gas measurements, and weaning indices were assessed including the Rapid Shallow Breathing Index (RSBI), negative inspiratory force (NIF), occlusion pressure (P0.1), and dynamic and static compliance (Cdyn and Cs). Results: total of 5502 patients were randomized (PW 2787; UC 2715), of which 167 patients died without ventilator weaning (PW 90; UC 77) and 645 patients were excluded (PW 365; UC 280). Finally, a total of 4200 patients were analyzed (PW 2075; UC 2125). The PW group displayed improvements in minute ventilation (P < 0.001), Cs and Cdyn (both P < 0.05), P0.1 (P < 0.001), NIF (P < 0.001), and RSBI (P < 0.001). Early re-intubation (≤48 h) rates were lower in the PW group (16.7% vs. 24.8%; P < 0.0001), as were late re-intubation rates (5.2% vs. 25.8%; P < 0.0001). Intubation duration was longer in the PW group (P < 0.001), however, hospital LOS was shorter (P < 0.001). Mortality was unchanged (P = 0.19). Conclusion: PW with RT-driven extubation decisions is safe, effective, and associated with decreased re-intubation (early and late), shorter hospital stays, increased intubation duration (statistically but not clinically significant), and unchanged in-patient mortality.

Use of video-assisted thoracoscopy surgery in the removal of an intrathoracic bullet: A case report Mustafa Erman Dorterler, Mehmet Cakmak, Tansel Gunendi, Osman Hakan Kocaman, Mehmet Emin Boleken International Journal of Critical Illness and Injury Science 2020 10(4):213-215 The use of video-assisted thoracoscopy surgery (VATS) as a minimally invasive surgical technique in many lung and pleural diseases is well-established. However, the efficacy of VATS in the removal of retained intrathoracic foreign bodies is unclear. Here, we report the use of VATS in the successful removal of an intrathoracic bullet from a 7-year-old patient.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,

Anatomiy

Implementation of competency based medical education in anatomy with poor teacher-student ratio: The utopia Vishram Singh, Ashok Sahai Journal of the Anatomical Society of India 2020 69(4):193-195

A computed tomography angiography study to correlate main renal artery diameter with presence of accessory renal artery in healthy live kidney donors Alka Nagar, Navbir Pasricha, Eti Sthapak, Deshraj Gurjar, Hira Lal Journal of the Anatomical Society of India 2020 69(4):196-200 Introduction: The chosen technique of surgery during nephrectomy can be influenced by the sudden discovery of an aberrant source of blood supply to the kidney. Thus, a prospective study was undertaken to investigate the relationship between the diameter of the main renal artery and the presence of an accessory renal artery by computed tomography (CT)-angiography. Material and Methods: The study was conducted on 115 healthy kidney donors who presented to the department of nephrology and radiology for voluntary kidney donation. All CT examinations were performed on a 64-slice CT scanner in the arterial phase. The number of the renal arteries supplying each kidney was evaluated and their diameters were measured. Results: Eighty-six of the right side and 88 of the left side of the 115 kidneys donors had a single renal artery whereas 29 had one or more accessory renal artery (aRA) on the right side and 27 had one or more aRA on the left side. The mean diameter of mRA was 5.4 ± 1.0 mm in kidneys without aRA and 4.6 ± 10 mm in kidneys with aRA on the right side and on the left side the mean diameter of mRA was 5.59 ± 1.12 mm in kidneys without aRA and 4.7 ± 1.2 mm in kidneys with aRA. Discussion and Conclusion: The presence of additional renal arteries is very probable when the main renal artery has a diameter of < 4.15 mm. Kidneys presenting a main renal artery > 5.5 mm very probably do not present additional renal arteries. Hence, the renal artery diameter is a factor which should be considered for predicting the presence of additional renal arteries.

Morphological side differences of the hemipelvis Gloria Maria Hohenberger, Angelika Maria Schwarz, Andreas Heinrich Weiglein, Sabine Kuchling, Georg Hauer, Uldis Berzins, Magdalena Holter, Christoph Grechenig, Renate Krassnig, Axel Gänsslen Journal of the Anatomical Society of India 2020 69(4):201-206 Introduction: Differences of anatomical characteristics regarding side and gender have been the topic of interest in various recent studies. Studies have reported either significant or insignificant differences of the bony pelvis. The aim of this study was to evaluate possible gender and side differences of the pelvis in a cadaveric model. Material and Methods: Fifty human cadaver pelves, preserved by the use of Thiel's method, underwent measurement during this study. Diverse parameters were measured on both hemipelves by three surgeons. Analysis of the morphology of the acetabular cavity was performed by measuring its longitudinal, horizontal, and maximal diameters. Results: The distance between the anterior superior iliac spine and the posterior superior iliac spine (females: mean of 15.9 cm; males: mean of 16.9 cm) and the horizontal diameter of the acetabular cavity (females: mean of 4.5 cm; males: mean of 4.9 cm) were statistically significantly shorter in females than in males. The subpubic angle was significantly (P < 0.001) larger in females (mean 61.4°; standard deviation [SD] 11.02°; range 37°–82°) when compared to males (mean 45.5°; SD 7.48°; range 35°–60°). The vertical diameter of the obturator foramen was significantly (P = 0.002) smaller for the right (mean 3.1; SD 0.56; range 1.9–4.6) in comparison to the left side (mean 3.4; SD 0.57; range 2.5–5.2). Discussion and Conclusion: Overall, a clear gender difference was observed for typical gender-specific parameters, whereas the anatomy of the hemipelves showed no relevant side differences.

The morphological variants of dural venous sinuses Sercan Ozkacmaz, Yeliz Dadali, Muhammed Alpaslan, Ilyas Uçar Journal of the Anatomical Society of India 2020 69(4):207-212 Introduction: In this study, we aimed to analyze the dural venous system variations in Turkey by magnetic resonance imaging examinations. Material and Methods: Images of a total of 200 patients (65 males, 135 females M/F: 0.48) who underwent a magnetic resonance venography examination were retrospectively screened. Results: Variation was detected in 101 patients (53.85% of males [35/65] and 48.89% of females [66/135]). In 16.5% of the patients, only one variation of dural venous system was detected, while the most common variation was left transverse hypoplasia in this group. Twenty-six percent of the patients had two variations of the dural venous system since the most common dual variations were left transverse hypoplasia + left sigmoid hypoplasia in this group. In 8% of the patients, three or more variations of the dural venous system were observed as the most common variations were right transverse hypoplasia + right sigmoid hypoplasia + presence of occipital sinus in this group. Discussion and Conclusion: It is essential to know the anatomical variations of the dural venous system for the discrimination between pathological processes such as thrombosis and physiologic conditions. Furthermore, the association of these variations with each other must be kept in mind for the explanation of the presence of multiple variations in the same individuals.

An evaluation on the morphology of the nasal bone, piriform aperture, and choana on dry skulls Anil Didem Aydin Kabakci, Duygu Akin Saygin, Şerife Alpa, Mustafa Buyukmumcu, Mehmet Tugrul Yılmaz Journal of the Anatomical Society of India 2020 69(4):213-219 Introduction: Piriform aperture (PA) and nasal bone (NBs) are important structures that contribute to the formation of the nose. Both anatomic structures show differences based on ethnicity, gender, and age. Hence, it is widely used to determine sex in science branches such as anthropology and forensic medicine. Furthermore, morphometry of the PA and choana is an important criterion for physiological nasal respiration of individuals. Recognition of structural differences of PA, NB, and choana along with all this information becomes important during maxillofacial procedures to be performed especially in plastic and reconstructive surgery. The aim of the present study is to determine the individual differences in NBs, PA, and choana. Material and Methods: This study was conducted on 83 Turkish dried skulls and PA, NBs, and choana was examined as morphometrically. PA was classified into seven types and NB was classified into eight subtypes. Results: The most common type of PA was found type 5 (20%–24.1%) and the least most common type of PA was type 7 (4%–4.8%). Type 1 was determined as the most common observed shape of the NB. The mean width of the choana on the right and left sides was found 13.21 ± 1.4 and 13.98 ± 1.81 mm, respectively. Moreover, the mean height of the choana on the right and left sides was found 25.56 ± 3.06 and 26.1 ± 2.5 mm, respectively. Discussion and Conclusion: We believe that obtained data from our study will constitute a morphometric data set and will be useful in a wide range of fields from forensic science to reconstructive surgery.

Morphological and morphometric study of the acetabulum of dry human hip bone and its clinical implication in hip arthroplasty Archana Singh, Rakesh Gupta, Arun Singh Journal of the Anatomical Society of India 2020 69(4):220-225 Introduction: The objective was to study the morphology of the acetabular margin and articular surface and to measure the various dimensions of the acetabulum in dry human hip bones. Material and Methods: A cross-sectional morphological and morphometric study was performed on 92 undamaged acetabulum of adult dry human hip bone of unknown age and gender. The shape of anterior margin of the acetabulum and shape of the anterior and posterior ends of the articular surface of the acetabulum were observed. Morphometry was done using a Vernier caliper of accuracy of 0.01 mm. Vertical diameter (VD), transverse diameter (TD), anteroposterior diameter (APD), internotch distance (ND), and depth of the acetabulum were measured. Surface area (SA) and volume (V) of the acetabulum were calculated by mathematical calculation of dome. Statistical analysis was done using SPSS software version 22.0 (IBM, SPSS statistics, UNICOM GLOBAL, California, United States). The Pearson's correlation test was used. Results: In the present study, the anterior acetabular ridge was curved in 45.7% (42), angulated in 26.17% (24), straight in 13% (12), and irregular in 13% (12) bones. The anterior end of the lunate articular surface was angulated, and the posterior end was lunate in shape in 45.7% (42), whereas in 54.3% (50), bone both the ends were lunate in shape. Morphometric values and mean ± standard deviation were as follows: 48.21 mm ± 3.31 mm (VD), 47.81 mm ± 3.37 mm (TD), 48.79 mm ± 4.08 mm (APD), 23.58 mm ± 2.77 mm (ND), 27.45 mm ± 3.02 mm (D), 4162.56 mm2 ± 755.58 (SA), and 36,563.65 mm3 ± 9408.67 (V). Discussion and Conclusion: The knowledge of these acetabular parameters is necessary for the creation of acetabular prosthesis and surgical procedures such as acetabular reconstruction in hip joint surgeries.

Polymorphic study of ataxin 3 gene in Eastern Uttar Pradesh population Barkha Singh, Prasenjit Bose, SN Shamal, Deepika Joshi, Royana Singh Journal of the Anatomical Society of India 2020 69(4):226-232 Introduction: Spinocerebellar ataxia type 3 (SCA3), or Machado-Joseph disease (MJD), is a prevalent autosomal dominant-inherited disease that causes progressive problems with movement. Abnormal repetitive expansion of CAG trinucleotide in the ATXN3 gene results in SCA3. This study was done to review the corporation of CAG repeats and polymorphisms in definitive genes with the occurrence of SCA3 in the Indian community, especially in the eastern UP population. Material and Methods: The 40 Ataxia's patient and their parents were listed after obtaining written consent from the participant's attendant/guardians. Out of these, we have identified polymorphism in three patients. Results: In one patient, we have found a single base change, g.31483A>T in Exon 10, which changes the nucleotide from Adenine to Thymine (A31483T), while in the second patient, we have identified an intronic change at g.35690A>G in Exon 10, which changes the nucleotide from Adenine to Guanine (A35690G) and in the third patient DNA sequence analysis identified an intronic change at g.35587A>G Exon 10, which changes the nucleotide from Adenine to Guanine (A35587G). Discussion and Conclusion: Although the partial loss of ATXN3 function may also contribute, the disease mechanism in MJD is believed to be a toxic gain-of-function. Several pathogenic cascades have been reported to be triggered by mutant ATXN3, but the critical molecular events driving MJD pathogenesis stay unresolved. While significant developments in studies have enhanced our knowledge of MJD, there is presently a lack of preventive treatment. Results presented here also expand our knowledge about MJD found in the eastern UP population.

An anatomical description of the vermian fossa: The reappraisal of an overlooked entity Jeshika S Luckrajh, J Naidoo, L Lazarus Journal of the Anatomical Society of India 2020 69(4):233-236 Introduction: The vermian fossa (VF) is a shallow depression at the inferior end of the internal occipital crest, which lodges the inferior part of the cerebellar vermis. Published literature describes the VF as having a highly variable incidence and morphology. The present study is aimed to investigate the incidence, morphology, and morphometry of the VF within a select South African population and to conduct a review of the literature regarding this structure. Material and Methods: A total of 100 dry, adult skulls of South African origin were analyzed to determine the morphological and morphometric parameters of the VF. Results: The VF was found to be present in 62% of cases. The shape of the VF was classified as triangular (27%), quadrangular (8%), and atypical (27%). The average length of the VF was 13.78 mm, and the average width was 11.62 mm. The morphometric findings of this study correlate with that of previous studies; however, the incidence of atypical shaped VF (27%) is higher in comparison to previous studies (9.7%). Discussion and Conclusion: The detailed anatomical description of the VF may aid in the study of diseases which cause alterations in the size and morphology of the vermis of the cerebellum as well as in transvermian approaches to tumors within the fourth ventricle. Furthermore, due to the paucity of anatomical descriptions of the VF, a reappraisal of this structure is warranted as it is of prime importance to clinicians operating in or interpreting radiological images of the posterior cranial fossa.

Considering the surface area and sagittal angle in a pair of lumbosacral facets: Determining the structural relevance of asymmetric facets at the lumbosacral junction Uchenna Kenneth Ezemagu, F Chinedu Akpuaka, Emmanuel C Iyidobi, Chike P Anibeze Journal of the Anatomical Society of India 2020 69(4):237-242 Introduction: The mechanism of spine dysfunction that was linked to asymmetry in facet joint planes remains poorly understood. We determined the surface area and sagittal angle in a pair of L4, L5, and S1 vertebral facets. We aimed to explain the structural relevance of asymmetric facets at the lumbosacral junction. Material and Methods: Vertebral columns of 45 adult male human cadavers were cut at the L3–L4 intervertebral disc. Each section was macerated and tied together in a sequence to obtain the value of sagittal angle of the superior facets of L4, L5, and S1 vertebrae and area of the inferior facets of L4 and L5 vertebrae, using a modified protractor and graph paper method, respectively. Asymmetry was determined using the formula propound by Plochocki (2002). Results: The mean value of surface area of the left and right inferior facets of L4 and the left and right inferior facets of L5 was 161 ± 24 and 168 ± 23 mm2 and 200 ± 28 and 218 ± 33 mm2, respectively. The mean value of sagittal angle of the left and right superior facets of L4, L5, and S1 was 37.71° ± 4.38°, 36.18° ± 4.8°, 46.96° ± 6.49°, 48.51° ± 6.25°, 52.49° ± 5.1°, and 54.67° ± 5.25°, respectively. The degree of asymmetry in the area of the inferior facets of L4 and L5 ranges from 0% to 30% and 0%–32.26%, respectively, and that for sagittal angle of the superior facets of L4, L5, and S1 was 0%–37.93%, 0%–30.95%, and 0%–26.32%, respectively. Discussion and Conclusion: This study would suggest that despite the statistically significant mean differences in the paired variables, the vertebrae were free of any pathological change but with consequent adaptive features. However, the stress effects would suggest that the left lumbosacral facet joints are predisposed to dysfunction of mechanical origin.

In vivo cross-sectional topographic anatomy at sternal angle on magnetic resonance imaging Rohit Aggarwal, Sreedhar Muthukrishnan Calicut, Raheem Abdul Sheik, Vijaya Sagar Theegala, Indrani Mukhopadhyay Journal of the Anatomical Society of India 2020 69(4):243-248 Introduction: The manubriosternal angle, first described by Louis in 1825, is an important landmark in the anatomy of the thorax and has been conventionally described as corresponding to the T4–5 IV disc level based on cadaveric dissections. The objective of this study was to document the level of the angle of Louis and various anatomic structures that also correspond to the same level in living individuals based on multiplanar magnetic resonance (MR) images. Material and Methods: We reviewed MR scans of the cervicodorsal spine of 262 individuals comprising 174 males and 88 females in the age range 14–76 years. For each individual, the vertebral level of the following structures was noted on T1-weighted (T1W)/T2-weighted (T2W) turbo spin echo (TSE) coronal and sagittal images, namely tracheal bifurcation (TB), aortic arch (AA), and sternal angle (SA). Results: The SA was most commonly seen corresponding to the T5 vertebral body level (45.20%) and at T4–5 IV disc level in only 20.45% of the individuals. The convexity of the arch of the aorta was seen in the majority of the individuals corresponding to the T3 vertebral body level (47.96%). TB was seen at T4 level in 34.35% and only in 22.69% at the T4–5 IV disc level. Discussion and Conclusion: The anatomical level of the SA, AA, and TB in living individuals as assessed on MR images is significantly different from the traditionally held belief based on cadaveric dissections.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Rural Medicine

Using Wisely: Our health workforce is our most valuable resource Margaret Tromp Canadian Journal of Rural Medicine 2021 26(1):3-3

Utiliser avec soin: Nos travailleurs en santé sont notre ressource la plus précieuse Margaret Tromp Canadian Journal of Rural Medicine 2021 26(1):4-4

President's Message. A productive fall council meeting Gabe Woollam Canadian Journal of Rural Medicine 2021 26(1):5-5

Message du président. Une productive réunion d'automne du conseil Gabe Woollam Canadian Journal of Rural Medicine 2021 26(1):6-6

Integration of care in Northern Ontario: Rural health hubs and the patient medical home concept Sarah Newbery, Josée Malette Canadian Journal of Rural Medicine 2021 26(1):7-13 Introduction: Primary care reform in Ontario that provides accessible, comprehensive patient-centred care has been a work in progress for more than a decade. With the recent emergence of Ontario Health Teams and the conclusion of the Rural Health Hub (RHH) pilot project, insight into the philosophy, culture and expectations of rural and remote centres with regard to primary care delivery is required. The concept of the patient medical home (PMH) and the RHH offers frameworks that emphasise positive attributes towards quality care systems – continuity, accessibility, comprehensiveness and localisation of services and funding for system efficiency. Methods: The application of these frameworks to rural and remote centres was explored via semi-directed face-to-face and phone interviews with physicians, patients and healthcare administrators at six rural centres in Northern Ontario. Results: Continuity of care, local integration and healthcare culture reform were cited by participants as the most important aspects of optimisation of primary care in their environments. Conclusion: These concepts support the RHH and PMH models and their further implementation as part of healthcare system transformation in Northern Ontario.

Fluoroquinolone use in a rural practice Len Kelly, Yoko S Schreiber, Josh Hopko, T Kirkwood, Ribal Kattini, Denise Poirier, Sharen Madden Canadian Journal of Rural Medicine 2021 26(1):14-18 Introduction: Fluoroquinolones (FQs) are a commonly prescribed class of antibiotics in Canada. Evidence of a constellation of possible adverse events is developing. Central and peripheral nervous system abnormalities and collagen-related events (including aortic aneurysm/dissection, tendinopathy/rupture and retinal detachment) are associated with FQ exposure in large population-based aftermarket studies. In 2017, Health Canada warned about rare FQ-related persistent or disabling side effects. This study explores FQ use in a rural community. Methods: Antibiotic prescriptions (including FQs) in the over 18 adult population (5416) were measured in the town of Sioux Lookout for 5 years, January 2013 to 31 December 2017. Results: FQ prescriptions accounted for 16.0% of adult antibiotics, superseded by penicillins (21.1%) and macrolides (18.2%). Ciprofloxacin accounted for one half of FQ use (51.2%), followed by levofloxacin (36.7%) and norfloxacin (13.3%). FQs were commonly used for respiratory (33%) and urinary tract infections (18%). Conclusion: Aftermarket evidence reports increased risk of 'disabling and persistent serious adverse events'(Health Canada) in patients using FQs. Appropriate clinical caution should be exercised in the prescribing of FQs. Common overuse seems to occur in the treatment of uncomplicated community-acquired pneumonia and cystitis, despite recommendations to use other antimicrobial agents as first-line treatments.

Shared medical appointments for Innu patients with well-controlled diabetes in a Northern First Nation Community Yordan Karaivanov, Emily E Philpott, Shabnam Asghari, John Graham, David M Lane Canadian Journal of Rural Medicine 2021 26(1):19-27 Introduction: The prevalence of diabetes and its complications in the Innu community of Sheshatshiu is high. We wanted to determine if shared medical appointments (SMAs) could provide culturally appropriate, effective treatment to Innu patients with relatively well-controlled diabetes, as an alternative to standard, 'one-on-one' care. Methods: We conducted a mixed-method study including a randomised controlled trial comparing standard care versus SMAs for patients aged 18–65 years with haemoglobin A1C (HbA1C) of ≤7.5%, followed by a qualitative study using semi-structured interviews with patients who attended SMAs. Results: Among 23 patients, 13 received the intervention. There were no significant differences of HbA1C level or HbA1C percentage of change between intervention and control groups at baseline, 6 months or 12 months. There were no statistical differences between standard care and SMA groups, concerning mortality or the need for haemodialysis. The qualitative analysis found that patients generally enjoyed the SMA model and the peer support and learning benefits of the SMAs. Patients did not believe that the SMA model was more or less culturally appropriate than standard care, but the majority said they felt that the SMAs were good for the community and could be a good venue for incorporating Innu healthy–lifestyle knowledge into medical diabetes care. Conclusions: SMAs may be an efficient way to manage well-controlled diabetic patients in the Innu community of Sheshatshiu and to provide peer support and opportunities for learning and incorporating community-specific knowledge into care.

Choosing Wisely Canada: Rural medicine list of recommendations Margaret Tromp, Alexandra Dozzi, Kathleen Walsh Canadian Journal of Rural Medicine 2021 26(1):28-30

The occasional anorectal abscess Rhiannan Pinnell, Mitchell Crozier, Sarah M Giles Canadian Journal of Rural Medicine 2021 26(1):31-34

A buprenorphine–naloxone induction in the North Marcella K Jones, Matthew Quinn Canadian Journal of Rural Medicine 2021 26(1):35-37

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Medicine

Editorial Rajendra N Srivastava Apollo Medicine 2020 17(4):239-239

Cytological evaluation of p16Ink4a in precancerous lesions of the cervix: Conventional papanicolaou smears Seema Singhal, Vinod Kumar Arora Apollo Medicine 2020 17(4):240-245 Background: Cancer of the uterine cervix is the second most common cancer among women worldwide. More than three fourths of these patients are diagnosed at advanced stages, leading to poor prospects of long term survival and cure. Introduction of Papanicolaou (Pap test) cytological screening for cervical precancerous lesions has significantly reduced the incidence and mortality of cervical cancer. Human papillomavirus (HPV) DNA testing has been recently demonstrated to be efficient to be integrated into screening programs, so it can be used to triage women with equivocal cytological abnormalities and also identifies women at risk of residual or recurrent disease after treatment of cervical intraepithelial neoplasia. However, it fails into triage low grade lesions. HPV DNA test confirms infection by the virus, present in 99% of cases. However, it does not discriminate between transient and persistent infection as it is crucial because it is the persistent infection which progresses to neoplasia. Histological assessment of cervical biopsy that is considered as “gold standard” can be hampered by intra and inter observer variability. A more specific triage marker is required to identify women who would need colposcopy. Hence, p16INK4a has emerged as a new diagnostic and prognostic biomarker. Aims and objectives: This study was conducted to evaluate the utility of staining of p16INK4a on conventional Pap smears and its comparison with corresponding biopsies. Material and Methods: 50 cases of conventional Papanicolaou stained cervical smears cases were randomly selected from the archive of cytopathology laboratory. The cervical smears were re-evaluated for adequacy, preservation of cells, cytomorphology and various lesions were categorized according to The Bethesda system 2001 (TBS) classification. Consecutive such cases were selected for which both cytological and histological material were available. Immunostaining of cervical cytological specimens for p16 was performed using monoclonal murine antibody, clone 16P04, JC2. Ready to use antibody was used for immunostaining as per manufacturer's protocol. Results: Out of the 50 smears of preneoplastic and invasive lesions, ASCUS was seen in 5 cases, LSIL in 10 cases, HSIL in 20 cases, SCC in 20 cases and AGUS in 5 cases. Of the 5 cases of ASCUS, histopathology showed 3 chronic cervicitis and 1 each in CIN-1 and CIN-2. Histopathological diagnosis of 10 cases of LSIL showed 6 CIN-1 and 2 each in CIN-2 and chronic cervicitis. Similarly, for 10 cases of HSIL, 3 were CIN-2, 5 CIN-3 and 2 SCC. All 20 cases of carcinoma showed SCC while 5 cases of AGUS showed 4 chronic cervicitis and one adenocarcinoma. Immunohistochemical staining of p16INK4A showed weak positivity in 3 cases of chronic cervicitis and 4 cases of CIN-1. In CIN-2 cases, 66.67% showed strong positivity, CIN-3 showed 80% while both carcinoma and adenocarcinoma showed 100% strong positivity. The sensitivity of immunohistochemical staining of p16INK4A was 77.5%, specificity was 100%, PPV 100% and NPV 52.6%. The relation between histological and cytological immunostaining of p16INK4A. Conclusion: p16INK4A is a reliable marker for dysplastic squamous and glandular cervical cells both in tissue sections and in cervical smears. p16 immunostaining can be easily performed on CPS, and there is high concordance of positivity on smears and tissue sections.

Intraoperative ultrasound in neurosurgical procedures V A Kiran Kumar, N A Sai Kiran, B Girija Kumari, Ranabir Pal, V Umamaheswar Reddy, Amit Agrawal Apollo Medicine 2020 17(4):246-251 Introduction: The objective of the present study was to study the utility and the effectiveness of intraoperative ultrasound in neurosurgical procedures and to assess the outcome. Material and Methods: In this prospective study, operative procedures by a single surgeon under intraoperative ultrasound localization for basal ganglia/thalamic haematoma or traumatic brain contusions or brain tumours were included. Ultrasound scanning of the brain was performed before and after the excision of the lesion and during the procedure to verify the extent of removal of the lesion. Results: 74 patients underwent surgery for brain tumor/basal ganglia bleed/head injury with hemorrhagic contusion with the help of intraoperative ultrasound. Gross tumor resection was noted in 25 out of 36 cases of brain tumors (69.44%), complete evacuation of hematoma was noted in 14 out of 34 cases(41.2%) of basal ganglia bleed and in 2 out of 4 cases (50%) of intracerebral contusion. As per Modified Rankin scale (MRS)score, among the brain tumor cases, all patients had fared well in recovery and had better MRS scores except in one patient who expired during postoperative period. Conclusions: IoUS is a widely accessible, cheap, portable and less space occupying and reliable imaging tool to follow and modify the surgical plan in real time, and is more accurate and helpful in complete tumor resection, evacuation of intracerebral bleeds and contusions, and biopsy of deep seated lesions. It is easy and safe to handle with no risk of radiation.

Prevalence of Side Effects of Propofol Anesthesia among Adult and Pediatric Patients Undergoing Surgery Khaled D Alsaeiti, Fathi M Elbraky, Salem A Ibkhatra, Khawla A Al-Zoubi, Ghada A Alagoury, Fatima F Al-Farajani, Hawa Al-Kharaz, Fatima A Al-Megrahi Apollo Medicine 2020 17(4):252-255 Introduction: Propofol is a short-acting medication that lowers awareness and causes a transient memory loss. It is given intravenously. The aim of this study was to assess the prevalence of various side effects of the use of propofol as an anesthetic in various surgical procedures and to compare their prevalence among adults and children. Materials and Methods: One hundred patients were included in the study, fifty adults and fifty of children, who underwent various types of surgery and received propofol anesthesia, at Pediatrics Hospital, Benghazi Medical Center (BMC) and Al-Hawari hospital, from September to November 2019. Results: The mean age was 6.37 ± 4.18 years in the pediatric group (ranging from 1 to 15 years) and 40.0 ± 17.03 years in the adult group (range from 16 to 97 years). The indication of surgery among the adult group was cholecystectomy (14 patients, 28%), followed by ENT operations (12 patients, 24%), while the indication of surgery among the pediatric group was tonsillectomy (20 patients, 40%), followed by hernia repair (15 patients, 30%). Thirty-five adults (70%) and 40 children (80%) suffered different types of complications during the study. Pain at the site of propofol injection was the most common complication. It was observed in 21 adult patients (42%) and 23 children (46%). Bronchospasm developed among 11 children who underwent tonsillectomy. Low blood pressure was more prevalent among adult patients (14 patients, 28%). An arrhythmia was developed in nine patients (six adults and three children). Two adults and five children experienced delayed recovery from anesthesia. The recovery time was 14.67 ± 8.37 min (5â€"45 min), Conclusion: Burning at site of propofol injection is the most common side effect of propofol anesthesia; other complications need further evaluation by more detailed studies.

A review of chronic relapsing inflammatory optic neuropathy Pushpendra Nath Renjen, Dinesh Mohan Chaudhari, Kamal Ahmad, Shivangi Garg, Anjali Mishra Apollo Medicine 2020 17(4):256-258 Chronic relapsing inflammatory optic neuropathy (CRION), initially described in 2003, is a form of recurrent optic neuritis (ON) that has relatively good response/dependency to steroid treatment. In demyelinating ON, patients present with periorbital ache and pain elicited by eye movement, which usually begins insidiously and worsens, in synchrony with or preceding a reduction in vision, which deteriorates over days. The etiology of CRION is unknown. However, the excellent response to corticosteroids and the need for immunosuppressive therapy to prevent relapse suggests an immunomediated origin.

Recurrent respiratory papillomatosis: A challenging clinical entity Santosh Kumar Swain, Sidharth Mohanty, Bulu Nahak, Mahesh Chandra Sahu Apollo Medicine 2020 17(4):259-263 Recurrent respiratory papillomatosis (RRP) is a benign lesion seen in the respiratory airway caused by human papillomatosis virus (HPV).RRP can affects children to young adults. Most of the childhood RRP occur at birth which contaminated from birth canals of the mother. In adult ages, the infections transmitted via sexual route. The lesions are often seen as exophytic nodules, mostly in the larynx and occasionally at the nasopharynx, tracheobronchial trees and lung parenchyma. This disease is often unpredictable and varies from spontaneous remission to aggressive persistent or recurrence in nature.RRP has chance for malignant transformation to squamous cell carcinoma although it is a rare happening. The diagnosis is confirmed by histopathological study. Presently there is no definite treatment for RRP available. Surgery is the treatment of choice along with several adjuvant therapies available. The aim of this review article is to describe the detail etiology, epidemiology, clinical presentations, investigations and treatment of RRP.

A Reflection on the Use of Additive Manufacturing in Nephrology for Education and Surgical Planning Azhar Equbal, Shahid Akhtar, Md. Asif Equbal Apollo Medicine 2020 17(4):264-266 Additive manufacturing (AM) or three-dimensional printing (3DP) is a new technology known for rapid fabrication of customized or finely detailed parts with decreased cost. The technology uses the principle of layer by layer-based manufacturing of parts following the bottom-up approach. In recent years, AM technologies have seen a rapid development in various fields of engineering, medical, and aeronautics. Development in technology and biomaterials has made AM more novel and approachable techniques for complex medical treatments. In the current work, a reflection on the use of AM technology in the field nephrology has been presented. At present, AM technologies are used in conceptualizing and fabricating urological instruments, planning surgeries, and educating the apprentices and patients. The review primarily aimed to present the use of AM for education and surgical planning in nephrology. The study will also discuss the limitation and future scope of AM in the field of nephrology.

Diabetes Mellitus and Periodontitis: Relevance of the Diabolic Duo in India Sumidha Bansal, Sangeeta Dhir, Subhash Kumar Wangnoo Apollo Medicine 2020 17(4):267-271 Diabetes and periodontitis are highly prevalent diseases. Chronic nature, along with shared risk factors, magnifies the complexity of both the diseases. Periodontal treatment results in clinically relevant reductions in HbA1c, and the presence of diabetes worsens the periodontal health and vice-versa. This paper presents an overview on the pathogenic mechanisms, impact of intervention, and significance of interprofessional collaborations for holistic management in diabetes and periodontitis.

Choleteryl ester storage disease: A rare cause of adrenal calcifications in children Fatiha Benmiloud, Maria Rkain, A El Aouali, A Babakhouya, Noufissa Benajiba Apollo Medicine 2020 17(4):272-274 Cholesteryl ester storage disease (CESD) in children is a rare anatomo-clinical entity, characterized by a secondary lysosomal accumulation and an autosomal recessive mutation in the LIPA gene, which results from a lysosomal acid lipase (LAL) deficiency. The work of this paper is based on our observation of a 25-month-old infant, who had an abdominal distension with a hepatomegaly of 13 cm. The abdomen X-ray has shown some bilateral adrenal calcifications. The results of the biological assessment : the hepatic check showed a slight cytolysis, triglycerides increased to 5.4 g.l with a reduced rate of high density lipoproteins. The blood smear has shown the presence of intracytoplasmic lipid vacuoles in the lymphocytes, with a positive MGG staining and a negative PAS staining. The activity of the LAL enzyme has decreased to 3.6%. This observation joins the rare pediatric cases of the CESD and highlights the interest in a simply available radiological examination to make a guidance diagnosis of a complex metabolic disorder.

Xanthogranulomatous osteomyelitis Seema Singhal, Chander Shekher Apollo Medicine 2020 17(4):275-276 Xanthogranulomatous osteomyelitis (XO) is a type of chronic osteomyelitis characterized by collection of foamy macrophages admixed with mononuclear cells. Xanthogranulomatous inflammation is characterized by the presence of histiocytes, foamy macrophages, activated plasma cells, and presence of suppurative foci and hemorrhage. It has been encountered in various tissues such as gallbladder, kidney, urinary bladder, fallopian tube, ovary, vagina, prostate, testis, epididymis, colon, and appendix. Very rarely, it can affect lungs, brain, or bone. Only three cases of XO have been described previously in the literature till date.

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