A 29-year-old man developed paraplegia at T-10 level due to road traffic accident in 1972. Both kidneys were normal and showed good function on intravenous urography. Division of external urethral sphincter was performed in 1973. In 1974, cystogram showed retrograde filling of left renal tract, which was hydronephrotic. Left ureteric reimplantation was performed. Following surgery, cystogram revealed marked retrograde filling of left renal tract as before. Penile sheath drainage was continued. In 1981, intravenous urography revealed bilateral severe hydronephrosis. Left ureteric reimplantation was performed again in 1983. Blood pressure was 220/140 mm Hg; this patient was prescribed atenolol. Cystogram showed gross left vesicoureteral reflux. Intermittent catheterisation was commenced in 2001. In 2007, proteinuria was 860 mg/day. This patient developed progressive renal failure and expired in 2012. In a spinal cord injury patient with vesicoureteral reflux, the treatment should focus on abolition of high intravesical pressures rather than surgical correction of vesicoureteric reflux. Detrusor hyperactivity and high intravesical pressures are the basic causes for vesicoureteral reflux in spinal cord injury patients. Therefore, it is important to manage spinal cord injury patients with neuropathic bladder by intermittent catheterisations along with antimuscarinic drug therapy in order to abolish high detrusor pressures and prevent vesicoureteral reflux. Angiotensin-converting enzyme inhibitors or angiotensin-receptor-blocking agents should be prescribed even in the absence of hypertension when a spinal cord injury patient develops vesicoureteral reflux and proteinuria.
Global and regional left ventricular (LV) systolic dysfunction is a marker of coronary artery disease (CAD), which is conventionally assessed using two-dimensional echocardiography. Tissue Doppler imaging (TDI) has emerged as an adjunct tool in the diagnosis of regional wall motion abnormalities from CAD. We performed a systematic review and meta-analysis to assess the efficacy of TDI indices in the diagnosis of CAD. We searched MEDLINE and the Cochrane Library for controlled studies comparing TDI measurements in those with and without CAD as confirmed by coronary angiography. Meta-analyses of mean differences in TDI velocities between these populations were performed. Screening of titles and abstracts followed by full-text screening identified 8 studies. At rest, TDI was associated with a significant decrease in the pooled maximum systolic velocity among CAD patients compared to those without CAD [mean difference (MD): -0.66; 95% confidence interval (CI): -0.98 to −0.34]. There were no significant differences in maximum early and late diastolic velocities. Post-stress, TDI was associated with a significant decrease in maximum early diastolic velocity (MD: -1.91; 95% CI: -2.74 to −1.09) and maximum late diastolic velocity (MD: -1.57; 95% CI: -2.95 to −0.18) among CAD patients compared to those without CAD. There was no significant difference in maximum systolic velocity post-stress. Our results suggest that TDI may have a role in the evaluation of CAD. Future studies should evaluate the incremental value of TDI velocities over LV ejection fraction and two dimensional wall motion analysis in the detection of CAD and assessment of its severity. (Word Count: 249)
Systematic review; Meta-analysis; Tissue Doppler; Echocardiography; Coronary artery disease
A male tetraplegic patient with, who had been taking warfarin, developed haematuria. Ultrasound scan revealed no masses, stones, or hydronephrosis. Urinary bladder had normal configuration with no evidence of masses or organised haematoma. Urine cytology revealed no malignant cells. Four months later, CT urography revealed an irregular mass at the base of urinary bladder. Cystoscopic biopsy revealed moderately differentiated adenocarcinoma, which contained goblet cells and pools of mucin showing strongly positive immunostaining for prostatic acid hosphatase and patchy staining for prostate specific antigen. Computed Tomography revealed multiple hypodense hepatic lesions and several osteolytic areas in femoral heads and iliac bone. With a presumptive diagnosis of prostatic carcinoma, leuprorelin acetate 3.75 mg was prescribed. This patient expired a month later. Conclusion. (i) Spinal cord injury patient, who passed blood in urine while taking warfarin, requires repeated investigations to look for urinary tract neoplasm. (ii) Anti-androgen therapy should be prescribed for 2 weeks prior to administration of gonadorelin analogue to prevent tumour flare causing bone pain, bladder outlet obstruction, uraemia, and cardiovascular risk due to hypercoagulability associated with a rapid increase in tumour burden. (iii) Spinal cord physicians should adopt a caring and compassionate approach while managing tetraplegic patients with several co-morbidities, as aggressive diagnostic tests and therapeutic procedures may lead to deterioration in the quality of life.
Cancer cells are hypersensitive to nutrient limitation because oncogenes constitutively drive glycolytic and tricarboxylic acid (TCA) cycle intermediates into biosynthetic pathways. Because the anaplerotic reactions that replace these intermediates are fueled by imported nutrients, the cancer cell’s ability to generate ATP becomes compromised under nutrient-limiting conditions. In addition, most cancer cells have defects in autophagy, the catabolic process that provides nutrients from internal sources when external nutrients are unavailable. Normal cells, in contrast, can adapt to nutrient stress that kills cancer cells by becoming quiescent and catabolic. We show that FTY720, a water soluble sphingolipid drug that is effective in many animal cancer models, selectively starves cancer cells to death by down-regulating nutrient transporter proteins. Consistent with a bioenergetic mechanism of action, FTY720 induced homeostatic autophagy. Cells were protected from FTY720 by cell permeable nutrients or by reducing nutrient demand, but blocking apoptosis was ineffective. Importantly, AAL-149, an FTY720 analog that lacks FTY720’s dose limiting toxicity, also triggered transporter loss and killed patient-derived leukemias while sparing cells isolated from normal donors. Because they target the metabolic profile of cancer cells rather than specific oncogenic mutations, FTY720 analogs like AAL-149 should be effective against many different tumor types, particularly in combination with drugs that inhibit autophagy.
bioenergetics; nutrient limitation; autophagy; FTY720; AAL-149
Condom catheters are indicated in spinal cord injury patients in whom intravesical pressures during storage and voiding are safe. Unmonitored use of penile sheath drainage can lead to serious complications.
A 32-year old, male person, sustained complete paraplegia at T-11 level in 1985. He had been using condom catheter. Eleven years after sustaining spinal injury, intravenous urography showed no radio-opaque calculus, normal appearances of kidneys, ureters and bladder. Blood urea and Creatinine were within reference range. A year later, urodynamics revealed detrusor pressure of 100 cm water when detrusor contraction was initiated by suprapubic tapping. This patient was advised intermittent catheterisation and take anti-cholinergic drug orally; but, he wished to continue penile sheath drainage. Nine years later, this patient developed bilateral hydronephrosis and renal failure. Indwelling urethral catheter drainage was established. Five months later, ultrasound examination of urinary tract revealed normal kidneys with no evidence of hydronephrosis.
Spinal cord injury patients with high intravesical pressure should not have penile sheath drainage as these patients are at risk for developing hydronephrosis and renal failure. Intermittent catheterisation along with antimuscarinic drug should be the preferred option for managing neuropathic bladder.
Background: The transporter associated with antigen processing (TAP) is an ABC transporter whose experimental structure is not known.
Results: We have modeled TAP based on the crystal structures of three related ABC transporters.
Conclusion: We identified a possible peptide binding conformation in the transport cycle of TAP.
Significance: These models help interpret experimental data and give information about the transport cycle of ABC transporters in general.
The human transporter associated with antigen processing (TAP) is a member of the ATP binding cassette (ABC) transporter superfamily. TAP plays an essential role in the antigen presentation pathway by translocating cytosolic peptides derived from proteasomal degradation into the endoplasmic reticulum lumen. Here, the peptides are loaded into major histocompatibility class I molecules to be in turn exposed at the cell surface for recognition by T-cells. TAP is a heterodimer formed by the association of two half-transporters, TAP1 and TAP2, with a typical ABC transporter core that consists of two nucleotide binding domains and two transmembrane domains. Despite the availability of biological data, a full understanding of the mechanism of action of TAP is limited by the absence of experimental structures of the full-length transporter. Here, we present homology models of TAP built on the crystal structures of P-glycoprotein, ABCB10, and Sav1866. The models represent the transporter in inward- and outward-facing conformations that could represent initial and final states of the transport cycle, respectively. We described conserved regions in the endoplasmic reticulum-facing loops with a role in the opening and closing of the cavity. We also identified conserved π-stacking interactions in the cytosolic part of the transmembrane domains that could explain the experimental data available for TAP1-Phe-265. Electrostatic potential calculations gave structural insights into the role of residues involved in peptide binding, such as TAP1-Val-288, TAP2-Cys-213, TAP2-Met-218. Moreover, these calculations identified additional residues potentially involved in peptide binding, in turn verified with replica exchange simulations performed on a peptide bound to the inward-facing models.
ABC Transporter; Molecular Docking; Molecular Dynamics; Molecular Modeling; Multidrug Transporters; Peptide Binding; Transporter Associated with Antigen Processing
Urological complications are the major cause of ill health in patients with spina bifida. Urinary sepsis accounted for the majority of admissions in patients with spina bifida. As the patient grows older, changes occur in the adult bladder, leading to increases in storage pressure and consequent risk of deterioration of renal function, which may occur insidiously.
A 34-year-old male spinal bifida patient had been managing neuropathic bladder by penile sheath. Intravenous urography revealed normal kidneys. This patient was advised intermittent catheterisations. But self-catheterisation was not possible because of long, overhanging prepuce and marked spinal curvature. This patient developed repeated urine infections. Five years later, ultrasound examination of urinary tract revealed hydronephrotic right kidney with echogenic debris within the collecting system. There was no evidence of dilatation of the ureter near the vesicoureteric junction. The left kidney appeared normal. There was no evidence of calculus disease seen in either kidney. Indwelling urethral catheter drainage was established.
Two years later, MAG-3 renogram revealed normal uptake and excretion by left kidney. The right kidney showed little functioning tissue. Following a routine change of urethral catheter this patient became unwell. Ultrasound examination revealed hydronephrotic right kidney containing thick hyper-echoic internal septations and debris in the right renal pelvis suspicious of pyonephrosis. Under both ultrasound and fluoroscopic guidance, an 8 French pig tail catheter was inserted into the right renal collecting system. 150 ml of turbid urine was aspirated immediately. This patient developed large left pleural effusion, collapse/consolidation of the left lower lobe, a large fluid collection in the abdomen extending into the pelvis and expired twenty days later because of sepsis and respiratory failure.
Although penile sheath drainage may be convenient for a spina bifida patient and the carers, hydronephrosis can occur insidiously. With recurrent urine infections, hydronephrotic kidney can become pyonephrosis, which is life-threatening. Therefore, every effort should be made to carry out intermittent catheterisations along with antimuscarinic drug therapy.
Open radical retropubic prostatectomy (RRP) has an average blood loss of over 1,000ml. This has been reported even from high volume centres of excellence.1–4 We have looked at the clinical and financial benefits of using intraoperative cell salvage (ICS) as a method of reducing the autologous blood transfusion requirements for our RRP patients.
MATERIALS AND METHODS
Group A comprised 25 consecutive patients who underwent RRP immediately prior to the acquisition of a cell saver machine. Group B consisted of the next 25 consecutive patients undergoing surgery using the Dideco Electa (Sorin Group, Italy) cell saver machine. Blood transfusion costs for both groups were calculated and compared.
The mean postoperative haemoglobin was similar in both groups (11.1gm/dl in Group A and 11.4gm/dl in Group B). All Group B patients received autologous blood (average 506ml, range: 103–1,023ml). In addition, 5 patients (20%) in Group B received a group total of 16 units (average 0.6 units) of homologous blood. For Group A the total cost of transfusing the 69 units of homologous blood was estimated as £9,315, based on a per blood unit cost of £135. This cost did not include consumables or nursing costs.
We found no evidence that autologous transfusions increased the risk of early biochemical relapse or of disease dissemination. ICS reduced our dependence on donated homologous blood.
Blood transfusion; Cell saver; Intraoperative cell salvage; Open radical retropubic prostatectomy; Prostate specific antigen
Background and Aims:
Alpha-2 agonists are being increasingly used as adjuncts in general anaesthesia, and the present study was carried out to investigate the ability of intravenous dexmedetomidine in decreasing the dose of opioids and anaesthetics for attenuation of haemodynamic responses during laryngoscopy and tracheal intubation.
One hundred patients scheduled for elective general surgery were randomized into two groups: D and F (n=50 in each group). Group D were administered 1 μg/kg each of dexmedetomidine and fentanyl while group F received 2 μg/kg of fentanyl pre-operatively. Thiopental was given until eyelash reflex disappeared. Anaesthesia was maintained with 33:66 oxygen: nitrous oxide. Isoflurane concentration was adjusted to maintain systolic blood pressure within 20% of the pre-operative values. Haemodynamic parameters were recorded at regular intervals during induction, intubation, surgery and extubation. Statistical analysis was carried out using analysis of variance, chi-square test, Student's t test and Mann–Whitney U test.
The demographic profile was comparable. The pressor response to laryngoscopy, intubation, surgery and extubation were effectively decreased by dexmedetomidine, and were highly significant on comparison (P<0.001). The mean dose of fentanyl and isoflurane were also decreased significantly (>50%) by the administration of dexmedetomidine. The mean recovery time was also shorter in group D as compared with group F (P=0.014).
Dexmedetomidine is an excellent drug as it not only decreased the magnitude of haemodynamic response to intubation, surgery and extubation but also decreased the dose of opioids and isoflurane in achieving adequate analgesia and anaesthesia, respectively.
Dexmedetomidine; fentanyl; heart rate; isoflurane; mean arterial pressure; pressor response
Some tetraplegic patients may wish to undergo urological procedures without anaesthesia, but these patients can develop autonomic dysreflexia if cystoscopy and vesical lithotripsy are performed without anaesthesia.
We describe three tetraplegic patients, who developed autonomic dysreflexia when cystoscopy and laser lithotripsy were carried out without anesthesia.
In two patients, who declined anaesthesia, blood pressure increased to more than 200/110 mmHg during cystoscopy. One of these patients developed severe bleeding from bladder mucosa and lithotripsy was abandoned. Laser lithotripsy was carried out under subarachnoid block a week later in this patient, and this patient did not develop autonomic dysreflexia.
The third patient with C-3 tetraplegia had undergone correction of kyphoscoliotic deformity of spine with spinal rods and pedicular screws from the level of T-2 to S-2. Pulmonary function test revealed moderate to severe restricted curve. This patient developed vesical calculus and did not wish to have general anaesthesia because of possible need for respiratory support post-operatively. Subarachnoid block was not considered in view of previous spinal fixation. When cystoscopy and laser lithotripsy were carried out under sedation, blood pressure increased from 110/50 mmHg to 160/80 mmHg.
These cases show that tetraplegic patients are likely to develop autonomic dysreflexia during cystoscopy and vesical lithotripsy, performed without anaesthesia. Health professionals should educate spinal cord injury patients regarding risks of autonomic dysreflexia, when urological procedures are carried out without anaesthesia. If spinal cord injury patients are made aware of potentially life-threatening complications of autonomic dysreflexia, they are less likely to decline anaesthesia for urological procedures. Subrachnoid block or epidural meperidine blocks nociceptive impulses from urinary bladder and prevents occurrence of autonomic dysreflexia. If spinal cord injury patients with lesions above T-6 decline anaesthesia, nifedipine 10 mg should be given sublingually prior to cystoscopy to prevent increase in blood pressure due to autonomic dysreflexia.
The Manchester Triage System is commonly used as the triage system in emergency departments of the UK. As per the Manchester Triage System, patients presenting with retention of urine to the accident and emergency department are categorized to yellow, which denotes that the ideal maximum time to first contact with a treating clinician will be 60 min. Cervical spinal cord injury patients, in whom urinary catheter is blocked, may develop suddenly headache, sweating, high blood pressure, cardiac dysrhythmia, convulsions, intracranial bleed, and acute neurogenic pulmonary oedema as a result of autonomic dysreflexia due to a distended bladder.
A 46-year-old male with C-6 tetraplegia developed urinary retention because of a blocked catheter. He was seen immediately on arrival in the spinal injuries unit. The blocked catheter was removed and a new catheter was about to be inserted. Then this patient said that the ceiling lights were very bright and glaring. Five milligrams of Nifedipine was given sublingually. This patient started having fits involving his head, face, neck and shoulders with loss of consciousness. A 14-French silicone Foley catheter was inserted per urethra without any delay and 300 ml of clear urine was drained. This patient recovered consciousness within 5 min. Computed tomography of the brain revealed no focal cerebral or cerebellar abnormality. There was no intra-cranial haemorrhage.
This case illustrates that spinal cord injury patients with lesion above T-6, who develop retention of urine because of a blocked catheter, may look apparently well, but these patients can develop suddenly life-threatening autonomic dysreflexia. Therefore, spinal cord injury patients, who present to the accident and emergency department or spinal units with a blocked urinary catheter, should be seen urgently although their vital signs may be stable on arrival. Increasing the awareness of staff in emergency departments regarding autonomic dysreflexia as well as education of the patient and carers will be useful in preventing this complication in persons with spinal cord injury.
Fibromatosis form a spectrum of clinicopathologic entities characterized by the infiltrative proliferation of fibroblasts that lack malignant cytologic features. The fibromatosis can be localized or infiltrative and multicentric and can involve internal tissues and organs as the mesentery, retroperitoneum, breast, and almost every organ and region of the body, including the bones, the meninges and the central nervous system. We report a case of 37-year-old male who presented with a right supraclavicular mass with superficial infiltrative type of fibromatosis and fine needle aspiration cytology (FNAC) was performed. We report this case because of limited literature of FNAC in fibromatosis and quick role of FNAC in the diagnosis of fibromatosis.
Fibromatosis; fine needle aspiration cytology; soft tissue lesions
Paravertebral block (PVB) is useful for post-operative analgesia after breast surgery. Bupivacaine is used for PVB at higher concentrations (0.5%), which may lead to systemic toxicity after absorption. Therefore, we proposed to evaluate the efficacy of lower concentrations of bupivacaine with and without fentanyl for thoracic PVB in patients undergoing surgery for carcinoma breast.
Forty-eight patients scheduled for surgery for breast cancer were enrolled in this prospective, randomized, double-blinded, placebo-controlled trial and were allocated to one of four groups: 0.25% bupivacaine with epinephrine 5 mcg/ ml, 0.25% bupivacaine + epinephrine 5 mcg/ ml with 2 mcg/ml fentanyl, 0.5% bupivacaine + epinephrine 5 mcg/ml or isotonic saline. PVB was performed and 0.3 ml/kg of the test drug was administered before induction of general anaesthesia. The primary outcome assessed was post-operative analgesic requirement for a period of 24 h. Secondary outcome measures were post-operative pain scores at rest and on movement of the arm, latency to first opioid, post-operative nausea and vomiting, quality of sleep, ability to move arm and patient satisfaction.
The patient characteristics and anaesthetic technique were comparable among the groups. The rescue analgesic consumption as well as cumulative pain scores at rest and on movement were significantly less in 0.25% bupivacaine+epinephrine with fentanyl and 0.5% bupivacaine+epinephrine groups (P<0.05). The average duration of analgesia was found to be 18 h after either 0.25% bupivacaine with epinephrine+fentanyl or 0.5% bupivacaine with epinephrine.
Lower concentrations of bupivacaine can be combined with fentanyl to achieve analgesic efficacy similar to bupivacaine at higher concentrations, decreasing the risk of toxicity in PVB.
Bupivacaine; fentanyl; mastectomy; paravertebral block; post-op analgesia
Cutaneous metastases from internal malignancies are rare with a reported incidence between 0.7% and 10%. We report a case with distant skin and subcutaneous metastases in abdominal skin from breast cancer detected on 18F-fluoro-deoxyglucose–positron emission tomography/computed tomography imaging.
Breast cancer; 18F-FDG–PET/CT; skin metastases
Although complications related to suprapubic cystostomies are well documented, there is scarcity of literature on safety issues involved in long-term care of suprapubic cystostomy in spinal cord injury patients.
A 23-year-old female patient with tetraplegia underwent suprapubic cystostomy. During the next decade, this patient developed several catheter-related complications, as listed below: (1) Suprapubic catheter came out requiring reoperation. (2) The suprapubic catheter migrated to urethra through a patulous bladder neck, which led to leakage of urine per urethra. (3) Following change of catheter, the balloon of suprapubic catheter was found to be lying under the skin on two separate occasions. (4) Subsequently, this patient developed persistent, seropurulent discharge from suprapubic cystostomy site as well as from under-surface of pubis. (5) Repeated misplacement of catheter outside the bladder led to chronic leakage of urine along suprapubic tract, which in turn predisposed to inflammation and infection of suprapubic tract, abdominal wall fat, osteomyelitis of pubis, and abscess at the insertion of adductor longus muscle
Suprapubic catheter should be anchored securely to prevent migration of the tip of catheter into urethra and accidental dislodgment of catheter. While changing the suprapubic catheter, correct placement of Foley catheter inside the urinary bladder must be ensured. In case of difficulty, it is advisable to perform exchange of catheter over a guide wire. Ultrasound examination of urinary bladder is useful to check the position of the balloon of Foley catheter.
When urethral catheterisation is difficult or impossible in spinal cord injury patients, flexible cystoscopy and urethral catheterisation over a guide wire can be performed on the bedside, thus obviating the need for emergency suprapubic cystostomy. Spinal cord injury patients, who undergo flexible cystoscopy and urethral catheterisation over a guide wire, may develop potentially serious complications. (1) Persons with lesion above T-6 are susceptible to develop autonomic dysreflexia during cystoscopy and urethral catheterisation over a guide wire; nifedipine 5–10 milligrams may be administered sublingually just prior to the procedure to prevent autonomic dysreflexia. (2) Spinal cord injury patients are at increased risk for getting urine infections as compared to able-bodied individuals. Therefore, antibiotics should be given to patients who get haematuria or urethral bleeding following urethral catheterisation over a guide wire. (3) Some spinal cord injury patients may have a small capacity bladder; in these patients, the guide wire, which is introduced into the urinary bladder, may fold upon itself with the tip of guide wire entering the urethra. If this complication is not recognised and a catheter is inserted over the guide wire, the Foley catheter will then be misplaced in urethra despite using cystoscopy and guide wire.
Single-walled carbon nanohorns (SWNHs) are new carbonaceous materials. In this paper, we report the first successful preparation of SWNHs encapsulating trimetallic nitride template endohedral metallofullerenes (TNT-EMFs). The resultant materials were functionalized by a high-speed vibration milling method and conjugated with CdSe/ZnS quantum dots (QDs). The successful encapsulation of TNT-EMFs and external functionalization with QDs provide a dual diagnostic platform for in vitro and in vivo biomedical applications of these new carbonaceous materials.
Carbon nanohorns; peapods; quantum dots; in vitro; in vivo
It is well known in the literature that imaging has almost no value for diagnosis of superficial bladder cancer. However, wide gap exists between knowledge on diagnosis of bladder cancer and actual clinical practice.
Delay in diagnosis of bladder cancer in a male person with tetraplegia occurred because of reliance on negative flexible cystoscopy and single biopsy, negative ultrasound examination of urinary bladder, and computerised tomography of pelvis. Difficulties in scheduling cystoscopy also contributed to a delay of nearly ten months between the onset of haematuria and establishing a histological diagnosis of vesical malignancy in this patient. The time interval between transurethral resection and cystectomy was 42 days. This delay was mainly due to scheduling of surgery.
We learn from this case that doctors should be aware of the limitations of negative flexible cystoscopy and single biopsy, cytology of urine, ultrasound examination of urinary bladder, and computed tomography of pelvis for diagnosis of bladder cancer in spinal cord injury patients. Random bladder biopsies must be considered under general anaesthesia when there is high suspicion of bladder cancer. Spinal cord injury patients with lesions above T-6 may develop autonomic dysreflexia; therefore, one should be extremely well prepared to prevent or manage autonomic dysreflexia when performing cystoscopy and bladder biopsy. Spinal cord injury patients, who pass blood in urine, should be accorded top priority in scheduling of investigations and surgical procedures.
Spinal cord injury; Urinary bladder; Carcinoma; Suprapubic cystostomy; Cystoscopy
Background and Aim:
There is scarcity of data from the Indian subcontinent regarding the profile and outcome of patients presenting with acute poisoning admitted to intensive care units (ICU). We undertook this retrospective analysis to assess the course and outcome of such patients admitted in an ICU of a tertiary care private hospital.
We analyzed data from 138 patients admitted to ICU with acute poisoning between July 2006 and March 2009. Data regarding type of poisoning, time of presentation, reason for ICU admission, ICU course and outcome were obtained.
Seventy (50.7%) patients were males and majority (47.8%) of admissions were from age group 21 to 30 years. The most common agents were benzodiazepines, 41/138 (29.7%), followed by alcohol, 34/138 (24.63%) and opioids, 10/138 (7.2%). Thirty-two (23%) consumed two or more agents. Commonest mode of toxicity was suicidal (78.3%) and the route of exposure was mainly oral (97.8%). The highest incidence of toxicity was due to drugs (46.3%) followed by household agents (13%). Organ failure was present in 67 patients (48.5%). During their ICU course, dialysis was required in four, inotropic support in 14 and ventilator support in 13 patients. ICU mortality was 3/138 (2.8%). All deaths were due to aluminium phosphide poisoning.
The present data give an insight into epidemiology of poisoning and represents a trend in urban India. The spectrum differs as we cater to urban middle and upper class. There is an increasing variety and complexity of toxins, with substance abuse attributing to significant number of cases.
Acute poisoning; intensive care unit; toxicology
Efforts to find a better adjuvant in regional anaesthesia are underway since long. Aims and objectives are to compare the efficacy and clinical profile of two α-2 adrenergic agonists, dexmedetomidine and clonidine, in epidural anaesthesia with special emphasis on their sedative properties and an ability to provide smooth intra-operative and post-operative analgesia. A prospective randomized study was carried out which included 50 adult female patients between the ages of 44 and 65 years of (American Society of Anaesthesiologists) ASAI/II grade who underwent vaginal hysterectomies. The patients were randomly allocated into two groups; ropivacaine + dexmedetomidine (RD) and ropivacaine + clonidine (RC), comprising of 25 patients each. Group RD was administered 17 ml of 0.75% epidural ropivacaine and 1.5 μg/kg of dexmedetomidine, while group RC received admixture of 17 ml of 0.75% ropivacaine and 2 μg/kg of clonidine. Onset of analgesia, sensory and motor block levels, sedation, duration of analgesia and side effects were observed. The data obtained was subjected to statistical computation with analysis of variance and chi-square test using statistical package for social science (SPSS) version 10.0 for windows and value of P < 0.05 was considered significant and P < 0.0001 as highly significant. The demographic profile, initial and post-operative block characteristics and cardio-respiratory parameters were comparable and statistically non-significant in both the groups. However, sedation scores with dexmedetomidine were better than clonidine and turned out to be statistically significant (P < 0.05). The side effect profile was also comparable with a little higher incidence of nausea and dry mouth in both the groups which was again a non-significant entity (P > 0.05). Dexmedetomidine is a better neuraxial adjuvant compared to clonidine for providing early onset of sensory analgesia, adequate sedation and a prolonged post-operative analgesia.
Clonidine; dexmedetomidine; epidural anaesthesia; ropivacaine; vaginal hysterectomy
Cancer during pregnancy is a rare situation which demands a multidisciplinary care involving the surgical oncologist, the medical oncologist, the obstetrician and a host of other care givers. The care of the patient is planned in a way to optimize the health care delivery to the mother without compromising on the care of the fetus. When this is not possible priorities need to be established and harsh decisions taken on an individual basis. The treatment of the cancer does not change from the standard outside the limits described above and the objective should be to stay as close to the standard of care treatment as possible.
The pedicled TRAM flap has been a workhorse of autologous breast reconstruction for decades. However, there has been a rising concern about the abdominal wall donor site morbidity with the use of conventional TRAM flap. This has generally been cited as one of the main reasons for resorting to “abdominal wall friendly” techniques. This study has been undertaken to assess the abdominal wall function in patients with pedicled TRAM flap breast reconstruction. The entire width of the muscle and the overlying wide disk of anterior rectus sheath were harvested with the TRAM flap in all our patients and the anterior rectus sheath defect was repaired by a Proline mesh.
Materials and Methods:
Abdominal wall function was studied in 21 patients who underwent simultaneous primary unipedicled TRAM flap reconstruction after mastectomy for cancer. In all the patients, the abdominal wall defect was repaired using wide sheet of Proline mesh both as inlay and onlay. The assessment tools included straight and rotational curl ups and a subjective questionnaire. The abdominal wall was also examined for any asymmetry, bulge, or hernia. The minimal follow-up was 6 months postoperative. The objective results were compared with normal unoperated volunteers.
Results and Conclusions:
The harvesting the TRAM flap certainly results in changes to the anterior abdominal wall that can express themselves to a variable degree. A relatively high incidence of asymptomatic asymmetry of the abdomen was seen. There was total absence of hernia in our series even after a mean follow-up period of 15.5 months. A few patients were only able to partially initiate the sit up movement and suffered an important loss of strength. In most patients, synergists took over the functional movement but as the load increased, flexion and rotation performances decreased. The lack of correlation between exercise tests and the results of the questionnaire suggests that this statistically significant impairment was functionally not important. The patients encountered little or no difficulty in theis day-to-day activities. Our modification of use of a wide mesh as inlay and onlay repair minimizes the donor site morbidity. This also avoids maneuvers meant for primary closure of the rectus sheath defects, which can result in distortion of umbilicus. Therefore, in conclusion, the unipedicled TRAM flap should be regarded as a valuable option in breast reconstruction provided careful repair of the abdominal wall defect is undertaken using Proline mesh.
Abdominal wall function; patient questionnaire; pedicled TRAM flap breast reconstruction; straight and lateral curl ups
Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. We propose that a list of “Never Events” is created for spinal cord injury patients in order to improve the quality of care. To begin with, following two preventable complications related to management of neuropathic bladder may be included in this list of “Never Events.” (i) Severe ventral erosion of glans penis and penile shaft caused by indwelling urethral catheter; (ii) incorrect placement of a Foley catheter leading to inflation of Foley balloon in urethra. If a Never Event occurs, health professionals should report the incident through hospital risk management system to National Patient Safety Agency's Reporting and Learning System, communicate with the patient, family, and their carer as soon as possible about the incident, undertake a comprehensive root cause analysis of what went wrong, how, and why, and implement the changes that have been identified and agreed following the root cause analysis.
Neuropathic urinary bladder is often colonised by multidrug-resistant bacteria. We report a 64-year-old male spinal cord injury patient with paraplegia, who received gentamicin on empirical basis before undergoing suprapubic cystostomy, as antibiotic sensitivity report of urine was not available. This patient developed fulminate septicaemia. Although appropriate antibiotic therapy (meropenem) was started when this patient manifested features of sepsis, acute renal failure occurred and he expired. Inappropriate initial antimicrobial therapy was the major contributory factor for this patient's mortality. Learning points from this case are (1) never do a cystostomy without prior urine culture and appropriate antibiogram; (2) in a chronic spinal cord injury patient, full blood count, liver function tests, albumin level, and albumin to globulin ratio should be performed before any surgical procedure.