Does the volume of supplemental intraligamentary injections affect the anaesthetic success rate after a failed primary inferior alveolar nerve block? A randomized-double blind clinical trial.

AIM: To investigate the efficacy of 0.2 mL vs. 0.6 mL of 2% lidocaine when given as a supplementary intraligamentary injection after a failed inferior alveolar nerve block (IANB). METHODOLOGY: Ninety-seven adult patients with symptomatic irreversible pulpits received an IANB and root canal treatment was initiated. Pain during treatment was recorded using a visual analogue scale (Heft-Parker VAS). Patients with unsuccessful anaesthesia (n = 78) randomly received intraligamentary injection of either 0.2 mL or 0.6 mL of 2% lidocaine with 1 : 80 000 epinephrine. Root canal treatment was reinitiated. Success after primary injection or supplementary injection was defined as no or mild pain (HP VAS score ≤54 mm) during access preparation and root canal instrumentation. Heart rate was monitored using a finger pulse oximeter. The anaesthetic success rates were analysed with Pearson chi-square test at 5% significance levels. The heart rate changes were analysed using t-tests. RESULTS: The intraligamentary injections with 0.2 mL solution gave an anaesthetic success rate of 64%, whilst the 0.6 mL was successful in 84% of cases with failed primary IANB. (χ2  = 4.3, P = 0.03). There was no significant effect of the volume of intraligamentary injection on the change in heart rate. CONCLUSIONS: Increasing the volume of intraligamentary injection improved the success rates after a failed primary anaesthetic injection.

Comparison of the anaesthetic efficacy of epinephrine concentrations (1 : 80 000 and 1 : 200 000) in 2% lidocaine for inferior alveolar nerve block in patients with symptomatic irreversible pulpitis: a randomized, double-blind clinical trial.

AIM: The aim of this randomized controlled, double-blind trial was to comparatively evaluate the anaesthetic efficacy and injection pain of 1.8 mL of 2% lidocaine with different concentrations of epinephrine (1 : 80 000 and 1 : 200 000) in patients with symptomatic irreversible pulpitis. METHODOLOGY: Sixty-two adult volunteers, actively experiencing pain, were randomly allocated into 2 groups and received 1.8 mL of 2% lidocaine with either 1 : 80 000 or 1 : 200 000 epinephrine concentration. Endodontic access preparation was initiated 15 min after the initial IANB. Pain during treatment was recorded using the Heft-Parker visual analogue scale (HP VAS). The primary outcome measure, and the definition of 'success', was the ability to undertake pulp access and canal instrumentation with no or mild pain (HP VAS score <55 mm). Secondary outcome measure was the pain experienced during LA solution deposition. Statistical analysis was performed using Mann-Whitney U-test and chi-square test. RESULTS: The anaesthetic success rates of 2% lidocaine solutions containing 1 : 80 000 and 1 : 200 000 epinephrine concentrations were 20% and 28%, respectively. The difference was not statistically significant. There was also no significant difference in the pain experienced during deposition of the solutions. CONCLUSIONS: Two percent lidocaine solution used for IANB achieved similar success rates when used with 1 : 80 000 or 1 : 200 000 epinephrine concentration.

Why Should I? Examining How Childhood Callous-Unemotional Traits Relate to Prosocial and Affiliative Behaviors and Motivations.

Childhood callous-unemotional (CU) traits are characterized by low empathy, limited prosocial behavior, and restricted social affiliation. However, few studies have investigated whether CU traits are associated with different subtypes of prosocial and affiliative behavior or the specific motivational difficulties underlying these behaviors. We addressed these questions using data from 135 young children (M = 5.48 years old; 58% female) who viewed depictions of adults or children in instrumental need, emotional need, or neutral situations. We assessed recognition, suggested initiation of, and motivation for prosocial or affiliative behavior in response to each depiction. We distinguished between subtypes of prosocial (instrumental and emotional) and affiliative (parallel, cooperative, associative) behavior, as well as self- versus other-orientated motivations. Parents reported on child CU traits and conduct problems. Overall, children accurately recognized prosocial and neutral situations, offered help, and expressed other-orientated motivations for prosocial behavior and social motivations for affiliative behavior. Higher CU traits were related to lower overall recognition accuracy, which was more pronounced for emotional need. Higher CU traits were also related to fewer offers of help and more denial of prosocial behavior, particularly for instrumental need. Finally, CU traits were related to lower probability of initiating affiliative behavior. CU traits were not differentially related to self- versus other-orientated motivations for prosocial or affiliative behavior. Findings demonstrate difficulties of children with CU traits in recognizing need and offering help. Interventions for CU traits could include modules that explicitly scaffold and shape prosociality and social affiliation.

Abolition of endocrine dimorphism in hyperthyroid males? An argument for the positive feedback effect of hyperoestrogenaemia on LH secretion.

Our aim was (i) to investigate the hypothalamo-hypophyseal-gonadal axis in hyperthyroid Indian males, (ii) to rule out the modulatory role of adrenal steroids on it and (iii) to determine if the simultaneous rise in oestradiol and luteinising hormone (LH) in hyperthyroid males is due to a positive feedback action of oestradiol on pituitary LH release. Age- and BMI-matched men were divided into two groups, I, euthyroid subjects (n = 17) and II, hyperthyroid patients (n = 12) on the basis of their thyroid hormone levels. Serum levels of thyroid-stimulating hormone, triiodothyronine, thyroxine, LH, follicle-stimulating hormone (FSH), prolactin, E(2), T, P(4), sex hormone binding globulin and dehydroepiandrosterone sulphate (DHEAS) were assayed. Mean levels of T and E(2) were approximately two times higher in group II in comparison with group I. DHEAS levels were similar in both groups ruling out any adrenal involvement. Mean serum LH level was 2.6 folds higher in group II in comparison with group I. Mean serum levels of FSH were higher in group II, it was marginally nonsignificant. On the basis of these and previous observations, we hypothesise that endocrinological dimorphism in human male and female is not rigid; a sustained rise in serum oestradiol probably induces a positive feedback action on pituitary leading to elevated gonadotrophin levels.

A study of risk factors of stroke in patients admitted in Manipal Teaching Hospital, Pokhara.

BACKGROUND: Stroke is usually end result of predisposing conditions that originated years before the ictus. Identification of its modifiable risk factors can help in planning preventive strategies. OBJECTIVE: To study the risk factors of stroke in adult patients. METHODS: A hospital based prospective cross sectional study was carried out in 160 stroke patients admitted in Manipal Teaching Hospital, Pokhara from November 2007- October 2010. Diagnosis of stroke was confirmed by CT scan of brain. Patients were then investigated for presence of conventional risk factors. The data was statistically analysed using Epi-Info. RESULTS: The mean age of stroke patients was 65.98 years +/- 10.69 with 126 (78.8%) of patients belonging to age group = 60 years. It afflicted higher percentage of males 104 (65%) than females 56 (35%). Analysis of stroke subtypes showed preponderance of haemorrhagic stroke in 85 (53.1%) as against infarction in 75 (46.9%) of cases. Other conventional modifiable risk factors were seen as follows: hypertension 98 (61.2 %), cigarette smoking 95 (59.4%), alcohol use 43 (26.9%), left ventricular hypertrophy 44 (27.5%), atrial fibrillation 37(23%), elevated triglyceride 37(23%), diabetes mellitus 15 (9.3%) and elevated total cholesterol 12 (7.5%). Multiple risk factors (=2) were seen in 122 (76.5 %) cases. CONCLUSIONS: The maximum occurrence of stroke was seen in patients > 60 years. Overall male preponderance and higher occurrence of haemorrhagic stroke was seen in our study. Significant risk factors in order of descending order were hypertension, cigarette smoking, left ventricular hypertrophy, alcohol use, atrial fibrillation and elevated triglycerides.

Anterior segmental osteotomies without orthodontics: practicability of the correction of dentoalveolar deformities.

We designed this study to determine the efficiency and stability of anterior segmental osteotomies (ASO) without orthodontics for various dentofacial deformities. Records of patients treated with maxillary or mandibular ASO, or both, without orthodontics in the past 15 years were analysed. The assessment included postoperative analysis of patients' aesthetics and functional satisfaction using a questionnaire and grading (score 0 - 4) system, and the amount of relapse calculated from 12-month postoperative cephalograms. A total of 26 ASO subjects (age range 13- 31 years) were studied (14 maxillary, two mandibular, and 10 bimaxillary). Long-term stability was acceptable in all cases with no significant relapse (p>0.05). No major complications were encountered. All patients reported good to excellent (score=3 to 4) satisfaction following surgery. Using meticulous planning and a careful surgical technique, ASO without orthodontics is a simple, quick, safe, and stable option for the correction of dentofacial deformities.

Core surgical field camps: a new deanery-based model for enhancing advanced skills in core surgical trainees through simulation.

Hands-on wet lab simulation training is a vital part of modern surgical training. Since 2010, surgical 'boot camps' have been run by many UK deaneries to teach core surgical trainees basic entry level skills. Training in advanced skills often requires attendance at national fee-paying courses. In the Wessex Deanery, multiple, free of charge, core surgical 'field camps' were developed to provide more advanced level teaching in the particular specialty preference of each core surgical trainee. After the COVID-19 pandemic, national hands-on courses will be challenging to provide and deanery-based advanced skills training may be the way forward for craft-based specialties. The experiences over 2 years of delivering the Wessex core surgical field camps are shared, giving a guide and advice for other trainers on how to run a field camp.

A hip fracture nurse specialist has a positive outcome on the length of stay for patients with hip fractures.

AIM: To determine if recruitment of a hip fracture nurse specialist has a reduction in length of stay for hip fracture patients. METHOD: Primary data was extracted from the National Hip Fracture Database (NHFD). The length of stay of hip fracture patients from 2011-2014 was compared to the period 2014-17, following appointment of a hip fracture nurse specialist in 2014. RESULTS: The average length of stay in the first group (2011-2014) was 19.94 days and in the second group (2014-2017) was 16.52 days. There was a reduction of 3.42 days (17.15%) and was statistically significant. There was also a reduction in the time to surgery (1.38 days versus 1.15 days) and the crude 30-day mortality (10% versus 6.06%) both of which were statistically significant. The two groups were well-matched with regards to age, female: male ratio and severity of co-morbidities (based on American Society of Anaesthesiologists physical status classification system). CONCLUSION: The introduction of a dedicated hip fracture nurse specialist has a positive outcome on hip fracture patients by reducing length of stay, time to surgery and the crude 30-day mortality.

Tuberculosis diagnosed / managed at NGMC, Teaching Hospital, Kohalpur: a joint private-public effort.

INTRODUCTION: Medical colleges both in public and private sector in Nepal have been supporting national TB control program (NTP) in its effort to control TB and its eventual elimination. Official collaboration between Nepalganj Medical College (NGMC), a private sector medical college and NTP was developed in 2000; a joint private-public initiative to contain TB. OBJECTIVES: This study has been done with the objectives a) to review the TB cases diagnosed/managed at NGMC Teaching Hospital (TH), Kohalpur, in Financial Year 2063/2064 (Shrawan 63 Asad 64) and b) to assess the contribution of NGMC, TH, Kohalpur towards TB control. METHODOLOGY: This is record based review of TB cases diagnosed, categorized, treated at NGMC TH, Kohalpur and referred to respective health facilities in Financial Year 2063/2064 (Shrawan 63 Asad 64). And case detection with respect to detected TB cases in Midwestern Region and entire country. RESULTS: Around 13% of detected TB cases for Mid Western Region and 1.5 % of detected TB cases at national level were diagnosed at NGMC, TH, Kohalpur. 35% of cases were of pediatric TB; lymph node TB, pleural effusion & abdominal TB were common form of extra pulmonary (EP) TB seen in children. 20.8%, 44.8% and 34.4% of cases in adults were of sputum smear (SS) + pulmonary TB (PTB), SS- PTB & EPTB respectively; pleural effusion, lymph node TB, Miliary & abdominal TB were common form of EPTB seen in adults. CONCLUSION: Contribution of NGMC, TH, Kohalpur towards case detection seems to be significant. The role of medical colleges in TB control can not be underestimated.

Effect of HRT and slurry concentration on biogas production in cattle dung based anaerobic bioreactors.

The effect of three different cattle dung slurry concentrations (1:1, 1:4 and 1:9) at three different HRTs of 20, 30 and 40 days was studied at pilot scale for one year. The results showed that both biogas yield and methane content of gas obtained in 1:4 and 1:9 slurry concentrations were significantly higher than those at 1:1 concentration for a given HRT. This was observed for all the three HRTs studied. At 1:1 and 1:4 slurry concentrations, methane yield was found to increase with HRT. However, at higher dilution of 1:9, increase in HRT from 30 to 40 days resulted in decrease in methane yield.

Tuberculosis: an unusual presentation.

Patient with tuberculosis may present with atypical, unusual or complex features. The reported case is of 31 years lady admitted with fever, breathlessness and features of cardiac failure. She was detected to have right lower lung consolidation, minimal bilateral pleural effusion, features suggestive of sub-acute pericarditis and subsequent chest x-ray revealed miliary mottling as well. Later on Acid Fast Bacilli were detected in sputum and pleural fluid. Clinicians need to keep complex presentation of TB in mind to manage the case at its earlier stage to avoid residual complication.

Situs inversus with dextrocardia with multiple cardiac lesions in adult.

Situs inversus with dextrocardia is the malposition most likely to occur with structurally normal heart; generally discovered on routine chest x-ray or physical examination performed for other reasons. These persons experience normal longevity of life and have similar risk of getting acquired disease as that of other person of same age and sex group. Symptoms related to acquired disorder may also lead to discovery of such cardiac malposition. Incidence of congenital cardiac anomalies in dextrocardia with situs inversus is very low globally but its figure in Nepal is not known. We report an adult of 43 years age having situs inversus with dextrocardia associated with multiple cardiac lesions i.e. ventricular septal defect, aortic regurgitation, mitral regurgitation and tricuspid regurgitation.

Human neurocysticercosis managed at Nepalganj Medical College, Teaching Hospital, Kohalpur, Nepal.

INTRODUCTION: Neurocysticercosis is the most common parasitic infection of the central nervous system. It is endemic in Central Europe, South Africa, South America and parts of Asia including Nepal. OBJECTIVE: This study has been conducted with the objectives to know the diagnostic criteria for neurocysticercosis and the outcome of treated cases. METHODOLOGY: This retrospective study was done at Nepalganj Medical College, Teaching Hospital, Kohalpur, by reviewing the record of the patients managed as case of neurocysticercosis in one financial year. RESULTS: All patients presented with seizure as a main symptom started in adult life. The mean age was 21 years; 80% were male and 20% female. The diagnosis seemed to be based on clinical presentation, CT scan findings and high index of suspicion. All were put on albendazole, steroids and anticonvulsant drugs; 93% was discharged when fits got controlled, one patient left against medical advice. Follow up record was not available to comment on resolution. CONCLUSION: Neurocysticercosis is difficult to diagnose and has a significant socioeconomic impact because of chronic morbidity, variable mortality, decreased productivity of affected persons, and high cost of medical diagnosis and treatment. It is therefore suggested to develop criteria for diagnosis of neurocysticercosis to be followed at national level.

The autogenous graft versus transport distraction osteogenesis for reconstruction of the ramus-condyle unit: a prospective comparative study.

This study aimed to compare the joint function and morphology achieved following condylar reconstruction using sternoclavicular grafts (SCG) versus transport distraction osteogenesis (TDO) in temporomandibular joint (TMJ) ankylosis patients. Twenty-two patients with TMJ ankylosis underwent TMJ reconstruction with SCG or TDO (n=11 each). Radiographic and clinical evaluations were performed at 1 week and at 1, 3, and 6 months post-surgery. Clinical criteria examined included the duration of surgery, mean postoperative mouth opening, excursive jaw movements, and pain scores. The radiographic evaluation 6 months postoperatively (computed tomography) included subjective assessment of joint morphology and measurements of the mean condylar height, width achieved, and amount of condylar resorption. The χ2 test and Student t-test were used to compare qualitative and quantitative variables, respectively. Similar mean mouth opening (SCG=31.8mm, TDO=32.1mm at 6 months), excursive movements, and pain scores were observed in the two groups throughout follow-up. Mean condylar resorption was significantly greater in the TDO group (TDO=7.0mm, SCG=2.7mm; P=0.005). The duration of reconstruction surgery was greater in the SCG group (P=0.035). A greater incidence of complications was observed with TDO. In conclusion, based on the protocols used in this study, SCGs are superior to TDO in terms of condylar morphology, stability, and surgical safety.

Effect of surgical mandibular advancement on pharyngeal airway dimensions: a three-dimensional computed tomography study.

The aim of this study was to quantify the changes in pharyngeal airway space (PAS) in patients with a skeletal class II malocclusion managed by bilateral sagittal split ramus osteotomy for mandibular advancement, using three-dimensional (3D) registration. The sample comprised 16 patients (mean age 21.69±2.80 years). Preoperative (T0) and postoperative (T1) computed tomography scans were recorded. Linear, cross-sectional area (CSA), and volumetric parameters of the velopharynx, oropharynx, and hypopharynx were evaluated. Parameters were compared with paired samples t-tests. Highly significant changes in dimension were measured in both sagittal and transverse planes (P<0.001). CSA measurements increased significantly between T0 and T1 (P<0.001). A significant increase in PAS volume was found at T1 compared with T0 (P<0.001). The changes in PAS were quantified using 3D reconstruction. Along the sagittal and transverse planes, the greatest increase was seen in the oropharynx (12.16% and 11.50%, respectively), followed by hypopharynx (11.00% and 9.07%) and velopharynx (8.97% and 6.73%). CSA increased by 41.69%, 34.56%, and 28.81% in the oropharynx, hypopharynx, and velopharynx, respectively. The volumetric increase was greatest in the oropharynx (49.79%) and least in the velopharynx (38.92%). These established quantifications may act as a useful guide for clinicians in the field of dental sleep medicine.

Direct-to-physician and direct-to-consumer advertising: Time to have stringent regulations.

BACKGROUND: Direct to physician advertisements and direct to consumer advertisement (DTCA) is a well-known marketing strategy of pharmaceutical companies. Studies from the West and also from the Indian sub-continent revealed several lacunae in such advertisements. OBJECTIVES: The present study was carried out to understand the international and national scenario regarding the lacunae in drug advertisements and the opinion of both physicians and patients regarding DTCA. METHODS: The present study was conducted after obtaining approval from the institutional ethics committee. Warning letters (WLs) issued to pharmaceutical companies by United States Food and Drug Administration (USFDA) and Therapeutic Goods Administration (TGA) due to discrepancies in the advertisements were analyzed for reasons that were grouped into one of the following categories: overstatement of efficacy; unapproved indication; lack of adequate directions to use; omission of adverse effects; misleading claims; advertisement made for an unapproved drug (investigational new product). Drug advertisements in Current Index of Medical Specialties (CIMS) April-July 2014 issue was also analyzed for lacunae depending on categories as mentioned above. Physicians and patients in a tertiary care medical college and hospital were administered a validated questionnaire exploring their views about crucial aspects of DTCA. Descriptive statistics was used for each of the categories. RESULTS: A total of 93 WLs issued by USFDA and 36 by TGA were assessed. Majority of the WLs by USFDA were issued for omission of adverse effects (61/93, 65.6%) followed by misleading claims (54/93, 58.1%). Similarly, WLs by TGA were also mainly issued for the presence of misleading claims (35/36, 97.2%) followed by overstatement of efficacy (26/36, 72.2%) and CIMS evaluation had revealed that 78/92 (84.8%) advertisements omitted adverse effects, 20/92 (21.7%) had misleading claims, 9/92 (9.8%) had unapproved indications and 7/92 (7.6%) overstated the efficacy. With regard to the opinion regarding DTCA, 69.9% physicians had a patient discussing DTCA that was clinically inappropriate. One hundred (64.5%) out of 155 physicians opined that DTCA encourage patients to attend physicians regarding preventive healthcare. On the contrary, 82/155 (52.9%) physicians felt that DTCA would damage the same. Similarly, 69 out of the total 100 patients felt that drug advertisements aid them to have better discussions with their treating physicians. Surprisingly, a large majority (91/100) were of the opinion that only safe drugs are allowed to be advertised. CONCLUSION: To conclude, from the findings of this study both the physicians and patients should be cautious and not overzealous while dealing with drug advertisements or promotional literature. More stringent scrutiny and issue of WLs or blacklisting of indulging pharmaceutical companies are mandatory by the regulatory agency to contain the same.

Cardiovascular and metabolic effects of insulin-like growth factor I at rest and during exercise in humans.

To determine whether insulin-like growth factor I (IGF-I) has systemic cardiovascular effects in humans, 60 micrograms/kg IGF-I or saline were injected sc in a cross-over, randomized, double blind fashion into eight healthy male volunteers. Cardiac function and performance were evaluated by echocardiography and exercise test. In parallel, the metabolic effects of IGF-I during exercise were investigated. IGF-I improved cardiac performance with a significant increase in stroke volume and cardiac output by 14% and 18% (P < 0.03 and P < 0.04), respectively. Ejection fraction increased by 9% after IGF-I treatment (P < 0.05). Heart rate was not significantly increased at rest or during exercise. Systolic blood pressure was slightly increased by IGF-I, whereas diastolic blood pressure was slightly decreased, resulting in a continuous increase in the blood pressure amplitude at rest and during exercise, but without reaching statistical significance. Maximal exercise duration and peak oxygen consumption were not changed. Exercise was uneventful, without pathological changes on electrocardiogram records. Glucose levels were unchanged, whereas insulin and C peptide levels were decreased by IGF-I at rest. During exercise, insulin levels were further decreased, and the insulin-sparing effect of exercise resulted in a further enhancement of tissue sensitivity to insulin. GH levels were suppressed by IGF-I treatment at rest, but were still stimulated by exercise. In conclusion, IGF-I has positive inotropic effects in man. Further investigation of the potential role of IGF-I in cardiac conditions such as heart failure appears to be warranted.