Safety and technical success of diphenhydramine as an alternative local anaesthetic agent for radiology procedures.

AIM: To evaluate retrospectively the safety and technical success of subcutaneous diphenhydramine as an alternative local anaesthetic for radiology procedures. MATERIALS AND METHODS: Between January 2000 and April 2021, 84 image-guided procedures were performed in 81 adult patients (mean age 61 years, 86% female) using 1% injectable diphenhydramine as a local anaesthetic. Indications were history of severe allergy to "-caine" local anaesthetics in 76 (90%) patients and recent administration of bupivacaine liposomal injectable suspension in eight (10%) patients. Twelve of the 84 (14%) procedures were performed with concomitant moderate sedation. Patient characteristics, procedural techniques, and clinical outcomes were reviewed. Early and delayed (30-day) complications were classified as either related to local diphenhydramine injection or to the procedure itself. Procedure-related complications were gradated using the Clavien-Dindo system. RESULTS: Percutaneous biopsy was the most frequently performed procedure (57/84, 67%). Fifty-nine (70%) of the 84 procedures were ultrasound guided. The most common procedural site was the breast (34/84, 40%). All procedures were technically successful. There were two minor injection-related complications related to post-procedural pain. A single minor procedure-related complication involved a patient requiring hospital admission for post-renal biopsy related haematuria. CONCLUSION: Injectable diphenhydramine appears to be a safe and effective local anaesthetic alternative in patients with "-caine" class contraindications undergoing radiology procedures. A future prospective trial would be useful to assess the safety profile in an large cohort of patients.

The clue is in the kidneys: greater renal contrast medium accumulation on ipsilateral side down CT myelogram after lateral decubitus digital subtraction myelogram as a predictor of laterality of cerebrospinal fluid leak.

AIM: To assess the potential correlation of the laterality of a cerebrospinal fluid (CSF)-venous fistula with the laterality of decubitus computed tomography (CT) myelogram (post decubitus digital subtraction myelogram) based on which side demonstrated more renal contrast medium excretion. MATERIALS AND METHODS: Patients with CSF-venous fistulas diagnosed at lateral decubitus digital subtraction myelograms were reviewed retrospectively. Patients who did not have CT myelogram following one or both left and right lateral decubitus digital subtraction myelograms were excluded. Two neuroradiologists independently interpreted the CT myelogram for the presence or absence of renal contrast, and whether subjectively more renal contrast medium was visualised on the left or right lateral decubitus CT myelogram. RESULTS: Renal contrast medium was seen in lateral decubitus CT myelograms in 28 of 30 (93.3%) patients with CSF-venous fistulas. Having more renal contrast medium in right lateral decubitus CT myelogram was 73.9% sensitive and 71.4% specific for the diagnosis of a right-sided CSF-venous fistula, whereas having more renal contrast medium in the left lateral decubitus CT myelogram was 71.4% sensitive and 82.6% specific for a left-sided CSF-venous fistula (p=0.02). CONCLUSION: When the CSF-venous fistula lies on the dependent side of a decubitus CT myelogram performed after decubitus digital subtraction myelogram, relatively more renal contrast medium is visualised compared to when the fistula lies on the non-dependent side.

Cecal volvulus following appendectomy in a teenage patient: A case report.

Patients mimicking appendicitis symptoms in a rural setting or those post-appendectomy, indicating cecal volvulus, should always be considered. Swift action can prevent catastrophic consequences. Abstract: We present a case of a 14-year-old female who initially underwent open appendectomy for acute appendicitis and subsequently experienced symptoms of abdominal distention, vomiting, and fever. Her condition deteriorated following the appendectomy, despite a prior appendectomy for similar symptoms at a different facility. A computed tomography (CT) scan identified cecal volvulus as the underlying issue. This led to the performance of a laparotomy, cecopexy, and decompressive ileostomy. After six weeks, ileostomy closure was successfully carried out, and the patient currently enjoys good health. This case highlights the significance of considering uncommon factors as potential contributors to postoperative complications in young patients.

Focal neurological manifestations in Legionellosis.

Legionnaires' disease is an atypical pneumonia with protean multisystem manifestations. Neurological involvement in legionellosis is rare and tends to be among the presenting manifestations. We report a previously healthy young lady who developed focal sensory deficits and cerebellar dysfunction after clinical recovery from Legionella pneumonia. The care is unusual for the delayed appearance of striking focal sensory abnormalities and cerebellar dysfunction.

Somatostatin: a metabolic regulator.

Somatostatin, the hypothalamic release-inhibiting factor, has been found to stimulate gluconeogenesis in rat kidney cortical slices. Stimulation by somatostatin was linear and dose-dependent. Other bioactive peptides such as cholecystokinin, gastrointestinal peptide, secretin, neurotensin, vasoactive intestinal peptide, pancreatic polypeptide, beta endorphin and substance P did not affect the renal gluconeogenic activity. Somatostatin-induced gluconeogenesis was blocked by phentolamine (alpha adrenergic antagonist) and prazosin (alpha1 adrenergic antagonist) but not by propranolol (beta adrenergic antagonist) and yohimbine (alpha2 adrenergic antagonist) suggesting that the effect is via alpha1 adrenergic stimuli. Studies on the involvement of Ca2+ revealed that tissue depletion and omission of Ca2+ from the reaction mixture would abolish the stimulatory effect of somatostatin. Furthermore, somatostatin enhanced the uptake of 45calcium in renal cortical slices which could be blocked by lanthanum, an inhibitor of Ca2+ influx. It is proposed that the stimulatory effect of somatostatin on renal gluconeogenesis is mediated by alpha1 adrenergic receptors, or those which functionally resemble alpha1 receptors and that the increased influx of Ca2+ may be the causative factor for carrying out the stimulus.

Psychiatric symptoms and CAG repeats in neurologically asymptomatic Huntington's disease gene carriers.

The putative relationship between the psychiatric profile of a sample of neurologically asymptomatic Huntington's disease gene carriers and CAG repeats was investigated. The psychiatric assessments (by consultant psychiatrist and computerised battery) were undertaken before the genetic testing was carried out. In this way, the informational distortions caused by neurological and cognitive deficits were avoided. The hypothesis that there is a relationship between psychiatric and CAG repeats was tested by seeking direct correlations between psychiatric systems and CAG repeats, and also by correcting the correlation by the number of years above or below the estimated age of onset in Huntington's disease. Scores for irritability and cognitive failures were high in the sample. There was no correlation between any psychiatric variable and CAG repeats. Possible explanations for this lack of correlations are discussed.

In vitro effect of intravenous immunoglobulin on serum opsonic activity in normal & intrauterine growth retarded neonates.

In vitro effect of intravenous immunoglobulin (IVIG), Intraglobin F, on serum opsonic activity against Staphylococcus aureus was studied in 26 full term normal healthy neonates and 18 intrauterine growth retarded (IUGR) neonates by the polymorphonuclear leucocyte overlay method (requiring only a few drops of blood). Cord IgG and IgM levels were determined by single radial immunodiffusion. Serum opsonic activity against Staph. aureus was significantly lower in the IUGR neonates (49.1 +/- 0.89), as compared to that in normal neonates (61.96 +/- 0.73; P less than 0.001). Immunoglobulin supplementation in vitro at a concentration of 5 g/dl significantly enhanced the opsonic activity of IUGR neonate sera. Cord IgG levels of IUGR neonates were significantly lower (P less than 0.01) than IgG levels of normal neonates. No significant difference was observed in cord IgM levels between the normal and IUGR neonates.

Patients with suicidal burns and accidental burns: a comparative study of socio-demographic profile in India.

This is a prospective study of 50 consecutive admissions to the burns unit. The socio-demographic data was collected using special proforma and interviewing the patients and relatives. All patients were administered the presumptive stressful life event scale (PSLES). Depending on the presence or absence of suicidal intent, patients were divided into two groups. The two groups were then compared with regards to their socio-demographic profile using the unrelated t-test and the Fisher's exact test. The two groups did not differ significantly with regards to age, sex, education, marital status, occupation or monthly per capita income. The patients who had suicidal intent came from joint family, had more stressful life events and suffered larger burns injuries compared with those who experienced accidental burn injuries. The majority of the patients were below the age of 35, unemployed and females outnumbered males in both the groups.

Removal of impacted basket during endoscopic papillotomy: a novel method using precut papillotome.

Basket impaction is a rare problem during endoscopic papillotomy and stone extraction for the bile duct. Mechanical lithotriptor is usually employed to break the stone, but a few patients may require surgery. We describe a patient in whom a precut papillotome was used to break the stone and remove the impacted basket.

Multiple mucosal bridges of esophagus: an unusual cause of dysphagia.

We describe the clinical, radiographic and endoscopic features of a young man presenting with dysphagia who was detected to have multiple esophageal mucosal bridges. This patients had no predisposing condition responsible for the bridge formation.

Topical pharyngeal anesthesia without intravenous sedation during upper gastrointestinal endoscopy.

BACKGROUND: There have been conflicting reports about the usefulness of topical pharyngeal anesthesia as a pre-endoscopic medication. AIMS: To assess the effect of topical pharyngeal anesthesia without intravenous sedatives on easing upper gastrointestinal endoscopy. METHODS: 153 consecutive consenting patients were randomized to receive either placebo (normal saline) spray (78 patients) or 80 mg of 4% lidocaine spray (75 patients). Difficulty of intubation was judged both by the patient and the physician on a linear analogue scale. RESULTS: There was no significant difference in the scores in the two groups (p > 0.05). The patient and physician assessments correlated well. CONCLUSIONS: Topical lignocaine spray does not facilitate upper gastrointestinal endoscopy in the absence of intravenous sedation.

Dilatation of radiation-induced esophageal strictures under sublingual buprenorphine analgesia: a pilot study.

BACKGROUND: Pain during dilatation of radiation strictures is a troublesome complaint. There is little information on sedation and analgesia during this procedure. We performed a pilot study to compare the analgesic efficacy of sublingual buprenorphine and intravenous pentazocine during dilatation of radiation-induced esophageal strictures. METHODS: Thirty-one patients with esophageal cancer who had radiation-induced strictures were randomized to receive either buprenorphine 0.2 mg sublingually two hours before dilatation (n = 17) or pentazocine 30 mg intravenously five minutes before dilatation (n = 14). Dilatation was considered successful if it could be performed to 12 mm diameter or more. Pain experienced during dilatation was graded as mild, moderate or severe. RESULTS: Sixteen patients in the buprenorphine group and 12 in the pentazocine group were dilated to > 12 mm size (p = ns). Twelve and nine patients respectively in the two groups experienced mild or no pain; ten and six patients had minor side-effects (p = ns). CONCLUSION: Buprenorphine is useful for sedoanalgesia during dilatation of radiation-induced strictures of the esophagus.

Massive lower gastrointestinal bleeding from cecal lymphoid polyp in renal transplant recipient.

A 25-year-old renal transplant recipient receiving anticoagulant therapy for renal vein thrombosis, presented with massive lower gastrointestinal bleeding. Superior mesenteric angiogram revealed active bleeding in the cecum. Colonoscopy revealed a sessile ulcerated polyp in the cecum with satellite polyps. The polyps were fulgurated with Nd:YAG laser. Colonoscopy later revealed a remnant of the polyp, which was excised. The histopathology revealed a lymphoid polyp.

Synchronous adenocarcinoma and lymphoma of the colon.

Synchronous lymphoma and adenocarcinoma of the colon are extremely rare. A 32-year-old woman was referred to us for colon cancer. Investigations revealed two primary tumors, one in the cecum and the other in the sigmoid colon. Subtotal colectomy with ileorectal anastomosis was performed. Histology revealed the cecal tumor to be non-Hodgkin's lymphoma, diffuse small cell type with plasmacytoid features. The sigmoid colon tumor was moderately differentiated adenocarcinoma. The patient received 6 cycles of chemotherapy postoperatively for lymphoma but died of recurrent disease after 17 months.

Endoscopic palliation of malignant obstructive jaundice using resterilized accessories: an audit of success, complications, mortality and cost.

OBJECTIVE: To assess the success, complications and cost of endoscopic endoprosthesis placement for palliation of obstructive jaundice caused by malignancy. METHODS: Four hundred and two consecutive patients with obstructive jaundice due to nonresectable malignancy undergoing endoscopic stenting were studied. Commercial or home-made 7F or 10F endoprostheses were placed using minor modifications of the standard technique. The accessories were sterilized and reused. RESULTS: Endoprosthesis placement was successful in 291 patients (72.4%, 95% CI 67.7-76.7)-241 in one attempt, 49 in two attempts, and one in three attempts. Fifty nine patients (14.6%, 95% CI 11.4-18.6) had procedure-related complications, including cholangitis (30), pancreatitis (15), perforation (3) and bleeding (11). The incidence of cholangitis was significantly higher in bifurcation blocks than in other lesions (17.6% vs 4.7%, p = 0.0005). The success rate did not differ between distal and proximal lesions (68.1% vs 72.9%). The procedural cost per patient could be reduced from Rs 14,850 to Rs 6565 by reusing accessories after sterilization, and using home-made stents. CONCLUSIONS: Endoscopic endoprosthesis placement is a safe and effective method for palliation of malignant obstructive jaundice. Preparation of indigenous stents and reuse of accessories can reduce the cost of the procedure by over 50%.

Neonatal osteomyelitis and septic arthritis.

The records of seventeen neonates (13 males and 4 females) with osteomyelitis and septic arthritis, who were admitted over a 3 year period, were reviewed. Neither prematurity nor low birth weight seemed to be a predisposing factor. The majority of the neonates (88.2%) had some antecedent illness or were subjected to certain procedures in the neonatal period. Paucity of movement of limb, fever and local swelling of the joint were the most frequent presenting symptoms. Deep soft tissue swelling was the frequently noted radiographic change (58.8%). Bone scintigraphy was abnormal in 7 out of 11 cases. Of the 21 sites involved, femur and humerus accounted for 76.1% of cases. Four of seventeen neonates had multiple bone involvement. Arthritis was present in fifteen neonates. Of the organisms isolated, Staphylococcus aureus was the commonest.