Total laparoscopic hysterectomy (TLH) with endosuturing compared with conventional technique using energy sources.

BACKGROUND: The aim of the study was to demonstrate the technique of total laparoscopic hysterectomy (TLH) with intra-corporeal endosuturing using simple sutures and basic surgical instruments and compare with TLH using electric coagulation equipment i.e. energy sources with regard to operative time, blood loss, postoperative stay and pain scores. METHODS: A retrospective study was undertaken, in Max Super Specialty Hospital Saket, from June 2015 to May 2018, which included 586 cases of TLH (for benign gynecological conditions), of which 287 were performed using intra-corporeal endosuturing (Group 1) and 299 were performed using energy sources (Group 2). To avoid bias, baseline matching was done for body mass index (BMI), indications for surgery, size of uterus, previous abdominal surgeries and comorbidities like diabetes and hypertension after which there were 172 patients in each group. RESULTS: The mean age of patients was 48.24 ± 6.76 years. All operative outcomes including operative time (104.1 ± 22.6 vs 107.6 ± 32.6 mins, p=0.25), blood loss (78.9 ± 101.6 vs 99.7 ± 177.6 ml, p=0.19), pain score (2.5 ± 1.3 vs 2.7 ± 1.2, p=0.13) and post-operative stay (2.05 ± 0.2 vs 2.07 ± 0.3 days, p=0.36) were similar between the two groups. Uterine size was the major determinant of operative time and operative blood loss. CONCLUSION: TLH with intracorporeal endosuturing can be performed safely and gives results comparable with TLH performed using energy sources. Advancement in suturing devices can decrease operative time further and potentially make it easier and more acceptable.

A Five-Year Study of Intrapleural Fibrinolytic Therapy in Loculated Pleural Collections.

BACKGROUND: Pleural fluid loculations due to complicated parapneumonic effusion (CPE), empyema, tubercular effusion and traumatic hemothorax can be managed either by video-assisted thoracoscopic surgery (VATS) or intrapleural ibrinolytic therapy (IPFT). The former is more invasive, not easily available and is also more expensive. On the other hand, IPFT is less invasive, cheaper, easily accessible and if used early, in loculated pleural collections, break loculations and early pleural peel, thereby facilitating pleural space drainage. OBJECTIVE: To study the efficacy of IPFT in facilitating pleural space drainage in loculated pleural collections of diverse aetiologies. METHODS: A five-year retrospective, observational study of 200 patients, with loculated pleural collections and failed tube drainage and managed with IPFT was carried out. Responders were defined as those with significant volume of fluid drained and significant radiological resolution. RESULTS: There were 106 (53%) cases of CPE, 59 (29.5%) cases of tubercular effusion, 23 (11.5%) cases of empyema and 12 (6%) cases of hemothorax. Responders were 148 (74%) in number. The distribution of responders as per type of loculated pleural collection was as follows: CPE 88 (83%), tubercular 37 (62.7%), empyema 14 (60.8%) and traumatic hemothorax 11 (91.6%). The adverse effects were mild and included chest pain in six patients and low-grade transient fewer in three cases. CONCLUSIONS: Intrapleural fibrinolytic therapy is a safe and cost-effective option in the management of selected patients with loculated pleural effusions.

Low dose methylprednisolone induced bradycardia.

Methylprednisolone induced arrhythmias, especially bradycardia, are well known. Most of the available reports suggest the occurrence of these arrhythmias with high dose intravenous therapy. We, hereby report a case of low dose methylprednisolone induced bradycardia.

Cytokine imbalance in systemic lupus erythematosus: a study on northern Indian subjects.

OBJECTIVE: The phenotype of systemic lupus erythematosus (SLE) in Asian Indians is more severe as compared with that in Caucasians. The reason is not clear. In this context, we studied serum levels of interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), interleukin-4 (IL-4) and interlekin-10 (IL-10). Their interrelations and correlation with SLEDAI scores were evaluated. MATERIALS AND METHODS: Forty patients with active SLE and 40 controls were studied. The mean SLEDAI score and anti-ds DNA level of the patients were 21.45 ± 8.61 and 176.68 ± 81.31 (IU/ml), respectively. Cytokines were estimated by enzyme-linked immunosorbent assay. RESULTS: In controls, the levels of IFN-γ were highest, followed by TNF-α, IL-10 & IL-4. In patients, however, the levels of TNF-α were highest, followed by IFN-γ, IL-10 & IL-4. IL-10 and IL-4 correlated negatively, and IFN-γ and TNF-α correlated positively with the SLEDAI scores. As compared with controls, in patients, the mean values of TNF-α, IL-10 and TNF-α/IL-10 ratio were higher by 6.9, 2.9 and 2.3 times, respectively (p < 0.001). Significant positive correlation was found between these two cytokines in patients (r = 0.327, p < 0.05) but not in controls. The levels and ratio of IL-4 and IFN-γ were comparable between patients and controls. These two cytokines correlated negatively both in controls (r = -0.358, p < 0.05) and patients (r = -0.990, p < 0.001). The ratio of TNF-α/IL-4 was 4.2 times higher, and those of IFN-γ/IL-4 and IFN-γ/IL-10 were 1.89 and 3.40 times lower in patients as compared with controls. A positive correlation between IL-10 and IL-4 (r = 0.345, p < 0.05) and a negative correlation between IL-10 and IFN-γ (r = -0.382, p < 0.05) were observed only in patients. CONCLUSION: This study showed a distinct profile of cytokine imbalance in patients with SLE from the northern plains of India. The levels, ratios and correlations of cytokines in patients suggested significant deviation from normal. Correlations of cytokines with SLEDAI scores indicated that TNF-α contributes significantly to the pathological manifestations of SLE in patients from the region. A detailed study is warranted.

Impact of optimal asthma education programme on asthma morbidity, inhalation technique and asthma knowledge.

INTRODUCTION: Optimal asthma education (comprising of information, self monitoring, regular medical reviews and a written action plan) significantly improves asthma management. The study was undertaken to assess the impact of optimal asthma education programme on asthma morbidity, inhalation technique and asthma knowledge. STUDY DESIGN: In non-randomized prospective trial asthma morbidity, (comprising of control of symptoms, unscheduled OPD visits and limitation of physical activities), inhalation technique and asthma knowledge were assessed before and one year after implementation of optimal asthma education programme. MATERIAL AND METHODS: One hundred and seventy two patients of persistent bronchial asthma aged 12 years or more, taking daily anti-inflammatory drugs and having not attended any type of asthma education programme before were included in the present study. RESULTS: There was significant improvement in asthma morbidity with increase in the number of patients with intermittent and mild persistent asthma and significant decrease in patients with moderate and severe persistent asthma. Before optimal AEP, 30 (17.4%) patients had visited hospital thrice or more due to asthma sickness, after optimal AEP only 5 (8.6%) patients made unscheduled visits only once to hospital (p<0.05). Limitation of physical activities was present in 80 (46.51%) patients before AEP which was significantly reduced to 15 (8.7%) patients after optimal AEP (p<0.05%). Before AEP, inhalation technique was incorrect in 140 (81.3%) patients and after AEP none of the patients had incorrect technique (p<0.001). Only 24 (13.9%) patients had satisfactory knowledge of asthma before AEP and after AEP the number increased significantly to 120 (69.7%) (p<0.001). CONCLUSION: Optimal asthma education is an integral part of asthma management which decreases asthma related morbidity, improves inhalation technique and asthma knowledge. Since our follow up was for one year and impact of asthma education programme is likely to decrease in absence of regular follow up, it is important to keep reminding patients about asthma education programme at each follow up visit.

Best Treatment Guidelines For Bronchial Asthma.

Asthma is a common disease worldwide with significant ethnic and regional variations. An increasing morbidity and mortality, as well as health care burden from asthma have been recognized lately. Several evidence based guidelines have been developed with an aim to standardize and improve the quality of management. These guidelines seek to translate the advances in the understanding of pathogenesis of asthma and in the development of new agents and strategies into practical application at all levels of healthcare. These advocate an assessment of the patients to classify the severity of diseases followed by a step-wise approach to treatment. With the current management we hope to achieve minimum or nil day time and night time symptoms, prevent acute exacerbations and attain normal or near normal lung function, thus improving the overall quality of life.

Laparoscopic creation of a neovagina in Mayer-Rokitansky-Kuster-Hauser syndrome by modification of Vecchietti's procedure.

We performed a modified Fedele technique for laparoscopic creation of a neovagina by Vecchietti's method to treat vaginal aplasia in three patients with Mayer-Rokitansky-Kuster-Hauser syndrome. Three beads forming a triangle, anchored to a disposable syringe mould, were applied to the vaginal dimple and pulled upward by two polypropylene sutures, and passed through the potential neovaginal space created laparoscopically. The women sat on ordinary bicycle seats to provide pressure from below, resulting in formation of neovagina over 10 to 12 days. Good results were obtained in all three women in both anatomy and sexual function.

The treatment of fractures of the tibial plateau by skeletal traction and early mobilisation.

We have treated all varieties of fractures of the tibial plateau, including lateral, medial and bicondylar fractures by skeletal traction and early mobilisation. A study of 50 such fractures is presented and the functional results are evaluated. The average follow up is 2 years. The results of skeletal traction and early mobilisation are shown to be good in 94% of the cases. We wish to demonstrate the extent of remoulding and ultimate reformation of the condyles which occurs, and the recovery of movement of the joint which is achieved by this method.

Extra peritoneal transposition of spleen in portal hypertension--a new operative technique.

The author describes a procedure for portal circulation bypass in the treatment of esophageal varices. The systemic circulation is shunted with the spleen, which is transposed extraperitoneally and thus will have a raw area on its convex surface, to adhere to the exposed muscle of the diaphragm, inner intercostal muscles of the posterior abdominal wall. The portal blood is thus partly directed to the inferior phrenic vein and the intercostal veins and ultimately drains into the azygous systems. With this procedure the ascites fluid seeps out of the peritoneal cavity along the edges of the spleen and therefore has a larger absorption surface in the extraperitoneal space, apart from the improved suprahepatic portal drainage provided.