Equal mixture of 2% lidocaine with adrenaline and 0.5% bupivacaine 20 mL provided faster onset of complete conduction blockade during ultrasound-guided supraclavicular brachial plexus block than 20 mL of 0.5% bupivacaine alone: a randomized double-blinded clinical trial.

INTRODUCTION: Recent evidence has questioned the advantage of local anesthetic (LA) combinations. This study tested the hypothesis that mixing rapid-onset (lidocaine) and long-duration (bupivacaine) LA would provide faster onset of complete conduction blockade (CCB) compared with bupivacaine alone and longer duration of analgesia compared with lidocaine alone during low-volume (20 mL) ultrasound-guided (USG) supraclavicular brachial plexus block (SCBPB). METHODS: Sixty-three patients receiving USG-SCBPB were randomly allocated into: group L: 20 mL 2% lidocaine with epinephrine 1:200 000; group B: 20 mL 0.5% bupivacaine; group LB: 20 mL of equi-volume mixture of both drugs. Sensory and motor blockade was recorded on a three point sensory and motor assessment scale at 10 min intervals for up to 40 min and the total composite score (TCS) at each time point was determined. The duration of analgesia was also noted. RESULTS: The mean time to CCB of group LB (16±7 min) was comparable (p>0.05) with group L (14±6 min) and group B (21±8 min) in patients who were attained CCB. However, the proportion of patients attaining complete conduction block (TCS=16/16) was significantly lower (p=0.0001) in group B (48%) when compared with group L (95%) and group LB (95%) at the end of 40 min. The median (IQR) duration of postoperative analgesia was longest in group B; 12.2 (12-14.5) hours, followed by group LB 8.3 (7-11) hours and 4 (2.7-4.5) hours in group L. CONCLUSION: At 20 mL LA volume, equal mixture of lidocaine and bupivacaine provided significantly faster onset of CCB compared with bupivacaine alone and longer duration of postoperative analgesia compared with lidocaine alone but shorter than bupivacaine alone during low-volume USG-SCBPB. TRIAL REGISTRATION NUMBER: CTRI/2020/11/029359.

Quantitative assessment of ultrasound-guided sciatic nerve block - A comparison of a single-point versus two-point injection technique: A randomised controlled, double-blinded trial.

Background and Aims: Sciatic nerve block at the popliteal level for lower limb procedures provides unpredictable success rates even with ultrasonographic (USG) guidance. This study aimed to compare USG-guided single-point versus two-point injection techniques. Methods: Sixty patients posted for foot surgeries under USG-guided sciatic nerve block were randomised into Group Single Point, receiving a single injection of 20 mL of 1.5% lignocaine with adrenaline just proximal to the sciatic nerve bifurcation, and Group Double Point, receiving two injections of 10 mL of 1.5% lignocaine with adrenaline, one at the point similar to the first group and a second injection 6 cm above the first point. Sensory blockade onset, time to complete sensory blockade, time to complete motor blockade, length of the nerve exposed and analgesia duration were evaluated. Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS) statistics version 20 software. Results: Double-point injection technique showed a significantly faster time to complete motor blockade [14.46 (9.93) min], increased length of nerve exposed to local anaesthetic [23.23 (7.209) cm] and extended duration of analgesia [420.40 (99.34) min] compared to the single-point injection technique [20.89 (12.62) min, 18.78 (5.95) cm and 344.28 (125.97) min, respectively]. The onset of sensory blockade and the time to complete sensory blockade were comparable between the two groups. Conclusion: USG-guided popliteal sciatic nerve block with a double-point injection technique does not significantly shorten the time to complete the sensory block. However, the time to complete motor nerve block and duration of analgesia are prolonged significantly, which may be clinically beneficial for postoperative analgesia.

Ultrasound measurement of the distance of the phrenic nerve from the brachial plexus at the classic interscalene point and upper trunk: A volunteer-based observational study.

Background and Aims: The method of blocking the brachial plexus at the level of the upper trunk has been gaining popularity as a phrenic nerve-sparing alternative for interscalene block. We aimed to measure the distance of the phrenic nerve from the upper trunk and compare it with the distance between the phrenic nerve and the brachial plexus at the classic interscalene point by using ultrasound. Method: In this study, after ethical approval and trial registration, 100 brachial plexus of 50 volunteers were scanned from the emergence of the ventral rami and its course was traced to the supraclavicular fossa. The distance of the phrenic nerve from the brachial plexus was measured at two levels: the interscalene groove along the cricoid cartilage (classic interscalene block point) and from the upper trunk. The presence of anatomical variations of the brachial plexus, the classic traffic light sign, vessels across the plexus, and the location of the cervical oesophagus were also noted. Results: At the classic interscalene point, the C5 ventral ramus was observed to be just emerging or to have fully emerged from the transverse process. The phrenic nerve was identified in 86/100 (86%) of scans. The median (IQR) distance of the phrenic nerve from the C5 ventral ramus was 1.6 (1.1-3.9) mm and that of the phrenic nerve from the upper trunk was 17 (12-20.5) mm. Anatomical variations of the brachial plexus, the classic traffic light sign, and vessels across the plexus were seen in 27/100, 53/100, and 41/100 scans respectively. The oesophagus was consistently located on the left side of the trachea. Conclusions: There was a 10-fold increase in the distance of the phrenic nerve from the upper trunk when compared to that from the brachial plexus at the classic interscalene point.

Molecular characterization and antibiotic resistance of Vibrio parahaemolyticus from Indian oyster and their probable implication in food chain.

Vibrio parahaemolyticus is one of the leading causes of diarrhoea and gastroenteritis in human on consumption of raw or insufficiently cooked seafood. This study was aimed at isolating and characterizing the pathogenic and pandemic V. parahaemolyticus from oysters (n = 90) in coastal parts of West Bengal, India; their antibiotic resistance and potential for involvement in the food chain. During bacteriological culture, typical V. parahaemolyticus colony was recovered in 88.9% samples followed by presumptive identification in 71 (78.9%) samples by characteristic biochemical (K/A) test. All the presumptive isolates (n = 71) were confirmed by species specific Vp-toxR PCR assay. Of these, 10 (14.08%) were tdh+ and none for the trh. Further, 5 (50%) of these tdh+ isolates were found to carry the pandemic potential gene in PGS-PCR assay; however, none in GS-PCR. Majority (80%) of these pathogenic (tdh+) isolates belonged to pandemic serovars (OUT: KUT; OUT: K24; O1: KUT; O1:K25; O10: KUT) and only 20% to non-pandemic serovars (OUT: K15; O9:K17). All the isolates (100%) exhibited resistance to cefpodoxime followed by ampicillin and cefotaxime (90%), ceftizoxime (60%), tetracycline (50%), ceftriaxone (40%), ciprofloxacin and nalidixic acid (10% each). Overall, the study findings suggested that 11.1% (10/90) of commonly marketed oysters in this area were harbouring pathogenic V. parahaemolyticus. Moreover, 5.5% (5/90) of the oyster population were harbouring pandemic strains of this pathogen. Besides, the pathogenic isolates from oysters were exhibiting a considerable genetic relatedness (53 to 70%) to human clinical isolates in PFGE analysis that relates to a substantial public health risk. Further, their multidrug resistance added gravity to the antimicrobial resistance (AMR), a globally growing public health threat and this is a critical area of concern especially during the treatment of foodborne gastroenteritis.

Choice of surgical approach influences the combined anteversion needed for a stable and impingement-free total hip arthroplasty.

BACKGROUND: Accurate component positioning is the key for successful outcome after total hip arthroplasty (THA). Positioning acetabular and femoral components in a safe zone of 25°-50° on the basis of combined anteversion (CA) has shown to reduce instability and impingement. This safe zone was described for THAs performed through the posterior approach and has not been validated for other surgical approaches. METHODS: Seventy patients who underwent unilateral uncemented THA were included in the study; 35 patients-using posterior approach and the remaining 35-using trans-gluteal approach. All patients included had a stable and impingement-free THA at a mean follow-up of 39.2 ± 9.5 months. CT scan was performed to assess component positioning by calculating CA. The values were compared between the two groups to study possible differences. RESULTS: CA in the trans-gluteal group was significantly lower (32° ± 3.7° vs 38.4° ± 4.6°, P < .001) compared to posterior group. The difference in CA was due to the differences in acetabular anteversion, which was significantly low in the trans-gluteal group than the posterior group (22.1° ± 3.6° vs 27.8° ± 4.2°, P < .001). The mean femoral anteversion was similar in both groups. All trans-gluteal hips fell within the safe zone of 20°-40°, and all posterior hips fell within the safe zone of 25°-50°. CONCLUSION: A safe zone of 25°-50° is valid for THAs performed from the posterior approach but not universally applicable. For trans-gluteal approach, a safe zone of 20°-40° is better to provide a stable and impingement-free THA. CA varies with the surgical approach. THAs performed through the trans-gluteal approach can be stable and impingement-free with lesser CA compared to THAs performed through the posterior approach.

Volar hook plate stabilization of volar marginal fragments in intra-articular distal radius fractures.

BACKGROUND: In the setting of intra-articular distal radius fractures, the volar lunate facet (VLF) is the only articular segment that resists volar carpal subluxation. So, it is important to achieve a stable fixation of this key fragment. The VLF, when small (also called as volar marginal fragment, VMF) is located distal to the watershed line making fixation with the conventional volar locking plates difficult or impossible. METHODS: 18 patients with either an AO: 2R3B3 or a C3 fracture consisting of a VMF underwent surgical repair through a volar approach. The VMF was stabilised using a anatomical volar hook plate. Remaining fracture components were stabilised using 2.4/ 2.0 mm locked plates. Fracture healing, ability of the hook plate to maintain reduction of the VMF and complications were assessed during follow up. Functional outcome was evaluated using Mayo score and patient rated wrist evaluation questionnaires. RESULTS: All fractures united at follow up. Reduction of the VMF was maintained through healing with a stable radiocarpal and distal radioulnar joint. The mean flexion - extension wrist arc was 105° ± 10.2° The mean grip strength reached 74.6 ± 6% of the opposite side. The mean Mayo wrist score was 75 ± 5.3 and the mean patient rated wrist evaluation (PRWE) score was 15.2 ± 4.3 indicating recovery of wrist function. CONCLUSION: It is important to identify VMFs in intra-articular distal radius fractures. Anatomically designed volar hook plate achieves excellent low-profile stable fixation of this key fragment to allow early mobilisation without fearing loss of reduction and volar carpal subluxation.

Trochanteric Flip (Ganz) Anterior Hip Dislocation for Fixation of Pipkin Fracture-Dislocations.

Safe surgical dislocation with a trochanteric flip osteotomy has been shown to be a reliable technique that provides excellent exposure for treating femoral-head fractures with minimal complications. This technique also allows associated labral injuries and acetabular fractures to be treated through the same approach. DESCRIPTION: The procedure is performed with use of a conventional Kocher-Langenbeck exposure with the patient in the lateral position. The trochanteric flip is performed, allowing exposure of the anterior capsule, which is incised to dislocate the head anteriorly. Fracture fixation is performed with use of mini-fragment screws followed by relocation of the head, closure of the capsulotomy, and fixation of the osteotomy. ALTERNATIVES: Fixation of femoral-head fractures can also be performed with use of alternate surgical approaches. Anterior-based surgical approaches like the Hueter approach or the Smith-Petersen approach are preferred with the goal of preserving the posterior extraosseous blood supply to the femoral head. The posterior Kocher-Langenbeck approach can also be utilized because there is no clear evidence suggesting that a properly performed posterior approach affects the blood supply of the femoral head. RATIONALE: Surgical hip dislocation is 1 of the preferred techniques for operative treatment of femoral-head fractures and is a versatile approach that provides circumferential exposure of the femoral head and acetabulum through an anterior dislocation. A compromised blood supply to the femoral head is much less likely with use of this approach compared with posterior-based surgical approaches. Compared with anterior-based surgical approaches, which are often restrictive, surgical dislocation is extensile and provides adequate exposure to treat associated injuries to the acetabulum and the labrum of the hip. EXPECTED OUTCOMES: Outcomes following surgical dislocation for femoral-head fractures are reportedly good to excellent in >80% patients. Urgent reduction of the hip joint followed by anatomical reduction of the fracture and stable fixation of the fracture and osteotomy leads to predictably good results. Notable complications include heterotopic ossification, which has been reported in up to 60% patients, as well as osteonecrosis of the femoral head (often related to the initial injury rather than the approach) and degenerative arthritis of the hip joint. IMPORTANT TIPS: The Gibson interval may be utilized to preserve the gluteus maximus.Identify all of the posterior structures starting proximally from the posterior border of the gluteus medius, and continuing to the piriformis, triceps coxae, quadratus femoris, and the vastus lateralis.Aim for a thickness of 1 to 1.5 cm when performing the osteotomy; an osteotomy that is either too thick or too thin can negatively affect outcomes. The osteotomy should begin just anterior to the posterior fibers of the gluteus medius to ensure that the osteotomy is anterior to the piriformis tendon. It should exit distally to the vastus lateralis origin.Carefully elevate the posterior margin of the gluteus minimis from the capsule to avoid the tethering effect during anterior translation of the osteotomized fragment.Capsular tears during the initial dislocation are common and should be incorporated into the anterior capsulotomy.Repair of large posterosuperior labral tears may improve outcomes.Fixation of the fracture can be performed with mini-fragment screws or headless screws. Non-fixable small fragments can be excised.The osteotomy should be reduced and fixed in a stable manner to prevent trochanteric nonunion and preserve abductor function.

PredictSuperFam-PSS-3D1D: A server for predicting superfamily for the annotation of twilight zone protein sequences.

Annotation of twilight zone protein sequences has been hitherto attempted by predicting the fold of the given sequence. We report here the PredictSuperFam-PSS-3D1D method, which predicts the superfamily for a given twilight zone (TZ) protein sequence. Earlier, we have reported that adding predicted secondary structure information into the threading methods could improve fold prediction especially for the TZ protein sequences. In this study, we have analysed the application of the same method to predict superfamilies. Here, in this method, the twilight zone protein sequence is threaded with the 3D1D profiles of the known protein superfamilies library. In addition, weightage for the predicted secondary structure (PSS) is also employed. The performance of the method is benchmarked with twilight zone sequences. In the benchmarks, 62 and 65 percentages of superfamily predictions are obtained with GOR IV and NPS@ predicted secondary structures, respectively. Receiver Operating Characteristic (ROC) curves indicate that the method is sensitive in predicting the superfamilies. A case study has been conducted with the hypothetical protein sequences of Schistosoma haematobium (Blood Fluke) using this method and the results are analyzed. Our method predicts the superfamily for TZ sequences for which, methods based on sequence similarity alone are inadequate. A web server has been developed for our method and it is available online at http://bioinfo.bdu.ac.in/psfpss.

A load-sharing nail - cage construct may improve outcome after induced membrane technique for segmental tibial defects.

INTRODUCTION: Induced membrane technique (IMT) is a well-established technique for treating segmental bone defects. Different variations of the technique have been described. Our objective was to evaluate radiological and functional outcome with IMT using a nail - graft filled titanium cage construct for segmental traumatic bone defects of the tibia. PATIENTS AND METHODS: 26 adult patients with moderate (> 5 cm) or large (> 10 cm) segmental tibial defects after acute open fractures or implant related infected nonunions underwent the procedure. The technique involved 2 stages. After standard debridement +/- implant removal and application of an antibiotic loaded cement spacer in stage 1, the second stage included placement of an intramedullary nail across the defect and an impacted graft filled titanium mesh cage was used to reconstruct the bone defect. Radiographic evidence of bony union, time to painless un-assisted weight bearing, return to work and functional evaluation with lower extremity functional scale (LEFS) were assessed. RESULTS: 5/26 cases were excluded due to failure in controlling infection. 100% union rates were achieved in the remaining 21 patients. 2 patients (9.5%) required repeat bone grafting. The mean time to painless un-assisted painless weight bearing was 26 ± 9.2 days and the mean time to return to work was 45 ± 12.5 days. The mean LEFS at a mean follow up of 27 months was 67 ± 4.7. CONCLUSIONS: Excellent union rates with good functional restoration can be achieved after IMT using the nail - cage construct for segmental tibial defects. Persistent infection is the biggest impediment for successful execution of the technique. Addition of a cage may also improve short-term functional outcome in terms of ability to weight bear and early return to work.

Assessment of predisposing factors in myofascial pain syndrome and the analgesic effect of trigger point injections - A primary therapeutic interventional clinical trial.

BACKGROUND AND AIMS: Myofascial pain syndrome (MPS) is a common cause of chronic musculoskeletal pain, characterised by myofascial trigger points (TPs). TP injection is an established technique for management of MPS. In this study, we analysed the efficacy of myofascial TP injection of lignocaine and the influencing biomechanical factors on MPS. METHODS: After obtaining ethical committee approval, we included the first 100 adult patients of MPS with failed physical therapy aged above 18 years, and with TPs in the trapezius, infraspinatus, and/or the levator scapulae muscles and Visual analog scale (VAS) >4. TP injection of 2% (2 ml) lignocaine was performed. Visual analogue scale (VAS) scores were recorded immediately and after 1 month. Number of repeat TP injections and use of oral analgesic in one month was noted. Results were analysed with the analysis of variance test. RESULTS: The mean VAS reduced significantly both immediately and 1 month after therapeutic injections (8.57 ± 0.77, 2.67 ± 1.43 and 2.82 ± 1.4, respectively, P < 0.01). Keeping the palm below the head during sleep was the major contributing factor for myofascial TP, followed by slanting the neck to use mobile phones. Repeat TP injection was used in 4% of cases. CONCLUSION: TP injection of 2 ml of 2% lignocaine along with correction of predisposing biomechanical factors provided significant pain relief for MPS in patients with failed physical therapy without any side effects.

Age-based Local Anesthetic Dosing in Pediatric Spinal Anesthesia: Evaluation of a New Formula - A Pilot Study in Indian Patients.

BACKGROUND: Spinal anesthesia is a safe alternative to general anesthesia and often the anesthetic technique of choice in many lower abdominal and lower limb surgeries in children. As the vertebral column and spinal cord grows variedly with age and not weight, we planned to administer an age-based dosing schedule of hyperbaric bupivacaine in the intra-thecal space in select infra umbilical surgeries in children. The aim was to find out the efficacy and complications associated with this dosage. METHODOLOGY: Twenty-five pediatric patients between 2 and 12 years, posted for elective infra umbilical surgeries were given a sedation as a combination of effective doses of pentazocine, midazolam, and atropine. In all those patients, spinal anesthesia was administered at a dose of age/5 of hyperbaric bupivacaine. The number of attempts, the onset of blockade, the mean sensory level, and the duration of anesthesia were noted. Any other complications were also noted. RESULTS: The mean and standard deviation of age is 7.68 ± 2.49 years. Intra-thecal anesthesia was administered successfully in the first attempt in 88% of cases whereas the remaining needed the second attempt. Three patients needed intravenous ketamine of 0.25 mg/kg additionally for preoperative sedation. The sensory level was between T6 and T10 with a mean of T8.5. There were no intra-operative complications. In all patients, surgery was finished within the duration of anesthesia of approximately 60 min. There was no conversion to general anesthesia in any case, but a three patients required dose of 0.25 mg/kg of intravenous ketamine as a calming dose. CONCLUSION: Administration of age-based local anesthetic dosing of hyperbaric bupivacaine in the intra-thecal space by utilizing a new formula of age/5 (Partha formula) is successful in a pilot study in Indian children for infra-umbilical surgeries. There were no observed complications.

Relative Efficacy of Ultrasound-guided Ilioinguinal-iliohypogastric Nerve Block versus Transverse Abdominis Plane Block for Postoperative Analgesia following Lower Segment Cesarean Section: A Prospective, Randomized Observer-blinded Trial.

BACKGROUND: Quality of postoperative analgesia after cesarean section makes difference to mother in child bonding, early ambulation, and discharge. Ilioinguinal iliohypogastric (ILIH) and transverse abdominis plane (TAP) block had been tried to reduce the opioid analgesics, but the relative efficacy is unknown. Hence, this study was designed to compare the efficacy of these two regional analgesic techniques in sparing postoperative rescue analgesic requirement following lower segment cesarean section (LSCS). METHODS: Sixty patients who underwent LSCS were randomly allocated into two groups to receive either US-guided TAP block or ILIH nerve block using sealed envelope technique at the end of the surgery. In the postoperative ward, whenever patient complained of pain, pain nurse in-charge administered the rescue analgesics as per the study protocol. A blinded observer visited the patient at 0, 2, 4, 6, 8, 10, 12, and 24 h postoperative intervals and recorded the quality of pain relief and the amount of rescue analgesic consumed. RESULTS: All patients in both the study groups required one dose of rescue analgesics in the form of injection diclofenac sodium 50 mg intravenously but subsequently 57% of patients did not require any further analgesics till 24 h in the TAP block group whereas in ILIH group, only 13% did not require further analgesics (P = 0.00), correspondingly the cumulative tramadol dose was significantly higher at all the time interval in the ILIH group when compared to the TAP group. CONCLUSION: Quality of postoperative analgesia provided by TAP block was superior to ILIH block following LSCS.

Successful Management of above Knee Amputation with Combined and Modified Nerve Blocks.

We report a successful management of a case of methicillin-resistant Staphylococcus aureus positive right lower limb cellulitis for above knee amputation under combined nerve blocks. The ongoing sepsis, thrombocytopenia, and severe respiratory infection with wheeze made us avoid both neuraxial block and general anesthesia and plan for a nerve block. We instituted a modified high inguinal femoral block along with sciatic and lateral femoral nerve blocks separately to successfully conduct the case. We decided to report as there were not as many cases as ours in the literature.

Comparison of success of tracheal intubation using Macintosh laryngoscope-assisted Bonfils fiberscope and Truview video laryngoscope in simulated difficult airway.

BACKGROUND AND AIMS: Restriction of head and neck movements prevents the alignment of the oral, pharyngeal, and laryngeal axes and increases the incidence of difficult tracheal intubation in patients with cervical spine fractures. Video laryngoscopes have gained an important role in the management of difficult intubation, especially in situations with limited head and neck movements. This study compares the success of intubation using Macintosh laryngoscope assisted Bonfils® fiberscope (ML-BF) with TruviewPCD video laryngoscope (TV) in patients with simulated restricted head and neck movements. MATERIAL AND METHODS: One hundred and fifty-two patients satisfying the inclusion criteria were randomly allocated to two groups of 76 each. Patients were made to lie supine on the table without a pillow and a soft collar was used to restrict head and neck movements. After a standardized premedication-induction sequence, tracheal intubation was done either with ML-BF or TV. Success of intubation, time taken for successful intubation, hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were noted. RESULTS: Intubation was successful in all the 76 patients in direct laryngoscopy-Bonfils fiberscope group and 75 out of 76 patients in TV group within the specified time (90 s). The median time taken for successful intubation with TV and ML-BF were 44 (range 26-80) s and 49 (range 28-83) s, respectively. Hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were similar in both groups. CONCLUSION: Both TV and ML-BF are equally effective for successful tracheal intubation in patients with simulated restricted head and neck movements. In cases of difficult laryngeal visualization with routine Macintosh laryngoscope, Bonfils can be used as an adjunct to achieve successful intubation in the same laryngoscopy attempt.