Interpretation of chest fluoroscopy: the risk of misdiagnosing atelectasis as pneumothorax due to greyscale inversion.

Anaesthetists may be required to work in hybrid theatres for procedures using fluoroscopic imaging. Adequate knowledge of fluoroscopic images allows prompt and effective emergency management of complications which arise during procedures. Here, we present a case of severe hypotension and hypoxia occurring shortly after induction of anaesthesia. Atelectasis was mistaken for a pneumothorax due to misinterpretation of fluoroscopic imaging, which demonstrated a dark pleural cavity peripheral to a partially collapsed left lung, leading to an incorrect diagnosis. This case highlights the importance of understanding greyscale inversion in fluoroscopy.

Obesity: An Impact with Cardiovascular and Cerebrovascular Diseases.

The authors sought to correlate the complex sequel of obesity with various parameters known to develop metabolic syndrome viz. insulin resistance, dyslipidemia, hypertension etc., as these anomalies are linked to vascular atherosclerosis and outbreak of cardiovascular and cerebrovascular diseases.  A comprehensive online survey using MEDLINE, Scopus, PubMed and Google Scholar was conducted for relevant journals from 1970 till present time (2023) with key search terms like: 'obesity', 'leptin', type-2 diabetes', 'atherosclerosis', 'cardiovascular and cerebrovascular diseases'. The findings of the reports were compared and correlated. The information was then collated for developing this review. Reports showed that in human obesity, hyper-leptinemia could induce hyperglycemia, which in turn templates hypercholesterolemia. Persisting hypercholesterolemia over a period of time may en-route atherosclerosis in blood vessels. Thus obesity has been considered as a template for originating hyperglycemia, hypercholesterolemia and outbreak of vascular atherogenesis or in other words, obesity in long run can trigger atherosclerosis and its related disorders e.g. heart attack and stroke. Literature survey shows that primarily, co-morbidities of human obesity start with leptin and insulin resistance and then multiplies with metabolic irregularities to an extreme that results in pathogenesis of heart attack and stroke. Atherosclerosis associated cardiovascular and cerebrovascular events are independent risks of obese subjects and particularly in the cases of persisting obesity.

Management of idiopathic granulomatous mastitis: a prospective study.

INTRODUCTION: Idiopathic granulomatous mastitis (IGM) is an evolving problem with varied presentation. No definite treatment guidelines are available at present that may reduce rate of recurrence. Current evidence suggests a ductal pathology behind IGM, which leads to periductal mastitis, leakage and sinus/fistula formation. Thus, excision of the sinus/fistulous tract with en-bloc wide local excision (WLE) of the lesion could be curative. The objective of this study was to look for the basic aetiology of IGM and evaluate the effectiveness of WLE with total or partial duct excision as a curative approach. METHODS: An institutional prospective comparative study was conducted over 4 years (2015-2019), in which 59 cases of IGM were randomly divided into three groups. After necessary investigations, patients in group A received steroid therapy, those in group B received WLE and patients in group C received WLE with total or partial duct excision as the mode of treatment. Postoperative follow-up was between 6 months and 3 years. RESULTS: Histopathological examination (HPE) was found to be the most suitable diagnostic procedure. Patients in group B showed the highest rate of recurrence (73.6%), followed by group A (35.0%) and group C (5.0%). Patients in group C had a significantly lower chance of recurrence compared with both group A and group B (p < 0.05). HPE reports of excised ducts from patients in group C showed ductal disruption and leakage along with periductal granuloma in 70% of cases. CONCLUSIONS: The presence of duct granuloma indicates the association of ductal pathology in IGM. IGM is therefore a disease of the mammary ducts and en-bloc duct excision is curative in non-responding cases.

Unsterile injection equipment associated with HIV outbreak and an extremely high prevalence of HCV-A case-control investigation from Unnao, India.

The integrated counseling and testing center (ICTC) located in the district hospital, Unnao in the northern state of Uttar Pradesh (UP), India witnessed an increased detection of HIV among its attendees in July 2017. Subsequently, health camps were organized by the UP State AIDS Control Society in the villages and townships contributing to such detection. We conducted a case-control study to identify factors associated with this increased detection; 33 cases and 125 controls were enrolled. Cases were individuals, detected HIV sero-reactive during November 2017-April 2018 from three locations namely Premganj, Karimuddinpur and Chakmeerapur in the Bangarmau block of the district of Unnao. Controls hailed from the same geographical setting and tested HIV sero-nonreactive either in health camps or at ICTC centers from where the cases were detected. Misclassification bias was avoided by confirming HIV sero-status of both cases as well as controls prior to final analysis. Study participants were interviewed on various risk practices and invasive treatment procedures. They were also tested for HIV and other bio-markers reflecting unsafe injecting and sexual exposures such as hepatitis B surface antigen (HBsAg), anti-HCV antibody (HCV Ab), anti-herpes simplex-2 Immunoglobulin G (HSV-2 IgG) and rapid plasma regain (RPR) test for syphilis. Secondary data analysis on three time points during 2015 through 2018 revealed a rising trend of HIV among attendees of the ICTCs (ICTC-Hasanganj, ICTC-Unnao district hospital and ICTC- Nawabganj) catering to the entire district of Unnao. While there was a seven fold rise of HIV among ICTC attendees of Hasanganj (χ2 value for trend 23.83; p < 0.001), the rise in Unnao district hospital was twofold (χ2 value for trend 4.37; p < 0.05) and was tenfold at ICTC-Nawabganj (χ2 value for trend 5.23; p < 0.05) indicating risk of infection prevailing throughout the district. Primary data was generated through interviews and laboratory investigations as mentioned above. The median age of cases and controls was 50 year (minimum 18 -maximum 68; IQR 31-57) and 38 year (minimum 18 -maximum 78; IQR 29-50) respectively. Thirty six percent of the cases and 47% of controls were male. A significantly higher proportion of cases (85%) had HCV Ab compared to controls (56%; OR 4.4, 95% CI 1.5-12.1); none reported injection drug use. However, cases and controls did not differ significantly regarding presence of HSV-2 IgG (6% versus 8% respectively). Neither any significant difference existed between cases and controls in terms of receiving blood transfusion, undergoing invasive surgical procedures, tattooing, tonsuring of head or skin piercing. In multivariate logistic regression model, 'unsafe injection exposure during treatment-seeking'(AOR 6.61, 95% CI 1.80-24.18) and 'receipt of intramuscular injection in last five years' (AOR 7.20, 95% CI 1.48-34.88) were independently associated with HIV sero-reactive status. The monophyletic clustering of HIV sequences from 14 cases (HIV-1 pol gene amplified) indicated a common ancestry. Availability of auto-disabled syringes and needles, empowerment of the local communities and effective regulatory practices across care settings would serve as important intervention measures in this context.

Clinico-epidemiological profile and high-risk sexual behavior among clients attending sexually transmitted infection clinic at a tertiary care hospital in North India.

CONTEXT: Sexually transmitted infections (STIs) are one of the most catastrophic events of health causing huge psychosocial and economic morbidity consequences. AIM: The study aims to study the clinico-epidemiological profile and high-risk sexual behavior among clients attending STI clinic at tertiary care hospital in North India. MATERIALS AND METHODS: The present study was conducted at STI clinic, King George's Medical University, Lucknow, Uttar Pradesh. Data from 1283 clients attending STI clinic between August 2015 and July 2016 were compiled using master client register and STI/reproductive tract infection patient-wise register, and a final completed data set of these patients was analyzed according to the aims and objectives. RESULTS: On analyzing the various factors associated with high-risk sexual behavior among clients attending STI clinic marital status, sexual preference and employment status were found to be significantly associated with high-risk sexual behavior (P < 0.05). On multivariate analysis, unmarried/divorced/widow/separated marital status (odds ratio [OR]: 14.72; 95% confidence interval [CI]: 1.89-114.17; P = 0.00) and unemployed status (OR: 6.10; 95% CI: 2.00-18.60; P = 0.02) were found to be independent predictors of high-risk sexual behavior (unprotected sex). CONCLUSIONS: Based on findings of study, it is highly recommended to provide periodic screening to these STI patients for assessment of their sexual behavior along with specific counseling session.

The JAK inhibitor tofacitinib suppresses synovial JAK1-STAT signalling in rheumatoid arthritis.

OBJECTIVE: Tofacitinib is an oral Janus kinase (JAK) inhibitor for the treatment of rheumatoid arthritis (RA). The pathways affected by tofacitinib and the effects on gene expression in situ are unknown. Therefore, tofacitinib effects on synovial pathobiology were investigated. METHODS: A randomised, double-blind, phase II serial synovial biopsy study (A3921073; NCT00976599) in patients with RA with an inadequate methotrexate response. Patients on background methotrexate received tofacitinib 10 mg twice daily or placebo for 28 days. Synovial biopsies were performed on Days -7 and 28 and analysed by immunoassay or quantitative PCR. Clinical response was determined by disease activity score and European League Against Rheumatism (EULAR) response on Day 28 in A3921073, and at Month 3 in a long-term extension study (A3921024; NCT00413699). RESULTS: Tofacitinib exposure led to EULAR moderate to good responses (11/14 patients), while placebo was ineffective (1/14 patients) on Day 28. Tofacitinib treatment significantly reduced synovial mRNA expression of matrix metalloproteinase (MMP)-1 and MMP-3 (p<0.05) and chemokines CCL2, CXCL10 and CXCL13 (p<0.05). No overall changes were observed in synovial inflammation score or the presence of T cells, B cells or macrophages. Changes in synovial phosphorylation of signal transducer and activator of transcription 1 (STAT1) and STAT3 strongly correlated with 4-month clinical responses (p<0.002). Tofacitinib significantly decreased plasma CXCL10 (p<0.005) at Day 28 compared with placebo. CONCLUSIONS: Tofacitinib reduces metalloproteinase and interferon-regulated gene expression in rheumatoid synovium, and clinical improvement correlates with reductions in STAT1 and STAT3 phosphorylation. JAK1-mediated interferon and interleukin-6 signalling likely play a key role in the synovial response. TRIAL REGISTRATION NUMBER: NCT00976599.

5HT3 antagonists for prophylaxis of postoperative nausea and vomiting in breast surgery: a meta-analysis.

BACKGROUND: Postoperative nausea and vomiting (PONV) are distressing adverse events following breast cancer surgery with an incidence of up to 80%. 5HT 3 antagonists are commonly employed as drugs of first choice for PONV although there is no clear evidence favoring one pharmacological approach over another. AIMS: The objective of this meta-analysis is to compare the efficacy of 5HT 3 antagonists against all non-5HT 3 antagonism-based pharmacological approaches as a preemptive strategy for PONV in women undergoing breast surgery. DESIGN: Meta-analysis of Randomized Controlled Trials. MATERIALS AND METHODS: Literature search was conducted through PUBMED, reference lists, and Cochrane Central Register of Controlled Trials till June 2010 to identify eligible studies. Trials comparing 5-HT 3 antagonists with placebo or active controls for prophylaxis against PONV in women undergoing breast surgery were included. Two reviewers extracted the data independently. Methodological quality of each trial was assessed using Jadad score. RESULTS: Nineteen trials were included. All trials were of good methodological quality (Jadad score >3). 5HT 3 antagonists were found superior to placebo [Odds ratio (OR)=0.18 (0.13-0.26)] or active controls [OR=0.65 (0.47-0.91)] in the prevention of PONV. 5HT 3 antagonists were also superior to placebo in preventing nausea alone [OR=0.51 (0.34-0.76)], vomiting [OR=0.31 (0.20-0.47)] and the use of rescue antiemetics [OR=0.18 (0.11-0.28)]. No significant difference was observed in the use of rescue antiemetics as compared to active controls [0.59 (0.19 to 1.86)]. CONCLUSION: 5HT 3 antagonists are superior to other pharmacological interventions for the prevention of PONV in patients undergoing breast surgery under general anesthesia.

A case control study on specific learning disorders in school going children in Bikaner city.

OBJECTIVE: To asses the prevalence of learning disorders in school going children and to compare the socio-demographic variables and other related factors with learning disorder. METHODS: All the 500 students of class III to V with all sections were given the dyslexia assessment questionnaire (DAQ) to fill; 468 students returned the completed forms.Statistical analysis was done using chi-square test. Only 68 children scored ≥ 4 on DAQ were given MISIC (Mallin's intelligence scale for Indian children) for IQ assessment and DST-J for dyslexia screening. Forty-eight students were labeled as dyslexia and further diagnosis was confirmed by DSM IV- TR classification. RESULTS: Prevalence of learning disorders (LD) was found to be 10.25% with higher in males than females (11.40% vs. 7.14%).The delivery complications (20.83% vs. 4.17%; X 2-4.667, p value-0.031) were more in LD and more family members were left handed (16.67% vs. 2.08%; X 2-4.41, p value-0.036) as compared to control group. In classroom behavior, children with LD asked questions less (10.42% vs. 75%; X 2-40.91, p value-0.0001), answered questions less frequently (6.25% vs. 79.16%; X 2-52.15, p value-0.0001) and took notes less attentively than control group (4.17% vs. 58.33%; X 2-32.77, p value-0.0001). CONCLUSIONS: The current study, therefore, is an attempt to identify children with learning disorders and explore the prevalence of the problem and etiological factors e.g., family environment, social factors and developmental issues of child and associated co-morbidities. More studies with larger sample size should be undertaken to get accurate picture of these disorders.There is also need for some community based programme to raise the level of awareness and knowledge about these disorders in general population.

Impact of donor cause of death on transplant outcomes: UNOS registry analysis.

Donor cause of death (DCOD) has been described to influence allograft survival. Whether this effect is independent of other donor characteristics and whether it is similar across different solid organ allografts is not known. The aim of our study was to determine the impact of DCOD on organ utilization and on transplantation outcomes-graft rejection, function, and survival. The registry data were provided by the United Network for Organ Sharing/Organ Procurement and Transplantation Network. Stroke, head trauma, and anoxia were the cause of brain death in 97% of the more than 86,000 donors whose data were recorded between 1989 and 2008. In univariate analysis, stroke DCOD was associated with worse graft survival across all organs. After adjustment in a multivariable analysis, modest differences persisted in survival of heart, kidney, and liver allografts. DCOD also appeared to affect the incidence of allograft rejection. Anoxia DCOD was associated with significantly less rejection relative to donor death caused by head trauma and stroke. In summary, this multi-institutional study confirms that DCOD is a modest predictor of survival and rejection of solid organ allografts of different types.

Profile of psychiatric disorders and life events in medically ill elderly: experiences from geriatric clinic in Northern India.

BACKGROUND: Morbidity among elderly people has an important influence on their psychological well-being. Evaluation of the morbidity profile and its determinants, which have implications for management of medical problems of elderly people, are scarce in developing countries. Even the physicians' detection rate of mental distress in elderly populations is low in medical outpatient clinics. This could be due to the large caseloads and also, importantly, underestimation of psychological concerns of the elderly. The objective of this study was to study the psychiatric co-morbidity and life events among elderly medical outpatients. METHODS: One hundred medically ill elderly (>60 years) patients attending the Geriatric Clinic at Bikaner (North India) constituted the study population. The physical diagnosis was made by a physician based on reported illness, clinical examination and medical records. Psychiatric diagnosis was made by detailed clinical psychiatric interview using ICD-10 guidelines. Life events were assessed by the Indian adaptation of Presumptive Stressful Life Events Scale. RESULTS: Hypertension was the most commonly reported physical diagnosis (50%), other specific medical illnesses were osteoarthritis (15%), diabetes (13%) and constipation (8%). The study found 18% subjects had depression and 11% had other mental disorders. Patients with mental disorders had suffered more recent stressful life events. Among life events, conflicts in family (16%); unemployment of self or children (9%) was reported by elderly psychiatric patients. Other reported life events in psychiatric diagnosed elderly were conflict in family (7%), illness of self (6%) or family members (5%) and death of family members (5%) or close relatives (4%). CONCLUSION: Mental disorders are common among medically ill elderly patients, but they are poorly recognized and treated. Assessment of the psychiatric morbidity will help in strengthening psycho-geriatric services and thus, improve the quality of life of the elderly.

Epidural morphine analgesia compared with intravenous morphine for oral cancer surgery with pectoralis major myocutaneous flap reconstruction.

BACKGROUND: Oral cancer surgery with reconstruction is a complex operative procedure with morbidities such as respiratory complications and post-operative pain. These morbidities may be reduced with appropriate operative and post-operative pain management. Epidural analgesia provides better pain control than intravenous opioids after major thoraco-abdominal surgical procedures. We planned to undertake a prospective study to compare the efficacy and side-effects of epidural morphine analgesia vs. intravenous morphine in patients undergoing oral cancer surgery with pectoralis major myocutaneous flap reconstruction. METHODS: Sixty patients undergoing a major surgical procedure for oral cancer with pectoralis major myocutaneous flap reconstruction were prospectively randomized to receive either epidural morphine or intravenous morphine in the post-operative period. The intensity of pain was assessed daily using a 100-mm visual analogue scale. The post-operative side-effects, time to ambulation, time to tolerate first nasogastric feed, total length of hospital stay and global satisfaction score were recorded. RESULTS: The epidural morphine group had statistically significant lower pain scores at the three evaluation times through the post-operative 48 h (P < 0.05). However, the mean visual analogue scores were always below 35 in the intravenous morphine group. Patients in the epidural morphine group ambulated and accepted nasogastric feed significantly earlier than those in the intravenous morphine group. The incidence of nausea/vomiting or pruritus, the length of hospital stay and the global satisfaction score were not statistically different between the groups. CONCLUSION: This study illustrates that epidural morphine offers better pain control than intravenous morphine after oral cancer surgery with pectoralis major myocutaneous flap reconstruction. Nevertheless, both methods appear to provide very good pain relief, and perhaps the extra risks inherent to epidural catheter insertion are not outweighed by the benefits in this type of surgery.

Neglected foreign body in oesophagus with an unusual presentation: A case report.

Foreign body in oesophagus is not an unusual finding, we report here a case of neglected foreign body in oesophagus with an unusual presentation which remained almost asymptomatic for three years before removal.

Airway management of patients undergoing oral cancer surgery: a retrospective study.

OBJECTIVE: This retrospective study aims to describe the airway management and benefits of nasotracheal intubation over tracheostomy in 260 patients with oral cancer undergoing surgery. METHODS AND RESULTS: The medical records of 260 patients undergoing surgery for oral cancer were reviewed for airway management during the perioperative period. Eighteen patients had previous surgery for oral cancer and were scheduled for flap reconstruction, recurrence or other complications. In 28 cases neck movement was restricted and decreased mouth opening was found in 50% of all patients because of a large growth or fixation of tissues of head and neck, oral cavity, pharynx or larynx by tumour, or radiation fibrosis. In 53 patients intubation was undertaken under spontaneous ventilation. In 20 cases the trachea was extubated in the immediate postoperative period. In 220 cases patients were extubated next morning in the intensive care unit. In none of the cases was elective tracheostomy under local anaesthesia performed before surgery for the maintenance of the airway for anaesthesia. Elective tracheostomies were done in 17 cases. Three patients remained intubated for 24-48 h because of a high suspicion of airway obstruction following extubation due to a large pectoralis major flap. These three patients received a tracheostomy because of increased oropharyngeal and laryngeal oedema. In three cases emergency tracheostomies were performed due to upper airway obstruction after extubation and in one case prolonged elective ventilation was required due to severe chest infection. CONCLUSION: Oral cancer patients have a potentially difficult airway but, if managed properly during perioperative period, morbidity and mortality can be reduced or avoided. Oral cancer patients can be managed safely without the routine use of a tracheostomy. Nasotracheal intubation is a safe alternative to tracheostomy in oral cancer patients except in some selected patients.

Granisetron and ondansetron for prevention of nausea and vomiting in patients undergoing modified radical mastectomy.

Modified radical mastectomy is associated with a relatively high incidence of postoperative nausea and vomiting (PONV). This study was undertaken to evaluate the comparative profile and efficacy of ondansetron and granisetron to prevent PONV after modified radical mastectomy. In a randomized, double-blind, placebo-controlled trial, sixty female patients received ondansetron 4 mg, granisetron 1 mg or saline intravenously just before induction of anaesthesia (n = 20 for each group). A standardized general anaesthetic technique was employed. The incidence of PONV and adverse events were recorded for the first 24h postoperatively. The incidence of PONV was 25% with ondansetron, 20% with granisetron and 70% with saline (P < 0.05, Chi-square test with Yates' correction factor). The incidence of adverse events was comparable among the groups. Ondansetron and granisetron are both effective for reducing the incidence of PONV in female patients undergoing modified radical mastectomy.

Pharmacologic pre-conditioning and controlled reperfusion prevent ischemia-reperfusion injury after 30 minutes of hypoxia/ischemia in porcine hearts.

BACKGROUND: Hearts from non-heart-beating organ donors are not transplanted because of risk of ischemia-reperfusion injury. We tested whether pharmacologic pre-conditioning with adenosine and the Na(+)/H(+) exchanger inhibitor, cariporide, combined with controlled reperfusion, would prevent injury in porcine hearts that had sustained 30 minutes of hypoxia/ischemia in closed-chest animals. METHODS: Hearts from Yorkshire pigs (100 kg) were studied in 3 groups. Group 1 (control) hearts were surgically removed while beating. Group 2 hearts were harvested from animals made hypoxic by discontinuing mechanical ventilation for 30 minutes. Group 3 hearts were hypoxic as in Group 2, but these animals received adenosine (40 mg) and cariporide (400 mg) 10 minutes before stopping ventilation. Cardiac function in all groups was assessed ex vivo in a working heart apparatus in which pressure and flow measurements were made over 3 hours. Controlled reperfusion in Group 3 hearts used leukocyte-depleted blood perfusate containing free radical scavengers. Myocardial injury was assessed on the basis of perfusate creatine phosphokinase activity and histopathologically determined injury score. RESULTS: Groups 1 and 3 hearts could be resuscitated to perform work equivalently during the entire reperfusion period and showed positive responses to increases in pre-load and norepinephrine. Group 2 hearts could not perform work. After 3 hours, Group 2 hearts showed significantly higher creatine phosphokinase and histopathologic injury scores compared to with Groups 1 and 3, which were not significantly different from each other. CONCLUSIONS: Pharmacologic pre-conditioning and controlled reperfusion effectively protect non-beating porcine hearts from injury after 30 minutes of hypoxia/ischemia in situ.

Antitumor immunity induced by laser immunotherapy and its adoptive transfer.

The ideal cancer treatment modality should not only cause tumor regression and eradication but also induce a systemic antitumor immunity, which is essential for control of metastatic tumors and for long-term tumor resistance. Laser immunotherapy using a laser, a laser-absorbing dye, and an immunoadjuvant has induced such long-term immunity in treatment of a mammary metastatic tumor. The successfully treated rats established total resistance to multiple subsequent tumor challenges. To further study the mechanisms of the antitumor immunity induced by this novel treatment modality, passive adoptive transfer was performed using splenocytes as immune cells. The spleen cells that were harvested from successfully treated tumor-bearing rats provided 100% immunity in the naive recipients. The passively protected first cohort rats were immune to tumor challenge with an increased tumor dose; their splenocytes also prevented the establishment of tumor in the second cohort of naive recipient rats. This immunity transfer was accomplished without the usually required T-cell suppression in recipients.

"Gilahari (lizard) syndrome" is it a new culture bound syndrome? - a case report.

Culture bound syndromes are generally limited to specific societies or cultural areas and are localized. Authors report a case which seems to be a new culture bound syndrome, has atypical presentation and difficult to categories but could be diagnosed as somatoform NOS (F-45.9). This syndrome is commonly called Gilahari (Lizard) among local public and considered to be very serious and fatal illness prevalent in areas of west Rajasthan. According to public a small swelling climbs from the back reaches to neck leading to obstruction of airways and followed by death, though after examination and investigation patient did not revealed any physical illness so is seems to be a new culture bound syndrome.