The Atypical Face of Neuroleptic Malignant Syndrome: A Case Report of Ileus and Absent Rigidity.

Neuroleptic malignant syndrome (NMS) is a rare life-threatening condition associated with the use of antipsychotic medications. This case report describes a male patient in his early 30s who presented with fever, breathlessness, and lower limb weakness, ultimately diagnosed with NMS despite the absence of muscular rigidity. On examination, he was febrile, tachycardic, and tachypneic with an oxygen saturation of 88% and elevated blood pressure. On auscultation diffuse crepitations in both lungs were revealed. Neurological assessment indicated motor strength of 3/5 in both lower limbs, without rigidity, sensory loss, or cerebellar signs. It was noted that he was on irregular atypical antipsychotic medication for the past one year. Laboratory investigations revealed leukocytosis, elevated transaminases, dyselectrolytemia, elevated creatine phosphokinase (CPK), and serum creatinine. NMS was not initially considered due to the lack of muscular rigidity. However, the patient later developed autonomic dysregulation manifestations, such as paralytic ileus. Once organic causes were excluded, NMS was diagnosed. Supportive therapy included 23 cycles of hemodialysis and colonic decompression for pseudo-obstruction. He was treated with intravenous fluids and dopamine receptor agonist medications. NMS usually presents with fever, muscular rigidity, altered mental status, and autonomic instability; yet, the absence of muscular rigidity in this patient is a distinctive and unusual feature.

Critical Evaluation of Lateral Calcaneal Artery Fascio-Cutaneous Flap in Re-Surfacing Posterior Heel Defects: A Review of 24 Cases.

Purpose and background: To assess feasibility and functional acceptability of lateral calcaneal artery fascio-cutaneous flap (LCAFCF) in providing cover to posterior heel defects in single stage. Aims and objectives: To provide stable and sensate cover to small and moderate posterior heel defects. Materials and methods: This review was conducted in department of Burns & Plastic Surgery of Postgraduate Institute of Medical Sciences (PGIMS), Rohtak, Haryana between October 2021 and September 2022 to analyse the clinical outcome of LCAFCF in 24 patients (18 males, 6 females) aged between 20 and 35 years who had chronic dry wounds n = 9, failed primary reconstruction by reverse sural flap n = 1, granulated wounds n = 8, exposed achilles tendons n = 4 and scarred tissue restricting ankle joint movements n = 2 in region of posterior heel following trauma, while riding motor-cycle. Course of lateral calcaneal artery was marked with hand-held doppler. Flap size ranged from 3 to 3.5 cm in width and 5.5-7.5 cm length. The donor sites were split skin grafted. Sutures were removed on 22nd day of surgery. Mean follow up was 13 months. Results: All flaps survived. Two had partial loss of skin graft and two developed hyperkeratosis on grafted site. Sensations in flap, regain of movements of ankle joint, comfort of walking and driving were acceptable. Conclusions: LCAFCF is handy, safe and reliable flap for re-surfacing difficult wounds of posterior heel, therefore should be included in surgical armamentarium.

Effects of circadian restricted feeding on parameters of metabolic syndrome among healthy subjects.

Experimental studies indicate that energy homeostasis to the circadian clock at the behavioral, physiological, and molecular levels, emphasize that timing of food intake may play a significant role in the development of obesity and central obesity. Therefore, resetting the circadian clock by circadian energy restriction via food intake in the morning or evening, may be used as a new approach for prevention of obesity, metabolic syndrome and related diseases. After ethical clearance and written, informed consent, free living subjects were included if they volunteered to take most of the total daily meals (approximately 2000 Kcal./day) in the evening (4 weeks) or morning (4 weeks). Of 22 adults, half were randomly selected by computer generated numbers to eat in the morning and the other half in the evening, after 8.00 PM. The eating pattern was changed after 4 weeks of intervention and a 4-week washout period, those who ate in the morning were advised to eat in the evening and vice versa. Validated questionnaires were used to assess food intakes, physical activity, and intake of alcohol and tobacco. Physical examination included measurement of body weight, height, and blood pressure (BP) by sphygmomanometer. Data were regularly recorded blindly, in all subjects at start of study and during follow-up. Blood samples were collected after an overnight fast for analysis of blood glucose and Hb1c. Feeding in the evening was associated with significant increase in body weight by 0.80 kg (P < .001), body mass index (BMI) by 0.30 kg/m2 (P < .001) and waist circumference by 1.13 cm (P < .05). Feeding the same amount of energy in the morning was not associated with any significant change in weight, BMI or waist circumference (P > .500). Lesser increases in all three variables were associated with AM versus PM feeding (P < .05). Systolic BP slightly increased on PM and decreased on AM feeding, with a difference between the two responses of 1.55 mmHg (P < .05). Fasting blood glucose was lower on AM than on PM feeding (74.86 vs. 77.95 mg/dl, paired t = 4.220, P < .001). Hb1C increased on PM feeding by 0.28 (from 4.45 to 4.73; t = 9.176, P < .001), but decreased on AM feeding by 0.077 (from 4.53 to 4.45; t = -6.859, P < .001). The difference in Hb1C response between AM and PM feeding is also statistically significant (t = -11.599, P < .001). Eating in the evening can predispose to obesity, central obesity and increases in fasting blood glucose and Hb1c that are indicators of the metabolic syndrome. By contrast, eating in the morning can decrease Hb1c and systolic BP, indicating that it may be protective against the metabolic syndrome.

Importance of the assessment of coenzyme Q10, alpha-tocopherol and oxidative stress for the diagnosis and therapy of infertility in men.

UNLABELLED: Male infertility is one of the most stressful factors of couples, being present in about 40% cases. It is usually caused by a low number of sperm (oligozoospermia) or poor sperm motility (asthenozoospermia). The sperm motility is used as an indicator of semen quality and male infertility. To the impairment of male reproduction health can contribute genetic, nutritional and environmental factors, smoking and drugs. It is well documented that excessive reactive oxygen species (ROS) production decreases sperm motility, impairs sperm function, damages the morphology of spermatozoa (1, 2). To the decreased sperm motility contribute also disturbances of sperm mitochondrial function and energy production, low levels of coenzyme Q10 and carnitine, as well as sperm mitochondrial deoxyribonucleic acid (DNA) defects. The origin of sperm dysfunction, however, is not well understood. BACKGROUND: Oxidative stress has been established as a major factor in the pathogenesis of male infertility. Low level of coenzyme Q10 contributes to the decreased sperm motility, which plays a vital role in sperm mitochondrial energy production and neutralization of reactive oxygen species (ROS).The aim of the present study was to find out, if an assessment of coenzyme Q10-TOTAL (CoQ10-TOTAL), α-tocopherol, γ-tocopherol and oxidative stress could contribute to the diagnosis of infertility in men. SUBJECTS AND METHODS: Two groups of infertile men, according to sperm motility (a+b and b+c) were included in the study. CoQ10-TOTAL, α-tocopherol, γ-tocopherol in plasma and seminal fluid, and parameter of oxidative stress (thiobarbituric acid reactive substances - TBARS) in plasma were determined. RESULTS: Higher sperm density and decreased sperm pathology were found in group a+b vs b+c (class a and b - fast and weak forward motility, class c - nonprogressive motility). Concentrations of CoQ10-TOTAL and α-tocopherol were significantly increased in seminal fluid of groups a+b vs b+c, opposite results were estimated in plasma. Concentrations of γ-tocopherol in plasma and seminal fluid of both groups were similar. Plasmatic TBARS concentrations were increased in both groups of infertile men. CONCLUSION: We suppose that incorporation of oxidative stress assessment, CoQ10-TOTAL and α-tocopherol concentrations in seminal fluid and plasma into routine andrology can play an important role for the diagnosis and targeted therapy of male infertility (Tab. 1, Ref. 16).

The tsim tsoum approaches for prevention of cardiovascular disease.

The Tsim Tsoum Concept means that humans evolved on a diet in which nature recommends to ingest fatty acids in a balanced ratio (polyunsaturated(P) : saturated(S) =w-6 : w-3 = 1 : 1)as part of dietary lipid pattern where monounsaturated fatty acids(MUFA) is the major fatty acid(P : M : S = 1 : 6 : 1) in the background of other dietary factors; antioxidants, vitamins, minerals and fiber as well as physical activity and low mental stress. Several hundred years ago, our diet included natural foods; fruits, vegetables, green vegetables, seeds, eggs and honey. Fish, and wild meat were also available to pre-agricultural humans which shaped modern human genetic nutritional requirement. Cereal grains (refined), and vegetable oils that are rich in w-6 fatty acids are relatively recent addition to the human diet that represent dramatic departure from those foods to which we are adapted. Excess of linoleic acid, trans fatty acids (TFA), saturated and total fat as well as refined starches and sugar are proinflammatory. Low dietary MUFA and n-3 fatty acids and other long chain polyunsarurated fatty acids (LCPUFA) are important in the pathogenesis of metabolic syndrome. Increased sympathetic activity with greater secretion of neurotransmitters in conjunction of underlying long chain PUFA deficiency, and excess of proinflammatory nutrients, may damage the neurons via proinflammatory cytokines, in the ventromedial hypothalamus and insulin receptors in the brain.Since, 30-50% of the fatty acids in the brain are LCPUFA, especially omega-3 fatty acids, which are incorporated in the cell membrane phospholipids, it is possible that their supplementation may be protective.Blood lipid composition does reflect one's health status: (a) circulating serum lipoproteins and their ratio provide information on their atherogenicity to blood vessels and (b) circulating plasma fatty acids, such as w-6/w-3 fatty acid ratio, give indication on proinflammatory status of blood vessels, cardiomyocytes, liver cells and neurones; (a) and (b) are phenotype-related and depend on genetic, environmental and developmental factors. As such, they appear as universal markers for holistic health and these may be important in the pathogenesis of cardiovascular diseases and cancer, which is the main consideration of Tsim Tsoum concept.

Self-inflicted macro urethro-cutaneous fistula.

An 18-year-old male having a 3 cm coronal macro urethro-cutaneous fistula, developing as a result of a strangulating rope tied at the coronal sulcus in an attempt to cause penile detumescence, is presented for its rare mode of self-inflicted penile trauma and unexpected postsurgical successful cosmetic and functional outcome.

Extra-hepatic biliary-ductal necrosis following acute pancreatitis: 10 years of follow-up.

This case report is 10 years follow-up of a child who presented with acute abdomen at the age of 8 years. Exploration revealed acute pancreatitis with the necrosis of common bile duct and almost whole of the common hepatic duct with bile leaking from the junctional stump of the right and left hepatic ducts. The patient was managed successfully by Roux-en-Y hepaticojejunostomy. After 10 years, the patient again presented with a recurrent discharging sinus from the anterior abdominal wall. On exploration, it was found to be a stitch granuloma near the site of hepaticojejunostomy. However, hepaticojejunostomy was found to function normally as seen on MRCP. This rare case highlights that extra-hepatic biliary-ductal necrosis is very unusual complication of acute pancreatitis; and it can be successfully managed by Roux-en-Y hepaticojejunostomy as evident from long-term follow-up.

Intraperitoneal rupture of cysticercosal cyst mimicking appendicular perforation.

Anaphylaxis following intraperitoneal rupture of a cysticercosal cyst mimicking pelvic peritonitis secondary to appendicular perforation is reported. Human cysticercosis occurs following ingestion of Taenia solium eggs, usually from faecally contaminated food. A case of pelvic cysicercosis presenting with signs and symptoms of anaphylaxis and peritonitis is reported, with plausible explanations for this unusual presentation.

Evaluation of the optimal preemptive dose of gabapentin for postoperative pain relief after lumbar diskectomy: a randomized, double-blind, placebo-controlled study.

We evaluated the optimal preemptive dose of gabapentin for postoperative pain relief after single-level lumbar diskectomy and its effect on fentanyl consumption during the initial 24 hours in a randomized, double-blinded, placebo-controlled study in 100 patients with American Society of Anesthesiologists physical status I and II. Patients were divided into five groups to receive placebo or gabapentin 300, 600, 900, or 1200 mg 2 hours before surgery. After surgery, patients were transferred to the postanesthesia care unit (PACU). A blinded anesthesiologist recorded the pain scores at time points of 6, 12, 18, and 24 hours in the PACU on a Visual Analog Scale (VAS; 0-10 cm) at rest. Patients received patient-controlled analgesia (fentanyl 1.0 mug/kg on each demand with lockout interval of 10 minutes); total fentanyl consumption during initial 24 hours was recorded. Data were entered into the statistical software package SPSS 9.0 for analysis (one-way analysis of variance and Student-Newman-Keuls test). Patients who received gabapentin 300 mg had significantly lower VAS score at all time points. They consumed less fentanyl (patients who received placebo processed 1217.5 +/- 182.0 versus 987.5 +/- 129.6 mug; P < 0.05). Patients who received gabapentin 600, 900, and 1200 mg had lower VAS scores at all time points than patients who received gabapentin 300 mg (P < 0.05). Increasing the dose of gabapentin from 600 to 1200 mg did not decrease the VAS score, nor did the increasing dose of gabapentin significantly decrease fentanyl consumption (702.5, 635, and 626.5 microg). Thus, gabapentin 600 mg is the optimal dose for postoperative pain relief following lumbar diskectomy.

Technical aspects in the management of complex vesicovaginal fistulae.

Thirteen complex vesicovaginal fistulae were successfully closed by a technique of wide separation and water-tight closure of vagina from the urinary bladder and augmentation of the repair with a pedicled omental interposition flap.

Intravenous lidocaine suppresses fentanyl-induced coughing: a double-blind, prospective, randomized placebo-controlled study.

IV lidocaine is effective in suppressing the cough reflex of tracheal intubation, extubation, bronchography, bronchoscopy, and laryngoscopy. We investigated this effect of lidocaine on fentanyl-induced cough in 502 patients of ASA physical status I and II scheduled for elective surgery. The patients were assigned to 2 equal groups to receive either lidocaine 1.5 mg/kg or placebo (0.9% saline) over 5 s 1 min before the administration of fentanyl 3 mug/kg in a randomized and double-blind fashion. Coughs were classified as coughing and graded as mild (1-2), moderate (3-4), or severe (5 or more). The results of the study suggest that IV lidocaine 1.5 mg/kg, when administered 1 min before fentanyl, is significantly effective in suppressing fentanyl-induced cough compared to placebo (0.9% saline) (218 versus 165 patients) (P < 0.002) but without affecting the severity of cough (P > 0.05).

Effect of preoperative dexamethasone on edema of oral and extra-oral structures following trans-oral decompression and posterior fusion.

We investigated the anti-edema effect of intravenous dexamethasone in a randomized, double-blinded, placebo-controlled study in 40 ASA physical status I and II patients scheduled for trans-oral decompression and posterior fusion. Patients were divided into two groups to receive either placebo or 10 mg dexamethasone one hour prior to induction of anesthesia. After anesthesia induction, oral structures were graded as swelling grade 0 at direct laryngoscopy. Duration of trans-oral surgery, duration of posterior fusion, and total duration of surgery were recorded. After completion of surgery, direct laryngoscopy was repeated, and swelling was graded from 1 to 4. Patients who had a swelling grade of 1 or 2 were extubated while grades of 3 and 4 were transferred to a neurosurgical intensive care unit, and re-assessments were performed 12 hours apart. Patients with swelling grades of 1 and 2 were extubated on each assessment. On statistical analysis of the results, the study found that in comparison to placebo, patients in the dexamethasone group were extubated earlier (P < 0.006, Chi Square for trend). Total duration of surgery and duration of posterior fusion were significantly greater (P < 0.05) in patients who had swelling grade >2 than in patients who had swelling grade < or =2 at completion of surgery (192.50 +/- 16.26, 356.07 +/- 17.06 minutes versus. 158.27 +/- 9.07, 311.41 +/- 14.06 minutes).

A new technique for correction of disproportionate preputial growth with phimosis.

A new surgical solution to correct the rare anomaly of asymmetric phimosis is described, with a note on its symptomatology and etiopathogenesis.

Tunica vaginalis interposition flap in the closure of massive disruption of the neourethral tube (macro urethrocutaneous fistulae).

The use of a tunica vaginalis interposition flap in the successful closure of 14 macro urethrocutaneous fistulae (2-4 cm long) is described.

Elastic and Velcro dressing for penis.

A simple, quick, painless, and versatile dressing that fulfills most of the criteria of an ideal hypospadias dressing is described.

Lessons learnt from Snodgrass tip urethroplasty: a study of 75 cases.

INTRODUCTION AND OBJECTIVES: Snodgrass tubularized incised plate urethroplasty and 2 modifications were evaluated in 75 hypospadiacs (distal and midpenile). PATIENTS AND METHODS: The initial 25 patients (group A), underwent Snodgrass tubularized incised plate urethroplasty. In the next 25 patients (group B), the urethral plate defining incision and Snodgrass urethrotomy were not extended distally to the glans tip and the neourethra was reconstructed (distal to proximal) over a spacer. In the last 25 patients (group C), dorsal free skin grafting of the raw area (following Snodgrass urethrotomy) was done. RESULTS: In group A, all patients developed meatal stenosis and required intermittent dilatation for 3 months. In groups B and C meatal stenosis did not occur. CONCLUSIONS: Restriction or elimination of the raw area in the region of the neomeatus as in groups B and C effectively prevents meatal stenosis following Snodgrass repair.

Investigation on the phenolics of some spices having pharmacotherapeuthic properties.

Spices are an important group of agricultural commodities being used by many civilizations all over the world to aid flavor, taste and nutritional values in the food. In traditional medical systems, their ability to heal various physical, mental and emotional problems has widely been reported. With this view, HPLC analysis was performed to estimate phenolic acids in 21 spices (asafetida, Bishop's weed, black mustard, coriander, cinnamon, clove, curry leaf, cumin black, cumin, fennel, fenugreek, garlic, ginger, Indian cassia, Indian dill or dill large cardamom, onion, saffron, tamarind, true cardamom, yellow mustard) commonly used in India in different forms. In all, 7 phenolic acids; viz., tannic, gallic, caffeic, cinnamic, chlorogenic, ferulic and vanillic acids could be identified on the basis of their retention time with standard compounds and co-chromatography. Several parts of the spices, for instance, seeds, leaves, barks, rhizomes, latex, stigmas, floral buds and modified stems were used in the study. Maximum amount of tannic and gallic acids was observed in black mustard and clove. Caffeic, chlorogenic and ferulic acids were found maximum in cumin while vanillic and cinnamic acids in onion seeds. The spices are known to significantly contribute to the flavor, taste, and medicinal properties of food because of phenolics.

Chronomics: circadian and circaseptan timing of radiotherapy, drugs, calories, perhaps nutriceuticals and beyond.

We suggest a putative benefit from timing nutriceuticals (substances that are both nutrients and pharmaceuticals) such as antioxidants for preventive or curative health care, based on the proven merits of timing nutrients, drugs, and other treatments, as documented, i.a., in India. The necessity of timing melatonin, a major antioxidant, is noted. A protocol to extend the scope of chronoradiotherapy awaits testing. Imaging in time by mapping rhythms and broader time structures, chronomes, for earliest diagnoses, for example detection of vascular disease risk, is recommended. The study of rhythms and broader chronomes leads to a dynamic functional genomics, guided by imaging in time of free radicals and antioxidants, amongst many other variables.

Partially de-epithelialized preputial flap (triangular soft tissue flap): an aid to prevent coronal urethrocutaneous fistulae.

A technique is described to fashion a partially de-epithelialized preputial flap, also called triangular soft tissue flap (TSTF), to cover the neourethra in the region of glans, corona and subcorona. This highly vascular TSTF acted as a mechanical barrier against coronal fistula formation in 16 subcoronal hypospadiacs aged 3-12 years who underwent Snodgrass tubularized incised plate urethroplasty. None had complications at 1-year of follow-up.

Plastic reconstruction of a mega vesicovaginal fistula using broad ligament flaps--a new technique.

Anew technique is described where medially based flaps raised from anterior folds of broad ligament were used to close a mega vesicovaginal fistula in a 35-year-old woman, with a successful outcome.