If a trauma patient is tachycardic, should we call for a counsellor?

BACKGROUND: It has been suggested in the literature that raised heart rate in the early period after trauma is associated with the development of post-traumatic psychopathology, but little account has been taken of the potential confounding effect of injury severity. MATERIALS AND METHODS: A cohort of 154 patients, studied as part of a wider investigation of trauma outcomes, was included. Initial heart rate in the accident & emergency department, and injury severity score and new injury severity scores were recorded. Patients completed the General Health Questionnaire (GHQ-28) as a measure of psychopathology at presentation and again at two- and six-month follow-up. RESULTS: There was no relationship between psychopathology at presentation and initial heart rate or injury severity. Raised heart rate was associated with post-traumatic psychopathology at two months but not at six months. When the potential confounding effect of injury severity was controlled for, there was no independent correlation between heart rate and post-traumatic psychopathology. Injury severity score and new injury severity scores were strongly associated with GHQ-28 caseness. CONCLUSION: Post-traumatic tachycardia is not associated with development of psychopathology, but injury severity is. Previous studies that have suggested a link between tachycardia and development of psychopathology are flawed because they have not considered the confounding effect of severity of injury.

Indigenously developed multipurpose acrylic head phantom for verification of IMRT using film and gel dosimetry.

The purpose of this study was to validate the newly designed acrylic phantom for routine dosimetric purpose in radiotherapy. The phantom can be used to evaluate and compare the calculated dose and measured dose using film and gel dosimetric methods. In this study, a doughnut-shaped planning target volume (8.54 cm3) and inner organ at risk (0.353 cm3) were delineated for an IMRT test plan using the X-ray CT image of the phantom. The phantom consists of acrylic slabs which are integrated to form a human head with a hole in the middle where several dosimetric inserts can be positioned for measurement. An inverse planning with nine coplanar intensity-modulated fields was created using Pinnacle TPS. For the film analysis, EBT2 film, flatbed scanner, in-house developed MATLAB codes and ImageJ software were used. The 3D dose distribution recorded in the MAGAT gel dosimeter was read using a 1.5 T MRI scanner. Scanning parameters were CPMG pulse sequence with 8 equidistant echoes, TR = 5600, echo step = 22 ms, pixel size = 0.5 × 0.5, slice thickness = 2 mm. Using a calibration relationship between absorbed dose and spin-spin relaxation rate (R2), R2 images were converted to dose images. The dose comparison was accomplished using in-house MATLAB-based graphical user interface named "IMRT3DCMP". For gel measurement dose grid from the TPS was extracted and compared with the measured dose grid of the gel. Gamma index analysis of film measurement for the tolerance criteria of 2%/2mm, 1%/1 mm showed more than 90% voxels pass rate. Gamma index analysis of 3D gel measurement data showed more than 90% voxels pass rate for different tolerance criteria of 2%/2 mm and 1%/1 mm. Overall both 2D and 3D measurement were in close agreement with the Pinnacle TPS calculated dose. The phantom designed is cost-effective and the results are promising, but further investigation is required to validate the phantom with other 3D conformal techniques for dosimetric purpose.

MAGAT gel and EBT2 film-based dosimetry for evaluating source plugging-based treatment plan in Gamma Knife stereotactic radiosurgery.

This work illustrates a procedure to assess the overall accuracy associated with Gamma Knife treatment planning using plugging. The main role of source plugging or blocking is to create dose falloff in the junction between a target and a critical structure. We report the use of MAGAT gel dosimeter for verification of an experimental treatment plan based on plugging. The polymer gel contained in a head-sized glass container simulated all major aspects of the treatment process of Gamma Knife radiosurgery. The 3D dose distribution recorded in the gel dosimeter was read using a 1.5T MRI scanner. Scanning protocol was: CPMG pulse sequence with 8 equidistant echoes, TR = 7 s, echo step = 14 ms, pixel size = 0.5mm × 0.5mm, and slice thickness of 2 mm. Using a calibration relationship between absorbed dose and spin-spin relaxation rate (R2), we converted R2 images to dose images. Volumetric dose comparison between treatment planning system (TPS) and gel measurement was accomplished using an in-house MATLAB-based program. The isodose overlay of the measured and computed dose distribution on axial planes was in close agreement. Gamma index analysis of 3D data showed more than 94% voxel pass rate for different tolerance criteria of 3%/2 mm, 3%/1 mm and 2%/2 mm. Film dosimetry with GAFCHROMIC EBT 2 film was also performed to compare the results with the calculated TPS dose. Gamma index analysis of film measurement for the same tolerance criteria used for gel measurement evaluation showed more than 95% voxel pass rate. Verification of gamma plan calculated dose on account of shield is not part of acceptance testing of Leksell Gamma Knife (LGK). Through this study we accomplished a volumetric comparison of dose distributions measured with a polymer gel dosimeter and Leksell GammaPlan (LGP) calculations for plans using plugging. We propose gel dosimeter as a quality assurance (QA) tool for verification of plug-based planning.

Intra-articular morphine and bupivicaine for post-operative analgesia in anterior cruciate ligament reconstruction: a prospective randomised controlled trial.

Anterior cruciate ligament reconstruction (ACLR) has the potential for significant post-operative pain. Conventional systemic opiate treatment may cause nausea and drowsiness, which may delay recovery. The use of intra-articular local anaesthesia has been shown to be effective. We wished to examine the additional effect of intra-articular morphine. This is a prospective, randomised, double-blind trial. Sixty patients were randomised to receive 20 ml 0.5% bupivicaine (group L, n = 30) or bupivicaine with 10 mg morphine (group M, n = 30) by intra-articular injection at the end of the operation. Visual analogue scores (VAS) were recorded before ACLR (expected pain) and repeated at 6 and 24 h after surgery. Time to first analgesic request and total systemic opiate and other analgesic use in the first 24 h was recorded. Pre-operative VAS measurements did not predict pain or analgesic use post-operatively. There were no significant differences between groups L and M with regard post-operative VAS or time to first analgesic request. Group M required less opiate analgesic post-operatively (oral morphine equivalent 50 mg for group L and 27 mg for group M, P < 0.007). There were no complications associated with the intra-articular analgesic. The simple addition of morphine to the intra-articular injection of bupivicaine gives a significant reduction in opiate analgesic requirement after ACLR.

COVID-19: Indian Society of Neuroradiology (ISNR) Consensus Statement and Recommendations for Safe Practice of Neuroimaging and Neurointerventions.

The ongoing COVID-19 pandemic has forced every radiology set-up to evolve and formulate guidelines for day-to-day functioning. The sub-speciality of neuroradiology, both diagnostic and neuro-intervention, forms a very important part of any radiology or 'neuro-care' set-up. The present document is a consensus statement of the Indian Society of Neuroradiology, prepared after reviewing the available data and working experience. It scientifically tries to answer many questions faced by neuroradiologists everyday in practice. It encompasses simple things such as which patients need to be imaged, what precautions are essential, the work-flows, cleaning of radiology equipment, how to carry out neuro-interventions in COVID-suspect patients, and what procedures/tests to avoid, or their alternatives, to minimise the spread of COVID infection both to the patients and health care personnel. As radiology set-ups can be large, every sub-speciality may have certain precautions which will not be covered in general guidelines, and this document tries to answer those for neuroradiologists. Carefully evolved Standards of Operating Procedure (SOPs) and guidelines are the need of the hour to guide in providing uninterrupted and adequate services to the needy without compromising the safety of the specialised work force and facilities involved.

Cerbera odollam toxicity: A review.

Cerbera odollam is a plant species of the Apocynaceae family. It is often dubbed the 'suicide tree' due to its strong cardiotoxic effects, which make it a suitable means to attempt suicide. The plant grows in wet areas in South India, Madagascar, and Southeast Asia; and its common names include Pong-Pong and Othalanga. The poison rich part of the plant is the kernel which is present at the core of its fruit. The bioactive toxin in the plant is cerberin, which is a cardiac glycoside of the cardenolide class. Cerberin has a mechanism of action similar to digoxin; hence, Cerbera odollam toxicity manifests similar to acute digoxin poisoning. Ingestion of its kernel causes nausea, vomiting, hyperkalemia, thrombocytopenia, and ECG abnormalities. Exposure to high doses of Cerbera odollam carries the highest risk of mortality. Initial management includes supportive therapy and administration of atropine followed by temporary pacemaker insertion. Administration of digoxin immune Fab may be considered in severe cases, although efficacy is variable and data limited to isolated case reports.

Endosulfan poisoning: An overview.

Endosulfan, an organochlorine (OC) insecticide, is a widely used agricultural pesticide, despite its life threatening toxic effects. In this review, the pharmacokinetics of endosulfan, mechanism of endosulfan toxicity, clinical presentations and management, histopathological findings, and toxicological analysis are described, in addition to its environmental toxicity. The toxic effects of endosulfan can affect many organs and systems presenting in a wide array of signs and symptoms. Although termed a restricted OC-classed pesticide, it continues to be used, especially in the developing world, owing to its beneficial effects on agriculture. Several cases of endosulfan poisoning have been reported from different regions of the world. Whether accidental or intentional, endosulfan ingestion proves to be fatal unless immediate, aggressive treatment is initiated. Management is mainly supportive as no antidote exists for endosulfan poisoning as yet. The use of endosulfan needs to be strictly regulated and eventually banned worldwide altogether to lower the current morbidity and mortality resulting from this pesticide. Additionally, monitoring biological samples, using non-invasive techniques such as breast milk sampling, can provide an effective method of observing the elimination of this environmentally persistent organic pollutant from the general population.

Lobed spleen: an autopsy case report with emphasis on surgical anatomy.

During the medico-legal autopsy of a male aged 45 years, a bilobed morphology of the spleen was observed. An oblique fissure was located longitudinally at the mid-region of the diaphragmatic surface of the spleen. The fissure was partially deep and observed throughout the diaphragmatic surface. The clinician should be aware of the developmental anomalies of the spleen; as such anomalies may cause confusion during the procedures like splenic biopsy and splenectomy. We believe that, the present case report is important to the radiologists and clinicians involved in the diagnosis and management of splenic pathology. The knowledge is also enlightening to the morphologists and embryologists. The radiologist and clinician should make sure that the fissure in a spleen is not misinterpreted as a laceration or rupture.

Propofol's derivative: a potential drug for erectile dysfunction?

Propofol, an intravenous anesthetic agent induces priapism in humans. We hypothesize the probable central nervous system and local mechanisms through which a similar molecule can be used as a therapy in erectile dysfunction. Previous literatures published over a period of 35 years (1976-2010) were searched using the key words, mechanisms were identified and discussed. In the central nervous system, propofol has an inhibitory effect on serotonin receptors and on gamma-aminobutyric acid A (GABA-A) receptors as well as a facilitatory action on N-methyl-D-aspartate (NMDA) mediated calcium response and agonistic action on dopaminergic D2 receptors, which might contribute towards maintaining erections. While in the penile tissue, propofol's action may be due to increased synthesis of nitric oxide (NO), the principal mediator of penile erection. In addition, it may also have inhibitory effect on thromboxane A2, a potent vasoconstrictor and stimulatory action on penile adenosine triphosphate (ATP) dependent potassium (K-ATP) channels, a potent vasodilator. In view of the above mechanisms, use of propofol or similar molecule in erectile dysfunction needs to be ascertained and evaluated.

Suicidal plant poisoning with Colchicum autumnale.

Colchicum autumnale is commonly known as autumn crocus, and as 'gowri gedde' in the southern region of Karnataka State in South India. It contains an alkaloid called colchicine, which blocks the cell division by inhibiting mitosis. We present a sporadic case of suicidal plant poisoning wherein a 24-year-old man consumed 'gowri gedde' to end his life. Initially he presented with severe vomiting, diarrhoea and epigastric pain. He died on the third day of ingestion due to multiorgan failure. Chemical analysis of blood and viscera obtained postmortem confirmed the presence of colchicine. Colchicine poisoning is potentially life threatening because of its high toxicity and unavailability of specific antidotal treatment. It classically presents with gastroenterocolitis, and may result in multiorgan failure in fatal cases.