Opioid-free anesthesia using a combination of ketamine and dexmedetomidine in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial

Background@#Opioids administered as bolus doses or continuous infusions are widely used by anesthesiologists worldwide for major and day care surgeries. Opioid-free anesthesia is a multimodal anesthesia and analgesia technique that does not use opioid drugs, thereby benefitting patients from opioid-related adverse effects. In this study, we compared the postoperative analgesic requirements of patients scheduled for elective laparoscopic cholecystectomy under opioid-free and opioid-based anesthesia. @*Methods@#This study included 88 patients aged 18–60 years with American Society of Anesthesiologists physical status 1 and 2 who underwent elective laparoscopic cholecystectomy. Participants were randomly divided into two groups with forty-four participants in each group. The opioid-free anesthesia group was administered an intravenous bolus of ketamine and dexmedetomidine, whereas the opioid-based group was administered fentanyl with conventional general anesthesia. The primary outcome was to compare the total amount of fentanyl consumed by both groups during the 6 h postoperative period following extubation. Episodes of postoperative nausea and vomiting (PONV) and vital signs were noted throughout the postoperative period to analyze the secondary outcomes. @*Results@#Both the groups had similar demographic characteristics. The opioid-free group required less postoperative analgesia within the first 2 h (61.4 ± 17.4 vs. 79.0 ± 19.4 of fentanyl, P < 0.001), which was statistically significant. However, fentanyl consumption was comparable between the groups at the sixth postoperative hour (opioid-free group 152 ± 28.2 vs. opioid group 164 ± 33.4, P = 0.061). Compared with 4.5% of the participants in the opioid-free group, 34% of those in the opioid-based group developed moderate PONV. @*Conclusions@#The opioid-free anesthesia technique in patients undergoing laparoscopic cholecystectomy reduced the requirement of analgesia in the first two hours of the postoperative period and was associated with decreased PONV.

Diagnostic Pitfall and Clinical Characteristics of Variant Versus Wild-Type Transthyretin Amyloid Cardiomyopathy in Asian Population: The Korean Nationwide Cohort Study

Background@#Transthyretin amyloidosis cardiomyopathy (ATTR-CM) is an under-recognized cause of heart failure (HF) with clinical phenotypes that vary across regions and genotypes.We sought to characterize the clinical characteristics of ATTR-CM in Asia. @*Methods@#Data from a nationwide cohort of patients with ATTR-CM from six major tertiary centres in South Korea were analysed between 2010 and 2021. All patients underwent clinical evaluation, biochemical laboratory tests, echocardiography, and transthyretin (TTR) genotyping at the time of diagnosis. The study population comprised 105 Asian ATTR-CM patients (mean age: 69 years; male: 65.7%, wild-type ATTR-CM: 41.9%). @*Results@#Among our cohort, 18% of the patients had a mean left ventricular (LV) wall thickness < 12 mm. The diagnosis of ATTR-CM increased notably during the study period (8 [7.6%] during 2010–2013 vs. 22 [21.0%] during 2014–2017 vs. 75 [71.4%] during 2018–2021).Although the duration between symptom onset and diagnosis did not differ, the proportion of patients with HF presenting mild symptoms increased during the study period (25% NYHA class I/II between 2010–2013 to 77% between 2018–2021). In contrast to other international registry data, male predominance was less prominent in wild-type ATTR-CM (68.2%). The distribution of TTR variants was also different from Western countries and from Japan.Asp38Ala was the most common mutation. @*Conclusion@#A nationwide cohort of ATTR-CM exhibited less male predominance, a proportion of patients without increased LV wall thickness, and distinct characteristics of genetic mutations, compared to cohorts in other parts of the world. Our results highlight the ethnic variation in ATTR-CM and may contribute to improving the screening process for ATTR-CM in the Asian population.

Incidental finding of cardiac hydatid cyst during autopsy

ABSTRACT Hydatidosis or echinococcosis is an endemic parasitic disease caused by the ingestion of eggs of echinococcal species worldwide. In India, the annual incidence varies from 1 to 200 per one 100,000 hab., with the highest prevalence reported in the Indian states of Andhra Pradesh and Tamil Nadu. The dog is the definitive host, while humans, sheep, and cattle are intermediate hosts. The disease usually involves the liver and lungs, with the kidney and other organs rare involvement. Cardiac hydatidosis is still further rare, seen in 0.2% to 2% of the patients who remain asymptomatic until the development of its complications. Sudden deaths in cardiac echinococcosis are mostly attributed to cardiac arrhythmias, coronary artery diseases, valvular diseases, cardiomyopathies, pericarditis, and cardiac tamponade. We, herein, report a rare case of cardiac hydatid cyst incidentally found during the autopsy of a 26-year-old male who died due to electrical injuries. A single greyish-white cystic mass measuring 1.5cm X 1.2cm was detected on the left anterior ventricular wall 4 cm above the apex and was confirmed microscopically as a hydatid cyst. The cause of death was attributed to external injury.

EVALUATION OF OUTCOME OF PROXIMAL HUMERUS FRACTURES MANAGED WITH PHILOS PLATE

INTRODUCTION: Proximal humeral fractures account for 4 to 5 percentage of all fractures.minimally displaced can be managed non-operatively in adults. Displaced and unstable fractures should be treated surgically to achieve painless shoulder and good range of movement. AIM AND OBJECTIVES: Our study Is to evaluate the clinical, functional and radiological result of operative proximal humerus fractures managed PHILOS Plating. MATERIAL AND METHODS: 26 patients with displaced proximal humeral fractures that were treated by PHILOS plating between June 2018 to December 2019 were included in this study. The Constant-Murley score (CMS) was used to evaluate the outcome. RESULT: Out of 26 patients 9 were male and 17 were female. The mean age was 52 years. The mean surgical time was 88 min. The mean fracture union time was 11.5 weeks. Outcome was excellent in 17 cases, Good in 6 and Fair in 3 cases. CONCLUSION: Fixation with PHILOS is associated with good to excellent outcomes. It gives high rate of union, good range of movement and has minimal complications.

Cross-sectional study to describe the severity, bio-chemical associations, and final outcomes of COVID-19-associated rhino-orbital-cerebral mucormycosis in a tertiary hospital of East India

Purpose: The second wave of coronavirus disease 2019 (COVID?19) pandemic triggered a mucormycosis epidemic in India. Diabetes mellitus and dysregulated immune response were contributors, and rhino?orbital?cerebral mucormycosis (ROCM) was the most common presentation. It is however not known whether bio?chemical parameters at presentation correlate with stage of ROCM or final outcome in terms of vision or mortality. Methods: This retrospective, hospital?based study included all in?patients of mucormycosis with ophthalmic manifestations at presentation admitted during June 1, 2021 to August 31, 2021. It aimed to evaluate the association between severity of infection, serum levels of HbA1c, ferritin, interleukin?6 (IL?6), C?reactive protein (CRP), and D?dimer levels at presentation and outcome. Results: There were altogether 47 eligible cases having a mean age of 48.8 ± 10.9 years with a male:female ratio of 2.6:1; forty?two (89.4%) had pre?existing diabetes, and five (10.6%) had steroid?induced hyperglycemia. The mean HbA1c among diabetics was 9.7 ± 2.1. HbA1c and serum CRP showed an increase over subsequent stages, which was not statistically significant (P = 0.31). IL?6 values for all stages were similar (P = 0.97). Only serum ferritin levels showed a statistically significant increase over stages (P = 0.04). IL?6 was significantly lower (P = 0.03) in patients who survived, whereas CRP levels were significantly lower in patients who had final visual acuity (VA) better than only perception of light (P = 0.03). Conclusion: Uncontrolled diabetes mellitus is a significant association of ROCM. Serum ferritin levels at presentation best correlate with extent of the disease. CRP levels are best to prognosticate cases that will have sufficient VA to carry on activities of daily living, whereas IL?6 levels are best associated with survival

Role of oral fluid, electrolytes and energy in various pediatric illnesses beyond diarrhea: an Indian expert panel consensus recommendation

Dehydration in non-diarrheal illnesses often goes unnoticed and there are no consensus treatment recommendations for management of dehydration in non-diarrheal illnesses. A multi-disciplinary committee of 10 experts from India gathered on virtual platform in September 2020 to develop consensus recommendation on current treatment strategies for managing oral fluid electrolyte and energy in pediatric patients during non-diarrheal illnesses and to identify unmet needs and gaps. A pre-meeting questionnaire-based voting system was adopted to reach consensus followed by a discussion between panel members. In absence of consensus, the topic was opened for debate to arrive at an aligned recommendation. Key clinical challenges include identifying dehydration in acute illnesses and recommending appropriate quantity and type of oral fluids based on symptom severity. This consensus statement provides guidance on management of dehydration in non-diarrheal illnesses including recommendation on oral fluid, electrolytes, and appropriate energy management in pediatric population. Oral fluid, electrolyte and energy supplementation were recommended based on symptoms in acute non-diarrheal illness increased insensible losses and/or decreased intake. Oral rehydration fluids should be prescribed accurately and at the right-time for countering dehydration, ideally early in the course of illness. Prescribing pattern should be precise and like intravenous fluids. Carbonated drinks and canned juices should not be recommended. Plain water may not be optimal in replacing electrolytes especially for anorexic patients who can only tolerate fluids. These clinical practice statements provide guidance for oral fluid, electrolytes, and energy recommendations for pediatric patients with various acute illnesses beyond diarrhea.

Screening practices for breast and cervical cancer and associated factors, among rural women in Vellore, Tamil Nadu

Background: Population-based screening coverage for breast and cervical cancer screening in the community is inadequately reported in India. This study assessed screening rates, awareness, and other factors affecting screening, among rural women aged 25� years in Vellore, Tamil Nadu. Methods: Women aged 25� years, from five randomly selected villages of a rural block were included in this cross-sectional study in Vellore, Tamil Nadu. Households were selected by systematic random sampling, followed by simple random sampling of eligible women in the house. A semi-structured questionnaire was used to assess screening practices, awareness, and other factors related to cervical and breast cancer. Results: Although 43.8% and 57.9% were aware of the availability of screening for cervical and breast cancer respectively, screening rates were only 23.4% (95% confidence interval [CI]: 18.4-28.4%) and 16.2% (95% CI: 11.9-20.5%), respectively. Adequate knowledge (score of ?50%) on breast cancer was only 5.9%, with 27.2% for cervical cancer. Only 16.6% of women had ever attended any health education program on cancer. Exposure to health education (breast screening odds ratio [OR]: 6.89, 95% CI: 3.34-14.21; cervical screening OR: 6.92, 95% CI: 3.42-14.00); and adequate knowledge (breast OR: 4.69, 95% CI: 1.55-14.22; cervix OR: 3.01, 95% CI: 1.59-5.68) were independently associated with cancer screening. Conclusion: Awareness and screening rates for breast and cervical cancer are low among rural women in Tamil Nadu, a south Indian state with comparatively good health indices, with health education being an important factor associated with screening practices.

A cross-sectional study to describe the spectrum of ocular manifestations and risk factors of mucormycosis presenting to a tertiary hospital of East India

Purpose: To report the clinico?demographic profile of rhino?orbito?cerebral mucormycosis (ROCM) in patients during the “second wave” of the COVID?19 pandemic in eastern India, and their ophthalmic manifestations at presentation to our tertiary institute. Methods: Cross?sectional study amongst patients presenting to our center based on their hospital records. Demographic information, history related to COVID?19, records of detailed ocular examination, and microbiological, radiological, and histopathological investigation were entered into an online worksheet and analyzed using SPSS 26.0. Results: A total of 219 patients with ROCM were treated from May to September 2021, and 110 of these had ocular manifestations at presentation (50.2%). The age of patients ranged from 22 to 83 years and the mean ± standard deviation (SD) age was 49.9 ± 12.9 years. Ninety (81.8%) patients had been diagnosed with diabetes mellitus, 31 (34%) had hypertension, and 10 had other comorbidities. The duration between the onset of COVID?19 and mucormycosis symptoms was 0 to 60 days with a mean ± SD interval of 20.9 ± 12.6 days. Fifty?six (50.9%) patients had a history of steroid use. Unrelenting ocular or facial pain was the most common presenting symptom, ptosis was the most common anterior segment manifestation, and ophthalmic artery occlusion was the most common posterior segment manifestation. Conclusion: Our data from eastern India reinforces the relationship between COVID?19, diabetes, corticosteroid use, and ROCM. Knowledge of various presenting anterior and posterior segment manifestations of the disease as described in the present study will guide clinicians to recognize the disease early and make every effort to prevent complications.

Feasibility of treatment-free remission with generic imatinib: Results of generic imatinib-free trial-in-chronic myeloid leukaemia chronic phase study

Background & objectives: Both innovator and generic imatinib are approved for the treatment of Chronic Myeloid Leukaemia-Chronic phase (CML-CP). Currently, there are no studies on the feasibility of treatment-free remission (TFR) with generic imatinib. This study attempted to determine the feasibility and efficacy of TFR in patients on generic Imatinib. Methods: In this single-centre prospective Generic Imatinib-Free Trial-in-CML-CP study, twenty six patients on generic imatinib for ?3 yr and in sustained deep molecular response (BCR ABLIS ?0.01% for more than two years) were included. After treatment discontinuation, patients were monitored with complete blood count and BCR ABLIS by real-time quantitative PCR monthly for one year and three monthly thereafter. Generic imatinib was restarted at single documented loss of major molecular response (BCR ABLIS>0.1%). Results: At a median follow up of 33 months (interquartile range 18.7-35), 42.3 per cent patients (n=11) continued to be in TFR. Estimated TFR at one year was 44 per cent. All patients restarted on generic imatinib regained major molecular response. On multivariate analysis, attainment of molecularly undetectable leukaemia (>MR5) prior to TFR was predictive of TFR [P=0.022, HR 0.284 (0.096-0.837)]. Interpretation & conclusions: The study adds to the growing literature that generic imatinib is effective and can be safely discontinued in CML-CP patients who are in deep molecular remission.

Role of machine learning techniques in classification of peripheral pulse morphology

Recording of peripheral pulse serves as a very important and essential non-invasive tool used widely by doctors for the diagnosis of various diseases. The morphology of pulse is seen to vary as a function of time in a given individual and also from individual to individual. There are many variations in morphological patterns of peripheral pulse in different disease conditions, which lead to difficulty in accurate diagnosis. The peripheral pulse waveforms are extracted from radial arteries as time series data using a peripheral pulse analyzer which is designed on the principle of impedance plethysmography. It was first introduced by Nyober in the mid-nineteen hundreds and ameliorated further by Kubicek. It involves the recording of the instantaneous blood volume by the measurement of electrical impedance as a function of time. Therefore, the study of peripheral pulse morphology has gained much attention in the past few years among researchers. Physiological variability is one of the recent investigations added during the last two decades for the objective assessment of autonomic function and the assessment of prognosis in severe sicknesses namely myocardial infarction, diabetic neuropathy, etc. In addition to heart rate variability studied worldwide, few researchers have studied blood pressure variability and peripheral blood flow variability. In this computer era, artificial intelligence and machine learning techniques have become more important day-by- day, and different types of algorithms were used for the identification of hidden patterns from plethysmographic observations on the radial pulse such as support vector machine as well as crisp and fuzzy clustering. Eight patterns were classified with a yield of 80%–90% and helped with the diagnosis of disorders such as myocardial infarction, pulmonary tuberculosis, coronary artery disorders, cirrhosis of the liver, and bronchial asthma. This paper briefly describes the use of machine learning techniques for the classification of peripheral pulse morphologies.

Outcome of Pediatric shaft Radius-Ulna Fractures managed with Titanium Elastic Nailing System

Aims and objectives: To study the functional outcome of TENS in Pediatric shaft radiusulna fracture.Introduction: Symmetrical bracing action of elastic nails inserted into the metaphysis, thatbears against the inner bone at three points is the principal of the titanium elastic nailing.Early stability to the involved bone fragments is the benefit of this method and it permitsearly mobilization and returns to the normal activities of the patients, with very lowcomplication rate.Materials and methods: A retrospective study of 40 pediatric patients with closed and opengrade 1 shaft radius-ulna fracture carried out at our institute between 2018-2019 treated withTENS and observed for a period of minimum 1.5 years.Conclusion : It can be concluded that TENS nailing in pediatric shaft radius-ulna fractures isan excellent modality of treatment and has very low complication rate.

A Case of Paediatric Non-union of Tibia Treated With Tibialization of Fibula

Management of non-union with bone gap in tibia is difficult, especially if superimposed by infection of bone. Various modalities have been described for the treatment of gap non-union, with their own advantages and disadvantages. A case of a paediatric patient with traumatic left tibia fracture which was complicated by subsequent osteomyelitis and non-union presented to tertiary care hospital. After failure of different modalities of treatment, to provide union, the patient was managed with tibialization of fibula with fibula strut graft supported by a rush nail

COARCTATION OF AORTA IN A 33 YEARS-OLD UNCONTROLLED HYPERTENSIVE FEMALE PATIENT – A CASE REPORT

We report a 33-year-female patient of hypertension detected at the age of 19 year. Her blood pressure was not well controlled. The case was investigated for secondary hypertension. CT Thoracic and Abdominal aorta Angiogram of the present case showing the narrowing in the thoracic aorta extending at the level of T8 to T10 vertebral body level for the length of 7.5cm. Reconstructed CT of the case showed multiple tortuous collaterals between the branches of internal mammary artery and external iliac artery and between axillary and intercostal artery. Relevant history was reviewed and discussed.

Dieulafoy’s lesion – A rare case of jejunal aneurysm

Despite being a rare condition, Dieulafoy's lesion, also known as the persistent artery, is a serious cause of gastrointestinal bleeding. Only 1–2% of acute gastrointestinal bleeding is caused by it. Most commonly affects the stomach and duodenum, rarely affecting jejunum, ileum, caecum, etc. Our case presents a 21-year-old male who presented with lower gastrointestinal bleeding secondary to jejunal dieulafoy’s lesion.

Interrogation of Superior Vena Cava by Deep Transgastric Transesophageal Echocardiography Imaging: Clinical Applications

The advantages of intraoperative deep transgastric interrogation by transesophageal echocardiography (TEE) of the superior vena cava (SVC) in comparison to the standard bicaval view was studied in pediatric cardiac surgical cases. The view was found to be helpful in obtaining additional data in pediatric cardiac surgical patients.

Aesthetic Space Management: A Case Series

A smile is one of the most critical components of aesthetic rehabilitation.Various anterior rehabilitation cases present in routine clinical practice with excess space, deficient ridge anatomy and malpositioned implant placement, one of the major challenges in any form of aesthetic dentistry is the efficient use of available the space, enhancing function and conservation of components that are already available. Taking into consideration these factors we need to optimise treatment modalities, enhance clinical knowledge, balancing the available resources and time so that a scientifically driven yet uncompromised treatment is embarked upon the patient leading to a long term dental and a systemic treatment; uplifting the patients dental health having a positive impact on the patients psychologic and general health

A study of the effect of yoga on C-reactive protein, lipid profile and insulin resistance in obese patients

Background: Obesity is defined as a state of excess adipose tissue mass. In the last decade, there has been an alarming prevalence of obesity in the developed and developing countries like India. While modern medicine has so far been unable to control the menace of obesity, yoga offers an alternative holistic approach to tackle the problem of obesity by inculcating an approach towards balanced diet (Satwik aahar), physical activity and behavior modification (through pranayama). In this study, we have included the core anthropometric parameters of obesity, as well as associated abnormalities secondary to obesity like, insulin resistance, glucose intolerance, hypertension, atherogenic dyslipidemia. Methods: The study was conducted in the department of medicine, L.L.R.M. Medical College and associated S.V.B.P. Hospital, Meerut, U.P. during 2020-2021 with the objective to assess the role of yoga therapy in modifying anthropometric and biochemical parameters of obese patients. It was a prospective, controlled trial in which 120 obese patients (BMI?25 kg/m2) were enrolled and followed for a period of six months.Results: Yoga therapy along with dietary restrictions is highly effective in improving the various anthropometric and biochemical parameters in obese patients and also beneficial in controlling complicationslike hypertension, diabetes and dyslipidemias secondary to obesity. It also improved the quality of life of these patients.Conclusions: This study is a modest attempt to ascertain the role of yoga in obesity and it hopes to encourage further research in the field.

Chest-X-ray-based scoring, total leukocyte count, and neutrophil-to-lymphocyte ratio to predict in-hospital mortality in COVID-19 patients: a retrospective study

Background:The objective of this study was to assess the demographical characteristic, laboratory and radiological findings associated with COVID-19 mortality in hospitalizedpatients and also to co-relate neutrophil-to-lymphocyte ratio (NLR)and chest x-ray (CXR)score with severity of the disease.Methods:This is a retrospective study done in Bowring and Lady Curzon hospital between the periodof May 2021 to July 2021. 100 patients who were tested positive for SARS-CoV2 with RT-PCR were taken for the study after fulfilling the inclusion criteria. On day 1 of admission, routine blood investigations including CBC with differential count and chestX ray is taken. From the above said data, NLR and CXR score is calculated and a comparison is made to determine severity and in-hospital mortality between mild, moderate and severe COVID pneumonia patients. This study is being carried out after obtaining institutional ethical committee approval clearance. All analysis were performed using SPSS software version 10.Results: The sample size studied was 100. The mean age of patients was 28.3 in mild, 49.9 in moderate and 62.6 in severe COVID patients. Among these 67% were males and 33% were females. It was noted that, leukocytosis(mean-13245), neutrophilia (mean-83.05%), lymphocytopenia (mean-10.45%) and chest X-ray score (mean-4.98) was seen among severe group with p value being significant.Conclusions: TLC, NLR and CXR score were significantly different between severe and non-severe patients, so assessment of these simple parameters may help identify high risk COVID-19 patients at an early stage in a resource limited setting from the data retrieved from our hospital, NLR and CXR Score showed an acceptable efficiency to separate COVID-19 patients among severe and non-severe patients with a significant p value thereby helping in triaging the patients and need for early ICU needs.

Indian Academy of Pediatrics Consensus Guidelines for Probiotic Use in Childhood Diarrhea

Justification: Several probiotic species and strains, single or combined, have been evaluated in childhood diarrheal disorders, and recommendations have ever been changing as newer trials are published. Therefore, there is a need to develop a guideline for Indian children describing the current role of probiotics in clinical practice. Objectives: To develop a guideline for the use of probiotics in children with diarrhea. Process: A national consultative group (NCG) was constituted by the Indian Academy of Pediatrics (IAP), consisting of subject experts. Sub-topics were allotted to various experts as paired groups for detailed review. Members reviewed the international and Indian literature for existing guidelines, systematic reviews, meta-analyses and trials. Thereafter, two virtual structured meetings of the group were held on 2nd and 22nd August, 2020. The management guidelines were formulated by the group and circulated to the participants for comments. The final guidelines were approved by all experts, and adopted by the IAP executive board. Recommendations: The NCG suggests Lactobacillus GG as a conditional recommendation with low-to-moderate level evidence or Saccharomyces boulardii as a conditional recom-mendation with very low-to-low level evidence as adjuvant therapy in acute diarrhea. The NCG also recommends the use of combination probiotics in neonatal necrotizing enterocolitis (NEC), as these reduce the risk of NEC stage II and above, late-onset sepsis, mortality and also time to achieve full feeds. The NCG does not recommend the use of any kind of probiotics in the therapy of acute dysentery, persistent diarrhea, Clostridium difficile diarrhea and chronic diarrheal conditions such as celiac disease, diarrheapredominant irritable bowel syndrome and inflammatory bowel disease in children. Risk of antibiotic-associated diarrhea (AAD) is high with some antibiotics and most of these cases present as mild diarrhea. The NCG recommends probiotics only in special situations of AAD. L. rhamnoses GG or S. boulardii may be used for the prevention of AAD. VSL#3, a combination probiotic, may be used as an adjuvant in active pouchitis, and for prevention of recurrences and maintenance of remission in pouchitis.