Comparison between caudal epidural block and popliteal nerve block for postoperative analgesia in children undergoing foot surgery: a randomized controlled trial

Background: Pain following surgery in children cause discomfort, restlessness and agitation in the postoperative period which may result in an increased incidence of nausea, vomiting and maladaptive behavioural changes. Regional anaesthesia is commonly used as an adjunct to general anaesthesia for perioperative analgesia in children as part of a multimodal approach of pain relief. This study is to compare between caudal epidural block and popliteal nerve block for postoperative analgesia in children undergoing foot surgery.Methods: A prospective randomized single blind study was carried out on 30 children aged 1-12 years of either sex undergoing foot surgery. Patients were randomly assigned into caudal epidural block group and Popliteal nerve block group, 15 children each. Both groups receive 1 ml/kg of 0.25% bupivacaine. Foot surgery was carried out under general anesthesia along with regional block for all children. After completion of surgery, children were shifted to PACU and HR, BP, SPO2 were monitored. Patient was discharged from PACU after CHEOPS (1-5 years) or VAS (6-12 years) <4. Parental satisfaction, sedation score, PONV, and any other side effects were recorded.Results: Demographic data and baseline vital signs were comparable between two groups. Statistically significant difference (p=0.025) in number of attempts in giving block in group A (1.20±0.41) than group B (1.80±0.86). The mean postoperative pain scores, CHEOPS and VAS were comparable in both groups.Conclusions: Both caudal epidural block and popliteal nerve block provides comparable and adequate analgesia in children undergoing elective foot surgery.

Clonality assessment of lymphoproliferative lesions using the polymerase chain reaction: An analysis of two methods.

Background: Lymphoid malignancies are a heterogeneous group of disorders which may be difficult to differentiate from reactive proliferations even after immunohistochemistry. Polymerase chain reaction (PCR) is believed to be a good adjunct tool for diagnosis. Materials and Methods: We examined 24 cases of neoplastic and non-neoplastic lymphoproliferative lesions in this study and evaluated the PCR as an additional tool in the confirmation of the diagnosis. Two different PCR methodologies were evaluated. Results: In the evaluation of the T-cell PCR, it was seen that the correlation using both the commercial kits and the custom-synthesized primers was highly significant at a P value of <0.05. In the evaluation of the B-cell PCR, it was seen that the correlation using both the commercial kits and the custom-synthesized primers was not significant using either method (P > 0.05). Conclusions: Both the methods showed an excellent concordance for T-cell γ gene rearrangements, However, the same was not seen in the B-cell receptor rearrangements. This may be because of the small sample size or the inability of consensus V primers to recognize complementary DNA sequences in all of the V segments.

Glomus tumor of the stomach.

Gastric glomus tumors are rare neoplasms. We report here a case of gastric glomus tumor in a 25-year-old female who presented with exsanguinating gastrointestinal hemorrhage. Clinically and on gross examination, the tumor was suspected to be a gastrointestinal stromal tumor (GIST). Histopathological and immunohistochemical evaluation revealed it to be a glomus tumor.

Chlamydia trachomatis seropositivity during pregnancy.

BACKGROUND: Chlamydia trachomatis infection in pregnant women can lead to serious maternal/neonatal antenatal or postnatal complications. The aim of this study was to find out the quantum of this problem in antenatal cases of Command Hospital, Kolkata. METHODS: Antibodies to C. trachomatis by ELISA method were tested in sera of 24 pregnant women and 10 nonpregnant controls. RESULTS: Five (20.83%) and 3 (12.5%) were positive and borderline positive for IgM and 1 (4.17%) and 2 (8.33%) were positive and borderline positive respectively for IgG antibodies i.e. an overall positivity of 45.83%. Only 1 (10%) of the controls was positive for IgA antibodies. CONCLUSIONS: This study highlights the importance of performing this simple blood test for detecting C. trachomatis infection in antenatal cases, to treat the infected and prevent the complications.

Recording of double atrial potentials as a marker for isthmus block during ablation of atrial flutter.

Radiofrequency ablation is an established method for treatment of type I atrial flutter. The assessment of creation of complete bidirectional isthmus block following linear ablation of the isthmus is an integral part of ablation procedure. Conventionally, bidirectional isthmus block is tested by pacing on either side of ablation line and looking for reversal of activation sequence in the right atrium. We looked at the feasibility of recording double potentials, separated by an isoelectric interval along the ablation line as an alternative method to demonstrate bidirectional isthmus block. An attempt was made to record the double potentials following linear ablation of the cavotricuspid isthmus. Following ablation, bidirectional isthmus block was also tested by pacing from the coronary sinus os and the low-lateral right atrium. We could demonstrate double potentials in 9 of the 11 patients in whom we attempted to record them following linear ablation of flutter. The presence of bidirectional block by pacing from coronary sinus os and low lateral right atrium could be demonstrated in 10 (91%) patients. Thus, double atrial potentials, separated by an isoelectric interval can be demonstrated following ablation of atrial flutter. Double potentials, if demonstrable on coronary sinus os and low lateral right atrium pacing, could serve as an alternative marker of isthmus block.

A study of yeast carriage on hands of hospital personnel.

The present study was conducted by culture with a modified broth wash technique to examine the frequency of yeast carriage on the hands of 60 nurses and 35 nonnursing hospital employees. Seventy two percent of the nurses and 80% of the nonnurses were harbouring yeast on their hands. Candida spp. were isolated in 57% on of nurses and 34% of nonnurses. Ninety percent of nurses working in nursing home care unit (NHCU), 50% working in intensive care unit (ICU) and 75% working in outpatient department (OPD) carried yeasts on their hands. Only 80% of nonnurses staff harboured yeasts on their hands.

Initial experience with day case laparoscopic cholecystectomy at a tertiary care hospital in India.

BACKGROUND: Cholecystectomy is one of the commonest general surgical operations. Laparoscopic cholecystectomy is currently the most favoured approach. As it is associated with less postoperative pain and ileus, it allows early discharge of patients from the hospital. Studies from the West have reported that 'day case laparoscopic cholecystectomy' is feasible and safe. In India, the current practice is to admit patients for laparoscopic cholecystectomy 24-48 hours prior to surgery and to discharge most patients within one to two days of surgery. There is no report from any Indian centre describing 'day case laparoscopic cholecystectomy'. We conducted a prospective study to assess the feasibility, safety and patients' acceptance of 'day case laparoscopic cholecystectomy' in a tertiary care hospital. METHODS: Eighty-four patients with symptomatic cholelithiasis, aged less than 65 years with ASA grade I and II, were offered day case laparoscopic cholecystectomy. Seventy-four patients consented to be included in the study. The nature of operation and likely postoperative course were explained in detail to the patients. Conventional 4-port laparoscopic cholecystectomy was attempted in all patients. The main outcome measures assessed were successful management of patients on day case basis and its acceptance by the patients. RESULTS: Sixty-eight (92%) patients underwent successful laparoscopic cholecystectomy. Fifty-five of these (81%) were successfully managed as day case procedures. There were no major complications. Three of the 55 patients (5.4%) needed re-admission and could be managed conservatively. Fifty-three (96%) patients described their experience as 'pleasant'. None of them described their experience to be 'unpleasant' or 'bad'. Fifty-four (98%) patients stated that they would recommend day case laparoscopic cholecystectomy to close friends and relatives. CONCLUSION: In selected patients, day case laparoscopic cholecystectomy is safe and feasible in a developing country.

Radiofrequency catheter ablation of common atrial flutter--acute and follow-up results.

Atrial flutter with a structurally well-defined macro-reentrant circuit in the right atrium has recently become amenable to radiofrequency ablation with the recognition of isthmus as a narrow zone of slow conduction. This study describes 20 consecutive and symptomatic patients with atrial flutter (15 males, 5 females; mean age 38.5 +/- 10.2 years) who underwent radiofrequency ablation in our institute in the last 18 months. Fourteen patients had structurally normal hearts, while the remaining six patients had specific disorders (prior surgery for closure of atrial septal defect-2, idiopathic restrictive cardiomyopathy-1, primary sinus node dysfunction-2, tachycardiomyopathy-1). The endpoints of a complete isthmus block and conversion to sinus rhythm were achieved in 19 of the 20 patients. Total number of pulses needed to attain the endpoints was a mean of 4.2 (range 1-5), each pulse being delivered for 90 seconds. At a mean follow up of 9.4 +/- 3.2 months (range 6-12 months), recurrence of atrial flutter was seen in one patient, atrial fibrillation in two and sinus node reentrant tachycardia in one. These results are comparable to those reported in the literature. Achievement of a complete isthmus block appears to be an important endpoint in obtaining optimal results. The issues of alternative sites of ablation, long-term results and advantages of an 8 mm tip catheter need to be examined further. In conclusion, radiofrequency ablation appears to be the preferred mode of treatment for patients with atrial flutter with excellent short-term and mid-term results.

Elective stent implantation after optimal debulking for complex coronary lesions: acute and mid-term results.

Between January 1995 to December 1997, 45 patients with complex lesions in coronary arteries were treated by using the strategy of initial debulking with an atherectomy device followed by elective stenting. Their age ranged from 35-73 years (mean +/- SD:53.9 +/- 9.1) and 93.3 percent were males. The lesion morphology was type B1 in 14 (31.1%), B2 in 16 (35.6%) and type C in 13 (28.9%) patients. The choice of atherectomy device, based primarily on the morphology of lesion, was rotational atherectomy in 23 (51.1%) and directional coronary atherectomy in 22 (48.9%) patients. While majority (73.9%) of the lesions treated by rotablation were long, diffuse and calcified, directional atherectomy was preferred for highly eccentric stenoses in large-sized arteries. All patients underwent elective stent implantation after optimal lesion debulking using a mean burr size of 1.74 +/- 0.2mm for rotablation and a 7Fr. atherocath in majority (90.9%) of patients treated by directional coronary atherectomy. Angiographic success was achieved in all, while clinical success was 97.8 percent. One patient died of acute-on-chronic renal failure during hospitalisation. There were no other major in-hospital adverse cardiac events. At a median follow-up of 13 months (range 1-36 months), recurrence of angina developed in 10 (22.7%), out in which target lesion revascularisation was required in 5 (11.4%) and elective coronary artery bypass graft surgery in one (2.2%) patient. The event-free survival as calculated by the Kaplan-Meier method was 85.8 percent at six, 77.2 at 12 71.7 percent at 18 months of follow-up. In conclusion, optimal debulking before stent implantation provides a larger lumen, and thus eliminates sub-acute stent thrombosis in complex coronary lesions. This strategy also resulted in a high incidence of event-free survival and a low frequency of target lesion revascularisation on mid-term follow-up.

Comparison of in-hospital and follow-up results of directional atherectomy and stenting for ostial lesions of the left anterior descending coronary artery.

Lesions at the ostium of the left anterior descending coronary artery constitute a distinct group because of suboptimal results and higher restenosis rate after balloon angioplasty. Several non-balloon devices have been used to improve the outcome of dilatation of such lesions. We retrospectively compared the in-hospital and follow-up results of directional coronary artherectomy and stents for the treatment of ostial lesions of the left anterior descending artery. Out of 37 patients, 12 underwent directional coronary atherectomy and 25, stent implantation. The two strategies were deployed at different periods over the past five years. The baseline clinical and angiographic characteristics were comparable in the two groups. Directional coronary atherectomy was done using 7Fr atherocath with adjunctive balloon angioplasty in all. All the stents were deployed using moderate to high pressure balloon inflation after adequate predilatation. While the pre-procedure luminal diameter stenosis was similar in the two groups (87.3 +/- 8.8% vs 89.3 +/- 7.2%; p = NS), the residual stenosis was significantly lower in the stent group (5 +/- 2.8%) compared to directional coronary atherectomy (18.7 +/- 9.8; p = 0.02). There was no significant difference in the primary success rate between the two devices (91.6% directional coronary atherectomy vs 100% stent; p = NS). One patient in the directional coronary atherectomy group developed acute closure followed by emergency coronary artery bypass graft surgery and death. No major complication was observed in the stent group. Over a mean follow-up of 9.9 +/- 11.6 months following directional coronary atherectomy and 8.6 +/- 4.4 months after stenting, significantly higher number of patients (60%) developed recurrence of angina or any event following directional coronary atherectomy compared to stent (15.8%; p < 0.02). There was no myocardial infarction, coronary artery bypass graft surgery or death in either group on follow-up. The need for target lesion revascularisation was significantly higher in the directional coronary atherectomy group (50%) compared to stenting (10.5%; p < 0.02). Comparing directional coronary atherectomy with stent, the event-free survival was 80 percent vs 94.7 percent at three months and 50 percent vs 84.7 percent, both at six and nine months, respectively. In conclusion, stenting of the left anterior descending artery ostial lesion results in a significantly lesser post-procedure residual stenosis, improved in-hospital outcome, a lesser need for target lesion revascularisation and much improved event-free survival on follow-up as compared to directional coronary atherectomy. Therefore, stenting appears to be a more favourable treatment option compared to directional coronary atherectomy for the treatment of ostial lesions in the left anterior descending artery.

Coronary artery stenting for isolated proximal left anterior descending stenosis: immediate and follow-up results.

Between February 1995 to August 1997, 120 patients underwent elective stent implantation for isolated proximal left anterior descending coronary artery stenosis. Their age ranged from 31 to 72 years (mean: 50.8 +/- 10.2) and the majority (89%) were males. All patients had angina, documented myocardial ischemia or both and 70 percent or more luminal diameter stenosis in the proximal left anterior descending before the origin of any branch. Majority (62.5%) of the treated lesions were type A. Successful deployment of the stent at the target site was achieved in all patients without any major in-hospital complications, including myocardial infarction, emergency bypass graft surgery or death. Clinical follow-up, ranging from 6 to 31 months (mean: 18.5 +/- 8.1, median: 20), was available in 87 out of 92 (94.5%) eligible patients who had completed at least six months after the procedure. Freedom from angina, myocardial infarction, target lesion revascularization and death was observed in 90.8, 100, 95.4 and 97.7 percent of patients, respectively. By the Kaplan-Meier estimate, an event-free survival (absence of death, myocardial infarction, recurrence of angina or revascularization) was 95.4 percent at six months, 89.5 percent at 12 and 18 months and 82.7 percent at 24 to 31 months of follow-up. Only 10 (11.5%) patients developed any event and TLR was required in 4.6 percent of patients. In conclusion, elective stenting for isolated proximal left anterior descending stenosis can be achieved safely and successfully in all patients without any adverse in-hospital events. This modality of treatment also provides long-term benefits in terms of reduction in major cardiovascular events and need for subsequent revascularization.

Antifungal susceptibility pattern of non-albicans Candida species & distribution of species isolated from Candidaemia cases over a 5 year period.

A marked increase in the incidence of patients of candidaemia is reported from a tertiary care hospital in north India over the last five years (15 patients in 1991 and 275 in 1995). The distribution of Candida species isolated from January 1991 through December 1995 was investigated. Antifungal susceptibility against amphotericin B, 5-fluorocytosine, ketoconazole and fluconazole of 100 randomly selected non-albicans Candida species isolated during 1995 was determined by an in-house standardized disc diffusion method and the standard broth dilution procedure recommended by the National Committee for Clinical Laboratory Standards (NCCLS, USA). The disc diffusion method correlated well with NCCLS method except for ketoconazole. Resistance against any antifungal was confirmed only by results of NCCLS method. A shift to higher isolation of non-albicans Candida species was observed during this period (52.6% in 1992 to 89.5% in 1995). Resistance was observed against 5-fluorocytosine in 3 per cent strains of C. krusei; and against fluconazole in 24.2 per cent of C. krusei, 15.4 per cent of C. guilliermondii and 5.7 per cent strains of C. tropicalis. No resistance was detected against amphotericin B and ketoconazole. Thus Candida species with fluconazole resistance have become more prominent in recent years.