Integrating perioperative medicine with anaesthesia in India: Can the best be achieved? A review.

Integrating perioperative medicine with anaesthesia is the need of the hour. Evolution of a new superspeciality called perioperative anaesthesia can improve surgical outcomes by quality perioperative care and guarantee imminent escalation of influence and power for anaesthesiologists. All original peer-reviewed manuscripts pertaining to surgery-specific perioperative surgical home models involving preoperative, intraoperative and postoperative initiatives spanning the past 5 years have been reviewed using PubMed and Google Scholar. Whether the perioperative surgical home model is feasible or still a distant dream in the Indian perspective has been analysed.

Saline conditions alter morpho-physiological intensification in purslane (Portulaca oleracea l.).

In this study, primary investigations of selected cultivar of purslane named as Tall Green under articular salinity stress were evaluated to understand the basic concept of different mechanisms of physiological attributes which will play an important role for molecular and proteomic level research. The evaluation of morphological and physiological attributes under 0 mM (without salt addition) 100 mM and 200 mM salt stress changed dramatically. The results showed high salt stress at 200 mM significantly decreasing the morphological attributes and performance of leaves, stems, and roots. At moderate salt stress levels, 100 mM, the ratio of Fv/Fm slightly increased compared to high stress. In addition, salt stress significantly decreased the total chlorophyll content (chl a+b) at 200 mM. The relative water content percentage was high at 0 mM. Moreover, the electrolyte leakage (EL) significantly increased with increasing salinity stress compared to control 0 mM.

Outcome of treatment of nonunion tibial shaft fracture by intramedullary interlocking nail augmentated with autogenous cancellous bone graft.

To assess results of operative treatment of non union fracture shaft of Tibia by intramedullary interlocking nail augmented with autogenous cancellous bone graft in our setup. A total of 25 nonunion tibial shaft fractures were evaluated among which 20 cases were male and 5 female with the mean age 31.84 years. Hypertrophic non-union were 14 and atrophic non union were 11. Upper one third of tibial diaphysis was involved in 4 cases, middle one third in 14 cases and lower one third in 7 cases. In all cases open reduction, interlocking nailing and autogenous cancellous bone graft was applied. The mean follow up was one year. Mean time for healing was 8.08 months. Mean operation time was 110 minutes (range 70 to 160 minutes). Satisfactory results (excellent and good) were achieved in 88% cases and unsatisfactory (fair and poor) results in 12% cases. This operative treatment option appears to have a high success rate and should be considered in nonunion of tibial diaphysis.

Comparative study in surgical outcome of intracapsular fracture neck of femur in active elderly patients treated with hemiarthroplasty with Austin Moore's and bipolar prosthesis.

Fracture neck of femur is most commonly encountered fractures in elderly population. Hemiarthroplasty is generally considered to be the treatment of choice in most active elderly patients. However, there is inadequate evidence to support the choice between unipolar or bipolar prosthesis. This study was conducted to analyze the outcome regarding pain, hip function, complication and acetabular erosion in patients randomly selected and treated with Austin Moore's or Bipolar hemiarthroplasty in our setup. The study included total of 40 patients (17 males and 23 females) with intracapsular neck of femur fractures with mean age of 67 years (55-85 years). 20 patients each were treated with Hemiarthroplasty using Austin Moore's and Bipolar prosthesis. The patients were followed up at intervals of 2 weeks, 6 weeks, 24 weeks and 1 year after the operation and evaluated clinically and radiologically. There were no significant differences between the groups regarding complication. The Harris hip score were 81.95% (SD - 2.99) in Austin Moore's hemiarthroplasty and 79.15% (SD - 2.94) in Bipolar hemiarthroplasty (p = 0.812), whereas acetabular erosion was 20.05% in Austin Moore's hemiarthroplasty and 5% in Bipolar hemiarthroplasty (p = 0.758) with no mortality seen during lyear follow up. The intracapsular neck of femur fracture in active elderly patients treated with Austin Moore's hemiarthroplasty had better outcome regarding pain and hip function whereas high acetabular erosion compared to patients treated with Bipolar hemiarthroplasty though the difference is statistically insignificant.

Diaphyseal femoral fractures in children treated with titanium elastic nail system.

Femur fractures are common long bone injuries in children which account for less than 2% of all paediatric fractures. Although these fractures are dramatic and disabling injuries for the child and parent, the good part is that they unite rapidly with minimal complications if aligned well. Various methods have been used successfully to treat these fractures, but they differ in their stability and potential for complications. The aim of our study was to see the outcome of titanium elastic nailing system in diaphyseal femoral fracture in children. The study included total of 30 children's (19 boys and 11 girls) of diaphyseal femoral fracture treated with titanium elastic nailing system and they were followed up at 2, 6, 12 and 24 weeks. The average duration of callus formation was 3.5 weeks with radiological union mean time of 9.5 weeks. Full weight bearing was possible in a mean time of 10 weeks. According to flynn's scoring criteria, excellent and good results were in 24 cases (80%) and 6 cases (20%) respectively. The nail irritation was present in 3 childrens and there was no post operative infection, physeal injury and implant failure. Titanium elastic nail is a safe and satisfactory mode of treatment and is relatively easy to perform in disphyseal fracture of femur in children. It avoids the chances of physeal injury, infection and offers rapid healing.

The treatment of trigger thumb in children: conservative or surgical?

The trigger thumb is an uncommon condition in infants and children which occurs due to pathology of flexor pollicis longus or A1 pulley. The objectives in our study were to determine the treatment outcome of trigger thumb. The study included total of 45 patients (24 males and 21 females) with trigger thumb. The mean age of onset was 28.5 months (3 months -7 years). There was overall success rate of 72.41% following conservative treatment and the success rate appears to be higher in the younger age group. The outcome of children who underwent surgery was 91.66% with recurrence rate of 8.33% and superficial wound infection rate of 4.16%. Our study suggests that surgery is not urgent, postponing surgery does not interfere with the result, trying conservative methods to get a higher chance of recovery is reasonable before the elective surgery. So conservative approach should be adopted in treating trigger thumb.

Outcome of pertrochantric fracture of the femur treated with proximal femoral locking compression plate.

Pertrochantric femoral fractures are one of the most common fracture in old patients with variety of complications. However fixing Pertrochantric femoral fractures properly is clinically challenging. We report the outcome of pertrochantric femoral fractures treated with Proximal Femoral Locking Compression Plate (PFLCP) using Minimal Invasive Percutaneous Plate Osteosynthesis (MIPPO) techniques which were evaluated clinically by Harris hip score and radiologically for a union at fracture site and implant related complication. The study included total of 33 patients (20 males and 13 females) with Pertrochantric femoral fractures. The mean ages of the patients were 57 years (23-88 years). Pertrochantric femoral fractures included both Intertrochantric and Subtrochantric femoral fractures. Patients were followed up at 2 weeks, 6 weeks, 3 months, 6 months and 1 year after the operation. Among the 33 patients, the union rate was 95% (31 patients). However there were 1 case of implant breakage and 1 case of non union. According to Harris Hip score the excellent and good results were 87.87% with no mortality during 1 year follow up period. The PFLCP can be feasible alternative to the treatment of Pertrochantric femoral fractures by providing biological healing and mechanical stability with limited occurrence of complications.

Staple versus locking compression plate fixation after lateral closing wedge high tibial osteotomy.

PURPOSE: To compare the results of staple versus locking compression plate fixation after closing wedge high tibial osteotomy. METHODS: A group of 23 patients (24 knees) who underwent box high tibial osteotomy and staple fixation was compared with another group of 19 patients (22 knees) who underwent a similar procedure but with locking compression plate fixation. Both groups were followed up for 3 years. The range of movement, Hospital for Special Surgery (HSS) Knee Score, time to full weight bearing, incidence of delayed union, femorotibial angle, and stage of osteoarthritis were compared. RESULTS: At 6 months after the operation, the median HSS score and the proportion of patients with excellent or good scores were significantly higher in the locking compression plate than the staple fixation group (76 vs 62, p=0.003; 75% vs 42%, p=0.0354), but not at one and 3 years. The range of movement was significantly greater in the locking compression plate fixation group in the short term (6 weeks, 3 and 6 months), but not after one year. The median time to full weight bearing was significantly shorter in the locking compression plate fixation group (86 vs 116 days, p<0.001). There were fewer delayed unions in the locking compression plate fixation group but not significantly (1 vs 5, p=0.198), possibly because of the small numbers involved. There was no difference, within the limits of measurement error, in the femorotibial angle or correction loss between the 2 groups. CONCLUSION: Locking compression plate fixation obviates the use of plaster casts, enables early mobilisation and bone union, and reduces the numbers with delayed union and the time to full weight bearing. Longer-term studies are needed to evaluate its effect on revarisation and arthropathy.

In vivo expression of myosin essential light chain using plasmid expression vectors in regenerating frog skeletal muscle.

It is well established that mutations in specific structural elements of the motor protein myosin are directly linked to debilitating diseases involving malfunctioning striated muscle cells. A potential way to study the relationship between myosin structure and function is to express exogenous myosin in vivo and determine contractile properties of the transgenic muscle cells. However, in vivo expression of functional levels of contractile proteins using transient transgenesis in skeletal muscle has not been demonstrated. Presently, we used in vivo gene transfer to express high levels of full-length myosin light chain (MLC) in skeletal muscle fibers of Rana pipiens. Anterior tibialis (AT) muscles were injected with cardiotoxin to cause degeneration and then injected at various stages of regeneration with plasmid expression vectors encoding full-length MLC1(f). In fibers from the most robustly transfected muscles 3 weeks after plasmid injections, trans-MLC1(f) expression averaged 22-43% of the endogenous MLC1(f). Trans-MLC1(f) expression was the same whether a small epitope tag was placed on the C- or N-terminus and was highly variable along individual fibers. Confocal microscopy of skinned fibers showed correct sarcomeric incorporation of trans-MLC1(f). The expression profile of myosin heavy chain isoforms 21 days after transfection was similar to normal AT muscle. These data demonstrate the feasibility of using in vivo gene transfer to probe the structural basis of contractile protein function in skeletal muscle. Based on these promising results, we discuss how further improvements in the level and consistency of myosin transgene expression may be achieved in future studies, and the therapeutic potential of plasmid gene transfer in regenerating muscle.

Bench-scale biofilter for removing ammonia from poultry house exhaust.

A bench-scale biofilter was evaluated for removing ammonia (NH3) from poultry house exhaust. The biofilter system was equipped with a compost filter to remove NH3 and calcium oxide (CaO) filter to remove carbon dioxide (CO2). Removal of NH3 and CO2 from poultry house exhaust could allow treated air with residual heat to be recirculated back into the poultry house to conserve energy during winter months. Apart from its use as a plant nutrient, NH3 removal from poultry house exhaust could lessen the adverse environmental impacts of NH3 emissions. Ammonia and CO2 were measured daily with gas detector tubes while temperatures in the poultry pen and compost filter were monitored to evaluate the thermal impact of the biofilter on treated air. During the first 37 days of the 54-day study, exhaust air from 33 birds housed in a pen was treated in the biofilter; for the final 17 days, NH3-laden exhaust, obtained by applying urea to the empty pen was treated in the biofilter. The biofilter system provided near-complete attenuation of a maximum short-term NH3 concentration of 73 ppm. During the last 17 days, with a mean influent NH3 concentration of 26 ppm, the biofilter provided 97% attenuation. The CaO filter was effective in attenuating CO2. Compared with a biofilter sized only for NH3 removal, an oversized biofilter would be required to provide supplemental heat to the treated air through exothermic biochemical reactions in the compost. The biofilter could conserve energy in poultry production and capture NH3 for use as plant nutrient. Based on this study, a house for 27,000 broilers would require a compost filter with a volume of approximately 34 m3.

Sarcomere number regulation maintained after immobilization in desmin-null mouse skeletal muscle.

The serial sarcomere number of skeletal muscle changes in response to chronic length perturbation. The role of the intermediate filament desmin in regulating these changes was investigated by comparing the architectural adaptations of the tibialis anterior, extensor digitorum longus (EDL) and soleus from wild-type mice with those of homozygous desmin knockout mice after hindlimb immobilization. After 28 days, serial sarcomere number increased significantly in the lengthened wild-type tibialis anterior (by approximately 9%) and EDL (by approximately 17%). Surprisingly, muscles from desmin knockout mice also experienced significant serial remodeling, with the serial sarcomere number of the tibialis anterior increasing by approximately 10% and that of the EDL by approximately 27%. A consistent result was observed in the shortened soleus: a significant decrease in sarcomere number was observed in the muscles from both wild-type (approximately 26%) and knockout (approximately 12%) mice. Thus, although desmin is not essential for sarcomerogenesis or sarcomere subtraction in mouse hindlimb muscles, the results do suggest subtle differences in the nature of sarcomere number adaptation. We speculate that desmin may play a role in regulating the optimal arrangement of sarcomeres within the muscle or in sensing the magnitude of the immobilization effect itself.

Chronic rhinosinusitis: allergy and sinus computed tomography relationships.

The management of chronic or recurrent rhinosinusitis problems is multifaceted and should include consideration of contributory and potentially correctable medical and anatomic factors. To date, the relationship between allergy and rhinosinusitis has not been clearly defined. The purpose of this study is to improve understanding of the relative roles of perennial and seasonal allergens in the cause of chronic rhinosinusitis. A retrospective review of 200 consecutive patients was carried out on patients who had chronic rhinosinusitis refractory to medical therapy and who subsequently underwent functional endoscopic sinus surgery. All of these patients had allergy testing for common perennial and seasonal inhalant allergens before surgery. Each patient had sinus CT imaging before undergoing the surgery. The CT scans of each patient were staged according to a validated, standardized grading system by investigators blinded to allergic profile. Allergy testing indicated that 84% of all patients tested positive for allergies. Moreover, 60% of all patients had significant allergic sensitivity; 52% of all patients had multiple allergen sensitivities. Furthermore, there was a predominance of perennial allergens, especially house dust mite over seasonal allergens. The vast majority of our patients undergoing functional endoscopic sinus surgery had concomitant allergy. This study highlights the potential contribution of perennial allergies to the development of rhinosinusitis. Given this direction, future studies may reveal that in the care of patients with perennial allergic rhinitis, early intervention with identification of the offending allergen(s), and subsequent treatment through avoidance, pharmacotherapy, and/or immunotherapy may help in the prevention of recurrent and chronic rhinosinusitis.

Laser in situ keratomileusis to correct residual myopia and astigmatism after radial keratotomy.

PURPOSE: To evaluate the safety and efficacy of laser in situ keratomileusis (LASIK) in selected post-radial-keratotomy (RK) eyes with residual myopia and astigmatism. SETTING: TLC-The Brea Laser Eye Center, Brea, California, USA. METHODS: Nine eyes of 6 patients who had had RK but had residual myopia and/or astigmatism had LASIK. All RK eyes had 8 radial incisions, were more than 1 year post-RK, had no epithelial inclusion cysts or corneal disease, and had had no subsequent ocular surgery. Follow-up was a minimum of 13 months, at which time uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), manifest refraction, cycloplegic refraction, keratometry, central and peripheral pachymetries, intraocular pressure, and a subjective assessment of visual function were obtained. RESULTS: At the last follow-up, the mean spherical equivalent (SE) was -0.156 diopter (D) +/- 0.174 (SD). All eyes treated for distance vision had a UCVA of 20/25 or better. No patient lost BCVA. No intraoperative or postoperative complications occurred. Seven eyes had morning and evening measurements. The mean change in manifest SE from morning to evening was -0.143 D. Six of the 7 eyes (86%) had 0 to 1 Snellen line change in UCVA from morning to evening. The subjective questionnaire revealed a high degree of satisfaction with overall vision, minimal glare, and less fluctuation in daily vision than before LASIK. CONCLUSION: Laser in situ keratomileusis is safe and efficacious for reducing residual myopia and astigmatism in properly selected RK patients.

Nontraumatic nasal septal abscesses in the immunocompromised: etiology, recognition, treatment, and sequelae.

Proper management of a nasal septal abscess requires prompt diagnosis, adequate surgical drainage, and antibiotics to prevent the potentially dangerous spread of infection and the development of severe functional and cosmetic sequelae. Most septal abscesses are the result of trauma to the nose with septal hematoma and subsequent infection. We present our experience with nasal septal abscesses in five immunocompromised patients without history of nasal trauma. All patients were treated with surgical drainage and antibiotics. The infections in four patients resolved, whereas in the fifth, the infection led to death. We report these cases to depict alternate etiologies of nasal septal abscess, particularly in the immunocompromised patient. Our review illustrates the wide spectrum of disease presentation, provides treatment strategies, and emphasizes the potentially catastrophic sequelae of this disease when unrecognized. With the growing number of immunocompromised individuals, it is important to recognize the potential for immunocompromise to influence the development of septal abscess.

Transmucosal fine-needle aspiration diagnosis of intraoral and intrapharyngeal lesions.

OBJECTIVES: The effectiveness of fine-needle aspiration biopsy (FNAB) for the diagnosis of neck, thyroid, and salivary gland masses is well documented. Very few reports explore the potential of an intraoral FNAB approach for the diagnosis of submucosal lesions. We describe our technique and present case examples of pertinent differential diagnostic entities. We recommend an expanded role for FNAB of the oral cavity and oropharynx. STUDY DESIGN: Retrospective review. METHODS: A uniform technique was employed for transmucosal FNAB of 76 patients with intraoral masses. In applicable cases, cytology results were compared with traditional biopsy methods and permanent histopathologic specimens for accuracy. RESULTS: Our experience demonstrates the high sensitivity (93%) and specificity (86%) of intraoral FNAB when compared with biopsy by conventional means. FNAB provides distinct advantages for the cytologic diagnosis of submucosal lesions, which may be difficult to reach and adequately sample through conventional biopsy. FNAB of the tonsil and tonsillar fossa provides a safe and effective means of diagnosing both lymphoma and squamous cell cancer. Transmucosal FNAB via the mouth led to rapid diagnosis of a number of benign and malignant lesions. Applying this uniform FNAB technique, we had no significant complications. CONCLUSION: We recommend transmucosal FNAB as an effective means for highly accurate diagnosis of submucosal lesions of the oral cavity and oropharynx. CLINICAL RELEVANCE: Traditional biopsy techniques in the oral cavity may require anesthesia and may have diagnostic difficulties, particularly for submucosal lesions. Transmucosal FNAB overcomes these shortcomings by providing a minimally invasive means to rapid diagnosis of intraoral lesions.

Transverse/sigmoid sinus dural arteriovenous fistulas presenting as pulsatile tinnitus.

OBJECTIVE/HYPOTHESIS: Transverse/sigmoid sinus dural arteriovenous fistula (TSDAVF) is a diagnostically elusive entity that is critical for the otologist to account for, when confronted by pulsatile tinnitus in the face of normal otoscopy. Left untreated, TSDAVF may result in catastrophic outcome. We have previously proposed a grading system specifically for TSDAVF based on venous restrictive disease. Our objective was to assess the validity of this grading system for clinical severity and therapeutic outcome. METHODS: Through a retrospective review of 41 patients with TSDAVF, we evaluated clinical presentation, diagnostic evaluation, therapy, and outcome. Patients were classified into four grades based on the severity of venous restrictive disease as determined by superselective angiography. Our treatment algorithm combined compression therapy, transarterial embolization, and for more severe grades, surgery. RESULTS: Pulsatile tinnitus was the chief complaint of all the patients in this series, and of 90% of all cases of TSDAVF treated at our institution. While angiography remains the gold standard, magnetic resonance imaging/magnetic resonance arteriography is far superior to computed tomography scanning in detecting dural arteriovenous fistulas. As normal venous outflow gives way to aberrant cortical venous drainage in higher grades, there is a dramatically increased risk for adverse consequences with therapeutic intervention. Using our treatment algorithm, 82% of patients achieved clinical resolution of symptoms. Half of these patients had complete angiographic obliteration of their TSDAVF. CONCLUSIONS: The TSDAVF-specific grading system for the severity of venous restrictive disease is reflective of clinical presentation, fundamental in planning treatment, and predictive of therapeutic outcome.