Radiological versus Traditional Parameters for Airway Assessment: A Comparison.

Background: The incidence of difficult tracheal intubation includes not only difficult and failed intubation but also difficult laryngoscopy (DL) and difficult mask ventilation. Aim: The study was done to compare the sonographic assessment of tongue thickness (TT) and condylar mobility with traditional airway assessment scores for prediction of difficult intubation (DI). Settings and Design: This experimental, randomized prospective study was conducted in the Department of Anaesthesia, Himalayan Institute of Medical Sciences, Dehradun. Materials and Methods: After obtaining approval from the Institutional Ethical and Research Committee, this study was conducted in the Department of Anaesthesiology, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Swami Ram Nagar, Dehradun. After obtaining written and informed consent, 385 subjects of either sex between 18 and 60 years of age, undergoing various elective surgeries under general anesthesia with endotracheal intubation, were selected. The number of attempts at intubation, the need for alternative DI approaches, and invasive airway access or cancellation of the procedure due to inability to secure the airway were noted. Statistical Analysis Used: Data analysis was done using SPSS 20.0. Categorical data were assessed by Chi-square test, while independent t-test/Mann-Whitney test was used to determine the association between continuous data. Results: Age, inter-incisor distance (IID), body mass index (BMI), and Mallampati score were positively correlated with TT. BMI (kg.m-2) >26.0, modified Mallampati scoring >2, IID ≤5 cm, TT >6 cm, and condylar mobility >10 mm were significantly more among subjects with DL and difficult tracheal intubation. Conclusion: Ultrasonography can be used in elective settings to rule out any possibility of difficult airway and to prevent airway-related complications.

Multidrug-Resistant Musculoskeletal Tuberculosis: An Aggressive Clinical, Radiological and Molecular Confirmation With Genotypic Drug Susceptibility Testing Approach.

Introduction Increasing evidence suggests that musculoskeletal tuberculosis (MSTB) causes significant morbidity due to the late presentation of symptoms and lack of accurate diagnosis. We aimed to assess the utility of two modalities, viz. radiology and molecular methods, in the early diagnosis of MSTB. Also, the rate of resistance to two basic first-line antitubercular drugs in musculoskeletal TB cases among clinically suspected patients was analyzed. Methods Samples from 119 patients with clinical suspicion of musculoskeletal TB were included. A radiological workup of patient and smear microscopy, mycobacterial culture, real-time multiplex polymerase chain reaction (PCR), cartridge based nucleic acid amplification test (CBNAAT), and line probe assay (LPA) of samples were carried out. Results Maximum positivity (69.74%) was observed by real-time multiplex, followed by CBNAAT and LPA (68.9%), mycobacterial culture (40.3%), and smear microscopy (19.3%). One additional advantage of using multiplex PCR was the detection of non-tuberculous mycobacteria (NTM) isolate. Forty-five strains (54.9%) on LPA were susceptible to rifampicin and isoniazid, eight (9.8%) were rifampicin mono-resistant, seven (8.5%) were isoniazid (INH) mono-resistant, and 22 (26.8%) were multidrug resistant. Conclusions MSTB diagnosis can be expedited by the combination of radiology and molecular methods. The positivity rate escalates, turnaround time improves, and the additional advantage of detection of drug resistance is added when this algorithm is included for clinching the diagnosis of MSTB.

Clinical, radiological and histopathological profile of patients with endobronchial lesions on fibreoptic bronchoscopy.

Various pulmonary diseases, both benign as well as malignant, manifest in the form of endobronchial lesions on bronchoscopy. Malignancy is frequently the provisional diagnosis in the mind of a chest physician undergoing an endobronchial biopsy. Other benign diseases, however, may present similarly on bronchoscopy and computerized tomography (CT) scan. This observational study was conducted to better understand why there is such a wide range of endobronchial lesions with even more diverse radiological and pathological presentations. The research was carried out at the Department of Respiratory Medicine, Himalayan Institute of Medical Science (HIMS), Swami Ram Nagar, Dehradun. Subjects were recruited from HIMS, Dehradun patients over a 12-month period (August 2020 to July 2021). The study included patients (over the age of 18) who had a fibreoptic bronchoscopy and were found to have an endobronchial lesion. After a thorough history, examination, and application of the inclusion and exclusion criteria, 120 patients were enrolled. The majority of patients were between the ages of 56 and 65, with males outnumbering females. The majority of the patients were smokers, and the most common complaint was shortness of breath. Poorly differentiated carcinoma and squamous cell carcinoma were the most common endobronchial lesions in men, while small cell carcinoma was the most common in women. A mass lesion was the most common radiological finding, followed by mediastinal lymphadenopathy, and an exophytic lesion was the most common endobronchial lesion detected in bronchoscopy. We looked at the diseases that cause endobronchial lesions and their clinico-radiological and histopathological profiles. This study clearly demonstrates the importance of studying the histopathological profiles of patients with endobronchial growth, which can mimic malignancy in rare cases.

Prediction of endotracheal tube size in children by predicting subglottic diameter using ultrasonographic measurement versus traditional formulas.

BACKGROUND: Paediatric airway assessment remains the most challenging task before the anaesthesiologists. Recent advancement in ultrasonography techniques should now allow for accurate and descriptive evaluation of paediatric airway. To compare calculated external diameters of the endotracheal tube from physical indices of traditional formulas and predetermined by ultrasound. MATERIALS AND METHODS: 100 subjects of either sex between 12-60 months of age, undergoing various elective surgeries under general anaesthesia requiring endotracheal intubation were enrolled in the study. The transverse diameter was measured at the level of cricoids cartilage by ultrasonography. The tracheal tube was considered best fit if air leak was satisfactory at 15-20 cm H2O of airway pressure. The obtained values were compared with the values of endotracheal tube size calculated by various age, height, weight based formulas and diameter of right and left little finger. The correlation of size of Endotracheal tube by different modalities was done and Pearson's correlation coefficient was obtained. RESULTS: According to Pearson's correlation there was a moderate correlation of best fit Endotracheal tube with endotracheal tube size by age based formula (r = 0.743), body length based formula (r = 0.683), right little finger based formula (r = 0.587), left little finger based formula (r = 0.587) and multivariate formula (r = 0.741). There was a strong correlation with ultrasonography (r = 0.943). CONCLUSION: Ultrasonography is a reliable method of estimation of subglottic diameter and for prediction of endotracheal tube size in children.

Gray Scale and Power Doppler Ultrasonographic Findings in the Assessment of Disease Activity and Their Correlation with Disease Activity Parameters in Rheumatoid Arthritis.

OBJECTIVES: To study the utility of gray scale and power Doppler ultrasonography in assessing the disease activity and correlation of ultrasonographic findings with disease activity parameters in Rheumatoid Arthritis (RA). MATERIALS AND METHODS: This cross-sectional study was conducted on 100 RA patients diagnosed as per 2010 classification criteria. Rheumatoid Factor (RF), serum Anti-cyclic Citrullinated Peptide Antibodies (ACPA), Erythrocyte Sedimentation Rate (ESR), C-reactive Protein (CRP), disease activity score with 28-joint counts and ESR (DAS28-ESR), Visual Analogue Scale (VAS) for global disease activity and Gray Scale Ultrasonography (GSUS) and Power Doppler Ultrsonography (PDUS) scores in hands and wrists were determined. RESULTS: Of 100 RA patients with clinically active arthritis, GSUS detected disease activity in all and PDUS in 95 (95%) patients. Of total 2200 joints assessed, disease activity was seen by clinical assessment in 51.31% (1116/2200), GSUS in 57.36% (1262/2200) and PDUS in 48.36% (1064/2200) joints. For detecting active arthritis, clinical assessment showed 79.5% sensitivity and 76.2% specificity while GSUS showed 100% sensitivity and 82.5% specificity using PDUS as a gold standard. GSUS findings of synovitis, joint effusion and bone erosions and PDUS score showed significant correlations with the swollen joint count, tender joint count, ESR and DAS28- ESR (p<0.05 each) but not with VAS, CRP, RF and ACPA (p>0.05 each). Multivariate analysis showed that swollen joint count was independently associated with synovitis (p=0.029) and tender joint count with PDUS score (p=0.036). CONCLUSIONS: GSUS and PDUS findings are useful in ascertaining the disease activity and correlate with clinical disease activity in joints in RA.

Estimation of entrance surface air kerma due to diagnostic X-ray examinations of adult patients in Uttarakhand, India and establishment of local diagnostic reference levels.

It is well established that diagnostic X-ray practices must be optimised to keep patient radiation dose as low as compatible with providing the diagnostic information required. For effective optimisation of diagnostic exposures, the International Commission on Radiological Protection (ICRP) introduced the concept of diagnostic reference levels (DRLs) in 1996. The present study aimed to carry out an extensive dose survey of diagnostic radiography installations in the Uttarakhand region of India to establish local DRL Values for the different diagnostic practices. During the survey, air kerma values were measured for 297 diagnostic X-ray machines installed at 270 medical centres in the region and the entrance surface air kerma (K a,e) was estimated for ten commonly performed radiographic projections. These included chest posterior-anterior (PA), cervical spine anterior-posterior (AP), skull PA, abdomen AP, KUB (kidney, ureter and bladder), lumbar spine AP, lumbar spine lateral (LAT), pelvis AP, thoracic spine AP, and thoracic spine LAT. Wide variations were observed in the estimated values of K a,e for individual projections. The third quartile of the distribution of the median values of the estimated K a,e for a given projection was calculated to establish local DRL Values. The majority of the acquired dose data were found to be comparable to or less than the proposed national and international DRLs. The local DRL Values reported in this study may be used to improve radiological practice by reducing patient doses during radiography examinations. The obtained data may also contribute to a national patient dose database for establishing future national DRLs.

Age-Wise Association of Carotid Intima Media Thickness in Ischemic Stroke.

BACKGROUND: Ischemic stroke is often a sequel of atherosclerotic risk factors. Carotid intima-media thickness (CIMT) is a surrogate marker of early atherosclerotic changes. PURPOSE: It was hypothesized that CIMT is associated with ischemic stroke in adults across all ages. METHODS: A case control study was performed on 163 diagnosed cases of first-time ischemic stroke and age-(±1 SD) and gender-matched healthy control attendants reporting at a tertiary care hospital. Data were collected on atherosclerotic risk factors for ischemic stroke. CIMT from both the carotids was measured using carotid vascular Doppler. The demographic profile and CIMT with atherosclerotic risk factors of cases and controls across different age groups were compared using unpaired t test if they passed the test of normality, else the Mann-Whitney test was used. OR for vascular risk factors for the development of stroke was calculated. The relationship of CIMT to atherosclerotic risk factors was analyzed by using Spearman correlation and regression analysis. The level of significance was set at 0.05. RESULTS: Age-specific value of CIMT was significantly higher in stroke cases than in age-matched controls across all age groups. Right CIMT, along with the history of hypertension (HTN; OR 2.3), are important risk factors for ischemic stroke in the younger age group (20-40 years). With increasing age along with the history of HTN and right CIMT (OR >7), presence of plaque (OR 6.3) and daily smoking (OR 5.1) are also significant risk factors. CIMT is significantly related to the daily alcohol and smoking intake and the presence of plaques. Right CIMT is positively related to increasing age in normal population (R2 = 0.041; p < 0.001). CONCLUSIONS: Right CIMT and comorbid HTN are significant risk factors associated with the development of ischemic stroke across all adult age groups.

Diagnostic performance of automated liquid culture and molecular line probe assay in smear-negative pulmonary tuberculosis.

The diagnosis of smear-negative pulmonary tuberculosis (PTB) is particularly challenging, and automated liquid culture and molecular line probe assays (LPA) may prove particularly useful. The objective of our study was to evaluate the diagnostic potential of automated liquid culture (ALC) technology and commercial LPA in sputum smear-negative PTB suspects. Spot sputum samples were collected from 145 chest-symptomatic smear-negative patients and subjected to ALC, direct drug susceptibility test (DST) testing and LPA, as per manufacturers' instructions. A diagnostic yield of 26.2% was observed among sputum smear-negative TB suspects with 47.4% of the culture isolates being either INH- and/or rifampicin-resistant. Complete agreement was observed between the results of ALC assay and LPA except for two isolates which demonstrated sensitivity to INH and rifampicin at direct DST but were rifampicin-resistant in LPA. Two novel mutations were also detected among the multidrug isolates by LPA. In view of the diagnostic challenges associated with the diagnosis of TB in sputum smear-negative patients, our study demonstrates the applicability of ALC and LPA in establishing diagnostic evidence of TB.

Transbronchial lung biopsy in patients with diffuse parenchymal lung disease without 'idiopathic pulmonary fibrosis pattern' on HRCT scan - Experience from a tertiary care center of North India.

BACKGROUND: Diffuse parenchymal lung diseases (DPLD) are a group of disorders characterized by chest radiological findings of bilateral diffuse shadowing. Lung biopsy is generally required to make an etiological diagnosis of DPLD's. Transbronchial lung biopsy (TBLB) is a minimally invasive method to achieve a lung sample which has been found to be a useful diagnostic tool in patients with DPLD. As per American Thoracic Society guidelines for management of idiopathic interstitial pneumonias, TBLB is not required in patients who have findings consistent with idiopathic pulmonary fibrosis (IPF) on HRCT scan thorax. Some Indian researchers have evaluated, on a small number of subjects, the role of TBLB in patients with DPLD, but they had not excluded patients with 'IPF pattern'. This study was planned to assess TBLB in patients with DPLD after excluding patients with 'IPF pattern'. MATERIALS AND METHODS: A prospective non-randomized study on 49 patients with DPLD without a characteristic 'IPF pattern' were subjected to TBLB. RESULTS: The overall diagnostic yield of TBLB was 85.7%. Non-specific interstitial pneumonitis, tuberculosis and sarcoidosis were the most common histology patterns found (22.4, 18.4 and 16.3%, respectively). Procedure-related mortality was nil. Iatrogenic pneumothorax occurred in five patients (10.2%). Minor complications included hemorrhage and transient hypoxia. CONCLUSION: TBLB is a safe and effective tool in the diagnosis of DPLD.

Kleine-Levin syndrome: a case report and review of literature.

BACKGROUND: Kleine-Levin syndrome presents with recurrent hypersomnia along with a number of other neuropsychiatric features, of which hyperorality has not been described frequently. METHOD: We report a male adolescent who presented with recurrent hypersomnia, hypersexuality, and hyperorality. Magnetic resonance imaging of the brain and overnight polysomnography followed by a multiple sleep latency tests were ordered. Excessive daytime sleepiness was assessed with the Epworth Sleepiness Scale. RESULTS: Magnetic resonance imaging of the brain did not reveal any abnormality. Overnight video-synchronized polysomnography and multiple sleep latency tests ruled out narcolepsy. Epworth Sleepiness Scale score at baseline was 22. He was prescribed lithium carbonate 300 mg twice a day. The symptoms improved within a week after starting lithium carbonate therapy. CONCLUSION: Kleine-Levin syndrome may present with hyperorality, and our patient responded well to lithium carbonate therapy.

Giant benign nodular hidradenoma of the shoulder: A rare tumor in orthopedic practice.

A clear cell hidradenoma is a rare dermal tumor, which is believed to originate from the apical portion of the sweat glands. The usual size reported is 5-30 mm. It is generally found in the head, face, and upper extremity regions. This lesion has not been reported to be large enough to impinge a joint range of motion. Hence, its description in the orthopedic literature is extremely rare. We present a giant benign nodular hidradenoma presenting as painful restriction of the right shoulder joint in a 35-year-old male.

Evaluation of hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate as a bone graft substitute for posterolateral spinal fusion.

BACKGROUND: Autologous cancellous bone is the most effective biological graft material. However, harvest of autologous bone is associated with significant morbidity. Since porous hydroxyapatite and beta-tricalcium phosphate are biodegradable materials and can be replaced by bone tissue, but it lacks osteogenic property. We conducted a study to assess their use as a scaffold and combine them with bone marrow aspirate for bone regeneration using its osteogenic property for posterolateral spinal fusion on one side and autologous bone graft on the other side and compare them radiologically in terms of graft incorporation and fusion. MATERIALS AND METHODS: Thirty patients with unstable dorsal and lumbar spinal injuries who needed posterior stabilization and fusion were evaluated in this prospective study from October 2005 to March 2008. The posterior stabilization was done using pedicle screw and rod assembly, and fusion was done using hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate as a bone graft substitute over one side of spine and autologous bone graft obtained from iliac crest over other side of spine. The patients were followed up to a minimum of 12 months. Serial radiographs were done at an interval of 3, 6, and 12 months and CT scan was done at one year follow-up. Graft incorporation and fusion were assessed at each follow-up. The study was subjected to statistical analysis using chi-square and kappa test to assess graft incorporation and fusion. RESULTS: At the end of the study, radiological graft incorporation and fusion was evident in all the patients on the bone graft substitute side and in 29 patients on the autologous bone graft side of the spine (P > 0.05). One patient showed lucency and breakage of distal pedicle screw in autologous bone graft side. The interobserver agreement (kappa) had an average of 0.72 for graft incorporation, 0.75 for fusion on radiographs, and 0.88 for the CT scan findings. CONCLUSION: Hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate seems to be a promising alternative to conventional autologous iliac bone graft for posterolateral spinal fusion.