Effect of Virtual Reality Glasses and Melody on Cortisol and Adrenocorticotropic Hormone Levels in Patients With Knee Replacement Surgery Under Combined Spinal Epidural Anaesthesia.

BACKGROUND: With advanced virtual reality (VR) technology, its usage in health care is creating an impact on patient outcomes. Patients undergoing knee replacement surgery are already anxious due to the surgery, anaesthesia, and unfamiliar environment of the operation theatre. In addition to that, the unpleasant noise of tools makes it worse. Peri-operative anxiety correlates with increased anaesthesia requirements and prolonged recovery. It causes the release of stress hormones such as cortisol, adrenaline, and norepinephrine, which can lead to difficult intravascular access due to vasoconstriction and heightened cardiovascular responses. Studies on music therapy have shown a reduction in cortisol levels, contributing to anxiety alleviation. VR glasses create immersive environments to distract patients from various stress factors. Investigating the use of VR/music on serum cortisol and adrenocorticotropic hormone (ACTH) levels in knee replacement surgery can improve peri-operative care, improving patient outcomes. AIM: The study was done to investigate the impact of virtual reality glasses and music therapy on serum cortisol and ACTH levels in patients undergoing knee replacement surgery under combined spinal epidural anaesthesia. METHODS: In this prospective randomised control, single-centric study, patients of either sex, aged between 18 and 65 years, undergoing knee replacement surgery under combined spinal and epidural (CSE) anaesthesia, were included. The primary objective was to compare serum cortisol and ACTH levels, while the secondary objective was to compare the State-Trait Anxiety Inventory for State Anxiety (STAI-SA) score and Patient Satisfaction Score (PSS) in the peri-operative period. A total of 100 patients were assessed for eligibility, and 66 patients met the inclusion and exclusion criteria and were finally randomised and equally assigned to group M-VR (music-virtual reality) and group C (control). Three blood samples were collected for serum cortisol and serum ACTH levels one hour before surgery (T1), one hour after skin incision (T2), and two hours after the completion of surgery (T3). STAI-SA was measured one hour before surgery (T1) and two hours after the completion of surgery (T2), while PSS was recorded two hours after the completion of surgery. Hemodynamic parameters were noted during the entire peri-operative period. RESULTS: The demographic and anthropometric parameters were comparable in both groups. Hemodynamic parameters (heart rate [HR], mean arterial pressure [MAP]) were found to be comparable in the pre-operative period, while significant differences (p > 0.05) were noted after 30 minutes of surgery and continued till the end of surgery. Serum cortisol and serum ACTH levels were comparable in the pre-operative period but showed significantly lower variations in group M-VR in comparison to group C in the intra-operative period. PSS was significantly higher in group M-VR in comparison to group C. CONCLUSION: This study substantiates the role of virtual reality and music therapy (VR/music) on anxiety reduction, improved satisfaction scores, and lesser ACTH/cortisol level variations in knee replacement surgery. It further emphasises larger randomised controlled studies in various other surgical populations, along with long-term follow-up and outcome assessment.

Priapism of the Newborn - A Case Report.

Neonatal Priapism is a rare condition and its causes differ from that in childhood and adult. Management also is challenging as the ultimate goal is the preservation of normal erectile function. Most of the cases are idiopathic. A spontaneous detumescence occurs in majority of cases, so initially conservative non-surgical treatment is advocated. Here we report a case of a newborn presenting with priapism on the 1st day of life. Detumescence was achieved on the 8th day of life with conservative treatment.

α1-Adrenoceptor and serotonin 5-HT(1A) receptor affinity of homobivalent 4-aminoquinoline compounds: an investigation of the effect of linker length.

α1-adrenoceptor (α1-AR) subtype-selective ligands lacking off-target affinity for the 5-HT(1A) receptor (5-HT(1A)-R) will provide therapeutic benefits in the treatment of urogenital conditions such as benign prostatic hyperplasia. In this study we determined the affinity of 4-aminoquinoline and eleven homobivalent 4-aminoquinoline ligands (diquinolines) with alkane linkers of 2-12 atoms (C2-C12) for α(1A), α(1B) and α(1D)-ARs and the 5-HT(1A)-R. These ligands are α(1A)-AR antagonists with nanomolar affinity for α(1A) and α(1B)-ARs. They display linker-length dependent selectivity for α(1A/B)-ARs over α(1D)-AR and the 5-HT(1A)-R. The C2 diquinoline has the highest affinity for α1A-AR (pKi 7.60±0.26) and greater than 30-fold and 600-fold selectivity for α(1A)-AR over α(1D)-AR and 5-HT(1A)-R respectively. A decrease in affinity for α1-ARs is observed as the linker length increases, reaching a nadir at 5 (α(1A/1B)-ARs) or 6 (α(1D)-AR) atoms; after which affinity increases as the linker is lengthened, peaking at 9 (α(1A/1B/1D)-ARs) or 8 (5-HT(1A)-R) atoms. Docking studies suggest that 4-aminoquinoline and C2 bind within the orthosteric binding site, while for C9 one end is situated within the orthosteric binding pocket, while the other 4-aminoquinoline moiety interacts with the extracellular surface. The limited α(1D)-AR and 5-HT(1A)-R affinity of these compounds makes them promising leads for future drug development of α(1A)-AR selective ligands without α(1D)-AR and the 5-HT(1A)-R off-target activity.

Brief reports: nerve stimulator evoked motor response predicting a successful supraclavicular brachial plexus block.

BACKGROUND: We examined the success rate of supraclavicular brachial plexus block after the different evoked motor responses to nerve stimulation. METHODS: This multicenter observational study included 377 patients. For each block, the evoked motor response elicited at 0.25 mA for 2 milliseconds was recorded, 30 mL bupivacaine 0.25% was injected, and the block was observed for success or failure. RESULTS: Complete anesthesia occurred in 317 cases (84.1%). The success rate was 100% when the evoked motor response was simultaneous flexion of the third and fourth digits or flexion of all 4 digits (digits 2-5) with or without thumb opposition. CONCLUSION: Simultaneous flexion of the third and fourth digits with or without other digits is associated with the highest success rate of supraclavicular brachial plexus block.

Airway management for cervical spine injury.

In this review, important factors related to initial management, diagnosis, airway, and anesthetic management of patients with cervical spine injury (CSI) are discussed. Early diagnostic and clinical evaluation is important in excluding CSI. In-line stabilization reduces movement of the cervical spine. Tracheal intubation under fiberscopic control, offers safety, and comfort to the patient. However, in cases of severe deterioration of vital functions, intubation must be performed without any delay at the site of the accident or in the emergency room. Early airway management and maintenance of spinal immobilization are more important factors in limiting the risk of secondary neurological injury than any particular technique. The current opinion is that oral intubation after intravenous induction of anesthesia and muscle relaxation along with in-line stabilization is the safest and quickest way to achieve intubation in a patient with suspected CSI.

Treatment of cervical disc prolapse by anterior cervical discectomy fusion and stabilization with plating.

Different types of surgical techniques are used for effective treatment of cervical disc prolapse. Techniques with fusion without stabilization have some disadvantages like collapse of the graft, extrusion of graft, nonunion and recurrence of symptoms. We have carried out this prospective interventional study between March 2001 to November 2007 on 129 cases of cervical disc prolapse treated with anterior cervical discectomy, fusion & stabilization with plating at IBN SINA Hospital, Dhanmondi, Dhaka, Al-Manar Hospital, Lalmatia and Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka. There were 106(82.17%) male and 23(17.82%) female patients. The commonest age group of the patients was 4th decade. The commonest level of disc prolapse was found in C5/6 level and in each case, diagnosis was made on the basis of clinical findings, plain X-ray and MRI of cervical spine. We performed anterior cervical discectomy, fusion and stabilization with plating in all cases. A per-operative marking film was taken in each case to identify proper level. Per-operative undue hemorrhage from donor site occurred in 1 case, 27 patients complained of dysphagia temporarily, 64 patients complained of donor site pain significantly which was relieved within 3-6 months of follow-up period. Donor site infection was found in 1 patient. The post operative follow-up period was 3 months to 6 years. The functional out come obtained excellent in 71.43%, good in 19.64%, fair in 8.93%, poor in 2.32% in this series.

Tramadol as an adjuvant to intravenous regional anesthesia with lignocaine.

OBJECTIVE: To assess the effect of different doses of tramadol when added to lignocaine during intravenous regional anesthesia (IVRA). METHODS: Sixty patients, scheduled for hand surgery under IVRA in King Fahd University Hospital, Al-Khobar, Saudi Arabia from January 2006 to January 2007 were randomly allocated into 3 groups (20 patients each) in a double blind controlled study. All patients received 0.5% lignocaine, 40ml plus 2ml of a study solution containing either isotonic saline control group, or tramadol 50mg (group T50) or tramadol 100 mg (group T100). Hemodynamic changes, sensory and motor block onset and recovery times, tourniquet tolerance time, the quality of intraoperative anesthesia and the duration of postoperative analgesia were assessed. RESULTS: All patients, 20 in each group completed the study period. Patients who received tramadol had earlier onset of sensory block (5.2 +/= 1.2; 4.9 +/= 1.2 min in the T50; and T100 groups) compared with the control group (7.6 +/= 1.4 min). Patients who received 100mg of tramadol had better tolerance of tourniquet (p=0.011), and less intraoperative fentanyl supplementation (p=0.042). They had also a longer time to the first postoperative analgesic request (p=0.001) compared with the control group. CONCLUSION: Tramadol 100 mg is a beneficial additive to lignocaine for IVRA since it shortened the onset of sensory block, enhanced the tourniquet tolerance and improved the perioperative analgesia.

The effect of etoricoxib premedication on postoperative analgesia requirement in orthopedic and trauma patients.

OBJECTIVE: We hypothesized that etoricoxib premedication would reduce the need for additional opioids following orthopedic trauma surgery. METHODS: A double blind, controlled study, conducted in King Fahd University Hospital, King Faisal University, Dammam, Kingdom of Saudi Arabia. After obtaining the approval of the Research and Ethics Committee and written consent, 200 American Society of Anesthesiology grade I & II patients that underwent elective upper limb or lower limb fracture fixation surgeries during the period from August 2005 to October 2007 were studied. Patients were randomly premedicated using 120 mg of etoricoxib or placebo n=100, each. To alleviate postoperative pain, a patient controlled analgesia device was programmed to deliver one mg of morphine intravenously lockout time, 6 minutes. Visual analog scale and total postoperative morphine consumption over 24 hours and the adverse effects were recorded. RESULTS: One hundred patients in each group completed the study period. Etoricoxib premedication provides a statistically significant postoperative morphine sparing effect over 24 hours postoperatively. Total morphine consumption was 44.2 (8.2) in the placebo and 35.17.0mg in the etoricoxib groups p<0.001. The incidence of nausea and vomiting requiring treatment was lower in the etoricoxib group, p=0.014. The postoperative blood loss was similar in both groups. CONCLUSION: Etoricoxib is a suitable premedication before traumatic orthopedic surgery as it enhanced postoperative analgesia and reduced the need for morphine.

Waist-to-height ratio is a better obesity index than body mass index and waist-to-hip ratio for predicting diabetes, hypertension and lipidemia.

Body mass index (BMI, kg/m.sq) and waist-to-hip ratio (WHR) are widely used as obesity indices for diabetes and cardiovascular risks. Lower adult height was related to diabetes and stroke. Waist-girth was proved important for visceral obesity. Incorporating waist-girth and height as waist-to-height ratio (WHtR), we reported earlier--"Waist-to-height ratio is an important predictor of hypertension and diabetes". We readdressed this index in a larger sample with two-sample OGTT and lipid profiles. In a cluster sampling of 16,818 rural inhabitants, considering age > or = 20 y, 5713 subjects were found eligible. Of them, 4923 (M/F=2321/2602) volunteered for height, weight, blood pressure, waist-girth and hip-girth. Fasting venous blood (5 ml) was drawn for plasma glucose, total cholesterol (T-chol), Triglycerides (TG) and high-density lipoprotien (HDL-c). Overall, 1565 participants were undertaken for OGTT. The mean (SD) values of BMI, WHR and WHtR for subjects with diabetes and hypertension were significantly higher in either sex. The level significance was highest for WHtR. The prevalence of diabetes and hypertension increased significantly with higher quintiles of BMI, WHR and WHtR (chi sq values were largest in WHtR for both events). Partial correlation coefficients, controlling for age and sex, showed that BMI, WHR and WHtR significantly correlated with systolic and diastolic BP, FBG, T-chol and TG. In the entire correlation matrix, the 'r' values were the highest for WHtR. Taking diabetes and hypertension as dependent variables, logistic regression also showed the highest odds ratio in higher WHtR than BMI and WHR. We conclude that WHtR was proved again a valuable obesity index for predicting diabetes, hypertension and lipidemia.

Sexually transmitted infections prevalence rates in slum communities of Dhaka, Bangladesh.

The study objective was to estimate the prevalence of selected sexually transmitted infections (STIs) and associated factors among Dhaka slum dwellers. Blood and urine specimens were collected from 1534 men and women. Participants in this cross-sectional study responded to a questionnaire, providing socioeconomic data, symptomatology and treatment-seeking behaviour. Specimens were tested for syphilis, hepatitis B (HBsAg), Neisseria gonorrhoeae, Chlamydia trachomatis, and HIV. Serologic evidence of syphilis infection was found in 6.0% of respondents, HBsAg in 3.8%. Prevalence rates of gonorrhoea and chlamydia were 1.7% and <1%, respectively. No HIV infections were found. Men were more than twice as likely as women to be infected with syphilis or HBsAg carriers. Behaviours facilitating STI transmission were common among men. Syphilis infection is prevalent enough to warrant the initiation of screening programmes in this population. The prevalence rate of hepatitis B carriage suggests that this population would benefit from universal vaccination against hepatitis B.

Intramolecular addition of acyl radicals to alpha-substituted vinylogous carbonates: demonstrating the effect of ring size on acyclic stereocontrol.

The level of stereocontrol obtained in the reduction of the free radical derived from the intramolecular addition of an acyl radical to an alpha-branched vinylogous carbonate is dependent upon the ring-size of the cyclic ether.

Clostridium difficile colitis associated with treatment of Helicobacter pylori infection.

Helicobacter pylori infection of the stomach is being detected and treated more often now than ever before. This is likely to result in an increase in complications such as antibiotic-associated diarrhea. However, there is no literature on the incidence of such diarrhea, particularly Clostridium difficile colitis, in patients treated for Helicobacter pylori infection. We report the case of a patient who developed Clostridium difficile colitis after treatment for Helicobacter pylori infection with metronidazole, amoxicillin, H2 blockers, and bismuth subsalicylate. This patient presented with severe diarrhea that responded to a course of metronidazole with rapid disappearance of symptoms. The incidence of Clostridium difficile colitis in patients treated for Helicobacter pylori infection has not been studied. This unique association, although not unexpected, has not yet been reported in the literature. The increasing number of patients being diagnosed and treated for this infection requires a heightened awareness on the part of physicians, to assure early diagnosis and treatment of this treatable, yet potentially dangerous, complication.

Psoriatic arthritis associated with dilated cardiomyopathy and Takayasu's arteritis.

A 40-year-old Japanese man with psoriatic arthritis (PA) involving the spine, sacroiliac and peripheral joints presented with dyspnoea and ankle oedema. Blood pressure was 180/110 and 114/80 mmHg in the right and left upper arms, respectively. Examinations showed left ventricular dilatation and diffuse hypokinesis of the left ventricle, with no involvement of the coronary arteries. Aortography detected total occlusion of the left subclavian artery and stenosis of the origin at the right renal artery. Dilated cardiomyopathy and Takayasu's arteritis associated with PA was diagnosed. A few cases of PA have been reported in association with cardiovascular diseases, but the association of these three diseases has not been documented in the literature to date. Dermatologists need to be aware of cardiovascular manifestations in patients with PA, because cardiovascular diseases are not rare in other seronegative spondyloarthropathies.

Mutations of the INK4a locus in squamous cell carcinomas of human skin.

The INK4a locus encodes two different, cell cycle-regulating proteins, p16INK4a and p19ARF. In this study, we screened mutations in all coding regions of the INK4a locus (exons 1 beta, 1 alpha, 2, and 3) in 21 squamous cell carcinomas (SCCs) of human skin by polymerase chain reaction-single strand conformation polymorphism analysis. Mutations were detected in 3 SCCs in exon 2, which is common to both p16INK4a and p19ARF. These included an in-frame deletion of 21 base pairs from codon 84 to 90, a frameshift mutation of CCC-->TC at codon 75, and a nonsense mutation of CGA-->TGA at codon 80 of the p16INK4a gene. These results suggest that inactivation of the INK4a locus has some relevance to the carcinogenesis in at least some of SCCs of human skin. This is the first demonstration of aberrations in the INK4a locus in SCCs of human skin.

A simple method to estimate CIE-L*a*b* values of the skin from its videomicroscopic image.

BACKGROUND/AIMS: The C I E (Commission Internationale de I'Eclairage)-L*a*b* is the most popular standardized color system. The purpose of this study was to develop a simple method for estimating C I E-L*a*b* values of the skin using a video microscope and a computer. METHODS: Skin images were obtained with a video microscope of various anatomical locations and ultraviolet B-induced erythema and pigmentation in seven subjects. R G B (red, green, and blue) color coordinates of the images were converted into quasi-L*a*b* values using formulae similar to those defined by C I E. These values were compared with C I E-L*a*b* values simultaneously measured with a colorimeter. RESULTS: The correlation coefficients between C I E- and quasi-L*a*b* values were 0.97 (L*), 0.91 (a*), and 0.84 (b* CONCLUSIONS: Our method may be useful for deriving CIE-L*a*b* values of the skin from its video microscopic image.

Color analysis of nevus of Ota for evaluation of treatment with a Q-switched alexandrite laser.

BACKGROUND/AIMS: The Q-switched alexandrite laser shows excellent results in treating nevi of Ota. This study sought to examine the utility of color monitoring of the lesion for quantifying the efficacy of laser treatment. METHODS: Lesion images were obtained from 12 patients using a video microscope before and after a series of laser treatments. The RGB color data in a 50 mm(2) area of the images were converted into coordinates of three color systems and compared with clinical evaluation. RESULTS: On three coordinates representing the brightness of skin color (the intensity, the L* and the melanin index), there were significant differences between data obtained before and after treatment (P<0.01), in accord with clinical impressions. Darker lesions tended to show more improvement. Coordinates based on chromaticity were less useful for evaluation of treatment. CONCLUSIONS: Color analysis of nevi of Ota is useful for quantifying efficacy of laser treatment, especially when assessed in a small area of the lesion.

Squamous cell carcinoma associated with verruciform xanthoma of the penis.

We report a case of squamous cell carcinoma of the penis that seemed to arise within a verruciform xanthoma of this organ. A lesion in the prepuce was initially diagnosed as a verruciform xanthoma histopathologically and was removed in part. Six years later, the patient exhibited a well-differentiated squamous cell carcinoma of the penis that contained many clusters of xanthoma cells in the stroma. Although the retrospective examination of biopsy specimens of the initial lesion in this patient showed the features mainly of verruciform xanthoma, significant architectural and cytological atypia was also present in the overlying epidermis. Thus, we must be careful not to overlook the presence of a squamous cell carcinoma arising within a benign reactive lesion such as a verruciform xanthoma.