Rectus Sheath Block Improves Patient Recovery Following Open Aortic Surgery.

BACKGROUND: Postoperative pain management remains a barrier to recovery following aortic surgery. Although epidural catheters help in adjunctive pain management, less is known about the use of rectus sheath blocks. We compared patient recovery following open abdominal aortic surgery (OAS) with and without adjunctive rectus block. METHODS: Adult patients undergoing open abdominal aortic aneurysm repair and aortobifemoral or aortoiliac bypass for occlusive disease were identified and stratified by use of general anesthesia alone (GA) versus adjunctive use of a rectus sheath block (GA + RB). A small number of patients with GA and concomitant epidural analgesia, along with patients that had retroperitoneal repairs, were not included in further analysis. Outcomes included time to extubation, intraoperative and postoperative morphine milligram equivalents (MME) utilization, length of stay, discharge MME, and postoperative complications. Categorial data were compared with Person Chi-Square tests or Fisher's exact tests. Continuous data were tested with independent t-tests or Mann-Whitney U-tests. RESULTS: From January 2017 to April 2022, there were 106 patients who underwent open aortic surgery, 55 patients with GA alone, 39 with GA + RB, and 12 patients who had a GA with concomitant epidural analgesia. Between GA and GA + RB, patients were comparable in both groups in terms of age, BMI (body mass index), smoking history, hypertension, diabetes, CAD (coronary artery disease), COPD (chronic obstructive pulmonary disease), and ASA (American Society of Anesthesiologists) class and prior opioid use. Patients with GA + RB were more likely to have scheduled elective procedures (80% GA cohort vs. 94.9% RB, P = 0.040), and a lower incidence of retroperitoneal exposure (14.5% GA cohort vs. 0% RB, P = 0.019). Patients with GA + RB had shorter time to extubation than GA (84.6% < 12 hr vs. 44.4%, P < 0.001), greater rate of procedural ketamine usage (GA + RB: 61.5% vs. GA: 40.0%, P = 0.049), lower MME at first postoperative day (median MME GA + RB: 25.0 vs. GA: 67.5, P = 0.002), lower discharge MME (median MME GA + RB: 142.5 vs. GA: 225.0, P = 0.036), and overall shorter length of stay (median stay GA + RB: 5 vs. GA: 6 days, P = 0.006). Postoperative complications were similar between groups. Similar findings were found in the comparison between elective-only GA and GA + RB patients and after exclusion of patients who only had a single shot of regional anesthesia. CONCLUSIONS: Patients that receive adjunctive rectus sheath blocks for pain control following OAS utilize fewer opioid medications during hospital stay and at discharge. Rectus sheath blocks represent an alternative option to other periprocedural analgesia following open aortic surgery.

Comparison of NLR (neutrophil/lymphocyte ratio) and PLR (platelet/lymphocyte ratio) as inflammatory markers in 1st episode mania and bipolar mania: A preliminary study.

Background: There are various factors including inflammation that have been studied in bipolar disorder. NLR (Neutrophil to lymphocyte ratio) and PLR (platelet to lymphocyte ratio) are one of them. Various psychotropic drugs can affect the inflammatory state. Aim: This study was planned to find NLR and PLR in bipolar disorder (mania) and psychotropic drug naïve 1st episode mania. Materials and Methods: Total of 120 subjects were chosen including, 40 bipolar mania, 40 drugs naïve 1st episode mania, and 40 healthy controls. The severity of mania was assessed by the Young Mania Rating Scale. Blood samples were collected in the morning hours in order to get blood counts. Results: A significantly higher values of neutrophil counts and NLR, while the significant lower values of lymphocyte counts in both 1st episode and bipolar mania compared to healthy control were observed. The first episode mania group had significantly higher neutrophil counts and NLR in comparison to bipolar mania. Conclusion: Results suggest a possible inflammatory pathophysiology of mania. Psychotropic medicines may have an anti-inflammatory effect, signified by the fact that 1st episode mania group has a greater level of inflammation in comparison to bipolar mania.

Study of Association of Various Psychiatric Disorders in Brain Tumors.

Background Brain tumors may be associated with high morbidity, and psychiatric symptoms may be an early manifestation. It is important to address mental symptoms as early as possible because they are prone to develop psychiatric comorbidities in future. If untreated, these situations may worsen and lead to burden upon caregivers. Methods A total of 176 brain tumor patients between January 2021 and January 2022 constituted the sample size. All recently diagnosed cases of brain tumor with age equal to or more than 18 years who can comprehend and answer questionnaires were included. Patients with a long history of brain tumor or who had a history of a psychiatric illness other than presenting symptoms or any other serious medical illness were excluded. Results Twenty-seven percent of brain tumor patients had psychiatric symptoms. Depressive symptoms were the most common, associated with 24% of patients, followed by anxiety disorders. Psychiatric disorders were more common in supratentorial compared to infratentorial tumors. Psychiatric symptoms seem to be associated more commonly with malignant tumors and peritumoral edema. Among malignant tumors, depressive symptoms tend to be related with high-grade glioma, and among benign tumors, they were more common in meningioma. No predilection to laterality and anatomical lobe involvement is reported. Conclusion Screening of psychiatric disorders should be a routine in brain tumor patients. An integrated approach is required to treat brain tumor patients. Healthcare professionals should be more vigilant about the onset of psychiatric symptoms and the need of palliative care to improve the quality of life.

Female Sex is Associated with Worse Outcomes following Complex Fenestrated or Branched Endovascular Aortic Repair.

BACKGROUND: Sex-related discrepancies after standard endovascular aneurysm repair (EVAR) are noted to disproportionally affect females. A growing body of literature suggests similar disparities may extend to complex fenestrated or branched endovascular aneurysm repair (FBEVAR). However, recent examination of complex FBEVAR by a consortium of high-volume centers noted equivalent mortality among sexes. Whether similar results extend to non-trial data is unknown. METHODS: We examined all juxta-renal through type IV thoraco-abdominal aneurysms (sealing zones 6-8) which underwent elective FBEVAR within the Vascular Quality Initiative (VQI) database from January 2012 to December 2020. Urgent, symptomatic, ruptured, and staged cases were excluded, as were parallel stent grafts. Demographics, comorbid conditions, and technical factors were compared between sexes. Univariate analysis with Wilcoxon ranked sum tests and Chi-square tests of proportion were performed, followed by multivariate logistic regression for failure of target vessel technical success, reintervention, complications, and in-hospital mortality. RESULTS: Our analysis included 1,521 patients, 1,180 males (77.6%) and 341 females (22.4%). There were noted differences in pre-operative demographics, medical optimization, and technical aspects of the procedure. However, no difference was noted in proximal or distal sealing stents, number of fenestrations, or immediate endoleaks. On a multi variate logistic regression, female sex was an independent predictor of failure of target vessel technical success (odds ratio (OR) 3.339, 95% confidence interval (CI): 2.173-5.132, P < 0.001), reintervention (OR 2.192, 95% CI: 1.304-3.683, P = 0.003), complications (OR 1.747, 95% CI: 1.282-2.381, P < 0.001), and in-hospital mortality (OR 2.836, 95% CI: 1.510-5.328, P = 0.001). CONCLUSIONS: Females suffer worse outcomes after FBEVAR despite similar extent of disease, number of fenestrations, and incidence of immediate endoleak. Notable discrepancies were higher rates of chronic obstructive pulmonary disease (COPD) and lower rates of pre-operative aspirin, statin, and beta blocker therapy in females. Controlling for pre-operative demographics, female sex remained an independent predictor of worse outcomes. These discrepancies warrant further examination and should impact case planning for female patients undergoing complex aortic aneurysm repair.

Intraoperative electroencephalographic changes during transcarotid artery revascularization are more frequent than previously reported.

OBJECTIVE: Up to 14% of patients undergoing carotid endarterectomy with continuous electroencephalographic (EEG) neuromonitoring will require shunt placement because of EEG changes. However, the initial studies of transcarotid artery revascularization (TCAR) found only one patient with temporary EEG changes. We report our experience with intraoperative EEG monitoring during TCAR. METHODS: We conducted a retrospective review of patients who underwent TCAR at two urban hospitals within an integrated healthcare network from May 2017 to January 2020. The data included demographic information, patient comorbidities, symptom status, previous carotid interventions, anatomic details, contralateral disease, intraoperative vital signs and EEG changes, and postoperative major adverse events (transient ischemic attack, stroke, myocardial infarction [MI], and death) both initially and at 30 days postoperatively. The Fisher exact test was used for categorical data and the Wilcoxon rank sum test for continuous data. RESULTS: A total of 89 patients underwent TCAR during the study period, of whom 71 (79.8%) received intraoperative EEG neuromonitoring. Of the 89 patients, 70.8% were men and 29.2% were women. The median age was 75 years (IQR, 68-82.5 years). Symptomatic patients accounted for 41.6% of the cohort. Of the 71 patients who received continuous neuromonitoring, 9 experienced EEG changes during TCAR (12.7%). The changes resolved in seven patients with pressure augmentation in three and switching to a low flow toggle in three. One patient who had sustained EEG changes had a new postoperative neurologic deficit. The median carotid stenosis percentage on preoperative computed tomography angiography was lower for patients with EEG changes than for those without (67% vs 80%; P = .01). No correlation was found between symptom status or 30-day stroke in patients with and without EEG changes (P = .49 and P = .24, respectively). Overall, three postoperative strokes, two postoperative deaths, and one MI occurred, for a composite 30-day stroke, death, and MI rate of 6.7%. CONCLUSIONS: Changes in continuous EEG monitoring were more frequent in our study than previously reported. Less severe carotid stenosis might be associated with a greater incidence of EEG changes. Limited data are available on the prognostic ability of EEG to detect clinically relevant changes during TCAR, and further studies are warranted.

High-power solid-state amplifier for superconducting radio frequency cavity test facility.

A horizontal test facility is set up at the Raja Ramanna Centre for Advanced Technology to test the superconducting radio frequency dressed cavities. Along with the cryomodule, control instrumentation, and the power coupler, this facility incorporates a high-power solid-state amplifier for establishing the desired cavity voltage gradient during the testing. This article describes the design, construction, rigorous testing, and measured results of this high-power solid-state radio frequency amplifier and its constituent components. Its maximum output power is 36 kW (average) at the operating frequency of 650 MHz. Its main features are its modular and scalable design with in-house developed constituent components. These components include 500 W, 20 dB gain modules, novel two-tier radial dividers, combiners, power sensors, and aperture-coupled directional couplers. Their excellent reprise performance for the multiple quantities confirms the design methodology presented here. The measured wall plug efficiency of this 36 kW amplifier is 43.6%, and its power gain is 86 dB. The designed radial combiner is highly efficient (power-combining efficiency of 98.4%), and the directional coupler exhibits a very low loss (insertion loss of 0.05 dB).

Study of Predictors of Quality of Life and its Association with Anxiety and Depression in Chronic Obstructive Pulmonary Disease in Industrial Workers.

INTRODUCTION: Chronic diseases such as chronic obstructive pulmonary disease (COPD) have an adverse impact on the quality of life (QOL) of the patient. Anxiety and depression have an association with QOL in COPD. However, this area has not been studied in the Indian subcontinent, especially in reference to the industrial population, which is vulnerable to such chronic disease. The present study aims to assess the prevalence of anxiety and depression and its association with QOL in COPD patients. This study has also examined the other predictive factors associated with QOL in COPD. MATERIALS AND METHODS: This cross-sectional study involved 50 cases of COPD and an equal number of age- and sex-matched healthy controls. The severity of COPD was classified as per the global initiative for chronic obstructive lung disease recommendation. Participants were assessed for anxiety, depression, and QOL on generalized anxiety disorder 7, Patient Health Questionnaire nine-item and WHOQOL (World Health Organization Quality of Life Instrument)-BREF, respectively. RESULTS: The study sample was predominantly of men (n = 47) with a mean age of 57 years. The mean score of QOL in all domains was significantly lower in COPD cases than control. The prevalence of anxiety and depression was 38% and 44%, respectively, among COPD cases. Odds ratios predicted more risk of developing anxiety and depression in COPD as the OR for depression and anxiety, with 95% confidence intervals were 3.2 (1.2-8.3 and 4.8 (1.8-12.8), respectively. QOL had a strong association with anxiety, depression, chronicity, and the severity of the disease. CONCLUSION: Anxiety and depression are highly prevalent in COPD and appear to be strong predictors of poor QOL.

Trichobezoar without a clear manifestation of trichotillomania.

Trichophagia is a compulsive condition characterized by eating hair, mostly seen in adolescent females. Persistence of ingestion of hair over many years results in the formation of trichobezoar. Surgical intervention is often needed in the management of large trichobezoars. We present a case of a 23 year old female with trichophagia which led to the formation of gastric trichobezoar. The patient reported with complaints of pain in abdomen for past 1-2 years, and loss of appetite and vomiting post meals for 6 months. On detailed examination, a diagnosis of trichobezoar was formed which was removed by laparotomy with gastrotomy under general anaesthesia. Psychiatric evaluation revealed a history of fluctuating mood symptoms during her childhood and depressive symptomatology presently without any associated urge of plucking hair and subsequent gratification. Hence, the management of the disease requires proper liaison between the surgeon, psychiatrist, and caregivers of the patient; and regular psychiatric follow-up and treatment of the underlying psychopathology to prevent the recurrent formation of bezoar.

Study of internet addiction and its association with depression and insomnia in university students.

INTRODUCTION: Use of internet has increased exponentially worldwide with prevalence of internet addiction ranging from 1.6% to 18 % or even higher. Depression and insomnia has been linked with internet addiction and overuse in several studies. AIMS AND OBJECTIVES: Present study has looked in to pattern and prevalence of internet addiction in university students. This study has also explored the association of internet addiction with depression and insomnia. MATERIAL AND METHODS: In this cross sectional study 954 subjects were enrolled who had been using internet for past 6 months. Information regarding pattern of use and socio demographic characteristics were recorded. Internet addiction Test (IAT), PHQ-9,and insomnia Severity Index (ISI) were applied to measure internet addiction, depression and insomnia respectively. RESULTS: Among 954 subjects, 518 (60.59%) were male and 376 (39.41%) were female with mean age of 23.81 (SD ± 3.72). 15.51% study subjects were internet addicts and 49.19% were over users. Several parameters including graduation level, time spent per day on line, place of internet use, smoking and alcohol had significant association with internet addiction. Internet addiction was predominantly associated with depression and insomnia. CONCLUSION: Internet addiction is a rising concern among youth. Several parameters including gender, time spent on line, alcohol, smoking predicts higher risk of internet addiction. Depression and insomnia are more common in internet addicts and overusers.

Outcomes of target vessel endoleaks after fenestrated-branched endovascular aortic repair.

OBJECTIVE: The objective of this study was to determine the incidence rate, outcomes, and risk factors of target vessel-related endoleaks after fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal aneurysms or thoracoabdominal aortic aneurysms (TAAAs). METHODS: We reviewed consecutive patients treated by F-BEVAR between 2007 and 2017. Target vessel endoleaks were identified by computed tomography angiography (CTA). Follow-up included CTA and duplex ultrasound before discharge, at 2 months, at 6 months, and annually thereafter. Primary endoleaks were detected by predismissal CTA; secondary endoleaks were absent on the first CTA and were identified during follow-up. End points were spontaneous resolution of primary endoleaks, secondary interventions, and aneurysm rupture. Multivariable analyses were performed for risk factors of target vessel endoleaks and predictors of spontaneous resolution. RESULTS: A total of 382 patients (mean age, 75 ± 8 years; 75% male) underwent F-BEVAR for 195 pararenal aneurysms and 187 TAAAs with 1204 renal-mesenteric arteries targeted by 981 fenestrations and 223 directional branches. Fifty-two target vessel endoleaks were identified in 41 patients; 41 were type IIIC (interattachment), 10 were type IC (distal bridging stent sealing zone), and 1 was type IIIB (bridging stent fabric tear). Thirty-three patients (9%) had primary target vessel endoleaks in 41 target vessels (3%). Eight patients (2%) developed 11 secondary target vessel endoleaks. Directional branches were more prone to primary endoleaks (13/223 [6%]) in comparison to fenestrations (28/981 [3%]; P = .03). However, branch endoleaks resolved more often spontaneously (11/14 [79%]) compared with fenestration endoleaks (14/38 [37%]; P = .008). Other risk factors for target vessel endoleaks included inner aortic diameter ≥30 mm at the target vessel origin, four or more targeted vessels, TAAA (for primary endoleaks), and physician-modified endograft (for secondary endoleaks). Four patients with primary endoleaks underwent successful reintervention before discharge, and 29 were observed with a mean follow-up of 24 ± 21 months. Of the 41 primary endoleaks, 25 resolved spontaneously in 20 patients (61%) at first follow-up with no recurrences. Of the observed endoleaks, 11 persisted in 9 patients, and 8 of those endoleaks were treated in 7 patients. All secondary target vessel endoleaks required reintervention. There was one possible aneurysm rupture attributed to persistent secondary target vessel endoleak. CONCLUSIONS: Target vessel endoleak on CTA at discharge occurs in 1 of 10 patients treated by F-BEVAR. Of these, two-thirds resolve spontaneously, especially those affecting directional branches. Among patients with a persistent endoleak, endovascular reintervention is usually successful and aneurysm rupture is rare.

Study of Fatigue and Associated Factors in Traumatic Brain Injury and Its Correlation with Insomnia and Depression.

INTRODUCTION: Fatigue has been cited as a common problem associated with traumatic brain injury. A positive association of fatigue has been suggested with insomnia and depression which are also considered to be significantly associated with traumatic brain injury. AIMS AND OBJECTIVES: The present study in post-traumatic brain injury patients is planned to assess the prevalence of fatigue, depression and insomnia, the correlation of fatigue with depression and insomnia and the risk factors associated with fatigue. MATERIAL AND METHODOLOGY: Total 100 patients were recruited in the present study. Interview was focused on assessment of severity of traumatic brain injury, fatigue, insomnia and depression using Glasgow Coma Scale, Fatigue Severity Scale, Insomnia Severity Index and Patients Health Questionnaire(PHQ-9) respectively. RESULTS: Prevalence of depression was found 84% while that of fatigue and insomnia was 50% and 49% respectively. All patients with fatigue had depression whereas those patients without fatigue were also found to have depression (68%) and this correlation was found statistically significant. Similarly, insomnia was reported in 70% of patients who were fatigued against 28% of patients with no fatigue. This was also found statistically significant (P <0.0002). CONCLUSION: Fatigue in common in post TBI patients. Insomnia and depression are closely associated with fatigue. Clinical and research investigations of fatigue in post-traumatic brain injury should include concomitant screening for treatable depressive symptoms and sleep disorders.