Asian Journal of Medical Sciences

Shiv-mix for perioperative hemodynamic stability and analgesia: A new paradigm for limited resource centres

Imran Ahmed Khan — 2023-03-01

Dear editor,

A very interesting article has been published in your esteemed journal titled “Effect of pre-emptive intravenous paracetamol, magnesium sulfate, and lignocaine on hemodynamic variables during perioperative period in pre-eclampsia patients scheduled for lower segment cesarean section under general anesthesia: A prospective randomized study” by Kothari et al., (December 2022|Vol 13|Issue 12). Research is not complete unless it reaches to its potential audience. We, firstly, would like to congratulate the authors and the journal for publishing their research on such a very important topic. Authors have described their findings in a clear and scientific manner. Randomized and double-blinded studies provide inferences which are considered more authentic. Authors in this study used envelop method for allocating patient in the two groups; the intervention and the control. Findings of this study will definitely help readers and practitioners in providing safe and stable anesthesia to their patients. In this prospective randomized study, authors concluded that combination of paracetamol, magnesium sulfate, and lignocaine is effective in attenuating hemodynamic responses to laryngoscopy and intubation. They also found better hemodynamic stability during intraoperative and post-operative period in pre-eclampsia patients scheduled for lower segment cesarean section under general anesthesia. Finally, they opined that when paracetamol, magnesium sulfate, and lignocaine are given together effective and prolonged post-operative analgesia can be obtained.

Authors discussed efficacy and safety of various medications (Lignocaine, fentanyl, esmolol, and magnesium sulfate) comparing with placebo and different combinations used to attenuate laryngoscopy and intubation response. However, in last paragraph of introduction and in discussion, authors wrote that they could not find any single study using all three drugs (intravenous paracetamol, magnesium sulfate, and lignocaine) simultaneously for attenuation of hemodynamic changes during laryngoscopy and intubation.

We would like to draw your kind attention published work that have utilized the same combination with similar effects and this study support the conclusions of those studies. We do agree that these were nor RCTs but case series. Two related articles are discussed here. Khan and Singh in their narrative review described efficacy, safety, and patient satisfaction of various combinations of paracetamol, tramadol, magnesium sulfate, and lignocaine (Shiv-mix 1, 2, and 3). Authors found the described opioid free anesthesia (OFA) regimen (Shiv-mix) very effective in attenuating laryngoscopic and intubation response. In their case series, they also found stable intraoperative hemodynamics and absence of some commonly seen post-operative complications such as PONV and shivering. In another case series by Ansari et al., using similar OFA describing ten cases of laparoscopic cholecystectomy, the authors found that OFA using Shiv-Mix (A combination of paracetamol, tramadol, magnesium sulfate, and lignocaine) infusion preoperatively was a safe, opioid‑sparing, and feasible option that provide good perioperative analgesia, stable hemodynamics, and an uneventful recovery profile.

We again support the findings of the study by Kothari et al. We hope that this discussion will help researchers and practitioners to provide effective and safe perioperative course of their patients and opening new horizons for multimodal analgesia.

Thoracic segmental spinal anaesthesia for laparoscopic cholecystectomy in a case of birt-hogg-dube syndrome

Tushar Kanti Ghosh — 2023-03-01

Birt-Hogg-Dube syndrome is an extremely rare genetic disorder featuring multiple lung cyst or bulla which lead to recurrent spontaneous pneumothorax. Laparoscopic cholecystectomy poses a significant challenge in such cases from anesthetic point of view. Thoracic segmental spinal anesthesia (TSS) is a relatively new and beneficial alternative to general anesthesia to avoid post-operative complications. In this report, we used thoracic segmental spinal successfully in a known case of Birt-Hogg-Dube syndrome to avoid post-operative pneumothorax and discussed the technique and anatomical and physiological consequences. We can conclude that thoracic segmental spinal anesthesia can be used safely and successfully in laparoscopic cholecystectomy specially in cases where general anesthesia is better avoided as in Birt-Hogg-Dube syndrome.

The incidence, risk factors, and outcome of new-onset diabetes among post-COVID-19 patients: A single-center study

Siddaganga — 2023-03-01

Background: Coronavirus disease 2019 (COVID-19) infection may elevate the risk of hyperglycemia and other complications in patients with and without prior diabetes history. It is not clear whether the virus induces type 1 or type 2 diabetes or instead causes a novel form of diabetes. Precise mechanism of diabetes onset in COVID-19 patients remains unresolved.

Aims and Objectives: The aims of this study were to know the incidence, risk factors, and outcome of new-onset diabetes among post-COVID-19 patients and association of disease severity and occurrence of new-onset diabetes in post-COVID-19 Patients.

Materials and Methods: Patients age more than 18 years, not known diabetic, tested positive with rapid antigen test or reverse transcription polymerase chain reaction admitted to a tertiary care hospital were included in the present prospective observational study. The patients who developed new-onset diabetes during the 3 months follow-up and, the risk factors associated with new-onset diabetes are assessed. Patients with hemoglobin (HbA1c) >6.5% were diagnosed with new-onset diabetes.

Results: Total 246 patients were non-diabetics at admission, at 1 week 188 were non-diabetics and 49 were diabetics, and nine were prediabetics. Patients were within the age range of 21–95 years with mean age of 49.46±17.02 years and male predominance (59.76%). Out of 188 non-diabetics, 19 (10.10%) developed new-onset diabetes, and 2 (1.06%) developed new-onset prediabetes after 3 months. Out of 49 diabetics, 19 (38.77%) became non-diabetic, 30 (61.22%) remained diabetic, and out of nine prediabetes 2 (22.22%) developed new-onset diabetes, 5 (55.55%) reversed to non-diabetic, and 2 (22.22%) remained prediabetic after 3 months. In total, from HbA1c at admission and 3 months, 51 subjects had new-onset diabetes (20.73%). Most common risk factors found with occurrence of new-onset diabetes were those on high dose of steroid (P=0.0001), family history of diabetes mellitus (DM) (P=0.001), over weight and obesity (P=0.0001), fungal infection (P=0.0001), and need of oxygen and intensive care unit requirement (P=0.0001). The patient with increased laboratory markers of inflammation such as ferritin, neutrophil leukocyte ratio, lactate dehydrogenase, and C-reactive protein D-dimer had strong association with occurrence of new-onset diabetes (P=0.0001).

Conclusion: COVID-19 infection confers an increased risk for type 2 diabetes. Patients of all ages and genders had an elevated incidence and risk for occurrence of new-onset diabetes. Moreover, it was strongly associated with overweight and obesity, steroid dosage, and its duration, disease severity, positive family history of DM, and increased laboratory markers of inflammation. Hence, particular attention should be paid during the first 3 months after COVID-19 infection and patients need to be under follow-up for blood glucose monitoring.

A cross-sectional study on the role of hematological and inflammatory biomarkers as predictor of mortality at the time of admission among COVID-19 patients

Sanjay Kumar Totade — 2023-03-01

Background: Whole world experienced COVID-19 pandemic with more than 155 million cases and >3.4 million deaths. Vasculitis and immune system activation plays a critical role in pathogenesis, especially in severely ill and non-survivors COVID-19 patients.

Aims and Objectives: The aim of the study was to establish the role of hematological indices and inflammatory biomarker as predictors of mortality among non-survivor and survivor COVID-19 cases at the time of admission.

Materials and Methods: The cross-sectional study was conducted at a dedicated COVID-19 referral hospital from July 2020 to August 2020, among 300 real time-polymerase chain reaction confirmed COVID-19 cases. Demographic, clinical, comorbidity, laboratory investigation, and outcome data were collected from patient’s medical record. Outcome variables – discharged (survived) or death (non-survived) were considered for comparison of various hematological indices and inflammatory biomarkers. Data are represented as median, IQR (Q1-Q3) and difference between median and proportions were calculated by Mann–Whitney U-test and χ² test. A predictive power of laboratory parameters between survivors and non-survivors was evaluated using receiver operant curve (ROC) analysis and area under the ROC curve (AUC).

Results: The median age of non-survivors was significantly higher than survivors. Hypertension was significantly associated with non-survivors. Hematological parameters such as total leukocyte count, absolute neutrophil count, Neutrophil: Lymphocyte ratio were significantly increased with lymphocytopenia (P=0.001), and Inflammatory biomarkers such as C-reactive protein (CRP), lactate dehydrogenase, D-dimer, ferritin, procalcitonin, and NT-Pro BNP, all were significantly increased in non-survivors patients (P=0.001). CRP and neutrophil lymphocyte ratio (NLR) showed “Good” predictive value for mortality with cutoff value of 74.0 mg/l (AUC=0.841, Sensitivity=80.4%, Specificity=73.0%) and 5.65 (AUC=0.805, Sensitivity=76.1%, Specificity=73.0%), respectively. Pro-BNP showed “Fair” predictive value for mortality with cutoff value of 330.5 pg/ml (AUC=0.726, Sensitivity=73.9%, Specificity=58.2%).

Conclusion: We suggest that CRP, NLR, and Pro-BNP can be used as a screening tool to predict mortality in COVID-19 patients for timely intervention to save valuable life, especially when sensitivity toward severity of COVID-19 among medical health professionals and general public is on decline.

Microbiological blood profile among COVID-19 patients hospitalized in a tertiary care hospital: An observational study

Mamta Meena — 2023-03-01

Background: Bacterial coinfection contributes to increase morbidity and morbidity of viral respiratory infections and may lead to fatal outcome during its course of illness.

Aims and Objectives: The main objective of this study was to determine the bacteriological profile of COVID-19 patients admitted in hospital, their antibiotic susceptibility, and their association with severity.

Materials and Methods: The present study was retrospective observational cross-sectional study of all patients admitted for COVID-19 at Gandhi Medical College and Hamidia Hospital, Bhopal (MP) between (March 2020 and December 2020). Demographic, comorbid conditions, and microbiological data were compared HBD and intensive care unit (ICU) admissions and role secondary coinfection in severity and mortality.

Results: Thirty percentages of percent of patients showed bacterial growth, Staphylococcus aureus was most common, followed by Pseudomonas aeruginosa. Mean±SD of age was 43.6±21.6. Antibiotic resistance of cefoxitin, cotrimoxazole, and azithromycin was seen in maximum Gram-positive growth, whereas sensitivity for linezolid and gentamicin was present in 10–16% cases. Highest antibiotic resistance in Gram-negative growth was seen for ceftozidime, amikacin, imipenem, and meropenem, whereas sensitivity of colistin antibiotic was highest in Gram-negative growth.

Conclusion: Coinfection rates increase in patients admitted to the ICU, despite frequent prescription of broad-spectrum antibiotics. Infectious diseases practitioners carry the burden of life-saving and provide for societal trust that is effective antibiotic therapy in the face of these changes. With a growing body of evidence supporting short-course, antimicrobial therapy “Shorter Is Better” should be the new mantra.

COVID-19 anxiety among undergraduate students of a medical college in Chengalpattu district – A cross-sectional study

Abhilash Bagavanantham Adiththan — 2023-03-01

Background: COVID-19 is caused by severe acute respiratory syndromes-CoV-2, a virus that affects the physical as well as mental health of people.

Aims and Objectives: Our study was conducted to estimate the COVID-19 anxiety prevalence and its associated sociodemographic factors in a medical college.

Materials and Methods: Undergraduate medical students of a medical college in Chengalpattu district were the study participants, with inclusion criteria of students above 18 years of age from 2nd, 3rd, and final year and interns being included for the study. Using simple random sampling, students were selected with a sample size of 197. After obtaining approval from the Institutional Human Ethics Committee and informed consent, data were collected using a structured and pre-tested questionnaire, with anxiety being assessed using coronavirus anxiety scale and data analyzed using SPSS version 21. The statistical tests used were proportions, Chi-square test. P<0.05 was considered to be statistically significant.

Results: Among the 197 students, males constituted 82 (41.6%) and females 115 (58.4%), of which 60 (73.1%) of males and 88 (76.5%) of females had COVID-19 anxiety. Overall 75.1% had COVID-19 anxiety. Based on the year of study, 43 (22%) 2nd-year students and 38 (19.3%) 3rd-year students, 29 (14.8%) final-year students, and 38 (19.3%) inters had COVID-19 anxiety. Sociodemographic factors such as the type of family, year of study, and staying with parents had a strong association with COVID-19 anxiety.

Conclusion: In our study, 75.1% experience Coronavirus related anxiety, and thus, there is need for focus on the mental well-being of undergraduate students requiring attention as well as support from college administration, family, and society to cope up with the pandemic situation.

Comparison between pre-treatment with nalbuphine vis-a-vis dexmedetomidine for prevention of etomidate induced myoclonus

Manoj Kumar Saha — 2023-03-01

Background: Etomidate is considered as an excellent drug for induction in anesthesia, although it has an undesirable side effect like myoclonus.

Aims and Objectives: The aims of this study were to compare the effect between pre-treatment with nalbuphine and dexmedetomidine for attenuation and severity of etomidate induced myoclonus and to assess their adverse drug reaction.

Materials and Methods: A prospective, randomized, and single-blinded study was conducted on patients undergoing elective surgery under general anesthesia. After selection of patients according to inclusion/exclusion criteria, nalbuphine (0.2 mg/kg) and dexmedetomidine (0.5 μg/kg) were infused 10 min before the induction of anesthesia. The vital parameters and any incidences of myoclonus during operation were observed at fixed interval.

Results: A total of 102 patients in the age group of 18–60 years of either sex were assessed. In Group D 7, out of 51 patients (13.7%) were found to have myoclonus, whereas, in Group N, it was observed in 21 out of 51 patients (41.2%). Difference between the two was found to be statistically significant (P<0.001). In Group D, grade 3 myoclonus was observed in 0% patients. About 2% patients had grade 2 and 11.8% had grade 3 myoclonus. In Group N, grade 3, 2, and 1 myoclonus was recorded as 3.9%, 11.8%, and 25.5%, respectively. The difference between the two groups is statistically significant (P<0.001).

Conclusion: Incidence and severity of etomidate induced myoclonus were less in patients who received pre-treatment with dexmedetomidine than those who underwent pre-treatment with nalbuphine. Furthermore, more hemodynamic stability was achieved with use of dexmedetomidine as the agent for pre-treatment.

Comparison between transdermal buprenorphine and intravenous paracetamol for post-operative analgesia after major plastic reconstructive surgery under general anesthesia – A randomized double-blind controlled trial

Arghya Maity — 2023-03-01

Background: Adequate pain management is an essential entity in reconstructive surgery to prevent adverse physiological and psychological outcome. Transdermal buprenorphine has been mostly studied in chronic pain and cancer related pain but hardly studies in acute pain are available.

Aims and Objectives: The aims of this study were to compare post-operative pain relief achieved by transdermal buprenorphine and IV paracetamol in terms of safety and efficacy. Sedation and adverse effects were also studied.

Materials and Methods: This is a prospective, parallel group, double-blind, and randomized trial. After ethics, clearance and consent from 46 patients undergoing major reconstructive surgery were allotted into Group B, (n=23) who received transdermal buprenorphine and Group P (n=23) who received m IV paracetamol 6 hourly. IV Paracetamol was taken as active control. Standard institutional protocol for general anesthesia was followed. Visual analog scale (VAS) score was measured postoperatively for 48 h. Diclofenac sodium was the rescue analgesic. Sedation was assessed by Ramsay Sedation score.

Results: Transdermal buprenorphine patch (TDB) gave superior pain relief in comparison to intravenous paracetamol 48 h postoperatively, P≤0.0.5 pin VAS score. The total amount of rescue analgesic required was high in Group P than Group B (P=0.034). Hemodynamic stability was better maintained with TDB with minimal sedation and side effect.

Conclusion: TDB (20 μg/h; 20 mg) can be safely used for post-operative analgesia with greater efficacy and minimal side effects when compared to intravenous paracetamol.

A comparative evaluation of dexmedetomidine and magnesium sulfate during awake fiber optic orotracheal intubation in patients scheduled for cervical spine surgeries: A prospective study

Ekta Bansal — 2023-03-01

Background: Fiber optic intubation has become an integral part in management of anticipated difficult airways. Various anesthetic drugs have been used to assist awake fiber optic intubation (AFOI) for producing conscious sedation to provide a calm, cooperative, and responsive patient without respiratory depression for successful awake fibre optic intubation.

Aims and Objectives: The aim of the present study was to compare the efficacy of dexmedetomidine and magnesium sulfate during awake fiber optic orotracheal intubation in patients scheduled for cervical spine surgeries.

Materials and Methods: A randomized, prospective, and comparative study design was conducted in 60 patients in JAH group of hospitals. All patients were randomly divided into two groups: Group A (n=30) patients received dexmedetomidine (1 μg/kg) and Group B (n=30) patients received magnesium sulfate (40 mg/kg) in 100 ml normal saline over 10 min. The fiber optic orotracheal intubation was performed and primary outcome was level of sedation assessed using Ramsay sedation score. Other parameters of study included cough score and intubation score to compare intubating conditions. The secondary outcomes of study included variations in hemodynamic parameters heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and SPO2 during drug infusion at 2-min interval, immediately after intubation and every 10 min after intubation till 30 min.

Results: Group A (Dexmedetomidine) had better sedation score, cough score, and intubation score with stable hemodynamic variables than Group B (Magnesium Sulphate) with statistically significant results.

Conclusion: Patients receiving dexmedetomidine had better sedation providing more optimum conditions for AFOI with stable hemodynamic parameters and lesser adverse effects during the procedure than magnesium sulfate.

Nasogastric tube insertion in anesthetized, intubated adult patients: A comparison between conventional blind insertion technique and “throat pack in situ” technique

Vaskar Roy — 2023-03-01

Background: Correct placement of nasogastric tube (NGT) placement often becomes difficult in anesthetized, intubated adult patients due to lack of cooperation from patient and the propensity of the tube to travel the same course of path. Preexisting throat pack is supposed to resist the normal passage of the NGT as per common belief. Only one study has evaluated this in pediatric population and the result is encouraging.

Aims and Objectives: Hence, the present study has been carried out in adult population to compare the success rate of correct placement of NGT in anesthetized intubated adult patients with the pharyngeal (throat) pack in its position in comparison with no throat pack. This is to examine the effect of preexisting throat pack whether it assists or resists the normal passage of the NGT.

Materials and Methods: One hundred and eighty patients were recruited for this interventional and single-blind study. After induction of anesthesia and intubation, the patients were randomized to receive NGT insertion following either blind insertion of the NGT without a pharyngeal pack (group A, n=90) or receive the NGT placement in the same technique but after placement of a pharyngeal pack. The success rate of correct placement of NGT in the first attempt (primary outcome), the procedure time, and adverse events was recorded.

Results: Successful insertion of NGT in first attempt was considerably higher in throat pack in situ group compared to blind insertion without a throat pack 81 (90%) versus 63 (70%), respectively (P=0.001). The procedure time for successful placement of NGT was found comparable between the two groups. Significant decrease in coiling is seen in “throat pack in situ” group compared with blind insertion technique (P=0.003).

Conclusion: In view of considerable higher success rate and reduced adverse events, it can be concluded that the pre-existing appropriately placed throat pack can facilitate the placement of NGT instead of putting any hindrance.

Effect of addition of intrathecal preservative free magnesium sulfate with 0.5% bupivacaine heavy and fentanyl with 0.5% bupivacaine heavy on post-operative pain relief in patients undergoing hysterectomy

Ankita Gupta — 2023-03-01

Background: Spinal anesthesia is the most common neuraxial anesthesia for infraumblical surgeries. The use of various adjuvants has become popular in today’s scenario to enhance its quality.

Aims and Objectives: The aim of this study was to evaluate the onset, duration of sensory and motor block, hemodynamic effects (if any), duration of post-operative analgesia, and adverse effects of fentanyl or magnesium given intrathecally with 0.5% bupivacaine heavy in patients undergoing hysterectomy.

Materials and Methods: This prospective randomized double-blinded study was conducted in total sixty patients undergoing hysterectomy, divided into two groups of 30 patients each. Group F received 25 μg fentanyl with 3 mL 0.5% bupivacaine heavy and Group M received 100 mg magnesium sulfate with 3 mL 0.5% bupivacaine heavy. The onset and duration of sensory and motor blockade, duration of analgesia, hemodyamics, and side effects were assessed.

Results: The mean time of onset of sensory and motor block was less in fentanyl (P<0.001). Duration of sensory, motor block, and duration of analgesia was more in fentanyl group (P<0.001), whereas incidence of side effects such as bradycardia, hypotension, and shivering was less in magnesium.

Conclusion: Our study concluded that addition of fentanyl as adjuvant effectively augmented the quality of spinal anesthesia, but magnesium provided stable hemodynamics and lesser side effects as compared to fentanyl.

Effect of single dose preemptive intravenous paracetamol, dexamethasone, and magnesium sulfate on perioperative hemodynamic variables and post-operative nausea, vomiting, and pain in open cholecystectomy done under general anesthesia: A prospective, randomized, and single-blind study

Dilip Kothari — 2023-03-01

Background: Pain due to open cholecystectomy can result in delayed recovery and poor operative outcomes. Multimodal approaches to pain control cause functional improvement. We compared the efficacy of paracetamol 1 g, dexamethasone 8 mg, and magnesium sulfate 2 g with normal saline in control over perioperative hemodynamics and post-operative pain in patients undergoing open cholecystectomy under general anesthesia.

Aims and Objectives: This study conducted to assess the effect of preemptive intravenous paracetamol, dexamethasone, and magnesium sulfate on perioperative hemodynamic variables (primary outcome) and post-operative nausea, vomiting, and pain (secondary outcome) in open cholecystectomy.

Materials and Methods: Sixty patients of ASA Grade I/II were randomized into two groups to receive either normal saline 100 ml iv (Group C, n=30) or infusion containing inj. paracetamol 1 g, inj. dexamethasone 8 mg and inj. magnesium sulfate 2 g iv (group PDM, n=30), 20 min before induction. Intraoperative and post-operative hemodynamic data, post-operative pain scores, and incidence of nausea vomiting were recorded.

Results: Intraoperative pulse rate was significantly higher at intubation and 15 min after intubation in the control group and intraoperative systolic, diastolic, and mean arterial blood pressure were significantly higher in control group at intubation and until 60 min. Post-operative pulse rate was significantly higher in the control groups at 180 min and incidence of PONV reduced in PDM group until 90 min.

Conclusion: Preemptive intravenous infusion of paracetamol, dexamethasone, and magnesium sulfate provided better stability over perioperative hemodynamics, reduced the incidence of post-operative nausea vomiting, and provided better post-operative pain control.

Efficacy of local infiltration analgesia in post-operative pain management following total knee replacement

Avinash TP — 2023-03-01

Background: Post-operative pain and prosthetic joint infections are two crucial impediments in providing a good quality of life after surgery.

Aims and Objectives: In this study, we evaluated the efficacy of local infiltrative anesthesia (LIA) in total knee arthroplasty (TKA) and to study associated complications.

Materials and Methods: The present study was conducted over 2 years. All patients who underwent total knee replacement for degenerative arthritis of the knee were considered for the study. Questionnaire consisted of three sections, first section: Demographic profile, second one: Laterality of knee, duration of surgery, final section: Consisted of pain evaluation by visual analog score. Pain assessment in post-operative period was done for 3 days (72 h) and was estimated using visual analogue score (0–10). Assessment was done at 6 h, 24 h, 48 h, and 72 h after surgery during rest and movement. Data collected were entered and analyzed using SPSS. Association between different variables was done using Chi-square test/Fishers exact test.

Results: Visual analog score was 3.4±1.31 in first 6 h. Visual analog scale scoring was significantly less 48 h of post-surgery. There were no postoperative surgical wound problems in any of the cases and no clinical signs of infection were identified at the end of 3-month post-surgery.

Conclusion: LIA can be considered a safe and effective modality for pain control in knee arthroplasties.

Efficacy of intravenous dexamethasone for post-operative pain relief in elective cesarean section

Swetha Purohit — 2023-03-01

Background: Various additives have been evaluated for the purpose of enhancing quality of analgesia and prolonging duration of spinal anesthesia.

Aims and Objectives: This randomized study was conducted to evaluate the efficacy of intravenous dexamethasone in spinal anesthesia.

Materials and Methods: A total of 100 patients scheduled for lower segment cesarean section under spinal anesthesia were randomly allocated into two groups, Group-1 and Group-2, including 50 patients each. All the patients received injection bupivacaine 0.5% heavy 10 mg for spinal anesthesia. Group-1 received injection dexamethasone 8 mg intravenously, and Group-2 received injection normal saline 2 cc immediately after spinal anesthesia. Duration of sensory and motor block, post-operative analgesia, visual analog pain scale (VAS) score, time of rescue analgesia, total analgesic requirement in the first 24 h, intra- and post-operative hemodynamics, and side effects if any were recorded.

Results: The mean duration of sensory block (min) in Group-1 and Group-2 was 162.50 and 106.17, respectively. Time to the requirement of first rescue analgesia was 8.67 h in Group-1 and 4.40 h in Group-2. Significant changes seen in VAS score in post-operative period after 1 h of surgery in Group-1 and Group-2. Group-1 had more duration of sensory block, prolonged requirement of first rescue analgesia. Duration of motor block and intra- and post-operative hemodynamic parameters was comparable in both the groups. No side effects were recorded in both the groups.

Conclusion: We conclude that administration of dexamethasone 8 mg intravenously prolongs the duration of post-operative analgesia and sensory block in patients undergoing lower segment cesarean section under spinal anesthesia.

Attenuation of hemodynamic pressor response to laryngoscopy and endotracheal intubation by intravenous fentanyl in elective surgery under general anesthesia: A randomized controlled trial using three different doses

Rajdip Hazra — 2023-03-01

Background: Direct laryngoscopy and endotracheal intubation elicit hemodynamic pressor responses which may be hazardous in high risk patients. Fentanyl, a low cost synthetic opioid, when used judiciously, may be a good option to attenuate this stress response.

Aims and Objectives: The present study has been conducted to compare the efficacy of three different doses of intravenous fentanyl in attenuation of hemodynamic pressor response to laryngoscopy and endotracheal intubation in elective surgery under general anesthesia.

Materials and Methods: It was a double-blinded randomized controlled trial. A total of 90 patients of American Society of Anesthesiologists physical status I and II, 55 male and 35 female, aged between 20 and 55 years, were randomized into three groups receiving 2, 3, and 4 μg/kg of injection fentanyl, respectively, administered intravenously 5 min before direct laryngoscopy and endotracheal intubation.

Results: There were significant differences in hemodynamic variables among all three groups at 1, 3, 5, and 10 min after endotracheal intubation. Just after endotracheal intubation; heart rate, mean arterial pressure, and diastolic arterial pressure – all these variables showed significance between 3 μg/kg and 4 μg/kg groups only. Incidence of nausea/vomiting showed statistical significance between 2 μg/kg and 4 μg/kg groups only.

Conclusion: In our double-blinded randomized controlled trial, 4 μg/kg of injection fentanyl administered 5 min before laryngoscopy and intubation, has showed superior efficacy in suppressing hemodynamic stress responses associated with it. Further, larger trials are needed to confirm our findings.

Effect of oral premedication with ivabradine on surgical field and intraoperative bleeding during functional endoscopic sinus surgeries: A prospective, randomized, and placebo-controlled study

Sowmya Madihalli Janardhan Iyengar — 2023-03-01

Background: Ivabradine is an effective drug to prevent abnormal increase in heart rate (HR).

Aims and Objectives: The aims of this study were to determine if a pre-operative oral dose of ivabradine (2.5 mg) reduces intraoperative bleeding during functional endoscopic sinus surgery (FESS) and improves visualization of operative field.

Materials and Methods: A prospective, randomized, and placebo-controlled study was carried out in 30 patients of ASA grade I and II, aged between 18 and 60 years undergoing FESS surgeries. The patients were randomly allocated into two groups. Group I – received 2.5 mg of tablet ivabradine and Group P – received a placebo (vitamin tablet) 1 h before surgery. Blood loss and hemodynamic parameters (HR, systolic, diastolic, and mean blood pressure) were assessed perioperatively. Surgical field was graded by operating surgeon using Fromme – Boezaart score (FBS) at the end of procedure. Post-operative monitoring for any complications was also done.

Results: Mean final blood loss in Group I was 165.73±43.48 mL and in Group P was 246.25±30.76 mL. There was a significant difference in mean final blood loss (mL) between two groups with P<0.001. In Group I – 13.33% had FBS 1 and 86.67% had FBS 2, whereas in Group P – 6.67% had FBS 2, 86.67% had FBS 3, and 6.67% had FBS 4. Thus, Group I had lower FBS scores than Group P and was statistically significant.

Conclusion: Pre-operative oral ivabradine helps in reducing intraoperative bleeding in FESS surgery and provides good surgical field compared to placebo.

Comparative study of propofol and dexmedetomidine Infusion for hypotensive anesthesia in FESS surgeries: A randomized prospective double-blind controlled study

Anesa Syed — 2023-03-01

Background: Intra operative bleeding is most common factor that diminishes visibility resulting in an increased incidence of complications in patients undergoing functional endoscopic sinus surgery (FESS). Methods to reduce intra-operative bleeding include Trendelenburg position, maintenance of normothermia, and controlled hypotension by various anesthetic techniques. Many studies have shown that propofol and dexmedetomidine infusion reduces the amount of bleeding in different surgeries.

Aims and Objectives: The aim of the study was to compare the effects of dexmedetomidine and propofol infusion over hemodynamic, quantity of blood loss, and quality of surgical field in patients undergoing FESS and to compare the side effects of dexmedetomidine and propofol infusion in cases undergoing FESS.

Materials and Methods: This was a comparative study conducted in the department of anesthesiology of a tertiary care medical college. The duration of study was 2 years. 60 patients of ASA Grades I and II with age between 20 and 60 years, including both males and females posted for FESS were included in this study on the basis of a predefined inclusion and exclusion criteria. Patients were divided into two groups (on the basis of whether they received propofol or dexmedetomidine infusion) of 30 patients each. Hemodynamic parameters (Heart rate and mean arterial pressure [MAP]) quantity of blood loss, quality of surgical field, and side effects were recorded and compared in both the groups. For statistical purposes, P<0.05 was taken as statistically significant.

Results: Antrochoanal polyp and chronic sinusitis were the most common indication of FESS in studied cases. Intraoperatively, heart rate was lower in both the groups as compared to baseline. However, the heart rate was lower in the Group D at all times as compared to Group P and the difference was statistically significant from 20 min onward after induction. The mean arterial blood pressure in both the groups was comparable till up to 15 min post induction with no statistical difference. Thereafter, the mean arterial blood pressure was lower in Group D than in Group P throughout the procedure, the difference being statistically significant (P<0.05). The isoflurane requirement in Group D was significantly lower starting from 5 min of induction to throughout the procedure as compared to Group P (P< 0.05). Mean blood loss in Group D was 115.0±16.78 ml and in Group P was 140.47±29.42 ml, the difference in blood loss was statistically significant (P<0.0001).

Conclusion: Dexmedetomidine is comparatively better than propofol in controlling heart rate and MAP, reducing the blood loss, and isoflurane requirement in patients undergoing FESS.

Evaluation of triglyceride-glucose index, triglyceride to high-density lipoprotein cholesterol ratio, and other lipid ratios in hypertension

Jyotsna Kiro — 2023-03-01

Background: Hypertension is one of the most common diseases with increasing morbidity and mortality. HTN is associated with cardiovascular risk factors such as insulin resistance (IR) and hyperlipidemia. Recently, triglyceride-glucose (TyG) index has been proposed as a marker for insulin resistance.

Aims and Objectives: This study aimed to assess TyG index, triglyceride to high-density lipoprotein ratio, and other lipid ratios in HTN patients.

Materials and Methods: The present study was conducted on 200 subjects and was categorized into two groups. 100 hypertensive patients were considered as cases and 100 healthy individuals as controls. Serum sample of the subjects was used for the estimation of total cholesterol, triglycerides (TG), and high-density lipoprotein cholesterol (HDL-C). Low-density lipoprotein (LDL) cholesterol was calculated. TyG index and TG/HDL ratio and other lipid ratios were calculated. Blood pressure (BP) was recorded.

Results: In this, BP, total cholesterol, TG, LDL, Very low-density lipoprotein cholesterol, Non-HDLC, TC/HDL ratio, TG/HDL ratio, and TyG index were increased in cases and HDL and HDL/LDL ratio were decreased. Study parameters were positively correlated with TyG index and TG/HDL ratio, except HDL, and HDL/LDL ratio.

Conclusion: The study concludes that significantly increased TyG index and TG/HDL ratio in hypertensive cases and their correlation with blood pressure.

Comparative analysis between fasting and postprandial apolipoprotein B and total cholesterol/high-density lipoprotein-cholesterol ratio for atherosclerosis risk prediction in type 2 diabetes mellitus subjects of central India

Rajesh K Jambhulkar — 2023-03-01

Background: Type 2 diabetes mellitus (Type 2 DM), characterized by a relative insulin deficiency or insulin resistance, is associated with a cluster of metabolic abnormalities, which includes glucose intolerance, hypertension, a unique dyslipidemia, a procoagulant state, and an increase in macrovascular diseases.

Aims and Objectives: The present study was conducted to correlate between fasting and postprandial apolipoprotein B and total cholesterol/high-density lipoprotein-cholesterol (TC/HDL-C) ratio for predicting the risk of atherosclerosis in T2DM subjects.

Materials and Methods: Sixty clinically diagnosed cases of T2DM (age group of 35–65 years and duration of diabetes of more than 5 years) were included in the study and sixty age- and sex-matched healthy subjects were taken as the controls. In both the study groups, we measured postprandial as well as fasting lipid profile, which comprised serum TC, triglycerides (TGs), HDL-C, low-density lipoprotein cholesterol (LDL-C), and apolipoprotein B. Ratio is calculated as TC/HDL-C in both fasting and postprandial state. The statistical analysis was done using the students unpaired’-test.

Results: The results of the present study showed significantly increased levels of postprandial serum TC, TGs, LDL-C, and apo B as compared to those in the fasting state (P<0.05). The serum HDL-C level was significantly lower in the postprandial state as compared to that in the fasting state (P<0.05). Postprandial TC/HDL-C and apo B are increased significantly as compared to fasting condition in type 2 diabetes subjects.

Conclusion: The findings suggest that postprandial lipid profile, apolipoprotein B, and TC/HDL-C ratio as a cardiovascular risk factor can be utilized as simple marker utilizing simple parameters in lipid profile that significantly increased in the postprandial state.Thus, Apolipoprotein B, the marker of the number of LDL particles (for atherosclerosis) in the circulation and TC/HDL-C ratio can be routinely estimated for the atherosclerosis risk assessment in type 2 diabetes subjects in the postprandial state.

Role of direct antiglobulin test in assessing the severity of extravascular hemolysis in autoimmune hemolytic anemia – analysis from a cross-sectional study

Anjaly Padmavilas Sasikala — 2023-03-01

Background: Autoimmune hemolytic anemia (AIHA) is an immune hemolytic disease characterized by hemolysis and anemia which results from increased red cell destruction due to auto antibodies directed against self-antigens on red cells. Clinical characteristics and potential associated hemolysis in AIHA can greatly depend on the serological characteristics.

Aims and Objectives: This study was done to find out the association of Grade of polyspecific Direct Antiglobulin test (DAT), complement involvement and immunoglobulin G (IgG) subclass with severity of hemolysis in an AIHA patients.

Materials and Methods: This was a cross-sectional study conducted for a period of 18 months from March 1, 2012, to August 31, 2013. Fifty consecutive AIHA patients diagnosed by a positive DAT in EDTA anticoagulated blood samples using poly specific anti human globulin reagent were followed up and results of various immunohematological tests such as polyspecific and monospecific DAT, IgG subtyping, and thermal amplitude were performed. Hematological and biochemical parameters such as hemoglobin, percentage of reticulocyte, total serum bilirubin, and serum lactate dehydrogenase also were recorded. Data were analyzed using SPSS v17.

Results: Majority of patients were belonging to 31–40 year age group and there was a remarkable female predilection. Secondary AIHA was more common (56%) than primary. SLE was identified as the most common underlying disorder in secondary AIHA. Majority (46%) were Grade 4 DAT positive. Predominant autoantibody identified was IgG (52%). Of the total IgG positive cases, IgG1 was the predominant subclass. C3d alone was detected in 18% of cases and C3d and IgG together in 30%. About 48% of our patients were of warm type, 32% mixed type, and 20% cold type. About 80% of the study population were treated with steroids alone. A small percentage of cases (16%) needed immunosuppressant in addition to steroids and still a smaller percentage (4%) needed splenectomy. Higher grades of DAT positivity were associated with more severe degree of anemia and hyperbilirubinemia. The study also demonstrated a positive correlation between DAT grade and severity of hemolysis.

Conclusion: AIHA patients in this study were predominantly of Warm AIHA with more of IgG1 involvement. A significant association is found between higher grades of DAT results and severity of anemia and jaundice in this study group. A positive correlation exists between grades of DCT and hemolysis as well.

Prevalence of protective antibody levels against hepatitis B infection among healthcare workers in a tertiary care hospital in India

Ramesh Thanikachalam — 2023-03-01

Background: Hepatitis B virus (HBV) infection affects more than 2 billion individuals globally HBV. The chance of dying from liver cirrhosis, acute fulminant liver disease, or hepatocellular carcinoma (HCC) is present in 240 million of these chronic HBV carriers
(HCC).

Aims and Objectives: This study aims to assess the anti-HBs antibody titer level against various levels of healthcare workers (HCWs) and to assess the need for booster dose hepatitis B vaccination.

Materials and Methods: This study was conducted at Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, India, from July 2022 to December 2022. A total of 218 HCWs were divided into two groups: Group A (vaccinated ≥5 years ago) and Group B (vaccinated in past 5 years). The serum from 2 mL blood was separated and tested for anti HBs antibody titer by electrochemiluminescense immunoassay method.

Results: The mean and standard deviation values of Anti-HBsAg titer between Group A and Group B was not statistically significant (P=0.08467).

Conclusion: Our study demonstrates that people who have had vaccinations are unsure of whether they are responders or non-responders, and to determine this, they must have had their titer evaluated only 1–2 months after receiving their third dosage of hepatitis B vaccine. As a result, they still run the risk of contracting hepatitis B and strongly need a booster dose of the hepatitis B vaccine.

Prevalence of hypertension and its associated risk factors among police personnel of a metropolitan city

Arunesh Kumar — 2023-03-01

Background: Hypertension is one of the diseases of occupational origin. It is ranked 5th among the 10 most important categories of occupational illness. Police personnel constitute a special occupational group with exposure to violence at work, which directly and indirectly affects their health. Various studies have reported significantly high prevalence of stress-related disorders such as hypertension, diabetes, and coronary heart disease among the policemen and found police occupation as a prominent risk factor for coronary heart disease.

Aims and Objectives: This study aims to estimate the prevalence of hypertension among police personnel of a metropolitan city.

Materials and Methods: A cross-sectional study was conducted among the police personal of a metropolitan city for a period of 1 year. Three hundred and fifty police personnel were contacted and interviewed using pre-designed, pre-tested, semi-structured pro forma. Police personnel were screened by taking two B.P. readings. Data analysis was done using SPSS 20.0 Statistical software. Chi-square/Fisher’s exact test was used to find the association. Statistical significance was considered at P<0.05.

Results: The prevalence of hypertension was 28% in the present study including 6% already detected and 22% newly detected. On multivariate logistic regression analysis, factors which were identified as risk factors for the development of hypertension among policemen were smoking, less physical activity, use of extra salt, mixed diet, and body mass index.

Conclusion: The prevalence of hypertension was high among police personnel. Effective intervention strategies such as lifestyle modification along with health-care strategies must be planned to keep the police force healthy and vigilant.

Treatment outcome of drug-resistant tuberculosis (DR-TB) following uptake of universal drug susceptibility testing: A record review from a nodal DR-TB center

Aditi Bharti — 2023-03-01

Background: There has been delay evident in diagnosing the drug resistance and non-initiation of appropriate treatment based on drug susceptibility pattern resulting in poor treatment outcome of drug-resistant tuberculosis (DR-TB).

Aims and Objectives: The aims of this study were to examine the treatment outcomes for DR-TB patients following universal drug susceptibility testing (UDST) and to examine the association of sociodemographic, behavioral factors, or comorbidities with outcome.

Materials and Methods: A retrospective study at a nodal DR-TB center was done for the past 2 years (2018–2019) following the district’s adoption of UDST. The study comprised patients registered between January 2018 and December 2019. Transferred out cases were excluded from the analysis. Cured or treatment completed were assigned as successful, whereas the treatment failed, lost to follow-up or died were adverse treatment outcome.

Results: A total of 201 patients were initiated on suitable DOTS regime and they continued the treatment from the center, during the study period. Altogether 129 (64.2%) patients had successful treatment outcome. None of the examined variable (age, sex, SES, Body mass index, and comorbidity) is found to have statistically significant association with outcome (P>0.05).

Conclusion: The UDST may be the reason for success rate shown here, higher than in literature published. Although a better stance is possible only by comparing the treatment outcome of pre- and post-uptake of UDST from same setting.

A study on cancer awareness among people attending a tertiary level care hospital in West Bengal

Debjani Sen Gupta — 2023-03-02

Background: A cross-sectional observational study conducted in the outpatient registration counter among people seeking registration ticket in a government Medical College. Sample size was 214 with equal representation of each sex.

Aims and Objectives: (1) The study’s aims at assessing the knowledge quotient about the occurrence, site presenting symptoms risk factors and outcome of various cancers. (2) Sex specific cancer screening program self-breast examination, mammography, pap smear awareness, and usage among females of study population have been investigated.

Materials and Methods: A cross-sectional observational study. Predesigned pretested questionnaire was administered to consenting participants among those registering for outpatient tickets at Calcutta National Medical college Hospital. Statistical analysis Used: Descriptive statistics was used with MS Excel.

Results: Awareness was 69.8% with 69% stating gastrointestinal tract to be the most common site, Of the population 70% stated pain was to be the most common presenting symptom, tobacco was said to be the most common causative agent by 72% and 70% stated it to be non-treatable. Among sex specific cancers 40% women identified breast as site of cancer presenting with nipple discharge and 34% stated the presenting feature to be lump. Screening method of self-breast examination and PAP smear was said by 5% and 2%, respectively.

Conclusion: The awareness regarding site cardinal signs outcome and risk factors was not good among study population. Much effort is to be given to address the state of things.

A cross-sectional study of extent and causes of interruption of treatment of tuberculosis in a tuberculosis unit of Purba Bardhaman district of West Bengal, India

Chinmay Nandi — 2023-03-01

Background: Tuberculosis (TB) is a communicable disease which requires prolonged treatment and having both medical and social dimensions. Adherence to treatment is very important issue in successful treatment of TB. Directly observed therapy was a key strategy in The Revised National TB Control Program. However, treatment interruption is very common.

Aims and Objectives: The objective of this study is to assess the nature, extent, and reasons for interruption of treatment in Bhatar TB Unit (TU) of Purba Bardhaman district of West Bengal.

Materials and Methods: The study was a descriptive and cross-sectional study with two components. The study was conducted in the area covered under Bhatar TU of Burdwan district of West Bengal. Complete enumeration technique was followed in the study. In the first component of the study, 231 study subjects were found by complete enumeration, out of which 26 were discarded due to incomplete records. In the other component, 90 study subjects were interviewed at the beginning of treatment and after treatment interruption, if any. Data were analyzed using RStudio.

Results: Out of the group with only record review, 205 subjects were included in the study, out of which 160 (78.05%) were male and 45 (21.95%) were female. In the other group with both record review and interview, out of 90 subjects, 64 (71.1%) were male and 26 (28.9%) were female. Out of 295 cases, 270 (91.5%) were new and 25 (8.5%) were previously treated. Out of 295 subjects, 36 (12.2%) had interrupted treatment. Seven persons out of 36 had interrupted more than once. Thirty-four persons had interrupted in intensive phase of treatment. Thirty-two persons had taken 10–20 days before interruption of treatment. The most common reason for interruption of treatment was “Not willing to take tablets.” Among the other reasons were “Side effects,” “Hospitalization,” “Away from home,” etc.

Conclusion: Non-compliance to anti-tubercular drugs remains an important issue in the elimination of TB.

Histomorphological study of lichenoid dermatitides – A retrospective study

Kalaivani Selvam — 2023-03-01

Background: Lichenoid dermatitis is a very common dermatological condition and is defined by features of basal cell damage and a dense band-like infiltration at the dermo-epidermal junction. There is a wide range of lesions included under this and the prototype lesion is Lichen Planus.

Aims and Objectives: The aims of this study were to study the histopathological spectrum of the conditions with lichenoid tissue reaction and to find clinicopathological concordance of the lichenoid lesions.

Materials and Methods: A retrospective study was conducted in a tertiary care center, where all the skin biopsy cases diagnosed clinically and/or histologically as lichenoid dermatitis for 2 years (2018–2019) were included in the study. Demographic details, clinical diagnosis, histological diagnosis, and the different histological features were collected from the respective case sheets and biopsy reports and entered in an excel worksheet. Frequency and percentages were used to represent the data.

Results: A total of 47 cases were clinically diagnosed as lichenoid dermatitis, of which 38 cases showed concordance between clinical and histopathological diagnosis. Nine cases showed discordance between clinical and histopathological diagnosis and were categorized as lesions without lichenoid features. Seven cases were diagnosed as lichenoid dermatitis only on the histopathological study with an absence of such a differential diagnosis clinically. Out of the total 45 cases diagnosed as lichenoid dermatitis, 27 were lichen planus, five were lichen planus pigmentosus, four were hypertrophic lichen planus, three were lichenoid dermatitis, and two cases each of lichen planopilaris, lichen keratosis, and lichen sclerosis. Lichenoid dermatitis was seen commonly among the 41–50 years age group. Females were more commonly affected than males.

Conclusion: Lichen planus is the prototype lesion among the lichenoid dermatitides. Definitive diagnosis of the specific entity among the lichenoid lesions is important as decision-making regarding the treatment modality and prognosis of the patient depends on it. Histopathological examination is vital for the definitive diagnosis, along with clinical correlation which concludes that clinicopathological correlation is the key.

Correlation between BISAP score and D-dimer level on their predictive ability to determine the severity of acute pancreatitis at 24-hours of hospital admission: an observational study

Sanjay Maitra — 2023-03-01

Background: Early prediction of severity of acute pancreatitis (AP) is important for management of AP patients with escalation of care and aggressive therapy which can reduce complications. Bedside index of severity in AP (BISAP) score is helpful in early diagnosis of severe AP. D-dimer, a biomarker of secondary fibrinolysis may be helpful in predicting the severity of pancreatitis.

Aims and Objectives: The objective of this study was to evaluate the two scoring systems - the BISAP score and D-dimer in early prediction (within 24 h) on the severity of AP and to analyze how D-dimer correlates with BISAP score.

Materials and Methods: Seventy-five patients, aged 18–70 years, suffering from AP due to any cause were included for this prospective, observational study. Within 24 h of admission D-dimer was estimated and BISAP score was calculated. The severity was assessed based on D-dimer level and BISAP scoring systems within 24 h of hospital admission and data were tabulated for analysis. The D-dimer level >2.5 mg/L was considered to be suggestive of severe pancreatitis. The BISAP score >2 in first 24 h was defined as predictive of severe pancreatitis. Spearman rank correlation was used for an analysis of the association between two set of data (BISAP scores and d-dimer levels) and thus to measure the strength and direction of the relationship between the two variables.

Results: In the present study, 37.3% of the patients had D-dimer ≤2.5 mg/L and 62.7% had D-dimer>2.5 mg/L’ on calculating the Pearson’s correlation on the ranked values of the data (BISAP scores and D-dimer levels), the correlation coefficient (Spearman’s Rho, designated as “rs”) was found to be 0.406 which indicates about moderate positive correlation.

Conclusion: D-dimer testing can be used as an alternative test to predict the severity of AP. It shows a moderate correlation with BISAP scoring.

Determinants of maternal near-miss event’s among pregnant women attending tertiary care hospital: A case–control study

Rutuja Patond — 2023-03-01

Background: Women who have survived complications during pregnancy and childbirth have been studied as surrogates of maternal deaths and have been termed as maternal near-miss. Study of such cases is considered a less threatening approach to improve maternal health care by the service providers. With this tool, we will be able to identify the delays. As near-miss occurs much more frequently than maternal deaths, a more reliable quantitative analysis can provide a comprehensive profile of the health system functioning. Near-misses are relatively simpler to analyze and easier to resolve. This knowledge will help in identifying the contributory factors of maternal deaths so that actions can be taken at community and health systems level.

Aims and Objectives: The objectives of this study were to determinants of maternal near-miss event’s among pregnant women attending tertiary care hospital.

Materials and Methods: This was a case–control study, conducted in the Department of Obstetrics and Gynecology at Government Medical College, Akola from January 2019 to January 2021. One hundred and twenty-five cases and 375 controls were included in the present study using EPI INFO in 2 years. Cases of near-miss events from hospital during study was identified and included in the study.

Results: In this study, a total of 500 persons were questioned (125 cases and 375 controls), with a 100% response rate. The average ages of the cases and controls were 26.5 (4.42) and 29 (59.9) years, respectively. Pre-existing medical disorders were substantially linked to maternal near miss (MNM). More over half of the patients (59.2%) and less than a third of the controls (23.21%) had a history of at least one pre-existing medical condition. After adjusting in the multivariate logistic regression model, multigravida, lack of antenatal care, induction of labor, and delays in reaching hospital were positively associated with a MNM. For instance, those mothers who were pregnant for the 2nd–4th times (AOR: 4.94 [95% CI: 1.46–16.8]) and more or equal to 5 times (AOR: 3.84 [95% CI: 1.23–11.91]) were nearly five-fold and four-fold more likely to experience MNM events respectively.

Conclusion: The factors that were found to be significant in our study are non-modifiable risk factors for maternal near-miss occurrences. These events can be prevented and mitigated by early detection and proper prenatal care.

A retrospective and observational study of urological anomalies in anorectal malformation in children at a tertiary care center in Telangana

Srinivas Srirampur — 2023-03-01

Background: Anorectal malformations (ARM) are one of the common congenital abnormalities in a pediatric surgical unit. Urological anomalies occur frequently with ARM and the incidence increases with increasing complexity of ARM having dramatic impact on quality of life.

Aims and Objectives: This study is done with an objective to know the incidence of various urological anomalies in ARM and comparing our observation with existing literature.

Materials and Methods: This is a retrospective study conducted in Pediatric Surgical unit, Gandhi Medical College and Hospital, Secunderabad, from January 2017 to December 2021 based on the records of 45 patients who were diagnosed to have ARM with urological anomalies. Incidence of urological anomalies in ARM is studied with respect to demographic data and pattern of coexistence.

Results: Total number of ARM cases noted during the period of study was 101, of which 45 cases had associated urological anomalies and these 45 cases were taken in this study. The overall incidence of urological anomalies was 42.5%. The incidence of urological anomalies was significantly swelled up in high ARM when compared with low lesion. Vesicoureteric reflux and hydroureteronephrosis were the most common anomalies observed in our study.

Conclusion: The high incidence of associated urological anomalies necessitates standardized protocol of investigating all ARM patients as it is an important cause of morbidity and mortality. Early diagnosis warrants timely intervention and prevents upper urinary tract deterioration.

Visual outcome following clear corneal incision phacoemulsification with rigid intra-ocular lens and small incision cataract surgery in low socioeconomic group patients: A comparative analysis in a teaching hospital in South India

Chethana Warad — 2023-03-01

Background: Cataract is the most common cause of curable blindness worldwide.

Aims and Objectives: A comparative analysis of clear corneal phacoemulsification with rigid intra-ocular Lens (IOL) and small incision cataract surgery (SICS) in low socioeconomic group patients in terms of post-operative visual outcome, surgically induced astigmatism (SIA), and intra-and post-operative complications.

Materials and Methods: A prospective hospital-based comparative study was conducted for 8 months in 424 eyes of 400 senile cataract patients divided into PHACO and SICS groups. Each group consisted of 212 eyes of 200 patients. Detailed examinations for best corrected visual acuity (BCVA), SIA, and complications were evaluated on the 1st post-operative day, 1st week and 6 weeks postoperatively.

Results: BCVA 6\18 or higher was 95.38% in the phacoemulsification group and 94.81% in the SICS group. The study revealed good visual outcome in both SICS and Phaco groups with no significant difference. The mean SIA was more in SICS group (−0.96±0.57) than in phaco group (−0.71±0.47) which was statistically significant. In terms of complications, no significant difference was noted between the groups.

Conclusion: The outcome of this study indicated that though SIA is more in SICS group than Phaco group, there is no difference between the groups in terms of visual outcome. The study has proven that SICS has comparable effectiveness as phacoemulsification with rigid IOL, which should be considered in low- and middle-income countries.

Outcome of intertrochanteric fracture managed with proximal femoral nail antirotation 2

Kathit Raj Ghimire — 2023-03-01

Background: Intertrochanteric fracture is a common condition seen in elderly population which is managed with operative procedure in the department of orthopedics. The proximal femoral nail antirotation (PFNA) system was developed by the AO/ASIF in 2004 for this fracture that provides optimal anchoring and stability when the implant is inserted into the osteoporotic bone. The main characteristic of the implant is the use of a single blade with a large surface area and insertion of the blade compacts the cancellous bone.

Aims and Objectives: The aim of the study was to study the functional outcome of intertrochanteric fracture managed with PFNA2.

Materials and Methods: The prospective and observational study was conducted in patients diagnosed with intertrochanteric fracture admitted in orthopedic ward, Western Regional Hospital, Pokhara. Pre- and post-operative fracture alignment, Harris hip score (HHS), post-operative complications were taken into account.

Results: Out of 55 cases taken into study, 36 (65.45%) were male and 19 (34.55%) were female. Maximum number of patients allocated in our study falls in 71–80 years group (29%) with least number in age group of 90 years or more (1.9%). Right-sided intertrochanteric fracture were 27 (49%) and left side involved were 28 (51%). Twenty-eight (51%) falls in Type II and 27 (49%) falls in Type III Boyd and Griffin intertrochanteric fractures. There was a marked improvement in fracture alignment after the operation with various parameters taken into consideration. Pre-operative HHS was 5.52±5.38 (Poor) and immediately after the procedure, it was 30.41±3.04 (Poor), 89.86±3.59 (Good) at 6 months, and 95.56±1.257 (Excellent) at 12 months. One case had blade cut out at immediate post-operative period, eight cases had surgical site infection, and five cases had GT fracture.

Conclusion: This study showed that PFNA2 is an effective operative procedure in management of intertrochanteric fractures by achieving better fixation through bone impaction especially in osteoporotic bone.

A clinico-pathological study of thyroid nodules and correlation among ultrasonographic, cytologic, and histologic findings

Rajarshi Sannigrahi — 2023-03-01

Background: Nodular thyroid is a common occurrence affecting 5% of the population.

Aims and Objectives: To find the prevalence of thyroid nodules, to study the clinico-biochemical profile of the patients with thyroid nodules and to establish a correlation between pre-operative ultrasonography and fine-needle aspiration cytology (FNAC) with post-operative histopathologic findings.

Materials and Methods: A prospective observational study was conducted in a tertiary care hospital in Kolkata over 1.5 years. Patients with clinically detectable nodules posted for surgery were evaluated clinically, biochemically, ultrasonographically (USG), and cytologically with FNAC. Histopathologic examination (HPE) was done post-surgery. Comparison was done between those with benign and malignant nodules. Correlation was done between pre-operative USG, FNA, and post-operative HPE of the nodules.

Results: Out of 322 cases during the study period, the prevalence of clinically detectable thyroid nodule posted for surgery was 39 (12.58%). Most of the patients were euthyroid (94.9%), had nodules in left lobe (41.5%). Most of the nodules were heteroechoic (56.5%) and majority were THY3 nodules (48.7%) on FNAC. On HPE, malignancy was found in 20.5% of the nodules. Compared to benign nodules, malignant nodules were more commonly larger, on the left lobe, solid, hypoechoic, with spiculated margins, punctate calcification, and having associated neck nodes (pall < 0.03). Out of 11 cases, which were radiologically predicted to be malignant, 10 had THY ≥3 on FNA, and 8 were malignant on HPE. USG had a sensitivity, specificity, positive, and negative predictive value of 87.5%, 87.1%, 63.63%, and 96.43% in predicting malignancy.

Conclusion: Pre-operative ultrasonography for thyroid nodules can predict malignancy with sufficient sensitivity and specificity and can obviate the need for unnecessary FNAC in many cases and also suggest imminent need for surgery rather than FNAC in very high risk cases.

Assessment of feasibility of cochlear sparing optimized radiotherapy in nasopharyngeal squamous cell carcinoma using high conformal radiation technique

Nikhila Ponnachiparambil Chandrabose — 2023-03-01

Background: One of the most prevalent head-and-neck tumors in Southeast Asia is nasopharyngeal carcinoma (NPC). Each year, NPC causes 84,400 new cases and 51,600 fatalities worldwide. Intensity-modulated radiation therapy (IMRT), which has good local control and few side effects on healthy tissue, is being used to treat NPC.

Aims and Objectives: Our study aims to assess the feasibility of cochlear sparing using volumetric-modulated arc therapy/IMRT technique.

Materials and Methods: Radiotherapy plans of 20 patients diagnosed with NPC who received curative concurrent chemoradiation (Weekly Cisplatin dose of 40 mg/m2) with RT dose of 66 −70 Gy at 1.8–2 Gy/# to a total of 33–35# delivered using True beam LINAC between the year 2020 and 2022 were analyzed retrospectively.

Results: Cochlea sparing reoptimization led to a considerable reduction in radiation dose for both cochleae as compared to the original treatment plans. The median D mean and D max for the left and right cochlea was found to be decreased. The difference in planning target volume (PTV)-D mean between the original and reoptimized plans was negligible. After reoptimization, the median PTV CI remained unchanged. The sparing of the left and right parotids and brain stem was not improved by reoptimization. A similar event was noted for the spinal cord, where the change from the median D max was not statistically significant.

Conclusion: Our investigation showed that a much-increased cochlea sparing is possible in the majority of patients while maintaining PTV dosage coverage and the other organs at risk. Clinical trials in the future, both retrospective and prospective, should examine the effects of this optimization.

Feasibility of vaginal dose points reporting in cancer cervix patients treated by external beam radiotherapy and brachytherapy

Grace Mercy Priscilla Balu — 2023-03-01

Background: Cervical cancer is the second most common malignancy among women in India. The standard of treatment for locally advanced lesions is Concurrent Chemoradiation with External Beam Radiotherapy followed by Intracavitary Brachytherapy (GEC-ESTRO). The dose received by the entire vagina cannot be accurately measured by a vaginal dose point assessment at the level of the ovoids alone.

Aims and Objectives: Our study aims to see the feasibility of measuring vaginal dose at various levels and define the dose points that can be practiced in 2D and 3D external radiation and brachytherapy (BT).

Materials and Methods: Radiotherapy plans of 29 patients with stages IIA to IVA cancer cervix treated with concurrent chemoradiation from January 2020 to December 2020 were retrospectively reviewed for the feasibility of measuring the vaginal dose points throughout the vagina. Every patient underwent cisplatin-based weekly chemotherapy along with BT and external beam radiotherapy. We have assessed the vaginal dose locations 2 cm above and below the point of the posteroinferior border of the pubic symphysis (PIBS). The superior surface of the ovoid to the PIBS point constitutes the vaginal reference length (VRL).

Results: The mean and median doses from external beam radiation therapy (EBRT) were 50Gy and 51 Gy at PIBS, 52 Gy and 53.5 Gy at +2 cm, and 18Gy and 28 Gy at -2 cm, respectively. The combined mean and median EQD2 doses from EBRT and BT at PIBS, PIBS+2, and at PIBS-2 were 56 and 57 Gy, 65 and 66 Gy, and 35 and 31 Gy, respectively. The mean VRL was 5.25 cm before EBRT and 4.75 cm before BT.

Conclusion: Our study found that it is feasible to measure the dose received by the vagina using the PIBS system and large dose variations throughout the vagina were observed.

Patterns of failure in locally advanced female breast carcinoma treated with neoadjuvant chemotherapy followed by surgery and radiotherapy – A prospective study

Shilpi Adhikary — 2023-03-01

Background: The use of combined modality therapy including surgery, chemotherapy, and radiotherapy increases five survival rates in stage IIA and stage IIIB disease to 80% and 45%, respectively. Neoadjuvant chemotherapy (NACT) eradicates micro metastasis present in the body and also improves resectability.

Aims and Objectives: The main aim of this study was to determine the locoregional recurrence and distant recurrence rates and thereby define clinical and pathological predictive factors for recurrence.

Materials and Methods: This was a single institutional prospective study carried out in the Department of Radiotherapy, RG Kar Medical College and Hospital, Kolkata. From January 2017 to December 2019, according to inclusion and exclusions criteria, a total of 1183 histologically and/or cytologically proven breast carcinoma patients were included in this prospective study.

Results: Breast conservative surgery was done in 16.5% of patients and the rest of the patients underwent modified radical mastectomy. Seven patients had undergone toilet mastectomy with the specimen. From the pathological review of the surgical specimens, 15.0% of patients achieved pathological complete response, while 19.4% of patients had clinical complete response. A total of 150 patients out of 1183 patients (12.67%) had disease recurrence.

Conclusion: Local treatments, either surgery alone and/or RT alone, are inadequate therapies for locally advanced breast cancer patients, and multidisciplinary treatment should be used, to reach better management. Inoperable locally advanced breast carcinoma can be converted into operable by NACT.

Comparative study between digital breast tomosynthesis plus digital mammography and digital mammography alone in symptomatic women using BI-RADS score

Syeed Aalishan Fatima — 2023-03-01

Background: Digital mammography (DM) is the only screening modality that has been proven to reduce mortality from breast cancer through early detection. However, to reduce false positive results and improve the sensitivity of DM, we undertook a study to compare the impact of digital breast tomosynthesis (DBT) to DM in the evaluation of symptomatic women using the breast imaging reporting and data system (BIRADS) score.

Aims and Objectives: The aim of the study was to compare the impact of DBT to DM in the evaluation of symptomatic women using BIRADS score.

Materials and Methods: This cross-sectional study of 100 symptomatic patients in the age group of 35–85 years who underwent DM and DBT was included in the study and was analyzed using the American College of Radiology-BIRADS score. Patients with a palpable breast lump, pain, nipple discharge, skin dimpling, or skin changes over breast and nipple inversion or other nipple abnormalities were included in the study.

Results: Comparison based on the diagnostic accuracy of mammography alone and mammography plus DBT based on BIRADS score revealed DM had a sensitivity of 96%, specificity of 40.6%, a positive predictive value (PPV) of 72.9% and negative predictive value (NPV) of 86.7% with an accuracy of 75.3% while DM plus DBT had a sensitivity of 98.1%, specificity of 46.9%, the PPV of 75.4%, and NPV of 78.8%. There was no significant increase in sensitivity (P=1.000), specificity (P=0.614), PPV (0.734), and accuracy (0.584).

Conclusion: DM plus DBT does not change the BIRADS scoring but its addition increases the diagnostic confidence while there is no significant increase in sensitivity/specificity/PPV/NPV or diagnostic accuracy using DM plus DBT.

Unexpected diagnosis in not so usual clinical scenarios: Acute promyelocytic leukemia – A tertiary care hospital experience

Rashmi Gautam — 2023-03-01

Background: Acute promyelocytic leukemia (APL) is a distinct subtype of Acute myeloid leukemia (AML) with arrest in maturation of cells of myeloid series in bone marrow. PML-RARA fusion resulting from t(15;17) translocation forms the genetic basis of this haematological malignancy. Introduction of specific differentiating targeted therapy i.e. All-trans retinoic acid (ATRA) have remarkably improved the outcome of this previously dreaded AML.

Aims and Objective: The current study presents five cases of Acute promyelocytic leukemia with unusual presentations followed by effective treatment to revert their adverse outcome.

Materials and Methods: In this retrospective evaluation of Acute Myeloid leukemia cases, five cases were included from duration of November 2019 to November 2021. The diagnosis of AMLs was made according to EGIL 1998/WHO 2016 guidelines. Peripheral blood (PB) and bone marrow aspirate (BMA) were stained with Giemsa and cytochemistry included myeloperoxidase (MPO) and periodic acid-schiff (PAS).

Results: Five color flowcytometric analyses were performed on BMA and PB samples. Chemotherapy was administered in the patients and follow-up was done. 03/05 patients faced mortality due to rapid disease progression.

Conclusion: The fast track clinical course from presentation to the outcome of APL is dreadful for the treating clinician and the heamatopathologist. Cytomorphology and Cytochemistry are as important in rapid recognition of APL as Immunophenotyping and Cytogenetics for establishing accurate diagnosis.

The tunnel versus medial versus lateral approach in laparoscopic right hemicolectomy in colon cancer: A retrospective study

Leesa Misra — 2023-03-01

Background: Laparoscopic right hemicolectomy for the right-side colon cancer is well-established and proven to be better than the open approach in terms of post-operative and overall hospital stay. Laparoscopic right hemicolectomy can be done by lateral to medial approach (LA), medial to lateral approach (MA), or tunnel/IRETA approach (TA). No previous study has been conducted to compare the clinical outcomes of all three approaches and the superiority of one approach over the other is still debatable.

Aims and Objectives: This retrospective study was conducted to compare all three approaches and to find the ideal one to practice.

Materials and Methods: This is a retrospective cohort study carried out to analyze 86 patients who were admitted to the department of General Surgery from March 2015 to December 2021 with a diagnosis of the right-side colon cancer and underwent laparoscopic right hemicolectomy with either of these three approaches. A total of 29 patients had operated with lateral to medial approach (LA), 29 patients with medial approach (MA), and 28 with tunnel (TA) approach. The patient’s baseline demographics, perioperative parameters, and post-operative outcomes were compared.

Results: Intraoperative blood loss was significantly lower in the medial to lateral approach and tunnel approach. Duration of surgery was less in the medial to lateral approach as compared to the other two approaches and was statistically significant. R0 resection, lymph node dissection, intraoperative and post-operative complications, morbidity, mortality, and conversion to open were similar in all three groups.

Conclusion: Laparoscopic medial to lateral to medial to lateral approach is feasible and safe and should be preferred approaches in laparoscopic right hemicolectomy.

A comparative study of laparoscopic cholecystectomy with and without abdominal drain

Soubhik Sarkar — 2023-03-01

Background: Laparoscopic cholecystectomy (LC) has been considered the Gold-standard for the management of benign gallbladder disease. With increasing surgeon experience and advancement of instrumentations and equipment, LC is approaching continuously toward a more safe and less invasive technique. There is a consensus that drainage should not be considered mandatory or standard after elective LC.

Aims and Objectives: The aims of this study were to assess the effectiveness of the LC without abdominal drain over sub hepatic drainage and to compare the post-operative outcome between two groups.

Materials and Methods: A descriptive observational comparison study has been carried out in the department of General Surgery BSMCH, from September 1, to December 1, in 130 patients undergoing elective LC. Patients have been divided into two groups: Comparison group and study group after proper matching. Data have been collected via interview, clinical examination, and scrutinizing relevant medical records. Each patient has been followed up after operation. Data have been summarized for estimating various parameters such as mean duration of surgery and hospital stay between the groups and proportion of patient complaining of pain 24 h after surgery.

Results: The mean duration of surgery in drainage group is 108 min which is significantly more than the non-drainage group 88 min. In this present study, the patients with abdominal drain are showing more incidence of post-operative nausea and vomiting (PONV) 21.53% compared to no-drain group 6.15%. In this study, 35.38% of patients with subhepatic drain developed pain after surgery, whereas only 12.3% of the patients with no drain experienced the same. Overall six patients from the drain group still had significant subhepatic collection and eight patients with no drain have the same. The mean duration of stay in hospital of the drain group is 4.06 days, whereas, in no-drain group, it is 2.26.

Conclusion: An uncomplicated gallstone disease can be treated by LC without need for drain with reasonable safety by an experienced surgeon. Hence, no use of drain scores over use of drain in terms of PONV, post-operative pain, and therefore, there is less use of analgesics and also short duration of hospital stay. When a dry operative field is achieved during LC the drain insertion may be avoided.

Skin and soft-tissue coverage for limb salvage in extensive diabetic foot ulcers: An institutional experience

Kiran Petkar — 2023-03-01

Background: Extensive diabetic foot ulcers (DFUs) with skin and soft-tissue defects need prompt coverage of the defect using plastic surgical means. The indication, timing, and techniques of wound coverage in DFUs are not adequately understood by all. Hence, an institutional experience of providing skin and soft-tissue coverage to extensive DFUs is reported.

Aims and Objectives: The aims of this study were to study the various types of DFU that needs surgical wound coverage and to understand the types of wound coverage surgeries, their timings, success rates, and final outcomes.

Materials and Methods: A retrospective-prospective study of all the DFUs managed using skin and soft-tissue coverage was conducted. Surgical and medical management and their outcomes were studied.

Results: Sixteen patients underwent skin graft or flap surgery for their DFU. All the limbs were salvaged and all wounds were covered with two reports of ulcer recurrences.

Conclusion: For optimal care of DFUs, the possible need for wound coverage, it’s timing, and aftercare are to be understood by all involved.

A clinical observational study of intestinal stoma and their complication from a tertiary care center in India

Tushar Kanti Saradar — 2023-03-01

Background: The present study is designed to deal with an indication of various stoma surgery, type of stoma formed, and various ju=of General surgery, RG Kar Medical College and hospital, Kolkata, from June 2020 to May 2021 The study includes patients 12 years and <65 years of populations All data were collected in a prospective manner with a questionnaire and analyzed.

Aims and Objectives: The aim of the study was to study various type of stoma and their indication and to identify the various complication encountered that occurs after the construction of intestinal stomas to assess the ways in which these complication can be minimized and managed in a better way.

Materials and Methods: This was a prospective and observational study conducted in the Department of General Surgery, R.G.KAR Medical College and Hospital both the emergency and elective department. The study was approved by the Institutional Ethics Committee.

Results: From the study, it was observed that among the study population, most were male 32 (80%) than female 8 (20%). There were two peak age group found to undergo stoma surgery most of which is 31–40 years consisting of 25 (27.5%) and 51–60 years consisting of 25 (27.5%). Most of the stoma surgery was found to be done in emergency 31 (77.5%) than in elective 9 (22.5%) setting. The most common cause of stoma formation was found to be hollow viscous perforation 12 (30%). Among the type of stoma ileostomy is more common than colostomy. Loop stoma formations are more common than end stoma and double barrel stoma. The most common complication following stoma surgery was found to be skin excoriation 30%.

Conclusion: Stoma surgery was associated with a high rate of complication irrespective of the surgical expertise, surgical setup, and per operative planning resulting in higher morbidity. With meticulous dissection, post-operative stoma care, early detection, and management of complications, also patient education helps to achieve good outcomes following stoma surgery.

A descriptive study of day care stapled hemorrhoidopexy surgery in grade-4 hemorrhoids under pudendal block

Arvind Kumar Shukla — 2023-03-01

Background: Hemorrhoids are one of the most common afflictions of human beings from times immemorial. It is said that 40% of population have symptoms due to hemorrhoids at some time in their lives. Stapled hemorrhoidopexy under local anesthesia has been emerging as the procedure of choice for symptomatic hemorrhoids.

Aims and Objectives: The objectives of the study are as follows: (1) To assess the advantage of performing stapled hemorrhoidopexy under local pudendal block. (2) To study the post-operative complications after stapled hemorrhoidopexy. (3) To assess the feasibility of stapled hemorrhoidopexy in grade IV hemorrhoids. (4) To assess the advantages of stapled hemorrhoidopexy in anal skin regression after surgery.

Materials and Methods: 50 patients of grade 4 hemorrhoids were operated by hemorrhoid stapler under local anesthesia.

Results: Stapled hemorrhoidopexy under local anesthesia can be safely performed as a day care procedure in grade IV hemorrhoids. Patients following stapled hemorrhoidopexy under local anesthesia have reduced post-operative pain, hospital stay, analgesic requirements, and earlier return to work, early mobility out of bed, less operative time, short learning curve, less operative complications, cost effectiveness, and good patient satisfaction.

Conclusion: Stapled hemorrhoidopexy under local anesthesia is feasible to be used in those patients who are unwilling and unfit for other modes of anesthesia with better results with lesser complication rate and as a day care procedure.

Reconstruction following full-thickness excision of abdominal wall tumors: A prospective observational study conducted in a tertiary care Government Hospital in Eastern India

Vikram Chaturvedi — 2023-03-01

Background: Reconstruction of abdominal wall defects following full-thickness excision of large tumors (primary or metastatic) has always been a challenge for the treating surgeon. A number of reconstructive techniques have been described in the literature, including different types of meshes, flaps, and component separation techniques (anterior and amp; posterior), with varying results. We conducted a prospective observational study of our three-layer technique of abdominal wall closure at Medical College Hospital, Kolkata, to assess the long-time success of the procedure, especially in terms of hernia rates.

Aims and Objectives: Reconstruction of abdominal wall defects following full-thickness excision of large tumors (primary or metastatic) has challenged surgeons for long, with several reconstructive techniques being described, with varying results. We conducted a prospective observational study of our three-layer technique of abdominal wall closure at Medical College Hospital, Kolkata, to assess the long-time success of our procedure, especially in terms of hernia rates.

Materials and Methods: Thirteen patients with abdominal wall primary and isolated metastatic tumors were included from January 2017 to January 2022 with follow-up period from 8 to 60 months. Tumors were dermatofibrosarcoma protuberans, sarcomas, desmoid tumors, and two abdominal wall metastases. All patients in our study underwent computed tomography scan, core needle biopsy, and immunohistochemistry for better surgical planning.

Results: Eight patients were male and five were female with mean age of 39 years and mean defect size of 10 cm. Polypropylene mesh was used, size varying from 15×15 to 30×30 cm with average operative time of 210 min. Post-operative superficial wound infection in 2 (15%), partial flap necrosis in 1 (7.6%), and tumor recurrence in one patient (7.6%) were seen.

Conclusion: For closure of such large abdominal wall defects, our three-layer reconstructive technique has shown good results in terms of zero hernia rates. We recommend our method of closure, where affordability of biological meshes, availability of expensive meshes, accessibility to plastic and reconstructive surgeons or non-acquaintance with complex closure techniques are present.

Influence of sociodemographic factors, diagnostic variations, and phenomenology toward the treatment response in adolescent catatonia in a tertiary care centre in Eastern India

Uttam Majumder — 2023-03-01

Background: Catatonia remains an area of lesser research especially in the adolescent age group. It has subtle differences in the presentation and background diagnoses as compared to adult catatonia. There is paucity of literatures regarding the role of different sociodemographic and clinical factors attributing to different treatment response.

Aims and Objectives: The aim of the study was to assess the association of socio-demographic features, background psychiatric diagnoses, and different catatonic symptoms with treatment outcome of adolescent catatonia.

Materials and Methods: The study considered 10–19 years old patients admitted in the in-patient department as per diagnostic and statistical manual diagnosis. They were assessed by Pediatric Catatonia Rating Scale (PCRS) and treated with lorazepam initially with varying dosage and duration. Modified electroconvulsive therapy was administered in resistance. Factors of these two groups were statistically analyzed to assess predictability towards outcome.

Results: There were 47 participants with mean age of 16.66±1.21 years of whom 29.8% showed positive family history of different psychiatric illnesses. Most of them came with schizophrenia and related disorders (53.2%), though mood disorders, conversion and organic brain diseases were also there. Among them 30 (63.8%) patients responded to lorazepam treatment. Positive family history, urban background, and catatonic severity in terms of higher PCRS score showed predictability to lorazepam non-response. Clinical features such as stupor, staring, negativism, withdrawal, mutism, urinary incontinence and refusal to eat or drink were associated with non-response, whereas waxy flexibility, stereotypy, verbigeration, and mannerism were seen in the response group.

Conclusion: There is need to identify warning signs such as family history, greater symptom load and certain clinical features that can lead to resistance to the treatment with benzodiazepines based on this study. It can necessitate further large-scale study to alleviate disease burden to this young and productive population.

Fossil detectives: How the 2022 noble prize winners unearthed the journey of human evolution

Ruby Dhar — 2023-03-01

What do scraps of bones discovered in a deserted Siberian Cave in Russia have to do with us? Or how do a few fragments of teeth in Gibraltar, an isolated British overseas territory located at the southern tip of the Iberian Peninsula, have to do with the genetic legacy of today’s living people across Asia? Well, it seems that about 40,000 years back, we humans were not the only inhabiting hominids on this planet Earth; we had other mysterious cousins, at least two of them known so far, who had left enough evidence and trails of DNA for the scientist to ponder. Like crime cases that run cold due to lack of solid evidence, paleontologists often tumble when encountering roadblocks; until Swedish Geneticists Svante Pääbo painstakingly developed the necessary tools and techniques to trace back our origin, 15000 years back when perhaps the three hominids even crisscrossed each other’s path. The Desonovians, the Nearthandals, and the modern-day humans. The two ancestors of humans perhaps arose from a common origin several thousand years back. We now know that the Desinovinans diverged from their close relatives, the Neanderthals, around 400,000 years ago, while they both diverged from modern Homo sapiens around 800,000 years ago. The Neanderthals were populated in Europe and Asia, while the more elusive Desonovians were restricted to Siberia, in regions of eastern and southern Eurasia.

Genomic homology studies revealed that the Denisova’s mitochondrial DNA differs from that of modern humans by 385 bases, whereas the difference with Neanderthals is around 202 bases. These numbers stand out from the difference between chimpanzees and modern humans, approximately 1462 base pairs. It is now conclusively known that sometimes in prehistoric times, there had been an event of DNA mixing between the Denisovans and modern humans, an event of actual sexual mating. The percentage of Denisovan DNA is highest in the Melanesian population (Melanesians are the indigenous inhabitants of Melanesia, from New Guinea to the Fiji Islands), lower in other Southeast Asian and Pacific Islander populations, with hardly any DNA detectable in other populations in the world. What is enigmatic is how this human cousin got extinct. Possibly a competition for resources was likely one reason the Denisovans went extinct. The evolutionary trajectory of the Nearthandals followed a different route. At least, two different groups of Neanderthals who lived in Southern Siberia seem to have migrated from Eastern Europe. Not only that, just that Denisovans also interbred with modern-day humans. This interesting phenomenon is called Introgression. It explains why modern-day humans have some Neanderthal DNA, roughly about 3%. Human ancestors only lived in Africa until they decided to migrate to Europe some 45,000 years ago. It’s there where they encountered its other ancestors, the Neanderthals (Homo neanderthalensis). Eventually, they mated and produced offspring resulting in Introgression. Since this mating event happened outside Africa, present-day African people have no traces of Neanderthal DNA. However, due to interesting adaptive advantages, modern-day humans (outside Africa) still retained 3% of Neanderthal DNA, a spectacular observation even 40,000 years after they might have last mated. This is called adaptive Introgression. This is also where Darwin’s principles of natural selection come in. Retaining the 3% Neanderthals might serve some advantage to Modern Humans for better adaptations, something that the sickle mutated DNA at one allele (heterozygous) got positively adapted in Africa due to its protective effect against the malarial parasite in malariaendemic areas. Things can get even interesting and weird with the findings that hybrid individuals were discovered who carried both the Denisovan as well as Neanderthal DNA. That’s what the team, led by palaeogeneticists Slon et al., reported in Nature. Named as “Denny,” this
child seems to be born from a Neanderthal mother and a Desinovan dad, some 90,000 years back. Denny seems to be born out of mating of two extinct hominid ancestors, acquiring one set of chromosomes from a Neanderthal and the other from a Denisovan.

Shaped by evolution and driven by its migratory nature, present-day human is the cumulative outcome of thousands of years of man’s struggle for its survival. Driven by the changing environmental its migration journey picked with it traces of DNA from its ancestral cousins that it encountered. Meticulous investigation of this apparently insignificant DNA holds the secret of thousands of years of human history and human migration. Relentless efforts by Prof Svante Pääbo and other researchers have shed light on our ancestral autobiography.