Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolaos,Crete 72100,Greece,tel :00302841026: 03/28/16

Δευτέρα 28 Μαρτίου 2016

Pap smear findings in uterine prolapse: a coincidence or indicator for impending malignancy

2016-03-28T09-16-37Z
Source: International Journal of Medical Science and Public Health
Hemali J Tailor, Vasudha M Bhagat, Prashant R Patel, Archana Patel, Sonal L Italiya.
Background: Uterine prolapse is a health problem affecting millions of women globally. If left untreated, it can lead to infection, bleeding, metaplasia, and, rarely, cancer. Objective: To evaluate the Pap smear finding in patients with uterine prolapse and compare it with nonprolapse cases. Materials and Methods: This was a retrospective study design. Pap smear data of 1,427 patients from January 2012 to December 2012 were analyzed for the history of prolapse and the pap smear findings such as squamous metaplasia, hyperkeratosis, parakeratosis, and reactive cellular changes. Result: Of 1,427 patients, a total of 233 patients complained different degrees of uterine prolapse, and, in comparison to nonprolapse cases, the pap smear findings of squamous metaplasia, hyperkeratosis, and parakeratosis were statistically significant. Reactive cellular changes were more common in prolapse cases, but the data were not statistically significant. Conclusion: Uterine prolapse is a health problem affecting millions of women globally. Today, by using an effective test such as pap smear, which is a simple, quick, and painless screening method for early diagnosis and subsequent reduction in the progression to invasive carcinoma, we are now positioned to more effectively evaluate this condition and to enhance our understanding of its outcomes through the pursuit of novel research.

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Firefighter/Paramedic - Pearland Fire Department

JOB SUMMARY: Protects life and property by performing firefighting, emergency aid, hazardous materials, and fire prevention duties. Maintains fire equipment, apparatus, and facilities. ESSENTIAL FUNCTIONS: Regular and timely attendance at work. Responds to emergencies, lays hose, performs fire combat, containment, extinguishment salvage, and overhaul tasks. Performs emergency aid activities including ...

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Neonatal septicemia: isolates and their sensitivity pattern with emergence of Citrobacter septicemia

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Ram Sunder Sharma, Manali Tiwari, Ram Pratap Bansal.
Background: Septicemia in neonates refers to bacterial infection documented by positive blood culture in the first 28 days of life and is one of the leading causes of neonatal mortality and morbidity in India. The aim of the study was to identify clinical neonatal sepsis cases and isolate responsible microorganism by blood culture and determine sensitivity pattern of isolates in a tertiary care hospital. Methods: It is a hospital based retrospective study involving neonates admitted in department of paediatrics at a medical college hospital. Two hundred twenty five blood samples were collected for blood culture from neonates with clinical sepsis with standard protocol. Isolation of microorganism and antibiotic sensitivity testing was done with disc diffusion method. Results: Blood culture reports were positive in 43.55% cases of clinical sepsis. Among positive blood culture reports gram negative isolates were more frequent (75.51%). Most commonly isolated was Klebsiella species (34.70%), most common gram positive isolate was Streptococcus (10.20%). Prevalence of Citrobacter species isolation was 16.12%. Among gram negative isolates best overall sensitivity was towards levofloxacin (97.3%) followed by amikacin (60.8%). Sensitivity to piperacillin+tazobactam (20.3%) and cefoperazone+sulbactam (23%) were very low. Gram positive isolates had best sensitivity to vancomycin and linezolid. Conclusions: Gram negative organisms (Klebsiella species, Citrobacter species), Streptococcus, Staphylococcus are leading cause of neonatal sepsis. There are high levels of resistance to routinely used antibiotics among them. Therefore results of this study suggest that we should revise our antibiotic treatment policy and emphasize on rationale antibiotic use.

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Spectrum of acute and chronic leukemia at a tertiary care hospital, Haryana, India

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Gajender Singh, Padam Parmar, Sant Prakash Kataria, Sunita Singh, Rajeev Sen.
Background: Leukemias are primary neoplasms arising from the malignant proliferations of blood cells or their precursors. Leukemias are classified into acute/chronic myeloid and lymphoid subtype. Typing of leukemia is essential for effective therapy because prognosis and survival rate are different for each type and sub-type. Methods: A total of 356 patients diagnosed to have acute/chronic leukemia were included in our study. Only newly diagnosed cases were included in this study and patients on cancer treatment and other primary hematological malignancies like lymphomas, plasma cells disorders and metastatic deposits were excluded. Findings of bone marrow aspiration and peripheral blood were interpreted in respect to history and clinical examination. FAB classification of acute leukemia was applied for sub-typing. Results: In our study, 66.8% of patients had acute leukemia while 33.2% had chronic leukemia. Overall male preponderance was found comprising 56.46% of all cases. Male to female ratio was 1.5:1. Acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) were found in 29.7% and 37.3% of the patients respectively. Of chronic type leukemia, 28.3% patients had chronic myeloid leukemia (CML) and only 4.7% had chronic lymphocytic leukemia (CLL). L2 was the most common (49.2%) subtype in ALL, followed by L1 (43.3%). AML sub-typing revealed M3 was the most common (50%), followed by M2 (28.7%). Adult patients (70.5%) were more commonly affected than children (29.5%). In paediatric patients ALL was the predominant diagnosis (65.71%), whereas in adult AML cases were maximum (77.27%). Conclusions: Detailed hematological analysis including peripheral blood and bone marrow aspiration smears examination with cytogentic analysis are necessary for early and definite diagnosis and effective management of hematological malignancies.

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Role of high resolution computed tomography in evaluation of diffuse lung diseases

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Bhuvan Krishna Pingile, Rajitha Kolan, Sravya Vadlamudi, H. R. Nagrale.
Background: Diffuse lung diseases are those in which the disease process is widespread involving both the lungs but need not affect all lung regions uniformly. Plain chest radiograph though inexpensive, excellent modality of choice, the pattern of diffuse lung disease on radiography is often nonspecific. HRCT can detect normal and abnormal lung interstitium and morphological characteristics of both localized and diffuse lung diseases. The aims and objectives was to study the normal anatomy of the lung with respect to secondary pulmonary lobule; to evaluate the importance of high resolution computed tomography in the diagnosis of diffuse lung diseases; to detect diffuse lung diseases in patients who had normal or questionable radiographic abnormalities with symptoms or pulmonary function tests suggestive of diffuse lung disease; to determine the site of CT guided lung biopsy for confirmation of diagnosis in suspicious diseases and to study the various patterns of diffuse lung diseases on HRCT. Methods: A total number of 50 patients with suspected or known interstitial lung disease were studied by high-resolution computed tomography (HRCT) over a period of 24 months. Results: In the current study the most common cases are of tuberculosis. Next common condition observed was idiopathic pulmonary fibrosis,12 (24%) cases out of 50 cases and most of them were having changes of end stage lung disease and had short lived history during the course of this study, followed by bronchiectasis, pulmonary edema and emphysema. Conclusions: HRCT is 16% more sensitive in detection of diffuse lung disease abnormalities than chest radiograph in our study.

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A retrospective study of analysis of various factors affecting the outcome of sepsis in neonates admitted to a tertiary care neonatal intensive care unit

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Krishnakumar Chinnusamy, Devimeenakshi K..
Background: Sepsis is an important contributor to neonatal mortality and morbidity. Our aim was to study the various factors determining the outcome in neonatal sepsis in tertiary care hospital. Study was conducted in NICU of Government Stanley medical college, Chennai, India. Methods: Designed as retrospective study, based on case records of babies admitted between July to December 2015. Out of the 320 cases admitted during the study period, 120 babies with clinical features suggestive of neonatal sepsis. Risk factors were analyzed for their association with the outcome. Results were statistically analyzed. Results: Among the parameters studied it was observed that birth weight of the baby (p

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Effect of α-tocopherol on antitubercular drugs induced hepatotoxicity

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Rajiv Nehra, Pinki Vishwakarma, Manju Nehra, Shashank Tyagi.
Background: Mycobacterium, the causative organism of tuberculosis, is notorious for its ability to develop resistance with monotherapy. To prevent emergence of resistance, combination of antitubercular drugs is given for months to years that can lead to side effects. Hepatotoxicity is one of the commonest side-effect with antitubercular drugs. This study was aimed to explore the hepatoprotective potential of α-tocopherol against experimentally induced hepatotoxicity in albino rabbits. Methods: This experimental study was carried out on 30 rabbits of either sex. They were divided into three groups comprising 10 animals each. Hepatotoxicity is induced experimentally in rabbits following a standard protocol. Group I received normal saline (10 ml/kg bw). Rabbits in group II were treated with first line antitubercular drugs isoniazid (5 mg/kg bw), rifampicin (20 mg/kg bw) and pyrazinamide (25 mg/kg bw) concurrently. Group III received α-tocopherol 200 mg/kg bw along with group II drugs. All drugs were administered by oral route for 90 days. On last day of experiment blood samples were taken to investigate the plasma levels of alanine aminotransferase (ALT), alkaline phosphatase (ALP) and serum total bilirubin. Results: Serum levels of ALT were found to be markedly elevated upon oral administration of antitubercular drugs for 90 days. A statistically significant reduction in ALT levels was noticed when α-Tocopherol was given in doses of 200mg/kg bw along with antitubercular drugs for same duration. Similar results were obtained with serum ALP & serum total bilirubin. Conclusions: α-tocopherol (200 mg/kg bw, oral) was found to have hepatoprotective effect against antitubercular drugs induced hepatotoxicity in albino rabbits.

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Peritonitis by Leclercia adecarboxylata in a patient with continuous ambulatory peritoneal dialysis: the first case report from India

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Roumi Ghosh, Richa Misra, Kashi Nath Prasad, Narayan Prasad.
Peritonitis is a major complication in patients on continuous ambulatory peritoneal dialysis (CAPD), which is increasingly being caused by rare, saprophytic microorganisms. We present a case having CAPD admitted in our hospital that came with complaint of pain abdomen and cloudy peritoneal effluent, from which pure culture of Leclercia adecarboxylata had been isolated L. adecarboxylata is a rarely reported gram negative human pathogen, very easily misdiagnosed as Escherichia coli.

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Cracking the diagnostic puzzle of tumours of adrenal cortex: a histopathological study

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Venugopal Madabhushi, Padmavathi Devi Chaganti, Ramya Katta, Nageswararao Kakumanu.
Background: Primary neoplasms arising in both adrenal cortex and adrenal medulla are rare tumors. Adrenal cortical tumours may be functional or non-functional. They may be found incidentally at the time of autopsy. In many cases adrenal lesions are identified during a radiologic investigation conducted for indications other than an evaluation for adrenal disease. Adrenocortical tumours can be categorized into adenomas and carcinomas, but the distinction becomes difficult in many cases. Several parameters have been applied to establish malignancy in these tumours. Histopathology is still the gold standard in diagnosis of adrenal tumours. This is a retrospective study and was to study the incidence of tumours of adrenal cortex and to assess the role of histopathological criteria and utility of immunohistochemistry in the diagnosis. Methods: Adrenal cortical tumors reported from August, 2008 to August, 2015 in the Department of Pathology, Guntur Medical College, Andhra Pradesh, India are taken for the study. Clinical data including age, sex and symptoms at presentation, are retrieved from the archives. The resected specimens received from Government General Hospital, Guntur, Andhra Pradesh, India are routinely processed and multiple sections stained with Haematoxylin & Eosin are examined. Modified Weiss criteria are applied for all adrenal cortical tumors in the study. Immunohistochemistry is done in relevant cases for confirmation of diagnosis. Results: The observations in the study including clinical presentation, gross and histological features are tabulated. Conclusions: The study highlights the crucial role of histopathological parameters, especially Weiss criteria in identifying malignancy in tumours of adrenal cortex and importance of immunohistochemistry in differential diagnosis.

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Can the mean platelet volume be a predictor of disease activity in primary Sjogren syndrome?

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Ahmet Omma, Orhan Kucuksahin, Sevinc Can Sandikci, Bahar Ozdemir, Sukran Erten, Yasar Karaaslan.
Background: Disease activity in primary Sjogren syndrome (PSS) is measured by the EULAR Sjogrens syndrome disease activity index (ESSDAI) and patient reported index (ESSPRI). Studies investigating the association between ESSDAI and ESSPRI and previously reported indicators of systemic inflammation are few in the literature. The aim of this study was to determine the clinical utility of the mean platelet volume (MPV) in predicting disease activity in PSS patients. Methods: A total of 190 subjects including ninety-five PSS patients and ninety-five healthy controls were enrolled. Associations between MPV and other known indicators of systemic inflammation (red cell distribution width (RDW), neutrophil to lymphocyte ratio (NLR) and patient clinical characteristic, ESSDAI and ESSPRI were investigated by using spearman correlation and linear regression analysis. Results: MPV levels were found to be significantly higher in the PSS group than the control group (10.5±1.2 versus 9.0±1; P

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Gitelman's syndrome - incidentally detected in an elderly female

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Rahul R.*, Raghava Sharma.
Potassium is critical for many important cell functions. Hereditary tubulopathies can also present in adults with symptoms of recurrent hypokalemia. A 60 year female who was worked up for persistent hypokalemia during repeated admission with different etiology and presenting complaints. Bartters syndrome and Gitelmans syndrome represent distinct variants of primary renal tubular hypokalemic metabolic alkalosis and are easily distinguished on the basis of urinary calcium levels. Therapeutic options in gitelmans syndrome include supplementation of potassium and magnesium along with avoiding sodium depletion.

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Hepatoprotective and antiproliferative activity of moringinine, chlorogenic acid and quercetin

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Fahmy T. Ali, Nahla S. Hassan, Rehab R. Abdrabou.
Background: The three well-characterized phytochemicals in Moringa oleifera leaves are moringinine, quercetin, and chlorogenic acid. Moringa oleifera is postulated to have the highest antioxidant content in food and also has a remarkable range of medicinal uses and high nutritional value. Methods: Evaluation of the antiproliferative effect of moringinine, quercetin and chlorogenic acid as well Moringa oleifera leaves extract on two human cell lines, breast cancer cell line (MCF7) and liver carcinoma cell line (HepG2) using the sulforhodamine B (SRB) assay. The efficacy on liver toxicity induced in rat by alloxan was carried out. Results: Our results indicated that both quercetin and moringinine are strong antitumor agents against the two human cell lines, the extract and its three active ingredients improved the induced liver toxicity. Conclusions: Quercetin and moringinine are responsible to a great extent for the antitumor activity of the whole extract. Chlorogenic acid is a potent hepatoprotective in alloxan induced liver toxicity.

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A study of nurses' observance rate of hygienic principles and nosocomial infections control

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Reza Faraji, Samaneh Mirzaei, Adel Eftekhari, Azam Pourghaffari Lahiji, Mohammad Hassan Mondegari Bamakan, Hamid Kabiri Rad.
Background: Health-care personnel's familiarity with infection control methods and pathogen transmission channels play a determining role in reducing nosocomial infections. This study aimed at investigating the nurses' performance in observing hygienic principles and nosocomial infections control. Methods: This descriptive cross-sectional study was conducted on 34 nurses working at Afshar Hospital in Yazd, Iran in 2016. Nurses' performance on infections prevention was surveyed via a checklist using self-reporting by nurses. The gleaned data were analyzed using independent t-test and ANOVA. Results: Our findings suggested that 69.5% of nurses had moderate performance on nosocomial infections control with regard to themselves, 63.2% had it with regard to patients, and 71.5% had it with regard to hospital setting. Also, there was a significant correlation between performance quality and nurses' working experience (P=0.01), on the one hand, and participation in an orientation workshop (P=0.001), on the other hand. Conclusions: Based on our findings, it is rendered as mandatory for hospital authorities to provide the required conditions for improving nurses' awareness and performance with regard to observing the hygienic principles and nosocomial infections control.

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Hydatid cyst-colonic fistula: an exceptional complication

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Madhuri Barabde, Pravin Bijwe, Saurabh Tiwari, Vasant Lavankar.
Hydatid disease is a worldwide zoonosis and is localized in the liver in most cases. Its complications are numerous and include those related to the compression of adjacent viscera, infection of the cyst's contents or perforation of the cyst. Spontaneous rupture of the hepatic hydatid cyst into colon is an extremely rare complication. The communication is, typically, not discovered until surgery. We present a case of a liver hydatid cyst communicating with the hepatic flexure of colon. The surgical treatment of the lesion and its complications was complex but successful and included partial cystectomy with prolonged external tube drainage.

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Role of recombinant SXP/RAL-2 family protein Wuchereria bancrofti L2 (rWbL2) as vaccine candidate in lymphatic filariasis in mastomys

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Dhananjay Andure, M. V. R. Reddy, Kiran Pote, Ramchandra Padalkar, Vishal Khatri, Nitin Amdare.
Background: Lymphatic filariasis is caused mainly by three lymph dwelling parasites; Wuchereria bancrofti, Brugia malayi and Brugia timori. It remains main cause of clinical morbidity in tropical and sub-tropical countries. Methods: In the present study, we evaluated the immunogenicity and efficacy of recombinant SXP/RAL-2 family protein, rWbL2 to induce protective immune response against B. malayi infection. Mastomys were immunized intraperitoneally with rWbL2 antigen and their ability to induce humoral response, cell mediated immune response and protective efficacy was evaluated. Results: The mastomys, which are fully permissible rodents for Brugia malayi when immunized with rWbL2 could induce 51.25% in situ cytotoxicity against Brugia malayi infective (L3) larvae. We also seen that, it is characterized by higher levels of WbL2- specific IgG1 and IgG2a antibodies and increased levels of IFN-γ, IL-4 and IL-10 cytokines production by the spleen cells. Conclusions: The findings suggest that cellular as well as humoral immune response in the immunized mastomys and may represent effective vaccine candidate for filariasis.

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Elevated levels of serum sialic acid and C-reactive protein: markers of systemic inflammation in patients with chronic obstructive pulmonary disease

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Mangala Sirsikar, Venkata Bharat Kumar Pinnelli, Raghavendra D. S..
Background: Chronic obstructive pulmonary disease (COPD) is a systemic chronic inflammatory disease with pulmonary and extra-pulmonary manifestations involving lungs causing airways dysfunction. C-reactive protein (C-RP) is a positive acute phase reactant and albumin a negative phase reactant during inflammation in COPD patients. Sialic acid (SA) prevalent in mucus rich tissues is gaining importance as biochemical marker in inflammatory immune response. Purpose of present study was to measure serum C-reactive protein (C-RP), total sialic acid and albumin levels in COPD patients and establish there association in COPD and compare with healthy controls. Methods: Seventy five clinically confirmed COPD patients, both male and female between the age group of 38-70 years were selected for the study and age/ sex matched healthy volunteers as controls were selected for comparison. Serum samples were analyzed for C-RP (mg/dl) by nephalometry and TSA (mmol/L) by periodate resorcinol method and albumin by dye binding method by spectrophotometer. Results: The mean value of serum C-RP in cases was 3.26±2.0 (mg/dl) and in controls 0.57±0.34 (mg/dl) with p

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Role of hyperglycemia in the pathogenesis of Na+/K+ disturbance

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Kumari Shipra Parmar, Samir Singh, Ganesh Kumar Singh.
Background: Electrolytes play an important role in maintaining acid-base balance, blood-clotting, control body fluid, muscle contraction, nerve conduction. The diabetic patients develop frequently a constellation of electrolyte imbalance. Imbalance in electrolyte concentration may affect the course of diabetes and its management. It has been reported that there is an inverse relationship between serum sodium (Na+) and potassium (K+) levels in diabetic patients. The aim of present study was to determine whether such relation is seen in context of Nepal and whether this inverse relation depends upon serum glucose levels in diabetic patients for their glycemic control. Methods: This is a retrospective study performed on records of 135 diabetic patients who were treated at out-patient clinic of Kist Medical College and Teaching Hospital from 15 June 2015-15 July 2015. Fasting blood glucose (FPG) level was analyzed with semiautomatic analyzer- humalyzer 3000 by GOD-POD method and Na+ and K+ levels were analyzed with ion selective electrode- nova electrolyte. The relationship among serum Na+ level, serum K+ levels and Fasting plasma glucose levels were determined by SPSS version 20. Results: Serum Na+ level was insignificantly negatively correlated (r=-0.091, p=0.296) with FPG level while a positive correlation of serum K+ level (r=0.235, p=0.006) was seen with FPG level and an inverse relation between serum Na+ and K+ was found. Age showed insignificant negative correlation with serum Na+ (r= -0.203, p=0.018), insignificant positive correlation with K+ (r=0.067, p=0.443) and insignificant negative correlation with FPG (r= -0.045, p=0.608). Conclusions: Hyperglycemia disrupts the balance of serum Na+ and K+ in uncontrolled diabetes mellitus.

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Histopathological study of thyroid lesions and correlation with ultrasonography and thyroid profile in western zone of Rajasthan, India

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Aahana Gupta, Durgashankar Jaipal, Sunita Kulhari, Neelu Gupta.
Background: To evaluate the different patterns of thyroid lesions in surgically resected specimens and biopsies received at department of pathology and correlate the various histo-morphological features with respect to clinical findings, USG and thyroid profile findings. Methods: Total 100 cases of partial or complete thyroidectomy were studied. A detailed clinical examination with USG examination and assessment of thyroid function test were carried out preoperatively. Results: The highest incidences (51%) of thyroid enlargements were found in age group of 21-40 years with females predominated (77%), ratio being 3.34:1. Out of total 100 cases, 28 were neoplastic and 72 were non-neoplastic. Thyroid function test was carried out of all 100 cases and out of them 81 were euthyroid. Most common clinical symptom in the patients of thyroid lesions was swelling in the neck which was present in all cases. Multinodular goiter was the most common radiological finding seen in 55% cases. Out of 55 cases of MNG one case turned out to be malignant after histopathological examination. USG diagnosed 10 cases were malignant, out of them 1 case turned out to be benign after histopathological examination. Conclusions: Taking into consideration histopathology report as a gold standard, correlation of USG finding with histopathology finding showed 90% sensitivity, 98.8% specificity with 90% positive predictive value.

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Clinicopathological representation of nonmetastatic Ewing sarcoma of the scapula - a case study

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Vinod Kumar A., Ramesh Shankar, Kaviraj Mahadevan, Susheela M..
Ewing sarcoma (ES) is a rare type of small cell tumor of the bone and soft tissues. About 50% of ES arise in the femur and pelvis. We present a case of ES of the scapula in a seven year old female child. Because of its similarity with other small cell tumors, the diagnosis of ES is challenging and requires a combination of methods like CT scan, MRI report, histopathological evaluation and IHC, etc. The MRI report of our case has shown a consistent 5×4 cm3 mass on the left scapula. Bone marrow aspiration and biopsy of the tumor has been further analyzed. Small, round and oval cells with densely packed nuclei and scanty cytoplasm, which are characteristic to ES were observed microscopically. A positive reaction to vimentin and CD99 and negative result for the biomarkers meant for other types of tumors, favours the diagnosis of ES. The chromosomes analyzed from the peripheral blood of the patient have shown a normal karyotype. Early diagnosis of ES is very crucial for treatment. Histopathology and IHC are indispensible tools in the diagnosis of ES.

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Comparison of clonidine and dexmedetomidine as an adjuvant to bupivacaine in supraclavicular brachial plexus block for upper limb orthopedic procedures

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Rajaclimax Kirubahar, Bose Sundari, Vijay Kanna, Kanakasabai.
Background: Supraclavicular brachial plexus block is used commonly for upper limb orthopedic procedures. Among the adjuvants used to improve the quality of block induced by bupivacaine the alpha 2 agonists are of new interest. This study was done to compare dexmedetomidine and clonidine as adjuvants to bupivacaine for supraclavicular brachial plexus block in upper limb orthopedic surgeries. Methods: 60 ASA I/II patients aged between 20 and 50 years undergoing upper limb orthopedic procedures were selected and divided into two groups of 30 each. Group C received 35 ml of 0.375% Bupivacaine and clonidine 2µg/kg while Group D received 35 ml of 0.375% bupivacaine and dexmedetomidine 2 µg/kg. Onset time to sensory and motor blockade, vitals, complete duration of motor and sensory block, total duration of analgesia and side effects were noted. Results: The mean time of onset for sensory block and motor block in Group D was lower when compared to Group C. Except at 5th minute the pulse rate and mean arterial pressure were lower in Group D when compared to Group C. The mean time for total duration of sensory block and motor block was more in Group D when compared to Group C. The total duration of analgesia was higher in Group D than in Group C. Conclusions: The addition of dexmedetomidine to bupivacaine during supraclavicular brachial plexus block produces a shorter onset of time to sensory and motor block with prolonged duration of analgesia when compared to clonidine added to bupivacaine.

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Aortic dissection: case series

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Bhavana Venkata Nagabhushana Rao.
Aortic dissection may not be attended by a physician in his lifetime, but he should possess all the clinical acumen to deal with as it is a catastrophic disease. Early and accurate diagnosis will save a life. Here we present three cases we faced in sequence over a period of two months. A case of extensive dissection arch to thoracic aorta, its display in detail. Second case eliciting ambiguity between coronary ischemia and aortic dissection. Management difficulties of such clinician situation are discussed. Third case, the fracture of a renal artery stent leading to severe hypertension, abdominal pain, and aortic dissection. Such case was not described in the literature to our knowledge.

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Incidence and distribution of congenital malformations clinically detected at birth: a prospective study at tertiary care hospital

2016-03-28T07-32-44Z
Source: International Journal of Research in Medical Sciences
Mohammad K. Gandhi, Upendra Rameshbhai Chaudhari, Nilesh Thakor.
Background: Congenital malformation represents defects in morphogenesis during early fetal life. Congenital anomalies account for 8-15% of perinatal deaths and 13-16% of neonatal deaths in India. The objective was to study overall and individual incidence and distribution of clinically detectable congenital malformations in newborns delivered at a tertiary hospital. Methods: The present study is a prospective study of all the newborns delivered at Obstetrics and Gynecology Department, New Civil Hospital, Surat, Gujarat, India for a period of one year from 1st January 2010 to 31st December 2010. Total 5518 consecutive births including both live born babies and still born babies were examined after taking verbal and written consent of their mothers for a visible structural anomalies to determine the overall incidence and distribution of congenital malformations. Data were statistically analyzed using SPSS software (trial version). Results: A total of 5518 babies were born out of which 75 were twins. Out of total 5518 newborns 5316 were live births and 202 were still births and out of 5316 live births 48 babies were malformed and out of 202 still births 20 babies were malformed. Total numbers of malformed babies were 68, so total point incidence of congenital anomalies turned out to be 1.23%. Out of total 5518 babies, 35 (0.63%) were having central nervous system malformations making its incidence of 6.34/1000 live births which turned out to be highest followed by gastrointestinal system (incidence of malformed babies: 5.44/1000 births) and genitor urinary system (incidence of malformed babies :1.09/1000 births). Commonest anomalies in central nervous system were meningomyelocele followed by hydrocephalus and anencephaly. Conclusions: From present study we conclude that incidence of congenital anomalies of CNS was highest amongst all types of congenital anomalies (meningomyelocele being the commonest). More emphasis should be given on prevention by regular antenatal care and avoidance of known teratogens and probable teratogenic agents.

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Vivid flashbacks after fatal drowning response

By EMT, 9 years in EMS

It was so hot that afternoon.

Among the many vivid memories I have of that day is how much I was sweating while standing on the beach of a river in Maryland and waiting for something to happen.

The call had come out for a possible drowning and our entire volunteer EMS, rescue and dive teams were dispatched. The first of many on scene, my partner and I questioned her boyfriend who had fallen asleep on the beach while she went swimming with their dog. Thirty minutes later, he awoke to the dog barking and no sign of his girlfriend.

As part of the EMS crew, I wasn't involved with the search and rescue. I was simply waiting for the boats and divers to find something. Forty minutes into the incident, I was sure they never would and we briefly discussed returning to service. I turned toward the water just in time to see a diver emerge from the water with her body over his shoulder, lifeless, pale and covered in sand.

Suddenly, he was walking toward me and though I had been in similarly serious situations, I was overcome with the idea that at that moment and in that place, I was expected to do something with her.

She was young, in her late twenties, though older than me, and I remember catching her head just as it was about to hit the stretcher – placed there by the diver. Then it all became automatic: assessment, compressions, pads, shock, intubation, oxygen, drugs, shock, transport, transfer of care and time of death.

We cleaned up, restocked and ran several more calls that day. My partner and I talked a little about the call, but nothing extraordinary.

Getting home that night I was already beginning to feel off: irritable, not hungry, very tired and anti-social. This being the opposite of my normal affect, I knew something was wrong, but didn't know what.

That evening, my roommate surprised me while coming around a corner and I reacted violently and foolishly, actually kicking a hole in the wall with my work boots still on.

This was the first of several nights without sleeping. At my office job the next day, I told the story of the drowning to some friends, but felt emotionally numb to the death I had witnessed. Two days later, having hardly eaten a thing, I broke down at the office and started crying in a bathroom stall for no apparent reason. I started having flashbacks to the scene. I would sit at my desk looking at the clock on my computer, followed by a memory so vivid I began sweating and when I returned 30 or 40 minutes had passed.

My partner called me later that week and asked how I was doing. I had to tell him the truth: not well. He suggested the name of a counselor who could talk to me about my symptoms and offer a path forward.

I went the next morning and as it happened, all I needed was to talk to someone unattached to the situation and to feel listened to. I told her that awful story and how I hadn't slept or eaten since it happened. I told her how numb I felt and I told her how it didn't seem any different than other serious calls I had been on in the past. She listened and talked to me about how acute stress reactions are normal for first responders. Within the next several hours and days, my appetite returned and I slept for the first time in a week.

Over time, what has really helped was to tell others what had happened and how it had affected me. Six years later, my memories are just as vivid and if I close my eyes I can bring myself to that beach and remember the dog, the boyfriend, the hot sun and her blonde hair.

I continue to volunteer to this day, owing these past several years entirely to my partner and mentor who recognized my symptoms and simply reached out to find out if I needed anything.

I had no history of mental illness and never thought I'd be so impacted by an EMS call.

I'm grateful for the projects like The Code Green Campaign, which shine a light on the difficulties many of us face with responding to harrowing scenes, day in and day out.

We must look out for one another and cannot be afraid to put our hands on the shoulder of our colleagues and ask how they're doing. I'm so very thankful that someone asked me.

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Prove It: Mechanical chest compression devices vs. manual compressions

Medic 58 responds with Engine 19 on a reported unconscious person. Engine 19 arrives to find a 60-year-old male who collapsed while watching a football game on television. Family members performed chest compressions with the assistance of the emergency medical dispatcher.

The crew from Engine 19 takes over chest compressions and immediately attaches the AED. The AED detects a shockable rhythm and recommends a shock. The crew momentarily interrupts CPR to deliver the shock and immediately resumes chest compressions.

Medic 58 arrives on scene before the AED completes a second analysis of the patient's cardiac rhythm. Medic 58 is equipped with a mechanical CPR device that delivers chest compressions via an integrated suction cup. During the set up of this device, the AED performs a second analysis and recommends another shock. After delivering the shock, the mechanical CPR device becomes operational and manual chest compressions cease.

One of the medics inserts a supraglottic airway and confirms proper placement. The initial end-tidal carbon dioxide (ETCO2) value is 18 mm Hg. The ECG monitor displays an organized rhythm at a rate of 30 complexes per minute. After administration of epinephrine, the rhythm rate begins to increase and the medics notice the ETCO2 value slowly begins to rise.

Eight minutes after arriving on scene, the ETCO2 value is 58 mm Hg. The patient has regained a pulse but remains unconscious and is not breathing. Medic Davis turns the mechanical chest compressor off but leaves the device in place. Before leaving the scene, Medic Gutierrez performs a 12-lead ECG, which reveals the presence of a large inferior wall ST-segment myocardial infarction (STEMI).

Transport to the STEMI center is uneventful and the patient is quickly transferred to the cath lab. The cardiologist congratulates the medics on a successful resuscitation, but the humble medics reply the switch from manual to mechanical chest compressions is primarily responsible for the save.

Study review
Some have argued that the failure to show improved outcomes associated with mechanical chest compression may be more reflective of the limitations and execution of the study designs than an indictment of the machines [1]. In an attempt to address this issue, a research team conducted a meta-analysis of all evidence, both randomized and observational, published on the subject since the year 2000 [2].

A meta-analysis is a rigorous review method that allows researchers to integrate the research findings of several small trials into one analysis [3]. By pooling these results in one analysis, researchers can establish a more accurate estimate of a treatment effect than can be determined by any single small study alone.

The ultimate goal of any resuscitation attempt is to return the patient to as normal a life as possible, i. e., discharge from the hospital with favorable neurologic function. However, this outcome measure is a reflection of both in-and out-of-hospital care, along with a number of other factors. In some cases, care delivered in the hospital could make prehospital interventions appear more or less effective than they really are. With this in mind, the research team chose survival to hospital admission as the primary outcome for the present investigation rather than discharge from the hospital.

The team also measured and reported on a number of secondary outcomes, such as return of spontaneous circulation (ROSC) in the field, survival to hospital discharge and favorable neurological outcome at discharge. These secondary outcomes provide useful information about CPR machines, but one must be careful when interpreting effectiveness based on secondary outcomes.

Study methodologies are determined by the research question and the primary outcome variable used to answer the question. Attempting to draw firm conclusions based on a secondary variable may require a completely different methodological approach.

In conducting this meta-analysis, the research team chose an inclusion period that utilized the European Resuscitation Council/American Heart Association guidelines from 2000, 2005 and 2010. Changes in assessment sequences, ventilation recommendations, compression rates and depths, and a host of other recommendations during this period, could have affected the outcome.

To address that concern, the research team conducted a sensitivity analysis, which allows the researchers to see the effects caused by changing any one of those variables. A sensitivity analysis allows the researchers to determine which variables have the most influence on the outcome [4].

Results of the meta-analysis
Twenty studies met the inclusion criteria for this meta-analysis. Of those, five had a randomized design and the remaining studies were observational in nature. The authors of the present study categorized the data from the five randomized trial as high quality with little risk of bias. The data from the observational studies was categorized as good to moderate quality.

Combining the study populations of each of the included investigations yielded a meta-analysis population of 21,363 patients, of which 9,391 received mechanical chest compressions and 11,972 received manual compression. EMS personnel used the Autopulse in 11 studies, the LUCAS device in 8 studies and both devices in one study.

For the primary endpoint of survival to hospital admission, the research team calculated odds ratios separately for the randomized (high quality data) and the observational studies (good to moderate data). Pooling data from the randomized studies did not alter the odds of survival to hospital admission between the two groups. However, after pooling data from the observational studies, patients who received mechanical chest compressions were 42 percent more likely to survive to hospital admission when compared to those patients receiving manual chest compression.

When using secondary outcome variables, the research team found very similar results. Pooling the high quality data from the randomized studies found no differences between the two groups in the likelihoods of achieving ROSC, surviving to hospital discharge, or having favorable neurological status at the time of discharge.

However, pooling data from the observational studies demonstrated a 74 percent increase in the likelihood of achieving ROSC for patients who received mechanical chest compressions. Unfortunately, survival to hospital discharge and favorable neurological status did not appear to be influenced by the use of mechanical chest compression devices.

Regardless of whether the patient received mechanical or manual chest compressions, there did not appear to be any differences in survival rates associated with the specific guidelines (year 2000, 2005, and 2010) used by the rescue teams.

What this means for you
This meta-analysis represents the most comprehensive review of the use of mechanical chest compression devices in the out-of-hospital environment to date. The routine application of mechanical chest compression devices does not appear to result in improved clinical outcomes for patients who suffer OOH cardiac arrest.

This meta-analysis confirmed the results of a previous meta-analysis of randomized trials of OOH cardiac arrest, which found the odds of achieving ROSC were not significantly different between mechanical CPR devices and manual CPR [5]. In the previous meta-analysis, patients who received CPR from a load-distributing band instead of manual CPR were 62 percent more likely to achieve ROSC. However, the variability of reporting longer-term outcome data in the studies used for the meta-analysis prohibited the authors from drawing any firm conclusions about whether mechanical CPR devices improve long-term survival.

Study limitations
In each patient encounter in the observational trials, EMS personnel had a choice of whether to provide manual CPR only or to apply a mechanical CPR device. This type of study protocol can lead to selection bias.

If, for example, rescuers believe mechanical CPR is superior to manual CPR, the rescue team could choose to apply the mechanical device only when they feel the patient has a good chance of survival — younger, presenting in a shockable ECG rhythm, witnessed cardiac arrest receiving bystander BLS, but perform manual CPR on those judged to be beyond help — older, unknown down time, presenting with asystole. Selection bias could make the mechanical CPR machine look more effective than it really is, which may have occurred in these observational trials.

Randomization helps to reduce the effects of selection bias. A meta-analysis that includes only randomized trial results provides a clearer picture of the effects of the intervention. One might ask then, why researchers do not design more randomized trials instead of observational trials. The simple answer is that randomized trials are significantly more complex and expensive to execute.

The current meta-analysis included five randomized trials with high-quality data. Even after pooling the data, limitations associated with the individual studies could explain why the meta-analysis did not find superiority of one CPR method to another.

For example, an independent data safety monitoring board prematurely halted the AutoPulse Assisted Prehospital International Resuscitation (ASPIRE) trial when an interim progress analysis discovered worsened neurological outcomes for patients who received mechanical chest compressions [6]. The ASPIRE authors noted a significant difference between the two groups in the amount of time it took to deliver the first defibrillation shock, with the mechanical compression group waiting an average of 2.1 minutes longer.

This delay could reflect the unintended consequences of on-scene prioritization of CPR machine deployment rather than early defibrillation. Likewise, enthusiasm for mechanical chest compressions may have resulted in resuscitation attempts for patients who otherwise might have been pronounced dead on the scene. This is supported by the fact that medics enrolled more asystolic patients in the mechanical chest compression group than in the manual compression group.

The multi-center LUCAS in Cardiac Arrest (LINC) trial had a similar limitation [7]. The study protocol required application and use of the CPR machine before delivering the first shock to the experimental group. This created a significant difference between how quickly patients in the two groups received the first shock after paramedics arrived on scene.

Since the American Heart Association acknowledges the most important interval directly affecting survival rates is the interval from arrival to first shock [8], this delay could have masked any survival benefits provided by mechanical CPR. Researchers in the LINC trial also did not monitor study protocol adherence however, an analysis of the defibrillation data suggests the medics did not follow the study protocol for the mechanical chest compression group in about one-fourth of the cases.

Similarly, only 60 percent of the patients randomized to receive mechanical chest compression actually did in the Pre-hospital Randomised Assessment of a Mechanical Compression Device in Cardiac Arrest (PARAMEDIC) trial [9]. Medics documented a number of reasons why patients in the remaining 40 percent did not receive mechanical chest compressions, including crew error, patients being too large or inadequate crew training in the use of the device.

In contrast, researchers in the Circulation Improving Resuscitation Care (CIRC) Trial did monitor protocol compliance in both the control and the experimental groups, although this trial used a load-distributing band instead of a device with an integrated suction cup [10]. In this trial, the medics appeared to follow the study protocol but still could not demonstrate superiority of one chest compression method over the other. Although the CIRC researchers did measure chest compression fractions in both groups (which were similar), they were not able to consistently measure chest compression depth. Therefore, any unknown dissimilarities in CPR depth could be responsible for the outcome.

In each of the randomized trials used for the meta-analysis, medics provided manual chest compressions while applying the mechanical compression devices. This essentially created study groups of manual and mechanical compressions versus manual compressions alone.

In one study, medics performed manual chest compressions for almost three minutes before having the mechanical chest compression device activated [11]. Poor quality manual compressions for this amount of time before beginning mechanical compressions could make the machines appear less effective.

Summary
Despite the perceived short term benefits associated with mechanical chest compression devices, this meta-analysis of the available research does not support a routine strategy of applying mechanical chest compression devices in an effort to improve clinical outcomes following out-of-hospital cardiac arrest.

Although the latest American Heart Association Guidelines establish manual chest compressions as the preferred method of initial circulatory support following cardiac arrest, they do acknowledge situations when mechanical chest compressions are an acceptable alternative [12]. These situations include conditions that make manual chest compressions impossible or unsafe to deliver, in situations where there are a limited number of rescuers, and in a moving ambulance. EMS personnel with access to these devices must be adequately trained in their efficient use and develop an application strategy that limits interruptions in chest compressions.

References

Paradis, N. A., Young, G., Lemeshow, S., Brewer, J. E., & Halperin, H. R. (2010). Inhomogeneity and temporal effects in AutoPulse Assisted Prehospital International Resuscitation—an exception from consent trial terminated early. Journal of Emergency Medicine, 28(4), 391-398. doi:10.1016/j.ajem.2010.02.002.
Bonnes, J. L., Brouwer, M. A., Navarese, E. P., Verhaert, D. V., Verheugt, F. W., Smeets, J. L., & de Boer, M. J. (2016). Manual cardiopulmonary resuscitation versus CPR including a mechanical chest compression device in out-of-hospital cardiac arrest: A comprehensive meta-analysis from randomized and observational studies. Annals of Emergency Medicine, 67(3), 349-360. doi:10.1016/j.annemergmed.2015.09.023
Haidich, A. B. (2010). Meta-analysis in medical research. Hippokratia, 14(Suppl 1), 29-37.
Taylor, M. (2009). What is a sensitivity analysis" Retrieved from http://ift.tt/1pUqTXR
Westfall, M., Krantz, S., Mullin, C., & Kaufman, C. (2013). Mechanical versus manual chest compressions in out-of-hospital cardiac arrest: A meta-analysis. Critical Care Medicine, 41(7), 1782–1789. doi:10.1097/CCM.0b013e31828a24e3
Hallstrom, A., Rea, T. D., Sayre, M. R., Christenson, J., Anton, A. R., Mosesso, V. N. Jr., Ottingham, L. V., Olsufka, M., Pennington, S., White, L. J., Yahn, S., Husar, J., Morris M. F., & Cobb, L. A. (2006). Manual chest compression vs. use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest. Journal of the American Medical Association, 295(22), 2620–2628. doi:10.1001/jama.295.22.2620
Rubertsson, S., Lindgren, E., Smekal, D., Östlund, O., Silfverstolpe, J., Lichtveld, R. A., Boomars, R., Ahlstedt, B., Skoog, G., Kastberg, R., Halliwell, D., Box, M., Herlitz, J., & Karlsten, R. (2014). Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of hospital cardiac arrest: The LINC randomized trial. Journal of the American Medical Association, 311(1), 53-61. doi:10.1001/jama.2013.282538
Sinz, E., Navarro, K, & Soderberg, E. (Eds.). (2013). ACLS for experienced providers. Dallas, TX: American Heart Association.
Perkins, G. D., Lall, R., Quinn, T., Deakin, C. D., Cooke, M. W., Horton, J., Lamb, S. E., Slowther, A. M., Woollard, M., Carson, A., Smyth, M., Whitfield, R., Williams, A., Pocock, H., Black, J. J., Wright, J., Han, K., Gates, S.; & the PARAMEDIC Trial Collaborators. (2015). Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): A pragmatic, cluster randomised controlled trial. Lancet, 385(9972), 947-955. doi:10.1016/S0140-6736(14)61886-9
Wik, L., Olsen, J. A., Persse, D., Sterz, F., Lozano, M. Jr., Brouwer, M. A., Westfall, M., Souders, C. M., Malzer, R., van Grunsven, P. M., Travis, D. T., Whitehead, A., Herken, U. R., & Lerner, E. B. (2014). Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRCtrial. Resuscitation, 85(6), 741-748. doi:10.1016/j.resuscitation.2014.03.005
Smekal, D., Johansson, J., Huzevka, T., & Rubertsson, S. (2011). A pilot study of mechanical chest compressions with the LUCASTM device in cardiopulmonary resuscitation. Resuscitation. 82(6), 702-706. doi:10.1016/j.resuscitation.2011.01.032
Brooks, S. C., Anderson, M. L., Bruder, E., Daya, M. R., Gaffney, A., Otto, C. W., Singer, A. J., Thiagarajan, R. R., & Travers, A. H. (2015). Part 6: Alternative techniques and ancillary devices for cardiopulmonary resuscitation. 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 132(suppl 2), S436–S443. doi:10.1161/CIR.0000000000000260

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Drowning patient resuscitation and monitoring

Use capnography to guide oxygenation and ventilation derangements in drowning patients

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Prove It: Mechanical chest compression devices vs. manual compressions

Meta-analysis of the available research looks at primary and secondary patient outcomes of applying mechanical chest compression devices following out-of-hospital cardiac arrest

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