Morphometric Study of Atlas Vertebra In Relation to Sulcus Arteriae Vertebralis

Background: Atlas(C1) is an atypical cervical vertebra shaped like a ring. Important structures like the vertebral artery, suboccipital plexus of veins and first cervical nerve pass through it. Knowledge of the variability of C1 is important for neurosurgeons, orthopaedicians, otorhynologists and other physicians who in everyday practice are in contact with disorders of the spine and their consequences. So, this study was undertaken to assess the various dimensions of the C1 in relation to the vertebral artery groove. Methods and materials: Fifty dried human atlas vertebrae were studied. Various measurements were done and statistically analysed. Results: Antero-posterior diameter (APD) of Foramen transversarium(FT) was measured as 7.73 ± 1.04mm on the right and 7.62 ± 0.90mm on left side. Transverse Diameter(TD) of FT was observed as 6.12 ± 0.97mm on the right side and 6.02 ± 0.97mm on the left side. Outer Distance of Vertebral Artery Groove(VAG) was measured as 26.22 ± 2.32mm and 25.84 ± 1.85mm on the right and left sides, respectively. Inner Distance of VAG was observed as 13.10 ± 1.66mm on right and 13.17 ± 1.57mm on the left side. APD of Superior Articular Facet(SAF) was 21.52 ± 2.36mm on right and 21.51 ± 2.07mm on left side.TD of SAF was 11.21 ± 1.47mm on right and 11.32 ± 1.53mm on left side. APD of Inferior Articular Facet(IAF) was observed as 17.54 ± 1.50mm on right and 17.70±1.60mm on left side. TD of IAF was observed as 14.99 ± 1.65mm on the right side and 14.94 ± 1.51mm on left side. Distance between lateral-most edge of both Foramen Transversaria was measured as 56.37 ± 4.11mm and distance between medial-most edge of both Foramen Transversaria was 44.78 ± 3.67mm. MaximumTD of Atlas was measured as 72.09± 5.59mm. Conclusion: The study will generate information that would be useful for geometric modelling of vertebrae and give necessary morphometric data on human atlas vertebra in Indian population.

A comparative study for surface dose evaluation in conventional treatment of carcinoma breast patients irradiated with Co-60 and 6 MV radiation beam

Aim: In the present study, surface doses within the target area and contralateral breast (CLB) received during conventional treatment of carcinoma breast are evaluate and compared for treatment on two different beam energies, i.e., Co-60 γ-ray and 6 MV X-ray beams with thermoluminescent dosimeter, LiF:Mg, Ti (TLD-100). Materials and Methods: The study includes a group of 23 patients comprising 11 patients treated with Co-60 γ-ray beam and 12 patients by 6 MV X-ray beam. Results and Discussion: The treatment using Co-60 γ-ray and 6 MV X-ray beams contributes an average percentage dose of 8.15% ± 0.56% and 4.73% ± 0.94%, respectively, to CLB in mastectomy patients. The contribution of tangential fields (mastectomy) to the CLB doses ranges between 12.71 and 16.40 cGy (5.45%–7.03%) for treatment with Co-60 γ-ray beam and 6.33–10.95 cGy (1.86–4.69%) for treatment with 6 MV X-ray beam. The supraclavicular field (SCF) contributes 1.45%–1.93% and 1.02%–1.43% for treatment with Co-60 γ-ray and 6 MV X-ray beams, respectively. The average surface dose (normalized with breast dose) 89.1% ± 8.5% for Co-60 beam in the SCF region differs significantly from the 60.2% ± 13.0% value for 6 MV X-ray beam. Conclusion: The CLB doses for mastectomy patients are higher for Co-60 beam as compared to 6 MV X-ray beam, and better dose homogeneity is achieved within the irradiated breast from 6 MV X-ray beam. The CLB doses are slightly higher for patients treated with breast conservative radiotherapy or lumpectomy. The average surface dose to SCF decreases by ~30% of treated breast dose for treatment with 6 MV X-ray beam

Floating knee an Uncommon Injury: Analysis of 12 Cases / Joelho flutuante, uma lesão incomum: análise de 12 casos

Abstract Objective Floating knee injuries are complex injuries and are usually caused by highvelocity trauma. These injuries are often associated with life treating injuries, which should take precedent over extremity injuries. The authors reviewed the outcomes of floating knee injuries managed in this institute from 2003 to 2015. Method A retrospective study was conducted of all patients with floating knee injuries from2003 to 2015. Twelve patients were included in the study. Data related to fracture type, associated injuries, treatmentmodalities, and complications were noted. Functional assessment was performed using themodified Karlstromand Olerud criteria after complete bony union. Result The mechanism of injury was motor vehicle accident in all patients. The mean follow up was four years. The mean age of patients was 34.75 year. The mean union time was 6.5 months in femurs and 6.7 month in tibias. The complications were knee stiffness, delayed union, and infection. According to modified Karlstrom criteria, there were three - excellent, five - good, three - fair, and one poor result. Conclusion Floating knee injuries are severe injuries and are usually associated withmultiorgan injuries. Early detection and appropriate management of associated injuries, early fixation of fractures, and postoperative rehabilitation are needed for good outcome. Complications are frequent, in the form of delayed union, knee stiffness, and infection.

Resumo Objetivo As lesões do tipo joelho flutuante (FKIs, na sigla em inglês) são complexas e são geralmente causadas por trauma de alta velocidade. Estas lesões são frequentemente associadas a lesões que causamrisco demorte, que devemter precedente sobre lesões nas extremidades. Os autores revisaram os resultados das lesões do tipo joelho flutuante tratadas nesta instituição entre 2003 e 2015. Método Foi realizado um estudo retrospectivo de todos os pacientes com FKIs de 2003 a 2015. Doze pacientes foram incluídos no estudo. Os dados relacionados ao tipo de fratura, lesões associadas, modalidades de tratamento e complicações foram observados. A avaliação funcional foi realizada utilizando os critérios de Karlstrom modificados após a união óssea completa. Resultados Omecanismo de lesão foi acidente automobilísticoemtodos os pacientes.O acompanhamentomédio foi de 4 anos.Amédia de idade dos pacientes foi de 34,75 anos.O tempo médio de união óssea foi de 6,5 meses nos fêmures e de 6,7 meses nas tíbias. As complicações foram rigidez do joelho, união óssea tardia e infecção. De acordo com os critérios modificados de Karlstrom, três resultados foram considerados excelentes, cinco bons, três razoáveis e um resultado foi considerado ruim. Conclusão Lesões do tipo joelho flutuante são graves e são geralmente associadas a lesões de vários órgãos. A detecção precoce e o tratamento adequado das lesões associadas, a afixação precoce das fraturas e a reabilitação pós-operatória são necessários para um bom resultado. As complicações são frequentes, sob a forma de união óssea tardia, rigidez do joelho e infecção.

Evaluation the pattern of adverse drug reactions by non-steroidal anti-inflammatory drugs at the outpatient orthopedics department of a university teaching hospital in north India

Background: The study was conducted with an aim to evaluate the pattern of occurrence of adverse drug reactions (ADRs) of Non-steroidal anti-inflammatory drugs (NSAIDs) in orthopedic patients in a tertiary care teaching hospital of North India.Methods: An observational study was carried out in the orthopedic outpatient department at the tertiary care hospital for the period of six months. All patients diagnosed with acute pain and receiving NSAIDs were included. The documented ADRs were assessed for causality, severity and preventability using Naranjo’s algorithm and WHO-UMC scale, modified Hartwig and Seigel Scale and modified Schumock and Thornton scale, respectively.Results: A total of 84 ADRs were reported from 51 patients. The most common ADRs observed were from gastrointestinal (38%) followed by skin (18%) and autonomic nervous system (12%). Maximum number of ADRs were reported in patients on diclofenac (47%) followed by piroxicam (44%). Upon causality assessment, majority of the reactions were possible (61.5% with WHO-UMC scale, and 57.1% with Naranjo’s algorithm). The association of results between the two scales was statistically significant (p<0.001). Majority of ADRs (73.4%) were assessed as mild and 66.7% of the ADRs were probably preventable.Conclusions: Authors conclude that incidence of ADRs can be decreased and compliance can be improved by early detection and management.

Endodontic management of a maxillary first molar with seven root canals using spiral computed tomography

The main objective of this case report is to present a rare root canal configuration of maxillary molar with seven root canals; three mesiobuccal, two palatal and two dis-tobuccal canals diagnosed during treatment procedure confirmed by spiral computed tomography. A thorough knowledge of root canal morphology, proper clinical and radiographic examination, and use of dental operating microscopes are necessary for successful clinical outcomes. This article highlights the variations in the morphology of maxillary first molar and use of the latest techniques in successful diagnosis and negotiation of the additional canals

Sulfasalazine Improves Insulin Resistance and Endothelial Dysfunction in Metabolic Syndrome Patients.

Aim: Metabolic syndrome (MetS) and all its components are independently characterized by the presence of low-grade chronic inflammation. The study aimed at controlling inflammation using sulfasalazine 500mg, once a day treatment in comparison to placebo in MetS patients. Study Design: Double blind, randomized, placebo controlled study. Place and Duration of Study: Sadbhavna Medical and Heart Institute, Patiala; and, Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, between January-November 2014. Methodology: 50 eligible subjects (Male / Female = 45/5, n=25/group), fulfilling the National Cholesterol education Program-Adult Treatment Panel (NCEP-ATP III) diagnostic criteria of MetS, were randomly assigned to once daily drug or placebo tablets for 20 weeks. Blood pressure, serum high sensitivity C-reactive protein (hsCRP), tumor necrosis factor–alpha (TNF-α), lipid profile, fasting plasma glucose and insulin levels, homeostatic model assessment-insulin resistance (HOMA-IR), endothelial-dependent flow-mediated dilation (FMD) of brachial artery, right common carotid artery’s intima-media thickness (IMT) and artery stiffness indices [(Young elastic modulus (YEM), stiffness index (SI) and carotid arterial compliance (CAC)] by Doppler Ultrasound were assessed at baseline and after 20 weeks treatment. Tolerability of drug was also measured using hematological and biochemical analysis. Statistical significance was accepted at p ≤.05. Results: FMD improved as 25.66±6.47% versus 12.41±3.22%, p<0.01; and insulin resistance (HOMA-IR) decreased as 7.05±3.48 versus 11.32±6.08, p<0.01, from baseline in drug group as compared to placebo group, whereas endothelium-independent vasodilatation (p=0.23) and baseline brachial artery diameter (p=0.95) remained unchanged in both the groups. Serum triglycerides (p=0.04), hsCRP (p<0.01) and TNF-α (p<0.01) levels were considerably altered, but there was no effect on carotid IMT, YEM, CAC and SI (all p≥0.05). Biochemical and hematological safety variables were significantly altered, but were still found with-in the normal limits. Conclusion: Thus, sulfasalazine may prevent cardiovascular disease risk in MetS patients by reducing insulin resistance and endothelial dysfunction via halting inflammatory process. Moreover, it was found tolerable.

Comprehensive Echocardiographic Assessment of the Right Ventricle in Murine Models

BACKGROUND: Non-invasive high-resolution echocardiography to evaluate cardiovascular function of small animals is increasingly being used due to availability of genetically engineered murine models. Even though guidelines and standard values for humans were revised by the American Society of Echocardiography, evaluations on murine models are not performed according to any standard protocols. These limitations are preventing translation of preclinical evaluations to clinical meaningful conclusions. We have assessed the right heart of two commonly used murine models according to standard clinical guidelines, and provided the practical guide and sample values for cardiac assessments. METHODS: Right heart echocardiography evaluations of CD1 and C57BL/6 mice were performed under 1–3% isoflurane anesthesia using Vevo® 2100 Imaging System with a high-frequency (18–38 MHz) probe (VisualSonics MS400). We have provided a practical guide on how to image and assess the right heart of a mouse which is frequently used to evaluate development of right heart failure due to pulmonary hypertension. RESULTS: Our results show significant differences between CD1 and C57BL/6 mice. Right ventricle structural assessment showed significantly larger (p < 0.05) size, and pulmonary artery diameter in CD1 mice (n = 11) compared to C57BL/6 mice (n = 15). Right heart systolic and diastolic functions were similar for both strains. CONCLUSION: Our practical guide on how to image and assess the right heart of murine models provides the first comprehensive values which can be used for preclinical research studies using echocardiography. Additionally, our results indicate that there is a high variability between mouse species and experimental models should be carefully selected for cardiac evaluations.

Study on Communicating Branches of Sural Nerve: Review of Literature and its Clinical Implications.

Introduction: Variations of nerve are not only of anatomic and embryological interest but also of clinical importance. Their adequate knowledge will help in increasing surgical precision and decreasing morbidity. Materials and Methods: In the present study the communicating branches of sural nerve were studied. The material for the present study comprised of 60 lower extremities belonging to 30 adult human cadavers obtained from Department of Anatomy, GMC, Amritsar, India. The sural nerve was identified and traced downward in the limb. Result: In the present study these communicating branches arose either from lateral sural cutaneous nerve (branch of common peroneal nerve) or superficial peroneal nerve (intermediate dorsal cutaneous branch) or from tibial nerve itself. Discussion: Sural nerve is usually used as grafting material. So these described variations are helpful for planning operative approaches that minimize risk of sural nerve injury. Moreover the anatomic course of nerve in distal leg and ankle makes it susceptible to local trauma and also to increased risk of injury during surgical intervention at ankle.

Association of Adipose-derived Hormones with Atherosclerosis Indices in Metabolic Syndrome Patients.

Aim: The study was aimed to determine the association of adipose derived hormones, adiponectin, leptin, and adiponectin/leptin (A/L) ratio with presence and degree of atherosclerosis in metabolic syndrome patients. Study Design: Open label, pilot, case-control study. Place and Duration of Study: Sadbhavna Medical and Heart Institute, Patiala and, Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, (INDIA), between January 2013 and December 2013. Methodology: Metabolic syndrome patients (n=55) with age ≥ 18 years, undergoing angiography for diagnosis and/or interventional treatment of atherosclerosis, and 25 matched control subjects were recruited. Evaluation of traditional and novel cardiovascular risk factors (adipose-derived hormones) and their association with angiographic-derived presence and degree of atherosclerosis indices (number of blocked vessels, severity index, and extent index) was carried out. Continuous variables were expressed as mean ± standard error mean and discrete variables were presented as frequencies and percentages. One way ANOVA was used to assess the difference b/w the groups characterized according to the number of vessels blocked. For each of the indices, the significant univariate predictors were entered into a forward stepwise multivariate regression model (model 1 and model 2) to determine the independent predictors. Statistical significance was accepted at P≤. 05. Results: The independent predictors of atherosclerosis for number of blocked vessels were low serum adiponectin and high total cholesterol level. For extent and severity index, low adiponectin level was the only significant and independent predictor. Leptin and A/L ratio could not prove as significant predictors (P≥. 05). Conclusion: Total cholesterol, adiponectin, leptin and A/L ratio might play a vital pathogenic role not only in the occurrence, but also in the severity, extent, number of vessels blocked complexity in metabolic syndrome patients.

Incidence and implications of coronary artery disease in patients undergoing valvular heart surgery: The Indian scenario.

Aims and Objectives: We evaluated the incidence and implications of coronary artery disease (CAD) in patients above 40 years presenting for valve surgery. Materials and Methods: Between January 2009 and December 2010, coronary angiography (CAG) was performed in all such patients ( n = 140). Results: Coronaries were normal in 119 (Group I), and diseased in 21 (Group II). In Group II, 11 patients were < 50 years, 3 were between 51 and 60 years and 7 were > 61 years. In 8 of these, only valve replacement was performed. Coronary artery bypass grafting (CABG) and aortic valve replacement was performed in 10, CABG and mitral valve replacement in 2 and CABG with mitral and aortic valve replacement in one. The number of vessels grafted in these 13 patients was 1.54 ± 0.66. Hypertension and diabetes were significant ( P < 0.05) in this group. The mortality was significant in Group II (11 vs. 6, P < 0.05). Six patients died in Group II, 5 had severe aortic stenosis and severe left ventricular hypertrophy; the sixth patient had severe mitral stenosis and was in CHF. The predominant cause of death was congestive heart failure (CHF). Conclusions: Fifteen percentage of these patients had CAD. CAG should be performed routinely in these patients while presenting for valve surgery. Combined CABG and valve replacement carries high mortality (28.5%), especially in patients with aortic stenosis. The study suggests that the cardio-protective measures should be applied more rigorously in this subset of patients.

The success rate and safety of internal jugular vein cannulation using anatomical landmark technique in patients undergoing cardiothoracic surgery.

Aims and objectives: Landmark-guided internal jugular vein (IJV) cannulation is a basic procedure, which every anesthetist is expected to acquire. A successful first attempt is desirable as each attempt increases the risk of complications. The present study is an analysis of 976 IJV cannulations performed in adults undergoing cardiothoracic surgery. Materials and Methods: The IJV was cannulated with a triple lumen catheter using the anatomical landmarks. The following data were recorded: Patient demographics, age, sex, body mass index, diagnosis, operative procedure, operator (resident/consultant), site of cannulation (central approach, right IJV, left IJV, external jugular vein), number of attempts and duration of cannulation, length of insertion of the catheter, number of correct placements on X-ray and any complications. Results: The success rate of IJV cannulation was 100%. In 809 (82.9%) patients, cannulation was performed in the first attempt. Residents performed 792 cannulations and the consultants performed 184 cannulations. In 767 patients, the residents were successful in inserting the catheter and in 25 they failed after 5 attempts, hence, they were cannulated by the consultant. The time taken for insertion of the catheter was 6.89 ± 3.2 minutes. Carotid artery puncture was the most common complication, it occurred in 22 (2.3%) patients. Conclusion: IJV cannulation with landmark technique is highly successful with minimal complications in the adult patients undergoing cardiothoracic surgery. Basic training of cannulating the IJV by landmark technique should be imparted to all the traines as ultrasound may not be available in all locations.

Developing a Biomedical Expert Finding System Using Medical Subject Headings / 대한의료정보학회지

OBJECTIVES: Efficient identification of subject experts or expert communities is vital for the growth of any organization. Most of the available expert finding systems are based on self-nomination, which can be biased, and are unable to rank experts. Thus, the objective of this work was to develop a robust and unbiased expert finding system which can quantitatively measure expertise. METHODS: Medical Subject Headings (MeSH) is a controlled vocabulary developed by the National Library of Medicine (NLM) for indexing research publications, articles and books. Using the MeSH terms associated with peer-reviewed articles published from India and indexed in PubMed, we developed a Web-based program which can be used to identify subject experts and subjects associated with an expert. RESULTS: We have extensively tested our system to identify experts from India in various subjects. The system provides a ranked list of experts where known experts rank at the top of the list. The system is general; since it uses information available with the PubMed, it can be implemented for any country. CONCLUSIONS: The expert finding system is able to successfully identify subject experts in India. Our system is unique because it allows the quantification of subject expertise, thus enabling the ranking of experts. Our system is based on peer-reviewed information. Use of MeSH terms as subjects has standardized the subject terminology. The system matches requirements of an ideal expert finding system.

Management of positive blood cultures at a city hospital in New York

We prospectively evaluated antimicrobial therapy in 205 episodes of positive blood cultures involving 85 patients admitted to the Medical Floors over a 6 month period. Of 205, 88 were contaminants and 117 episodes were true/probable bacteremias. Assessment of antimicrobial therapy for bacteremias revealed that 71/98 [72%] empirical antibiotics were appropriate; 80/108 [76%] antibiotics after gram stain were appropriate and 72/103 [70%] antibiotics after susceptibility results were appropriate Inappropriate antimicrobial therapy was most often due to incorrect dosing for renal function and severity of infection as well as with regard to combination used and susceptibility profile. Of 88 contaminants, 20 [23%] were treated after gram stain result and 10 [11.4%] were treated after identification of the organism. Vancomycin was used in 60 of 205 [29%] episodes and was inappropriate in 19 of 60 [32%]. This study underscores the need for continued education of physicians in the field of antimicrobial therapy

Effect of muscle relaxants on heart rate, arterial pressure, intubation conditions and onset of neuromuscular block in patients undergoing valve surgery.

Sixty six patients undergoing elective valve surgery were randomized to receive rocuronium bromide 0.6 mg/Kg (Group R, n=22), pancuronium bromide 0.1 mg/Kg (Group P, n= 22) and vecuronium bromide 0.1 mg/Kg (Group V, n=22), Measurements of heart rate and arterial pressure (systolic, diastolic and mean) were noted at the following stages: 1) baseline when haemodynamics were stable for 2 minutes after induction of anaesthesia (2) one, (3) three, (4) five minutes after administration of muscle relaxants, (5) One, (6) three, and (7) five minutes after intubation. In group R, the heart rate decreased 5 min after injection of muscle relaxant from 93.9 +/- 21.3 to 82.4 +/- 20.7 beats/min (p<0.001). However, it increased to 128.3 +/- 25.8 beats/min (p<0.001) following intubation and returned to baseline at 5 min after intubation. In group P, heart rate increased from 98.8 +/- 32.6 to 109.6 +/- 32.7 beats/min (p<0.001), 1 min after injection of pancuronium and this increase persisted throughout the study period. In group V, heart rate decreased from 99.9 +/- 22.3 to 83.8 +/-19.6 beats/min (p<0.001) at 5 min after injection of the drug. It increased to 118.6 +/- 22.4 beats/min (p<0.001), 1 min after intubation and returned to baseline at 5 min after intubation. The decrease in heart rate in group R and V was accompanied by a significant decrease in systolic, diastolic and mean arterial pressure. In group P, only the systolic pressure decreased significantly at 5 min after injection of the drug. Intubation was accompanied by a significant increased in systolic, diastolic and mean arterial pressure in all the groups. Excellent intubation conditions (intubation score 3-4) were observed with all the three drugs, however, there were number of patients in group P who showed diaphragmatic movement during intubation. Onset of action of muscle relaxant, was fastest with rocuronium (group R=132.7 +/- 0.3 sec, P=182.6 +/- 68.5 sec, V= 144.8 +/- 46.1 sec, Group P vs Group R). To conclude, pancuronium causes significant increase in heart rate and should be preferred in patients with regurgitant lesions having slower baseline heart rate. Vecuronium and rocuronium decrease the heart rate and should be preferred in patient with faster baseline heart rate. In terms of intubating conditions rocuronium and vecuronium provide best conditions, but onset is faster with rocuronium.