Heart rate variability follow-up during COVID-19 -a case report- / 대한마취과학회지

Background@#To detect an early increase in the inflammatory response might prove to be vital for mitigating the deleterious effects of the disease over time.Case: A 52-year-old obese man with moderate asthma and hypertension, who developed COVID-19 and had moderate symptoms, used a wearable device to record heart rate variability (HRV) during his illness. He had low parasympathetic tone, which decreased daily until it reached almost 2 standard deviations (SD) below normal values at the end of the second week. His sympathetic tone increased from > 3 SD to > 5 SD. @*Conclusions@#These findings suggest an altered modulation of the sympathetic and parasympathetic nervous systems in COVID-19, such that the sympathetic tone is augmented and the parasympathetic tone is reduced. Population norms of COVID-19 infections should be further studied over the short-term and using 24 h HRV measurements.

Forced cough for witnessed extreme bradycardia in hip arthroplasty: a maneuver in extremis / 대한마취과학회지

No abstract available.

Lumbosacral osteosarcoma with dural spread, skip lesions and intravascular extension: A case report

Primary osteosarcoma of the spine is indeed rare and onlyseveral sporadic cases have been reported. It tends to occurin a slightly older age group than those with appendicularskeleton tumours. We present here an unusual case ofaggressive lumbosacral osteosarcoma in a young teenagercomplicated by extensive dural spread, skip lesions andintravascular extension. Although a histopathologicalexamination is mandatory to establish the diagnosis, thiscase emphasises the need of imaging to ascertain the fullextent of disease spread especially in deciding the type oftreatment to be instituted and to evaluate the response tothe treatment.

MR neurography of median nerve using diffusion tensor imaging (DTI) and its efficacy to diagnose carpal tunnel syndrome in Malaysian population

@#Objective: This study evaluates the feasibility of diffusion tensor imaging(DTI) in assessing median nerve by measuring diffusion parameters such as fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) at different sites of median nerve and evaluating their differences in patients with and without carpal tunnel syndrome (CTS) in local setting. Methods: A prospective cross sectional study was performed with 9 female patients diagnosed with CTS by clinical evaluation and nerve conduction study and 8 age and sex matched normal patients. Magnetic resonance imaging (MRI) wrist was performed with pre-set axial PD and DTI protocol on a 3T MRI, images post-processed using 3D SLICER software to generate median nerve tract and measure diffusion parameters FA, MD, AD and RD in segments and focal points. Results: The FA values were significantly lower in CTS patients, 0.454 (± 0.065), p< 0.002 and demonstrates negative correlation with disease severity, r = - 0.510, p = 0.002.The mean MD, 1.090 (± 0.178) and mean RD, 0.834 (± 0.128) is higher in CTS patients, p = 0.041 and p = 0.014 respectively. They show an increasing trend with increasing disease severity. Negative correlation was noted between the FA values and age groups. FA cut of value of ≤ 0.487 with sensitivity 70.6 % and specificity 76.5%, is suggested for diagnosing CTS.Conclusion: MR neurography using DTI can be utilised to detect CTS. Patients with CTS demonstrate lower FA and higher MD and RD values.

Comparison of sucrose intake and production of elimination spots among adult Musca domestica, Musca autumnalis, Phormia regina and Protophormia terraenovae

Objective To compare the differences in intake and excretion between Musca domestica and other three species from families Muscidae and Calliphoridae which may help explaining the significance of house fly in the transmission of pathogens. Methods The four adult species were supplied with two concentrations of sucrose via modified capillary feeder assay system. The two sucrose concentrations were applied to one adult male/each experiment and the elimination spots were counted. Using 0.25 mol/L sucrose + 0.25% bromophenol blue, one active non-starved male/cup was observed carefully for 1 h to record its behavior. As a growing medium used in bacterial transmission experiments, undiluted trypticase soy broth was used to feed 3-day-old females and males of Musca domestica following two different diets upon emergence and the frequency of elimination spots was estimated. Results The two Musca species have half the weight of the two Phormia species. Comparing the volume of intake per hour, house fly took as much as the other species, all of which were larger. House fly produced twice, or more, the number of elimination spots/h than the other three species. Feeding the flies a sugar liquid diet resulted in producing more fecal spots than regurgitation spots. The male house flies produced less elimination spots/h when fed with trypticase soy broth than with the two sucrose solutions. Conclusions House flies eliminated more than the other examined fly species and most of these elimination events were defecation which implicates the fecal route for pathogen transmission by this important vector.

Ultrasonography in the evaluation of carpal tunnel syndrome: Diagnostic criteria and comparison with nerve conduction studies

Ultrasound criteria for carpal tunnel syndrome (CTS) may vary in different populations. To determine the ultrasonographic criteria for CTS in a Malaysian population and compare its usefulness with nerve conduction studies (NCS), we studied patients clinically diagnosed with CTS and normal controls by ultrasonography. All patients also underwent standard NCS. Median nerve Cross-Sectional Area (CSA) and Flattening Ratio (FR) at 3 different levels – proximal to tunnel inlet, at tunnel inlet and tunnel outlet were measured. Receiver operator characteristic (ROC) analyses were used to calculate the optimal discriminatory threshold values for CTS. Of 54 CTS hands, NCS was positive in 85.2%. Median nerve CSA at all 3 levels, were signifi cantly greater in CTS hands.FR was signifi cantly greater at tunnel inlet. A CSA threshold of 0.1 cm2 proximal to and at tunnel inlet had sensitivities of 70.4% and 63% and specifi cities of 85.2% and 88.5 % respectively. CSA at tunnel outlet had lower specifi city. If CSA of 2 levels (viz. proximal to or at tunnel inlet) were considered together, sensitivity and specifi city improved to 81.5% and 83.3%. Qualitative loss of fascicular discrimination of the nerve proximal to the inlet had sensitivity and specifi city of 77.8% and 96.3%. The most useful ultrasonographic parameter was median nerve CSA either proximal to or at tunnel inlet. However, the sensitivities were lower compared to NCS. Qualitative appearance of the median nerve is a useful adjunct to diagnosis. In conclusion, ultrasonography play an important complementary role to NCS in the diagnosis of CTS.

Skin lesions in renal transplant recipients: A single center analysis.

Background: The chronic use of immunosuppressants in renal transplant recipients (RTRs) predisposes them to a variety of skin manifestations. Studies on skin lesions in RTRs from India have been limited. Aim: To study the prevalence and clinical spectrum of skin diseases in RTR in patients attending the Nephrology clinic of a tertiary care hospital in South India. Methods: Between October 2002 and June 2003, 365 RTRs were evaluated for skin lesions, including 280 examined after renal transplant (group A) and 85 examined once before and then monthly after transplant for a period of 6 months (group B). Results: A total of 1163 skin lesions were examined in 346 RTRs (94.7%) including lesions of aesthetic interest (LAI) [62.3%] followed by infections [27.3%]. All LAI were drug-related manifestations, making it the most common skin lesion, while fungal (58.7%) and viral (29.3%) infections constituted majority of lesions caused by infection. Lesions related to neoplasms were relatively uncommon (2.1%) and all lesions were benign. Miscellaneous lesions constituted 8.3% of skin lesions, which included vaccine-induced necrobiotic granulomas at the site of Hepatitis B vaccination and acquired perforating dermatoses. Conclusion: Skin lesions among RTRs from India consist predominantly of drug-related LAI and infections and are different from the West in view of the paucity of neoplastic lesions.

An evaluation of the role of noninvasive positive pressure ventilation in the management of acute respiratory failure in a developing country.

OBJECTIVE: Noninvasive positive pressure ventilation (NIPPV) has been shown to decrease the need for invasive mechanical ventilation (MV) in patients presenting with acute respiratory failure (ARF). We conducted a prospective study to assess if NIPPV use, in a developing country, was associated with clinical and physiological improvements. DESIGN: Prospective observational study. MATERIALS AND METHODS: Forty patients admitted to a medical intensive care unit during a 2-year period who fulfilled criteria for inclusion formed the study cohort to receive NIPPV. FINDINGS: Baseline (mean +/- SD) pH, PaCO 2 and PaO 2 were 7.25 +/- 0.08, 76.6 +/- 20.9 and 79.18 +/- 40.56 mmHg respectively. The primary indication for NIPPV was hypercapnic respiratory failure (n = 36, 90%). The success rate with NIPPV was 85%, with 34 of 40 patients weaned successfully. Significant improvements were observed at 1 hour following institution of NIPPV in pH (7.31 +/- 0.09, P 2 (65 +/- 17.9, P 2 54.7 +/- 20) and maintained (within 12 h) postweaning from the ventilator (pH 7.39 +/- 0.08, PaCO 2 51.9 +/- 12.4). No significant change in the PaO 2 was observed during NIPPV; PaO 2 after 1 h, prior to weaning and after weaning was 90.53 +/- 42.85, 84.80 +/- 33.76, 78.71 +/- 43.81 respectively. CONCLUSION: This study has demonstrated benefits of NIPPV in avoiding the need for invasive MV in patients presenting with ARF of diverse etiology, with results comparable to developed nations. Increased use of NIPPV in ARF is likely to impact favorably in nations with limited resources.

Infections with atypical mycobacteria in renal transplant recipients.

Infections due to atypical mycobacteria are infrequent in renal transplant recipients but they cause serious morbidity. These pathogens are common in patients with acquired immune deficiency syndrome (AIDS). We report four proven cases of infections caused with atypical mycobacteriae from 1997 to 2003, by different organisms namely, M. chelonei, M.fortuitum, M. abcessus and M. terrae in renal transplant recipients. Infection with M. terrae documented here is the first occurrence in a renal transplant patient. Histopathological examination of aspirates or biopsy specimens from involved areas and staining and culture for mycobacteriae are essential for diagnosis. Treatment involves antimycobacterial therapy, reduction in immunosuppression and surgery, if indicated. Atypical mycobacterial infections, though currently uncommon, are significant and could prove to be an emerging pathogen in renal transplant recipients in the context of the AIDS epidemic in India.

Prevalence of proteinuria in rural adult population in Tamil Nadu.

BACKGROUND & OBJECTIVES: Presence of proteinuria is considered as an early marker of an increased risk of progressive kidney disease. Angiotensin converting enzyme (ACE) inhibitors (ACEi) and angiotensin II receptor blockers (ARB) treatment to persons with proteinuria and chronic kidney disease has been shown to decrease the progression to endstage renal disease. As the exact prevalence of proteinuria is not known in the general population, we undertook this study to estimate the same in a rural adult population in Vellore district, Tamil Nadu. METHODS: A convenient sample of 5,043 adults was included. All individuals were tested for albuminuria by albumin dipstick examination in an untimed urine sample. Individuals who tested positive for albuminuria underwent a second dipstick examination after a gap of one week. Individuals with persistent albuminuria on the second dipstick examination underwent further evaluation which included medical history, physical examination, 24 h urine protein estimation, total serum protein and albumin estimation. Ultrasound of the abdomen was done in patients with renal failure and renal biopsy was performed in selected patients. RESULTS: Of the total 5,043 individuals screened, 63.1 per cent were females. Mean age of the study population was 50.94 +/- 11.2 yr. First dipstick test identified 594 individuals positive for albuminuria. Repeat dipstick could be done in only 576, of whom 212 showed persistent albuminuria. Significant proteinuria was detected in 24 individuals of the 208 who had 24 h urine protein measured. Of these 24 patients, 3 were found to have chronic renal failure, 12 were presumed to have diabetic nephropathy clinically, one each had focal segmental glomerulosclerosis and biopsy proven diabetic nephropathy, and 7 patients had proteinuria of unknown aetiology. INTERPRETATION & CONCLUSION: The prevalence of proteinuria in this adult rural population was 0.47 per cent (0.30-0.67%). The detection and treatment of chronic kidney disease in 24 individuals is bound to reduce the rate of decline of renal functions. Screening programme for proteinuria in different parts of country may be an effective measure to bring a decline in rate of progression of chronic kidney disease in general population.

Granulocyte macrophage colony stimulating factor augmented hepatitis B vaccine protocol for rapid seroprotection in voluntary kidney donors.

BACKGROUND & OBJECTIVES: Conventional hepatitis B vaccine protocols do not provide rapid seroprotection against hepatitis B. This randomized controlled trial was carried out to investigate the efficacy of granulocyte macrophage-colony stimulating factor (GM-CSF) augmented double-dose vaccine protocol in voluntary kidney donors prior to donor nephrectomy. METHODS: A total of 54 kidney donors, who had no history of hepatitis B infection, hepatitis B vaccination and tested negative for anti-HBs and anti-HBc antibodies were randomly allocated to the control or test groups. GM-CSF (300 microg) was administered subcutaneously on day 0, followed by 40 microg of recombinant hepatitis B vaccine intramuscularly on the same deltoid on day 1. The control group received only 40 microg of intramuscular hepatitis B vaccine. Anti-HBs titres were measured at the end of 4 wk. RESULTS: Of the 54 donors studied, there was a significant (P<0.003) seroconversion in the GM-CSF group (82%) compared to the control group (37%), after a single immunization with double-dose recombinant hepatitis B vaccine by 4 wk. Minor side effects such as fever in four patients and myalgia in three were noticed. INTERPRETATION & CONCLUSION: GM-CSF augmented double-dose hepatitis B vaccine could be used in unvaccinated patients when a rapid response is desired.

Exclusive carbon dioxide-guided renal artery stenting in a case of Takayasu's arteritis with a solitary functioning kidney.

We report the case of a 28-year-old female with type II Takayasu's arteritis affecting her single functioning kidney. Impaired renal function precluded the use of conventional contrast media. We used carbon dioxide-guided renal angioplasty to successfully treat the patient.

Acute fatty liver of pregnancy: a report of two cases.

Acute fatty liver of pregnancy is an uncommon, potentially fatal disorder. Between 1998 and 2000, two patients with acute fatty liver of pregnancy presented at the Christian Medical College Hospital, Vellore. Both patients were in the thirty-sixth week of pregnancy. jaundice and encephalopathy were the predominant symptoms. Both the mothers died after they delivered a stillborn Infant each. The maternal deaths were due to multiorgan failure and/or postpartum haemorrhage and sepsis. The route of delivery was vaginal in both the patients. Extrahepatic and metabolic complications in both cases Included renal failure, sepsis, hypoglycaemia, disseminated intravascular coagulation and gastrointestinal bleeding. Liver biopsy done in both patients was consistent with the diagnosis of acute fatty liver of pregnancy. To the best of our knowledge, this is the first report from India on acute fatty liver of pregnancy.