Non-traumatic esophageal perforation: A case report on Boerhaave’s syndrome

Boerhaave’s syndrome is a potentially fatal condition characterized by spontaneous perforation of a previously healthy esophagus, due to severe vomiting or straining. It often presents with non-specific symptoms such as fever, pain, and vomiting and hence may go undiagnosed. The Makler’s triad, consisting of vomiting, chest pain, and subcutaneous emphysema, may be seen in only 50% of cases. Delayed diagnosis may result in complications such as sepsis, mediastinitis, pneumothorax, and multi-organ dysfunction. In general, patients presenting later than 48 h are conservatively managed with esophageal stenting. Surgical repair is usually reserved for those patients who present within 24 h, or are managed conservatively and develop complications. Mortality rises from 0% if treated within 24 h to about 29% if delayed more than 48 h. We present a case of Boerhaave’s syndrome in a 35-year-old male who presented with spontaneous respiratory distress and hemodynamic instability, about 36 h after the onset of vigorous vomiting. The case was managed initially with endoscopic insertion of a self-expanding metallic stent, followed later by surgical closure of the esophageal perforation. The patient, however, developed post-operative septic complications and died after a week

Numbness Following Total Knee Arthroplasty: Role of Incision Length And Position -A Randomized Study

Background@#One of the symptoms annoying patients after total knee replacement (TKR) is numbness around the operative scar. Some studies have shown that altering the incision in terms of placement or length may decrease the incidence of numbness. It still remains unknown whether numbness affects patient-reported outcomes. @*Methods@#We conducted a randomized study to compare a short-length incision (n = 50) and a lateral exit incision (n = 50) with a standard midline TKR incision (n = 50) in terms of the incidence of numbness and its progress over 1 year of follow-up. Our secondary objective was to look at the involved zone, area of numbness, and secondary symptoms. We also looked at patient-reported outcome in terms of satisfaction in all groups using a visual analog scale and Forgotten Joint Score. @*Results@#At 3 months postoperatively, the incidence of numbness was least in the lateral exit group: 46.2% as compared to midline (62%) and short (58.3%), but the difference was not significant (p = 0.07). At 6 months, the short incision group had a significantly lower incidence (8%) of residual numbness as compared to 30% in the other two groups (p = 0.003). At 1 year, most patients recovered sensation loss and had similar function. @*Conclusions@#Placement or length of an incision did not significantly affect the incidence of numbness; however, the short incision led to early recovery of numbness. At 1 year of follow-up, most patients did not complain of loss of sensation and had similar functional outcome.

Does Risk Mitigation Reduce 90-Day Complications in Patients Undergoing Total Knee Arthroplasty?: A Cohort Study

Background@#With ever-increasing demand for total knee arthroplasty (TKA), most healthcare systems around the world are concerned about its socioeconomic burden. Most centers have universally adopted well-defined clinical care pathways to minimize adverse outcomes, maximize volume, and limit costs. However, there are no prospective comparative trials reporting benefits of these risk mitigation (RM) strategies. @*Methods@#This is a prospective cohort study comparing post-TKA 90-day complications between patients undergoing RM before surgery and those following a standard protocol (SP). In the RM group, we used a 20-point checklist to screen for modifiable risk factors and evaluate the need for optimizing non-modifiable comorbidities. Only when optimization goals were achieved, patients were offered TKA. @*Results@#TKA was performed in 811 patients in the SP group and in 829 in the RM group, 40% of which were simultaneous bilateral TKA. In both groups, hypertension was the most prevalent comorbidity (48%), followed by diabetes (20%). A total of 43 (5.3%) procedure-related complications were seen over the 90-day postoperative period in the SP group, which was significantly greater than 26 (3.1%) seen in the RM group (p = 0.039). The commonest complication was pulmonary thromboembolic, 6 in each group. Blood transfusion rate was higher in the SP group (6%) than in the RM group (< 1%). @*Conclusions@#Screening and RM can reduce 90-day complications in patients undergoing TKA.

Everolimus plus octreotide long-acting repeatable in advanced neuroendocrine tumors in the routine tertiary cancer care setting: An Indian experience.

BACKGROUND: Neuroendocrine tumors (NETs) are rare, heterogeneous, indolent tumors that are relatively insensitive to systemic chemotherapy. Therapeutic strategies for NETs broadly include somatostatin analogs, antiangiogenic therapy, and most recently, mammalian target of rapamycin inhibition. Combination therapy has shown promising antitumor activity and good tolerability in the randomized phase III trials. AIM: The aim was to evaluate the safety and efficacy of Everolimus plus Octreotide long‑acting repeatable (LAR) in patients with advanced NETs in the routine tertiary cancer care setting in India in this postapproval, noninterventional trial. PATIENTS AND METHODS: Patients presenting to selected centers between 2011 and 2013 with histologically confirmed low‑, intermediate‑ or high‑grade advanced NETs who may have had prior exposure to cytotoxic chemotherapy (≤2 lines) were treated with oral Everolimus (10 mg/day) plus intramuscular Octreotide LAR (30 mg once every 28 days) until disease progression or unacceptable toxicity was seen. Patients were evaluated every 3 months for a response to therapy as per Response Evaluation Criteria in Solid Tumors. RESULTS: Everolimus plus Octreotide LAR was associated with a clinical benefit rate of 69% (best evaluable responses: Stable disease [SD] in 10 patients [63%], partial response in 1 patient [6%]). The average duration of therapy was 4.8 cycles, and 3 (17%) patients continued therapy for ≥12 cycles (all achieved SD). The therapy was found to be well‑tolerated in all patients. CONCLUSIONS: Everolimus plus Octreotide LAR appears to be safe and efficacious in patients with advanced NETs who may have had prior exposure to chemotherapy – a finding consistent with recently conducted major trials.

An in vitro evaluation of pH variations in calcium hydroxide liners.

The purpose of this present study was to determine the pH changes of five different commercially available calcium hydroxide liners and variations of pH at different time intervals. The following commercially available materials were investigated: Dycal (LD Caulk); Calcimol (Vocco Products); calcium hydroxide powder (Deepti Products); Calcimol LC (Vocco Products); Lime-Lite (Pulpdent Corporation). Five samples were prepared from each liner. The pH measurements were recorded at time intervals of 1 h, 24 h, 3 days and 7 days after mixing of the liner. The pH variations of each material at the given time intervals were recorded and the means were calculated. Comparison of the mean values at all time intervals with the statistical analysis showed significantly high differences (P < 0.001) between pH values induced by each material at all time intervals. Among the water-insoluble products, Dycal had the strongest alkaline effect after 7 days interval. The materials that chemically hardened produced higher pH values than materials that hardened by a visible light source after 7 days.

Antegrade versus antegrade with retrograde delivery of cardioplegic solution in myocardial revascularisation. A clinical study in patients with triple vessel coronary artery disease.

The effects of antegrade and antegrade with retrograde delivery of cardioplegic solution were evaluated in 60 patients who underwent myocardial revascularisation. All patients had triple vessel coronary artery disease and underwent revascularisation using arterial and vein grafts. Myocardial protection consisted of administration of the St.Thomas' Hospital cardioplegic solution, topical slushed ice and systemic hypothermia (28 degrees C-30 degrees C). The patients were categorised into: group A (n=30), who received antegrade cardioplegia alone, and group B (n=30), who received antegrade and retrograde cardioplegia. With the exception of the total dose of cardioplegic solution ('p'=0.02), there was no significant difference between the two groups. Cardiac function was assessed before and after the patient was weaned from the cardio-pulmonary bypass. There was a significant increase in the right atrial pressure and a significant decrease in the mean arterial pressure from the baseline ('p'<0.05), 10 minutes after cardiopulmonary bypass in group A. All patients in-group B had a spontaneous return to sinus rhythm after release of the aortic cross clamp, whereas 3 patients in group A required defibrillation to restore sinus rhythm. Intra aortic balloon pump support was necessary in 4 patients in group A, as against 1 patient in group B to terminate the cardiopulmonary bypass. The clinical outcome was similar in both groups. We conclude that the use of a combination of retrograde and antegrade cardioplegia facilitates early recovery of left ventricular function after coronary artery bypass grafting.

Use of Arginine Vasopressin in the Management of Vasodilatory Shock After CABG - A Clinical Tria.

Vasodilatory shock requiring treatment with catecholamines occurs in some patients following cardiopulmonary bypass. We investigated the use of vasopressin in the treatment of this syndrome. Forty patients with a left main coronary artery disease and a poor left ventricular function (ejection fraction <30%) were studied. Only those patients (n=12, 30%) in whom difficulty was experienced in maintaining a mean arterial pressure of > 60 mm Hg and a systemic vascular resistance of greater than 900 dynes.sec.cm5 on maximal doses of pharmacological and mechanical support were selected. Patients underwent a standard cardiac anaesthesia protocol. All patients had a Swan-ganz catheter inserted pre-operatively. Arginine vasopressin was administered as a bolus of 0.015 units/kg intravenously followed by an infusion of 0.03 units/kg/hour. This dose increased the mean arterial pressure from 67+/-7 to 95+/-5 mm Hg and the systemic vascular resistance from 860+/-55 to 1502+/-71 dynes.sec.cm-5. It was also associated with a decrease in pharmacological support. All subjects responded to vasopressin administration. Vasopressin is an effective pressor in vasodilatory shock after cardiopulmonary bypass.