Effect of intraoperative alveolar recruitment maneuver on intraoperative oxygenation and postoperative pulmonary function tests in patients undergoing robotic-assisted hysterectomy: a single-blind randomized study

Abstract Background Robotic-Assisted Hysterectomies (RAH) require Trendelenburg positioning and pneumoperitoneum, which further accentuate alteration in respiratory mechanics induced by general anesthesia. The role of Recruitment Maneuver (RM) as a lung-protective strategy during intraoperative surgical settings has not been much studied. We planned this study to evaluate the effect of RM on perioperative oxygenation and postoperative spirometry using PaO2/FiO2 and FEV1/FVC, respectively in patients undergoing RAH. Methods Sixty-six ASA I‒II female patients scheduled for elective RAH were randomized into group R (recruitment maneuver, n = 33) or group C (control, n = 33). Portable spirometry was done one day before surgery. Patients were induced with general anesthesia, and mechanical ventilation started with volume control mode, with Tidal Volume (TV) of 6-8 mL.kg−1, Respiratory Rate (RR) of 12 min, inspiratory-expiratory ratio (I: E ratio) of 1:2, FiO2 of 0.4, and Positive End-Expiratory Pressure (PEEP) of 5 cmH2O. Patients in group R received recruitment maneuvers of 30 cmH2O every 30 minutes following tracheal intubation. The primary objectives were comparison of oxygenation and ventilation between two groups intraoperatively and portable spirometry postoperatively. Postoperative pulmonary complications, like desaturation, pulmonary edema, pneumonia, were monitored. Results Patients who received RM had significantly higher PaO2 (mmHg) (203.2+-24.3 vs. 167.8+-27.3, p < 0.001) at T2 (30 min after the pneumoperitoneum). However, there was no significant difference in portable spirometry between the groups in the postoperative period (FVC, 1.40 ± 0.5 L vs. 1.32 ± 0.46 L, p= 0.55). Conclusion This study concluded that intraoperative recruitment did not prevent deterioration of postoperative spirometry values; however, it led to improved oxygenation intraoperatively.

Open globe injuries from projectile impact: Initial presentation and outcomes

Purpose: To describe the characteristics and correlates of open globe injuries secondary to projectile injury and outcomes following surgical open globe repair at an urban tertiary referral center. Methods: Records of all patients with a history of open globe injury secondary to projectile injury and surgical open globe at a tertiary referral hospital between January 1, 2010 and December 31, 2016 were reviewed. Demographics, type of trauma, wound extent, presence of foreign body, and presenting clinical findings are reported. Outcomes for patients with greater than 6 months of follow?up included additional surgeries, final visual acuity, and clinical findings. Results: Of 214 patients who underwent open globe repair, 73 (34.1%) were due to projectile impact. Mean age was 37.9 years and patients were primarily male (n = 66, P < 0.001). Most injuries resulted in globe laceration (68.5%, P < 0.001), and wound extent was zone 1 (45.2%), zone 2 (20.5%), zone 3 (27.4%), or unknown (6.8%). Associated findings included foreign body (35.6%) and orbital fracture (15%). Of 41 patients with at least 6 months of follow?up, 70% had additional surgeries following their initial surgical repair. Laceration injuries tended to be more anterior (P = 0.002) with better visual outcomes (P = 0.045) than those with globe rupture, and concomitant orbital fracture associated with poor visual outcomes. Overall, 58.5% of patients had 20/40 or better final best?corrected visual acuity. Conclusion: This is the largest report of open globe injury due to projectile impact. Visual prognosis in this population is very good, with most patients achieving better than 20/40 vision in our study

Single layer versus double layer intestinal anastomoses: a comparative study

Background: There are still conflicting views regarding suitability of single layer and double layer anastomotic technique. This prospective single blinded randomized comparative study conducted at Rajendra Institute of Medical Sciences to assess various aspects viz. safety, efficacy, duration of hospital stays and chances of perforation in single- and double-layer anastomotic surgery.Methods: 26 patients each in single layer and double layer anastomosis group were included in the study.  Single layer intestinal anastomosis was carried using extramucosal technique with 2-0 vicryl suture (round body). Double layer anastomosis was carried out using interrupted 3-0 silk lembert sutures for the outer layer and a continuous 2-0 vicryl for the inner layer. End to end colocolic, end to end ileocolic, end to side ileocolic, end to end ileoileal, side to side ileoileal, end to end jejunoileal and end to end jejunojejunal anastomosis were performed. Each group was compared for anastomotic leak, time required to construct the anastomosis, cost incurred, and length of hospital stay.Results: Findings of the study indicated that single layer is economical in comparison to double layer anastomosis and took significant less time to operate. There was no significant difference in hospital stay of the patients in two groups. There was no anastomotic leak in group-S (single layer) while one (3.8%) patient in group-D (double layer) suffered from anastomotic leak.Conclusions: It was concluded that single layer anastomosis method is beneficial and safe as it required less operative time, suturing material and no leak took place after surgery.

Effects of Loose Housing Designs on Expressions of Milking Parlour Behaviours and Milk Yield of Crossbred Jersey Cows

Milking behaviour of dairy cows has serious impacts on their production efficiency. A number of genetic and environmental factors controls and influences milking behaviour of dairy cow. The aim of present study was to investigate the influence of housing comfort on expressivity of milking behaviours of cows in parlour, milk yield and compositions. Forty Jersey crossbred cows of similar production levels were selected and divided into 2 groups based on age, production and parity. Subsequently, cows were kept in two different types of loose house; each containing 20 animals. Two types of housing patterns were compared - (i) Traditional shed (T0) and (ii) Thermo-comfortable shed (T1). Impact of housing comfort significantly transformed the expressions of dairy cows behaviour even in milking parlour. Milking temperament scores and stepping during milking were significantly lower in cows kept in T1 compared to that of T0. Cows of thermo-comfortable shed showed more docile, calm and less nervous behaviour than those kept in traditional shed. Housing patterns significantly influenced daily milk yield (kg) being 2.86% more in T1 as compared to T0. Similarly milk compositions were better and significantly higher in T1 group of cows than that of T0. It was concluded that staying comfort of living by resignificantly modulated the expression of dairy cows behaviours even in milking parlour, demonstrated favourable milking temperament, reduced nervousness, enhanced milk yield and showed better milk compositions in Jersey crossbred cows

Resistance to anti leprosy drugs in multi-bacillary leprosy: A cross sectional study from a tertiary care centre in eastern Uttar Pradesh, India

Background: WHO MDT is the main drug regimen for treating leprosy and has been used for more than three decades. Many cases of relapse of leprosy have been reported, which points towards the emergence of drug resistance with the antileprotic drugs. Objectives: To find the resistance with the antileprotic drugs by detecting the mutations in drug resistance determining region of the rpoB, folP1 and gyrA genes of Mycobacterium leprae. Methods: Leprosy patients with bacterial index ≥2 were included in the study. The slides were further processed to extract genomic DNA, and polymerase chain reactions were performed to amplify the drug resistance determining region (DRDR) of rpoB, folP1 and gyrA genes. The samples in which genes could be amplified were subjected to DNA sequencing to detect mutations. Results: Out of 78 samples rpoB gene was amplified in 39 (50%), folP1 in 32 (41%) and gyrA in 45 (57.7%). In 20 (25.6%) samples no gene was amplified. Only 32 samples of rpoB, 25 samples of folP1 and 38 samples of gyrA gene were included in the study, rest were excluded due to sequencing error. No mutation was seen in rpoB gene and in folP1 gene. In gyrA gene samples mutations were seen in 8 (21%) samples, and were present at codon 91 GCA → GTA (Alanine → Valine). Limitations: Small sample size and less efficient method to detect resistance. Conclusion: Resistance is not a problem with conventional drugs in MDT. It is more common with quinolones.

Bilateral Supernumerary Heads of Biceps Brachii.

The Biceps brachii is a muscle of flexor compartment of the arm. The biceps brachii muscle shows variation in the number of heads, with an estimated 9–22% of all people having a supernumerary head. Themost common variation is third head, but four, five, or even seven heads have been reported. Although supernumerary heads of the biceps brachii muscle have been frequently reported, bilateral asymmetric occurrence of supernumerary heads is relatively rare. During a routine cadaveric dissection at the Department of Anatomy, National Medical College, Birgunj, Nepal, we encountered bilateral supernumerary heads of the biceps brachii muscle; Three heads on the right arm and four heads on the left arm in a 68 year old male cadaver. These additional heads were supplied by branches from the musculocutaneous nerve. No additional anomalies were found on the remainder of both upper limbs of the same cadaver. It may cause compression of surrounding neurovascular structures or itmay lead to variation of normalmechanical actions and also can cause erroneous interpretation during routine surgeries.

Hepatitis B and/or C co-infection in HIV infected patients: A study in a tertiary care centre from south India.

Background & objectives: Co-infection with hepatitis B virus (HBV) and hepatitis C virus (HCV) in human immunodeficiency virus (HIV) infected individuals results in increased hepatic complications. We undertook this study to evaluate the presence of HBV and HCV in HIV infected individuals attending a tertiary care centre in southern India. Methods: A total of 120 cases with HIV infection and 120 healthy adult control subjects were included in the study. Samples were tested for hepatitis B surface antigen (HBsAg) and anti-HCV antibodies by enzyme linked immunosorbent assay (ELISA) method. HBsAg and anti-HCV positive serum samples were further tested for the presence of hepatitis B e antigen (HBeAg), anti-HBe antibodies, HBV-DNA and HCV-RNA. Results: The most common mode of transmission was sexual promiscuity (79%), followed by spouse positivity (15%) and history of blood transfusion (6%). HBsAg and anti-HCV were positive in 18 (15%) and 10 (8.3%) HIV infected patients; the corresponding figures in healthy controls being 2 (1.6%) 0 (0%) (P<0.0001). Among HIV infected patients, presence of HBeAg and anti-HBe antibodies was seen in 33.3 and 55.5 per cent, respectively; both HBeAg and anti-HBe antibodies were negative in 11.1 per cent. HBV DNA and HCV RNA were positive in 10 of 18 and in all anti-HCV positive samples. Triple infection with HBV, HCV and HIV was seen in three patients. CD4+ T-lymphocyte count less than 200/μl was seen in 22 of 28 co-infected cases. Interpretation & conclusions: The findings of our study showed presence of HBV (15%) and HCV (8.3%) co-infections in HIV positive patients which was higher than that seen in HIV negative controls. Co-infection with HBV and HCV is a common problem in HIV infected patients in India. Hence, all HIV patients need to be routinely tested for markers of HBV and HCV infection.

Dengue fever presenting with acute colitis.

Gastrointestinal manifestations of dengue fever are mainly in the form of bleeding or liver function abnormalities. Dengue fever presenting as acute colitis-like picture is not reported to date. We report a 50-year-old man with dengue fever presenting with lower gastrointestinal bleeding and colonoscopic features of acute inflammatory colitis.

Choriocarcinoma - a rare association with squamous cell carcinoma of esophagus.

Extragenital choriocarcinoma involving the gastrointestinal tract is rare. We report a 60-year-old woman with squamous cell carcinoma of esophagus with a choriocarcinomatous focus. She was palliated with chemotherapy and an endoprosthesis.

Clinical and aetiological profile of hepatoma at a tertiary care centre.

Hepatocellular carcinoma (HCC) is one of the most common cancers in the world. Infection with the hepatitis B virus (HBV) is one of the high-risk factors for the development of HCC, particularly in Asia and Africa. Other risk factors include hepatitis C virus (HCV) infection and, to a certain extent, exposure to a liver-specific carcinogen such as aflatoxin B, and alcohol consumption. In the present retrospective study, we analysed the clinical profile and aetiological role of HBV and HCV in HCC. A total of 40 cases of HCC (33 males and 7 females, age range 22-80 years) were seen from January 1999 to June 2001 at our institute. A detailed history of age, sex, past history of liver disease, clinical symptoms and presenting complaints was recorded. The most common presenting complaints were abdominal distention, pedal oedema and pain abdomen. Underlying cirrhosis of the liver was seen in 30 cases (75%), Child's A in 6, Child's B in 11 and Child's C in 13 cases. A history of alcoholism was present in 6 patients. All the patients were tested for HBsAg and anti-HCV by ELISA. HBsAg and anti-HCV was positive in 19 (47.5%) and 8 patients (20%), respectively. The diagnosis in the majority of cases was derived by FNAC and in a few by imaging techniques plus alfa-fetoprotein (AFP) evaluation. The diagnosis was confirmed by FNAC in 34, CT scan and AFP in 2, and ultrasound abdomen and AFP in 4 cases. We conclude that viral infection (HBV > HCV) is still a major aetiological factor and the incidence of HCV infection appears to be increasing. The majority of the cases of HCC studied had a cirrhotic background.

Molecular cloning, characterization and expression of a nitrofuran reductase gene of Escherichia coli.

Mini-mu derivatives carrying plasmid replicons can be used to clone genes in vivo. This method was adopted to generate phasmid clones which were later screened for their ability of restore nitrofurantoin sensitivity of a nitrofuran-resistant host by eliciting nitroreductase activity. One phasmid-derived clone (pAJ101) resulted in considerable increase in nitroreductase activity when introduced into a nitrofurantoin-resistant mutant of Escherichia coli with reduced nitroreductase activity. Subsequently, a 1·8 kb fragment obtained from pAJ101 by partial digestion with 5au3A, was subcloned into pUC18 to yield pAJ102. The nitroreductase activity attributable to pAJ102 was capable of reducing both nitrofurantoin and nitrofurazone. The polypeptides encoded by pAJ102 were identified by the minicell method. A large, well-defined band corresponding to 37 kDa and a smaller, less-defined band corresponding to 35 kDa were detected. Tnl000 mutagenesis was used to delineate the coding segment of the 1·8 kb insert of pAJ102. Α 0·8 kb stretch of DNA was shown to be part of the nitroreductase gene. The gene was mapped at 19 min on the Escherichia coli linkage map.