Efficacy of dexmedetomidine as adjuvant to ropivacaine in paravertebral block for post-operative analgesia in breast cancer surgery

Background: Paravertebral block can be given for pain management after modified radical mastectomy (MRM). Although many additives to ropivacaine in PVB have been tried for post-operative analgesia, none has been found ideal. Aims and Objectives: We have compared the duration of analgesia in PVB using adjuvant like dexmedetomidine with ropivacaine after MRM. Materials and Methods: Sixty female patients posted for MRM and axillary dissection were split into two groups. Group R administered ultrasound-guided PVB with 20 ml ropivacaine 0.5% and Group RD administered 20 ml of 0.5% ropivacaine with dexmedetomidine 1 mcg/kg. After confirming PVB, surgery was done under general anesthesia in all patients. Time for 1st analgesia requirement was the main objective of our trial. Other objectives were to record visual analog scale scores and total analgesic need. Results: Post-operative analgesia duration was increased in the group RD (7.11 ± 1.42 h) in contrary to Group R (3.68 ± 1.85 h). Total paracetamol consumption post-operative 24 h was decreased in Group RD (1.63 ±0.89 g) in contrary to Group R (2.74 ± 0.76 g). Conclusion: Dexmedetomidine in PVB provides prolonged pain relief after MRM.

Etiological causes and epidemiological characteristics of patients with occupational corneal foreign bodies: A prospective study in a hospital-based setting in India

Purpose: Corneal foreign bodies (CFBs) due to occupational exposure have been largely ignored in Indian literature, especially nonmetal workers. Our study looks at a broad range of occupations and settings that contribute to CFB in our local Indian population. The study objective was to determine the occupations, level of education and demographics of patients presenting with CFB acquired during occupational work. Methods: Prospective hospital-based study at a tertiary eye hospital in Gurgaon, Haryana, India, within duration of 9 months. Patients presenting with CFB were asked a set of questions relating to their occupation, level of education, understanding of the potential complications of CFB, and demographics. Results: A total of 83 patients were included in the study. CFB were attributed only to males. 66% of patients were in the age group of 14--29 years. 30% of patients were in the age group 30--44 years and 4% of patients were between 45 and 60 years old. The metal work industry was responsible for 47% of presentations. The construction industry was responsible for 27% of presentations. Electricians and carpenters combined were responsible for 10% of presentations and 17% of presentations occurred in other sectors. Conclusion: CFB occur across a number of occupations in the construction industry, not just metallic workers. Among a population that is generally poorly educated and have nominal understanding of the impact that CFB can have on vision, occupational hazard education is necessary to address this problem.

Clinical Profile of Childhood Tuberculosis in a Tertiary Care Rural Hospital

Introduction: Tuberculosis (TB) remains a major public health problem, despite noteworthy socioeconomic development and advances in medical science. It is a curable disease but still millions of people suffer every year and a number of them die from this infectious disease, resulting in devastating social and economic impact. TB treatment requires several months of swallowing a combination of 3 to 4 drugs every day. Patients often forget to take their medicines or stop taking them when they start to feel better. The Revised National TB Control Programme (RNTCP), based on the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy was launched. Studies of paediatric TB are scantily available both in global and national context. Reliable data on the treatment of paediatric TB and its follow up are not available. Hence, a study of paediatric TB is designed to evaluate the clinical profile of childhood tuberculosis and following up the treatment outcome upto 6 months Materials and methods: The study was carried out in the Department of Pediatrics at Dhiraj Hospital, Piparia. Recruitment took place from February 2014 to February 2015. The clinical profile of 71 patients was studied. Results: There was preponderance of males (60.56%, n=43) in study population as compared to females (39.44%, n=28). Most of the patients were belonging to age group of <6 years (32.4%, n=23) and >10 years (38.0%, n=27). Among 6 to 10 years, 21 (29.6%) patients were included in study. Most common form of TB was extra-pulmonary TB (60.56%, n=43) followed by pulmonary TB (39.43%, n=28). Non-specific symptoms like fever (82.5%, n=66) was the commonest presenting symptoms. Other symptoms included cough (33.8%, n=24), altered sensorium (19.71%, n=14), swelling (15.5%, Muley P, Odedara T, Memon R, Sethi A, Gandhi D. Clinical Profile of Childhood Tuberculosis in a Tertiary Care Rural Hospital. IAIM, 2017; 4(6): 109-124. Page 110 n=11). From all, the patient with follow up (n=50), 44 (88.0%) were cured, 3 (6.0%) patients expired during the course of treatment, 3(6.0%) patient showed no improvement. Conclusion: Diagnosis of paediatric tuberculosis still continues to be a challenge. In the study TB was more common in extra-pulmonary than pulmonary forms in our setting. Diagnosis was based on a combination of epidemiological and clinical suspicion supported by results of various investigations. Presence of paediatric TB is an indication of prevalence of TB in that community. As the source of transmission of TB to children is usually an adult, control of tuberculosis in adult is necessary to decrease the prevalence of TB in children. DOTS is an effective strategy for treatment of TB.

Pre-operative intravenous fluid therapy with crystalloids or colloids on post-operative nausea & vomiting.

BACKGROUND & OBJECTIVE: Post-operative nausea and vomiting (PONV) is a frequent complication and may be a reason for increased morbidity and cost of treatment. Following elective surgery, it is believed to result from gut ischaemia consequent to hypovolemia from overnight fasting. This study was carried out to study the effects of pre-operative intravenous fluid supplementation, either crystalloids or colloids, on PONV. METHODS: In this prospective randomized clinical trial, 60 female patients undergoing elective open cholecystectomy were randomly allocated to three equal groups A, B and C. All patients received preoperative fluid supplementation. Group A patients received 2 ml/kg Ringer lactate iv (intravenously) and served as control, Group B patients received 12 ml/kg Ringer lactate iv whereas Group C patients received 12 ml/kg of 4.5 per cent hydroxyethylstarch (Hetastarch) iv. All patients underwent cholecystectomy under standard anaesthesia technique with intraoperative fluid replacement by Ringer's lactate (6 ml/kg/h). An independent blinded observer assessed PONV during first 24 h following surgery using visual analogue scale (VAS) score (0 = no nausea, 10 = worst imaginable nausea or vomiting). Rescue antiemetic was given whenever VAS was > 5. RESULTS: The three groups were comparable in terms of age, body weight and duration of surgery. VAS scores in Groups B and C patients were less than that of Group A patients at all time intervals post-operatively and became significantly different at 4 h post-operatively. The VAS scores of Groups B and C patients were comparable throughout. A significantly large number (90%) of Group A patients required rescue antiemetic as compared to 50 and 55 per cent patients in Group B and Group C, respectively. INTERPRETATION & CONCLUSION: Pre-operative intravenous fluid supplementation using crystalloids and colloids results in significantly decreased incidence of PONV. Both, crystalloids as well as colloids were found to be equally effective in preventing PONV.

Teaching exercise of drug utilization by medical students.

The prescription is a vital written document communicating between the physician, the patient and the pharmacist. The audit of prescribing pattern is a component of medical audit, which seeks monitoring, evaluation and necessary modifications in the prescribing practices of prescribers to achieve rational and cost effective medical care for the patients, The present drug utilization study was conducted by fourth year MBBs students during their research posting in the department of Pharmacology at B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan. The prescriptions were randomly collected from BPKIHS pharmacy over a period of 3 weeks. The auditing was done in the form of a semi structured performa containing the patients particulars with regard to age, sex, and residence, the details of the illness and prescribed drug information. The data was analyzed at the end of the study. The study points out that the maximum (27.5%) prescriptions were from General Outpatient Department (GOPD) followed by ENT (16.5%), Internal medicine (15.5%) and General surgery (10%). This indicates the distribution of patient load in hospital and the dominant areas to be targeted for intervention. Further, the proportion of antimicrobial agents (AMAs) i.e. 26.03% use was low and was prescribed empirically in most of the cases. There was use of expensive AMAs and irrational prescribing of combinations of AMAs in some prescriptions. Other prevailing drugs which were prescribed were analgesics. The usage of nimesulide and rofecoxib. withdrawn by FDA were used recurrently in this setup. There was greater use of dubious drugs of unproven benefit like vitamins, calcium etc. The diagnosis of the disease were not mentioned in 32.5% of prescriptions, The dose, frequency and duration of drugs were unascertained in majority of prescriptions that might lead to health hazards. This exercise might change the behavior of existing prescribers and also of the future doctors.

Socio-demographic profile of leprosy patients in two districts of western Uttar Pradesh.

Despite achieving the goal of national elimination of leprosy, it remains a serious public health problem in the high prevalence states of Uttar Pradesh, Bihar and Orissa. A significant percentage of newly detected cases are Multibacillary. It underscores the importance of developing a more effective strategy to combat the disease in high prevalence pockets of the country. A glance into sociodemographic profile of the leprosy patients of one the high prevalence states might help in understanding the current ground situation better. A questionnaire based study was conducted at health care center of two districts of Uttar Pradesh (Rampur and Moradabad).Data on demographic profile of leprosy patients attending these centers were collected. The leprosy patients were more frequently males (63.8%). The duration of time before presentation was significantly longer for semiskilled workers (Kuppuswami Scale classification), p = 0.029. Patients with multibacillary disease were younger (mean age 31.04 yrs) as compared to paucibacillary leprosy (mean age 38.7yrs), p value = 0.041. These observations suggests that a specific population based approach is required to detect new cases early. Certain groups of the population might benefit from active surveillance.

Recent trends and directions in the rationalization of pharmacotherapy of bronchial asthma: probing for alternatives.

Although tremendous progress has been made in the understanding of Bronchial Asthma (BA) over the past decade, asthma remains a frequently encountered challenging condition for the physicians in the health care locale. Inflammation is distinguished as the most important event in the pathogenesis and the knowledge that asthma is an inflammatory disorder has become elementary to our explanation of asthma; this has broadened the perspective for the treatment of BA. However, bronchodilators and corticosteroids are still the mainstay of asthma treatment over the decades. The introduction of superior derivatives of corticosteroids and beta agonists, the choice, safety, duration of action and ease of delivery have enhanced progressively. Surrogated anti-inflammatory agents have been used in severe disease, but have been limited by adverse effects. The introduction of new agents affecting leukotrienes synthesis and action provides an alternative strategy but it needs to be confirmed on a large subset of population of asthmatics. In fact, the past decade has been witnessed by a proliferation of scientific information and a widespread addition of anti-inflammatory therapy to improve asthma outcomes along with the recommended therapies. In this context, there has been much advancement in the available pharmacologic panorama for both chronic and acute therapy and the development and approval of novel medications. Yet, many controversies abound this disorder, and further fundamental developments in novel therapeutics are imminent. This review of asthma for the practicing clinician will summarize these developments and their implications in treatment of BA.

Antimicrobial utilization pattern in out patient services of ENT department of tertiary care hospital of Eastern Nepal.

OBJECTIVE: The objective of this study was to monitor the antimicrobial utilization in ENT out patient services in a tertiary care hospital of Nepal. MATERIALS & METHODS: A total of 191 prescriptions were randomly audited at varying time interval from the department of ENT in the year 2003. The data was collected in customized Performa in the form of antibacterial audit questionnaires. It also contained Patient particulars, diagnosis, investigations, drug details and information from the prescriber regarding the indication for prescribing antimicrobial agent, suspecting organism underlying infection, duration of therapy and details of any concomitant medications. RESULTS: The incidence of use of antimicrobial agents (AMA) in 191 prescriptions was analyzed from the enrolled prescriptions, a total of 218 antimicrobials i.e.1.4 antimicrobial agent per patient were prescribed. .The AMAs were indicated therapeutically in 73.29% of patients & 19.37% patients for prophylaxis. The AMAs were advised for more than 72 hours for prophylaxis in 86.48%. In the concomitant medications antihistaminic were prescribed in 32.62% and NSAIDS in 21.98% cases. Most of patients reported with upper respiratory tract infections (URTI-32.56%), Chronic Suppurative otitis Media (CSOM-18.3%), sinusitis (6.28%), tonsillitis (5.75%),. Pharyngitis (3.66%), Acute Suppurative Otitis Media (ASOM-2.61%) and others. The diagnosis was established clinically in 42.40% and confirmative in 35.60%. In 21.46% the diagnosis was not disclosed. Out of 191 patients, culture sensitivity tests were performed for only 31 patients and 13 patients depicted a positive culture sensitivity tests. The common microbes isolated from the culture were staphylococcus aureus (69.2%). Streptococcus (7.7%), Enterobacteriacae (7.7%), Pseudomonas auroginosa (7.7%) & psendomanas mirabilis (7.7%). Clinically suspected organism were mentioned in only 32 prescriptions and most prescriber presumed the infections due to staphylococci & pseudomonas (43.75%), streptococci (21.8%),Gram negative organisms (12.5%) and H influenza (9.3%).The use of a single drug was abundant (89.52%), two drugs (9.94%), and three drugs (0.52% )prescriptions. Ciprofloxacin (23.85%) was preferred, followed by amoxycillin (20.06%), combination of ampicillin + cloxacillin( 9.17%), doxycyclin (5.96%). Erythromycin (4.58%) and cotimoxazole (4.58%). Expensive drugs i.e azithromycin (2.75%), roxithromycin (1.37%) and cephalosporins (3.21%) were also prescribed. The causative microbes were sensitive to amoxycillin (53.84%), cloxacillin (53.84%) ciprofloxacin (46.15%), gentamicin (46.15%), and cephalosporin (46.15%). But resistant to erythromycin, tetracycline, cotrimoxazole and norfloxacin) CONCLUSIONS: Majority of patients were prescribed drugs irrationally with misleading indications without confirming the bacteriological culture and sensitivity.

Adenoid cystic carcinoma of the lacrimal gland.

Adenoid cystic carcinoma (ACC) of the lacrimal gland is a rare tumor from the epithelial structure. It is rare in children. The authors report a case of ACC in a girl child. Extensive excision of the tumor is advised to prevent later recurrences. Local control can be better achieved by a combination of radiochemotherapy as ACC has been shown to recur event after 10 years.

Gabapentin and lamotrigine in Indian patients of partial epilepsy refractory to carbamazepine.

52 patients (25 males and 27 females) suffering from refrectory partial seizures, of not more than two years duration and on carbamazepine monotherapy were enrolled in this study. Patients were randomly put on gabapentin (19 males and 8 females) or lamotrigine (6 males and 19 females) as add on therapy. The efficacy of the drugs was assessed by the seizure frequency, pattern of seizures and seizure free interval. The safety was evaluated from the biochemical investigations and the adverse effects observed or reported by the patients during the course of the study. The average frequency of basal partial seizures was 6.26+3.86 and 5.04+2.47 which decreased significantly (p<. 001) after 12 weeks of add on therapy to 1.75+2.16. and 1.68+2.94 in the GBP and LTG group respectively. However, there was no significant difference between the two drugs after 12 weeks of add on therapy. The PCB (primary change in basal seizure frequency) values decreased to -72+34.92 and -76.22+29.68 in the GBP and LTG group respectively. The difference in these two groups was not significant. The responder rate was 77.7% and 92% respectively in GBP and LTG group respectively. GBP was found to be more effective in partial seizures with secondarily generalization while LTG was effective in all subtypes of partial seizures. The abnormal scalp EEG was recorded in 33.3% (9 of 27 patients) in GBP group and 40 %( 10 of 25 patients) in LTG group and it did not revert to normal in 33.3% and 40% of patients in either of groups (GBP/LTG). Minor side effects which were self limiting were noticed in 80% in groups I and 74% were groups II.

Respiratory failure in acute intermittent porphyria.

We report two patients of acute intermittent porphyria (AIP) who presented with acute respiratory failure. Only one such previous report could be found. Occasionally, neuropathy may be the presenting feature in AIP which may progress to respiratory embarrassment. The cause of this neuropathy has been hypothesized to be direct neurotoxicity of delta-ALA by interaction with GABA receptor, altered tryptophan metabolism and may be heme depletion in nerve cells.

Childhood proptosis: the invaluable but overlooked peripheral blood smear.

Two cases of granulocytic sarcoma presenting as childhood proptosis are described. This highlights the significance of peripheral blood smear examination in establishing the diagnosis of Acute Myeloid Leukaemia (AML).

Extended survival of carcinoma head of pancreas following palliative treatment.

A 48 year old woman presented with obstructive jaundice 10 years back. Upper gastrointestinal endoscopy revealed a growth infiltrating the ampulla of Vater, which was confirmed to be adenocarcinoma on cytology. At laparotomy, a large nodular growth was seen in the head of pancreas. Surgical resection could not be done because of encasement of superior mesenteric vessels, hence a cholecystojejunostomy was performed. The patient remained asymptomatic for 9 years, when she developed cholangitis. Duodenoscopy at this stage revealed an ulcerated growth at the ampulla and biopsy from the growth confirmed a well differentiated adenocarcinoma. A straight flap 10 F stent was placed in the common bile duct. Thereafter the patient has remained asymptomatic for more than a year.

Sensory nerve conduction during cold pressor response in humans.

A study was carried out to find the correlation, if any of autonomic responses and experimental pain induced during the cold pressor test (CPT) with the median nerve sensory conduction velocity (SCV). In 19 healthy subjects who volunteered for the study, the nondominant hand of each was subjected to the CPT and, pain parameters, heart rate, blood pressure and SCV were recorded. Dominant median nerve SCV was measured by orthodromic stimulation of the index finger and evoked responses were recorded at the wrist. In each subject, 32 evoked action potential responses were averaged to determine the SCV. Median nerve SCV of 57.8 +/- 5.2, 56.6 +/- 5.1, 57.0 +/- 5.2 and 57.8 +/- 5.1 m/sec were recorded before, during, immediately after and after ten minutes of the CPT, respectively. The SCV and the amplitude of the evoked response were significantly (P < 0.001 and P < 0.01 respectively) decreased during the CPT. A significant relationship (P < 0.05) was found between nerve conduction parameters and diastolic blood pressure recorded before the CPT. These findings suggest that sympathetic overactivity and/or cold induced pain interacts with sensory conduction in the contralateral median nerve so as to decrease its conduction velocity. There also exists a relationship between SCV and vasomotor mechanisms controlling peripheral resistance, and hence the diastolic pressure.

Brain stem auditory evoked responses during the cold pressor test.

This study was conducted to determine changes, if any, in Brain stem auditory evoked responses (BAEP's) during the cold pressor test (CPT) in healthy human subjects. Thirteen subjects (age 18-25 yrs) were selected for the study. Their BAEP's were recorded using standardized technique employing 10-20 international electrode placement system and sound click stimuli of specified intensity, duration and frequency. The standard CPT was performed in the non-dominant hand and the BAEP's, heart rate and blood pressure were recorded before and during the CPT. The values of absolute peak latencies and amplitude of evoked responses were statistically analysed. The amplitude of wave V showed a significant increase (P < 0.05) during the CPT (0.47 +/- 0.203 and 0.37 +/- 0.174 mu v before and during CPT respectively). This could be due to interaction of activated central ascending monoaminergic pathways or nociceptive afferents with the midbrain auditory generator so as to increase it's activity.

Congenital adrenal hyperplasia: experience at intersex clinic, AIIMS.

During 1981-88, 63 cases of female pseudohermaphroditism (FPH) were seen at the Intersex clinic at AIIMS, of whom 34 (54%) were diagnosed as due to congenital adrenal hyperplasia (CAH). Though ambiguity was present at birth in most cases, only one child was brought immediately after birth, while 14 presented after one year. Family history of affected siblings and fetal wastage was present in 10. Salt wasting symptoms were present in 13 (38.2%), evidence of early virilization in 10 (29.4%) and generalised hyperpigmentation in 7 (20.6%). Clitoromegaly was present in 30 children with labial fusion in 10 and scrotalisation of labia in 6. The urogenital opening was single in 25 (73.5%). Buccal smear was positive for sex chromatin in 19. Chromosomal pattern showed 46 XX in 33. Dyselectrolytemia was present in 16 children. Bone age was advanced in all. Adrenal hyperplasia could be documented in 3 on CT scan. All the girls were put on hydrocortisone or prednisolone, and fluodrocortisone was given only to children with salt wasting CAH. Children with CAH are being brought to medical attention much too late and investigative and therapeutic facilities are grossly inadequate. There is a need to educate primary care physicians for early case detection and provide minimum diagnostic and therapeutic facilities in regional centres.