Comparison of dexmedetomidine versus propofol-based anaesthesia for controlled hypotension in functional endoscopic sinus surgery

Background: Increased intraoperative bleeding during functional endoscopic sinus surgery (FESS) affects operative field visibility, which increases both duration of surgery and frequency of complications. Controlled hypotension is an anaesthetic technique in which there is deliberate reduction of systemic blood pressure during anaesthesia. The aim of the study was to compare the efficacy of dexmedetomidine against propofol infusion when used for controlled hypotension during FESS. Methods: A randomised, prospective, and single-blinded study was carried out, which included 80 patients of either sex of ASA grade І & ІІ who underwent elective FESS. Patients were randomly assigned to two groups: Group A (dexmedetomidine), Group B (propofol). Intraoperative mean arterial pressure (MAP), heart rate (HR), surgical grade of bleeding (based on the Fromme­ Boezzart scale), and amount of bleeding were recorded. Results: Groups were well matched for their demographic data. There was a statistically significant difference (p < 0.05) between Group A and Group B in heart rate, mean arterial pressure (MAP) and mean total blood loss, with Group A being effectively in controlled on all three parameters during FESS. However, there was no significant difference (p > 0.05) in terms of surgical grade of bleeding between Group A and Group B. Conclusions: Both dexmedetomidine and propofol infusion are efficacious to facilitate controlled hypotension and haemodynamic stability intraoperatively

Intercostal drainage tube or intracardiac drainage tube.

Although insertion of chest drain tubes is a common medical practice, there are risks associated with this procedure, especially when inexperienced physicians perform it. Wrong insertion of the tube has been known to cause morbidity and occasional mortality. We report a case where the left ventricle was accidentally punctured leading to near‑exsanguination. This report is to highlight the need for experienced physicians to supervise the procedure and train the younger physician in the safe performance of the procedure.

IAP Position Paper on Burden of Mumps in India and Vaccination Strategies.

Justification: Mumps, despite being a widely prevalent disease in the country, is considered as an insignificant public health problem mainly because of poor documentation of clinical cases and lack of published studies. In the absence of adequate published data on disease burden, Government of India has recently decided to introduce measles-rubella (MR) vaccine in its National Immunization Program and neglected mumps component. Process: Following an IAP ACVIP meeting on December 6 and 7, 2014, a detailed review of burden of mumps in India along with vaccination strategies to control the disease was prepared. The draft was circulated amongst the members of the committee for review and approval. Revised final draft was later approved by IAP executive board in January 2015. Objectives: To provide a review of community burden of mumps in India; and to discuss the vaccination strategies to impress upon policymakers to include mumps vaccination in National immunization program. Recommendations : A total of 14 studies and two media reports on mumps outbreak were retrieved. The outbreaks were reported from all the regions of the country. Mumps meningoencephalitis was responsible for 2.3% to 14.6% of all investigated hospitalized acute encephalitis syndrome or viral encephalitis cases in different studies. Data from Infectious Disease Surveillance (ID Surv) portal of IAP and Integrated Disease Surveillance Program (IDSP) of Government of India (GoI) were also reviewed. While a total of 1052 cases were reported by the IDSurv, IDSP had investigated 72 outbreaks with 1564 cases in 14 states during different time periods. Genotypes G (subtype G2) and C were found to be main genotypes of the mumps virus circulating in the country. Three studies studied serological status of young children and adolescents against mumps, and found susceptibility rates ranging from 32% to 80% in different age groups. Conclusions: Mumps poses a significant disease burden in India. This calls for inclusion of mumps vaccine in the National immunization program.

A rare case of Histoplasma fungemia in an AIDS patient.

Disseminated cases of histoplasmosis in acquired immune deficiency syndrome (AIDS) are rarely reported from India. Most of these cases report isolation of this fungus from the bone marrow, lymph node aspirate, spleenic aspirate, and biopsies. We report isolation of Histoplasma capsulatum from the blood of an AIDS patient. A 30-year-old male from Utter Pradesh was admitted with fever, loss of appetite, and nausea since two months. Few intracellular and extracellular budding cells were observed on bone marrow examination on the fifth day of admission. Diagnosis was confirmed by blood cultures taken on the 11th day of admission. Amphotericin B was started, but the patient's condition deteriorated and he died.

Injection safety and Indian Academy of Pediatrics.

A major proportion of injections administered in India are unsafe. Unsafety is due to (1) steps that are associated with increased risk of spread of blood borne viruses and (2) errors related to technique of injection and faulty habits. Recommendations of Indian Academy of Pediatrics revolve round the following points: Equipment related, safe injection practices, best injection techniques, rational injection practices, prevention of needle stick injuries and reducing disease transmission recommendation for HIV-PEP (postexposure prophylaxis), HBV-PEP, disposal of syringes and sharps. The points have been discussed elaborately.

Biphasic demyelination of the nervous system following anti-rabies vaccination.

Acute disseminated encephalomyelitis (ADEM) is an acute or subacute condition characterized by widespread multifocal neurological deficits of variable severity. We report a case of a 45-year-old man with ADEM following anti-rabies vaccine (ARV).

Pharmacoeconomics.

Today, spiraling costs of medical care coupled with limited resources have led to an explosive increase in the number of pharmacoeconomic analyses being carried out. The first step in a pharmacoeconomic analysis is to measure the costs and benefits of the therapeutic regimens being compared. Then one compares these costs and benefits by calculating a cost: benefit ratio for each regimen. Four types of economic analyses are commonly used for this purpose. While cost minimization analysis ignores the benefits and focuses only on costs of treatment, cost-effectiveness analysis measures costs in monetary terms and benefits or outcome in their natural clinical units. Cost benefit analysis on the other hand, places monetary values on both-costs and outcome of therapy. Finally, cost utility analysis measures costs in monetary terms, and outcome in a single utility-based unit of measurement. Utility based measures like quality adjusted life-years (QALY) measure the contribution made by the regimens to the patient's quality of life. Finally study designs generally used for generating data for a pharmacoeconomic analysis are mentioned, and concepts like marginal analysis, sensitivity analysis and discounting are explained in the context of health economics.

Hypertension in the elderly.

OBJECTIVES: To study the clinical profile of hypertension in the elderly, development of end organ complications and the effect of hypertension with other risk factors in producing these complications. METHODS: One hundred and thirty six elderly patients attending the Hypertension Clinic were included in the study. A detailed history was taken that included presenting illness, family history of hypertension, diabetes, coronary artery disease, dyslipidaemia and history of addictions. Physical examination included systemic examination with measurement of waist to hip ratio and fundoscopy for retinopathy. Renal and liver function tests (RFT, LFT), blood sugar, lipid profile, X-ray chest, electrocardiography (ECG), 2-D echocardiography, abdominal ultrasound and computed tomography (CT) scan head (if indicated) were other important investigations done. RESULTS: Seventy-nine patients were in the age group of 60-65 years, of which 42 (30.9%) were males. Headache was the commonest chief complaint in 77.9% patients; whereas 24 patients were asymptomatic. Obesity, diabetes, alcohol, dyslipidaemia and family history were important determinants of hypertension. Lipid profile was abnormal in 55.9% patients. Isolated systolic hypertension (ISH) was found in 56.6% patients. Grade II hypertensive retinopathy was observed in 29.4% patients with uncontrolled blood pressure. Left ventricular hypertrophy (LVH) was the commonest ECG manifestation seen in 36.8% patients of which 26.5% had uncontrolled blood pressure. LVH could be diagnosed in 46.4% patients by 2-D echo. Patients with uncontrolled blood pressure and ISH had increased incidence of cardiovascular and cerebrovascular complications. Cardiovascular complications were seen in 19.1% patients having dyslipidaemia and hypertension. Cerebrovascular complications were seen in 15.4% patients having hypertension with LVH. Treatment included calcium channel blockers and/or other drugs. CONCLUSIONS: The elderly hypertensive patients tend to have ISH. Family history of hypertension is an important determinant of hypertension. Uncontrolled hypertension, ISH, LVH and other associated risk factors are responsible for cardiovascular and cerebrovascular morbidity.