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.

A Case of Neonatal Severe Hyperparathyroidism: Challenges in Management

Neonatal severe hyperparathyroidism is a rare disorder arising from inherited defects in the calcium sensing receptor (CaSR) that presents early in life with severe hypercalcemia, failure to thrive, and developmental retardation. The authors describe an infant with neonatal severe hyperparathyroidism due to homozygous CaSR gene mutation presenting with recurrent episodes of severe hypercalcemia, growth retardation, and developmental delay. Medical management served as an efective bridge therapy to surgery. Total parathyroidectomy with right hemithyroidectomy was performed at 7 mo of age and resulted in successful cure and normalization of growth and developmental milestones. Timely medical and surgical management can help prevent mortality and morbidity in the form of neurodevelopmental sequelae. Life-long monitoring and treatment is mandatory for the resultant hypoparathyroidism.

Large axillary accessory breast hamartoma: a rare entity

Hamartomas are uncommon benign tumours of axilla and breast. They show varied imaging appearances depending upon the proportion of various tissue elements present. The mammographic, ultrasound and elastographic appearances of a case of left axillary hamartoma is described in a 49 years old Indian patient.

Exclusive breastfeeding: awareness, perceptions and practices among antenatal multigravida women

Background: Breastmilk is considered the most complete source of nutrition for the new-born as it contains all necessary components such as proteins, carbohydrates and fats, water, vitamins and minerals and immunological factors required for the new-born in appropriate amounts. Breastfeeding is advantageous to the infant as well as the nursing mother in many ways. There are various benefits to the new-born both immediate as well as in the long run.Methods: A multiple-choice questionnaire was used to interview the participants during data collection.Results: Using the IBM SPSS version 20 software, descriptive analysis of the categorical variables has been presented using frequency and percentage tables.Conclusions: Though the knowledge about exclusive breast feeding was not extraordinary among the participants, they had a very favourable attitude towards the same. Almost all patients were also extremely receptive and inquisitive during the session for discussion about the same.

Effectiveness of an educational session to sensitise the resident medical officers of a medical teaching institute in Mumbai towards cadaveric organ donation

Background: Resident medical officers play a critical role in facilitating conversion of potential deceased donors to actual donors. Since residency is the last opportunity for formal medical training, we contemplated deficiencies in knowledge might originate and a session of sensitization would disseminate updated information about organ donation. This study aims to assess the change in the knowledge and attitude of resident doctors towards organ donation after a programme of sensitization.Methods: A cross sectional study was conducted in March 2018 among newly inducted resident medical officers of KEM Hospital, Mumbai, after obtaining the institutional ethical approval and written informed consent. Using complete enumeration, 75 newly inducted resident doctors were approached out of which 49 consented to participate in the study. A self-administered questionnaire was used to assess the knowledge and perception before and after a programme of sensitization using a pre-test post-test study design.Results: Few numbers (18.36%) of resident doctors were aware of the various terminologies related to organ donation. There are lacunae in knowledge about difference between brainstem death, cardiac death and the organs that can be donated in each case. Moreover, participants who were initially unwilling to pledge for organ donation, were ready to pledge their organs post the sensitisation session (Z=-3.162, p=0.002).Conclusions: Participants knowledge improved over the programme of sensitization.

Anaesthetic Management of a Case of Necrotising Fascitis with Uncorrected Tetralogy of Fallot with Scoliosis Posted for Debridement

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, characterized by aortic overriding, right ventricular hypertrophy, pulmonary stenosis (PS) and ventricular septal defect (VSD). When left untreated, survival to adulthood is rare. There are few case reports of uncorrected TOF surviving to adulthood and then presenting for noncardiac surgeries. We present a case of debridement of a necrotizing fasciitis under low dose spinal anaesthesia, in a patient of uncorrected TOF with scoliosis and cushingoid features.

Evaluation of Blood Pressure and Anthropometric Measurements in School Children

The prevalence of hypertension in children and adolescents seems to be increasing. The present study aimed to investigate the best anthropometric determinants of high blood pressure in school children. Methods: The present study was conducted in the department of Community Medicine. It comprised of 1160 school children age ranged 12-16 years of both genders. In all children, height (cm), weight (kg), systolic and diastolic blood pressure, Body mass index (kg/m2), Waist circumference (cm) Triceps skinfold (mm) was recorded. Results: Maximum boys were in age 12 years and 16 years and girls in age 14 years, followed by 70 boys in 12 years, 80 in 15 years and 60 in 14 years. 48 girls in 15 years, 42 in 13 years, 38 in 12 years and 17 in 16 years. Boys had 22% and girls had 20% of prevalence of hypertension. The mean height in males was 155.2 cm and in girls was 146.2 cm, weight was 37.4 kg in boys and 32.1 kg in girls, SBP was 132.4 mm Hg in boys and 124.6 mm Hg in girls. DBP was 86.2 mm Hg in boys and 74.6 mm Hg in girls. Conclusion: There is a positive correlation of weight of subjects and systolic and diastolic blood pressure in subjects. Early screening for high blood pressure in school students and introducing effective lifestyle modifications at an early age to prevent the epidemic of non-communicable diseases in future is the need of hour.

A Cross Sectional Study to Evaluate Knowledge and Attitude towards HIV Infection in Rural Population

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is a major and one of the most serious public health challenges in today’s world. The present study was conducted to assess knowledge and attitude regarding HIV in rural population. Methods: The present cross sectional study was conducted by involving 960 rural population of both genders. Study participant should be more than 15 years of age and resident of the same village was used as inclusion criteria. General information such as name, age, gender etc. was recorded. A questionnaire was prepared which were related to knowledge and attitude of rural population regarding HIV. Respondents were instructed to respond in yes or no. Results: Out of 960 subjects 620 were aware of HIV/AIDS, 680 were aware of VCCT, 650 were aware of VCCT centre, 830 had heard of condom and 760 were aware of ARV. The difference was significant (P< 0.05). Conclusion: Authors found that respondents had sufficient knowledge and attitude regarding HIV infection.

Determination of Stress Factors in General Population

Stress is an important reference point in health studies and it is related to both an individual's general health status and different illnesses, including mental disorders, cancer, cardiovascular disease, drug abuse, chronic diseases, etc. Hence; under the light of above mentioned data, the present study was planned to assess various determinants of stress factors among general population. Methods: A total of 200 subjects were included in the present study. A selfframed questionnaire was given to all the subjects for obtaining complete demographic and clinical details of all the subjects. Second part of the questionnaire included assessment of information in relation stress related personal life parameters. The Nordic Questionnaire for Psychological and Social Factors at Work (QPS Nordic) in order to assess perceived stress was given to all subjects and asked to respond. All the answers were graded into three categories as follows: Category A: None or minimal stress, Category B: Stress to some extent, and Category C: Very much stress. All the results were recorded in Microsoft excel sheet and were analyzed by SPSS software. Results: Among subjects less than 30 years of age, 25 subjects had category B stress, while 20 subjects had category C stress. Significant results were obtained while assessing the distribution of stress among males and females. Also significant results were obtained while assessing the distribution of stress among employed people. Conclusion: Stress is particularly common in employed subjects, especially males.

To Assess Risk Factors of Chronic Diseases in Geriatrics

The present study was conducted to assess risk factors of chronic diseases in geriatrics. Methods: The present study was conducted on 86 patients aged >60 years of age of both genders. Patients were of diabetes, hypertension, arthritis, angina, chronic lung disease and stroke. In all subjects risk factors for chronic diseases were assessed. Results: Out of 86 patients, males were 52 and females were 34. Diabetes was present in 26, hypertension in 22, arthritis in 15, angina in 8, chronic lung disease in 11 and stroke in 4. The difference was significant (P< 0.05). The most common risk factor in diabetes patients was low socioeconomic status and primary education, in hypertension was primary education and low socioeconomic status, in arthritis was low SES, in angina was tobacco, in chronic lung disease was tobacco and in stroke was tobacco and alcohol. Conclusion: Common risk factors were low socioeconomic status, alcohol, tobacco and primary education.

Unilateral mydriasis: a complication of spine surgery in prone position / Midríase unilateral: uma complicação da cirurgia de coluna em decúbito ventral

Abstract Prone position though is commonly used for better access to surgical site, but may be associated with a variety of complications. Perioperative Visual Disturbances or loss is rare but a devastating complication that is primarily associated with spine surgeries in prone position. In this case we report a 42 year old ASA-II patient who developed anisocoria with left pupillary dilatation following lumbar microdiscectomy in prone position. Following further evaluation of the patient, segmental pupillary palsy of the left pupillary muscles was found to be the possible cause of anisocoria. Anisocoria partially improved but persisted till follow up.

Resumo O posicionamento em decúbito ventral, embora comumente usado para melhorar o acesso ao local cirúrgico, pode estar associado a uma variedade de complicações. Distúrbios ou perda visual no Perioperatório é uma complicação rara, mas devastadora, que está principalmente associada à cirurgia de coluna vertebral em decúbito ventral. Relatamos aqui o caso de um paciente de 42 anos de idade, ASA - II, que desenvolveu anisocoria com dilatação pupilar esquerda após microdiscetomia lombar em decúbito ventral. Após uma avaliação adicional do paciente, observamos que a paralisia segmentar dos músculos pupilares esquerdos seria a possível causa de anisocoria. A anisocoria melhorou parcialmente, mas persistiu até o acompanhamento.

A Comparative Study of Autonomic Cardiovascular Parameters in Obese and Non-Obese Adults

Globally, the epidemic of obesity in children and young adults is on a constant rise over the past decade. Obesity makes individual highly susceptible to a variety of chronic diseases and their complications. An altered autonomic response in the form of enhanced baseline sympathetic activity, feeble response to sympathetic stimuli and compromised parasympathetic activity is observed in obesity. We have assessed potentially perturbed autonomic responses in young overweight/obese first year medical students. Methods: This cross sectional analytical study was undertaken in the research lab of the Department of Physiology, M.K.C.G. Medical College over a period of 12 months on 300 students (both males and females) to determine sympathetic and parasympathetic responses to stress using hand-grip dynamometer and sinus arrhythmia test respectively. Independent ‘t’ test, Pearson’s correlation coefficient and multiple linear regression analysis in SPSS 20.0 was used to statistically ascertain the differences for the aforementioned parameters between obese and non-obese adults. Results: Weight, Body mass index (BMI), waist hip ratio (WHR), Pulse rate (PR), baseline systolic blood pressure (BSBP) & baseline diastolic blood pressure (BDBP) is significantly greater in obese than in non-obese. BMI shows positive correlation with BSBP & BDBP (r=0.660**; p<0.001 & 640**; p<0.001) and negative correlation with ΔDBP, and E/I Ratio. A negative correlation is appreciated amongst ΔDBP and BMI (R2 = 39.6). A similar negative correlation is again seen between E/I ratio and BMI (R2 = 37.2). Conclusion: Obesity potentially alters autonomic balance with increased sympathetic and reduced parasympathetic tone posing elevated risk of cardiovascular and cerebrovascular accidents.

Apert Syndrome: Anaesthetic Challenges In Child Posted For VP Shunting.

Apert Syndrome or “Acrocephalosyndactyly” is a rare syndrome comprising of multiple congenital anomalies, like turribrachycephaly, midface hypoplasia, syndactyly, orbital hypertelorism, small mandible etc., most of which complicate the airway management. Raised intracranial pressure and difficult venous access are other major challenges in the anesthetic management. We hereby describe our experience of anesthetic management of a 5 year old child with this syndrome posted for Ventriculoperitoneal shunting.

Efficacy of preoxygenation using tidal volume breathing: a comparison of Mapleson A, Bain's and Circle system / Eficácia da pré-oxigenação usando respiração em volume corrente: uma comparação dos sistemas Mapleson A, Bain e Circular

Abstract Background: Efficacy of preoxygenation depends upon inspired oxygen concentration, its flow rate, breathing system configuration and patient characteristics. We hypothesized that in actual clinical scenario, where breathing circuit is not primed with 100% oxygen, patients may need more time to achieve EtO2 ≥ 90%, and this duration may be different among various breathing systems. We thus studied the efficacy of preoxygenation using unprimed Mapleson A, Bain's and Circle system with tidal volume breathing at oxygen flow rates of 5 L.min−1 and 10 L.min−1. Methods: Patients were randomly allocated into one of the six groups, wherein they were preoxygenated using either Mapleson A, Bain's or Circle system at O2 flow rate of either 5 L.min−1 or 10 L.min−1. The primary outcome measure of our study was the time taken to achieve EtO2 ≥ 90% at 5 and 10 L.min−1 flow rates. Results: At oxygen flow rate of 5 L.min−1, time to reach EtO2 ≥ 90% was significantly longer with Bain's system (3.7 ± 0.67 min) than Mapleson A and Circle system (2.9 ± 0.6, 3.3 ± 0.97 min, respectively). However at oxygen flow rate of 10 L.min−1 this time was significantly shorter and comparable among all the three breathing systems (2.33 ± 0.38 min with Mapleson, 2.59 ± 0.50 min with Bain's and 2.60 ± 0.47 min with Circle system). Conclusions: With spontaneous normal tidal volume breathing at oxygen flow rate of 5 L.min−1, Mapleson A can optimally preoxygenate patients within 3 min while Bain's and Circle system require more time. However at O2 flow rate of 10 L.min−1 all the three breathing systems are capable of optimally preoxygenating the patients in less than 3 min.

Resumo Justificativa: A eficácia da pré-oxigenação depende da concentração inspirada de oxigênio, do fluxo de gases, da configuração do circuito respiratório e das características do paciente. Nossa hipótese foi que, no cenário clínico real, no qual o circuito respiratório não é preparado com 100% de oxigênio, os pacientes podem precisar de mais tempo para atingir EtO2 ≥ 90% e essa duração pode ser diferente entre vários circuitos de respiração. Avaliamos, portanto, a eficácia da pré-oxigenação com o uso dos circuitos não preparados Mapleson A, Bain e Circular com volume corrente de respiração com um fluxo de oxigênio de 5 L.min−1 e 10 L.min−1. Métodos: Os pacientes foram alocados aleatoriamente em um dos seis grupos, nos quais foram pré-oxigenados com o uso do circuito Mapleson A, Bain ou Circular com um fluxo de O2 de 5 L.min−1 ou 10 L.min−1. O desfecho primário de nosso estudo foi o tempo necessário para atingir EtO2 ≥ 90% com um fluxo de 5 e 10 L.min−1. Resultados: Com um fluxo de oxigênio de 5 L.min−1, o tempo para atingir EtO2 ≥ 90% foi significativamente maior com o circuito Bain (3,7 ± 0,67 min) do que com os circuitos Mapleson A e Circular (2,9 ± 0,6 e 3,3 ± 0,97 min, respectivamente). No entanto, com o fluxo de oxigênio de 10 L.min−1 foi significativamente menor e comparável entre os três circuitos respiratórios (2,33 ± 0,38 min com Mapleson; 2,59 ± 0,50 min com Bain e 2,60 ± 0,47 min com o Circular). Conclusões: Durante respiração espontânea com volume corrente normal e com um fluxo de oxigênio de 5 L.min−1, o sistema Mapleson A pode pré-oxigenar o paciente de forma ideal dentro de três minutos, enquanto os sistemas Bain e Circular requerem mais tempo. Porém, com um fluxo de O2 de 10 L.min−1, todos os três circuitos respiratórios podem pré-oxigenar o paciente de forma ideal em menos de três minutos.

Rare postoperative delayed malignant hyperthermia after off‑pump coronary bypass surgery and brief review of literature.

Postoperative malignant hyperthermia (MH) is a very rare phenomena. It is generally observed within less than an hour after discontinuation of the anesthetic trigger. Present case describes rare delayed postoperative presentation of MH after off‑pump coronary bypass surgery. Prompt recognition and immediate treatment with dantrolene can effectively treat the fatal syndrome. Family education and genetic counseling should be encouraged.

Gender Preference for Auditory Versus Visual Routes for Memorization.

Objective: Memory is formed on the basis of sensory stimuli perceived. Vision and Auditory sense are the most common modes to form visual and auditory memory. This study was planned to find the preferred sense route for the formation of memory, between the two genders. Method: In the present cross sectional experimental study, 40 male and 40 female subjects between 18- 20 years of age were tested for visual & auditory memory. Results: The results suggested statistically significant higher scores of ‘Memory Test’ in women in comparison to men (F479 3.312, p=<0.001). The mean score for memory subtests was best for black & white pictures followed by colored pictures, visual words, visual digits, auditory digits and auditory words in that order in men, whereas in women, mean score was best for colored pictures followed by black & white pictures, auditory words, auditory digits, visual words and visual digits. Conclusion: It may be concluded that in men visual sense and in women auditory sense are more effectual for the formation of memory.

Growth and obesity status of children from the middle socioeconomic group in Lucknow, northern India: A comparison with studies on children from the upper socioeconomic group.

Background. Children from the upper socioeconomic group in India currently show a modest positive secular trend in height, accompanied by a high prevalence of obesity. We examined the anthropometric pattern among children from the middle socioeconomic group. Methods.A cross-sectional study of anthropometry in 3794 schoolchildren from the middle socioeconomic group in the city of Lucknow, Uttar Pradesh, India. Results. Results. A comparison with the data of a 20-year-old study of children from the upper socioeconomic group showed that the height of boys in our study was at par with or higher than that of boys of the same (Lucknow–Allahabad–Varanasi) region or national data, at all centiles. In contrast, girls in our study were shorter than national data at all centiles and shorter than girls of the same region at the 3rd centile. Children from the middle socioeconomic group did not show the large increase in weight centiles seen in the recent data of the upper socioeconomic group. The values of body mass index at the 85th and 95th percentile at 17 or 18 years of age in girls and boys were 23 and 25 kg/m2, respectively. Obesity was prevalent in 1% of children of the middle socioeconomic group and an additional 5.7% were overweight. Conclusions.Children from the middle socioeconomic group in Lucknow have grown taller than their 20-year-old counterparts from the upper socioeconomic group. Boys have fared better than girls. Children from the middle socioeconomic group in Lucknow are at present spared from the epidemic of obesity.

Modified silicone sling assisted temporalis muscle transfer in the management of lagophthalmos.

Aim: To evaluate the efficacy of modified temporalis muscle transfer (TMT) by silicone sling for the management of paralytic lagophthalmos. Settings and Design: Prospective interventional study. Materials and Methods: Ten patients of lagophthalmos due to facial palsy underwent modified TMT using silicone sling. The patients were followed‑up for a period of 3 months. Palpebral aperture in primary gaze and during eye closure were assessed both pre‑ and postoperatively along with problems associated with lagophthalmos like exposure keratopathy and lacrimation. Statistical Analysis: Paired t‑test was applied to measure the statistical outcome. Results: Eight patients achieved full correction of lagophthalmos with no lid gap on closing the eye. The mean (standard deviation (SD)) lid gap on eye closure was 7.7 (0.86) mm preoperatively, 0.5 (0.47) mm at 1st postoperative day, and 0.7 (0.75) mm at 3rd month. There was a reduction in mean lid gap on eye closure of 7 mm at 3 months (P < 0.0001) which is highly significant. The mean (SD) vertical interpalpebral distance during primary gaze was 12.05 (1.12) mm preoperatively, 10 (0.94) mm at 1st postoperative day, and 10.35 (1.08) mm at 3rd month. There was a reduction in mean vertical inter palpebral distance of 1.7 mm at 3 months (P = 0.001) which is significant. Exposure keratitis decreased in five out of six patients at 3 months. Conclusion: Modified TMT by silicone sling is a useful procedure with lesser morbidity and good outcomes for the treatment of paralytic lagophthalmos due to long standing facial palsy.

Aflatoxin contamination in stored rice variety PAU 201 collected from Punjab, India.

Background & objectives: The present study was carried out on stored rice variety PAU 201 in Punjab that was not permitted for milling and public distribution due to the presence of damaged grains at levels exceeding the regulatory limits of 4.75 per cent. The aim of the study was to determine fungal and aflatoxin contamination in the rice samples to assess hazard from the presence of damaged grains. Presence of iron in discoloured rice grains was also assessed. Methods: Stored samples of paddy of PAU 201 rice variety were collected from six districts of Punjab, milled and analysed for presence of fungal and aflatoxin contamination. Scanning electron microscopy (SEM), energy dispersive X-ray (EDX) analysis and Prussian blue staining was used to determine fungal spores and presence of iron, respectively. Results: Aflatoxin analysis of rice samples indicated that none exceeded the Food Safety and Standards (Contaminants, Toxins and Residues) Regulations, 2011 tolerance limit of 30 μg/kg and majority of the samples had levels <15 μg/kg. The proportion of damaged grains exceeding the limit of 5 per cent was observed in 85.7 per cent of the samples. SEM and Prussian blue staining and EDX analysis of black tipped and pin point damaged rice grains did not show presence of fungal structures and presence of iron. Interpretation & conclusions: The results of the study indicated that the stored rice samples did not pose any health concern with respect to aflatoxin contamination as per the criteria laid down by the Food Safety and Standards Authority of India.