Comparison of two different volumes of 0.5%, ropivacaine used in ultrasound-guided adductor canal block after knee arthroplasty: A randomized, blinded, controlled noninferiority trial.

Background and Aims: The aim of this study was to establish noninferiority of 10 mL of 0.5% ropivacaine as compared to 20 mL of 0.5% ropivacaine; for choosing right dose in adductor canal block (ACB) after knee arthroplasty (KA), this trial was conducted. Material and Methods: Forty patients undergoing bilateral KA with postoperative ultrasound-aided ACB were randomized: Group A patients received 20 mL 0.5% ropivacaine in the right limb and 10 mL 0.5% ropivacaine in the left limb. Group B patients received 10 mL of 0.5% ropivacaine in the right limb and 20 mL of 0.5% ropivacaine in the left limb. Catheter is positioned for intermittent boluses every 12-h up to 48 h. Results: In the final analysis (excluding six patients) based on split-body design between Group I (comprising 34 limbs which received 20 mL of 0.5% ropivacaine) and Group II (comprising 34 limbs which received 10 mL of 0.5% ropivacaine), baseline demographic data were collected. Length of the limb from anterior superior iliac spine (ASIS) to the base of the patella was comparable between two groups: Group I (in cm; 149 ± 1.63) versus Group II (in cm; 149.5 ± 1.51) (P = 0.49, 95% CI of - 1.98 to 0.98). Primary outcomes, that is, quadriceps muscle strength, show a significant difference (P < 0.025) at various timeline. Secondary outcome pain scores and degree of knee flexion at various time intervals showed no significant difference. There was zero incidence of fall of the patient and no significant complication due to catheter was reported leading to discontinuation of catheter use in both groups. Conclusion: 10 mL of 0.5% ropivacaine is noninferior to 20 mL of 0.5% ropivacaine in providing postoperative analgesia with preserved quadriceps muscle strength.

Prevalence and pattern of geriatric emergencies in a teaching hospital of North India.

INTRODUCTION: Changing demographic patterns worldwide and improvement in healthcarehas contributed to increasing visits to the emergency department byelderly patients. Geriatric patients usually have multiple co-morbidities and declining physiological functional status. This complex interplay of various factors requires a specific and curated approach from the emergency physicians. Our aim was to study the pattern and prevalence of geriatric emergencies and the profile of infectious and non-infectious causes of fever in geriatric population in our tertiary care center. MATERIALS AND METHODS: This retrospective descriptive study was carried out at a tertiary care hospital of north India and included all patients aged more than 18 years who visited the emergency department over a period of six months (July 2018 to December 2018). Detailed data regarding demographic, clinical and diagnosis was obtained retrospectively from the hospital records system. The patients were divided into two groups, age less than 60 years and elderly patients more than 60 years of age for comparison. RESULTS: A total of 24768 patients above the age of 18 years visited the emergency department over a period of six months. Out of which 5399 (27.5%) patients belonged to the geriatric age group more than 60 years of age. 2474 (45.8%) geriatric age group patientswere triaged to critical areas level one and level two as compared to 4668 (24.1%) patients aged less than 60 years. Ninety (1.8%) geriatric patients succumbed to death as compared to 77 (0.4%) patients aged less than 60 years. 651 (21.9%) geriatric patients were shifted to intensive care unit as opposed to 1038 (14.8%) patients of the younger age group.226 (4.2%) geriatric patients presented with fever in the emergency department.116 (73.4%) patients having underlying co-morbidities , had fever due to infectious causes whereas 42 ( 26.5%) patients had fever due to non-infectious causes. CONCLUSION: The clinical presentation mortality and morbidity pattern of geriatric patients differs significantly from that of younger population and requires a customized approach and dedicated emergency setups.

Effectiveness of a Simulation-Based Training Program in Improving the Preparedness of Health Care Workers Involved in the Airway Management of COVID-19 Patients.

Background Coronavirus disease 2019 (COVID-19) has currently emerged as a global threat and a significant public health issue. The role of simulation-based training (SBT) during such a pandemic becomes more relevant for teaching a team approach and building capacity especially when there is a threat to health care workers due to aerosol generation and there is a huge demand for manpower during the pandemic. Objective To assess the effectiveness of a simulation-based training program in improving knowledge and concept of teamwork of health care workers involved in airway management of suspected or confirmed COVID-19 patients. Methods After institutional review committee approval, a prospective analytical study was conducted in the department of medical education on participants from various specialties undergoing COVID-19 airway training. The purpose of the study was to assess team dynamics during simulation scenarios and compare test scores at baseline, immediately post-training, and seven days post-training (using online forms). Scores were compared using the Friedman test followed by post-hoc testing. Sub-group comparison was done using an unpaired t-test. Results Median scores were significantly higher in the immediate post-training test and seven days post-training test (online) compared to baseline pretest scores in the overall participant group and in individual sub-groups. There was no significant difference in immediate versus seven-day post-training test scores overall and in all subgroups. In the sub-group comparisons, median improvement in score was significantly better in the non-anesthesia group and in the resident group. It was observed that team performance in terms of role clarity, closed-loop communication, and idea acceptance improved substantially during the subsequent scenarios. Conclusion Simulation-based training was effective in improving knowledge and team dynamics amongst health care workers regarding airway management in COVID-19 patients, with retention of up to one week. Similar future research can be planned for the affective and psychomotor domains.

A case of organophosphate poisoning with intermediate syndrome and acute pancreatitis - A rare complication.

Organophosphate (OP) poisoning is one of the serious occupational hazards worldwide and easily accessible pesticides for suicidal poisoning. It is associated with high mortality and morbidity. OP poisoning is characterized by three main syndromes - cholinergic syndrome, intermediate syndrome and syndrome of delayed polyneuropathy. Other rare complications of OP poisoning are arrhythmias, pancreatitis and hepatic dysfunction. We present 46-year-old male patient with history of OP poisoning, who developed features of intermediate syndrome and pancreatitis. The patient was immediately intubated and managed on mechanical ventilation. Patient was given symptomatic treatment and recovered completely on day 14 of illness.

Acute undifferentiated febrile illness: Protocol in emergency department.

Fever accounts for around 15% of emergency visits in elderly age group and around 5% in adults. The spectrum of etiologies ranges from non-infectious to infectious etiologies. There are very few studies done in the past highlighting the approach of patients with acute febrile illness without any localizing signs and symptoms. OBJECTIVES: The aim of the study was to formulate a targeted approach for evaluation and treatment of patients with acute undifferentiated febrile illness without evidence of localizing symptoms and signs. The secondary objective was to study the etiology and final outcome of patients with acute undifferentiated febrile illness. MATERIALS AND METHODS: A protocol was devised for patients aged more than 18 years, who presented in emergency department with complaints of fever without localizing symptoms or signs of sepsis over a period of 6 months from April 2018 to September 2018. Patient's data were collected retrospectively from the hospital record section. RESULTS: A total of 212 patients of undifferentiated acute febrile illness were enrolled in the study. Maximum number of patients [n = 69 (32.5%)], presented on second day of illness. All the patients presenting within 1 or 2 days of fever experienced defervescence. Out of these 69 patients, 35 (36.4%) were investigated of which in 29 (82.2%) investigations were not found to be useful; 75 (78.1%) patients with 1 or 2 days history of fever improved without investigations. Surprisingly, 54 patients (72%) with 1 or 2 days' history of acute febrile illness experienced defervescence without the need of antibiotics. CONCLUSION: There is an urgent need to devise a standardized protocol for diagnosis and treatment of patients with acute undifferentiated febrile illness in order to avoid unnecessary investigations and antimicrobial use.

Post-traumatic diaphragmatic hernia: Diagnostic dilemma in primary care.

Diaphragmatic hernia (DH) is a common condition following blunt trauma to upper abdomen and is also a commonly missed diagnosis. Its early anticipation in post-traumatic setting is very important to avoid any further life-threatening sequelae. X-ray chest with a nasogastric tube is a simpler way to diagnose this condition. CT scan is a gold standard tool to confirm diagnosis. Due to wide availability of ultrasound (US) in emergency room (ER), this tool will decide the correct way of further evaluation avoiding unnecessary delays in management. We present a case of a diaphragmatic hernia followed by blunt injury abdomen with multiple herniated abdominal contents successfully managed by early intervention.

Shigella flexneri associated reactive arthritis - GI transmitted or sexually transmitted?

The pathogenic association of reactive arthritis with human immunodeficiency virus (HIV) needs more attention. In this case report we described a case of 22 year old male patient suffering from severe HIV infection. He presented with the complaints of left knee joint pain associated with swelling and tenderness. He also developed keratotic papules on palms and soles and polycyclic erosions on the glans penis. He was diagnosed as a case of reactive arthritis with HIV infection. The patient was treated with sulfasalazine and anti retroviral therapy. We, hereby discuss the underlying pathogenesis and treatment modalities in patients of reactive arthritis with underlying HIV infection. The treatment of reactive arthritis with HIV is a challenge due to limited options of immunosupressive agents.