Comparative Assessment of Revascularization Versus Drug Management in Coronary Artery Disease (CAD) Associated with Left Ventricular Dysfunction (EF < 40%) - A 12 Month Study with FDG PET and SPECT MPI Analyses.

AIM OF THE STUDY: Left Ventricular (LV) function and myocardial viability is the key predictor of prognosis after myocardial infarction. Management of ischemic cardiomyopathy (revascularization and or drugs alone) is the objective of this study. METHODOLOGY: 72 patients were assigned to revascularization and medical management group based on the inclusion criteria Follow up was done upto 12 months with advanced imaging techniques (FDG PET and SPECT MPI analyses). RESULTS: Subjects with significant viable myocardium, revascularization resulted in significant improvement in heart failure symptoms. The mean NYHA functional class improved from 2.9 ± 0.3 to 2.3 ± 0.5(mean ± SD) after 6 months of revascularization (p < 0.01). This improvement in functional class was maintained after 12 months of revascularization (2.0 ± 0.4 (mean ± SD). Subjects on medical management with a baseline NYHA functional class 2.7 ± 0.5, at 6 months of follow, there was no significant change in functional class (2.8 ± 0.3) (p<0.24). However at 12 months follow up functional class had dropped to 3.0 + 0.3, which was significant as compared to baseline (p <0.03). CONCLUSION: coronary revascularization has a protective effect on patients with ischemic coronary who have viable myocardium and reversible myocardial ischemia as assessed by 18F-FDG PET and SPECT MPI Imaging.

Visualising the topography of the acoustic radiation in clinical diffusion tensor imaging scans.

PURPOSE: It has long been thought that the acoustic radiation (AR) white matter fibre tract from the medial geniculate body of the thalamus to the Heschl's gyrus cannot be reconstructed via single-fibre analysis of clinical diffusion tensor imaging (DTI) scans. A recently developed single-fibre probabilistic method suggests otherwise. The method uses dynamic programming (DP) to compute the most probable paths between two regions of interest. This study aims to observe the ability of single-fibre probabilistic analysis via DP to visualise the AR in clinical DTI scans from legacy pilot cohorts of subjects with normal hearing (NH) and profound hearing loss (HL). METHODS: Single-fibre probabilistic analysis via DP was applied to reconstruct 3D models of the AR in the two cohorts. DTI and T1 data at 1.5 T for subjects with NH (n = 11) and HL (n = 5), as well as 3 T for NH (n = 1) and HL (n = 1), were used. RESULTS: The topographical features of AR previously observed in post-mortem and multi-fibre analyses can be visualised in DTI scans of 16 subjects and 2 atlases with a success rate of 100%. Relative to MNI coordinates, there was no significant difference in the varifold distances between the topography of the tracts in the 1.5 T cohort. CONCLUSION: The AR can be visualised in clinical 1.5 T and 3 T DTI scans using single-fibre probabilistic analysis via DP, hence, the potential for DP to visualise the AR in medical and pre-surgical applications in pathologies such as vestibular schwannoma, multiple sclerosis, thalamic tumours and stroke as well as hearing loss.

Fiddlehead Fern Poisoning: A Case Report.

Outdoor enthusiasts are at a high risk of poisonous side effects after ingestion of wild and raw edible fiddlehead ferns, such as the ostrich fern (Matteuccia struthiopteris) and bracken (Pteridium genus) species, in the United States and Canada. The acute onset of nonlethal side effects manifests with gastrointestinal signs and symptoms and can last from 24 h up to 3 d. This case report is the first to outline the presentation of ingestion of a wild fiddlehead plant in the Carrabassett Valley in Maine, as well as the supportive management for this concerning and self-limiting illness.

Association of obesity with failure of ultrasound-guided axillary brachial plexus block: a two-centre, prospective, observational, cohort study.

The objective of this study was to evaluate whether the failure rate of ultrasound-guided axillary brachial plexus block is similar in obese patients compared with non-obese patients when performed as the primary anaesthetic technique. We recruited 105 obese (body mass index ≥ 30 kg.m-2 ) and 144 non-obese patients to this prospective, observational, cohort study conducted at two Canadian centres. A perineural technique of axillary brachial plexus block was performed using 30 ml ropivacaine 0.5% under real-time ultrasound guidance. Sensory and motor block assessment was carried out every 5 min until 30 min after block completion in all four terminal nerve distributions (radial, median, ulnar and musculocutaneous nerve). A composite score consisting of three sensory points and three motor points was used for assessment in each nerve distribution. A failed block was defined as a score of less than 14 points out of a possible 16 points, or a sensory block score less than 7 out of 8 points 30 min after block completion. Thirty minutes after block completion, obese patients had a higher failure rate of 33.7% (34/101) compared with 17.8% (24/135) for non-obese patients, with a failure rate difference (95%CI) of 15.9% (6.4-27.1%) between the groups. The median (IQR [range]) time to achieve a successful block in obese patients was 25 (20-30 [5-30]) min, compared with non-obese patients at 20 (15-30 [5-30]) min (p = 0.003). Despite a higher sensory-motor failure rate as per the composite score, the axillary brachial plexus block provided adequate surgical anaesthesia as indicated by a low need for conversion to general anaesthetic in obese (8.6%) and non-obese patients (7.0%; p = 0.656). This study showed that despite ultrasound guidance, obese patients had a slower onset time and higher axillary brachial plexus block failure rate at 30 min compared with non-obese patients.

Onset of labour epidural analgesia with low-dose bupivacaine and different doses of fentanyl.

This study investigated the effects of different doses of epidural fentanyl on the time to onset of epidural analgesia in women in early labour. We hypothesised that onset of epidural labour analgesia (the primary outcome defined as time in minutes from completion of epidural bolus to the first uterine contraction with a numeric pain rating scale [NPRS] score ≤ 3) would be faster with 100 µg of fentanyl epidural bolus compared with 20 µg or 50 µg. Epidural labour analgesia was initiated with 20 µg of fentanyl (F20 group), 50 µg (F50 group) or 100 µg (F100 group) along with 10 ml bupivacaine 0.08% as the loading dose. We randomly allocated 105 patients, with 35 patients in each group. Median (IQR [range]) time to achieve NPRS ≤ 3 was 18 (11-30 [6-20]) min in F20, 10 (8-19 [4-30]) min in F50 and 10 (6-16 [3-30]) min in F100 groups. There was a significant difference in onset times comparing F100 with F20 (p < 0.001) and F50 with F20 (p = 0.007), but not significantly different comparing F100 with F50 (p = 0.19). The median (IQR [range]) time from the epidural loading dose to first patient controlled epidural analgesia bolus was 61 min (20-165 [20-420]) in F20, 118 min (66-176 [20-396]) in F50 and 150 min (66-214 [30-764]) in F100 groups. This was not statistically significant (p = 0.16) comparing the F20 with the F100 group. There were no significant differences in maternal side-effects, mode of delivery, patient satisfaction scores or neonatal Apgar scores between all groups. We conclude that the 50 µg and 100 µg fentanyl doses were associated with reduced onset times to effective analgesia compared with the 20 µg dose.

A randomised comparison between ultrasound and nerve stimulation for infraclavicular catheter placement.

We conducted this study to determine if placement of infraclavicular catheters guided by ultrasound is quicker than placement guided by nerve stimulation. Infraclavicular brachial plexus catheters were inserted in 210 randomly allocated patients who were scheduled for elective hand or elbow surgery. Needle and catheter placement was guided by ultrasound (n = 105) or by nerve stimulation (n = 105). The primary outcome was time to sensory block success. Success rate was similar between the two techniques (83.2% vs 81.4%, p = 0.738). However, placement of ultrasound-guided catheters took less time (7.2 [2.5] vs 9.6 [3.6] min, p < 0 .001). Pain and satisfaction scores, and incidence of nerve deficit, were also similar with both techniques.

Comparative evaluation of the visibility and block characteristics of a stimulating needle and catheter vs an echogenic needle and catheter for sciatic nerve block with a low-frequency ultrasound probe.

BACKGROUND: Clear visibility of the needle and catheter tip is desirable to perform safe and successful ultrasound-guided peripheral nerve blocks. This can be challenging with deeper blocks in obese patients. This study compared the visibility of echogenic and non-echogenic block needles and catheters in proximal sciatic blocks when performed with a low-frequency curved probe. METHODS: Seventy-eight patients undergoing total knee joint arthroplasty were randomized to receive an ultrasound-guided continuous sciatic nerve block using either a non-echogenic needle and stimulating catheter or an echogenic needle and echogenic non-stimulating catheter. Block needles in both groups were placed using both neurostimulation and ultrasound guidance, after which the catheter was positioned using either neurostimulation alone (Stimulating group) or imaging alone (Echogenic group). Three anaesthetists blinded to group allocation graded video clips recorded during the blocks for nerve, needle and catheter visibility. Performance characteristics and block parameters were also compared. RESULTS: No significant differences between the two groups were observed with regard to needle or catheter visibility (P=0.516). The Stimulating group required more needle redirections (P=0.009), had a longer procedure time [Echogenic median 274 s vs Stimulating 344 s (P=0.016)], and resulted in greater patient discomfort (P=0.012). There were no significant differences between the two groups in terms of block onset or completion time. CONCLUSIONS: Use of echogenic needles and catheters reduced procedure time and patient discomfort compared with a stimulating catheter system. There were no differences in the visibility scores of the two systems. CLINICAL TRIAL REGISTRATION: CTR Protocol ID: R-11-495, Clinical Trials.Gov ID: NCT 01492660.

Management of labour and delivery in congenitally corrected transposition of great arteries.

A descriptive case report of the labour and delivery management of a 28-year-old woman who presented with congenitally corrected transposition of great arteries, dextrocardia, systemic ventricular dysfunction and junctional tachycardia. Patients with congenitally corrected transposition have a thin-walled morphological right ventricle as the systemic circulatory pump. The stress of increased cardiac output can lead to congestive heart failure, systemic atrioventricular valve regurgitation and arrhythmias. We used minimally invasive continuous cardiac output monitoring, fluid balance optimization and good maternal pain control to prevent decompensation and achieve vaginal delivery with a good maternal and neonatal outcome.

Recent advances in the management of graft-versus-host disease.

Graft-versus-host disease (GvHD) remains a significant hurdle in overcoming the morbidity and mortality associated with haemopoietic stem cell transplantation in children. Better understanding of its pathobiology is facilitating the development of biomarkers for the severity of acute GvHD and treatment response, and has led to the introduction of a more prognostically relevant grading system for chronic GvHD. These enable stratification of appropriate prophylactic and treatment strategies according to the risk profiles of individual patients. Steroid-refractory acute GvHD has a poor prognosis, but early reports of the use of new immunosuppressive drugs and especially cellular treatments with extracorporeal photopheresis and mesenchymal stem cells suggest improved short-term outcomes and offer the promise of increased longer-term survival rates.

Efficacy of ultrasound-guided transversus abdominis plane blocks for post-cesarean delivery analgesia: a double-blind, dose-comparison, placebo-controlled randomized trial.

BACKGROUND: The analgesic benefit of TAP (transversus abdominis plane) blocks for cesarean delivery pain remains controversial. We compared the analgesic efficacy of two doses of local anesthetic for TAP blocks after cesarean delivery. METHODS: Sixty women having cesarean delivery under spinal anesthesia were randomized to receive ultrasound-guided TAP blocks using either high-dose ropivacaine (3mg/kg), low-dose ropivacaine (1.5mg/kg) or placebo. Patients received intrathecal 0.75% bupivacaine 10-12mg, fentanyl 10µg and morphine 150µg and standard multimodal analgesia. The primary outcome was the difference in pain with movement using a numeric rating scale at 24h. Other outcomes included time to first request for analgesia, pain scores at 6, 12, 36, 48h and at 6 and 12weeks, opioid consumption, adverse effects, quality of recovery, and satisfaction. RESULTS: There were no differences between groups in the primary outcome. Mean ± SD pain scores (0-10) with movement at 24h were: high-dose ropivacaine 3.6±1.5, low-dose ropivacaine 4.6±2.1 and placebo 4.1±1.7. With respect to secondary outcomes, the mean ± SD pain scores at 6h were lower in the high-dose group 2.0±1.8 compared to the low-dose 3.4±2.7 and placebo groups 4.2±2.0 (P=0.009). Pain scores at 12h were also lower in the high-dose group 2.2±2.0 compared to the low-dose group 4.1±2.7 and placebo group 4.0±1.3 (P=0.011). There was no difference in other outcomes between groups. CONCLUSIONS: Neither high- or low-dose TAP blocks as part of a multimodal analgesia regimen including intrathecal morphine improved pain scores with movement at 24h after cesarean delivery when compared to placebo TAP blocks. High-dose TAP blocks may improve pain scores up to 12h after cesarean delivery.

Oxidative desulfurization: kinetic modelling.

Increasing environmental legislations coupled with enhanced production of petroleum products demand, the deployment of novel technologies to remove organic sulfur efficiently. This work represents the kinetic modeling of ODS using H(2)O(2) over tungsten-containing layered double hydroxide (LDH) using the experimental data provided by Hulea et al. [V. Hulea, A.L. Maciuca, F. Fajula, E. Dumitriu, Catalytic oxidation of thiophenes and thioethers with hydrogen peroxide in the presence of W-containing layered double hydroxides, Appl. Catal. A: Gen. 313 (2) (2006) 200-207]. The kinetic modeling approach in this work initially targets the scope of the generation of a superstructure of micro-kinetic reaction schemes and models assuming Langmuir-Hinshelwood (LH) and Eley-Rideal (ER) mechanisms. Subsequently, the screening and selection of above models is initially based on profile-based elimination of incompetent schemes followed by non-linear regression search performed using the Levenberg-Marquardt algorithm (LMA) for the chosen models. The above analysis inferred that Eley-Rideal mechanism describes the kinetic behavior of ODS process using tungsten-containing LDH, with adsorption of reactant and intermediate product only taking place on the catalyst surface. Finally, an economic index is presented that scopes the economic aspects of the novel catalytic technology with the parameters obtained during regression analysis to conclude that the cost factor for the catalyst is 0.0062-0.04759 US $ per barrel.

Comparative evaluation of ultrasound-guided continuous infraclavicular brachial plexus block with stimulating catheter and traditional technique: a prospective-randomized trial.

BACKGROUND: Secondary catheter failure has been reported in up to 40% of patients with continuous peripheral nerve blocks resulting in failure to provide pain relief after the initial block wears off. Introduction of stimulating catheters as well as ultrasound for regional anaesthesia has facilitated correct placement of catheter tip, closer to the plexus. This randomized study was conducted to compare the efficacy of continuous infraclavicular brachial plexus blocks using non-stimulating catheter, stimulating catheter and ultrasound-guided catheter placement with nerve stimulation assistance. METHODS: Patients undergoing elective hand surgery were randomly allocated to receive continuous infraclavicular brachial plexus block using non-stimulating catheter [group traditional nerve stimulation (TR)], stimulating catheter [group stimulating catheter (ST)] or ultrasound-guided catheter placement with nerve stimulation assistance [group ultrasound guidance with nerve stimulation assistance (US)]. Motor and sensory blocks were assessed every 5 min and primary block success was determined at 30 min. After resolution of the primary block, threshold stimulating current and resulting response, spread of drug on re-injection as seen ultrasonographically and the capacity to re-establish block was documented. Complications and need for supplement was noted. RESULTS: The primary block success was significantly higher in the US group [96% US, 58% ST, 59% TR (P=0.0005)]. Secondary catheter failure was significantly lower in the US group [9% US, 17% ST, 86% TR (P<0.0001)]. Axillary nerve was blocked more predictably in the US group (100% US, 79% ST, 50% TR (P=0.0003). CONCLUSION: In this study, ultrasound guidance with nerve stimulation assistance significantly improved primary success and reduced secondary catheter failure in continuous infraclavicular brachial plexus blocks.

Epigenetic programming of phenotypic variations in reproductive strategies in the rat through maternal care.

Studies across multiple organisms reveal considerable phenotypic variation in reproductive tactics. In some species, this variation is associated with maternal effects in which variation in maternal investment results in stable individual differences in reproductive function. Recent studies with the rat suggest that maternal effects can alter the function of neuroendocrine systems associated with female sexual behaviour as well as maternal behaviour. These maternal effects appear to be mediated by epigenetic modifications at the promoter for oestrogen receptor alpha (ERalpha) and subsequent effects on gene expression. The tissue-specific nature of such effects may underlie the co-ordinated variation in multiple forms of reproductive function, resulting in distinct reproductive strategies.

Use of ultrasound guidance and contrast enhancement: a study of continuous infraclavicular brachial plexus approach.

PURPOSE: We describe our experience of combining the use of ultrasound (US) guidance with contrast enhancement and peripheral nerve stimulation for the insertion of infraclavicular brachial plexus catheters. METHODS: Thirty patients scheduled to have upper limb surgery under regional block were studied. Under US guidance and peripheral nerve stimulation assistance, continuous peripheral nerve block needle and stimulating catheter were placed in the infraclavicular area. Needle and catheter tip location was confirmed with agitated 5% dextrose and seen under colour Doppler with US before injecting local anaesthetic (LA). Patients were evaluated in terms of onset times and efficacy of block. Post-operatively, on block recession a catheter was stimulated and visualization of spread of LA during injection through the catheter was done. Secondary block (subsequent to re-injection of LA) was assessed. Patients were followed-up for a week. RESULTS: Mean time to onset of block was 19.7 (+/- 4.9) min. There were no incomplete blocks and all components of the plexus were blocked completely. Post-operatively, in 95.7% of patients, the spread of hand-agitated LA via the catheter could be seen by color Doppler with ultrasonography. All patients had excellent post-operative analgesia and high degree of satisfaction. There were no complications. CONCLUSION: Contrast enhancement with US guidance during infraclavicular brachial plexus block enables direct visualization of needle and catheter tip location. Our early experience suggests that this leads to successful initial and subsequent post-operative block. Further controlled studies are needed to compare this technique with more prevalent and conventional techniques of catheter insertion.

Ocular fireworks injuries. Clinical features and visual outcome.

In a prospective analysis of ocular fireworks injuries over three consecutive years (1997 to 1999) during the Indian festival of Diwali, 42 patients presented with various types of fireworks-related ocular injuries. Twenty two (52%) patients had to be admitted for the management of their ocular injuries.

Suprasellar malignant mixed germ cell tumour presenting as craniopharyngioma.

A 15 year old boy presented with diminution in vision of both eyes, diabetes insipidus and hypopituitarism. MRI was suggestive of a large suprasellar and retrosellar craniopharyngioma with stretching of the optic chiasma. Histopathological findings on the first surgical specimen were interpreted as a craniopharyngioma. He was reoperated on account of clinical deterioration and increase in tumour size. Histological examination this time revealed derivatives of all three germ cell lineages along with areas of embryonal carcinoma, and yolk sac tumour besides squamous cysts, establishing the diagnosis of malignant mixed germ cell tumour. Serum and CSF were strongly positive for alpha foetoproteins.