Central bronchial carcinoid: Management of a case and anesthetic perspectives.

Obstructing lesions of the central airways present with a variety of symptoms and are often associated with pneumonia or asthma-like states. Anesthesia to these patients often presents challenges right from the preoperative stabilization of underlying lung condition, mask ventilation in the supine position to maintaining oxygenation and ventilation in the intraoperative and postoperative period. We present here a case of a young woman with a central bronchial tumor with significant airway obstruction with potential for major bleeding and subsequent anesthetic management without lung sacrificing measures and cardiopulmonary bypass assistance.

Pneumatic stabilization of iatrogenic flail chest with CPAP: a case report.

Iatrogenic flail chest following resection of part of the chest wall in postoperative patients is a challenging scenario for the anesthetist. It can lead to long term morbidity and even death, if adequate management is not instituted. We describe the management of postoperative flail chest, following resection of upper two-third of the sternum along with costal cartilages for a malignant thymoma invading the sternum in an adult male with the use of continuous epidural analgesia and continuous positive airway pressure (CPAP), which provided pneumatic stabilization and an excellent recovery.

Characterization of intrinsic variability of Mesorhizobium ciceri isolates of cultivated fields.

A large number of putative rhizobial isolates were obtained from the root nodules of various chickpea cultivars growing in agricultural research fields. Of these, thirty were selected and characterized for traits, such as, generation time, intrinsic azide resistance and several symbiotic characters.

The first successful simultaneous pancreas-kidney transplant in India.

Insulin-dependent diabetes mellitus is associated with renal failure, diabetic retinopathy, neuropathy and vasculopathy. We report the first successful simultaneous pancreas-kidney transplant in India in a young diabetic with renal failure. The dual transplant has cured his diabetes and renal failure and has had a beneficial effect on his neuropathy, retinopathy and quality of life. Obstacles to dual transplant in India include a lack of suitable recipients and a cadaver donor programme that is still in its infancy.

Effect of epidural morphine on minimum alveolar concentration of isoflurane in humans.

BACKGROUND AND AIMS: The anaesthetic potency of volatile anaesthetic agents is measured by the minimum alveolar concentration (MAC) required to suppress response in 50% of subjects. We studied the effect of epidural morphine on MAC of isoflurane in humans. SETTINGS AND DESIGN: A prospective single-blind study designed to study the effect of epidural morphine on MAC of isoflurane. SUBJECTS AND METHODS: Forty-eight patients were randomly divided into two groups - Group I patients received 3 mg morphine in 10 ml saline, and Group II patients received 10 ml saline epidurally. Anaesthesia was induced with isoflurane in oxygen and nitrous oxide. Later nitrous oxide was discontinued and MAC of isoflurane determined using modified Dixon's method of sequential sampling. RESULTS: Epidural morphine resulted in a significant reduction in MAC of isoflurane, 0.98 vs. 1.14 in control group (p<0.05). CONCLUSIONS: Epidural administration of 3 mg morphine in 10 ml saline decreased the MAC of isoflurane.

Feasibility and safety of day care laparoscopic cholecystectomy in a developing country.

BACKGROUND: Although day care laparoscopic cholecystectomy (DCLC) has been shown to be safe in centres with adequate infrastructure for day care surgery, its feasibility and safety in developing countries has never been studied. Because of differences in the quality of health care delivery, western guidelines for day care surgery cannot be universally applied to developing countries. PATIENTS AND METHODS: Patients less than 65 years who were graded I and II on the American Society of Anesthesiologists physical status score, irrespective of their educational status, living within 20 km, and willing to make their own arrangements for a return to hospital in case of problems were selected for DCLC. Follow up was done by patients calling the hospital the morning after surgery. RESULTS: 50% of the eligibility criteria were new; 313/383 patients were suitable for DCLC. The commonest cause for rejection was that the patient lived out of the defined area (50%). Altogether 92% were discharged within eight hours of surgery. The reasons for failure to discharge were the presence of abdominal drains in four (2%), nausea and vomiting in nine (3%), and conversion to open surgery in five (2%). Ten patients (3%) were readmitted; of these only two (<1%) had complications needing re-exploration. Analysis of results showed that the inclusion and discharge criteria were valid and that the readmission and complication rates as well as the ease and accuracy of follow up were comparable to published data. DCLC reduced waiting times and increased patient turnover and may have a positive impact on resident training. CONCLUSIONS: DCLC is safe, feasible, and has potential benefits for health care delivery in developing countries. Each surgical service needs to develop their own guidelines based on local patient demography.

Anesthetic management of a parturient with cerebellopontine-angle meningioma.

Cerebellopontine-angle meningioma is a rare intracranial neoplasm. It presents a difficult problem in pregnancy. A 27-year-old multigravida presented with headache, vomiting and visual disturbances at 30 weeks' gestation and cerebellopontine angle meningioma and hydrocephalus were diagnosed. A ventriculoperitoneal shunt was placed under general anesthesia to reduce the symptoms of raised intracranial pressure and to prevent the risk of cerebellar herniation. At 32 weeks a cesarean section was performed under general anesthesia and a healthy baby delivered. A smooth induction and maintenance of anesthesia along with lidocaine and mannitol were used to prevent a rise in intracranial pressure. The intraoperative and postoperative course was uneventful. Thus, immediate neurosurgical decompression improved the patient's condition, and allowed time for fetal maturity and uneventful delivery by cesarean section under general anesthesia.

Lipochitooligosaccharides and legume Rhizobium symbiosis--a new concept.

Legume-Rhizobium symbiosis is a multistep process characterized by the formation of root nodules on the host plant. A number of genes from both symbiotic partners share information during the interaction process. Nodulation genes (nod, nol and noe) have been classified as common nodulation genes and host specific (hsn) nodulation genes. Though common nodulation genes are enough to form root nodules, host specific nodulation genes are needed for specific interaction leading to formation of functional nodules. Core lipochitooligosaccharides (LCOs), the products of common nodulation genes are modified by the action of host specific nodulation genes. LCOs seem to be present in legumes as well as nonlegume and are known to act as a morphogen by acting as auxin-transport inhibitor. The understanding of Nod factor may contribute to reveal complex biological functions such as developmental regulation, signal transduction and plant morphogenesis.

Pre-emptive analgesia with epidural morphine or morphine and bupivacaine.

Studies of preemptive analgesia in humans have shown conflicting results. The study design, patient population and the duration of assessment of postoperative pain are important in the evaluation of preemptive analgesia. We carried out a prospective, randomized, double-blind controlled study in 80 patients of physical status ASA 1-3 undergoing upper abdominal and thoracic surgery. Patients received two epidural injections, one 20 minutes before induction and the other at the end of surgery. Study solution was either morphine (50 micrograms/kg), with or without 0.1% bupivacaine in 10 ml of normal saline, or normal saline alone. The study groups (Pre M, Pre MB) were given either morphine or morphine-bupivacaine before induction and saline at the end of surgery. The control groups (Post M, Post MB) were given saline before induction and morphine or morphine-bupivacaine at the end of surgery. Postoperative pain was assessed with a Visual Analogue Scale (VAS) during coughing and deep breathing at six-hourly intervals for five days. Epidural morphine was given if the VAS exceeded 4. Pre MB compared to Post MB had a significantly increased interval between the analgesic top-ups (P < 0.01) and decreased total postoperative morphine requirements (P < 0.0001) and number of top-ups (P < 0.001). Pre M and Post M were comparable. Pre MB compared to Pre M had significantly decreased total postoperative morphine requirements (P < 0.0001) and number of top-ups (P < 0.0001). Epidural morphine plus bupivacaine is effective as a preemptive analgesic. Morphine plus bupivacaine has better efficacy than morphine given alone before the induction of anaesthesia.

Pulmonary edema following intrauterine methylene blue injection.

Methylene blue is a commonly used dye in diagnostic procedures such as fistula detection, delineation of body tissues during surgery and for checking the patency of fallopian tubes. Many such dyes interfere with accurate measurement of oxygen saturation by a pulse oximeter. We report here a case in which methylene blue hot only interfered with pulse oximetery but also caused pulmonary edema in an ASA grade 1 patient.

Arterial desaturation during induction with and without preoxygenation: evaluation of four techniques.

The incidence and degree of hypoxaemia during induction of balanced anaesthesia and endotracheal intubation were studied prospectively in 80 healthy adults undergoing elective surgery randomly divided into four equal groups of 20. Group 1 was preoxygenated for three minutes. The other three groups were not preoxygenated. Groups 1 and 2 were ventilated with 100% oxygen, while Groups 3 and 4 were ventilated with 50% and 33% oxygen respectively. Anaesthesia was induced with thiopentone 3-5 mg/kg and endotracheal intubation was done after ventilating for one minute with the chosen gas. Arterial desaturation was measured by pulse oximetry. In Groups 1-3 there was a significant increase and in Group 4 a significant decrease in saturation from the preinduction value. The arterial oxygen saturation was similar in Groups 1 and 2. Two patients in Group 3 and four in Group 4 had hypoxaemia. This incidence was not statistically significant. We conclude that ventilation with 100% oxygen for one minute prior to intubation and preoxygenation for three minutes are equally effective in preventing hypoxaemia during induction.

Postoperative pulmonary complications in patients with preoperative lung disease.

A prospective study was carried out on the incidence of pulmonary complications in 728 patients who underwent major surgical procedures at a reputed hospital in New Delhi. These patients were preoperatively assessed on the basis of history, clinical examination and bedside pulmonary function tests including PEFR, VC, FVC and FEV1. On the basis of these criteria, 212 patients had significant preoperative pulmonary disease, while 516 had normal lung functions. Postoperative pulmonary complications developed in 7.69 per cent of the patients. They were more frequent in smokers (P < 0.001) and in those with preoperative pulmonary dysfunction (P < 0.001). Their incidence was greater following thoraco-abdominal and musculoskeletal and miscellaneous operations compared to lower abdominal surgery (P < 0.001). The incidence was also higher following exposure to general anaesthesia compared to regional anaesthesia (P < 0.05). Pneumonia and atelectasis were the most common postoperative pulmonary complications. It was observed that the recovery of pulmonary functions was delayed in patients who developed postoperative pulmonary complications.

Construction of a gene bank of Rhizobium leguminosarum Rld 164.

The total genomic DNA of R. leguminosarum Rld164 (trp, sms, azi) was cloned in the EcoR1 site of the wide host and conjugally transferable cosmid vector pLAFR1. The average insert size in the gene clones of the bank was found to be 21.3 Kb. The strain R. leguminosarum Rld7 (leu-1) was employed as recepient to conjugally transfer and thus isolate the complementary leu+ allele carrying clones from the gene bank.

Rhizobium meliloti genes required for nodule development are related to chromosomal virulence genes in Agrobacterium tumefaciens.

Symbiotically essential genes have been identified in Rhizobium meliloti that are structurally and functionally related to chromosomal virulence (chv) genes of Agrobacterium tumefaciens. Homologous sequences also exist in the genomes of other fast-growing rhizobia including Rhizobium trifolii, Rhizobium leguminosarum, and Rhizobium phaseoli. In Agrobacterium, the chvA and chvB loci are known to be essential for oncogenic transformation of dicotyledonous plants and for attachment to plant cells [Douglas, C. J., Staneloni, R. J., Rubin, R. A. & Nester, E. W. (1985) J. Bacteriol. 64, 102-106], and the chvB locus has been implicated in the production of (1-->2)-beta-glucan, a unique exopolysaccharide component [Puvanesarajah, V., Schell, F. M., Stacey, G., Douglas, C. J. & Nester, E. W. (1985) J. Bacteriol. 164, 102-106]. Site-directed transposon insertion mutants in the chvA and chvB-equivalent regions of R. meliloti are symbiotically defective. Mutants in the chvB-equivalent region have been examined in detail and have been found to induce the formation of nodule-like structures on alfalfa that are devoid of bacteroids, lack infection threads, and cannot fix nitrogen. Such mutants fluoresce normally in the presence of Calcofluor, a histochemical stain for beta-linked polysaccharides, and produce normal amounts of total exopolysaccharide. The Rhizobium loci have been designated ndv because of their requirement for nodule development.