A survey in the West Midlands of the United Kingdom of current practice in managing hypotension in lower segment caesarean section under spinal anaesthesia.

BACKGROUND: Spinal anaesthesia, the most common form of anaesthesia for caesarean section, leads to sympathetic blockade and profound maternal hypotension resulting in adverse maternal and neonatal outcomes. Hypotension, nausea and vomiting remain common but until the publication of the National Institute of Health and Care Excellence (NICE) 2021 guidance, no national guideline existed on how best to manage maternal hypotension following spinal anaesthesia for caesarean section. A 2017 international consensus statement recommended prophylactic vasopressor administration to maintain a systolic blood pressure of >90% of an accurate pre-spinal value, and to avoid a drop to <80% of this value. This survey aimed to assess regional adherence to these recommendations, the presence of local guidelines for management of hypotension during caesarean section under spinal anaesthesia, and the individual clinician's treatment thresholds for maternal hypotension and tachycardia. METHODS: The West Midlands Trainee-led Research in Anaesthesia and Intensive Care Network co-ordinated surveys of obstetric anaesthetic departments and consultant obstetric anaesthetists across 11 National Health Service Trusts in the Midlands, England. RESULTS: One-hundred-and-two consultant obstetric anaesthetists returned the survey and 73% of sites had a policy for vasopressor use; 91% used phenylephrine as the first-line drug but a wide range of recommended delivery methods was noted and target blood pressure was only listed in 50% of policies. Significant variation existed in both vasopressor delivery methods and target blood pressures. CONCLUSIONS: Although NICE has since recommended prophylactic phenylephrine infusion and a target blood pressure, the previous international consensus statement was not adhered to routinely.

Automated chest radiography and mass systematic screening for tuberculosis.

BACKGROUND: Systematic screening for TB using automated chest radiography (ACR) with computer-aided detection software (CAD4TB) has been implemented at scale in Karachi, Pakistan. Despite evidence supporting the use of ACR as a pre-screen prior to Xpert® MTB/RIF diagnostic testing in presumptive TB patients, there has been no data published on its use in mass screening in real-world settings.METHOD: Screening was undertaken using mobile digital X-ray vehicles at hospital facilities and community camps. Chest X-rays were offered to individuals aged ≥15 years, regardless of symptoms. Those with a CAD4TB score of ≥70 were offered Xpert testing. The association between Xpert positivity and CAD4TB scores was examined using data collected between 1 January and 30 June 2018 using a custom-built data collection tool.RESULTS: Of the 127 062 individuals screened, 97.2% had a valid CAD4TB score; 11 184 (9.1%) individuals had a CAD4TB score ≥70. Prevalence of Xpert positivity rose from 0.7% in the <50 category to 23.5% in the >90 category. The strong linear association between CAD4TB score and Xpert positivity was found in both community and hospital settings.CONCLUSION: The strong association between CAD4TB scores and Xpert positivity provide evidence that an ACR-based pre-screening performs well when implemented at scale in a high-burden setting.

A comparative study of "Idiopathic catatonia" with catatonia in schizophrenia.

Catatonia has been defined as a cluster of signs and occurs secondary to or as a subgroup of schizophrenia, mood disorders or organic syndrome. This study specifically examined the distinct variety of catatonia that did not meet any standard psychiatric diagnostic criteria on globally recognised psychiatric rating tools and compared the clinical features with the catatonia that occurred in association with a diagnosis of schizophrenia. The inpatients in a tertiary psychiatric ward in Ahmedabad, India, between 2002 and 2005 who presented with two or more catatonic signs present for more than 24h period were assessed on Structured Clinical Interview for DSM IV tool. Those with catatonic signs that met diagnostic criteria for schizophrenia (n=21) were compared, with those without any disorder called Idiopathic catatonia (n=13), on measures of Bush Francis Catatonia Rating Scale (BFRCS), Brief Psychiatric Rating Scale (BPRS) and Scale for Assessment of Negative Symptoms (SANS). The scores on duration of illness (U=14.00; p<0.001) and mean BPRS (t=6.76; df=32; p<0.001) were significantly higher in schizophrenia group. The Idiopathic group had significantly higher scores on mean total BFCRS (t=-3.50; df=32; p=0.001) and also on subscores of negativism (p=0.02), waxy flexibility (p=0.02), mitgehen (p<0.05) and ambitendency (p=0.01). The results indicate that the Idiopathic catatonia present early in their course and have fewer general psychopathologies; however have higher number and severity of catatonic signs. The study also supports the current concept that there does exists, a distinct variety of catatonia that probably has its own course and prognosis, which need further consideration and more studies to explore this.

Incisional cellulitis after total hip replacement.

We report 16 cases of erythematous eruption on the skin within the flaps of the surgical incision after primary total hip replacement over an eight-year period. The symptoms began within nine months of operation in 13 hips, and two to three years after in three. Four patients had recurrent episodes. All were treated with antibiotics (15 intravenous, one oral) with complete resolution of the eruption within one to six days. The mean follow-up after the last episode of cellulitis was 27 months (14 to 76). There were no cases of periprosthetic sepsis or other sequelae.

The reliability of monopolar and bipolar fine-wire electromyographic measurement of muscle fatigue.

Bipolar intramuscular wire electrodes and spectral analysis of the electromyographic signal have been used to measure fatigue in muscles that cannot be studied with surface electrodes. Intramuscular electrodes can detect a greater range of frequencies from muscle, obtain a less distorted signal, and are therefore felt to be more sensitive to detecting fatigue. To determine the reliability and sensitivity of electrode placement (with a fixed distance) for assessing muscle fatigue, we placed three intramuscular electrodes in and two surface electrodes on the biceps brachii of 30 healthy male subjects. With these electrodes, we devised eight configurations that were analyzed separately for reliability. Subjects performed four, 30-s isometric fatiguing contractions divided between two testing sessions. Mean and median frequency of the power density spectrum were plotted against time. Linear regression was performed to obtain slopes, which were used as indicators of fatigue. The bipolar surface electrode configuration displayed mean and median frequency intrasession and mean frequency intersession reliability for slope. All four bipolar fine-wire configurations had mean and median frequency intrasession reliability (P < or 0.05). Only three of the four bipolar fine-wire configurations approached mean frequency intersession reliability, and none fo the four displayed median frequency intersession reliability. the configuration with distal bipolar intramuscular electrodes placed 1 cm apart was the most reliable intramuscular technique. The bipolar fine-wire configuration studied showed a trend toward better reliability than monopolar fine-wire configurations. No intramuscular technique, however, was reliable enough for clinical use in the study of fatigue.

Is spectral analysis of the surface electromyographic signal a clinically useful tool for evaluation of skeletal muscle fatigue?

Normal values for initial median frequency (IMF) of the electromyographic (EMG) power-density spectrum must be determined before EMG spectral analysis can be used to evaluate clinically muscle fatigue. This study attempts to establish normal values in four muscles. Thirty-one healthy subjects performed isometric contractions of the biceps brachii, triceps, deltoid, and tibialis anterior muscles at 50% maximum voluntary contraction. Linear regression analysis was used to compute the IMF and the slope of the median frequency as it decayed with fatigue over 45 seconds. The IMF of the tibialis anterior (mean +/- standard deviation, 116 +/- 20 Hz) was significantly higher (p < 0.001) than that of the biceps (90 +/- 18 Hz), triceps (85 +/- 18 Hz), and deltoid (87 +/- 15 Hz). The deltoid and tibialis anterior had the steepest slopes. The IMF of all muscles was greater in men than in women, but gender did not affect the slope. This study attempted to establish normal values for IMF and slope in specific muscles. However, the range of normal values is so broad that it may preclude the clinical use of spectral analysis to evaluate muscle fatigue.

Uptake of 99mTc-MDP after uncemented hip arthroplasty: a quantitative analysis of findings around the femoral component in asymptomatic patients.

We studied the pattern of 99mTc-methylene diphosphonate uptake around uncemented femoral components in 44 asymptomatic hip arthroplasties, performing isotope scans at intervals from 4 to 48 months after operation. We used phase-II images obtained with a high-resolution gamma camera and measured the activity in various zones using a specially designed computer program. The components studied at 4, 6, 9 and 12 months were coated with hydroxyapatite (HA) and those studied at 18, 24, 36 and 48 months were not coated. We found a statistically significant fall in activity between four and six months around HA-coated prostheses in all five femoral periprosthetic zones. After six months activity was relatively uniform, but remained higher than that in normal femoral bone at 48 months in non-coated prostheses. We discuss the application of these patterns in the evaluation of painful cementless hip arthroplasties.

Supracondylar femoral fracture above a PFC posterior cruciate-substituting total knee arthroplasty treated with supracondylar nailing. A unique technical problem.

Supracondylar fracture above a total knee arthroplasty with a posterior cruciate-substituting design presents a challenging problem to the orthopaedic surgeon. The standard treatment using a intramedullary rod is made difficult by the design of the PFC cruciate-substituting total knee arthroplasty (Johnson & Johnson Orthopaedics, Raynham, MA), which prevents entry of a standard supracondylar nail to the medullary canal of the femur. A technique for using an interlocking intramedullary rod to treat a supracondylar fracture above a posterior cruciate-substituting total knee arthroplasty is described. A case is presented illustrating this technique.

A comparative study of early motion and immediate plaster splintage after internal fixation of unstable fractures of the ankle.

We reviewed 47 patients following operatively treated ankle fracture-dislocation, at an average of 15 months after injury, to assess the outcome of two different postoperative regimens. Of the 47 patients, 27 received early active and passive ankle exercises, and 20 patients received immediate plaster splintage. Patients were assessed clinically by an independent surgeon and subjective, objective and radiological criteria recorded. No significant difference was apparent between the two groups on any of the criteria, although the early movement group contained more patients who were completely pain free, had a normal gait and no radiological signs of arthrosis (P < 0.05). This was achieved at the expense of a longer stay in hospital (average 10.2 days versus 7.4 days for plaster splintage) and more ankle swelling.

Prevalence of psychiatric disorders in ahmedabad (an epidemiological study).

A psychiatric survey was carried out in an urban area of Ahmedabad which consisted mainly of middle class population. 461 families were surveyed which consisted of a total number of 2712 persons.The data was collected in a predetermined form. The index cases were individually evaluated in detail with the help of a structured Psychiatric proforma, case work and psychiatric examination by a consultant for psychiatric diagnosis. Out of the total of 2712 persons surveyed, 128 were found to be suffering from psychiatric disorders, the prevalance rate being 4.7% (47.2 per thousand).