A Comparative Study of Ultrasound-Guided Quadratus Lumborum Block and Transversus Abdominis Plane Block for Postoperative Analgesia Following Total Abdominal Hysterectomy.

BACKGROUND:  Total abdominal hysterectomy (TAH) results in remarkable postoperative pain. Truncal nerve blocks like the quadratus lumborum (QL) block and transversus abdominis plane (TAP) block are described to combat this pain. The aim of the present study was to compare the effectiveness of the QL block with the TAP block in terms of numeric rating scale (NRS) scores as the primary outcome for postoperative pain in TAH. The secondary outcome was time of the first analgesic demand, total analgesic demands required in 24 hr, and patient satisfaction level. METHODS:  Seventy patients of American Society of Anesthesiologists (ASA) physical status class I and II, aged 35-65 years with a body mass index (BMI) 18-30 kg/m2 planned for elective TAH under spinal anaesthesia were randomly allocated into two groups. Group Q received QL block and Group T received TAP block under ultrasound guidance with 40 ml of 0.25% bupivacaine of which 20 ml was injected on either side. RESULTS:  Demographic data of both groups was comparable. The NRS pain score was significantly lower in Group Q compared to Group T at the fourth and sixth hour. The mean first analgesic demand was significantly early in Group T compared to Group Q (5.69 ± 0.87 hr vs. 11.23 ± 2.22 hr) and total analgesic demands were significantly greater in Group T than Group Q. The mean patient satisfaction score was significantly high in Group Q compared to Group T (5.8 ± 0.41 vs. 4.74 ± 0.44). CONCLUSION: The combined posterior and anterior approach of the QL block may represent a more efficacious alternative to the TAP block in patients after TAH. Further studies are recommended to evaluate the ideal dose, volume and approach for the QL block.

Acute necrotic arachnidism with necrotising fasciitis and recurrent pneumothorax.

A male infant presented with swelling of the left leg and fever. Over the next 2 days, the area developed fasciitis extending to the left thigh, abdomen, and lower chest. Meanwhile, the parents found a giant brown spider within the infant's cot belonging to the genus Loxosceles, otherwise called the brown recluse spider. The dermo-myonecrosis progressed to deeper tissues involving the lung parenchyma requiring invasive ventilation. CT of the thorax showed multiple pneumatoceles, and lung biopsy showed alveolar necrosis. The infant was treated with intravenous antibiotics and corticosteroids. We drained the pneumothoraces by thoracostomy and insertion of intercostal drainage tubes. The infant required respiratory support initially by conventional ventilation, which was escalated to high-frequency oscillatory ventilation. He had refractory hypoxaemia and died. This is the first fatal case of acute spider envenomation described in India. Spider envenomation must be considered in patients with sudden onset, rapidly progressive necrotising fasciitis unresponsive to antibiotic therapy.

Effect of niacin therapy on cardiovascular outcomes in patients with coronary artery disease.

BACKGROUND: Niacin or nicotinic acid (vitamin B3) raises the levels of high-density lipoprotein cholesterol (HDL) by about 30% to 35%. In patients with prior coronary disease, 7 trials have been published on clinical cardiovascular disease outcomes and the results, not surprisingly, are inconsistent. Hence, we performed this meta-analysis of randomized placebo-controlled trials (RCTs) to evaluate the effect of niacin on cardiovascular outcomes in patients with coronary artery disease. METHODS: A systematic search using PubMed, EMBASE, and Cochrane library databases was performed. Seven studies with a total of 5137 patients met our inclusion criteria. Heterogeneity of the studies was analyzed by the Cochran Q statistics. The significance of common treatment effect was assessed by computing the combined relative risks using the Mantel-Haenszel fixed-effect model. A 2-sided alpha error of less than .05 was considered statistically significant (P < .05). RESULTS: Compared to placebo group, niacin therapy significantly reduced coronary artery revascularization (RR [relative risk]: 0.307 with 95% CI: 0.150-0.628; P = .001), nonfatal myocardial infarction ([MI]; RR: 0.719; 95% CI: 0.603-0.856; P = .000), stroke, and TIA ([transient ischemic attack] RR: 0.759; 95%CI: 0.613-0.940; P = .012), as well as a possible but nonsignificant decrease in cardiac mortality (RR: 0.883: 95% CI: 0.773-1.008; p= 0.066). CONCLUSIONS: In a meta-analysis of seven trials of secondary prevention, niacin was associated with a significant reduction in cardiovascular events and possible small but non-significant decreases in coronary and cardiovascular mortality.

Screening guidelines for coronary heart disease in diabetes: current recommendations.

Diabetes and cardiovascular disease are so intertwined with one another that the presence of one prompts a search for the other. Diabetes has been considered to be equivalent to coronary heart disease (CHD), and conversely many patients with known CHD have concomitant diabetes or its pre-states. This review has been compiled based on the guidelines of the American Diabetes Association, the Third Report of the National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III), the European Society of Cardiology, and the European Association for the Study of Diabetes. A systematic approach was developed by the European Society of Cardiology and the European Association for the Study of Diabetes recently to help detect CHD in patients with diabetes and to detect metabolic diseases in patients with CHD.This article is intended for the clinician in everyday practice focusing on the impact of recent advances in the prevention and management of CHD in diabetic patients and the background behind it.

Impact of subclinical thyroid disorders on coronary heart disease, cardiovascular and all-cause mortality: a meta-analysis.

BACKGROUND: Previous studies have suggested that sub-clinical thyroid states may have detrimental effects on the coronary heart disease (CHD). Whether subclinical thyroid dysfunction is a risk factor for the above is controversial. METHODS: A systemic search of the literature using Pubmed, Medline and Ovid online tool was performed to identify relevant studies. Amongst the clinical studies, crossectional study and studies with follow-up period ranging between 4 and 20 yr were identified (Walsh JP, Bremner AP, Bulsara MK, et al. Subclinical thyroid dysfunction as a risk factor for cardiovascular disease. Arch Intern Med 2005 Nov 28;165 (21):2467-72.; Rodondi N, Newman AB, Vittinghoff E, et al. Subclinical hypothyroidism and the risk of heart failure, other cardiovascular events, and death. Arch Intern Med 2005 Nov 28; 165 (21):2460-6.; Rotterdam study, Imaizumi M, Akahoshi M, Ichimaru S, et al. Risk for coronary heart disease and all-cause mortality in subclinical hypothyroidism. J Clin Endocrinol Metab 2004 Jul; 89 (7):3365-70.; Capolla et al.; Parle JV, Maisonneuve P, Sheppard MC, Boyle P, Franklyn JA. Prediction of all-cause and cardiovascular mortality in elderly people from one low serum thyrotropin result: a 10-year cohort study. Lancet 2001 Sep 15; 358 (9285):861-5). RESULTS: Sub-clinical hypothyroidism: The pooled estimate of the relative risk of CHD revealed significant difference both at baseline [RR with 95% CI: 1.533 (1.312-1.791), P<0.05] and at follow-up [RR with 95% CI: 1.188 (1.024-1.379), P<0.05]. The relative risk of all-cause mortality at follow-up revealed no significant difference. However, the relative risk of death from cardiovascular causes at follow-up was significantly higher [RR with 95% CI: 1.278 (1.023-1.597), P<0.05]. Sub-clinical hyperthyroidism: The pooled estimate of the relative risk of CHD revealed no significant difference both at baseline [RR with 95% CI: 1.156 (0.709-1.883)] and at follow-up [RR with 95% CI: 1.207 (0.780-1.870)].The relative risk of death from cardiovascular causes at follow-up was also not significantly higher. CONCLUSION: The present meta-analysis indicates that sub-clinical hypothyroidism is associated with both, a significant risk of CHD at baseline and at follow-up. In addition, mortality from cardiovascular causes is significantly higher at follow-up. Sub-clinical hyperthyroidism is not associated with CHD or mortality from cardiovascular causes.

Cardiovascular risk with subclinical hyperthyroidism and hypothyroidism: pathophysiology and management.

Previous studies have suggested that subclinical thyroid dysfunction, as manifested by abnormalities in thyroid-stimulating hormone (TSH) levels, are associated with detrimental effects on the cardiovascular system. Subclinical hypothyroidism is characterized by abnormal lipid metabolism, cardiac dysfunction, diastolic hypertension conferring an elevated risk of atherosclerosis, and ischemic heart disease. Similarly, patients with subclinical hyperthyroidism have nearly 3 times the likelihood of atrial fibrillation over a 10-year follow-up interval, raising the question of whether patients with subclinical hyperthyroidism should be treated to prevent atrial fibrillation. A single measurement of low serum TSH in individuals aged 60 years or older has been reported to be associated with increased mortality from all causes and in particular from circulatory and cardiovascular disease in a 10-year follow-up study. Subclinical thyroid dysfunction is currently the subject of numerous studies and remains controversial, particularly as it relates to cardiovascular morbidity and mortality and clinical applications.

Enoxaparin-induced skin necrosis: a fatal outcome.

Enoxaparin, a low-molecular-weight heparin used to treat and prevent deep venous thrombosis, has been evaluated in several clinical trials. Thrombosis induced by enoxaparin with no evidence of heparin-induced thrombocytopenia (HIT) is seldom described. We report a rare case in which an 89-year-old African-American female developed large, multiple, painful lesions induced by enoxaparin administration. Laboratory investigations for HIT, disseminated intravascular coagulation, protein C, protein S, factor V, factor VIII, antithrombin III, and homocysteine deficiency were negative. Unfortunately, despite aggressive management for 2 weeks, the patient developed severe sepsis and died.

Utility of esmolol in thyroid crisis.

Thyroid storm is an uncommon but potentially life-threatening manifestation of hyperthyroidism. Mortality can be 30-60% in hospitalized patients unless appropriately treated by combined therapy. We report a case of a 25-year-old African American woman with past medical history of Graves disease and moderately persistent asthma who presented to the emergency department with signs and symptoms of thyrotoxic crisis. Therapy instituted and included the use of an esmolol infusion for control of hypersympathetic activity. A review of the clinical presentation, diagnosis, and management of thyrotoxic crisis is presented along with a discussion on the choice of beta blockade therapy.