Anatomical variation of median nerve: cadaveric study in brachial plexus.

Median nerve is formed by lateral root from lateral cord and medial root from medial cord of brachial plexus. Formation of median nerve occur in front or lateral to axillary artery in axilla. In the present study we observed anatomical variations of median nerve formation in the brachial plexus. We examined formalin fixed 60 upper limbs from 30 adult cadavers (15 males and 15 females) which were above the age 40 years from the department of Anatomy. All the cadavers were dissected on both sides according to Cunningham's Manual of Practical Anatomy. Normal formation of median nerve by two roots noted in 42 (70.0%) of upper limb specimen. Variation of median nerve formation noted in 18 (30.0%) upper limb specimen. Three roots taking part in the formation of median nerve in 13 (21.7%) upper limb specimen where additional root coming from lateral cord of brachial plexus. Four roots taking part in formation of median nerve in 3 (5.0%) upper limb specimen, where additional roots coming from lateral cord and posterior cord of brachial plexus. Lateral root crossed the axillary artery anteriorly to join with medial root lying medial to axillary artery. The median nerve formed medial to third part of axillary artery. Additional communication with musculocutaneous nerve with median nerve seen in 2 (3.3%) upper limb specimen. Knowledge of such anatomical variations is of interest to the anatomist and clinician alike. Surgeons who perform procedures involving neoplasm or repairing trauma need to be aware of these variations. Median nerve variation may lead to confusions in surgical procedures and axillary brachial plexus nerve block anesthesia.

Improved kala-azar case management through implementation of health facility-based sentinel sites surveillance system in Bihar, India.

BACKGROUND: Visceral leishmaniasis (VL), also known as kala-azar (KA), is a neglected vector-borne disease, targeted for elimination, but several affected blocks of Bihar are posing challenges with the high incidence of cases, and moreover, the disease is spreading in newer areas. High-quality kala-azar surveillance in India, always pose great concern. The complete and accurate patient level data is critical for the current kala-azar management information system (KMIS). On the other side, no accurate data on the burden of post kala-azar dermal leishmaniasis (PKDL) and co-infections are available under the current surveillance system, which might emerge as a serious concern. Additionally, in low case scenario, sentinel surveillance may be useful in addressing post-elimination activities and sustaining kala-azar (KA) elimination. Health facility-based sentinel site surveillance system has been proposed, first time to do a proper accounting of KA, PKDL and co-infection morbidity, mortality, diagnosis, case management, hotspot identification and monitoring the impact of elimination interventions. METHODOLOGY/PRINCIPAL FINDINGS: Kala-azar sentinel site surveillance was established and activated in thirteen health facilities of Bihar, India, using stratified sampling technique during 2011 to 2014. Data were collected through specially designed performa from all patients attending the outpatient departments of sentinel sites. Among 20968 symptomatic cases attended sentinel sites, 2996 cases of KA and 53 cases of PKDL were registered from 889 endemic villages. Symptomatic cases meant a person with fever of more than 15 days, weight loss, fatigue, anemia, and substantial swelling of the liver and spleen (enlargement of spleen and liver).The proportion of new and old cases was 86.1% and 13.9% respectively. A statistically significant difference was observed for reduction in KA incidence from 4.13/10000 in 2011 to 1.75/10000 in 2014 (p<0.001). There were significant increase (0.08, 0.10 per 10 000 population) in the incidences of PKDL and co-infection respectively in the year 2014 as compared to that of 2011 (0.03, 0.06 per 10 000 population). The proportion of HIV-VL co-infection was significantly higher (1.6%; p<0.05) as compared to other co-infections. Proportions of male in all age groups were higher and found statistically significant (Chi-square test = 7.6; P = 0.026). Utilization of laboratory services was greatly improved. Friedman test showed statistically significant difference between response of different anti kala-azar drugs (F = 25.0, P = 0.004).The initial and final cure rate of AmBisome was found excellent (100%). The results of the signed rank sum test showed significant symmetry of unresponsiveness rate (P = 0.03). Similarly, relapse rate of sodium antimony gluconate (SAG) was also found significantly higher as compared to other drugs (95%CI 0.2165 to 19.7035; P = 0.03). A statistically significant difference was found (p<0.001) between villages having 1-2 cases (74%) and villages with 3-5 cases (15%). Significantly higher proportion (95%) of cases were captured by existing Govt. surveillance system (KMIS) (p<0.001), as compared to private providers (5%). CONCLUSIONS/SIGNIFICANCE: Establishment of a sentinel site based kala-azar surveillance system in Bihar, India effectively detected the rising trend of PKDL and co-infections and captured complete and accurate patient level data. Further, this system may provide a model for improving laboratory services, KA, PKDL and co-infection case management in other health facilities of Bihar without further referral. Program managers may use these results for evaluating program's effectiveness. It may provide an example for changing the practices of health care workers in Bihar and set a benchmark of high quality surveillance data in a resource limited setting. However, the generalizability of this sentinel surveillance finding to other context remains a major limitation of this study. The justifications for this; the sentinel sites were made in the traditionally high endemic PHC's. The other conditions were Program commitment for diagnostic (rk-39) and the first line anti kala-azar drug i.e. miltefosine throughout the study period in the sentinel sites. In addition, there were clause of fulfillment of readiness criteria at each sentinel site (already described in the line no 171 to 180 at page no-8, 181-189 at page no-9 and 192-212 at page no-10). Rigorous efforts were taken to improve all the sentinel sites to meet the readiness criteria and research activities started only after meeting readiness criteria at the site. Therefore sentinel site surveillance described under the present study cannot be integrated into other set up (medium and low endemic areas). However, it can be integrated into highly endemic areas with program commitment and fulfillment of readiness criteria.

Conversion of asymptomatic infection to symptomatic visceral leishmaniasis: A study of possible immunological markers.

INTRODUCTION: Presence of asymptomatic individuals in endemic areas is common. The possible biomarkers in asymptomatic individuals once they get exposed to infection as well as following conversion to symptomatic disease are yet to be identified.We identified asymptomatic Visceral leishmaniasis (VL) infection amongst rK39+sorted direct agglutination test positive (DAT+) endemic healthy population and confirmed it by quantitative PCR(qPCR).The immunological determinants such as Adenosine deaminase (ADA), Interferon gamma (IFN-γ), Tumour Necrosis Factor alpha (TNF-α) and Interleukin 10 (IL-10)were examined to predict probable biomarkers for conversion to symptomatic VL. METHODS: Sample size was 5794 healthy individuals from VL endemic region. Antibody tests(DAT &rK39) were performed and later a qPCR assay was employed using kDNA specific primers and probes. Immunological biomarkers examined were ADA level by ADA-MTP kit and quantitative cytokines(IFN-γ, IL-10 and TNF-α) by ELISA. RESULTS: 120 asymptomatic individuals of 308 rK39 sero-positives were DAT positive comprising of 56 with previous history and 64 with no history of VL. RT-PCR confirmed asymptomatic VL in 42 sero-positives. These were followed up through repeated qPCR and evaluation of immunological determinants. We observed10 symptomatic cases converted from a total of 42 asymptomatic individuals identified at base-line. The level of ADA, IL-10 and IFN-γ remained consistently high in asymptomatic cases and amongst these, ADA and IL-10 but not IFN-γ remained higher at the development of clinical symptoms into active VL. On the contrary, there was no significant change in the mean concentration of TNF-α at both stages of the disease. DISCUSSION: We surmise from our data that considerable proportion of asymptomatic cases can be a reservoir and may play a crucial role in transmission of visceral leishmaniasis in endemic areas. The data also suggests that ADA and IL-10 can serve as a potential biomarker during the conversion of asymptomatic into symptomatic VL.

Evaluation of the iPACK block injectate spread: a cadaveric study.

BACKGROUND AND OBJECTIVES: Ultrasound-guided infiltration of the interspace between the popliteal artery and capsule of the knee (iPACK) block, a new regional analgesic technique, is believed to relieve posterior knee pain, after total knee arthroplasty, by targeting the articular branches innervating posterior aspect of the joint. The extent of injectate spread and the number of articular branches affected is currently unknown. This cadaveric study aimed to compare the area of dye spread and frequency of articular branches staining following a proximal versus distal injection technique. METHODS: An ultrasound-guided iPACK injection (10 mL of methylene blue dye solution) was performed in 14 lightly embalmed specimens: 7 injected using a proximal injection technique (1 fingerbreadth above base of patella) and 7 using a distal injection technique (at the superior border of the femoral condyles). Following injection, dissection, digitization, and 3D modeling were performed to map the area of dye spread and determine the frequency of nerve staining. RESULTS: Both injection techniques achieved a similar mean area of injectate spread. Of the four articular branches supplying the posterior knee joint capsule, the genicular branch of posterior division of obturator nerve was stained in all specimens. The proximal injection resulted in staining of superior medial genicular nerve, due to dye spread through the adductor hiatus, whereas superior lateral genicular nerve and anterior branch of common fibular nerve were consistently stained following distal injection. Other articular branches were stained with variable frequency. CONCLUSIONS: Both proximal and distal iPACK injection techniques provided a similar area of dye spread in the popliteal region and extensive staining of the articular branches supplying the posterior capsule. The proximal injection technique promoted greater anteromedial dye spread, while the distal injection had more anterolateral spread. Further clinical study is required to confirm our cadaveric findings. .

Gossypiboma mimicking posterior urethral stricture.

INTRODUCTION: Foreign bodies in the urogenital tract are not uncommon. Hairpins, glass rods, umbilical tapes, ball point pen are described in lower urogenital tract. Retained gauze piece (gossypiboma) in posterior urethra may cause diagnostic dilemma. Symptoms and investigations may mimic stricture of posterior urethra. PRESENTATION OF CASE: Two cases of retained gauze pieces in the urethra are described here. The micturating cystourethrogram was suggestive of posterior urethral stricture. DISCUSSION: Two cases described here had retained gauze piece as a cause of filling defect and abnormal appearance in the micturating cystourethrogram. Gossypiboma may be a possibility where posterior urethral stricture are seen after previous surgery in paediatric age group. CONCLUSION: In the setting of previous urogenital surgery gossypiboma should be kept in the differential diagnosis where posterior urethral stricture are seen in the paediatric age group.