Comparison of 0.5% Bupivacaine and 0.5% Ropivacaine epidurally in lower limb orthopaedic surgeries

Background: Ropivacaine in equi-potent concentrations with bupivacaine, the degree of motor blockade is less pronounced with ropivacaine, and there is a greater propensity for blocking pain transmitting A-delta and C fibres rather than A-α motor fibres. It appears to have most of the blocking characteristics of bupivacaine. So we have undertaken the study to compare ropivacaine 0.5% (20ml) and bupivacaine 0.5% (20ml) for epidural anaesthesia in patients undergoing lower limb orthopaedic surgeries.Methods: This double-blind, randomized study involves 60 patients who were undergone orthopaedic surgery, having ASA-I or ASA-II physical status. Out of 60, 30 patients received 20 ml of 0.5% ropivacaine and 30 patients received 20 ml of 0.5% bupivacaine at the L3, 4 interspace. Parameters measured were the onset time, duration and spread of sensory block, the onset time, peak time, duration and degree of motor block, the quality of anaesthesia and the heart rate and blood pressure profile during block onset.Results: Epidurally, Ropivacaine in comparison to Bupivacaine provides quicker onset, early peak effect and prolonged duration of sensory block and shorter duration of motor block. Ropivacaine provides prolonged effective analgesia. It reduces requirement of rescue analgesics and related side effects.Conclusions: Ropivacaine 0.5% is safer and effective alternative to Bupivacaine in epidural anaesthesia and post operative pain relief

Open appendicectomy stump: invaginate or not to invaginate?

Acute appendicitis remains the most common abdominal surgical emergency. Appendicectomy is the standard treatment of acute appendicitis, which performed by open or laparoscopic approach. During open method, after removal of appendix, stump simple ligation or simple ligation and invagination. A prospective randomized study conducted at Smt SCL General Hospital, Smt NHL municipal Medical College, Ahmedabad between October 2009 to September 2011 to evaluate the necessity of appendicular stump invagination during appendicectomy. A total 110 patients were studied and randomized into two group, Group I stump simple ligation, transfixation and invagination and Group II stump simple ligation and transfixation only. There was no statically significant difference in the rate of postoperative complication and post operative hospital stay between the two groups. The mean operating time was significantly shorter in group without invagination. The rate of postoperative paralytic ileus was more in group I. We conclude that simple ligation of the appendicular stump during appendicectomy is safe, simple and shortens operating time

Quality of life after postmastectomy radiotherapy in patients with intermediate-risk breast cancer (SUPREMO): 2-year follow-up results of a randomised controlled trial

Background Postmastectomy radiotherapy in patients with four or more positive axillary nodes reduces breast cancer mortality, but its role in patients with one to three involved nodes is controversial. We assessed the effects of postmastectomy radiotherapy on quality of life (QOL) in women with intermediate-risk breast cancer. Methods SUPREMO is an open-label, international, parallel-group, randomised, controlled trial. Women aged 18 years or older with intermediate-risk breast cancer (defined as pT1–2N1; pT3N0; or pT2N0 if also grade III or with lymphovascular invasion) who had undergone mastectomy and, if node positive, axillary surgery, were randomly assigned (1:1) to receive chest wall radiotherapy (50 Gy in 25 fractions or a radiobiologically equivalent dose of 45 Gy in 20 fractions or 40 Gy in 15 fractions) or no radiotherapy. Randomisation was done with permuted blocks of varying block length, and stratified by centre, without masking of patients or investigators. The primary endpoint is 10-year overall survival. Here, we present 2-year results of QOL (a prespecified secondary endpoint). The QOL substudy, open to all UK patients, consists of questionnaires (European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-BR23, Body Image Scale, Hospital Anxiety and Depression Scale [HADS], and EQ-5D-3L) completed before randomisation, and at 1, 2, 5, and 10 years. The prespecified primary outcomes within this QOL substudy were global QOL, fatigue, physical function, chest wall symptoms, shoulder and arm symptoms, body image, and anxiety and depression. Data were analysed by intention to treat, using repeated mixed-effects methods. This trial is registered with the ISRCTN registry, number ISRCTN61145589. Findings Between Aug 4, 2006, and April 29, 2013, 1688 patients were enrolled internationally and randomly assigned to receive chest wall radiotherapy (n=853) or not (n=835). 989 (79%) of 1258 patients from 111 UK centres consented to participate in the QOL substudy (487 in the radiotherapy group and 502 in the no radiotherapy group), of whom 947 (96%) returned the baseline questionnaires and were included in the analysis (radiotherapy, n=471; no radiotherapy, n=476). At up to 2 years, chest wall symptoms were worse in the radiotherapy group than in the no radiotherapy group (mean score 14·1 [SD 15·8] in the radiotherapy group vs 11·6 [14·6] in the no radiotherapy group; effect estimate 2·17, 95% CI 0·40–3·94; p=0·016); however, there was an improvement in both groups between years 1 and 2 (visit effect −1·34, 95% CI −2·36 to −0·31; p=0·010). No differences were seen between treatment groups in arm and shoulder symptoms, body image, fatigue, overall QOL, physical function, or anxiety or depression scores. Interpretation Postmastectomy radiotherapy led to more local (chest wall) symptoms up to 2 years postrandomisation compared with no radiotherapy, but the difference between groups was small. These data will inform shared decision making while we await survival (trial primary endpoint) results. Funding Medical Research Council, European Organisation for Research and Treatment of Cancer, Cancer Australia, Dutch Cancer Society, Trustees of Hong Kong and Shanghai Banking Corporation

The analgesic efficacy of ultrasound-guided modified rectus sheath block compared with wound infiltration in reduction of postoperative morphine consumption in women undergoing open hysterectomy or myomectomy: A randomized controlled trial 14/09/2012 trial

Introduction: As ultrasound allows more accurate placement of local anesthetic (LA), ultrasound-guided modified rectus sheath block (MRSB) was compared with wound infiltration (WI) in women having open hysterectomy or myomectomy for fibroids via a Pfannenstiel incision under general anesthesia. Materials and Methods: Forty-two American Society of Anesthesiologists Class ASA I,II and III patients were recruited into two groups in a randomized patient-blinded controlled trial excluding those with coagulopathy, infection, or LA allergy. At the end of surgery, in the study group (Group U), an MRSB, under ultrasound guidance, was administered with 20 ml 0.25% levobupivacaine through a single skin puncture in the midline, 2 cm below the umbilicus, on either side of the midline, above the posterior sheath. In the control group (Group W), WI with 20 ml 0.5% levobupivacaine was done by the surgeon. The primary outcome measure was the amount of morphine consumed in the first 24 h after the surgery in the ward. Statistical analysis was performed with SPSS v.14.0. Results: Morphine consumption in the intraoperative and recovery periods was 10 mg and 0.0 mg, respectively, in both groups. In both the groups, pain measured by visual analog scale correct (VAS) (both at rest and on movement), morphine consumption (12.0 mg [18.0 mg] vs. 12.0 mg [23.0 mg], median interquartile range [IQR], p = 0.950), and the number of oral analgesic doses administered during the study period were comparable. However, number of patients who were "extremely satisfied" compared to "satisfied" with the analgesia were more in the Group U than in Group W (15/6 vs. 4/17, P-0.001). Sedation, nausea and vomiting, and antiemetic doses given were minimal and comparable in both groups. Conclusion: Ultrasound-guided MRSB does not show any significant difference in the 24 h morphine consumption as compared to WI

Consensus statement for the diagnosis and treatment of urticaria: A 2017 update

This article is developed by the Skin Allergy Research Society of India for an updated evidence-based consensus statement for the management of urticaria, with a special reference to the Indian context. This guideline includes updated definition, causes, classification, and management of urticaria. Urticaria has a profound impact on the quality of life and causes immense distress to patients, necessitating effective treatment. One approach to manage urticaria is by identification and elimination of the underlying cause(s) and/or eliciting trigger(s) while the second one is by treatment for providing symptomatic relief. This guideline recommends the use of second-generation nonsedating H1-antihistamines as the first-line treatment. The dose can be increased up to four times to meet the expected results. In case patients still do not respond, appropriate treatment options can be selected depending on the associated medical condition, severity of the symptoms, affordability of the drugs, and accessibility of modern biologics such as omalizumab

Spectrum of Esophageal Motility Disorders in Patients with Motor Dysphagia and Noncardiac Chest Pain ‑ A Single Center Experience

Aims and Objective: High‑resolution esophageal manometry is the most important investigation for the evaluation of patients with dysphagia and noncardiac chest pain (NCCP). Chicago Classification (CC) utilizing an algorithmic approach in analyzing high‑resolution manometry has been accepted worldwide, and an updated version, CC v3.0, of this classification has been developed by the International high‑resolution manometry working Group in 2014. Data on the spectrum of esophageal motility disorders in Indian population are scarce as well as a newer version of CC has not been used to classify. The aim of our study is to evaluate clinical presentation and manometric profile of patients with suspected esophageal motility disorders using CC v3.0. Methodology: In this retrospective study, consecutive patients referred for esophageal manometry at our center from 2010 to 2015 were included in the study. High‑resolution esophageal manometry was performed with 22‑channel water‑perfusion system (MMS, The Netherlands). Newer version of CC (CC v3.0) was used to classify motility disorders. Results: A total of 400 patients were included, with a mean age of 44 years and 67.5% were males. Out of these, 60% (n = 240) patients presented with motor dysphagia while 40% (n = 160) had NCCP. Motility disorder was present in 50.5% (n = 202) of the patients while 49.5% (n = 198) patients had normal manometry. Disorders of esophagogastric junction outflow were the predominant type of disorder, found in 33.75% (n = 135). About 14.25% (n = 57) of the patients had minor disorders of peristalsis while 5% (n = 20) of the patients had other major disorders of peristalsis. Achalasia was the most common motility disorder present in 30% (n = 120) patients. Conclusion: Dysphagia was the most common esophageal symptom followed by NCCP in our series. Achalasia was the most common esophageal motility disorder followed by fragmented peristalsis

Assessment of Allergic and Anaphylactic Reactions to mRNA COVID-19 Vaccines With Confirmatory Testing in a US Regional Health System

Importance: As of May 2021, more than 32 million cases of COVID-19 have been confirmed in the United States, resulting in more than 615 000 deaths. Anaphylactic reactions associated with the Food and Drug Administration (FDA)-authorized mRNA COVID-19 vaccines have been reported. Objective: To characterize the immunologic mechanisms underlying allergic reactions to these vaccines. Design, setting, and participants: This case series included 22 patients with suspected allergic reactions to mRNA COVID-19 vaccines between December 18, 2020, and January 27, 2021, at a large regional health care network. Participants were individuals who received at least 1 of the following International Statistical Classification of Diseases and Related Health Problems, Tenth Revision anaphylaxis codes: T78.2XXA, T80.52XA, T78.2XXD, or E949.9, with documentation of COVID-19 vaccination. Suspected allergy cases were identified and invited for follow-up allergy testing. Exposures: FDA-authorized mRNA COVID-19 vaccines. Main outcomes and measures: Allergic reactions were graded using standard definitions, including Brighton criteria. Skin prick testing was conducted to polyethylene glycol (PEG) and polysorbate 80 (P80). Histamine (1 mg/mL) and filtered saline (negative control) were used for internal validation. Basophil activation testing after stimulation for 30 minutes at 37 °C was also conducted. Concentrations of immunoglobulin (Ig) G and IgE antibodies to PEG were obtained to determine possible mechanisms. Results: Of 22 patients (20 [91%] women; mean [SD] age, 40.9 [10.3] years; 15 [68%] with clinical allergy history), 17 (77%) met Brighton anaphylaxis criteria. All reactions fully resolved. Of patients who underwent skin prick tests, 0 of 11 tested positive to PEG, 0 of 11 tested positive to P80, and 1 of 10 (10%) tested positive to the same brand of mRNA vaccine used to vaccinate that individual. Among these same participants, 10 of 11 (91%) had positive basophil activation test results to PEG and 11 of 11 (100%) had positive basophil activation test results to their administered mRNA vaccine. No PEG IgE was detected; instead, PEG IgG was found in tested individuals who had an allergy to the vaccine. Conclusions and relevance: Based on this case series, women and those with a history of allergic reactions appear at have an elevated risk of mRNA vaccine allergy. Immunological testing suggests non-IgE-mediated immune responses to PEG may be responsible in most individuals

Unusual Source of Gastrointestinal Bleed and Endoscopic Management

Gastrointestinal (GI) bleeding due to jejunal diverticula is very rare. Capsule endoscopy is a useful diagnostic tool for localizing the bleeding site, but single‑balloon enteroscopy is a good therapeutic modality for the management. Here, we report two cases, in whom the cause of GI bleeding was jejunal diverticula and they managed successfully with endoscopic management