Low-concentration, continuous brachial plexus block in the management of Purple Glove Syndrome: a case report

<p>Abstract</p> <p>Introduction</p> <p>Purple Glove Syndrome is a devastating complication of intravenous phenytoin administration. Adequate analgesia and preservation of limb movement for physiotherapy are the two essential components of management.</p> <p>Case presentation</p> <p>A 26-year-old Tamil woman from India developed Purple Glove Syndrome after intravenous administration of phenytoin. She was managed conservatively by limb elevation, physiotherapy and oral antibiotics. A 20G intravenous cannula was inserted into the sheath of her brachial plexus and a continuous infusion of bupivacaine at a low concentration (0.1%) with fentanyl (2 μg/ml) at a rate of 1 to 2 ml/hr was given. She had adequate analgesia with preserved motor function which helped in physiotherapy and functional recovery of the hand in a month.</p> <p>Conclusion</p> <p>A continuous blockade of the brachial plexus with a low concentration of bupivacaine and fentanyl helps to alleviate the vasospasm and the pain while preserving the motor function for the patient to perform active movements of the finger and hand.</p

Interleukin 10-Mediated Response and Correlated Anemia in a Patient with Advanced Non-Small Cell Lung Carcinoma

Anemia in cancer patients is associated with poor quality of life, reduced response to therapy, and decreased overall survival. We describe a case of a 56-year old woman with advanced metastatic non-small cell lung carcinoma who demonstrated marked response to a novel combinational immunotherapy approach involving a long-acting PEGylated construct of recombinant human Interleukin-10 with Nivolumab, an anti-PD-L1 checkpoint inhibitor. While on treatment, the patient developed severe anemia and hyper-ferritinemia requiring RBC transfusion support. Here we discuss a possible novel immune mechanism of IL10-mediated anemia in correlation with tumor response

Screening for Lung Cancer Has Limited Effectiveness Globally and Distracts From Much Needed Efforts to Reduce the Critical Worldwide Prevalence of Smoking and Related Morbidity and Mortality

Lung cancer is the leading cause of cancer-related mortality worldwide in both men and women. Efforts to reduce lung cancer mortality using chest x-rays (CXRs) for early detection did not show improvements in mortality. More recently, results of the National Lung Screening Trial (NLST), which used low-dose computed tomography (LDCT) scans, appear to improve mortality outcomes. However, LDCT imaging comes at prohibitive costs because of the high number needed to screen as well as inadequate biopsy yields from screen-positive cases. Thus, it is imperative that attempts be made to either improve the efficiency of lung cancer screening or reduce the prevalence of smoking. The latter is especially important considering population increases and the consequently higher prevalence of active smokers. The 2015 WHO report on the global tobacco epidemic highlights that tobacco-related deaths continue to claim more lives than AIDS, malaria, and tuberculosis combined. Hence, continued attempts to reduce the prevalence of smoking are more likely to produce greater mortality reductions than lung cancer screening strategies. Primary preventive strategies have proven benefits but remain underused. We describe the effectiveness of strategies for smoking control and tobacco-related diseases. We also explain why it is more relevant to increase implementation of these methods than the promotion of screening techniques for lung cancer, especially in low- and middle-income countries

Sri Lankan Journal of Anaesthesiology 16(2) : 104 – 107 (2008) MONITORED ANAESTHESIA CARE

Key words: monitored anaesthesia care; pharmacology Monitored Anaesthesia Care (MAC) refers to a clinical service wherein an anaesthesiologist provides analgesia and sedation for a diagnostic or therapeutic procedure, and the patient is able to protect his airway for the majority of the procedure. 1 It involves the administration of medication that can potentially lead to loss of consciousness and normal protective reflexes. There is possibility of a deeper plane of sedation compared to ‘sedation/analgesia ’ which is provided by a non-anaesthesiologist. 2 Therefore, the ASA recommends that the standards of care be same as for general or regional anaesthesia, with regard to pre-operative evaluation, intra-operative monitoring of the cardio-respiratory system, the physical presence of an anaesthesiologist at all time, and the administration of oxygen and other medications to keep the patient safe and comfortable. 1 MAC should invoke less physiological disturbance and allow a more rapid recovery compared to a general anaesthetic. Therefore, it is not surprising to note that it is the technique of choice in up to 30 % of the surgical procedures. The three essential components of MAC are – safe sedation, anxiolysis and analgesia. 3 However, patient comfort, cardio-respiratory stability, good operating conditions and minimal side effects are equally important. Preoperative assessment The preoperative evaluation (history, examination and review of investigations) and optimization should be as for a general or regional anaesthetic. However, there are certain factors unique fo

The effects of propofol and isoflurane on intraoperative motor evoked potentials during spinal cord tumour removal surgery - A prospective randomised trial

Background and Aims: Transcranial electrical stimulation (TES) elicited intraoperative motor evoked potentials (iMEPs), are suppressed by most anaesthetic agents. This prospective randomised study was carried out to compare the effects of Isoflurane and Propofol on iMEPs during surgery for spinal cord tumours. Methods: A total of 110 patients were randomly divided into two groups. In group P, anaesthesia was maintained with intravenous propofol (6.6 ± 1.5 mg/kg/hr) and in group I anaesthesia was maintained with isoflurane (0.8 ± 0.1% minimal alveolar concentration (MAC). An Oxygen- air mixture (FiO2-0.3) was used in both groups. TES-iMEPs were recorded from tibialis anterior, quadriceps, soleus and external anal sphincter muscles in 60 of 90 patients. Statistical analysis was performed with Pearson correlation and Paired 't' tests. Results: Successful baseline iMEPs were recorded in 74% of patients in Group P and in 50% of patients in Group I. Age and duration of symptoms influenced the elicitation of baseline iMEPs under isoflurane (r = −0.71, −0.66 respectively, P < 0.01) as compared to propofol (r = −0.60, −0.50 respectively, P < 0.01). The mean stimulus strength required to elicit the baseline iMEPs were lesser in propofol (205 ± 55Volts) as compared to isoflurane (274 ± 60 Volts). Suppression of the iMEP responses was less under propofol (7.3%) as compared to isoflurane anaesthesia (11.3%) in patients with no preoperative neurological deficits. Conclusion: iMEPs are better maintained under propofol anaesthesia (6-8 mg/kg/hr) when compared with isoflurane (0.7-0.9 MAC). in patients undergoing surgery for excision of spinal cord tumours

Physiology and clinical significance of natriuretic hormones

The natriuretic system consists of the atrial natriuretic peptide (ANP) and four other similar peptides including the wrongly named brain natriuretic peptide (BNP). Chemically they are small peptide hormones predominantly secreted by the cardiac myocytes in response to stretching forces. The peptide hormones have multiple renal, hemodynamic, and antiproliferative effects through three different kinds of natriuretic receptors. Clinical interest in these peptide hormones was initially stimulated by the use of these peptides as markers to differentiate cardiac versus noncardiac causes of breathlessness. Subsequently work has been done on using these peptides to prognosticate patients with acute and chronic heart failure and those with acute myocardial infraction. Synthetic forms of both atrial- and brain-natriuretic peptides have been studied and approved for use in acute heart failure with mixed results. This review focuses on the biochemistry and physiology of this fascinating hormone system and the clinical application of these hormones

IGH/BCL2 status better predicts clinico-pathological behavior in primary splenic follicular lymphoma than histological grade and other molecular markers

Splenic lymphoma may be primary or secondary. Primary splenic lymphoma\u27s are rare and usually of follicular cell origin representing \u3c 1% of Non-Hodgkin\u27s Lymphoma\u27s. Most are secondary with 35% representing Marginal Cell sub-type with the rest being Diffuse Large B-Cell Lymphoma\u27s. Unlike the uniformly aggressive clinical course of Diffuse Large B-Cell Lymphoma\u27s, biological behavior of Primary Splenic CD10-Positive Small B-Cell Lymphoma/Follicular Lymphoma remains less well defined. We present here a solitary splenic mass confirmed as Primary Splenic CD10-Positive Small B-Cell Lymphoma/Follicular Lymphoma after a diagnostic splenectomy. Biopsy revealed monomorphic small lymphoid cells with low grade mitotic activity. Flow cytometry showed a lambda restricted population of B-Cells displaying dim CD19 and CD10. The cells were negative for CD5, CD11c, and CD103. FISH was negative for IGH/BCL2 fusion unlike nodal Follicular Lymphoma\u27s which are usually positive for this translocation. Evidence from this case and a review of literature support the finding that Primary Splenic CD10-Positive Small B-Cell Lymphoma/Follicular Lymphoma is less likely to have the classic IGH-BCL2 fusion and the associated chromosomal 14;18 translocation. This profile is associated with less aggressive clinical behavior even when histopathology represents a high-grade pattern. In such cases splenectomy alone is adequate for localized disease when negative for IGH/BCL2 fusion regardless of histological grade