Environmental Disease

Potential health risks of long-term e-cigarette use Eric A Klomparens, Yuchuan Ding Environmental Disease 2019 4(1):1-5 E-cigarettes are becoming increasingly popular in recent years, especially among adolescents. Many healthcare professionals are unsure of what health consequences can be expected after long-term use of e-cigarettes. This review focuses on the currently published data of long-term e-cigarette vapor exposure in cells, animals, and humans. Most research suggests that e-cigarettes are not harmless. Increased oxidative stress from free radicals and systemic inflammation occur after weeks or months of exposure. E-cigarette vapor contains multiple known human carcinogens which are found in the serum of users, and DNA damage is seen in exposed animals. Pulmonary changes seen after months of exposure in mice are reminiscent of chronic obstructive pulmonary disease (COPD), and human users report increased respiratory symptoms. Cardiovascular disease risk is also likely, with e-cigarette use leading to multiple pathophysiological changes and possibly associated with an increased risk of myocardial infarction. Limitations of the current research are discussed, including the retrospective nature of most human data to date. A call for large, longitudinal prospective studies is deemed necessary to better understand the causal role of long-term e-cigarette use in chronic disease formation.

Bisphenol A (BPA) in liquid portions of canned foods obtained from domestic and Asian markets in the United States Aby Joiakim, David Kaplan, David A Putt, Julia Matzenbacher Santos, Klaus Friedrich, So Hee Kim, Hyesook Kim Environmental Disease 2019 4(1):6-11 Bisphenol A (BPA) is a phenolic environmental estrogen that disrupts endocrine activity thereby increasing the risk of hormone-related health problems. The human population is highly exposed to BPA and food is believed to be a primary source of BPA exposure. The aim of this study was to test the sensitivity and specificity of a BPA enzyme-linked immunosorbent assay (ELISA) and to measure levels of BPA in supernatants obtained from various canned foods from different countries. The concentration of BPA was measured in supernatant from different types of canned soup and vegetable mixes produced by US companies and two companies each from three different Asian countries (Korea, Japan and China), which are available at markets in the USA. ELISA results were confirmed by LC/MS/MS and shown to be in agreement. Cross-reactivity tests demonstrated that BPA ELISA kit does not cross-react with other tested phenolic compounds. There was no significant difference of BPA levels in different types of soups from different US companies. However, levels of BPA in supernatants of canned vegetable mixes of a company in the USA were 200-fold lower than the levels in canned vegetable soups of the US companies. BPA levels varied greatly among canned foods among companies in various countries. Thus, this study validated the use of a simple ELISA assay to measure levels of BPA in supernatants of canned food, which would facilitate the routine monitoring of dietary exposure to BPA. Decreasing the consumption of BPA will lead to a reduction in the risk of adverse health effects.

Seroprevalence of Toxocara canis and the parasitic effect on plasma cytokines in children aged 6 to 11 years in Saki-East local government area in Nigeria Mathew Folaranmi Olaniyan, Mufutau M Azeez Environmental Disease 2019 4(1):12-16 Study Background: Toxocara canis is a helminths parasite known as dog worm but infects human through infected dog feces or contaminated dirt. It is a neglected disease in economically less privileged areas. The parasitic infection can generate inflammatory process. Aim and Objective: This work was designed to determine the seroprevalence of T. canis and the parasitic effect on plasma cytokines in children aged 6–11 years in Saki-East local government area in Nigeria. Materials and Methods: Two hundred children aged 6–11 years (female – 100 and male – 100) were recruited across Saki-East local government area. One hundred and sixty-one of them not infected with any of the infectious agents were studied as control. Sputum, blood, stool, skin snip, and urine samples were obtained for microscopic identification of parasites. Sputum sample was also used for Ziehl–Neelsen staining to demonstrate acid-fast bacilli, while ELISA technique was used for determination of T. canis, anti-hepatitis C virus (HCV), HBsAg, HIV1-p24 antigen, tumor necrosis factor-alpha (TNFα), and interleukin (IL)-10. Results: The results obtained showed overall seroprevalence of T. canis among the children as 9.5% (19) including 6% (12) male and 3.5% (7) female children. This included 5.5% (11) monoinfected with T. canis; 1% (2) were T. canis coinfected with Ascaris lumbricoides; 1% (2) were T. canis coinfected with hepatitis B virus; 1% (2) were T. canis coinfected with Plasmodium spp.; 0.5% (1) were T. canis coinfected with hookworm; and 0.5% (1) were T. canis coinfected with Schistosoma haematobium. There is no coinfection with either HIV or HCV among the children. 10% (20) were infected with infectious agents but seronegative to T. canis. There was a significant increase in the plasma values of cytokines TNFα and IL-10 in T. canis monoinfected children compared with the control (P < 0.05). Conclusion: The work revealed an overall seroprevalence of T. canis as 9.5% including 5.5% monoinfection and a significant increase in plasma TNFα and IL-10 in T. canis monoinfection.

Method for estimation of hippuric acid as a biomarker of toluene exposure in urine by high-performance liquid chromatography after extraction with ethyl acetate Anupa Yadav, Anirban Basu, Amit Chakarbarti Environmental Disease 2019 4(1):17-22 Aim: This study aimed to establish liquid–liquid extraction (LLE) for estimation of hippuric acid (HA) in urine as a biomarker of the toluene exposure by high-performance liquid chromatography equipped with photodiode array detector (HPLC-PDAD). Method: HA in urine was extracted by LLE and determined by HPLC-PDAD. The operating conditions with HPLC were ODS-2 hypersil column (250 mm × 4.6 mm, 5 μm), 0.1% trifluoro acetic acid (TFA) in acetonitrile and 0.1% TFA in water as mobile phase, 1 ml/min flow rate, and wavelength of 205 nm. The validity of the present method was tested by the estimation of HA in urine samples, collected from toluene-exposed (shoe workers) and unexposed or control subjects. Results: Binary gradient system was used to achieve optimum separation. The analytical curve prepared for HA in aqueous solution in the range of 0.5–10 μg/ml showed determination coefficient value (R2) 0.998. Limit of detection and quantification (LOQ) were 0.46 and 1.53 μg/ml, respectively. The coefficients of variance for intraday precision were 1.4% for HA standard (5 μg/ml) and 1.1% for pooled urine, whereas inter-day precision values were 3.2% and 4.9% for HA standard and pooled urine, respectively. Method recovery obtained was 96%–120% for HA solutions containing 2, 3, and 5 μg/ml, demonstrating that precision and recovery of method were satisfactory. Compared to unexposed group, exposed group had significantly more HA. It was found significantly (P < 0.05) higher in urine of exposed workers (32.52 ± 10.91) than unexposed group (16.21 ± 10.14). Conclusion: Sample preparation by LLE is simple and cost-effective for the determination of HA as a biomarker of toluene exposure by HPLC-PDAD. It can be used to detect HA in urine for population exposed to toluene.

A comparison of clinical characteristics and outcome in pyogenic liver abscess patients with and without diabetes mellitus: A case-control study Haitao Sun, Yuxian Yang, Eric A Klomparens, Dong Zhao Environmental Disease 2019 4(1):23-27 Background: Pyogenic liver abscess (PLA) is a relatively rare and potentially life-threatening disease. The incidence of PLA has been increasing steadily over the past few decades. PLA is relatively common in patients with diabetes mellitus (DM). Although multiple studies have explored the relationship between PLA and DM, it remains controversial, and the evidence comes primarily from case reports. Because of this, more studies are necessary to compare the characteristics of PLA patients with and without DM to explore the relationship between PLA and DM. Materials and Methods: A total of 115 PLA patients admitted in Beijing Luhe Hospital from December 2012 to August 2017 were divided into two groups based on the presence of DM (the DM group and the non-DM group) for the comparison of clinical characteristics and outcomes of patients. Chi-square, Fisher's exact, and t-tests were used to analyze the differences between the two groups. Results: Of 115 patients included, 50.4% of patients had DM. The DM group had a lower prevalence of abdominal pain (28% vs. 51%, P = 0.011) and pain to palpation (48% vs. 67%, P = 0.046). Moreover, the DM group had a higher prevalence of misdiagnosis (45% vs. 16%, P = 0.001) and poor outcomes (9% vs. 0%, P = 0.03). Conclusions: We found that patients with DM may have less typical symptoms of PLA than those without DM, which may explain the higher prevalence of misdiagnosis of PLA in patients with DM. Moreover, patients with DM have worse outcomes than those without DM.

Cardiac Anaesthesia

Argon: The Future Organ Protectant? Suresh G Nair Annals of Cardiac Anaesthesia 2019 22(2):111-112

Propofol for sedation for direct current cardioversion Bruna Galvão de Wafae, Rose Mary Ferreira da Silva, Henrique Horta Veloso Annals of Cardiac Anaesthesia 2019 22(2):113-121 Direct current cardioversion is a low-risk and standard procedure to restore normal sinus rhythm in patients with tachyarrhythmias. It requires sedation to facilitate the procedure, as it is painful and distressful. The preferred anesthetic drug must be short acting, producing conscious sedation, to enable rapid recovery after the procedure. In this sense, this narrative review focuses on the critical analysis of recent randomized studies and presents about the safety and effectiveness of propofol, comparing it with other established sedatives, mainly etomidate and midazolam. The research was performed on MEDLINE database with Propofol and Cardioversion keywords. In most cases, propofol comes to be the best option, with a quick recovery time and low rates of side effects. Different studies have demonstrated no inferiority when comparing to other drugs and, when these adverse events happened, they were easily and quickly handled. Exceptions in this scenario are those patients, particularly the elderly, with baseline important structural heart disease, in which etomidate with fentanyl has been pointed to lead to better hemodynamic stability.

A complete review of preclinical and clinical uses of the noble gas argon: Evidence of safety and protection Francesca Nespoli, Simone Redaelli, Laura Ruggeri, Francesca Fumagalli, Davide Olivari, Giuseppe Ristagno Annals of Cardiac Anaesthesia 2019 22(2):122-135 The noble gas argon (Ar) is a “biologically” active element and has been extensively studied preclinically for its organ protection properties. This work reviews all preclinical studies employing Ar and describes the clinical uses reported in literature, analyzing 55 pertinent articles found by means of a search on PubMed and Embase. Ventilation with Ar has been tested in different models of acute disease at concentrations ranging from 20% to 80% and for durations between a few minutes up to days. Overall, lesser cell death, smaller infarct size, and better functional recovery after ischemia have been repeatedly observed. Modulation of the molecular pathways involved in cell survival, with resulting anti-apoptotic and pro-survival effects, appeared as the determinant mechanism by which Ar fulfills its protective role. These beneficial effects have been reported regardless of onset and duration of Ar exposure, especially after cardiac arrest. In addition, ventilation with Ar was safe both in animals and humans. Thus, preclinical and clinical data support future clinical studies on the role of inhalatory Ar as an organ protector.

Terlipressin versus norepinephrine to prevent milrinone-induced systemic vascular hypotension in cardiac surgery patient with pulmonary hypertension Mai Mohsen Abdelazziz, Hadil Magdi Abdelhamid Annals of Cardiac Anaesthesia 2019 22(2):136-142 Introduction: Milrinone at inotropic doses requires the addition of a vasoconstrictive drug. We hypothesized that terlipressin use could selectively recover the systemic vascular hypotension induced by milrinone without increasing the pulmonary vascular resistance (PVR) and mean pulmonary artery pressure (MPAP) as norepinephrine in cardiac surgery patients. Patients and Methods: Patients with pulmonary hypertension were enrolled in this study. At the start of rewarming a milrinone 25 μg/kg bolus over 10 min followed by infusion at the rate of 0.25 μg/kg/min. Just after the loading dose of milrinone, the patients were randomized to receive norepinephrine infusion at a dose of 0.1 μg/kg/min (norepinephrine group) or terlipressin infusion at a dose of 2 μg/kg/h (terlipressin group). Heart rate, mean arterial blood pressure (MAP), central venous pressure, MPAP, systemic vascular resistance (SVR), PVR, cardiac output were measured after induction of anesthesia, after loading dose of milrinone, during skin closure, and in the intensive care unit till 24 h. Results: Milrinone decreased MAP (from 79.56 ± 4.5 to 55.21 ± 2.1 and from 78.46 ± 3.3 to 54.11 ± 1.1) and decreased the MPAP (from 59.5 ± 3.5 to 25.4 ± 2.6 and from 61.3 ± 5.2 to 25.1 ± 2.3) in both groups. After norepinephrine, there was an increase in the MAP which is comparable to terlipressin group (P > 0.05). Terlipressin group shows a significant lower MPAP than norepinephrine group (24.5 ± 1.4 at skin closure vs. 43.3 ± 2.1, than 20.3 ± 2.1 at 24 h vs. 39.8 ± 3.8 postoperatively). There is a comparable increase in the SVR in both group, PVR showed a significant increase in the norepinephrine group compared to the terlipressin group (240.5 ± 23 vs. 140.6 ± 13 at skin closure than 190.3 ± 32 vs. 120.3 ± 10 at 24 h postoperatively). Conclusion: The use of terlipressin after milrinone will reverse systemic hypotension with lesser effect on the pulmonary artery pressure.

Comparison of full outline of unresponsiveness score and Glasgow Coma Scale in Medical Intensive Care Unit Jamileh Ramazani, Mohammad Hosseini Annals of Cardiac Anaesthesia 2019 22(2):143-148 Context: The Glasgow Coma Scale (GCS) is the most commonly used scale, and Full Outline of Unresponsiveness (FOUR) score is new validated coma scale as an alternative to GCS in the evaluation of the level of consciousness. Aim: The aim of the current study was to evaluate FOUR score and GCS ability in predicting the outcomes (Survivors, nonsurvivors) in Medical Intensive Care Unit (MICU). Setting and Design: This was an observational and prospective study of 300 consecutive patients admitted to the MICU during a 14 months' period. Materials and Methods: FOUR score, GCS score, and demographic characteristics of all patients were recorded in the first admission 24 h. Statistical Analysis Used: A receiver operator characteristic (ROC) curve, Hosmer–Lemeshow test, and Logistic regression were used in the statistical analysis (95% confidence interval). Results: Data analysis showed a significant statistical difference in FOUR score and GCS score between survivors and nonsurvivors (P < 0.0001, P < 0.0001; respectively). The discrimination power was good for both FOUR score and GCS (area under ROC curve: 87.3% (standard error [SE]: 2.1%), 82.6% [SE: 2.3%]; respectively). The acceptable calibration was seen just for FOUR score (χ2 = 8.059, P = 0.428). Conclusions: Both FOUR score and GCS are valuable scales for predicting outcomes in patients are admitted to the MICU; however, the FOUR score showed better discrimination and calibration than GCS, so it is superior to GCS in predicting outcomes in this patients population.

In search of a better measuring scale of consciousness Jayantee Kalita, Usha K Misra Annals of Cardiac Anaesthesia 2019 22(2):149-150

The effect of perioperative magnesium sulfate on blood sugar in patients with diabetes mellitus undergoing cardiac surgery: A double-blinded randomized study Rabie Soliman, Hussein Nofal Annals of Cardiac Anaesthesia 2019 22(2):151-157 Objective: The aim of the present study was to evaluate the perioperative effect of magnesium infusion on blood sugar level in patients with diabetes mellitus undergoing cardiac surgery. Design: This was a double-blind randomized study. Setting: The study was conducted at cardiac center. Patients: The study included 122 adult patients. Intervention: Group M – The patients received a continuous infusion of magnesium sulfate (without a loading dose) at 15 mg/kg/h. The infusion rate was started 20 min before induction maintained during surgery and the first postoperative 24 h. The medication was prepared by adding 5 g magnesium sulfate in 50 ml syringe. Group C – The patients received equal amount of normal saline. Measurements: The monitors included heart rate, mean arterial blood pressure, central venous pressure, urine output, blood levels of magnesium, sugar, and potassium. Results: The blood sugar level and the required insulin significantly decreased with Group M than Group C (P < 0.05). There were minimal changes in the potassium level in Group M, but potassium decreased in patients of Group C (P < 0.05). The amount of urine output was too much higher in Group M than Group C (P < 0.05). The pharmacological and mechanical support significantly decreased with Group M than Group C (P < 0.05). The hospital and Intensive Care Unit length of stay significantly decreased with Group M than Group C (P < 0.05). Conclusion: The magnesium sulfate produced a better-controlled effect on the blood sugar level. It decreased the requirement of insulin infusion and minimized the changes in the blood level of potassium.

The effect of cerebral oximeter use on the shunt placement concerning carotid endarterectomy surgery Dilek Ceyhan, Cengiz Ovali Annals of Cardiac Anaesthesia 2019 22(2):158-161 Background: During carotid arterial endarterectomy (CAE) surgery, an intraluminal shunt is used to prevent hypoperfusion, which can be caused by a cross-clamping cerebral ischemia. However, routine shunt use is not recommended. Various cerebral monitoring techniques are used to determine the need for shunt placement. In this study, retrospective analysis of data on the efficacy of cerebral oximetry in the decision of shunt use during elective CAE surveys was planned. Materials and Methods: We collected data on 68 patients operated under general anesthesia between December 2016 and December 2017. Patients were evaluated for near infrared spectrometry (NIRS) and stump pressure values and whether shunt was placed or not. Results: Eight (11.7%) patients were shunting. NIRS value after cross-clamping was lower in patients with shunt. Stump pressure values were below 40 mmHg. Conclusions: Cerebral monitoring in elective CAE operations has great importance in determining the necessity of using intraluminal shunt to reduce the complications that may occur.

Hyperkalemia in ambulant postcardiac surgery patients during combined therapy with angiotensin-converting enzyme inhibitor, spironolactone, and diet rich in potassium: A report of two cases and review of literature Aanchal Dixit, Gauranga Majumdar, Prabhat Tewari Annals of Cardiac Anaesthesia 2019 22(2):162-168 Introduction: Potassium is the most abundant cation in intracellular compartment. A deficiency or excess of its serum concentration can be deleterious to the one suffering from a cardiac ailment. Post cardiac surgery patients are often on multiple drugs like angiotensin receptor blockers (ARBs), angiotensin converting enzyme inhibitors (ACEI), diuretics including potassium sparing diuretics which are known to predispose for hyperkalemia. We report two postoperative cases who developed life threatening hyperkalemia despite normal renal function due to a combination of factors like treatment with ACEI, potassium sparing diuretics, high dietary intake of potassium and we also discuss renal handling of potassium in this review of literature. Methodology: We present a case series of two cases of cardiac surgery, who presented in the emergency department with hyperkalemia, managed conservatively and detailed history revealed that patient were also on very high nutritional potassium. Result: Both the patients responded to conservative management and there was no recurrence of such episodes once the dose of diuretics was adjusted and diet modification advised. Conclusion: In India, many patients are from a low socioeconomic background and often resort to cheap and filling food items like bananas. This dietary factor should be kept in mind while prescribing patients with these medications and adequate counseling regarding diet should be done.

Perioperative anesthesia management for pulmonary endarterectomy: Adopting an established European Protocol for the Asian Population Yufan Chen, Zihui Tan, Shitalkumar S Shah, Kenny W T Loh Annals of Cardiac Anaesthesia 2019 22(2):169-176 Background: Anesthesia for pulmonary endarterectomy (PEA) has always been one of the challenges of anesthesia. As one of the leading cardiothoracic institutions in Southeast Asia, our hospital has vast interest in this subject. A local multidisciplinary team was deployed to an expert center in the United Kingdom (UK), and the experience was then integrated to the care of our patients. We present a case series of ten patients undergoing anesthesia for PEA, a first for our institution, and discuss techniques as well as potential complications. Methods: Patients with chronic thromboembolic pulmonary hypertension were reviewed by a multidisciplinary team, and those who were suitable for surgical intervention subsequently underwent PEA. A total of ten patients were identified and operated on. The perioperative management and conduction of anesthesia for all patients followed a protocol adapted from the expert center in the UK, with revisions to cater to our Asian population. Results: In the ten patients operated on, eight of them were successfully extubated on the first postoperative day. Apart from one incident of prolonged ventilator usage due to reperfusion lung injury and pneumonia, there were no major respiratory or hemodynamic complications. Certainly, six of the ten patients developed subdural hemorrhage after the commencement of enoxaparin, although none of them sustained any permanent neurological deficits. Conclusion: We have demonstrated that with careful planning and a well-outlined protocol, anesthesia for PEA in an Asian population can be achieved with favorable outcomes. Further fine-tuning of the protocol is still required based on local expertise.

Pain

Pain management in the eyes of a surgeon: A reality check in combating the epidemic of persistent post operative pain Tariq Mansoor Indian Journal of Pain 2019 33(1):1-2

Consensus on evidence and experience: Future road map for framing guidelines Gautam Das, Pankaj Surange, Debjyoti Dutta, Jeshnu Prakash Tople, Suspa Das Indian Journal of Pain 2019 33(1):3-6 The approach to management of any patient is justified when based on evidence rather than experiences. However, there may be a class of patients for whom experience-based approach shows much better results. This article is an analysis of evidence-based guidelines versus experience-based approach. Although the protocols and guidelines deduced from evidence-based medicine appear infallible, the essential loopholes in standardization of this approach include turning a blind eye to the facts that publications may be company sponsored, with secondary gains intended, unfit for all socioeconomic strata, with a flaw in the review process itself, and many more. It would not be an overstatement that the experience of clinicians may be seriously ignored when adhering to evidence-based guidelines alone. A thorough knowledge of the subject based on the evidence, clinical experience, and clinical acumen together plays a vital role in prescribing the treatment to an individual. While framing the clinical practice guidelines, the role of an experienced clinician also needs to be highlighted. A proposed road map to formulation of the Indian Pain Practice guidelines should be such that an equal emphasis is given to expert opinion as well study-based evidence-based medicine. Among several other aspects, it is also emphasized that practitioners with more than 7 years of experience with dedicated pain practice will be sought for and considered as experts.

Role of interventional treatment in acute pain of herpes zoster and prevention of postherpetic neuralgia Shubhangi Mishra, Adil Rasul, Hammad Usmani Indian Journal of Pain 2019 33(1):7-10 Acute pain associated with herpes zoster (HZ) is the most debilitating symptom, which if not treated in early phase may lead to postherpetic neuralgia (PHN), a potentially crippling disorder with prolonged intractable chronic pain. The socioeconomic consequences secondary to prolonged severe pain include decreased socialization, depression, fatigue, restricted daily activities, and poor quality of life. HZ and PHN impose a significant economic burden in the form of direct inpatient care and loss of productivity. Early interventional treatments attenuate central sensitization by interrupting the transmission of nociceptive afferent impulses to the central nervous system and minimize nerve damage by improving blood flow to the nervous tissue in addition to the local anti-inflammatory action of corticosteroids. Interventions treatment options have been increasingly used as a part of multimodal approach in the management of acute pain of HZ in addition to pharmacological agent. This article reviews the various interventional treatment options which have used in the recent years for the management of acute pain of HZ and subsequent prevention of PHN.

Combination of critical care pain observation tool and face, legs, activity, cry, consolability scale in assessment of postoperative pain severity in postanesthesia care unit: A prospective cross-sectional analytical study Debanjali Ray, Sudesna Gupta, Subrata Ray Indian Journal of Pain 2019 33(1):11-14 Context: Effective post-operative pain assessment is mandatory to exclude overdose of analgesics and avoid adverse effects. Patients in PACU have impaired ability to communicate making pain assessment challenging. This study aims to establish agreement between two pain scales, CPOT (Criticalcare Pain Observation Tool) and FLACC (Face, Legs, Activity, Cry, Consolability) and to find out specificity of combination of scales. Methods: Taking sample size of 50 patients of either sex, aged 18-80 years, ASA-PS I-III, undergoing elective surgeries were chosen, study period being June-September 2017. Adequately reversed, extubated patients not receiving sedatives, analgesics and local anaesthetics within 15 minutes before end of operation were included while patients with ASA-PS more than III or on ventilator were excluded. Assessment was done upto 2 hours at 30 minutes interval using CPOT tool and FLACC scale simultaneously by two observers, both being blinded about study. Results: Combination of two scales show high odds ratio (41%) and kappa coefficient (0.78) suggesting excellent agreement. Specificity of combination of scales is very high (95.2%) than individual test. Conclusion: CPOT and FLACC scale together has excellent agreement and their combination are more specific to assess the severity of post-operative pain than when used individually.

Clinical efficacy of oral gabapentin versus clonidine for preemptive analgesia in knee arthroplasty under epidural anesthesia with 0.75% Ropivacaine – A comparative study Ivesh Singh, Kumkum Gupta, Salony Agarwal, Manoranjan Kumar Bansal, Abdul Samad, Pavitra Kalra Indian Journal of Pain 2019 33(1):15-19 Background: The preemptive analgesia for knee arthroscopic repair may reduce the postoperative pain without affecting the mobility of patients. The present study was designed to compare the clinical efficacy of oral gabapentin with clonidine as preemptive analgesic to epidural ropivacaine (0.75%) for knee arthroscopic repair, done under epidural anesthesia. Patients and Methods: Sixty adult patients of both genders of the American Society of Anesthesiologists physical status I and II aged 20–58 years, scheduled for knee arthroscopic repair under epidural anesthesia, were randomized into two groups of 30 patients each. Patients of Group RG were given oral gabapentin 300 mg, and patients of Group RC received oral clonidine 100 μg, 90 min before surgery with sip of water. All patients received epidural anesthesia with 15 ml of 0.75% ropivacaine. Groups were compared for onset and duration of sensory and motor blockade and postoperative analgesia as primary end points. Intraoperative hemodynamic changes, sedation score, or any side effects were evaluated as secondary end points. Results: The onset of complete sensory block to T10 (15.4 ± 4.7 vs. 17.5 ± 3.8 min) and time to achieve complete motor block (23.7 ± 3.3 vs. 26.9 ± 1.4 min) was earlier in patients of Group RC. Postoperative analgesia was prolonged in patients of Group RG (248.17 ± 19.6 vs. 217.36 ± 12.3 min). Intraoperative hemodynamic changes showed no significant difference. There was an increased incidence of nausea and vomiting in clonidine group. Conclusion: Oral gabapentin proved to be better as preemptive adjuvant for providing postoperative analgesia and good sedation during knee arthroscopic repair.

Noninvasive neuromodulation of supraorbital and occipital nerves as an adjunct to management of chronic headache: A pilot study Nazia Tauheed, Aftab Hussain, Hira Afzal, Lubna Zafar, Hammad Usmani Indian Journal of Pain 2019 33(1):20-24 Background: Chronic daily headache (CDH) results in significant distress and a substantial impact on the quality of life. Due to its nature of refractoriness to conservative management, exploring other modalities seems worthwhile. Invasive nerve stimulation, though promising, has seen complication rates in plenty. The goal of the present study was to assess the efficacy of noninvasive neuromodulation of supraorbital and occipital nerves (SON and ON) using hybrid pulsed radiofrequency device (Stimpod NMS460) in patients of CDH. Methods: Thirty patients suffering from CDH were enrolled in this randomized double-blind sham-controlled trial and randomly allocated to two groups of 15 patients each. SON and ON stimulations were given using the device Stimpod NMS460 thrice a week for 3 weeks. Follow-up visits were scheduled at 6 and 12 weeks of therapy. Pain relief was measured using numerical rating scale score. The overall change in quality of life (measured by Short Form-12 Health Survey) and associated complications were also noted. Results: Successful stimulation (50% or greater decrease in pain intensity) was seen in 66.67% patients; inadequate response in 33.3% in the intervention group. The 50% responder rate in sham control group was 13.3%; remaining 86.6% showed an inadequate response. This response remained sustained up to 12 weeks of follow-up. Similar changes were observed in the quality of life of patients. No adverse effect was documented during the study period. Conclusion: Noninvasive neuromodulation may serve as a safer and cost-effective treatment option in CDH refractory to conservative management.

A Comparative study of intra-articular injection of steroid versus prolotherapy for pain relief in patients of osteoarthritis knee Sarita Singh, Shashank Kumar, Hemlata , Ajay Chaudhary, Anita Malik Indian Journal of Pain 2019 33(1):25-30 Background: Osteoarthritis (OA) is a major source of disability owing to pain and loss of function. Intra-articular (IA) injection is the last nonoperative modality that can be used. We compared the efficacy of IA steroids and prolotherapy for relieving pain in patients of knee OA. Materials and Methods: We conducted a randomized, double-blind comparative study on 56 patients of OA knee assigned into two groups: steroid and prolotherapy group. Injections were given at 0, 1, and 2 months. During 6-month follow-up, patients were evaluated for pain relief by visual analog scale (VAS) score, quality of life (QOL) score, and requirement of rescue analgesic. Results: At baseline, mean VAS score of prolotherapy group (6.71 ± 0.94) and steroid group (6.36 ± 0.99) were comparable (P = 0.166). After 6 months, mean VAS score in prolotherapy group was 4.07 ± 1.44 as compared to 3.14 ± 0.89 in steroid group, and difference was statistically significant (P = 0.009). Furthermore, at baseline, QOL score of prolotherapy group (81.75 ± 4.69) and steroid group (79.29 ± 3.89) were comparable. After 6 months, it was found to be 70.43 ± 4.97 in prolotherapy group and 67.36 ± 2.74 in steroid group, the difference being highly significant (P = 0.007). Number of patients requiring rescue analgesia (P = 0.280) and the mean number of doses of rescue analgesic consumed (P = 0.538), both were slightly higher in prolotherapy group. Conclusion: Intra-articular steroid was better than prolotherapy in relieving pain of OA knee.

Dexmedetomidine with 0.375% bupivacaine for prolongation of postoperative analgesia in supraclavicular brachial plexus block Jaya Lalwani, Rashmi Naik Bhuaarya, Nasir Ali, Pratibha Jain Shah Indian Journal of Pain 2019 33(1):31-34 Background: Regional anesthesia is the recommended technique for upper-limb surgeries with better postoperative profile. Various agents have been used as adjuvants to prolong the duration of action and improve the efficacy of local anesthetic agents, α2-agonists being the most recent ones. We evaluated the effect of dexmedetomidine with bupivacaine for prolongation of the duration of analgesia in supraclavicular brachial plexus block. Materials and Methods: After Institutional Ethics and Scientific Committee approval and written informed consent, this prospective, observational study was carried out on 64 ASA Grade I and II patients of either sex, aged 18–60 years who underwent upper-limb surgery under brachial plexus block. Patients received either bupivacaine or bupivacaine with dexmedetomidine and were randomly divided into two groups. The primary outcome was duration of analgesia, and the secondary outcome was onset and duration of sensory and motor blockade, Ramsay sedation score, and side effects, if any observed at scheduled intervals. Results: Duration of analgesia in Group B was 391.46 ± 30.66 min and in Group BD was 810 ± 39.52 min (P < 0.0001), onset of sensory block in Group B was 7.9 ± 1.33 min and in Group BD was 5.65 ± 0.68 min (P < 0.0001), onset of motor block in Group B was 15.65 ± 1.66 min and in Group BD was 8.93 ± 0.788 min (P < 0.0001), duration of sensory block in Group B was 236.43 ± 17.52 min and in Group BD was 479.68 ± 40.50 min (P < 0.0001), duration of motor block in Group B was 206.09 ± 24.26 min and in Group BD was 447.81 ± 41.88 min, and slightly higher Ramsay sedation score was seen in Group BD as compared to Group B. The side effects were found to be insignificant and incidental. Only two cases of bradycardia(6.25%) and one case(3.12%) of hypotension were noticed in group BD. Conclusion: Addition of dexmedetomidine to bupivacaine was associated with prolonged analgesia, prolonged sensory and motor blockades with mild sedation.

To compare the efficacy of preemptive oral pregabalin versus oral pregabalin with intravenous ketamine as premedication on early postoperative pain Shivi , Shashank Bhardwaj Indian Journal of Pain 2019 33(1):35-38 Background and Objectives: Using opioid alone for postoperative pain relief is usually inadequate, and higher doses can cause a multitude of complications. A drug, which has anxiolytic property without the adverse effects of traditional analgesics mentioned, may be an attractive choice for postoperative analgesia. This study was done to compare analgesic efficacy of different nonopioid drugs on early postoperative pain and thus opioid-sparing effect. Materials and Methods: It was a randomized controlled trial. Sixty patients scheduled to undergo elective abdominal surgery under general anesthesia were assessed in the study. Primary Objective: The primary objective of this study was to observe the effect of preemptive pregabalin and pregabalin with intravenous (IV) ketamine on Cumulative analgesic requirement postoperatively. Secondary Objective: The secondary objective of this study was to observe the effect of preemptive pregabalin and pregabalin with IV ketamine on (1) analgesia and (2) adverse effects. Patients were randomly divided into two groups each containing 30 patients. Group P received 150 mg of oral pregabalin, 2 h before induction of anesthesia. Group PK received 150 mg of oral pregabalin, 2 h before induction of anesthesia, and injection ketamine 0.15 mg/kg intravenously just before induction of anesthesia. Heart rate and mean blood pressure (MBP) were observed and recorded at different time intervals during surgery. Heart rate, MBP, time to first analgesic demand, visual analog scale (VAS) score, total postoperative analgesic requirement, sedation score, and side effects were recorded in postoperative period. Results: In Group P, the mean total analgesia requirement in postoperative period was 44.47 ± 5.06 mg, whereas in Group PK, it was 41.8 ± 2.34 mg (P = 0.006). VAS score and time to first analgesic demand were insignificantly higher in Group P. No statistically significant difference was found in side effect profile among the two groups. Conclusion: From our study, it could be concluded that a combination of oral pregabalin and IV ketamine when administered preoperatively can decrease opioid consumption while providing good pain control.

Increased neuropathic pain following cervical epidural steroid injection Nana Morkane, Manoj Shinde, Kailash Kothari, Vishal Gunjal Indian Journal of Pain 2019 33(1):39-41 To draw attention to an uncommon complication that could arise from routinely performed procedure in pain practice like cervical epidural steroid injection. We report a case of 47-year-old female whose neuropathic pain was increased after cervical epidural steroid injection. Cervical epidural injection with methylprednisolone and lignocaine produced transient paresthesia during injection followed by a dull ache with pronounced allodynia in fingers. Next day, the patient reported severe pain in left forearm and hand with burning and sensitivity to light touch and swelling of the dorsum of the hand. On examination, there was marked allodynia, warmth, erythema, and swelling of the left hand. Sensory examination showed decreased sensation to pinprick. Patient was prescribed a tapering dose of oral steroids, pregabalin, and analgesic-muscle relaxant combination. Symptoms gradually resolved on weekly follow-ups for 4 weeks and no further intervention was needed. Increased neuropathic pain after cervical epidural steroid injection may result from either a direct nerve root irritation caused by the steroid solution or nerve root injury. Direct nerve root irritation by steroid injection is most probable cause in midline approach.

Left ventricular (LV) dyssynchrony in patients with ST elevation myocardial infarction (STEMI)

Left ventricular dyssynchrony assessment using tissue synchronization imaging in acute myocardial infarction
Ahmed S Azazy, Mahmoud Soliman, Rehab Yaseen, Morad Mena, Haitham Sakr

Avicenna Journal of Medicine 2019 9(2):48-54

Objectives: To assess left ventricular (LV) dyssynchrony in patients with ST elevation myocardial infarction (STEMI). Background: Mechanical synchronization disorder leads to a decrease in LV ejection fraction (LVEF) and stroke volume, an abnormal distribution of wall tension, and increase in workload during cardiac contraction. Methods: We enrolled 56 participants, 36 with acute STEMI and 20 healthy controls. The automatically color-coded time to peak myocardial velocity was measured using a 6mm sample volume, manually positioned within the two-dimensional-tissue strain image of the 12 basal and middle LV segments. Results: A significant delay was found between the septal-lateral and septal-posterior walls in patients with STEMI compared to patients in the control group (36.36 vs. −6.0ms, P = 0.036; and 42.7 vs. 23.94ms, P = 0.042, respectively). Furthermore, all segment maximum differences and all segment standard deviation (SD; dyssynchrony index) were found to be significantly higher in the STEMI group (131.28 vs. 95.45ms, P = 0.013; and 44.47 vs. 26.45ms, P = 0.001, respectively). A significant delay between the septal-lateral walls and septal-posterior walls, all segment maximum difference, and all segment SD (dyssynchrony index) were found in patients with complicated STEMI (70.89 vs. 15.83ms, P = 0.038; 57.44 vs. 19.06ms, P = 0.040; 138.11 vs. 100.0ms, P = 0.035; and 45.44 vs. 32.50ms, P = 0.021, respectively). There was a significant negative correlation between tissue synchronization imaging parameters and LVEF, and a positive correlation with LV end systolic dimension. Conclusion: Patients with acute STEMI showed significant LV dyssynchrony, which was an independent predictor of inhospital complications.

Multiple hormonal deficiencies suggestive of pseudo-pseudohypararthyroidism

CASE REPORT

Year : 2018  |  Volume : 7  |  Issue : 3  |  Page : 141-144

Pseudopseudohypoparathyroidism: an unusual case

Srinivasa P Munigoti
Department of Diabetes and Endocrinology, Fortis Hospital, Bengaluru, Karnataka, India

Date of Web Publication

8-Apr-2019

Correspondence Address:
Srinivasa P Munigoti
Department of Diabetes and Endocrinology, Fortis Hospital, 154, 9, Bannerghatta Road, Opposite IIM-B, Bengaluru - 560 076, Karnataka 
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCSR.JCSR_43_18

Abstract

We report unusual case of a 22-year-old male patient who presented with phenotypic features of Albright's hereditary osteodystrophy, but had associated multiple hormonal deficiencies suggestive of pseudo-pseudohypararthyroidism.

Keywords: Albright's hereditary dystrophy, Pseudohypoparathyroidism, Pseudopseudohypoparathyroidism

How to cite this article: Munigoti SP. Pseudopseudohypoparathyroidism: an unusual case. J Clin Sci Res 2018;7:141-4

How to cite this URL: Munigoti SP. Pseudopseudohypoparathyroidism: an unusual case. J Clin Sci Res [serial online] 2018 [cited 2019 Apr 9];7:141-4. Available from: http://www.jcsr.co.in/text.asp?2018/7/3/141/255667

Introduction

Albright's hereditary osteodystrophy (AHO) is characterised by short stature, varying degree of mental retardation, obesity with round facies, brachydactyly (i.e., shortening of the metacarpal bones, particularly the third, fourth and fifth) and dental hypoplasia.^[1]Pseudohypoparathyroidism (PHP) is a term used to describe the condition involving parathyroid hormone (PTH) resistance and is subclassified into 1a, 1b, 1c and Type 2.

Although connected by a common gene defect, AHO and PHP are not interchangeable. These two conditions are heterogeneous manifestations of a defect caused by gene mutation in the GNAS gene, which may lead to the partial or total deficiency of Gsα activity. Impaired Gsα activity, in turn, causes disruption of the biochemical pathways responsible for the activation of various peptide hormone receptors.^[2] The GNAS gene itself is subject to 'genomic imprinting', a phenomenon that leads to gene expression in a parent-of-origin-specific manner.^[3]

Case Report

A 22-year-old male patient from Bangladesh presented with 'abnormal growth of fingers and toes' since childhood. He reported similar abnormalities in paternal great-grandmother. The patient was the only child to his parents. Accompanying him to the clinic, his father reports delayed intellectual and emotional maturity of his son compared to his peers (delayed academic progress - 11^th grade at the age of 22).

On examination, his height was 1.55 m and his weight was 55.5 kg. Examination of the external genitalia revealed bilaterally descended testes of about 8–10 mL in volume. His genitalia otherwise was fully virilised with normal male pattern pubic hair distribution. He had scant chest and axillary hair with no facial hair. Neurological examination was completely normal. Archibald's sign (dimpled knuckles) and shortened toes typical of Albright's phenotypic features were prominent [Figure 1] and [Figure 2]. Laboratory investigations are listed in [Table 1], [Figure 3] and [Figure 4]. Computed tomography of the brain did not reveal any sellar abnormalities. He was diagnosed to have phenotypic features of AHO and pseudo-PHP (PPHP).

Figure 1: Clinical photograph showing shortening of third, fourth and fifth digits in the hand Click here to view

Figure 2: X-ray of both hands (antero-posterior view) showing shortening of third, fourth and fifth metacarpal Click here to view

Table 1: Laboratory Investigations Click here to view

Figure 3: Clinical photograph showing shortening of third, fourth and fifth digits in the feet Click here to view

Figure 4: X-ray of both feet (antero-posterior view) showing shortened third, fourth and fifth metatarsal Click here to view

Discussion

Patients with AHO having GNAS mutations on maternally inherited alleles exhibit resistance to multiple hormones that use the alpha-subunit of the stimulatory G protein to enhance cyclic adenosine monophosphate (cAMP) production. Resistance to PTH manifests as hypocalcaemia and hyperphosphataemia in the presence of elevated serum PTH. In addition to PTH, resistance to many other hormones such as thyroid-stimulating hormone (TSH), gonadotrophins, adrenocorticotrophic hormone (ACTH), growth-hormone-releasing hormone and vasopressin are also well-recognised. This group of patients with resistance to actions of multiple hormones are classified to have PHP1a.^[4],[5] On the other hand, patients with AHO having GNAS mutations on paternally-inherited alleles have the phenotypic features of AHO but manifest no resistance to hormones and are labelled as having 'PPHP'.^[2]

The patient in our case exhibited clinical and radiological features of AHO with normal calcium, phosphorus and PTH result. Many patients with PHP 1a are well-recognised to present with overt or subclinical hypothyroidism in infancy, as a result of resistance to TSH action. The patient had mild biochemical hypothyroidism as evidenced by a small rise in TSH value and this is presumed to be due to primary hypothyroidism (subclinical) in the absence of proof of antibodies. Resistance to TSH is generally mild, with TSH levels that are only minimally elevated and thyroid hormone levels that are normal or slightly low as in our case.^[6] Partial TSH resistance in keeping with the GNAS mutation also remains a possibility with this patient given the clinical heterogeneity of this syndrome.^[7]

Resistance to the actions of the gonadotropins with PHP 1a presenting with menstrual irregularities in women is well-recognised. This is thought to be due to a partial resistance of the theca and granulosa cells of the ovary to gonadotropins due to deficient Gsα activity. Hormonal evaluation in such women shows elevated gonadotropin levels with subnormal oestrogen.^[8] Patients with PHP-Ia (especially women), present with clinical evidence of hypogonadism. However, studies have not been able to consistently establish that they have increased basal or gonadotrophin hormone-releasing hormone stimulated levels of circulating gonadotropins. This is likely to be the cause of absence of gonadotropins elevation despite the low testicular volume in our patient. Unlike in women, such clinical and biochemical features with partial resistance are less well-identified and described in men. Nevertheless, patient in our case had hypogonadotropic hypogonadal biochemistry with bilaterally descended testes with post-pubertal volume (8–10 mL) and fully virilised genitalia that is classically not expected in patients with PHP1a. Given normal 17-OH-progesterone levels 30 min post-ACTH stimulus, late-onset congenital adrenal hyperplasia as a possibility to explain his virilisation is unlikely.

In most patients with PHP1a, responses to corticotrophin and vasopressin are clinically unaffected.^[9] Interestingly, our patient has hypocortisolaemia as demonstrated by the subnormal response to exogenous ACTH. Only one such case in association with GNAS mutation has been reported in the published literature in the past.^[10] It is worth mentioning that ACTH acts through melanocortin-2 receptor whose second messenger is cAMP and the receptor acts through GSα. Thus, primary adrenal failure of unknown aetiology seems unlikely in our case.

Overall, although our patient's phenotypic features resemble that of AHO, associated hormonal tests are not in keeping with classic presentation of PHP1a and hence PPHP is the primary diagnosis by exclusion. Nevertheless, clinical heterogeneity with variable expression of phenotypes, presenting with overlap between different subtypes, even amongst patients with the same GNAS mutation, is acknowledged to be a challenge in subtyping and classification of patients with this disease.^[11] Although genetic diagnosis could not be established in our patient, this well-recognised heterogeneity of GNAS mutations provides an opportunity for further study in patients like ours whose phenotypic presentation does not fit into well-defined subtypes of PHP. Further, hormone resistance in other axes may be present even when there is no PTH resistance in PPHP as illustrated in our case.

Acknowledgements

We would like to acknowledge the Departments of Biochemistry and Radiology for their kind help in providing reports of the investigations mentioned in the case report and Dr C. V. Harinarayan, Director, Department of Endocrinology and Metabolic Bone Disease, Sakra World Hospital, Bengaluru, for input and discussions in this case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 

References

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8.	Namnoum AB, Merriam GR, Moses AM, Levine MA. Reproductive dysfunction in women with Albright's hereditary osteodystrophy. J Clin Endocrinol Metab 1998;83:824-9.
9.	Mantovani G, Maghnie M, Weber G, De Menis E, Brunelli V, Cappa M, et al. Growth hormone-releasing hormone resistance in pseudohypoparathyroidism type Ia: New evidence for imprinting of the gs alpha gene. J Clin Endocrinol Metab 2003;88:4070-4.
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Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]