Craniovertebral Junction and Spine

Is central atlantoaxial instability the nodal point of pathogenesis of "idiopathic" dorsal spinal kyphoscoliosis? Atul Goel Journal of Craniovertebral Junction and Spine 2019 10(1):1-2

Treatment algorithm for spontaneous spinal infections: A review of the literature Fabrizio Gregori, Giovanni Grasso, Giancarlo Iaiani, Nicola Marotta, Fabio Torregrossa, Alessandro Landi Journal of Craniovertebral Junction and Spine 2019 10(1):3-9 Background: Primary spinal infections are rare pathologies with an estimated incidence of 5% of all osteomyelitis. The diagnosis can be challenging and this might result in a late identification. The etiological diagnosis is the primary concern to determine the most appropriate treatment. The aim of this review article was to identify the importance of a methodological attitude toward accurate and prompt diagnosis using an algorithm to aid on spinal infection management. Methods: A search was done on spinal infection in some databases including PubMed, ISI Web of Knowledge, Google Scholar, Ebsco, Embasco, and Scopus. Results: Literature reveals that on the basis of a clinical suspicion, the diagnosis can be formulated with a rational use of physical, radiological, and microbiological examinations. Microbiological culture samples can be obtained by a percutaneous computed tomography-guided procedure or by an open surgical biopsy. When possible, the samples should be harvested before antibiotic treatment is started. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and failure of conservative treatment. Conclusion: A multidisciplinary approach involving both a spinal surgeon and an infectious disease specialist is necessary to better define the treatment strategy. Based on literature findings, a treatment algorithm for the diagnosis and management of primary spinal infections is proposed.

Diffusion tensor imaging as an additional postoperative prognostic predictor factor in cervical myelopathy patients: An observational study Sunil Bhosale, Pramod Ingale, Sudhir Srivastava, Nandan Marathe, Prajakta Bhide Journal of Craniovertebral Junction and Spine 2019 10(1):10-13 Introduction: Multiple investigation modalities have been invented for diagnosis and for planning management of degenerative cervical myelopathy, which include magnetic resonance imaging (MRI), computed tomography scan, and plain X-rays. Diffusion tensor imaging (DTI) of the spinal cord is a special variety of MRI where diffusion of water molecules across and along the tracts is mapped. The changes in anisotropy at the stenotic level can be a postoperative prognostic factor. The aim of this study was to establish postoperative prognostic predictive value of DTI in cases of degenerative cervical myelopathy. Materials and Methods: The study included 30 indoor patients in a tertiary care hospital diagnosed with degenerative compressive cervical myelopathy based on both clinical and radiological parameters with complete clinical data including follow-up. All patients with medical neurological diseases, cases who underwent repeat surgery, cases who developed surgical site infection, and those patients who were lost to follow-up were excluded from the study. The patients underwent operative decompression through either anterior or posterior approach with or without fixation with titanium implants as per indication. All patients underwent pre- and postoperative DTI. The fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were noted in both pre- and postoperative imaging. Epidemiological data such as age and sex were noted. Pre- and postoperative modified Japanese Orthopedic Association (mJOA) scores were calculated. Results: There was a significant improvement in FA values postoperatively. Preoperatively, both FA and ADC values showed a significant correlation with preoperative Neurological status of the patient while postoperatively only FA values were found to be significantly correlated. The regression equations for determining postoperative mJOA score based on preoperative FA and ADC values revealed mJOA = 9.77 + 12.1 (FA), mJOA = 14.2 + 2408.4 (ADC), and mJOA = 9.54 + 11.2 (FA) +1575.5 (ADC). This means that postoperative mJOA score, i.e., postoperative clinical status improvement can be determined using DTI variables which are an objective preoperative data. However, relative strength of prediction for FA value is 66.7% and for ADC value is 28.7%. Conclusion: DTI tractography of the spinal cord will be a helpful objective prognostic factor for patients in whom surgery is planned. However, a study with larger subject size is required to increase the accuracy of determination of regression coefficient.

Effectiveness of titanium plate usage in laminoplasty Arya Nick Shamie, Hamed Yazdanshenas Journal of Craniovertebral Junction and Spine 2019 10(1):14-18 Background: Laminoplasty is an established technique for the treatment of cervical stenosis. However, the usage of plates to maintain patency of the laminoplasty door has not been well reported. This study plans to compare the clinical outcomes of laminoplasty with the usage of Sofamor-Danek laminoplasty plates versus techniques without plate usage. Materials and Methods: This study conducted a 2-year medical record review of all patients with multilevel cervical myelopathy who were treated with laminoplasty at UCLA or Cedars-Sinai medical center. Of 46 patients 18 had sufficient documentation to assess clinical outcome, 11 of which had placement of laminoplasty plates. Clinical outcomes were assessed using Odom's scoring criteria. Results: Blood loss and hospital stay are decreased with plate usage during laminoplasty. Average Estimated Blood Loss (EBL) was 160 cc with plate and 380 cc without. Hospital stay was 4.8 days with plate and 5.6 days without. There were no complications during any of the laminoplasty procedures regardless of instrumentation. All patients demonstrated improvement in symptoms after laminoplasty, with 73% of patients in the plate cohort having Odom Scores of “Excellent” versus 44% in the nonplate group. All patients, regardless of technique, showed improvement in symptoms. Conclusions: Laminoplasty with plate utilization is an effective treatment for cervical myelopathy. The similarity in outcomes and complications between these two similar cohorts suggests plate usage in laminoplasty is an attractive alternative to other methods. We hope that future efforts will continue to demonstrate the effectiveness and perhaps superiority of plate utilization in laminoplasty.

Is cervical instability the cause of lumbar canal stenosis? Atul Goel, Ravikiran Vutha, Abhidha Shah, Survendra Rai, Abhinandan Patil Journal of Craniovertebral Junction and Spine 2019 10(1):19-23 Aim: On the basis of an experience with 12 cases, the validity and rationale of cervical spinal stabilization for cases having both cervical and lumbar spinal canal stenosis is analyzed. Materials and Methods: From March 2017 to May 2018, 12 patients presented with a major symptom of neurogenic claudication pain generally related to lumbar canal stenosis in addition to other symptoms related to cervical myelopathy. The average age was 57 years. All patients were clinically and radiologically diagnosed to have both cervical and lumbar spinal canal stenosis. Based on the concept that degenerative spinal spondylotic myelopathy is an outcome of spinal instability, all patients underwent cervical spinal stabilization. No decompression by bone resection was done. The lumbar spine was not surgically treated. Visual analog scale, the Japanese Orthopaedic Association, and Oswestry Disability Index were used to monitor patients before and after surgery. Results: There was dramatic relief from symptoms related both to cervical and to lumbar canal stenosis in the postoperative period. During the average period of follow-up of 12 months, none of the patients have experienced recurrence of lumbar pain or needed any surgery. Conclusion: The report highlights the possibility of recovery in lumbar canal stenosis related symptoms following cervical spinal stabilization surgery for associated cervical spinal stenosis. We conclude that in select cases, cervical spinal instability may be the cause of clinical and radiological observations in cases having lumbar canal stenosis.

Effect of posterior fusion surgery on idiopathic scoliosis in Iran Masih Falahatian, Mohammad Farid Masaeli Journal of Craniovertebral Junction and Spine 2019 10(1):24-27 Background: Scoliosis is a sideways curve in the spine. Considering that postoperative complications are common among these patients, the aim of this study is to examine the postoperative complications of posterior fusion surgery with instrumentation among adult patients with idiopathic scoliosis. Methods: In this cross-sectional descriptive study, the postoperative complications were examined among 93 patients with idiopathic scoliosis who underwent posterior fusion surgery with instrumentation. The convenience sampling was used by referring to the files of these patients. The patients were classified into four groups according to the type of scoliosis deformity (long C-shaped, thoracic, thoracolumbar/lumbar, and double-curve) and the complications were compared together. Results: Postoperative respiratory problems were significantly different between the four groups of scoliosis deformity (P = 0.009); 35 cases of postoperative complications occurred and 20 of them were related to postoperative pulmonary complications. Conclusion: Postoperative complications are common among patients with idiopathic scoliosis who underwent posterior fusion surgery with instrumentation; in addition, pulmonary complications are the most common postoperative complication among these patients.

Clinical presentation and outcome after anterior cervical discectomy and fusion for degenerative cervical disc disease Ninad N Srikhande, V A. Kiran Kumar, NA Sai Kiran, Amrita Ghosh, Ranabir Pal, Luis Rafael Moscote-Salazar, V Anil Kumar, Vishnu Vardhan Reddy, Amit Agrawal Journal of Craniovertebral Junction and Spine 2019 10(1):28-32 Background: Anterior cervical discectomy and fusion (ACDF) is a well-described surgical approach for symptomatic degenerative cervical disc disease which does not respond to conservative management. In the present study, we assessed clinical presentation and outcomes of ACDF. Materials and Methods: The present study was conducted from October 1, 2015, to October 31, 2017, in the Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, among 100 consecutive adult patients who underwent single- or two-level ACDF for degenerative cervical disc disease. Results: The mean age was 47.2 ± 12.8 years (range: 20–74 years). Majority of the patients were male (86/100). Presenting symptoms were neck pain (77%), limb weakness (73%), paresthesias (53%), radicular pain (49%), stiffness in limbs (16%), and bladder involvement (13%). Fusion was done with stand-alone titanium cage/bone graft or titanium cage/bone graft with anterior cervical plate. At the time of discharge, significant improvement in preoperative symptoms (neck pain [47/77-61%], radicular pain [31/49-63%], limb weakness [53/73-72.6%], paresthesias [44/53-83%], stiffness in limbs [13/16-81%], and bladder symptoms [8/13-61%]) was reported by majority of these patients. Majority of these patients also reported improvement in preoperative sensory deficits at the time of discharge. Postoperative complications were hoarseness of voice (22%), dysphagia (16%), deterioration of motor power (8%), and postoperative hematoma (7%). Conclusions: A significant proportion of patients with degenerative cervical disc disease show remarkable recovery after ACDF.

Lumbar rocking test: A new clinical test for predicting lumbar instability Ashok Keshav Rathod, Bipul Kumar Garg, Varun Mukesh Sahetia Journal of Craniovertebral Junction and Spine 2019 10(1):33-38 Purpose: Significant number of low back pain is caused by spinal instability. Clinical and radiological tests are used to diagnose lumbar instability, but the practical utility of clinical tests has not been studied extensively. Hence, it was decided to study lumbar rocking test and passive lumbar extension (PLE) clinical tests to identify their accuracy for lumbar instability, in comparison to the radiological assessment. Materials and Methods: This cross-sectional prospective study was conducted in 2017 at an Indian tertiary care center, after Ethics Committee approval. No financial transection involved anywhere at any stage of the study. Patients of 30–65 years having low back pain were included following informed consent. Clinical tests conducted were rocking test and PLE tests. All patients were subjected to a neutral anteroposterior, lateral and flexion-extension X-rays of lumbosacral spine. The association between clinical tests and lumbar instability was represented by Chi-square analysis. The rest of the findings were represented as descriptive statistics. Results: Fifty patients enrolled in the study, of which 28 (56%) were females. On X-rays, the maximum angular rotation and sagittal translation were seen at L5–S1 level. 35 (70%) and 46 (92%) patients showed positive PLE and rocking test, respectively. Significant association (P < 0.05) was seen between rocking test and lumbar instability. The sensitivity of rocking test was 95.56% and positive predictive value as 93.47%. Conclusion: Clinical tests can be used effectively for the diagnosis of lumbar spine instability. Rocking test was found to be accurate and sensitive for detecting subtle lumbar instability.

Proposal of a new anatomical landmark to identify the disc space in endoscopic lumbar discectomy Keyvan Mostofi, Morad Peyravi, Babak Gharaei Moghaddam, Reza Karimi Khouzani Journal of Craniovertebral Junction and Spine 2019 10(1):39-41 Introduction: In endoscopic lumbar discectomy for posterolateral disc herniation, we determined some anatomical landmarks for improved disc space access. These landmarks are based on the beginning of the insertion of the ligamentum flavum (LF) to vertebral lamina. Materials and Methods: In 978 patients operated by posterolateral disc herniation, we measured prospectively the distance between the beginning of the insertion of the LF and space disc rostrally. Results: The distance between the beginning of the insertion of the LF and space disc was broader at the level of L3–L4, with an average of 14 mm. At L4–L5, the average distance was 13.5. At L5–S1, the average distance was 12 mm. Conclusion: Knowing the accurate distance between the insertion of LF and disc space contributes to reducing the average duration of the surgical procedure to avoid empirical search of disc space by a surgeon and avoiding unnecessary and excessive LF and bone removal.

Superficial anterior atlanto-occipital ligament: Anatomy of a forgotten structure with relevance to craniocervical stability Shogo Kikuta, Joe Iwanaga, Koichi Watanabe, R Shane Tubbs Journal of Craniovertebral Junction and Spine 2019 10(1):42-45 Introduction: The superficial anterior atlanto-occipital ligament (SAAOL) is a narrowband located anterior to the anterior atlanto-occipital membrane. Nearly forgotten, it has not been well described in older anatomical textbooks and is missing in the current anatomical literature. As all of the binding structures of the craniocervical junction (CCJ) are important in maintaining stability, this study aims to clarify the anatomy and potential function of the SAAOL. Materials and Methods: The CCJ from ten fresh-frozen cadavers was studied. These specimens were derived from three males and seven females, and the age at death ranged from 57 to 91 years (mean, 79.8 years). The length, width, and thickness of the SAAOL were measured. In five specimens, the force to failure was recorded. Results: The SAAOL was found between the anterior tubercle of the atlas and the occiput and located as central thick fibers in front of the anterior atlanto-occipital membrane in 9 (90%) specimens. In one specimen, the vertical band to the occipital bone did not attach to the anterior tubercle of the atlas, but extended to the anterior aspect of the axis. The mean length, width, and thickness of the SAAOL were 19.8, 6.2, and 0.6 mm, respectively. The force to failure for the ligament was 38.8 N. Conclusion: The SAAOL was a constant structure of the anterior atlanto-occipital joint. This ligament seems to be a secondary stabilizer of the CCJ by limiting the extension of CCJ. Knowledge of this ligament may help in further understanding of craniocervical stability.

Neurology

Cross-cultural differences in dementia: Indian etiquette of honorifics Apoorva Pauranik Annals of Indian Academy of Neurology 2019 22(2):129-130

Can we treat secondary progressive multiple sclerosis now? Rohit Bhatia, Nishita Singh Annals of Indian Academy of Neurology 2019 22(2):131-136 Secondary progressive multiple sclerosis (SPMS) is characterized by progressive accumulation of disability without intermittent recovery. Treatment of these patients is challenging due to limited understanding of pathogenesis and fewer therapeutic options. This article summarizes difficulties in defining and conducting trials in SPMS, review major clinical trials on therapies approved and unapproved in SPMS and lastly, therapies in pipeline for use in SPMS.

Expert group meeting on aphasia: A report Apoorva Pauranik, Annamma George, Aparna Sahu, Ashima Nehra, Avanthi Paplikar, Chitralekha Bhat, Gopee Krishnan, Harsimar Kaur, Jitendra Saini, PA Suresh, Pawan Ojha, Pinky Singh, Pratap Sancheti, Prathibha Karanth, PS Mathuranath, Satyapal Goswami, Sonal Chitnis, N Sundar, Suvarna Alladi, Yasmeen Faroqi-Shah Annals of Indian Academy of Neurology 2019 22(2):137-146 A multidisciplinary team of experts took stock of the current state of affairs about many aspects of aphasia in India, including community burden, diagnostic assessment, therapy, rehabilitation, research, education, and advocacy. The broad spectrum of aphasiology was matched by the types of participants ranging from neurologists, speech-language pathologists, clinical psychologists, linguists, to experts in neuroimaging and computer sciences. Threadbare discussion in 16 sessions over 3 days leads to the identification of pressing problems and possible solutions. Many action plans have been envisaged and recommendations made. A few examples with high priority are community-based and hospital-based study incidence and prevalence of aphasia, development of test batteries for the assessment of many components of speech and communication in Indian languages which are validated on rigorous psychometric, and linguistic criteria, national registry for aphasia, educational modules about aphasia for different target groups, resources for advocacy and its training, a bank of research questions and outlines of research protocols for young professionals to pursue. The expert group will continue to oversee execution of some of the actionable plans in short and long term.

Aspirin and clopidogrel resistance in Indian patients with ischemic stroke and its associations with gene polymorphisms: A pilot study Samir Patel, Vandana Arya, Amrita Saraf, Manorama Bhargava, CS Agrawal Annals of Indian Academy of Neurology 2019 22(2):147-152 Introduction: Antiplatelet resistance is one of the urgent issues in current stroke care. One-third to one-half of the patients who experience a recurrent stroke is already on antiplatelet medications. We studied resistance to aspirin and clopidogrel in Indian stroke patients and its association with gene polymorphisms. Methods: Platelet function testing by light transmission aggregometry was performed on 65 patients with ischemic stroke who were stable on dual antiplatelet therapy (clopidogrel 75 mg OD and aspirin 75 mg OD) along with 65 age-matched controls. Aspirin resistance was considered as mean platelet aggregation ≥70% with 10 μM adenosine diphosphate (ADP) and ≥20% with 0.75 mM arachidonic acid. Clopidogrel resistance was defined as <10% decrease from the baseline in platelet aggregation in response to ADP 10 μM and semi-response as <30% decrease from the baseline. Polymorphisms CYP2C19 * 2 and GPIIb/IIIa (PLA1/A2) were genotyped by polymerase chain reaction-restriction fragment length polymorphism. Results: We found 64.6% (42/65) patients with inadequate response to clopidogrel (15.4% [10/65] resistant and 49.2% [32/65] semi-responders) and 4.6% (3/65) patients with inadequate response to aspirin (3.1% [2/65] resistant and 1.5% [1/65] semi-responder). The frequency of CYP2C19*2 mutant genotype was significantly higher in clopidogrel nonresponders compared to responders (P = 0.014). Clopidogrel nonresponsiveness was much higher in small vessel stroke. Conclusion: Unlike aspirin, a high proportion of nonresponders to clopidogrel was identified. In an interim analysis on 65 Indian patients, a significant association was found between CYP2C19*2 and clopidogrel nonresponsiveness.

Scrub typhus-associated opsoclonus: Clinical course and longitudinal outcomes in an Indian cohort Ravikar Ralph, AT Prabhakar, Sowmya Sathyendra, Ronald Carey, John Jude, George M Varghese Annals of Indian Academy of Neurology 2019 22(2):153-158 Context: Opsoclonus, a rare neurological manifestation in scrub typhus, causes significant distress and disability. There is a paucity of clinical data and outcomes in these patients. Aim: This study aims to describe the clinical and laboratory profile and longitudinal outcomes in a scrub typhus patient cohort with opsoclonus. Settings and Design: This retrospective study was conducted in a 2700-bed teaching hospital in South India, in scrub typhus patients with opsoclonus over a 5-year period. Patients and Methods: Clinical, laboratory, and radiological data and outcomes at discharge and 6- and 12-weeks postdischarge were documented. Results: Of 1650 scrub typhus patients, 18 had opsoclonus. 17 had opsoclonus at presentation, while one patient developed opsoclonus on the 5th admission day, 1-day postdefervescence. Opsoclonus was first noted after a median interval of 11 (7–18) days from fever onset. It was associated with myoclonus in 94% (17/18), cerebellar dysfunction in 67% (12/18), extrapyramidal syndrome (EPS) in 33% (6/18), and aseptic meningitis in 17% (3/18) patients. Mean cerebrospinal fluid (CSF) white blood cell (WBC) count was 9 ± 2.7 cells/cumm, with mean CSF protein 118.5 ± 53.9 mg% and mean CSF glucose 97 ± 13 mg% in 1l/15 patients. Brain magnetic resonance imaging was unremarkable in 75% (9/12). Case-fatality rate was 5.5% (1/18). Complete resolution of the index neurological syndrome occurred at 12-week postdischarge. Conclusions: Opsoclonus is a rare neurological manifestation in scrub typhus, usually occurring in association with myoclonus, cerebellar dysfunction, or EPS. It appears to occur during the resolving febrile phase, with neurological deficits completely resolving at 12 weeks.

Study of wrist ratio and wrist-to-palm index radio in individuals suffering from carpal tunnel syndrome Suchitra Sachin Palve, Sachin Bhaskar Palve Annals of Indian Academy of Neurology 2019 22(2):159-163 Background: Carpal tunnel syndrome (CTS) is the commonest median nerve entrapment neuropathy, with preponderance in females. Aims and Objective: The aim of the present study was to find out wrist ratio (WR) and wrist/palm ratio (WPR) in clinically diagnosed patients of CTS. Methodology: One hundred individuals (fifty patients of CTS and fifty as control group) aged between 30 and 50 years were recruited for the study. Early confirmation of clinically suspected patients of CTS was done by performing electrodiagnostic tests of median and ulnar nerves. Motor and sensory conduction velocities, distal motor and sensory latencies, and F-wave latencies were performed in the recruited volunteers. Results: The values for mean wrist ratio in control groups were 0.694, 0.703 respectively, and in patients with carpal tunnel syndrome, it was 0.704 and 0.719 respectively in moderate and severe type. The mean wrist to palm ratio (WPR) in control group was 0.371, while in patients with CTS, it was 0.374, 0.382, 0.387, and 0.401 based on progression of severity. Both were statistically significant for the last two groups (wrist to index finger [WIF] >4.4 m/s, moderate, and WIF nonrecordable, severe). Statistically significant (P < 0.001) decrease of motor conduction velocities for median nerve was seen in the CTS group as compared to control group. Statistically significant (P < 0.001) increase in distal motor and sensory latencies was observed for both median and ulnar nerves in CTS group with more increase in distal motor latency than sensory latency. Increase in F-wave latencies of both nerves was seen in CTS group. Conclusion: The study results confirm selective slowing of sensory and motor conduction within wrist-to-palm segment in patients of CTS. Both WR and WPR have a progressive correlation with the severity of CTS, but statistically significant changes were seen in the groups with moderate and severe CTS. Thus, WR/WPR can act as one of the essential parameters in the diagnosis of CTS with moderate-to-severe CTS.

A study of assessment of knowledge of childhood autism among medical students in Mumbai Samia D Ellias, Henal R Shah Annals of Indian Academy of Neurology 2019 22(2):164-169 Aims: This study is to study the knowledge and awareness on autism among medical students and the factors which impact their knowledge on autism. Settings and Design: For the study, a multicenter cross-sectional research has been carried out among medical students in seven medical colleges in Mumbai. Subjects and Methods: A total of 201 final-year medical students from seven medical colleges in Mumbai completed the knowledge on childhood autism among healthcare workers (KCAHW) survey and a semi-structured pro forma. Of the 201 students, 152 are from the public medical colleges and 37 from the private medical colleges. Statistical Analysis Used: Data collected have been represented in the form of frequency and percentage. SPSS 20.0 is used to analyze the mean distribution of KCAHW scores. A value of P < 0.05 is regarded as statistically significant. Results: The total mean score in the KCAHW questionnaire is 11.85 ± 3.15 out of 19. This is considered as poor knowledge. Our study reveals that students' knowledge on autism is limited. Knowledge gaps identified in certain autism spectrum disorder (ASD) symptoms are associated with the obsessive and compulsive repetitive pattern of behavior and that autism is associated with epilepsies. Conclusions: It is thus important that these children displaying ASD symptoms are diagnosed correctly and at the earliest. To enable this, doctors in all fields must be able to accurately identify the diagnostic features of autism both within and outside the four walls of the hospital.

Storage, degradation, and new connectivity of face-related semantic memory in Alzheimer's disease Sandip Pal, Prasenjit Sengupta, Malay Ghosal, Asutosh Pal, Rudraprasad Acharya, Debsadhan Biswas Annals of Indian Academy of Neurology 2019 22(2):170-174 Background: Excepting amnesia, impairment of other domains also hampers the activity of daily living in Alzheimer's disease (AD). Although prosopagnosia poses problem in interacting with other persons, it rarely causes problem during interaction with close relatives as known voice acts as cue for recognition. Objective: In a cohort of AD, we planned to study errors in recognition, naming, and assigning relationship of close relatives, to assess the type and frequency of errors and to explain with current knowledge and hypothesis. Materials and Methods: This cross-sectional study was conducted in Memory Clinic of Medical College Hospital, Kolkata, India, between July 2013 and June 2015. Patients were evaluated by history, general neurological examination, and neuropsychological tests. A structured questionnaire was used to assess recognition (use of honorifics) and naming defect of close relatives. Results: AD was diagnosed in 42 patients. Prosopagnosia was found in 14 and anomia in 6 patients. Four patients exhibited problem during conversation with close relatives. They assigned name and relation of one generation earlier to close relatives with proper recognitions. Discussion: We got predictive error of name and relation assignment of close relatives by one generation back with normal recognition. It can be explained by two memory traces in connection of face-visual and name (with/without relation) representation, earlier being hierarchically older and more resistant to wearing. Conclusions: We hypothesize that the name/relation store is orderly conserved. In AD, after degradation of part of name/relation store, a new wiring might be built up between these two traces.

Terminal latency index, residual latency, and median-ulnar F-wave latency difference in carpal tunnel syndrome Aslihan Uzunkulaoglu, Sevgi Ikbali Afsar, Betul Tepeli Annals of Indian Academy of Neurology 2019 22(2):175-179 Introduction: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, but no electrodiagnostic test alone shows sufficient sensitivity for CTS. We aimed to investigate the value of median motor terminal latency index (mTLI), median motor residual latency (mRL), and median-ulnar F-wave latency difference (FdifMU) as additional tests to nerve conduction studies which are performed traditionally in electromyography laboratories. Methods: This is a retrospective study. The results of electrodiagnostic studies performed on patients with CTS were examined. We divided the enrolled hands of the patients diagnosed with CTS into two groups: affected hands with abnormal electroneuromyographic parameters indicating CTS diagnosis (CTS group) and hands with normal electroneuromyographic parameters (control group). Then, we analyzed the results of these completed electrodiagnostic studies. Results: A total of 320 hands of 160 patients were studied. FdifMU and mRL were found to be significantly higher in CTS group compared with the control group (P < 0.001). mTLIs were found to be significantly higher in control group compared with the CTS group (P < 0.001). Given that, the area under the curve is more than 70% for mTLI and mRL, but not for FdifMU. Conclusion: When combined with mMDL, both mTLI and mRL have excellent specificity for the diagnosis of mild and moderate CTS. However, the sensitivities for both parameters were lower. In suspected patients, FdifMU can be an additional tool for the diagnosis of CTS also, but alone it is not valuable.

Vasculitic neuropathy: A retrospective analysis of nerve biopsies and clinical features from a single tertiary care center Monalisa Hui, AK Meena, Liza Rajasekhar, Yareeda Sireesha, Jabeen Afshan, Rukmini Mridula, Rupam Borgohain, Megha S Uppin Annals of Indian Academy of Neurology 2019 22(2):180-186 Objective: Vasculitic neuropathy can be either restricted to the peripheral nerves or associated with systemic involvement of other organs. The objective of this study was to analyze the nerve biopsies reported as “vasculitic neuropathy” with clinical features. Materials and Methods: All cases diagnosed with vasculitic neuropathy were retrospectively analyzed and categorized as systemic vasculitis and nonsystemic vasculitic neuropathy based on the clinical features. The histological features were further evaluated and classified according to the Peripheral Nerve Society Guidelines. Results: Of the 126 cases, there were 65 nonsystemic vasculitis, 45 secondary systemic vasculitis, and 16 primary systemic vasculitis. Definite vasculitis was more common in the systemic vasculitis group. The epineurial vessels were predominantly involved with chronic axonal changes. Conclusion: The sensitivity of definite vasculitis on nerve biopsy was 54.76%. The sensitivity increases when the diagnostic criteria of definite and probable vasculitis were applied taking into account perivascular inflammation accompanied by vascular changes and axonopathy.

Dental Research

Role of dentist in genetic counseling: A critical appraisal of the current practices and future requirements in Indian scenario Ruchika Gupta, BR Chandra Shekar, Pankaj Goel, Sudheer Hongal, Rahul Ganavadiya Dental Research Journal 2019 16(3):131-138 Genetic disorders are showing an upward trend. The social and economic impact of genetic disorders on individual, family and society is enormous. There is an urgent need to explore alternate strategies to mitigate the burden of genetic disorders. This is especially true with regard to developing countries such as India where there is a shortage of health personnel adequately trained in genetic counseling at present. Dental professionals have a unique opportunity to observe the development of preadolescent and adolescent patients during periods when important growth and development changes occur. The objective of this study was to review the existing literature on the role of dentist in genetic counseling with a critical appraisal on the current practices among dentists on genetic services in India, the need, scope, and future requirements. The literature on genetic services and genetic counseling was identified by searching the biomedical databases for primary research material by one investigator over a period of 8 weeks. The articles related to dentist's role in genetic counseling were assessed and discussed in the present review. A total of 239 resource materials were retrieved in the initial search. The literature from these sources was thoroughly scrutinized by the authors, and the literature (review articles, descriptive studies, or any form of study) focusing on role of dentist in genetic counseling was finally considered for critical appraisal in the present review. The role of genetics in health and oral health care has not received due attention of the dental practitioners who otherwise are in a crucial position in identifying the patients with genetic disorders and offer requisite counseling and referral to designated genetic centers. The short training courses for practicing dentists, faculty members, and a small change in dental curriculum to make provision for teaching genetics to undergraduate students may go a long way in filling the void created by these obstacles.

Anxiety, depression, and oral health: A population-based study in Southeast of Iran Tayebeh Malek Mohammadi, Amin Sabouri, Salehe Sabouri, Hamid Najafipour Dental Research Journal 2019 16(3):139-144 Background: Depression and anxiety are two psychosocial illnesses that mostly are comorbid. The prevalence of these diseases is increasing worldwide. Both can affect general health also oral and dental health. The effects can be physiological and behavioral. Patients with these disorders are not willing to keep oral hygiene. The purpose of this study was to investigate the association between depression/anxiety and oral health indices in the 15–75-year-old population of Kerman. Materials and Methods: This cross-sectional study recruited 5900 people aged 15–75 years through one-stage cluster sampling (Kerman coronary artery disease risk factors study, KERCADRS). Data were collected through beck questionnaires for anxiety and depression and clinical examinations. Oral health indices including decayed, missing, filled teeth, gingival index (GI), and community periodontal index (CPI) were also measured. Data were analyzed by SPSS 21 software. Chi-square, t-test and regression analysis were used to determine the relationship between the variables. P ≤0.05 was considered as the level of statistical significance. Results: In the study, 1975 (33.6%) of patients showed moderate-to-severe anxiety and 3502 (59.5%) got the scores as depressed. There was a significant difference between GI and CPI indices of the normal and depressed group (P < 0.01), but the difference in the anxious and normal group was not statistically significant (P > 0.05). Conclusion: The results of the study showed a significant relationship between depression and oral health indices but not with anxiety. Therefore, the present study suggests that more attention should be paid to the oral health of people with a history of depression.

A three-dimensional finite element analysis of the influence of varying implant crest module designs on the stress distribution to the bone Shweta Maruti Patil, Abhijit Suresh Deshpande, Rahul Ramesh Bhalerao, Suryakant Bhanudas Metkari, Prithviraj Maruti Patil Dental Research Journal 2019 16(3):145-152 Background: The aim of this study is the effect of stress distribution within the bone with varying implant crest module designs. Materials and Methods: Finite element models of a straight two-piece 4 mm × 13 mm screw-shaped threaded implant with divergent, straight, and convergent implant crest module with their surrounding suprastructure embedded in mandibular second premolar area were created with ANSYS software. Different implant crest module designs incorporated in D2 types of bone under 100N axial and 100N at 20° oblique load were created to evaluate stress distribution in the crestal bone around implant crest module. Results: Maximum von Mises stress was observed at the crestal region of the bone and at crest module region of the implants in all the models. Divergent crest module design shows minimum von Mises stress at crestal bone during vertical loading within bone and at implant crest module. Straight crest module designs result in minimum stresses during oblique loading than vertical loading. Convergent crest module design shows maximum von Mises stress. Conclusion: Within limitations of the study, it was concluded that stress distribution in adjacent compact bone is greatly influenced by implant crest module design. Divergent crest module designs result in minimum stresses at crestal bone and in the implant crest module region, followed by straight and convergent crest module in ascending order of stress distribution.

The antibacterial activity of "Satureja hortensis" extract and essential oil against oral bacteria Leila Golpasand Hagh, Atefe Arefian, Ahmad Farajzade, Sana Dibazar, Neda Samiea Dental Research Journal 2019 16(3):153-159 Background: Recently, there has been an increasing growth in research on medical plant's effect on dental plaque bacteria. The aim of this study was to determine the antibacterial effects of Satureja hortensis extract and its essential oil (EO) on Streptococcus salivarius, Streptococcus sanguis, and Streptococcus mutans as important bacteria in early supragingival dental plaque formation. Materials and Methods: In this in vitro study, different concentrations of S. hortensis extract and its EO were prepared using double dilution method. The disc diffusion method was used to determine antibacterial activity. Based on these measurements, the minimal inhibitory concentration value was reported for each bacterium. Antibiotics used as positive controls in this study were erythromycin (15 μg) and tetracycline (30 μg). t-test and ANOVA were used for statistical analysis (P < 0.05). Results: Aqueous and methanolic extract did not show significant antibacterial activity, but the EO significantly inhibited the growth of the test bacteria compared to positive control (P < 0.05). High concentrations of EO processed greater antimicrobial effects against three oral bacteria than other low concentrations (P < 0.0001). For S. mutans, the inhibition effect of tetracycline 30 μg was similar with 50% (P = 0.789) and 25% (P = 0.158) dosages of the EO. For S. salivarius, the effect of tetracycline 30 μg was similar to 50% dosages of the EO (P = 0.122). For S. sanguis, the effect of erythromycin 15 μg was lower than 50% (P = 0.0006) and 25% (P = 0.003) dosages of the EO. The inhibition effects of all concentrations of EO were higher for S. sanguis. S. salivarius and S. sanguis are more sensitive than S. mutans to S. hortensis EO. Conclusion: Due to the strong antibacterial effect of S. hortensis EO on the oral bacteria growth, it can be served as herbal mouth rinse, while to confirm this antibacterial effect, further clinical studies are necessary.

The coronal pulp cavity index: A forensic tool for age determination in adults Swati Shrikant Gotmare, Tanmik Shah, Treville Periera, Mandavi S Waghmare, Subraj Shetty, Sushama Sonawane, Maina Gite Dental Research Journal 2019 16(3):160-165 Background: Various biochemical and histological methods are available for human age determination which are invasive and may require extraction of teeth. The present study aims to assess the accuracy of age estimation from tooth-coronal index (TCI) of known age and sex individuals and to present a noninvasive method for age estimation. Materials and Methods: This retrospective study comprised 88 patients, which included 54 males and 34 females. An orthopantomogram of these individuals were taken, and premolars and molars in the same were evaluated. The height of the crown (coronal height [CH]) and the height of the coronal pulp cavity (coronal pulp cavity height [CPCH]) was digitally measured on the computer screen. The TCI given by Ikeda et al. in 1985 (TCI = [CPCH × 100]/CH.) was computed on each tooth and regressed on real age of the sample. The mean, median, range, and standard deviation of the computed index were calculated. The correlation between the actual age and the estimated age was calculated using t-test. P < 0.05 was considered significant. Results: Results revealed that there is a significant correlation between the TCI with age. Increase in TCI observed with age; however, it showed no significant sex difference. Conclusion: TCI is a precise, noninvasive and easily used reliable biomarker for age estimation and is applicable to both living and dead individuals.

In vitro evaluation of dentin tubule occlusion by three bioactive materials: A scanning electron microscopic study Maryam Ghafournia, Maryam Hajnorouzali Tehrani, Afsaneh Nekouei, Reyhaneh Faghihian, Mehrnaz Mohammadpour, Atiyeh Feiz Dental Research Journal 2019 16(3):166-171 Background: Dentin hypersensitivity (DH) is a common problem characterized by a short, sharp pain. Reduction of dentin permeability by occluding dentin tubules is considered as a method for treating DH. Many substances are available to decrease hypersensitivity. The aim of this study is to evaluate the ability of three different remineralizing agents for occluding dentinal tubules in comparison with positive and negative controls. Materials and Methods: In this in vitro scanning electron microscopic (SEM) study, 75 extracted premolars were cut into crown and root fragments with a bur and divided into five groups: group 1: Sodium fluoride 5% varnish was applied (positive control), Group 2: No treatment (negative control), Group 3: Treated with Remin Pro (contains hydroxyapatite and fluoride), Group 4: Treated with MI paste (contains casein phosphopeptide-amorphous calcium phosphate [CPP-ACP]) and Group 5: Treated with GC tooth mousse (contains CPP-ACP). SEM images were obtained and mean tubular diameter was measured in each group. One-way ANOVA and Duncan's tests were used for statistical analysis. A significant level of α = 0.05 was set for comparison between the groups. Results: Statistically significant difference was observed between Group 2 (negative control) and other four groups (P < 0.05). There was no significant difference between Groups 1, 3, 4, and 5 (P > 0.05). Conclusion: Under the limitations of the present in vitro study, it can be concluded that the application of a CPP-ACP paste as well as a paste which contains fluoride is effective on reduction of dentin permeability.

Effectiveness of placement of second miniplates as tension band unit in mandibular parasymphysis fractures Javad Yazdani, MohamadAli Ghavimi, Mahsa Taghizadeh, Yousef Kananizadeh, Milad Ghanizadeh Dental Research Journal 2019 16(3):172-178 Background: The ideal position of the plates and the need for additional plates are discussed continuously. In mandible, the tensile forces at the fracture line should be neutralized with a tension band. This study evaluated the role of the mandibular arch bar as a tension band eliminating the need for an upper miniplate (tension band plate) in cases of parasymphysis fractures. Materials and Methods: In this randomized control trial, a total of 90 patients with mandibular parasymphysis fractures underwent treatment in two groups. Group A was treated with one titanium miniplate along with Erich's arch bar. In Group B, two titanium miniplates were placed across the fracture site along with Erich's arch bar. Then, the complications and duration of the operation time were compared between two groups. The results were considered statistically significant when the P < 0.05. Results: No significant difference was observed between the groups regarding postoperative complication rate. 1 month after surgery in Group A, number of patients with sensory impairment (17%) was significantly lower than Group B (37%) (P = 0.029). Furthermore, the operation time of Group A was significantly shorter than Group B (P < 0.001). Conclusion: In the presence of arch bar, placing one miniplate instead of the routine technique of placing two, do not increase complication rates. Furthermore, it reduces the operation time and costs and results in a better neurosensory recovery outcome in short time.

In vitro effect of XP-Endo finisher on the amount of residual debris and smear layer on the root canal walls Shahrzad Azimian, Hengameh Bakhtiar, Shahram Azimi, Ehsan Esnaashari Dental Research Journal 2019 16(3):179-184 Background: A successful endodontic treatment depends on efficient cleaning and shaping and effective irrigation of root canals. The irrigating solution may not be effective in some areas in the canal. The manufacturer of XP-Endo finisher claims that it can effectively clean the root canals with complex morphology. This study aimed to assess the effect of XP-Endo finisher on the amount of residual debris and smear layer on the root canal walls of mandibular second premolars. Materials and Methods: In this In vitro study Fifty extracted mandibular second premolars with a root curvature <20° were collected. Root canals were prepared using BioRaCe rotary system. The root canals were in contact with the file and different irrigating solutions for 1 min. The teeth were then randomly divided into four experimental (n = 10) and one positive control group as follows: (1) XPF + saline, (2) XPF + ethylenediaminetetraacetic acid (EDTA), (3) XPF + sodium hypochlorite (NaOCl), (4) XPF + EDTA + NaOCl and (control) EDTA + NaOCl. The teeth were longitudinally sectioned into two halves and the amount of debris and smear layer remaining in the coronal, middle, and apical thirds of the roots was quantified and scored under an electron microscope. The Kruskal–Wallis test was used to compare the groups, and P < 0.05 was considered statistically significant. Results: The highest mean amount of residual debris (2.9 ± 1.13) was noted in XPF + saline group (P < 0.05). XPF + saline and XPF + NaOCl (3.8 ± 0.60) had the lowest efficacy for smear layer removal (P < 0.05) with no significant within-group difference. No significant difference was noted between Groups 2, 3, and 4 with the positive control group regarding debris removal. Groups 2 and 4 had no significant difference with the positive control group regarding smear layer removal. Conclusion: Use of XP-Endo finisher has no superiority to the standard protocol for the use of irrigating solutions (EDTA + NaOCl) for debris and smear layer removal, but in some cases, such as second appointment of regeneration treatment we cannot use NaOCl because of its destructive effects on stem cells; thus, we can benefit from the synergistic effects of XPF and EDTA for better smear layer removal.

Comparison of color stability and fracture resistance of two temporary fiber-reinforced fixed partial denture materials Ramin Mosharraf, Pirouz Givehchian, Farzin Ansaripour Dental Research Journal 2019 16(3):185-192 Background: Temporary crown and bridge materials have to fulfill a couple of important functions within the timeframe between tooth preparations until luting of the definitive restoration. The aim of the current study was to evaluate the color stability and fracture resistance of two fiber-reinforced provisional fixed partial denture (FPD) materials. Materials and Methods: In this in vitro study Using a plexiglass mold, 96 bar-shaped specimens (4 mm × 2 mm × 20 mm) were fabricated and divided into four groups (n = 24): nonreinforced composite (NRC) resin, glass fiber-reinforced composite resin (RC), nonreinforced polymethylmethacrylate (PMMA), and glass fiber-reinforced PMMA. Values of CIEL*a*b* were recorded for all the samples. Then, the samples were immersed in coffee, chlorhexidine mouthrinse, and distilled water. After 1 day and 1 and 4 weeks, CIEL*a*b* values were recorded again and color differences (ΔE) were calculated. All the specimens immersed in distilled water were then subjected to force to measure their fracture resistance. Data were analyzed with one-way ANOVA, honestly significant difference Tukey tests, and paired t-test (α = 0.05). Results: The NRC group, immersed in coffee for 1 month, exhibited the highest ΔE (17.1 ± 0.69) and the lowest ΔE belonged to the RC group immersed in water for 1 day. The RC group, immersed in water, exhibited the highest fracture resistance. Conclusion: Coffee is considered as one of the most important factors affecting color changes in provisional FPDs, either in composite resins or in PMMAs. Fracture resistance of both composite resin and PMMA FPDs revealed no significant differences between the groups; however, there were significant differences between the nonreinforced and fiber-reinforced FPDs in both groups.

Effect of ceramic translucency and luting cement shade on the color masking ability of laminate veneers Bassem S. M. Kandil, Amena M Hamdy, Ahmed K Aboelfadl, Mohamed I El-Anwar Dental Research Journal 2019 16(3):193-199 Background: The aim of this study was to evaluate the effect of ceramic material types, degree of veneer translucency, and luting cement shades on masking the underlying dark dental substrate to achieve best esthetics. Materials and Methods: In this in vitro study, 56 specimens each of 0.5-mm thickness were fabricated from two esthetic veneer materials Vita Enamic and Vita Suprinity, with two different translucencies, i.e., HT and T. To simulate the color of a dark underlying dental structure, background discs with C3 shade were fabricated using resin composite. The ceramic specimens with varying translucencies were cemented on the dark background of the resin composite with A1 and opaque white shades of resin luting cement. Color difference (ΔE) values from a reference color (A1 shade) were calculated using a spectrophotometer. The results were then statistically analyzed using three-way ANOVA test (α = 0.05). Results: The ΔE values of both ceramic systems were affected by both the degree of veneer translucency (P = 0.00) and the luting agent shade (P = 0.016). The use of an opaque luting agent and T translucency resulted in a decrease in the ΔE* values for all ceramics tested, regardless to the material type. Suprinity and Enamic showed similarity in the masking ability of dark substrate after cementation. Conclusion: None of the 0.5-mm veneers of the two ceramic systems could reach A1 shade without a detectable color difference after cementation. The change in degree of veneer translucency was more effective than the change in luting agent shade in masking the underlying dark substrate.

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.