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Pheochromocytoma is a rare tumor of adrenal gland, treatable, curable cause of hypertension and may lead to premature death if not treated early. Medical management by multidisciplinary team is essential for hemodynamic stability during the perioperative period. General anaesthesia with thoracic epidural block offers adequate stress control as hemodynamic fluctuations are quite common and significant during induction, peritoneal insufflation and tumor manipulation. Newer modalities of diagnosis, short acting drugs to control hypertension, vigilant anaesthetic management with beat to beat monitoring of hemodynamics significantly improves patient’s safety. Laparoscopic mobilisation of the adrenal helps in minimal manipulation of the tumour and thus minimising the resultant catecholamine surge. However, hypotension upon ligation of adrenal vein is inevitable. Noradrenaline (NA) remains the vasopressor of choice which has to be continued post operatively. A thorough pre-anaesthetic evaluation, preparation and execution with a multimodal analgesic pain management in a high dependency unit aid in early ambulation and discharge of the patient. Keywords: Adrenal tumour, Catecholamine, Laparoscopy, Multiple Endocrine Neoplasia. more...

According to the latest statistics of the World Health Organization (WHO), approximately 260 million people suffer from respiratory problems such as asthma or chronic obstructive pulmonary disease (COPD). The research work focuses on developing a smartphone-based wireless handheld unit that can be attached to the asthma inhaler for measuring the intensity of respiratory diseases and tracking the lung reaction to treatment. The work provides a low-cost design to develop an ultrasonic data acquisition module for determining the breathed airflow rate and the utmost expelled air volume. This device helps in achieving the detailed analysis of parameters associated with measurements including its graphical plots. This has the advantage of using ultrasonic technology to measure airflow without moving parts, thereby eliminating inaccuracy due to instrument errors. The research also focuses on real-time tracking of the atmospheric vital parameters such as temperature, humidity, and gas contents that trigger these respiratory diseases. These vital parameters are recorded, and the inhaler unit gives a warning or alert regarding the surrounding air quality of the patient. All these real-time recorded airflow rate parameters of the patient and environmental triggers are sent to the cloud so that they can be accessed by the physician on a smartphone for easy diagnosis. The system design is also capable of displaying the balance medicine left in the inhaler which helps the patient to act accordingly. more...

A typical antipsychotics are at a lower risk of developing extra-pyramidal symptoms (EPS). But now, atypical antipsychotics are increasingly being associated with neurological side effects such as tardive dyskinesia, tardive dystonia, akinesia, parkinsonism, akathisia, bradykinesia, tremor etc. in which one of the major cases reported is Olanzapine induced tardive dyskinesia (TD). Schooler and Kane criteria is used for diagnosing tardive dyskinesia. Many cases have been published on this particular drug-induced side effect. In many instances tardive dyskinesia is misdiagnosed as tardive dystonia. Here we report the case of tardive dyskinesia associated with the use of antipsychotic drugs in a 50-year-old adult male suffering from persistent delusional disorder in a tertiary health care centre in India. The patient was on Olanzapine therapy for more than 2 years. Upon recurrent episodes of somatic delusions, Olanzapine dose was increased. When the patient developed symptoms of TD, the dose of Olanzapine was de-escalated. Even though the drug dose was reduced, the symptoms persisted which lead to the diagnosis of olanzapine induced TD. Based on this, Olanzapine was stopped and Clozapine treatment was initiated. On follow up, the patient was found to be relieved of the symptoms and complete recovery was achieved after 2 months of clozapine treatment. more...

Background Castleman’s disease is a rare lymphoproliferative disease which can mimic other malignant tumours and can be associated with paraneoplastic pemphigus especially in the paediatric age group. This presentation can be challenging even to the seasoned anaesthesiologist when it comes to managing such a case presenting for laparotomy. Case presentation Here such a case in a 12-year-old who was initially diagnosed as retroperitoneal sarcoma complicated with paraneoplastic pemphigus and inferior venacaval thrombus is presented and its anaesthetic management and challenges are discussed. Special care needs to be taken while anaesthetizing such a patient keeping in mind the difficult airway, adrenocortical suppression, and exacerbation of skin lesions due to various anaesthetic procedures. For this case, the histopathology turned out to be Castleman’s disease. Conclusion The anaesthetic challenges associated with paraneoplastic pemphigus in paediatric age group receiving perioperative thromboprophylaxis need special mention. Here we are discussing the challenges and anaesthetic management of such a case as literature on this aspect is few. more...

SUMMARYSynthetic biology has established powerful tools to precisely control cell function. Engineering these systems to meet clinical requirements has enormous medical implications. Here, we adopted a clinically driven design process to build receptors for the autonomous control of therapeutic cells. We examined the function of key domains involved in regulated intramembrane proteolysis and showed that systematic modular engineering can generate a class of receptors we call SyNthetic Intramembrane Proteolysis Receptors (SNIPRs) that have tunable sensing and transcriptional response abilities. We demonstrate the potential transformative utility of the receptor platform by engineering human primary T cells for multi-antigen recognition and production of dosed, bioactive payloads relevant to the treatment of disease. Our design framework enables the development of fully humanized and customizable transcriptional receptors for the programming of therapeutic cells suitable for clinical translation. more...

Intratracheal (IT) and intravenous (IV) lignocaine suppress airway reflex and hemodynamic response during extubation, but studies regarding this are sparse. The primary aim was to compare the effect of IT and IV lignocaine on attenuation of airway reflex to endotracheal extubation and the secondary aim was to compare the hemodynamic responses to extubation, using lignocaine by the two different routes.Seventy-five female patients with comparable age, body mass index, and American Society of Anesthesiologists Physical Status undergoing carcinoma breast surgery were randomized into three groups. Group A received 2% lignocaine 3 mg/kg intratracheally 5 min and Group B received 2% lignocaine 1.5 mg/kg intravenously 3 min before extubation. Group C was control group. The airway and hemodynamic responses were noted in terms of episodes of cough during emergence and extubation. Categorical variables assessed using Fisher's exact test and continuous variables assessed using one-way analysis of variance.Cough suppression was present in Groups A and B, with better results observed with IT than with IV lignocaine. In the control group, Grade III cough reflex was present predominantly. There was a statistically significant difference (p0.001) in blood pressure and heart rate between Group A versus Group C and in Group B versus Group C, but not between Group A and Group B.IT lignocaine administered before extubation significantly attenuates post-extubation cough reflex than IV lignocaine. Both IT and IV lignocaine can effectively attenuate the airway and hemodynamic response to extubation. more...

A prospective observational cohort study was conducted on 144 patients admitted with UTI for a period of 1 year and observed for the recurrence for next 1year. The objective was to study the antibiotic resistance pattern of uropathogens in UTI and to assess the antimicrobial utilization pattern in the pediatric ward of a tertiary care hospital. The confirmatory test used for UTI was urine culture. The most common causative agent for UTI was found to be Escherichia coli followed by Klebsiella. Antibiotic testing of E.coli and other isolates was done which showed greater sensitivity to meropenem and amikacin compared to other antibiotics tested. This isolates showed increasing resistance to commonly used antibiotics. Most of the children (74.31%) were treated with a single antimicrobial agent. Cephalosporins (n = 87; 60.41%) were prescribed to majority of the children, followed by Penicillin derivatives (n = 42; 29.17%) and Carbapenems (n = 16; 11.11%). The percentage of antimicrobials administered by parenteral route was found to be 79.17%. The major problems encountered in the management are relapse of UTI and treatment failure. Out of 144 children, 40 children had recurrent UTI. Among them for 25 children, antibiotics were not given according to the culture sensitivity pattern during their first UTI. Recurrent UTI can occur if adequate antimicrobial therapy based on antimicrobial susceptibility test is not given during initial UTI. This demonstrates the need for rational use of antimicrobials and judicious prescribing. The implementation of antibiotic policy and treatment guidelines based on regional data on antimicrobial susceptibility of uropathogens with periodic assessment of the clinical pharmacist in the study area is recommended. more...

The fat-soluble vitamin D is synthesized when the ultraviolet rays strike the surface of skin. The relationship between cardiovascular disease mainly arterial hypertension with low vitamin D levels is supported by literature. It has been observed that arterial hypertension has been associated with low levels of vitamin D. Obesity and reduced sunlight exposure are factors associated with lower serum vitamin D levels. Isolated systolic hypertension has been associated with vitamin D deficiency and insufficiency. Protective mechanism implicated in lowering the blood pressure is the suppression of renin angiotensin aldosterone pathway with optimal vitamin D levels. But randomised controlled trials are necessary to clarify whether vitamin D supplementation is beneficial in the control of blood pressure; as the results of many studies do not consistently favor the association of low vitamin D levels with hypertension. more...

Tubercular meningitis (TBM) constitute 5% of all cases of extra pulmonary tuberculosis but a presentation leading to an ischemic stroke in a young adult is a rare clinical entity. In a case of TB vasculopathy, vasculitis, venous thrombosis and aneurysm may be the underlying events leading to a stroke. Stroke in TBM is seen in the tubercular zone which encompasses internal capsule, thalamus and caudate nucleus. Inflammatory mediators like TNF alpha, Interferon gamma and vascular endothelial growth factor have been implicated in the pathogenesis of arteritis. Imaging modalities like MRI show lesions which are usually bilateral in the territory of the perforating vessels. We report a case of 24 year old Asian male who presented with complaints of headache, projectile vomiting and altered sensorium. On examination his Glasgow Coma Scale (GCS) was 10/15, with left oculomotor and left facial nerve palsy, and hypotonia of all 4 limbs with bilateral plantar reflexes being mute. Contrast MRI of brain showed acute infarct, meningeal enhancement and basal exudates. He was started on Anti-tubercular therapy and steroids, but had a poor clinical outcome, due to his late presentation. more...

Background: Vitamin D, a fat-soluble vitamin is produced when ultraviolet rays from sunlight strike the skin. Literature data supports, there is a relationship between low vitamin D and pathogenesis of cardiovascular diseases and arterial hypertension. It had been seen that lower circulating 25(OH)D levels were associated with higher blood pressures. Aim was to study the correlation between serum vitamin D3 levels and blood pressure in patients with essential hypertension and normotensive individuals.Methods: An observational study was conducted on 60 individuals in the OPD at MGMCRI between January 2018 and December 2018. Based on history and blood pressure values (JNC 7), the population was divided into cases and controls in accordance with the age and sex. Serum Vitamin D levels were measured by chemiluminescence assay and classified into deficiency ( more...

Background context Transforaminal lumbar interbody fusion (TLIF) is increasingly popular for the surgical treatment of degenerative lumbar disease. The optimal construct for segmental stability remains unknown. Purpose To compare the stability of fusion constructs using standard (C) and crescent-shaped (CC) polyetheretherketone TLIF cages with unilateral (UPS) or bilateral (BPS) posterior instrumentation. Study design Five TLIF fusion constructs were compared using finite element (FE) analysis. Methods A previously validated L3–L5 FE model was modified to simulate decompression and fusion at L4–L5. This model was used to analyze the biomechanics of various unilateral and bilateral TLIF constructs. The inferior surface of the L5 vertebra remained immobilized throughout the load simulation, and a bending moment of 10 Nm was applied on the L3 vertebra to recreate flexion, extension, lateral bending, and axial rotation. Various biomechanical parameters were evaluated for intact and implanted models in all loading planes. Results All reconstructive conditions displayed decreased motion at L4–L5. Bilateral posterior fixation conferred greater stability when compared with unilateral fixation in left lateral bending. More than 50% of intact motion remained in the left lateral bending with unilateral posterior fixation compared with less than 10% when bilateral pedicle screw fixation was used. Posterior implant stresses for unilateral fixation were six times greater in flexion and up to four times greater in left lateral bending compared with bilateral fixation. No effects on segmental stability or posterior implant stresses were found. An obliquely-placed, single standard cage generated the lowest cage-end plate stress. Conclusions Transforaminal lumbar interbody fusion augmentation with bilateral posterior fixation increases fusion construct stability and decreases posterior instrumentation stress. The shape or number of interbody implants does not appear to impact the segmental stability when bilateral pedicle screws are used. Increased posterior instrumentation stresses were observed in all loading modes with unilateral pedicle screw/rod fixation, which may theoretically accelerate implant loosening or increase the risk of construct failure. more...

The biomechanical fixation strength afforded by pedicle screws has been strongly correlated with bone mineral density. It has been postulated that "hubbing" the head of the pedicle screw against the dorsal laminar cortex provides a load-sharing effect, thereby limiting cephalocaudad toggling and improving the pullout resistance of the pedicle screw.To evaluate the pullout strength (POS) of monoaxial hubbed pedicle screws versus standard fixation in the thoracic spine.Biomechanical investigation.Twenty-two human cadaveric thoracic vertebrae were acquired and dual-energy X-ray absorptiometry scanned. Osteoporotic (n = 16) and normal (n = 6) specimens were instrumented with a 5.0 × 35-mm pedicle screw on one side in a standard fashion. In the contralateral pedicle, 5.0 × 30-mm screw was inserted with hubbing of the screw into the dorsal lamina. A difference in screw length was used to achieve equivalent depth of insertion. After 2,000 cycles of cephalocaudad toggling, screws were pulled out with the tensile force oriented to the midline of the spine and peak POS measured in newtons (N). Four additional specimens were subjected to microcomputed tomography (micro-CT) analysis to evaluate internal pedicle architecture after screw insertion.Hubbed screws resulted in significantly lower POS (290.5 ± 142.4 N) compared with standard pedicle screws (511.5 ± 242.8 N; p = .00). This finding was evident in both normal and osteoporotic vertebrae based on independent subgroup post hoc analyses (p.05). As a result of hubbing, half of the specimens fractured through the lamina or superior articular facet (SAF). No fractures occurred on the control side. There was no difference in mean POS for hubbed screws with and without fracture; however, further micro-CT analysis revealed the presence of internal fracture propagation for those specimens that did not have any external signs of failure.Hubbing pedicle screws results in significantly decreased POS compared with conventional pedicle screws. Hubbing predisposes toward iatrogenic fracture of the dorsal lamina, transverse process, or SAF during insertion. more...

Dermatitis and pimples vulgaris is regular place pores and skin issue, occurring in around 85– 95% of young people. It is related with filaggrin gene and Propionibacterium acnes contamination individually. Our motivation of present research is to outline new cream which diminish Itching because of Dermatitis and follow up on skin break out Vulgaris. Following cream is unpredictable total of Salicylic corrosive and retinol which benefits as wonderful pores and skin treatment. The patch test for affectability testing has additionally been proficient and no confirmation of pores and skin irritation and unfavorably susceptible signs and side effects likewise stability testing of cream test has been directed in the natural chamber with temperature 25 ± 10C and mugginess 60 ± 10% RH. the merchandise no flag of segment partition and no exchange inside the shading. The work essentially centers around microbial quality control and Dermatitis enthusiasm of planned cream. In future this detailed cream will convey promises to healthy skin and Anti – Itching with mending impacts. more...

Some postoperative complications after anterior cervical fusions have been attributed to anterior cervical plate (ACP) profiles and the necessary wide operative exposure for their insertion. Consequently, low-profile stand-alone interbody spacers with integrated screws (SIS) have been developed. Although SIS constructs have demonstrated similar biomechanical stability to the ACP in single-level fusions, their role as a stand-alone device in multilevel reconstructions has not been thoroughly evaluated.To evaluate the acute segmental stability afforded by an SIS device compared with the traditional ACP in the setting of a multilevel cervical arthrodesis.In vitro human cadaveric biomechanical analysis.Thirteen human cadaveric cervical spines (C2-T1) were nondestructively tested with a custom 6 df spine simulator under axial rotation, flexion-extension, and lateral bending loading. After intact analysis, eight single-levels (C4-C5/C6-C7) from four specimens were instrumented and tested with ACP and SIS. Nine specimens were tested with C5-C7 SIS, C5-C7 ACP, C4-C7 ACP, C4-C7 ACP+posterior fixation, C4-C7 SIS, and C4-C7 SIS+posterior fixation. Testing order was randomized with each additional level instrumented. Full range of motion (ROM) data were obtained and analyzed by each loading modality, using mean comparisons with repeated measures analysis of variance. Paired t tests were used for post hoc analysis with Sidak correction for multiple comparisons.No significant difference in ROM was noted between the ACP and SIS for single-level fixation (p.05). For multisegment reconstructions (two and three levels), the ACP proved superior to SIS and intact condition, with significantly lower ROM in all planes (p.05). When either the three-level SIS or ACP constructs were supplemented with posterior lateral mass fixation, there was a greater than 80% reduction in ROM under all testing modalities (p.05), with no significant difference between the ACP and SIS constructs (p.05).The SIS device may be a reasonable option as a stand-alone device for single-level fixation. However, SIS devices should be used with careful consideration in the setting of multilevel cervical fusion. However, when supplemented with posterior fixation, SIS devices are a sound biomechanical alternative to ACP for multilevel fusion constructs. more...

Objectives. Previous research has indicated a high incidence of cetuximab hypersensitivity reactions in the southern US. This study documents the incidence of hypersensitivity reactions in North Carolina, and explores whether factors such as patient demographics, allergy history, premedications, and cancer type are potential predictors for cetuximab reactions. Methods. This retrospective chart review consisted of 72 consecutively treated patients from Duke University’s Morris Oncology treatment center between September 2005 and August 2007. Data regarding stage of malignancy, premedications, and hypersensitivity reactions were collected from electronic databases. The number and type of reactions were characterized. Patients with and without hypersensitivity reactions were compared using bivariate statistics and multivariate logistic regression. Results. Of the 72 patients, 21 (29%) experienced hypersensitivity reactions. The majority of reactions (62%) were grades III or IV. Of the 21 patients having a reaction, 9 (43%) were sent to the emergency room and 5 (24%) had an overnight hospitalization. Three hospitalized patients were admitted to the intensive care unit. Both male gender (p = 0.039) and head/neck cancer (p = 0.014) were related to an increased likelihood of hypersensitivity reaction in bivariate analyses. In multivariate analyses, controlling for demographics, allergy history, premedications, and cancer type/stage, only type of cancer was predictive of hypersensitivity reaction (colon vs head/neck OR = 0.177; 95% CI 0.036—0.858). Conclusion. This study confirms a high rate of cetuximab hypersensitivity reactions in a southern region of the US. Patients with head/neck cancers were significantly more likely to have hypersensitivity reactions than patients with colon cancers. J Oncol Pharm Practice (2011) 17: 125—130. more...

A promising therapeutic approach to diminish pathological inflammation is to inhibit the synthesis and/or biological activity of macrophage migration inhibitory factor (MIF). Prior studies have shown that intraperitoneal administration of small-molecule inhibitors targeting the catalytic pocket of MIF (e.g., ISO-1) elicits a therapeutic effect in mouse inflammation models. However, it remains to be elucidated whether these tautomerase activity inhibitors block the synthesis and/or biological activity of MIF. In this study, we investigated and compared the activity of representative MIF inhibitors from isoxazole series (fluorinated analog of ISO-1; ISO-F) and substituted quinoline series (compound 7E; 7E). Our results demonstrate that ISO-F is a more potent MIF inhibitor than 7E. Both ISO-F and 7E do not inhibit MIF synthesis but "bind-onto" MIF thereby blocking its recognition. However, in contrast to 7E, ISO-F docks well in the active site of MIF and also has a stronger binding affinity towards MIF. In line with these observations, ISO-F, but not 7E, robustly inhibits the biological function of MIF. Most importantly, ISO-F, when administered orally in a therapeutic regimen, significantly suppresses dextran sulphate sodium (DSS)-induced murine colitis. This study, which provides mechanistic insights into the anti-inflammatory efficacy of ISO-F, is the first documented report of in vivo anti-inflammatory efficacy of a MIF inhibitor upon oral administration. Moreover, the findings from this study reinforce the potential of catalytic site of MIF as a target for eliciting therapeutic effect in inflammatory disorders. Compounds (e.g., ISO-F) that block not only the recognition but also the biological function of MIF are potentially attractive for reducing pathological inflammation. more...