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Cystic fibrosis-related diabetes (CFRD) is a well-known comorbidity among the CF population. To investigate whether CFRD impacts health-related quality of life (HRQoL), domain scores from the Cystic Fibrosis Questionnaire-Revised for adolescents and adults over 14 years old (CFQ-R 14+) were compared between CF individuals with CFRD on insulin, CFRD not on insulin, impaired glucose tolerance, and normal blood glucose tolerance. The median score for the Treatment Burden domain was significantly worse for individuals with CFRD on insulin (p 0.001) compared to the other diagnostic groups, and this association remained significant following adjustment for confounding variables. In conclusion, the additional requirement for insulin significantly contributes to treatment burden in adults with CFRD and therefore novel strategies to reduce treatment burden for this group are urgently needed.

Background and aims To determine whether the addition of dexmedetomidine either in peripheral block or via systemic route leads to prolongation of the duration of analgesia is inconclusive. The present study aimed to assess the duration of postoperative analgesia with dexmedetomidine used as an additive with bupivacaine for ultrasound-guided femoral nerve block (FNB) and to compare it with intramuscular dexmedetomidine along with FNB. Material and methods A prospective, double-blind randomized clinical trial involving adult patients undergoing elective hip surgery, performed under subarachnoid block. When sensory block receded to T12 after the surgery, FNB was given for postoperative analgesia. Patients were randomized into three groups; Group A received FNB with 40 mL 0.25% bupivacaine and 0.5 mL saline as IM injection, Group B received FNB with 39.5 mL of 0.25% bupivacaine + 0.5 mL (50 mcg) of dexmedetomidine in the affected limb and 0.5 mL saline IM injection, and Group C received FNB with 40 mL of 0.25% bupivacaine and 0.5 mL (50 mcg) of dexmedetomidine as IM injection. Postoperative pain was assessed and for pain with VAS score >3, intravenous tramadol was given as rescue analgesia. Chi-square test for categorical variables and one-way ANOVA for continuous variables. Results The mean duration of analgesia in groups A, B, and C was 671, 676, and 490 min, respectively which was not significant. A 24 h analgesic requirement was also not different between the groups. Conclusion The use of dexmedetomidine perineurally or systemically did not prolong the duration of analgesia as compared to bupivacaine alone for femoral nerve block.

A 50-year-old male was admitted to Intensive Care Unit with head and chest injury needed multiple central venous catheter (CVC) for the long-term intravenous access. Right internal jugular vein was cannulated uneventfully, and the tip of CVC was confirmed in the chest radiograph along the right border of the mediastinum. After few days, left subclavian vein was cannulated and the procedure was uneventful. However, the postprocedure Chest X-ray showed the CVC along the left border of mediastinum rather than the right border. Possibility of CVC in one of the tributaries of left brachiocephalic vein was thought. Due to uncertainty in position of left CVC, we inserted CVC in right-sided subclavian vein, which was in normal position along the right border of mediastinum. Left subclavian CVC was removed. Reviewing the patient's thoracic computed tomography scan revealed, patient had congenital anomaly and double superior vena cava that explained the abnormal course of left subclavian CVC along the left border of mediastinum.

A planar support for a hypergraph is a planar graph that captures the structural properties of the hypergraph. In this paper, we show, using elementary techniques, that a wide class of geometric hypergraphs of planar non-piercing regions admit a planar support. We also discuss some direct consequences of our results.

Aims The aim of this study was to evaluate improvements in the quality and safety of paediatric spinal surgery following the implementation of a specialist Paediatric Spinal Surgical Team (PSST) in the operating theatre. Patients and Methods A retrospective consecutive case study of paediatric spinal operations before (between January 2008 and December 2009), and after (between January 2012 and December 2013) the implementation of PSST, was performed. A comparative analysis of outcome variables including surgical site infection (SSI), operating time (ORT), blood loss (BL), length of stay (LOS), unplanned staged procedures (USP) and transfusion rates (allogenic and cell-saver) was performed between the two groups. The rate of complications during the first two postoperative years was also compared between the groups. Results There were 130 patients in the pre-PSST group and 277 in the post-PSST group. The age, gender, body mass index (BMI), preoperative Cobb angle of the major curve and the number of levels involved were similar between the groups. There were statistically significant differences in SSI, ORT, LOS, allogenic blood transfusion volume (ABTV), and USPs between the groups. There was a 94% decrease in the rate of SSI's in the post-PSST group. Patients in the post-PSST group had a mean reduction in ORT of 53 minutes (sd 7.7) (p = 0.013), LOS by 5.4 days (sd 1.8) (p = 0.019), and ABTV by 226.3 ml (sd 28.4) (p < 0.001). There were significantly more USPs in the pre-PSST group (6.2%) compared with the post-PSST group (2.9%) (p = 0.001). Multivariate regression showed that the effect of PSST remained significant for ORT, LOS, BL, ABVT and cell-saver amount transfused (p = 0.0001). The odds of having a SSI were tenfold higher and the odds of receiving a blood transfusion were 2.4 times higher, respectively, in the pre-PSST group (p = 0.004 and p = 0.011). The rate of complications within the first two postoperative years was significantly higher in the pre-PSST group (13.1%) compared with the post-PSST group (4.3%) (p Conclusion The implementation of a PSST in the operating theatre significantly improves the outcomes in paediatric spinal surgery. Cite this article: Bone Joint J 2018;100-B:493–8.

Early results of MIS in AIS have been promising; however, longer-term follow-up data remains limited. Our objective was to compare perioperative outcomes as well as radiographic and clinical outcomes between MIS and standard open posterior spinal instrumentation and fusion (PSIF) at 2-year follow-up. Advantages of MIS in AIS were related to intra-operative blood loss, cell saver transfusion rates, and LOS; however, significant increases in ORT, lower mean percent curve correction, and a higher complication rate of MIS in AIS were also noted. Despite these variations, no clinical differences in SRS-22 scores were found at 2 years postop between the groups.

Background: Transdermal buprenorphine, which is used in chronic pain management, has rarely been studied for use in acute pain management. The aim of this study was to compare the safety and efficacy of transdermal buprenorphine patch to oral tramadol for post-operative analgesia, following proximal femur surgeries. Methodology: Fifty adult patients undergoing surgery for hip fracture under spinal anaesthesia were included in this study. One group (Group TDB) received transdermal buprenorphine 10 mcg/h patch applied a day before the surgery and other group received oral tramadol 50 mg three times a day for analgesia (Group OT). They were allowed to take diclofenac and paracetamol tablets for rescue analgesia. Pain scores at rest, on movement, rescue analgesic requirement and side effects were compared between the groups over 7 days. Chi-square and independent sample t -test were used for categorical and continuous variables, respectively. Results: Resting pain scores and pain on movement were significantly lower in TDB Group on all 7 days starting from 24 h post-operatively. Rescue analgesic requirement was significantly lower in TDB Group compared to OT Group. All the patients needed rescue analgesic in OT Group whereas 68% of the patients needed the same in TDB Group. Incidence of vomiting was less and satisfaction scores were much higher in TDB Group as compared to OT Group (79% vs. 66%, P Conclusion: Transdermal buprenorphine can be safely used for post-operative analgesia and is more efficacious in reducing post-operative pain after 24 hours, with fewer side effects when compared to oral tramadol.

Undesired noise and vibrations have a detrimental effect in many areas. Hence the control of vibrations has become a relevant technological challenge. Active vibration control of structures using smart materials is especially in vogue. This involves sensing the motion of the structure using sensors, generating a control signal using a controller and applying a control force on the structure using actuators. To design the control system of any vibrating structure, the mathematical model of the system is required. However, it is difficult to theoretically construct a model of complex structures. On the other hand, it is relatively simpler to model such systems in a Finite Element (FE) environment like ANSYS©. This paper deals with the extraction of the full and reduced mathematical models of a cantilever beam into MATLAB© from its FE model. The full model of the beam is reduced by discarding those modes which do not contribute to the overall response. It is found that the frequency and transient responses of the full and reduced models match closely. Hence the reduced model may be used to represent the system which in turn reduces the computational time. The controller is designed using proportional-integral-derivative theory with output feedback. SIMULINK© is then used to create a working block diagram of the control system and perform the control action. The transient responses of the controlled full and reduced models are then plotted which are found to be in close agreement. The procedure for the design of the controller described in this paper may be extended to control the vibrations of any real life system.

A 32-year-old male presented with a history of consuming some organophosphorous compound with suicidal intention. He was treated with atropine, pralidoxime, ventilator support. During stay patient had persistent irritability, tachycardiaand hypertension despite sedation and labetalol infusion. He developed headache, visual blurring hemiparesis and focal seizures. Magnetic resonance imaging of the brain revealed multifocal hyperintensities mainly in subcortical areas of parietal and occipital regions in T2-weighted images, with increased values of Apparent Diffusion Coefficient, suggesting posterior reversible encephalopathy syndrome (PRES). The possibilities of PRES caused by organophosphorous poisoning either due to hypertension caused by autonomic deregulation or direct neurological toxicity has been discussed.

Background: The effect of HIV on obstetric complications is known to vary across regions of world. The variation may be due to HIV infection per se or it may be due to complex interaction of related medical and social conditions that affect pregnancy. Incidence of these obstetric complications in HIV infected pregnant women is not well reported in India. So, this prospective cohort study was carried to observe the demographics and incidence of obstetrics complications like abortions, still birth, premature rupture of membranes, preterm delivery, opportunistic infections in HIV infected pregnant women.Methods: All pregnant women who were screened positive for HIV test, irrespective of their gestational age were included in the study. Apart from routine obstetric care, CD4 cell count was carried out. The patients were followed up till term, delivery and up to 6-week postpartum period. Obstetric outcomes like incidence of abortion, intrauterine death, preterm delivery and premature rupture of membrane were noted. Baby`s birth weight and the incidence of maternal opportunistic infection were noted and correlated with maternal CD4 cell count.Results: Maternal HIV infection is associated pre-term labour in 34.5%, PROM in 30%, low birth weight in 52.3%. Increased incidences of these adverse outcomes have an inverse relationship with CD4 count.Conclusions: Maternal HIV infection is associated with increased incidence of adverse obstetric outcome and opportunistic infection, and their incidences increase with lower CD4 count.

Purpose A pilot study with short-term outcomes of a combined surgical and medical intervention for management of generalized lower limb spasticity, hip displacement and contractures of adductors in children with bilateral spastic cerebral palsy. Methods A prospective cohort study of 16 children (9 boys and 7 girls) aged 2–6 years with bilateral spastic cerebral palsy was performed. At entry, 5 were classified as level III and 11 as level IV, according to the Gross Motor Function Classification System (GMFCS). The intervention consisted of surgical lengthening of adductor longus and gracilis combined with the phenolization of the anterior branch of the obturator nerve, using 1 ml of 6% phenol, applied under direct vision at the time of lengthening of adductor longus. The hamstring and calf muscles were each injected with Botulinum neurotoxin A at a dose of 4 U/kg/muscle. Serial clinical (hip, knee, ankle joint range of motion), radiographic (migration percentage) and functional data—taken from a functional mobility scale (FMS) or GMFCS—were collected at 3, 6, 12 and 24 months post-operatively. Results There was a significant increase in hip abduction, knee extension (popliteal angle) and ankle dorsiflexion, maintained for 24 months; mean hip migration percentage decreased from 29 to 21% ( P < 0.001). Using a validated mobility scale, significant improvements were noted in gross motor function. There were no complications related to the intervention. Conclusions The combined surgical–medical intervention resulted in a reduction of spastic hip subluxation and improvements in gross motor function, as determined by the FMS. The combined intervention is, thus, useful as a temporizing measure, before definitive decisions are made considering such interventions as dorsal rhizotomy, intrathecal baclofen and single-event, multilevel surgery.

Background: The Ponseti method of manipulation is widely used in the treatment of clubfoot. Monitoring of correction is usually based on clinical judgment, and there is a need for an objective method of evaluation. The small bones of the newborn foot are essentially cartilaginous and can be visualized well on sonography as against radiographs. Methods: A prospective study was conducted on 32 clubfeet (26 subjects; age range, 12 days to 3 months) using ultrasound. Sonography was performed using the coronal medial projection at the start of treatment, when midfoot Pirani score was zero (foot fully abducted), and at the end of treatment. The medial malleolus to navicular distance and the talo-cuneiform angle were measured with foot position at rest and during the simulated Ponseti maneuver. The normal feet in unilateral cases served as controls. Results: With the Ponseti method of manipulation, there was a significant increase in the medial malleolus to navicular distance and improvement in the talo-cuneiform angle at the end of treatment, when compared with the pretreatment values (P < 0.001). All feet were clinically well corrected. However, 5 feet (15%) showed a "spurious correction," which was only detected on ultrasound. This was identified by the fact that the navicular was not fully reduced over the head of the talus, and there was a break in the naviculo-cuneiform joint. It was difficult to predict which feet were likely to develop a spurious correction, although the 5 feet in our study were stiffer, more severely deformed, and showed less correction on initial manipulation as compared with the feet that corrected well. Conclusions: Clubfoot correction during serial manipulation can be monitored using sonography. An accurate realignment of the talonavicular joint can be demonstrated, and presence of spurious correction can be detected early.

Sir, Pneumocephalus has been described subsequent to the detection of epidural space with loss of resistance to air technique. There are very few reports of pneumocephalus following spinal anaesthesia. We noted a case of pneumocephalus following spinal anaesthesia administered for laminectomy. A 53-year-old male with diagnosis of L5-S1 prolapsed intervertebral disc and was posted for laminectomy and discectomy. He was a known hypertensive on amlodipine and telmisartan for control of blood pressure. His pre-operative blood pressure was about 160/96 mm of Hg. Spinal anaesthesia and need for prone position during the surgery was explained to the patient. Standard monitoring with electrocardiography, non-invasive blood pressure, and pulse oximeters was established. Dural puncture was attempted with 25 gauge Quincke needle in L4-5 space, but could succeed only on 4th attempt due to technical difficulty (first 2 attempts by postgraduate student). After noting the free flow of cerebrospinal fluid (CSF), 3.2 ml of 0.5% hyperbaric bupivacaine along with 90 μg of buprenorphine was given. The table was maintained in neutral position and subarachnoid block was established up to T8 level. Patient was positioned in the prone position 10 min after the block and level was confirmed to be T8. Intra-operative hypotension (up to 100/56 mmHg for about 10 min) was treated with boluses of ephedrine and mean blood pressure was maintained above 70 mm of Hg throughout the perioperative period. Even though the patient was cooperative, he was taking deep breaths due to anxiety. Surgery was uneventful and there was no obvious dural damage during the surgery. Patient was comfortable and haemodynamics were stable in the post-operative care-unit. Four hours after the surgery, the patient was restless, complained of weakness of right upper limb and was not able to talk. Examination by neurophysician confirmed the monoparesis and aphasia and no other neurological deficits. Magnetic resonance imaging of brain was performed, which revealed acute infarcts in fronto-parietal and temporal areas corresponding to the distribution of middle cerebral artery [Figure 1]. Along with this, pneumocephalus was noted in the left sylvian fissure and basal cisterns, which was seen compressing the middle cerebral artery branches, which lead to the infarction [Figure 2]. He was observed in Intensive Care Unit with oxygen by face mask. About 10 h postoperatively, patient started vocalising and after about 15 h postoperatively, power returned in the monoparetic limb. By next day, the patient was comfortable without any neurologic deficits. Computed tomography scan performed after 2 days showed complete reabsorption of pneumocephalus. He was discharged from the hospital without any neurological deficits. Figure 1 Magnetic resonance imaging of the brain showing acute infarction in Broca's area and post-central gyrus (indicated by arrows) Figure 2 Magnetic resonance imaging of the brain showing multiple hypoechoic area indicating the air pockets in the subarachnoid space. Arrow indicating air pocket compressing the middle cerebral artery branches in the left sylvian fissure Spinal anaesthesia is an effective alternative to general anaesthesia for lumbar spine surgery and has a reduced rate of minor complications.[1] It is common practice in our centre to perform single level discectomy surgeries under spinal anaesthesia in cooperative patients. In this patient, multiple punctures were done due to difficulty in getting the subarachnoid block. Normally, dural rents will be covered by the soft tissues of the back, but in our patient, surgical exposure for laminectomy possibly exposed the dural rents to atmospheric air. Animal studies have shown that CSF pressure can vary similar to hydrostatic pressure and lumbar CSF pressure can be negative in different body positions.[2] Lumbar CSF being at higher level than right atrium in prone position is expected to have very low, if not negative, pressure. Furthermore negative intrathoracic pressure during deep inspiration can lead to decrease in subarachnoid pressure below the atmospheric pressure.[3] As our patient was breathing spontaneously in prone position, we hypothesise that spontaneous ventilation with negative pressure in the subarachnoid space allowed air entry through the dural puncture site. Air pockets caused the compression of branches of middle cerebral artery leading to symptoms of acute infarct. Pneumocephalus has been rarely reported following subarachnoid block. Avellanal reported a case where the patient had a series of coughs followed by deep inspiratory efforts when spinal needle was in subarachnoid space, just before the local anaesthetic was injected.[4] Patient developed pneumocephalus which was explained by deep inspiratory efforts producing negative pressure in subarachnoid space and presence of spinal needle open to atmosphere allowing entry of air. This is very much similar to our case, except that opening to atmosphere in our case was provided by the surgical exposure rather than the needle. Another case of pneumocephalus has been reported following multiple spinal injections without any obvious cause for air entry in subarachnoid space.[5] In our patient, we could observe the air pocket compressing on the branches of left middle cerebral artery leading to the symptoms in the area of its distribution. Pneumocephalus has a tendency to resolve spontaneously and usually it is absorbed within few days. Since the amount of air entering the subarachnoid space following spinal anaesthesia is very small, it is expected to be absorbed early and hence compression symptoms resolve much faster.[5] The treatment of pneumocephalus consists on administration of 40-100% oxygen in the supine position. Spinal anaesthesia is considered as an acceptable technique for simple spine surgeries and many cases are performed without much complication. We could not find any other case of pneumocephalus following spine surgery in spinal anaesthesia. Looking at the overall number of cases of spine surgeries done under spinal anaesthesia, this complication appears quite rare. But the possibility of pneumocephalus should be kept in mind in spontaneously breathing patient with dural rent exposed to atmosphere. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Putative phthalic acid degrader Pseudomonas aeruginosa HNYM 41 and Bacillus cereus BVC 11 isolated from plastic dumping ground area of Ahmednagar city. Here we report the genome sequence of HNYM 41and BVC 11, which have capacity to degradation capacity up to 1500 and 3000 ppm in absent of other carbon source.

Context: Combination antiemetics are recommended as prophylaxis for PONV in moderate to high risk patients. Commonly dexamethasone and 5 HT3 receptor antagonists are used as combination antiemetics. There is questionable benefit of adding dexamethasone to ramosetron for PONV prophylaxis. There are no studies comparing efficacy of combination of dexamethasone with single dose of ondansetron and ramosetron. Aims: To evaluate the efficacy of ramosetron and dexamethasone combination and compare it with ondansetron and dexamethasone in preventing PONV after middle ear surgery under general anaesthesia, in patients who are moderate to severe risk of PONV. Settings and Design: Peri-operative and up to 48 hours postoperative. Prospective, randomised, double blind study. Methods and Material: One hundred and forty four adult patients undergoing middle ear surgeries were allocated to receive either dexamethasone 8 mg and ondansetron 4 mg (n = 72) or dexamethasone 8mg and ramosetron 0.3 mg (n = 72). The incidence and severity of PONV, need of rescue antiemetics and the side effects of the antiemetics were noted for the first 48 h after surgery. Statistical analysis used: Chi-square test or Fisher’s exact test, independent sample t-test. Results: There was no significant difference in the incidence and severity of nausea between groups at 2, 2-12, 12-24 and 24-48 hour interval. The incidence of vomiting and use of rescue antiemetic was also not different between groups at all the time intervals. Percentage of patients with no PONV in 48 hours was 78% and 76% in dexamethasone ondansetron and dexamethasone ramosetron groups respectively. Conclusions: Combination of dexamethasone and ramosetron has equal efficacy as ondansetron with dexamethasone in reducing PONV after middle ear surgery. Key-words: Postoperative nausea and vomiting, Middle ear surgery, Ondansetron, Ramosetron, Dexamethasone. Key Message: Combination of dexamethasone and ramosetron has equal efficacy as

Infantile botulism is the result of ingestion of Clostridium botulinum spores, and is the most common form of infection with botulism in the United States. Ninety percent of cases occur in infants6 months old. The infants typically present with vague symptoms such as hypotonia and poor feeding. This article reports an infant with confirmed infantile botulism that presented to the Emergency Department (ED) with complaints of decreased feeding and absence of bowel movements for1 week.Review a case of infantile botulism, its diagnosis, and treatment.A 4-month-old healthy Caucasian male presented to the ED with a 6-day history of decreased feeding after referral from the pediatrician. He had not had a bowel movement for 9 days, and his parents were also concerned about increasing weakness, as he was no longer able to hold his head up on his own. In the ED, he was minimally interactive. His vital signs were within normal limits, and he had hypoactive bowel sounds and decreased tone throughout. He was admitted to the Children's Hospital and eventually transferred to the Pediatric Intensive Care Unit requiring intubation and mechanical ventilation. The botulism immunoglobulin was administered, and a diagnosis was confirmed with positive botulinum toxin in the stool samples. Full recovery was made by the infant.Awareness of the symptoms of botulism and a high degree of clinical suspicion is needed to make a prompt diagnosis.

Background: The purpose of this study was to evaluate the relationship between walking ability, as determined with use of the Gross Motor Function Classification System (GMFCS), and the outcome of hip adductor surgery used to prevent hip displacement in children with cerebral palsy. Methods: We performed a retrospective review of the records of all children with cerebral palsy whose index surgery, performed between January 1994 and December 2004 at one tertiary-level pediatric hospital, was bilateral hip adductor releases. All children had a hip migration percentage of >30% in at least one hip prior to the adductor surgery, and the minimum duration of follow-up was twenty-four months. Kaplan-Meier survivorship curves were generated by determining the time from the index surgery to “failure,” defined as either the need for subsequent surgical procedures or a migration percentage of ≥50% in either hip. Hazard ratios were calculated for sex, migration percentage at the time of the index surgery, age at the time of the index surgery, and GMFCS level. Results: Three hundred and thirty children were included in the study; 73% (242) were nonambulatory (GMFCS level IV or V). The mean age at the time of the index surgery was 4.2 years, the mean migration percentage was 43%, and the mean duration of postoperative follow-up was 7.1 years. Surgery consisted of open lengthening of the adductor longus and gracilis muscles in all children, with additional procedures as deemed necessary. “Success” was defined as the absence of subsequent surgical procedures during the study period and a migration percentage of

The impact of the HDP-CVD process on Si surfaces has been studied. It has been shown that the sputter component in the process enhances the features and the detection of Si surface defects. These defects, 0.16-0.30 /spl mu/m in size, are correlated to other characterization techniques such as capacitance-voltage measurements, plasma damage monitoring, and photoconductance decay spectroscopy. We show that these defects are a result of the interaction between the energetic ions in the deposition process and the crystal-originated voids during the Czochralski crystal growth. We show how these defects can be modulated among different processing conditions. The learning has been applied to optimizing the initial steps of plasma deposition in the HDP-CVD process for shallow trench isolation and pre-metal dielectric applications. This work also underscores the importance of applying low information content sensors to the early detection and control of plasma damage in high density plasma applications.