Oligoanalgesia in the emergency setting – An Indian review

Pain is a result of nociceptive tissue injury and results in acute and chronic impact to patients. Acute pain management is the need of the hour as untreated or under-treated pain may progress to chronic pain. Pain irrespective of its temporality causes a negative impact on the quality of life of the patients. Many Indian emergency settings are not adequately equipped to handle pain due to the heavy load of patients and the lack of awareness about the pain management guidelines. This leads to undertreatment of pain or ‘oligoanalgesia’. A pain management protocol can help prevent oligoanalgesia in an emergency setting. Proper utilization of triage systems that incorporate pain as one of the vital signs is necessary. The categorization of pain with the help of a pain scale helps determine the severity of pain and its appropriate management. Pain management is an ongoing process that does not end with the discharge of the patient. Post discharge management of pain is also an important factor to prevent chronic pain. This may involve various modalities for pain management under the preview of multimodal management of pain.     

Tumours of the talus – A pictorial review

BackgroundPrimary bone tumours of the talus are a rare entity and seldom described in the literature. Due to this, often the diagnosis and management of such cases are delayed. This study aims to describe a spectrum of lesions identified within our department and provide a pictorial review with the goal to aid radiologists in the evaluation and diagnosis of such lesions.Materials & methodsA retrospective study was conducted within our department, identifying all talar lesions, confirmed on histopathological and radiological diagnosis.ResultsResults revealed 75 cases of talar lesions. Benign tumours formed the bulk of the lesions identified accounting for 85% of all cases. The most common benign tumour was chondroblastoma (n = 23). Malignant tumours were detected in 6 cases. Other lesions included osteomyelitis and avascular necrosis.ConclusionWe present a variety of tumours and tumour-like conditions of the talus. Radiologists as well as orthopaedic surgeons need to be aware of such lesions, to prompt early diagnosis and initiate management in timely fashion.     

Primary open elbow arthrolysis in post-traumatic elbow stiffness – A comparison of outcomes in severity of elbow injury

PurposeStiffness is a sequelae of elbow trauma. Arthrolysis may be considered to increase range of movement (ROM). Little is published on the outcomes/complications of elbow arthrolysis. We present our series of primary open arthrolysis in posttraumatic elbow stiffness.MethodsA consecutive series of patients that underwent primary open arthrolysis for posttraumatic elbow stiffness in our unit (2011–2018) were analysed. All procedures were performed by an elbow surgeon. Postoperative rehabilitation followed protocol with early motion; continuous passive motion (CPM) was utilised if requested. Data collected included patient demographics, traumatic injury type, arthrolysis technique, preoperative, intraoperative and postoperative elbow ROM, complications and postoperative Oxford Elbow Score (OES).Results41 patients were included. 59% were male. Mean age at time of arthrolysis was 43 years (range 12–79 years). Mean duration of follow-up was 53 months (range 8–100 months). Median duration from time of injury to arthrolysis was 11 months (range 2–553 months). Mean preoperative flexion-extension arc (FEA) was 70°, improving to 104° postoperatively (p < 0.001). Mean preoperative pronosupination arc (PSA) was 125°, improving to 165° postoperatively (p < 0.001). Mean postoperative OES was 37 (n = 28). Complication rate was 24% with 7 recurrence requiring surgery, 2 nerve injuries and 1 infection. CPM, 10 patients, saw mean FEA improvement of 56°. Mean PSA improvement was 36°. Complication rate for these patients was 40%. Severe traumatic injury was associated with increased preoperative stiffness (FEA 61° vs 84°, PSA 111° vs 149°) but larger improvements in ROM (postoperative FEA 98° [p < 0.001], PSA 165° [p < 0.001]).ConclusionThis series demonstrates improvement in elbow ROM following open arthrolysis with significantly higher gain in pronosupination for those withsevere injury. Moderate results were seen in a patient reported outcome measure. Patients considering arthrolysis should be counselled regarding expectations/complication rate.     

Which primary shoulder and elbow replacement? A review of the results of prostheses available in the UK.

To assist surgeons select a suitable prosthesis, we have undertaken a detailed review of all shoulder and elbow replacements currently marketed in the UK. Twenty shoulder and 8 elbow implants, manufactured by 16 companies, have been identified. Twelve of the shoulder and one of the elbow implants have been introduced or modified in the last 8 years and have no clinical results published in peer-reviewed journals. Only the Biomodular, Bipolar, Copeland, Isoelastic, Neer hemi, Neer II, Roper-Day and Select shoulders accounting for less than 40% of the UK shoulder market, possess published results. The Capitello-condylar, Coonrad-Morrey, GSB III, Kudo, Liverpool, Roper-Tuke and Souter-Strathclyde elbows all have published results. These account for over 95% of all UK elbow replacements. The implications of these findings in an era of evidence-based medicine is discussed. Reviewing the clinical results should be of primary importance in the selection of a suitable prosthesis. Implants with a proven long-term record must represent the 'gold standard'. New or modified implants should only be used if they are part of a properly conducted clinical trial.     

Bilateral musculus sternalis – An anatomical and clinical review

The musculus sternalis is an extremely rare anatomical variant of the anterior chest wall. A detailed review of the anatomy, historical background and prevalence of the sternalis muscle is presented, with both the significant radiological and surgical implications of this variant specifically discussed.     

Preservation of the Endothelium in Cardiovascular Surgery – Some Practical Suggestions – A review

Objective: Critical aortic stenosis with or without coronary artery disease is increasingly common in octogenarians. Surgery is the treatment of choice, but indications and results of aortic valve replacement (AVR), particularly when combined with coronary artery bypass grafting (CABG) are debated. We investigated whether the combined procedure of AVR and CABG increased postoperative risk compared with isolated AVR in otherwise healthy octogenarians. Design: In the period 1994-1998, AVR was performed in 94 patients above 80 years, the majority in NYHA class III and IV. Combined AVR and CABG was performed in 52/94 patients. The patients were studied retrospectively by collecting data from hospital records and followed for 0-7 years. Results: Mean age was 82 &;#45 2.3 years, sex (male/female) 33/61, left ventricular ejection fraction 70 &;#45 18%, transvalvular peak pressure gradient 63 &;#45 20 mmHg and aortic valve area 0.5 &;#45 0.2 cm 2 . Early mortality (< 30 days) was 4/42 (9.5%) after AVR and 4/52 (7.6%) after AVR and CABG ( p = NS between groups). Three-year survival was 33/42 (78.5%) after AVR and 42/52 (80.7%) after AVR and CABG ( p = NS between groups). Conclusion: AVR with concomitant CABG in octogenarians with aortic stenosis who are otherwise healthy, may be performed without increased risk.     

Current trends in the management of carcinoma penis – a review

AIMS AND INTRODUCTION: To review the current literature, recent advances and recent trends in the management of squamous cell carcinoma of the penis so as to have a broad overview of penile cancer and its current management. The review was considered keeping in mind that squamous penile carcinoma is an infrequently encountered malignancy and that the etiology is still unclear though certain predisposing conditions are known to exist and also that controversy still exists as to the appropriate management of inguinal adenopathy. We also reviewed the etiological factors, clinical presentation, diagnosis, staging, prognostic factors in addition to management and prophylaxis. METHODS: A literature search was carried out from Pubmed for indexed articles published over the last 50 years using the key words 'Management penile carcinoma', 'Squamous cell carcinoma penis' and 'inguinal lymphadenectomy'. RESULTS: The search yielded over 1500 indexed published articles and reports. Important major reports and studies were reviewed, screened and tracked for recent changes and trends in the management of penile cancer. These were analyzed, tabulated and discussed. CONCLUSIONS: Newer approaches to the management of penile cancer include use of laser, photodynamic therapy, neoadjuvant therapy and sentinel node mapping by lympho-gamma-scintigraphy. The current approach towards managing inguinal adenopathy shows an increasing trend towards the use of these newer modalities as well as the use of certain modifications in lympadenectomy such as (the use of ligasure, modified dissection, saphenous vein sparing and lymphoscintigraphy, etc.) thereby making the procedure considerably less morbid than before.     

Anaesthesia for vascular emergencies – a state of the art review

In this state-of-the-art review, we discuss the presenting symptoms and management strategies for vascular emergencies. Although vascular emergencies are best treated at a vascular surgical centre, patients may present to any emergency department and may require both immediate management and safe transport to a vascular centre. We describe the surgical and anaesthetic considerations for management of aortic dissection, aortic rupture, carotid endarterectomy, acute limb ischaemia and mesenteric ischaemia. Important issues to consider in aortic dissection are extent of the dissection and surgical need for bypasses in addition to endovascular repair. From an anaesthetist's perspective, aortic dissection requires infrastructure for massive transfusion, smooth management should an endovascular procedure require conversion to an open procedure, haemodynamic manipulation during stent deployment and prevention of spinal cord ischaemia. Principles in management of aortic rupture, whether open or endovascular treatment is chosen, include immediate transfer to a vascular care centre; minimising haemodynamic changes to reduce aortic shear stress; permissive hypotension in the pre-operative period; and initiation of massive transfusion protocol. Carotid endarterectomy for carotid stenosis is managed with general or regional techniques, and anaesthetists must be prepared to manage haemodynamic, neurological and airway issues peri-operatively. Acute limb ischaemia is a result of embolism, thrombosis, dissection or trauma, and may be treated with open repair or embolectomy, under either general or local anaesthesia. Due to hypercoagulability, there may be higher numbers of acutely ischaemic limbs among patients with COVID-19, which is important to consider in the current pandemic. Mesenteric ischaemia is a rare vascular emergency, but it is challenging to diagnose and associated with high morbidity and mortality. Several peri-operative issues are common to all vascular emergencies: acute renal injury; management of transfusion; need for heparinisation and reversal; and challenging postoperative care. Finally, the important development of endovascular techniques for repair in many vascular emergencies has improved care, and the availability of transoesophageal echocardiography has improved monitoring as well as aids in surgical placement of endovascular grafts and for post-procedural evaluation.     

Outcome of simple decompression of the compressed ulnar nerve at the elbow – influence of smoking,gender, and electrophysiological findings

Background: Compression of the ulnar nerve at elbow is frequently treated with simple decompression. Knowledge about factors influencing results of surgery of the nerve is limited and contradictory. The primary aim was to evaluate outcome of simple decompression of the nerve using a QuickDASH questionnaire, and to investigate any influence of smoking, gender, and preoperative electrophysiological findings. A second aim was to estimate the relation between QuickDASH score and a clinical assessment of outcome by the surgeon.

Methods: Patients who were operated on with simple decompression of the ulnar nerve, excluding reoperations, from September 2009 to February 2011 were evaluated before and at 1 year after surgery using QuickDASH. Data were collected from medical records and from a self-reported health declaration.

Results: There were no differences in QuickDASH scores or change in total score between smokers and non-smokers or between women and men. Nerve pathology, assessed by preoperative electrophysiology, did not affect outcome. The surgeon’s assessment of outcome mirrored QuickDASH score. Among all patients, 12/33 (36%) did not have a decrease in QuickDASH score >8, which is considered as a minimal clinically important difference.

Conclusion: Smoking, gender, and preoperative electrophysiological findings do not affect outcome of surgery. There are a high number of patients who do not benefit from simple decompression of the ulnar nerve at the elbow. Patients who are planned for surgery should be informed that there is a risk for persistent problems. A simple outcome assessment by the surgeon mirrors QuickDASH score at 1 year.     

Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis

Study DesignSystematic review.IntroductionNo consensus exists as to which are the most effective methods to treat the symptoms associated with lateral elbow tendinopathy (LET). Research has suggested that joint mobilizations may assist in the recovery of patients with LET.Purpose of the StudyTo determine if joint mobilizations are effective in improving pain, grip strength, and disability in adults with LET.MethodsSearches in 3 databases were performed to identify relevant clinical trials. Reviewers independently extracted data and assessed the methodological quality. Summary measures of quantitative data were extracted or calculated where possible. Appropriate data were pooled for meta-analysis using a random-effects model.ResultsA total of 20 studies met the inclusion criteria; 7 were included in the meta-analysis. Studies were broadly classified into 3 groups: mobilization with movement (MWM), Mill's manipulation, and regional mobilization techniques. Pooled data across all time periods demonstrated a mean effect size of 0.43 (95% confidence interval [CI]: 0.15-0.71) for MWM on improving pain rating, and 0.31 (95% CI: 0.11-0.51) for MWM on improving grip strength, 0.47 (95% CI: 0.11-0.82) for Mill's manipulation on improving pain rating. A mean effect size of ?0.01 (95% CI: ?0.27 to ?0.26) shows Mill's manipulation did not improve pain free grip strength. Functional outcomes varied considerably among studies. Pain, grip strength, and functional outcomes were improved with regional mobilizations.ConclusionThere is compelling evidence that joint mobilizations have a positive effect on both pain and/or functional grip scores across all time frames compared to control groups in the management of LET.     

Adjunctive treatments for the management of septic shock – a narrative review of the current evidence

Septic shock is a leading cause of death and morbidity worldwide. The cornerstones of management include prompt identification of sepsis, early initiation of antibiotic therapy, adequate fluid resuscitation and organ support. Over the past two decades, there have been considerable improvements in our understanding of the pathophysiology of sepsis and the host response, including regulation of inflammation, endothelial disruption and impaired immunity. This has offered opportunities for innovative adjunctive treatments such as vitamin C, corticosteroids and beta-blockers. Some of these approaches have shown promising results in early phase trials in humans, while others, such as corticosteroids, have been tested in large, international, multicentre randomised controlled trials. Contemporary guidelines make a weak recommendation for the use of corticosteroids to reduce mortality in sepsis and septic shock. Vitamin C, despite showing initial promise in observational studies, has so far not been shown to be clinically effective in randomised trials. Beta-blocker therapy may have beneficial cardiac and non-cardiac effects in septic shock, but there is currently insufficient evidence to recommend their use for this condition. The results of ongoing randomised trials are awaited. Crucial to reducing heterogeneity in the trials of new sepsis treatments will be the concept of enrichment, which refers to the purposive selection of patients with clinical and biological characteristics that are likely to be responsive to the intervention being tested.     

Health Related Quality of Life in burn patients – A review of the literature

The burn trauma is multifactorial and involves pathophysiologic processes of all of the body's systems. The impact it could have on a person's life includes impairments on their esthetic appearance, interpersonal relationships, psychological, social and physical functioning. Previously, the outcomes of burn care were confined in the context of mortality and length of hospital stay. Currently, a shift is afoot from defining good health care as merely the reduction of morbidity and mortality to a more holistic approach that involves aspects of Health Related Quality of Life. In this article we aim to present a concise review of the relevant literature and relevant topics pertaining Health Related Quality of Life and burn.     

Primary small cell neuroendocrine carcinoma of the breast – A case report and review of the literature

IntroductionPrimary small cell neuroendocrine carcinoma of the breast (SCNCB) is a very uncommon type of breast cancer. Histology and morphology are virtually indistinguishable from small cell neuroendocrine carcinomas of the lung (SCNCL), mandating a search for a primary site elsewhere in the body. There is no standard approach to treatment as there are only a limited number of cases reported in the literature. This report summarizes a case of primary SCNCB and presents a review of the literature.Presentation of caseA 65-year-old female presented to her gynecologist with a right breast mass. After biopsy, she was diagnosed with a primary SCNCB with regional lymph node involvement. She was treated with chemotherapy and radiation therapy with a good clinical response.DiscussionDue to the rare nature of this tumor, no standard treatment exits. Case reports have described breast conserving therapy combined with neoadjuvant or adjuvant chemotherapy as well as chemoradiation therapy alone for metastatic disease. Both chemotherapy regimens, those used to treat SCNCL and invasive breast cancer, have been described in these reports.ConclusionPrimary SCNCB is a very rare type of breast cancer with no standard treatment. Further research is needed to better understand the behavior of this rare tumor in order to develop a standard approach to treatment.     

Progress in the treatment of varus-posteromedial rotation instability of the elbow北大核心CSCD

肘关节内翻-后内侧旋转不稳定(VPMRI)发病率低,受伤机制复杂,X线片往往显示无明显脱位等,常被诊断为单纯冠状突骨折,极易造成漏诊和误诊。对VPMRI的治疗方案也有争议,保守治疗或不恰当的治疗均可能引起严重的并发症,因此,针对这一临床上少见且难以治疗的复杂肘关节损伤,本文从损伤机制、解剖结构、冠状突骨折O'Driscoll分型、影像学检查、治疗方式和术后康复等方面进行了文献的回顾和综述。     

Changing practices in the surgical management of hyperparathyroidism – A 10-year review

AimParathyroid surgery has undergone a paradigm shift over the last decade, with a move from traditional bilateral neck exploration to minimally invasive parathyroidectomy (MIP), and increasing reliance on pre- and intra-operative localization of overactive glands. We aimed to assess changing surgical practices and their impact on the management of parathyroid disease in a tertiary referral centre in the West of Ireland.MethodsA retrospective cohort analysis of those patients undergoing a surgical intervention for parathyroid disease in the period between 1999 and 2009 in our centre was carried out. Data was analysed using PASW (v18) software.Results248 procedures were performed, increasing from an annual rate of 6 in 1999 to 45 in 2009. 129 procedures were completed by minimally invasive means, following the introduction of MIP in 2003. Single-gland disease accounted for 87% of cases (n = 216) with carcinomas in 2 patients (0.8%). Pre-operative localization had disappointing diagnostic value, with high false negative rates for both ultrasound (37.3%) and Sestamibi Scanning (35.81%). Intra-operative adjuncts were more helpful, with intra-operative Parathyroid hormone monitoring facilitating curative resection of adenomas in 94.03% at 10 min. Median length of post-operative stay has significantly decreased from 6 days in 1999 to 1 night only in 2009 (p < 0.01, ANOVA). Those patients undergoing MIP had shorter stay than the open group (1.71 days -v-4.73, p = 0.003,t-test).ConclusionThe practice in our centre has shifted to a less invasive approach. Increased utilisation of intra-operative adjuncts has facilitated this change, and resulted in favourable changes in length of stay, extent of dissection, and number of patients treated.