Effects of stellate ganglion block on cerebral haemodynamics as assessed by transcranial Doppler ultrasonography

Background. Stellate ganglion block (SGB) causes vasodilatationin the skin of the head and neck because of regional sympatheticblock. Its effects on cerebral haemodynamics, in health or indisease, are not clear. We evaluated the effects of SGB on ipsilateralmiddle cerebral artery flow velocity (MCAFV), estimated cerebralperfusion pressure (eCPP), zero flow pressure (ZFP), carbondioxide reactivity (CO₂R) and cerebral autoregulation usingtranscranial Doppler ultrasonography (TCD). Methods. Twenty male patients, with pre-existing brachial plexusinjury, and undergoing SGB for the treatment of complex regionalpain syndrome of the upper limb, were studied. For SGB, 10 mlof plain lidocaine 2% was used and the onset of block was confirmedby presence of ipsilateral Horner's syndrome. The MCAFV, eCPP,ZFP, CO₂R, and cerebral autoregulation were assessed beforeand after SGB using established TCD methods. The changes inthese variables were analysed using Wilcoxon's signed rank test. Results. The block caused a significant decrease in MCAFV frommedian (inter-quartile range) value of 61 (53, 67) to 55 (46,60) cm s^–1, a significant increase in eCPP from 59 (51,67) to 70 (60, 78) mm Hg, and a significant decrease in ZFPfrom 32 (26, 39) to 25 (16, 30) mm Hg. There were no significantchanges in CO₂R or cerebral autoregulation. Conclusion. The increase in eCPP, decrease in ZFP, and no changesin CO₂R or cerebral autoregulation suggest that the SGB decreasescerebral vascular tone without affecting the capacity of thevessels to autoregulate. These effects may be of therapeuticadvantage in relieving cerebral vasospasm in certain clinicalsettings.     

P-QOL: a validated questionnaire to assess the symptoms and quality of life of women with urogenital prolapse

To develop a simple, valid, reliable questionnaire to assess the severity of symptoms and their impact on the quality of life in women with urogenital prolapse. Women recruited from gynaecology outpatient clinics were asked to complete a prolapse quality of life questionnaire (P-QOL) before their hospital visit. At the time of the visit, they were examined supine using the International Continence Society (ICS) prolapse score (POP-Q). A second P-QOL was posted and completed by patients 2 weeks later. The validity was assessed by measuring levels of missing data, comparing symptom scores between affected and asymptomatic women and comparing symptom scores with objective prolapse stages. The internal reliability was assessed by measuring the Cronbach alpha coefficient; 155 symptomatic and 80 asymptomatic women were studied. Severity according to P-QOL strongly correlated with the vaginal examination findings (p<0.01, rho>0.5). The total scores for each P-QOL domain were significantly different between symptomatic and asymptomatic women (p<0.001). All items achieved a Cronbach alpha greater than 0.80 showing good inter-rater reliability. The test-retest reliability confirmed a highly significant correlation between the total scores for each domain. A P-QOL questionnaire for English-speaking patients has been developed which is reliable and valid.Editorial Comment: This paper introduces a new questionnaire to assess the symptoms and quality of life of women with urogenital prolapse. The authors have compared symptomatic woman with asymptomatic women in the evaluation of this new tool. Using well-controlled statistical analysis, a patient-directed diagnostic tool has been formulated. The role of this questionnaire and its applicability to clinical practice is widespread. This gives the clinician the ability to correlate symptom bother with actual physical findings. Additionally, quality of life parameters can be used in the postoperative period to gain insight into patients subjective assessment of their surgical outcomes     

Juvenile hyaline fibromatosis in siblings

Juvenile hyaline fibromatosis (JHF) is a rare, autosomal recessively inherited disorder. We report two siblings with multiple large tumors on the scalp, translucent papules on the nape of the neck, hypertrophic gingiva, and severe flexural contractures of large joints. The histopathology from the skin lesions showed features characteristic of juvenile hyaline fibromatosis. The cases are being reported on account of the extreme rarity of the condition.     

Hyperhomocysteinemia as a risk factor for ischemic stroke: an Indian scenario

BACKGROUND: Hyperhomocysteinemia has been proposed as an important risk factor for ischemic stroke worldwide, but data available from the Indian subcontinent is scarce. AIM: To study homocysteine levels in patients with ischemic stroke and compare it with age- and sex-matched controls. SETTINGS AND DESIGN: Case-control prospective study. MATERIALS AND METHODS: Fifty-seven patients with ischemic stroke and 30 controls were recruited for the study. They were subdivided into two subgroups (< 40 years and> 40 years of age) and plasma fasting total homocysteine (tHcy) levels were measured. STATISTICAL ANALYSIS USED: Student's 't' test and chi-square test. RESULTS: The tHcy were significantly high in patients with stroke, compared to controls (9.91 +/- 2.25 vs 8.00 +/- 2.74 micromol/l; P vs 8.45 +/- 2.72 micromol/l; P = 0.01) and female patients compared to controls (9.08 +/- 1.81 vs 6.79 +/- 2.60 micromol/l; P = 0.04). The tHcy levels were significantly high in patients with hypertension compared to normotensive patients (10.96 vs 9.49 micromol/l; P = 0.01) and smokers compared to nonsmokers (11.17 vs 9.33 micromol/l; P = 0.01). CONCLUSIONS: Hyperhomo-cysteinemia emerged as an important independent risk factor for ischemic stroke. A strong positive correlation was also observed between hypertension, smoking, and high-tHcy levels in the present study.     

Caesarean section is protective against stress urinary incontinence: an analysis of women with multiple deliveries

All women who had three elective caesarean sections were selected from a database of 40,000 women delivering between 1977 and 1998, and age-matched with women having three vaginal births. They all completed a (validated) urinary and bowel symptom questionnaire. Women who had vaginal births had a significantly higher prevalence of stress incontinence but not other urinary or faecal symptoms compared with those delivered by caesarean section. The prevalence of faecal incontinence was lower than the prevalence of urinary incontinence. Although the prevalence of faecal incontinence was lower after caesarean delivery, this was not statistically different. These data have shown that caesarean section was associated with a lower risk of urinary incontinence, although a protective effect on development of faecal symptoms was not seen.     

The relationship between urinary symptom questionnaires and urodynamic diagnoses: an analysis of two methods of questionnaire administration

OBJECTIVE: To assess whether method of administration of a standard urinary symptom questionnaire alters the relationship of symptoms with urodynamic diagnoses. DESIGN: Randomised crossover study. SETTING: Tertiary Urogynaecology Unit, London, UK. PARTICIPANTS: One hundred and fourteen women attending a tertiary urogynaecology clinic. METHODS: Women were randomised to either an initial interview-assisted questionnaire in the clinic with a follow up postal questionnaire or an initial pre-outpatient questionnaire followed by an interview-assisted questionnaire at the clinic visit. Video cystourethrography or saline cystometry was performed at the clinic visit. MAIN OUTCOME MEASURES: Question responses were compared with urodynamic diagnoses. RESULTS: With an interview method, only severity of incontinence was significantly associated with detrusor overactivity (U= 593.5, P= 0.012). With self-completion, severity of nocturia (U= 477, P < 0.05), urgency (U= 395, P= 0.003), urge urinary incontinence (U= 392, P= 0.003), leakage without warning (U= 443, P= 0.035) and incomplete voiding (U= 413, P= 0.01) were significantly associated with detrusor activity. On interview the symptom of stress urinary incontinence (U= 523, P= 0.002) and use of pads (U= 564.5, P= 0.011) were significantly associated with a diagnosis of urodynamic stress incontinence. Severity of stress urinary incontinence (U= 276, P < 0.001), frequency of leakage (U= 348.5, P= 0.004), use of protection (U= 432.5, P < 0.018), nocturnal incontinence (U= 393.5, P= 0.002) and quantity of leakage (U= 441.5, P < 0.05) on self-completion were strongly associated with diagnosed urodynamic stress incontinence. There was no association between the symptoms of urgency or urge incontinence and the urodynamic stress incontinence. CONCLUSIONS: Postal questionnaire responses have a better relationship with urodynamics, both for urodynamic stress incontinence and detrusor over activity, than interview-assisted questionnaire responses. However, no symptom has a high enough specificity and sensitivity to replace urodynamic testing.     

Risk factors in the primary management of anorectal malformations in Northern India

The purpose of this study was to determine the major factors influencing the survival of babies with anorectal malformation (ARM) during the primary management in the neonatal period in a tertiary referral center. The outcome of 125 neonates with ARM, treated in a single hospital during a 2-year period, was analyzed retrospectively with particular reference to birth weight, time of arrival, and the type of ARM, including pouch colon and major associated anomalies, to see whether any of them had a significant effect on initial survival. High ARM (HARM) was present in 75, low ARM (LARM) in 36, and pouch colon in 14 babies. There were a total of 28 deaths (22%). In babies with isolated HARM weighing >2.5 kg and brought to the hospital within the first 48 h of life, the survival was 100%, which dropped to 80% when brought later than 48 h. Of the babies with birth weight <2.5 kg and isolated HARM but who were brought to the hospital within the first 48 h of life, 80% survived, whereas of those reaching the hospital after 48 h, only 55% survived. Two babies with pouch colon and two of the four babies with LARM and associated anomalies died. In the HARM group, of the 31 babies with major associated anomalies, only 37% with birth weight <2.5 kg and 58% with birth weight >2.5 kg survived. Low birth weight, major associated anomalies, and delay in referral were the three important factors that influenced the outcomes of babies with ARM during the neonatal period.     

Narrow pubic arch and increased risk of failure for vaginal hysterectomy

OBJECTIVE: The purpose of this study was to evaluate the risk factors involved in failed vaginal hysterectomies. METHODS: Data on all vaginal hysterectomies performed by a single gynecologic surgeon were collected prospectively. Patients requiring pelvic floor repair were excluded. Any procedure converted to the abdominal approach was classified as a failed vaginal hysterectomy and comprised the study group. For every woman who had a failed vaginal hysterectomy, the next 2 women who had successful vaginal hysterectomies immediately after the failed vaginal hysterectomy were taken as controls. Risk factors such as age, parity, body weight, surgical indication, uterine size, presence of leiomyomata in the anterior lower uterine segment, previous pelvic surgeries, abdominopelvic adhesions, location and length of cervix, narrow pubic arch, intraoperative complications such as bleeding requiring transfusion, visceral injury, nulliparity, and adnexal removal were compared between groups. RESULTS: We compared 25 failed vaginal hysterectomies with 50 controls whose procedures were completed successfully through the vagina. Among all the factors gynecologists can assess preoperatively, only the presence of a narrow pubic arch increased the risk of failure for vaginal hysterectomy (odds ratio [OR] 4.1; 95% confidence interval 1.32-12.69). Intraoperative bleeding with transfusion was also found as an independent cause for conversion to laparotomy (OR 7.37; 95% confidence interval 1.75-31.06). CONCLUSION: Women with a narrow pubic arch are not good candidates for vaginal hysterectomy. The most common unpredictable cause for conversion to laparotomy from the vaginal approach is intraoperative bleeding requiring transfusion. LEVEL OF EVIDENCE: II-2