Demographic profile of traumatic spinal cord injuries admitted at Indian Spinal Injuries Centre with special emphasis on mode of injury: a retrospective study

Objectives:To identify the demographic profile of persons with traumatic spinal cord injury (TSCI) admitted at the center.Setting:Indian Spinal Injuries Centre.Study design:Retrospective analysis.Methods:Information was collected in 2010 from case sheets of 1138 persons with TSCI admitted from January 2002 to May 2010. A telephonic survey was conducted to get further insight into fall from height (FFH) or road traffic accident (RTA) as a mode of injury.Results:The mean, median and mode for the age were 34.4, 32 and 30 years, respectively. Male:female ratio was 5.9:1 and 63.18% (n=719) were married. RTA was the most common (45%) and FFH the second most common (39.63%) mode of injury. Overall, 66.67% suffered from paraplegia and 71.18% had complete injuries.Conclusion:As compared to other Indian published studies, our study had a much larger number of persons with TSCI and could be considered as the most representative amongst available literature for the Indian population. The study suggests that the demographics of spinal injury in India differs significantly from that in the developed countries since there was a lower mean age, much larger number of males, married individuals, injuries due to two wheeler accidents/falls, paraplegics and complete injuries. In contrast to other published Indian pilot studies, RTA was the most common mode of injury. Our study brings out the need for a proper epidemiological study and for establishing services for pre-hospital and acute care.     

Vertebral cryptococcosis simulating tuberculosis

Infection with the fungus Cryptococcus neoformans is seen predominantly in two forms: (a) pulmonary and (b) cerebromeningeal. Skeletal cryptococcosis is uncommon. There have been only occasional case reports of thoracic vertebral cryptococcosis presenting as cord compression. A young female had cervical lymphadenopathy diagnosed as tuberculosis by fine needle aspiration cytology (FNAC) and was on antitubercular therapy (ATT) for 5 months. She developed rapidly progressive paraparesis and imaging demonstrated a destructive vertebral body lesion involving T2-3 with a paraspinal abscess producing cord compression. A costotransversectomy with excision of the diseased bone and bone grafting was done. Histopathological examination revealed cryptococcosis. The patient was put on antifungal medication, but expired 2 weeks after surgery. Radiological, magnetic resonance imaging and surgical finding of vertebral cryptococcosis can mimic tuberculosis. The definite diagnosis of cryptococcosis depends upon microscopic identification of the organism. A high index of suspicion leading to early surgical confirmation and institution of anti fungal therapy is necessary to reduce the mortality and morbidity.     

Brachial plexus block with midazolam and bupivacaine improves analgesia

PURPOSE: Adjuncts to local anesthetics for brachial plexus block may enhance the quality and duration of analgesia. Midazolam, a water-soluble benzodiazepine, is known to produce antinociception and enhance the effect of local anesthetics when given epidurally or intrathecally. The purpose of this study was to assess the effect of midazolam added to brachial plexus anesthesia. METHODS: A prospective, randomized, double blind study was conducted on 40 ASA I or II adult patients undergoing upper limb surgeries under supraclavicular brachial plexus block. Patients were randomly divided into two groups. Patients in Group B (n = 20) were administered 30 mL of 0.5% bupivacaine and Group BM (n = 20) were given 30 mL of 0.5% bupivacaine with midazolam 50 microg x kg(-1). Hemodynamic variables (i.e., heart rate, noninvasive blood pressure), pain scores and rescue analgesic requirements were recorded for 24 hr postoperatively. RESULTS: The onset of sensory and motor block was significantly faster in Group BM compared to Group B (P < 0.05). Pain scores were significantly higher in Group B compared to Group BM from two hours to 24 hr postoperatively (P < 0.05). Rescue analgesic requirements were significantly less in Group BM compared to Group B (P < 0.05). Hemodynamics and sedation scores did not differ between groups in the post-operative period. CONCLUSION: Midazolam (50 microg x kg(-1)) in combination with 30 mL of bupivacaine (0.5%) hastened onset of sensory and motor block, and improved postoperative analgesia when used in brachial plexus block, without producing any adverse events.     

Decompressive surgery for acute subdural haematoma leading to contralateral extradural haematoma: a report of two cases and review of literature

Development of a contralateral epidural haematoma during or immediately after cranial surgery is a well-described entity. However, in a case of acute subdural haematoma where the brain is usually tense, postoperative development of contralateral extradural haematoma is uncommon. We report two cases of contralateral extradural haematoma after decompressive surgery for acute subdural haematoma. We recommend routine postoperative CT immediately after cranial surgery for head trauma. This would help in timely detection and treatment of such a complication.     

A health economic analysis of the use of rhBMP-2 in Gustilo–Anderson grade III open tibial fractures for the UK, Germany, and France

The purpose of this study was to determine the cost savings from a societal perspective for recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) in grade III A and B open tibial fractures treated with a locked intramedullary nail and soft-tissue management in the UK, Germany, and France. Health care system costs (direct health care costs) and costs for productivity losses (indirect health care costs) were calculated using the raw data from the Bone Morphogenetic Protein Evaluation Group in Surgery for Tibial Trauma “BESTT study”. Return-to-work time for estimation of productivity losses was assumed to correspond with the time of fracture healing. For calculation of secondary interventions costs and productivity losses the respective 2007/2008 national tariffs for surgical procedures and average national wages for the UK, Germany, and France were used. For a 1 year perspective, overall treatment costs per patient after the initial surgery of the control vs. the rhBMP-2 group were €44,757 vs. €36,847 for the UK, €50,197 vs. €40,927 for Germany and €48,766 vs. €39,474 for France in favour of rhBMP-2 with overall savings overall savings per case of rhBMP-2 treatment of €7911 for the UK, €9270 for Germany, and €9291 for France which was mainly due to reduced productivity losses by significant faster fracture healing in the rhBMP-2 group (p = 0.01). These savings largely offset the upfront price of rhBMP-2 of €2266 (£1790) in the UK, €2970 in Germany, and €2950 in France. Total net savings can be estimated to be €9.6 million for the UK, €14.5 million for Germany, and €11.4 million for France. The results depend on the methodology used particularly for calculation of productivity losses and return-to-work time which was assumed to correspond with fracture healing time. In summary, despite the apparent high direct cost of rhBMP-2 in grade III A and B open tibial fractures, at a national level there are net cost savings from a societal perspective for all three countries.     

Human immunodeficiency virus infection in a child presenting as herpes zoster ophthalmicus

Herpes zoster is mainly a disease of the elderly. Its occurrence in younger age should be viewed with suspicion. A 9-year-old boy presented with herpes zoster ophthalmicus. He had a history of abdominal surgery one and half years back during which he had received blood transfusion. A year following the surgery he developed general malaise and fever with progressive weight loss. He was treated by local doctors. Subsequently he developed eruptions of blisters around right eye for a duration of 8 days, with which he presented to the department of ophthalmology, Pt JNM Medical College, Raipur. On investigations he was found to have infected with human immunodeficiency virus. Systemic acyclovir along with antiretroviral treatment was started, to which he showed favourable response.     

Physician communication styles in initial consultations for hematological cancer

Objective

To characterize practices in subspecialist physicians’ communication styles, and their potential effects on shared decision-making, in second-opinion consultations.

Methods

Theme-oriented discourse analysis of 20 second-opinion consultations with subspecialist hematologist-oncologists.

Results

Physicians frequently “broadcasted” information about the disease, treatment options, relevant research, and prognostic information in extended, often-uninterrupted monologs. Their communicative styles had one of two implications: conveying options without offering specific recommendations, or recommending one without incorporating patients’ goals and values into the decision. Some physicians, however, used techniques that encouraged patient participation.

Conclusions

Broadcasting may be a suboptimal method of conveying complex treatment information in order to support shared decision-making. Interventions could teach techniques that encourage patient participation.

Practice implications

Techniques such as open-ended questions, affirmations of patients’ expressions, and pauses to check for patient understanding can mitigate the effects of broadcasting and could be used to promote shared decision-making in information-dense subspecialist consultations.