Conversion of regional to general anaesthesia at caesarean section: increasing the use of regional anaesthesia through continuous prospective audit

BackgroundAnaesthetic-related maternal deaths have largely been attributed to complications of general anaesthesia. In our unit a retrospective audit conducted between 1997 and 2002 showed a 9.4% conversion rate to general anaesthesia for caesarean sections amongst women with epidural catheters in-situ. The Royal College of Anaesthetists has stated that <3% of cases should need conversion to general anaesthesia. To improve our figures, from 2004 to 2007 we prospectively audited all caesarean sections requiring general anaesthesia.MethodsData were collected on the number of caesarean sections, initial anaesthetic technique used, need for conversion either pre- or intra-operatively and the use of labour epidural analgesia, where an epidural had been in-situ.ResultsThere were 2273 caesarean sections during the audit period. Neuraxial anaesthesia rates were for elective cases 95.3% (2004), 96.3% (2005), 98.3% (2006) and 98.2% (2007) and for emergency cases 82.3% (2004), 88.6% (2005), 87.0% (2006) and 85.7% (2007). Common reasons given for not using a regional technique were urgency of delivery (category 1) or anticipated large blood loss. Conversion rates from regional to general anaesthesia for elective cases were 0.8% (2004), 2.5% (2005), 0.5% (2006) and 0% (2007), and for emergencies 7.8% (2004), 2.7% (2005), 3.7% (2006) and 5.4% (2007). Improvements were seen in all but category-1 caesarean sections.ConclusionsProspective audit has been associated with improved rates for neuraxial anaesthesia and reduced need for conversion to general anaesthesia in all but category-1 caesarean sections. The Royal College of Anaesthetists standards may need to be reviewed to become category-specific.     

Manometric and symptomatic spectrum of motor dysphagia in a tertiary referral center in northern India

Background  

We studied the spectrum of motor dysphagia in a northern Indian tertiary referral center.     

Acute lymphoblastic leukemia masquerading as juvenile rheumatoid arthritis: diagnostic pitfall and association with survival

Acute lymphoblastic leukemia (ALL) often presents with osteoarthritic manifestations which may lead to misdiagnosis with juvenile rheumatoid arthritis (JRA). This study was designed to identify ALL patients with initial diagnosis of JRA, compare their clinicolaboratory characteristics and outcome with other ALL patients treated at our center. Case records of 762 patients with ALL were analyzed. Information regarding the clinical-demographic profile, therapy and outcome were recorded. Of the children, 49 (6.4%) had initial presentation mimicking JRA. Asymmetric oligoarthritis was the most common pattern of joint involvement. Majority presented with fever, pallor, arthritis, night pain, and bone pain. None of the routine prognostic factors including age, gender, lymphadenopathy, hepatosplenomegaly, total leukocytes count (TLC), and platelet count were significantly associated with relapse/death. The mean symptom-presentation interval (SPI), hemoglobin was significantly higher whilst the TLC was significantly lower in these patients compared to other ALL patients. The 5 year overall-survival was better than other patients with ALL (p?=?0.06, by logrank test). Significantly longer SPI in these patients underscores the need for prompt and early investigations to rule out ALL in patients of JRA with atypical features and pointers of ALL. Children with ALL-mimicking JRA may belong to a subgroup of ALL with a better prognosis.     

Long-term response to deferiprone therapy in Asian Indians

Deferiprone (L1) has been used in several countries for iron chelation therapy for over one decade. Long-term results on the drug are lacking. In the present study, data of 110 patients on deferiprone (L1) for up to 17 years were analyzed. On a mean L1 dose of 70.2 mg/kg/day (range 44–100), serum ferritin level showed a very steady decrease with time from an initial mean (±SD) of 3,033.61 ± 1,468.04 ng/ml to final of 1,665.08 ± 949.93 ng/ml after a mean (±SD) of 6.1 ± 3.8 years. In total, 13 patients discontinued L1 therapy. Major complications of L1 requiring permanent discontinuation of treatment included arthropathy (n = 8, 7.2%) and neutropenia/agranulocytosis (n = 5, 4.5%). Lesser complications permitting continued L1 treatment included transient mild leucopenia or thrombocytopenia (n = 3) and gastrointestinal problems (n = 5). There were a total of three deaths attributed to agranulocytosis. Although the complications associated with L1 treatment are significant and require close monitoring, they do not preclude effective long-term therapy in the vast majority of patients. A longer duration of therapy is required for effective response in chronically iron-overloaded patients. Further well-controlled prospective studies of L1 are required to identify factors affecting individual response to therapy.     

Severe hypernatraemia associated with growth hormone replacement therapy in a patient with septo-optic dysplasia

Background The anti-natriuretic properties of growth hormone (GH) are well established. Growth hormone deficiency (GHD) results in salt and water depletion and studies confirm that replacement leads to sodium and vasopressin-mediated water retention in patients with intact posterior pituitary function. Methods We report the case of a 20-year-old male patient with septo-optic dysplasia, fixed cranial diabetes insipidus (DI) and an abnormal thirst threshold. With careful parental support, his sodium levels remained stable for many years on a fixed dose of DDAVP and a supervised fluid intake of 2.5 l/day. Several years after the original diagnosis, he was found to be ACTH deficient and following commencement of hydrocortisone replacement therapy became hypernatraemic. A new sodium homoeostasis was established with a higher dose of DDAVP. Subsequently, he developed symptoms typical of GHD and, after biochemical confirmation, GH replacement was commenced. Results There was an immediate clinical improvement (increased alertness, improved concentration) but severe hypernatraemia developed (peak 169 mmol/l) necessitating revision of his desmopressin and fluid intake regimen. Conclusion Most GHD patients have intact posterior pituitary function. This case report highlights the powerful anti-natriuretic properties of GH. Endocrine physicians should be alert to this in patients with fixed DI and an abnormal thirst threshold.     

Association of alpha subunit of GABAA receptor subtype gene polymorphisms with epilepsy susceptibility and drug resistance in north Indian population

GABA (γ-amino butyric acid) receptors have always been an inviting target in the etiology and treatment of epilepsy because of its role as a major inhibitory neurotransmitter in the brain. The aim of our study was to find out the possible role of single nucleotide polymorphisms (SNPs) present in GABRA1 IVS11 + 15 A > G (rs2279020) and GABRG2 588C > T (rs211037) genes in seizure susceptibility and pharmaco-resistance in northern Indian patients with epilepsy. A total of 395 epilepsy patients and 199 control subjects were enrolled for present study. The genotyping was done by PCR-RFLP methods. The GABRA1 IVS11 + 15 A > G polymorphism conferred high risk for epilepsy susceptibility at genotype ‘AG’ (P = 0.004, OR = 1.77, 95% CI = 1.20–2.63), ‘GG’ (P = 0.01, OR = 1.80, 95% CI = 1.15–2.80) and G allele level (P = 0.001, OR = 1.50, 95% CI = 1.16–1.92). Moreover this polymorphism was also associated with multiple drug resistance in patients with epilepsy for homozygous variant ‘GG’ genotype (P = 0.031, OR = 1.84, 95% CI = 1.05–3.23) and G allele (P = 0.020, OR = 1.43, 95% CI = 1.05–1.95). However GABRG2 588C > T polymorphism was not found to be associated either with epilepsy susceptibility or with drug resistance. Overall results indicate differential role of different subunits of GABA_A receptor subtypes in epilepsy susceptibility and pharmacotherapy.