Ultrasound-Guided Greater Occipital Nerve Hydrodissection for Treatment of Cervicogenic Headache: A Case Report

We describe an innovative technique of ultrasound-guided greater occipital nerve (GON) hydrodissection for treatment of cervicogenic headache and occipital neuralgia. A 35-year-old female presented to the pain clinic with severe chronic cervicogenic headache impacting her sleep, work and activities of daily living. Conservative management had failed to adequately resolve her pain. Ultrasound-guided suboccipital hydrodissection of the greater occipital nerve was performed with the patient in the prone position. After skin sterilization, the linear ultrasound transducer was oriented in a transverse orientation at the level of the C2-C3 vertebrae. The needle was advanced from medial to lateral “in-plane” under direct ultrasound visualization, until the needle was positioned at the C2 lamina. After confirming the needle tip position, 10 ml of hydrodissection fluid was injected with good visualization of distribution of the solution. The patient described immediate and significant improvement in her symptoms. She reported a sustained decrease in pain scores when followed up in the pain clinic at six and twelve weeks respectively. To the best of our knowledge this is the first application of ultrasound-guided hydrodissection of the GON for cervicogenic headache. It offers a novel, safe and effective technique to aid in the diagnosis and treatment of a common pain condition.

Ultrasound-Guided Dorsal Scapular Nerve Blockade in the Diagnosis and Management of Neck Pain

Neck pain is common and has multiple sources, but correct diagnosis and matched treatment provide the best outcomes. The first description of ultrasound-guided dorsal scapular nerve blockade using a single-shot local anesthetic technique for the diagnosis and treatment of neck pain is reported. A 38-year-old female patient presented with neck pain, and the history and clinical examination strongly suggested myofascial pain affecting the middle scalene muscle. The pain had been unresponsive to pharmacological therapy or physiotherapy. After identifying the dorsal scapular nerve (DSN) in the body of the middle scalene muscle, an ultrasound-guided nerve block was performed using a single injection of local anesthetic to alleviate the patient’s pain. It has been demonstrated that the dorsal scapular nerve can be identified in the neck and effectively blocked using ultrasound guidance. This technique has the potential to assist in the diagnosis and treatment of neck pain originating from the middle scalene muscle.

Management of Rhabdomyolysis and Acute Renal Failure Following Strenuous Exercise in Young Adult: A Case Report

Introduction: Rhabdomyolysis is severe and life threating condition in which skeletal muscles are damaged by dissolution of striped muscles. Acute kidney injury (AKI) has been widely reported (13% - 50%) as a complication of Rhabdomyolysis in which the main pathophysiological mechanisms are intra-renal vasoconstriction, intraluminal cast formation (Tamm-Horsefall) and direct myoglobin toxicity. In this report we are going to describe the management of Acute Kidney Injury due to Rhabdomyolysis that is not responding to vigorous rehydration. Objective: Reporting about acute renal failure induced by Rhabdomyolysis due to Excessive Exercise and dehydration in young patient. Case Report: A 20 years male came to the outpatient clinic complaining of sever lower limb pain, back pain and vomiting. He was anuric and hypertensive (BP = 150/90 mmHg) with serum creatinine and urea levels of 15.72 mg/dl and 235 mg/dl, respectively. The diagnosis was based on the laboratory finding of creatine kinase = 3127 IU/l. The patient, then, has been referred to the emergency department. The Management plan was based on two arms: Emergency Management with Urgent Hemodialysis for AKI and high fluid replacement therapy. Patient started to recover after three hemodialysis sessions but the peak of recovery was noted after starting manual fluid replacement therapy with a target urine output of greater than 2 ml/kg, a urine pH of greater than 6. Manual fluid replacement therapy consisted of loop diuretics, intravenous fluids and intravenous sodium bicarbonate 1.26%. Full recovery was noted after one month of hospital admission with inpatient care and regular follow-up. A follow-up after one month has been set to assess the patient progression and monitor his kidney functions. Relevance and Impact: Home messages and lessons are;Firstly, young adults are vulnerable to Rhabdomyolysis, second, the diagnosis of Rhabdomyolysis can be made on the clinical bases but a confirmatory laboratory test of Creatine Kinase is mandatory, and lastly’ acute kidney injury needs to be treated urgently. Also, reducing the risk of infection is one of the management objectives to achieve recovery.

Miller Fisher Syndrome Induced by Chemotherapy in Known Case of Acute Lymphocytic Leukaemia: A Case Report

Introduction: Guillain-Barre Syndrome (GBS) is an acute-onset autoimmune-mediated neuropathy. Guillain-Barre Syndrome can be divided into three subtypes: acute inflammatory demyelinating poly-radiculo-neuropathy (AIDP), acute motor axonal neuropathy (AMAN), and acute motor sensory axonal neuropathy (AMSAN). About 20% of patients with GBS develop respiratory failure and require mechanical ventilation. We are presenting a variant of GBS (Miller Fisher Syndrome, or MFS), which has been confirmed by nerve conduction studies along with the triad of ophthalmoplegia, ataxia, and areflexia. The objective of this study is to present a rare case of chemotherapy-induced GBS. Important clinic findings: A 25-year-old gentleman with acute lymphocytic leukemia on active chemotherapy treatment presented with lower limb weakness. This weakness started after his fifth chemotherapy session. After the sixth chemotherapy, he developed complete paralysis of the left lower limb. Later, he developed right lower limb paralysis. He was also complaining of eye dryness and incomplete closure of both eyes. While inpatient, he developed upper-limb weakness. His chemotherapy consisted of MESNA, cyclophosphamide, doxorubicin, vincristine, cyorabine, and methotrexate. He had ptosis and ophthalmoplegia in the left abducent and right oculomotor regions. He had bilateral facial nerve palsy. He was hypotonic with power grade 3 in the upper limbs and grade 0 in the lower limbs with areflexia. His sensation was intact in the upper limbs but lost in the lower limbs. His planter reflexes were mute. Diagnoses and Management: Intravenous immunoglobulins were given for 5 days. A nerve conduction study showed severe demyelinating sensorimotor polyradoculoneuropathy with secondary axonal loss. The triad of ataxia, ophthalmoplegia, and areflexia was consistent with MFS. The patient improved over the course of the hospital stay but did not reach full recovery. Conclusion: Although GBS is uncommon, it must be taken into account when making a differential diagnosis for any patient presenting with progressive weakness. Drug history is important in all GBS cases.

Randomized study comparing incidence of radial artery occlusion post-percutaneous coronary intervention between two conventional compression devices using a novel airinflation technique

AIM To compare post-percutaneous coronary intervention(PCI) radial artery occlusion(RAO) incidence between two conventional radial artery compression devices using a novel air-inflation technique.METHODS One hundred consecutive patients post-PCI were randomized 1:1 to Safeguard or TR band compression devices. Post-radial sheath removal, each compression device was inflated with additional 2 m L of air above index bleeding point during air-filled device application and gradually down-titrated accordingly. RAO was defined as absence of Doppler flow signal performed at 24 h and at 6 wk post-PCI. Patients with missing data were excluded. Statistical significance was defined as P < 0.05.RESULTS All patients had 6 F radial sheath inserted. No significant differences were observed between Safeguard Radial(n = 42) vs TR band(n = 42) in terms of age(63 ± 11 years vs 67 ± 11 years), clinical presentation(electives, n = 18 vs n = 16; acute coronary syndrome, n = 24 vs n = 26) and total procedural heparin(7778 ± 2704 IU vs 7825 ± 2450 IU). RAO incidence was not significantly different between groups at 24 h(2% vs 0%, P = 0.32) and 6 wk(0%, both).CONCLUSION Safeguard Radial and TR band did not demonstrate significant between-group differences in short-term RAO incidence. Lack of evidence of RAO in all postPCI patients at 6 wk follow-up, regardless of radial compression device indicate advantage of using the novel and pragmatic air-inflation technique. Further work is required to more accurately confirm these findings.

Agreement and conversion formula between mini-mental state examination and montreal cognitive assessment in an outpatient sample

AIM To explore the agreement between the mini-mental state examination(MMSE) and montreal cognitive assessment(Mo CA) within community dwelling older patients attending an old age psychiatry service and to derive and test a conversion formula between the two scales.METHODS Prospective study of consecutive patients attending outpatient services.Both tests were administered by the same researcher on the same day in random order.RESULTS The total sample(n = 135) was randomly divided into two groups.One to derive a conversion rule(n = 70),and a second(n = 65) in which this rule was tested.The agreement(Pearson's r) of MMSE and Mo CA was 0.86(P < 0.001),and Lin's concordance correlation coefficient(CCC) was 0.57(95%CI:0.45-0.66).In the second sample Mo CA scores were converted to MMSE scores according to a conversion rule from the first sample which achieved agreement with the original MMSE scoresof 0.89(Pearson's r,P < 0.001) and CCC of 0.88(95%CI:0.82-0.92).CONCLUSION Although the two scales overlap considerably,the agreement is modest.The conversion rule derived herein demonstrated promising accuracy and warrants further testing in other populations.

Benefits of post-operative oral protein supplementation in gastrointestinal surgery patients: A systematic review of clinical trials

AIM: To evaluate published trials examining oral postoperative protein supplementation in patients having undergone gastrointestinal surgery and assessment of reported results.METHODS: Database searches(MEDLINE, BIOSIS, EMBASE, Cochrane Trials, Cinahl, and CAB), searches of reference lists of relevant papers, and expert referral were used to identify prospective randomized controlled clinical trials. The following terms were used to locate articles: "oral'' or "enteral'' and "postoperative care'' or "post-surgical'' and "proteins' ' or "milk proteins' ' or "dietary proteins' ' or "dietary supplements' ' or "nutritional supplements' '. In databases that allowed added limitations, results were limited to clinical trials that studied humans, and publications between 1990 and 2014. Quality of collated studies was evaluated using a qualitative assessment tool and the collective results interpreted.RESULTS: Searches identified 629 papers of which, following review, 7 were deemed eligible for qualitative evaluation. Protein supplementation does not appear to affect mortality but does reduce weight loss, and improve nutritional status. Reduction in grip strength deterioration was observed in a majority of studies, and approximately half of the studies described reduced complication rates. No changes in duration of hospital stay or plasma protein levels were reported. There is evidence to suggest that protein supplementation should be routinely provided post-operatively to this population. However, despite comprehensive searches, clinical trials that varied only the amount of protein provided via oral nutritional supplements(discrete from other nutritionalcomponents) were not found. At present, there is some evidence to support routinely prescribed oral nutritional supplements that contain protein for gastrointestinal surgery patients in the immediate post-operative stage.CONCLUSION: The optimal level of protein supplementation required to maximise recovery in gastrointestinal surgery patients is effectively unknown, and may warrant further study.

Repeatability of two-dimensional chemical shift imaging multivoxel proton magnetic resonance spectroscopy for measuring human cerebral choline-containing compounds

AIM To investigate the repeatability of proton magnetic resonance spectroscopy in the in vivo measurement of human cerebral levels of choline-containing compounds(Cho).METHODS Two consecutive scans were carried out in six healthy resting subjects at a magnetic field strength of 1.5 T. On each occasion, neurospectroscopy data were collected from 64 voxels using the same 2 D chemical shift imaging(CSI) sequence. The data were analyzed in the same way, using the same software, to obtain the values for each voxel of the ratio of Cho to creatine. The Wilcoxon related-samples signed-rank test, coefficient of variation(CV), repeatability coefficient(RC), and intraclass correlation coefficient(ICC) were used to assess the repeatability. RESULTS The CV ranged from 2.75% to 33.99%, while the minimum RC was 5.68%. There was excellent reproducibility, as judged by significant ICC values, in 26 voxels. Just three voxels showed significant differences according to the Wilcoxon related-samples signed-rank test. CONCLUSION It is therefore concluded that when CSI multivoxel proton neurospectroscopy is used to measure cerebral choline-containing compounds at 1.5 T, the reproducibility is highly acceptable.

Trochanteric bursitis information on the internet;can we trust the information presented?

Trochanteric bursitis is one of the most common causes of lateral hip pain in adults.The prevalence of unilateral trochanteric bursitis is 15.0%in women and 8.5%in men.Access to internet based information has increased dramatically and health related information is now one of the most popular searches in online activity,despite this the quality of information can vary.The objective of this paper is to examine the quality and readability of internet based information of trochanteric bursitis.Overall,we have found a high variability among not only the quality but also the readability of information published.Websites that appeared first on each search engine for trochanteric bursitis did not necessarily score better,demonstrating the importance of providing patients with high quality resources.Future articles should use more critical appraisal tools in order to provide the reader with more high quality and readable information.

Effect of institutional volume on laparoscopic cholecystectomy outcomes: Systematic review and metaanalysis

AIM: To determine whether institutional laparoscopy cholecystectomy(LC) volume affects rates of mortality, conversion to open surgery, bile leakage and bile duct injury(BDI).METHODS: Eligible studies were prospective or retrospective cohort studies that provided data on outcomes from consecutive LC procedures in single institutions. Relevant outcomes were mortality, conversion to open surgery, bile leakage and BDI. We performed a Medline search and extracted data. A regression analysis using generalized estimating equations were used to determine the influence of annual institutional LC caseload on outcomes. A sensitivity analysis was performed including only those studies that were published after 1995.RESULTS: Seventy-three cohorts(127404 LC procedures) were included. Average complication rates were 0.06% for mortality, 3.23% for conversion, 0.44% for bile leakage and 0.28% for bile duct injury. Annual institutional caseload did not influence rates of mortality(P = 0.142), bile leakage(P = 0.111) or bile duct injury(P = 0.198) although increasing caseload was associated with reduced incidence of conversion(P = 0.019). Results from the sensitivity analyses were similar.CONCLUSION: Institutional volume is a determinant of LC complications. It is unclear whether volume is directly linked to complication rates or whether it is an index for protocolised care.

Months backward test:A review of its use in clinical studies

AIM: To review the use of the Months Backwards Test(MBT) in clinical and research contexts.METHODS: We conducted a systematic review of reports relating to the MBT based upon a search of Psych INFO and MEDLINE between January 1980 and December 2014. Only reports that specifically described findings pertaining to the MBT were included. Findings were considered in terms of rating procedures, testing performance, psychometric properties, neuropsychological studies and use in clinical populations.RESULTS: We identified 22 data reports. The MBT is administered and rated in a variety of ways with very little consistency across studies. It has been used to assess various cognitive functions including focused and sustained attention as well as central processingspeed. Performance can be assessed in terms of the ability to accurately complete the test without errors("MB accuracy"), and time taken to complete the test("MB duration"). Completion time in cognitively intact subjects is usually < 20 s with upper limits of 60-90 s typically applied in studies. The majority of cognitively intact adults can complete the test without error such that any errors of omission are strongly suggestive of cognitive dysfunction. Coverage of clinical populations, including those with significant cognitive difficulties is high with the majority of subjects able to engage with MBT procedures. Performance correlates highly with other cognitive tests, especially of attention, including the digit span backwards, trailmaking test B, serial threes and sevens, tests of simple and complex choice reaction time, delayed story recall and standardized list learning measures. Test-retest and inter-rater reliability are high(both > 0.90). Functional magnetic resonance imaging studies comparing the months forward test and MBT indicate greater involvement of more complex networks(bilateral middle and inferior frontal gyri, the posterior parietal cortex and the left anterior cingulate gyrus) for backwards cognitive processing. The MBT has been usefully applied to the study of a variety of clinical presentations, for both cognitive and functional assessment. In addition to the assessment of major neuropsychiatric conditions such as delirium, dementia and Mild Cognitive Impairment, the MBT has been used in the assessment of concussion, profiling of neurocognitive impairments in organic brain disorders and Parkinson's disease, prediction of delirium risk in surgical patients and medication compliance in diabetes. The reported sensitivity for acute neurocognitive disturbance/delirium in hospitalised patients is estimated at 83%-93%. Repeated testing can be used to identify deteriorating cognitive function over time.CONCLUSION: The MBT is a simple, versatile tool that is sensitive to significant cognitive impairment. Performance can be assessed according to accuracy and speed of performance. However, greater consistency in administration and rating is needed. We suggest two approaches to assessing performance- a simple(pass/fail) method as well as a ten point scale for rating test performance(467).

Delirium,insulin-like growth factor I,growth hormone in older inpatients

BACKGROUND Delirium is a common disorder in elderly medical inpatients with serious adverse outcomes and is characterized by sudden onset,disturbance in attention,awareness,consciousness and cognition,and often with behavioural disturbances.Central to understanding delirium,is understanding mechanisms by which body and brain wellbeing are linked and in particular how brain responses to bodily homeostatic stress is mediated.A number of studies have investigated the relationship between insulin-like growth factor I(IGF-I)and delirium in medically ill hospitalised patients with conflicting results.However,none have investigated growth hormone(GH)which is related to IGF-I via negative feedback.AIM To investigate the relationship between serum levels of IGF-I and GH,and the occurrence of delirium.METHODS Prospective,longitudinal,observational study.Consecutive elderly inpatients(aged 70+),were assessed twice weekly with Montreal cognitive assessment(MoCA),Confusion assessment method(CAM),Acute Physiology and Chronic Health Evaluation II.Delirium was defined using CAM.Previous history of dementia was evaluated with the Informant Questionnaire on Cognitive Decline in the Elderly.IGF-I and GH levels were estimated with the ELISA method.Generalized estimating equations(GEE)model was applied for the first five assessments to analyze those longitudinal data.RESULTS The sample consisted of 198 participants(mean age 80.63±6.81;range 70-97).Of these 92(46.5%)were females.Eighty six(43.4%)were identified with a history of dementia.Incident or prevalent delirium during hospitalisation was identified with CAM in 40 participants(20.2%).Evaluation of missing values with Little's MCAR test indicated that they were missing completely at random(MCARχ2=12.24,u:9,P=0.20).Using GEE for the analysis we found that low MoCA scores,low levels of IGF-I and high levels of GH were significantly associated with any delirium(prevalence,incident,or fluctuating,during the study period(Waldχ2=12.231;u:1,P<0.001,Waldχ2=7.196,u:1,P=0.007,Waldχ2=6.210;:u:1,P=0.013 respectively).CONCLUSION The results show that low levels of IGF-I,high levels of GH and low scores in cognition are independently associated with the occurrence of any delirium during the hospitalisation of medically ill older people.The results of the study supports the hypothesis that deficits in the immunoreactivity of the brain(low cerebral reserve)may be associated with delirium.

Role of H2 receptor blocker famotidine over the clinical recovery of COVID-19 patients: A randomized controlled trial

BACKGROUND Coronavirus disease 2019(COVID-19)is a global pandemic putting the population at a high risk of infection-related health hazards,mortality and a potential failure of proper medical therapies.Therefore,it is necessary to evaluate the potential use of the existing drugs that could be used as options for the medical management of COVID-19 patients.AIM To evaluate the role of the H_(2) receptor blocker“famotidine”in COVID-19 illness.METHODS This study was done on seriously ill COVID-19 patients admitted to the intensive care unit(ICU)from different institutes in Bangladesh.Patients were divided into famotidine treatment group“A”(famotidine 40 mg to 60 mg oral formulation every 8 h with other treatment as given),and control group“B”(treatment as given).National early warning score(NEWS)-2,and sequential organ failure assessment day-1 score was calculated to evaluate the outcome.Outcomes were evaluated by the time required for clinical improvement,characterized as duration required from enrollment to the achievement of NEWS-2 of≤2 maintained for 24 h;time to symptomatic recovery,defined as the duration in days(from randomization)required for the recovery of the COVID-19 symptoms;mortality rate;duration of ICU and hospital stay;total period of hospitalization;the rate of supplementary oxygen requirement;the computed tomography(CT)chest recovery(%),the time required for the viral clearance and“NEWS-2”on discharge.RESULTS A total of 208 patients were enrolled in this study with 104 patients in each group.The famotidine treatment group had comparatively better recovery of 75%and a low mortality of 25%than the control with a recovery of 70%and a mortality of 30%.Duration of clinical improvement(group A 9.53 d,group B 14.21 d);hospitalization period among the recovered patients(group A 13.04 d,group B 16.31 d),pulmonary improvement in chest CT(group A 21.7%,group B 13.2%),and the time for viral clearance(group A 20.7 d,group B 23.8 d)were found to be statistically significant P≤0.05.However,the Kaplan Meier survival test was not significant among the two study groups,P=0.989.CONCLUSION According to our study,treatment with famotidine achieved a better clinical outcome compared to the control group in severe COVID-19 illness,although no significant survival benefit was found.

Historical development of mesenteric anatomy provides a universally applicable anatomic paradigm for complete/total mesocolic excision

Although total mesorectal excision has now become the‘gold standard’for the surgical management of rectal cancer,this is not so for colon cancer.Recent data,provided by Hohenberger and West et al.and others,have demonstrated excellent oncological outcomes when mesenterectomy is extensive(as is implicit in the concept of a‘high tie’)and the mesenteric package not violated.Such studies highlight the importance of understanding the basics of the mesenteric organ(including the small intestinal mesentery,mesocolon,mesosigmoid and mesorectum)and of abiding to principles of planar surgery.In this review,we first offer classic descriptions of the mesocolon and then detail contemporary thinking.In so doing,we provide an anatomical basis for safe and effective complete mesocolic excision(CME)in the management of colon cancer.Finally we list opportunities associated with the new anatomical paradigm,demonstrating benefits across multiple disciplines.Perhaps most importantly,we feel that a crystallized view of mesenteric anatomy will overcome factors that have hindered the general uptake of CME.