Santokba Durlabhji Memorial hospital

Abstract Comprehensive rehabilitation is essential to enhance the quality of life and cognitive performance of traumatic brain injury (TBI) survivors. Virtual reality (VR) has emerged as a promising tool for TBI rehabilitation due to its ability to provide an engaging and tailored environment.This was a randomized comparative study conducted at tertiary hospital and included individuals aged between 18 and 60 with mild-to-moderate cognitive impairment due to TBI. The participants were divided into a case group receiving intensive VR rehabilitation and a control group receiving standard care. Cognitive assessments were conducted before and after treatment, and during follow-up.VR rehabilitation demonstrated significant improvements in cognitive function. The VR group exhibited remarkable progress in the Montreal Cognitive Assessment (MoCA), Tower of London (TOL), and Trail Making Test (TMT) scores. Baseline MoCA, TOL, and TMT scores (mean value) of case group 16.5, 11.75, and 14.05 and for control group 17, 10, and 13 were respectively. All the parameters of case group improved at the time of discharge (MoCA: 24.3, TOL: 22, TMT: 27.5) and in follow-up (MoCA: 28.5, TOL: 32.5, TMT: 42.07) as compared with control group at discharge (MoCA: 19, TOL: 13, TMT: 17) and in follow-up (MoCA: 21, TOL: 15, TMT: 19), which shows significant improvement in case group (p < 0.001) as compared with control group.VR rehabilitation significantly improves cognitive outcomes in TBI patients. It has the potential to be a significant tool in TBI rehabilitation.

MTP has been legalized in India through the Medical Termination of Pregnancy Act, of 1971, which allows pregnancy termination up to 20weeks. The present study included second-trimester pregnancy terminations and the main aim of the study is to compare the efficacy and safety of tablet mifepristone 24h before vaginal tablet misoprostol in group-I with vaginal tablet misoprostol alone in group-II as a method of second-trimester pregnancy termination. It was a prospective randomized comparative study conducted at the Department of Obstetrics and Gynaecology, R.N.T. Medical College, Udaipur, Rajasthan, by selecting 100 patients, with equal no, i.e., 50 in each group who attended the inpatient department for second-trimester pregnancy termination (who were fulfilling the criteria as per MTP Act). From the data analysis of 100 subjects in this study, we observed that the most common indication for second-trimester pregnancy termination was indication (III), which accounts for a total of 60%. Majority of the patients in either group were in the age group between 20 and 30years, and there was more multigravida as compared to primigravida. The induction termination interval in the Mife-Miso group (group-I) was shorter, i.e., 10.21h as compared to the Miso group (group-II), i.e.,18h, and the difference between them was found to be statistically significant (P-value 0.004). The complete expulsion rate within 24h in group-I was 92% as compared to 72% in group-II. The pretreatment with oral mifepristone, provides a more safe, non-invasive, and effective regimen for second-trimester termination of pregnancy, which significantly reduces induction termination interval with more success rate.

This study aimed to assess 30-day morbidity and mortality rates following cholecystectomy for benign gallbladder disease and identify the factors associated with complications. Although cholecystectomy is common for benign gallbladder disease, there is a gap in the knowledge of the current practice and variations on a global level. A prospective, international, observational collaborative cohort study of consecutive patients undergoing cholecystectomy for benign gallbladder disease from participating hospitals in 57 countries between January 1 and June 30, 2022, was performed. Univariate and multivariate logistic regression models were used to identify preoperative and operative variables associated with 30-day postoperative outcomes. Data of 21,706 surgical patients from 57 countries were included in the analysis. A total of 10,821 (49.9%), 4,263 (19.7%), and 6,622 (30.5%) cholecystectomies were performed in the elective, emergency, and delayed settings, respectively. Thirty-day postoperative complications were observed in 1,738 patients (8.0%), including mortality in 83 patients (0.4%). Bile leaks (Strasberg grade A) were reported in 278 (1.3%) patients and severe bile duct injuries (Strasberg grades B-E) were reported in 48 (0.2%) patients. Patient age, ASA physical status class, surgical setting, operative approach and Nassar operative difficulty grade were identified as the five predictors demonstrating the highest relative importance in predicting postoperative complications. This multinational observational collaborative cohort study presents a comprehensive report of the current practices and outcomes of cholecystectomy for benign gallbladder disease. Ongoing global collaborative evaluations and initiatives are needed to promote quality assurance and improvement in cholecystectomy.

Pseudoaneurysm usually occurs after vascular injuries or erosions such as in trauma or inflammation like pancreatitis and is associated with high morbidity and mortality. The aim of study is to assess efficacy and safety of EUS-guided thrombin injection in pseudoaneurysm. Prospective data collection was done at SMS Hospital, Jaipur, from January 2015 to March 2023. All patients with pseudoaneurysm were consecutively enrolled. Twenty patients (M/F, 18:2) with median age of 41 years (25-58 years), were studied. Underlying etiology of pseudoaneurysm was chronic pancreatitis in 75% of the patients, blunt trauma abdomen in 15% of the patients, recurrent acute pancreatitis in 5%, and idiopathic in 5% of the patients. At the time of admission, mean hemoglobin was 6.7 g/dL (3.4-8.2), with median blood transfusion requirement was 2 units (0-6 units). Hemoglobin values after 4-6 weeks showed a significant improvement ( t = 9.21, P < 0.05).Mean dose of human thrombin required for complete obliteration of pseudoaneurysm was 520 ± 188.6 IU per patient (300-800 IU). Amount of thrombin (IU) dose needed to achieve complete obliteration correlated well significantly with the dimension of pseudoaneurysm, P value less than 0.05 ( R = 0.80). Median follow-up duration in this study was 44 months (3-84 months), which was the longest follow-up period by far. Endoscopic ultrasound-guided thrombin injection in visceral artery pseudoaneurysm is a safe and effective alternative for patients not amenable for digital subtraction angiography-guided angioembolization.

There is a direct correlation between the degree of obesity and the severity of associated complications including diabetes, postpartum hemorrhage, fetal macrosomia , preterm delivery, intrauterine fetal death, and extended postpartum hospitalization, failure of lactation, neonatal intensive care unit (NICU) admissions, Optimal intrapartum management of the obese gravida requires that the obstetrician work closely with the labor and delivery nurse, obstetric anesthesiologist, nurse anesthetist, and pediatrician to ensure that all are aware of, and prepared for, potential complications

Objective To study the etiological profile of pediatric headaches (PH) in a tertiary child neurology clinic and to determine the utility of diagnostics, interventions, and long-term prognosis. Methods Children (ages 4-15) observed over four years were recruited retrospectively. In primary headaches, the headache frequency and impact on quality of life (QOL) parameters at pre-treatment (T1) were compared post-treatment at follow-up (T2). Results Of the 311 eligible patients, 285 had primary headaches (Tension-Type Headache {TTH}: 156; Migraine: 129), and 26 had secondary headaches. The mean (±SD) onset age was 10 (±3) years with a male-to-female ratio of 2.3:1. Migraine was more common in children aged less than seven years (17/28) and TTH in older patients (146/283). The most common causes of secondary headache were intracranial hypertension (ICH) in 11/26 patients (fouridiopathic intracranial hypertension (IIH), four following aseptic meningitis, three with cortical vein thrombosis), and ophthalmologic causes in 7/26 (of these five had convergence insufficiency). Hypertension was a rare cause of secondary headaches (2/26 patients). Neuroimaging was performed in 173/311 (56%), primarily for parental anxiety (160/173; 92%), and was abnormal in only four. At T2 (Median time to follow-up: 29 months; Interquartile range: 22-37 months), data were collected in 207/285 patients with primary headaches (TTH: 109; Migraine: 98). In both migraine and TTH groups, there were statistically significant reductions (p-value <0.0001) in headache frequency and QOL parameters. Conclusion In our study, TTH wasthe most common cause of PH. Neuroimaging was normal in most cases. Psychological interventions were effective but underutilized. The symptoms of primary headaches improved significantly over time, despite poor adherence to prophylactic medications.

Sir, A vaginal hysterectomy was planned for a 54-year-old woman, weighing 80 kg with a body mass index (BMI) of 33, who had complaints of abnormal uterine bleeding. She complained of intermittent lower back pain for which she was advised magnetic resonance imaging (MRI) of lumbo-sacral spine, which showed a 2 × 4 cm intraspinal cystic lesion of cerebrospinal fluid intensity extending from first (L1) lumbar to fourth (L4) lumbar level. She did not provide any history of previous surgery or anaesthesia exposure and had good effort tolerance. Pre-anesthesia check up (PAC) fitness was given with routine preoperative orders. In our institute, we follow a two tier system, where after preliminary PAC by a resident, it is reviewed by a consultant anaesthetist next day prior to surgery. This second checkpoint helps to review the PAC and check consent documentation after proper patient identification. This practice at times is beneficial, as described in the present case, where on review it was found that the patient had been reluctant in sharing medical history. This prompted the anaesthetist to closely scrutinise the history of past medical illness and seek elaborate details revealing that the patient had suffered from myasthenia gravis (MG) 5 years ago. She had received treatment for 4 years and was asymptomatic for the last year and since all medications were stopped. The patient felt that since she had been cured of the illness she did not need to disclose it. We discussed the same with the surgeon but considering the semi-emergency of a bleeding patient we took a combined decision to proceed, but with a written consent of the patient and the relatives, reflecting the risk of morbidity associated, i.e., the risk of postoperative prolonged ventilatory support in intensive care unit (ICU). Regional anesthesia is preferred in MG considering the pathophysiology of the disease. However, since our patient had a collection in lumbar area, indicating a possible infection, central neuraxial block was contraindicated. Therefore, general anaesthesia was the only option left for us. After attaching monitors and obtaining intravenous access, fentanyl injection (1.5 μg/kg) was administered. Inj. propofol 1.5 mg/kg, sevoflurane 2.5% with oxygen were given after pre-oxygenation. After additional 30mg propofol bolus, laryngoscopy was attempted and endotracheal intubation was done with ease and anaesthesia was maintained with 50% O2 and 50% N2O along with sevoflurane 2.5% with intermittent boluses of propofol as per vitals. Toward the end of surgery (1.5 hours), inhalational agents were discontinued and patient was safely extubated after being fully awake and confirming adequate respiratory efforts. She was monitored in recovery for 1 hour and then in ICU for 24 hours. She remained well and was discharged on 3rd day after neurological consultation. Anaesthesia risks for a MG patient are well described in the literature. It affects the neuromuscular junction (NMJ) and its interaction with anaesthesia drugs, especially neuromuscular blocking drugs (NMBDs) poses a challenge for the anaesthetist. Therefore, regional anaesthesia is preferred to avoid postoperative respiratory depression and delayed recovery due to sensitivity to muscle relaxants.[1] Auto-antibodies develop against acetylcholine nicotinic postsynaptic receptors (AChR). Patients become symptomatic once receptors are reduced to 30% of normal. Antibodies reduce the number of functional receptors by increasing their degradation via complement-induced damage to NMJ. Antibodies are detected in sera of 85-90% MG cases. Cured MG must be assumed to be in active phase. The concept of cured is not valid in MG as functional receptor population is reduced/depleted. Muscle weakness becomes apparent when >70% AchR are blocked but in MG this “margin of safety,” i.e., presence of excess of receptors is reduced. Case reports have reported safe use of intermediate acting muscle relaxants (10-50% dose reduction). Though the patients may be symptom-free and in remission, they are sensitive to neuromuscular blocking drugs (NMBDs) as per one case report.[2] Due to non-availability of sugammadex, we avoided using non-depolarising NMBDs. MG cases are unpredictably resistant to depolarising NMBDs and unpredictably sensitive to non-depolarising NMBDs.[3] Hence, a MG patient, despite being in remission or cured, must be considered active, with planned anaesthesia according to surgery being vital to reduce morbidities. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Abstract Rothmund-Thomson syndrome (RTS) is a rare autosomal recessive disorder caused by homozygous or compound heterozygous mutations in RECQL4 gene and has characteristic clinical features of poikiloderma, congenital bone defects, gastrointestinal disturbances such as chronic diarrhea and vomiting, and an increased susceptibility to malignancy. A 2½-year-old Indian boy presented with reticulate hyperpigmented erythema with superimposed hypopigmented atrophic macular lesions over the cheeks and diffuse background hyperpigmentation with multiple discrete atrophic hypopigmented macules of variable size over the abdomen and extensor aspects of the forearms. X-rays suggested metaphyseal irregularity around knee joint and radioulnar synostosis. Whole-exome sequencing was suggestive of a de novo novel RECQL4 gene mutation causing RTS Type II. There is an overlapping of clinical features of the group of syndrome associated with skin lesions, skeletal, and gastric manifestations. All these conditions present a challenge to the clinician. Thus, molecular diagnosis is the only way to resolve these phenotypically similar conditions. This report expands the RECQL4 gene pathogenic mutations spectrum.