Correlation of Prepontine Cisternal Space Thickness with the Severity of Neurovascular Conflict and its Role in Predicting Outcome of Medical Management in Cases of Trigeminal Neuralgia

Background

Trigeminal neuralgia (TN) is a debilitating disorder that presents with sudden onset of severe, unilateral, paroxysmal, and lancinating pain usually lasting for few seconds to few minutes.

Aims and Objectives

The main aim of our study was to correlate the prepontine cisternal space thickness, with a severity of neurovascular compression (NVC) and percentage reduction of pain (patient outcome).

Materials and Methods

Ours is an observational prospective study of 40 patients presenting with TN for magnetic resonance imaging in our department. Patients were followed up on medical treatment and their pain severity evaluated on their follow-up visit. Patients were divided into two groups based on prepontine cisternal space (Group A: ≤4 mm, Group B: >4 mm) and into three groups based on the percentage reduction of pain, Group 1 (0-35%), Group 2 (36-70%), and Group 3 consisted of patients with pain reduction of more than 70%. Ipsilateral prepontine cisternal space thickness was correlated with grade of NVC and percentage reduction of pain.

Results

Mean percentage of pain reduction in group A and group B was 34.12 and 60.68%, respectively. Approximately 23.80% of grade1 NVC were seen in group A and 76.20% in group B, while 80% of grade 3 NVC were seen in group A and only 20% were seen in group B.

Conclusion

There was poor response to medical treatment, in patients with narrowed prepontine cisternal space thickness with an inverse relationship between the grade of NVC and cisternal space thickness.

498 Junior Doctor Checklist for the Management of Neck of Femur Fracture: A Quality Improvement Project

Aim

Patients admitted with Neck of Femur (NOF) fracture are often complex and frail. Junior doctors in our institution are first on call and have minimal orthopaedic experience. Anecdotal experience has shown that patients are often inadequately optimised. For example, fluids not prescribed, and anticoagulants not reversed which could lead to further complications and delay to surgery, affecting patient outcomes. Therefore, we developed a junior doctor checklist to improve the quality of care for patients with NOF fracture.

Method

A plan-do-study-act (PDSA) methodology was utilized in designing this project. Data was collected prospectively from 50 patients presented with NOF fracture pre and post intervention. Clerking proforma, drug chart and electronic systems were reviewed. Outcome measures were prescription of analgesia, fluids, anti-emetics and laxatives, completion of venous thromboembolism (VTE) prophylaxis, abbreviated mental test (AMT), group and save and reversal of anticoagulation, if available. Intervention included production of a checklist outlining the management plan which was distributed to junior doctors.

Results

Areas for improvement identified from pre intervention cycle were prescription of fluids, anti-emetics, laxatives, and anticoagulant reversal, with a compliance of 56%, 44%, 42% and 50%. Other parameters had a compliance of >90% pre and post intervention. Post intervention compliance was 90% for fluids, 66% for anti-emetics, 74% for laxatives and 80% for anticoagulant reversal.

Conclusion

Introduction of a checklist is effective in improving the quality of care for patients with neck of femur fracture. More interventions incorporating the PDSA methodology will be carried out to strive for further quality improvement.

1159 Ring-Fenced Arthroplasty Unit: The Need of The Hour During Winter and A Pandemic Crisis

Aim

Winter pressures along with the COVID-19 pandemic, have caused cancellation of elective services, prolonged waiting times, patient dissatisfaction and financial implications. Length of stay (LOS) following joint replacements is variable. The availability of ring-fenced beds and enhanced recovery protocol (ERP) can improve these outcomes. The performance of a stand-alone arthroplasty unit in an acute NHS Trust was assessed regarding safety, LOS and complications.

Method

Patient data was collected for total hip & knee replacements (TJAs) between the months of December to March of 2018-19 and 2019-20. Demographics, ASA, transfusion rates, LOS and 90-day reattendance was analysed. Modified ERP implemented in late 2019 included changes in analgesia and early post-operative mobilisation. The performance was then compared with DGHs within the region.

Results

In 2019-20, of 280 TJAs performed, there was a mean LOS of 43 hours. This shows a reduction compared with LOS of 69 hours in 2018-19, where 288 TJAs were performed. In 2019-20, 74% of cases had early discharge within 36 hours of surgery, versus 24% in 2018-19. This accumulates to 333 inpatient days saved. Note that following ERP modification, 6 patients were discharged on the day of surgery. Surgery related complications within 3 months which required reattendance, were seen in only 2 patients. This unit performed an average of 335 TJA’s in these winter months, the highest average in comparison to other DGHs in the East Midlands region, which had an overall average of 165 cases.

Conclusions

A ring-fenced arthroplasty service with adherence to ERP significantly decreases LOS and increases productivity.

THERMAL ANALYSIS OF INTRAOCULAR ELECTRONIC DISPLAY PROJECTOR VISUAL PROSTHESIS

Corneal opacity is a leading cause of blindness, accounting for about 4% of global blindness. With corneal opacity, light is unable to pass through the cornea to form a clear image on the retina, resulting in blindness. To address this condition, an intraocular projection device has been designed. This device, while in use, would produce heat. According to international standard regulations, the temperature on the surface of the tissues should not increase more than 2°C due to medical devices. In order to establish the power budget of this intraocular electronic device, a steady state thermal finite element analysis was conducted on two different eye models. The device was placed at 9.98 mm from the retina, and was seen to run up to a maximum power of 82 mW for the first model and 91 mW for the second model. To reduce heating of tissues, the device was extended by 0.5 mm to create an air gap which acted as an insulator. The temperature in the nearest living tissue then dropped below the prescribed limit of 2°C at 100 mW.

The blood oxygen level-dependent functional MR imaging signal can be used to identify brain tumors and distinguish them from normal tissue

BACKGROUND AND PURPOSE

In neuro-oncology, a major problem is clear identification of tumor from the surrounding normal tissue. We hypothesized that we could use the blood oxygen level-dependent functional MR imaging (BOLD fMRI) signals from tumors and normal brain to identify the tumors and distinguish them from the surrounding brain.

MATERIALS AND METHODS

Fourteen patients with meningiomas, gliomas, and metastatic tumors were scanned before surgery. All subjects performed a motor task; 2 subjects were also scanned while in a resting state. The BOLD signals were taken from selected points within the tumor and from the surrounding normal brain and were analyzed by using correlation analysis to determine how closely they were related.

RESULTS

The BOLD signals from all of the tumors were significantly different from those in the surrounding normal tissue. In meningiomas and gliomas, selection of a voxel in the tumor for signal-intensity analysis highlighted the entire tumor mass while excluding the normal tissue. The BOLD signal intensity was the same whether the subjects were motionless or finger tapping.

CONCLUSIONS

Analysis of the BOLD signal intensity provides a relatively simple and straightforward method for identifying brain tumors and distinguishing them from normal tissue. This approach may be of use in neurosurgery.

Dammarane triterpene saponin from Bacopa monniera as the superoxide inhibitor in polymorphonuclear cells

The hydroalcoholic extract of the whole plant of Bacopa monniera Wettst. (Scrophulariaceae), exhibited an inhibitory effect on superoxide released from polymorphonuclear (PMN) cells in the nitroblue tetrazolium (NBT) assay. The major saponin bacoside A(3) was found to be responsible for this effect in the herb. This compound showed 85, 91.66, 91.66, and 83 % inhibitions of NBT reduction at the concentrations of 200, 100, 50, and 25 microg/ml, respectively, with an IC(50) value of 10.22 microg/ml. These inhibitory effects were compared with those of the standard positive controls, quercetin and ascorbic acid with IC(50) of 111 and 14.16 microg/ml, respectively. Another major saponin bacopasaponin C was found to be much less potent as compared to bacoside A(3) whereas the remaining two mixtures of saponins were found to be inactive.

Spontaneous perirenal hematoma. A case report and review of literature

Spontaneous perirenal hematoma (SPH) is a clinical entity that poses a diagnostic and therapeutic challenge. We report a case of SPH in an adult where the cause could not be determined at first presentation, even with computed tomography (CT) of the abdomen and angiography. He was under close follow-up, and it was only with a repeat CT scan after 3 months that a mass lesion in the kidney was identified as the underlying cause. We also present a review of the literature so that a logical approach can be adopted for this problem.

Primary malignant bladder carcinoid--a diagnostic and management dilemma

A middle-aged man who presented with gross hematuria and irritative voiding symptoms was found to have an invasive infiltrating primary bladder carcinoid after radical cystoprostatectomy. Hurricane chest secondaries were prominent in the follow-up evaluation. The immunohistochemical markers for neuroendocrine differentiation were substantiated. The published reports of primary bladder carcinoid tumors are discussed.

Quinine-associated acute interstitial nephritis

Quinine-induced acute renal failure attributed to the hemolytic-uremic syndrome has been infrequently reported. A case of acute renal failure due to acute interstitial nephritis associated with ingestion of quinine and the subsequent response to steroid therapy is described.

Effect of corticosteroid therapy on human immunodeficiency virus-associated nephropathy

PURPOSE

Human immunodeficiency virus-associated nephropathy (HIV-AN) occurs predominantly in blacks and is characterized histologically by focal segmental glomerulosclerosis or mesangial proliferation and a lymphohistiocytic tubulointerstitial infiltrate. Patients manifest heavy proteinuria and, once azotemia occurs, progress rapidly to end-stage renal disease within 2 to 6 months. No treatment has been shown to be useful for HIV-AN. The purpose of this study was to determine the effect of corticosteroid agents on the progression of HIV-AN.

PATIENTS AND METHODS

Four consecutive HIV-infected adults with fewer than 200 CD4 cells/microL, moderate to severe renal insufficiency, proteinuria greater than 2 g per 24 hours, and HIV-AN demonstrated by renal biopsy were treated with 60 mg of prednisone daily for 2 to 6 weeks. Patients were followed with respect to serum creatinine level, 24-hour protein excretion, adverse drug reactions, and the occurrence of opportunistic infections.

RESULTS

CD4 counts ranged from 30 to 80 cells/microL before therapy with steroids. The mean (+/- SD) pretreatment serum creatine concentration was 9.1 +/- 5.7 mg/dL and decreased to 3.3 +/- 1.8 mg/dL (P < 0.05) after 2 to 6 weeks of corticosteroid therapy. Twenty-four hour protein excretion did not change (5.2 +/- 2.4 g pretreatment versus 4.6 +/- 4.1 g posttreatment). One patient was able to discontinue dialysis after 10 days. Two patients developed Mycobacterium avium-complex infections and steroid-associated psychosis. One of these patients developed a recurrence of genital herpes, and the other developed dermatomal zoster. None of the four required dialysis during a 1.5- to 5.5-month period of follow-up after cessation of steroid treatment.

CONCLUSION

In selected patients with HIV-AN, short-term treatment with corticosteroid agents improves renal function and prevents the development of end-stage renal disease during a 1.5- to 5.5-month period of observation, but may be associated with an increased risk of opportunistic infection.