Central vein stenosis is common because of the placement of venous access and cardiac intravascular devices and compromises vascular access for dialysis. Endovascular intervention with angioplasty and/or stent placement is the preferred approach, but the results are suboptimal and limited. Primary patency after angioplasty alone is poor, but secondary patency can be maintained with repeated angioplasty. Stent placement is recommended for quick recurrence or elastic recoil of stenosis. Primary patency of stents is also poor, though covered stents have recently shown better patency than bare metal stents. Secondary patency requires repeated intervention. Recanalization of occluded central veins is tedious and not always successful. Placement of hybrid graft-catheter with a combined endovascular surgical approach can maintain patency in many cases. In the presence of debilitating symptoms, palliative approach with endovascular banding or occlusion of the access may be necessary. Prevention of central vein stenosis is the most desirable strategy.
Angioplasty ; Constriction, Pathologic* ; Dialysis ; Recurrence ; Stents ; Veins*

Neural fibrolipomatous hamartoma is a rare benign tumour commonly involving the median nerve. Other less frequently involved nerves include the ulnar, radial, brachial plexus, superficial peroneal nerve, inferior calcaneal nerve and median plantar nerve. Involvement of sural nerve has not been reported in the available literature so far. A three-year-old female child presented with a painless swelling over the posterolateral aspect of left leg with no associated motor or sensory deficits. Radiological investigations revealed a fat density lesion with interspersed neural element in the subcutaneous plane of the left leg. Histopathological examination of the excised specimen showed features of a fibrolipomatous hamartoma of the nerve. This report describes the occurrence of fibrolipomatous hamartoma in the sural nerve for the first time in the literature. This rare tumour should be considered in the differential diagnosis of such lesions.
Hamartoma ; Sural Nerve

BACKGROUND: Establishment of laparoscopic cholecystectomy as an outpatient procedure has accentuated the clinical importance of reducing early postoperative pain, as well as postoperative nausea and vomiting (PONV). We therefore planned to evaluate the role of a multimodal approach in attenuating these problems. METHODS: One hundred and twenty adult patients of ASA physical status I and II and undergoing elective laparoscopic cholecystectomy were included in this prospective, randomized, placebo-controlled study. Patients were divided into four groups of 30 each to receive methylprednisolone 125 mg intravenously or etoricoxib 120 mg orally or a combination of methylprednisolone 125 mg intravenously and etoricoxib 120 mg orally or a placebo 1 hr prior to surgery. Patients were observed for postoperative pain, fentanyl consumption, PONV, fatigue and sedation, and respiratory depression. Results were analyzed by the ANOVA, a Chi square test, the Mann Whitney U test and by Fisher's exact test. P values of less than 0.05 were considered to be significant. RESULTS: Postoperative pain and fentanyl consumption were significantly reduced by methylprednisolone, etoricoxib and their combination when compared with placebo (P<0.05). The methylprednisolone + etoricoxib combination caused a significant reduction in postoperative pain and fentanyl consumption as compared to methylprednisolone or etoricoxib alone (P<0.05); however, there was no significant difference between the methylprednisolone and etoricoxib groups (P>0.05). The methylprednisolone and methylprednisolone + etoricoxib combination significantly reduced the incidence and severity of PONV and fatigue as well as the total number of patients requiring an antiemetic treatment compared to the placebo and etoricoxib (P<0.05). CONCLUSIONS: A preoperative single-dose administration of a combination of methylprednisolone and etoricoxib reduces postoperative pain along with fentanyl consumption, PONV, antiemetic requirements and fatigue more effectively than methylprednisolone or etoricoxib alone or a placebo.
Adult ; Cholecystectomy, Laparoscopic* ; Fatigue ; Fentanyl ; Humans ; Incidence ; Methylprednisolone* ; Outpatients ; Pain, Postoperative* ; Postoperative Nausea and Vomiting* ; Prospective Studies* ; Respiratory Insufficiency

BACKGROUND: Bertolotti's syndrome (BS), a form of lumbago in lumbosacral transitional vertebrae, is an important cause of low back pain in young patients. The purpose of this study was to assess the etiology of low back pain and the efficacy of treatment offered to patients with BS. METHODS: All patients of BS Castellvi type1a during a period of 6 months were enrolled in the study. The patients underwent interventional pain procedures for diagnosis and pain relief. Response to the therapy was assessed based on VAS and ODI scores. A 50% decrease in VAS score or a VAS score less than 3 would be considered adequate pain relief. RESULTS: All 20 patients diagnosed with BS during the 6-month observation period had scoliosis. Common causes of back pain were the ipsilateral L5-S1 facet joint, neoarticulation, the SI joint, and disc degeneration. Responses to various interventions for pain relief were different and inconsistent from patient to patient. In particular, responses to interventions for neoarticular pain were generally poor. CONCLUSIONS: Pain in patients with BS does not usually respond to interventional pain treatment. A very dynamic treatment approach must be pursued while managing BS patients, and the treatment plan must be individualized at various stages in order to obtain satisfactory pain relief.
Back Pain ; Humans ; Intervertebral Disc Degeneration ; Joints ; Low Back Pain ; Scoliosis ; Spine ; Zygapophyseal Joint

No abstract available.
B-Lymphocytes ; Humans ; Precursor Cell Lymphoblastic Leukemia-Lymphoma

BACKGROUND: Valsalva maneuver reduces pain by activating sinoaortic baroreceptor reflex arc. We planned this study to evaluate the role of valsalva in attenuating spinal needle-puncture pain. METHODS: Ninety American Society of Anesthesiologists (ASA) grade I and II enrolled patients undergoing elective surgery were randomized into 3 groups of 30 each. Group I (Control): didn't blow; group II (Distraction): patients blew into rubber tube; Group III (Valsalva): blew into sphygmomanometer tube and raise mercury column up to 30 mmHg for at least 20 seconds. During above procedures, spinal puncture was performed with 25-gauge spinal needle. RESULTS: Eighty-two patient data were analyzed. Incidence of spinal puncture pain was reduced to 10% (3 of 27) in Valsalva group as compared to 100% (28 of 28 in control group and 27 of 27 in Distraction group) observed in other two groups (P < 0.05). Severity of lumbar puncture pain as assessed by visual analog scale (0-10; where 0 is no pain and 10 is the worst imaginable pain) presented as Median (Interquartile range) were significantly reduced in the Valsalva group (0.0 [0.0] as compared to other 2 groups 2.0 [0.0] in the Distraction group and 3.0 [0.8] in Control group) (P < 0.05). Regarding time taken by CSF to fill spinal needle hub, there was no difference among the three groups (P > 0.05). None patient of all groups had post dural puncture headache (P > 0.05). CONCLUSIONS: Valsalva can be performed routinely in ASA I and II patients undergoing spinal anesthesia as it is safe, painless and non-pharmacological method of pain attenuation.
Anesthesia, Spinal* ; Baroreflex ; Humans ; Incidence ; Needles ; Post-Dural Puncture Headache ; Punctures* ; Rubber ; Skin* ; Sphygmomanometers ; Spinal Puncture ; Valsalva Maneuver* ; Visual Analog Scale

Wolff Parkinson White (WPW) syndrome is a condition in which there is an aberrant conduction pathway between the atria and ventricles, resulting in tachycardia. A 42-year-old patient, who was treated for WPW syndrome previously, presented with chronic somatic pain. With her cardiac condition in mind, she was thoroughly worked up for a recurrence of disease. As part of routine screening of all patients at our pain clinic, she was found to have severe depression as per the Patient Health Questionnaire–9 (PHQ–9) criteria. After ruling out sinister causes, she was treated for depression using oral Duloxetine and counselling. This led to resolution of symptoms, and improved her mood and functional capability. This case highlights the use of psychological screening tools and diligent examination in scenarios as confusing as the one presented here. Addressing the psychological aspects of pain and adopting a holistic approach are as important as treatment of the primary pathology.
Adult ; Chest Pain* ; Chronic Pain ; Depression* ; Duloxetine Hydrochloride ; Humans ; Mass Screening ; Nociceptive Pain ; Pain Clinics ; Pathology ; Recurrence ; Tachycardia ; Thorax* ; Wolff-Parkinson-White Syndrome*

Wolff Parkinson White (WPW) syndrome is a condition in which there is an aberrant conduction pathway between the atria and ventricles, resulting in tachycardia. A 42-year-old patient, who was treated for WPW syndrome previously, presented with chronic somatic pain. With her cardiac condition in mind, she was thoroughly worked up for a recurrence of disease. As part of routine screening of all patients at our pain clinic, she was found to have severe depression as per the Patient Health Questionnaire–9 (PHQ–9) criteria. After ruling out sinister causes, she was treated for depression using oral Duloxetine and counselling. This led to resolution of symptoms, and improved her mood and functional capability. This case highlights the use of psychological screening tools and diligent examination in scenarios as confusing as the one presented here. Addressing the psychological aspects of pain and adopting a holistic approach are as important as treatment of the primary pathology.
Adult ; Chest Pain* ; Chronic Pain ; Depression* ; Duloxetine Hydrochloride ; Humans ; Mass Screening ; Nociceptive Pain ; Pain Clinics ; Pathology ; Recurrence ; Tachycardia ; Thorax* ; Wolff-Parkinson-White Syndrome*

BACKGROUND: Diabetic ketoacidosis (DKA) is characterized by a biochemical triad of hyperglycemia, acidosis, and ketonemia. This condition is life-threatening despite improvements in diabetic care. The purpose of this study was to evaluate the clinical and biochemical prognostic markers of DKA. We assessed correlations in prognostic markers with DKA-associated morbidity and mortality. METHODS: Two hundred and seventy patients that were hospitalized with DKA over a period of 2 years were evaluated clinically and by laboratory tests. Serial assays of serum electrolytes, glucose, and blood pH were performed, and clinical outcome was noted as either discharged to home or death. RESULTS: The analysis indicated that significant predictors included sex, history of type 1 diabetes mellitus or type 2 diabetes mellitus, systolic blood pressure, diastolic blood pressure, total leukocyte count, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, blood urea nitrogen, serum creatinine, serum magnesium, serum phosphate, serum osmolality, serum glutamic oxaloacetic transaminases, serum glutamic pyruvic transaminases, serum albumin, which were further regressed and subjected to multivariate logistic regression (MLR) analysis. The MLR analysis indicated that males were 7.93 times more likely to have favorable outcome compared with female patients (odds ratio, 7.93; 95% confidence interval, 3.99 to 13.51), while decreases in mean APACHE II score (14.83) and serum phosphate (4.38) at presentation may lead to 2.86- and 2.71-fold better outcomes, respectively, compared with higher levels (APACHE II score, 25.00; serum phosphate, 6.04). CONCLUSION: Sex, baseline biochemical parameters such as APACHE II score, and phosphate level were important predictors of the DKA-associated mortality.
Acidosis ; APACHE ; Blood Pressure ; Blood Urea Nitrogen ; Creatinine ; Diabetes Mellitus, Type 1 ; Diabetes Mellitus, Type 2 ; Diabetic Ketoacidosis* ; Electrolytes ; Female ; Glucose ; Humans ; Hydrogen-Ion Concentration ; Hyperglycemia ; Hyperglycemic Hyperosmolar Nonketotic Coma ; Ketosis ; Leukocyte Count ; Logistic Models ; Magnesium ; Male ; Mortality ; Osmolar Concentration ; Serum Albumin ; Transaminases

No abstract available.
Abdominal Wall*