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Filler injections have become very popular in recent years, and injectors globally use them for facial shaping and reversing age-related changes. Detailed knowledge about important vessels' and tissue planes' anatomy is essential for injectors. While giving the filler injections, injectors tend to gently pinch or pull the tissue fold with the nondominant hand during the procedure. The deformational forces cause some changes in the anatomy of tissue layers held in a pinch. During the pinch and "pinch and pull" maneuver, the crucial vessels in the area can get pulled up in the tissue layers in a pinch or stay in their position unaffected depending on the force applied. The "pinch and pull" maneuver also increases the tissue space for injections by moving the mobile tissue layers away from the fixed ones. The injector can use knowledge of the "'pinch anatomy" in the forehead to avoid important arteries and place filler in the correct plane. With the understanding of the anatomical changes occurring during the pinched state of tissue layers, filler injection can be performed in the right and safer tissue plane in the forehead. This study reflects level of evidence V., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Minimally invasive and noninvasive facial aesthetic treatments are increasingly popular, and a greater understanding of patient perspectives on facial aesthetic priorities is needed., Objectives: The authors surveyed facial aesthetic concerns, desires, and treatment goals of aesthetically conscious men and women, and physicians, in 18 countries., Methods: This was a global, internet-based survey on desired appearance and experiences with, or interest in, facial aesthetic treatments. Eligible respondents were aesthetically conscious adults (21-75 years). Eligible aesthetic physicians were required to see ≥30 patients per month for aesthetic reasons, have 2 to 30 years of experience in clinical practice, and spend ≥70% of their time in direct patient care., Results: A total of 14,584 aesthetically conscious adults (mean age, 41 years; 70% women) and 1315 aesthetic physicians (mean age, 45 years; 68% men) completed the survey. Most respondents (68%) reported that aesthetic procedures should be sought in their 30s to 40s; physicians recommended patients seek treatment earlier. Respondents expressed greatest concern over crow's feet lines, forehead lines, facial skin issues, hair-related concerns, and under-eye bags or dark circles; in contrast, physicians tended to underestimate concerns about under-eye bags or dark circles, mid-face volume deficits, and skin quality. Although both physicians and respondents cited cost as a major barrier to seeking aesthetic treatments, respondents also emphasized safety, fear of injections or procedure-related pain, and concern about unnatural-looking outcomes., Conclusions: This global survey provides valuable insight into facial aesthetic concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments., (© 2021 The Aesthetic Society.)

Background: Comprehensive patient assessment and planning are central to esthetic treatment with injectables. MD ASA™ (Multi-Dimensional Aesthetic Scan Assessment) is a novel tool developed for this purpose., Aims: To describe the MD ASA technique and present its preliminary application., Methods: MD ASA breaks down the face into five hierarchies (H1-H5). H1 shifts patients' focus from "distractions" (individual lines and folds) toward the overall messages their face portrays, based on eight Emotional Attributes: four negative (tired, sad, angry, and saggy); four positive (youthful, attractive, contoured, and feminine/masculine). Three priority Emotional Attributes are selected for each patient. This is followed by a process of narrowing down through facial thirds (H2), periorbital and perioral dynamics (H3), facial units (H4), and subunits (H5), to arrive at a final assessment. Based on the key facial signs identified, this can be translated into MD Codes equations and thus a treatment formula. A retrospective analysis was performed based on 12 female patients injected by expert clinicians at an educational event. All patients were selected for, and treated using, a single MD Codes formula derived from a common MD ASA work-up., Results: There were substantial differences between patients and clinicians in their views of which anatomical areas needed treatment-but good alignment on priority Emotional Attributes. Patients were treated only for three negative Emotional Attributes, but improvements were observed across all eight attributes., Conclusions: MD ASA provides a practical method for translating facial messages into actionable injectable treatment plans and facilitates greater patient-clinician alignment. Prospective studies are warranted., (© 2021 Wiley Periodicals LLC.)

Filler injections have become exceedingly popular in the last decade, and injectors across the globe are using them for facial contouring and reversing the age-related changes. Thorough knowledge about the anatomy of important vessels and tissue planes is essential for injectors. During filler injections, injectors generally tend to pinch or pull the tissues with the nondominant hand for the ease of the procedure. These deformational forces lead to some changes in the anatomy of tissue layers held in a pinch. During pinch maneuver, the important arteries in that region can get pulled up in the tissue layers held in a pinch or stay in their position unaffected. The pinch can also increase the tissue space for injections by moving the mobile tissue layers away from the fixed ones. Knowledge of this "pinch anatomy" in the temple can be used to the injector's advantage to avoid important arteries and to place filler in the correct plane., (© 2020 Wiley Periodicals LLC.)

Strict infection control measures in response to the current COVID-19 pandemic are expected to remain for an extended period. In aesthetic clinics, most procedures are provided on one to one basis by the physician or therapist. In such a scenario, guidelines detailing the infection control measures for aesthetic clinics are of particular importance. An online meeting of an international group of experts in the field of aesthetic medicine, with experience in administration of an aesthetic clinic, was convened. The meeting aimed to provide a set of consensus guidelines to protect clinic staff and patients from SARS-CoV-2 infection. Consensus guidelines for "preferred practices" were provided for scheduling of patients, patient evaluation and triaging, and for safety precautions about the different procedures. Procedures were categorized into low-risk, moderate risk, and high-risk based on the likelihood of transmission of SARS-CoV-2 virus from the patient to the treating physician or therapist. While not intended to be complete or exhaustive, these guidelines provide sound infection control measures for aesthetic practices. Since guidelines regarding safety measures and use of PPEs may vary from country to country, the local guidelines should also be followed to prevent COVID-19 infection in aesthetic clinics., (© 2020 Wiley Periodicals LLC.)

Background: With the increase in the use of soft-tissue fillers worldwide, there has been a rise in the serious adverse events such as vascular compromise and blindness. This article aims to review the role of fillers in causing blindness and the association between hyaluronic acid (HA) filler and blindness., Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to report this review., Results: A total of 190 cases of blindness due to soft-tissue fillers were identified, of which 90 (47%) cases were attributed to autologous fat alone, and 53 (28%) cases were caused by HA. The rest of the cases were attributed to collagen, calcium hydroxylapatite, and other fillers., Conclusions: Autologous fat was the most common filler associated with blindness despite HA fillers being the most commonly used across the globe. However, the blindness caused by other soft-tissue fillers like collagen and calcium hydroxylapatite was represented. It was also evident through the review that the treatment of HA-related blindness was likely to have better outcomes compared with other fillers due to hyaluronidase use.

Background: Surgery is a very stressful experience for patients. Children are the most susceptible to fear, anxiety, and stress due to their limited cognitive capabilities and dependency. In children, pharmacologic agents are frequently used as premedication to relieve the fear of surgery, to make child-parental separation easy, and to carry out a smooth induction of anesthesia. We conducted this study to compare the efficacy of intranasal fentanyl, midazolam, and dexmedetomidine as premedication in pediatric patients., Materials and Methods: The present study was conducted prospectively on 75 patients in the age group of 2-6 years of either sex of the American Society of Anesthesiologists physical Class I or II admitted in Guru Nanak Dev Hospital, attached to Government Medical College Amritsar, scheduled to undergo surgery under general anesthesia. The patients were divided into three groups of 25 each. Group F received intranasal fentanyl 1.5 μg/kg body weight, Group M received intranasal midazolam 0.3 mg/kg body weight, and Group D received intranasal dexmedetomidine 1 μg/kg body weight as nasal drops 50 min before surgery., Results: Children who received intranasal fentanyl and intranasal midazolam had early onset of anxiolysis and sedation as compared to dexmedetomidine. In child-parent separation, quality of induction was better with fentanyl and dexmedetomidine as compared to midazolam. Intravenous cannulation score was best achieved with fentanyl as premedicant. Postoperative sedation was better with dexmedetomidine as compared to fentanyl and midazolam., Conclusion: Onset of action of fentanyl and midazolam is early as compared to that of dexmedetomidine. However, fentanyl provided better conditions for induction and emergence than midazolam. With dexmedetomidine onset of action was delayed and duration of action was prolonged which helped child to remain calm and sedated even after the surgery., Competing Interests: There are no conflicts of interest.

Background: Multimodal analgesia is currently recommended for effective postoperative analgesia., Aim: The aim of this study is to compare the efficacy of transversus abdominis plane (TAP) block with intermittent transcutaneous electrical nerve stimulation (TENS) in postoperative patients after infraumbilical surgeries under spinal anesthesia with respect to postoperative analgesia, rescue analgesia, hemodynamic changes, block characteristics, nausea/vomiting score, sedation score, adverse effects, and patient satisfaction., Settings and Design: This was a prospective, observational study randomized controlled trial., Methods: A total of 60 American Society of Anesthesiologists physical status Classes I and II patients of 20-60 years scheduled for infraumbilical surgeries were randomized by a computer-generated list into two groups of 30 each, to receive either TAP Block (Group TAP: 15 ml of 0.25% levobupivacaine on each side of abdomen) or TENS (Group TENS: TENS with frequency of 50 Hz and intensity of electrical stimulation 9-12 mA, continued for 30 min every 2 h till 24 h). The primary outcome was to compare the postoperative analgesia as assessed using visual analog scale score. Secondary objectives were to compare rescue analgesia, nausea/vomiting score, sedation score, the block characteristics, adverse effects, hemodynamic changes, and patient satisfaction., Statistical Analysis Used: Student's t -test, Chi-square test as applicable and Statistical Package for Social Sciences (version 23.0, 2017, SPSS Inc., Chicago, IL, USA) were used., Results: Time to the first analgesic requirement was 12.87 ± 4.72 h in Group TAP and 9.93 ± 3.63 h in Group TENS ( P < 0.008), the difference between two groups was significant., Conclusion: TAP block is better modality due to ease of application and prolonged analgesia., Competing Interests: There are no conflicts of interest.

Background: Indians constitute one of the largest population groups in the world. Facial anthropometry, morphology, and age-related changes in Indians differ from those of other ethnic groups, necessitating a good understanding of their facial structure and the required aesthetic treatment strategies. However, published recommendations specific to Indians are few, particularly regarding combination treatment., Methods: The Indian Facial Aesthetics Expert Group (19 dermatologists, plastic surgeons, and aesthetic physicians with a mean 15.5 years' aesthetic treatment experience) met to develop consensus recommendations for the cosmetic facial use of botulinum toxin and hyaluronic acid fillers, alone and in combination, in Indians. Treatment strategies and dosage recommendations (agreed by ≥ 75% of the group) were based on results of a premeeting survey, peer-reviewed literature, and the experts' clinical experience., Results: The need for combination treatment increases with age. Tear trough deficiency is the most common midface indication in Indian women aged 20-40 years. In older women, malar volume loss and jowls are the most common aesthetic concerns. Excess medial soft tissue on a relatively smaller midface precedes age-related sagging. Hence, in older Indians, fillers should be used peripherally to achieve lift and conservatively in the medial zones to avoid adding bulk medially. The shorter, wider lower face requires 3-dimensional correction, including chin augmentation, to achieve increased facial height and the oval shape desired by most Indian women., Conclusions: These recommendations give physicians treating Indians worldwide a better understanding of their unique facial characteristics and provide treatment strategies to achieve optimal aesthetic outcomes.

Context: Inguinal hernia repair (IHR) is a common surgical procedure which can be performed under general, regional, or peripheral nerve block anesthesia., Aim: The aim of our study was to compare the efficacy of paravertebral block (PVB) with spinal anesthesia (SA) for IHR with respect to postoperative analgesia, ambulation, and adverse effects., Settings and Design: This was a prospective, single-blind randomized controlled trial., Materials and Methods: Sixty American Society of Anesthesiologists Class I-II patients of 20-60 years scheduled for IHR were randomized by a computer-generated list into two groups of thirty each, to receive either PVB (Group PVB: at T12-L2 levels, 10 ml of 0.5% levobupivacaine at each level) or SA (Group SA: at L3-L4/L2-L3 level, 2.5 ml of 0.5% levobupivacaine). Primary outcome was duration of postoperative analgesia and time to reach discharge criteria. Secondary outcome was time to ambulation, time to perform the block, time to surgical anesthesia, total rescue analgesic consumption, adverse effects, hemodynamic changes, patient, and surgeon satisfaction., Statistical Analysis Used: Student's t -test, Chi-square test as applicable, and Statistical Package for Social Sciences (version 14.0, SPSS Inc., Chicago, IL, USA) were used., Results: Time to the first analgesic requirement was 15.17 ± 3.35 h in Group PVB and 4.67 ± 1.03 h in Group SA ( P < 0.001). Time to reach the discharge criteria was significantly shorter in Group PVB than Group SA ( P < 0.001)., Conclusion: PVB is advantageous in terms of prolonged postoperative analgesia and encourages early ambulation compared to SA., Competing Interests: There are no conflicts of interest.

Introduction: Anesthesia and surgery have proved to be highly anxiety provoking and with the rise of elective surgery, its aspect of patient's experience has become prominent in time. However, our fault as anesthesiologists is that we have not made people get versed with what we people as anesthesiologist do in the operating room. Hence, keeping in view all this, a study was carried out, in which video information/images regarding anesthesia and surgical procedure was shown to patients on PowerPoint Presentation. Different images showing previous patient's hospital journey were shown to educate patients., Methods: Two hundred patients scheduled to undergo elective surgery were taken and were divided into two groups of 100 each. Patients (study group or Group I) were shown video clippings/images of other previously operated patients and their hospital journey including surgery and anesthesia for which patient came in hospital. The study was carried out on the patient in each group while Group II was treated in normal way and not shown any type of images/videos. Hamilton Anxiety Rating Scale was used as a criterion to measure the level of anxiety in Group I and II at four different intervals that are before pre anesthetic check up (PAC), after showing videos and images in Group I, 1 h before surgery and 8 h after surgery., Statistical Analysis: The results of observation of both the groups at different intervals time were statistically compared and analyzed. These characteristics were analyzed using the "Chi-square tests" and "unpaired t -test.", Results: Video and images information if done preoperatively have been shown to reduce patient's anxiety, although little is known regarding the effects of the method., Conclusion: Showing videos/images of hospital journey for educating the patients before the operation is beneficial to patients undergoing elective surgery., Competing Interests: There are no conflicts of interest.

Introduction: Postoperative pain is a major cause of fear and anxiety in hospitalized patients and so if patients remain pain-free during this period, they can cooperate with the circumstances well, leading to early recovery. Over the last two decades, there has been considerable revival of interest in the use of regional anesthesia techniques for surgery and pain management. As very few studies have been conducted using ropivacaine with dexmedetomidine and magnesium sulfate (MgSO 4 ) as adjuvants, the present study was undertaken with primary aims to compare the hemodynamic stability, onset and duration of sensory and motor block and with secondary aims of the postoperative analgesic effect of dexmedetomidine and MgSO 4 along with ropivacaine., Materials and Methods: After getting the Institutional Ethics Committee approval, this study was conducted on fifty patients of the American Society of Anesthesiologists physical Status I and II aged between 20 and 65 years of either sex and scheduled to undergo infraumbilical surgeries under spinal anesthesia. They were divided into two groups of 25 each. Group D patients received 3 ml of 0.75% isobaric ropivacaine hydrochloride with 10 μg of dexmedetomidine whereas Group M patients received 75 mg of MgSO 4 in the place of dexmedetomidine. The quality of surgical analgesia and quality of intraoperative muscle relaxation were assessed and graded., Results: We found out that onset of sensory and motor block was earlier in Group D in comparison to Group M. There was a significant reduction in the time to the first rescue analgesia in group receiving intrathecal dexmedetomidine., Conclusion: It is concluded from our study that ropivacaine plus dexmedetomidine group are better than ropivacaine plus MgSO 4 in providing early onset of sensory and motor block as well as in providing postoperative analgesia., Competing Interests: There are no conflicts of interest.

Background: Intravenous (IV) fluids are an integral part of perioperative management. Intraoperative hyperglycemia is associated with poor clinical outcomes in patients undergoing major surgeries even in nondiabetics., Aim: This study was conducted to observe the effect of different maintenance fluid regimens on intraoperative blood glucose levels in nondiabetic patients undergoing major surgeries under general anesthesia., Settings and Design: Randomized double-blind study., Materials and Methods: One hundred nondiabetic patients of either sex were divided randomly into two Groups I and II of 50 each undergoing elective major surgeries of more than 90 min duration under general anesthesia. Both groups were given calculated dosage of IV fluids accordingly 4-2-1 formula while Group I was given Ringer lactate (RL) and Group II was given 0.45% dextrose normal saline and potassium chloride 20 mmol/L. Changes in vital parameters, % oxygen saturation, and urine output were monitored at regular intervals. Capillary blood glucose (CBG) was measured half-hourly until end of surgery. If CBG level was more than 150 mg%, then calculated dose of human insulin (CBG/100) was given as IV bolus dose., Statistical Analysis: Statistical analysis was done using SPSS 22.0 software (IBM Corporation, Armonk, New York, USA), paired t -test and Chi-square test., Results: A significant increase of CBG level and was observed during intraoperative and immediate postoperative period ( P < 0.001) in Group II., Conclusion: RL solution is probably the alternative choice of IV fluid for perioperative maintenance and can be used as replacement fluid in nondiabetic patients undergoing major surgeries.

Difficult airway, a scenario with potentially life threatening outcome, is routinely encountered by an anesthesiologist leaving him with the dilemma of whether to use regional anesthesia (RA) or general anesthesia. Our study aims to look into this problem. The literature search was performed in the Google, PubMed, and Medscape using key words "regional anesthesia, difficult airway, pregnancy, ventilation, intubation, epidural anesthesia, nerve blocks." More than 38 free full articles and books published from the year 1987 to 2014 were retrieved and studied. At first sight, RA may appear to offer an ideal solution as it helps to avoid the problem of difficult airway. However, the possibility of a total spinal block, failed or incomplete RA, local anesthetic toxicity or unforeseen surgical complication may make it imperative that the airway is secured. The correct decision can only be made by the anesthetist when all the relevant clinical information is taken into account. It is also important to ensure that before considering RA in a patient of difficult airway, an anesthesiologist must have a preformulated strategy for intubation.

Aims of Study: To evaluate the efficacy, hemodynamic changes, and patient comfort during awake fiberoptic intubation done under combined regional blocks., Materials and Methods: In the present observational study, 50 patients of American Society of Anesthesiologists ( ASA) Grade I-II, Mallampati Grade I-IV were given nerve blocks - bilateral glossopharyngeal nerve block, bilateral superior laryngeal nerve block, and recurrent laryngeal nerve block before awake fiberoptic intubation using 2% lidocaine., Results: Procedure was associated with minimal increases in hemodynamic parameters during the procedure and until 3 min after it. Most of the intubations were being carried out within 3 min. Patient comfort was satisfactory with 90% of patients having favorable grades., Discussion: The most common cause of mortality and serious morbidity due to anesthesia is from airway problems. One-third of all anesthetic deaths are due to failure to intubate and ventilate. Awake flexible fiberoptic intubation under local anesthesia is now an accepted technique for managing such situations. In awake patient's anatomy, muscle tone, airway protection, and ventilation are preserved, but it is essential to sufficiently anesthetize the upper airway before the performance of awake fiberoptic bronchoscope-guided intubation to ensure patient comfort and cooperation for which in our study we used the nerve block technique., Conclusion: A properly performed technique of awake fiberoptic intubation done under combined regional nerve blocks provides good intubating conditions, patient comfort and safety and results in minimal hemodynamic changes.

Context: While giving low-flow anesthesia, it is a routine practice to give fixed duration of initial high-flow. This study was conducted to show the use of equilibration point as changeover point from initial high-flow to low-flow., Aims: It was to compare the use of equilibration point, hemodynamics, end-tidal agent concentration, recovery time, and recovery score between isoflurane and sevoflurane., Settings and Design: It was a prospective randomized study conducted on 100 patients who were admitted for elective surgery expected to be < 2 h duration., Materials and Methods: Patients were randomly assigned to one of the two groups of 50 each. Group I received isoflurane and Group S sevoflurane as an inhalational agent., Statistical Analysis: The observations obtained in both the groups were recorded and compared. Analysis was done using unpaired t-test and Chi-square test., Results: Hemodynamic parameters were comparable in both the groups. The mean equilibration times obtained for sevoflurane and isoflurane were 8.22 ± 1.060 min and 17.24 ± 10.2 min, respectively. The drift in end-tidal agent concentration over time was less in sevoflurane group. Mean recovery time was 7.92 ± 1.56 min in the sevoflurane group and 12.89 ± 3.45 min in the isoflurane group (P = 0.001). There was no significant difference between intraoperative and postoperative complications., Conclusion: Use of equilibration time of the volatile anesthetic agent as a changeover point, from high-flow to low-flow, can help us to use circle system with low-flow anesthesia in a more efficient way, especially with newer anesthetics such as sevoflurane.

The aim of this study was to review the various anesthetic options which can be considered for laparoscopic surgeries in the patients with the chronic obstructive pulmonary disease. The literature search was performed in the Google, PubMed, and Medscape using key words "analgesia, anesthesia, general, laparoscopy, lung diseases, obstructive." More than thirty-five free full articles and books published from the year 1994 to 2014 were retrieved and studied. Retrospective data observed from various studies and case reports showed regional anesthesia (RA) to be valid and safer option in the patients who are not good candidates of general anesthesia like patients having obstructive pulmonary diseases. It showed better postoperative patient outcome with respect to safety, efficacy, postoperative pulmonary complications, and analgesia. So depending upon disease severity RA in various forms such as spinal anesthesia, paravertebral block, continuous epidural anesthesia, combined spinal epidural anesthesia (CSEA), and CSEA with bi-level positive airway pressure should be considered.

Background: The challenging task of postoperative pain relief comes within the realm of the anesthesiologist. Combined spinal epidural (CSE) anesthesia can be used as the sole technique for carrying out surgical procedures and managing postoperative pain using various drug regimes. Epidural administration of opioids in combination with local anesthetic agents in low dose offers new dimensions in the management of postoperative pain., Aims: Comparative evaluation of bupivacaine hydrochloride with nalbuphine versus bupivacaine with tramadol for postoperative analgesia in lower limb orthopedic surgeries under CSE anesthesia to know the quality of analgesia, incidence of side effects, surgical outcome and level of patient satisfaction., Settings and Design: A prospective, randomized and double-blind study was conducted involving 80 patients of American Society of Anesthesiologists physical status I and II coming for elective lower limb orthopedic surgeries carried under spinal anesthesia., Materials and Methods: Anesthesia was given with 0.5% of 2.5 ml bupivacaine intrathecally in both the groups. Epidurally 0.25% bupivacaine along with 10 mg nalbuphine (group A) or tramadol 100 mg (group B) diluted to 2 ml to make a total volume of 10 ml was administered at sensory regression to T10., Statistical Analysis: The data were collected, compiled and statistically analyzed with the help of MS Excel, EPI Info 6 and SPSS to draw the relative conclusions., Results and Conclusions: The mean duration of analgesia in group A was 380 ± 11.49 min and in group B was 380 ± 9.8 min. The mean sedation score was found to be more in group B than group A. The mean patient satisfaction score in group A was 4.40 ± 0.871 and in group B was 3.90 ± 1.150 which was found to be statistically significant (P < 0.05). We concluded that the addition of nalbuphine with bupivacaine was effective for postoperative analgesia in terms of quality of analgesia and patient satisfaction score as compared to tramadol.

The Anesthesiologist provides continuous medical care before, during, and after operation to permit the surgeons to perform surgeries; sometimes quite challenging that could otherwise cause substantial threats to the patient's survival. Anesthesiologists, because of their combination of skills are uniquely qualified to care for dying patients suffering from end diseases like cancer. These skills include knowledge of analgesic and sedative pharmacology for the management of pain, awareness of perceptual alterations along with well-known skills in drug titration and experience with critically ill and highly anxious, often agitated patients under stressful circumstances. Anesthesiologists are physicians who provide medical care to patients in a wide variety of situations. This includes preoperative evaluation, consultation with the surgical team, creation of a plan for the anesthesia (which is different in each patient), airway management, intraoperative life support, pain control, intraoperative stabilization of all the vitals, postoperative pain management. Outside the operating room, Anesthesiologist's spectrum of action includes with general emergencies, trauma, intensive care units, acute and chronic pain management. In spite of providing these highly skilled services, Anesthesiologists are facing a lot of stress these days which predisposes them to burnout, fatigue, substance abuse, and suicide. The practice of anesthesia in Indian scenario is different as compared to the western countries. In India, the Anesthesiologists are dependent on surgeons for their work. The degree of stress faced is due to a number of factors like the type and quality of work, his/her relationship with surgeons and the support he/she receives from colleagues and family.

Trauma is a leading cause of death worldwide, and almost 30% of trauma deaths are due to blood loss. A number of concerns have been raised regarding the advisability of the classic principles of aggressive crystalloid resuscitation in traumatic hemorrhagic shock. Some recent studies have shown that early volume restoration in certain types of trauma before definite hemostasis may result in accelerated blood loss, hypothermia, and dilutional coagulopathy. This review discusses the advances and changes in protocols in fluid resuscitation and blood transfusion for treatment of traumatic hemorrhage shock. The concept of low volume fluid resuscitation also known as permissive hypotension avoids the adverse effects of early aggressive resuscitation while maintaining a level of tissue perfusion that although lower than normal, is adequate for short periods. Permissive hypotension is part of the damage control resuscitation strategy, which targets the conditions that exacerbate hemorrhage. The elements of this strategy are permissive hypotension, minimization of crystalloid resuscitation, control of hypothermia, prevention of acidosis, and early use of blood products to minimize coagulopathy.

Background: Neuraxial labor analgesia using new local anesthetics such as levobupivacaine has become very popular by virtue of the safety and lesser motor blockade caused by these agents. Combined spinal-epidural analgesia (CSEA) has become the preferred method for labor analgesia as it combines benefits of both spinal analgesia and flexibility of the epidural catheter. Adding opioids to local anesthetic drugs provide rapid onset and prolonged analgesia but may be associated with several maternal and fetal adverse effects. The purpose of this study is to compare fentanyl and tramadol used in CSEA in terms of duration of analgesia and frequency of the adverse fetomaternal outcome., Materials and Methods: A total of 60 primiparas with a singleton pregnancy in active labor were given CSEA after randomly allocating them in two groups of 30 each. Group I received intrathecal 2.5 mg levobupivacaine + 25 μg fentanyl followed by epidural top ups of 20 ml 0.125% solution of the same combination. Group II received 25 mg tramadol instead of fentanyl. Epidural top ups were given when parturient complained of two painful contractions (visual analogue scale ≥ 4). Data collected were demographic profile of the patients, analgesic qualities, side- effects and the fetomaternal outcome., Results: Patients in Group II had significantly prolonged analgesia (145 ± 9 minutes) than in Group I (95 ± 7 minutes). Patients receiving fentanyl showed rapid onset of analgesia, but there were more incidence of side-effects like shivering, pruritus, transient fetal bradycardia, hypotension, nausea and vomiting. Only side-effect in the tramadol group was nausea and vomiting. During labor, maternal satisfaction was excellent., Conclusions: Adding tramadol to local anesthetic provides prolonged analgesia with minimal side effects. Fentanyl, when used as adjuvant to local anesthetic, has a rapid onset of analgesia but has certain fetomaternal side-effects.

Background: Infraclavicular brachial block with coracoids approach has gained popularity because of consistent bony landmarks and less chances of vascular puncture and pneumothorax., Aim: The aim of this study was to evaluate the effect of adding clonidine to bupivacaine or ropivacaine on the onset and duration of sensory and motor block and duration of analgesia in infraclavicular block., Materials and Methods: In a prospective randomized double-blind study, 60 patients of 18-65 years were randomly divided in to two groups of 30 each. Infraclavicular block was performed with 30 ml of 0.75% ropivacaine + 150 μg clonidine in group R and 30 ml of 0.5% bupivacaine + 150 μg clonidine in group B and were compared for onset and duration of sensory and motor block, postoperative analgesia, side-effects and complications., Results: Significant differences were observed in the time for onset of sensory block (5.80 ± 5.12 min in group R and 4.87 ± 1.46 min in group B, P < 0.05); onset of motor block (11.37 ± 2.66 min in group R and 9.60 ± 1.78 min in group B, P < 0.05); duration of sensory and motor block (10.07 ± 0.91 and 9.03 ± 0.89 h in group R and 12.50 ± 1.14 and 10.67 ± 1.18 h in group B respectively, P < 0.01) and duration of analgesia (15.30 ± 1.39 h in group R and 18.07 ± 1.66 h in group B). No significant difference was observed in hemodynamics, sedation, side-effects and complications., Statistical Analysis: Variables were compared using Chi-square test for nonparametric data and Student's t-test for parametric data., Conclusion: Addition of clonidine to bupivacaine lead to early onset and prolonged duration of sensory and motor block with prolonged analgesia as compared to the addition of clonidine to ropivacaine.

We report a case of acute and recurrent accelerated wear of the polyethylene bushings of the hinge mechanism in the Zimmer Segmental Knee System. This resulted in an unacceptable recurvatum deformity leading to multiple revision knee operations, which was unexpected in a modern design hinged knee system. A custom modification of the original design was used to prevent further recurvatum deformity. The current design of the hinge post mechanism in this system appears to be inadequate, which led to the development of a significant recurvatum deformity in our patient. Surgeons should be aware of this potential complication when considering the use of this revision knee system., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Osteolysis tends to remain clinically silent and presents a treatment challenge. In the past, the progression of implant wear was used to determine the timing of interventions. Recent reports of lesions associated with metal-on-metal implants and trunnion corrosion with femoral head sizes larger than 32 mm suggest that other mechanisms of wear debris production may be present; observation alone may not provide adequate monitoring. Advanced imaging modalities, such as MRI, should be used along with routine radiography to assess soft-tissue involvement and the size of osteolytic lesions. Intraoperative mechanical stress applied to the acetabular cup helps determine if revision or retention is selected when osteolysis is present. Options for the management of acetabular osteolysis include porous metal cups, oblong cups, antiprotrusio cages, impaction grafting, structural grafts, and, more recently, versatile porous metal cups. Porous metal cups can be used with or without augments or as cup-cage constructs. Porous metal cups have shown excellent results at short-term follow-ups. Modular, uncemented, titanium stems are now more commonly used for femoral revisions. Impaction grafting and allograft-prosthesis composites are occasionally useful in femoral revision surgery. A high incidence of adverse tissue reactions has been reported with metal-on-metal bearings with large heads. Recent focus also has been directed to debris generation by the modular junctions in these bearings. Removal of all sources of debris generation should be attempted during revision of metal-on-metal hip replacements. A thorough débridement of soft-tissue masses and the use of ceramic heads should be considered.

Many patients with psychiatric illnesses are prescribed long-term drug treatment, and the anaesthesiologist must be aware of potential interactions with anaesthetic agents. Psychotropic drugs often given in combination with each other or with other non-psychiatric drugs generally exert profound effects on the central and peripheral neurotransmitter and ionic mechanisms. Hence, prior intake of these drugs is an important consideration in the management of the patient about to undergo anaesthesia and surgery. This article highlights the effects of anaesthetics on patients taking antipsychotics, tricyclic antidepressants, monoamine oxidase inhibitors and lithium carbonate. The risk that should be considered in the perioperative period are the extent of surgery, the patient's physical state, anaesthesia, the direct and indirect effects of psychotropics, risk of withdrawal symptoms and risk of psychiatric recurrence and relapse.

Background: Elastophagocytosis, or elastic fiber phagocytosis by multinucleate macrophages, has been observed in different skin conditions that may or may not occur on sun-exposed skin. Although loss of elastic fibers has been well documented in the homogenized papillary dermal zone in lichen sclerosus (LS), elastophagocytosis, to the best of our knowledge, has never been observed., Methods: We encountered striking elastophagocytosis in a case of extragenital LS which prompted us to review all cases of LS diagnosed at the Skin Pathology Laboratory at Boston University over a 2-year period to assess for the presence of elastophagocytosis., Results: In 7 of 35 patients diagnosed with LS (20%), we found prominent elastophagocytosis to be present either immediately below or at the junction of the homogenized collagen and the normal underlying reticular dermis. Interestingly, all the cases in which elastophagocytosis was observed were in extragenital locations., Conclusion: Elastophagocytosis was observed in 20% of LS cases, all of which were extragenital. We hypothesize that elastophagocytosis in LS, especially in extragenital sites, may not be an epiphenomenon but rather represents a contributing factor to elastic fiber loss in the hyalinized papillary dermal collagen that typifies this disease.

Background: Rapid and safe endotracheal intubation is of paramount importance in general anaesthesia. The aim of this study was to compare the intubating conditions of succinylcholine with rocuronium bromide and vecuronium bromide using "Timing principle". The timing principle entails administration of a single bolus dose of nondepolarizing muscle relaxant, followed by an induction drug at the onset of clinical weakness. PATIENTS #ENTITYSTARTX00026;, Methods: 75 patients were divided into three groups of 25 each. Patients allocated to Groups A and B received rocuronium 0.6 mg kg(-1) and vecuronium 0.12 mg kg(-1) respectively. At the onset of clinical weakness (ptosis), anesthesia was induced with propofol 2.5 mg kg(-1); intubation was accomplished after 60 seconds of induction agent in both groups. Patients in Group C received propofol 2.5mg kg(-1) followed by succinylcholine 2mg kg(-1) and their tracheas were intubated at 60s.Train of four count was assessed at adductor pollicis muscle using nerve stimulator at intubation and time to loss of TOF was observed. in group A and B. Intubating conditions were assessed according to a grading scale and haemodynamic variables were compared at 1,3 and 5 minutes after intubation., Results: Intubating conditions were either excellent(84% in group A,48% in group B and 88% in group C) or good (16% in group A, 48% in group B and 12 %in group C)and only 4% pt had poor intubating conditions in group B. Patients were interviewed postoperatively, and all were satisfied with the technique of induction of anesthesia.Rocuronium and Vecuronium are haemodynamically stable drugs as compared to Succinylcholine., Conclusion: Rocuronium 0.6 mg kg(-1) provides good to excellent intubating conditions at 60 s comparable to succinylcholine after the induction of anesthesia using the timing principle.

Telemedicine is the use of electronic information and communication technology to provide and support healthcare when distance separates the participants. India is characterised by low penetration of healthcare services where primary healthcare facilities for rural population are highly inadequate. The majority of doctors practice in urban and semi-urban areas, whereas the major proportion of population lives in rural areas. This calls for the innovative methods for utilisation of science and technology for the benefit of our society. There are few reports in the literature which support the use of telemedicine technology for pre-operative assessment, intra-operative consultation, monitoring and post-operative follow-up, which is discussed in this article.

We were capable of undertaking a histological and ultrastructural evaluation of an intact Leeds-Keio ligament implanted 20 years ago to assess the neoligamentization process inside this artificial ligament. The histological evaluation disclosed a collagen fibrils orientation very close to the structure of a normal anterior cruciate ligament (ACL) where the collagen fibres are multidirectional [Strocchi et al. in J Anat 180(3):515-519, 1992]. On the other hand we found an unimodal distribution of collagen fibrils in the reconstructed ACL. This suggests that even at long-term follow-up stress exerts a variable influence. The multidirectional arrangement of collagen fibres resembles a normal ACL, but the unimodal distribution of fibrils is quite different from those seen in normal tendon and ligaments which tend to have a bimodal peak [Decker et al. in J Submicrosc Cytol Pathol 23:9-21, 1991; Strocchi et al. in J Anat 180(3):515-519, 1992]. Studies based on biopsy suffer from the potential weakness that the specimen may not have been representative of the entire prosthesis. Further long-term studies, possibly with the entire prosthesis and not only a biopsy, would highlight the behaviour and remodelling of this artificial ligament in greater detail and could be important for the development of future generations of artificial ligaments or tissue engineering ACL reconstruction.

Background: It has been suggested that multiple stacked pulses of lower fluence may have a similar effect on targets as a single pulse of higher fluence. When treating vascular lesions, increasing the fluence beyond a certain point will increase the risk of purpura given a constant pulse duration. Stacking pulses of lower fluence may have the advantage of heating vessels to a critical temperature without creating purpura., Objective: To determine whether stacking low-fluence pulses of a variable-pulse pulsed-dye laser would improve clinical results without significantly increasing side and adverse effects., Methods: Twenty-five patients between the ages of 18 and 65 years with facial telangiectasia and skin types I-IV were enrolled in the study. For each subject, the cheek or nasal ala areas on either side of the facial midline with similar telangiectasia density ratings were randomized to single pulse and multiple stacked pulse groups. One side of the cheek or nasal ala was treated with single nonoverlapping pulses with the Candela Vbeam 595-nm pulsed-dye laser. The opposite side of the cheek or nose was treated with the same parameters but with three or four pulses stacked on top of each other at a 1.5-Hz repetition rate. Patients were asked to rate the pain of the procedure on each side on a 0 to 3 scale. Investigators rated the erythema and edema after the procedure as well as vessel clearing and overall telangiectasia density scale at 1 and 6 weeks after the procedure., Results: Twenty-three patients completed the study. The mean pain rating was 1.58 for the pulse stacked side and 1.38 for the single-pass side. The mean erythema score after the procedure was 1.17 for the pulsed stacked side and 1.09 for the single pulsed side. The mean vessel clearing 1 week after the treatment was 74.3% for the pulse stacked side and 58.5% for the single pulsed side. The mean vessel clearing 6 weeks after the treatment was 87.6% for the pulse stacked side and 67.4% for the single pulsed side. The mean telangiectasia density scale score before treatment was 2.67 for the pulse stacked side and 2.59 for the single pulsed side. At 1 week after treatment, the mean telangiectasia density scale score was 1.06 for the pulsed stacked side and 1.5 for the single pulsed side. At 6 weeks after treatment, the mean telangiectasia density scale score was 0.72 for the pulsed stacked side and 1.30 for the single pulsed side. No patients experienced purpura in either group, and there were no cases of hyperpigmentation, hypopigmentation, or scar formation. One patient experienced significant edema on the side of the cheeks treated with pulse stacking., Conclusions: Treating superficial facial telangiectasia with a pulse stacking technique may improve clinical results without significantly increasing adverse effects.

Background: The clinical presentation of tinea is usually, but not always, characteristic. The purpose of this study was to determine whether the routine use of the periodic acid-Schiff (PAS) stain in inflammatory skin disorders is requisite for identifying clinically undiagnosed tinea cases and to ascertain whether there are histopathologic clues that suggest the diagnosis of a dermatophyte infection., Methods: Hematoxylin and eosin (H&E)-stained slides from 60 PAS-positive tinea cases were examined histologically by two observers. One observer, aware of the diagnosis of tinea, searched for hyphal elements and also recorded in detail epidermal, dermal, and follicular changes. The second observer, not aware of the diagnosis beforehand, reviewed the same slides, together with randomly mixed slides from 21 non-tinea cases, recording the same parameters as the first reviewer., Results: Of the 60 cases of tinea, only 45% were diagnosed clinically. Histologic examination of H&E sections by the two observers disclosed the presence of hyphal elements in 68 and 45%, respectively. No significant histologic differences, except for the presence of hyphae, were observed between tinea and non-tinea cases., Conclusions: The finding that only 57% of PAS-positive cases of tinea showed hyphal elements on H&E examination alone, together with no other differentiable histologic characteristics, lends strong support for the routine use of PAS-staining for inflammatory skin disorders.

Background and Objectives: This study was designed to evaluate the safety and effectiveness of a small, low energy light based system for hair removal, when used by non-healthcare professionals ("patients") for self treatment in home-like environment following instructions and guidance provided by a physician., Study Design/materials and Methods: A total of 73 patients between the ages of 19 and 54 years with skin types I through IV were enrolled in the study out of which 67 completed the study. Two treatment sites were chosen from among the arms, axilla, legs, bikini, back, belly, chest or face. The hair on the sites was trimmed and photographed. Each patient performed two self-treatments, using the hair removal device on their designated body sites, under the Investigator's direction. The first self-treatment was performed at the Investigator's office by the patient while the second self-treatment was performed 4 weeks later at a hotel room, simulating the home environment. Follow-up visits to evaluate the safety and efficacy of the treatments were performed 2 and 12 weeks following the last self-treatment., Results: The mean hair reduction was 33.6%, 4 weeks after the first self-treatment, 44.3%, 2 weeks following the last self-treatment, and 32.3%, 12 weeks following the last treatment. All the noted side effects were mild and transient. Transient erythema was noted in 47.5% of the patients. Other transient side effects reported include edema (5%), hyperpigmentation (4.75%), crusting (2.35%), hypopigmentation (1.55%), and blistering (1.4%). All noted side effects were resolved by the 12-week follow-up visit., Conclusions: With adequate training and instruction, patients may administer self-treatments for hair removal with this small light based unit in a safe and effective manner., (Copyright 2003 Wiley-Liss, Inc.)

Background: Granuloma faciale has been treated in the past with different modalities but the majority have had the risk of scarring., Objective: Based on the principle of selective photothermolysis, we considered using the newer long-pulsed tunable dye laser for the treatment of granuloma faciale to target the vessels and minimize scarring., Methods: Confirmation of the diagnosis by a punch biopsy of the lesion was followed by three treatments on separate occasions 6 weeks apart with the long-pulsed tunable dye laser., Results: There was significant flattening of the lesions after two treatments, with complete clearing after the third. No scarring was detectable and there was no recurrence in the 9-month follow-up., Conclusion: We conclude that granuloma faciale may be successfully treated with the long-pulsed tunable dye laser with minimal risk of scarring, especially in cosmetically sensitive areas.