Background: The aim of the present prospective randomised double-blind clinical study was to compare the incidence of pain-free injection following the use of this new formulation (propofol with medium-chain triglycerides [MCT] and long-chain triglycerides [LCT]) with propofol dissolved in LCT with added 2% lignocaine in patients undergoing various surgical procedures under general anaesthesia. Methods: Sixty adult patients (age range 18–50 years) were randomised to receive either 20 mL propofol dissolved in a mixture of MCT–LCT [Group L (n = 30)] or 18 mL propofol dissolved in LCT with added 2 mL 2% lignocaine [Group S (n = 30)]. A specially trained clinical research investigator assessed the occurrence of injection pain using a four-graded pain scale. Results: There was no significant difference in propofol injection pain among patients who received either LCT propofol with added lidocaine, (Group S) (33.3%) or new formulation propofol (Group L) (30.0%) (P = 0.993). Conclusions: The newer formulation, MCT–LCT propofol, is equally effective vis-à-vis the conventional propofol with added lignocaine to reduce the incidence of pain, thereby eliminating the need for addition of another drug, lignocaine.

Objectives: There is considerable debate in the surgical management of epidermoid cyst whether gross total or subtotal resection yields better long term outcomes. We present our institutional experience in evaluating the clinical presentation, diagnosis and surgical strategy and extent of resection in the management of intracranial epidermoid cyst. Methods: We retrospectively reviewed the case records of 38 patients with intracranial epidermoid tumors surgically treated at our institution between 2010 and 2019. Results: A total of 38 patients who underwent surgery for intracranial epidermoid lesions were identified. Of these 17 were supratentorial, 20 were infratentorial lesions and one case lesion was extending from cerebellopontine region to middle fossa. The mean duration from onset of symptoms to surgery was 3.9 years. Cranial nerve dysfunction was noted in 73% of patients preoperatively most of them being the Cerebellopontine angle epidermoids. Total removal was achieved in 28 patients, near-total removal in 8 patients, and subtotal removal in 2 patients. 6 patients developed recurrence radiologically of them only one patient became symptomatic. Of the six 2 were patients who underwent gross total resection and the remaining 4 were from near and subtotal resection. The mean duration of follow-up was 3.8 years. The content of the tumor was pearly white/white material in all cases. complications noted in the present series were not related to the completeness of excision. Mortality was noted in one patient. Conclusions: The present study highlights various precautions to be taken intraoperatively in the prevention of development of aseptic meningitis and concludes that total removal of epidermoids does not result in significantly increased morbidity and mortality and should be the goal of surgical treatment. However, near/subtotal resection oflesions that are densely adherent to neurovascular structures is justified, as there is no significant difference in the rate of recurrence. An endoscope can be used to assess the completeness of surgery.

Background: Enterogastric reflux of bile is a major cause of morbidity following distal gastrectomy. Various reconstructive methods were developed to overcome this. Methods: A prospective randomised study included all patients undergoing distal gastrectomy for gastric cancer was conducted during the period June 2012 and November 2016. After resection, they were randomized to undergo Billroth II with Braun anastomosis (BEE) (n = 28) or Roux-en-Y (RY) gastrojejunostomy (n = 26). Endoscopy and biliary scintigraphy were done at 3 months to assess the severity of gastritis and the presence of bile reflux in remnant stomach. Stomach was biopsied for histopathology. Quality of life (QOL) was assessed using gastric cancer-specific questionnaire. Results: Demographics and nutritional status was similar. Intraoperative variables, post-operative recovery and hospital stay were not statistically different. Remnant stomach in BEE group showed more severe and extensive gastritis than RY group. The incidence of bile reflux on endoscopy was statistically significantly high in BEE (P < 0.0001). The histological findings of endoscopic biopsies were similar. The incidence of bile reflux on scintigraphy was lower in RY group (10.7% vs. 46.2%; P = 0.03). The QOL symptom score was similar. Conclusions: The incidence of bile reflux and severity of gastritis is less in patients who underwent RY gastrojejunostomy when compared to Billroth II with Braun anastomosis without any significant difference in QOL.

Background: Few Indian studies are available which have examined the risk factors and extracranial and intracranial vascular observations in patients with stroke. Methods: We prospectively studied the burden of intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS) in patients (n = 300) with acute ischaemic stroke and study the vascular disease to the outcome of the patients. Results: Their mean age was 57.8 ± 14.2 years; there were 183 (61%) males. The frequency of risk factors were hypertension (73%), diabetes mellitus (46%), tobacco smoking (34%), dyslipidaemia (39.3%), alcoholism (27%), previous stroke (21%), chronic kidney disease (CKD) (9%) and hyperhomocystinaemia (15%). Multiple and single territory infarction was evident in 103 (34.3%) and 197 (65.7%), respectively. Both ICAS and ECAS were evident in 117 (39%), whereas 111 (37%) had ICAS and 36 (12%) had ECAS. On univariate analysis, the presence of CKD (P = 0.01), previous stroke (P = 0.02), ICAS and combined ICAS plus ECAS were associated with unfavourable outcome (P = 0.0001). On multivariable analysis, age >58 years (odds ratio [OR] 1.04, 95% confidence intervals [CI] 0.71–0.89, P < 0.0001), female gender (OR 0.6, 95% CI 0.41–0.87, P = 0.008), National Institutes of Health Stroke Scale score >18 (OR 0.75, 95% CI (0.71–0.80, P < 0.0001) were associated poor functional outcome. Conclusions: ICAS was more common than ECAS. ICAS and combined ICAS plus ECAS were associated with unfavourable outcome.

Background: Sparse published data are available regarding electrolyte abnormalities in elderly patients admitted to hospital with infection. Methods: We retrospectively studied the case records of 115 elderly patients (aged >60 years) admitted with 131 episodes of admissions due to various infections to the geriatric medicine wards and intensive care unit in our tertiary care teaching hospital during January 2018– September 2019. Results: Their mean age (years) was 79.1 ± 8.2 years; there were 58 (50.4%) females. Seven patients were admitted twice; one patient was admitted thrice with infection. The common sites of infection were lower respiratory tract (n = 58, 44.3%); urinary tract (n = 56, 42.7%); cellulitis, wound and soft-tissue infections (n = 22, 16.8%); and sepsis and related syndromes (n = 11, 8.4%). The common comorbid conditions included hypertension (67.8%), diabetes mellitus (45.2%), coronary artery disease (26.1%) and chronic kidney disease (12.2%). Hyponatraemia was the most common electrolyte abnormality seen in 53/131 (40.5%) episodes followed by hypocalcaemia (35/112, 31.2%), hypokalaemia (22/131, 16.8%), hypernatraemia (n = 1), hyperkalaemia (n = 9), hypercalcaemia (n = 2), hypomagnesaemia (n = 15), hypophosphataemia (n = 11) and hyperphosphataemia (n = 3). All patients with dyselectrolytaemia were receiving multiple (median [interquartile range (IQR)] 6 [3.75–8]) drugs. The median (IQR) duration of hospital stay was 6 (4–10) days. Eight of the 115 (7%) patients died; four of these eight patients had been admitted more than once with infection. There was no statistically significant difference in the proportion of patients with hyponatraemia (65/108 vs. 3/8; P = NS) and hypokalaemia (8/108 vs. 1/8; P = NS) among survivors and non-survivors. Conclusions: Dyselectrolytaemia is a common correctable metabolic abnormality seen in elderly patients hospitalised with infections. Careful monitoring and instituting correction can be life-saving.

Background: Laryngoscopy and tracheal intubation initiate tremendous changes in heart rate (HR) and blood pressure which could be associated with deleterious consequences in susceptible individuals. Methods: The effect of gabapentin on the haemodynamic responses to laryngoscopy and intubation in adults undergoing elective non-cardiac surgeries was investigated in the present study. Sixty adult patients of the American Society of Anaesthesiologists Grade I aged between 18–65 years and scheduled for different types of elective non-cardiac surgeries under general anaesthesia were randomly allocated to receive gabapentin 1200 mg or placebo capsules, at 6 h intervals starting the evening before surgery. After standard routine induction, succinylcholine was used to facilitate intubation. HR, systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded before and after the administration of the induction agent, immediately after laryngoscopy and intubation and at 1, 3, 5 and 10 min thereafter. Results: Patient characteristics were similar in both the groups. When compared to placebo group, Gabapentin group showed significantly lower HR (at post-induction, 0, 1 and 3 min; P < 0.05), SBP (at 0, 1 and 3 min; P < 0.05), DBP (at 0 and 1 min, P < 0.05) and MAP (at 0, 1 and 3 min, P = 0.05) after laryngoscopy and intubation. Conclusions: Gabapentin, under the present study design, attenuated the pressor response to laryngoscopy and intubation in terms of HR, SBP, DBP and MAP in patients undergoing elective non-cardiac surgeries.

The coronavirus disease 2019 (COVID-19) pandemic has caused and continues to cause a great deal of morbidity and mortality among patients worldwide. The unrelenting pandemic has raised important issues with regard to the need for rationing healthcare services in general and oncology care in particular, in the context of strained resources and crisis-handling capacity. The management outcomes of cancer patients amidst the COVID-19 pandemic are not well characterised, and we review the limited available evidences in this regard. These evidences seem to suggest that it is wise to continue standard cancer treatments especially so for patients who test negative for COVID-19 amidst the pandemic, unless there is a compelling reason to consider a deviation. The final decision for starting, delaying or deviating from the standard protocols should ideally be made as a part of a shared multidisciplinary decision-making process and should further be individualised for each patient. Although the exact magnitude of the disruptions on cancer care is difficult to quantify as yet, the oncology community will have to study and introspect on the collateral damage caused by the COVID-19 pandemic on the long-term outcomes of cancer patients. The world has witnessed many prior pandemics and humanity has survived them all and has eventually emerged stronger, and we hope that this time it will be no different. The need of the hour is for the scientific community to rise, learn from this unprecedented experience and align together towards creating a stronger and safer future.

Meningitis, when caused by fungi such as Cryptococcus, is usually seen in immunocompromised hosts. However, immunocompetent patients are rarely susceptible to cryptococcal meningitis (CM). We report the case of a 22-year-old immunocompetent male who presented with fever, headache for which he received treatment initially as viral/bacterial meningitis; but as there was no response further diagnostic work-up confirmed the diagnosis of CM. We report this case in view of the rarity of cryptococcal infection in immunocompetent hosts and also to increase the awareness among physicians to consider fungal infections in one of the differentials early in the hospital course while managing patients with meningitis even if they are immunocompetent. This helps in early targeted therapy and thus reduces the morbidity and mortality associated with this deadly disease.

Paragangliomas (PGLs) are rare tumours arising from sympathetic and parasympathetic paraganglial neural crest cells. Functional PGLs usually present with manifestations of catecholamine excess such as hypertension, flushing and diaphoresis. Non-functional PGLs are diagnosed incidentally during imaging studies and pose a significant diagnostic challenge. Here, we report the case of 42-year-old female patient with carcinoma cervix who presented with a non-fluorodeoxyglucose-avid PGL. This case report highlights the importance of considering PGL in differential diagnosis and the management of retroperitoneal tumours.