BACKGROUND Because of its alpha and beta agonist properties, norepinephrine infusion is currently being studied for the prevention of spinal hypotension during caesarean delivery. Vasopressor infusions are not always possible if there is an unavailability of infusion pumps. Leg wrapping with crepe bandage is an effective technique for prevention of postspinal hypotension and could be useful in resource-poor settings. OBJECTIVE The aim of this study was to compare the incidence of hypotension with norepinephrine infusion or leg wrapping with a control group in women undergoing caesarean delivery with spinal anaesthesia. DESIGN Randomised, double-blind, controlled trial. SETTING Single centre, tertiary level institute, India. Study period 3 April 2018 to 31 March 2019. PATIENTS One hundred and forty-four women aged 19 to 40 years with a singleton pregnancy. INTERVENTION In group Leg Wrapping, crepe bandage was applied tightly from metatarsus to groin. Group Norepinephrine and the control group received sham leg wrapping. In group Norepinephrine, the women received a norepinephrine infusion according to their body weight, while group Leg Wrapping and the control group received a 0.9% normal saline infusion at a similar rate. All three groups received a 500 ml co-load of Ringer's solution over 15 min. Noninvasive SBP was monitored every 2 min until delivery, and every 5 min thereafter. Any hypotensive event (SBP < 20% of baseline) was treated with an intravenous bolus of norepinephrine (7.5 μg). MAIN OUTCOME MEASURES The primary outcome was the incidence of hypotension. The secondary outcomes were performance error measurements, and the incidences of hypertension, bradycardia, norepinephrine rescue bolus and neonatal outcomes. RESULTS The incidences of hypotension were significantly lower in the norepinephrine infusion group and the leg wrapping groups than the control group (P values 0.021 for both). Performance error calculations showed that SBP was maintained closer to baseline with the norepinephrine infusion. CONCLUSION Norepinephrine infusion and leg wrapping can both reduce the incidence of postspinal hypotension during elective caesarean delivery compared with saline infusion alone. TRIAL REGISTRATION Clinical trial number and registry URL: CTRI/2018/04/012917 registered at Clinical Trial Registry of India http://www.ctri.nic.in/Clinicaltrials/login.php.

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The pandemic of coronavirus disease 2019 (COVID-19) struck the globe in December 2019, killing lakhs of people and it is continuing in many countries to create havoc. There are lakhs of publications creating evidence about the management of the disease. After seeing thousands of cases, we formed opinions in each field of management and these findings may look more logical. We accept that our opinions differ subtly from the evidence. Regarding the transmission of the disease, it is spread from person to person through inhaled aerosols. If this is going to be 100% true, then the need for personal protective equipment covering the legs seems illogical. Povidone-iodine is antiviral and spreading the same as an ointment inside the nose must be effective to decrease viral load. The other antivirals with questionable efficiency like remdesivir are being used frequently, especially in the pulmonary phase. There are no clear-cut guidelines for primary contacts. Any protective drug intake could have decreased the transmission. It’s a simple logic that the act of sneezing will decrease the viral load. The practice of inhaling turmeric smoke to induce sneezing in the outdoor could have decreased the viral load. We opine that a lymphopenia of <15% can predict a worse outcome in the next 2 days. A computerized computed tomography scan of the chest is to be taken 7 days after the onset of symptoms as the disease usually enters the pulmonary phase only then. The date of onset of symptoms rather than the positive testing date should be considered for timeline management of the case. The undue tachycardia in the 1st week and desaturation below 92% in the 2nd week are the warning signs. The steroids are to be usually prescribed after the 5–6 days. The roles of psychiatric counseling and nutrition were largely underplayed.

Asternia is the rarest of developmental anomalies which affect the sternum. The first case of asternia documented in an English publication was in 1968.1 Subsequently seven more have been described. We report absence of the sternum in a child with an associated skin defect, successfully repaired by pectoral fasciorrhaphy and a rectus abdominis myocutaneous flap. Case reportA 4 year old Yemeni girl was admitted to King Khalid University Hospital, Riyadh, in January 1985 with a history of recurrent chest infection and bluish discolouration of her lips when she cried excessively. She was the child of a consanguineous marriage and was delivered normally at full term. On examination there was a depression over the sternal area of the chest. The overlying skin, measuring 7 x 5 cm, was replaced by a papery thin hypopigmented scar, which flapped in and out during respiration. The scar extended down along the midline to the umbilicus (fig 1). Bony resistance was not felt underneath the scar. The medial ends of the clavicles and the anterior ends of the ribs were felt in a row, away from the midline. Plain radiography of the chest showed complete absence of the sternum. This was confirmed by computed tomography and a bone scan (using technetium methylene diphosphonate).Surgical correction was undertaken after correction of anaemia. At operation the scar, which was firmly adherent to the pericardium, was carefully excised. The pectoral fascia was then widely mobilised from each side and approximated in the midline with 3/0 prolene. As soon as the fasciorrhaphy was complete the mediastinal flutter disappeared. A rectus abdominis myocutaneous flap, based on the left superior epigastric vessels, was used to provide skin cover. Preoperative internal mammary angiography confirmed the presence of the left superior epigastric artery.The postoperative period was uneventful. The child has a well stabilised chest wall and is healthy and symptom free 15 months after operation. Accepted 12 December 1986 in the midline gives rise to a range of defects, from absence of the sternum to varying degrees of sternal clefts.2 This complex process is closely related to the development and descent of the septum transversum and therefore sternal defects may be associated with anomalies of the heart, pericardium, diaphragm, and anterior abdominal wall.13 The aetiology is not yet known. Nutritional deficiencies and hypovitaminosis in early pregnancy have been blamed.4 Major sternal defects make the chest wall unstable, resulting in paradoxical movements of the thoracic viscera during respiration. Some infants suffer attacks of cyanosis and recurrent chest infection because of the abnormal movements.5 The heart and other mediastinal structures, owing to lack of sternal support, are prone to injury. Thus all children born with major sternal defects, symptomatic or otherwise, need surgical correction.It is generally agreed that the best time to operate is during infancy. The defect widens with advancing age, owing to rapid growth of the intra-abdom...