Perioperative myocardial ischemia contributes to postoperative morbidity and mortality. Remote intermittent ischemia (RI) has been shown to benefit patients undergoing coronary artery bypass graft (CABG) surgery by decreasing postoperative cardiac troponin levels. In addition, there is evidence that volatile anesthetics may provide myocardial protection. In this prospective randomized controlled trial we tested the hypothesis that RI is cardioprotective under a strict anesthetic regime with volatile anesthesia until cardiopulmonary bypass (CPB). We also assessed whether RI modulates postoperative cytokine and growth factor concentrations. Fifty-four patients referred for elective CABG surgery without concomitant valve or aortic surgery were randomized to three 5-min cycles of left upper limb ischemia by cuff inflation (RI) or placebo without cuff inflation (Plac). All patients received the volatile anesthetic isoflurane (1.15-1.5 vol%) before CPB and the intravenous anesthetic propofol (3-4 mg/kg/h) thereafter until the end of surgery. Cardiac arrest during CPB was induced by intermittent cross-clamp fibrillation, or by blood cardioplegia. We excluded patients older than 85 years, with unstable angina, significant renal disease, and those taking sulfonylureas. Troponin I (cTnI) was measured preoperatively and after 6, 12, 24 and 48 h. In addition, brain natriuretic peptide (BNP), creatine kinase (CKMB) and a panel of cytokines and growth factors were analyzed perioperatively. Although cTnI, BNP and CKMB all increased post-CABG, there were no significant differences between RI and Plac groups; area under the curve for cTnI 189.4 (183.6) ng/mL/48 h and 183.0 (155.2) ng/mL/48 h mean (SD), p = 0.90, respectively, despite a tendency to a shorter (p < 0.07) cross-clamp time in the treatment group. Similarly, there were no differences between groups in the central venous concentrations of numerous cytokines and growth factors. In patients undergoing CABG surgery RI does not provide myocardial protection under a strict anesthetic regime with volatile anesthesia until CPB, and RI was not associated with changes in cytokines.

Background: Acute appendicitis is a common cause of abdominal pain and can be difficult to diagnose, especially during its early stages.  The diagnosis of acute appendicitis is based on clinical history, examination combined with investigations. The purpose of this study is to compare between the RIPASA score and Alvarado score in the diagnosis of acute appendicitis. The aim of the present study was to compare the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of Alvarado and RIPASA score.Methods: The cases for the study will be sourced from cases admitted in SVMCH and RC, Puducherry during the period of November 2016 to June 2018.Results: Out of the 144 patients in our study 133 patients were diagnosed with acute appendicitis as per HPE report.As per our study, sensitivity, specificity, PPV, NPV of RIPASA and Alvarado scoring system is 96.2%, 57.1%, 97.7% and 44.4%; 81.9%,85.7%, 95.1% and 20%  respectively. The diagnostic accuracy of RIPASA score is 94.3 as compared to 82.1 of Alvarado score.Conclusions: The RIPASA scoring system is a promising and has good sensitivity, specificity and diagnostic accuracy when compared to Alvarado scoring for Asian Population.RIPASA scoring system is an easy and reliable, cost effective diagnostic tool which reduce negative appendicectomy rates and the expensive radiological investigations for the diagnosis of acute appendicitis.

propofol TCI was reduced to 3 mg ml 21. However, this information was not included in the Methods section of our article. In contrast, however, BIS was relatively low at 3 mg ml 21 of TCI. Although the TCI system does not predict plasma propofol concentration completely, a BIS monitor can be used during general anaesthesia. Remifentanil, however, affects the EEG characteristics during propofol anaesthesia. 2 Therefore, we also wanted to know how remifentanil affects BIS per se during propofol anaesthesia. Unexpectedly, our findings indicate the possibility that BIS does not reflect the actual plasma propofol concentration when co-administered with remifentanil. Thus, anaesthetic depth management using propofol TCI with remifentanil co-administration may be complicated, even when surgical stimulation is absent. Because remifentanil is used under surgical stimuli in a clinical setting, we think that further studies are necessary to clarify the effect of remifentanil on plasma propofol concentration or BIS during surgical stimulation. We cannot say whether presenting TCI is acceptable in scientific journals, but we believe that our findings are important for readers, especially those who use propofol TCI clinically.

Although, intussusception is a common cause of intestinal obstruction in children, it is a rare event in the adult population. It has long been known that various acquired immune deficiency syndrome related conditions of the bowel such as lymphoma, lymphoid hyperplasia, cytomegalovirus colitis and Kaposi's sarcoma can lead to intussusception. The diagnosis is particularly difficult in this population of patients due to the non-specific nature of the symptoms as well as the depressed immune response obscuring inflammation or ischemia. Though the reported acquired immune deficiency syndrome associated cases of intussusception refer to patients with known human immunodeficiency virus infection, in our case we present an intestinal intussusception as the first manifestation of human immunodeficiency virus infection. CASE PRESENTATIONA 50-year-old heterosexual woman with a clean medical record and no history of abdominal operation presented to our ER with symptoms and signs suggestive of bowel obstruction. Plain abdominal radiographs were highly suspicious for intussusception, which we confirmed on a computed tomography scan. The patient was prepared for surgery and on routine investigations before surgery serology confirmed retroviral disorder, the patient was operated 3 days later and this confirmed the diagnosis of small-bowel invagination due to a 4cm polypoid growing intraluminal tumor, the pathologic examination of which revealed a diffuse high-grade B cell lymphoblastic lymphoma. CONCLUSIONHuman immunodeficiency virus infection may have a silent course and gastrointestinal manifestations of the disease leading to intussusception might be the first clinical sign. Patients with intestinal intussusception and the presence of risk factors for human immunodeficiency virus infection should be eligible for serologic tests for human immunodeficiency virus infection.

Introduction: Diabetes mellitus with its associated complications is a major cause of morbidity and mortality worldwide. The development and progression of chronic complications of diabetes are closely related to glycaemic control. Diabetic foot is one of the most frequent reasons for hospitalization in a surgical ward; its complications include abscess formation, cellulitis, ulceration and gangrene. Hence, the aim of this study was to correlate the severity of diabetic foot lesions by Wagner grading with Ankle Brachial Index in diabetic patients on a Doppler-based evaluation. Material and methods: In this observational study, about 50 cases of "Diabetic Foot" were studied from May 2011 to May 2013 admitted in Krishna Institute of Medical Sciences, Karad. Diabetic patients who were 18 years or above irrespective of the type of diabetes and gender with suspected peripheral vascular insufficiency or complaints of numbness, discoloration of periphery or ulceration were included in this study. Patients with history of arterial graft procedures and present with blisters, cellulitis, abscess, gangrene lesions was present other than the diabetes were not included in the study. Results: The most common mode of presentation was ulcer in 19 cases followed by 14 cases of Cellulitis based on the mode of clinical presentation. In the present study, about 23 patients had hypertension followed by 8 cases of COPD and 5 cases of IHD. Maximum number cases (15) were seen in Grade III Wagner's Grading The maximum number of patients (14) had moderate ankle brachial index. Conclusion: It was found in the present study that vascular insufficiency was present in 62% of the patients with dorsalispaedis being the commonest site of involvement. In patients exhibiting doppler-documented vasculopathy, the mean duration of disease was almost a decade. Hence, colour doppler sonography can locate the site and extent of stenosis/occlusion accurately.