Positioning for placement of an epidural catheter can be quite painful for patients with lower limb injuries. We randomly allocated 50 patients scheduled for surgery after lower limb injuries for placement of a lumbar epidural catheter in the sitting position with the back in the neutral unflexed position by either the midline or paramedian approach. If the approach failed after two attempts, patients were placed in a flexed-spine position, and the procedure was attempted again. Technical difficulties and complications were recorded. In 17 patients in the midline group, and 1 patient in the paramedian group, it was not possible to insert the needle initially, and a flexed-spine position was required (P < 0.05). The incidences of resistance to catheter insertion (eight versus one), paresthesia (seven versus zero), and appearance of blood in the catheter (six versus zero) were significantly more frequent in the midline compared with the paramedian approach. The midline group also experienced more discomfort than the paramedian group. We conclude that, with the patient sitting with an unflexed spine, it is usually possible to insert an epidural catheter with the paramedian approach.

Background:Occurrence of pneumonia challenges the medical management of patients who have undergone surgery for aneurysmal subarachnoid hemorrhage, and is associated with significant mortality and morbidity. There are very few studies evaluating the incidence and outcome of postoperative pneumonia in patients undergoing microsurgical clipping of ruptured intracranial aneurysms. The aim of this study was to determine the incidence, risk factors, and outcome of postoperative pneumonia in patients undergoing surgery for ruptured intracranial aneurysms.Methods:All patients operated for intracranial aneurysms, over a period of 9 months, were included prospectively. They were studied for risk factors predisposing them to pneumonia and their outcomes were noted at discharge. Patients with predisposing chronic lung disease, preexisting pneumonia, and chronic smoking habits were excluded.Results:One hundred and three patients [Mean age: 46.01 years; M:F – 58:45] underwent microsurgical clipping of aneurysm during the study period. Of these, 28 patients (27.2%) developed postoperative pneumonia. The variables associated with postoperative pneumonia were: [Preoperative] age >50 years, Glasgow Coma Scale (GCS) at presentation <15 and Hunt and Hess grade before surgery >2; [postoperative] duration of surgery >3 hours, GCS <15 after complete reversal from anesthesia, duration of intubation in the postoperative period >48 hours, tracheostomy, postoperative ventilation, intensive care unit (ICU) stay >5 days. Predictive factors for postoperative pneumonia by multivariate analysis were: Postoperative endotracheal intubation >48 hours, tracheostomy and ICU stay >5 days.Conclusions:There is a high incidence of postoperative pneumonia and mortality associated with pneumonia (27.2% and 9.7%, respectively in our study) in patients of ruptured intracranial aneurysms undergoing microsurgical clipping at our center, with Acinetobacter species being the predominant causative organism.

In December 2019, with pneumonia-like clinical manifestations, a new severe acute respiratory syndrome coronavirus 2 emerged and quickly escalated into a pandemic. Since the first case detected in early March of last year, 8668 have died with an infection mortality rate of 1.52%, as of March 20, 2021. Bangladesh has been struck by the 2nd wave from mid-march 2021. As data on the second wave are sparse, the present study observed the demographic profile, symptoms, and outcomes of Coronavirus Disease 2019 (COVID-19) patients during this wave. The study was conducted at Sheikh Russel National Gastroliver Institute on 486 admitted cases during the 2nd wave of COVID-19 in Bangladesh (March 24–April 24, 2021) using a cross-sectional study design and a convenient sampling technique. Out of 486 cases, 306 (62.9%) were male, and 180 were female, with a mean age of 53.47 ± 13.86. The majority of patients (32.5%) were between the ages of 51 and 60. While fever and cough being the predominant symptoms (>70% cases), the most common co-morbidities were hypertension (41.4) and diabetes mellitus (39.4). Intensive care unit utilization rate was 25%, and a half of the patients had 51% to 70% tomographic lung involvement with an overall mortality rate of 19.3%. Older age, chronic renal disease, percentage of lung involvement, and intensive care unit necessity were important mortality determinants. The present study gives an insight into the demographic profiles and outcomes of admitted patients with COVID-19 during the second wave at a covid dedicated hospital in Bangladesh.

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A 4 year old girl presented with keratitis and ataxia. Over the next two months she developed profound hearing loss, arthritis, and polychondritis. A diagnosis of Cogan's syndrome was made. The literature on the condition is reviewed and the importance of early diagnosis to prevent hearing loss is highlighted. (Arch Dis Child 1994; 71: 163-164) Non-syphilitic interstitial keratitis with vestibuloauditory dysfunction (Cogan's syndrome)1 is an uncommon clinical entity. Although a condition affecting mainly young people, only three children have so far been reported with the condition.2 3 In addition to photophobia, redness of the eyes, vertigo, ataxia and hearing loss, there is often systemic involvement as a result of widespread vasculitis.2 Despite its rarity, it is an important condition to recognise because early treatment may prevent the onset of profound deafness.4Case report A 4 year old girl developed acute onset of ataxia, rapidly progressive hearing loss, and vomiting. The illness was preceded by intermittent attacks of red eyes and photophobia for several months. Six weeks after the onset of the ataxia she developed polyarthritis affecting knees, hips, wrists, and finger joints. The joint disease resembled juvenile rheumatoid arthritis but without rash, fever, lymphadenopathy, or splenomegaly. During the course of her illness she developed a haemorrhagic polychondritis of the pinnae of both ears leading to considerable destruction of the cartilage and a vasculitic rash on her buttocks that was initially haemorrhagic, then ulcerated, and was slow to heal.At the most active stage of her illness she had a mild increase of both neutrophils (8 7 X 1 09/1), and lymphocytes (6-2X Computed tomography and magnetic resonance imaging of the brain showed no structural lesion. A slit lamp examination of the eyes showed bilateral interstitial keratitis. Pure tone audiometry (using a Kamplex audiometer fully masked in a sound proofed room) showed a 90 decibel (dB) loss in the left ear and 100-110 dB loss in the right ear. The hearing loss was sensorineural.Cogan's syndrome was diagnosed on the basis of the interstitial keratitis and vestibuloauditory dysfunction in the absence of syphilis.Initially she was given a number of nonsteroidal anti-inflammatory drugs including ibuprofen and naproxen with little benefit. A dramatic improvement was obtained with steroids. Her balance, polychondritis, vasculitis, ocular, and joint symptoms improved but deafness persisted necessitating the use of bilateral hearing aids.She has been on prednisolone 5 mg on alternate days for 24 months. Any attempt to reduce this dose has been associated with a recurrence in joint pain and stiffness, polychondritis and the vasculitic rash. There has been no improvement in the hearing loss. Her ability to wear hearing aids is impaired by the destruction of ear cartilage. DiscussionUsing Cogan's original criteria,l Vollertsen et al reviewed all the cases reported in the English literature to date (78 cases).5 In this series the median ...