Background and Aims: Central venous catheterization is a frequently performed procedure in anesthesia and critical care, and is indispensable in the practice of emergency medicine. Correct positioning of the central venous catheter (CVC) tip is often regarded as a secondary goal and there are various complications that can occur due to abnormal position of the catheter tip. Different methods have been advocated to guide accurate prediction of optimal CVC depth insertion before or during the procedure at the bedside. Material and Methods: A prospective randomized double blinded study was conducted in 180 patients aged between 18 to 65 years requiring central venous catheterization. The optimal depth of insertion of right internal jugular vein (IJV) catheter using three different techniques, Peres' formula method, Landmark technique and Intra atrial Electrocardiography (ECG) guided technique was performed and the three techniques were compared with respect to optimal positioning using carina as a landmark in post procedural chest radiograph. Correct position of the catheter tip was considered upto 1 cm above or below the carina in post procedure X ray. Results: The average final depth of insertion was 15.30 ± 0.62 cms in the Formula group, 12.74 ± 0.77 cms in landmark group and 12.64 ± 0.70 cms in ECG group. The vertical distance from carina was 0.91 ± 0.94 cms in formula group, 0.54 ± 0.67 cms in landmark group and 0.53 ± 0.43 cms in ECG group. The CVC tip was properly positioned within 1 cm above and below the carina in 58.33% patients in the formula group, 93.33% patients in landmark group and 96.67% patients in ECG group. Conclusion: We conclude that both landmark guidance and ECG guidance are comparable with regard to accurate central venous catheter tip positioning when CVCs are placed through right internal jugular vein whereas formula based technique is least accurate and results in over insertion of CVCs.

Introduction During vascular anastomosis the kidney graft slowly gain temperature and becomes warm. Regional hypothermia is shown to be effective to reduce rewarming of the kidney during robotic assisted laparoscopic kidney transplantation (RKT). Currently there is no study available to compare impact of regional hypothermia versus no hypothermia during RKT. Here we present data of RKT with and without regional hypothermia. Material and methods RKT was carried out in 100 patients; the first 50 cases had regional hypothermia and later 50 cases did not have hypothermia. Regional hypothermia was created by introducing 250-300 ml of ice slush around the kidney before carrying out vascular anastomosis. Body surface warming was carried out in all cases of regional hypothermia. Living donor kidney with single renal artery and vein was used in all cases. Results No case was converted to open operation. Longer anastomosis time and operative time in initial 50 cases represents learning curve of RKT.No delayed graft function was observed in any case and graft function was measured in terms of serum creatinine. (Figure-1). At 3 years there was no difference in graft and patient survival in either group (Figure-2a and 2b). Three patients in regional hypothermia group developed severe systemic hypothermia (temp. 94 degree F) and needed extubation in intensive care unit 6-12 hours after completion of surgery. Conclusion Regional hypothermia using ice slush may be useful during learning of RKT; however, once anastomosis time is reduced to less than 40 minutes, outcome of RKT without reginal hypothermia are similar to RKT with regional hypothermia. Severe systemic hypothermia may occur and intra-operative warming is required in patients subjected to regional hypothermia.

The Journal is the primary organ of Continuing Paediatric Medical Education in Sri Lanka. The journal also has a website. Free full text access is available for all readers.The Sri Lanka Journal of Child Health is now indexed in SciVerse Scopus (Source Record ID 19900193609), Index Medicus for South-East Asia Region (IMSEAR), CABI (Centre for Agriculture and Bioscience International Global Health Database), DOAJ and is available in Google, as well as Google Scholar.The policies of the journal are modelled on the Committee on Publication Ethics (COPE) Guidelines on Principles of Transparency and Best Practice in Scholarly Publishing. Sri Lanka Journal of Child Health is recognised by the International Committee of Medical Journal Editors (ICMJE) as a publication following the ICMJE Recommendations.

Keloids are benign fibroproliferative tumors of the skin which commonly occur after injury mainly in darker skinned patients. Medical treatment is fraught with high recurrence rates mainly because of an incomplete understanding of the biological mechanisms that lead to keloids. The purpose of this project was to examine keloid pathogenesis from the epigenome perspective of DNA methylation. Genome-wide profiling used the Infinium HumanMethylation450 BeadChip to interrogate DNA from 6 fresh keloid and 6 normal skin samples from 12 anonymous donors. A 3-tiered approach was used to call out genes most differentially methylated between keloid and normal. When compared to normal, of the 685 differentially methylated CpGs at Tier 3, 510 were hypomethylated and 175 were hypermethylated with 190 CpGs in promoter and 495 in nonpromoter regions. The 190 promoter region CpGs corresponded to 152 genes: 96 (63%) were hypomethylated and 56 (37%) hypermethylated. This exploratory genome-wide scan of the keloid methylome highlights a predominance of hypomethylated genomic landscapes, favoring nonpromoter regions. DNA methylation, as an additional mechanism for gene regulation in keloid pathogenesis, holds potential for novel treatments that reverse deleterious epigenetic changes. As an alternative mechanism for regulating genes, epigenetics may explain why gene mutations alone do not provide definitive mechanisms for keloid formation.

Perianal fistula is a common manifestation of Crohn's disease. Adenocarcinoma arising from perianal fistulae in patients with Crohn’s disease is rare. There are only 65 cases in English literature with anorectal adenocarcinoma arising from a perianal fistula in patients with Crohn's disease reported from January 1946 until September 2009. We present a case of 44 year old male diagnosed with Crohn’s disease in 2012. Patient presented with worsening perirectal fistulas and posterior anal mass in 2014. Biopsy of posterior anal mass and right lateral anal margin, revealed mucinous adenocarcinoma. Given the findings of a perianal adenocarcinoma and extensive perianal Crohn’s disease, the patient underwent neoadjuvant treatment, followed by abdominoperineal resection. Tumor size was 4.0 cm, estimated, as a discreet mass was not seen. This moderately differentiated adenocarcinoma was arising from the lining of the perianal fistulae tracts. The malignant cells and mucinous pools were diffusely involving the anal canal and part of the perianal fibroadipose tissue. The tumor demonstrated irregularly shaped tubules lined by cells with basally located, uniform, and hyperchromatic nuclei with abundant mucinous cytoplasm. The positive staining with CK20 and CDX2 in the tumor cells by immunohistochemistry suggests that tumor originated from colonic epithelium lining the fistula tracts. This case is unusual because of the very short duration between the first time diagnosis of Crohn's disease and development of adenocarcinoma in the perianal fistula tracts.

We present a unique case of diffusely extensive Chronic Inflammatory Demyelinating Polyneuropathy (CIDP). Typically affecting the peripheral nervous system and manifesting with muscle weakness, breakdown or paresthesia, we present a case that additionally demonstrates; cranial nerve involvement, central nervous system parenchymal lesions, and chronic osseous remodeling of the nerve tracts. Cranial nerve involvement to this extent has only been described in one other case report to our knowledge. Central nervous system parenchymal lesions are extremely rare in CIDP and no discrete discussion about osseous remodeling has been presented, thus far, in the literature. The findings illustrated in this case may spur further understanding of imaging characteristics most associated with chronic CIDP disease and care measures that could help stratify patients most at risk for severe symptomologies.

BACKGROUND AND AIMS:Minimal consumption of local anesthetic and opioid for epidural labor analgesia has been advocated for safe obstetric outcome and superior maternal satisfaction. The primary objective of this study was to evaluate and compare the analgesic efficacy of mode of administration of epidural 0.1% ropivacaine with 0.0002% fentanyl via continuous infusion or intermittent boluses during labor.MATERIAL AND METHODS:Sixty term primi or second gravida healthy parturients in labor requesting epidural analgesia were recruited in this study. Lumbar epidural catheter was inserted, and analgesia initiated with 0.2% ropivacaine. Patients were randomized to receive ropivacaine 0.1% with fentanyl 0.0002% via either continuous infusion (Group A) or intermittent boluses (Group B) on an hourly basis. If the parturient complained of pain and visual analog scale (VAS) score was >3, an additional bolus of the study drug was given. VAS score, motor blockade, maternal hemodynamics and fetal heart sounds were frequently monitored. Side effects, mode of delivery and neonatal outcome were noted.RESULTS:To achieve similar VAS, the mean total dose of ropivacaine was 18.78 ± 3.88 mg in Group A and 16.86 ± 4.3 mg in Group B, the difference being statistically significant (P = 0.04). Seventeen out of 30 patients in Group A that is, 56.6% and nine patients in Group B that is, 30% required additional top-ups, and this was significantly higher (P = 0.037). Side effects, mode of delivery and neonatal outcome were comparable in both groups.CONCLUSION:Intermittent bolus administration provides a more efficacious route of drug delivery when compared to continuous infusion by significantly decreasing the total amount of local anesthetic plus opioid without adversely affecting patient safety or maternal satisfaction.

Since the first laparoscopic nephrectomy was reported in 1991, this technique has evolved rapidly and laparoscopic donor nephrectomy has emerged as a standard of care in many institutions. However, recipient renal transplantation is still performed by the traditional open approach. There is only one case report of laparoscopic kidney transplantation (LKT) from Spain in 2009. LKT is a technically demanding surgery for a urologist and equally challenging for an anesthesiologist as he has to be vigilant because of the major perturbations in the cardiorespiratory system due to steep trendelenberg position and pneumoperitoneum; additionally, the pneumoperitoneum can have deleterious effects on blood flow and function of the transplanted kidney. We herewith present our experience with anesthesia of the first laparoscopic dual kidney transplantation from a deceased donor performed in our center.

Objective: To summarize the experience of perioperative hemodynamic changes and recovery profile during laparoscopic versus open adrenalectomy for pheochromocytoma Design: Retrospective study Settings: Department of Anesthesia and Critical Care and Department of Urology, IKDRC and ITS, Ahmedabad, India Subjects: Twenty-eight patients who underwent lap aroscopic surgery were compared to fifteen patients who underwent open surgery under general anesthesia Interventions: Open or laparoscopic adrenalectomy Main Outcome Measures: Preoperative medical history and therapy, intraoperative hemodynamic data, blood loss and postoperative outcome Results: Preoperative therapy with alpha-adrenergic blockers was comparable in both the groups. There was conversion to the open procedure in three patients in the laparoscopic surgery group. A comparison between the open and laparoscopic procedures did not show any significant difference between the maximum intraoperative systolic blood pressure (p = 0.232) and heart rate (p = 0.729) values although intraoperative blood pressure peaks were seen more frequently during laparoscopic adrenalectomy (17 patients [60.7%]) as compared to six (40%) of the open group). The operative time, intraoperative blood transfusion and perioperative morbidity did not differ significantly between the two groups (p > 0.05). 10% of patients in the laparoscopic group required rescue analgesia. Length of postoperative hospital stay was shorter in the laparoscopic group as compared to open surgery and the difference was statistically significant (p = 0.0001). Conclusion: The intraoperative hemodynamic stability was comparable in open as well as lap aroscopic adrenalectomy for pheochromocytoma. Patients who underwent lap aroscopic surgery required lesser postoperative analgesia and had a faster postoperative recovery. Therefore, the laparoscopic approach is better.

A tissue field of somatic genetic alterations precedes the histopathological phenotypic changes of carcinoma. Genomic changes could be of potential use in the diagnosis and prognosis of pre-invasive squamous head and neck carcinoma (HNSCC) lesions and as markers for cancer risk assessment. Studies of sequential molecular alterations and genetic progression of pre-invasive HNSCC have not been clearly defined. Studies have shown recurring alterations at chromosome 9p21 (location of the CDKN2A) and TP53 mutations in the early stages of HNSCC. However, gene silencing via hypermethylation is still a relatively new idea in the development of HNSCC and little is known about the contribution of epigenetics to the development of neoplasia, its transformation, progression, and recurrence in HNSCC. This review examines the role of promoter hypermethylation of tumor suppressor genes in the progression continuum from benign papillomas to malignancy in HNSCC.

1. Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth 2005;94:7‐17. 2. Sites BD, Gallagher JD, Cravero J, Lundberg J, Blike G. The learning curve associated with a simulated ultrasound‐guided interventional task by inexperienced anesthesia residents. Reg Anesth Pain Med 2004;29:544‐8. 3. Emergency ultrasound guidelines. Approved by the ACEP Board of Directors, June 1, 2001. Available from: http://www. acep.org/NR/rdonlyres/8024079E‐28E8‐4875‐93E6‐6867EA70 5A2A/0/ultrasound_guidelines.pdf. 4. Minimum training guidelines. European Federation of Societies for Ultrasound in Medicine and Biology. Available from: http://www.efsumb.org/efsumb/Guidelines/list.htm. Accessed August 11, 2013. 5. Sites BD, Chan VW, Neal JM, Weller R, Grau T, Koscielniak‐Nielsen ZJ, Ivani G; American Society of Regional Anesthesia and Pain Medicine; European Society Of Regional Anaesthesia and Pain Therapy Joint Committee. The American Society of Regional Anesthesia and Pain Medicine and the European Society Of Regional Anaesthesia and Pain Therapy Joint Committee recommendations for education and training in ultrasound‐guided regional anesthesia. Reg Anesth Pain Med 2009;34:40‐6.

Introduction: Pyogenic granuloma (PG) or granuloma pyogenicum is essentially a capillary hemangioma on the skin or a mucosal surface which shows an exophytic growth pattern and has a lobulated appearance. The most common sites are skin (40%) and mucosal surfaces (predominantly oral cavity, 60%). We intend to report all available cases of PG of gastrointestinal (GI) tract, diagnosed at the Henry Ford hospital, a tertiary referral center. Patients and Methods: A retrospective review of pathological database was performed on all GI biopsies in the last 10 years using diagnostic codes and pathology codes searching for PG of the GI tract. Results: A total of 23 cases of pathologically diagnosed PG was diagnosed over a 10 year period. The median age of patients was 64 with almost equal gender distribution (47.8% were males, and 52.2% were females). The most common location of PG was sigmoid colon (65.2%), esophagus (17.4%) and transverse colon (13%). PG presented as a polyp in 16 patients (69.6%). The most common indication for endoscopy in these cases was screening colonoscopy (30.4% cases). Discussion: PG of GI tract is rare. To date, only about 15–20 cases have been reported in the literature and most cases have been reported from Japan and Korea. This is the largest case series of this rare pathological lesion of the GI tract. Most cases of PG were diagnosed on an endoscopy done for an unrelated reason in our series. Hence, most cases were asymptomatic, unlike previously reported cases which were mostly associated with GI bleeding.

Reversal of pregnancy induced immunosuppression may also have added to the hyper inflammatory responses in the present case there by worsening the clinical symptoms.[5] Isolation of tubercle bacilli from the cultures after excluding treatment failure, drug resistance, underlying new infection and drug hypersensitivity correlated with development of this syndrome. Interestingly, the features of IRIS manifested at an earlier stage as well following initiation of ATT.