Head Ring Research Articles

TO EVALUATE THE ACCURACY OF PRE-OPERATIVE DIGITAL TEMPLATING IN FINDING THE PROBABALE FEMORAL HEAD SIZE TO THAT OF ACTUAL INTRAOPERATIVE SIZE IN BIPOLAR HEMIARTHROPLASTY OF HIP.

Purpose: To evaluate the accuracy of pre-operative digital templating in nding the probable femoral head size to that of actual intra-operative size in bipolar hemiarthroplasty of hip. After obtaining ethical committee clearanc Methods: e, 33 patients were included in the study who met the Inclusion criteria. They were subjected to pre operative X rays using a 5 Rupee coin as a reference template. The actual Femoral head size calculated intra-operatively using the head ring template was then compared to that of the probable head size derived as per formula. The study period was for 1 year and it was a prospective study. Pearson correlation r value Results: is .755; p<0.05 which indicates there is positive correlation between B1 Actual size of the Femoral head in cm with Formula value. Pearson correlation r value is .961; p<0.05 which indicates there is highly positive correlation between B1 Actual size of the Femoral head in cm with B2 Radiographic size of Femoral head in cm. Conclusion: This method is a convenient and practical method of scaling magnication which can be applied in everyday X-ray procedures. The current results support the hypothesis that this method enables accurate templating with digital X-rays.

Anesthesia mumps with airway obstruction after radical nephrectomy: A case report and literature review.

Anesthesia mumps have rarely been reported. This article presents the diagnosis and treatment of a case of anesthesia mumps with airway obstruction in the urology department and reviews previous cases of the disease. A 58-year-old man had a history of hypertension and diabetes, and his blood pressure and glucose levels were well controlled. He underwent laparoscopic radical nephrectomy for a right renal tumor. Postoperatively, a swelling of approximately 5 × 4 cm was observed in the left parotid region and left eyelid, no palpable crepitation was detected, and the skin overlying the left parotid gland was mildly hyperemic and tender. Enhanced computed tomography of the head and neck revealed obvious swelling of the laryngopharyngeal airway, and electronic laryngoscopy showed narrow airway. Laboratory test results including white blood cell count, C-reactive protein, serum amylase, and lipase levels were normal. Glycosylated hemoglobin level was 6.8%, and the salivary culture from Stensen's duct was negative. The patient was managed with endotracheal intubation and a ventilator to maintain breathing along with anti-infection, expectorant, and symptomatic treatment. The swelling in the left parotid gland gradually resolved without recurrence, and the patient was extubated on the 7th postoperative day. In this case, the pathophysiology of anesthesia mumps may have been related to the incorrect positioning of the thick short neck and the use of a head ring, which can result in the squeezing of vessels. In most cases, the salivary gland swelling resolves with observation and symptomatic treatment. In patients with anesthesia mumps, emergency airway management and careful observation are necessary if upper airway obstruction occurs. This case report should increase awareness of anesthesia mumps and its complications among anesthesiologists, surgeons, and postoperative caregivers.

Pressure ulcers in patients with COVID-19 acute respiratory distress syndrome undergoing prone positioning in the intensive care unit: A pre- and post-intervention study.

Prone positioning has been widely used to improve oxygenation and reduce ventilator-induced lung injury in patients with severe COVID-19 acute respiratory distress syndrome (ARDS). One major complication associated with prone positioning is the development of pressure ulcers (PUs). This study aimed to determine the impact of a prevention care bundle on the incidence of PUs in patients with COVID-19 ARDS undergoing prone positioning in the intensive care unit. This was a single-centre pre and post-test intervention study which adheres to the Standards for Reporting Implementation Studies (StaRI) guidelines. The intervention included a care bundle addressing the following: increasing frequency of head turns, use of an open gel head ring, application of prophylactic dressings to bony prominences, use of a pressure redistribution air mattress, education of staff in the early identification of evolving PUs through regular and rigorous skin inspection and engaging in bedside training sessions with nursing and medical staff. The primary outcome of interest was the incidence of PU development. The secondary outcomes of interest were severity of PU development and the anatomical location of the PUs. In the pre-intervention study, 20 patients were included and 80% (n= 16) of these patients developed PUs, comprising 34 ulcers in total. In the post-intervention study, a further 20 patients were included and 60% (n= 12) of these patients developed PUs, comprising 32 ulcers in total. This marks a 25% reduction in the number of patients developing a PU, and a 6% decrease in the total number of PUs observed. Grade II PUs were the most prevalent in both study groups (65%, n= 22; 88%, n= 28, respectively). In the post-intervention study, there was a reduction in the incidence of grade III and deep tissue injuries (pre-intervention 6%, n= 2 grade III, 6% n= 2 deep tissue injuries; post-intervention no grade III ulcers, grade IV ulcers, or deep tissues injuries were recorded). However, there was an increase in the number of unstageable PUs in the post-intervention group with 6% (n= 2) of PUs being classified as unstageable, meanwhile there were no unstageable PUs in the pre-intervention group. This is an important finding to consider as unstageable PUs can indicate deep tissue damage and therefore need to be considered alongside PUs of a more severe grade (grade III, grade IV, and deep tissue injuries). The use of a new evidence-based care bundle for the prevention of PUs in the management of patients in the prone position has the potential to reduce the incidence of PU development. Although improvements were observed following alterations to standard practice, further research is needed to validate these findings. The use of a new, evidence-based care bundle in the management of patients in the prone position has the potential to reduce the incidence of PUs.

FEA Analysis and Experimental Investigation of the Ceramic Coating on Aluminum Piston Material By Plasma Spray Coating Technique

Abstract: Functionally graded materials are of widespread interest because of their superior properties such as corrosion, erosion and oxidation resistance, high hardness, chemical and thermal stability at cryogenic and high temperatures. These properties make them useful for many applications, including Thermal Barrier Coating (TBC) on metallic substrates used at high temperatures in the fields of aircraft and aerospace, especially for thermal protection of components in gas turbines and diesel engines. The application of TBC reduces the heat loss to the engine cooling-jacket through the surface exposed to the heat transfer such as the cylinder head, liner, piston crown and piston rings. The insulation of the combustion chamber with ceramic coating affects the combustion process and, hence, the performance and exhaust emissions characteristics of the engines improve. In this project, the main emphasis is placed on the study of thermal behavior of functionally graded coatings obtained by means of using a commercial code, ANSYS on aluminum and steel piston surfaces and the results are verified with numerical and experimental works. Keywords: Thermal Barrier Coating, Piston, Insulation, Corrosion, ANSYS, engine cooling-jacket.

Study on Fracture Assessment for BWR Reactor Pressure Vessel Steel by GTN model

In the JSME fitness-for service code, fracture evaluation methodology based on linear elastic fracture mechanics is provided for reactor pressure vessel (RPV) components by considering brittle fracture due to neutron irradiation in the RPV beltline region. However, in order to make a rational fracture evaluation for the RPV component such as bottom head component of boiling water reactor (BWR), where irradiation embrittlement is not concerned, it is necessary to consider the applicability of the ductile fracture evaluation methodology consistent with material fracture behavior. In this study, the applicability of the damage mechanics analysis method using Gurson-Tvergaard-Needleman (GTN) model, which is a numerical analysis method for ductile failure, was investigated for RPV bottom head component. Mechanical properties tests and fracture tests with plate specimens were performed using RPV law alloy steel (LAS) material. GTN model parameters of RPV LAS material that can reproduce stress-strain curve and load-displacement curve were determined. Fracture analyses of the plate specimens were performed using determined parameters as well. The load-Crack Mouth Opening Displacement (CMOD) curves and fracture behavior of the fracture tests were compared with the analyses results. The analyses predicted the maximum loads of the tests within an error of 4% and the fracture behavior between the tests and analyses was consistent. The results in this study clearly supported the applicability of the GTN model to RPV bottom head ring component.

Nova metoda določanja velikosti obraza v tridimenzionalni fotogrametriji

Contemporary craniofacial surgery includes the pre- and post-operative optical 3D scanning of faces as a method for diagnosing and verifying the achieved results. The influence of head size in 3D scans must be excluded in order to accurately and uniformly compare different three-dimensional facial shapes in craniofacial surgery. Regarding this purpose, different head-size parameters must be measured to obtain the scaling factor. A special device, a so-called head ring, has been produced as a structure that can be fixed to a person’s head. Among defined points, different linear distances (head width, length and height) and volumetric parameters (lower and upper head volumes) were calculated and compared to body-size measurements. Measurements were performed on 3D scans of the heads of 26 healthy adults with normocclusion (12 men and 14 women) taken using the head ring set. Body mass index (BMI) statistically significantly correlates with the lower and whole-head volume in men, while in women more precisely with the upper-head volume. BMI in men does not correlate with any linear distance, while in women it is closely connected to the facial width. In men the head width and lower head volume are the main contributors to head size, while in women the crown-to-chin length and upper volume determine the size of the head. A conclusion can be made that the correlation between the head volume, the BMI and the linear head parameters exists and is gender dependent.

Computer Simulation Research on Flow Field of SRM High Altitude Simulation Test

The simulation test of passive ejection type high-altitude solid rocket motor (SRM) was simulated by computer. For SRM passive ejector type high-altitude test, the tempering in the process of engine ignition and flameout poses a serious threat to the nozzle of the engine test device and circuit arrangement in the upper compartment. Using the N-S equation and Spalart-Allmaras model: numerical simulation on the flow structure of engine pressurize, decompression and stratochamber air phase in the testing process, and flow field of the diffuser and the cabin altitude simulation, analyzing the flow field structure of high-altitude experiment stages. The results showed the rough coincidence between the simulation curve and the measured data, with slight difference at the initial stage of air supply, the measured data and the simulation data reach the overall high degree of coincidence. During the process of building a compression and decompression, the adiabatic measures should be taken to prevent high temperature gas from damaging the engine, especially the nozzle and the head ring, in addition, the reasonable design of the nozzle contour surface can control gas separation tempering, reducing the influence caused by tempering. Stability of the flow field in the high altitude chamber of the pressure will not affect the engine.

Stigmatopora harastii, a new species of pipefish in facultative associations with finger sponges and red algae from New South Wales, Australia (Teleostei, Syngnathidae).

A new species of pipefish, Stigmatopora harastiisp. nov., is described based on the male holotype and two female paratypes, 136.3–145.5 mm SL, collected from red algae (sp.?) at 12 meters depth in Botany Bay, New South Wales (NSW), Australia. The new taxon shares morphological synapomorphies with the previously described members of Stigmatopora, including principle body ridges, fin placement, slender tail, and absence of a caudal fin. It is morphologically and meristically similar to Stigmatopora nigra, including snout length and shape, dorsal-fin origin on 6th–7th trunk ring, and lateral trunk ridge terminating on the first tail ring. Stigmatopora harastiisp. nov. is distinguished from its congeners, however, by characters of the head and first trunk ring, distinct sexual dimorphic markings on sides and venter of anterior trunk rings, and red background coloration in life. The new taxon can be further differentiated by genetic divergence in the mitochondrial COI gene (uncorrected p-distances of 9.8%, 10.1%, 10.7%, and 14.6%, from S. argus, S. macropterygia, S. narinosa, and S. nigra, respectively). The type locality is characterised by semi-exposed deep-water sandy areas interspersed with boulders, flat reefs, and an absence of seagrass beds, in which S. harastii has been observed living in facultative associations with a finger sponge and red algae at depths of 10–25 meters, compared to the shallow coastal and estuarine habitats preferred by the fucoid algae and seagrass-associating members of Stigmatopora. Stigmatopora harastiisp. nov. represents the fourth species of Stigmatopora recorded in temperate southern Australia.

Rigid Cranial Fixation for Robot-Assisted Stereoelectroencephalography in Toddlers: Technical Considerations.

Stereoelectroencephalography (sEEG) using depth electrodes has become a mainstay of pediatric epilepsy surgery. This technique relies on rigid cranial fixation using skull pins, which forms the basis for accurate stereotactic navigation. The use of cranial fixation pins poses the threat of traumatic skull injuries in young children because of inadequate cranial bone thickness. To describe a rigid cranial fixation technique involving the integrated Gel Head Ring from the DORO QR3 multipurpose skull clamp set (Pro Med Instruments) with superimposed pin fixation in children below the age of 36 mo undergoing sEEG. Patients were placed in the supine position and the head was fixed using a DORO skull clamp with 3 pediatric cranial pins. The head was supported on the integrated Gel Head Ring, and a pin pressure of 20 pounds was applied. The DORO skull clamp set was then attached to the ROSA neurosurgical robot support telescopic arm for stereotactic navigation. We present an illustrative series of 2 patients below the age of 3 yr with medicallyrefractory epilepsy who underwent sEEG using our modified cranial fixation technique. Head position and reference registration were stable throughout the surgeries. Postoperative volumetric computed tomography scans of the head showed accurate placement of sEEG depth electrodes and did not reveal any fractures or epidural hematoma. No other complications related to cranial fixation were noted. Concurrent use of rigid and nonrigid cranial fixation using the DORO skull clamp set provides safe and effective cranial fixation in infants and toddlers undergoing sEEG.

The Additive Manufacturing Process of Electric Power Fittings Fabricated by Metal Droplet Deposition

Metal droplet deposition is a kind of additive manufacturing (3D Printing) technique that fabricates near-net part through droplets deposition with lower cost and higher efficiency. This paper proposed a solution to problems of electric power fittings that large inventories, high procurement costs, low manufacturing efficiency and transportation cost. Using additive Manufacturing technique - metal droplet deposition, electric power fittings fabricated on power construction site. This paper describes the manufacturing process of typical thin-walled samples (the structure optimized based on additive manufacturing principle) and ball head rings of electric power fittings. Aiming at the integral AM forming for ball and ball socket electric power fitting workpiece, a novel easy removal forming support material (ceramics and gypsum mixed with UV cured resin) have been developed. Here this support material was used to fabricate nested integral workpieces. Dimensional accuracy and microstructure of the test pieces were analyzed. The error of the height and width of the forming workpiece is within 5%. No obvious overlap trace (such as overlap line and cracks) observed, and the internal microstructure is equiaxial crystal. The average density of the component is 99.51%, which measured by drainage method and 13.39% higher than the cast raw material.

Comparing the Ease of Mask Ventilation, Laryngoscopy, and Intubation in Supine and Lateral Position in Infants with Meningomyelocele.

Background:The biggest anesthetic challenge in infants with thoracolumbar /sacral meningomyelocele is securing the airway. For securing the airway, most of the anesthesiologist's practices supine position with doughnut or head ring placed around the swelling to prevent rupture, which has got disadvantages like risk of rupture, infection and damage to neural structure. Left lateral position has been recommended previously for tracheal intubation in post-tonsillectomy hemorrhage. Several studies have shown successful ventilation in lateral position using laryngeal mask airway and intubation using video laryngoscopes.Aims and Objectives:Primary objective is to compare the time taken for intubation, number of attempts required for intubation. Secondary objective is to compare ease of mask ventilation, Cormack Lehane grading and Backwards Upward Rightwards Pressure [BURP] manoeuvre.Materials and Methods:A comparative, prospective randomized, controlled trial of 60 infants undergoing thoracolumbar/sacral meningomylocele repair. Infants were allocated to one of two groups of 30 patients each, by computer-generated randomization into Group S: mask ventilation, laryngoscopy and intubation in supine position and Group L: mask ventilation, laryngoscopy and intubation in lateral position.Statistical Methods:Chi-square/Fisher Exact test was used to find the significance of study parameters on categorical scale between two or more groups.Results:Mean intubation time of sixteen seconds were clinically acceptable and comparable in each of the two positions P = 0.145. Ten patients in the left lateral position, eight patients in the supine position required second intubation attempts before the airway was secured. Only 8.3% of our patients required third intubation attempts.Conclusion:Anesthesiologist should pay more attention to the safety and quality of mask ventilation, laryngoscopy and intubation in meningomylocele infants. Both supine and lateral position were comparable.

Towards frameless maskless SRS through real-time 6DoF robotic motion compensation

Stereotactic radiosurgery (SRS) uses precise dose placement to treat conditions of the CNS. Frame-based SRS uses a metal head ring fixed to the patient’s skull to provide high treatment accuracy, but patient comfort and clinical workflow may suffer. Frameless SRS, while potentially more convenient, may increase uncertainty of treatment accuracy and be physiologically confining to some patients. By incorporating highly precise robotics and advanced software algorithms into frameless treatments, we present a novel frameless and maskless SRS system where a robot provides real-time 6DoF head motion stabilization allowing positional accuracies to match or exceed those of traditional frame-based SRS. A 6DoF parallel kinematics robot was developed and integrated with a real-time infrared camera in a closed loop configuration. A novel compensation algorithm was developed based on an iterative closest-path correction approach. The robotic SRS system was tested on six volunteers, whose motion was monitored and compensated for in real-time over 15 min simulated treatments. The system’s effectiveness in maintaining the target’s 6DoF position within preset thresholds was determined by comparing volunteer head motion with and without compensation. Comparing corrected and uncorrected motion, the 6DoF robotic system showed an overall improvement factor of 21 in terms of maintaining target position within 0.5 mm and 0.5 degree thresholds. Although the system’s effectiveness varied among the volunteers examined, for all volunteers tested the target position remained within the preset tolerances 99.0% of the time when robotic stabilization was used, compared to 4.7% without robotic stabilization. The pre-clinical robotic SRS compensation system was found to be effective at responding to sub-millimeter and sub-degree cranial motions for all volunteers examined. The system’s success with volunteers has demonstrated its capability for implementation with frameless and maskless SRS treatments, potentially able to achieve the same or better treatment accuracies compared to traditional frame-based approaches.

Research on the manufacturing of electrical power fittings based on metal droplet deposition

Molten metal droplets deposition is an additive process in which parts are produced from molten materials in a single operation without the use of any mold or other tooling. Near-net shaped parts are fabricated by sequentially depositing molten droplets layer by layer. For larger inventories, higher purchase cost, and lower production efficiency of Electrical power fittings now; this paper puts forward an innovation method to manufacture Electrical power fittings using the process of metal droplet deposition, meeting the needs of electrical repairs, while reducing installation costs and achieving zero inventories. In accordance with the structure features, through reasonable selection of process parameters, the typical thin-walled parts and ball head rings of Electrical power fittings were realized; meanwhile, microstructure analysis and performance tests of the parts were carried out. The result showed that the structures were reasonable and the mechanical properties were excellent. The works should be helpful for the process optimization and non-destructive detection of drop-based rapid prototyping techniques.

A Randomized Study Comparing the Sniffing Position with Simple Head Extension for Glottis Visualization and Difficulty in Intubation during Direct Laryngoscopy.

Background:Proper positioning of the head and neck is important for an optimal laryngeal visualization. Traditionally, sniffing position (SP) is recommended to provide a superior glottic visualization, during direct laryngoscopy, enhancing the ease of intubation. Various studies in the last decade of this belief have challenged the need for sniffing position during intubation. We conducted a prospective study comparing the sniffing head position with simple head extension to study the laryngoscopic view and intubation difficulty during direct laryngoscopy.Materials and Methods:Five-hundred patients were included in this study and randomly distributed to SP or simple head extension. In the sniffing group, an incompressible head ring was placed under the head to raise its height by 7 cm from the neutral plane followed by maximal extension of the head. In the simple extension group, no headrest was placed under the head; however, maximal head extension was given at the time of laryngoscopy. Various factors as ability to mask ventilate, laryngoscopic visualization, intubation difficulty, and posture of the anesthesiologist during laryngoscopy and tracheal intubation were noted. In the incidence of difficult laryngoscopy (Cormack Grade III and IV), Intubation Difficulty Scale (IDS score) was compared between the two groups.Results:There was no significant difference between two groups in Cormack grades. The IDS score differed significantly between sniffing group and simple extension group (P = 0.000) with an increased difficulty during intubation in the simple head extension. Patients with simple head extension needed more lifting force, increased use of external laryngeal manipulation, and an increased use of alternate techniques during intubation when compared to SP.Conclusion:We conclude that compared to the simple head extension position, the SP should be used as a standard head position for intubation attempts under general anesthesia.

A preplanning method for stereotactic radiosurgery to improve treatment workflow.

Frame‐based stereotactic radiosurgery (SRS) requires fixation of an invasive head ring to ensure accurate targeting. Minimizing waiting time with a fixed head ring is important for patient comfort and satisfaction. We report a practical preplanning solution for the Brainlab iPlan treatment planning system that reduces waiting time by expediting the planning process on treatment day. A water‐filled anthropomorphic head phantom was used to acquire a surrogate CT image set for preplanning and fused with patient's MRI, which was obtained before the day of treatment. Once an acceptable preplan was obtained, it was saved as a plan template and the phantom image set was removed from the Brainlab database to prevent any confusion and mix‐up of image sets. On the treatment day, the patient's CT and MRI were fused, and the customized beam settings of the preplan template were then applied and optimized. Up to 10‐fold of reduction in treatment plan time was demonstrated by bench testing with multiple planners and a variety of cases. Loading the plan template and fine‐tuning the preconfigured beam settings took only a small fraction of the preplan time to restore the conformity and dose falloff comparable to those of the preplan. For instance, preplan time was 2 hr for a two‐isocenter case, whereas, it took less than 20 min for a less experienced planner to plan it on the day of treatment using the preplan method. The SRS preplanning technique implemented in this study for the Brainlab iPlan treatment planning system offers an opportunity to explore possible beam configurations thoroughly, optimize planning parameters, resolve gantry angle clearance issues, and communicate and address challenges with physicians before the treatment day. Preplanning has been proven to improve plan quality and to improve efficiency in our clinic, especially for multiple‐isocenter and dosimetrically challenging cases.PACS number(s): 87.53.Ly, 87.55.D‐, 87.55.Gh, 87.55.tm

Setup uncertainties in linear accelerator based stereotactic radiosurgery and a derivation of the corresponding setup margin for treatment planning

PurposeIn the present study, clinical stereotactic radiosurgery (SRS) setup uncertainties from image-guidance data are analyzed, and the corresponding setup margin is estimated for treatment planning purposes. MethodsPatients undergoing single-fraction SRS at our institution were localized using invasive head ring or non-invasive thermoplastic masks. Setup discrepancies were obtained from an in-room x-ray patient position monitoring system. Post treatment re-planning using the measured setup errors was performed in order to estimate the individual target margins sufficient to compensate for the actual setup errors. The formula of setup margin for a general SRS patient population was derived by proposing a correlation between the three-dimensional setup error and the required minimal margin. ResultsSetup errors of 104 brain lesions were analyzed, in which 81 lesions were treated using an invasive head ring, and 23 were treated using non-invasive masks. In the mask cases with image guidance, the translational setup uncertainties achieved the same level as those in the head ring cases. Re-planning results showed that the margins for individual patients could be smaller than the clinical three-dimensional setup errors. The derivation of setup margin adequate to address the patient setup errors was demonstrated by using the arbitrary planning goal of treating 95% of the lesions with sufficient doses. ConclusionsWith image guidance, the patient setup accuracy of mask cases can be comparable to that of invasive head rings. The SRS setup margin can be derived for a patient population with the proposed margin formula to compensate for the institution-specific setup errors.

Use of Different Sizes of Head- Ring for Positioning During Induction of Anaesthesia in Paediatric Spine Surgeries.

Sir, Spinal surgeries are quite common in children of all age groups. Most of the spine surgeries are performed in the prone position. An anaesthetist faces most of the difficulties during induction of anaesthesia in a child with spinal mass as it is very difficult to maintain a proper supine position in these patients. There are various methods described in literature to handle such situations, but here we are describing an additional method to maintain supine position in these paediatric patients. In children, spinal surgery is required for a various underlying pathology like congenital defects, primary or metastatic tumours, haematomas, abscesses, trauma, arteriovenous malformations (AVMs) and herniated discs etc. Among these the neural tube defects and their associations (tethered cord, diastematomyelia, and syringomyelia) require surgery on the spinal cord. All spinal surgeries are done to correct or limit neurological deficit. Positioning during anaesthesia and monitoring, must take consideration of the associated medical problems and age-related pathophysiology. There are various methods to intubate a child with meningomyelocele or encephalocele. Intubation in these cases commonly performed in lateral decubitus position, or with the swelling supported by a doughnut, and even by placing the child’s head beyond the edge of the table, supported by an assistant [1]. But paediatric anaesthetists find it difficult to position a child with spine defects (e.g. meningomyelocele, spinal mass etc.,) optimally during induction of anaesthesia. They usually induce the patient either in lateral or supine position. The supine position is often maintained by placing gauze bandages under the patient. Here we are describing an additional method to maintain supine position during induction of anaesthesia in such patients. To get the proper supine position during induction of anaesthesia, we use either close or open head rings made up of soft material [Table/Fig-1]. We use them below the head and different parts of spine to accommodate the swelling [Table/Fig-2]. [Table/Fig-1]: Head rings of different shape and size. [Table/Fig-2]: Putting various size of rings underneath to maintain supine position. After intubation in the supine position, the patient was turned prone for the procedure. Particular attention should be given when placing a child in prone position to avoid life threatening complications [2]. Bolsters should be under the chest and pelvis to avoid abdominal compression otherwise it will impede ventilation, compress vena cava and increase epidural venous pressure and bleeding. Avoid extreme flexion of neck and pressure on the eyes. So, a safe and better anaesthetic management can be provided by understanding the pathophysiology and planning the anaesthetic technique accordingly. Hope our alternative technique used for positioning a child with spine defect could be useful to our colleagues.

General anaesthesia for parturients with spondyloepiphyseal dysplasia: Risky but possible!

Sir, A 28-year-old primigravida, 135 cm tall and a known case of spondyloepiphyseal dysplasia (SED), with 37 weeks of gestation, was scheduled for elective caesarean section. The patient was unable to walk and was wheelchair bound. The flexion deformity of the knee joint, as well as the hip joint, made it difficult for the patient to lie down straight [Figure 1]. In addition, she had flexion deformities of the elbow and wrist joints.Figure 1: Patient with fixed flexion deformities of the knee and hip jointsThe patient was the first child of her parents who had non-consanguineous marriage. The other siblings of the patient also had similar deformities. Patient's biochemical, haematological investigations, echocardiography and pulmonary function tests were unremarkable. The patient had limited neck movements but had modified Mallampati Airway Class 3. The patient's neck extension was two-thirds restricted and her mouth opening was about 40 mm. Other airway parameters were within normal limits. Examination of the spine revealed scoliosis, and intervertebral spaces were difficult to palpate. Radiographic examination (pre-pregnancy) revealed platyspondyly, reduced disc height as well as features of premature secondary arthritis in both hip joints [Figure 2]. She was unable to position herself for regional anaesthesia. The fixed flexion deformity of the knee prevented lateral supine positioning of the patient. She could sit with two pillows behind her back and a pillow below her knee, and slept in head-up position.Figure 2: X-ray of the hip joints showing early osteoarthritis resulting in fixed flexion deformityThe patient did not consent for regional anaesthesia. Hence, it was decided to conduct caesarean section under general anaesthesia. She was positioned with a pillow under the knees along with a wedge under the abdomen. The head was also supported on a head ring with two pillows below her head. Intravenous line was secured with an 18 gauge cannula and infusion of Ringer lactate was started. Routine monitors were connected and basal readings noted. Awake nasal fibre-optic intubation was performed with small size of endotracheal tube (ETT) using cuffed polyvinyl chloride 6.5 mm ETT uneventfully. The rest of the anaesthetic and post-operative period was uneventful. SED is an extremely rare genetic entity with incidence of 1–4 per million. Regional anaesthesia is the method of choice in parturients with SED although it is technically difficult and has variable effects. Administration of general anaesthesia in such patients is not without risks. The presence of kyphoscoliosis in SED may lead to significant respiratory compromise that gets exaggerated in pregnancy due to diaphragmatic splinting caused by gravid uterus.[1] Pregnancy further exaggerates the already existing respiratory compromise and enhances aortocaval compression. The presence of atlantoaxial instability due to odontoid hypoplasia, central anterior pointing of the cervical spine along with ligamentous laxity in SED may increase the risk of severe spinal cord compression. Tetraparesis has been reported after intubation in these patients due to cervical spine instability.[2] Pregnancy also poses an added risk for aspiration.[1] Patients with SED may have associated laryngotracheal stenosis, which may pose difficulty in airway management. There are reports of intubation being guided by lightwand.[3] Intubation with video laryngoscope could be another tangible alternative.[4] However, video laryngoscope was unavailable during intubation in the management of the present patient. Thus, patients with SED with pregnancy can pose a special challenge for the anaesthesiologist. However, while administering general anaesthesia, proper assessment and monitoring for cervical spine stability and respiratory status, positioning of the patient so as to prevent any untoward neurological injury and meticulous planning of airway management and perioperative care may go a long way in successful outcome. Declaration of Patient Consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgement We would like to acknowledge Dr. P. N. Gupta, Associate Professor, Department of Orthopaedics, Government Medical College and Hospital, Chandigarh, for his help.

Application of Halo-vest head ring in replantation of total scalp avulsion

To investigate the clinical effect of Halo-vest head ring in the treatment of replantation of total scalp avulsion. We treated 11 cases of total scalp avulsion with the anastomosis of arteriovenous vessels and Halo-vest head ring from December 2006 to February 2015. One patient's replanted scalp got necrosis because of serious contusion which was healed without hair growth after free skin graft and dressing. All the scalp flaps in the other 10 patients survived. After 3-96 months follow-up, the wound completely healed, the scalp and hair grew well with satisfactory appearance. The use of Halo-vest head ring for replantation of total scalp avulsion can effectively improve the survival rate and survival area.

Pharmacognostic evaluation of the leaves and stem bark of <i>Euphorbia lateriflora</i> schum&thonn (Euphorbiaceae)

Euphorbia lateriflora is well known in Nigerian ethnomedicine for its usefulness in the treatment of skin mucosae, veneral disease, cutaneous and subcutaneous parasitic infections and as remedy for head lice and ring worm. This study is aimed at establishing the pharmacognostic profile of the plant with the hope of assisting in its proper identification as well as standardisation and quality control of its products. The fresh and powdered samples were examined to determine the macromorphological, micromorphological, chemomicroscopy and physiochemical parameters such as moisture content, total ash, acid insoluble ash, sulphated ash and extractive values. The macro and microscopic studies indicated that the bark is smooth and transversely fractured with the surface being granular. The epidermal walls are straight with distinctively shaped calcium oxalate crystals clustered in the row of parenchymatous cells. The starch grains are of varying sizes and contains eccentric helium. The trichomes are uniserrate and the fibre is spindle – shaped. Chemomicroscopy revealed the presence of cellulose, lignin, tannins, starch and oil. The physicochemical constants are; moisture content 16.5± 0.05, total ash value 10.0% ± 0.05, acid insoluble-ash 1.0% ± 0.01, sulphated ash value 8.0% ± 0.05 alcohol soluble extractive 0.42 ± 0.01 and water soluble extractive 0.96 ± 0.02.