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SummaryWe report the occurrence of an accidental pleural puncture by an epidural catheter that happened during the attempted induction of thoracic epidural anaesthesia using a paramedian approach in an awake patient. The incorrect placement of the catheter was recognised while the patient was undergoing thoracoscopic surgery. The possibility of accidental pleural puncture during attempted thoracic epidural catheter placement by either the paramedian or the midline approach should be borne in mind. A misplaced catheter may injure lung tissue and result in a potentially dangerous intra-operative tension pneumothorax.Keywords Anaesthetic techniques, regional; epidural, thoracic. Complications. ...................................................................................... Correspondence to: Dr A. Zollinger Accepted: 23 March 1997 Thoracic epidural anaesthesia is frequently used in combination with general anaesthesia to achieve excellent peri-operative analgesia in patients undergoing upper abdominal and thoracic surgery [1, 2]. The technique may be associated with beneficial respiratory and haemodynamic effects [3][4][5]. However, this procedure is not free from complications, which include dural puncture with high spinal block [6, 7], blood vessel puncture with subsequent formation of an epidural haematoma [8,9], prolonged arterial hypotension, transection and knotting of the catheter [10], infection [11,12] and neurological sequelae [13]. Only a few cases of accidental puncture of the pleural cavity after thoracic epidural anaesthesia have been reported [14][15][16]. We report a case with direct intraoperative visualisation of the thoracic epidural catheter perforating the parietal pleura in a patient undergoing video-assisted thoracoscopic surgery. Case historyA 73-year-old female patient (height: 149 cm, weight: 60 kg) with chronic pneumonia of the right lower lobe was referred for diagnostic thoracoscopic lung biopsy. Her chest X-ray showed an encapsulated pleural effusion in the midzone of the right lung. Pre-operative laboratory data, lung-function tests and electrocardiogram were all normal. The patient had no history of spinal pathology.Routine monitoring was attached to the patient, who was positioned in the right lateral position with her knees bent and her spine flexed. The space between the spinous processes of the sixth and seventh thoracic vertebrae (T 6/7 interspace) was infiltrated with local anaesthetic. A 16G Tuohy needle (Portex Ltd, Hythe, Kent, UK) was inserted into the T 6/7 interspace using a right-sided paramedian approach (2 cm to the right of the midline). The loss-ofresistance technique was used with the aid of a 10-ml saline-filled glass syringe. The needle was advanced perpendicular to the skin until it hit the vertebral lamina on the right side. The tip of the needle was then redirected in the mediocranial direction and the typical loss of resistance was felt 7 cm deep to the skin. The epidural catheter was threaded 3 cm beyond the tip of the needle without any problems...

Early graft dysfunction after renal transplantation manifests as acute rejection (AR) or acute tubular necrosis (ATN). Blood oxygen level-dependent (BOLD) magnetic resonance (MR) imaging is a noninvasive method of assessing tissue oxygenation, which may be useful for predicting acute allograft dysfunction. This was a prospective study involving 40 patients scheduled for renal transplantation from August 2012 to August 2014. In addition, 15 healthy donors were also enrolled in this study. All recipients underwent BOLD MR imaging (MRI) and R2* mapping 10–20 days after transplant, and additionally within 48 h of biopsy if there was any evidence of graft dysfunction. The healthy donors underwent BOLD MRI 1–2 days before surgery. The biopsies were grouped into AR, ATN, and no evidence of AR or ATN. The mean medullary R2*, cortical R2*, corticomedullary gradient, and medullary: cortical R2* ratio were compared between groups using one-way analysis of variance. Spearman's correlation and multinomial linear regression were applied to determine the influence factors of R2* value. Overall, nine patients had graft dysfunction. Six were reported as AR, two as ATN, and one as no evidence of ATN or rejection. The mean medullary and cortical R2* were significantly higher in ATN group compared with AR and normal group, whereas the mean medullary and cortical R2* of AR group were significantly lower than normal group. The corticomedullary gradient of AR group was significantly lower compared with ATN and normal group. Medullary R2*:cortical R2* ratio was significantly lower in AR group compared with normal group. No significant difference was noted between the 15 donors and patients with normal graft function. R2* values on BOLD MRI are significantly decreased in AR allografts and increased in an early stage of ATN allografts, suggesting that BOLD MRI can become a valuable tool for discriminating between AR and ATN.

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Introduction: Paper demonstrates effect of the active molluscicidal components arjunolic acid (Terminalia arjuna bark) and procynadine (Tamarindus indica seed) on the activity of acetylcholinesterase (AChE) and phosphatases (ACP/ALP) in the cerebral ganglion of snail Lymnaea acuminata. Materials and Methods: Kinetics of AChE/ACP/ ALP inhibition in the cerebral ganglion of snail Lymnaea acuminata was studied via in vivo (40% and 80% of 96 h LC 50 ) and in vitro treatments (0.3 µg to 7.0 µg) of the column purified fractions, arjunolic acid and procynadine. Results: In vivo exposure of procynadine and arjunolic acid significantly inhibit acetylcholinesterase (AChE), acid phosphatase (ACP) and alkaline phosphatase (ALP) activities in the cerebral ganglion of L. acuminata exposed to 80% of 96h LC 50 . In in vitro treatment maximum inhibition in AChE/ACP/ALP activities in the cerebral ganglion of snail were noted when exposed to 7.0 µg of arjunolic acid and 0.9 µg of procynadine. Column purified fraction of T. arjuna bark and T. indica seed caused non-competitive and uncompetitive inhibition of AChE activity, respectively. Column purified fraction and arjunolic acid of T. arjuna bark caused uncompetitive inhibition of ACP while column purified fraction and procynadine of T. indica seed caused competitive inhibition. Competitivenon-competitive inhibition of ALP activity in the cerebral ganglion of L. acuminata was observed after treatment of column purified active components of both plants. Conclusions: The molluscicidal activity of T. arjuna bark (arjunolic acid) and T. indica seed (procynadine) against snail L. acuminata is due to the inhibition of AChE/ACP/ ALP. Their inhibition kinetics against AChE/ACP/ALP, were different in cerebral ganglion of snail.

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Background: Characterizing a hepatic lesion as benign or malignant is essential for correct therapeutic plan and surgical triage. USG plays major role in screening of a liver lesion. Conventional CT with only portal venous phase has certain limitations including its inability to detect lesions which enhances in early arterial phase like HCC and those enhancing in delayed phase like Cholangiocarcinoma. Triphasic CT utilizes three phases and offers a comprehensive and accurate determination. Design: This prospective study included 100 patients with clinical suspicion of hepatic masses. Materials and Methods: All patients underwent both USG and triple phase CT, accuracy, sensitivity and specificity of both the modalities were calculated. Results: USG proved to be a good screening modality with a sensitivity of 82.7%, specificity 95.6%, PPV 82.7% and NPV 95.6% (p value<0.001, kappa value 0.678). Triple phase CT is excellent for characterisation and better evaluation of hepatic masses with sensitivity of 91.3%, specificity 97.8%, PPV 91.3% and NPV 97.8% (p value <0.001, kappa value 0.847). Malignant hepatic lesions can be diagnosed by triphasic CT with accuracy of 93%, sensitivity and specificity of 93.3% and 92.5% respectively and with PPV and NPV of 94.9% and 90.2% respectively and by USG with accuracy of 87%, sensitivity and specificity of 90% and 82.5% respectively and PPV and NPV of 88.5% and 84.6% respectively. Conclusion: Ultrasonography must be performed in all patients with clinical suspicion of hepatic masses for initial detection and localisation of lesion. Also it is widely available, less expensive and with no radiation exposure. But in comparison to triple phase CT it has lower sensitivity in differentiating benign hepatic lesions from malignant, determining accurate extension of tumor with vascular invasion.

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