1. Introduction

Nasal polyposis is chronic inflammatory disease nasal mucosa and of sinus resulting in oedematous polyp protruding in nasal cavity [1]. It is also known as chronic rhinosinusitis with nasal polyps (CRSwNP) [2]. The striking feature of nasal polyposis is nasal discharge, congestion, nasal blockage and obstruction [3]. There is reduction or complete loss of smell in patients suffering from nasal polyposis. The presence of 2 or more symptoms are sufficient to make diagnosis. Endoscopy shows presence of polyps and mucopurulent discharge from the middle meatus or oedema, mucosal obstruction primarily in the middle meatus [4].

Chronic RS (CRS) is those which is present for longer duration of time. It may be divided into those in which nasal polyps are present and those in which they are absent [5]. A thorough clinical, histopathologic features and CT is useful in making diagnosis. CT scan of sinuses shows mucosal changes within the osteomeatal complex and/or sinuses. Interleukin profile is also necessary for the diagnosis [6].

Management of patients of nasal polyposis comprised of intranasal steroids. Patients taking systemic steroids shows improvement of air flow, reduction in polyp size and decrease recurrence of polyps [7]. In patients where symptomatic treatment with topical or systemic steroids fails, surgical management is regarded best treatment option and for patients with complications. Functional endoscopic sinus surgery (FESS) is one of the treatment options highly efficacious in relieving symptoms, improving sinus ventilation and drainage and for removing polyps [8]. Patients being treated for polyp disease derive the greatest benefit from functional endoscopic sinus surgery, and those whose main preoperative symptom is nasal obstruction or headache report higher benefit [9]. In this prospective observation study, we studied 82 cases of nasal polyposis undergoing functional endoscopic sinus surgery (FESS).

2. Methodology

This prospective observation study, a total of 82 patients presenting with the symptoms of nasal polyposis were studied. It comprised of 38 male patient and 44 female patients. Higher authorities' approval was sorted. A written informed consent was taken before starting this project. The inclusion criteria consisted of patients with nasal polyposis confirmed with CT, age above 18 years of either sex, absence of comorbidities, patients not responding to medicinal treatment.

All patients were clinically evaluated with anterior rhinoscopy and nasal endoscopy was performed by otorhinolaryngologist pre and post operatively. FESS was performed following all aseptic standardized procedure. Parameters assessed were NOSE score and nasal endoscopy score. NOSE score comprised of recording of symptoms such as nasal congestion, nasal obstruction, trouble nasal breathing, trouble sleeping and unable to get enough air through nose during exercise and it is either not a problem, very mild problem, moderate problem, fairly bad problem and severe problem having score 0,1,2,3,4 respectively. Nasal endoscopy score comprised of factors such as polyp, discharge, oedema, scarring and crusting with score 0, 1 and 2. Results of study were recorded and subjected for statistical inferences using Mann Whitney U test. The level of significance was significant if p value is below 0.05.

3. Results

Age wise distribution of patients is presented in Table 1. Maximum patients were seen in age group 18-28 years ie 35 (42.6%), followed by 28-38 years 20 (24.3%), 38-48 years 15(18.2%), 48-58 years 7 (8.5%) and >58 years 5 (6%).

Table 1. Age wise distribution of patients.

Age group	Number	Percentage
18-28 years	35	42.6
28-38 years	20	24.3
38-48 years	15	18.2
48-58 years	7	8.5
>58 years	5	6

Significance, \(< 0.05\), Mann Whitney U Pre- operative NOSE score was \(65.2\pm 5.7\), at 6 months was \(28.4\pm 4.1\) and at 12 months post- operatively was \(24.2\pm 3.6\). Mann Whitney U test showed significant p value \(< 0.05\) (Table 2, Figure 1).

Table 2. NOSE score.

Duration	Mean	SD	P value
Pre- operative	65.2	5.7	Significant, P< 0.05
6 months	28.4	4.1
12 months	24.2	3.6

A pre- operative nasal endoscopic score was 6.02, 6 months score was 3.1 and 12 months score was 2.5. Mann Whitney U test showed significant with p value < 0.05 (Figure 2).

4. Discussion

We studied 82 cases of nasal polyposis undergoing functional endoscopic sinus surgery (FESS). Chronic rhinosinusitis (CRS) is a common health problem which leads to frequent visits to primary care physicians and ear, nose, throat specialists [10]. In spite of the recent advances, the etiology, pathogenesis and treatment of CRS is a matter of debate [11]. Nasal polyposis (NP) is considered as a subgroup of CRS with an incidence of 4% in general population and 25-30% in patients suffering from CRS. Nasal polyps (NP) are mucosal sacs containing oedema, fibrous tissue, vessels, inflammatory cells and glands [12]. Functional endoscopic sinus surgery (FESS) is the treatment of choice for CRS patients not responding to drug therapy. It is a multifactorial disease linked to bacterial infection, allergy, biofilms and recently superantigens. The symptom manifestation of CRS is varied [13]. Therefore, clinical assessment by major and minor criteria, assisted by nasal endoscopy and CT scan are the usual methods of diagnosis and management. The universal rationale of treatment is adequate drainage and aeration of the sinus [14].

There were 38 male patient and 44 female patients. A study by Nair et al., [15] included 90 patients of nasal polyposis undergoing FESS. It was found in our study that maximum patients were seen in age group 18-28 years ie 35 (42.6%), followed by 28-38 years 20 (24.3%), 38-48 years 15(18.2%), 48-58 years 7 (8.5%) and >58 years 5 (6%). Nair et al., [15] study on 38 patients of chronic rhinosinusitis and 52 patients of nasal polyps showed that patients of nasal polyp group presented with increased severity of symptoms of nasal blockage, nasal discharge and reduced sense of smell as compared to the chronic rhinosinusitis group who had significantly higher presentation of headache and facial pain. The preoperative CT scan revealed significantly higher bilateral disease with increased involvement of multiple sinuses in nasal polyp group. Post endoscopic sinus surgery both the groups showed significant improvement in their symptoms with the nasal polyp group demonstrating reduction in improvement on 1 year follow up.

Pre- operative NOSE score was \(65.2\pm 5.7\), at 6 months was \(28.4\pm 4.1\) and at 12 months post- operatively was \(24.2\pm 3.6\). A study by Kayat et al., [16] on 50 patients diagnosed with nasal polyposis underwent recoding of Lund-Mackay CT scan score, pre-operative nasal endoscopy score and pre-operative NOSE score followed by post- operative score recording at 6 months and 12 months. Both NOSE score and Nasal Endoscopy Score showed statistically significant improvement between Pre-operative and Post-operative 6 months score. However no statistically significant improvement between post- operative 6 months score and post-operative 12 months score. The Pre-operative CT Scan score had poorly positive correlation with Pre-operative Nasal Endoscopy Score. The Pre-operative Nasal Endoscopy Score correlated negatively with Preoperative NOSE score.

A pre- operative nasal endoscopic score in our patients was 6.02, 6 months score was 3.1 and 12 months score was 2.5. Kenny et al., [17] correlated smell sense with radiological findings only and found it significant. Significant correlation of olfactory scores with each of CT, endoscopic, and subjective scores both before and 3 months after sinus surgery. Ryan et al., [18] correlated symptomatology, endoscopic, and radiological criteria in CRS patients and found poor correlation but found subjective impaired sense of smell to be correlating closely with abnormal endoscopic findings. Rosbe et al., [19] studied whether symptoms and endoscopic grade could be predicted by CT scan. For patients with objective findings on imaging and endoscopy, nasal obstruction and postnasal drainage were the most likely to correlate, and headache and facial pain were the least likely.

Wang et al., [20] undertook study of surgical outcomes of functional endoscopic sinus surgery and radical sinus surgery for refractory rhinosinusitis on 56 cases with refractory rhinosinusitis which were classified into functional endoscopic surgery group (FESS group) and radical sinus surgery group (RSS group). On comparison of age, gender, complicated with allergic rhinitis and asthma, no significant difference between two groups was observed (P> 0.05). However, there was significant difference between two groups in the number of patients with previous surgery (P< 0.05). Pre-operative VAS symptom score, Lund-Kennedy score and Lund-Mackay score were higher in RSS group than in FESS group. VAS symptom score (P< 0.01), Lund-Kennedy score (P< 0.01), Lund-Mackay score (P< 0.01) were significantly lower after surgery. There was no significant difference in VAS symptom scores between two groups postoperatively (P> 0.05). However, Lund-Kennedy score (P< 0.01) and Lund-Mackay score (P< 0.01) were lower in RSS group postoperatively. Among patients with surgery history, Lund-Kennedy score (P< 0.01) and Lund-Mackay score (P< 0.01) were also lower in RSS group at one year follow-up.

5. Conclusion

Functional endoscopic sinus surgery is treatment of choice in patients with chronic rhinosinusitis with nasal polyps. Patients Endoscopy Score and NOSE symptom score was improved after treatment.

Author Contributions

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest

The author declares no conflict of interest.

1. Introduction

Diabetes mellitus type 2 (DM2) is a metabolic disorder of multiple etiologies due to disturbances of carbohydrate, fat, and protein metabolism [1]. It is characterized by chronic hyperglycemia, and it is associated with cardiovascular and renal complications. These complications result in diminished quality of life and reduced life expectancy [2]. In addition, the disease places a considerable economic burden on worldwide healthcare resources [3]. The estimated number of deaths due to diabetes is similar to the combined number of deaths from several infectious diseases such as human immunodeficiency virus (HIV)/AIDS, malaria, and tuberculosis [4].

The estimated diabetes prevalence worldwide for 2010 was 285 million people corresponding to 6.4% of the world's adult population [5]. By 2030, 438 million (7.8%) people of the adult population is expected to have diabetes similarly; for India, this increase is estimated to be 87 million in 2030 [6]. Insulin helps sugar get into cells to maintain normal blood sugar (glucose) levels. It often begins after the age of 40 years, but age range can start from 20+ years [7] The prevalence of type 2 diabetes is increasing globally and represents a heavy burden on public health and socioeconomic development of all nations. Type 2 diabetes is a multifactorial disease and due to a combination of environmental and genetic risk factors (many environmental risk factors contribute to the pathogenesis of type 2 diabetes, including lifestyles such as sedentary behavior, diet, smoking and alcohol consumption, internal environmental factors such as inflammatory factors, adipocytokines and hepatocyte factors, external environmental factors such as environmental endocrine disruptors) [8].

Genetic base in type 2 DM is complex and incompletely defined. So no isolated known defect predominates, as is the case with HLA connection with type 1 DM. Type 2 DM is more common in certain ethnic and racial groups [9]. Considering this, the present study aimed at assessing risk factors for development of type II diabetes.

2. Methodology

This cross- sectional case control prospective study was conducted after obtaining permission from Ethical review and clearance committee. Inclusion criteria was 80 patients of type 2 diabetes mellitus >40 years of age and those who gave their permission to participate in this study. Exclusion criteria was type I diabetes patients and those who had not given written consent.

Patients were randomized into two groups. Group 1 were type 2 diabetes mellitus patients and group 2 were healthy subjects irrespective of gender. A 5ml venous blood was drawn and collected in a test tube for assessment of fasting blood glucose level. A value more than 126 mg/dl considered diabetics. Glycosylated blood glucose level above 6.4% was designated as diabetes. Factors such as family history, physical activity, blood pressure, alcohol consumption and BMI was recorded. Results of the present study after recording all relevant data were subjected for statistical inferences using chi- square test. The level of significance was significant if p value is below 0.05 and highly significant if it is less than 0.01.

3. Results

Group 1 had 50 males and 30 females and group 2 had 40 males and 40 females (Table 1).

Table 1. Patients distribution.

Groups	Group1	Group 2
Status	Diabetes	Healthy
M:F	50:30	40:40

From Table 2 and Figure 1, we can observe that the alcohol consumption was present in 45 in group 1 and 20 un group 2, family history was positive in 65 group 1 and 12 in group 2, sedentary life was seen in 52 group 1 and 25 in group 2, BMI was underweight seen in 14 in group 1 and 5 in group 2, normal12 in group 1 and 46 in group 2, overweight 30 BMI was underweight seen in 14 in group 1 and 5 in group 2, normal12 in group 1 and 14 in group 2 and obese 22 and 15 46 in group 2. Blood pressure was normal seen 16 in group 1 and 42 in group 2, pre- hypertension 24 in group 1 and 26 in group 2, hypertension stage 1 in 30 in group 1 and 10 in group 2 and hypertension stage 2 seen in 10 in group 1 and 2 in group 2. A significant difference was observed (P< 0.05).

Table 1. Patient parameters.

Parameters	Characteristics	Group 1	Group 2	P value
Family history	Yes	65	12	0.05
	No	15	68
Physical activity	Sedentary life	52	25	0.02
	Yes	28	55
Alcohol consumption	Present	45	20	0.03
	Absent	35	69
BMI (Kg/m2)	Underweight	14	5	0.01
	Normal	12	46
	Overweight	30	14
	Obese	22	15
Blood pressure	Normal	16	42	0.05
	Pre- hypertension	24	26
	Hypertension stage 1	30	10
	Hypertension stage 2	10	2

4. Discussion

Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both [10,11]. The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of different organs, especially of eyes, kidneys, nerves, heart, and blood vessels [12]. The main forms of diabetes are divided into those caused by lack of insulin secretion, due to damage of ß-cells of the pancreas (type 1 DM), and those that are a consequence of insulin resistance that occurs at the level of skeletal muscles, liver and adipose tissue, with varying degrees of ß-cells damage (type 2 DM) [13,14]. Type II DM patients generally carry a number of risk factors for CVD, including hyperglycemia, abnormal lipid profiles, alterations in inflammatory mediators and coagulation/thrombolytic parameters, as well as other 'non-traditional' risk factors, many of which may be closely associated with insulin resistance. Therefore, successful management of CVD associated with diabetes represents a major challenge to the clinicians [15].

In present study we assessed risk factors for development of type II diabetes. Nandimath et al., [16] determined the prevalent risk factors of type 2 diabetes mellitus and to estimate strength of association of these risk factors and occurrence of the disease. A total of 300 type 2 diabetes mellitus cases and 600 control subjects were included in this study. About 54.33% of cases were observed in the age group of >40-50 years. About 69.66% were male and 30.34% female cases. There was significant association between modifiable risk factors and type 2 diabetes mellitus, while nonmodifiable risk factors (age, gender) were not significantly associated.

Our study demonstrated that alcohol consumption was present in 45 in group 1 and 20 un group 2, family history was positive in 65 group 1 and 12 in group 2, sedentary life was seen in 52 group 1 and 25 in group 2, BMI was underweight seen in 14 in group 1 and 5 in group 2, normal12 in group 1 and 46 in group 2, overweight 30 BMI was underweight seen in 14 in group 1 and 5 in group 2, normal12 in group 1 and 14 in group 2 and obese 22 and 15 46 in group 2. Begic et al., [17] evaluated questionnaires on the assessment of risk factors for Diabetes Mellitus type 2.

Analyzed questionnaires showed relatively low risk of getting diabetes in the next ten years in the majority of the population. These results are rather encouraging but may in some way be in confrontation with the statistics which show a rapid outburst of diabetes. Murad et al., [18] determined the common risk factors of diabetes mellitus type 2 (DM2) and the demographic background of adult Saudi patients with DM2. Known diabetic patients were recruited as cases, while nondiabetic attendants were selected as controls. A pretested designed questionnaire was used to collect data from 159 cases and 128 controls. Cases were more likely than controls to be men (P < 0.0001), less educated (P < 0.0001), natives of eastern Saudi Arabia (P < 0.0001), retired (P < 0.0001), lower-salaried (P < 0.0001), or married or divorced (P < 0.0001). By univariate analysis cases were likely to be current smokers (P < 0.0001), hypertensive (P < 0.0001), or overweight/obese (P < 0.0001). Cases were also more likely to have a history of DM in a first-degree relative (P = 0.020). By multivariate analysis, cases were more likely to be older than 40 years (P < 0.0001), less educated (P = 0.05), married or divorced (P = 0.04), jobless/housewives (P < 0.0001), or current smokers (P = 0.002). They were also more likely to have salaries.

We observed that Blood pressure was normal seen 16 in group 1 and 42 in group 2, pre- hypertension 24 in group 1 and 26 in group 2, hypertension stage 1 in 30 in group 1 and 10 in group 2 and hypertension stage 2 seen in 10 in group 1 and 2 in group 2. Rehman et al., [19] estimated the proportion of people with diabesity and assess the sociodemographic, dietary, and morbidity related factors associated with diabesity. The mean (standard deviation) age of 151 study participants was 58.2 (11.8) years with 66% (n = 100), 77% (n = 116) and 40% (n = 60) being females, sedentary workers and belonging to lower socioeconomic status, respectively. Of total, 71% (n = 107) had hypertension, 66% (n = 99) had uncontrolled fasting blood sugar (FBS) level and 74% (n = 111) did not consume fruits daily. The proportion of diabesity was found to be 66.9%. After adjusting for other factors, obesity was significantly high among T2DM patients aged 50 years and less 1.4; compared to >60 years. Having uncontrolled FBS values deficient in calorie intake deficient in fruits intake and high fat consumption had significant association with diabesity.

5. Conclusion

Common risk factors in diabetes was overweight, hypertension, lack of physical activity and alcohol consumption.

Author Contributions

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

1. Introduction

The number of solid organ transplants performed worldwide is ever increasing. The improved survival rates are the result of well-established surgical techniques and effective immunosuppressive therapy [1]. All this has led to an increase in number of patients who present for either elective or emergency non-transplant surgery [2]. Laparotomy for small bowel obstruction, hip arthroplasty given the increased risk of fracture and avascular necrosis as a result of chronic steroid use causing bone demineralization and osteoporosis, lymph node excision and biopsy because of increased risk of lymphoproliferative disease, native nephrectomy in kidney transplant recipients, bronchoscopy in lung recipients, biliary tract interventions in liver recipients, and abscess drainage because of increased risk of infection are just a few of the increased surgical needs in this population [3].

Vigilant intraoperative monitoring, optimization of intravascular fluid volume status to maintain maximum kidney perfusion, to avoid fluid overload, and early correction of electrolyte abnormalities are the crux of short and long term success of renal transplants [4]. With the expanding criteria for taking patients for kidney transplantation, anesthesiologists are likely to be encountered with more problems of the interaction of other co-morbid diseases and multiple drug therapies in the near future. Recipients involving cadaveric donor organs are often scheduled as urgent or emergency procedures [5]. However, a well-preserved kidney provides enough time to prepare the recipient and if necessary dialyze to normalize electrolyte and volume imbalance. Successful use of regional anaesthesia has been reported by some centers. Certain factors to be considered for the use of regional anaesthesia are uraemic bleeding tendency, effect of residual heparin given during dialysis, altered platelet function, decrease in coagulation factors and the duration of surgery [6]. Considering this, we attempted present study to evaluate anesthetic management in renal transplant patients.

2. Methodology

This retrospective study was initiated once the approval from Ethical review and clearance committee was obtained. All patients managed in the department in last 1 years (Ninety- two) were part of the study.

Patients' case record files were retrieved from the department. Parameters such as type of transplant, reason for chronic kidney disease, preoperative data, history of dialysis, preoperative anesthesia management, monitoring details and the outcome were recorded. Results of the present study after recording all relevant data were subjected for statistical inferences using chi- square test. The level of significance was significant if p value is below 0.05 and highly significant if it is less than 0.01.

3. Results

Common reasons for end stage kidney disease was chronic glomerulonephritis (CGN) in 28 (30.4%), chronic interstitial nephritis (CIN) in 20 (21.7%), polycystic kidney disease (PCKD) in 11 (11.9%), obstructive nephropathy (Ob. N) in 4 (4.3%), diabetic nephropathy (DN) in 8 (8.7%), hereditary nephropathy in 3 (3.2%), reflux nephropathy in 12 (13%) and membranoproliferative glomerulonephritis (MPGN) in 6 (6.5%). A significant difference was observed \((P< 0.05)\) (Table 1, Figure 1).

Table 1. Reason for end stage kidney disease.

Variables	Parameters	Number	P value
Reason for injury	RTA	62	Significant <0.05
	Fall	40
	Domestic violence	10
Associated fracture	Trans-scaphoid   fracture	23	Significant <0.05
	Radial styloid fractures	14
Mayo wrist score	Excellent to good	70	Significant <0.05
	Fair to poor	42
Lyon wrist score	Excellent to good	64	Significant <0.05
	Fair to poor	48
Wrist   flexion/extension arc		49.1 degree	-
Wrist radial/ulnar deviation arc		18.2 degree	-
Wrist   radial ulnar movement arc		50.4 degree	-
Forearm   supination/pronation arc		82 degree	-
Grip   strength		68.2%	-

It was found in 32 (35.6%) patients, isoflurane was inhalational agent and recovery time was 25.1 minute, in 40 (43.4%), desflurane was inhalational agent and recovery time was 22.7 minutes and in 20 (21.7%), sevoflurane was inhalational agent and recovery time was 32.1 minutes. A significant difference was observed (P< 0.05) (Table 2).

Table 2. Recovery time amongst inhalational agents used.

Inhalational agents	Number (%)	Recovery time (in mins)	P value
Isoflurane	32 (35.6%)	25.1	0.05
Desflurane	40 (43.4%)	22.7
Sevoflurane	20 (21.7%)	32.1

Post- operative complications were acute graft rejection in 6 (6.5%), pneumonia in 3 (3.2%), pulmonary edema in 4 (4.3%) and re-exploration in 1 (1%). A significant difference was observed \((P< 0.05)\) (Table 3, Figure 2).

Table 3. Postoperative complications in renal transplant recipients.

Complications	Number (%)	P value
Acute graft rejection	6 (6.5%)	0.05
Pneumonia	3 (3.2%)
Pulmonary edema	4 (4.3%)
Re-exploration	1 (1%)

4. Discussion

This study was conducted among 92 patients who received renal transplant in last 1 year. It had 43 males and 49 females. Successful use of regional anaesthesia has been reported by some centers. Certain factors to be considered for the use of regional anaesthesia are uraemic bleeding tendency, effect of residual heparin given during dialysis, altered platelet function, decrease in coagulation factors and the duration of surgery. The advantages of combined spinal-epidural technique are rapid onset and good muscle relaxation from spinal and supplemental analgesia through epidural during and after surgery [7]. Most centers however use balanced general anaesthesia to provide stable hemodynamics, excellent muscle relaxation and predictable depth of anaesthesia. Standard ASA monitors are adequate, although, patients with more advanced co-morbid conditions require extensive monitoring such as continuous arterial pressure or CVP monitoring. Those with the most severe co-morbid conditions, such as symptomatic CAD or history of congestive heart failure, should be monitored with a pulmonary artery catheter or transesophageal echocardiography. Strict asepsis should be maintained at all times [8].

Our results found that chronic glomerulonephritis (CGN) in 28 (30.4%), chronic interstitial nephritis (CIN) in 20 (21.7%), reflux nephropathy in 12 (13%), polycystic kidney disease (PCKD) in 11 (11.9%), diabetic nephropathy (DN) in 8 (8.7%), membranoproliferative glomerulonephritis (MPGN) in 6 (6.5%), obstructive nephropathy (Ob. N) in 4 (4.3%) and hereditary nephropathy in 3 (3.2%) were common reasons for end stage kidney disease. Tiwari et al., [9] included 100 patients with end stage renal disease and found that 92% were living and 8% were cadaveric related transplant. 92% were done electively. Most common co-morbidity recorded was hypertension in 49% patients. Predominant cause of end stage renal disease was chronic glomerulonephritis (41%). General anesthesia was technique of choice in all patients, 27 also received epidural. Invasive blood pressure monitoring was done in 3 patients with cardiac co-morbidities. 15% patients required blood transfusion. CVP maintained > 12 mmHg and maximum at de-clamping. Mean arterial pressure maintained above 95 mmHg. Ionotropic support required in 2 patients. 76% patients were transfused with only crystalloid (NS and/or RL) while 24 patients received a combination of both crystalloid and colloid. 97% patients were extubated postoperatively while 3% required ventilator support. Recovery time with desflurane was significantly less as compared to other inhalational agents. One patient died postoperatively.

It was observed that in 32 (35.6%) patients, isoflurane was inhalational agent and recovery time was 25.1 minute, in 40 (43.4%), desflurane was inhalational agent and recovery time was 22.7 minutes and in 20 (21.7%), sevoflurane was inhalational agent and recovery time was 32.1 minutes. Hadimioglu et al., [10], the authors found that lactated ringer's used in the perioperative period of renal transplant surgeries, resulted in similar potassium levels during the postoperative period, higher bicarbonate and pH levels, and also lower chlorides, despite using the similar infusion volume in comparison to normal saline solutions.

Low serum albumin levels leads to an increase in free fraction of the drug in plasma while uremia associated altered blood brain barrier can increase the levels of unbound drug crossing the blood brain barrier into CNS receptors. Hence, the dose of induction agents may need to be adjusted according to the volume status, acidic pH and increased sensitivity of the nervous system to these drugs. In chronic renal failure patients, the underlying rate and extent of thiopental distribution and elimination are much the same as in normal patients [11]. However, a higher dose of propofol is required to reach the clinical end point of hypnosis and bispectral index of 50. The hyperdynamic circulation and high plasma volume resulting from anemia can counteract the effect of low serum albumin explaining the higher dose requirement with propofol. Ketamine pharmacokinetics are not significantly changed by renal disease, but the hypertensive effects make it undesirable in patients with underlying hypertension. Etomidate is well tolerated and preserves hemodynamic stability [12].

5. Conclusion

Anesthesia management has made renal transplantation safe and predictable. Postoperative maintenance of renal transplant patients have contributed to the success of renal transplant programme.

Author Contributions

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

1. Introduction

The patella is the largest sesamoid bone; it is embedded in the quadriceps tendon, provides the mechanical advantage and leverage that increases the force of knee extension [1]. Tensile forces are transmitted from the quadriceps to the tibia via the patella, the patella is also subjected to compressive forces at the articulation with the femur [2].

Displaced patella fractures or those which disrupt the extensor mechanism are usually managed operatively. The current standard remains a tension band wire (TBW) construct, with the option of additional cerclage wiring or TBW through cannulated screws [3]. Elderly patients and particularly those with comminuted patella fracture are "difficult patella fractures" as their osteopenic bone often lacks the strength to support a TBW and/or cerclage, resulting in fixation failure prior to bone union [4]. Fractures of the patella may be treated conservatively or surgically. Conservative management may be ideal for the patient who is non-ambulatory, had a prior failed extensor mechanism, those with an ankylosed joint, or particular fracture characteristics [5]. Typically, this involves immobilization of the extremity in full extension with partial weight bearing for several weeks. If the injury is not amendable to conservative management, then surgical intervention is merited to mitigate disability [6]. However, surgical management of patellar fractures is complicated secondary to its various tendinous attachments, which serve as displacing vectors on fracture fragments making fracture alignment not easily amenable to fixation [7].

Of all surgical management of patellar fractures such as modified tension band wiring (TBW), cerclage wiring, screw fixation, plating, and partial or total patellectomy, cerclage wiring and TBW are popular [8]. Tension band wiring (TBW) technique, one of the most commonly used surgical methods in treating a tension fracture, has a sound biomechanical advantage such that it can convert a tensile force into a compressive force when the joint is brought through a range of motion [9]. Percutaneous cerclage wiring for patella fracture can be applied through several small skin incisions without dissecting the fractured region and surrounding soft tissues and provides a minimally invasive approach to this procedure [10]. Considering this, the present study was conducted with the aim to compare tension band wire and circumferential wiring for patellar fractures.

2. Methodology

One hundred twenty adult patients in age ranged 18- 50 years of either gender was enrolled in the study. The consent was sought from Ethical review and clearance committee. All enrolled patients were made aware of the study and consent (written) was obtained. They were randomly divided into groups: group 1 treated with tension band wire and group 2 with circumferential wiring for patellar fractures. Patients below 18 years of age were not considered in the study. Check X-ray of knee in AP and lateral views were done. Reich and Rosenberg scale, rage of motion and complications were recorded in both groups and compared. Results of the present study after recording all relevant data were subjected for statistical inferences using chi- square test. The level of significance was significant if p value is below 0.05 and highly significant if it is less than 0.01.

3. Results

Group 1 had 32 males and 28 females and group 2 had 35 males and 25 females (Table 1).

Table 1. Demographic characteristics.

At 4 weeks in group 1 and group 2, restriction of last \(10^0- 20^0\) was seen in 24 and 27, restriction of \(20^0-50^0\) was seen in 14 and 13, restriction \(>50^0\) was observed in 22 and 20. At 8 weeks, no restriction was seen in 8 and 9, restriction of last \(10^0- 20^0\) was seen in 38 and 39, restriction of \(20^0-50^0\) was seen in 10 and 9, restriction \(>50^0\) was seen in 4 and 3. At 12 weeks, no restriction was seen in 15 and 20, restriction of last \(10^0- 20^0\) was seen in 35 and 32, restriction of \(20^0-50^0\) was seen in 8 and 7 and restriction >500 was seen in 2 and 1 in group 1 and 2 patients respectively. A significant difference was observed \((P< 0.05)\) (Table 2, Figure 1).

Table 1. Post- operative range of motion in both groups.

Duration	ROM	Group 1	Group 2	P value
4 weeks	No restriction	0	0	0.05
	Restriction of last 100- 200	24	27
	Restriction of 200-500	14	13
	Restriction >500	22	20
8 weeks	No restriction	8	9	0.05
	Restriction of last 100- 200	38	39
	Restriction of 200-500	10	9
	Restriction >500	4	3
12 weeks	No restriction	15	20	0.05
	Restriction of last 100- 200	35	32
	Restriction of 200-500	8	7
	Restriction >500	2	1

Table 2. Reich and Rosenberg scale.

Results	Group 1	Group 2	P value
Excellent	20	22	0.05
Good	32	30
Fair	5	7
Poor	3	1

Results were excellent in 20 in group 1 and 22 in group 2, good in 32 in group 1 and 30 in group 2, fair in 5 in group 1 and 7 in group 2 and poor in 3 in group 1 and 1 in group 2. A non- significant difference was observed (P> 0.05) (Table 3).

Joint stiffness was seen in 4 in group 1 and 3 in group 2, superficial skin infection was seen in 2 in each group and deep infection 1 in group 1 and 2 in group 2. A non- significant difference was observed (P> 0.05) (Table 4, Figure 2).

Table 3. Comparison of complications.

Complications	Group 1	Group 2	P value
Joint Stiffness	4	3	0.05
Superficial skin infection	2	2
Deep Infection	1	2

4. Discussion

We attempted this study on 120 patients having patellar fractures. They were divided into two groups based on treatment provided. Group 1 were treated with tension band wire and group 2 with circumferential wiring. Patellar fractures are common and it constitutes about 1% of all skeletal injuries resulting from either direct or indirect trauma [11]. As the patella is present subcutaneously, it is more prone for fractures through direct trauma and through indirect trauma by quadriceps contracting violently [12]. Any improper and inadequate treatment would inevitably lead to a great deal of disability which would be most perceptibly felt in a country like India, where squatting is an important activity in daily life [13]. Controversy exists regarding treatment of patellar fracture since the earliest time. Conservative treatment is done if patellar fractures are displaced less than 3mm [14]. Of all surgical management of patellar fractures such as modified tension band wiring (TBW), cerclage wiring, screw fixation, plating, and partial or total patellectomy, cerclage wiring and TBW are popular [15].

Our results showed that group 1 had 32 males and 28 females and group 2 had 35 males and 25 females. Asimuddin et al., [16] in their study clinical and radiological investigations were carried out. Patients underwent Tension Band Wiring or Circumferential Wiring for the sustained fracture. Patients were followed up at 4 weeks, 8 weeks, 12 weeks till fracture union and once at 1 year after surgery using Reich and Rosenberg criteria. There was no significant difference regarding the mean age, gender, and mechanism of the fractures in patients treated by two methods of TBW and CW. 1 case of superficial infection and 3 cases of joint stiffness were noted after CW and 1 case of superficial infection and 2 cases of joint stiffness had occurred after TBW. 60% excellent, 25% good, 5% fair and 10% poor results were observed after Circumferential Wiring and 65% excellent, 15% good, 15% fair and 5% poor results after TBW. Patients of both groups showed an appreciable and statistically significant improvement in functional outcome at 3 months follow-up period as evidenced by Reich and Rosenberg Criteria that reveals no major difference. Furthermore, the difference in improvement between the two groups was not statistically significant at 3 months.

We observed that at 4 weeks in group 1 and group 2, restriction of last \(10^0- 20^0\) was seen in 24 and 27, restriction of \(20^0-50^0\) was seen in 14 and 13, restriction \(>50^0\) was observed in 22 and 20. At 8 weeks, no restriction was seen in 8 and 9, restriction of last \(10^0- 20^0\) was seen in 38 and 39, restriction of \(20^0-50^0\) was seen in 10 and 9, restriction \(>50^0\) was seen in 4 and 3. At 12 weeks, no restriction was seen in 15 and 20, restriction of last \(10^0- 20^0\) was seen in 35 and 32, restriction of \(20^0-50^0\) was seen in 8 and 7 and restriction \(>50^0\) was seen in 2 and 1 in group 1 and 2 patients respectively. We observed that results were excellent in 20 in group 1 and 22 in group 2, good in 32 in group 1 and 30 in group 2, fair in 5 in group 1 and 7 in group 2 and poor in 3 in group 1 and 1 in group 2. Our results demonstrated that joint stiffness was seen in 4 in group 1 and 3 in group 2, superficial skin infection was seen in 2 in each group and deep infection 1 in group 1 and 2 in group 2. Passias et al., [17] reviewed the multiple different patella fixation strategies and to evaluate the outcomes and complications associated with each. One hundred and fifteen patients who underwent patellar fracture fixation at an urban Level I-Trauma center were retrospectively reviewed. Operative treatment included open reduction and internal fixation with plate and screw devices, tension band wiring (TBW), cannulated screw tension band wiring (CS-TBW), isolated interfragmentary screw fixation, or partial patellectomy with soft tissue repair and tendon advancement. Patient demographics, fracture and injury characteristics, operative variables, radiographic information, and post-operative outcome measurements were recorded for each patient assessed in the study. Results demonstrated that plating techniques had the highest overall rate of union. Furthermore, a significant decrease in implant removal with utilization of isolated suture/wire was appreciated compared to other fixation groups \((p< 0.01)\).

5. Conclusion

Both techniques for the management of patellar fractures were equally effective in achieving functional outcome.

Author Contributions

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

1. Introduction

Lichen planus is frequently occurring muco- cutaneous disease. It is one of the auto-immune inflammatory disease which has high impact on mental health of life. It is commonly occurring in females and middle age group is leading affected group [1]. It occurs in various forms such as reticular, bullous, erosive, erythematous, plaque, annular, papular etc [2,3,4]. It is one of the potentially malignant disorder in where chances of conversion to oral cancer is high [5]. Erosive form has high malignant potential [6]. The most striking oral feature of oral lichen planus is the presence of wickham striations. These are radiating greyish whitish striations commonly occur in buccal mucosa [7]. Other sites involved are lips, gingiva, soft palate etc. The predisposing factor for lichen planus is stress, depression, anxiety, psychiatric disorders [8].

Various treatment options are available for the management of lichen planus such as use of topical, systemic steroids, immunomodulators, herbal products etc [9]. Triamcinolone acetonide is one of the topical corticosteroids found to be effective in the management of oral lichen planus. Topical steroids is preferred over systemic steroids owing to its less side effects [10,11]. Methotrexate is one of the immunosuppressant drug inhibiting dihydrofolate reductase competitively, therefore hinder replication and function of T and B lymphocytes [12]. Its efficacy against cutaneous, oral erosive and vulvovaginal LP found be high [13]. Few studies have demonstrated equal effect of corticosteroids and methotrexate in oral lichen planus cases [14,15,16]. Considering this, this study was undertaken with the aim to compare 0.1% topical triamcinolone acetonide, oral methotrexate, and a combination of 0.1% topical triamcinolone acetonide and oral methotrexate in the management of oral lichen planus.

2. Methodology

This prospective, observation, comparative study was commenced with the permission of ethical clearance committee of the institute. It has 60 cases (males- 20, females- 40). Inclusion criteria used was occurrence of moderate to severe LP, age group 18-60 years, biopsy approved cases and those giving consent. Exclusion criteria was cases not in specified age group and those having contraindication to v methotrexate.

A computer-generated randomization of patients was done into 3 groups. Group T was given 0.1% topical triamcinolone acetonide, group M was given topical methotrexate and group C was given combination of both 0.1% topical triamcinolone acetonide and oral methotrexate. 0.1% topical triamcinolone acetonide was prescribed three times daily and methotrexate 0.3 mg/kg once/week. Patients were advised to continue the treatment for 4 months. Remission was defined absence of signs and symptoms of lesions. Live function test and complete blood count was determined. Clinical severity score was also calculated. The objective improvement was graded as excellent, good, poor, no response and worsening. Visual analog scale (VAS) was used for pain assessment. Results of the present study after recording all relevant data were subjected for statistical inferences using chi- square test. The level of significance was significant if p value is below 0.05 and highly significant if it is less than 0.01.

3. Results

Group T had 3.2 years, group M had 3.1 years and group C had 3.3 years of duration of symptoms. A non- significant difference between groups was observed (P> 0.05) (Table 1).

Table 1. Comparison of symptoms.

Parameters	Group T	Group M	Group C	P value
Duration of symptoms (years)	3.2	3.1	3.3	>0.05
Difficulty in eating and/or drinking (%)	85%	90%	94%	>0.05

It was observed that mean CSS at baseline was 5.4 in group T, 4.2 in group M and 4.1 in group C and at 4 months was 2.6 in group T, 2.1 in group M and 0.82 in group C. Baseline VAS was 6.5 in group T, 6.2 in group M and 7.1 in group C and at 4 months was 2.5 in group T, 1.3 in group M and 0.25 in group C. A significant difference between groups was observed (P< 0.05) (Table 2, Figures 1 and 2).

Table 2. Comparison of CSS and VAS in all groups.

Parameters	Group T	Group M	Group C	P value
Baseline CSS	5.4	4.2	4.1	>0.05
4 months CSS	2.6	2.1	0.82	>0.05
Baseline VAS	6.5	6.2	7.1	>0.05
4 months VAS	2.5	1.3	0.25	>0.05

4. Discussion

This was an observational study attempted to compare different treatment modalities in oral lichen planus patients. We involved 60 patients which were randomly divided equally 3 groups of 20 each based on treatment option adopted. The result of our study showed that Group T had 3.2 years, group M had 3.1 years and group C had 3.3 years of duration of symptoms. Chauhan et al., [17] evaluated the clinical efficacy and safety of topical triamcinolone 0.1% oral paste, oral methotrexate and a combination of these in symptomatic moderate-to severe OLP. Forty-five patients were recruited and were allocated to three treatment arms. It was observed that all three treatment modalities were effective. The patients in the combination group had significantly better reduction in the outcome parameters assessed compared to the other two groups. 9 patients observed complete clinical remission, 6 in the combination group and 3 in the topical triamcinolone group. Systemic methotrexate, alone or in combination with topical triamcinolone, is effective in management of moderate to severe OLP.

It was observed in our study that mean CSS at baseline was 5.4 in group T, 4.2 in group M and 4.1 in group C and at 4 months was 2.6 in group T, 2.1 in group M and 0.82 in group C. Baseline VAS was 6.5 in group T, 6.2 in group M and 7.1 in group C and at 4 months was 2.5 in group T, 1.3 in group M and 0.25 in group C. Malhotra et al., [18] involved 49 patients with moderate to severe oral lichen planus. Group A patients received either OMP comprising 5 mg of betamethasone orally on 2 consecutive days per week, group B received triamcinolone acetonide (0.1%) paste application thrice daily for 3 months. 23 of 25 patients in group A and 23 of 24 patients in group B completed the study. Good to excellent response was seen in 17 of 25 (68.0%) patients in group A as compared with 16 of 24 (66.0%) in group B at 6 months. Symptom-free state was achieved in 13 of 25 (52%) patients in group A and 12 of 24 (50%) in group B. The difference in the mean scores within each group was statistically significant from the fourth week onward in group A and eighth week onward in group B, whereas in patients with erosive disease it was second and twelfth week onward, respectively. Chamani et al., [19] compared effects of tacrolimus, clobetasol, and pimecrolimus on OLP and found that there was insufficient evidence to support superior efficacy of any specific treatment out of these three agents.

In our study in group C, combination of methotrexate and topical triamcinolone was significantly better than the other groups. This better result can be presumed to be due to the synergistic anti-inflammatory effects of methotrexate and triamcinolone as they seem to suppress inflammation via different pathways. Another advantage of this combination could be that topical corticosteroids help to reduce the dose of systemic therapy.

The term lichen planus was termed by Wilson in 1869. Cutaneous lesions typically present as small (2 mm) pruritic, white to violaceous flat-topped papules, which can increase in size to as much as 3 cm. Lichen planus patient usually manifests with burning sensation in oral cavity, the eating, speaking and drinking become difficult. Extreme painful condition make patient weak as ingestion become difficult. Reticular lichen planus is most common form occurs in 60-65% of cases. The interlacing striations give rise of red dot called stria of Wickham. Biopsy of the lesion reveal presence of colloid bodies, civatte bodies and hyaline bodies. Basal cell degeneration and saw tooth rete pegs are characteristic features [20]. The differential diagnosis should include lichenoid reactions, leukoplakia, squamous cell carcinoma, pemphigus, mucous membrane pemphigoid, and candidiasis. Lichenoid reactions in the oral cavity are invariably drug-induced lesions. The erosive or atrophic types that affect the gingiva should be differentiated from pemphigoid, as both may have a desquamative clinical appearance. Lupus erythematosus often has white plaque-like lesions with an erythematous border. In some cases, erythema multiforme can resemble bullous lichen planus, but it is more acute and generally involves the labial mucosa [21].

5. Conclusion

The result of our study showed that combination of triamcinolone and methotrexate exhibited maximum relieve of symptoms in patients with oral lichen planus.

Author Contributions

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest

The authors declare no conflict of interest.