A Randomized Controlled Trial of Intrathecal versus Caudal Morphine-Bupivacaine on Postoperative Analgesia and Cortisol Levels in Pediatric Patients

BACKGROUND

Morphine is commonly used in pediatric caudal blocks. We compared the analgesic efficacy and effect on cortisol levels of intrathecal morphine and bupivacaine with caudal morphine and bupivacaine in children undergoing lower abdominal surgeries.

METHODS

Forty children undergoing lower abdominal surgeries were randomized to receive 4 μg/kg of intrathecal morphine and 0.5% hyperbaric bupivacaine (n = 20), or caudal morphine 40 μg/kg and 0.25% bupivacaine (n = 20). Postoperative analgesia was provided with intravenous (IV) paracetamol (PCM). The primary outcome was time to reach Face, Legs, Activity, Cry, and Consolability (FLACC) score ≥4 postoperatively. Secondary outcomes were perioperative serum cortisol levels, analgesic requirement, and parent satisfaction.

RESULTS

Since seventy 5% of patients receiving intrathecal morphine and bupivacaine did not reach a FLACC score ≥4 within 24 hours, the primary outcome was presented as the Kaplan-Meier curve. The probability of FLACC score <4 was significantly higher with intrathecal morphine and bupivacaine than with caudal morphine and bupivacaine (P < .001). The unadjusted and adjusted (for gender) hazard ratio (95% confidence interval [CI]) of occurrence of pain (FLACC score ≥4) was 0.07 (0.03-0.15, P < .001) and 0.06 (0.03-0.14, P < .001), respectively. The difference in means (95% CI) of cortisol levels between caudal morphine (with bupivacaine) and intrathecal morphine (with bupivacaine) groups were after intubation -0.667 (-4.99 to 3.65, P = .76), at 2 hours intraoperatively 7.88 (3.55-12.2, P < .001), 6 hours postoperatively 16.8 (12.5-21.1, P < .001), and 24 hours postoperatively 15.4 (11.1-19.7, P < .001) μg/dL. Intraoperatively, rescue fentanyl was required by 60% of patients on caudal morphine and bupivacaine against 20% of patients receiving intrathecal morphine and bupivacaine (absolute risk-reduction [95% CI] of 40% [12%-68%]; P = .010). Postoperative rescue fentanyl was required in 45% of patients on caudal morphine and bupivacaine and 5% of patients on intrathecal morphine and bupivacaine. All (100%) patients on caudal morphine and bupivacaine required postoperative PCM against 6 (30%) patients on intrathecal morphine and bupivacaine (absolute risk-reduction [95% CI] of 70% [50%-90%]; P < .001).The median (interquartile range [IQR]) parent satisfaction score for patients on caudal morphine (with bupivacaine) and intrathecal morphine (with bupivacaine) was 0(0-0) and 2(2-2) at 12 hours postoperatively (P < .001) and 0(0-1) and 2(1.5-2) at 24 hours postoperatively (P < .001). One patient in each group developed nausea and vomiting, and 1 patient in the intrathecal group developed pruritus. There was no incidence of respiratory depression.

CONCLUSIONS

Intrathecal morphine and bupivacaine results in longer duration of analgesia, lower analgesic consumption, prevents surgical-stress-related elevation of serum cortisol, and improves parent satisfaction compared to caudal morphine with bupivacaine in children undergoing lower abdominal surgeries.

How does changing the vector of transport disc distraction affect the outcomes of surgery in patients of temporomandibular joint ankylosis with obstructive sleep apnea?

PURPOSE

Temporomandibular joint ankylosis (TMJA) in children is associated with retrognathia, reduction in pharyngeal airway volume (PAV), and obstructive sleep apnea (OSA). Distraction-osteogenesis (DO) is the proven method in the management of OSA. There is paucity in literature about the effect of distraction vector on PAV. It can be expected that an oblique vector would improve PAV and relieve OSA. Thus, the study was designed to explore the feasibility, advantages, and disadvantages of this modified technique for managing TMJA and OSA simultaneously.

MATERIALS AND METHOD

The investigators designed a prospective study on patients of TMJA with retrognathia. Ethical approval was obtained (IECPG-547/14.11.2018). In all patients, simultaneous ankylosis release and mandibular distraction were performed. Primary outcome variables were improvement in 3-dimensional (3D) PAV and maximal interincisal opening (MIO). Secondary outcome variables were changed mandibular length, distraction relapse, and re-ankylosis. Paired t-test and multivariate ANOVA were used to assess all the parameters.

RESULT

The study included 13 joints in 8 patients of TMJA with retrognathia (2 unilateral and 6 bilateral ankylosis) with mean age of 14.25 ± 7.37 years. Mean distraction performed was 19 ± 4.0 mm. There was a statistically significant improvement of PAV by 225% (p = 0.002), a reduction in Epworth's scale (p = 0.017), an increase in MIO (p = 0.001), and an increase in mandibular length. Three patients had re-ankylosis at the 25-month follow-up.

CONCLUSION

The results of the present study conclude that modification of distraction vector improves 3D PAV and MIO in TMJA patients, with the added advantage of a reduction in overall treatment time and improved patient compliance.

To assess the analgesic efficacy of adjuvant magnesium sulfate added with ropivacaine over ropivacaine alone as a continuous infiltration in total abdominal hysterectomy wound: A randomized controlled trial

Background and Aims

Magnesium sulfate (MgSO4) has been demonstrated to have analgesic property in various clinical settings. This study explores if addition of MgSO4 to ropivacaine increases its analgesic efficacy when infiltrated continuously in the postsurgical wound following total abdominal hysterectomy.

Material and Methods

This randomized controlled trial was conducted at a tertiary care referral hospital in New Delhi, India. Fifty-two patients were randomized into two groups to receive the intervention of which 48 were able to complete the study. The first group (n = 26) received 0.25% ropivacaine infiltration and the second group (n = 26) received 0.25% ropivacaine with 5% MgSO4 at the incision site for 48 h postoperatively. Primary objective was to compare the total postoperative opioid (morphine) consumption by the study participants in both the groups and the secondary objectives were pain scores at rest and at movement, patient satisfaction score, and wound quality of life on the 7th postoperative day among the two groups.

Results

Both the groups were comparable in their demographic characteristics. The median morphine consumed at 48 h postoperatively was 16.5 [0-77] mg in the ropivacaine group and 13[1-45] mg in the ropivacaine with MgSO4 group and the difference was statistically insignificant (P = 0.788). There was no statistical difference between the groups with respect to the pain scores, patient satisfaction, or wound quality of life at 7 days.

Conclusion

The addition of MgSO4 to ropivacaine does not confer any additional postoperative analgesic benefits over ropivacaine alone in continuous wound infiltration following total abdominal hysterectomy.

Malarial Antibodies and Endemicity: Does It Affect SARS-CoV-2 Severity and Outcomes?

Background India has a disproportionately lower rate of coronavirus disease 2019 (COVID-19) severe disease and lower death rates with respect to other parts of the world. It has been proposed that malaria-endemic countries such as India are relatively protected against severe COVID-19 disease and deaths. Methods This was a cross-sectional, analytical, observational study conducted from August 2020 to July 2021 at a tertiary care COVID-19-designated center in New Delhi, India. It aimed to study the association between antimalarial antibody levels and COVID-19 disease severity and outcomes. Results One hundred forty-six patients were included in the final analysis. The mean (standard deviation {SD}) age of the study population was 44.6 (17.2) years, and there were 85 (58.2%) males. Sixty-five patients had mild disease, 14 patients had moderate disease, and 67 patients had severe disease at the time of enrolment in the study. Forty-six patients expired during the hospital stay. For the antimalarial antibody, there was a statistically significant difference between mild and moderate (p=0.018), mild and severe (p=0.016), and mild and combined moderate and severe diseases (p=0.013). However, there was no difference between the patients who survived and those who did not. Conclusion Antimalarial antibody levels may not be associated with the outcomes of COVID-19 during hospital stay. However, this study has provided some insights into the relationship between the severity and outcomes of COVID-19 and the levels of antimalarial antibodies.

Bone mineral density, vertebral fractures and trabecular bone score in primary ovarian insufficiency

PURPOSE

Bone health in primary ovarian insufficiency (POI) is under-investigated. We assessed patients with spontaneous POI for vertebral fractures (VFs) and related parameters of bone health.

METHODS

70 cases with spontaneous POI (age 32.5 ± 7.0 years) and an equal number of controls were assessed for BMD, TBS, and VFs. BMD at the lumbar-spine (L1-L4), left hip, non-dominant forearm, and TBS (iNsight software) were measured on a dual-energy X-ray absorptiometry (DXA) machine. VFs were assessed by Genant's classification. Serum FSH, LH, estradiol, T4, TSH, iPTH, serum 25(OH)D, total calcium, and inorganic phosphorus were measured.

RESULTS

BMD at the lumbar-spine, hip and forearm was reduced by 11.5%, 11.4% and 9.1% in POI as compared to controls (P < 0.001). Degraded or partially degraded microarchitecture on TBS was observed in 66.7% of patients and 38.2% of controls (P = 0.001). 15.7% of the POI patients had VFs, compared to 4.3% of controls (P = 0.045). Age, duration of amenorrhea and duration of HRT use were the significant predictors of TBS (P < 0.01). Serum 25(OH)D was the significant determinant of VFs. TBS abnormalities were higher in patients with POI and VFs. BMD was not significantly different in patients with and without VFs.

CONCLUSION

Thus, lumbar-spine osteoporosis, impaired TBS and VFs were present in 35.7%, 66.7% and 15.7% of patients with spontaneous POI in their early third decade. This indicates need for rigorous investigations for impaired bone health in these young patients and management with HRT, vitamin-D, and possible need for bisphosphonate therapy.

Comparative evaluation of the analgesic efficacy of ultrasound-guided erector spinae plane block versus intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery: A prospective randomized pilot study

OBJECTIVES

Existing research on erector spinae plane block and intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery is limited.

METHODS

In this prospective, randomized study, 60 patients aged between 18 and 60 years were randomized into two groups (erector spinae plane block and intrathecal morphine). In the erector spinae plane block group, ultrasound-guided erector spinae plane block was performed, following which a mixture of 20 mL of 0.375% ropivacaine and 0.5 mcg/kg of clonidine was injected. In the intrathecal morphine group, 150 mcg preservative-free morphine with 2 mL of normal saline was administered intrathecally. The primary outcome was to evaluate the perioperative opioid consumption in the first 24 h. The secondary outcomes were to evaluate hemodynamic response to surgical stimulus, visual analogue scale score, time to first analgesic requirement, postoperative nausea and vomiting, postoperative opioid consumption, urethral irritation, and incidence of drug-related adverse effects.

RESULTS

Total perioperative opioid consumption in the erector spinae plane block group was 355.0 (265.0, 485.0) μg and 240.0 (145.0, 370.0) μg in the intrathecal morphine group (P = 0.09). However, the patients in the erector spinae plane block group had significantly greater postoperative fentanyl consumption (235.0 [120.0, 345.0] μg) compared with those in the intrathecal morphine group (105.0 [30.0, 225.0] μg). There were no statistically significant differences noted for intraoperative opioid consumption, postoperative visual analogue scale score, time to first analgesic request, postoperative nausea and vomiting, and catheter irritation between the two groups.

CONCLUSIONS

Although no statistically significant difference in intraoperative opioid consumption was seen between the erector spinae plane block and intrathecal morphine groups, postoperative opioid consumption was significantly higher in the erector spinae plane block group than in the intrathecal morphine group in patients undergoing percutaneous nephrolithotomy surgery.

Onset Time of Spinal Anaesthesia in Pregnant Females in Knee-Chest Position: A Randomized Controlled Study

Objective

To assess the efficacy of knee-chest position in shortening the time of spinal induction in pregnant women undergoing elective cesarean section. We also assessed for any untoward adverse events that might limit their usefulness in real-life clinical scenarios.

Methods

Prospective, randomized controlled study was done in maternity operating room of tertiary care institution in 45 ASA II pregnant women undergoing elective cesarean section under spinal anaesthesia. Patients were randomly assigned to groups S (supine) and K (knee-chest position). After performing subarachnoid block (9 mg of 0.5% hyperbaric bupivacaine and 25 µg fentanyl) in the sitting position, women in group K were maintained in the knee-chest position for 60 seconds. Time to attain block height of T6 and maximum sensory blockade, intraoperative hemodynamics, Bromage score, intraoperative fluid, vasopressor requirement, and respiratory parameters were recorded. The newborn was evaluated using Apgar scores at 1 and 5 minutes.

Results:

Data of 45 patients were analyzed. Time to attain T6 block height (group K = 2.1 ± 0.65 minutes, 95% CI: 1.83-2.39; group S = 6.4 ± 0.77 minutes, 95% CI: 6.10-6.78) and time to achieve maximum sensory block height were significantly lower in group K (group K = 3.2 ± 1.35 minutes, 95% CI: 2.61-3.78; group S = 6.6 ± 0.89 min, CI: 6.19-6.98). The degree of motor block was higher in group K than that of group S at 2 minutes (P = .0002), 4 minutes (P < .0001), and 6 minutes (P < .0001), with no difference at 8 minutes. No statistically significant difference was observed in fluids and vasopressors requirement intraoperatively.

Conclusions

This study provides evidence that the onset of adequate surgical anaesthesia for the cesarean section can be hastened by placing the patient in the knee-chest position for a minute after performing the subarachnoid block in the sitting position.

Optimum time of LMA ProSeal removal in adult patients undergoing isoflurane anesthesia: A randomized controlled trial

Background and Aims:

Optimum timing of laryngeal mask airway (LMA) removal after general anesthesia with isoflurane is debatable. The objective was to investigate the potential benefits of removing LMA ProSeal at ≤0.4 Minimum alveolar concentration (MAC) isoflurane over awake and “deep plane” extubation after short duration laparoscopic gynecological surgery.

Material and Methods:

In this prospective randomized trial 90 adult female patients undergoing elective laparoscopic surgery under general anesthesia using LMA ProSeal™ as airway device were included. At the end of surgery, LMA ProSeal™ was removed when the patient was awake, could open mouth following verbal command (Group A); at MAC ≤0.4 (Group B); or at MAC of 0.6 (Group C). Adverse airway events like nausea, vomiting, airway obstruction, coughing, bucking, laryngospasm were noted. Statistical analyses were done by SPSS statistical software (IBM SPSS Statistics for Mac OS X, Version 21.0. IBM Corp, Armonk, NY).

Results:

Baseline demographic characteristics were comparable in all three groups. Coughing or bucking at the time of LMA removal was higher in group A (P = 0.004). Snoring and airway obstruction after LMA removal was significantly higher in group C compared to group A and group B (P = 0.002 and P = 0.011, respectively). There was significant change in mean arterial pressure and heart rate between before and after LMA removal on group A (P = 0.008 and P < 0.001, respectively) but not in other groups.

Conclusion:

MAC ≤0.4 can be considered optimum depth of anesthesia for removal of LMA Proseal in adult patients undergoing isoflurane anesthesia.

Challenges during bilateral total temporomandibular joint replacement for ankylosis in ankylosing spondylitis patient-a case report

Alloplastic replacement of temporomandibular joint is the preferred treatment for temporomandibular joint ankylosis (TMJA) in ankylosing spondylitis (AS) patients. These patients exhibit neck rigidity due to fixed flexion deformity or fusion of vertebrae that make the intubation and surgical positioning of patients difficult and challenging. Chin on the chest makes tracheostomy almost impossible. Fiberoptic-assisted intubation is recommended. It is mandatory that no neck flexion or rotation is performed during intubation or surgical positioning. The use of an operating table that permits lateral tilt is recommended for surgical positioning. 15-20-degrees tilt of table or a lateral positioning of the patient, can provide sufficient neck support and reduce the chances of lateral neck rotation or neck flexion. Improper positioning may result in readjusting the patient's neck repeatedly during operative procedure. This may cause serious neurological injury. Minimal documentation exists for proper and secure positioning of the patient for bilateral alloplastic joint replacement in AS patients. The authors present a case of bilateral TMJA in AS patient who was managed successfully by awake fiberoptic intubation and lateral positioning for alloplastic total joint replacement (TJR).

Comparison of Efficacy of Dexmedetomidine and Clonidine Infusion to Produce Hypotensive Anesthesia in Patients Undergoing Orthognathic Surgery: A Randomized Controlled Trial

PURPOSE

The purpose of the study was to compare the efficacy of dexmedetomidine (DEX) and clonidine (CLON) infusion to produce hypotensive anesthesia in patients undergoing orthognathic surgery.

MATERIAL AND METHODS

The investigators designed a randomized controlled trial on patients undergoing orthognathic surgery. Patients were randomized into 2 groups (DEX and CLON group). The DEX group patients received loading dose of 1 ug/kg DEX over 10 minutes followed by 0.2 to 0.5 ug/kg/hour as maintenance dose. Similarly, CLON group patients received 3 ug/kg loading dose followed by maintenance dose of 0.3 to 2 ug/kg/hour. Primary objectives were to compare the quality of surgical field, duration of surgery, amount of blood loss and secondary objectives were to compare total and rescue analgesia used, need for blood transfusion and associated adverse effects. The P value of <.05 was taken significant at confidence interval of 95%.

RESULTS

The study sample included 30 patients (15 in each group), (m:f = 1:1.1) requiring orthognathic surgery. Single jaw cases were 11 (DEX:CLON = 4:7) and bijaw cases were 19 (DEX:CLON = 11:8) in number. There was statistically insignificant difference in quality of surgical field between 2 groups (P = .15). Duration of surgery was 293.33 ± 58.75 and 247 ± 70.45 minutes in the DEX and the CLON group, respectively (P = .06). Blood loss was more in the DEX group (316.61 ± 147.19 mL) than the CLON group (263.33 ± 112.54 mL), (P = .71). Total drug used (P = .33) and rescue analgesia (P = .25) was less in the DEX group. Adverse effects were more in the CLON than the DEX group.

CONCLUSION

The results of the present study showed no significant difference between the 2 groups for any parameter. It can be concluded that both dexmedetomidine and clonidine are effective and safe in achieving controlled hypotension and safe operative field visibility.

Alloplastic total joint replacement in management of temporomandibular joint ankylosis

Both autogenous and alloplastic material have been used in management of temporomandibular joint (TMJ) ankylosis. Second surgical site, donor site morbidity, possibility of over/undergrowth, graft fracture or resorption and increased surgical time are the disadvantages of autogenous graft. Alloplastic total joint replacement (TJR) has become a promising technique in management of adult temporomandibular joint ankylosis (TMJA). This paper intends to present the role of alloplastic TJR in management of TMJA. There is significant current evidence of the role of alloplastic TJR in the management of TMJA. Results in TMJA are excellent with sustained improvement in pain free mouth opening, correction of facial asymmetry, reduction in recurrence and improved quality of life. TMJ TJR is becoming the gold standard of care in the management of TMJA, although costs can sometime preclude access to this mode of therapy.

Does Bilateral Gap Arthroplasty Increase the Severity of Obstructive Sleep Apnea in Patients With Temporomandibular Joint Ankylosis?

PURPOSE

Obstructive sleep apnea (OSA) is common in patients with bilateral temporomandibular joint ankylosis (TMJA). The purpose of this study was to compare the preoperative and postoperative apnea-hypopnea index (AHI) in patients with TMJA undergoing bilateral gap arthroplasty (BGA).

METHODS

The investigators implemented a prospective cohort study on patients with bilateral TMJA treated with BGA. The primary predictor variable was time (before and after BGA). The primary outcome variable was AHI and secondary outcome variable included posterior airway space, skeletal changes, Epworth sleepiness scale, minimum oxygen_, average oxygen saturation, and maximal incisal opening at preoperative time (T0), 1 month (T1), and at 6 months (T2). The statistical test used were Greenhouse-Geisser test, repeated measure ANOVA (1 way), followed by post hoc Bonferroni test. The P-value was taken significant when <0.05 at a confidence interval of 95%.

RESULTS

The study sample included 12 (m:f = 1:2) patients of bilateral TMJA with a mean age of 14.9 ± 4.8 years and mean follow-up of 6 months. Mean duration of ankylosis was 10.5 ± 6.9 years (median = 12). Trauma was the main etiological factor in 11 (91.7%) patients followed by infection in 1 (8.3%) patient. The mean increase in AHI was 8.6 (T0 to T1) with P-value = .002 and 23.4 (T1 to T2) and was statistically significant (P = .001). The mean decrease in posterior airway space was 4.5 ± 1.0 to 3.5 ± 0.5 (T0 to T2) and was statistically significant (P = .02). Mean difference in minimum oxygen was 6.8 (P-value = .015). Skeletal changes are consistent with clockwise rotation of the mandible and statistically significant changes in horizontal and vertical dimension. The mean change in average oxygen was statistically insignificant (P = 1.0).

CONCLUSIONS

The present study concludes that gap arthroplasty in patients with bilateral TMJA can lead to development or worsening of pre-existing mild to moderate OSA. Ramus-condyle reconstruction should be performed to prevent the retropositioning of mandible and worsening of OSA.

Efficacy of Local Anesthetic Wound Infiltration in Temporomandibular Joint Ankylosis Surgery for Control of Postoperative Pain: A Prospective, Randomized Controlled, and Double-Blinded Trial

PURPOSE

This study aimed to compare the analgesic efficacy of wound infiltration with ropivacaine alone or with adjuvants clonidine or dexamethasone for postoperative pain in temporomandibular joint ankylosis (TMJA) surgery.

MATERIALS AND METHODS

The investigators implemented a randomized controlled trial with 3 parallel groups, among the patients of bilateral TMJA visiting the maxillofacial surgery unit between March 12, 2015 and February 5, 2017. At the completion of surgery, wound infiltration was done with 0.25% of ropivacaine (R group), 0.25% of ropivacaine with 0.5 mcg/kg of clonidine (RC group), 0.25% of ropivacaine with 0.1 mg/kg of dexamethasone (RD group), and 0.2 mL/kg of drug volume on each side. The primary outcome variables were total opioid consumption (fentanyl in micrograms/kilogram) and visual analog scale for pain at rest and movement for 24 hours after surgery. The secondary outcome variables were time (minutes) to first rescue analgesic requirement and patient satisfaction scores. The patients, surgeons, and anesthesiologists collecting the data were blinded to the group allocation. Continuous and qualitative data were summarized using mean (standard deviation) and frequency distribution, respectively.

RESULTS

About 45 patients were randomized into 3 equal groups. Mean age of the sample was 17.6 ± 8.04 years (males = 24 [53%]; females = 21 [47%]). Surgery for TMJA included gap arthroplasty (n = 17), interpositional arthroplasty (n = 24), and total TMJ replacement (n = 4). Total fentanyl (micrograms) consumption during 24 hours was comparable between all the 3 groups and statistically not significant (P = .40). The pain scores (visual analog scale at rest and movement) were comparable at all time points. No significant difference was noted for time to first rescue analgesic requirement (P = .31). Patient satisfaction was higher in RC group as compared with R group (P = .009). No adverse effects were noted in any group.

CONCLUSIONS

Within the confines of the sample size and the absence of power calculation, the study implies that wound infiltration with ropivacaine was as efficacious as when mixed with adjuvants, either clonidine or dexamethasone, for control of postoperative pain for 24 hours.

Outcome of Stock Total Joint Replacement With Fat Grafting in Adult Temporomandibular Joint Ankylosis Patients

PURPOSE

Adult temporomandibular joint ankylosis (TMJA) lacks a uniform management protocol. The purpose of the study was to evaluate the outcome of stock total joint replacement (TJR) along with fat grafting around the joint in adult TMJA patients. Specific aim was to find out whether TJR can be a definitive management for adult TMJA.

METHODS

The investigators implemented a prospective study on adult TMJA patients treated with ostearthrectomy of ankylosis and stock temporomandibular joint (TMJ) TJR with fat grafting. Concomitant orthognathic correction of facial asymmetry was performed in some unilateral cases. Follow-up was carried out at regular intervals for assessing primary outcome variable of maximal incisal opening (MIO) and reankylosis. Secondary outcome variable included demographic data, etiology, duration of ankylosis (DOA), correlation between DOA and preoperative and postoperative MIO, occlusion and complications of hemorrhage, facial nerve paresis, periprosthetic joint infection, dislocation, and implant failure.

RESULTS

The study sample was composed of 41 patients (54 joints) (bilateral, n = 13; unilateral, n = 28 [right side, n = 12; left side, n = 16]). The number of recurrent cases was 15. Trauma as etiology of ankylosis was seen in n = 30 (73.2%), infection in n = 7 (17.1%), unknown in n = 3 (7.3%), and ankylosing spondylitis in n = 1 (2.4%) cases. Mean DOA was 11.95 years. Paired t test revealed a statistically significant difference between preoperative and follow-up MIO (P < .001). None of the cases showed reankylosis in the follow-up period. Pearson correlation revealed statistically negative correlation between DOA and postoperative MIO.

CONCLUSIONS

The result of this study suggests that stock TMJ TJR along with fat grafting around the joints provides adequate mouth opening without any sign and symptoms of reankylosis. Stock TMJ TJR with fat grafting can be considered as a definitive treatment modality in adult TMJA with minimum comorbidity.

Clonidine and Morphine as Adjuvants for Caudal Anaesthesia in Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Objective

The aim of this systematic review and meta-analysis is to compare the outcomes of morphine vs. clonidine use as adjuvants in caudal anaesthesia. We are specifically focused on analgesic and side effect profiles.

Methods

We searched databases and trial registration sites and include here randomised controlled trials that compare the analgesic effects of caudal clonidine vs. morphine as adjuvants on postoperative pain. The risk ratio for evaluating pain scores, the need for rescue analgesia and all adverse effects were assessed. The i2 statistic was used to assess heterogeneity. We also assessed risk of bias with Cochrane’s Collaboration tool. The quality of evidence was assessed with Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Results

Four randomised controlled trials (including 166 patients) that evaluated the use of clonidine vs. morphine as adjuvants in caudal block were included in this systematic review and meta-analysis. The pooled estimate for postoperative analgesia revealed no statistically significant differences between the clonidine group compared to morphine group (MD=2.90; 95% CI 4.05 to 9.85; i2 93%). Significantly less postoperative nausea and vomiting were reported among the patients that received clonidine vs. those that were treated with morphine (RR 0.57, 95% CI −0.36 to −0.90, i2 26%). There were no statistically significant differences between the two groups in assessments that included urinary retention, pain scores or need for rescue analgesia at 24 hours.

Conclusion

Clonidine is just as effective as morphine when used an adjuvant to local anaesthetic for caudal block, and has a more desirable side effect profile, particularly with respect to postoperative nausea and vomiting.

Low-Dose Ketamine for Outpatient Hysteroscopy: A Prospective, Randomised, Double-Blind Study

Objective

Outpatient hysteroscopy is often accompanied by pain and discomfort along with frequent occurrence of bradycardia and hypotension. This study aimed to observe if intravenous low-dose ketamine reduces the pain scores along with lowering the incidence of bradycardia and hypotension during hysteroscopy.

Methods

This prospective, randomised, double-blind trial was conducted in operating rooms in a tertiary care hospital. In this study, we enrolled 72 patients with American Society of Anesthesiologists status I to II undergoing hysteroscopy. We randomised patients into two groups, and both groups received paracervical block. The control group received intravenous pentazocine and promethazine along with saline infusion. The ketamine group received ketamine infusion (0.75 mg kg⁻¹ bolus followed by infusion at the rate of 10 mcg kg⁻¹ min⁻¹). We analysed visual analogue scale (VAS), rescue analgesic consumption, hemodynamic parameters, lowest recorded heart rate, blood pressure, level of sedation, patient’s comfort, surgeon’s satisfaction and nursing staff’s satisfaction.

Results

Analysis of the data revealed that the pain scores were similar in both the groups (p=0.493, p<0.001). Rescue analgesic was required by 47% patients in control group, compared to only 5.6% patients in ketamine group. Episodes of bradycardia and hypotension were more pronounced in the control group than in the ketamine group [77.4±10.9 vs. 78.4±5.5; 67.6±8 vs. 70.1±6 respectively] (p<0.001). Patient comfort and surgeon’s satisfaction were higher in the ketamine group, but nursing satisfaction was higher in the control group. Disorientation was present in 75% patients in the ketamine group as compared to none in the control group.

Conclusion

We concluded that low-dose ketamine in day-care hysteroscopy is an effective and safe agent.

Comparative Evaluation of Two Doses of Etoricoxib (90 mg and 120 mg) as Pre-Emptive Analgesic for Post-Operative Pain Relief in Mandibular Fracture Surgery Under General Anaesthesia: A Prospective, Randomised, Double-Blinded, Placebo-Controlled Trial

Objective

This trial investigated the post operative analgesic efficacy of oarl etoricoxib 90 mg and 120 mg and a placebo in mandibular fracture pain model.

Methods

A total of 63 adult patients with mandibular fractures who were scheduled to undergo maxillofacial surgery were randomly allocated to receive etoricoxib 90 mg, etoricoxib 120 mg and a placebo 1 hour before the surgery. Patients were followed-up till 24 hours after the surgery. Duration of analgesia, intra-operative and post-operative analgesic requirement, pain score, post-operative patient satisfaction and adverse effects were measured.

Results

The baseline demographic parameters were similar in all the groups. Duration of analgesia was longer in both the E120 (6.00±0.816 hours) and E90 (4.37±1.008 hours) groups (p<0.05) as compared to the placebo group (2.60±0.821 hours). Mean difference of duration of analgesia between E120 and E90 was 1.62 (95% confidence interval: 0.234–3.484; p>0.05). Post-operative pain intensity was significantly lower in both the E120 and E90 groups as compared to the C group. Both the etoricoxib groups required less intra-operative (p=0.002) and post-operative (p=0.001) analgesic supplementation as compared to the placebo group. The patient satisfaction score and rate of occurrence of significant adverse effects were similar among all the three groups.

Conclusion

Etoricoxib 90 mg is equally efficacious to etoricoxib120 mg with a similar side effect profile in a severely acute setting.

AMBU® LMA® in Children With Cleft Palate for Ophthalmic Surgery: A Case Report

Airway management remains a challenge in children, and the presence of a cleft palate further complicates the scenario. Endotracheal intubation, although definitive and most preferred, may be avoided for certain short-duration procedures wherein the use of laryngeal mask airway can allow quicker emergence. We present the successful airway management of 2 pediatric patients with cleft palate undergoing ophthalmological surgery, using AMBU® LMA® as the airway device of choice, which was further used as a rescue airway device in an emergent situation of "difficult to ventilate."

Dexmedetomidine-assisted drug interviews: an observation in psychiatric setting

Drug-assisted interviews are an effective tool in the management of various psychiatric illnesses where psychopharmacological, as well as routine psychological interventions, do not prove beneficial. These have most commonly been done by using barbiturates and benzodiazepines that have given favourable results for a long time. However, they carry the risk of respiratory depression and difficulty in maintaining the plane of sedation where the patient is amenable to interviewing. In our experience of drug-assisted interviews with two patients we used intravenous dexmedetomidine, which is being used in anaesthesia practice for conscious sedation or sedation in the intensive care unit. We found dexmedetomidine to be superior to thiopentone in achieving a level of conscious sedation where the patients were amenable for an interview, with no significant adverse events and faster post-anaesthetic recovery.

Randomized controlled trial to compare oral analgesic requirements and patient satisfaction in using oral non-steroidal anti-inflammatory drugs versus benzydamine hydrochloride oral rinses after mandibular third molar extraction: a pilot study

Background

Third molar extraction is associated with considerable pain and discomfort, which is mostly managed with oral analgesic medication. We assessed the analgesic effect of benzydamine hydrochloride, a topical analgesic oral rinse, for controlling postoperative pain following third molar extraction.

Methods

A randomized controlled trial was conducted in 40 patients divided into two groups, for extraction of fully erupted third molar. Groups A received benzydamine hydrochloride mouthwash and group B received normal saline gargle with oral ibuprofen and paracetamol. Oral ibuprofen and paracetamol was the rescue analgesic drug in group A. Patients were evaluated on the 3^rd and 7^th post-operative days (POD) for pain using the visual analogue score (VAS), trismus, total number of analgesics consumed, and satisfaction level of patients.

Results

The VAS in groups A and B on POD3 and POD7 was 4.55 ± 2.54 and 3.95 ± 1.8, and 1.2 ± 1.64 and 0.95 ± 1.14, respectively and was statistically insignificant. The number of analgesics consumed in groups A and B on POD3 (5.25 ± 2.22 and 6.05 ± 2.43) was not statistically different from that consumed on POD7 (9.15 ± 5.93 and 10.65 ± 6.46). The p values for trismus on POD3 and POD7 were 0.609 and 0.490, respectively and those for patient satisfaction level on POD3 and POD7 were 0.283 and 0.217, respectively.

Conclusions

Benzydamine hydrochloride oral rinses do not significantly reduce intake of oral analgesics and are inadequate for pain relief following mandibular third molar extraction.

Sono-anatomical analysis of right internal jugular vein and carotid artery at different levels of positive end-expiratory pressure in anaesthetised paralysed patients

Background and Aims:

Increasing the cross-sectional area (CSA) of the internal jugular vein (IJV) improves the success rate of cannulation and decreases complications. Application of positive end-expiratory pressure (PEEP) may increase the CSA of IJV beyond that achieved in Trendelenburg position. However, the optimum PEEP to achieve maximal increase in CSA of IJV and the effect of PEEP on IJV and CA relationship is not known.

Methods:

In this prospective, blinded, randomised controlled study, 120 anesthetised paralysed patients of the American Society of Anesthesiologists physical Status I–II were placed in 20° Trendelenburg position. Patients were randomised into four groups as follows: PEEP of 0, 5, 10 and 15 cmH₂O. CSA, anteroposterior (AP) diameter and transverse diameter (Td) of IJV and overlapping of IJV with CA were assessed using two-dimensional ultrasound. Statistical analysis was performed in SPSS version 21.0 software using Chi-square/Fisher's exact test (categorical data) and analysis of variance (continuous data) tests and P < 0.05 was considered statistically significant.

Results:

There was significant increase in AP diameter, CSA and Td with the application of PEEP 10–15 cmH₂O. Increase in CSA up to 25% with PEEP 10 and 44% with PEEP 15 was noted. There was a significant decrease in the overlapping of the internal CA with an increase in PEEP. It ranged from 21% at P0 to 17% P15.

Conclusion:

Application of PEEP 10–15 cmH₂O in Trendelenburg position significantly increased CSA and AP diameter of IJV and decreased CA overlap of IJV in anesthetised paralysed patients.

Assembly of bipolar microtubule structures by passive cross-linkers and molecular motors

During cell division, sister chromatids are segregated by the mitotic spindle, a bipolar assembly of interdigitating antiparallel polar filaments called microtubules. The spindle contains the midzone, a stable region of overlapping antiparallel microtubules, that is essential for maintaining bipolarity. Although a lot is known about the molecular players involved, the mechanism underlying midzone formation and maintenance is still poorly understood. We study the interaction of polar filaments that are cross-linked by molecular motors moving directionally and by passive cross-linkers diffusing along microtubules. Using a particle-based stochastic model, we find that the interplay of motors and passive cross-linkers can generate a stable finite overlap between a pair of antiparallel polar filaments. We develop a mean-field theory to study this mechanism in detail and investigate the influence of steric interactions between motors and passive cross-linkers on the overlap dynamics. In the presence of interspecies steric interactions, passive cross-linkers mimic the behavior of molecular motors and stable finite overlaps are generated even for non-cross-linking motors. Finally, we develop a mean-field theory for a bundle of aligned polar filaments and show that they can self-organize into a spindlelike pattern. Our work suggests possible ways as to how cells can generate spindle midzones and control their extensions.

Typing of Plasmodium falciparum DNA from 2 years old Giemsa-stained dried blood spots using nested polymerase chain reaction assay

A panel of 129 Giemsa-stained thick blood spots (TBS) confirmed for Plasmodium falciparum infection having different levels of parasite density were collected from a malaria endemic area. DNA was extracted and nested polymerase chain reaction (PCR) assay was performed to amplify P. falciparum DNA. Nested PCR assay successfully amplified P. falciparum DNA at a very low parasitaemia of ~10 parasites/μl of blood. Current PCR assay is very simple and can be used retrospectively to monitor the invasion and prevalence of different Plasmodium species in endemic areas.

Central bronchial carcinoid: Management of a case and anesthetic perspectives

Obstructing lesions of the central airways present with a variety of symptoms and are often associated with pneumonia or asthma-like states. Anesthesia to these patients often presents challenges right from the preoperative stabilization of underlying lung condition, mask ventilation in the supine position to maintaining oxygenation and ventilation in the intraoperative and postoperative period. We present here a case of a young woman with a central bronchial tumor with significant airway obstruction with potential for major bleeding and subsequent anesthetic management without lung sacrificing measures and cardiopulmonary bypass assistance.

Generation of stable overlaps between antiparallel filaments

During cell division, sister chromatids are segregated by the mitotic spindle, a bipolar assembly of interdigitating antiparallel polar filaments called microtubules. Establishing a stable overlap region is essential for maintenance of bipolarity, but the underlying mechanisms are poorly understood. Using a particle-based stochastic model, we find that the interplay of motors and passive cross-linkers can robustly generate partial overlaps between antiparallel filaments. In this situation, motors reduce the overlap in a length-dependent manner, whereas passive cross-linkers increase it independently of the length. In addition to maintaining structural integrity, passive cross-linkers can thus also have a dynamic role for overlap size regulation.

The Effect of Subchronic Dosing of Ciproxifan and Clobenpropit on Dopamine and Histamine Levels in Rats

The present study was designed to investigate the effect of once daily for 7-day (subchronic treatment) dosing of histamine H₃ receptor antagonists, ciproxifan (CPX) (3 mg/kg, i.p.), and clobenpropit (CBP) (15 mg/kg, i.p), including clozapine (CLZ) (3.0 mg/kg, i.p.) and chlorpromazine (CPZ) (3.0 mg/kg, i.p.), the atypical and typical antipsychotic, respectively, on MK-801(0.2 mg/kg, i.p.)-induced locomotor activity, and dopamine and histamine levels in rats. Dopamine and histamine levels were measured in striatum and hypothalamus, respectively, of rat brain. Atypical and typical antipsychotics were used to serve as clinically relevant reference agents to compare the effects of the H3 receptor antagonists. MK-801-induced increase of horizontal activity was reduced with CPX and CBP. The attenuation of MK-801-induced locomotor hyperactivity produced by CPX and CBP was comparable to CLZ and CPZ. MK-801 raised dopamine levels in the striatum, which was reduced in rats pretreated with CPX and CBP. CPZ also lowered striatal dopamine levels, though the decrease was less robust compared to CLZ, CPX and CBP. MK-801 increased histamine content although to a lesser degree. Subchronic treatment with CPX and CBP exhibited further increase in histamine levels in the hypothalamus compared to the MK-801 treatment alone. Histamine H₃ receptor agonist, R-α methylhistamine (10 mg/kg, i.p.) counteracted the effects of CPX and CBP. In conclusion, the subchronic dosing of CPX/CBP suggests some antipsychotic-like activities as CPX/CBP counteracts the modulatory effects of MK-801 on dopamine and histamine levels and prevents MK-801-induced hyperlocomotor behaviors.

Anesthetic dilemma in planning bilateral cataract surgery for an infant associated with congenital cardiac anomaly

In a patient with tetralogy of Fallot (TOF) and pulmonary atresia, treating the cardiac problem or the associated congenital illness is always a challenge. We describe the challenges and successful initial management of bilateral cataract to prevent visual loss in an infant with TOF with pulmonary atresia.

Comparative Sonoanatomy of Classic "Short Axis" Probe Position with a Novel "Medial-oblique" Probe Position for Ultrasound-guided Internal Jugular Vein Cannulation: A Crossover Study

BACKGROUND

Ultrasound (US)-guided short-axis approach for internal jugular vein (IJV) cannulation does not fully protect patients from inadvertent carotid artery (CA) puncture. Carotid puncture is not rare (occurring in up to 4% of all IJV cannulations) despite the use of US.

OBJECTIVES

Compare the sonoanatomy of the "medial-oblique approach" probe position with the classic US-guided "short-axis" probe position, specifically: relation of internal CA and IJV; vertical and horizontal diameter of IJV; and degree of overlapping of IJV with CA.

METHODS

One hundred consecutive patients between the ages of 18 and 50 years, both male and female, and American Society of Anesthesiologists Physical Status classification system (ASA PS) I-II undergoing elective surgery under general anesthesia were recruited in this prospective, randomized, crossover, parallel-group study.

RESULTS

The transverse diameter of the IJV was found to be significantly higher in the medial-oblique probe position (p = 0.000, mean difference 0.43 cm; 95% confidence interval [CI] 0.34-0.52). The percentage of overlap was also significantly lower in the medial-oblique probe position (48.7 ± 10.7% in short-axis vs. 36.3 ± 13.2% in medial-oblique probe position; p = 0.000; mean difference 12.4%, 95% CI 9.1-15.8). However, there was no statistically significant difference in the anteroposterior diameter of the IJV between the two probe positions (1.11 ± 0.26 cm in short axis vs 1.07 ± 0.25 cm in medial oblique; p = 0.631).

CONCLUSION

The medial-oblique probe position for IJV cannulation provides sonoanatomic superiority over the classic short-axis probe position. Further randomized, controlled trials may confirm the medial-oblique view's clinical benefit in the future.

Modeling effects of SGLT-2 inhibitor dapagliflozin treatment versus standard diabetes therapy on cardiovascular and microvascular outcomes

AIMS

Dapagliflozin, a sodium-glucose cotransporter 2 (SGLT-2) inhibitor, has been shown to lower glycated hemoglobin (HbA1c), weight, blood pressure and serum uric acid in clinical trials. Plasma lipids were also evaluated as exploratory variables. The goal of this study was to estimate the long-term cardiovascular (CV) and microvascular outcomes of dapagliflozin added to the standard of care (SOC) versus SOC using simulation methodology.

METHODS

The Archimedes Model, a validated model of human physiology, diseases and healthcare systems, was used to model a type 2 diabetes mellitus (T2DM) population derived from National Health and Nutrition Examination Survey (NHANES) with HbA1c 7-10%, taking a single oral antidiabetic agent [metformin, sulfonylureas SU or thiazolidinedione (TZD)] at the beginning of the trial. A 20-year trial was simulated comparing dapagliflozin 10 mg, given in addition to SOC, with SOC alone. SOC was based on American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) 2012 guidelines and included diet, metformin, SU, TZD, dipeptidyl peptidase-4 (DPP-4), glucagon-like peptide-1 (GLP-1), and insulin therapies, with usage levels reflective of those in NHANES. Dapagliflozin effects were derived from phase 3 clinical trial results. End points included CV and microvascular outcomes.

RESULTS

Over a 20-year period, patients on dapagliflozin were projected to experience relative reductions in the incidence of myocardial infarction (MI), stroke, CV death, and all-cause death of 13.8, 9.1, 9.6 and 5.0%, respectively, and relative reductions in the incidence of end-stage renal disease (ESRD), foot amputation, and diabetic retinopathy of 18.7, 13.0 and 9.8%, respectively, when compared with SOC.

CONCLUSIONS

On the basis of simulation results, adding dapagliflozin to currently available treatment options is projected to further decrease the CV and microvascular complications associated with T2DM.

Segregation of diffusible and directionally moving particles on a polar filament

Directed transport in living cells relies on the action of motor proteins. These enzymes can transform chemical energy into mechanical work and move directionally along filamentous tracks. At the same time, these filaments serve as a substrate for the binding of proteins performing other functions, but that also obstruct the motors' motion. Motivated by the mobile cross-linker Ase1, we theoretically study a system of molecular motors in the presence of diffusible particles. Both the motors and the obstacles shuttle between the filament and its surrounding. Numerical simulations of this system show a segregation between motors and obstacles if the filament ends act as diffusion barriers for the obstacles. A phenomenological mean-field theory captures the essential effects observed in the simulations.

Spectrally resolved photon-echo spectroscopy of Rhodamine-6G

Wavelength dependent study of a laser dye: Rhodamine-6G (Rh6G) by using spectrally resolved photon-echo spectroscopy is presented. The coherence and population dynamics of Rh6G solution in methanol changes as the excitation wavelength is tuned near its absorption maxima of 528 nm. Specifically, the central wavelength of the femtosecond laser pulse was set to 535 nm and to 560 nm while the respective spectra of the photon-echo signals were collected. This gives information on how the ultrafast dynamics of the Rh6G molecule changes with a change in the excitation wavelength.

Effect of zinc in animal models of anxiety, depression and psychosis

The role of zinc (Zn) in anxiety, depression and psychosis was studied in rodents. Zn was administered at doses of 15 and 20 mg/kg intraperitoneally for 7 days. Both doses of Zn reduced the immobility time and increased the swimming time in the modified forced swim test. In the elevated plus maze test, increases in the number of open arm entries and time spent in the open arms were observed with both doses of Zn. In the amphetamine (1 and 2 mg/kg subcutaneously) induced locomotor activity test both doses of Zn produced reduction in the total movement time, mean velocity and stereotypic movements. Extrapyramidal symptoms such as catalepsy in animals are usually observed with conventional antipsychotic agents; but in the present study, Zn at doses of 15 and 20 mg/kg did not produce any cataleptic state in mice. The results of the present study demonstrated the anxiolytic, antidepressant and antipsychotic-like effects of Zn metal ion, which may be due to its N-methyl d-aspartate receptor antagonistic activity. Concurrent administration of a lower dose of Zn with standard existing anxiolytic and antidepressant drugs in this study showed potentiating effect, suggesting that Zn could exert beneficial role when prescribed as add-on medicine in the psychiatric illnesses. The results obtained in this study are preliminary, as further research is required to confirm the exact role of Zn metal in the investigated central nervous system disorders.

Cooking fuel type, household ventilation, and the risk of acute lower respiratory illness in urban Bangladeshi children: a longitudinal study

Acute lower respiratory illnesses (ALRI) are the leading cause of death among children <5 years. Studies have found that biomass cooking fuels are an important risk factor for ALRI. However, few studies have evaluated the influence of natural household ventilation indicators on ALRI. The purpose of this study was to assess the association between cooking fuel, natural household ventilation, and ALRI. During October 17, 2004-September 30, 2005, children <5 years living in a low-income neighborhood of Dhaka, Bangladesh, were assessed weekly for ALRI and surveyed quarterly about biomass fuel use, electric fan ownership, and natural household ventilation (windows, ventilation grates, and presence of a gap between the wall and ceiling). Bivariate and multivariate analyses were performed using generalized estimating equations. Six thousand and seventy-nine children <5 years enrolled during the study period (99% participation) experienced 1291 ALRI. In the multivariate model, ≥2 windows [OR = 0.75, 95% CI = (0.58, 0.96)], ventilation grates [OR = 0.80, 95% CI = (0.65, 0.98)], and not owning an electric fan [OR = 1.50, 95% CI = (1.21, 1.88)] were associated with ALRI; gap presence and using biomass fuels were not associated with ALRI. Structural factors that might improve household air circulation and exchange were associated with decreased ALRI risk. Improved natural ventilation might reduce ALRI among children in low-income families.

PRACTICAL IMPLICATIONS

The World Health Organization has stated that controlling pneumonia is a priority for achieving the fourth Millennium Development Goal, which calls for a two-third reduction in mortality of children <5 years old compared to the 1990 baseline. Our study represents an important finding of a modifiable risk factor that might decrease the burden of respiratory illness among children living in Bangladesh and other low-income settings similar to our study site. We found that the existence of at least two windows in the child's sleeping room was associated with a 25% decreased ALRI risk. Increasing available natural ventilation within the household in similar settings has the potential to reduce childhood mortality because of acute lower respiratory illnesses.

Chirp and polarization control of femtosecond molecular fragmentation

We explore the simultaneous effect of chirp and polarization as the two control parameters for non-resonant photo-dissociation of n-propyl benzene. Experiments performed over a wide range of laser intensities show that these two control knobs behave mutually exclusively. Specifically, for the coherently enhanced fragments (C3H3+, C5H5+) with negatively chirped pulses and C6H5+ with positively chirped pulses, polarization effect is the same as compared to that in the case of transform-limited pulses. Though a change in polarization affects the overall fragmentation efficiency, the fragmentation pattern of n-propyl benzene molecule remains unaffected in contrast to the chirp case.

Epidemiology and Risk Analysis of Malaria among Pregnant Women

Malaria remains a complex problem during the pregnancy, which threatens > 35 millions pregnant women every year. Malaria pathogenesis in pregnancy results in accumulation of infected RBCs in the intervillous spaces causing severe alterations leading to the reduced materno-foetal exchanges. In this article we have revisited the current evidences of clinical implications and overall burden of malaria in pregnancy. Many adverse aftermaths including, low birth weight, intrauterine growth retardation, preterm delivery, stillbirth and anemia were found associated with malaria in pregnant women. Despite of worldwide comprehensive control programmes for malaria in pregnancy, the disease control has been a daunting task everywhere. Socio cultural, economical, lack of awareness and various logistic problems compound the disease in developing countries. Thorough evidence based information and estimates, education and awareness and strengthening of prevention programmes are needed urgently to achieve success in malaria control in pregnancy.