Effectiveness of high flow nasal cannula (HFNC) versus bilevel positive airway pressure (BiPAP) in preventing tracheal reintubation in patients with high risk of extubation failure in intensive care unit - A randomised comparative trial

Background and Aims

The incidence of tracheal extubation failure in high-risk patients is higher, and non-invasive ventilation is suggested to avoid tracheal reintubation. This study compares the effectiveness of bilevel positive airway pressure (BiPAP) and high flow nasal cannula (HFNC) to reduce the rate of reintubation in intensive care unit (ICU) patients with increased risk of extubation failure.

Methods

This randomised comparative trial was conducted on 60 high-risk patients on mechanical ventilators admitted to the ICU, ready for weaning after a spontaneous breathing trial. They were randomised to Group H for HFNC and Group B for BiPAP therapy. Designated therapy was administered in these high-risk patients for up to 48 hours after tracheal extubation. Haemodynamic parameters [mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), a saturation of peripheral oxygen (SpO2), electrocardiogram (ECG)], arterial blood gas analysis (ABG) parameter [potential of hydrogen (pH), partial pressure of carbon dioxide (pCO2), partial pressure of oxygen/fraction of inspired oxygen (paO2/FiO2) ratio], the effectiveness of cough, comfort level was recorded and continuous monitoring for signs of respiratory distress and failure was done.

Results

Most of the patients were obese and had more than two risk factors for extubation failure. Several patients in Group B have significantly higher successful extubation than in Group H (P = 0.044). Most of the reintubation took place within 24 hours. The HFNC therapy was more comfortable and acceptable to patients.

Conclusion

BiPAP therapy was more efficient than HFNC in preventing tracheal reintubation among patients with a high risk of extubation failure.

Outcomes of Rubber Band Ligation in Haemorrhoids Among Outdoor Patients

Background: Out of all anorectal diseases, haemorrhoids are the most common benign disease. Haemorrhoids can be treated by various treatment modalities like medical, surgical, and instrumental. Instrumental treatment comprises rubber band ligation, sclerotherapy, and infrared and laser therapy. Out of these modalities, the rubber band ligation technique is the least invasive with a reduced rate of complications and without the need for hospitalization. Hence, the current study was conducted to evaluate the outcomes with respect to the effectiveness of rubber band ligation in grade II and III internal haemorrhoids along with the magnitude and pattern of post-procedural complications.

Methods: This is a prospective observational study, conducted on a sample of 100 patients who presented to our outdoor patient’s department and were diagnosed with haemorrhoids, either grade II or III. All enrolled study patients having haemorrhoids were banded with rubber band by Barron Ligator (Precise, Canada) with local anaesthetic agent xylocaine jelly in a single session. All patients were followed on the 10th day, 1st month, and 6th month after the procedure to assess symptomatic improvement. The endpoint of this study is to know the effectiveness of rubber band ligation in different clinical parameters such as post-ligation pain or discomfort, the requirement of analgesic, any complication, and time off work.

Results: Out of 100 patients 17 patients had grade II and 83 patients had grade III haemorrhoids. Among them, 89% were symptomatically relieved after rubber band ligation whereas the rest 11% of patients had residual symptoms.

Conclusion: Thus, we conclude that rubber band ligation for grade II and III haemorrhoids is simple, safer, easy-to-perform daycare procedure with lesser requirements of analgesics and without any need for anaesthesia.

Comparative Study of Intranasal Dexmedetomidine Versus Intranasal Ketamine as Premedicant in Children

Background: Pre-operative anxiety in children not only makes induction difficult but it is also associated with an increase in the requirement of analgesics, the incidence of post-operative nausea and vomiting (PONV), emergence delirium (ED), and postoperative maladaptive behavioral changes. It can be reduced effectively by pharmacological interventions. In a quest to find the ideal premedicant and non-invasive way of its administration, we decided to compare intranasal (IN) dexmedetomidine with IN ketamine as a premedicant in pediatric patients.

Aims and objectives: To compare sedation score, mask acceptance score (MAS) during induction, the incidence of ED, and other adverse events in both groups.

Material and methods: Some 60 children, between 1 and 8 years of age of either sex undergoing surgical procedures were included in this study and randomly divided into two groups (Group D and Group K). Thirty minutes prior to induction of anesthesia, patients of Group D received dexmedetomidine 1 mcg kg^-1 in 1 mL of 0.9% saline intranasally and patients of Group K received ketamine 5 mg kg^-1 in 1 mL of 0.9% saline intranasally through calibrated dropper (0.5 mL in each nostril) in a recumbent position. Incidences of sneezing or coughing after IN administration of study drugs were recorded. The subsequent sedation scores were assessed using MOASS at 15 min, then at 30 min following premedication at the time of parental separation. After shifting patients to operation theater inhalation induction was done. MAS at induction and any adverse effects were recorded.

Results: Children in Group K were found to be significantly more sedated at 30 min after administration of premedication and mask acceptance was also better (p value < 0.0001 with a confidence interval, CI=95%). But the incidence of ED and PONV was high.

Conclusion: Intranasal dexmedetomidine (1 mcg kg^-1) is clinically less effective as a premedicant in terms of sedation and mask acceptance in older children as compared to ketamine (5 mg kg^-1), but associated with fewer incidence of ED and PONV. We recommend the usage of IN dexmedetomidine in a higher dose (1.5-2 mcg kg^-1), through nebulization/atomizer for the desired level of sedation and mask acceptance.

The Effect of Midazolam and Dexmedetomidine Sedation on Block Characteristic Following Spinal Bupivacaine: A Randomized Comparative Study

Background:

Dexmedetomidine is widely used as an adjunct to general as well as regional anesthesia.

Aims:

This study was conducted to compare and evaluate the synergistic effect of single intravenous (i.v.) bolus dose of dexmedetomidine with midazolam on spinal block duration, analgesia, and sedation in patients undergoing infra-umbilical surgeries.

Settings and Design:

Prospective, randomized, comparative, and double-blinded study.

Materials and Methods:

One hundred patients between 18 and 60 years of age of American Society of Anesthesiologists physical status I and II posted for elective infra-umbilical surgery under subarachnoid block were randomly divided into two groups (Group D and Group M). Patients of Group D received i.v. dexmedetomidine 0.5 μg.kg⁻¹ and of Group M received i.v. midazolam 0.05 mg.kg⁻¹ as premedication 5 min before spinal anesthesia over 10 min. Vital parameters, Ramsay sedation score, level of sensory and motor block, recovery time for sensory blockade, postoperative numerical rating scale, time of requirement of the first dose of postoperative rescue analgesic, and duration of analgesia were recorded and analyzed.

Statistical Analysis:

Chi-square test, t-test, and analysis of variance test were applied to analyze data using SPSS package for Windows.

Results and Conclusion:

Premedication with single i.v. dexmedetomidine prolonged the duration and increased the maximum upper level of only sensory component of spinal anesthesia (6.42 ± 3.21 vs. 4.8 ± 1.21 thoracic segments higher than with midazolam sedation). This property can be beneficial in preventing undesirable prolongation of motor block and facilitating early ambulation in shorter duration of infra-umbilical surgeries. In addition, dexmedetomidine slowed the regression of sensory block and increased the time of the first request of analgesic.

Chromium (VI) induced oxidative stress in halotolerant alga Dunaliella salina and D. tertiolecta isolated from sambhar salt lake of Rajasthan (India)

Chromium (Cr) is one of the most serious pollutants in aquatic systems. This study was performed to understand the effect of Cr (VI) on halophilic algal strains of D. salina and D. tertiolecta. The results revealed good tolerance of D. salina towards chromium (VI) up to 8 ppm concentration, whereas tolerance level in D. tertiolecta was up to 2 ppm concentration. Cr (VI) not only inhibited the growth of D. tertiolecta, but also showed increased inhibition in the level of photosynthetic pigments, protein and carbohydrate. Results have revealed that chromium (VI) induced higher increase in lipid peroxidation and H2O2 production in D. tertiolecta than the D. salina, particularly at higher concentration of chromium (VI). Chromium (VI) induced increase in the rate of RNO bleaching, loss of pigments and thiol (-SH) group was relatively higher in D. tertiolecta than the D. salina, which is indicating that D. tertiolecta was prone to Cr (VI) induced oxidative stress. Results on RNO bleaching in the presence of radical quenchers suggested that OH° radical played an important role in the chromium (VI)-induced general oxidative stress in D. tertiolecta.

Electric-field-induced patterns in soft viscoelastic films: from long waves of viscous liquids to short waves of elastic solids

We show that the electric field driven surface instability of viscoelastic films has two distinct regimes: (1) The viscoelastic films behaving like a liquid display long wavelengths governed by applied voltage and surface tension, independent of its elastic storage and viscous loss moduli, and (2) the films behaving like a solid require a threshold voltage for the instability whose wavelength always scales as approximately 4xfilm thickness, independent of its surface tension, applied voltage, loss and storage moduli. Wavelength in a narrow transition zone between these regimes depends on the storage modulus.

Deformation of metallic liquid drop by electric field for contacts in molecular–organic electronics

We study and use the behaviour of a metallic liquid drop in the presence of an external electric field (EF). The droplet profile is governed by the stabilizing surface energy and the destabilizing electrostatic energy, with a critical voltage beyond which the droplet becomes unstable. We explore the EF-induced behaviour of low melting temperature alloy in the liquid state and observe that the droplet modifications in the linear response regime can be retained upon cooling the drop to the solid state. We demonstrate that this procedure can be used as an electrode with precise dimensions for applications in molecular and polymer electronics.

Urinary bladder paraganglioma in a case of von Hippel-Lindau disease

Pheochromocytoma is a well-known association in patients with von Hippel-Lindau disease. However, extra-adrenal pheochromocytoma or paraganglioma with this association is rare. We describe a patient with von Hippel-Lindau disease who presented with haematuria and was diagnosed to have a urinary bladder paraganglioma, which is an extremely rare tumour. Herein we report this case which, to the best of our knowledge, represents the first case highlighting the association of urinary bladder paraganglioma with von Hippel-Lindau disease.

Rigid nasendoscope with video camera system for intubation in infants with Pierre-Robin sequence

We describe an alternative intubation technique using a rigid nasendoscope and a video camera monitor system in two infants with Pierre-Robin sequence presenting for palatoplasty. After induction with an inhalational anaesthetic technique, the tracheas of the infants could not be intubated with direct laryngoscopy using a Wisconsin blade. In the absence of a flexible paediatric fibrescope, a rigid endoscope (2.7 mm, 70 degrees lateral illumination) was passed orally to provide a view of the glottis on the monitor screen. A tracheal tube, bent into a J-shape using a stylet, was inserted orally and manipulated into the trachea, under video guidance. This technique proved to be simple, permitting a favourable view of the glottis. It should be considered for passing a tracheal tube through the vocal cords in infants who present with a difficult airway.

Efficacy of turmeric on blood sugar and polyol pathway in diabetic albino rats

In the traditional system of medicine, Ayurveda, several spices and herbs are thought to possess medicinal properties. Among the spices, turmeric rhizomes (Curcuma longa. Linn.) are used as flavoring and coloring agents in the Indian diet everyday. In this research, we studied the effect of turmeric and its active principle, curcumin, on diabetes mellitus in a rat model. Alloxan was used to induce diabetes. Administration of turmeric or curcumin to diabetic rats reduced the blood sugar, Hb and glycosylated hemoglobin levels significantly. Turmeric and curcumin supplementation also reduced the oxidative stress encountered by the diabetic rats. This was demonstrated by the lower levels of TBARS (thiobarbituric acid reactive substances), which may have been due to the decreased influx of glucose into the polyol pathway leading to an increased NADPH/NADP ratio and elevated activity of the potent antioxdiant enzyme GPx. Moreover, the activity of SDH (sorbitol dehydrogenase), which catalyzes the conversion of sorbitol to fructose, was lowered significantly on treatment with turmeric or curcumin. These results also appeared to reveal that curcumin was more effective in attenuating diabetes mellitus related changes than turmeric.

Is open pyeloplasty still justified?

OBJECTIVE

To determine the success rate, complications and morbidity from open pyeloplasty.

PATIENTS AND METHODS

The study included 63 patients with confirmed pelvi-ureteric junction (PUJ) obstruction who underwent 66 pyeloplasties. Their records were analysed retrospectively for age, clinical presentation, serum creatinine level, presence of infection, surgical technique, and pre- and post-operative isotopic renography. The mean (range) follow-up was 15.5 (3-60) months.

RESULTS

Pain was the most common presenting symptom; most pyeloplasties were dismembered and 77% of the procedures were performed by urological trainees. Retrograde pyelography did not alter the management in any patient. The complications were persisting PUJ obstruction in four, urinary leakage in two, transient vesico-ureteric obstruction in two and meatal stenosis in one. There were no complications in non-intubated pyeloplasties. Pain was successfully relieved in 98% of patients, renal function improved or remained stable in 92% and deteriorated in 7.7%. One patient underwent a revision pyeloplasty and another required nephrectomy. A younger patient, absence of urinary tract infection and absence of palpable mass were favourable factors.

CONCLUSION

Pyeloplasty is the most effective and permanent treatment for PUJ obstruction. Newer endoscopic procedures currently used must be carefully assessed against this 'gold standard' before becoming widespread.