Fentanyl Versus Dexmedetomidine for the Prevention of Emergence Agitation in Children After Sevoflurane Anaesthesia: A Comparative Clinical Study

Introduction

Sevoflurane is widely used in pediatric anesthesia due to its rapid onset and offset of action, smooth induction, and less hepatotoxicity. However, it is associated with emergence agitation, which can be frightening and harm the patient or the caregiver. While a definite preventive measure of emergence agitation is in search, the use of some drugs is associated with a lesser incidence of emergence related to sevoflurane. 

Aims and objective

This study aimed to compare the efficacy of fentanyl with dexmedetomidine in preventing emergence agitation in children undergoing surgery with sevoflurane anesthesia. Also, we assessed the perioperative hemodynamic and postoperative recovery characteristics and side effects, if any, between children receiving the two groups of drugs.

Material and method

We conducted a prospective, double-blinded, randomized controlled trial after getting approval from the institutional ethical committee. A total of 120 patients were recruited into the study and divided into two groups, F and D, of 60 patients each. Patients in group F received an infusion of injection fentanyl at 1 mcg/kg and patients in group D received infusions of injection dexmedetomidine at 0.15 mcg/kg, respectively, after induction of general anaesthesia. Additionally, all patients received a caudal epidural block with 0.125% isobaric levobupivacaine. After the conclusion of surgery, we transferred the patients to the post-anaesthesia care unit for further observation and assessment.

Result

The Pediatric Anesthesia Emergence Delirium (PAED) score for emergence agitation was significantly greater in the fentanyl group compared to the dexmedetomidine group at 0 minutes (7.08 ± 1.03 vs. 6.43 ± 1.33, p = 0.003) and 15 minutes (5.51 ± 1.7 vs. 4.01 ± 1.08, p = 0.0001) postoperative period. The mean time to eye-opening was significantly earlier amongst children receiving fentanyl than those receiving dexmedetomidine (9.3 ± 1.1 min vs. 10.12 ±1.05 min, p = 0.0001). The modified Aldrete Score for adequacy of recovery was statistically insignificant initially, but as the duration progressed to 15 minutes, the children in the fentanyl group had significantly higher scores than those in the dexmedetomidine group (8.05 ± 0.67 vs. 7.76 ± 0.62, p = 0.01).

Conclusion

Prophylactic administration of dexmedetomidine (0.15 mcg/kg) or fentanyl (1 mcg/kg) administered is effective in preventing emergence agitation. Although we found emergence agitation was higher amongst children receiving fentanyl than those receiving dexmedetomidine during the early recovery period, this difference became insignificant as the postoperative period increased to 30 minutes. 

An Incidental Finding of Congenital Complete Heart Block Presenting in Active Labor: A Multidisciplinary Approach

Congenital complete heart block is a rare occurrence. In some cases, it remains asymptomatic until adulthood or in the case of women until pregnancy. It is usually secondary to placental transfer of maternal antibodies and is associated with high mortality and morbidity. We present a case of a parturient who presented in active labor with premature rupture of membranes and decreased fetal movements. We found that the patient had a complete heart block with mild effort intolerance on evaluation. Markers for metabolic and ischemic causes were negative, and we made a provisional diagnosis of congenital complete heart block. The patient underwent a lower section cesarian section under spinal anesthesia with temporary pacemaker backup. Postoperatively, the patient underwent permanent pacemaker implantation. This case report underlines the importance of standard American Society of Anesthesiologists (ASA) monitoring, including a 12-lead electrocardiogram (ECG), which could prove decisive and life-saving in dire circumstances.

A Conserved Plasmodium Structural Integrity Maintenance Protein (SIMP) is associated with sporozoite membrane and is essential for maintaining shape and infectivity

Plasmodium sporozoites are extracellular forms introduced during mosquito bite that selectively invade mammalian hepatocytes. Sporozoites are delimited by a cell membrane that is linked to the underlying acto-myosin molecular motor. While membrane proteins with roles in motility and invasion have been well studied, very little is known about proteins that maintain the sporozoite shape. We demonstrate that in Plasmodium berghei (Pb) a conserved hypothetical gene, PBANKA_1422900 specifies sporozoite structural integrity maintenance protein (SIMP) required for maintaining the sporozoite shape and motility. Sporozoites lacking SIMP exhibited loss of regular shape, extensive membrane blebbing at multiple foci and membrane detachment. The mutant sporozoites failed to infect hepatocytes, though the altered shape did not affect the organisation of cytoskeleton or inner membrane complex (IMC). Interestingly, the components of IMC failed to extend under the membrane blebs likely suggesting that SIMP may assist in anchoring the membrane to IMC. Endogenous C-terminal HA tagging localized SIMP to membrane and revealed the C-terminus of the protein to be extracellular. Since SIMP is highly conserved amongst Plasmodium species, these findings have important implications for utilising it as a novel sporozoite specific vaccine candidate.

Addition of Clonidine or Dexmedetomidine With Bupivacaine to Prolong Caudal Analgesia in Children Undergoing Infraumbilical Surgery

Introduction

Clonidine, a selective α2 adrenergic receptor agonist, combined with caudally administered bupivacaine, is frequently used in children to prolong the duration of postoperative analgesia following infraumbilical surgery. On the other hand, dexmedetomidine is highly selective and has a greater affinity toward α2 adrenergic receptors, especially toward its α2a subtype, accountable for more analgesic and hypnotic effects than clonidine.

Aims and objectives

We designed a prospective, double-blinded, randomized controlled trial to compare the analgesic efficacy and adverse effects of clonidine and dexmedetomidine when combined with bupivacaine for caudal analgesia in children undergoing infraumbilical surgeries.

Materials and methods

A total of 60 children aged one to eight years were randomly assigned into two different groups in a double-blinded manner. Following induction of general anesthesia, every patient received a single dose of caudal bupivacaine 0.25% (0.75 ml/kg) mixed with either clonidine (1 µ/kg) in normal saline or dexmedetomidine (1 µ/kg) in normal saline. We noted the hemodynamic variables and postoperative sedation scores. Duration and quality of postoperative analgesia and the number of rescue analgesic drug doses required were recorded during the first 24 hours postoperatively. We also observed the patients for any adverse effects to the study drugs.

Result

Adding dexmedetomidine to caudally administered bupivacaine significantly increased the duration of analgesia (15 ± 0.78 hours) and decreased the need for rescue drug doses than the addition of clonidine to bupivacaine (9.63 ± 1.95 hours) in children undergoing infraumbilical surgeries. Incidences of hemodynamic changes or other side effects were comparable between patients of two groups.

Conclusion

The addition of dexmedetomidine to caudally administered bupivacaine in children undergoing infraumbilical surgeries may provide a longer duration of analgesia than the addition of clonidine, with less requirement of rescue analgesic doses and without any significant differences in the hemodynamic parameters or other side effects.

Punzi-loss:: a non-differentiable metric approximation for sensitivity optimisation in the search for new particles

We present the novel implementation of a non-differentiable metric approximation and a corresponding loss-scheduling aimed at the search for new particles of unknown mass in high energy physics experiments. We call the loss-scheduling, based on the minimisation of a figure-of-merit related function typical of particle physics, a Punzi-loss function, and the neural network that utilises this loss function a Punzi-net. We show that the Punzi-net outperforms standard multivariate analysis techniques and generalises well to mass hypotheses for which it was not trained. This is achieved by training a single classifier that provides a coherent and optimal classification of all signal hypotheses over the whole search space. Our result constitutes a complementary approach to fully differentiable analyses in particle physics. We implemented this work using PyTorch and provide users full access to a public repository containing all the codes and a training example.

MicroRNA 155:145 ratio as a marker of atherogenic tilt manifested across different age groups and risk factor profiles

Funding Acknowledgements

Type of funding sources: None.

Background

 Differential expression of microRNAs is critical in the genesis and progression of atherosclerosis. MiR145 has atheroprotective role through improved homeostasis of smooth muscle cells (SMC). MiR155 is pro-atherogenic due to its suppression of Bcl6, which antagonises NF-κB and modulates macrophages.

Purpose

  Our purpose was to determine if the differential expression of miR 155 & 145 (expressed as miR 155:145 ratio) across various age groups and risk factor profiles correlates with atherosclerotic cardiovascular disease (ASCVD).

Materials and Methods

  This observational cross-sectional study was done between Feb"19 & Jan"20 on 108 patients divided equally into 3 age groups: <18, 18-45 & >45yrs. Family history (of ASCVD or risk factors) and risk factor profile were assessed in all 3 groups; and in the latter two, presence or absence of ASCVD was additionally evaluated by coronary angiogram and/or carotid IMT. MiR155 & 145 were measured in all by RT-PCR, & the results were then compared after calculating the ratio.

Results

 miR 155:145 ratio was significantly increased in <18yrs aged subjects with a positive family history(p = 0.001). Multivariate regression analysis revealed a significant positive correlation of miR155:145 with family history of risk factors or ASCVD in this group(p < 0.001).

In the 18-45yrs age group, the miR 155:145 ratio was found to be significantly increased in patients with diabetes(p = 0.037) and significant coronary artery disease(CAD) as determined by Syntax score(p < 0.001). In multivariate regression analysis, a significant positive correlation was found between miR 155:145 and Syntax score(p < 0.001) – a ratio of 155:145 > 1 implied a greater chance of CAD, with increased numerical values correlating with increased severity of disease as evidenced by Syntax score; and a ratio < 1 decreased the chances of significant CAD considerably. A positive association was also discovered for this ratio with hypertension, diabetes, tobacco exposure and a combination of multiple risk factors, but none of them were statistically significant.

In the age group of >45 yrs, regression analysis revealed a statistically insignificant positive association of the miR 155:145 ratio with Syntax score, hypertension, dyslipidaemia and a combination of risk factors.

Conclusion

 MiR 155:145, when >1, can point towards an ‘atherogenic tilt’, and greater increase in the ratio numerically may denote more severe disease, as indicated by a positive association with Syntax Score. This atherogenic tilt occurs very early in life, even before 18 years with significant family history. Above 18 years, with addition of other risk factors, this tilt is further compounded, and correlated well with Syntax score and such risk factors. Therefore, miR 155:145 ratio may help in identifying the individuals at risk for development of clinically significant CAD and can be utilised for development of future therapeutic strategies as well as prognostication. Abstract Figure 1  Abstract Figure 2

A Rare Case of Urachal Cyst in a Patient With Uterine Fibroids

A 41-year-old woman presented to the emergency department with pain in her abdomen during menstruation. On examination, we detected a cystic lump in the midline, just below the umbilicus. Ultrasonography of the whole abdomen was suggestive of uterine fibroids with a probable mesenteric cyst. Computed tomography of the abdomen confirmed an otherwise asymptomatic, silent, urachal cyst connected to the umbilicus and urinary bladder by obliterated bands. The cyst was explored and removed surgically under combined spinal-epidural anesthesia, following a single-staged approach. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was subsequently performed. Urachal cysts are rare congenital anomalies. Any unexpected finding on clinical examination should alert clinicians for further evaluation and treatment.

Bilateral obstructive megaureter with right lower ureteric urothelial carcinoma: a very rare coalition

Upper tract urothelial cancers account for 5% of all urothelial cancers. Among these, more than 90% of tumours are located in the renal pelvis, while ureteric tumours are extremely rare. The distal ureter is the most common location, although multifocal implants may also occur. Megaureter is a common cause of obstructive uropathy in neonates and children. Nevertheless, it may be unnoticed, if asymptomatic. Megaureter may be obstructing or refluxing. Long-standing urinary stasis and recurrent urinary tract infection in megaureter may cause chronic irritation of the ureteric mucosa leading to dysplasia and malignancy. We report a 55-year-old man diagnosed with bilateral obstructive megaureter with right lower ureteric urothelial cancer and review the current literature.

A Rare Case of Partial Volvulus of the Gall Bladder Detected Preoperatively

A middle-aged woman with uterine fibroids presented with menorrhagia and diffuse abdominal pain. The patient was anemic, afebrile, anicteric, and had a palpable tender gall bladder. Initial whole abdomen ultrasonography was inconclusive, and computed tomography of her abdomen revealed partial volvulus of the gall bladder. Following optimization, the patient had undergone open cholecystectomy under general anesthesia. Intraoperatively, the gall bladder was distended, with edematous walls and rotated clockwise (270°) along the long axis to the cystic duct. We noted no gangrenous changes, and we performed detorsion of the gall bladder and cholecystectomy. Volvulus of the gall bladder can be associated with high mortality and morbidity. Good clinical examination, a high degree of suspicion given the presentation of the case, proper investigation, and timely management prevented poor outcomes in our case.

Precise Measurement of the D^{0} and D^{+} Lifetimes at Belle II

We report a measurement of the D^{0} and D^{+} lifetimes using D^{0}→K^{-}π^{+} and D^{+}→K^{-}π^{+}π^{+} decays reconstructed in e^{+}e^{-}→cc[over ¯] data recorded by the Belle II experiment at the SuperKEKB asymmetric-energy e^{+}e^{-} collider. The data, collected at center-of-mass energies at or near the ϒ(4S) resonance, correspond to an integrated luminosity of 72  fb^{-1}. The results, τ(D^{0})=410.5±1.1(stat)±0.8(syst)  fs and τ(D^{+})=1030.4±4.7(stat)±3.1(syst)  fs, are the most precise to date and are consistent with previous determinations.

Search for B^{+}→K^{+}νν[over ¯] Decays Using an Inclusive Tagging Method at Belle II

A search for the flavor-changing neutral-current decay B^{+}→K^{+}νν[over ¯] is performed at the Belle II experiment at the SuperKEKB asymmetric energy electron-positron collider. The data sample corresponds to an integrated luminosity of 63  fb^{-1} collected at the ϒ(4S) resonance and a sample of 9  fb^{-1} collected at an energy 60 MeV below the resonance. Because the measurable decay signature involves only a single charged kaon, a novel measurement approach is used that exploits not only the properties of the B^{+}→K^{+}νν[over ¯] decay, but also the inclusive properties of the other B meson in the ϒ(4S)→BB[over ¯] event, to suppress the background from other B meson decays and light-quark pair production. This inclusive tagging approach offers a higher signal efficiency compared to previous searches. No significant signal is observed. An upper limit on the branching fraction of B^{+}→K^{+}νν[over ¯] of 4.1×10^{-5} is set at the 90% confidence level.

Risk Association, Clinical Presentation and Management of Uterine Leiomyoma

Uterine leiomyoma is a common gynecological problem throughout the world. As 50% hysterectomies in black and 40% in Australians are performed due to fibroid, in our country also it is assumed that about 40%-50% hysterectomies are done due to fibroid uterus. Thus leiomyoma constitute a major public health cost to the community in terms of outpatient attendance and hospital cost for surgery. This is a descriptive type of cross sectional study among 50 patients having leiomyoma of uterus in the department of Obs and Gynae, BSMMU hospital from March 2011 to August 2011. The objective of the study is to find out the risk associated with leiomyoma, to find out the common presenting features of uterine leiomyoma and to find out best options for management. Study results showed that 62% patients were in the age group 36-45 years, 48%patients were in para1-2 group, 32% patients used combined oral contraceptive pill for contraception. Sixty percent (60%) patients presented with progressive menorrhagia and palpable mass was found in 62% cases. About 46% patients had associated medical conditions like hypertension, diabetes, obesity. Total abdominal hysterectomy was done in 32% cases. TAH with unilateral or bilateral salpingoophorectomy was done in 40% cases. Myomectomy was done in 20% cases. There is a scope for large scale study about risk factors of uterine leiomyoma like obesity, diabetes mellitus, hypertension, use of hormonal contraceptive, racial differences, different treatment modalities etc. Treatment should be individualized. However in this connection a good referral system and good communication has got a tremendous contribution in the proper management of such problems.

Versatility Of Square Flaps In Post-Burn Contractures Involving Upper Limb

Post-burn contractures are a common problem and functionally limiting for upper limbs. Many different techniques have been described in the literature for their treatment. Z-plasty and release with SSG cover are the commonest procedures done for post-burn contractures. In this study we assess the use of the square flap technique in post-burn contractures of upper limb. Eleven patients with a total number of twelve upper limb contractures (mild to moderate) involving axilla, elbow and finger underwent release by standard square flap technique. All cases were followed up for at least 6 months and analyzed for range of motion and aesthetic outcome. Patient and surgeon satisfaction was recorded. All operated cases achieved a satisfactory range of movement post-operatively without any recurrence. The number of patients who were satisfied with the surgery were 7 out of 11, and 4 patients were somewhat satisfied with the results obtained. In contrast, the surgeons were satisfied in all cases. Square flap is shown to be an easy and reliable flap for mild to moderate contractures of the anterior or posterior axillary folds, elbow contractures and finger contractures with low recurrence rate.

Evaluation of Electrolyte Imbalance in Patients With Traumatic Brain Injury Admitted in the Central ICU of a Tertiary Care Centre: A Prospective Observational Study

Introduction Electrolyte imbalance is a salient finding in traumatic brain injury which can derail their clinical course of recovery in physical and cognitive health while prolonging the hospital stay. Objective This study aims to understand the variation in electrolyte profile that occurs in traumatic brain injury patients which can help in better patient management. Materials and method 50 trauma patients with head injury (Group A) and 50 patients without head injury (Group B) admitted in Central ICU (CICU) under the Department of Anaesthesiology, Assam Medical College and Hospital (AMCH) were selected and analysed with regard to their electrolyte variability. Result All trauma patients with head injury developed an imbalance to one or more electrolytes. Then mean electrolyte level in trauma patients with a head injury and in trauma patients without head injury were 139.3±7.45 vs 143.65±8.89, p<0.05 (sodium), 3.49±0.44 vs 3.88±0.49, p<0.05 (potassium), 7.81±0.5 vs 8.9± 0.35, p<0.05 (calcium) and 2±0.33 vs 2.47±0.41, p<0.05 (magnesium) respectively. Also, patients in the head injury group had a higher incidence of hypoalbuminemia than patients without head injury 2.47±0.67 vs 2.83±0.74 (p<0.05). Conclusion We conclude that traumatic brain injury patients have a greater risk of electrolyte imbalance, viz. hyponatremia, hypokalaemia, hypocalcaemia as well as hypomagnesemia, and hypophosphatemia along with hypoalbuminemia.

Obstetric Outcome of Multiple Pregnancy in a Medical College Hospital

The Incidence of twin and high order multiple gestation has increased significantly over the past 15 years primarily because of the availability and increased use of ovulation inducing drugs and assisted reproductive technology. Both maternal and perinatal mortality and morbidity is higher in multiple pregnancy than in singleton pregnancy. Proposed study is designed to determine the incidence and obstetric outcome of multiple pregnancy which is a high-risk pregnancy in a tertiary referral hospital. The purpose of this study is to evaluate obstetric outcome of multiple pregnancy. This prospective observational study was carried out in the Department of Obs and Gynae, Mymensingh Medical College Hospital, Mymensingh from December 2011 to May 2012. Patients were selected by purposive way. In this study it was observed that incidence of twin pregnancy was 1.66% common age group 30-35 years (48%), common in multipara (74%), no pregnancy crossed EDD. Family history of twin was 32% and unknown etiology 58%. Most common maternal complication was preterm labour (60%). Commonest mode of delivery was LSCS (64%), incidence of perinatal mortality 15%, 36% baby had birth weight in between 2.1-2.5kg, all the baby requiring admission in neonatal unit. This prospective observational study revealed that perinatal mortality was high in our center, there was no maternal mortality.

Socio-demographic Profile of COVID-19 Patients and Difficulties Faced by Them while Testing RT-PCR: A Multi-center Cross-sectional Study

This study was aimed to find out the socio-demographic profiles as well as difficulties of Reverse transcription polymerase chain reaction (RT-PCR) testing faced by Coronavirus Disease 2019 (COVID-19) patients. This cross-sectional study was conducted from 10th August to 7th September 2020. Data were collected by telephone interview using a pre-designed questionnaire after taking verbal consent from the participants. Out of 281 COVID-19 patients, 279 were diagnosed by RT-PCR; 10.3% were asymptomatic. Off them 67.6%were males, 24% were hospital staffs. Majority (66.2%) were from the non-city corporation area. History of recent contact with known COVID-19 patients was present in 56.9% cases. Fever (78.3%) and cough (58%) were the most common symptoms. One third of the patients faced difficulty to test RT-PCR for COVID-19. Sixteen percent patients complained of difficulty of getting serial for testing, the maximum waiting time was one week before giving samples. Thirty patients (10.8%) had to wait longer than usual time after reaching the center before giving sample. Hospital staffs were unable to co-operate in 2.5% of the patients while difficulty of managing transport to the hospital for suspected COVID-19 patient was an issue in 2.2% of the patients. Though testing was more difficult in city corporation areas (p=0.028), delay of getting test result was less (p<0.001). Maximum delay of getting test result was 10 days. Finding out the difficulties of COVID-19 testing will help to point out the issues behind these and will help to take necessary steps to tackle this matter. Testing rate can be increased to contain this highly contagious virus in this densely populated country.

Antibiofilm and anti-quorum sensing activities of eugenol and linalool from Ocimum tenuiflorum against Pseudomonas aeruginosa biofilm

AIMS

The aim of this study is to determine the ability of two bioactive compounds, namely, eugenol and linalool, purified from leaves of Ocimum tenuiflorum for eradication of biofilm produced by Pseudomonas aeruginosa.

METHODS AND RESULTS

The phytoextract of O. tenuiflorum (KT), a common ethno-botanical plant of India, was purified through high-performance liquid chromatography and was analysed using ultraviolet (UV) spectroscopy and gas chromatography-mass spectrometry (GC-MS). Eugenol and linalool were found to be the most active amongst all phytocompounds present in phytoextract and showed a significant reduction in the viability of sessile cells of P. aeruginosa and the minimum revival after withdrawal of phyto-challenge. They could bring about notable reduction in the protein and carbohydrate content of exopolysaccharide of biofilm. Eugenol and linalool could affect the synthesis of quorum sensing (QS) proteins like LasA and LasB as well as virulence factors such as pyocyanin, and rhamnolipids, which seriously hamper the formation of biofilm. The biofilm framework was extremely affected by the phytocompounds through the reduction of protein and carbohydrate content of extracellular polymeric substance (EPS). Another interesting found out was that they brought about maximum inhibition to the genomic DNA and RNA content. The studies were supported by in silico interaction between eugenol and linalool with the QS proteins. The antibiofilm efficacies of eugenol, linalool and phytoextract (KT) were further confirmed by microscopic studies with scanning electron microscopy (SEM), atomic force microscopy and fluorescence confocal microscopy microscopic studies.

CONCLUSIONS

The phytocompounds are proved to be more effective than conventional antibiotics in inhibiting the biofilm forming sessile cells and can be used as a replacement for antibiotic.

SIGNIFICANCE AND IMPACT OF THE STUDY

Pure eugenol extracted from common basil leaves can be used as a safe substitute for common antibiotic for treatment of chronic infections caused by P. aeruginosa. It will be cost effective, devoid of notable side effects and will not generate antibiotic resistance in host body.

The safety and efficacy of day-case total joint arthroplasty

INTRODUCTION

The popularity of day-case arthroplasty has been fuelled by focus on its cost effectiveness for the healthcare system. Safety concerns still remain. The aim of this review was to compare readmission rates after total joint arthroplasty for patients undergoing day-case surgery and for inpatients.

METHODS

A comprehensive online search of databases was performed for all published articles in the English language evaluating readmission rates after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Seventeen studies were deemed eligible and included in the meta-analysis.

RESULTS

All studies included in the meta-analysis described readmission rates following THA/TKA. The readmission rate for day-case patients was 1.9% (n=124) whereas for inpatients, it was 2.0% (n=12,399). Compared with inpatient arthroplasty, day-case arthroplasty was associated with lower total readmission rates (odds ratio [OR]: 0.77, 95% confidence interval [CI]: 0.63-0.94, p=0.01). Furthermore, day-case surgery conferred a decrease in readmission rates for both THA (1.3% vs 7.0%) and TKA (2.7% vs 4.3%). Moreover, day-case THA and TKA were both associated with a decreased chance of readmission (OR: 0.27, 95% CI: 0.17-0.42, p<0.00001; and OR: 0.55, 95% CI: 0.42-0.72, p<0.00001 respectively).

CONCLUSIONS

This review emphasises that with a thoughtful, designated protocol and with careful patient selection, day-case arthroplasty is a safe and effective option.