Caudal Additives in Pediatrics: A Comparison Among Midazolam, Ketamine, and Neostigmine Coadministered with Bupivacaine

Single-shot "kiddie caudal" with bupivacaine alone is losing popularity because of its duration of 4-8 h. In a prospective randomized double-blind clinical study, we assessed and compared the efficacy of ketamine, midazolam, and neostigmine coadministered with bupivacaine in a caudal epidural to provide intraoperative and postoperative pain relief. Eighty children (ASA status I) aged 5-10 yr undergoing unilateral inguinal herniotomy were allocated randomly in equal numbers (n = 20) into 4 groups to receive a caudal injection of 0.25% bupivacaine (1 mL/kg) with or without ketamine (0.5 mg/kg), midazolam (50 microg/kg), and neostig-mine (2 microg/kg), after the induction of standardized general anesthesia without premedication. Monitoring for pain, sedation, postoperative nausea/vomiting, dizziness, and pruritus was performed by anesthesiologists blinded to the study allocation. The time to first analgesic administration (paracetamol syrup) was longer (P < 0.05) in the bupivacaine-neostigmine group and the bupivacaine-midazolam group than in the other groups. Undesirable effects, such as emesis, pruritus, and dizziness, were comparable in all groups. However, the incidence of hallucination was more frequent in the bupivacaine-ketamine group compared with the other groups. This study shows that single-shot caudal coadministration of bupivacaine-neostigmine and bupivacaine-midazolam was associated with an extended duration of postoperative pain relief.

Variability of milk fat globule membrane protein gene between cattle and riverine buffalo

A study on butyrophilin (BTN) gene was conducted to detect variability at nucleotide level between cattle and buffalo. Hae III PCR-RFLP was carried out in crossbred cattle and it revealed polymorphism at this locus. Three genotypes namely, AA, BB and AB and two alleles were observed with frequencies 0.78, 0.17, 0.04 and 0.87, 0.13, respectively. The sequences of different cattle, buffalo and sheep breeds have been reported in the EMBL gene bank with accession numbers: AY491468 to AY491475. The nucleotides, which have been substituted from allele A to B, were found to be C to G (71st nucleotide), C to T (86th nucleotide), A to T (217th nucleotide), G to A (258th nucleotide), A to C (371st nucleotide) and C to T (377th nucleotide). The nucleotide substitution at 71st, 86th and 377th position of the fragment were expected to be a silent mutation where as nucleotide changes at 217th, 258th and 371st positions were expected to be substituted by lysine with arginine, valine with isoleucine and leucine with proline in allele B. The differences of nucleotides and amino acids between cattle, buffalo and sheep breeds have been revealed and on the basis of nucleotide as well as protein variability the phylogenetic diagram have been developed indicating closeness between cattle and buffalo.

Histology, Immunohistochemistry and Ultrastructure of the Equine Palatine Tonsil

The palatine tonsils of five young horses formed 10-12 cm elongated follicular structures extending from the root of the tongue on either side to the base of the epiglottis and lateral to the glossoepiglottic fold. The stratified squamous non-keratinized epithelium of the outer surface was modified into crypts as reticular epithelium by heavy infiltration of lymphoid cells from underlying lymphoid follicles. In places, lymphoid tissue reaching almost to the surface and with only one to two cell layers intact was identified as the lymphoepithelium. Langerhans cells with Birbeck granules were interspersed between epithelial cells. Lymphoid tissue organized in lymphoid follicles constituted the parenchyma of the palatine tonsil. CD4-positive cells were more numerous and CD8-positive lymphocytes less numerous compared with their distribution in the lingual tonsil. B cells and macrophages were also more numerous than in the lingual tonsil and lectins showed a different pattern of attachment. M cells were not observed. High endothelial venules with well-developed vesiculo-vacuolar organelle had structural evidence of transendothelial and interendothelial migration of lymphocytes. Striated muscles as seen in the deeper lamina propria mucosae of the lingual tonsil were absent. The immunohistological and ultrastructural characteristics of the equine palatine tonsil are similar to those of humans but differ from those of the lingual tonsil and are consistent with a role as an effector and inductor immunological organ.

Histology, Immunohistochemistry and Ultrastructure of the Equine Tubal Tonsil

The tubal tonsil of the horse surrounds the pharyngeal opening of the eustachian tube and is lined by pseudostratified columnar ciliated epithelium interspersed with areas of follicle-associated epithelium (FAE) heavily infiltrated by lymphocytes but devoid of goblet and ciliated cells. Scanning and transmission electron microscopy revealed microvillous cells and cells with features characteristic of M cells such as reduced microvilli or depressed bare surface, more numerous mitochondria, small vesicles and lysosomes, as well as vimentin filaments and epitopes specific for GS 1-B4 as previously seen in the nasopharyngeal tonsil. M cells were also identified in areas of respiratory epithelium not associated with lymphoid follicles and appeared to be the nasal mucosal counterparts of recently described intestinal villous M cells in the mouse. The underlying lymphoid tissue of the FAE was generally organized as solitary lymphoid follicles without germinal centres in contrast to the diffuse and large amount of organized lymphoid follicles with germinal centres that characterize the nasopharyngeal tonsil. CD8+ T and B-lymphocytes were much fewer than in the nasopharyngeal tonsil. High endothelial venules were mainly oriented towards the parafollicular area and contained much fewer endothelial pores and vesiculo-vacuolar organelles. Finally, scattered small clusters of mucus acini and striated muscles were other features that differentiated the tubal and nasopharyngeal tonsils.

Annual risk of tuberculous infection in four defined zones of India: a comparative picture

SETTING

Twenty-six selected districts in India.

OBJECTIVES

To estimate the average annual risk of tuberculous infection (ARTI) in four defined zones in the country.

STUDY DESIGN

A tuberculin survey was conducted in selected clusters of 26 districts in four defined zones of India. Children 1-9 years of age were subjected to tuberculin testing with ITU PPD RT23 with Tween 80, and the maximum transverse diameter of induration was measured 72 h later. Prevalence of infection was estimated using the cut-off point method (Method I) and the mirror-image technique (Method II) among children without bacille Calmette-Guérin scar. Results from individual zones have been reported earlier, and the results from all four zones are presented here as a consolidated summary.

RESULTS

The ARTI computed from estimated prevalence was found to be lowest in the southern zone (Method I: 1.1%, Method II: 1.0%). It was higher in the eastern zone (1.3% by both methods) and highest in the western (Method I: 1.8%, Method II: 1.6%) and northern zones (1.9% by both methods). The proportion of infected children was found to be significantly higher in urban than in rural areas in all zones.

CONCLUSION

The intensified tuberculosis control efforts need to be sustained for many years.

Gene activation and protein expression following ischaemic stroke: strategies towards neuroprotection

Current understanding of the patho-physiological events that follow acute ischaemic stroke suggests that treatment regimens could be improved by manipulation of gene transcription and protein activation, especially in the penumbra region adjacent to the infarct. An immediate reduction in excitotoxicity in response to hypoxia, as well as the subsequent inflammatory response, and beneficial control of reperfusion via collateral revascularization near the ischaemic border, together with greater control over apoptotic cell death, could improve neuronal survival and ultimately patient recovery. Highly significant differences in gene activation between animal models for stroke by middle cerebral artery occlusion, and stroke in patients, may explain why current treatment strategies based on animal models of stroke often fail. We have highlighted the complexities of cellular regulation and demonstrated a requirement for detailed studies examining cell specific protective mechanisms after stroke in humans.

Histology and Ultrastructure of the Equine Lingual Tonsil. II. Lymphoid Tissue and Associated High Endothelial Venules

The stratified squamous epithelium of the lingual tonsil of five young horses was infiltrated with CD4 and CD8 positive cells, which were very numerous in the crypt reticular epithelium along with macrophages and IgGb and IgA positive cells. Lymphoid follicles of the lamina propria mucosae consisted of a parafollicular area, corona and germinal centre. The parafollicular area was populated by large numbers of CD4 and CD8 positive lymphocytes as well as macrophages, inter-digitating cells, and a few B-lymphocytes. The germinal centre contained mainly IgGb and IgG(T) positive cells, plasma cells and small numbers of follicular dendritic cells, macrophages, CD4, CD8 and IgA positive cells. Some venules in the parafollicular and inter-follicular areas had features characteristic of high endothelial venules with irregular nuclei and cytoplasmic processes on the luminal surface. In addition to the normal cytoplasmic organelles, a novel vesiculo-vacuolar organelle was observed in small clusters toward the lateral, luminal and abluminal surfaces of these high endothelial venules. These vesiculo organelles along with their stomata and diaphragms, communicated with each other and with inter-endothelial clefts forming a structural basis for enhanced permeability and extravasation of macromolecules. The presence of lymphocytes in the high endothelial venules is consistent with transmural and inter-endothelial passage of these cells.

The prevalence of pressure ulcers in hospitalised patients in a university hospital in India

OBJECTIVE

To estimate the prevalence of pressure ulcers in hospitalised patients and any underlying or predisposing factors to ulceration.

METHOD

This cross-sectional study took place in a university hospital in Varanasi, India. A total of 445 patients hospitalised in medical and surgical wards were examined in a single day for the number, site and grade of pressure ulcers. Haemoglobin, serum albumin and blood sugar levels of patients with pressure ulcers were recorded.

RESULTS

The prevalence of pressure ulcers was high (4.94%). Anaemia, malnutrition and diabetes were important risk factors, while morbidity due to pressure ulcers in long-stay wards, such as neurology, was exceptionally high (40.9%).

CONCLUSION

Pressure ulcers remain one of the most neglected aspects of health-care provision in India and identifying their associated risk factors at an early stage may go a long way in preventing their occurrence.

Histology and Ultrastructure of the Equine Lingual Tonsil. I. Crypt Epithelium and Associated Structures

The microstructural and ultrastructural features of the equine lingual tonsil were studied in five young horses. Located at the root of the tongue it presented an irregular surface with rounded elevations, numerous folds and crypts. Stratified squamous non-keratinized epithelium lining its outer surface was modified by heavy infiltration of lymphoid cells to form reticular epithelium within the crypt. The latter implies a role in initiating and maintaining immune responses to incoming infectious agents and antigens. Lamellated structures resembling Hassall's corpuscle were observed towards the outer surface epithelium. Microplicae were visible by scanning electron microscopy on the surface of both the outer and reticular epithelia. No microvillus cells resembling M cells were observed. The stratum superficiale of the reticular epithelium showed strong affinity for Soybean (SBA), Phosphocarpus tetragonolobus 1 (WBA 1), Ulex europaeus (UEA) and Griffonia simplicifolia 1 isolectin-B4 (GS1-B4). The characteristic lectin binding patterns may be useful for embryological and microbiological investigations. Vimentin filaments were not detected consistent with absence of M cells. Mucus glandular acini in the deeper lamina propria mucosae contained glycogen, acidic, neutral and weakly sulphated mucopolysaccharides. Transmission electron microscopy revealed that the layers of the outer surface and reticular epithelia shared characteristic features except the stratum superficiale, which had nuclei of varying shapes and an abundance of cell organelles. A few mast cells with electron lucent granules and myelinated nerve fibres were localized in the deeper portion.

Randomised trial of intravenous infusion of ephedrine or mephentermine for management of hypotension during spinal anaesthesia for Caesarean section

This study compared the effects of intravenous infusions of ephedrine and mephentermine for maintenance of maternal arterial pressure and neonatal outcome in pregnant women receiving subarachnoid block for lower segment Caesarean section. Sixty patients who developed hypotension following subarachnoid block for Caesarean section were randomly divided into two groups of 30 each to receive an intravenous infusion of ephedrine or mephentermine. Hypotension was defined as a decrease in systolic blood pressure of > or = 20% from the baseline value or an absolute value of <100 mmHg, whichever was higher. The vasopressor infusion was titrated to maintain systolic blood pressure between 'hypotension' and baseline values. Baseline haemodynamic parameters, haemodynamic changes subsequent to the start of vasopressor infusion, duration of hypotension and amount of vasopressor required were statistically similar for both groups. Neonatal APGAR scores and acid-base profiles were also comparable. To conclude, mephentermine can be used as safely and effectively as ephedrine for the management of hypotension during spinal anaesthesia in patients undergoing elective Caesarean section.

Carbon dioxide sensitivity during hypoglycaemia-induced, elevated metabolism in the anaesthetized rat

We have utilized an anaesthetized rat model of insulin-induced hypoglycaemia to test the hypothesis that peripheral chemoreceptor gain is augmented during hypermetabolism. Insulin infusion at 0.4 U kg (-1)min(-1) decreased blood glucose concentration significantly to 3.37 +/- 0.12 mmol l(-1). Whole-body metabolism and basal ventilation were elevated without increase in P(a,CO(2)) (altered non-significantly from the control level, to 37.3 +/- 2.6 mmHg). Chemoreceptor gain, measured either as spontaneous ventilatory airflow sensitivity to P(a,CO(2)) during rebreathing, or by phrenic minute activity responses to altered P(a,CO(2)) induced by varying the level of artificial ventilation, was doubled during the period of hypermetabolism. This stimulatory effect was primarily upon the mean inspiratory flow rate, or phrenic ramp component of breathing and was reduced by 75% following bilateral carotid sinus nerve section. In vitro recordings of single carotid body chemoafferents showed that reducing superfusate glucose concentration from 10 mM to 2 mM reduced CO(2) chemosensitivity significantly from 0.007 +/- 0.002 Hz mmHg(-1) to 0.001 +/- 0.002 Hz mmHg(-1). Taken together, these data suggest that the hyperpnoea observed during hypermetabolism might be mediated by an increase in the CO(2) sensitivity of the carotid body, and this effect is not due to the insulin-induced fall in blood glucose concentration.