Comparative Study between Ultrasound-Guided Quadratus Lumborum Block Type 2 Versus Lumbar Epidural Analgesia as a Perioperative Analgesic Technique for Pelvic Cancer Surgeries

Background: The effect of the quadratus lumborum block (QLB) is believed to result from a spread of LA from its lumbar deposition cranially into the thoracic paravertebral space.The aim of this study is to compare the analgesic efficacy of an Ultrasound-guided quadrates lumborum type II block versus lumbar epidural analgesia or conventional analgesia after pelvic cancer surgeries regarding intraoperative fentanyl consumption, postoperative pain scores and morphine consumption in the first 24 hours.Methods: This study was conducted on 90 patients of American Society of Anesthesia (ASA) physical status II scheduled for elective pelvic cancer operations. Patients were randomized into three equal groups of 30 patients: Group Q: received bilateral QLB by 20ml of 0.25% bupivacaine in each side, Group E: received continuous lumbar epidural block analgesia ((0.125 % bupivacaine at infusion rate of 6ml/hour for 24 hours). Group C (Control group): were transferred to operation room without further intervention.Results: End tidal sevoflurane was significantly decreased in group Q than group C and in group E than group C at all time measurements. VAS at 0.5, 1, 8. 16 and 24 hours was significantly increased in group C than Group Q and group E. Time to first rescue dose of morphine was significantly increased in Group E than Group Q (P1 <0.001) and was significantly decreased in group C than Group Q (P2 <0.001) and was significantly decreased in group C than Group E (P3 <0.001). Total dose of morphine in 1st 24 hours was significantly increased at group C than group Q and group E (P <0.001) but there was an insignificant difference between Group Q and E.Conclusion: When compared to the control group, QLB and epidural block resulted in decreased VAS, intraoperative sevoflurane and fentanyl use and postoperative morphine consumption with a greater level of patient satisfaction. Epidural block, on the other hand, resulted in less intraoperative sevoflurane usage than QLB.

The Safety and Feasibility of a Family First Aid Approach for the Management of Postpartum Hemorrhage in Home Births: A Pre-post Intervention Study in Rural Pakistan

Objective

To evaluate the safety and feasibility of a Family First Aid approach whereby women and their families are provided misoprostol in advance to manage postpartum hemorrhage (PPH) in home births.

Methods

A 12-month prospective, pre-post intervention study was conducted from February 2017 to February 2018. Women in their second and third trimesters were enrolled at home visits. Participants and their families received educational materials and were counseled on how to diagnose excessive bleeding and the importance of seeking care at a facility if PPH occurs. In the intervention phase, participants were also given misoprostol and counselled on how to administer the four 200 mcg tablets for first aid in case of PPH. Participants were followed-up postpartum to collect data on use of misoprostol for Family First Aid at home deliveries (primary outcome) and record maternal and perinatal outcomes.

Results

Of the 4008 participants enrolled, 97% were successfully followed-up postpartum. Half of the participants in each phase delivered at home. Among home deliveries, the odds of reporting PPH almost doubled among in the intervention phase (OR 1.98; CI 1.43, 2.76). Among those reporting PPH, women in the intervention phase were significantly more likely to have received PPH treatment (OR 10.49; CI 3.37, 32.71) and 90% administered the dose correctly. No maternal deaths, invasive procedures or surgery were reported in either phase after home deliveries.

Conclusions

The Family First Aid approach is a safe and feasible model of care that provides timely PPH treatment to women delivering at home in rural communities.

A double-blind, randomized controlled trial to explore oral tranexamic acid as adjunct for the treatment for postpartum hemorrhage

BACKGROUND

Oral tranexamic acid (TXA), if effective in reducing blood loss after delivery for women experiencing primary PPH, could be administered where parenteral administration is not feasible. This trial assessed the efficacy, safety, and acceptability of oral TXA when used as an adjunct to sublingual misoprostol to treat postpartum hemorrhage (PPH) following vaginal delivery.

METHODS

From October 2016 to January 2018, women presenting at four hospitals in Senegal and Vietnam for vaginal delivery were screened for enrollment in the trial. Women diagnosed with postpartum hemorrhage (defined as blood loss ≥700 ml) were randomized to receive either oral TXA (1950 mg) or placebo in addition to 800 mcg sublingual misoprostol. Postpartum blood loss was measured using a calibrated drape. Blood loss for all PPH cases was recorded for 2 h after administration of the drugs. The primary outcome measure was the proportion of women with bleeding controlled with the trial regimen without recourse to further treatment. Secondary outcomes including the rate of severe PPH, mean/median blood loss, use of additional uterotonics and/or interventions side effects, and acceptability were also recorded.

RESULTS

Of the 258 women who received treatment for PPH, 128 received placebo and misoprostol and 130 received TXA and misoprostol. The proportion of women who had active bleeding controlled with trial drugs alone and no additional interventions was similar in both groups: 77(60.2%) placebo; 74 (56.9%) TXA, p = 0.59). Use of other interventions to control bleeding, including uterotonics, did not differ significantly between groups. Median blood loss at PPH diagnosis was 700 ml in both groups. Uterine atony alone or in addition to another cause contributed to over 90% of PPH cases reported (92.2% placebo vs. 91.5% TXA), other causes included perineal and cervical lacerations and retained placenta. Reports of side effects and acceptability were similar in the two groups.

CONCLUSION

Adjunct use of oral TXA with misoprostol to treat PPH resulted in similar clinical and acceptability outcomes when compared to treatment with misoprostol alone.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov, number NCT02805426. Registered on 3 September 2016.

Acceptability and feasibility of outpatient medical abortion with mifepristone and misoprostol up to 70 days gestation in Singapore

OBJECTIVES

The aim of the study was to examine the acceptability and feasibility of using a combined regimen of 200 mg mifepristone and 800 μg buccal misoprostol in an outpatient abortion service in Singapore, where mifepristone is not currently registered.

STUDY DESIGN

The pilot prospective study enrolled 130 women who sought termination of pregnancies up to 70 days gestation at two public hospitals in Singapore. Women received 200 mg mifepristone to take at the clinic or at home, followed 24 h later by 800 μg buccal misoprostol administered at home. A follow-up visit was scheduled seven to ten days after mifepristone to confirm the outcome of the abortion. The primary outcome was rate of successful abortion and secondary outcomes were women's preference for location of mifepristone administration and satisfaction with the method.

RESULTS

The large majority of women (96.8%) had successful abortions without recourse to surgical intervention. Most women (88.2%) chose to take mifepristone at the clinic. Most women reported the side effects as acceptable (68.3%) or neutral (26.0%). Almost all women (94.4%) were very satisfied or satisfied with the method.

CONCLUSIONS

Outpatient medical abortion with mifepristone and misoprostol up to 70 days gestation is acceptable and feasible and has the potential to expand available options in Singapore.

Misoprostol for prevention and treatment of postpartum hemorrhage: what do we know? What is next?

Misoprostol is an effective and safe uterotonic for the prevention and treatment of postpartum hemorrhage (PPH). A 600-μg oral dose of misoprostol has been shown to prevent PPH in community-based randomized controlled trials. An 800-μg sublingual dose of misoprostol appears to be a good first-line treatment for controlling PPH. Adverse effects after use of misoprostol for PPH prevention or treatment may include shivering and fever. These effects are transient, resolve on their own, and are not life threatening. Misoprostol can play an important role in settings with limited access to oxytocin, and where there is no other option for PPH care.

Angiotensin-converting enzyme (ACE) serum levels and gene polymorphism in Egyptian patients with systemic lupus erythematosus

Objectives: to investigate the association of angiotensin-converting enzyme (ACE) gene polymorphism and serum ACE level among Egyptian SLE patients and its relation to disease activity parameters. Subjects and methods: we enrolled 50 Egyptian female systemic lupus erythematosus (SLE) patients and 29 healthy controls. Measurement of serum ACE level was done using ELISA, and the ACE genotype was determined by polymerase chain reaction using genomic DNA from peripheral blood. Results: a significant difference was found in ACE genotypes between SLE patients and controls (χ2 = 7.84, p = 0.02). The frequency of ACE DD versus (DI and II) genotypes was significantly higher in SLE patients compared with controls (χ2 = 5.57, p = 0.018 and OR for risk of SLE was 3.1 with 95% confidence interval: 1.198.06). Mean serum ACE level was significantly higher in the SLE group compared with controls ( p = 0.006). Subjects with DD genotype had a significantly higher mean level than those with DI ( p = 0.015) and II genotypes ( p = 0.02). Lupus nephritis patients had a significantly higher frequency of DD versus DI and II genotypes compared with lupus patients without nephritis (Fisher's exact test, p = 0.025) and controls (χ 2 =8.74, p = 0.003). SLE patients with vasculopathy had a significantly higher frequency of DD versus DI/II genotypes compared with SLE patients without vasculopathy (Fisher's exact test, p = 0.04) and controls (χ2 = 9.84 and p = 0.002). Mean serum ACE level was significantly higher in the lupus nephritis and SLE patients with vasculopathy compared with controls ( p = 0.008, p = 0.001, respectively). Significant positive correlations were found between serum ACE level and serum creatinine and 24 h proteinuria ( p = 0.03, 0.009, respectively). SLE patients with DD genotype had a statistically significant higher mean SLEDAI score than those with (DI/II) genotypes ( p = 0.02). Significant positive correlation was found between serum ACE levels and SLEDAI scores ( p = 0.04). Conclusion: ACE genotype and subsequently serum ACE level could be associated with the disease activity of Egyptian SLE patients; in addition, ACE deletion polymorphism might be used as one of the predictive factors for the activity of SLE. Further studies on a larger number of patients should be done to determine the exact prevalence of ACE gene polymorphism among Egyptian SLE patients.

[Characteristics of patients suffering from multiple sclerosis according to professional situation]

AIM

To describe the health and professional status of multiple sclerosis patients of working age and to compare a group of patients in work (group T1) with a group of unemployed patients (group T2).

MATERIALS AND METHODS

A case-controlled study was performed. In the course of a specific consultation with a neurologist, demographic, medical and professional data were gathering using a questionnaire. Descriptive and comparative statistical analyses were then performed.

RESULTS

A total of 76 patients were included in the study: 54 were in work (group T1) and 22 were unemployed (group T2). Hence, the employment rate was 71%, with an average time since disease onset of nine years at the time of the study. Low educational level (p=0.02), disease progression (p=0.0001), the presence of motor symptoms (p=0.01), cerebellar symptoms (p=0.02) or cognitive symptoms (p=0.03), a worse EDSS (p=0.0001) and a job requiring force (p=0.05) or manual dexterity (p=0.05) were found to be negative factors. Employment in the public sector (p=0.003) or large companies (p=0.03) were found to be protective factors. Access to the workplace was better for currently employed patients (p=0.03).

CONCLUSION

This study shows that differences exist within the MS patient population according to the professional situation. It underlines the importance of clinical and demographics variables as determinants of differences in employment status. Not surprisingly, unemployed patients are more likely to have been classified as handicapped workers. Factors linked to work-induced constraints did not emerge from the survey because the questionnaire items were not appropriate for addressing this latter issue.

Analysis of pyridoquinoline derivatives by liquid chromatography/atmospheric pressure chemical ionization mass spectrometry

A method using liquid chromatography/atmospheric pressure chemical ionization mass spectrometry (LC/APCI-MS) has been developed for the characterization and determination of pyridoquinoline derivatives 4,6-bis(dimethylaminoethylamino)-2,8,10-trimethylpyrido[3,2-g]quinoline, 4,6-bis(dimethylaminoethoxy)-2,8,10-trimethylpyrido[3,2-g]quinoline and 4,6-bis[(dimethylaminoethyl)thio]-2,8,10-trimethylpyrido[3,2-g] quinoline, all with potential antitumor properties. LC separation was performed on a conventional C18 column using a binary mobile phase composed of acetonitrile and 50 mM aqueous ammonium formate at pH 3. The APCI mass spectra obtained showed that proton addition giving [M + H]+ was the common mode of ionization to the amino- and thiopyridoquinolines, whereas the alkoxypyridoquinoline was identified by the main formation of the [M - (C2H3)N(CH3)2 + H]+, followed by the [M + H]+ ion. The LC separation conditions and MS detection parameters were optimized for the determination. The analytical method was also applied to the determination of these pyridoquinoline derivatives in fetal calf serum using liquid-liquid extraction with dichloromethane. Acceptable recovery values were obtained, ranging between 45 and 98%.

Unreamed femoral nailing

Sixty one femoral fractures treated with ACE unreamed titanium nail (AIM femoral nail, ACE Medical, Los Angeles, CA) were studied. Ten patients died before bony union and three were lost to follow up. Forty eight fractures were followed up for an average of 11.2 months (4-31 months). All fractures united except one in which plating and bone grafting was performed at 6 months due to failure of progression of union. The mean time to bony union was 6.2 months. There was no implant failure but one distal interlocking bolt broke at 6 weeks. No incidence of adult respiratory distress syndrome (ARDS) was observed. Malunion was seen in one patient whereas three cases had shortening of more than 2 cm. Our results show that unreamed femoral nailing using titanium nail is a safe and effective procedure for the treatment of femoral shaft fractures.

Endurance exercise training in Guillain-Barre syndrome

The purpose of this case study was to determine whether an individual who had residual deficits following an acute incidence of Guillain-Barre Syndrome (GBS) would experience improved physiological adaptations following aerobic endurance training. A 57-year-old man who needed the aid of a crutch for walking three years following an acute bout of GBS participated in this study. Peak work level (watts), oxygen consumption (VO2 mL/min; mL/kg.min), and ventilation (VE, L/min) were determined on a bicycle ergometer (BE), a Schwinn Air-Dyne ergometer (SAE), and an arm crank ergometer (ACE) before and after exercise training. Isokinetic leg strength measured using a dynamometer and total work capacity in watts using BE were also determined before and after training. The subject trained for 16 weeks at an approximate frequency of 3 days/week, an average duration of 30 minutes, and an average intensity of 75% to 80% of pretraining peak HR. A 9% and 11% improvement was seen in peak oxygen consumption for the SAE and BE, respectively. For peak ventilation, a 23% and 11% improvement was seen for the SAE and BE, respectively. For the ACE, a 16% increase in peak ventilation was seen, with no improvement in aerobic capacity. Total work capacity on the BE was improved by 29% following training. Positive improvements were also seen in isokinetic leg strength. This study demonstrated that a man still suffering residual symptoms following an incidence of GBS was able to improve his cardiopulmonary and work capacity and isokinetic strength of his legs following a supervised training program using the SAE. The subject also reported improvements in activities of daily living.