Large-scale annotated dataset for cochlear hair cell detection and classification

Our sense of hearing is mediated by cochlear hair cells, of which there are two types organized in one row of inner hair cells and three rows of outer hair cells. Each cochlea contains 5-15 thousand terminally differentiated hair cells, and their survival is essential for hearing as they do not regenerate after insult. It is often desirable in hearing research to quantify the number of hair cells within cochlear samples, in both pathological conditions, and in response to treatment. Machine learning can be used to automate the quantification process but requires a vast and diverse dataset for effective training. In this study, we present a large collection of annotated cochlear hair-cell datasets, labeled with commonly used hair-cell markers and imaged using various fluorescence microscopy techniques. The collection includes samples from mouse, rat, guinea pig, pig, primate, and human cochlear tissue, from normal conditions and following in-vivo and in-vitro ototoxic drug application. The dataset includes over 107,000 hair cells which have been identified and annotated as either inner or outer hair cells. This dataset is the result of a collaborative effort from multiple laboratories and has been carefully curated to represent a variety of imaging techniques. With suggested usage parameters and a well-described annotation procedure, this collection can facilitate the development of generalizable cochlear hair-cell detection models or serve as a starting point for fine-tuning models for other analysis tasks. By providing this dataset, we aim to give other hearing research groups the opportunity to develop their own tools with which to analyze cochlear imaging data more fully, accurately, and with greater ease.

Large-scale annotated dataset for cochlear hair cell detection and classification

Our sense of hearing is mediated by cochlear hair cells, localized within the sensory epithelium called the organ of Corti. There are two types of hair cells in the cochlea, which are organized in one row of inner hair cells and three rows of outer hair cells. Each cochlea contains a few thousands of hair cells, and their survival is essential for our perception of sound because they are terminally differentiated and do not regenerate after insult. It is often desirable in hearing research to quantify the number of hair cells within cochlear samples, in both pathological conditions, and in response to treatment. However, the sheer number of cells along the cochlea makes manual quantification impractical. Machine learning can be used to overcome this challenge by automating the quantification process but requires a vast and diverse dataset for effective training. In this study, we present a large collection of annotated cochlear hair-cell datasets, labeled with commonly used hair-cell markers and imaged using various fluorescence microscopy techniques. The collection includes samples from mouse, human, pig and guinea pig cochlear tissue, from normal conditions and following in-vivo and in-vitro ototoxic drug application. The dataset includes over 90'000 hair cells, all of which have been manually identified and annotated as one of two cell types: inner hair cells and outer hair cells. This dataset is the result of a collaborative effort from multiple laboratories and has been carefully curated to represent a variety of imaging techniques. With suggested usage parameters and a well-described annotation procedure, this collection can facilitate the development of generalizable cochlear hair cell detection models or serve as a starting point for fine-tuning models for other analysis tasks. By providing this dataset, we aim to supply other groups within the hearing research community with the opportunity to develop their own tools with which to analyze cochlear imaging data more fully, accurately, and with greater ease.

Runx1 controls auditory sensory neuron diversity in mice

Sound stimulus is encoded in mice by three molecularly and physiologically diverse subtypes of sensory neurons, called Ia, Ib, and Ic spiral ganglion neurons (SGNs). Here, we show that the transcription factor Runx1 controls SGN subtype composition in the murine cochlea. Runx1 is enriched in Ib/Ic precursors by late embryogenesis. Upon the loss of Runx1 from embryonic SGNs, more SGNs take on Ia rather than Ib or Ic identities. This conversion was more complete for genes linked to neuronal function than to connectivity. Accordingly, synapses in the Ib/Ic location acquired Ia properties. Suprathreshold SGN responses to sound were enhanced in Runx1CKO mice, confirming the expansion of neurons with Ia-like functional properties. Runx1 deletion after birth also redirected Ib/Ic SGNs toward Ia identity, indicating that SGN identities are plastic postnatally. Altogether, these findings show that diverse neuronal identities essential for normal auditory stimulus coding arise hierarchically and remain malleable during postnatal development.

Celiac Plexus Denudation in Triangle Dissection in Pancreatico Duodenectomy: Perioperative Anesthetic Implications

This is a case report of inadvertent right celiac plexus denudation during triangle dissection during the surgery for carcinoma of pancreas under combined general epidural anaesthesia. Operative removal of the ganglia has its own autonomic effects, which are important to observe for anesthesiologists and perioperative critical care physicians alike.

The Immunoglobulin Superfamily Member Basigin Is Required for Complex Dendrite Formation in Drosophila

Coordination of dendrite growth with changes in the surrounding substrate occurs widely in the nervous system and is vital for establishing and maintaining neural circuits. However, the molecular basis of this important developmental process remains poorly understood. To identify potential mediators of neuron-substrate interactions important for dendrite morphogenesis, we undertook an expression pattern-based screen in Drosophila larvae, which revealed many proteins with expression in dendritic arborization (da) sensory neurons and in neurons and their epidermal substrate. We found that reporters for Basigin, a cell surface molecule of the immunoglobulin (Ig) superfamily previously implicated in cell-cell and cell-substrate interactions, are expressed in da sensory neurons and epidermis. Loss of Basigin in da neurons led to defects in morphogenesis of the complex dendrites of class IV da neurons. Classes of sensory neurons with simpler branching patterns were unaffected by loss of Basigin. Structure-function analyses showed that a juxtamembrane KRR motif is critical for this function. Furthermore, knock down of Basigin in the epidermis led to defects in dendrite elaboration of class IV neurons, suggesting a non-autonomous role. Together, our findings support a role for Basigin in complex dendrite morphogenesis and interactions between dendrites and the adjacent epidermis.

Ultrasound Guided Stellate Ganglion Block with Dexmedetomidine as an Adjuvant in Complex Regional Pain Syndrome (CRPS)

This is a case report of successful use of ultrasound for stellate ganglion (SG) blocks in CRPS I in 11 patients using local anesthetic bupivacaine with injection dexmedetomidine as an adjunct. Ultrasound helped us to deposit Local anesthetics in target area without any noticeable side effects and trauma to adjacent structures.

Unexpected Sudden Bouts of Coughing During Endourology Procedures: Sign of Impending Doom

Endourological procedures are commonly performed in our daily practice. Most of the time, this type of surgery is usually performed under regional anesthesia and is usually not associated with any complications. The irrigation pump used in such procedures consists of irrigating fluid flowing in high pressure. If left unnoticed, sometimes irrigating fluid can lead to passage of air into the patient venous system leading to air embolism. This can be a disastraous complication leading to even sudden mortality. Here we present a case of such incident where patient has sudden coughing followed by drop in oxygen saturation.

Sensory Neuron Diversity in the Inner Ear Is Shaped by Activity

In the auditory system, type I spiral ganglion neurons (SGNs) convey complex acoustic information from inner hair cells (IHCs) to the brainstem. Although SGNs exhibit variation in physiological and anatomical properties, it is unclear which features are endogenous and which reflect input from synaptic partners. Using single-cell RNA sequencing, we derived a molecular classification of mouse type I SGNs comprising three subtypes that express unique combinations of Ca²⁺ binding proteins, ion channel regulators, guidance molecules, and transcription factors. Based on connectivity and susceptibility to age-related loss, these subtypes correspond to those defined physiologically. Additional intrinsic differences among subtypes and across the tonotopic axis highlight an unexpectedly active role for SGNs in auditory processing. SGN identities emerge postnatally and are disrupted in a mouse model of deafness that lacks IHC-driven activity. These results elucidate the range, nature, and origins of SGN diversity, with implications for treatment of congenital deafness.

Regional Anaesthesia in Clavicle Surgery

In routine practice, regional anaesthesia is less commonly used for clavicular fracture compared to general anaesthesia. We report two cases of clavicle fracture for which operative treatment was done under combined superficial cervical plexus and interscalene brachial plexus block. In both the cases combination of ropivacaine and dexmeditomidine was used for block. Both the patients exhibited comfort and there was no additional analgesic demand in both the cases. Thus combination of interscalene and superficial cervical plexus block can prove to be useful in patients with clavicle fracture where administration of general anaesthesia and its adverse effects could be avoided.

Universal health coverage in a regional Nepali hospital: who is exempted from payment?

This study assessed the characteristics of beneficiaries of a government-led policy of exemption for payment being provided in a regional hospital in Nepal. In January and February 2012, 9547 patients sought services at the out-patient clinic, the majority (83%) of whom were from the same district although this was a referral hospital for 15 districts. Only 10.8% received exemption from payment; 66% of the individuals aged >60 years and eligible for exemption were missed. These shortcomings highlight intrinsic weaknesses in the current implementing mechanisms for payment exemption, which may not be providing financial protection. This hampers efforts towards achieving universal health coverage.

Integrins establish dendrite-substrate relationships that promote dendritic self-avoidance and patterning in drosophila sensory neurons

Dendrites achieve characteristic spacing patterns during development to ensure appropriate coverage of territories. Mechanisms of dendrite positioning via repulsive dendrite-dendrite interactions are beginning to be elucidated, but the control, and importance, of dendrite positioning relative to their substrate is poorly understood. We found that dendritic branches of Drosophila dendritic arborization sensory neurons can be positioned either at the basal surface of epidermal cells, or enclosed within epidermal invaginations. We show that integrins control dendrite positioning on or within the epidermis in a cell autonomous manner by promoting dendritic retention on the basal surface. Loss of integrin function in neurons resulted in excessive self-crossing and dendrite maintenance defects, the former indicating a role for substrate interactions in self-avoidance. In contrast to a contact-mediated mechanism, we find that integrins prevent crossings that are noncontacting between dendrites in different three-dimensional positions, revealing a requirement for combined dendrite-dendrite and dendrite-substrate interactions in self-avoidance.

Study of haemodynamic and endocrine stress responses following carbon dioxide pneumoperitonium

BACKGROUND

The aim of the study is to investigate the effect of oral gabapentin or clonidine versus placebo premedication on haemodynamic and endocrine responses in patients of American Society of Anesthesiology (ASA) physical status I and II undergoing laparoscopic cholecystectomy.

METHODS

This was a randomized prospective double-blinded comparative study of 75 ASA I and II patients with three groups: clonidine, gabapentin and placebo group having 25 patients in each. They were randomly allocated to receive 600 mg oral gabapentin or clonidine 150 mcg one hour prior to induction of anesthesia and a placebo group. Hemodynamic parameters were recorded before pneumoperitonium (PP) and every 5 minutes till 35 minutes of post PP. Blood samples for serum glucose and cortisol were collected before PP and 10 mins after PP. The investigators were blinded to what the patients received.

RESULTS

With similar demographic profiles and baseline haemodynamics in three groups (p>0.05) significant rise in haemodynamic parameters were observed in placebo group at different time points before and following PP where as those parameters remained stable in gabapentin and clonidine group (p<0.05). The serum cortisol level was high in placebo group before PP than in two other groups, p<0.05. The same marker measured at 10th minute after PP was significantly higher in placebo group than that in clonidine or gabapentin group, p<0.05.

CONCLUSIONS

Oral clonidine or gabapentin premedication offers intraoperative haemodynamic stability in laparoscopic cholecystectomy. When serum cortisol is taken as a stress marker, gabapentin group exhibited significant attenuation of stress of PP, p<0.05.

Nerve stimulation under ultrasound guidance expedites onset of axillary brachial plexus block

BACKGROUND

Axillary block is popular technique in upper extremity surgery. Nerve stimulation is used for location of nerves to provide effective blockade. The advent of ultrasound imaging technique in regional anaesthesia has increased the accuracy of needle placement and local anaesthetic deposition around the nerve. The aim of this study is to find out if the nerve stimulation technique with ultrasound guidance has advantages over sole nerve stimulation technique. The outcome measures studied were onset of sensory and motor block, procedure time, number of skin puncture, vascular puncture and paresthesia during nerve stimulation.

METHODS

This is a prospective randomized comparative study conducted in KMCTH from June 2009 to March 2010 on patients of American Society of Anaesthesiologist I and II requiring upper arm surgery under axillary block. The study comprised of two groups: ultrasound with nerve stimulation group (n=35) and nerve stimulation group (n=35). 24 ml of Bupivacaine 0.5% with injection Dexamethasone 4 mg was used to block the individual four nerves with 6 ml of the local anaesthetic solution per nerve namely ulnar, radial, median and musculocutaneous. The data were recorded by blinded observer. In case of partial block or block failure, the patients were supplemented with Fentanyl or subjected to laryngeal mask placement.

RESULTS

Demographic characteristics (age, weight) in either group were similar (p>0.05). The male and female ratio (M: F) in ultrasound with nerve stimulation group was 12:16. The ratio was 18:17 in nerve stimulation group. The onset of complete sensory block was earlier and the onset of motor block was faster in ultrasound with nerve stimulation group than in sole nerve stimulation group (p=0.001). Ultrasound guidance decreased the number of skin puncture during the nerve stimulation, p= 0.02. The incidence of paresthesia was encountered during nerve location (14%), which could be minimized using ultrasound (7%). The success rate of the block was 93% with ultrasound assistance. The procedure time was not different in both techniques. The surgery duration was not significant statistically in either of the group, p=0.715.

CONCLUSIONS

This study showed that the onset of sensory and motor block was faster with ultrasound assistance nerve stimulation. Complications can be decreased with the use of ultrasound in axillary block.

Ultrasound Versus the Landmark Technique: A Prospective Randomized Comparative Study of Internal Jugular Vein Cannulation in an Intensive Care Unit

OBJECTIVE: The aim of this study is to find out if an ultrasound technique has advantages over the conventional landmark technique. METHODS: This is a prospective randomized comparative study on 120 patients requiring central venous cannulation of the right internal jugular vein. The study comprised of two groups: ultrasound and landmark groups, each consisting of 60 patients. The outcome measures were compared between the groups. RESULTS: Cannulation of the internal jugular vein was successful in 58 patients in the ultrasound group and in 53 in the landmark group. The number of attempts was 1.5 (1 - 3) and 2 (1 - 3) in the ultrasound and landmark group respectively (p = 0.001). The time taken for the successful cannulation was 4.9 +/- 1.7 minutes in the ultrasound approach and 8.0 +/- 2.8 minutes in the landmark approach (p = 0.00). The internal jugular vein diameter in the supine position was 11.2 +/- 1.5 mm which increased to 15.04 +/- 1.5 mm with a 15 degrees head-down position in the USG group (p = 0.001). The first attempt success rate was 39/60 (63%) in the ultrasound group and 19/60 (32%) with the landmark technique. The seven (12%) failure cases in the landmark group were rescued by the ultrasound technique. Inadvertent carotid artery puncture occurred in 2/60 (3%) and 6/60 (10%) of patients in the ultrasound and land mark group respectively. CONCLUSIONS: Ultrasound improves success rate, minimizes cannulation time and complications during internal jugular vein cannulation. It can be employed as a rescue technique in cases of a failed landmark technique. Keywords:cannulation, central, landmark, technique, ultrasound.

Ultrasound versus the landmark technique: a prospective randomized comparative study of internal jugular vein cannulation in an intensive care unit

OBJECTIVE

The aim of this study is to find out if an ultrasound technique has advantages over the conventional landmark technique.

METHODS

This is a prospective randomized comparative study on 120 patients requiring central venous cannulation of the right internal jugular vein. The study comprised of two groups: ultrasound and landmark groups, each consisting of 60 patients. The outcome measures were compared between the groups.

RESULTS

Cannulation of the internal jugular vein was successful in 58 patients in the ultrasound group and in 53 in the landmark group. The number of attempts was 1.5 (1 - 3) and 2 (1 - 3) in the ultrasound and landmark group respectively (p = 0.001). The time taken for the successful cannulation was 4.9 +/- 1.7 minutes in the ultrasound approach and 8.0 +/- 2.8 minutes in the landmark approach (p = 0.00). The internal jugular vein diameter in the supine position was 11.2 +/- 1.5 mm which increased to 15.04 +/- 1.5 mm with a 15 degrees head-down position in the USG group (p = 0.001). The first attempt success rate was 39/60 (63%) in the ultrasound group and 19/60 (32%) with the landmark technique. The seven (12%) failure cases in the landmark group were rescued by the ultrasound technique. Inadvertent carotid artery puncture occurred in 2/60 (3%) and 6/60 (10%) of patients in the ultrasound and land mark group respectively.

CONCLUSIONS

Ultrasound improves success rate, minimizes cannulation time and complications during internal jugular vein cannulation. It can be employed as a rescue technique in cases of a failed landmark technique.

Early Experience of Day Care Surgery in Nepal

INTRODUCTION: The day care laparoscopic cholecystectomy (DCLC) is found to be safe and effective in developed countries. However, it has not been well accepted in our part of the world probably because of lack of infrastructures,established norms and published reports. We have analyzed the safety and feasibility of the procedure in the recently established first dedicated day care surgery centre of the country. METHODS: All the patients with American society of anaesthesiologist (ASA) score I and II admitted for laparoscopic cholecystectomy are included. Operation are performed in the morning and closely observed till evening. Patients found to be medically fit to discharge; having a responsible person at home and who can make their own arrangements in case of problems were advised for discharge. Follow up was done by telephone call from next morning. RESULTS: Total 35 patients underwent laparoscopic cholecystectomy. Age range was between 16-65 years and most of them were females (88%). Only 30 patients were operated in early morning and were eligible for day care surgery. 25 (83%) Patients were advised for discharge but only 10 (33%) could make arrangement. Other 15 patients could not go home mainly due to different psychosocial reasons. Only one patient needed readmission and Complications observed were minor and relatively few. CONCLUSIONS: Day care laparoscopic cholecystectomy is safe and feasible in our set up. Acceptance of the procedure is expected to increase once it is regularly practiced and awareness in improved. Keywords: day care, laparoscopic cholecystectomy, surgery, Nepal.

Early experience of day care surgery in Nepal

INTRODUCTION

The day care laparoscopic cholecystectomy (DCLC) is found to be safe and effective in developed countries. However, it has not been well accepted in our part of the world probably because of lack of infrastructures,established norms and published reports. We have analyzed the safety and feasibility of the procedure in the recently established first dedicated day care surgery centre of the country.

METHODS

All the patients with American society of anaesthesiologist (ASA) score I and II admitted for laparoscopic cholecystectomy are included. Operation are performed in the morning and closely observed till evening. Patients found to be medically fit to discharge; having a responsible person at home and who can make their own arrangements in case of problems were advised for discharge. Follow up was done by telephone call from next morning.

RESULTS

Total 35 patients underwent laparoscopic cholecystectomy. Age range was between 16-65 years and most of them were females (88%). Only 30 patients were operated in early morning and were eligible for day care surgery. 25 (83%) Patients were advised for discharge but only 10 (33%) could make arrangement. Other 15 patients could not go home mainly due to different psychosocial reasons. Only one patient needed readmission and Complications observed were minor and relatively few.

CONCLUSIONS

Day care laparoscopic cholecystectomy is safe and feasible in our set up. Acceptance of the procedure is expected to increase once it is regularly practiced and awareness in improved.

Cardiac arrest during laparoscopic cholecystectomy under general anaesthesia: A study into four cases

Laparoscopic cholecystectomy (LapChole) has virtually superseded the more conventional open abdomen approach for the surgical treatment of symptomatic cholelithiasis. LapChole is however not a risk free procedure and serious, potentially fatal intra-operative complications can occur. Here we present case reports of four patients who suffered from intra-operative cardiac arrest during LapChole. All four recovered without residual morbidity and three of them underwent successful surgery in the same setting. No definite cause could be identified in any of the patients. We outline several possible mechanisms that could have been involved and discuss these events in face of published reports describing similar incidences. We infer that the creation of carbon-dioxide (CO(2)) pneumoperitoneum was involved in the causation of the cardiac arrest because all four incidences occurred within minutes thereafter. Although rare, such complications can be fatal and are thus demanding to the anaesthesiologist.

Retrograde intubation: an alternative way for the management of difficult airway

Inserting a retrograde wire into the pharynx through a cricothyroid puncture can facilitate tracheal intubation in difficult situations where either a flexible fiber-optic bronchoscope or an expert user of such a device is not available. Even in cases when fibropric can not be negotiated for the purpose, this method has been claimed to be useful to manage the airway. Some mouth opening is essential for the oral or nasal retrieval of the wire from the pharynx. Here, a case of post mandibular reconstructed wound infection required surgical debridement and plate removal from reconstructed lower mandible under general anesthesia. We retrieved the guide wire passed through a cricothyroid puncture and subsequently accomplished wire-guided oro-tracheal intubation. In the absence of a flexible fiber-optic bronchoscope, this technique is a very useful aid to intubate patients with limited mouth opening.

Diagnostic variability and therapeutic efficacy of ECT in Nepalese sample

BACKGROUND

Though electroconvulsive therapy (ECT) has been used in Nepal for last twenty years, researches regarding its use, its efficacy and other data are non-existent.

AIMS

The objective of this study was to know about diagnostic variability and therapeutic efficacy of the use of ECT in hospitalized patients.

METHODS

This is a prospective comparative study between patients who received ECT and who did not using ICD-10 as diagnostic confirmation. Psychopathology was evaluated using Brief Psychiatric Research Scale (BPRS), Hamilton Depression Rating Scale (HAM-D) and Young Mania Rating Scale (YMRS) between the groups at admission, at discharge, at 1st month, at 6th month and at 12th month. Functional assessment of patients was done using Global Assessment of Function (GAF). Modified ECT was performed using general anaesthetic agent.

RESULTS

47 patients received ECT as compared to 78 patients who were non-receivers. The patients with most common five diagnosis were paranoid schizophrenia (14.4%); psychotic depression (13.6%) ; undifferentiated schizophrenia (8.8%) ; bipolar mania (7.2% ) ;severe depression without psychosis (5.6%) . There was significant decrease in BPRS in ECT receiver as compared to non-receivers at discharge (p=0.0001), 1st month (p=0.0001), 6th month (p=0.0001) and 12th month (p=0.0001) ; in YMRS at discharge (p=.008), 1st month (p=.002) and at 12th month (p=.015) ; in HAMD-M at discharge (p=0.0001), at 1st month (p=0.0001), at 6th month (p=0.0001) and at 12th month (p=0.0001) ; in GAF at discharge (p=0.0001), at 6th month (p=0.0001) and at 12th month (p=0.0001).

CONCLUSION

There was significant improvement in overall psychopathology of patients who received ECT as compared to non-receivers. The improvement was shown by decrement in scores in BPRS, YMRS, HDRS and GAF at the time of discharge, 1st month, 6th month and 12th month which were statistically significant. Day to day functional status of patients also improved as shown by GAF. The efficacy of ECT was very significantly shown in this study with all the psychiatric spectrum disorders.

Oral administration of intravenous solution of midazolam mixed in syrup of paracetamol is an effective way of premedicating children undergoing surgery under general anaesthesia

OBJECTIVE

The purpose of this study was to evaluate the efficacy of injection midazolam administered by oral route mixed in paracetamol syrup as a premedication in children undergoing surgery.

METHODS

60 children undergoing elective hernia repair under general anaesthesia were randomized into two groups: the study group (group A) was given oral midazolam 0.5 mg/kg (mixed in paracetamol syrup) and the control group (group B) was given just the paracetamol syrup before bringing them inside the operating theater. They were evaluated for ease of separation from their parents, ease of i.v. cannulation and induction, and for recovery time from anaesthesia.

RESULTS

it was found that in group A - 96.7% of children showed satisfactory parent child separation while in group B - only 53.3% of children showed satisfactory separation (P < 0.05). Similarly in group A - 73.3 % of children shad satisfactory induction while in group B only 33.3% of children had satisfactory induction. The recovery time from general anaesthesia did not differ in the two groups. No significant peri operative complications directly related to oral midazolam was noted.

CONCLUSION

It was concluded that injection midazolam mixed in syrup paracetamol administered orally is a convenient and efficient method of premedicating children undergoing general anaesthesia. Parent-child separation and induction of anaesthesia was smooth and the recovery uneventful in children premedicated with oral midazolam.

Comparative study between tramadol and dexamethasone as an admixture to bupivacaine in supraclavicular brachial plexus block

This is a prospective, randomized, double blind study to evaluate the postoperative analgesia following supraclavicular brachial plexus block with Tramadol or Dexamethasone as an admixture to bupivacaine in upper extremity surgery. Total 60 patients of ASA I and II undergoing upper extremity surgery under brachial plexus block with Bupivacaine were randomly divided in to two groups; one group received Tramadol (2 mg/kg) and the other group received Dexamethasone (8 mg) as an admixture to Bupivacaine. The duration of postoperative analgesia was recorded in both groups using pain VAS score which was determined by maximum VAS score of 8-10 and when patient demands for additional analgesics. The mean duration of postoperative analgesia in the Dexamethasone group was 1028.00 minutes while in the tramadol group it was 453.17 minutes We concluded that Dexamethasone with local anaesthetic prolongs postoperative analgesia significantly than Tramadol (P<0.05) when used as admixture to local anaesthetic in brachial plexus block in upper extremity surgery.

Do we have to hyperventilate during laparoscopic surgery?

PURPOSE

The purpose of this study was to assess the effects of hyperventilation on patients undergoing laparoscopic surgeries on haemodynamics, partial pressure of carbon dioxide and acid base status.

METHODS

60 patients undergoing laparoscopic surgeries under General Anaesthesia were randomized into two groups, "control group" ventilated with tidal volume of 10 ml/kg and respiratory rate of 12/minute and "study group" same tidal volume with respiratory rate of 15/ minute. Hemodynamic variables (heart rate and mean arterial pressure) recorded and End tidal C02, PaC02, pH and Bicarbonate estimation done before, during and after C02 pneumoperitoneum and analyzed.

RESULTS

There was no significant difference in hemodynamic variables but there was linear increase in ETC02 and PaC02 measurements in higher normal levels in control group (ETC02 33.3+/-3.20, 37.93+/-3.95 and 43.20+/-3.40; PaC02 30.08+/-2.35, 34.80+/-4.01 and 41.94+/-3.66 mmHg before, during, and after pneumoperitoneum respectively) compared to study group in which these parameters were in lower normal levels (ETC02 33.33+/-4.11, 28.00+/-4.10 and 36.73+/-2.49 mmHg and PaC02 31.80+/-2.73, 29.36+/-3.16 and 35.15+/-1.32 mmHg before, during, and after pneumoperitoneum respectively). There was highly significant difference in these parameters when intergroup comparison was done during and after pneumoperitoneum period. pH and bicarbonate levels were within normal limits but there was decreasing tendency towards acidosis side in control group.

CONCLUSION

10-15% increment in Minute Volume is beneficial during C02 pneumoperitoneum to prevent adverse effects of hypercarbia and acidosis.

Comparative study of esmolol and labetalol to attenuate haemodynamic responses after electroconvulsive therapy

OBJECTIVE

The study was designed to evaluate the hemodynamic effects of Esmolol and labetalol in patients undergoing electroconvulsive therapy.

MATERIALS AND METHODS

Ninety patients undergoing electroconvulsive therapy treatment were studied according to randomized, double blind placebo controlled protocol. Ninety patients were divided into three groups with thirty patients in each group. Patients received either Esmolol (1 mg/kg), Labetalol (0.25 mg/kg) or Normal Saline (placebo) intravenously just after induction with propofol. The baseline heart rate and blood pressure were recorded. Hemodynamic parameters before and after drug therapy and after the ECT current application, were recorded at different time intervals.

RESULTS

It was found that Esmolol significantly attenuated the degree of tachycardia and hypertension after ECT in comparison with placebo in the first three minutes (p<0.05), whereas the rise in HR and blood pressure was significantly blunted in the labetalol group in comparison to placebo, from three minutes onward till ten minutes. (p<0.05).

CONCLUSION

It was concluded that Esmolol is effective in blunting the hemodynamic response after ECT stimulus in the first three minutes after application of the electrical current, whereas Labetalol is effective after five minutes onwards till ten minutes.

Ultrasound: an extension of clinical examination

AIMS AND OBJECTIVES

To study the impact the use of portable ultrasound can have for the benefit of the patients when used by doctors other than radiologist, in this case surgeons.

METHODS

Ultrasound performed by surgeons in the pre-operative, operative and post-operative period was studied. Patients presenting to the Hospital with acute abdomen was subjected to ultrasound. They were either pre-operative or post-operative patients. Five patients were scanned intraoperatively. The impact of these scans to the patients as well as the clinicians was studied.

RESULTS

This is an ongoing study and preliminary results of the scans show two pre-operative diagnosis of acute appendicular collection and one acute hydronephrosis. In the operation room, ultrasound was done on 5 cases. On three occasions, it was to locate renal stones so that it could be extracted with ease. On two of the case, it was t to confirm the adequacy of common bile duct exploration thereby allowing primary closure of the common bile duct. Post-operatively, it was used in four cases of which in two cases post-operative hemorrhage were detected timely within hours. In the other two cases, the surgical team was assured that the patient's complaint was not surgically related.

CONCLUSION

Ultrasound should be an extension of the clinical examination when indicated and all clinicians should be proficient in its use in their respective fields.

Plant regeneration from cell suspension-derived protoplasts of Phalaenopsis

Protoplasts isolated from cell suspension culture of Phalaenopsis "Wataboushi" were cultured by (a) embedding in gellan gum-solidified hormone-free 1/2 New Dogashima medium (1/2 NDM) containing 0.44 M sorbitol, 0.06 M sucrose and 0.1 g/l L-glutamine (standard method) and (b) beads method using beads of gellan gum or sodium alginate as the gelling agents which were surrounded by liquid NDM. Although, the two beads methods gave less frequency of initial protoplast division than the standard method, the former finally resulted in higher frequency of microcolony formation than the latter. The highest frequency of microcolony formation (23%) was obtained when protoplasts were embedded in 1% Ca-alginate beads and subcultured every two weeks by replacing the surrounding liquid culture medium with a decrease in sorbitol concentration by 0.1 M. Colonies visible to the naked eyes were observed within 2 months of culture and the regenerated calluses were transferred onto hormone-free NDM supplemented with 10 g/l maltose and 0.3% (w/v) gellan gum, on which PLBs were formed and proliferated profusely. The PLBs were regenerated into plantlets after changing the carbon source to 10 g/l sorbitol and successfully acclimatized to greenhouse conditions.

Comparative study between bupivacaine heavy vs pethidine intrathecally to study early haemodynamic changes and postoperative analgesia in patients undergoing caesarean section

OBJECTIVE

To study early hemodynamic changes and duration of postoperative analgesia between two study groups of intrathecal pethidine and bupivacaine heavy in patients undergoing caesarean section.

METHODOLOGY

Total number of 60 patients of ASA I and II, undergoing caesarean section were enrolled in the study. All the patients were divided into two groups: Pethidine and Bupivacaine heavy. The dose of pethidine for subarachnoid block was 1mg/kg and in Bupivacaine group 2.2 ml of 0.5% bupivacaine heavy was given intrathecally. Heart rate and blood pressure of all the patients were recorded before subarachnoid block. After giving spinal anesthesia, the heart rate and blood pressure were monitored and recorded in different time intervals. The duration of postoperative analgesia in all patients was recorded in postoperative ward. The APGAR Scores of the babies were recorded in 1 and 5 minutes after delivery. The data were statistically compared using independent sample t-test.

CONCLUSION

The hemodynamic parameters (HR & BP) were compared in different time intervals. The difference in heart rate and blood pressure at different time intervals in the two study groups were statistically insignificant as (p > 0.05). The total duration of postoperative analgesia in patients receiving sole intrathecal pethidine was 8 hours and 30 minutes. Where as, in Bupivacaine group the duration was 2 hrs and 36 minutes. This has been found statistically significant (p<0.05).

Peripartum cardiomyopathy undergoing caesarean section under epidural anaesthesia

PURPOSE

To report a case of peripartum dilated cardiomyopathy presenting for emergency caesarean section, this was successfully managed with Epidural Anaesthesia.

CLINICAL FEATURES

A parturient suffering from idiopathic peripartum cardiomyopathy (E.F. 18%) was brought for an emergency caesarean section. Epidural anaesthesia was performed and 2% Lignocaine with adrenaline total 13 ml was injected into the epidural space. The patient's haemodynamic status was monitored with NIBP, ECG, pulse oximetry. Patient's perioperative course was uneventful.

CONCLUSION

In patients suffering from peripartum cardiomyopathy, undergoing caesarean section epidural anaesthesia is an acceptable anaesthetic alternative.

Amyloid beta peptide adversely affects spine number and motility in hippocampal neurons

Elevated levels of amyloid-beta peptide (Abeta) are found in Down's syndrome patients and alter synaptic function during the early stages of Alzheimer's disease. Dendritic spines, sites of most excitatory synaptic contacts, are considered to be an important locus for encoding synaptic plasticity. We used time-lapse two-photon imaging of hippocampal pyramidal neurons in organotypic slices to study the effects of Abeta on the development of dendritic spines. We report that exposure of hippocampal neurons to sub-lethal levels of Abeta decreased spine density, increased spine length and subdued spine motility. The effect of Abeta on spine density was reversible. Moreover, Abeta's effect on dendritic spine density was blocked by rolipram, a phosphodiesterase type IV inhibitor, suggesting the involvement of a cAMP dependent pathway. These findings raise the possibility that Abeta-induced spine alterations could underlie the cognitive defects in Alzheimer's disease and Down syndrome.

Bilateral simultaneous total knee replacement under combined spinal epidural anaesthesia

This is a case report of 68 yrs old lady who underwent simultaneous both knee joint replacement for chronic and advanced osteoarthritis. The case was performed solely under combined spinal and epidural anaesthesia (CSE). CSE is a neuroaxial block performed for different types of lower limb and abdominal surgeries.

Tramadol along with local anaesthetics in the penile block for the children undergoing circumcision

OBJECTIVE

This study was to find out the total duration of postoperative analgesia following circumcision in children when Tramadol was used as an adjunct to local anaesthetics in penile block.

METHODS

Forty children of age 5 - 13 yrs, ASA I & II were enrolled in this study. Patients were premedicated with ketamine and atropine intramuscularly prior to separation from their parents and IV cannulation. Penile block was then performed under strict aseptic precautions with paramedian approach by 3 cm long 23 g ordinary needle where 4 ml of mixture of local anaesthetics and tramadol was given on each side of the base of penis at 11 and 2 o clock positions. Duration of analgesia was recorded from the time of completion of surgery till the patients' first complain of pain and when additional analgesic was given. Intraoperative analgesia duration achieved by the penile block was not included in this study due to unavoidable overlapping of sedation and analgesia produced by the premedicated IM Ketamine (4-5 mg/kg) ,which lasts for 25 minutes to 30 minutes. Unless complicated, this is the usual surgery time in our hospital for this procedure. Because of this reason, the sedation score was not used in this study. Moreover, paediatric sedation score remains too impractical and unreliable in our context.

RESULTS

Addition of Tramadol with local anaesthetics in penile block prolonged the postoperative analgesia even up to 40 hours.

CONCLUSION

Tramadol as an adjunct with Local Anaesthetics extends the duration of postoperative analgesia and can be used safely for this purpose in the children.

A comparison of haemodynamic response with pethidine vs. butorphanol in open cholecystectomy cases

OBJECTIVE

The present study was undertaken to compare the haemodynamic responses with pethidine vs. Butorphanol intraoperatively in open cholecystectomy cases in KMCTH.

METHOD

In this randomized study, all together 40 patients undergoing routine cholecystectomy surgery were included. Group A received Pethidine 1 mg/kg and Group B received Butorphanol 0.04 mg/kg intraoperatively. Heart rate and blood pressure were recorded before injection of the drug, after injection, before intubation, after intubation, before skin incision, after incision, before extubation and after extubation data analysis was done using independent sample t test.

RESULT

Our study showed no statistical significance in haemodynamic responses with either pethidine or Butorphanol in open cholecystectomy cases.

CONCLUSION

Both drugs appear equally good analgesics in our study.

A comparison of 25 gauge Quincke spinal needle with 26 gauge Eldor spinal needle for the elective Caesarian sections: insertion characteristics and complications

OBJECTIVE

The study was designed to compare the insertion characteristics and incidence of PDPH between 25 gauge Quincke needle and 26 gauge Eldor needle for spinal anaesthesia in elective c/s.

METHOD

60 pregnant women (aged 19-35 yrs and weighing 58 -67 kg) undergoing elective caesarean section were randomized into group A (Quincke spinal needle group) or group B (Eldor spinal needle group). Spinal anaesthesia was performed with 2.9 ml 0.5% heavy bupivacaine using 25 gauge Quincke spinal needle in group A and 26 Gauge Eldor spinal needle in group B. Onset, time of first identification of backflow of CSF, number of attempts, level of sensory and motor blockade, failure of anaesthesia, inadequate anaesthesia and incidence of PDPH were recorded.

RESULT

Quincke spinal needle was found easy at insertion, first attempt was successful in 90% of cases, whereas Eldor spinal needle was successful at first attempt in only 60% of cases. Early identification of CSF was seen in Eldor spinal needle group in 3.5 seconds vs. 5.2 seconds in Quincke spinal needle group. Blood mixed CSF was seen in 8 Quincke spinal needle group vs. none in Eldor spinal needle group. Onset was similar between both groups i.e. in 6 minutes. Failure of anaesthesia was none in Eldor spinal needle group vs. 2 in quincke spinal needle group. Height of sensory block achieved was T4 level in 26 parturients,T6 in 1 ,T8 in 1 and no anaesthesia at all in another 2 parturient as compared to T4 level in 29 and T3 in 1 parturient in Eldor spinal needle group. The degree of motor block with the use of Bromage criteria showed a motor score of 1 or 2 in 26 parturients in Quincke spinal needle group vs. same in all cases in Eldor spinal needle group. The total incidence of PDPH was 8.3 % (5 out of 60 parturient) which occurred all in Quincke spinal needle group. 2 parturient who developed severe PDPH required epidural blood patch.

CONCLUSION

26 gauge Eldor spinal needle was found to be better than 25 gauge Quincke spinal needle for caesarian sections to decrease the incidence of PDPH, though not all insertion characteristics were in favour of the Eldor needle.

Supraclavicular brachial plexus block with and without dexamethasone - a comparative study

To compare the analgesic efficacy of local aesthetic with and without dexamethasone in supraclavicular brachial plexus block.

METHODS

Forty patients undergoing arm, forearm and hand surgeries were randomly selected. The forty patients were divided in two groups of 20 each. In-group one, a brachial plexus block was done with 40-50 ml of local anaesthetic with 1:200,000 adrenaline and in the other group the block was performed with the same amount of local anaesthetics with dexamethasone. The onset of action and duration of analgesia in the two groups were compared and any complications of the procedure were noted. Statistical analysis was done using the independent sample t-test.

RESULTS

The two groups were comparable in respect to age, sex, and weight. There was significant faster onset of action and prolonged duration of analgesia in the dexamethasone group than in the other group. There were no complications.

CONCLUSION

Addition of dexamethasone for brachial plexus block significantly prolongs the duration of analgesia without any unwanted effects.

Three in one block for unilateral knee arthrotomy in an old lady

An old lady having septic arthritis of right knee joint underwent arthrotomy under three in one block for femoral, obturator and lateral cutaneous nerve of thigh in inguinal region, with catheter in situ. She was a case of chronic obstructive airway disease with ischaemic heart disease, so operation and postoperative pain management was planned under regional block. Anaesthesia was started by giving regional block with 0.25% bupivacaine at first and maintained with intermittent injection of 0.125% bupivacaine. The patient was pain free and comfortable though out the perioperative period.

Interpleural catheter technique for perioperative pain management

Management of pain in surgical patient is very crucial. It is more so in thoracic and upper abdominal surgery. Lots of technique and drugs have been used to control postoperative pain including thoracic epidural analgesia. We describe a case in whom Intraoperative and Postoperative pain was managed by injecting 0.5% bupivacaine 20 ml in the interpleural space through the catheter, followed by continuous infusion of 0.1% bupivacaine 10 ml/ hour for 24 hours. The whole perioperative and postoperative period was uneventful. The first series of patients in whom this technique was used was described by Murphy in 1983, (1) who used it in patients with multiple fractured ribs and in postoperative patients after gallbladder and kidney surgery. One year later, Reiestad and Kvalheim published their results of continuous intercostal nerve block for postoperative pain relief and presented their modification of the technique, which is now termed interpleural analgesia.

Socioeconomic barriers to cataract surgery in Nepal: the South Asian cataract management study

BACKGROUND

Previous studies have shown that, despite an increasing availability of cataract surgery, important socioeconomic barriers exist in the acceptance of surgery in many rural areas of south Asia. Nepal has developed a comprehensive national network of eye hospitals but the surgical coverage for the treatment of cataract blind is still low.

AIMS

To determine the utilisation of cataract surgery and the level of physical and psychosocial impairment and the socioeconomic barriers to surgery in a group of non-acceptors of surgery.

METHODS

Of 319 cataract patients identified in a field screening 96 non-acceptors of surgery were interviewed 1 year after an offer to undergo surgery. The interview included questions on visual function, quality of life, and socioeconomic variables on acceptance of cataract surgery. The quality of life questionnaire was based on the field validated protocol addressing the impact of visual impairment on physical and psychosocial functions. The questionnaire was adapted to the local conditions after pretesting. Data were analysed by degree of visual impairment.

RESULTS

Of 319 cataract patients identified only 45.5% accepted surgery, with men accepting surgery more readily than women (RR = 1.31; 95% CI = 1.04-1.67) because of a significantly greater acceptance of surgery in men in the non-blind group. The acceptance rate was significantly higher in the blind group (RR = 1.74; 95% CI = 1.36-2.22) compared with those patients having impairment of vision and severe loss of vision. Of 96 non-acceptors interviewed only a further 13% accepted surgery after a second counselling. The most frequent reasons given for not accepting surgery were economic (48%) and logistical (44.8%) constraints followed by fear of surgery (33.3%) and lack of time (18.8%). Half of the subjects complained of problems with self care but only 10% needed help for their most basic every day activities. 17.7% said they needed help to visit neighbours and 26% needed help to attend the field or market.

CONCLUSIONS

It was found that in this population with a majority of patients with severe vision loss and blind, even when offered transport and free surgery the utilisation of cataract surgery is below 60%. Medicine tends to be prescriptive based on technological advances that it is able to offer. Medical practice needs to develop a more holistic understanding of the needs of the communities cultivating a greater capability to analyse the role of cultural, social, and economic factors when planning medical services for the population.

Seasonal hyperacute panuveitis of unknown etiology

A severe form of unilateral uveitis, which in most cases leads to blindness within hours of its onset, has been seen in Nepal since 1975. This disease appears with the onset of autumn in early September and lasts until the end of December in two-year cycles (1975, 1977, 1979). However, some cases occurred in 1980 as well. As expected there was an outbreak of this disease in 1981. Although early cases were seen in patients from Western Nepal, the disease has since been identified in patients from various parts of the country. In one of the outbreaks (1977) in western Nepal some patients or their parents gave a history of a white moth sitting on the child's face or arm prior to the onset of ocular symptoms. Some of these were claimed to be followed by blister formation at the point of contact. These moths were presumed to be responsible for producing this uveitis in those cases. The present report describes the clinical features of the cases seen from the time the disease was first recognized, case histories of four cases seen during the last outbreak, results of laboratory experiments using the aqueous humor of these patients, and the results of experiments using three different varieties of moths.

Antiemetic prophylaxis against postoperative nausea and vomiting with ondansetron-dexamethasone combination compared to ondansetron or dexamethasone alone for patients undergoing laparoscopic cholecystectomy

Background: Postoperative nausea and vomiting (PONV) is a common distressing experience in patients following laparoscopic surgeries. This study was aimed at comparing the efficacies of Ondansetron-Dexamethasone combination with each drug alone as a prophylaxis against PONV in patients after elective laparoscopic cholecystectomy done under general anaesthesia. Materials and methods: Hundred and fifty ASA I and II patients, aged 23 to 65 yrs, were enrolled in this prospective, randomized, double-blind trial to receive one of three treatment regimens: 4 mg Ondansetron (Group O), 8 mg Dexamethasone (Group D) or 4 mg Ondansetron plus 8 mg Dexamethasone (Group OD) (n=50 for each). A standardized balanced general anaesthetic technique was employed. Any episode of PONV and need for rescue antiemetic were assessed at six, 12 and 24 hrs post operation. Complete response was defined as no PONV in 24 hrs and need for rescue antiemetic was considered as failure of prophylaxis. Pain scores, time to first analgesia demand, amount of Meperidine consumption, adverse event(s) and duration of hospital stay were recorded. Results: Complete response occurred in 66.7, 66.0 and 89.4% in Groups O, D and OD respectively. Rescue antiemetics were required in 29.2, 31.9 and 8.5% of patients in Groups O, D, and OD respectively. Significantly high incidence of vomiting and failure of prophylaxis (19.1%) occurred in group D during the first six hrs (P=0.023 versus O & 0.008 versus OD). More frequent antiemetic rescue was required in group O at 6 to 24 hr interval as compared to group OD (P=0.032). Conclusion: Combination of Ondansetron and Dexamethasone is better than each drug alone in preventing PONV after laparoscopic cholecystectomy. Dexamethasone alone is significantly less effective in preventing early vomiting compared to its combination with Ondansetron; whereas Ondansetron alone is less effective against late PONV as compared with combination therapy. Key words: Antiemetic prophylaxis; Dexamethasone; laparoscopic cholecystectomy; Ondansetron; postoperative nausea and vomiting (PONV) doi: 10.3126/kumj.v6i3.1706 Kathmandu University Medical Journal (2008), Vol. 6, No. 3, Issue 23, 319-328