Trans-nasal sphenopalatine ganglion block for post-dural puncture headache management: a meta-analysis of randomized trials

Abstract Objective: To evaluate the efficacy and safety of trans-nasal Sphenopalatine Ganglion (SPG) block over other treatments for Post-Dural Puncture Headache (PDPH) management. Methods: A systematic literature search was conducted on databases for Randomized Controlled Trials (RCTs) comparing trans-nasal SPG blockade for the management of PDPH over other treatment modalities. All outcomes were pooled using the Mantel-Haenszel method and random effect model. Analyses of all outcomes were performed as a subgroup based on the type of control interventions (conservative, intranasal lignocaine puffs, sham, and Greater Occipital Nerve [GON] block). The quality of evidence was assessed using the GRADE approach. Results: After screening 1748 relevant articles, 9 RCTs comparing SPG block with other interventions (6 conservative treatments, 1 sham, 1 GON and 1 intranasal lidocaine puff) were included in this meta-analysis. SPG block demonstrated superiority over conservative treatment in pain reduction at 30 min, 1 h, 2 h, 4 h after interventions and treatment failures with "very low" to "moderate" quality of evidence. The SPG block failed to demonstrate superiority over conservative treatment in pain reduction beyond 6 h, need for rescue treatment, and adverse events. SPG block demonstrated superiority over intranasal lignocaine puff in pain reduction at 30 min, 1 h, 6 h, and 24 h after interventions. SPG block did not show superiority or equivalence in all efficacy and safety outcomes as compared to sham and GON block. Conclusion: Very Low to moderate quality evidence suggests the superiority of SPG block over conservative treatment and lignocaine puff for short-term pain relief from PDPH. PROSPERO Registration: CRD42021291707.

Dexmedetomidine versus clonidine as an adjuvant to local anaesthetic in brachial plexus blocks: a metaanalysis of randomised controlled trials

Abstract Objective: This meta-analysis aimed to compare the efficacy and safety of dexmedetomidine and Clonidine as an adjuvant to local anesthetics in BPBs. Methods: Two investigators independently searched databases to identify all RCTs comparing the efficacy and/or safety of dexmedetomidine and Clonidine as an adjuvant to local anesthetics in BPBs. All outcomes were pooled using the inverse variance method with a random-effect model. An I2 test was used to assess heterogeneity. The source of heterogeneity was explored through meta-regression. The quality of the evidence was assessed using the GRADE approach. Results: Out of 123 full texts assessed, 24 studies (1448 patients) were included in the analysis. As compared to Clonidine, dexmedetomidine groups showed significantly longer sensory block duration (MD = 173.31; 95% CI 138.02-208.59; I2 = 99%; GRADE approach evidence: high); motor block duration (MD = 158.35; 95% CI 131.55-185.16; I2 = 98%; GRADE approach evidence: high), duration of analgesia (MD = 203.92; 95% CI 169.25-238.58; I2 = 99%; GRADE approach evidence-high), and provided higher grade quality of block (RR = 1.97; 95% CI 1.60-2.41 ; I2 = 0%; GRADE approach evidence: moderate). The block positioning technique (regression coefficient: 51.45, p = 0.005) was observed as a significant predictor of the heterogeneity in the case of sensory block duration. No significant difference was observed for the risk of hypotension (RR = 2.59; 95% CI 0.63-10.66; I2 = %). Conclusion: Moderate to high-quality evidence suggests dexmedetomidine is a more efficacious adjuvant to local anesthetic in BPBs than Clonidine.

Assessment and comparison of distal radial artery diameter in anatomical snuff box with conventional radial artery before coronary catheterization

Background: The distal radial artery (dRA) approach at anatomical snuff box has gained attention of the interventional cardiologist in last few years. The procedural success rate by this novel approach depends on size of the radial artery and therefore the study was planned to study the size of distal radial artery. Methods: Total of 1004 patients of >18 years of age undergoing coronary catheterization were included in the study. The vessel diameter was measured from media to media in the anatomical snuff box a day prior to coronary catheterization. Results: The mean diameter of right radial artery at conventional access site was 2.56 ± 0.35 mm and at distal access site 2.23 ± 0.39 mm (p < 0.001). Females had significantly smaller radial artery diameter as compared to males at right conventional access site (2.42 ± 0.36 mm vs 2.60 ± 0.34 mm; p < 0.001) and distal access site (2.09 ± 0.38 mm vs 2.27 ± 0.39 mm; p < 0.001). The diameter of the right dRA was not significantly correlated with age (r2 linear ¼ 0.002, p ¼ 0.0475) but was positively correlated with height and weight (r2 linear ¼ 0.076, p ¼ <0.001 and r2 linear ¼ 0.005, p ¼ <0.001) and negatively correlated with BMI (r2 linear ¼ 0.076, p ¼ 0.519). Conclusions: This study has shown the size of right dRA 2.27 þ 0.39 mm in males and 2.09 þ 0.38 mm in females. Diabetes, hypertension, height and weight are important predictors of dRA diameter

Linking of different ethnicities, races and religions to lipid profile patterns and hypolipidaemic drug usage patterns in coronary artery disease patients

Background: Coronary artery disease (CAD) is the consequence of atherosclerosis in which inadequate blood flow in the coronary arteries leads to myocardial necrosis. The impact of ethnic on CAD might be underestimated within Indian communities. There have never been any studies done associating them to lipid profile patterns in the Indian setup hence this study is the first of its kind to work towards attending the absence of data in this direction.The study aimed to evaluate the presence of ethnic differences in lipid profile patterns and hypolipidemic drug use in CAD patients.Methods: An 8-week cross-sectional prospective study was conducted in the cardiology OPD of a tertiary care hospital. Adult CAD patients prescribed with at least one hypolipidaemic drug, having their lipid profile values and willing to give informed consent were selected. The prescription pattern was noted, and the lipid profile values of the patients classified as per ATP III guidelines by NCEP. Atherogenic dyslipidaemia was considered when patients had triglyceride levels >150 mg/dl and HDL<40 mg/dl. The collected data was analyzed using SPSS. P value less than 0.05 was considered as statistically significant.Results: A total of 123 patients enrolled. Out of these, 115 were Hindus and among Hindus, most were Brahmins (34). The most prescribed hypolipidaemic drug was Rosuvastatin. Thirty six patients had high triglyceride levels out of which 35 were Hindus. Low HDL (<40 mg/dl) was present in 70 patients out of which 64 were Hindus. Atherogenic dyslipidaemia was seen in 44 patients. Majority of them belonged to the age group of 51-60 years (43.2%) and were Patels. Total cholesterol and LDL were high in 1 and 2 Jains respectively. Lipid values were higher in Tier-3 city patients.Conclusion: Hindu patients in this study showed a poorer lipid profile while among the castes, Jains and Patel’s fared poorly. It was seen that atherogenic dyslipidemia is on a rise in the Indian population.

Comparison of Beers criteria and EU(7) potentially inappropriate medications list for the potentially inappropriate medications in Indian elderly inpatients

Background: Use of inappropriate medication is an important problem in present geriatric clinical practice. No specific potentially inappropriate medications (PIM) tools are available considering the availability of drugs in India. Aim and objective were to assess prevalence and pattern of potentially inappropriate medication (PIM) use in elderly inpatients by updated Beers criteria 2015 and EU(7) PIM list 2015.Methods: This cross-sectional study was carried out on medical records of elderly patients (?65 yrs) admitted in the internal medicine wards and intensive care units (ICU) over a period of 6 weeks. The medications were evaluated for the PIM use as per Beers criteria and EU(7) PIM list.Results: A total of 225 patients (mean age- 71.48 yrs) were admitted in internal medicine wards and ICU during study period. Total 184 PIM belonged to 33 different medications were used during study period. The prevalence of PIM in internal medicine wards and ICUs were 51.96% and 57.14%, respectively. The prevalence of PIM was significantly higher with the EU(7) PIM list than Beers criteria (49.77% vs. 21.77%) [p<0.0001]. The commonly prescribed PIM were dextromethorphan (13.33%), ranitidine (11.11%) and glipizide (10.22%).Conclusions: Elderly patients frequently receive PIM. EU(7) PIM list identifies more PIM among elderly inpatients than Beers criteria.

Adverse drug reactions in a tertiary care teaching hospital in India: analysis of spontaneously reported cases.

Background: Epidemiological data are limited regarding clinical characteristic of adverse drug reactions (ADRs) in India. Aim: The aim was to assess ADRs with reference to the causative drugs, seriousness and their other clinical characteristics in Indian tertiary care teaching hospital. Methods: A spontaneous reporting based ADR monitoring study was conducted over a period of 2 years. The World Health Organization (WHO) definition of an ADR and its seriousness was adopted. The organ system involvement was labeled by WHO-ADR terminology. ADRs were analyzed for causality by Naranjo’s algorithm, preventability by modified Schumock and Thornton’s criteria and types of reactions by Rawlins and Thompson classification. Subgroup analysis was performed between serious and non-serious reactions. Results: Of the total of 135 reactions reported 111 reactions from 97 patients were included for analysis. The incidences of overall and serious ADRs were 0.25 and 0.06 per 1000 patients, respectively. The most commonly implicated organ systems were skin and appendages (52.25%). The major causative drug classes were antimicrobials (40.28%), central nervous system (23.61%) and autacoids (15.97%). About twothirds of the reactions (65.77%) were classified as probable and one-tenth (8.10%) as preventable. The factors significantly associated with serious reactions were age group 40-60 years (odds ratio [OR]: 5.51), parenteral drugs (OR: 2.96), central and peripheral nervous system disorders (OR: 5.06), body as a whole - general disorders (OR: 9.05) and acute onset reactions (OR: 52.62). Conclusion: Antimicrobials are common causative agents. Cohort study is recommended to confirm the risk factors of serious ADRs in Indian population.

A systematic review of the drug-induced Stevens-Johnson syndrome and toxic epidermal necrolysis in Indian population.

Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare severe cutaneous drug reactions. No large scale epidemiological data are available for this disorder in India. Aims: To carry out a systematic review of the published evidence of the drug-induced SJS and TEN in Indian population. Methods: Publications from 1995 to 2011 describing SJS and TEN in Indian population were searched in PubMed, MEDLINE, EMBASE and UK PUBMED Central electronic databases. Data were collected for the causative drugs and other clinical characteristics of SJS and TEN from the selected studies.Results: From 225 references, 10 references were included as per selection criteria. The major causative drugs were antimicrobials (37.27%), anti-epileptics (35.73%) and non-steroidal anti-inflammatory drugs (15.93%). Carbamazepine (18.25%), phenytoin (13.37%), fluoroquinolones (8.48%) and paracetamol (6.17%) were most commonly implicated drugs. Regional differences were observed for fluoroquinolones, sulfa drugs and carbamazepine. Total 62.96% of patients showed systemic complications. Most common complications were ocular (40.29%) and septicemia (17.65%). Higher mortality was observed for TEN as compared to SJS (odd ratio-7.19; 95% confidence interval (CI) 1.62-31.92; p = 0.0023). Observed mortality is higher than expected as per SCORTEN score 3. Duration of hospital stay was significantly higher in TEN (20.6 days; 95% CI 14.4-26.8) as compared to SJS (9.7 days; 95% CI 5.8-13.6; p = 0.020). Cost of management was significantly higher in TEN (Rs. 7910; 95% CI 5672-10147; p < 0.0001) as compared to SJS (Rs 2460; 95% CI 1762-3158). No statistical data were described for steroid use in the studies included. Conclusion: Carbamazepine, phenytoin, fluoroquinolones and paracetamol were the major causative drugs. TEN is showing higher mortality, morbidity and economic burden than SJS.

Hepatotoxicity studies of nimesulide in litters of rat.

Abstract : Present study was carried out to evaluate hepatotoxicity of nimesulide by single dose and seven days administration in sub therapeutic, therapeutic and supra therapeutic doses in litters of rat. Single dose and seven days administration hepatotoxicity studies of nimesulide were carried out in litters of rat of either sex. They were further subdivided into sub therapeutic (20 mg/kg), therapeutic (30 mg/kg) and supra therapeutic (100 mg/kg) groups. Effect of nimesulide on liver functions were analysed by serum glutamate oxaloacetate transaminase (SGOT), serum glutamate pyruvate transaminase (SGPT), alkaline phosphatase (ALP) and histopathological examination of liver through scoring system. Histopathological changes in liver were observed in therapeutic and supra therapeutic doses in single dose groups and sub therapeutic, therapeutic and supra therapeutic doses in seven days groups. In single dose of nimesulide in litters, there were significant increases in biochemical parameters (p< 0.05) in supratherapeutic doses. However, in seven days studies of nimesulide in litters, there were significant increases in biochemical parameters (p< 0.05) in therapeutic and supratherapeutic doses. The present study indicates that nimesulide causes significant hepatotoxicity in litters of rat.

Safety and efficacy of indigenously developed and manufactured bivalirudin in moderate/high-risk Indian patients undergoing percutaneous coronary intervention: the Bivaflo Registry.

BACKGROUND: Current treatment strategies for percutaneous coronary intervention (PCI) and acute coronary syndrome (ACS) include concomitant use of glycoprotein IIb/IIIa inhibitors (GPI) and antithrombotic therapy such as aspirin, clopidogrel, and unfractionated or low-molecular-weight heparin. The "direct thrombin inhibitor" bivalirudin has been associated with better efficacy and safety than heparin. OBJECTIVE: The present study is performed to evaluate the safety and efficacy of an indigenously developed and manufactured bivalirudin (Bivaflo; Sun Pharmaceutical Industries Ltd., Mumbai) as the primary anticoagulation strategy during PCI in moderate-high risk patients with only provisional use of GPI. METHODS: This prospective multicentered registry enrolled 439 patients in 11 tertiary care centers across India. Patients who had ACS or other clinical/angiographic characteristics, which increase risk during PCI, were enrolled in the registry. Bivaflo was administered as a bolus dose of 0.75 mg/kg, followed by infusion at a rate of 1.75 mg/kg/h during the procedure and optionally 0.25 mg/kg/h for 4 hours after the procedure at investigator's discretion. GPI use was discouraged except as bailout. The primary endpoints were composite and individual incidences of death, myocardial infarction (MI), urgent revascularization, subacute stent thrombosis (SAT), or bleeding at day 7/hospital discharge, whichever was earlier. The secondary endpoints were 30-day composite and individual incidences of death, MI, urgent revascularization, and SAT. RESULTS: The mean age of the group was 58 +/- 10 years and 83% were males. Bivaflo was administered for a mean duration of 102 +/- 79 minutes, and 65% patients received Bivaflo infusion post-PCI. ACT values measured at 10 minutes after bolus and at the end of the PCI were found to be 339 +/- 110 and 336 +/- 104 seconds, respectively. GPI was provisionally used in only 4% (16) patients mostly due to new or suspected thrombus and obstructive dissection with decreased flow. At day 7/hospital discharge, there were no incidences of major adverse cardiac events or major bleeding. Minor bleeding occurred in only 4 patients (0.9%). The 30-day composite major adverse cardiac event rate was 0.68%. One death and two subacute thrombosis occurred during the 30-day follow-up. CONCLUSION: Bivaflo is safe and effective sole anticoagulation strategy during PCI of moderate-high risk patients. Bivaflo administration was associated with no major bleeding events and extremely low in hospital and 30-day MACE rate. These rates were lower than expected MACE rates for such a subgroup of patients based on historical controls.

Transradial primary angioplasty and stenting in Indian patients with acute myocardial infarction: acute results and 6-month follow-up.

BACKGROUND: Coronary angioplasty and stent implantation is effective as primary intervention in acute myocardial infarction. Because of fewer puncture site complications and improved patient comfort, transradial access has been increasingly used as an alternative to transfemoral access for percutaneous coronary interventions. METHODS AND RESULTS: We studied 103 patients (94 men, 9 women: mean age 52.5 +/- 11.96 years) with a diagnosis of acute myocardial infarction (<12 hours after onset), who underwent primary percutaneous coronary intervention. Transradial access was used in all patients with a normal Allen's test and transfemoral access was used additionally only if intra-aortic balloon counterpulsation was required. Follow-up duration was 6 months. Transradial access was successfully achieved in all patients. Radial artery cannulation took <2 min in more than 85% patients. During percutaneous coronary intervention, cannulation to balloon inflation times and total procedure times were 11.3 +/- 5.2 min and 19.9 +/- 10.8 min, respectively. Stents were implanted in 99 (96.1%) patients andplain balloon angioplastywas performed in 3.9%. The primary success rate was 98.1%, with no major bleeding complications. Total length of hospitalization averaged 2.4 +/- 0.8 days. In-hospital major adverse clinical events rate was 5.9%. Six-month clinical follow-up was achieved for 84 (86.6%) patients. Six (7.1%) patients died during follow-up. Follow-up coronary angiography was performed in 22 (26.2%) patients. After 6 months, 7 patients required revascularizationof the target lesion. The rate of survival without myocardial infarction, bypass surgery or repeat coronary angioplasty was 88.5% at 6 months. CONCLUSIONS: Transradial access may represent a safe and feasible technique for performing primary percutaneous coronary intervention with good acute results and without major bleeding complications.

The modified Inoue technique: a simple troubleshooting approach to a proximal segment tear of an Inoue balloon.

A tear in the proximal segment of an Inoue balloon was encountered during the dilatation of a calcific mitral stenosis. As a troubleshooting measure, we modified the steps of the standard Inoue technique. The mitral valve was successfully dilated using the same Inoue balloon.

Successful retrieval of transradially delivered unexpanded coronary stent from the left main coronary artery.

Stent dislodgment during percutaneous coronary intervention is a rare complication. We report a case of successful retrieval of a dislodged stent from the left main coronary artery. It was retrieved via the transradial route using a 6 F coronary guiding catheter supported by an inflated percutaneous transluminal coronary angioplasty balloon distal to the stent.

Direct coronary stenting through the radial approach in an anomalous coronary artery.

An anomalous origin of the coronary artery is an infrequent finding on coronary angiogram. Percutaneous coronary intervention may sometimes be difficult in such situations. We report two cases of anomalous coronary arteries in whom direct stenting was done via the radial approach.