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.

Comparative Study of Dexamethasone and Buprenorphine as Adjuvant to Ropivacaine for Supraclavicular Block

Background: Ropivacaine is an amino-amide, local anaesthetic with higher toxic threshold, having less cardiac and central nervous system effects, less motor block and a similar duration of action of sensory analgesia compared to Bupivacaine. The addition of dexamethaxone or buprenorphine to the local anaesthetic improves the quality of block. This study was conducted to evaluate the effect of dexamethaxone and buprenorphine on characteristics of ropivacine induced supraclavicular block. Methods: A total of 120 patients, 40 patients in each of the three groups were randomly selected for study. Patients were randomly allocated to each of the three groups. Group R: Ropivacaine (0.5%) (36ml) + Normal saline (2ml). Group RD: Ropivacaine (0.5%) (36ml) + 8mg (2ml) Dexamethasone. Group RB: Ropivacaine (0.5%) (36ml) + 0.3mg (1ml) Buprenorphine +(1ml) Normal saline. Results: The duration of analgesia lasted significantly longer in patients of group RD and group RB as compared to group R. The Mean ± SD time for the group R, RB, RD were 479.27 ± 140.51 mins, 718.12 ± 217.74 mins, 983.30 ± 330.21 mins respectively. The p value between group R vs RB (0.001), R vs RD (0.001), RB vs RD (0.001) i.e. statistically significant. In group R the mean time of first rescue analgesic was 9.17 ± 1.98 hrs, group RB was 15.82 ± 4.54 hrs, group RD was 19.22 ± 5.60 hrs. The p value between the group R vs RB, R vs RD, RB vs RD was < 0.001 i.e. highly significant. The number of doses of rescue analgesic in R group has a mean value of 2.4 ± 0.74, in RB group is 1.41 ± 0.59, in RD group 1.3 ± 0.46. The overall p value is 0.001, the p value between R vs RB and R vs RD is statistically significant, p value between RB vs RD > 0.05 i.e. insignificant. Statistical significant difference in sedation score was noted between group RB and RD, RB and R group. The changes in VAS score was low in the first 5hrs, pain increased in group R in 6 - 10 hrs, while in group RB the pain started increasing in 12 -16 hrs, while in group RD the pain started increasing in 16 - 20 hrs. Conclusion: Both dexamethasone and buprinorphine have been found to have favourable effect on brachial plexus block characteristics with side effects slighty higher in buprenorphine group. Though a significant prolongation of duration of post operative analgesia is noted in dexamethasone group.

Changing Trends in the Histological Types of Lung Carcinoma

Introduction: Lung cancer is a major cause of cancer-relatedmortality and morbidity in males and females. Althoughsmoking is the major cause of lung cancer, only 10 % of heavysmokers develop lung cancer suggesting that other factorsmay also act independently or synergistically with smoking.Recent studies have suggested that there are changes inhistological type in recent years.Objectives: This study was to determine incidence of varioushistological types of lung carcinoma and analyse their changingtrends.Material and Methods: This is a prospective study. A total of184 cases of lung carcinoma were undertaken to analyse from2011 to 2014 in a tertiary care centre.Results: Overall adenocarcinoma was found to be mostcommon with 73 (39.67%) cases followed by squamous cellcarcinoma with 68 (36.96%) cases. However, in malessquamous cell carcinoma still remains predominant with 59(43%) cases followed by adenocarcinoma with 49 (35.7%)cases .Male to female ratio was 2.9:1. In females,adenocarcinoma was the most common type.Conclusion: Overall adenocarcinoma was the mostpredominant variant of lung carcinoma in our region closelyfollowed by squamous cell carcinoma. However, in malessquamous cell carcinoma was most common histological type.Incidence of lung tumor also shows increase in femalesthereby decreasing the male to female ratio to 2.9.

Correlation between masseter muscle activity and maximum bite force among various facial divergence pattern / Correlación entre la actividad muscular masetera y la fuerza máxima de mordida entre varios patrones de divergencia facial

Objective: To comparatively assess electromyographic (EMG) activity of masseter muscle and maximum bite force among various facial divergence pattern. To compare bilateral variation therefore derive the clinical importance changes in masseter EMG activity. Materials and Methods: The sample size comprised of 90 subjects, age ranging from 16-25 years. They were further classified under three subgroups-normodivergent, hypodivergent and hyperdivergennt based on the cephalometric values. Tekscan Flexiforce B201H sensor along with the associated software was used to record the bite force. The EMG of the superficial masseter muscle was recorded using Biotech Neurocare 2000 surface electromyography machine. The muscle activity was recorded bilaterally from the superficial masseter. The data obtained were statistically analyzed using ROC curve at p<0.05. Results: The bite force of the Hypodivergent group (571.83N±36.65) was more than the Normodivergent (387.26±27.20) and Hyperdivergent groups (373.21N±29.23). The EMG recording of masseter muscle activity in Hypodivergent group was significantly higher than Normodivergent and Hyperdivergent groups. (p-value= <0.01). A significant correlation existed between masseter activity and bite force. Conclusion: The bite force of Hypodivergent jaw base individuals is highest followed by Normodivergent and least in Hyperdivergent individuals.The strong correlation between the muscular activity and the bite force is definitely a contributor to the anchorage value during treatment by fixed Orthodontics.

Objetivo: evaluar comparativamente la actividad electromiográfica (EMG) del músculo masetero y la fuerza de mordida máxima entre varios patrones de divergencia facial. Para comparar la variación bilateral, por lo tanto, derive la importancia clínica de los cambios en la actividad EMG del masetero. Materiales y métodos: El tamaño de la muestra comprende 90 sujetos, con edades comprendidas entre 16 y 25 años. Además, se clasificaron en tres subgrupos: normodivergente, hipodivergente e hiperdivergénico según los valores cefalométricos. Se usó el sensor Tekscan Flexiforce B201H junto con el software asociado para registrar la fuerza de mordida. La EMG del músculo masetero superficial se registró utilizando la máquina de electromiografía de superficie Biotech Neurocare 2000. La actividad muscular se registró bilateralmente a partir del masetero superficial. Los datos obtenidos se analizaron estadísticamente utilizando la curva ROC a p<0,05. Resultados: la fuerza de mordida del grupo hipodivergente (571.83N±36.65) fue mayor que la de los grupos normodivergentes (387.26±27.20) y los hiperdivergentes (373.21N±29.23). El registro EMG de la actividad muscular masetera en el grupo hipodivergente fue significativamente más alto que en los grupos normodivergente e hiperdivergente. (valor de p=<0.01). Existía una correlación significativa entre la actividad del masetero y la fuerza de mordida. Conclusión: la fuerza de mordedura de los individuos hipodivergentes de la mandíbula es más alta seguida por la de Normodivergent y menos en los individuos hiperdivergentes. La fuerte correlación entre la actividad muscular y la fuerza de mordedura definitivamente contribuye al valor de anclaje durante el tratamiento con ortodoncia fija.

Safety and efficacy of Ahmed glaucoma valve implantation in refractory glaucomas in northern Indian eyes

To evaluate the safety and efficacy of Ahmed glaucoma valve [AGV] implantation in refractory glaucoma in Northern Indian eyes. The success rate of trabeculectomy remains low in cases of refractory glaucoma even with the use of antifibrotics. Glaucoma drainage devices have proven to be more efficacious in reducing intraocular pressure [IOP] in these glaucomas. Retrospective records of 55 consecutive patients who underwent AGV implantation at Dr. Shroff's Charity Eye Hospital, New Delhi, India from January 2003 to December 2012 were reviewed. Pre-operative data included age, gender, eye laterality, specific diagnosis, number of anti-glaucoma medications, number of prior incisional surgeries, visual acuity and IOP on medical treatment. Postoperative data included visual acuity and IOP on day one, 1 week, 1 month, 3 months, 6 months, 1 year and yearly thereafter, number of anti-glaucoma medications, any complication or additional surgical intervention required. Success was defined as IOP >5 and <22 mmHg with or without treatment. Mean IOP decreased from 39.71 +/- 8.99 pre-operatively to 17.52 +/- 5.72 mmHg at last follow-up [p < 0.001] and number of medications reduced from 3.27 +/- 0.84 to 1.25 +/- 0.88 [p < 0.001]. Visual acuity remained within one Snellen line or improved at last follow-up in 47 cases [85.4%]. The cumulative probability of success was 85.45% at 1 year and 79.63% at 3 years. The incidence of post-operative complications was 25.45%.AGV implantation has proven to be safe and is effective in controlling IOP in refractory glaucoma in Northern Indian eyes

Prophylactic effects of asiaticoside-based standardized extract of Centella asiatica (L.) Urban leaves on experimental migraine: Involvement of 5HT1A/1B receptors / 中国天然药物

The present study aimed at evaluation of prophylactic efficacy and possible mechanisms of asiaticoside (AS) based standardized extract of Centella asiatica (L.) Urban leaves (INDCA) in animal models of migraine. The effects of oral and intranasal (i.n.) pretreatment of INDCA (acute and 7-days subacute) were evaluated against nitroglycerine (NTG, 10 mg·kg(-1), i.p.) and bradykinin (BK, 10 μg, intra-arterial) induced hyperalgesia in rats. Tail flick latencies (from 0 to 240 min) post-NTG treatment and the number of vocalizations post-BK treatment were recorded as a measure of hyperalgesia. Separate groups of rats for negative (Normal) and positive (sumatriptan, 42 mg·kg(-1), s.c.) controls were included. The interaction of INDCA with selective 5-HT1A, 5-HT1B, and 5-HT1D receptor antagonists (NAN-190, Isamoltane hemifumarate, and BRL-15572 respectively) against NTG-induced hyperalgesia was also evaluated. Acute and sub-acute pre-treatment of INDCA [10 and 30 mg·kg(-1) (oral) and 100 μg/rat (i.n.) showed significant anti-nociception activity, and reversal of the NTG-induced hyperalgesia and brain 5-HT concentration decline. Oral pre-treatment with INDCA (30 mg·kg(-1), 7 d) showed significant reduction in the number of vocalization. The anti-nociceptive effects of INDCA were blocked by 5-HT1A and 5-HT1B but not 5-HT1D receptor antagonists. In conclusion, INDCA demonstrated promising anti-nociceptive effects in animal models of migraine, probably through 5-HT1A/1B medicated action.

Cavernous haemangioma of cervix mimicking malignancy: a case report and review of the literature.

Haemangiomas are defined as benign neoplasm arising from blood vessels, either in internal organs or in the skin. There are two types of haemangioma: capillary and cavernous. Capillary haemangioma is usually seen at the top layer while cavernous is often found at deeper layer. These are characterized by abnormal accumulation or growth of blood vessels filled with blood. The cavernous haemangiomas occur less frequently than the capillary ones. These are usually soft to touch. Although some haemangiomas involve large portion of body, most are localized. The majority of lesions are superficial, often of head and neck, but can occur internally. The internal organs mostly affected are liver, spleen, pancreas, GIT, skin, uterus and sometimes the brain. The cervical localization is low. Most of cervical haemangiomas are incidental findings and show asymptomatic behaviour. They sometimes may cause abnormal vaginal bleeding as menorrhagia, metrorrhagia or post coital bleeding and dyspareunia. The most common differential diagnosis include cervical malignant tumor. The treatment is the surgical excision.

Study of parents of β-thalassemia major children to determine cutoff values of hematological parameters for diagnosis of β-thalassemia trait and assessment of anemia in them.

Background: Because of the overlapping MCV, MCH and HbA 2 values in BTT and non-BTT subjects our laboratory determined own cutoffs. Aims: To establish cutoff values by investigating the parents of thalassemia major children and to assess the degree of anemia in BTT subjects. Materials and Methods: Study includes 179 parents of thalassemia major children (BTT cases) and 287 non-BTT controls. Samples were analyzed on an electronic hematology analyzer. The samples having MCV ≤ 76 fl and MCH ≤ 27 pg were quantified for HbA 2 by cellulose acetate electrophoresis and grey zone samples were confirmed on HPLC. Statistical Analysis Mean ± SD, sensitivity, specificity, PPV, NPV and accuracy were calculated. The histograms were plotted for MCV, MCH and HbA 2 . Results: Cases having MCV ≤ 76 fl and MCH ≤ 27 pg if considered as suspected cases of BTT then we could have missed five known BTT samples. Sensitivity increased to 100% in all three diagnostic parameters when the cutoff values were raised and specificity for MCV and MCH was decreased. But specificity was 100% with raised cutoff for HbA 2 . Hb and HCT mean values were significantly reduced in BTT cases compared to controls (P < 0.001). In 100% females and 84.9% males having BTT, mild to moderate anemia was observed. Conclusion: In our setup, the cutoff values are MCV (≤78.0 fl), MCH (≤28 pg) and HbA 2 (>3.8%) for BTT diagnosis and there is a mild to moderate anemia in BTT cases.

Dental trauma and replantation of avulsed teeth.

Avulsion of tooth or teeth is defined as displacement of tooth from its socket. An avulsed permanent tooth is one of the few real emergency situations in dentistry. Avulsion of teeth occurs most often in children between 7 and 9 years of age. It requires quick emergency intervention for favourable healing followed by evaluation and possible treatment at decisive times during the healing phase. Replantation is the first line of treatment for avulsed teeth when extraoral time is less and minimal damage to the PDL. It includes stabilization of teeth in its normal position which helps in reattachment and reorganization of the periodontal ligament. Every possible effort should be made to replant it in order to avoid esthetic, masticatory, phonetic difficulties and avoid arch length discrepancy.