Chest ultrasonography in emergency Cesarean delivery in multi-valvular heart disease with pulmonary edema during spinal anesthesia.

Valvular heart disease in a parturient presenting for Cesarean section is challenging. A 25 year old primigravida parturient with severe mitral stenosis, mild mitral regurgitation, mild aortic regurgitation, and mild pulmonary arterial hypertension required Cesarean delivery after developing pulmonary edema. Low-dose spinal with hyperbaric bupivacine 0.5% 1.8 mL plus 25 µg of fentanyl was used for anesthesia. Chest ultrasonography (US) and transthoracic echocardiography (TTE) were used for monitoring purposes. Spinal-induced preload reduction improved the pulmonary edema, as evidenced by chest US. Chest US and TTE helped in fluid management.

CSF p-Tau levels in the prediction of Alzheimer's disease.

The two hallmarks of Alzheimer's disease (AD) are neurofibrillary tangles and amyloid plaques. Neurofibrillary tangles are formed due to the hyperphosphorylation of tau protein. There is an urgent need to develop a reliable biomarker for the diagnosis of AD. Cerebrospinal fluid (CSF) is surrounding the brain and reflects the major neuropathological features in the AD brain. Diagnosis, disease progression and drug actions rely on the AD biomarkers. Mainly CSF tau and phosphorylated tau (p-Tau) have been observed to serve the purpose for early AD. Keeping in view the early appearance of p-Tau in CSF, we analyzed p-Tau levels in 23 AD, 23 Non AD type dementia (NAD), 23 Neurological control (NC) and 23 Healthy control (HC) North Indian patients. The levels of p-Tau were found to be increased in AD patients (67.87±18.05 pg/ml, SEM 3.76) compared with NAD (47.55±7.85 pg/ml, SEM 1.64), NC (34.42±4.51 pg/ml, SEM 0.94) and HC (27.09±7.18 pg/ml, SEM 1.50). The resulting sensitivity for AD with NAD was 80.27% whereas with respect to the NAD, NC and HC was 85.40%. Therefore elevated levels of p-Tau in AD can be exploited as a predictive biomarker in North Indian AD patients.

Apo-Eε4 allele in conjunction with Aß42 and tau in CSF: biomarker for Alzheimer's disease.

The objective of this study was to elucidate an association between Apo- Eε4 allele and CSF biomarkers Aß42 and tau for the diagnosis of Alzheimer's Disease (AD) patients. Aß42 and tau protein concentrations in CSF were measured by using ELISA assays. The levels of Aß42 were found to be decreased where as tau levels increased in AD patients. Moreover in AD patients Apo-Eε4 allele carriers have shown low Aß42 levels (328.86 ± 99.0 pg/ml) compared to Apo-Eε4 allele non-carriers (367.52 ± 5 7.37 pg/ml), while tau levels were higher in Apo-Eε4 allele carriers (511 ± 44.67 pg/ml) compared to Apo-Eε4 allele non-carriers (503.75 ± 41.08 pg/ml). Combination of Aß42 and tau resulted in sensitivity of 75.38% and specificity of 94.82% and diagnostic accuracy of 84.30% for AD compared with the controls. Therefore low Aß42 and elevated tau concentrations in CSF may prove to be a better diagnostic marker for AD along with the Apo-Eε4 allele.

Cerebrospinal fluid profile of amyloid ß42 (Aß42), hTau and ubiquitin in North Indian Alzheimer's disease patients.

Alzheimer's disease (AD) is the most common form of dementia, and is characterized by the degeneration of neurons and their synapses, and a higher number of amyloid plaques and neurofibrillary tangles (NFTs) compared with that found in non-demented individuals. Amyloid-ß-peptides (Aß) are major components of amyloid plaques in AD brain whereas NFTs are composed of Tau and associated with ubiquitin. The aim of the present study was to analyze the levels of Aß42, hTau (total Tau) and ubiquitin in CSF of North Indian population. CSF Aß42, Tau and ubiquitin were measured in CSF of AD patients as well as controls using ELISA assays. Here we report low Aß42 levels in AD patients (324.24±76.38pg/ml) as compared to those in non-AD (NAD) (668.34±43.13pg/ml), neurological controls (NCs) (727.28±46.49pg/ml) and healthy controls (HCs) (976.47±124.46pg/ml). In contrast, hTau and ubiquitin levels were significantly high (568.65±48.89pg/ml and 36.82±4.34ng/ml, respectively) in AD patients compared to those in NAD, NC and HC. The hTau levels were 267.37±36.64pg/ml, 167.34±44.27pg/ml and 107.62±24.27pg/ml in NAD, NC and HC, respectively. Similarly, ubiquitin levels were 23.57±2.32ng/ml, 19.76±3.64ng/ml and 13.24±4.56ng/ml in NAD, NC and HC, respectively. In conclusion, low Aß42 and high Tau-ubiquitin levels were found in North Indian AD patients.

Efficacy of orally disintegrating ondansetron in preventing postoperative nausea and vomiting after laparoscopic cholecystectomy: a randomised, double-blind placebo controlled study.

Peri-operative prophylactic anti-emetics are commonly used parenterally. Orally disintegrating ondansetron is efficacious during chemotherapy. Therefore, we aimed to study the efficacy of orally disintegrating ondansetron for postoperative nausea and vomiting. In a randomised, double-blind, placebo controlled trial on 109 patients scheduled for laparoscopic cholecystectomy, oral ondansetron was compared to intravenous ondansetron and placebo. The anaesthetic technique was standardised. Mean time (SD) to tolerating oral intake was delayed in the placebo group to 366.1 (77.6) min compared to oral 322.9 (63.7) min and intravenous 322.4 (65.2) min groups. This is corroborated by a higher incidence of nausea and vomiting in the control group during the first 6 h postoperatively (control 44.4%, oral 17.7%, intravenous 18.2%). There was no significant difference between oral and intravenous groups. In conclusion, orally disintegrating ondansetron was as efficacious as intravenous ondansetron in the peri-operative phase and may be a viable option for prophylaxis of emesis in day care surgery.

Heterogeneous disease modeling for Hardy-Weinberg disequilibrium in case-control studies: application to renal stones and calcium-sensing receptor polymorphisms.

Renal stone formation due to hypercalciuria is a relatively common disorder with clear evidence for genetic predisposition, but cryptic phenotypic heterogeneity has hampered identification of candidate genes. The R990G single-nucleotide polymorphism (SNP) of the calcium sensing receptor (CASR) gene has been associated with hypercalciuria in stone formers and shows the appropriate functional phenotype in cell culture. In our preliminary association analysis of a case-control cohort, however, we observed significant Hardy-Weinberg disequilibrium (HWD) for the cases (n= 223), but not controls (n= 676) at the R990G locus, pointing us toward the general disease model incorporating HWD. Because there is an adjacent CASR SNP, A986S, which is in negative linkage disequilibrium with R990G, we extended the general disease model to enable testing of a two-site hypothesis. In our data set, there is no lack of fit (P= .345) for the single-locus model for the R990G genotype, and likelihood ratio testing favors a recessive effect with an eight-fold increase in risk (P < .001) for GG homozygotes, relative to wild-type, based on a population prevalence of 2%. Addition of the A986S genotype provides no additional information either by itself or when included in our two-site model.

A single dose of preoperative gabapentin for pain reduction and requirement of morphine after total mastectomy and axillary dissection: randomized placebo-controlled double-blind trial.

BACKGROUND: Gabapentin has been recently found to be useful for reducing acute postoperative pain when administered preoperatively. Although various dose regimens have been tried in different surgical settings, the minimum effective dose is not established. AIMS: We aimed to evaluate the analgesic efficacy of single low dose gabapentin in patients undergoing total mastectomy and axillary dissection. SETTINGS AND DESIGN: Prospective randomized placebo-controlled double-blind trial in a tertiary care teaching hospital. MATERIALS AND METHODS: Fifty women scheduled for total mastectomy and axillary dissection were randomized to receive either gabapentin 600 mg or placebo orally 1 h preoperatively. The intraoperative and postoperative management was standardized. Postoperative pain was assessed at rest and on movement for 12 h using the numerical rating scale (NRS). Morphine was administered if NRS exceeded 30. Primary outcome measure was total morphine consumption. STATISTICAL ANALYSIS: The morphine consumption was compared using independent t test while pain and sedation scores were analyzed using Mann-Whitney U test. RESULTS: Forty-six patients completed the trial. The postoperative morphine consumption was significantly less (5.8 +/- 4.2 vs. 11.0 +/- 3.4 mg; P 0.001) and the median [IQR] time to first analgesic was significantly longer (90 [37.5-120] vs. 0 [0-90] min; P 0.001) in the gabapentin group than in the placebo group. The incidence of side effects was similar in the two groups. CONCLUSIONS: A single low dose of 600 mg gabapentin administered 1 h prior to surgery produced effective and significant postoperative analgesia after total mastectomy and axillary dissection without significant side effects.

Assessment of the effectiveness of peripheral administration of fentanyl with lidocaine in inflamed dentoalveolar tissues.

Peripheral action of opioids for pain control, for which local inflammation has been shown to be crucial, is being increasingly used in clinical practice. The aim of this study was to evaluate the hypothesis that addition of fentanyl to lidocaine, when injected into inflamed dentoalveolar tissues, can improve the quality of analgesia during surgery. Seventy-one patients reporting with pain and tenderness in the maxillary tooth were assigned into the experimental (LAF) or control (LA) group in a prospective, randomized double-blind trial. The LAF group (n = 36) was injected submucosally with a mixture of 40 microg of fentanyl (0.8 ml) and 2% lidocaine hydrochloride with 1:200000 adrenaline (2 ml). In the LA group (n = 35) 0.9% of saline (0.8 ml) was added instead of fentanyl. The pain scores were recorded before injecting, 5 min after injection, and immediately after surgery using a visual analogue scale. The mean pain scores were not significantly different at all time intervals. Twelve patients in the LAF group (2.75+/-0.72 ml) and ten patients in the LA (2.90+/-0.70 ml) group required additional local anaesthetic to achieve pain control. In conclusion, there was no improvement in quality of intraoperative analgesia on addition of fentanyl to lidocaine in inflamed dentoalveolar tissues.

Prevalence of weight gain in patients with better renal transplant function.

AIMS: This study investigates the association between renal function and change in weight after kidney transplantation. METHODS: Retrospective analyses of 165 transplant patients on maintenance steroids who were followed-up for 6.2 +/- 2.4 years. RESULTS: 101 males and 64 females participated in the study. Results are expressed as mean +/- SD. At the first post-transplant outpatient visit (time 0), BMI was 25.3 +/- 4.8 kg/m2. It increased significantly by 7.7 +/- 10.8% and 10.9 +/- 12.6% at 1 and 5 years. 18 and 29% of patients had a BMI > 30 kg/m2 at times 0 and 5 years, respectively. Thereafter, diminishing glomerular filtration rate (GFR) was associated with the loss of the excess weight. Multivariate analysis showed that GFR, but not age, race, sex, source of graft, number of HLA mismatches or length of dialysis was significant to post-transplant weight gain. 38 patients gained weight > 1 SD above the mean of the population and were designated the high weight gain (HWG) group. 41 patients gained weight < the mean - 1 SD of the population and were designated the low weight gain (LWG) group. GFR in the high and low weight gain groups at time 0 was 71.8 +/- 20.3 ml/min/1.73 m2 and 66.4 +/- 23.1 ml/min/1.73 m2, respectively (p = NS), as compared to 77.4 +/- 23.3 ml/min/1.73 m2 and 61.5 +/- 24.5 ml/min/ 1.73 m2 at 6 months, respectively (p < 0.01) and continued to be significant thereafter (72.7 +/- 17.2 ml/min/1.73 m2 and 58.9 +/- 19.8 ml/min/1.73 m2, p < 0.05 at 6 years). CONCLUSIONS: Patients with relatively better renal transplant function gained more weight, suggesting a pivotal role of improved appetite on weight gain post transplantation. Most of the weight gain occurred during the first year.

Effect of varying doses of fentanyl with low dose spinal bupivacaine for caesarean delivery in patients with pregnancy-induced hypertension.

The purpose of this study was to evaluate haemodynamic stability, perioperative analgesia and neonatal outcome following intrathecal 0.5% bupivacaine 7.5 mg with varying doses of fentanyl, in parturients with pregnancy-induced hypertension. Forty-five parturients with pregnancy-induced hypertension scheduled for caesarean section were randomly allocated to receive 7.5 mg bupivacaine with saline 1 mL (group B), fentanyl 10 microg (group Bf10) or fentanyl 20 microg (group Bf20) intrathecally. Heart rate, blood pressure, and sensory block were recorded at regular intervals. Pain, nausea, vomiting, pruritus or any other side effects were sought. Neonatal outcome was assessed using Apgar score and umbilical artery blood gas analysis. Adequate surgical anaesthesia was established in all three groups. There was a statistically significant fall in mean arterial pressure in all three groups within 4-6 min of subarachnoid block (P<0.05), but the decrease in MAP was <20% of baseline in all three groups. Pain and discomfort during surgery were experienced more frequently in group B than in groups Bf10 and Bf20 (P<0.05). Duration of postoperative analgesia was significantly longer in group Bf20 (5.55+/-1.18 h) than in group Bf10 (3.97+/-2.12 h) and group B (3.27+/-1.8 h) (P<0.05). Neonatal outcome was similar in the three groups. Intrathecal fentanyl with low dose bupivacaine provides good surgical anaesthesia and prolongs the duration of analgesia without haemodynamic or neonatal compromise in patients with pregnancy-induced hypertension undergoing caesarean delivery.

Intrathecal fentanyl added to intrathecal bupivacaine for day case surgery: a randomized study.

BACKGROUND AND OBJECTIVE: The implication of intrathecal lidocaine in neurological toxicity has made intrathecal bupivacaine the commonly used drug for local anaesthesia in ambulatory surgery. However, in high doses intrathecal bupivacaine may produce a high level of sensory and motor block, and arterial hypotension; discharge from hospital may be delayed. Intrathecal opioids added to low-dose local anaesthetics produce a synergistic effect without increasing the sympathetic block or delaying discharge. The aim of our study was to identify the minimum effective dose of intrathecal fentanyl that in combination with low-dose intrathecal bupivacaine would provide adequate surgical conditions without prolonging recovery. METHODS: A prospective, single, blind, randomized study was conducted in 45 adult males scheduled for minor urological procedures using intrathecal anaesthesia on a day care basis. Patients were randomly assigned to one of three groups (n = 15 each). They received bupivacaine 0.17% 5 mg--with either fentanyl 7.5 microg (fenta-7.5), 10 microg (fenta-10) or 12.5 microg (fenta-12.5) intrathecally in a total volume of 3 mL. The quality of anaesthesia, haemodynamic stability, time to two-segment and S2 regression, time to micturition, and time to discharge were assessed. RESULTS: The time to two-segment regression and S2 regression with fenta-12.5 was significantly longer than with fenta-7.5 and fenta-10 (P < 0.01). Fenta-7.5 had a significantly higher number of failed blocks (four patients) compared with fenta-12.5 (P < 0.05). The time out of bed, time to micturition and time to discharge were significantly longer with fenta-10 and fenta-12.5 compared with fenta-7.5, and also with fenta-12.5 compared with fenta-10 (P < 0.01). Haemodynamic stability did not differ for all the drug combinations. CONCLUSIONS: Fentanyl 12.5 microg added to low-dose bupivacaine (5 mg) intrathecally provides better surgical anaesthesia and increased reliability of block than intrathecal fentanyl 7.5 or 10 microg. Haemodynamic stability was the same for all dose combinations used.

Tetanus.

Tetanus is a potentially life threatening disease affecting nearly 50,000 to 1 million people world wide every year. Four major clinical forms of tetanus are described i.e. generalized, cephalic, localized and neonatal. Neonatal tetanus is particularly common in developing countries, due to unhygienic child birth practices, social taboos and improper immunization of pregnant mothers. Management of this disorder involves a team approach and aims at eradicating focus of infection, neutralizing the toxin, controlling spasms and dysautonomia and providing adequate ventilatory and supportive care. Metronidazole may be the preferred antibiotic although penicillin is still used frequently. Adequate wound debridement is necessary to prevent spore germination. Spasms are usually managed by sedatives like diazepam and neuromuscular blocking agents. Magnesium sulphate is an attractive substitute and may be tried if ventilatory facilities are unavailable. Use of baclofen is potentially advantageous but cannot be routinely prescribed. Dysautonomia is difficult to manage and requires therapy with benzodiazepines, morphine, magnesium sulphate, adrenergic blockers and recently tried baclofen therapy. Supportive care including ventilatory assistance are highly essential for successful outcome of the patients. It is imperative that complications are diagnosed early and managed appropriately. Immunization is extremely effective and is the key to prevention. Adequate steps and measures should be taken to increase awareness of this potentially preventable disease.

A comparative study of caudal bupivacaine and midazolam-bupivacaine mixture for post-operative analgesia in children undergoing genitourinary surgery.

OBJECTIVE: This study was designed to evaluate the analgesic efficacy of caudal midazolam-bupivacaine combination in providing post-operative pain relief in children undergoing genitourinary surgery and to study the occurrence of adverse effects. SUBJECTS AND METHODS: Thirty children, aged 2 to 8 years, scheduled for genitourinary surgery were allocated randomly to receive either 0.25% bupivacaine 0.5 ml/kg (group B; n = 15) or 0.25% bupivacaine 0.5 ml/kg with 50 microg/kg midazolam (group BM; n = 15) by the caudal route immediately after induction of general anesthesia. Heart rate, arterial blood pressure and oxygen saturation were monitored throughout the study period. Postoperative pain was assessed at regular intervals for 12 hours using an objective pain score. Analgesia was supplemented whenever the pain score was > or = 4. Duration of analgesia, as well as the requirement of additional analgesics, were noted. RESULTS: Lowest pain scores were observed with the addition of midazolam to caudal bupivacaine (p < 0.01). Duration of analgesia was longer in group BM (11 +/- 0.5 h) as compared to group B (7.4 +/- 2.1 hours) (p < 0.05). Fewer children (26.6%) required additional analgesia in the combination group whereas in group B, 60% of the children received analgesic supplements within 6 hours after surgery (p < 0.05). There were no significant changes in heart rate, blood pressure and oxygen saturation in both groups. We observed no untoward event in either of the groups. CONCLUSION: Caudal administration of bupivacaine-midazolam mixture prolongs post-operative analgesia compared to bupivacaine alone without causing any adverse effects.

Anaesthetic and intensive care aspects of spinal injury.

Over the last few years, spinal injuries have been classified depending upon their causative mechanism and on the basis of three column concept of the structure of vertebral column. The concept of primary and secondary injury has laid more stress on prevention and treatment of secondary injury. Methyl prednisolone still remains the drug of choice for prevention of secondary injury. Spinal injury involves all organ systems of the body depending on the level of lesion. Immobilisation of injured spine and maintenance of adequate airway after spinal injury need immediate attention. Orotracheal intubation under general anaesthesia, with manual in-line traction, is still considered the best method. Hypotension, hypertension and hyperglycaemia should be avoided during anaesthesia. Care should be taken to avoid effects of autonomic hyper reflexia. Spinal cord functions should be monitored and, if required, induced hypotension can be used with adequate monitoring.

Intracranial pressure changes with different doses of lignocaine under general anaesthesia.

The effect of intravenous lignocaine on intracranial pressure (ICP) was studied on thirty patients of either sex, aged above 5 years and scheduled for elective ventriculoperitoneal shunt surgery. The patients were randomly divided into 3 groups, which received intravenous lignocaine in the dose of 1 mg, 1.5 mg and 2 mg/kg body weight respectively. Intracranial pressure, heart rate, ECG, arterial pressure and arterial blood gases were monitored at various intervals for a period of 30 minutes. Maximum decrease in ICP was seen at 2 minutes after IV lignocaine in all the three groups (p<0. 001). The fall in ICP was significantly more in group II and group III (35.65% and 37.5% respectively) as compared to group I (17.47%) (p<0.001). This fall in ICP in all the three groups persisted below the basal level, throughout the study period. None of the groups showed any significant change in the heart rate, but a statistically significant fall in arterial pressure was observed in group III (p<0. 05). In conclusion intravenous lignocaine, in a dose of 1.5 mg/kg, causes significant fall in ICP without causing any untoward cardiovascular effects and is recommended for routine clinical use.