Eco-physiological trait variation in widely occurring species of Western Himalaya along elevational gradients reveals their high adaptive potential in stressful conditions.

Species distributed across a wide elevation range have broad environmental tolerance and adopt specific adaptation strategies to cope with varying climatic conditions. The aim of this study is to understand the patterns of variation in leaf eco-physiological traits that are related to the adaptation of species with a wide distribution in different climatic conditions. We studied the variability in eco-physiological traits of two co-occurring species of Western Himalaya (Rumex nepalensis and Taraxacum officinale), along elevational gradients. We conducted our study in elevations ranging from 1000 to 4000 m a.s.l. in three transects separated in an eco-region spanning 2.5° latitudes and 2.3° longitudes in the Western Himalaya. We hypothesized substantial variation in eco-physiological traits, especially increased net rate of photosynthesis (PN), Rubisco specific activity (RSA), and biochemicals at higher elevations, enabling species to adapt to varying environmental conditions. Therefore, the photosynthetic measurements along with leaf sampling were carried out during the months of June-August and the variations in photosynthetic performance and other leaf traits were assessed. Data was analyzed using a linear mixed effect model with 'species,' 'elevation' as fixed and 'transect' as random factor. Elevation had a significant effect on majority of traits. It was found that PN and maximum carboxylation rate of Rubisco (Vcmax) have unimodal or declining trend along increasing elevations. High RSA was observed at higher elevations in all the three transects. Trends for biochemical traits such as total soluble sugars, total soluble proteins, proline, and total phenolics content suggested an increase in these traits for the survival of plants in harsh environments of higher elevations. Our study reveals that although there is considerable variation in the eco-physiological traits of the two species across elevational gradients of different transects, there are certain similarities in the patterns that depict their high adaptive potential in varying climatic conditions.

Time-series RNA-Seq transcriptome profiling reveals novel insights about cold acclimation and de-acclimation processes in an evergreen shrub of high altitude.

The high-altitude alpine regions are characterized by highly variable and harsh environmental conditions. However, relatively little is known about the diverse mechanisms adopted by alpine plants to adapt to these stressful conditions. Here, we studied variation in transcriptome and physiological adjustments occurring across the year at high elevation environments in the leaf tissue of Rhododendron anthopogon, an evergreen shrub of Himalaya. The samples were collected at 12 different time-points, from August until snowfall in November 2017, and then from June to September 2018. It was observed that with a drop in both ambient air temperature and photoperiod towards onset of winter, the freezing resistance of plants increased, resulting in 'cold acclimation'. Further, 'de-acclimation' was associated with a decrease in freezing resistance and increase in photosynthetic efficiency of leaves during spring. A considerable amount of variation was observed in the transcriptome in a time-dependent sequential manner, with a total of 9,881 differentially expressed genes. Based on gene expression profiles, the time-points could be segregated into four clusters directly correlating with the distinct phases of acclimation: non-acclimation (22-August-2017, 14-August-2018, 31-August-2018), early cold acclimation (12-September-2017, 29-September-2017), late cold acclimation (11-October-2017, 23-October-2017, 04-November-2017, 18-September-2018) and de-acclimation (15-June-2018, 28-June-2018, 14-July-2018). Cold acclimation was a gradual process, as indicated by presence of an intermediate stage (early acclimation). However, the plants can by-pass this stage when sudden decrease in temperature is encountered. The maximum variation in expression levels of genes occurred during the transition to de-acclimation, hence was 'transcriptionally' the most active phase. The similar or higher expression levels of genes during de-acclimation in comparison to non-acclimation suggested that molecular functionality is re-initiated after passing through the harsh winter conditions.

First-pass Success Rate and Number of Attempts Required for Intubation in Anticipated Difficult Airway: Comparison between Macintosh and Channeled King Vision Video Laryngoscopes.

Background and Aims: Video laryngoscopy has been shown to improvise Cormack-Lehane grading and rate of successful tracheal intubation and is now incorporated in most of the difficult airway guidelines. Since there is scarce literature regarding the use of channeled blade of King Vision video laryngoscope (KVVL) in anticipated difficult intubation, we planned to undertake this randomized control trial to assess the performance of channeled blade of KVVL and Macintosh laryngoscope in patients with anticipated difficult intubation. Design and Setting: This prospective randomized study was conducted in a tertiary care hospital. Materials and Methods: Patients fulfilling the inclusion criteria were randomly assigned equally to the KVVL group or Macintosh group. The primary outcome of the study was intubation success in the first attempt and number of attempts required for intubation, and the secondary outcomes were Cormack-Lehane grading and time required to intubate in both the groups. Results: The first-pass success of intubation was 88.6% in the KVVL group and 76.5% in the Macintosh group (P = 0.035). The second attempt of intubation was required in 11.4% and 20.6% of patients in the KVVL and Macintosh groups, respectively. Cormack Lehane Grade I was achieved in 100% of patients of the KVVL group as compared to 29.4% of patients in the Macintosh group. Moreover, the difference was statistically significant (P = 0.035). The mean duration of intubation was prolonged in the KVVL group as compared to the Macintosh group, and the difference was statistically significant (P = 0.04). Conclusion: The channeled blade of KVVL had a higher first-pass success rate and required fewer attempts to intubate when used in patients with anticipated difficult intubation. Further, the KVVL was found to be significantly better than the Macintosh laryngoscope in terms of Cormack-Lehane grading, but the time taken to intubate the trachea was more in the KVVL group.

Comparative Evaluation of McGrath MAC, Truview Video Laryngoscopes and Macintosh Laryngoscope for Endotracheal Intubation in Patients Undergoing Surgery under General Anaesthesia.

BACKGROUND: Videolaryngoscopy is a newly developed technique to improve tracheal intubation success. It was made to bypass the need of directly visualising the glottic inlet. These devices are advantageous as there is no need of aligning the laryngeal, pharyngeal and oral axes for a clear view, thus making intubation easier and faster. AIM AND OBJECTIVES: Primary objective of the study was to determine the duration of laryngoscopy and intubation and Cormack - Lehane grading when intubating with McGrath MAC, Truview video laryngoscope and Macintosh laryngoscope. Secondary objectives of the study were to determine the number of attempts and optimization manouveres required to intubate. MATERIALS AND METHODS: This study was conducted on total of 120 patients in age 20-70 years, either sex, with American Society of Anaesthesiologists physical status classes I or II scheduled for elective surgery under general anaesthesia. They were randomly assigned equally to group 1, 2 and 3 (n = 40) to be intubated by Mcgrath MAC video laryngoscope, Truview video laryngoscope and Macintosh laryngoscope respectively. Parameters recorded were duration of laryngoscopy and intubation, Cormack Lahane grading, ease of intubation, number of attempts and optimisation manouveres required for intubation. STATISTICAL ANALYSIS: Comparison of mean value among the three groups was done using student t test and percentage comparison was done using chi square test. To compare more than two variables ANOVA test was used. The P values of less than 0.05 was considered statistically significant. RESULTS: Duration of laryngoscopy was significantly less in McGrath MAC group when compared to Truview group (P = 0.02) and to Macintosh group (P < 0.001) and the duration of intubation was comparable among all three study groups (P > 0.05). The difference in Cormack - Lehane grading was not significant between McGgrath MAC and Trueview (P = 0.71) but was significant between McGrath MAC and Macintosh (P = 0.002) and Trueview and Macintosh (P = 0.002). Ease of intubation was better in McGrath MAC and Truview groups compared to Macintosh group (P < 0.05). Intubation was successful in the first attempt in 39 (97.50%) patients in McGrath MAC group, 40 (100%) patients in Truview group and 35 (87.50%) patients in Macintosh group. McGrath MAC and Truview groups performed better with respect to optimization manoeuvres compared to Macintosh group (P < 0.05). Trauma was observed in 2 (5%) patients in Truview group and 5 (12.50%) patients in Macintosh group. In McGrath MAC group, no patient underwent any trauma. CONCLUSION: Although duration of laryngoscopy was significantly shorter in McGrath as compared to Truview video laryngoscope and Macintosh laryngoscope but the duration of intubation was comparable between the three groups. Both these video laryngoscopes performed significantly better than Macintosh laryngoscope with respect to laryngoscopic view, requirement of optimization manoeuvre and need for second attempt for intubation.

Coblation-Assisted Turbinoplasty: A Comparative Analysis of Reflex Ultra and Turbinator Wand.

Coblation is a novel technology and has a wide application in the field of otorhinolaryngology. We conducted a randomized, noncontrolled study to compare the effectiveness of 2 types of wands used for turbinoplasty for nasal obstruction due to inferior turbinate hypertrophy. Reflex Ultra and Turbinator wands were compared on a total of 150 patients. These patients were divided into a group of 75 patients each in a randomized manner. Results were compared based on the visual analog scale, and objective assessment was done on the basis of endoscopic assessment, that is, Nasal Endoscopic Score (NES). Assessment was done on postoperative day 7, first month, third month, and first year. Both groups demonstrated significant and similar results in long term, but an immediate improvement at 1 week was seen in the Turbinator group. Hence, we conclude that coblation turbinoplasty is an effective technique for turbinate reduction and both wands are equally effective in long term. However, Reflex Ultra has the advantage of mucosal preservation and minimal morbidity, and Turbinator has the advantage of immediate relief in nasal symptoms.

Therapeutic Efficacy of Two Different Doses of Dexmedetomidine on the Hemodynamic Response to Intubation, the Intubating Conditions, and the Effect on the Induction Dose of Propofol: A Randomized, Double-Blind, Placebo-Controlled Study.

CONTEXT: The hemodynamic response associated with laryngoscopy and tracheal intubation is a common concern for the anesthesiologist, especially in high-risk patients. The use of dexmedetomidine has found favor in obtunding this response, in addition to providing better intubating conditions and reducing the dose of other anesthetic drugs. Most of the current literature states a loading dose of 1 µg/kg dexmedetomidine to be superior to lower doses in this regard. However, using a lower dose may be advantageous by reducing incidence of adverse effects such as hypotension and bradycardia which are likelier with the use of higher dose, in addition to being more cost-effective. AIMS: The aim of the study was (1) to evaluate and compare the effect of loading doses of 1 µg/kg and 0.5 µg/kg dexmedetomidine on attenuation of hemodynamic response to laryngoscopy and intubation and (2) to evaluate the efficacy of dexmedetomidine in reducing the induction dose of propofol for achieving better intubating conditions. MATERIALS AND METHODS: A randomized, double-blind, placebo-controlled study was planned on ninety American Society of Anesthesiologists I and II patients scheduled for elective surgery under general anesthesia. Patients were divided into three groups. Two groups received different loading doses of dexmedetomidine infusion before induction and the third group was a control group. The induction dose of propofol required to abolish the verbal response was noted and compared in all the three groups. All patients were assessed for the intubating conditions and hemodynamic response. STATISTICAL ANALYSIS: Nonparametric data were compared using the Chi-square test and parametric data were compared using Student's t-test using SPSS 16.0 software. RESULTS: Both the loading doses of 1 µg/kg and 0.5 µg/kg dexmedetomidine were equally effective in reducing the induction dose of propofol, improving the intubating conditions and blunting the hemodynamic response to laryngoscopy and intubation. The incidence of adverse effects such as hypotension and bradycardia was lesser with the loading dose of 0.5 µg/kg. CONCLUSIONS: Dexmedetomidine when used as infusion in the loading dose of 0.5 µg/kg is therapeutically as effective as when used in the dose of 1.0 µg/kg not only in reducing the induction dose of propofol but also in providing good intubating conditions and blunting the hemodynamic response to intubation. A lower dose is associated with a lesser incidence of adverse effects such as hypotension and bradycardia.

Anesthetic Management for Fracture Head of Radius in a Child with Glutaric Aciduria type-1.

Glutaric aciduria Type 1 (GA-1) is an autosomal recessive metabolic disorder that results from deficiency of enzyme glutaryl-CoA dehydrogenase. This gives rise to elevated neurotoxic glutaric acid and 3-hydroxyglutaric acid as well as nontoxic glutarylcarnitine in body fluids. The enzyme defect leads to secondary damage to central nervous system due to the accumulation of glutaric acid. Approximately 90% people will develop the neurological disease during a finite period of brain development (3-36 months) following an acute encephalopathic crisis often precipitated by gastroenteritis, immunization, surgical intervention, and intercurrent febrile illness. GA-1 can also develop insidiously without clinically apparent crisis in 10%-20% of the patients. We present a 10-year-old male child with GA-1 who required anesthetic care for fracture (left) neck of radius. Strategies for anesthetic management should include prevention of hypoglycemia, dehydration, electrolyte imbalance, and sufficient analgesia to prevent surgical stress.

Role of Oral Prednisolone in the Management of Postdural Puncture Headache after Spinal Anesthesia in Urological Patients.

BACKGROUND AND AIMS: Postdural puncture headache (PDPH) is a frequently encountered complication of spinal anesthesia and may be associated with significant morbidity in some patients. Parenteral corticosteroids have been used in the management of PDPH both prophylactically and after the occurrence of headache. The aim of this study was to evaluate the effect of oral prednisolone in the management of PDPH after spinal anesthesia in urological patients. MATERIALS AND METHODS: Sixty adult patients who developed PDPH after spinal anesthesia for urological surgeries were randomly allocated to two groups. Group C patients (n = 30) were managed conservatively, and Group P patients (n = 30) were given 20 mg of oral prednisolone for 4 days in addition to the conventional treatment. The intensity of headache was measured using visual analog scale (VAS). VAS score was taken just before the start of treatment (0 h) and at 12, 24, 48, 72, and 96 h after the start of treatment. STATISTICAL ANALYSIS: Statistical analysis was performed using Statistical Packages for Social Science version 19 (SPSS, Inc., Chicago, IL, USA). RESULTS: There was no statistically significant difference in the VAS score in patients before the start of treatment (0 h) and at 12 h after the start of treatment. The VAS scores were less and statistically significant in Group P at 24, 48, 72 and 96 h after the start of treatment (P < 0.05). CONCLUSION: The use of oral prednisolone is effective in reducing the severity and duration of PDPH.

Securing a Difficult Airway: Tracheal Intubation Achieved after Deliberate Placement of an Endotracheal Tube in Esophagus: A New Approach.

Enlarged thyroid gland with retrosternal extension has an increased incidence of difficult intubation, and it poses real airway challenge for the anesthesiologists. Here, we present a case of successful management of a difficult airway in a female patient of enlarged thyroid gland, planned for open reduction and internal fixation of the upper end of humerus. Endotracheal intubation was achieved after deliberate insertion of an endotracheal tube in esophagus. The patient was extubated over a ventilating bougie, with uneventful postoperative course.

Clonidine as an Adjuvant in Fluoroscopic-guided Transforaminal Epidural Steroid Injection in a Patient of Chronic Lumbosacral Radiculopathy.

Transforaminal epidural steroid injection (TFESI) is a minimally invasive modality used to treat patients with lumbosacral radiculopathy secondary to prolapsed intervertebral disc or spinal canal stenosis. In this case report, we describe the management of a patient with chronic lumbosacral radiculopathy secondary to intervertebral disc herniation which was seen as a right paracentral disc protrusion at levels L4-L5, L5-S1 causing thecal sac indentation, effacement of the right lateral recess and right exiting nerve root impingement as was seen on the magnetic resonance image. Diffuse disc bulge at levels L4-L5 and L5-S1 caused thecal sac indentation with right neural foraminal narrowing. There was no evidence of associated facet joint arthropathy. Owing to the persistence of symptoms for >6 weeks despite medicines and an ESI through the caudal route 4 weeks back, anticipation of efficacy of TFESI with methylprednisolone using clonidine as an adjuvant in our patient was justifiable.

Comparison of fluoroscopic Guided Transforaminal Epidural Injections of Steroid and Local Anaesthetic with Conservative Management in Patients with Chronic Lumbar Radiculopathies.

BACKGROUND: Chronic lumbar radiculopathy is a common medical problem and the treatment modalities used over years have been many ranging from conservative or symptomatic management to open decompression surgery. This study was aimed at to compare two modalities of treatment, i.e., conservative and lumbar transforaminal epidural steroid injections (TFESIs). MATERIALS AND METHODS: A total of 120 patients of American Society of Anesthesiology class - (a healthy patient or a patient with mild systemic disease) were randomized to two groups. Group C (n = 60) were managed conservatively with bed rest, analgesics, and physiotherapy. Group T (n = 60) received lumbar TFESIs with methylprednisolone 40 mg with 2 ml bupivacaine (0.5%). Measurements using visual analog scale (VAS) were taken before treatment and at various time intervals after the start of treatment. RESULTS: There was no statistically significant difference regarding the demographic characteristics of both groups. The VAS scores were less and statistically significant in Group T after 30 min postinjection, at the 2nd week and after 1 month. Recovery rate of straight leg raise test was found to be 98% in those treated with TFESI. The Group T had significantly better patient satisfaction score and additionally there was drug dose intake reduction before and after the treatment. CONCLUSION: Patients treated with fluoroscopic-guided TFESI have better pain relief, quality-of-life, and less analgesic requirement than those managed conservatively.

Thoracic combined spinal epidural anesthesia for laparoscopic cholecystectomy: A feasibility study.

BACKGROUND AND AIMS: The use of regional anesthesia for laparoscopic cholecystectomy has been reserved for patients who are at high-risk under general anesthesia (GA). The aim of this study was to assess whether thoracic combined spinal epidural (CSE) anesthesia is a feasible option for American Society of Anesthesiologists (ASA) physical status I and II patients undergoing elective laparoscopic cholecystectomy. MATERIAL AND METHODS: Thirty ASA physical status I and II patients undergoing elective laparoscopic cholecystectomy received thoracic CSE anesthesia at T9-T10 or T10-T11 interspinous space using the midline approach. Two ml of isobaric levobupivacaine 0.5% with 25 µg of fentanyl was given intrathecally. RESULTS: Surgery was conducted successfully in all except one patient. Thoracic CSE was performed at T9-T10 interspace in 25 patients and T10-T11 interspace in five patients. Paresthesia occurred in two patients (6.6%) transiently on Whitacre needle insertion that disappeared spontaneously. Dural puncture on epidural needle insertion occurred in one patient, and intrathecal placement of epidural catheter occurred in one. Ten patients (33%) complained of shoulder pain. Conversion to GA was done in one patient due to severe shoulder pain and anxiety. Hypotension occurred in 11 patients (36%) and all responded to single dose of mephenteramine 6 mg and fluid bolus. Bradycardia occurred in six patients (20%) which was managed in all with a single dose of atropine. CONCLUSION: Thoracic CSE anesthesia can be used effectively for ASA I and II patients undergoing laparoscopic cholecystectomy with significant postoperative benefits.

Thoracic combined spinal epidural anesthesia for laparoscopic cholecystectomy in a geriatric patient with ischemic heart disease and renal insufficiency.

Older people undergoing any surgery have a higher incidence of morbidity and mortality, resulting from a decline in physiological reserves, associated comorbidities, polypharmacy, cognitive dysfunction, and frailty. Most of the clinical trials comparing regional versus general anesthesia in elderly have failed to establish superiority of any single technique. However, the ideal approach in elderly is to be least invasive, thus minimizing alterations in homeostasis. The goal of anesthetic management in laparoscopic procedures includes management of pneumoperitoneum, achieving an adequate level of sensory blockade without any respiratory compromise, management of shoulder tip pain, provision of adequate postoperative pain relief, and early ambulation. Regional anesthesia fulfills all the aforementioned criteria and aids in quick recovery and thus has been suggested to be a suitable alternative to general anesthesia for laparoscopic surgeries, particularly in patients who are at high risk while under general anesthesia or for patients unwilling to undergo general anesthesia. In conclusion, we report results of successful management with thoracic combined spinal epidural for laparoscopic cholecystectomy of a geriatric patient with ischemic heart disease with chronic obstructive pulmonary disease and renal insufficiency.

MALPOSITIONED LMA CONFUSED AS FOREIGN BODY IN NASAL CAVITY.

We present a case of confusing white foreign body in the nasal cavity detected during Endoscopic Sinus Surgery (ESS) in a 35-yr-old male which turned out to be a malposition of classic laryngeal mask airway (LMA). Although malposition of LMA is a known entity to the anesthesiologist, if ventilation is adequate, back folded LMA in nasal cavity might not be recognized by the surgeon and lead to catastrophic consequences during endoscopic sinus surgery. In principle, misfolding and malpositioning can be reduced by pre usage testing, using appropriate sizes, minimizing cuff volume, and early identification and correction of malposition.

Evaluation of hemodynamic changes using different intra-abdominal pressures for laparoscopic cholecystectomy.

Biliary diseases known since ages constitute major portion of digestive tract disorders world over. Among these cholelithiasis being the fore runner causing general ill health, thereby requiring surgical intervention for total cure. The study was undertaken in an attempt to compare the hemodynamic changes in patient undergoing laparoscopic cholecystectomy using different intra-abdominal pressures created due to carbon dioxide insufflation. The patients were randomly allocated to one of the three groups in which different levels of intra-abdominal pressures (8-10 mmHg,11-13 mmHg and 14 mmHg and above) were maintained. The base line parameters monitored were heart rate, non invasive blood pressur(systolic and mean)and end tidal carbon dioxide. All the parameters were monitored at various intervals i.e. Immediately during insufflation, 5 min, 10 min, 20 min, 30 min after CO2 insufflation and after every 10 min if surgery exceeds 30 min, at exsufflation,10 min after CO2 exsufflation. Patients were ventilated with Pedius Drager Ventilator keeping tidal volume 8-10 ml/kg and respiratory rate 12-14 breaths/min. During surgery patients were placed in reverse Trendlenburg position (head up) at 15 °. The results obtained were evaluated statistically and analyzed. Baseline characteristics were found to be comparable. Hemodynamic variables were reported as mean and standard deviation. Statistical significance among groups was evaluated using Analysis of Variance and unpaired student t test (two tailed). Inter-group comparisons were made using Bonferroni test. A p-value of <0.05 was considered as statistically significant. In all the three groups the mean heart rate (baseline 84.08 ± 12.50, 87.96 ± 15.73 and 86.92 ± 17.00 respectively) increased during CO2 insufflation and the rise in heart rate continued till exsufflation after which it decreased and at 10 min after exsufflation the heart rates were comparable with the baseline. The inter-group comparison of mean heart rate between I & III was statistically significant at 10, 20, 30 min after CO2 insufflation which continued at exsufflation and 10 min after CO2 exsufflation [p < 0.05]. The inter-group comparison between I & III showed statistically significant difference in systolic blood pressure at 10, 20, 30 min after CO2 insufflation, at exsufflation and 10 min after exsufflation [p = 0.0001] and mean arterial pressure at 5, 10, 20, 30 min after CO2 insufflation, at exsufflation and 10 min after exsufflation [p = 0.0001]. Comparison between Group I and Group III & between Group II and Group III showed highly significant statistical difference in EtCO2 immediately after insufflation and the same trend was seen till the completion of surgery and even 10 min after exsufflation [p = 0.001]. The conclusion drawn from the study was that laparoscopic cholecystectomy induces significant hemodynamic changes intraoperatively, the majority of pathophysiological changes are related to cardiovascular system and are caused by CO2 insufflation .A high intra-abdominal pressure due to CO2 insufflation is associated with more fluctuations in hemodynamic parameters and increased peritoneal absorption of CO2 as compared to low intraabdominal pressure so low pressure pneumoperitoneum is feasible for laparoscopic cholecystectomy and minimizes the adverse hemodynamic effects of CO2 insufflation.