Gestational Diabetes Mellitus - The Modern Indian Perspective.

Gestational diabetes mellitus (GDM) is a serious and most frequent health complication during pregnancy which is associated with a significant increase in the risk of maternal and neonatal outcomes. GDM is usually the result of ß-cell dysfunction along with chronic insulin resistance during pregnancy. Seshiah et al. pioneer work led to the adoption of Diabetes in Pregnancy Study Group in India criteria as the norm to diagnose GDM, especially in the community setting. In 2014, the Maternal Health Division of the Ministry of Health and Family Welfare, Government of India, updated guidelines and stressed upon the proper use of guidelines such as using a glucometer for self-monitoring and the use of oral hypoglycaemic agents. The 2018 Government of India guidelines stress the importance of counselling about lifestyle modifications, weight control, exercise, and family planning.

Effectiveness of Face mask only oxygenation and apnoeic oxygenation in addition to face mask in sustaining PaO2 during rapid sequence induction - A randomized control trial.

Background and Aims: Apnoeic oxygenation, although useful during elective intubations, has not shown consistent beneficial results during emergency intubations in critically ill patients. We aimed to study the effectiveness of adding apnoeic oxygenation to our routine practice of using facemask alone, in emergency laparotomy patients needing rapid sequence induction (RSI), for sustaining partial pressure of oxygen (PaO2). Material and Methods: Seventy-two patients undergoing RSI for emergency laparotomy were randomly allocated to either receive pre-oxygenation with 5 L/min of oxygen (O2) with a facemask (Group-FM) or apnoeic oxygenation with 10 L/min of O2 through a nasal catheter in addition to pre-oxygenation (Group-NC). Apnoea (90 s) was allowed from the removal of the facemask before the resumption of ventilation. Arterial blood gas analysis was done at the baseline, following pre-oxygenation and after 90 s of apnoea to study the PaO2 and partial pressure of carbon dioxide (PaCO2). The circuit O2 concentrations (fraction of inspired [FiO2] and end-tidal [EtO2]) were also noted to ensure a steady state of O2 uptake was reached. Results: The circuit O2 concentrations were 90 ± 4% in group FM and 93 ± 5% in Group-NC. The FiO2-EtO2 difference was 4% in both groups. During the 90 s apnoea following pre-oxygenation, there was a fall in the PaO2 by 38% in Group-FM and 12% in Group-NC (P = 0.000). Increase in PaCO2 was similar in both groups (Group-FM: 44 [range: 32-55] mmHg; Group-NC: 42 [range: 33-54] mmHg, P = 0.809). Conclusion: Apnoeic insufflation of O2 using a nasopharyngeal catheter along with facemask oxygenation is more effective in sustaining PaO2 for 90 s during RSI than facemask-only oxygenation in patients undergoing emergency laparotomy.

Quantitative assessment of ultrasound-guided sciatic nerve block - A comparison of a single-point versus two-point injection technique: A randomised controlled, double-blinded trial.

Background and Aims: Sciatic nerve block at the popliteal level for lower limb procedures provides unpredictable success rates even with ultrasonographic (USG) guidance. This study aimed to compare USG-guided single-point versus two-point injection techniques. Methods: Sixty patients posted for foot surgeries under USG-guided sciatic nerve block were randomised into Group Single Point, receiving a single injection of 20 mL of 1.5% lignocaine with adrenaline just proximal to the sciatic nerve bifurcation, and Group Double Point, receiving two injections of 10 mL of 1.5% lignocaine with adrenaline, one at the point similar to the first group and a second injection 6 cm above the first point. Sensory blockade onset, time to complete sensory blockade, time to complete motor blockade, length of the nerve exposed and analgesia duration were evaluated. Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS) statistics version 20 software. Results: Double-point injection technique showed a significantly faster time to complete motor blockade [14.46 (9.93) min], increased length of nerve exposed to local anaesthetic [23.23 (7.209) cm] and extended duration of analgesia [420.40 (99.34) min] compared to the single-point injection technique [20.89 (12.62) min, 18.78 (5.95) cm and 344.28 (125.97) min, respectively]. The onset of sensory blockade and the time to complete sensory blockade were comparable between the two groups. Conclusion: USG-guided popliteal sciatic nerve block with a double-point injection technique does not significantly shorten the time to complete the sensory block. However, the time to complete motor nerve block and duration of analgesia are prolonged significantly, which may be clinically beneficial for postoperative analgesia.

Quercetin activates vitamin D receptor and ameliorates breast cancer induced hepatic inflammation and fibrosis.

Aims: To explore the hepatoprotective role of quercetin and its novel molecular mechanism of action on breast cancer associated hepatic inflammation and fibrosis via Vitamin D receptor (VDR). Main methods: We used Ehrlich Ascites Carcinoma (mouse mammary carcinoma) model for our in-vivo experiments and human breast cancer cell lines for in-vitro assays. We inoculated 1.5 × 106 Ehrlich ascites carcinoma cells into female Swiss albino mice. Quercetin (50 mg/kg) was administered intraperitoneally for 15 days. Liver enzymes activity was determined using a spectrophotometric assay. The hallmarks of inflammation and fibrosis were determined using Immunohistochemistry. The effect of quercetin on tumor formation was elucidated using human breast cancer cell lines and chick chorioallantoic membrane assay. Docking study was performed to explore the binding mode of quercetin with VDR. Key findings: In EAC tumor-bearing mice, cell numbers, tumor volume, body weight and liver weight were dramatically increased, while they significantly decreased in mice treated with quercetin. Additionally, the peritoneal neo-angiogenesis was also significantly suppressed in the quercetin-treated mice, compared to the control. In addition, quercetin treated EAC tumor bearing mice had lower levels of liver enzymes, decreased hepatic inflammation and fibrosis compared with EAC tumor bearing mice. Docking study confirmed VDR-quercetin interaction. Furthermore, in-vitro assays and chick chorioallantoic membrane assay revealed the Vitamin D mimicking effect of quercetin. Significance: Dietary flavonoid, quercetin could act as a promising therapeutic drug to suppress the breast cancer induced tumor angiogenesis, hepatic inflammation, and fibrosis possibly via activation of VDR.

Competency-based postgraduate training: Mentoring and monitoring using entrustable professional activities with descriptive rubrics for objectivity- A step beyond Dreyfus.

Background At Sri Balaji Vidyapeeth, a competency-based learning and training (CoBaLT©) model for postgraduate (PG) curriculum, within the regulatory norms, was implemented in 2016 after adequate faculty development programmes. This focused on well-defined outcomes. Methods A review of the outcomes was undertaken in 2018 as part of internal quality assurance receiving feedback from all stakeholders, viz. students, alumni and faculty. Recent publications were also reviewed. A major problem identified was lack of clarity in definition of levels leading to subjectivity in assessment while grading. It was also noted that the process needed to be aligned with the programme outcomes. Further refinements were, therefore, made to align and objectivize formative assessment using entrustable professional activities (EPA) with the aid of descriptive rubrics of sub-competencies and milestones. Addition of detailed rubrics for objectivity takes assessment a step beyond the Dreyfus model, aligning overall to the programme outcomes. Results Achievement of appropriate grades in EPAs by individual candidates ensures entrustability in professional activities by the time of completion of the PG programme. The modification was found more transparent and objective with reference to grading by the teachers and more conducive to reflections by the residents on their performance and how to improve it. Conclusions The use of descriptive rubrics along with EPAs brings transparency and plays a key role as an objective assessment tool, which can lend direction to individual resident learning and entrustability. This is an important component of outcome-based education.

Baska Mask is non-inferior to tracheal tube in preventing airway contamination during controlled ventilation in elective nasal surgeries: A randomised controlled trial.

BACKGROUND AND AIMS: Baska Mask, a newly designed third-generation supraglottic device, has a sump where the pharyngeal secretions can collect and be suctioned out continuously. We aimed to study the effectiveness of Baska Mask in preventing airway contamination during nasal surgeries. Our primary objective was to assess airway soiling using fibreoptic bronchoscopy. Total airway manipulation time, haemodynamic parameters during device insertion and post-operative oro-pharyngeal morbidities were the secondary objectives. METHODS: Eighty-four participants undergoing nasal surgeries were randomised to either have their airway maintained with Baska Mask (Group-BM) or Endotracheal tube (Group-TT). Fibreoptic bronchoscopy was performed at the end of the surgery and the airway was inspected for signs of contamination. Total airway manipulation time, haemodynamic parameters during device insertion and post-operative oro-pharyngeal morbidities were also assessed. Unpaired Student's t test was used for parametric data and Chi-square test for nonparametric data. One-way analysis of variance (ANOVA) was used for the intra-group analysis of haemodynamic data. RESULTS: Tracheal contamination was not observed in any patient in either group. Time taken for device insertion (Group TT: 24.24 ± 6.86 s vs. Group BM: 24.22 ± 7.3 s; P = 0.97) was similar in both the groups. The total airway manipulation time was 2 min longer in Group-TT (P = 0.000) due to additional time taken for insertion of throat pack. Haemodynamic parameters during device insertion were stable and post-operative oro-pharyngeal morbidities were fewer with Baska Mask when compared to Tracheal tube. CONCLUSIONS: Baska Mask is non-inferior to tracheal tube in preventing tracheal contamination in patients undergoing nasal surgeries.

Innervation Patterns of the Pronator Teres Muscle and Their Possible Role in Neurotization: A Systematic Review of Cadaveric Studies.

BACKGROUND: Contrary to the classic anatomical description, many recent studies have reported wide variations in branching patterns and location of motor branches that are supplying the pronator teres muscle. To understand these variations and their implications in surgical procedures of the nerve transfers, a systematic review was performed on the innervation of pronator teres muscle from cadaveric studies. METHODS: A systematic literature search was performed in databases such as Medline, PubMed, Google Scholar, SciELO, ScienceDirect, Cochrane reviews and orthopedics textbooks using the search terms "pronator teres nerve branches"; AND "number" OR "location" OR "length" OR "diameter" yielded 545 article links. Articles were evaluated according to PRISMA guidelines. RESULTS: A total of twenty cadaveric studies including 648 branches have registered 52.9% of two branch innervation pattern followed by 31.3%-single branch pattern; 13.5%-three branch pattern; 1.7%-four branch pattern, and 0.4%-five branch patterns, respectively. Of the 403 branches studied for their location in relation with the humeral intercondylar line, most branches were located distal to the line (50.3%), followed by 32.7% (proximal to it) and 16.8% at the line, respectively. The distance of branches located proximal and distal to humeral intercondylar line was in the range of 1.25-10 cm, and 1.1-7.5 cm, respectively. The mean length and diameter of nerves reported were 4.37 ± 2.43 cm, and 1.5 mm, respectively. CONCLUSIONS: Our data defined the morphometrics of nerve branches and they often met the required diameter for neurotization procedures. Our findings also demonstrated that the morphometrics, branching pattern and their location vary between populations and this information is very vital for surgeons during the nerve transfers.

Hemodynamic changes under spinal anesthesia after elastic wrapping or pneumatic compression of lower limbs in elective cesarean section: A randomized control trial.

BACKGROUND AND AIMS: In spite of adequate fluid loading and left lateral tilt, parturients develop hypotension under spinal anesthesia during cesarean section. Elastic crepe bandage (CB) or pneumatic compression device (PCD) can be utilized to prevent the pooling of blood in lower limbs and thereby it may reduce the incidence of hypotension in these patients. This study was formulated to analyze the hemodynamic effects of leg wrapping with elastic CB and PCD in parturients undergoing for cesarean section under anesthesia. MATERIAL AND METHODS: Ninety term obstetric patients posted for elective cesarean section under spinal anesthesia were randomized into 3 groups: Group 1 (control), Group 2 (CB), and Group 3 (PCD). All the parturients had their legs wrapped with an elastic bandage and pneumatic sleeve applied over it. In Group 1 (Control), patients had their legs wrapped with CB loosely and pneumatic sleeve also applied was switched on. In Group 2, patients the CB was applied by stretching the bandage (15 cm width and 4 m stretched length). The PCD was not switched on in this group. In Group 3, the legs were wrapped with the CB loosely. The pneumatic sleeve was applied over the bandage, and the machine was switched on with a preset pressure of 40-50 mmHg after spinal anesthesia. Incidence of maternal hypotension and ephedrine requirement to maintain systolic blood pressure, neonatal Apgar score were recorded. RESULTS: The incidence of hypotension was significantly lower in Group 2 and 3 than the control group. Similarly, the requirement of ephedrine was significantly high in control group compared to CB and PCD. The incidence of hypotension was lower in group CB than group PCD. Meantime to receive the first dose of ephedrine was significantly low in control (7.37 ± 4.94 min) as compared to CB (10 ± 2.8 min) and PCD (13.88 ± 9.23). CONCLUSION: Leg-wrapping with CB is cost-effective, non-invasive, non-pharmacological, and effective tool to reduce the incidence of hypotension after spinal anesthesia in a parturient.

Truncal injection brachial plexus block: A Description of a novel injection technique and dose finding study.

BACKGROUND AND AIMS: Brachial plexus (BP) blocks continue to be described with reference to anatomical landmarks (Interscalene and Supraclavicular), even after the introduction of ultrasound which enables us to directly identify the roots, trunks and divisions of the BP. The aim of this study was to describe a novel injection technique targeting trunks of BP and to determine the minimum effective local anaesthetic volume (MELAV) required to produce BP block with this approach. METHODS: Twenty-one male patients in the age group 20-40 years, undergoing elective forearm bony procedures received an ultrasound-guided truncal injection BP block. MELAV50 was determined using the Dixon and Mood up-and-down method. Initial volume of local anaesthetic (LA; 50:50 mixture of bupivacaine 0.5% and lignocaine 2% with 5 µg/ml epinephrine) injected was 6 ml in each trunk, which was varied by 1 ml/trunk for each consecutive patient according to the response of the previous patient. The MELAV50, MELAV95 and MELAV99 were calculated using Probit transformation and logistic regression. RESULTS: Out of the 21 patients, 13 patients had a successful block. The MELAV50, MELAV95 and MELAV99 were 7.41, 10.47 and 12 ml, respectively. Eight patients in whom block failed had sparing in the ulnar and median nerve territories. CONCLUSION: Trunks of the brachial plexus can be identified and targeted for the injection of local anaesthetics. The MELAV50 and MELAV95 required for ultrasound-guided truncal injection brachial plexus block were 7.4 and 10.4 ml, respectively.

Development of a scoring system for predicting difficult intubation using ultrasonography.

BACKGROUND AND AIMS: Ultrasound measurement of anterior neck soft tissue thickness by skin to epiglottis distance (SED) has been shown to predict difficult laryngoscopy. In this study, we developed an airway scoring system incorporating SED into three clinical predictors and assessed whether it would improve accuracy in prediction of difficult intubation. METHODS: Mentohyoid distance, mandibular subluxation, head extension and ultrasound measurement of skin to epiglottis distance were measured a day before surgery in 310 adult patients. During direct laryngoscopy, Cormack-Lehane grading was noted (Grade 1 and 2 = Easy, Grade 3 and 4 = Difficult). We constructed a score named MSH, which included mentohyoid distance, mandibular subluxation and head extension. Then, SED was added to the MSH score to form another new score named USED-MSH. Student's t-test, Mann-Whitney U test and Chi-square test or Fisher exact tests were used. Both scoring systems were compared under the receiver-operating characteristic curve and area under the curve (AUC) were calculated. RESULTS: Difficult intubation was observed in 62/310 patients (20%). The AUC for USED-MSH score was greater than the MSH score (0.93, 95% CI [0.89-0.97] vs 0.76, 95% CI [0.69-0.84], P value <0.001). USED-MSH score had higher sensitivity (93.6% vs 59.7%) and lower specificity (85.9% vs 91.1%) with similar positive predictive value (62.7% vs 62.4%) in comparison with MSH score. CONCLUSION: An airway scoring system using the ultrasound measurements of skin-to-epiglottis distance along with the clinical predictors would be helpful in the prediction of difficult intubation.

Competency-based learning and training for medical postgraduates within regulatory guidelines in India: The SBV Competency-Based Learning and Training Model©.

Postgraduate medical education in India is beset with many problems including lack of a uniform national syllabus, nonexistence of an accepted list of competencies across disciplines, lack of uniformity in teaching/learning methods between different institutions, a poor evaluation system which focuses on a day's performance rather than the whole course and lack of attention to attitude and professionalism both in the training and evaluation processes. Since there is no national-level quality control of the outgoing postgraduates, there is no uniformity either in knowledge or skill level among them. Regulatory control over the whole process inhibits institutions from making any changes. Furthermore, the summative examination process is entirely under regulatory guidelines, with little or no option to universities and institutions to change the same. In this scenario, Sri Balaji Vidyapeeth, Puducherry, introduced and implemented a competency-based training programme for medical postgraduates, which is now in the 4th year. This model is suitable for the Indian milieu as it can be implemented within the regulatory guidelines. The model has been described with details of the processes involved in preparation, implementation, monitoring and overcoming possible hurdles and pitfalls in the Indian context.

Frontiers of monoclonal antibodies: Applications in medical practices.

With the flourishing of innovation in drug discovery into a new era of personalized therapy, the use of monoclonal antibodies (mAbs) in the treatment of various ailments lies at the forefront. Major improvements in genetic sequencing and biomedical techniques as well as research into mAbs emphasize on determining new targets for advanced therapy while maximizing efficacy for clinical application. However, a balance has to be achieved concerning developing a target with low toxicity combined with high specificity and versatility, to allow a specific antibody to facilitate several biotic effects, ranging from neutralization of virus mechanisms to modulation of immune response and maintaining low global economic cost. Presently, there are approximately 30 mAbs' permitted for therapeutic use with many more being tested in clinical trials. Nevertheless, the heavy cost of mAbs' production, stowage and management as well as the subsequent hindrances to their development are outweighed by mAbs' clinical advantages. Compared to conventional drugs, since mAbs use as pharmacologic iotas have specific physical features and modes of action, they should be considered as a discrete therapeutic category. In this review, the history of mAb generation and the innovative technological applications of mAbs that has advanced in clinical practices is reviewed.

Two unusual cases of microvascular thrombosis in the immediate posttransplant period.

We present two unusual cases of microvascular thrombosis in the immediate posttransplant period resulting in graft loss. The first was a 20-year-old female with a cadaveric renal transplant with immediate graft dysfunction due to microthrombi of probable donor origin, with nonrecovery of renal function nine months' posttransplant. The second was a 23-year-old male with unrelated live kidney transplant with hyperacute rejection due to anti-endothelial antibodies.

Comparison of success of tracheal intubation using Macintosh laryngoscope-assisted Bonfils fiberscope and Truview video laryngoscope in simulated difficult airway.

BACKGROUND AND AIMS: Restriction of head and neck movements prevents the alignment of the oral, pharyngeal, and laryngeal axes and increases the incidence of difficult tracheal intubation in patients with cervical spine fractures. Video laryngoscopes have gained an important role in the management of difficult intubation, especially in situations with limited head and neck movements. This study compares the success of intubation using Macintosh laryngoscope assisted Bonfils® fiberscope (ML-BF) with TruviewPCD video laryngoscope (TV) in patients with simulated restricted head and neck movements. MATERIAL AND METHODS: One hundred and fifty-two patients satisfying the inclusion criteria were randomly allocated to two groups of 76 each. Patients were made to lie supine on the table without a pillow and a soft collar was used to restrict head and neck movements. After a standardized premedication-induction sequence, tracheal intubation was done either with ML-BF or TV. Success of intubation, time taken for successful intubation, hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were noted. RESULTS: Intubation was successful in all the 76 patients in direct laryngoscopy-Bonfils fiberscope group and 75 out of 76 patients in TV group within the specified time (90 s). The median time taken for successful intubation with TV and ML-BF were 44 (range 26-80) s and 49 (range 28-83) s, respectively. Hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were similar in both groups. CONCLUSION: Both TV and ML-BF are equally effective for successful tracheal intubation in patients with simulated restricted head and neck movements. In cases of difficult laryngeal visualization with routine Macintosh laryngoscope, Bonfils can be used as an adjunct to achieve successful intubation in the same laryngoscopy attempt.

Quality of Labor Epidural Analgesia and Maternal Outcome With Levobupivacaine and Ropivacaine: A Double-Blinded Randomized Trial.

BACKGROUND: Quality of labor analgesia plays a vital role in the maternal outcome. Very few literature are available analyzing the quality of epidural labor analgesia. AIM: The aim of this study was to compare the effectiveness of 0.1% levobupivacaine and 0.1% ropivacaine with fentanyl as an adjuvant for epidural labor analgesia in terms of onset, duration, quality of analgesia, and degree of motor blockade. METHODOLOGY: Sixty nulliparous parturients, with singleton uncomplicated pregnancy, were recruited by continuous sampling. Parturients were randomized to receive either levobupivacaine 0.1% or ropivacaine 0.1% with 2 µg/ml fentanyl as an intermittent epidural bolus. The epidural analgesia was initiated with 12 ml of study drug solution in the active stage of labor (cervix 3 cm dilated). Demand bolus was given whenever the visual analog scale (VAS) score >3. Onset, duration, and quality of analgesia and degree of motor blockade were analyzed. Maternal outcome was evaluated in terms of mode of delivery, duration of labor, and assisted vaginal delivery. STATISTICAL ANALYSIS: All the data were recorded in Microsoft Office Excel. Statistical analysis was carried out using SPSS version 19.0 (IBM SPSS, USA) software with Regression Modules installed. Descriptive analyses were reported as mean and standard deviation of continuous variables. RESULTS: The mean onset of analgesia was shorter in ropivacaine (21.43 ± 2 min) than in levobupivacaine group (23.57 ± 1.71 min) (P = 0.000). Duration of analgesia was shorter in ropivacaine (60 ± 14 min) than levobupivacaine (68 ± 11 min) (P = 0.027). Levobupivacaine produced a better quality of analgesia in terms of not perceiving pain and uterine contraction during labor analgesia but was associated with 37% incidence of instrumental delivery. Duration of labor and rate of cesarean section were comparable between the groups. CONCLUSION: Quality of analgesia in labor epidural was superior to levobupivacaine but was associated with higher incidence of instrumental vaginal delivery.