Ultrasound-guided suprainguinal fascia iliaca block to position the patient for neuraxial anaesthesia in acetabular surgery - a randomized controlled pilot study.

INTRODUCTION: Neuraxial anaesthesia is a common choice for most hip and lower limb operations. Pain associated with positioning is often a deterrent, and the vast literature suggests different regional blocks and opioids for these patients. Patients with acetabular fractures may experience increased pain, and thus are more difficult to position for the neuraxial block. We conducted a randomized controlled pilot study to assess and compare the analgesic efficacy of ultrasound-guided suprainguinal fascia iliaca block (SFICB) versus systemic fentanyl to facilitate positioning for combined spinal epidural (CSE) anaesthesia in patients undergoing acetabular fracture surgery. MATERIAL AND METHODS: Twenty patients referred for surgical repair of acetabular fractures were randomly assigned to receive either ultrasound-guided SFICB (group B) or intravenous fentanyl (group F). Changes in visual analogue scale (VAS) scores in supine and sitting position, improvement in sitting angle (SA), positioning quality, rescue analgesic requirement, total opioid consumption, comfort VAS scores, and complications were noted to compare both groups. RESULTS: The post-intervention VAS score in the sitting position was significantly lower in group B than in group F (5.9 ± 2.1 vs. 3.5 ± 1.5, P = 0.01). Group B also had more significant improvement in SA (27.5° (20.75-36.5°), in comparison to group F (10 (5-18.75), P = 0.006). The positioning quality was better in group B, with 70% of patients achieving an optimal position compared to only 10% in group F ( P = 0.02). CONCLUSIONS: Ultrasound-guided SFICB, as compared to systemic fentanyl, provided better analgesia and helped to achieve a better and more comfortable position to perform the neuraxial block.

Analgesic efficacy of classical thoracolumbar interfascial plane block versus modified thoracolumbar interfascial plane block in patients undergoing lumbar disc surgeries: A comparative, randomised controlled trial.

Background and Aims: We compared classical (medial) and modified (lateral) thoracolumbar interfascial plane block (TLIP) with only general anaesthesia (GA) using multimodal analgesia in patients undergoing lumbar disc surgeries. Methods: In this study, 100 patients aged 18-70 years were randomised to Group cTLIP (conventional TLIP block with 20 mL of 0.25% ropivacaine with GA), Group mTLIP (modified TLIP block with 20 mL of 0.25% ropivacaine with GA), and Group C (only GA using multimodal analgesia). The primary outcome was to assess the total peri-operative opioid consumption in the first 24 h. The secondary outcomes were to assess pain score upon arriving in the post-anaesthesia care unit, time to first analgesic need after surgery, post-operative opioid consumption in 24 h, and incidence of nausea and vomiting. Results: The total peri-operative opioid consumption in Group cTLIP (507.58 (258.55) µg) and Group mTLIP (491.67 (165.39) µg) was significantly lower than that in Group C (1225.4 (237.03) µg); (P < 0.001). However, it was comparable between groups cTLIP and mTLIP (P = 0.767). Pain score was comparable in groups cTLIP and mTLIP. It was significantly lower than Group C (P = 0.001). Rescue analgesia was needed in all (100%) patients of Group C but in only 15.2% of patients of the cTLIP and mTLIP groups. No patient in groups cTLIP and mTLIP complained of nausea and vomiting in the first 24 h, whereas it was significantly higher (61.8%) in Group C (P = 0.001). Conclusion: The analgesic effect of the modified TLIP block was not superior to the conventional TLIP block. Both techniques provided the same intra-operative and post-operative analgesia for lumbar disc surgeries.

Comparison of gastric emptying time between breast-fed and formula milk-fed infants less than 6 months old, using gastric ultrasound-An observational study.

BACKGROUND: Fasting before elective anesthesia care is a standardized practice worldwide. The aim is to decrease the risk of aspiration leading to pulmonary complications such as aspiration pneumonitis during anesthesia care. There are different guidelines for elective preoperative fasting in children. However, there is insufficient literature measuring gastric emptying time after breast milk or formula milk feeding in infants. OBJECTIVE: This study used gastric ultrasound to determine the gastric emptying time for breast milk and formula milk in children below 6 months of age. We also compared the calculated gastric volumes among breast-fed and formula milk-fed based on Schmitz's and Spencer's formula. MATERIALS AND METHODS: This prospective observational study was conducted at a tertiary care center in India between November (2017-2019). A total of 52 infants less than 6 months of age were recruited. The study population was divided into two groups (breast-fed and formula milk-fed) of 26 patients each. Ultrasound was used to measure the antral cross-sectional area of the stomach and to calculate the gastric volume using the two classical formulas (Schmitz and Spencer's). Gastric emptying was reported when the bull's eye appearance of the gastric antrum was seen or when the antral cross-sectional area was less than 3.07 cm2. RESULTS: The number of breast-fed children whose antral cross-sectional was greater than 3.07 cm2 (cut-off value for aspiration risk) beyond 1 h was 14/26 (53.84%) while none (0) children went beyond 3 h. The number of formula-fed children whose antral cross-sectional was greater than 3.07 cm2 beyond 1 h was 17/26 (65.38%) while one child (3.84%) went beyond 3 h. Using Schmitz's formula, mean (SD) gastric emptying times were 0.35 ± 0.68 h (95% CI 0.35 ± 0.185, range 0.165-0.535) for breast-fed patients and 0.35 ± 0.69 h (95% CI 0.35 ± 0.188, range 0.162-0.538) for formula-fed patients, and were thus neither clinically nor statistically different (p = .73) Using Spencer's formula, the mean gastric emptying times were 0.12 ± 0.33 h (95% CI 0.12 ± 0.09, range 0.03-0.21) for breast-fed patients and 0.04 ± 0.20 h (95% CI 0.04 ± 0.05, range -0.01 to 0.09) for formula-fed patients, and were also neither clinically nor statistically different p = .13. CONCLUSION: In our series, the gastric emptying times in breast-fed and formula-fed infants less than 6 months old were similar. Our results support the fasting guidelines of the European Society of Anaesthesiology and Intensive Care 2022, that is, 3 h for breastfeeding and 4 h for formula milk feeding. In addition, this shows that the Schmitz's and Spencer's formulae used to calculate the gastric volume based on ultrasound measurement of the antral cross-sectional area are not comparable in infants less than 6 months.

Air-Q ILA as a conduit for orotracheal intubation in children: A randomized control trial for comparison between supine and lateral patient positions.

Background and Aims: Airway management in children is always challenging and becomes a concern if required in the lateral position. We evaluated the efficacy of orotracheal intubation using the Air-Q intubating laryngeal Airway (Air-Q ILA) in supine and lateral positions in children. Material and Methods: This study included 100 children weighing 7-30 kg, scheduled for elective surgeries under general anesthesia. They were randomized into the supine (S) group or lateral (L) group. After anesthesia induction, the child was placed in a standard sniffing position for conventional laryngoscopy in the S group, and the child was turned into the lateral position in the L group. Both Air-Q ILA and endotracheal tube were placed blindly in the supine position in the S group and lateral position in group L. The grading of glottic view, success rate, insertion time of the Air-Q ILA, and endotracheal intubation were noted in both the groups. Results: The Air-Q ILA was successfully placed at the first attempt in 47 children in group S and 48 in group L. The overall blind orotracheal intubations, including first and second attempts, were successful in 45 children in the S group and 47 in the L group (P = 0.715). Eighty percent of patients in group L and 70% in group S had glottis grade 1 or 2 compared to grade 3, 4,5 (P = 0.249). The mean time of Air-Q ILA placement in groups S and L was 15.73 ± 5.64 s and 14.42 ± 4.16 s (P = 0.195). The mean duration of blind endotracheal intubation through the Air-Q ILA was 24.88 ± 14.75 s in group S and 17.57 ± 5.35 s in group L (P = 0.002). In both the groups, none of the children had bronchospasm, laryngospasm, desaturation, or aspiration. The airway trauma evident by blood staining on the Air-Q ILA on removal was revealed in 2 cases in group S, and 3 cases in group L. None of the children in group S and 4 children in group L had postoperative stridor. Postoperative hoarseness was reported in 3 children in group S and none in group L within 24 hours. Conclusion: The Air-Q ILA can be used as a conduit for blind orotracheal intubation in children in both supine and lateral positions while maintaining an effective airway seal.

Comparative evaluation of the analgesic efficacy of ultrasound-guided erector spinae plane block versus intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery: A prospective randomized pilot study.

OBJECTIVES: Existing research on erector spinae plane block and intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery is limited. METHODS: In this prospective, randomized study, 60 patients aged between 18 and 60 years were randomized into two groups (erector spinae plane block and intrathecal morphine). In the erector spinae plane block group, ultrasound-guided erector spinae plane block was performed, following which a mixture of 20 mL of 0.375% ropivacaine and 0.5 mcg/kg of clonidine was injected. In the intrathecal morphine group, 150 mcg preservative-free morphine with 2 mL of normal saline was administered intrathecally. The primary outcome was to evaluate the perioperative opioid consumption in the first 24 h. The secondary outcomes were to evaluate hemodynamic response to surgical stimulus, visual analogue scale score, time to first analgesic requirement, postoperative nausea and vomiting, postoperative opioid consumption, urethral irritation, and incidence of drug-related adverse effects. RESULTS: Total perioperative opioid consumption in the erector spinae plane block group was 355.0 (265.0, 485.0) µg and 240.0 (145.0, 370.0) µg in the intrathecal morphine group (P = 0.09). However, the patients in the erector spinae plane block group had significantly greater postoperative fentanyl consumption (235.0 [120.0, 345.0] µg) compared with those in the intrathecal morphine group (105.0 [30.0, 225.0] µg). There were no statistically significant differences noted for intraoperative opioid consumption, postoperative visual analogue scale score, time to first analgesic request, postoperative nausea and vomiting, and catheter irritation between the two groups. CONCLUSIONS: Although no statistically significant difference in intraoperative opioid consumption was seen between the erector spinae plane block and intrathecal morphine groups, postoperative opioid consumption was significantly higher in the erector spinae plane block group than in the intrathecal morphine group in patients undergoing percutaneous nephrolithotomy surgery.

Cadaveric Study of Topographic Anatomy of Temporal and Marginal Mandibular Branches of the Facial Nerve in Relation to Temporomandibular Joint Surgery.

PURPOSE: Detailed anatomy of the facial nerve, including the variations among different ethnic groups, is essential to prevent an iatrogenic injury. The purpose of the study was to document topographic anatomy of temporal and marginal mandibular (MM) branches of the facial nerve in relation to temporomandibular joint (TMJ) surgery. The specific aim was to demonstrate detailed course of temporal and MM nerves, their surgical implications, and to compare the results obtained with the previous studies. METHODS: The investigators implemented a prospective cadaveric study. A dissection was carried out on 52 facial halves. The facial nerve was dissected according to the instructions described in the Cunningham's dissection manual. Anatomic landmarks were selected as determined by Al-Kayat and Bramley, and results obtained were compared with previous published articles. RESULTS: The study sample was composed of 52 facial halves (males, n = 35; females, n = 17). The number of branches of temporal nerve varied in dissected facial halves from 3 (n = 37 [70%]), 2 (n = 14 [26%]), to 1 (n = 1 [2%]). The distance between the lowest concavity of the bony external auditory meatus to the point at which the facial nerve bifurcates (distance B) was considerably less in the study population (1.79 cm) when compared with the reported literature (2.3 cm). There was no significant influence of gender and cephalic index on distances measured. There was 1 branch in 15% of the dissected facial halves (1 in 52) and 2 branches in 85% (44 of 52). The MM nerve was seen coursing below the inferior border of the mandible, and in 44 (85%), the nerve was present above the inferior border of mandible all along the course. CONCLUSIONS: The topographic anatomy of the temporal and MM nerves is the same as reported in the literature. The only considerable difference was found in distance B; hence, surgical procedures involving the distance B require special consideration.

Evaluation of Success of Transport Disc Distraction Osteogenesis and Costochondral Graft for Ramus Condyle Unit Reconstruction in Pediatric Temporomandibular Joint Ankylosis.

PURPOSE: The costochondral graft (CCG) is considered the reference standard for pediatric temporomandibular joint reconstruction. It has the disadvantages of unpredictable growth, donor site morbidity, and the need for intermaxillary fixation. It has been reported that transport disk distraction osteogenesis (TDDO) can result in the formation of a neocondyle and disc. We performed a randomized trial to measure and compare clinically relevant outcomes of ramus-condyle unit (RCU) reconstruction using CCG and TDDO for pediatric temporomandibular joint ankylosis (TMJA). MATERIALS AND METHODS: In the present randomized controlled trial (block randomization with a variable block size), pediatric patients with unilateral, nonrecurrent TMJA aged 3 to 16 years who had presented to our unit from December 2015 to June 2017 were enrolled. Instead of temporalis myofascial flap interposition, a buccal fat pad was used to fill the gap created by osteoarthrectomy. The primary outcome parameter was mouth opening. A mouth opening of at least 25 mm at the median follow-up point was considered success. The secondary outcome parameters were occlusion, laterotrusion, protrusion, reankylosis, neocondyle, chin deviation, facial asymmetry, midline shift, and neo-disc formation. Data were analyzed using the independent t test and rank sum test. RESULTS: A total of 24 patients were enrolled in the CCG and TDDO groups (n = 12 in each group). Trauma (40.9%) was the most common etiology with a slight male preponderance (59.09%). The mean age was 10.32 ± 2.85 years. The average distraction achieved in the TDDO group was 10.42 mm. The median follow-up duration was 31.5 months (range, 24 to 39 months). The mean preoperative maximal incisal opening had improved from 8.5 ± 4.1 and 9.5 ± 7.1 mm in the CCG and TDDO groups preoperatively to 35.7 ± 2.7 and 34.4 ± 8.9 mm, respectively, at the median follow-up point (P < .005). RCU reconstruction with both modalities resulted in improvement in all the parameters; however, the intergroup comparison showed statistically non-significant differences. No reankylosis or open bite was found. The 3-hour delayed gadolinium-enhanced magnetic resonance imaging scan showed successful neo-disc formation. CONCLUSIONS: Similar success can be achieved in RCU reconstruction using either CCG or TDDO for pediatric TMJA. Both techniques have some advantages and disadvantages. RCU reconstruction using CCG or TDDO results in formation of a neocondyle, maintenance of occlusion, and correction of facial asymmetry.

Effect of entropy-guided low-flow desflurane anaesthesia on laryngeal mask airway removal time in children undergoing elective ophthalmic surgery - A prospective, randomised, comparative study.

BACKGROUND AND AIMS: In children, entropy-guided titration of isoflurane and sevoflurane leads to faster recovery after anaesthesia. However, role of entropy in recovery following desflurane anaesthesia is not known. Hence, we compared laryngeal mask airway (LMA) removal time and desflurane consumption with entropy and minimal alveolar concentration-guided titration in children given low-flow desflurane anaesthesia. METHODS: After ethics committee approval and parental consent, 80 American Society of Anesthesiologists grade I-II children, age 2-14 years, undergoing elective ophthalmic surgery were randomised into entropy and minimal alveolar concentration-guided groups. After LMA insertion, anaesthesia was maintained using oxygen, air (FiO2 0.5) and desflurane using low fresh gas flow of 0.75 L/min. In the entropy-guided group, desflurane was titrated to maintain state entropy between 40 and 60. In the minimal alveolar concentration-guided group, desflurane was titrated to maintain a minimal alveolar concentration between 1 and 1.3. We recorded LMA removal time (from switching off desflurane at the end of surgery till removal of LMA), haemodynamic parameters, uptake and consumption of desflurane between the groups. RESULTS: LMA removal time was significantly decreased in the entropy-guided group in comparison to the minimal alveolar concentration-guided group (4.34 ± 2.03 vs 8.8 ± 2.33 min) (P < 0.0001). Consumption of desflurane was significantly less in the entropy-guided group compared with the minimal alveolar concentration-guided group (18.7 ± 5.07 vs 25.3 ± 8.11 mL) (P < 0.0001). CONCLUSION: Entropy-guided low-flow desflurane anaesthesia is associated with faster LMA removal and reduced consumption of desflurane in children undergoing ophthalmic surgery.

Evaluation of performance of C-MAC® video laryngoscope Miller blade size zero for endotracheal intubation in preterm and ex-preterm infants: A retrospective analysis.

BACKGROUND AND AIMS: The preterm and ex-preterm babies form a separate group among the paediatric population with unique airway anatomy. The utility of C-MAC® Video laryngoscope (VL) for routine intubation of preterm babies has not been evaluated. The purpose of this study is to report the performance of C-MAC® VL Miller blade size-0 for endotracheal intubation in preterm babies at our institute. METHODS: After Institute Ethics Committee approval, a retrospective study was designed to evaluate the performance of C-MAC® VL for intubation in preterm and ex-preterm babies. The medical files, and video recordings of preterm babies up to 60 weeks of post-gestational age who had undergone surgery for retinopathy of prematurity from January 2014 to April 2016 were reviewed. All babies were intubated with C-MAC® Miller blade size-0. Demographic parameters, time to best glottic view (TTGV), time to intubate (TTI), ease and number of intubation attempts were assessed. Episodes of desaturation and complications related to intubation were recorded. RESULTS: Data of 37 preterm and ex-preterm babies were analysed. The mean age and weight at the time of surgery were 40.5 (±4.9) weeks and 2532 (±879) grams respectively. The median TTGV and TTI were 11.0 and 22.0 seconds. A total of 32 babies (86.5%) were intubated on initial attempt and five were intubated on second attempt. Stylet was used to facilitate intubation in all infants. There was no incidence of desaturation, mucosal injury or bleeding. CONCLUSION: C-MAC video laryngoscope Miller blade size 0 is suitable for endotracheal intubation in preterm and ex-preterm infants.

Multistep Grading System for Evaluation of Chronic Ocular Sequelae in Patients With Stevens-Johnson Syndrome.

PURPOSE: To propose a new scoring system for grading of chronic ocular sequelae in Stevens-Johnson syndrome (SJS). DESIGN: Reliability and validity analysis. METHODS: Participants: Four hundred eyes of 200 patients with chronic ocular SJS/toxic epidermal necrolysis (TEN) were included in the study. SETTINGS: Single-center, tertiary eye care referral center. PROCEDURE: All patients with SJS/TEN with chronic (more than 1 year) ocular sequelae were recruited for the study. Corneal, eyelid, and conjunctival signs were evaluated and given scores ranging from 0 to 5 depending on the increasing severity. Twelve signs (6 corneal, 3 conjunctival, and 3 eyelid) were evaluated to obtain the total severity score for each eye. Based on the corrected distance visual acuity (CDVA) and total score, each eye was graded using receiver operating characteristic (ROC) analysis. MAIN OUTCOME MEASURES: Correlation of CDVA with the severity score determined on the basis of 12 corneal, eyelid, and conjunctival signs. RESULTS: Mean age was 24.09 ± 10.9 years. The most common inciting agent for SJS was oral medications (85%). The scores of 12 ocular surface parameters correlated significantly with CDVA (P < .001). ROC analysis revealed 4 grades of total severity score of 0-11 (stage 0), 12-16 (stage 1), 17-22 (stage 2), and 23-53 (stage 3). The total severity score correlated significantly with logMAR visual acuity grades with an agreement of 60.7% using Cohen's kappa analysis (kappa coefficient = 0.420 ± 0.03). The most common stage of total severity score was stage 3 in 49% of eyes (196/400), followed by stage 0 (107/400, 26.7%). CONCLUSIONS: The multistep scoring system of chronic ocular features in SJS/TEN sequelae is a useful tool to grade all levels of severity. This may help to evaluate the efficacy of the surgical intervention by comparing preoperative with postoperative ocular grades.

Comparison of the C-MAC video laryngoscope size 2 Macintosh blade with size 2 C-MAC D-Blade for laryngoscopy and endotracheal intubation in children with simulated cervical spine injury: A prospective randomized crossover study.

BACKGROUND AND AIMS: CMAC video laryngoscope size 2 D-Blade has been recently introduced for management of pediatric difficult airway. Our primary outcome was to compare glottic view, intubation time, and ease of intubation with the size 2 Macintosh versus D-Blade of C-MAC video laryngoscope in simulated cervical injury in children. MATERIAL AND METHODS: This randomized crossover study was conducted in a tertiary care hospital of Northern India. Forty children of 4-14 years of age were enrolled in this study. After induction of anesthesia, video laryngoscopy was performed either with size 2 CMAC Macintosh (group M) or D-Blade (group D) with manual in-line stabilization. After removal of the first blade, second video laryngoscopy was performed with the alternative blade. Endotracheal intubation was done with the second laryngoscopy. Best glottic view, time for best glottic view, and difficulty in blade insertion were recorded during both the video laryngoscopies. During second video laryngoscopy, difficulty of tube insertion and time for intubation were noted. RESULTS: The glottic view grade was significantly better in group D compared with the group M (P = 0.0002). Insertion of D-Blade was more difficult than Macintosh blade (P = 0.0007). There was no statistical difference in terms of time for best glottic view in group M and group D (13.40 ± 4.90 vs 13.62 ± 5.60 s) and endotracheal tube insertion time (24.80 ± 7.90 vs 27.90 ± 10.90 s), respectively. Number of intubation attempts was similar in both the groups. CONCLUSIONS: Size 2 D-Blade of C-MAC video laryngoscope provided a better glottic view in children with simulated cervical spine injury as compared with CMAC Macintosh blade. Success of intubation, intubation time, and ease of intubation were comparable with both the blades.

Comparison between Critical-Care Pain Observation Tool and physiologic indicators for pain assessment in the critically ill, mechanically ventilated adult patients.

BACKGROUND AND OBJECTIVES: Pain assessment of nonverbal, critically ill patients continues to present a challenge in Intensive Care Unit (ICU). The Critical-Care Pain Observation Tool (CPOT) rates critically ill patients' pain based on clinical observation. In the present study, the accuracy of CPOT was compared with physiological indicators of pain in mechanically ventilated, critically ill patients. METHODS: This quantitative prospective observational study was conducted to assess pain in the critically ill, mechanically ventilated patients in comparison to physiologic indicators such as blood pressure and heart rate. A repeated measures design was chosen, and a sample size of 180 was taken from 60 patients with sepsis, acute exacerbations of chronic obstructive pulmonary disease, community-acquired pneumonia, and postsurgical patients in the ICU. The two painful procedures chosen were tracheal suction and patient positioning. The data were collected at rest, at tracheal suctioning, 20 min later at positioning of the patient, and final reading 20 min later. Three testing periods, each including 4 assessments for a total of 12 pain assessments with sixty patients, were completed during each patient's ICU course. A total of six assessments were done with the patient at rest and three each with pain stimulus of tracheal suctioning and patient positioning. RESULTS: There was a significant increase in both hemodynamic variables (systolic blood pressure and diastolic blood pressure) during painful procedures except for the heart rate during positioning. The correlation between the CPOT and Ramsay scale was negative and significant. CONCLUSIONS: The present study provides evidence that the CPOT has good psychometric properties. It might prove useful for pain assessment in uncommunicative critically ill patients.

Pain assessment in the critically ill mechanically ventilated adult patients: Comparison between skin conductance algesimeter index and physiologic indicators.

BACKGROUND AND OBJECTIVES: Critically ill patients are unable to communicate effectively, so it is difficult to assess their pain and analgesic requirement. Skin conductance algesimeter (SCA) index is a device that primarily measures changes in skin conductance real time to assess pain. METHODS: We planned this quantitative prospective observational study to assess pain in the critically ill mechanically ventilated patients in comparison to physiologic indicators such as blood pressure and heart rate. A repeated measures design was chosen, and a sample size of 180 was taken from 60 patients with sepsis, acute exacerbations of chronic obstructive pulmonary disease, community-acquired pneumonia, and postsurgical patients in the Intensive Care Unit (ICU). The two painful procedures chosen were tracheal suction and patient positioning. The data were collected at rest, at tracheal suctioning, 20 min later at positioning of the patient, and final reading 20 min later. Three testing periods, each including 4 assessments for a total of 12 pain assessments with sixty patients, were completed during each patient's ICU course. A total of six assessments were done with the patient at rest and three each with pain stimulus of tracheal suctioning and patient positioning. RESULTS: There was a significant increase in both hemodynamic variables during painful procedures except for the heart rate during positioning. The correlation between the SCA index and Ramsay scale was negative and significant. CONCLUSIONS: This instrument might prove useful to measure pain in uncommunicative critically ill patients and to evaluate the effectiveness of analgesic treatment and adapt it.

Nutritional risk factors and status of serum 25(OH)D levels in patients with breast cancer: A case control study in India.

To study the nutritional risk factors and status of serum 25(OH)D levels in patients with breast cancer. A total of 100 women (cases) with confirmed breast cancer (BC) matched with equal number of healthy females (controls) of similar age and socioeconomic status (SES) were included in study. Controls included were nonbreast cancer patients who accompanied the patients to a tertiary care hospital. All the subjects (cases and controls) were administered a questionnaires to collect data on socioeconomic status, dietary pattern and the frequency of food consumption using a validated food frequency questionnaire. Anthropometric assessment was done for waist and hip circumference to calculate waist to hip ratio (WHR). Non fasting blood samples were collected for serum 25-hydroxyvitamin D [25(OH)D] levels estimation using chemiluminescent immunoassay technique and total serum calcium levels by colorimetric assay technique. Serum 25(OH)D and total calcium levels were expressed in ng/ml and mg/dl. Vitamin D deficiency was defined as per the guidelines set by United States Endocrine Society. The mean age of cases and controls was 45±9 and 46±10 years respectively. On multivariate analysis, an inverse association with BC was found for less frequency of fruits consumption with an adjusted (ORs, 95% CI) (2.7, 0.5-15.7) respectively. Mushroom intake was inversely associated with risk of BC (ORs, 95% CI) (5.6, 1.9-16.6). Saturated fat intake and high WHR were significantly associated with high risk of BC with adjusted ORs, 95% CI of (3.4, 1.4-8.1) and (5, 1.4-17). A significant association (p<0.05) was found between low serum 25(OH)D levels and the risk of BC with adjusted ORs, 95% CI of (2.5, 0.9-7.4). Majority of the patients with BC were suffering from vitamin D deficiency. Dietary intake of mushrooms containing vitamin D naturally was found to be associated with decreased risk of breast cancer. A significant association was found between low serum 25(OH)D levels (<20ng/ml) with the risk of BC. Obesity as a consequence of nutritional risk factors determined by higher WHR was found to be significantly associated with the risk of BC.

Pectoral nerve blocks to improve analgesia after breast cancer surgery: A prospective, randomized and controlled trial.

STUDY OBJECTIVE: To evaluate the analgesic efficacy of ultrasound guided combined pectoral nerve blocks I and II in patients scheduled for surgery for breast cancer. DESIGN: Prospective, randomized, control trial. SETTING: Operating rooms in a tertiary care hospital of Northern India. PATIENTS: Sixty American Society of Anesthesiologists status I to II adult women, aged 18-70years were enrolled in this study. INTERVENTIONS: Patients were randomized into two groups (30 patients in each group), PECS (P) group and control (C) group. In group P, patients received both general anesthesia and ultrasound guided combined pectoral nerve blocks (PECS I and II). In group C, patients received only general anesthesia. MEASUREMENTS: We noted pain intensity at rest and during abduction of the ipsilateral upper limb, incidence of postoperative nausea and vomiting; patient's satisfaction with postoperative analgesia and maximal painless abduction at different time intervals in both groups. MAIN RESULTS: There was significant decrease in the total amount of fentanyl requirement in the in P group {(140.66±31.80µg) and (438±71.74µg)} in comparison to C group {(218.33±23.93µg) and (609±53.00µg)} during intraoperative and post-operative period upto 24h respectively. The time to first analgesic requirement was also more in P group (44.33±17.65min) in comparison to C group (10.36±4.97min) during post-operative period. There was less limitation of shoulder movement (pain free mobilization) on the operative site at 4h and 5h after surgery in P group in comparison to C group. However there was no difference in the incidence of post-operative nausea and vomiting (22 out of 30 patients in group P and 20 out of 30 patients in group C) but patients in group P had a better satisfaction score with postoperative analgesia than C group having a p value of <0.001(Score 1; 5 VS 20; Score 2; 12 VS 9; Score 3; 13 VS 1). CONCLUSIONS: Ultrasound guided combined pectoral nerve blocks are an effective modality of analgesia for patients undergoing breast surgeries during perioperative period. CLINICAL TRIAL REGISTRATION: CTRI/2015/12/006457.

Evaluation of optimum time for intravenous cannulation after sevoflurane induction of anesthesia in different pediatric age groups.

BACKGROUND AND AIMS: The ideal time for intravenous (IV) cannulation following inhalational induction in children is debatable. The effect of age on this time has not been studied. We evaluated the optimum time for IV cannulation after sevoflurane induction of anesthesia in different pediatric age groups. MATERIAL AND METHODS: A prospective interventional study based on Dixon's sequential up and down method was conducted in children of age 1-10 years. They were grouped according to their age - Group 1: 1-3 years, Group 2: >3-7 years, and Group 3: >7-10 years. Anesthesia was induced with 8% sevoflurane in 5 L of 100% oxygen. IV cannulation was attempted at 3.5 min in the first child in each group. The time for cannulation in the next child was stepped up or down by 30 s depending on positive or negative response, respectively, in the previous child. Children were recruited till a minimum of six pairs of failure-success sequence which was obtained in each group. The mean of midpoints of the failure-success sequence was calculated to obtain the time for cannulation in 50% of the children in each group. RESULTS: Total number of children in Groups 1, 2, and 3 were 24, 23, and 24, respectively. The mean (95% confidence level) time for IV cannulation after sevoflurane induction in Groups 1, 2, and 3 was 53.6 (40.0-67.1), 105 (62.6-147.4), and 143.6 (108.8-178.4) s, respectively. This time was significantly shorter in Group 1 compared to those in Groups 2 and 3. CONCLUSION: The optimum time for IV cannulation in 50% of the children after sevoflurane induction of anesthesia was shorter in children of age 1-3 years than in older children.

Is perioperative administration of 5% dextrose effective in reducing the incidence of PONV in laparoscopic cholecystectomy?: A randomized control trial.

STUDY OBJECTIVE: To compare the incidence of postoperative nausea and vomiting (PONV) during perioperative administration of 5% dextrose and normal saline in laparoscopic cholecystectomy. DESIGN: Prospective, randomized, double-blind trial. SETTING: Operating rooms in a tertiary care hospital of Northern India. PATIENTS: One hundred patients with American Society of Anesthesiologists status I to II undergoing laparoscopic cholecystectomy were enrolled in this study. INTERVENTIONS: Patients were randomized into two groups [normal saline (NS) group and 5% dextrose (D) group]. Both the groups received Ringer acetate (Sterofundin ISO) intravenously as a maintenance fluid during intraoperative period. Besides this, patients of group NS received 250ml of 0.9% normal saline and patients of group D received 5% dextrose @ 100ml/h started at the time when gall bladder was taken out. It was continued in the postoperative period with the same rate till it gets finished. MEASUREMENTS: Incidence of PONV, Apfel score, intraoperative opioids used and consumption of rescue antiemetics. MAIN RESULTS: Demographic data was statistically similar. Out of total 100 patients, 47 patients (47%) had PONV. In group D, 14 patients (28%) had PONV while in group NS, 33 patients (66%) had PONV within 24h of surgery (p value 0.001). The incidence of PONV was reduced by 38% in group D which is significantly lower when compared with that of group NS (p value 0.001). The consumption of single dose of rescue antiemetics in group D was also reduced by 26% when compared to that of group NS (p value 0.002). CONCLUSIONS: Perioperative administration of 5% dextrose in patients undergoing laparoscopic surgery can reduce PONV significantly and even if PONV occurs, the quantity of rescue antiemetics to combat PONV is also reduced significantly.

Prognostic Utility of Clinical Epilepsy Severity Score Versus Pretreatment Hypsarrhythmia Scoring in Children With West Syndrome.

This cross-sectional study assessed the impact of clinical epilepsy severity and pretreatment hypsarrhythmia severity on epilepsy and cognitive outcomes in treated children with West syndrome. Thirty-three children, aged 1 to 5 years, with infantile spasms were enrolled if pretreatment EEG records were available, after completion of ≥1 year of onset of spasms. Neurodevelopment was assessed by Development Profile 3 and Gross Motor Function Classification System. Epilepsy severity in the past 1 year was determined by the Early Childhood Epilepsy Severity Score (E-Chess). Kramer Global Score of hypsarrhythmia severity was computed. Kramer Global Score (≤8) and E-Chess (≤9) in the past 1 year were associated with favorable epilepsy outcome but not neurodevelopmental or motor outcome.