Lyme Borreliosis, a public health concern in India: Findings of Borrelia burgdorferi serosurvey from two states.

Background: Lyme borreliosis is a public health concern in India. The prevalence of the disease is still undetermined with major entomological and epidemiological gaps. The present study was conducted to determine the seropositivity of Borrelia burgdorferi in Sikkim and Arunachal Pradesh, India. Methods: A cross-sectional serosurvey was conducted in Sikkim and Arunachal Pradesh. Data collection tools were developed and standardized for the collection of clinico-socio-demographic data. Sample size for each site was calculated using the formula for the estimation of a single proportion. Qualitative detection of IgG antibodies in serum samples was done using NovaLisa™ Lyme Borrelia IgG ELISA kit. Results: A total of 793 participants were enrolled, 484 (61%) from Arunachal Pradesh and 309 (39%) from Sikkim. Out of 793 participants, 21 (2.7%), 22 (2.8%), 6 (0.8%), 29 (3.7%), 44 (5.5%), and 16 (2.1%) gave history of tick bite, rash, erythema migrans, migratory muscle pain, migratory joint pain, and numbness, respectively, in the past one year. The adjusted seroprevalence (for sensitivity and specificity of kit) for the study is 3.7 (2.4-5.2). No signs or symptoms were found to be associated with IgG ELISA positivity. The state-wise distribution of seropositivity for Arunachal Pradesh and Sikkim was 4.1 (95% CI: 2.5-6.3) and 2.3 (95% CI: 0.9-4.6), respectively. Conclusion: This study establishes the state of Sikkim as a new endemic area in India of Lyme disease besides its already reported endemicity in Arunachal Pradesh. No association was conclusively established between symptoms of Lyme and IgG seropositivity emphasizing the need for detailed history taking and clinical suspicion in endemic areas.

Role of cosyntropin in the prevention of post-dural puncture headache: a propensity-matched retrospective analysis.

BACKGROUND: Post-dural puncture headache (PDPH) is a well-documented complication of accidental dural puncture in obstetric patients. Reports have shown successful treatment with adrenocorticotropic hormone (ACTH) but evidence remains low and limited. In this retrospective analysis, we assessed whether prophylactic administration of cosyntropin, a synthetic derivative of ACTH, reduced the incidence of PDPH after accidental dural puncture in parturients. METHOD: The study population included 132 women with an accidental dural puncture over a three-year period (June 1, 2018 to Oct 31, 2021) at a large tertiary-care center. Patient electronic medical records were reviewed for patient characteristics, prophylactic administration of cosyntropin, PDPH diagnosis, and need for epidural blood patch. Typically, 1 mg of cosyntropin was administered as an intravenous bolus or infusion post-delivery. The propensity score was calculated based on the following factors: age, body mass index, and placement of an intrathecal catheter. Patients were matched allowing 10% variation in scores to reduce potential treatment assignment bias. RESULTS: A total of 115 patients were included in the final analysis. Intravenous cosyntropin was administered to 65 patients (55.6%). Among those who received cosyntropin, 37 (56.9%) developed PDPH compared with 29 patients (58%) in the no-cosyntropin group (P = 0.08). Epidural blood patch was performed in 21 patients (56.8%) who received cosyntropin and 13 patients (61.7%) who did not (P = 0.70). CONCLUSION: Prophylactic administration of cosyntropin is not associated with a reduced incidence of PDPH.

A study of the pharmacokinetics and pharmacodynamics of oxytocin at elective caesarean delivery.

Oxytocin is widely used to prevent atonic postpartum haemorrhage after caesarean delivery. Initial treatment failure rates are high and inadequate dosing may contribute. Excessive doses, however, are associated with serious adverse effects. The pharmacokinetic data from this context are sparse and there is a lack of data in the immediate postpartum minutes after an initiating bolus. The pharmacodynamic data from this context are exclusively from dose-effect studies, with some suggesting that higher doses of oxytocin are required to provide adequate uterine tone in obese compared with non-obese women. We aimed to perform a pharmacokinetic and pharmacodynamic study that would facilitate more precise weight-based oxytocin dosing. We measured arterial oxytocin concentration, uterine tone and haemodynamic parameters in 25 women in the first 40 min after exogenous oxytocin administration at elective caesarean delivery. Serum oxytocin concentrations varied considerably between individuals. We constructed a one-compartment pharmacokinetic model of exogenous oxytocin deposition, after its administration with an initiating bolus and a maintenance infusion, at elective caesarean delivery. Body weight was evaluated as a potential covariate but was not included in the model due to lack of statistically significant reduction in the objective function. We calculated the volume of distribution and clearance (mean [coefficient of variation]) as 156.1 l [18%] and 83 ml.s-1 [32%] but found no within-individual correlation between serum oxytocin concentration and uterine tone or haemodynamic parameters. In conclusion, we observed a large variation in serum oxytocin concentrations between individuals receiving similar doses of oxytocin and were unable to establish weight-based dosing of exogenous oxytocin at caesarean delivery. Our findings suggest that future studies on oxytocin pharmacokinetics would need large sample sizes. In the absence of such data, oxytocin dosing should continue to be guided by uterine tone assessments and adjusted according to a strategy based on the best evidence from dose-effect studies.

Prognostic factors for chronic post-surgical pain after lung and pleural surgery: a systematic review with meta-analysis, meta-regression and trial sequential analysis.

Chronic post-surgical pain is known to be a common complication of thoracic surgery and has been associated with a lower quality of life, increased healthcare utilisation, substantial direct and indirect costs, and increased long-term use of opioids. This systematic review with meta-analysis aimed to identify and summarise the evidence of all prognostic factors for chronic post-surgical pain after lung and pleural surgery. Electronic databases were searched for retrospective and prospective observational studies as well as randomised controlled trials that included patients undergoing lung or pleural surgery and reported on prognostic factors for chronic post-surgical pain. We included 56 studies resulting in 45 identified prognostic factors, of which 16 were pooled with a meta-analysis. Prognostic factors that increased chronic post-surgical pain risk were as follows: higher postoperative pain intensity (day 1, 0-10 score), mean difference (95%CI) 1.29 (0.62-1.95), p < 0.001; pre-operative pain, odds ratio (95%CI) 2.86 (1.94-4.21), p < 0.001; and longer surgery duration (in minutes), mean difference (95%CI) 12.07 (4.99-19.16), p < 0.001. Prognostic factors that decreased chronic post-surgical pain risk were as follows: intercostal nerve block, odds ratio (95%CI) 0.76 (0.61-0.95) p = 0.018 and video-assisted thoracic surgery, 0.54 (0.43-0.66) p < 0.001. Trial sequential analysis was used to adjust for type 1 and type 2 errors of statistical analysis and confirmed adequate power for these prognostic factors. In contrast to other studies, we found that age had no significant effect on chronic post-surgical pain and there was not enough evidence to conclude on sex. Meta-regression did not reveal significant effects of any of the study covariates on the prognostic factors with a significant effect on chronic post-surgical pain. Expressed as grading of recommendations, assessment, development and evaluations criteria, the certainty of evidence was high for pre-operative pain and video-assisted thoracic surgery, moderate for intercostal nerve block and surgery duration and low for postoperative pain intensity. We thus identified actionable factors which can be addressed to attempt to reduce the risk of chronic post-surgical pain after lung surgery.

Uterine externalization versus in situ repair of hysterotomy during cesarean delivery: a systematic review, equivalence meta-analysis, and trial sequential analysis.

BACKGROUND: Uterine positioning during hysterotomy repair is controversial, with both in situ and externalized approaches commonly performed. Despite many published trials, clinical equipoise remains. This meta-analysis and trial sequential analysis (TSA) summarizes studies comparing both techniques. METHODS: A systemic search for randomized controlled trials comparing in situ with externalized hysterotomy repair during cesarean delivery was performed. The primary outcomes were estimated blood loss (EBL) and surgical duration. Secondary outcomes were need for blood transfusion, incidence of endometritis, hospital length of stay, intra-operative hypotension, return of bowel function, intra-operative vomiting, intra-operative pain, and need for postoperative analgesia. Cochrane methodology was used to assess risk of bias. Data are presented as mean difference/standardized mean difference or odds ratio/risk difference with 95% confidence intervals (CI). RESULTS: Nineteen studies enrolling 20 739 patients were included. Estimated blood loss and surgical duration were equivalent between methods, with TSA confirming adequate information size for surgical duration but not EBL. In situ repair was associated with faster return of bowel function (MD -0.76 days; 95% CI -1.36 to -0.15; P=0.01) and a reduction in need for breakthrough postoperative analgesia (OR 0.44; 95% CI 0.28 to 0.68; P <0.01). CONCLUSIONS: This analysis revealed equivalence between methods for EBL and surgical duration. While the small reduction in EBL with externalized repair was not clinically or statistically significant, TSA analysis revealed an unmet information size, suggesting a potentially inconclusive result. In situ repair may be associated with less breakthrough postoperative analgesia requirement and faster return of bowel function.

Efficacy of regional blocks or local anaesthetic infiltration for analgesia after caesarean delivery: a network meta-analysis of randomised controlled trials.

Caesarean delivery is common and can cause severe postoperative pain but injection of local anaesthetic at various sites for regional blocks or local anaesthetic infiltration may reduce this. We aimed to compare and rank these sites. We searched PubMed, Google Scholar, EMBASE and CENTRAL to June 2021 for randomised controlled trials and performed a random-effects Bayesian model network meta-analysis. The primary outcome was dose of parenteral morphine equivalents in the first 24 postoperative hours. We used surface under cumulative ranking probabilities to order techniques. We analysed 114 trials (8730 participants). The ordered mean (95% credible interval) reduction in morphine equivalents, from 34 mg with placebo, were as follows: ilio-inguinal 15 (1-32) mg; ilio-inguinal-iliohypogastric 13 (6-19) mg; transversalis fascia 11 (4-26) mg; erector spinae 11 (10-32); transverse abdominis 9 (4-13) mg; wound catheter infusion 8 (2-15) mg; quadratus lumborum 8 (1-15) mg; wound infiltration 8 (2-13) mg; and no intervention -4 (-10 to 2) mg. Ordered efficacies for injection sites were different for other relevant outcomes, including pain (to 4-6 h and to 24 h) and time to rescue analgesia: there was no single preferred route of injection. The ordered mean (95% credible interval) reduction in dynamic pain scores (0-10 scale) at 24 h compared with placebo were as follows: wound infusion 1.2 (0.2-2.1); erector spinae 1.3 (-0.5 to 3.1); quadratus lumborum 1.0 (0.1-1.8); ilio-inguinal-iliohypogastric 0.6 (-0.5 to 1.8); transverse abdominis 0.6 (-0.1 to 1.2); wound infiltration 0.5 (-0.3 to 1.3); transversalis fascia -0.8 (-3.4 to 1.9); ilio-inguinal -0.9 (-3.6 to 1.7); and no intervention -0.8 (-1.8 to 0.2). We categorised our confidence in effect sizes as low or very low.

Polio switch strategy: An obituary in the making?

India was certified free of polio in 2014. Until now, the oral polio vaccine (OPV) was being used in India. As the OPV is a live vaccine, vaccine-associated paralytic poliomyelitis may occur after its use. The aim is to replace the OPV with injectable polio vaccine. The Polio Eradication and Endgame Strategic Plan 2013-2018 has been made to eradicate polio. A switch from the trivalent OPV (tOPV) to bivalent OPV (bOPV) has been undertaken in all countries since April 2016. tOPV vials have been withdrawn and replaced by bOPV. In addition, the inactivated polio vaccine (IPV) has been introduced. The next step would be to remove the type 3 virus component followed by complete cessation of the OPV and a final switch to the IPV. The timeline has been fixed as 2018-2019. Replacement of a vaccine may raise fears in the community that need to be addressed. Re-emergence of circulating vaccine-derived poliovirus after withdrawal of the tOPV may occur. Proper disposal of vaccine vials needs to be ensured. Proper training of vaccinators is important. All stakeholders need to be incorporated, and focus should be more on deprived populations. The switch marks a significant step towards the final goal of polio eradication. Finally, the importance of community participation cannot be overemphasized. Sustained surveillance is the key to prevent occurrence of cases in polio-free countries through importation.

The association between post-dural puncture headache and needle type during spinal anaesthesia: a systematic review and network meta-analysis.

Post-dural puncture headache is one of the most undesirable complications of spinal anaesthesia. Previous pairwise meta-analyses have either compared groups of needles or ranked individual needles based on the pooled incidence of post-dural puncture headache. These analyses have suggested both the gauge and needle tip design as risk-factors, but failed to provide an unbiased comparison of individual needles. This network meta-analysis compared the odds of post-dural puncture headache with needles of varying gauge and tip design. We searched randomised controlled trials in medical databases. The primary outcome measure of the network meta-analysis was the incidence of post-dural puncture headache. Secondary outcomes were procedural failure, backache and non-specific headache. Overall, we compared 11 different needles in 61 randomised controlled trials including a total of 14,961 participants. The probability of post-dural puncture headache and procedural failure was lowest with 26-G atraumatic needles. The 29-G cutting needle was more likely than three atraumatic needles to have the lowest odds of post-dural puncture headache, although with increased risk of procedural failure. The probability rankings were: 26 atraumatic > 27 atraumatic > 29 cutting > 24 atraumatic > 22 atraumatic > 25 atraumatic > 23 cutting > 22 cutting > 25 cutting > 27 cutting = 26 cutting for post-dural puncture headache; and 26 atraumatic > 25 cutting > 22 cutting > 24 atraumatic > 22 atraumatic > 25 atraumatic > 26 cutting > 29 cutting > 27 atraumatic = 27 cutting for procedural success. Meta-regression by type of surgical population (obstetric/non-obstetric) and participant position (sitting/lateral) did not alter these rank orders. This analysis provides an unbiased comparison of individual needles that does not support the use of simple rules when selecting the optimal needle. The 26-G atraumatic needle is most likely to enable successful insertion while avoiding post-dural puncture headache but, where this is not available, our probability rankings can help clinicians select the best of available options.

Choice of local anaesthetic for epidural caesarean section: a Bayesian network meta-analysis.

Rapid-onset epidural local anaesthesia can avoid general anaesthesia for caesarean delivery. We performed a Bayesian network meta-analysis of direct and indirect comparisons to rank speed of onset of the six local anaesthetics most often used epidurally for surgical anaesthesia for caesarean delivery. We searched Google Scholar, PubMed, EMBASE, Ovid, CINAHL and CENTRAL to June 2019. We analysed 24 randomised controlled trials with 1280 women. The mean (95%CrI) onset after bupivacaine 0.5% was 19.8 (17.3-22.4) min, compared with which the mean (95%CrI) speed of onset after lidocaine 2% with bicarbonate, 2-chloroprocaine 3% and lidocaine 2% was 6.4 (3.3-9.6) min faster, 5.7 (3.0-8.3) min faster and 3.9 (1.8-6.0) min faster, respectively. Speed of onset was similar to bupivacaine 0.5% after ropivacaine 0.75% and l-bupivacaine 0.5%: 1.6 (-1.4 to 4.8) min faster and 0.4 (-2.2 to 3.0) min faster, respectively. The rate (95%CrI) of intra-operative hypotension was least after l-bupivacaine 0.5%, 315 (236-407) per 1000, and highest after 2-chloroprocaine 3%, 516 (438-594) per 1000. The rate (CrI) of intra-operative supplementation of analgesia was least after ropivacaine 0.75% 48 (19-118) per 1000 and highest after 2-chloroprocaine 3%, 250 (112-569) per 1000.

Carbetocin reduces the need for additional uterotonics in elective caesarean delivery: a systematic review, meta-analysis and trial sequential analysis of randomised controlled trials.

BACKGROUND: Carbetocin has been found to be superior to oxytocin in terms of need for additional uterotonics and prevention of postpartum haemorrhage at caesarean delivery. However, this is based on combined data from labouring and non-labouring parturients and it remains unclear how effective carbetocin is in the purely elective setting. The aim of this review was to compare carbetocin to oxytocin in elective caesarean delivery. METHODS: Medline, Embase, CINAHL, Web of Science, and the Cochrane databases were searched for randomised controlled trials in any language. The primary outcome was need for additional uterotonics. Secondary outcomes were mean blood loss, need for blood transfusion and incidence of postpartum haemorrhage >1000 mL. RESULTS: Nine studies with a total of 1962 patients were included. Trial sequential analysis confirmed that the information size (n=1692) had surpassed that required (n=1166) in order to demonstrate a statistically significant reduction in the use of additional uterotonics. Need for additional uterotonics was reduced by 53% with carbetocin compared to oxytocin (OR 0.47, 95% CI 0.34 to 0.64; P <0.001, I2=63.5). The number needed-to-treat was 11. The risk of bias, data heterogeneity and inconsistency in reporting bleeding outcomes made it difficult to reach definite conclusions about prevention of PPH. CONCLUSIONS: Carbetocin is associated with a reduced need for additional uterotonics when compared with oxytocin at elective caesarean delivery. Standardisation of bleeding-related outcomes in studies is necessary to facilitate synthesis of data in future analyses.

Phytochemical and antioxidative potential of orange, red, yellow, rainbow and black coloured tropical carrots (Daucus carota subsp. sativus Schubl. & Martens).

This study was executed to determine phytochemical content i.e. total carotenoids, phenolics and flavonoids, and antioxidant ability expressed in the form of FRAP, CUPRAC and ABTS activity among different coloured tropical carrots (orange, red, yellow, rainbow and black carrot) developed at ICAR-IIVR, Varanasi, Uttar Pradesh, India. Overall, within different colour group, the extent of variation for various phytochemical content and antioxidant potentiality is narrow i.e. ranged from 1.04- to 3.21-fold; but at the same time, the genotypic variability across genotypes is too wide which varied 20.90- to 57.92-fold for phytochemical and antioxidants is an indication of broad genetic base of carrot germplasm. Among all the carrots, black carrot had an exceptionally high content of total phenolics and flavonoids, and thereby led to the highest antioxidant ability in the terms of FRAP, CUPRAC and ABTS activity expressing about 76-83% relative potentiality followed by rainbow carrot, and least in orange, red and yellow carrot (black carrot > rainbow carrot > red carrot ≈ orange carrot ≈ yellow carrot). The content of phenolics and flavonoids were highly correlated with antioxidant activity (0.955** to 0.992**). However, the most cultivated and consumed carrots, orange and red one, possessed higher amount of carotenoids. The content of carotenoids negatively correlated with total phenolics, flavonoids and antioxidants activity (- 0.612** to - 0.627**). Broad genetic base and selection based on total phenolics content could be pivotal in the future breeding to harness the genetic wealth of carrot efficiently.

Wolbachia: The selfish Trojan Horse in dengue control.

Dengue fever has re-emerged as a major public health challenge. Of late, several promising attempts have been made to control the disease with limited success. An innovative method of biological control of dengue is the use of the bacterium Wolbachia. Selected strains of Wolbachia have been introduced into Aedes aegypti to prevent transmission of dengue viruses by the vector. Wolbachia prevents dengue transmission by either directly blocking the virus or by decreasing the lifespan of the vector. The mechanism by which it causes these effects is not clearly understood. The main concern of this technique is the emergence of a new dengue virus serotype which may evade the protection offered by Wolbachia. The technique is environment friendly and holds promise for control of other vector borne diseases.

Effect of introduction of a new electronic anesthesia record (Epic) system on the safety and efficiency of patient care in a gastrointestinal endoscopy suite-comparison with historical cohort.

BACKGROUND: Use of electronic medical record systems has increased in the recent years. Epic is one such system gaining popularity in the USA. Epic is a private company, which invented the electronic documentation system adopted in our hospital. In spite of many presumed advantages, its use is not critically analyzed. Some of the perceived advantages are increased efficiency and protection against litigation as a result of accurate documentation. MATERIALS AND METHODS: In this study, retrospective data of 305 patients who underwent endoscopic retrograde cholangiopancreatography (wherein electronic charting was used - "Epic group") were compared with 288 patients who underwent the same procedure with documentation saved on a paper chart ("paper group"). Time of various events involved in the procedure such as anesthesia start, endoscope insertion, endoscope removal, and transfer to the postanesthesia care unit were routinely documented. From this data, the various time durations were calculated. RESULTS: Both "anesthesia start to scope insertion" times and "scope removal to transfer" times were significantly less in the Epic group compared to the paper group. Use of Epic system led to a saving of 4 min of procedure time per patient. However, the mean oxygen saturation was significantly less in the Epic group. CONCLUSION: In spite of perceived advantages of Epic documentation system, significant hurdles remain with its use. Although the system allows seamless flow of patients, failure to remove all artifacts can lead to errors and become a source of potential litigation hazard.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations.

BACKGROUND: During the last two decades, an increasing number of bariatric surgical procedures have been performed worldwide. There is no consensus regarding optimal perioperative care in bariatric surgery. This review aims to present such a consensus and to provide graded recommendations for elements in an evidence-based "enhanced" perioperative protocol. METHODS: The English-language literature between January 1966 and January 2015 was searched, with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded. After critical appraisal of these studies, the group of authors reached a consensus recommendation. RESULTS: Although for some elements, recommendations are extrapolated from non-bariatric settings (mainly colorectal), most recommendations are based on good-quality trials or meta-analyses of good-quality trials. CONCLUSIONS: A comprehensive evidence-based consensus was reached and is presented in this review by the enhanced recovery after surgery (ERAS) Society. The guidelines were endorsed by the International Association for Surgical Metabolism and Nutrition (IASMEN) and based on the evidence available in the literature for each of the elements of the multimodal perioperative care pathway for patients undergoing bariatric surgery.

A comparison of single dose dexmedetomidine with propofol for the prevention of emergence delirium after desflurane anaesthesia in children.

Emergence delirium is a common problem in children recovering from general anaesthesia. We performed a study comparing emergence characteristics in 100 patients who were randomly allocated to receive either 0.3 µg.kg(-1) dexmedetomidine, 1 mg.kg(-1) propofol or saline 0.9% and undergoing infra-umbilical surgery. The Pediatric Anesthesia Emergence Delirium scale was used to grade emergence delirium. Emergence delirium occurred in 9.4% of children in the dexmedetomidine group compared with 13.9% in the propofol group and 40.6% in the control group (p = 0.004). In the dexmedetomidine group, sedation occurred in 62.5% of children at 10 min after transfer to the recovery area, compared with 44.4% in the propofol group and 12.5% in the control group (p = 0.010). We conclude that dexmedetomidine significantly reduced the incidence of emergence delirium but this was at the expense of a greater incidence of sedation in the recovery period.