Randomized clinical study comparing safety and efficacy of adjuvant intrathecal clonidine versus normal saline along with bupivacaine anaesthesia in lower limb surgery patients

Background: Various adjuvants have been used in intrathecal anesthesia to avoid intraoperative visceral and somatic pain and prolong postoperative analgesia. Clonidine, partially selective α2-agonist, is being evaluated as a neuraxial adjuvant with intrathecal bupivacaine. The objective of the study was to evaluate and compare safety and efficacy of intrathecal clonidine as adjuvant to bupivacaine with control normal saline.Methods: American Society of Anesthesiologist grade 1 and 2 patients (60 patients) were randomly divided into two groups of 30 patients each for lower limb surgeries. Study group injected with intrathecal 3ml of 0.5% Bupivacaine heavy (15mg) + 1µg/kg of clonidine and control group injected with 3ml of 0.5% Bupivacaine heavy (15mg) + equivalent dose of normal saline. The onset and duration of sensory and motor block, duration of analgesia, and the incidence of side effects in both groups were observed and compared.Results: Time for 2 segment regressions in study group was 186.17±25.92 minutes compared to control was 103.20±19.15 minutes (p value<0.001). Total duration of analgesia in control was 226.50±35.69 minutes and in the study group was 465.67±100.37 minutes (p value<0.001). The average duration of motor block in control group was 181.17±26.12 minutes compared to study group was 217.80±41.51 minutes (p value<0.001). The small dose of intrathecal clonidine is not significantly associated with systemic side effects such as bradycardia and hypotension.Conclusions: Clonidine added to bupivacaine for intrathecal anesthesia effectively increases the duration of sensory block, duration of motor block and duration of analgesia and does not produce any significant hemodynamic changes. No significant side effects are associated with it

EVALUATION OF CAUSATIVE FACTORS IN AMLODIPINE INDUCED PEDAL EDEMA

Objective: To study the edema causing factors in hypertensive, amlodipine-induced pedal edema patients.Methods: The present was a prospective, observational study. A total of one hundred and twenty-four essential hypertensive patients, of either gender attending the outpatient department of cardiology and medicine, were recruited for this study. Out of the 124 patients, 62 were of the amlodipine-induced pedal edema [AIPE] group and other 62 patients were amlodipine-treated non-edema [ATNE] group. All the patients were receiving a dosage of amlodipine 5 mg/day. All recruited patients completed the study. The present study conducted at Kasturba Hospital, Manipal.Results: The vanillyl mandelic acid (VMA) (mean±SD) 7.08±2.3 mg/24 h and 4.9±1.7 mg/24 h in AIPE and ATNE groups respectively. Blood pressure (BP) and VMA was higher in AIPE group than the ATNE group (p&lt;0.001). Pulse rate (PR), serum proteins, creatinine, sodium, osmolality, did not show any significant difference between the two study groups.Conclusion: In essential hypertensive patients with AIPE group presented with a higher VMA level than the ATNE group. The elevated catecholamine's possibly the causative factor for AIPE

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

The Cholecystectomy As A Day Case (CAAD) Score: A Validated Score of Preoperative Predictors of Successful Day-Case Cholecystectomy Using the CholeS Data Set

Background Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Silver scurf of potatoes

4 p.: ill.; 28 cm

Efficiency of RCC piles with helical grooves subjected to axial and lateral loads in cohesionless soil

AbstractThis paper presents an experimental and numerical investigation of RCC (Reinforced Concrete) piles with helical grooves under axial and lateral loads in cohesionless soil. A set of experiments is carried out to assess the performance of RCC piles with helical grooves. To replicate the experimental findings, the Finite Element Method (FEM) is employed using Abaqus software. Three-dimensional (3D) models are created to represent both the pile and the soil using Abaqus. The paper compares settlement characteristics and lateral displacement of plain RCC piles and RCC piles with helical grooves. This study also evaluates the impact of varying the pitch of helical grooves on enhancing pile performance. The results indicate that RCC piles with helical grooves outperform plain RCC piles in terms of both axial and lateral load-carrying capacity, inferred from both experimental and analytical techniques

A study on self-medication in ophthalmic emergencies in the rural population of South India

Background: Self-medication has been defined as the taking of drugs, herbs, or home remedies on one's own initiative and advice from another person without consulting a medical specialist. The objective of the study was to identify the pattern of self-medication in ophthalmic emergencies in patients attending the emergency department in a peripheral rural setup in south India. Materials and Methods: This was a descriptive, cross–sectional, questionnaire-based observational study. The patients selected were above 18 years of age. Informed consent was taken. A questionnaire on the demographic characteristics, level of literacy, history of the ophthalmic condition for which the patient had self-medicated, type of self-medication resorted to , reasons for resorting to ocular self–medication, and the adverse effects reported were all noted in the study. Results: The study included 100 subjects. Fifty-three percent were male and 47% were female. Among the 100 subjects, 10% of the individuals were educated above primary school level. Thirty-five percent had only primary school level education and the remaining 55% had not been to a formal school and had no basic education. Among our respondents, the most commonly used self-medication was antibiotic drops (24%), followed by expired medication (23%). 20% used steroid drops. 15% had tried traditional eye medication (TEM). Herbal and other indigenous medications were used by 12% of the responders. 7% used oral nonsteroidal anti-inflammatory drug agents. None of the responders were aware of the adverse effects of self-medication. The most common ophthalmic emergency symptoms faced by our responders were excessive watering (37%), pain (28%), foreign body in the eye (14%), redness and discharge (12%), decreases vision (5%), and pain in the eye (4%). The common reasons given by our responders for not accessing health-care facilities were distance (living far from health-care facilities), advice from family and friends, belief if local healers, lack of finances and poverty, and lack of prioritizing health care. Following self–medication, 30% of the patients had infectious keratitis, 28% had conjunctivitis, 25% had epithelial defects, and 17% glaucoma. Conclusion: Irrational long-term use of drugs/traditional eye medicine or even the usage for ophthalmic emergencies can have dangerous visual outcomes. The study highlights the need of effective execution and establishment of high-quality accessible primary eye care services and health-care referral network in rural India