Premedication and sedation during ophthalmic surgery

Introduction: The anesthesiologist in ophthalmic surgery has a number of tasks: a) safely eliminate tension and anxiety in polymorbid aged patients; b) to provide comfort on the operating table of those suffering from chronic osteoarthritis pain; c) to enable the surgeon to operate on a cooperating patient with no sudden fluctuations in consciousness. Purpose: to assess the level of satisfaction of patients and surgeons with the applied premedication and sedation. Method: Preoperative and intraoperative levels of anxiety were assessed through a survey conducted in two stages: during pre-anesthesia consultation and postoperatively. NIBP and HR values were registered on admission and immediately preoperatively. Patients with known anxiety disorder were excluded from the study. Among 746 patients admitted for operation, 13% (n-103) reported moderate and high levels of anxiety. Mildly anxious patients 32%(n-244) received premedication with Hydroxyzine hydrochloride (Atarax®) 25 mg po. Patients with severe chronic pain syndrome of osteoarthritis origin were premedicated with Tramadol hydrochloride / Paracetamol (Paratramol®) 37.5 mg / 325 mg - 75 mg / 650 mg po - depending on the patient's weight and pain intensity. Sedation with combination of Midazolam and Fentanyl were used in patients with moderate to high level of anxiety, or in cases of prolonged and traumatic surgery. Midazolam administration begins 30-60 minutes preoperatively. The drug is titrated at 0.25 - 0.5 mg iv every 15-20 minutes. After positioning on the operating table and monitoring, patients are treated with Fentanyl 10-25mg iv, and sedation is maintained by mentioned intermittent doses of Midazolam. Information was collected on the surgeons' satisfaction with the patient's level of cooperation and theirs immobility during the operation. Result: A state of tranquillity and relaxation was achieved without suppressing breathing and consciousness. Patients reported reduced level of anxiety and ability to go calmly through the retrobulbar block, the preparation of the operative field and the operation itself. Surgeons’ satisfaction of scored very high. Conclusion: intentional screening for patients with preoperative anxiety and the application of early-onset low-dose sedation can meet the needs of the patient and the surgeon and also be safe

Exfoliation and pigmentary glaucoma – overlap syndrome

Introduction: Concomitant signs, characteristic for both pigmentary dispersion syndrome (PDS) and exfoliation syndrome (XFS) can cause sudden IOP spike, and lead to optic nerve damage progression and associated visual field (VF) loss. This development often remains undetected. Purpose: To describe the characteristic signs of XFS and pigmentary glaucoma (PG), and to discuss the specific management of overlap syndrome. Methods: A retrospective analysis of 40 consecutive patients diagnosed with overlap syndrome for a period of 18 months and follow up period of 9 to 18 months. Accumulation of abnormal material on lens capsule and pupil, iris transillumination defects, Krukenberg’s spindle, trabecular pigmentation, increased IOP and more difficult control of IOP are main features. Treatment: topical medications, laser peripheral iridotomy (LPI), and surgical - trabeculectomy (TE) or ExPress implant. Results: Most patients had typical signs of PDS and XFS, with XFS predominating over PDS. Patients with overlap syndrome were 50-65 years of age. Glaucoma progression was registered in all overlapping forms. In 25 (62%) patients we achieved good pressure lowering effect with medication and LPI. At lack of IOP control 15 patients underwent surgery - TE (9) and ExPress implantation (6). In 3 patients with TE additional needling with 5-FU was necessary. In 2 patients with ExPress transient posterior pole edema was registered. As a result of our treatment approach, no progression of glaucoma damage was observed. Visual impairment was due to late referral with very high levels of IOP and advanced VF defects. Conclusion: Awareness of sequential appearance and overlap of those two forms of glaucoma is of decisive importance for appropriate management. The alarming signs of unexcpected loss of IOP control, rapid progression of glaucomatous optic nerve changes and VF loss indicate of need for more aggressive treatment

Cooperative research projects of master's students (education programs) in the open informational educational environment

© Authors. Relevance of the research problem stems from the need to meet the challenges of personal growth of each participant of the educational process, a productive exchange of information and personalized contribution to the overall result of the conducted educational research. The aim of this paper is to improve joint training activities as the basis for future studies of masters that will be implemented in an open information and education space. The key approach to the study of the problems of the joint educational researches relies on the conceptual ideas of experiments conducting in joint environment in which access to individual and shared data in an open information education environment is restricted. Theoretical and technological tools were developed for working with factorial data of collaborative research in open educational environment. As a result these conceptual ideas were formulated for joint training of master's studies: the stages to improve joint research activities were grounded, the technology of forming joint bank of comparable research materials was created, the system of algorithms for collaborative (joint) working with experimental data was proposed, the strategy ensuring the adequacy of the joint pilot materials for attaining general and private purposes was worked out. This strategy also should be applied to the value and usefulness of collected data. The collected, studied, processed and presented in the paper unique experimental material can be useful both for solving current individual research tasks of undergraduates and for the development of new roles in research

Early anti-VEGF treatment in CRVO assures better prognosis

Introduction: Central retinal vein occlusion (CRVO) is the second most common cause of visual impairment due to retinal vascular disease in developed countries. The prevalence of CRVO is ranging from 0.1 to 0.5%. Risk factors are numerous, and fluctuations of IOP and thrombophilic conditions are considered to be the most important. Recently, extremely high levels of intraocular vascular endothelial growth factor (VEGF) were demonstrated in CRVO, leading to increased vascular permeability and leakage. Our objective is to present our approach in the management of treatment-naïve patients with CRVO. Methods: All consecutive patients with CRVO referred to our tertiary eye hospital for a period of 2 years were evaluated. Inclusion criteria: retinal and optic disk edema, dilatation and turtuosity of all retinal veins, widespread deep and superficial hemorrhages, cotton wool spots. We performed comprehensive eye exam, detailed medical history, specialized imaging methods, glaucoma evaluation, (AS-OCT, gonioscopy, IOP control), as well as hematological investigation in all patients. Treatment included intravitreal anti-VEGF application with personalized regimen. Glaucoma patients were treated with medications, laser and trabeculectomy (TE). We analyzed several variables: the period between the CRVO diagnosis and the start of anti-VEGF treatment, number of injections, changes in central macular thickness (CMT) and in visual acuity (VA). Results: Our pool of patients consisted of 38 persons, mean age 66.4 (29 -86). In 21 (56%) the CRVO is ischemic type, in 16 (42%) patients we diagnosed initial glaucoma damage (in 15 patients exfoliation syndrome was present). An interesting observation was the high number of patients - 13 (35%) with narrow, closed or occludable anterior chamber angle, diagnosed soon after the first CRVO symptoms. This finding was associated with history of accidental transient vision blurring and pain. In patients with start of treatment at the very beginning of macular edema we achieved immediate and excellent response after the first anti-VEGF application, and fast disappearance of exudations and hemorrhages. Hematologic studies demonstrated different types of hereditary thrombophilia in 7 patients. Conclusions: Our clinical experience demonstrate that best results in CRVO treatment could be obtained at early diagnosis, close follow up and early start of anti-VEGF treatment before pronounced macular edema occurs. Detailed evaluation of anterior chamber angle configuration and glaucoma management are mandatory for successful outcome in patients with initial CRVO symptoms

An apprach to generate large and small leptonic mixing angles

We take up the point of view that Yukawa couplings can be either 0 or 1, and the mass patterns of fermions are generated purely from the structure of the Yukawa matrices. We utilize such neutrino as well as charged leptonic textures which lead to (maximal) mixing angles of $\pi/4$ in each sector for relevant transitions. The combined leptonic CKM mixing angles are $\pi/4 \pm \pi/4$ which lead to very small $\sin^2 2 \Theta$ relevant to solar neutrino and LSND experiments. We propose that on the other hand the absence of the charged leptonic partner of the sterile neutrino maintains the angle $\pi/4$ from the neutrino sector for the transition $\nu_\mu \leftrightarrow \nu_s$ and hence atmospheric neutrino anomaly is explained through maximal mixing

Two clinical cases with explantation and reposition of Express- implant

Въведение: В хирургичната лечение на глаукомата напоследък широко приложение намира Ехрrеss- имплантът. Наблюдавано късно постоперативно усложнение е компрометиране на филтрацията. Цел: Да представим 2 клинични случая на експлантация и репозиция на Express- имплант. Клинични случаи: Р.Х. на 42 г. с напреднала пигментна глаукома. През 2013г. в друга клиника е извършена филтрираща операция с имплантация на Express на ляво око, a през март 2014г.- филтрираща операция с Express имплант и Ологен на дясно око. Шест месеца по- късно ние измерихме вътреочно налягане (В ОН) на дясното око до 38,0 mmHg. Проведохме ревизия и установихме срастване на еклералното ламбо, поради което имплантът се постави под ново ламбо в съседство. Д. Б. на 80 г. през 2008 г. е диагностицирана другаде с напреднала ексфолиативна глаукома на двете очи. Поради намалено зрение и високо вътреочно налягане на дясното око по спешност е извършена трабекулектомия и е назначена максимална медикаментозна терапия за лявото око с нормализиране на налягането на двете очи. След 3 mдини, при преглед при нас поради влошаване на зрението на ляво око, установихме тромбоза на vena centralis retinae и повишаване на ВОН до 38,0 mmHg на ляво око. Извършихме по спешност филтрираща операция с Express имплант с компенсация на ВОН за период от 4 mдини. През 2015 г. измерихме отново повишено ВОН до 39,0 mmHg с оплоскостяване на филтрациоината възглавничка на лявото око. При извършената ревизия установихме, че Express шънтът е непроходим и преминахме към стандартна трабекулектомия с Митомицин С на съседно място. Заключение: Лечението на глаукомата чрез поставяне на Express- имплант е иновативен метод с редица предимства, но както всяка оперативна интервенция в редки случаи могат да се наблюдават ранни или късни усложнения.Introduction: In the surgical treatment of glaucoma Express- implant is widely used recently. Rarely observed late postoperative complication is deterioration of filtration. Objective: We present two clinical cases of explantation and reposition of Express - implant. Clinical cases: R.H. - 42 years old, female, with advanced pigmentary glaucoma. In 2013 filtering surgery with Express implant on the left еуе was performed, and in March 2014 - filtering operation with Express implant and Ologen on the right еуе elsewhere. Six months later we measured intraocular pressure of the right еуе up to 38,0 mmHg. We performed revision and found scarring of the scleral flap. The same implant was placed under a new flap. D. B.- 80 years old, female. In 2008 the patient was diagnosed with advanced exfoliative glaucoma in both eyes. Urgent trabeculectomy of the right eye was performed and a maximal medical therapy for the left eye was prescribed. In 2011 a central retinal vein thrombosis of the left eye and intraocular pressure 38,0 mmHg was found and a filtering operation with Express implant was performed. During follow-up in 2015 a bleb scarring of the left eye and intraocular pressure 38,0 mmHg was found. A revision with explantation of the occluded Express shunt was performed. A standard trabeculectomy with Mitomycin C in a close location was done. Conclusion: Treatment of glaucoma by applying Express- implant is a modem method with a number of advantages, but likewise any surgery in rare cases early or late complications may occur

Neutrino Oscillations and the Early Universe

The observational and theoretical status of neutrino oscillations in connection with solar and atmospheric neutrino anomalies is presented in brief. The effect of neutrino oscillations on the early Universe evolution is discussed in detail. A short review is given of the standard Big Bang Nucleosynthesis and the influence of resonant and nonresonant neutrino oscillations on active neutrinos and on primordial nucleosynthesis of He-4. BBN cosmological constraints on neutrino oscillation parameters are discussed.Comment: 21 p., 6 figures, a review based on raview talk at NCYA Conference and a presentation at CAPP200

Prognosis in patients with myocardial infarction with ST-elevation depending on the timing of interventional revascularization

Проверена е прогнозата (болничния и следболничния леталитет до края на 6-ия месец) при 300 болни (212 мъже и 88 жени) с първи миокарден инфаркт със ST- елевация (STEMI) на средна възраст 62.9 год. в зависимост от срока на извършената първична коронарна интервенция (PCI) след началото на симптомите. В зависимост от срока на извършената РСІ болните са разделени на 4 групи: до 3-ия, до 6-ия, до 12-ия и до 24-ия час след началото на инфаркта. Болничният леталитет за всички болни е 6.3%, a до края на 6-ия месец - 13.3%, еднакъв при І-ва и ІІ-ра група и достоверно по-малък, отколкото при ІІІ-та и ІV-та група, по-голям при жените, при болните над 65 г., с ФИ <35.0% и с тромботична оклузия на LM и LAD.The prognosis (in-hospital and post-hospitalization lethality by the end of the 6th moth) of 300 patients (212 men and 88 women) with a first myocardial infarction with ST-elevation (STEMI) at an average age of 62.9 years was studied depending on the timing of the conducted primary coronary intervention (PCI) after the onset of symptoms. Depending on the timing of the conducted PCI, the patients were divided into 4 groups: by the 3rd, 6th, 12th, and 24th hour after the onset of the infarction. The patients` in-hospital lethality was 6.3%, and that by the end of the 6th month - 13.3%. It was the same for groups I and II and significantly lower than in groups III and IV; higher in women, in patients over 65 years of age, with ejection fraction (EF) <35.0% and with thrombotic occlusion of LM and LAD

Neutrino-Mixing-Generated Lepton Asymmetry and the Primordial 4^4He Abundance

It has been proposed that an asymmetry in the electron neutrino sector may be generated by resonant active-sterile neutrino transformations during Big Bang Nucleosynthesis (BBN). We calculate the change in the primordial $^4$He yield $Y$ resulting from this asymmetry, taking into account both the time evolution of the $\nu_e$ and $\bar\nu_e$ distribution function and the spectral distortions in these. We calculate this change in two schemes: (1) a lepton asymmetry directly generated by $\nu_e$ mixing with a lighter right-handed sterile neutrino $\nu_s$; and (2) a lepton asymmetry generated by a $\nu_\tau\leftrightarrow\nu_s$ or $\nu_\mu\leftrightarrow\nu_s$ transformation which is subsequently partially converted to an asymmetry in the $\nu_e\bar\nu_e$ sector by a matter-enhanced active-active neutrino transformation. In the first scheme, we find that the percentage change in $Y$ is between -1% and 9% (with the sign depending on the sign of the asymmetry), bounded by the Majorana mass limit m_{\nu_e}\la 1 eV. In the second scheme, the maximal percentage reduction in $Y$ is 2%, if the lepton number asymmetry in neutrinos is positive; Otherwise, the percentage increase in $Y$ is \la 5% for m^2_{\nu_\mu,\nu_\tau}-m^2_{\nu_s}\la 10^4 eV. We conclude that the change in the primordial $^4$He yield induced by a neutrino-mixing-generated lepton number asymmetry can be substantial in the upward direction, but limited in the downward direction.Comment: 15 pages, 7 figures, submitted to PR

Proposal for SPS beam time for the baby MIND and TASD neutrino detector prototypes

The design, construction and testing of neutrino detector prototypes at CERN are ongoing activities. This document reports on the design of solid state baby MIND and TASD detector prototypes and outlines requirements for a test beam at CERN to test these, tentatively planned on the H8 beamline in the North Area, which is equipped with a large aperture magnet. The current proposal is submitted to be considered in light of the recently approved projects related to neutrino activities with the SPS in the North Area in the medium term 2015-2020