Spinal Anesthesia in General Surgical Patients: Comparison of 0.75% and 0.5% Hyperbaric Bupivacaine

Objective: To appraise clinical effects of 0.5% and 0.75% hyperbaric bupivacaine in general surgical patients undertaking procedure in spinal anesthesia employing crystalloid fluid preload / co-load. Place and Duration: Islam Teaching Hospital, Islam Medical College, Sialkot and Rawal General and Dental Hospital, Rawal Institute of Health Sciences, Islamabad from 03-4-2012 to 18-9-2012 and from 19-9-2017 to 30-5-2018. Methodology:  The study consisted of one hundred and twenty-four cases which were divided by lottery into two equal components i.e group-1 and group-2 using 0.5% and 0.75% hyperbaric bupivacaine respectively for intrathecal block in general surgical patients. After spinal block hemodynamic monitoring continued at one-minute interval for fifteen minutes than at 5 minutes interval. Intravascular fluids colloids/crystalloid were given as preload and coload. After the procedure, monitoring continued in post-anesthesia care unit. Statistical analysis was done by SPSS version 19. Results: In group-1 in two cases (3.22%) and in group-2 in thirteen cases(20.96%) required vasopressors. The mean systolic and diastolic blood pressure(mmHg) in group-1 being 135.70(with SD of 26.37) and 78.70(with SD of 32.5), similar readings in group-2 being 131.78( SD of 26.25) and 79.36(SD of 32.50) respectively. Pearson’s Chi-square test, comparing two quantitative variables i.e. systolic blood pressure readings between both groups was performed p-value came out to be <0.05 and considered statistically significant. Conclusion: There was no significant statistical hemodynamic difference between the two groups however in 0.5% hyperbaric solution, vasopressor and atropine need was significantly less with more stable hemodynamic profile in the study

Post- Operative Recovery Profile after Laparoscopic Cholecystectomy: Comparing Inhalational Versus Intravenous Anaesthetic Regimen

Background: To compare inhalational anaesthetic regimen with intravenous regimen with regard to post operative recovery after laparoscopic cholecystectomy Methods: In this comparative study 166 patients were selected by lottery and assigned into two groups. Induction was done with sevoflurane 8% in 50% nitrous oxide in oxygen (group-A) and propofol 2mg/kg (group-B).All patients had volume controlled ventilation and standard monitoring.Before shifting Fast Track criteria was used inside operating room and Post Anaesthesia Discharge score employed in recovery area. Spearman’s Rank correlation was used to check interdependence between the two recovery scores i.e.Fast-Track criteria and Post Anaesthesia Discharge score in both groups. Results: Fast track criteria and post op anaesthesia scores were equal in both groups.Inhalation induction(group-A) was slightly slower as compared to intravenous induction with propofol (group-B) but a higher incidence of un-expected movement/cough was noted during propofol induction as compared to sevoflurane. ASA physical status classes of both groups are identical. Though different anaesthesia techniques were used in both groups while standardizing anaesthetic maintenance factors and per-operative medications, no clinical superiority in recovery times was noted in ambulatory laparoscopic cholecystectomy. The value of correlation co-efficient(r) was .372 and .556 respectively in both groups and significant at 0.01 level

The role of micro health insurance in providing financial risk protection in developing countries- a systematic review.

BACKGROUND: Out of pocket payments are the predominant method of financing healthcare in many developing countries, which can result in impoverishment and financial catastrophe for those affected. In 2010, WHO estimated that approximately 100 million people are pushed below the poverty line each year by payments for healthcare. Micro health insurance (MHI) has been used in some countries as means of risk pooling and reducing out of pocket health expenditure. A systematic review was conducted to assess the extent to which MHI has contributed to providing financial risk protection to low-income households in developing countries, and suggest how the findings can be applied in the Pakistani setting. METHODS: We conducted a systematic search for published literature using the search terms Community based health insurance AND developing countries , Micro health insurance AND developing countries , Mutual health insurance AND developing countries , mutual OR micro OR community based health insurance Health insurance AND impact AND poor Health insurance AND financial protection and mutual health organizations on three databases, Pubmed, Google Scholar and Science Direct (Elsevier). Only those records that were published in the last ten years, in English language with their full texts available free of cost, were considered for inclusion in this review. Hand searching was carried out on the reference lists of the retrieved articles and webpages of international organizations like World Bank, World Health Organization and International Labour Organization. RESULTS: Twenty-three articles were eligible for inclusion in this systematic review (14 from Asia and 9 from Africa). Our analysis shows that MHI, in the majority of cases, has been found to contribute to the financial protection of its beneficiaries, by reducing out of pocket health expenditure, catastrophic health expenditure, total health expenditure, household borrowings and poverty. MHI also had a positive safeguarding effect on household savings, assets and consumption patterns. CONCLUSION: Our review suggests that MHI, targeted at the low-income households and tailored to suit the cultural and geographical structures in the various areas of Pakistan, may contribute towards providing protection to the households from catastrophe and impoverishment resulting from health expenditures. This paper emphasizes the need for further research to fill the knowledge gap that exists about the impact of MHI, using robust study designs and impact indicators

Nitrous Oxide in Oxygen and Air in Oxygen for Perioperative Analgesia : A Comparative study

Background: To determine that additional dose of nalbuphine is required while using medical air instead of nitrous oxide in oxygen to maintain anaesthesia so that inadequate intra-operative analgesia could be avoided. Methods: This quasi experimental study was carried out in the Department of Anaesthesia, Holy Family Hospital, Rawalpindi, from October 2007 to March 2008. One hundred patients were selected by non probability convenient sampling. Patients between 20 to 40 years of age were included, belonging to ASA Class-I and II. They were divided into two groups (A and B) scheduled for different elective surgical procedures under general anaesthesia. Group A comprised of fifty patients who received medical air in oxygen. Group B comprised of fifty patients who received nitrous oxide in oxygen. The conduct of anaesthesia was kept same in both the groups. Patients heart rate, mean arterial pressure, pulse oximetry, ECG were monitored and requirement of additional dose of nalbuphine in both the groups was noted. Intra-operative tachycardia and hypertension indicated additional dose of nalbuphine. Average value of heart rate and blood pressure of each case was determined and the data compared and analyzed by SPSS-10. Results: Forty patients in group A did not require intra-operative additional nalbuphine while the remaining ten patients required it. Forty eight patients in group B did not require additional intra-operative nalbuphine and only two patients required it. Conclusion: The use of nitrous oxide significantly reduces the intra-operative narcotic analgesia requirement

Climate Change and Citrus

Climate change is the change in the statistical distribution of weather patterns that lasts for an extended period. Climate change and agriculture are interrelated processes and affect in many ways. Citrus fruits are one of the largest fruit crops in the world. Yield loss at a drastic level due to abiotic stress annually in which temperature and water stress are the main environmental factors. These factors cause biochemical, anatomical, physiological, and genetic changes in plant structure and lead to defective growth, development, and reproduction, which ultimately cause a reduction in the economic yield of the crop. An increase in temperature and water stress at critical phenological stages of citrus results in reduced tree fruit set, decrease in fruit growth and size, increase in fruit acidity, low tree yield, reduced fruit peel thickness, and pre-harvest fruit drop. Stomatal conductance and net carbon dioxide assimilation in citrus leaves can be reduced by super optimal leaf temperature. Water deficit reduces the transpiration rate, stomatal conductance by stomatal closure associated with ABA content and causes an abrupt decrease in photosynthesis and CO2 assimilation in citrus which reduce trees overall growth and production. Interventions in agronomic practices, breeding strategies, and biotechnological approaches can mitigate climate change effects on citrus. The groundwork against climate change is compulsory for better global livelihood and food security

Short-term adverse effects of COVID-19 vaccines after the first, second, and booster doses : a cross-sectional survey from Punjab, Pakistan, and the implications

Safety and efficacy concerns regarding coronavirus disease 2019 (COVID-19) vaccines are common among the public and have a negative impact on their uptake. We aimed to report the adverse effects currently associated with the vaccine in Pakistan to build confidence among the population for its adoption. A cross-sectional study was conducted in five districts of the Punjab province of Pakistan between January and March 2022. The participants were recruited using convenience sampling. All data were analyzed using SPSS 22. We recruited 1622 people with the majority aged between 25-45 years. Of these, 51% were female, including 27 pregnant women and 42 lactating mothers. Most participants had received the Sinopharm (62.6%) or Sinovac (17.8%) vaccines. The incidences of at least one side effect after the first (N = 1622), second (N = 1484), and booster doses (N = 219) of the COVID-19 vaccine were 16.5%, 20.1%, and 32%, respectively. Inflammation/erythema at the injection site, pain at the injection site, fever, and bone/muscle pain were common side effects of vaccination. No significant differences were observed in the adverse effect scores between all demographic variables except for pregnancy (P = 0.012) after the initial dose. No significant association was observed between any variable and the side effect scores of the second and booster doses of the vaccine. Our study showed a 16-32% prevalence of self-reported side effects after the first, second, and booster COVID-19 vaccinations. Most adverse effects were mild and transient, indicating the safety of different COVID-19 vaccines

Inhibition of G-protein signalling in cardiac dysfunction of intellectual developmental disorder with cardiac arrhythmia (IDDCA) syndrome

Background: Pathogenic variants of GNB5 encoding the β5 subunit of the guanine nucleotide-binding protein cause IDDCA syndrome, an autosomal recessive neurodevelopmental disorder associated with cognitive disability and cardiac arrhythmia, particularly severe bradycardia. Methods: We used echocardiography and telemetric ECG recordings to investigate consequences of Gnb5 loss in mouse. Results: We delineated a key role of Gnb5 in heart sinus conduction and showed that Gnb5-inhibitory signalling is essential for parasympathetic control of heart rate (HR) and maintenance of the sympathovagal balance. Gnb5-/- mice were smaller and had a smaller heart than Gnb5+/+ and Gnb5+/-, but exhibited better cardiac function. Lower autonomic nervous system modulation through diminished parasympathetic control and greater sympathetic regulation resulted in a higher baseline HR in Gnb5-/- mice. In contrast, Gnb5-/- mice exhibited profound bradycardia on treatment with carbachol, while sympathetic modulation of the cardiac stimulation was not altered. Concordantly, transcriptome study pinpointed altered expression of genes involved in cardiac muscle contractility in atria and ventricles of knocked-out mice. Homozygous Gnb5 loss resulted in significantly higher frequencies of sinus arrhythmias. Moreover, we described 13 affected individuals, increasing the IDDCA cohort to 44 patients. Conclusions: Our data demonstrate that loss of negative regulation of the inhibitory G-protein signalling causes HR perturbations in Gnb5-/- mice, an effect mainly driven by impaired parasympathetic activity. We anticipate that unravelling the mechanism of Gnb5 signalling in the autonomic control of the heart will pave the way for future drug screening

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial