Oral versus intramuscular midazolam for paediatric preanaesthetic medication

Background: The need for effective preanesthetic medication in children is obvious and midazolam has proven to be one reliable choice. The aim of the present study was to compare the efficacy, acceptability and reliability of the oral and intramuscular routes of administration of midazolam towards paediatric preanesthetic medication at various doses.Methods: Hundred eligible patients in the age group of 1 to 10 years undergoing ambulatory or routine planned, minor or major surgery during study period were allocated to one of the four groups of 25 participants each, formed on the basis of premedication they received. Haemodynamic parameters, level of sedation and anxiety and induction score were noted before premedication and after each 15 minutes interval for next 45 minutes in all the four groups. Postoperative assessment included sleep level, anterograde amnesia, picture recall and occurrence of complications.Results: The sedative and anxiolytic effects were observed to be maximum at 45 minutes after premedication in all the four groups and better sedation, anxiolysis and quality of induction were achieved with higher doses for both oral as well as intramuscular routes. Postoperatively, the sleep level did not increase with higher dose and 64% patients were awake with 0.75 mg/kg oral midazolam. The sleep level was more with higher dose with the Intramuscular route, with 60% patients feeling drowsy with 0.1mg/kg dose. 0.75 mg/kg dose showed better anterograde amnesia (64%) than 0.5 mg/kg (28%), while it was present in 64% participants premedicated with 0.8 mg/kg intramuscular does and 72% in 0.1 mg/kg intramuscular dose.Conclusions: Intramuscular midazolam at 0.1 mg/kg dose seems to be the ideal dose and route for paediatric preanesthetic medication, with oral midazolam at 0.75 mg/kg to be considered an effective and acceptable alternative.

Anaesthetic management of neonate with giant occipital meningoencephalocele: case report

Meningoencephalocele is herniation of cerebrospinal fluid, brain tissue and meninges through the skull defect. The anaesthetic management of occipital meningoencephalocele is challenging because of the difficulty in securing airway, prone position, blood loss and, perioperative care. The two major aims of the anaesthesiologists while caring for children with occipital encephalocoele intraoperatively are to avoid premature rupture of the encephalocoele and to manage a possible difficult airway due to restricted neck movement and inability to achieve optimal position for intubation of the trachea. We report a case of giant occipital meningoencephalocele presented for surgical excision. Perioperative management of patients with giant meningoencephalocele may be challenging for both anaesthesiologist and neurosurgeon. These patients must be managed closely with an interdisciplinary approach

Bupivacaine 0.5% vs. levobupivacaine 0.5% for epidural anaesthesia for caesarean section: a comparative study

Background: Levobupivacaine has been purported to be as efficacious as Bupivacaine for epidural anaesthesia in recent literature.Methods: With the intent to study the same in caesarean section cases in our set up, we observed various intra- and post-operative variables in two groups (Levobupivacaine and Bupivacaine) of 60 healthy parturients. Sixty parturients for elective caesarean section were allocated randomly to receive epidural block with 10-20 ml of either 0.5% Levobupivacaine with Fentanyl 25µg or 0.5% Bupivacaine with Fentanyl 25µg to reach T6 level.Results: Mean total volume in Bupivacaine group was 15.23ml and in Levobupivacaine group was 12.76 ml. The difference was statistically significant. There was significant difference between the groups in the sensory block. The onset of analgesia was earlier in Levobupivacaine group. Mean time was 6.20 minutes in Bupivacaine group and 4.36 minutes in Levobupivacaine group. The duration of motor block was significantly short in Levobupivacaine group. Mean Time for recovery from motor block in Bupivacaine group was 2.5 hours and in Levobupivacaine group 1.5 hours. Mean time to achieve T6 height was earlier in Levobupivacaine group i.e. 16.46 minutes in Bupivacaine group and 13.26 minutes in Levobupivacaine group. Duration of postoperative analgesia was similar. There was no significant difference in neonatal outcome.Conclusions: Levobupivacaine was found to fare better than Bupivacaine in the studied intra and post-operative parameters and is hence recommended over racemic Bupivacaine for epidural block in patients undergoing elective cesarean section

Identifying Prognostic Groups Using Machine Learning Tools in Patients Undergoing Chemoradiation for Inoperable Locally Advanced Nonsmall Cell Lung Carcinoma

Introduction Unresectable stage III nonsmall cell lung cancer (NSCLC) continues to have dismal 5-year overall survival (OS) rate. However, a subset of the patients treated with chemoradiation show significantly better outcome. Prediction of treatment outcome can be improved by utilizing machine learning tools, such as cluster analysis (CA), and is capable of identifying complex interactions among many variables. We have utilized CA to identify a cluster with good prognosis within stage III NSCLC. Materials and Methods Retrospective analysis of treatment outcomes was done for 92 patients who underwent chemoradiation for inoperable locally advanced NSCLC from 2012 to 2018. Using various patient- and treatment-related variables, an exploratory factor analysis was performed to extract factors with eigenvalue > 1. An appropriate number of homogeneous groups were identified using agglomerative hierarchical cluster analysis. Further K-mean cluster analysis was applied to classify each patient into their homogeneous clusters. The newly formed cluster variable was used as an independent variable to estimate survival over time using Kaplan–Meier method. Results With a median follow-up of 18 months, median OS was 14 months. Using CA, three prognostic clusters were obtained. Cluster 2 with 36 patients had a median OS of 36 months, whereas Cluster 1 with 34 patients had a median OS of 20 months (p = 0.004). Conclusion A cluster could thus be identified with a relatively good prognosis within stage III NSCLC. Using CA, we have attempted to create a model which may provide more specific prognostic information in addition to that provided by tumor node metastasis-based models

Plan quality assessment of modern radiotherapy delivery techniques in left-sided breast cancer: an analysis stratified by target delineation guidelines

Objective: This study compares planning techniques stratified by consensus delineation guidelines in patients undergoing whole-breast radiotherapy based on an objective plan quality assessment scale. Methods: 10 patients with left-sided breast cancer were randomly selected, and target delineation for intact breast was performed using Tangent (RTOG 0413), ESTRO, and RTOG guidelines. Consensus Plan Quality Metric (PQM) scoring was defined and communicated to the physicist before commencing treatment planning. Field-in-field IMRT (FiF), inverse IMRT (IMRT) and volumetric modulated arc therapy (VMAT) plans were created for each delineation. Statistical analyses utilised a two-way repeated measures analysis of variance, after applying a Bonferroni correction. Results: Total PQM score of plans for Tangent and ESTRO were comparable for FiF and IMRT techniques (FiF vs IMRT for Tangent, p = 0.637; FiF vs IMRT for ESTRO, p = 0.304), and were also significantly higher compared to VMAT. Total PQM score of plans for RTOG revealed that IMRT planning achieved a significantly higher score compared to both FiF and VMAT (IMRT vs FiF, p &lt; 0.001; IMRT vs VMAT, p &lt; 0.001). Conclusions: Total PQM scores were equivalent for FiF and IMRT for both Tangent and ESTRO delineations, whereas IMRT was best suited for RTOG delineation. Advances in knowledge: FiF and IMRT planning techniques are best suited for ESTRO or Tangent delineations. IMRT also yields better results with RTOG delineation. </jats:sec

"More than just a medical student”: a mixed methods exploration of a structured volunteering programme for undergraduate medical students

Background As a result of the COVID-19 pandemic Imperial College School of Medicine developed a structured volunteering programme involving 398 medical students, across eight teaching hospitals. This case study aims to illuminate the experiences of volunteers, mechanisms of learning and draw lessons for future emergencies and curriculum improvements. Methods Using an illuminative approach to evaluation we invited all volunteers and supervisors to complete a mixed-methods survey. This gathered nominal demographic information and qualitative data related to motivations, experiences, insights into learning, processual and contextual factors. Qualitative responses were coded, thematically organised, and categorised into an overarching framework. Mann-Whitney U tests determined whether volunteers’ overall rating of the experience varied according to demographic features and modulating factors. Spearman’s rank correlation assessed the relationship between aspects of induction and supervision, and overall volunteering rating. Follow up interviews were carried out with students to check back findings and co-create conclusions. Results Modulating factors identified through thematic analysis include altruistic motivation, engaged induction and supervision, feeling valued, having responsibility and freedom from the formal curriculum. Statistically significant positive correlations are identified between volunteers overall rating and being a year 1 or 2 student, ability to discuss role and ask questions during induction, being male, and having regular meetings and role support from supervisors. Qualitatively reported impacts include improved wellbeing, valuable contribution to service and transformative learning. Transformative learning effects included reframing of role within the multidisciplinary team, view of effective learning and view of themselves as competent clinicians. The number of weeks, number of shifts per week, and the role the volunteers performed, did not significantly impact experiences. Conclusions While acknowledging the uniqueness of the situation presented by the first wave COVID-19, we suggest the features of a successful service-learning programme include: a learner-centred induction, engaged and appreciative supervisors, and the entrustment of students with meaningful work with reciprocal benefits to services. Programmes in similar settings may find that 1) volunteering is best appreciated in years 1 or 2, 2) students with altruistic motivations and meaningful work may flourish without formal outcomes and assessments, and 3) that female volunteers may experience emergency learning differently to men