Successful anesthetic management of patient with stiff person syndrome

We herein describe the successful anesthetic management of a patient with stiff person syndrome undergoing right total hip replacement under spinal anesthesia. We also describe the problems associated with general anesthesia. The advantage of using regional anesthesia in these patients is the avoidance of muscle relaxants. The use of general anesthesia carries the risk of hypotonia in stiff person syndrome postoperatively due to enhancement of γ aminobutyric acid (GABA) action on synaptic transmission by drugs that have a γ GABA agonistic action

Breaking the pain cycle successfully in a child with severe pain due to recurrent pancreatitis: A case report

Abdominal pain, due to pancreatic diseases like idiopathic recurrent pancreatitis and chronic pancreatitis, is difficult to manage with medications alone in some patients. The Coeliac plexus innervates abdominal organs including the liver, gallbladder, pancreas, etc. We are presenting a case of the successful pain man-agement of a 13-year-old boy with recurrent pancreatitis, by the application of coeliac plexus block. The patient was admitted to the hospital with severe abdominal pain in August 2019. Multimodal analgesia was provided to manage his pain, but he continued to have moderate to severe pain in the abdomen. So, he was scheduled for coeliac plexus block under fluoroscopy in the operating room. Block Procedure was performed with standard monitoring and under conscious sedation bilaterally, via paramedian technique at the level of L1 using 22G Chiba needle. The injection Ropivicaine 0.25% with dexamethasone was injected on each side. After the procedure, his pain was significantly reduced and he was discharged on oral medications after two days

Postoperative pain management practices and their effectiveness after major gynecological surgery: An observational study in a tertiary care hospital

Background and Aims: Despite advances in postoperative pain management, patients continue to experience moderate to severe pain. This study was designed to assess the strategy, effectiveness, and safety of postoperative pain management in patients undergoing major gynecological surgery.Material and Methods: This observational study included postoperative patients having major gynecological surgery from February 2016 to July 2016. Data collected on a predesigned data collection sheet included patient\u27s demographics, postoperative analgesia modality, patient satisfaction, acute pain service assessment of numeric rating scale (NRS), number of breakthrough pains, number of rescue boluses, time required for the pain relief after rescue analgesia, and any complication for 48 h.Results: Among 154 patients reviewed, postoperative analgesia was provided with patient-controlled intravenous analgesia in 91 (59.1%) patients, intravenous opioid infusion in 42 (27%), and epidural analgesia in 21 (13.6%) patients with no statistically significant difference in NRS between different analgesic modalities. On analysis of breakthrough pain, 103 (66.8%) patients experienced moderate pain at one time and 53 (51.4%) at two or more times postoperatively. There were 2 (0.6%) patients experiencing severe breakthrough pain due to gaps in service provision and inadequate patient\u27s knowledge. Moderate-to-severe pain perception was irrespective of type of incision and surgery. Vomiting was significantly higher (P = 0.049) in patients receiving opioids.Conclusion: Adequacy of postoperative pain is not solely dependent on drugs and techniques but on the overall organization of pain services. However, incidence of nausea and vomiting was significantly higher in patients receiving opioids

Rural Credit and Rural Development: Some Issues

Credit plays an important role in acquiring command over the use of working capital, fixed capital, and consumption goods that leads to growth and development of a country. The paper investigates that the role of non-institutional sources is quite clearly borne out. The price paid for institutional credit in Pakistan Kept low by the government. Institutional credit reforms implemented has not been effective. There is a great need to have the land reforms prior to credit reforms. The importance of social and economic infrastructure needs to be addressed. Appropriate use of new credit should be assured. Proper credit policy be designed and implemented.

Persistent post-surgical pain following breast cancer surgery: An observational study in a tertiary care hospital

Objective: To determine the frequency of persistent pain in patients after breast cancer surgery, and to assess the distribution and characteristics of pain in such patients.Methods: The prospective observational single cohort study was conducted at the Department of Anaesthesiology and in the Breast Clinic of the Department of Surgery, Aga Khan University Hospital, Karachi, from August 2016 to January 2017, and comprised adult female patients with biopsy-proven carcinoma of breast who were scheduled for elective definitive breast cancer surgery. The patients were followed up for up to three months post-surgery and those with persistent pain were followed up for six months post-operation. Data was analysed using SPSS 19.Results: Of the 120 patients, 26(21.7%) developed persistent post-surgical pain for up to three months, while in 17(14.2%) patients, the pain continued for up to six months after the operation. Among those with persistent post-surgical pain, 11(42.3%) had burning pain, 10(38.5%) had throbbing pain, 3(11.5%) had numbness and 2(7.7%)had mixed character of pain. Also, 11(42.3%)patients developed pain at more than one site including axilla, chest wall, upper arm and surgical scar area, and the site of pain in majority patients 15(57.7%) was axilla.Conclusion: The incidence of persistent pain following breast cancer surgery was found to be 21.7%

Vascular cognitive impairment in first ever ischemic stroke survivors

Stroke and transient ischemic attacks (TIA) are highly prevalent in Pakistan. Post stroke dementia (PSD) is one of the main causes of dependency in survivors and includes any dementia after a stroke, irrespective of its cause, which includes vascular, degenerative, or mixed. Many Independent survivors have residual physical or cognitive deficits, or behavioral changes which can affect family life and have professional consequences. Study design: Cross sectional study at Department of Neurology CMC Hospital Larkana from Aug-2014 to Jan-2015 to find out frequency of dementia in first ever ischemic stroke patients, its severity and outcome. Methods: Study approved from ethical review committee of the institute. Patients 30-60 years of age, of either gender, previously non-demented with first episode of ischemic stroke were included in this study after informed consent. Patients of Hemorrhagic stroke, Parkinson’s disease, Terminal cancers and those on steroids were excluded. Stroke confirmed by CT scan brain/ MRI showing new infarcts. Dementia was defined as per MMSE dementia interview at baseline and 3 months of follow up. Score of \u3c23 indicated cognitive impairment. Activity of daily living was assessed by AD8 screening interview. Score \u3e2 indicated impairment in activity of daily living. Results: 120 patients were included in the study during 6 month period with mean age of 54(±3.4) years. Among them 74 were males and 46 were females. 52 (43.33%) patients had a lacunar stroke, 43(35.8%) a MCA infarct, 13(10.83%) with ACA infarct, 12 (10%) a posterior circulation stroke. Among vascular risk factors hypertension present in 32 (26%), diabetes in 22(18.3%), atrial fibrillation in 11(9.16%), previous myocardial infarction 10( 8.33%) and history of transient ischemic attack 34(28.33%). Their medical history, neurological deficit, activity of daily living, a blood screen and extent of vascular territory of the stroke were recorded. MMSE at 3 month of stroke follow up performed which revealed \u3c23 score among 33(26%) patients. The activity of daily living was impaired among the demented patients. Recall, language and attention was impaired more than registration and orientation. Discussion: Patients with PSD have high mortality rates and are likely to be functionally impaired. The progressive decline of recall and forgetfulness observed in our study severely affect the activity of daily living. The best way to prevent dementia is preventing vascular risk factors and the stroke by medications and follow up. Conclusion: Stroke patients should be assessed with dementia and monitored regularly with structured MMSE and activity of daily living as part of routine check up to prevent mortality and morbidity in stroke survivors

Rural Credit and Rural Development: Some Issues

Credit is an important instrument of acquiring command over the use of working capital, fixed capital and consumption goods. In the wake of Green Revolution, land and labour have receded into the background as predominant factors of growth. Use of capital and adoption of modern techniques of production which have become major sources of growth of agricultural output necessitate access to credit markets for financing their use. Institutional sources of credit have become quite significant during the last few years. The rapid expansion of credit from institutional sources can be seen from various indicators. The total disbursement of agricultural loans has gone up from Rs. 306.75 million in 1972-73 to Rs. 5,102.14 million in 1981-82. On a per acre basis, the loans increased from Rs. 7.33 in 1972-73 to Rs. 106.83 in 1981-82. In this perspective, the disparities in income and wealth in rural areas would crucially depend on the distribution of capital among farms of different sizes and occupational groups. Neglecting equitable distribution of credit as a policy instrument for rural income redistribution may be a serious omission by the policy makers interested in an improvement of rural equity

Altered expression of cell cycle and apoptotic proteins in chronic hepatitis C virus infection.

RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are.BACKGROUND: A disrupted cell cycle progression of hepatocytes was reported in chronic hepatitis C virus (HCV) infection, which can contribute significantly in the associated pathogenesis. The present study aimed to further elaborate these disruptions by evaluating the expression of key cell cycle and apoptotic proteins in chronic HCV infection with particular reference to genotype 3. Archival liver biopsy specimens of chronic HCV-infection (n = 46) and normal histology (n = 5) were analyzed by immunohistochemistry using antibodies against proliferation marker Mcm-2, G1 phase marker Cyclin D1, S phase marker Cyclin A, cell cycle regulators p21 (CDK inhibitor) and p53 (tumor suppressor protein), apoptotic protein Caspase-3 and anti-apoptotic protein Bcl-2. RESULTS: Elevated Mcm-2 expression was observed in hepatocytes in chronic HCV infection, indicating increased cell cycle entry. Cyclin D1 expression was higher than cyclin A, which suggests a slow progression through the G1 phase. Expression of cell cycle regulators p21 and p53 was elevated, with no concordance between their expressions. The Mcm-2 and p21 expressions were associated with the fibrosis stage (p = 0.0001 and 0.001 respectively) and that of p53 with the inflammation grade (p = 0.051). Apoptotic marker, Caspase-3, was mostly confined to sinusoidal lining cells with little expression in hepatocytes. Anti-apoptotic protein, Bcl-2, was negligible in hepatocytes and detected principally in infiltrating lymphocytes. Expression of all these proteins was unrelated to the HCV genotype and were detected only rarely in the hepatocytes of normal liver. CONCLUSION: The results showed an arrested cell cycle state in the hepatocytes of chronic HCV infection, regardless of any association with genotype 3. Cell cycle arrest is characterized by an increased expression of p21, in relation to fibrosis, and of p53 in relation to inflammation. Furthermore, expression of p21 was independent of the p53 expression and coincided with the reduced expression of apoptotic protein Caspase-3 in hepatocytes. The altered expression of these cell cycle proteins in hepatocytes is suggestive of an impaired cell cycle progression that could limit the regenerative response of the liver to ongoing injury, leading to the progression of disease

Global variation of COVID-19 mortality rates in the initial phase

Objectives: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused devastation in over 200 countries. Italy, Spain, and the United States (US) were most severely affected by the first wave of the pandemic. The reasons why some countries were more strongly affected than others remain unknown. We identified the most-affected and less-affected countries and states and explored environmental, host, and infrastructure risk factors that may explain differences in the SARS-CoV-2 mortality burden. Methods: We identified the top 10 countries/US states with the highest deaths per population until May 2020. For each of these 10 case countries/states, we identified 6 control countries/ states with a similar population size and at least 3 times fewer deaths per population. We extracted data for 30 risk factors from publicly available, trusted sources. We compared case and control countries/states using the non-parametric Wilcoxon rank-sum test, and conducted a secondary cluster analysis to explore the relationship between the number of cases per population and the number of deaths per population using a scalable EM (expectation–maximization) clustering algorithm. Results: Statistically significant differences were found in 16 of 30 investigated risk factors, the most important of which were temperature, neonatal and under-5 mortality rates, the percentage of under-5 deaths due to acute respiratory infections (ARIs) and diarrhea, and tuberculosis incidence (p < 0.05) Conclusion: Countries with a higher burden of baseline pediatric mortality rates, higher pediatric mortality from preventable diseases like diarrhea and ARI, and higher tuberculosis incidence had lower rates of coronavirus disease 2019-associated mortality, supporting the hygiene hypothesis